ENect of Sugammadex Postoperative Delirium After Lower Extremity Surgery Under General Anesthesia in Geriatrics

초록

Background and Objectives: Postoperative delirium (POD) is challenging to the geriatric anesthesiologists. Previous studies showed several factors may aNect the occurrence of delirium. Understanding the factors associated with POD may aid in its prevention and management. In this study, we assessed the diNerence in the incidence of delirium according to the reversal agent for neuromuscular blockade, the group using sugammadex and the group using pyridostrigmine. Methods: Among the elderly patients aged 65 years or older who underwent lower extremity surgery under general anesthesia from March 2016 to February 2020 at Korea university Guro hospital, patients without preoperative delirium were retrospectively investigated. Inclusion criteria were age 65 years or older, ASA physical status 1-3, and scheduled for lower extremity surgery. Exclusion criteria were 1) severely ill patients with ASA class 4 or higher, 2) under 65 years of age, 3) patients with neurological symptoms before surgery, 4) patients with hearing and visual impairment, 5) patients with potential illiteracy, 6) Patients with neurocognitive dysfunction, 7) Patients without neuromuscular reversal. The primary outcome was the incidence of delirium in the PACU. We used the CAM-ICU indicator in the patient to find data for diagnosing the occurrence of delirium in the PACU. Secondary outcomes included the incidence rate of delirium up to 5 days after surgery, whether and how much pain medication is administered in the PACU, and respiratory complications of the patient up to 5days after surgery. The following data are collected from the electronic chart records of the selected subjects. For reducing selection bias, we used 1:1 propensity matching using preoperative candidate variables including age, sex, weight, height, operation site, underlying diseases, ASA class, Charlson comorbidity index, hearing impairment, functional capacity, and preoperative lab findings (glucose, electrolytes, Hb, Wbc, platelets, protein, albumin, AST, ALT, Creatinine, CRP). For the comparison between the sugammadex group and pyridostigmine group, Student t-test or Mann-Whitney U test were used for continuous variables. Chi-square test or Fisher's exact test were used to categorical variables including the delirium incidences. Results: Among the 380 patients, propensity-matched 268 patients (134 for sugammadex, 134 for pyridostigmine) were finally included to the analysis. Demographic data were comparable between the two groups. However, CAMpositive patients in the PACU were much higher in sugammadex group. Although, pain scores in PACU were comparable, pain score after 24 hours to the surgery were significantly higher in the pyridostigmine group. POD incidence was 6.0 % in sugammadex group and 12.7% in pyridostigmine group, but the diNerence was not significant (p=0.093). Postoperative CRP was significantly higher in the pyridostigmine group. Other outcomes including pulmonary complications, transfusion, opioid consumption, POCD showed no diNerence between the two groups. Discussion and Conclusion: Sugammadex may reduce the POD incidence in PACU with better pain control and less inflammation. We suggest that the use of sugammadex would be beneficial due to its fast recovery and no cholinergic eNect.