Delirium, Dexmedetomidine, Esketamine, Intensive Care Unit, Older Patients, Postoperative Care
Conditions
Keywords
Older patients, Postoperative care, Intensive Care Unit, Dexmedetomidine, Esketamine, Delirium
Brief summary
Patients in the intensive care unit (ICU) often develop anxiety and agitation, sleep disturbances, and delirium. Delirium occurrence is associated with worse early and long-term outcomes. Dexmedetomidine and ketamine are recommended for sedation and analgesia in postoperative ICU patients, but each may induce side effects. The sedative effects of dexmedetomidine can help mitigate the neuropsychiatric side effects of esketamine. Recent studies showed that dexmedetomidine-esketamine combination improved analgesia and sleep quality without increasing side effects. This trial is designed to test the hypothesis that dexmedetomidine-esketamine combination for sedation and analgesia in postoperative ICU patients may reduce delirium.
Detailed description
An estimated 300 million surgical procedures are performed globally each year. Patients who have complex conditions and an elevated risk of postoperative complications frequently require admission to the intensive care unit (ICU). Among these, a subset are admitted to ICU with an endotracheal tube and continue to receive mechanical ventilation. Sleep disturbances are highly prevalent in ICU patients due to environmental factors, underlying diseases, therapeutic interventions, and pain-related stimuli. Mechanical ventilation, painful stimulation, and sleep disturbances are important risk factors of delirium in ICU patients. Delirium is an acutely occurred brain dysfunction symdrome characteristized with fluctuating disturbances in attention, cognition, and consciousness, and is reported to occur in up to 80% of ICU patients with mechanical ventilation. Delirium occurrence is associated with worse outcomes, including prolonged mechanical ventilation, extended ICU and hospital stays, increased healthcare burden and costs, and elevated mortality risk, as well as long-term sequelae including cognitive decline, reduced quality of life, and decreased survival. Dexmedetomidine is a highly selective α2-adrenergic receptor agonist with sedative, analgesic, and anxiolytic effects. It exerts effects by activating the endogenous sleep-promoting pathways, inducing a state like non-rapid eye movement sleep. Ketamine is a non-competitive N-methyl-D-aspartate (NMDA) receptor antagonist. Esketamine, a more potent enantiomer of ketamine, has a higher affinity for the NMDA receptor and is approximately twice as potent as ketamine. Both dexmedetomidine and ketamine are recommended for sedation and analgesia in postoperative ICU patients. However, sedative dose dexmedetomidine is associated with bradycardia and hypotension. Even low-dose esketamine can induce neuropsychiatric side effects such as dissociation, hallucinations, and nightmares. The sedative effects of dexmedetomidine can help mitigate the neuropsychiatric side effects of esketamine. Recent studies showed that low-dose dexmedetomidine-esketamine combination improved analgesia and sleep quality without increasing side effects. It is hypothesized that dexmedetomidine-esketamine combination for sedation and analgesia in postoperative ICU patients may reduce delirium.
Interventions
DRUGDexmedetomidine
For patients with endotracheal intubation, nighttime (20:00-06:00) sedation is initiated with 0.2 μg/kg/h dexmedetomidine and increased/decreased by 0.1 μg/kg/h dexmedetomidine every 15 min, until the Richmond Agitation-Sedation Scale (RASS) reaches -2 to -1, maximal infusion rate reaches 0.7 μg/kg/h dexmedetomidine, or adverse reactions occur. Daytime (06:00-20:00) sedation is provided as above when considered necessary, with a target RASS score of -2 to +1. For patients without endotracheal intubation, nighttime (20:00-06:00) sedation is initiated with 0.10 μg/kg/h dexmedetomidine and increased/decreased by 0.05 μg/kg/h dexmedetomidine every 15 min, until the RASS reaches -1, maximal infusion rate reaches 0.2 μg/kg/h dexmedetomidine, or adverse reactions occur. Daytime (06:00-20:00) sedation is typically not provided.
For patients with endotracheal intubation, nighttime (20:00-06:00) sedation is initiated with 0.1 μg/kg/h dexmedetomidine and 0.05 mg/kg/h esketamine, increased/decreased by 0.05 μg/kg/h dexmedetomidine and 0.025 mg/kg/h esketamine every 15 min, until the RASS reaches -2 to -1, maximal infusion rate reaches 0.35 μg/kg/h dexmedetomidine and 0.175 mg/kg/h esketamine, or adverse reactions occur. Daytime (06:00-20:00) sedation is provided as above when considered necessary, with a target RASS score of -2 to +1. For patients without endotracheal intubation, nighttime (20:00-06:00) sedation is initiated with 0.05 μg/kg/h dexmedetomidine and 0.025 mg/kg/h esketamine, and increased/decreased by 0.025 μg/kg/h dexmedetomidine and 0.0125 mg/kg/h esketamine every 15 min, until the RASS reaches -1, maximal infusion rate reaches 0.1 μg/kg/h dexmedetomidine and 0.05 mg/kg/h esketamine, or adverse reactions occur. Daytime (06:00-20:00) sedation is typically not provided.
Sponsors
Peking University First Hospital
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
PREVENTION
Masking
QUADRUPLE (Subject, Caregiver, Investigator, Outcomes Assessor)
Eligibility
Sex/Gender
ALL
Age
60 Years to No maximum
Healthy volunteers
No
Inclusion criteria
1. Aged 60 years or older; 2. Admitted to the intensive care unit (ICU) after surgery; 3. Expected to stay in the ICU for at least one night.
Exclusion criteria
1. History of schizophrenia, epilepsy, Parkinson's disease, or myasthenia gravis; 2. Presence of preoperative delirium, or inability to communicate due to coma, severe dementia, or language barrier; 3. Previously diagnosed obstructive sleep apnea, judged to be at high risk of moderate-to-severe obstructive sleep apnea according to the STOP-Bang questionnaire, or have a body mass index \>30 kg/m²; 4. Preoperative left ventricular ejection fraction \<30%, sick sinus syndrome, severe sinus bradycardia (heart rate \<50 bpm), second-degree or higher atrioventricular block without a pacemaker, or systolic blood pressure \<90 mmHg despite use of vasopressors; 5. Comorbid with hyperthyroidism or pheochromocytoma; 6. Severe liver dysfunction (Child-Pugh Class C), severe renal dysfunction (requiring dialysis), or expected survival ≤24 hours; 7. After traumatic brain injury or neurosurgery; 8. Allergy to dexmedetomidine and/or esketamine; 9. Other conditions that are considered unsuitable for study participation.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Incidence of delirium within 7 days | Up to 7 days after surgery | Delirium will be assessed twice daily (8:00-10:00, 18:00-20:00) for 7 days or until hospital discharge. Patients with endotracheal intubation will be assessed with the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Patients without endotracheal intubation will be assessed with the 3-Minute Diagnostic Assessment for Delirium using the Confusion Assessment Method (3D-CAM). Positive result of delirium assessments at any timepoint is defined as occurrence of delirium. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Total sleep time (TST) on the first postoperative night | From 20:00 on the night of surgery to 06:00 the next morning | Total sleep time will be monitored using an actigraphy device. |
| Postoperative pain score within 7 days | Up to 7 days after surgery | Pain intensity will be assessed twice daily (8:00-10:00, 18:00-20:00) for 7 days or until hospital discharge, using the 11-point Numeric Rating Scale (NRS; 0 = no pain, 10 = worst pain) or the Behavioral Pain Scale (BPS; range 4-16, with higher scores indicating more severe pain; for patients with deep sedation). |
| Postoperative subjective sleep quality within 7 days | Up to 7 days after surgery | Subjective sleep quality will be assessed once daily (08:00-10:00) for 7 days or until hospital discharge, using an 11-point Numeric Rating Scale (0 = best sleep, 10 = worst sleep) |
| Length of stay in the ICU | Up to 30 days after surgery | Length of stay in the ICU |
Countries
China
Contacts
PRINCIPAL_INVESTIGATORDong-Xin Wang, MD, PhD
Peking University First Hospital
Outcome results
None listed