Estrategias anestésicas para la prevención de delirium postoperatorio en adultos mayores
Artículo de Revisión
DOI:
https://doi.org/10.69825/cienec.v8i34.379Abstract
El delirium postoperatorio es una de las complicaciones neurocognitivas más frecuentes en adultos mayores sometidos a cirugía y se asocia con mayor mortalidad, estancia hospitalaria prolongada, deterioro funcional persistente e institucionalización. Su fisiopatología es multifactorial e involucra vulnerabilidad cerebral relacionada con envejecimiento, neuroinflamación, alteraciones neurotransmisoras y factores perioperatorios modificables. El objetivo de este trabajo fue sintetizar la evidencia sobre estrategias anestésicas dirigidas a prevenir delirium postoperatorio en población geriátrica. Se realizó una revisión de la literatura en bases de datos biomédicas internacionales, incluyendo ensayos clínicos aleatorizados, estudios observacionales, revisiones sistemáticas y metaanálisis publicados en los últimos años. Se incluyeron investigaciones en adultos mayores sometidos a cirugía que evaluaran intervenciones anestésicas asociadas con reducción de delirium. La evidencia muestra que la elección entre anestesia regional y general no presenta diferencias consistentes en la incidencia de delirium. En contraste, evitar anestesia excesivamente profunda mediante monitorización electroencefalográfica y titulación anestésica hacia planos más ligeros se asocia con menor riesgo en varios ensayos clínicos, aunque con heterogeneidad entre estudios. A nivel farmacológico, la dexmedetomidina perioperatoria es la intervención con mayor respaldo, mostrando reducciones significativas del delirium en ensayos y metaanálisis. Por el contrario, la ketamina subanestésica no demostró beneficio preventivo. Las guías actuales recomiendan un enfoque multimodal que combine optimización anestésica, estabilidad hemodinámica, analgesia adecuada y medidas no farmacológicas. En conclusión, la prevención del delirium postoperatorio en adultos mayores requiere estrategias integradas centradas en la modulación de la profundidad anestésica y sedación neurocognitivamente favorable
References
Inouye SK, Westendorp RGJ, Saczynski JS. Delirium in elderly people. Lancet. 2014;383(9920):911–22. doi:10.1016/S0140-6736(13)60688-1
Oh ES, Li M, Fafowora TM, et al. Preoperative risk factors for postoperative delirium following hip fracture repair: a systematic review. Int J Geriatr Psychiatry. 2015;30(9):900–10. doi:10.1002/gps.4233
Maldonado JR. Neuropathogenesis of delirium: review of current etiologic theories and common pathways. Am J Geriatr Psychiatry. 2013;21(12):1190–222. doi:10.1016/j.jagp.2013.09.005
Cunningham C, Maclullich AMJ. At the extreme end of the psychoneuroimmunological spectrum: delirium as a maladaptive sickness behaviour response. Brain Behav Immun. 2013;28:1–13. doi:10.1016/j.bbi.2012.07.012
Evered L, Silbert B. Postoperative cognitive dysfunction and noncardiac surgery. Anesth Analg. 2018;127(2):496–505. doi:10.1213/ANE.0000000000003514
Sanders RD, Pandharipande PP, Davidson AJ, Ma D, Maze M. Anticipating and manag-ing postoperative delirium and cognitive decline in adults. BMJ. 2011;343:d4331. doi:10.1136/bmj.d4331
Chan MTV, Cheng BCP, Lee TMC, Gin T. BIS-guided anesthesia decreases postopera-tive delirium and cognitive decline. J Neurosurg Anesthesiol. 2013;25(1):33–42. doi:10.1097/ANA.0b013e3182712fba
Su X, Meng ZT, Wu XH, et al. Dexmedetomidine for prevention of delirium after non-cardiac surgery in elderly patients. Lancet. 2016;388(10054):1893–902. doi:10.1016/S0140-6736(16)30580-3
Aldecoa C, Bettelli G, Bilotta F, et al. European Society of Anaesthesiology evi-dence-based and consensus-based guideline on postoperative delirium. Eur J Anaesthe-siol. 2017;34(4):192–214. doi:10.1097/EJA.0000000000000594
10. Slor CJ, de Jonghe JFM, Vreeswijk R, Groot E, Ploeg TVD, van Gool WA, et al. Anesthesia and postoperative delirium in older adults undergoing hip surgery. J Am Geri-atr Soc. 2011;59(7):1313-9. doi:10.1111/j.1532-5415.2011.03452.x
Chan MTV, Cheng BCP, Lee TMC, Gin T; CODA Trial Group. BIS-guided anesthesia decreases postoperative delirium and cognitive decline. J Neurosurg Anesthesiol. 2013;25(1):33-42. doi:10.1097/ANA.0b013e3182712fba
Radtke FM, Franck M, Lendner J, Krüger S, Wernecke KD, Spies CD. Monitoring depth of anaesthesia in a randomized trial decreases the rate of postoperative delirium but not postoperative cognitive dysfunction. Br J Anaesth. 2013;110 Suppl 1:i98-i105. doi:10.1093/bja/aet055
Su X, Meng ZT, Wu XH, Cui F, Li HL, Wang DX, et al. Dexmedetomidine for preven-tion of delirium in elderly patients after non-cardiac surgery: a randomised, double-blind, placebo-controlled trial. Lancet. 2016;388(10054):1893-902. doi:10.1016/S0140-6736(16)30580-3
Avidan MS, Maybrier HR, Abdallah AB, Jacobsohn E, Vlisides PE, Pryor KO, et al. In-traoperative ketamine for prevention of postoperative delirium or pain after major surgery in older adults: an international, multicentre, double-blind, randomised clinical trial. Lan-cet. 2017;390(10091):267-75. doi:10.1016/S0140-6736(17)31467-8
Wildes TS, Mickle AM, Ben Abdallah A, Maybrier HR, Oberhaus J, Budelier TP, et al. Effect of electroencephalography-guided anesthetic administration on postoperative de-lirium among older adults undergoing major surgery: The ENGAGES randomized clinical trial. JAMA. 2019;321(5):473-83. doi:10.1001/jama.2018.22005
Evered LA, Chan MTV, Han R, Chu MHM, Cheng BP, Scott DA, et al. Anaesthetic depth and delirium after major surgery: a randomised clinical trial. Br J Anaesth. 2021;127(5):704-12. doi:10.1016/j.bja.2021.07.021
Li T, Li J, Yuan L, Wu J, Jiang C, Daniels J, et al. Effect of regional vs general anesthesia on incidence of postoperative delirium in older patients undergoing hip fracture surgery: The RAGA randomized trial. JAMA. 2022;327(1):50-8. doi:10.1001/jama.2021.22647
Ming S, Zhang X, Gong Z, Duan Y, Li Y, Li Y, et al. Perioperative dexmedetomidine and postoperative delirium in non-cardiac surgery: a meta-analysis. Ann Palliat Med. 2020;9(4):2640-9. doi:10.21037/apm.2020.02.27
Wang Y, Wang M, Ye J, Zhang Y, Chen L, Qian L. The effect of anesthetic depth on postoperative delirium in older adults: a systematic review and meta-analysis. BMC Geri-atr. 2023;23:719. doi:10.1186/s12877-023-04432-w
Patel V, Champaneria R, Dretzke J, Yeung J. Effect of regional versus general anaesthe-sia on postoperative delirium in elderly patients undergoing surgery for hip fracture: a systematic review. BMJ Open. 2018;8(12):e020757. doi:10.1136/bmjopen-2017-020757
Swarbrick CJ, Partridge JSL. Evidence-based strategies to reduce the incidence of postoperative delirium: a narrative review. Anaesthesia. 2022;77 Suppl 1:92-101. doi:10.1111/anae.15607
Deblois S, Bouchard M, Carrier FM, Laflamme MH, Geadah D, Turgeon AF. The pre-vention and treatment of postoperative delirium in the elderly: a narrative systematic re-view of reviews. Anaesth Crit Care Pain Med. 2025;44(2):101485. doi:10.1016/j.accpm.2024.101485
Aldecoa C, Bettelli G, Bilotta F, Sanders RD, Audisio R, Borozdina A, et al. European Society of Anaesthesiology evidence-based and consensus-based guideline on postopera-tive delirium. Eur J Anaesthesiol. 2017;34(4):192-214. doi:10.1097/EJA.0000000000000594
Inouye SK, Westendorp RGJ, Saczynski JS. Delirium in elderly people. Lancet. 2014;383(9920):911-22. doi:10.1016/S0140-6736(13)60688-1
Gleason LJ, Schmitt EM, Kosar CM, Tabloski P, Saczynski JS, Robinson T, et al. Effect of delirium and other major complications on outcomes after elective surgery in older adults. JAMA Surg. 2015;150(12):1134-40. doi:10.1001/jamasurg.2015.2606
Deiner S, Silverstein JH. Postoperative delirium and cognitive dysfunction. Br J Anaesth. 2009;103 Suppl 1:i41-i46. doi:10.1093/bja/aep291
American Geriatrics Society Expert Panel on Postoperative Delirium in Older Adults. Postoperative delirium in older adults: best practice statement. J Am Coll Surg. 2015;220(2):136-48.e1. doi:10.1016/j.jamcollsurg.2014.10.019
Hshieh TT, Yue J, Oh E, Puelle M, Dowal S, Travison T, et al. Effectiveness of multi-component nonpharmacological delirium interventions: a meta-analysis. JAMA Intern Med. 2015;175(4):512-20. doi:10.1001/jamainternmed.2014.7779
Marcantonio ER. Delirium in hospitalized older adults. N Engl J Med. 2017;377(15):1456-66. doi:10.1056/NEJMcp1605501
Aldecoa C, Bettelli G, Bilotta F, Sanders RD, Audisio R, Borozdina A, et al. European Society of Anaesthesiology evidence-based and consensus-based guideline on postopera-tive delirium. Eur J Anaesthesiol. 2017;34(4):192-214. doi:10.1097/EJA.0000000000000594
Hughes CG, Boncyk CS, Culley DJ, Fleisher LA, Leung JM, McDonagh DL, et al. American Society for Enhanced Recovery and Perioperative Quality Initiative joint con-sensus statement on postoperative delirium prevention. Anesth Analg. 2020;130(6):1572-90. doi:10.1213/ANE.0000000000004641
Evered L, Silbert B, Knopman DS, Scott DA, DeKosky ST, Rasmussen LS, et al. Rec-ommendations for the nomenclature of cognitive change associated with anaesthesia and surgery. Br J Anaesth. 2018;121(5):1005-12. doi:10.1016/j.bja.2017.11.087
Oh ES, Li M, Fafowora TM, Inouye SK, Chen CH, Rosman LM, et al. Preoperative risk factors for postoperative delirium following hip fracture repair: a systematic review. Int J Geriatr Psychiatry. 2015;30(9):900-10. doi:10.1002/gps.4248.
Downloads
Published
How to Cite
Issue
Section
License
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
This is a human-readable summary of (and not a substitute for) the license.
You are free to:
Share — copy and redistribute the material in any medium or format
Adapt — remix, transform, and build upon the material
The licensor cannot revoke these freedoms as long as you follow the license terms.
Under the following terms:
Attribution — You must give appropriate credit, provide a link to the license, and indicate if changes were made. You may do so in any reasonable manner, but not in any way that suggests the licensor endorses you or your use.
NonCommercial — You may not use the material for commercial purposes.
ShareAlike — If you remix, transform, or build upon the material, you must distribute your contributions under the same license as the original.
No additional restrictions — You may not apply legal terms or technological measures that legally restrict others from doing anything the license permits.
Notices:
You do not have to comply with the license for elements of the material in the public domain or where your use is permitted by an applicable exception or limitation.
No warranties are given. The license may not give you all of the permissions necessary for your intended use. For example, other rights such as publicity, privacy, or moral rights may limit how you use the material.
