Effect of Goal-Directed Intraoperative Blood Pressure Management on Postoperative Delirium in Older Patients Undergoing Hip Fracture Surgery: A Randomized Controlled Trial.

Abstract

Postoperative delirium is a frequent and serious complication in older patients after surgery, particularly following hip fracture repair surgery, with an incidence of 10% to 55%. This study investigated whether goal-directed intraoperative blood pressure management could reduce the incidence of postoperative delirium in older patients undergoing hip fracture repair surgery. In this single-center randomized controlled trial, 188 older patients (over 65 years) scheduled for elective hip fracture repair surgeries under spinal anesthesia were randomized to either goal-directed arterial blood pressure (ABP) group or control group. The goal-directed ABP group maintained systolic blood pressure (SBP) >80% preoperative values with continuous infusion of norepinephrine, while the control group aimed to keep SBP ≥90 mm Hg using intermittent administration of phenylephrine or ephedrine. The primary outcome was the incidence of postoperative delirium, assessed twice daily using the Confusion Assessment Method (CAM) until hospital discharge. Incidence of postoperative intensive care unit (ICU) admittance was also compared between groups. Quality of life was followed-up via telephone 3 months after surgery using the 3-level version of EuroQol Five Dimensional Questionnaire (EQ-5D-3L). Accumulative time spent under 80% preoperative systolic blood pressure (SBP) values was significantly shorter in goal-directed ABP group than in control group (0 [0-8] vs 12 [0-38] minutes; P < 0.001). Incidence of postoperative delirium was 26.6% (25/94) in the goal-directed ABP group and in 36.2% (34/94) in the control group, with an absolute risk reduction (ARR) of 9.6% (95% confidence interval [CI], -3.6 to 22.8), relative risk of 0.735 (95% CI, 0.478-1.130), P = .162. There was no difference in the incidence of postoperative ICU admittance or quality of life at 3 months follow-up. Goal-directed intraoperative blood pressure management did not significantly reduce postoperative delirium in older patients undergoing hip fracture repair surgery under spinal anesthesia.