The Preventive Effect of Dexmedetomidine Against Delirium in Patients with Aortic Dissection: A Retrospective Cohort Study
Keywords:aortic dissection, delirium, dexmedetomidine, intensive care unit
Background: Dexmedetomidine (DEX) is often used to reduce the incidence of delirium in intensive care unit (ICU) patients. However, it was found in our clinical practice that the incidence of delirium in some patients with aortic dissection (AD) remained high even after using DEX. The aim of the present study was to clarify whether the protective effects of DEX against delirium were different between Stanford type A and B AD patients during ICU stay.
Methods: Data of patients with Stanford type A or B AD who were treated in the ICU of our hospital between 2015 and 2018 retrospectively were reviewed. They were divided into four groups: A1 group (Stanford type A AD patients using DEX), A2 group (Stanford type A AD patients without using DEX), B1 group (Stanford type B AD patients using DEX), and B2 group (Stanford type B AD patients without using DEX). Patients in A1 and B1 groups received intravenous administration of DEX within 1 h admission to the ICU and after surgery or stent implantation at a loading dose of 1 µg/kg, followed by continuous infusion of 0.2–0.7 µg/(kg·h) for >24 h. The mortality rate, delirium incidence, length of ICU stay, and drug administration were compared between the four groups.
Results: After intravenous administration of DEX, the delirium incidence in B1 group was reduced significantly compared with that in B2 group (2.8% vs. 17.8%, P = 0.04), while there was no significant difference between A1 and A2 group (20.8% vs. 24.3%, P = 0.7). However, DEX administration significantly reduced the use of anti-hypertensive drugs (P = 0.04) and morphine (P = 0.02) in Stanford type A AD patients.
Conclusion: The use of DEX reduced the incidence of delirium in Stanford type B AD patients during ICU stay, therefore reducing the risk of medical accidents and risk of rupture of the aortic dissecting aneurysm. The preventive effect of DEX against delirium in Stanford type A AD patients was not obvious, and whether increasing the dosage of DEX could enhance the therapeutic efficacy in this group of patients needs to be further observed in future studies.
Chen SL, Chai YF, Wang ZH, et al. 2020. Effects of dexmedetomidine on heart rate control and pre-operative outcome in patients with acute aortic dissection: a propensity-matched analysis. Ann Palliat Med. 9(5):2886-2894.
Chiu P, Miller DC. 2016. Evolution of surgical therapy for Stanford acute type A aortic dissection. Annals of cardiothoracic surgery. Jul;5(4):275-95.
Conzelmann LO, Hoffmann I, Blettner M, Kallenbach K, Karck M, Dapunt O, et al. 2012. Analysis of risk factors for neurological dysfunction in patients with acute aortic dissection type A: data from the German Registry for Acute Aortic Dissection type A (GERAADA). European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery. Sep;42(3):557-65.
Endlich M, Hamiko M, Gestrich C, Probst C, Mellert F, Winkler K, et al. 2016. Long-Term Outcome and Quality of Life in Aortic Type A Dissection Survivors. The Thoracic and cardiovascular surgeon. Mar;64(2):91-9.
Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, Eggebrecht H, et al. 2014. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). European heart journal. Nov 1;35(41):2873-926.
Fukui T. 2018. Management of acute aortic dissection and thoracic aortic rupture. Journal of intensive care. 6:15.
Guerrero-Garcia C, Rubio-Guerra AF. 2018. Combination therapy in the treatment of hypertension. Drugs in context. 7:212531.
Gusmao-Flores D, Salluh JI, Chalhub RA, Quarantini LC. 2012. The confusion assessment method for the intensive care unit (CAM-ICU) and intensive care delirium screening checklist (ICDSC) for the diagnosis of delirium: a systematic review and meta-analysis of clinical studies. Critical care (London, England). Jul 3;16(4):R115.
Hosokawa K, Shime N, Kato Y, Taniguchi A, Maeda Y, Miyazaki T, et al. 2010. Dexmedetomidine sedation in children after cardiac surgery. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies. Jan;11(1):39-43.
Keating GM. 2015. Dexmedetomidine: A Review of Its Use for Sedation in the Intensive Care Setting. Drugs. Jul;75(10):1119-30.
Lau C, Leonard JR, Iannacone E, Gaudino M, Girardi LN. 2019. Surgery for Acute Presentation of Thoracoabdominal Aortic Disease. Seminars in thoracic and cardiovascular surgery. Spring;31(1):11-6.
Liu Z, Pang X, Zhang X, Cao G, Fang C, Wu S. 2017. Incidence and Risk Factors of Delirium in Patients After Type-A Aortic Dissection Surgery. Journal of cardiothoracic and vascular anesthesia. Dec;31(6):1996-9.
Merkle J, Sabashnikov A, Liebig L, Weber C, Eghbalzadeh K, Liakopoulos O, et al. 2019. Factors predictive for early and late mortality after surgical repair for Stanford A acute aortic dissection. Perfusion. Jul;34(5):375-83.
Rudolph JL, Marcantonio ER. 2011. Review articles: postoperative delirium: acute change with long-term implications. Anesthesia and analgesia. May;112(5):1202-11.
Rylski B, Perez M, Beyersdorf F, Reser D, Kari FA, Siepe M, et al. 2017. Acute non-A non-B aortic dissection: incidence, treatment and outcome. European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery. Dec 1;52(6):1111-7.
Seto M, Matsuda M, Narihira K, Kikuta T. 2016. Oral surgery under local anesthesia with dexmedetomidine sedation in a morbidly obese patient with aortic dissection. Journal of the Korean Association of Oral and Maxillofacial Surgeons. Jun;42(3):162-5.
Shehabi Y, Grant P, Wolfenden H, Hammond N, Bass F, Campbell M, et al. 2009. Prevalence of delirium with dexmedetomidine compared with morphine based therapy after cardiac surgery: a randomized controlled trial (DEXmedetomidine Compared to Morphine-DEXCOM Study). Anesthesiology. Nov;111(5):1075-84.
Shehabi Y, Howe BD, Bellomo R, Arabi YM, Bailey M, Bass FE, et al. 2019. Early Sedation with Dexmedetomidine in Critically Ill Patients. The New England journal of medicine. Jun 27;380(26):2506-17.
Shi C, Jin J, Qiao L, Li T, Ma J, Ma Z. 2019. Effect of perioperative administration of dexmedetomidine on delirium after cardiac surgery in elderly patients: a double-blinded, multi-center, randomized study. Clinical interventions in aging. 14:571-5.
Shi Q, Mu X, Zhang C, Wang S, Hong L, Chen X. 2019. Risk Factors for Postoperative Delirium in Type A Aortic Dissection Patients: A Retrospective Study. Medical science monitor : international medical journal of experimental and clinical research. May 18;25:3692-9.
Sievers HH, Rylski B, Czerny M, Baier ALM, Kreibich M, Siepe M, et al. 2020. Aortic dissection reconsidered: type, entry site, malperfusion classification adding clarity and enabling outcome prediction. Interactive cardiovascular and thoracic surgery. Mar 1;30(3):451-7.
Skrobik Y, Duprey MS, Hill NS, Devlin JW. 2018. Low-Dose Nocturnal Dexmedetomidine Prevents ICU Delirium. A Randomized, Placebo-controlled Trial. American journal of respiratory and critical care medicine. May 1;197(9):1147-56.
Su X, Meng ZT, Wu XH, Cui F, Li HL, Wang DX, et al. 2016. Dexmedetomidine for prevention of delirium in elderly patients after non-cardiac surgery: a randomised, double-blind, placebo-controlled trial. Lancet (London, England). Oct 15;388(10054):1893-902.
Wang J, Li Y, Li Y, Ren Z, Chen P, Qian X, et al. 2016. Endovascular Stent-Graft Placement in Patients with Stanford Type B Aortic Dissection in China: A Systematic Review. Annals of vascular surgery. Oct;36:298-309.
Wang XT, Lyu L, Tang B, Wang C, Liu DW. 2017. Delirium in Intensive Care Unit Patients: Ten Important Points of Understanding. Chinese medical journal. Oct 20;130(20):2498-502.
Wee I, Varughese RS, Syn N, Choong A. 2019. Non-operative Management of Type A Acute Aortic Syndromes: A Systematic Review and Meta-Analysis. European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery. Jul;58(1):41-51.
Wu L. 2018. The pathogenesis of thoracic aortic aneurysm from hereditary perspective. Gene. Nov 30;677:77-82.
Xu H, Zhou J, Han Y. Analgesic efficacy of dexmedetomidine combined with morphine in patients with acute ascending aortic dissection. Zhong Hua Ma Zui Xue Za Zhi. 2016;36(5):574-7.
How to Cite
Author Disclosure & Copyright Transfer Agreement
In order to publish the original work of another person(s), The Heart Surgery Forum® must receive an acknowledgment of the Author Agreement and Copyright Transfer Statement transferring to Forum Multimedia Publishing, L.L.C., a subsidiary of Carden Jennings Publishing Co., Ltd. the exclusive rights to print and distribute the author(s) work in all media forms. Failure to check Copyright Transfer agreement box below will delay publication of the manuscript.
A current form follows:
The author(s) hereby transfer(s), assign(s), or otherwise convey(s) all copyright ownership of the manuscript submitted to Forum Multimedia Publishing, LLC (Publisher). The copyright transfer covers the exclusive rights to reproduce and distribute the article and the material contained therein throughout the world in all languages and in all media of expression now known or later developed, including but not limited to reprints, photographic reproduction, microfilm, electronic data processing (including programming, storage, and transmission to other electronic data record(s), or any other reproductions of similar nature), and translations.
However, Publisher grants back to the author(s) the following:
- The right to make and distribute copies of all or part of this work for use of the author(s) in teaching;
- The right to use, after publication in The Heart Surgery Forum, all or part of the material from this work in a book by the author(s), or in a collection of work by the author(s);
- The royalty-free right to make copies of this work for internal distribution within the institution/company that employs the author(s) subject to the provisions below for a work-made-for-hire;
- The right to use figures and tables from this work, and up to 250 words of text, for any purpose;
- The right to make oral presentations of material from this work.
Publisher reserves the right to grant or refuse permission to third parties to republish all or part of the article or translations thereof. To republish, such third parties must obtain written permission from the Publisher. (This is in accordance with the Copyright Statute, United States Code, Title 17. Exception: If all authors were bona fide officers or employees of the U.S. Government at the time the paper was prepared, the work is a “work of the US Government” (prepared by an officer or employee of the US Government as part of official duties), and therefore is not subject to US copyright; such exception should be indicated on signature lines. If this work was prepared under US Government contract or grant, the US Government may reproduce, royalty-free, all or portions of this work and may authorize others to do so, for official US Government purposes only, if the US Government contract or grant so requires.
I have participated in the conception and design of this work and in the writing of the manuscript and take public responsibility for it. Neither this manuscript nor one with substantially similar content under my authorship has been published, has been submitted for publication elsewhere, or will be submitted for publication elsewhere while under consideration by The Heart Surgery Forum, except as described in an attachment. I have reviewed this manuscript (original version) and approve its submission. If I am listed above as corresponding author, I will provide all authors with information regarding this manuscript and will obtain their approval before submitting any revision. I attest to the validity, accuracy, and legitimacy of the content of the manuscript and understand that Publisher assumes no responsibility for the validity, accuracy, and legitimacy of its content. I warrant that this manuscript is original with me and that I have full power to make this Agreement. I warrant that it contains no matter that is libelous or otherwise unlawful or that invades individual privacy or infringes any copyright or other proprietary right. I agree to indemnify and hold Publisher harmless of and from any claim made against Publisher that relates to or arises out of the publication of the manuscript and agree that this indemnification shall include payment of all costs and expenses relating to the defense of any such claim, including all reasonable attorney’s fees.
I warrant that I have no financial interest in the drugs, devices, or procedures described in the manuscript (except as disclosed in the attached statement).
I state that the institutional Human Subjects Committee and/or the Ethics Committee approved the clinical protocol reported in this manuscript for the use of experimental techniques, drugs, or devices in human subjects and appropriate informed consent documents were utilized.
Furthermore, I state that any and all animals used for experimental purposes received humane care in USDA registered facilities in compliance with the “Principles of Laboratory Animal Care” formulated by the National Society for Medical Research and the “Guide for the Care and Use of Laboratory Animals” prepared by the Institute of Laboratory Animal Resources and published by the National Institutes of Health (NIH Publication No. 85-23, revised 1985).