Acetaminophen Lowers In-hospital Delirium in Post-Cardiac Surgery

Acetaminophen added to combination of propofol or dexmedetomidine after cardiac surgery was associated with a reduction in in-hospital delirium, according to new study results published in JAMA.

Researchers for the DEXACET study, a randomized, placebo-controlled trial, enrolled 120 patients aged 60 years or older who were undergoing coronary artery bypass graft (CABG) or combined CABG/valve surgeries at a single U.S. center between September 2015 and April 2018 (followed up completed in 2019). Patients were assigned to one of four groups receiving postoperative analgesia with acetaminophen or placebo every 6 hours for 48 hours as well as sedation with dexmedetomidine or propofol for up to 6 hours. The groups consisted of 29 patients receiving acetaminophen and dexmedetomidine, 30 patients receiving placebo and dexmedetomidine, 31 receiving acetaminophen and propofol, and 30 receiving propofol and placebo.

In this randomized trial, IV #acetaminophen reduced in-hospital #delirium compared with placebo when given to older patients after cardiac surgery. https://t.co/zR12zLULbN pic.twitter.com/rkpJD9A44S

— JAMA (@JAMA_current) February 20, 2019

Acetaminophen Linked with Reductions

The primary study outcomes were the incidence of postoperative in=hospital delirium as assessed using the Confusion Assessment Method, and secondary outcomes included delirium duration, cognitive decline, breakthrough analgesia with the initial 48 hours, and length of hospital/ICU stay.

According to the study results, patients treated with intravenous acetaminophen saw a reduction in delirium (10% vs 28% for placebo; difference, −18%; 95% CI, −32% to −5%; P=0.01; HR=2.8; 95% CI, 1.1 to 7.8). In patients receiving dexmedetomidine versus propofol, no significant differences in delirium were reported. Acetaminophen was associated with a reduction in three secondary outcomes as well, including delirium duration, length of stay and breakthrough analgesia.

“If our findings are replicated in a larger, multicenter study, postoperative intravenous administration of acetaminophen could become a standard of care in all cardiac surgical patients and could be incorporated in cardiac surgery recovery protocols,” study author Balachundhar Subramainam, MD, PhD, director of the Center for Anesthesia Research Excellence at Beth Israel Deaconess Medical Center, said in a press release.

Congratulations to my colleagues and friends Bala Subramaniam and Shaz Shaefi on their JAMA paper this week! Doing @BIDMCAnesthesia proud!! 💪 https://t.co/1Nal7psSdS

— Sara Neves (@saraeneves) February 19, 2019

Lessening Opioid Dependence

The study results also suggested a reduction in the need for opioid pain killers in patients receiving acetaminophen added to their postoperative care.

“Postoperative pain is known to increase the risk for postoperative delirium, as is the use of opioids to manage postoperative pain,” he said. “We found that the use of IV acetaminophen provided effective pain control, and we observed a noticeable sparing of opioids in the postoperative period with decreased duration of delirium and intensive care unit length of stay.”

Hot of the press today in @JAMA_current looking at the intersection between postop analgesia, specifically opioid sparing, and delirium, in thus study in cardiac surgeryhttps://t.co/zWO0UtzXuR

— SPAQI (@SPAQIedu) February 20, 2019

How do you decrease #delirium after major cardiac surgery?

Apparently intravenous TYLENOL!

Big effect size in a small single center RCT. Wonder if this will hold in a replication trial. Until then, given how cheap & safe it is, Tylenol post-op for all?https://t.co/MbEbci4u9c

— Anil Makam (@AnilMakam) February 20, 2019

https://twitter.com/RMShah91/statuses/1098035463519129602

Small numbers, but interesting. Also I think most give oral acetaminophen currently so not sure that the control group is relevant. Hypothesis generating! https://t.co/cO48xtq6xU

— Ron Ree (@ronmree) February 20, 2019

Source: JAMA