British Journal of Anaesthesia, xxx (xxx): xxx (xxxx)
CORRESPONDENCE
Dexmedetomidine administration during brain tumour resection
and postoperative delirium: a randomised controlled trial.
Comment on Br J Anaesth 2023; 130: e307ee316
Bas‚ak Akça1,*, Charlotte S. Salaj2 and Federico Bilotta2
1
Department of Anaesthesiology and Reanimation, Hacettepe University School of Medicine, Ankara, Turkey and
2
Department of Anaesthesiology and Reanimation, Sapienza University of Rome, School of Medicine, Rome, Italy
*Corresponding author. E-mail: drbasakakca@gmail.com
Keywords: brain tumour resection; craniotomy; dexmedetomidine; intracranial procedures; postoperative delirium
EditordWe read with interest the article by Li and colleagues1 on
dexmedetomidine administration for brain tumour resection
and postoperative delirium. The primary hypothesis of this
randomised trial is that intraoperative dexmedetomidine
administration reduces postoperative delirium at 5 days. We
believe that some aspects are worthy of further discussion.
An interesting and controversial result of this study was
the incidence of postoperative delirium. The overall incidence
of postoperative delirium in the trial was 46% in the placebo
group and 22% in the dexmedetomidine group. The authors
highlighted the fact that neurosurgical patients have a high
risk of postoperative delirium ranging from 10% to 43%.
Reviewing the cited articles, we realised that the actual inci-
dence of postoperative delirium reported in the literature is
from 10% to 19.6%.2e5 Tanaka and colleagues6 reported a
higher incidence (42%) of delirium in patients with Parkinson’s
disease undergoing deep brain stimulation surgery, but this
very specific group of patients is not within the scope of the
current study.
Postoperative delirium is a serious health issue, as it has a
strong positive correlation with long-term morbidity and
mortality.7 It is accepted that routine diagnostic and preven-
tive measures should be carried out for every postoperative
patient, especially patient groups with specific risk factors
(for example, age ˃65 yr, cognitive functional impairment, and
presence of neurocognitive disorders).8 As previously reported
risk factors include advanced age ˃65 yr, the authors should
justify the high incidence of postoperative delirium in their
study as the median age of their patients was 45 (36e53) yr. In a
recent prospective cohort study, the incidence of post-
operative delirium in a group of neurosurgical patients with a
mean age of 44 yr was 20%.9 The significant difference
© 2023 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.
For Permissions, please email: permissions@elsevier.com
between these two studies should be discussed and clarified
by the authors.
Dexmedetomidine, an alpha-2 adrenergic agonist, has a
range of effects that can be beneficial during the postoperative
period, including opioid-sparing properties, decreased anaes-
thetic requirements, and neuroprotective effects.10 Because of
these favourable characteristics, multiple studies have
evaluated the effects of dexmedetomidine on postoperative
delirium. A multicentre, double-blind, randomised, placebo-
controlled trial that randomly assigned patients to dexmede-
tomidine or saline placebo infusion during surgery and for 2 h in
the recovery room evaluated the preventive effects of intra-
operative dexmedetomidine on postoperative delirium in older
adults. Dexmedetomidine did not reduce the incidence of
delirium over saline placebo: 12.2% (23 of 189) of patients who
received dexmedetomidine and 11.4% (23 of 201) of patients
who received placebo experienced delirium, which was not
considered a clinically or statistically significant difference.10 In
this study, dexmedetomidine administration was restricted to
the intraoperative period and the 2 h following; in other words,
the drug was not infused over a prolonged postoperative period.
The authors also concluded that, when used as a general
anaesthetic, the pharmacokinetics (duration of action) and
neurochemical properties of dexmedetomidine make it un-
likely for intraoperative dexmedetomidine to have residual
postoperative effects. The protocol for administration of
dexmedetomidine in this trial has much in common with the
protocol used by Li and colleagues,1 as both had a restricted
duration of infusion. Although dexmedetomidine is the drug of
choice for many clinical settings, there are conflicting results
regarding its effects in preventing postoperative delirium as
shown in the studies cited above.
e1
 e2 - Correspondence
The underlying mechanism of the effects of dexmedeto-
midine on postoperative delirium in the study by Li and
colleagues1 is not explained. There have been several studies
reporting various results associated with postoperative
delirium and various drugs such as dexmedetomidine, but the
large discrepancy between incidence rates among studies with
very similar drug protocols is confusing and unexplained. If
these important aspects are clarified and the findings are
supported by further studies, this study by Li and colleagues1
would have significant clinical implications.
Declaration of interest
The authors declare that they have no conflicts of interest.
References
1. Li S, Li R, Li M, et al. Dexmedetomidine administration
during brain tumour resection and postoperative
delirium: a randomised trial. Br J Anaesth 2023; 130(2):
e307e16
2. Wang CM, Huang HW, Wang YM, et al. Incidence and risk
factors of postoperative delirium in patients admitted to
the ICU after elective intracranial surgery: a prospective
cohort study. Eur J Anaesthesiol 2020; 37: 14e24
3. Chen H, Jiang H, Chen B, et al. The incidence and
predictors of postoperative delirium after brain tumor
resection in adults: a cross-sectional survey. World Neu-
rosurg 2020; 140: e129e39
4. Matano F, Mizunari T, Yamada K, et al. Environmental and
clinical risk factors for delirium in a neurosurgical center:
a prospective study. World Neurosurg 2017; 103: 424e30
5. van den Boogaard M, Schoonhoven L, van der Hoeven JG,
et al. Incidence and short-term consequences of delirium
in critically ill patients: a prospective observational cohort
study. Int J Nurs Stud 2012; 49: 775e83
6. Tanaka M, Tani N, Maruo T, et al. Risk factors for post-
operative delirium after deep brain stimulation surgery
for Parkinson disease. World Neurosurg 2018; 114: e518e23
7. Evered LA, Chan MTV, Han R, et al. Anaesthetic depth and
delirium after major surgery: a randomised clinical trial.
Br J Anaesth 2021; 127: 704e12
8. Viderman D, Brotfain E, Bilotta F, Zhumadilov A. Risk
factors and mechanisms of postoperative delirium after
intracranial neurosurgical procedures. Asian J Anesthesiol
2020; 58: 5e13
9. Bharadwaj S, Kamath S, Chakrabarti D, Shetty P. Inci-
dence of and risk factors for emergence delirium and
postoperative delirium in neurosurgical patients - a pro-
spective cohort study. Neurol India 2021; 69: 1579e85
10. Deiner S, Luo X, Lin HM, et al. Intraoperative infusion of
dexmedetomidine for prevention of postoperative
delirium and cognitive dysfunction in elderly patients
undergoing major elective noncardiac surgery: a ran-
domized clinical trial. JAMA Surg 2017; 152: e171505
doi: 10.1016/j.bja.2023.04.012