Spinal Dexamethasone Effect on Cognitive Disorders After Hip Surgery

Abstract

Background: Proximal femoral fractures (PrFF) are one of the most common causes of emergency admission in the elderly population. The majority of patients have pre-existing conditions that get worsened by unplanned surgery. Objective: Purpose of this article was to evaluate if a is single shot of dexamethasone with levobupivacaine administered intrathecally reduces postoperative pain and cognitive complications in patients with proximal femoral fractures. Methods: The study was performed at a level II trauma center which is a part of a teaching hospital with a catchment population of around 300,000 patients, the first author’s affiliation. Around 500 PrFF are performed yearly in the center. All participants gave oral and written informed consent before randomization. Results: In total, 60 patients with a PrFF, ASA status 2 or 3 were randomized into two groups for spinal anaesthesia as DLSA study group (received 8 mg of dexamethasone and 12.5 mg of 0.5 % levobupivacaine) or LSA control group (received 12.5 mg of 0,5 % levobupivacaine). Postoperative cognitive disturbance was evaluated using simplified Confusion Assessment Method (CAM) scale, pain intensity was measured using Visual Analogue Scale (VAS) and blood samples for defining cortisol concentrations were taken before and after the surgical procedure. The primary outcomes were effects of intrathecal dexamethasone on plasma cortisol affecting cognitive disturbances. Secondary outcomes included pain scores and length of hospital stay. The DLSA group demonstrated a reduced incidence of postoperative cognitive dysfunction (POCD), p=0.043, longer analgesia duration, p<0.001, decreased cortisol levels and shorter hospitalization p=0.045. Intrathecal dexamethasone was the only significant predictor of postoperative delirium, OR 7.76, p=0.019. Conclusion: Single shot intrathecal administration of dexamethasone with levobupivacaine used in anaesthesia for proximal femoral fractures reduces the stress response by decreasing plasma cortisol concentrations prolonging analgesia. Complications such as delirium and POCD occurred with significantly lower frequency allowing better postoperative rehabilitation and shortening the hospitalization.

The Utilization of Preoperative Steroids Safely Decreases the Risk of Postoperative Delirium in Geriatric Patients after Hip Fracture Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

“…1). 13,[17][18][19] All 4 articles underwent a full reference search, and no additional RCTs that met the inclusion criteria of this study were obtained. Included articles focusing on 1 condition included a 60-patient proximal femoral fracture cohort from a 2023 study by Sakic et al, 18 a 160-patient intertrochanteric fracture cohort from a 2023 study by Huang et al, 12 and a 120-patient hip fracture cohort from a 2023 study by Clemmesen et al 19 One article including femoral neck fractures, trochanteric fractures, and subtrochanteric fractures from a 79-patient, 2021 study by Kluger et al 17 was also included.…”

“…2 and Supplemental Digital Content 1, http://links.lww.com/ JOT/C201). 13,[17][18][19] Entire Cohort Demographics…”

“…PFF in elderly adults represents a significant economic and health burden in the medical field, with patient outcomes further complicated by adverse events such as postoperative delirium during the hospital stay after hip fracture surgery. [1][2][3]8,13,[17][18][19] Indeed, delirium has been associated with a .60% increase in risk of mortality within 1 year after hospitalization. 12 This meta-analysis of RCTs provides high-level evidence that focuses specifically on the efficacy and safety of preoperative steroids as a treatment intervention to reduce the incidence of delirium after hip fracture repair in elderly patients.…”

“…[8][9][10][11][14][15][16] One such strategy is the use of preoperative steroids to reduce the incidence and severity of postoperative delirium. 9,[13][14][15][17][18][19] To date, numerous systematic reviews and/or metaanalyses have examined the topic of preoperative steroid usage to improve delirium outcomes. However, these studies did not synthesize data specific to hip fracture surgery and combined heterogenous procedures (ie, cardiac surgery, neurosurgery, and orthopaedic surgery) in meta-analysis.…”

Sevoflurane and desflurane effects on early cognitive function after low‐risk surgery: A randomized clinical trial

“…On the other hand, volatile anesthetics, and surgery itself have been associated with the disruption of the blood-brain barrier through inflammatory pathways (Huang et al, 2023;Nakao et al, 2019;Wu et al, 2012). Inflammatory hypothesis of POCD is supported by some recent studies showing beneficial effect of steroids or probiotics in reducing cognitive impairment postoperatively (Sakic et al, 2023;Wang et al, 2021).…”