Dataset Information

Effects of Glucocorticoids on Postoperative Neurocognitive Disorders in Adult Patients: A Systematic Review and Meta-Analysis

ABSTRACT:

Background

Postoperative neurocognitive disorders (PNDs) is common among surgical patients, however, the effect of glucocorticoids for preventing PNDs is not clear. This review aims to evaluate the effect of glucocorticoids on the incidence of PNDs in adult patients undergoing surgery.

Methods

The databases of PubMed/Medline, Embase, the Cochrane Library, and Web of science were searched for all available randomized controlled trials (RCTs) from inception to April 30, 2022. RCTs comparing the effect of glucocorticoids with placebo on the incidence of PNDs in adult surgical patients (≥18 years old) were eligible. Subgroup analyses and meta-regressions were performed to evaluate sources of clinical heterogeneity. The level of certainty for main outcomes were assessed by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.

Results

Eleven trials with a total of 10,703 patients were identified. Compared with the control group, glucocorticoids did not reduce the incidence of PNDs (RR: 0.84, 95% CI: 0.67 to 1.06, P = 0.13, GRADE = moderate). Secondary analyses for primary outcome did not change the result. In addition, the length of ICU stay was decreased in glucocorticoids group (RR: −13.58, 95% CI: −26.37 to −0.80, P = 0.04, GRADE = low). However, there were no significant differences between groups with regards to the incidence of postoperative infection (RR: 0.94, 95% CI: 0.84 to 1.06, P = 0.30, GRADE = moderate), blood glucose level (RR: 1.05, 95% CI: −0.09 to 2.19, P = 0.07, GRADE = low), duration of mechanical ventilation (RR: −2.44, 95% CI: −5.47 to 0.59, P = 0.14, GRADE = low), length of hospital stay (RR: −0.09, 95% CI: −0.27 to 0.09, P = 0.33, GRADE = moderate) and 30-day mortality (RR: 0.86, 95% CI: 0.70 to 1.06, P = 0.16, GRADE = moderate).

Conclusions

This meta-analysis suggests that perioperative administration of glucocorticoids may not reduce the incidence of PNDs after surgery. The effect of glucocorticoids on decreased length of ICU stay needs further researches. Future high-quality trials using acknowledged criteria and validated diagnostic tools are needed to determine the influence of glucocorticoids on long-term PNDs.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022302262, identifier: CRD42022302262.

SUBMITTER: Xie X

PROVIDER: S-EPMC9284274 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:BackgroundThe effects of intravenous glucocorticoids on postoperative delirium (POD) in adult patients undergoing major surgery remain controversial. Therefore, we conducted this meta-analysis to assess whether intravenous glucocorticoids can decrease POD incidence in the entire adult population undergoing major surgery and its association with patients age, type of surgery, and type of glucocorticoid.MethodsWe searched the relevant literature published before November 3, 2023, through Cochrane Library, PubMed, Embase, and Web of Science. The primary outcome was POD incidence. The risk ratio for the primary outcome was calculated using the Mantel-Haenszel method. The secondary outcomes included 30-day mortality, length of hospital stay, ICU duration, mechanical ventilation duration, and occurrence of glucocorticoid-related adverse effects (e.g., infection and hyperglycemia). This meta-analysis was registered in PROSPERO: CRD42022345997.ResultsWe included eight randomized controlled studies involving 8972 patients. For the entire adult population undergoing major surgery, intravenous glucocorticoids reduced the POD incidence (risk ratio = 0.704, 95% confidence interval, 0.519-0.955; P = 0.024). However, subgroups defined by type of surgery showed differential effects of glucocorticoids on POD. Intravenous glucocorticoids can not reduce POD incidence in adult patients undergoing cardiac surgery (risk ratio = 0.961, 95% confidence interval, 0.769-1.202; P = 0.728), with firm evidence from trial sequential analysis. However, in major non-cardiac surgery, perioperative intravenous glucocorticoid reduced the incidence of POD (risk ratio = 0.491, 95% confidence interval, 0.338-0.714; P < 0.001), which warrants further studies due to inconclusive evidence by trial sequence analysis. In addition, the use of glucocorticoids may reduce the mechanical ventilation time (weighted mean difference, -1.350; 95% confidence interval, -1.846 to -0.854; P < 0.001) and ICU duration (weighted mean difference = -7.866; 95% confidence interval, -15.620 to -0.112; P = 0.047).ConclusionsFor the entire adult population undergoing major surgery, glucocorticoids reduced the POD incidence. However, the effects of glucocorticoids on POD appear to vary according to the type of surgery. In patients receiving major non-cardiac surgery, glucocorticoid may be an attractive drug in the prevention of POD, and further studies are needed to draw a definitive conclusion. In cardiac surgery, intravenous glucocorticoids have no such effect.

Project description:ImportancePostoperative neurocognitive disorders (PNDs) after surgical procedures are common and may be associated with increased health care expenditures.ObjectiveTo quantify the economic burden associated with a PND diagnosis in 1 year following surgical treatment among older patients in the United States.Design, setting, and participantsThis retrospective cohort study used claims data from the Bundled Payments for Care Improvement Advanced Model from 4285 hospitals that submitted Medicare Fee-for-service (FFS) claims between January 2013 and December 2016. All Medicare patients aged 65 years or older who underwent an inpatient hospital admission associated with a surgical procedure, did not experience a PND before index admission, and were not undergoing dialysis or concurrently enrolled in Medicaid were included. Data were analyzed from October 2019 and May 2020.ExposuresPND, defined as an International Classification of Diseases, Ninth or Tenth Revision, diagnosis of delirium, mild cognitive impairment, or dementia within 1 year of discharge from the index surgical admission.Main outcomes and measuresThe primary outcome was total inflation-adjusted Medicare postacute care payments within 1 year after the index surgical procedure.ResultsA total of 2 380 473 patients (mean [SD] age, 75.36 (7.31) years; 1 336 736 [56.1%] women) who underwent surgical procedures were included, of whom 44 974 patients (1.9%) were diagnosed with a PND. Among all patients, most were White (2 142 157 patients [90.0%]), presenting for orthopedic surgery (1 523 782 patients [64.0%]) in urban medical centers (2 179 893 patients [91.6%]) that were private nonprofits (1 798 749 patients [75.6%]). Patients with a PND, compared with those without a PND, experienced a significantly longer hospital length of stay (mean [SD], 5.91 [6.01] days vs 4.29 [4.18] days; P < .001), were less likely to be discharged home (9947 patients [22.1%] vs 914 925 patients [39.2%]; P < .001), and had a higher incidence of mortality at 1 year after treatment (4580 patients [10.2%] vs 103 767 patients [4.4%]; P < .001). After adjusting for patient and hospital characteristics, the presence of a PND within 1 year of the index procedure was associated with an increase of $17 275 (95% CI, $17 058-$17 491) in cost in the 1-year postadmission period (P < .001).Conclusions and relevanceThe findings of this cohort study suggest that among older Medicare patients undergoing surgical treatment, a diagnosis of a PND was associated with an increase in health care costs for up to 1 year following the surgical procedure. Given the magnitude of this cost burden, PNDs represent an appealing target for risk mitigation and improvement in value-based health care.

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