Impact of Methylprednisolone on Postoperative Quality of Recovery and Delirium in the Steroids in Cardiac Surgery Trial

Abstract

Background Inflammation after cardiopulmonary bypass may contribute to postoperative delirium and cognitive dysfunction. The authors evaluated the effect of high-dose methylprednisolone to suppress inflammation on the incidence of delirium and postoperative quality of recovery after cardiac surgery. Methods Five hundred fifty-five adults from three hospitals enrolled in the randomized, double-blind Steroids in Cardiac Surgery trial were randomly allocated to placebo or 250 mg methylprednisolone at induction and 250 mg methylprednisolone before cardiopulmonary bypass. Each completed the Postoperative Quality of Recovery Scale before surgery and on days 1, 2, and 3 and 1 and 6 months after surgery and the Confusion Assessment Method scale for delirium on days 1, 2, and 3. Recovery was defined as returning to preoperative values or improvement at each time point. Results Four hundred eighty-two participants for recovery and 498 participants for delirium were available for analysis. The quality of recovery improved over time but without differences between groups in the primary endpoint of overall recovery (odds ratio range over individual time points for methylprednisolone, 0.39 to 1.45; 95% CI, 0.08–2.04 to 0.40–5.27; P = 0.943) or individual recovery domains (all P > 0.05). The incidence of delirium was 10% (control) versus 8% (methylprednisolone; P = 0.357), with no differences in delirium subdomains (all P > 0.05). In participants with normal (51%) and low baseline cognition (49%), there were no significant differences favoring methylprednisolone in any domain (all P > 0.05). Recovery was worse in patients with postoperative delirium in the cognitive (P = 0.004) and physiologic (P < 0.001) domains. Conclusions High-dose intraoperative methylprednisolone neither reduces delirium nor improves the quality of recovery in high-risk cardiac surgical patients.

Glucocorticoid attenuates acute lung injury through induction of type 2 macrophage

“…Therefore, it is widely used to treat a variety of acute and chronic inflammatory diseases including acute lung inflammation, asthma, and rheumatoid arthritis [1]. A number of studies have been reported for the anti-inflammatory properties of MP [2–4]. For instance, MP induces anti-inflammatory cytokines expression such as IL-10.…”

Is cerebrovascular autoregulation associated with outcomes after major noncardiac surgery? A prospective observational pilot study

“…At the time of study design and sample size calculation, the presence of preoperative baseline cognitive frailty in elderly patients was unrecognized. Subsequently, 32%‐51% of patients in clinical trials were found to have cognitive frailty . The PostopQRS test terminology classifies this as low baseline cognition, which occurred in 42% of patients in our study.…”

“…Another possible limitation is the presence of delirium. In a recent study, patients with delirium diagnosed using the Confusion Assessment Method had significantly worse PostopQRS cognitive recovery over the first three postoperative days than patients who were not delirious . Although not formally evaluated, the diagnosis of delirium is not incompatible with our study aim.…”

“…The PostopQRS has been previously validated as a screening tool for quality of postoperative recovery . It is designed for repeated measurements, can be administered face to face, or via telephone interview.…”

“…These “low baseline” scores are attributable to pre‐existing subclinical cognitive frailty in increasingly unwell patients . The incidence of low baseline cognitive scores is variable and dependent on the sampled population, ranging from 0% in healthy young volunteers to 51% in a higher risk cardiac surgery cohort …”