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Perioperative Epidural Use and Risk of Delirium in Surgical Patients

A Secondary Analysis of the PODCAST Trial

Vlisides, Phillip E., MD*,†; Thompson, Aleda, MS*; Kunkler, Bryan S., MD*; Maybrier, Hannah R., BS; Avidan, Michael S., MBBCh; Mashour, George A., MD, PhD*,† on behalf of the PODCAST Research Group

doi: 10.1213/ANE.0000000000004038
Neuroscience and Neuroanesthesiology: Original Clinical Research Report

BACKGROUND: Postoperative delirium is an important public health concern without effective prevention strategies. This study tested the hypothesis that perioperative epidural use would be associated with decreased risk of delirium through postoperative day 3.

METHODS: This was a secondary, observational, nonrandomized analysis of data from The Prevention of Delirium and Complications Associated With Surgical Treatments Trial (PODCAST; NCT01690988). The primary outcome of the current study was the incidence of delirium (ie, any positive delirium screen, postanesthesia care unit through postoperative day 3) in surgical patients (gastrointestinal, hepatobiliary-pancreatic, gynecologic, and urologic) receiving postoperative epidural analgesia compared to those without an epidural. As a secondary outcome, all delirium assessments were then longitudinally analyzed in relation to epidural use throughout the follow-up period. Given the potential relevance to delirium, postoperative pain, opioid consumption, sleep disturbances, and symptoms of depression were also analyzed as secondary outcomes. A semiparsimonious multivariable logistic regression model was used to test the association between postoperative epidural use and delirium incidence, and generalized estimating equations were used to test associations with secondary outcomes described. Models included relevant covariates to adjust for confounding.

RESULTS: In total, 263 patients were included for analysis. Epidural use was not independently associated with reduced delirium incidence (adjusted odds ratio, 0.65 [95% CI, 0.32–1.35]; P = .247). However, when analyzing all assessments over the follow-up period, epidural patients were 64% less likely to experience an episode of delirium (adjusted odds ratio, 0.36 [95% CI, 0.17–0.78]; P = .009). Adjusted pain scores (visual analog scale, 0–100 mm) were significantly lower in the epidural group on postoperative day 1 (morning, −16 [95% CI, −26 to −7], P < .001; afternoon, −15 [95% CI, −25 to −5], P < .01) and postoperative day 3 (morning, −13 [95% CI, −20 to −5], P < .01). Adjusted mean oral and IV morphine equivalents were also significantly lower on postoperative day 1 in the epidural group (74% lower [95% CI, 55%–85%]; P < .0001). Finally, postoperative epidural use was not significantly associated with new sleep disturbances or changes in depression symptoms.

CONCLUSIONS: Postoperative epidural use was not associated with a reduced overall incidence of delirium. However, longitudinal analysis revealed reduced adjusted odds of experiencing an episode of delirium in the epidural group. Epidural use was also associated with reduced postoperative pain and opioid consumption. An appropriately designed follow-up study is warranted to further analyze the relationship among epidural use, postoperative delirium, and related outcomes.

From the *Department of Anesthesiology

Center for Consciousness Science, University of Michigan Medical School, Ann Arbor, Michigan

Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri.

Published ahead of print 20 December 2018.

Accepted for publication December 20, 2018.

Funding: Supported by the National Institutes of Health (grant T32GM103730).

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website. Identifier: NCT01690988.

A full list of contributors can be found at the end of the article.

Reprints will not be available from the authors.

Address correspondence to Phillip E. Vlisides, MD, Department of Anesthesiology, University of Michigan Medical School, 1H247 UH, SPC-5048, 1500 E Medical Center Dr, Ann Arbor, MI 48109. Address e-mail to

© 2019 International Anesthesia Research Society
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