Article

Delirium in older persons.

Department of Medicine, Harvard Medical School, Boston, USA.
New England Journal of Medicine (Impact Factor: 54.42). 04/2006; 354(11):1157-65. DOI: 10.1056/NEJMra052321
Source: PubMed
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    ABSTRACT: Introduction: Corticosteroids are often used to suppress the inflammatory response to cardiac surgery and are known to increase plasma levels of glucose, a direct precursor of lactate. Lactate is a strong predictor of outcome in intensive care (ICU) patients. The effect of corticosteroids on plasma lactate levels after cardiac surgery has not been studied in a large randomised trial. We aimed to investigate the effect of a single, intraoperative, high dose of dexamethasone on plasma lactate and glucose levels in patients who underwent cardiac surgery. Methods: The DExamethasone for Cardiac Surgery (DECS) trial was a multicentre randomised trial (n = 4,494) that investigated the effect of dexamethasone on outcomes of cardiac surgery with cardiopulmonary bypass. We studied participants operated at one centre, where computerised glucose regulation (GRIP) was used routinely in the ICU. Patients were randomised to receive 1 mg/kg dexamethasone or placebo after induction of general anaesthesia. The primary outcome of this study was postoperative plasma glucose and lactate level, observed in the first 16 hours after ICU admission. Results: 497 patients met the inclusion criteria. Of 476 (96%) patients, sufficient data on the primary outcome was available. 239 patients were randomised to dexamethasone and 237 to placebo. Plasma lactate and glucose area-under-the-curve in the first 16 hours after ICU admission (mmol · L–1 · h–1) were significantly higher in the dexamethasone group: lactate 29.2 vs. 22.8, P < 0.0001 186 EACTA 2013 | Abstracts | Free Oral Sessions and glucose 112.9 vs. 98.9, P < 0.0001. Regression analysis showed that glucose level but not allocation to dexamethasone was an independent predictor of postoperative lactate levels. Discussion: Dexamethasone administered for cardiac surgery causes an increase in lactate levels that can be explained by its hyperglycaemic effect, thus suggesting that dexamethasone has no direct impact on perioperative causes of hyperlactataemia such as the adrenergic stress response. Trial Registration: clinicaltrials.gov Identifier NCT00293592
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    ABSTRACT: Cardiac surgery can be complicated by postoperative cognitive decline (POCD), which affects quality of life and increases resource consumption [1]. POCD is thought to be the result of micro-embolic injury, cerebral hypoperfusion, the postoperative inflammatory response to cardiopulmonary bypass and major surgery, or a combination of these factors [1,2]. Because cardiac surgery is associated with postoperative cerebral edema and because POCD appears to be related to intensity of the postoperative inflammatory response [3,4], it was hypothesized that suppression of this response with an antiinflammatory drug may improve cognitive outcome. We conducted a study to evaluate the effect of a single intraoperative injection of dexamethasone (1 mg/kg) versus the effect of placebo (NaCl 0.9%) in 290 patients who underwent on-pump cardiac surgery, on the incidence of POCD. The project is part of the DExamethasone in Cardiac Surgery (DECS) trial, a multicenter randomized placebo controlled trial in 4494 adults undergoing cardiac surgery with cardiopulmonary bypass. The primary outcome (the effect of intraoperative dexamethasone on major adverse events in the first month after randomization) has been published recently [5]. The subjects in the present sub study were recruited in three Dutch heart centers and underwent a neuropsychological test battery before their surgery and at 1 and 15 month follow-up. The test battery included the Rey Auditory Verbal Learning Test, the Grooved Pegboard Test, the Trail Making Test Part A and B, the Digit Span and Corsi Block Tapping Test. The primary outcome measure was the incidence of cognitive decline at 1-month follow-up. Cognitive decline was defined as deterioration beyond the normal variation in cognitive performance observed within a control population of 50 volunteers with cardiac disease, not undergoing surgery. After obtaining informed consent, 290 underwent baseline neuropsychological testing and were randomized. Cognitive 1-month follow-up was completed in 279 (96%) patients. The 15-month follow-up will be completed by February 2013. After determining the presence or absence of cognitive decline in each patient at both time-points, the dataset will be de-blinded. The results will be presented on the 28th Annual Meeting of the European Association of Cardiothoracic Anaesthesiologists, June 2013. This work was supported by grants 80- 82310-98-08607 from the Netherlands Organization for Health Research and Development (ZonMw) and 2007B125 from the Dutch Heart Foundation, as well as the 2011 SCA Mid-Career Grant (awarded to DvD).
    EACTA 2013: The 28th Annual Meeting of the European Association of Cardiothoracic Anaesthesiologists, Barcelona, Spain; 06/2013

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