Original Article
The Association Between Enhanced Recovery After Cardiac Surgery–Guided Analgesics and Postoperative Delirium

https://doi.org/10.1053/j.jvca.2022.12.023Get rights and content

Objectives

Delirium is a common postoperative complication associated with death and long-term cognitive impairment. The authors studied the association between opioid-sparing anesthetics, incorporating Enhanced Recovery After Cardiac Surgery (ERACS)-guided analgesics and postoperative delirium.

Design

The authors performed a retrospective review of nonemergent coronary, valve, or ascending aorta surgery patients.

Setting

A tertiary academic medical institution.

Participants

The study authors analyzed a dataset of elective adult cardiac surgical patients. All patients ≥18 years undergoing elective cardiac surgery from November 2, 2017 until February 2, 2021 were eligible for inclusion.

Interventions

The ERACS-guided multimodal pain regimen included preoperative oral acetaminophen and gabapentin, and intraoperative intravenous lidocaine, ketamine, and dexmedetomidine.

Measurements and Main Results

Delirium was measured by bedside nurses using the Confusion Assessment Method for the intensive care unit (ICU). Delirium occurred in 220 of the 1,675 patients (13.7%). The use of any component of the multimodal pain regimen was not associated with delirium (odds ratio [OR]: 0.85 [95% CI: 0.63-1.16]). Individually, acetaminophen was associated with reduced odds of delirium (OR: 0.60 [95% CI: 0.37-0.95]). Gabapentin (OR: 1.36 [95% CI: 0.97-2.21]), lidocaine (OR: 0.86 [95% CI: 0.53-1.37]), ketamine (OR: 1.15 [95% CI: 0.72-1.83]), and dexmedetomidine (OR: 0.79 [95% CI: 0.46-1.31]) were not individually associated with postoperative delirium. Individual ERACS elements were associated with secondary outcomes of hospital length of stay, ICU duration, postoperative opioid administration, and postoperative intubation duration.

Conclusions

The use of an opioid-sparing perioperative ERACS pain regimen was not associated with reduced postoperative delirium, opioid consumption, or additional poor outcomes. Individually, acetaminophen was associated with reduced delirium.

Section snippets

Study Design

The study authors performed a historical cohort study of patient data from a tertiary academic medical institution to examine the associations between ERACS treatments and the development of postoperative delirium, additional organ injuries, and indicators of protracted recovery. This study was approved by the authors’ university's Institutional Review Board, with a waiver of the requirement for written, informed consent, and adhered to the Strengthening the Reporting of Observational Studies

Patient Characteristics

Of the 1,695 total patients, 20 (1.3%) were excluded from the analysis—2 for lack of recorded height and body mass index, 3 for not being admitted to the ICU postoperatively, 3 for dying within the operating room, and 12 for lack of baseline creatinine measurement. A total of 1,000 patients (59.7%) received at least 1 of the 5 ERACS medications, whereas 675 patients (40.3%) did not receive any. Acetaminophen and gabapentin were administered to 465 (27.8%) and 405 (24.2%) patients, respectively.

Discussion

In this single-center, retrospective cohort study of cardiac surgery patients, there was little association between the use of opioid-sparing ERACS medication and the development of delirium. Acetaminophen, however, was associated with nearly half the odds of postoperative delirium. The authors failed to detect any other association between delirium and ERACS treatment.

Postoperative, systematic delirium screening is recommended in the guidelines for perioperative care in cardiac surgery

Conflict of Interest

None.

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    • Cited by (2)

    Dr Frederic T. Billings’ IV research is supported by R01GM11287 from the NIH, and Dr Robert Freundlich's research is supported by K23HL148640 from the NIH-NHLBI and UL1TR002243 from the NCATS.

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