| <!DOCTYPE html> |
| <html lang="en-US"> |
| <head> |
| <meta charset="UTF-8"> |
| <title>6c46927b-ae99-4127-9213-1a3afb06732f</title> |
| <meta name="viewport" content="width=device-width, initial-scale=1"> |
| <link rel="stylesheet" href="https://cdn.mathpix.com/fonts/cmu.css"/> |
| <style>html,body { |
| width: 100%; |
| height: 100%; |
| } |
| *, *::before,*::after { |
| box-sizing: border-box; |
| } |
| body { |
| margin: 0; |
| color: #1E2029; |
| font-size: 14px; |
| line-height: normal; |
| } |
| hr { |
| box-sizing: content-box; |
| height: 0; |
| overflow: visible; |
| } |
| h1, h2, h3, h4, h5, h6 { |
| margin-top: 0; |
| margin-bottom: 0.5em; |
| color: rgba(0, 0, 0, 0.85); |
| font-weight: 500; |
| } |
| p { |
| margin-top: 0; |
| margin-bottom: 1em; |
| } |
| ol, ul, dl { |
| margin-top: 0; |
| margin-bottom: 1em; |
| } |
| ol ol, ul ul, ol ul, ul ol { |
| margin-bottom: 0; |
| } |
| dt { |
| font-weight: 500; |
| } |
| dd { |
| margin-bottom: 0.5em; |
| margin-left: 0; |
| } |
| blockquote { |
| margin: 0 0 1em; |
| } |
| dfn { |
| font-style: italic; |
| } |
| b, strong { |
| font-weight: bolder; |
| } |
| small { |
| font-size: 80%; |
| } |
| sub, sup { |
| position: relative; |
| font-size: 75%; |
| line-height: 0; |
| vertical-align: baseline; |
| } |
| sub { |
| bottom: -0.25em; |
| } |
| sup { |
| top: -0.5em; |
| } |
| a { |
| color: #0B93ff; |
| text-decoration: none; |
| background-color: transparent; |
| outline: none; |
| cursor: pointer; |
| transition: color 0.3s; |
| } |
| a:hover { |
| color: #33aaff; |
| } |
| a:active { |
| color: #0070d9; |
| } |
| a:active, a:hover { |
| text-decoration: none; |
| outline: 0; |
| } |
| a[disabled] { |
| color: rgba(0, 0, 0, 0.25); |
| cursor: not-allowed; |
| pointer-events: none; |
| } |
| pre, code, kbd, samp { |
| font-size: 1em; |
| } |
| pre { |
| margin-top: 0; |
| margin-bottom: 1em; |
| overflow: auto; |
| } |
| figure { |
| margin: 0 0 1em; |
| } |
| img { |
| vertical-align: middle; |
| border-style: none; |
| } |
| svg:not(:root) { |
| overflow: hidden; |
| } |
| table { |
| border-collapse: collapse; |
| } |
| caption { |
| padding-top: 0.75em; |
| padding-bottom: 0.3em; |
| color: rgba(0, 0, 0, 0.45); |
| text-align: left; |
| caption-side: bottom; |
| } |
| th { |
| text-align: inherit; |
| } |
| mjx-container[jax="SVG"] { |
| direction: ltr; |
| } |
| |
| mjx-container[jax="SVG"] > svg { |
| overflow: visible; |
| min-height: 1px; |
| min-width: 1px; |
| } |
| |
| mjx-container[jax="SVG"] > svg a { |
| fill: blue; |
| stroke: blue; |
| } |
| |
| mjx-container[jax="SVG"][display="true"] { |
| display: block; |
| text-align: center; |
| margin: 1em 0; |
| } |
| |
| mjx-container[jax="SVG"][display="true"][width="full"] { |
| display: flex; |
| } |
| |
| mjx-container[jax="SVG"][justify="left"] { |
| text-align: left; |
| } |
| |
| mjx-container[jax="SVG"][justify="right"] { |
| text-align: right; |
| } |
| |
| g[data-mml-node="merror"] > g { |
| fill: red; |
| stroke: red; |
| } |
| |
| g[data-mml-node="merror"] > rect[data-background] { |
| fill: yellow; |
| stroke: none; |
| } |
| |
| g[data-mml-node="mtable"] > line[data-line], svg[data-table] > g > line[data-line] { |
| stroke-width: 70px; |
| fill: none; |
| } |
| |
| g[data-mml-node="mtable"] > rect[data-frame], svg[data-table] > g > rect[data-frame] { |
| stroke-width: 70px; |
| fill: none; |
| } |
| |
| g[data-mml-node="mtable"] > .mjx-dashed, svg[data-table] > g > .mjx-dashed { |
| stroke-dasharray: 140; |
| } |
| |
| g[data-mml-node="mtable"] > .mjx-dotted, svg[data-table] > g > .mjx-dotted { |
| stroke-linecap: round; |
| stroke-dasharray: 0,140; |
| } |
| |
| g[data-mml-node="mtable"] > g > svg { |
| overflow: visible; |
| } |
| |
| [jax="SVG"] mjx-tool { |
| display: inline-block; |
| position: relative; |
| width: 0; |
| height: 0; |
| } |
| |
| [jax="SVG"] mjx-tool > mjx-tip { |
| position: absolute; |
| top: 0; |
| left: 0; |
| } |
| |
| mjx-tool > mjx-tip { |
| display: inline-block; |
| padding: .2em; |
| border: 1px solid #888; |
| font-size: 70%; |
| background-color: #F8F8F8; |
| color: black; |
| box-shadow: 2px 2px 5px #AAAAAA; |
| } |
| |
| g[data-mml-node="maction"][data-toggle] { |
| cursor: pointer; |
| } |
| |
| mjx-status { |
| display: block; |
| position: fixed; |
| left: 1em; |
| bottom: 1em; |
| min-width: 25%; |
| padding: .2em .4em; |
| border: 1px solid #888; |
| font-size: 90%; |
| background-color: #F8F8F8; |
| color: black; |
| } |
| |
| foreignObject[data-mjx-xml] { |
| font-family: initial; |
| line-height: normal; |
| overflow: visible; |
| } |
| |
| mjx-container[jax="SVG"] path[data-c], mjx-container[jax="SVG"] use[data-c] { |
| stroke-width: 3; |
| } |
| #setText > div { |
| justify-content: inherit; |
| margin-top: 0; |
| margin-bottom: 1em; |
| |
| |
| } |
| #setText div:last-child { |
| margin-bottom: 0 !important; |
| } |
| #setText > br, #preview-content br { |
| line-height: 1.2; |
| } |
| #preview-content > div { |
| margin-top: 0; |
| margin-bottom: 1em; |
| |
| } |
| .proof > div, |
| #preview-content .proof > div, #setText .proof > div, |
| .theorem > div, |
| #preview-content .theorem > div, #setText .theorem > div { |
| margin-top: 1rem; |
| } |
| mjx-container { |
| text-indent: 0; |
| overflow-y: hidden; |
| overflow-x: auto; |
| padding-top: 1px; |
| padding-bottom: 1px; |
| |
| } |
| .math-inline mjx-container { |
| display: inline-block !important; |
| page-break-inside: avoid; |
| max-width: 100%; |
| padding: 0; |
| line-height: 0; |
| } |
| .math-inline[data-overflow="visible"] mjx-container { |
| overflow: visible; |
| } |
| .math-inline mjx-container mjx-assistive-mml { |
| max-width: 100%; |
| } |
| .math-block { |
| align-items: center; |
| page-break-after: auto; |
| page-break-inside: avoid; |
| margin: 0; |
| display: block; |
| } |
| .math-inline { |
| display: inline-flex; |
| max-width: 100%; |
| } |
| .math-block[data-width="full"] { |
| overflow-x: auto; |
| display: flex; |
| } |
| .math-block[data-width="full"] mjx-container[jax=SVG][display=true] { |
| display: flex; |
| flex: 1 1; |
| justify-content: center; |
| } |
| svg .math-inline { |
| display: initial; |
| max-width: initial; |
| } |
| svg .math-inline mjx-container { |
| max-width: initial; |
| } |
| svg mjx-container { |
| overflow: visible; |
| padding: 0; |
| } |
| svg .math-block[data-width="full"] { |
| overflow: visible; |
| } |
| .math-block, .math-inline { |
| --mmd-highlight-color: rgba(0, 147, 255, 0.25); |
| --mmd-highlight-text-color: #1e2029; |
| } |
| .math-block[data-highlight-color] mjx-container[jax="SVG"] > svg { |
| background-color: var(--mmd-highlight-color); |
| } |
| .math-block[data-highlight-text-color] mjx-container[jax="SVG"] > svg { |
| color: var(--mmd-highlight-text-color); |
| } |
| .math-inline[data-highlight-color] mjx-container[jax="SVG"] { |
| background-color: var(--mmd-highlight-color); |
| } |
| .math-inline[data-highlight-text-color] mjx-container[jax="SVG"] { |
| color: var(--mmd-highlight-text-color); |
| } |
| .math-block p { |
| flex-shrink: 1; |
| } |
| .math-block mjx-container { |
| margin: 0 !important; |
| } |
| .math-error { |
| background-color: yellow; |
| color: red; |
| } |
| #preview-content img, #setText img { |
| max-width: 100%; |
| } |
| #preview-content blockquote, #setText blockquote { |
| page-break-inside: avoid; |
| color: #666; |
| margin: 0 0 1em 0; |
| padding-left: 3em; |
| border-left: .5em solid #eee; |
| } |
| #preview-content pre, #setText pre { |
| border: none; |
| padding: 0; |
| overflow: auto; |
| font-size: 85%; |
| line-height: 1.45; |
| border-radius: 6px; |
| box-sizing: border-box; |
| background: #f8f8fa; |
| } |
| #preview-content pre code, #setText pre code { |
| padding: 1rem; |
| display: block; |
| overflow-x: auto; |
| line-height: 24px; |
| } |
| #preview-content table, #setText table { |
| display: table; |
| overflow: auto; |
| max-width: 100%; |
| border-collapse: collapse; |
| page-break-inside: avoid; |
| margin-bottom: 1em; |
| } |
| #preview-content table th, #setText table th { |
| text-align: center; |
| font-weight: bold; |
| } |
| #preview-content table td, #setText table td, |
| #preview-content table th, #setText table th { |
| border: 1px solid #dfe2e5; |
| padding: 6px 13px; |
| } |
| #preview-content table tr, #setText table tr { |
| background-color: #fff; |
| border-top: 1px solid #c6cbd1; |
| } |
| #preview-content table tr:nth-child(2n), #setText table tr:nth-child(2n) { |
| background-color: #f6f8fa; |
| } |
| .main-title, |
| #preview-content .main-title, #setText .main-title { |
| text-align: center; |
| line-height: 1.2; |
| margin: 0 auto 1em auto; |
| } |
| .author, |
| #preview-content .author, #setText .author { |
| text-align: center; |
| margin: 0 auto; |
| display: flex; |
| justify-content: center; |
| flex-wrap: wrap; |
| } |
| .author p, |
| #preview-content .author p, #setText .author p { |
| min-width: 30%; |
| max-width: 50%; |
| padding: 0 7px; |
| } |
| .author > p > span, |
| #preview-content .author > p > span, #setText .author > p > span { |
| display: block; |
| text-align: center; |
| } |
| .section-title, |
| #preview-content .section-title, #setText .section-title { |
| margin-top: 1.5em; |
| } |
| .abstract, |
| #preview-content .abstract, #setText .abstract { |
| text-align: justify; |
| margin-bottom: 1em; |
| } |
| .abstract p, |
| #preview-content .abstract p, #setText .abstract p { |
| margin-bottom: 0; |
| } |
| #preview-content sup, #setText sup { |
| top: -.5em; |
| position: relative; |
| font-size: 75%; |
| line-height: 0; |
| vertical-align: baseline; |
| } |
| .text-url, |
| #preview-content .text-url, #setText .text-url { |
| color: #0B93ff; |
| cursor: text; |
| pointer-events: none; |
| } |
| .text-url a:hover, |
| #preview-content .text-url a:hover, #setText .text-url a:hover { |
| color: #0B93ff; |
| } |
| mark, |
| #preview-content mark, #setText mark { |
| background-color: #feffe6; |
| } |
| span[data-underline-type] mark, |
| #preview-content span[data-underline-type] mark, |
| #setText span[data-underline-type] mark { |
| background: inherit; |
| background-color: #feffe6; |
| padding-top: 0; |
| padding-bottom: 0; |
| } |
| *[data-has-dotfill] { |
| position: relative; |
| overflow: hidden; |
| } |
| *[data-has-dotfill] .dotfill::after { |
| position: absolute; |
| padding-left: .25ch; |
| content: " . . . . . . . . . . . . . . . . . . . " |
| ". . . . . . . . . . . . . . . . . . . . . . . " |
| ". . . . . . . . . . . . . . . . . . . . . . . " |
| ". . . . . . . . . . . . . . . . . . . . . . . " |
| ". . . . . . . . . . . . . . . . . . . . . . . " |
| ". . . . . . . . . . . . . . . . . . . . . . . " |
| ". . . . . . . . . . . . . . . . . . . . . . . "; |
| text-align: right; |
| } |
| .smiles, |
| #preview-content .smiles, #setText .smiles { |
| text-align: center; |
| } |
| div.svg-container, |
| #preview-content > div.svg-container, |
| #setText > div.svg-container { |
| display: flex; |
| justify-content: center; |
| } |
| @media print { |
| #preview { |
| font-size: 10pt !important; |
| } |
| .math-block svg, .math-inline svg { |
| shape-rendering: crispEdges; |
| margin-top: 1px; |
| } |
| #preview-content img, #setText img { |
| display: block; |
| } |
| #preview-content .figure_img img, #setText .figure_img img { |
| display: inline; |
| } |
| #preview-content h1, #preview-content h2, #preview-content h3, |
| #preview-content h4, #preview-content h5, #preview-content h6, |
| #setText h1, #setText h2, #setText h3, |
| #setText h4, #setText h5, #setText h6 { |
| page-break-inside: avoid; |
| position: relative; |
| border: 2px solid transparent; |
| } |
| #preview-content h1::after, #preview-content h2::after, #preview-content h3::after, |
| #preview-content h4::after, #preview-content h5::after, #preview-content h6::after, |
| #setText h1::after, #setText h2::after, #setText h3::after, |
| #setText h4::after, #setText h5::after, #setText h6::after { |
| content: ""; |
| display: block; |
| height: 100px; |
| margin-bottom: -100px; |
| position: relative; |
| } |
| } |
| #preview-content code, #setText code { |
| font-family: Inconsolata; |
| font-size: inherit; |
| display: initial; |
| background: #f8f8fa; |
| } |
| #preview-content .mmd-highlight code, #setText .mmd-highlight code, |
| #preview-content pre.mmd-highlight code, #setText pre.mmd-highlight code { |
| background-color: transparent; |
| } |
| #preview-content pre code, #setText pre code { |
| font-family: 'DM Mono', Inconsolata, monospace; |
| color: #333; |
| font-size: 15px; |
| } |
| .hljs-comment, .hljs-quote, |
| #preview-content .hljs-comment, #setText .hljs-comment, |
| #preview-content .hljs-quote, #setText .hljs-quote { |
| color: #998; |
| font-style: italic; |
| } |
| .hljs-command, |
| #preview-content .hljs-command, #setText .hljs-command { |
| color: #005cc5; |
| } |
| .hljs-keyword, .hljs-selector-tag, .hljs-subst, |
| #preview-content .hljs-keyword, #setText .hljs-keyword, |
| #preview-content .hljs-selector-tag, #setText .hljs-selector-tag, |
| #preview-content .hljs-subst, #setText .hljs-subst { |
| color: #d73a49; |
| font-weight: bold; |
| } |
| .hljs-number, .hljs-literal, .hljs-variable, |
| .hljs-template-variable, .hljs-tag .hljs-attr, |
| #preview-content .hljs-number, #setText .hljs-number, |
| #preview-content .hljs-literal, #setText .hljs-literal, |
| #preview-content .hljs-variable, #setText .hljs-variable, |
| #preview-content .hljs-template-variable, #setText .hljs-template-variable, |
| #preview-content .hljs-tag .hljs-attr, #setText .hljs-tag .hljs-attr { |
| color: #005cc5; |
| } |
| .hljs-string, .hljs-doctag, |
| #preview-content .hljs-string, #setText .hljs-string, |
| #preview-content .hljs-doctag, #setText .hljs-doctag { |
| color: #24292e; |
| } |
| .hljs-title, .hljs-section, .hljs-selector-id, |
| #preview-content .hljs-title, #setText .hljs-title, |
| #preview-content .hljs-section, #setText .hljs-section, |
| #preview-content .hljs-selector-id, #setText .hljs-selector-id { |
| color: #6f42c1; |
| font-weight: bold; |
| } |
| .hljs-subst, |
| #preview-content .hljs-subst, #setText .hljs-subst { |
| font-weight: normal; |
| } |
| .hljs-type, .hljs-class .hljs-title, |
| #preview-content .hljs-type, #setText .hljs-type, |
| #preview-content .hljs-class .hljs-title, #setText .hljs-class .hljs-title { |
| color: #458; |
| font-weight: bold; |
| } |
| .hljs-tag, .hljs-name, .hljs-attribute, |
| #preview-content .hljs-tag, #setText .hljs-tag, |
| #preview-content .hljs-name, #setText .hljs-name, |
| #preview-content .hljs-attribute, #setText .hljs-attribute { |
| color: #000080; |
| font-weight: normal; |
| } |
| .hljs-regexp, .hljs-link, |
| #preview-content .hljs-regexp, #setText .hljs-regexp, |
| #preview-content .hljs-link, #setText .hljs-link { |
| color: #009926; |
| } |
| .hljs-symbol, .hljs-bullet, |
| #preview-content .hljs-symbol, #setText .hljs-symbol, |
| #preview-content .hljs-bullet, #setText .hljs-bullet { |
| color: #990073; |
| } |
| .hljs-built_in, .hljs-builtin-name, |
| #preview-content .hljs-built_in, #setText .hljs-built_in, |
| #preview-content .hljs-builtin-name, #setText .hljs-builtin-name { |
| color: #24292e; |
| } |
| .hljs-meta, |
| #preview-content .hljs-meta, #setText .hljs-meta { |
| color: #999; |
| font-weight: bold; |
| } |
| .hljs-meta-keyword, |
| #preview-content .hljs-meta-keyword, #setText .hljs-meta-keyword { |
| color: #d73a49; |
| } |
| .hljs-meta-string, |
| #preview-content .hljs-meta-string, #setText .hljs-meta-string { |
| color: #032f62; |
| } |
| .hljs-deletion, |
| #preview-content .hljs-deletion, #setText .hljs-deletion { |
| background: #fdd; |
| } |
| .hljs-addition, |
| #preview-content .hljs-addition, #setText .hljs-addition { |
| background: #dfd; |
| } |
| .hljs-emphasis, |
| #preview-content .hljs-emphasis, #setText .hljs-emphasis { |
| font-style: italic; |
| } |
| .hljs-strong, |
| #preview-content .hljs-strong, #setText .hljs-strong { |
| font-weight: bold; |
| } |
| .table_tabular, |
| #preview-content .table_tabular, #setText .table_tabular { |
| overflow-x: auto; |
| padding: 0 2px 0.5em 2px; |
| } |
| .tabular, |
| #preview-content .tabular, #setText .tabular { |
| display: inline-table !important; |
| width: auto; |
| table-layout: auto; |
| border-collapse: collapse; |
| border-spacing: 0; |
| margin: 0 0 1em; |
| font-size: inherit; |
| height: fit-content; |
| } |
| .tabular th, |
| #preview-content .tabular th, #setText .tabular th { |
| border: none !important; |
| padding: 6px 13px; |
| background-color: transparent; |
| font-weight: bold; |
| } |
| .tabular tr, |
| #preview-content .tabular tr, #setText .tabular tr { |
| border-top: none !important; |
| border-bottom: none !important; |
| background-color: transparent; |
| } |
| .tabular td, |
| #preview-content .tabular td, #setText .tabular td { |
| border-style: none !important; |
| background-color: #fff; |
| border-color: #000 !important; |
| word-break: keep-all; |
| padding: 0.1em 0.5em !important; |
| } |
| .tabular td > p, |
| #preview-content .tabular td > p, #setText .tabular td > p { |
| margin-bottom: 0; |
| margin-top: 0; |
| } |
| .tabular td._empty, |
| #preview-content .tabular td._empty, #setText .tabular td._empty { |
| height: 1.3em; |
| } |
| .tabular td .f, |
| #preview-content .tabular td .f, #setText .tabular td .f { |
| opacity: 0; |
| } |
| #preview-content .sub-table table, #setText .sub-table table { |
| margin-bottom: 0; |
| } |
| html[data-theme="dark"] .tabular tr, |
| html[data-theme="dark"] #preview-content .tabular tr, html[data-theme="dark"] #setText .tabular tr, |
| html[data-theme="dark"] .tabular td, |
| html[data-theme="dark"] #preview-content .tabular td, html[data-theme="dark"] #setText .tabular td { |
| background-color: #202226; |
| border-color: #fff !important; |
| } |
| .figure_img, |
| #preview-content .figure_img, #setText .figure_img { |
| margin-bottom: 0.5em; |
| overflow-x: auto; |
| } |
| div.figure_img img, |
| #preview-content div.figure_img img, #setText div.figure_img img { |
| display: inline; |
| margin: 0; |
| } |
| ol.enumerate, ul.itemize, |
| #preview-content ol.enumerate, #setText ol.enumerate, |
| #preview-content ul.itemize, #setText ul.itemize { |
| padding-inline-start: 40px; |
| margin: 0 0 1em 0; |
| } |
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| </head> |
| <body> |
| <div id="preview" class="preview scrollEditor"> |
| <div id="container-ruller" /> |
| <div id="preview-content"> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="supplementary-appendixes"> |
| SUPPLEMENTARY APPENDIXES</h2> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="contents"> |
| Contents</h2> |
| <div>eAPPENDIX 1. STUDY PROTOCOL AND STATISTICAL ANALYSIS PLAN<br> |
| eAPPENDIX 2. FAST TRACK PROTOCOL AND INTRAVENOUS DRUG ADMINISTRATION GUIDELINES</div> |
| <div>REFERENCES</div> |
| <div>This supplementary material has been provided by the authors to give readers additional information about their work.</div> |
| <div>Effect of Postoperative Intravenous Acetaminophen versus Placebo, Combined with Propofol or Dexmedetomidine, on Postoperative In-Hospital Delirium Among Older Patients Following Cardiac Surgery: The DEXACET Randomized Clinical Trial<br> |
| eAPPENDIX 1. STUDY PROTOCOL AND STATISTICAL ANALYSIS PLAN</div> |
| <div class="table_tabular" style="text-align: center"> |
| <div class="inline-tabular"><table class="tabular"> |
| <tbody> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top-style: solid !important; border-top-width: 1px !important; width: auto; vertical-align: middle; "><figure style="text-align: center"><img src="https://cdn.mathpix.com/cropped/6c46927b-ae99-4127-9213-1a3afb06732f-02.jpg?height=194&width=159&top_left_y=375&top_left_x=367" alt="" data-align="center"></figure></td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top-style: solid !important; border-top-width: 1px !important; width: auto; vertical-align: middle; ">Beth Israel Deaconess Medical Center</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top-style: solid !important; border-top-width: 1px !important; width: auto; vertical-align: middle; "><div class="inline-tabular sub-table"><table class="tabular"> |
| <tbody> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left: none !important; border-bottom: none !important; border-top: none !important; width: auto; vertical-align: middle; "><figure style="text-align: center"><img src="https://cdn.mathpix.com/cropped/6c46927b-ae99-4127-9213-1a3afb06732f-02.jpg?height=103&width=88&top_left_y=435&top_left_x=1181" alt="" data-align="center"></figure></td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left: none !important; border-bottom: none !important; border-top: none !important; width: auto; vertical-align: middle; ">HARVARD MEDICAL TEACHING HOSPITA</td> |
| </tr> |
| </tbody> |
| </table> |
| </div></td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Principal Investigator:</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; " class="_empty"></td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Balachundhar Subramaniam, MD, MPH</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Study Sponsor:</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; " class="_empty"></td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Mallinckrodt Pharmaceuticals</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Study Coordinating Center:</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; " class="_empty"></td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Beth Israel Deaconess Medical Center</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Original Protocol Version Date:</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">01/29/2015</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; " class="_empty"></td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">IRB Protocol Number:</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">2014P000413</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; " class="_empty"></td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Clinicaltrials.gov NCT:</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">NCT02546765</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; " class="_empty"></td> |
| </tr> |
| </tbody> |
| </table> |
| </div></div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="study-protocol"> |
| STUDY PROTOCOL</h2> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="purpose"> |
| Purpose</h2> |
| <div>The goal of this randomized clinical trial is to evaluate the effect of intravenous (IV) acetaminophen vs placebo, combined with IV propofol vs dexmedetomidine, for postoperative sedation and analgesia respectively, in adult patients 60 years or older undergoing coronary artery bypass grafting (CABG) or combined CABG/valve surgeries to assess the incidence of postoperative delirium with the Confusion Assessment Method (CAM or CAM-ICU). It is possible that there may be a benefit to those enrolled in the dexmedetomidine and acetaminophen group, as their incidence of delirium could possibly be reduced, however we cannot guarantee this.</div> |
| <div>Additionally, this study will assess postoperative cognition following cardiac surgery through 1 -year using a cognitive assessment scale and compare postoperative analgesic requirements in patients with and without IV acetaminophen.</div> |
| <div>Effect of Postoperative Intravenous Acetaminophen versus Placebo, Combined with Propofol or Dexmedetomidine, on Postoperative In-Hospital Delirium Among Older Patients Following Cardiac Surgery: The DEXACET Randomized Clinical Trial</div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="study-summary"> |
| Study Summary</h2> |
| <div class="table_tabular" style="text-align: center"> |
| <div class="inline-tabular"><table class="tabular"> |
| <tbody> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top-style: solid !important; border-top-width: 1px !important; width: auto; vertical-align: middle; ">Title</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top-style: solid !important; border-top-width: 1px !important; width: auto; vertical-align: middle; ">Effect of Postoperative Intravenous Acetaminophen versus Placebo, Combined with Propofol or Dexmedetomidine, on Postoperative InHospital Delirium Among Older Patients Following Cardiac Surgery: The DEXACET Randomized Clinical Trial</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Objective</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">To evaluate the effect of postoperative IV acetaminophen (paracetamol) vs placebo, combined with IV propofol vs dexmedetomidine, on postoperative delirium among older patients undergoing cardiac surgery</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Inclusion Criteria</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Patients 60 years or older undergoing CABG with or without aortic and/or mitral valve replacement requiring cardiopulmonary bypass</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Exclusion Criteria</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Patients with preoperative left ventricular ejection fraction (LVEF) <30%, pre-existing cognitive impairment, Alzheimer's disease, Parkinson's disease, medications for cognitive decline, history of recent seizures, serum creatinine <span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.566ex;" xmlns="http://www.w3.org/2000/svg" width="10.434ex" height="2.262ex" role="img" focusable="false" viewBox="0 -750 4611.8 1000"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mo"><path data-c="3E" d="M84 520Q84 528 88 533T96 539L99 540Q106 540 253 471T544 334L687 265Q694 260 694 250T687 235Q685 233 395 96L107 -40H101Q83 -38 83 -20Q83 -19 83 -17Q82 -10 98 -1Q117 9 248 71Q326 108 378 132L626 250L378 368Q90 504 86 509Q84 513 84 520Z"></path></g><g data-mml-node="mn" transform="translate(1055.8,0)"><path data-c="32" d="M109 429Q82 429 66 447T50 491Q50 562 103 614T235 666Q326 666 387 610T449 465Q449 422 429 383T381 315T301 241Q265 210 201 149L142 93L218 92Q375 92 385 97Q392 99 409 186V189H449V186Q448 183 436 95T421 3V0H50V19V31Q50 38 56 46T86 81Q115 113 136 137Q145 147 170 174T204 211T233 244T261 278T284 308T305 340T320 369T333 401T340 431T343 464Q343 527 309 573T212 619Q179 619 154 602T119 569T109 550Q109 549 114 549Q132 549 151 535T170 489Q170 464 154 447T109 429Z"></path></g><g data-mml-node="mi" transform="translate(1555.8,0)"><path data-c="1D45A" d="M21 287Q22 293 24 303T36 341T56 388T88 425T132 442T175 435T205 417T221 395T229 376L231 369Q231 367 232 367L243 378Q303 442 384 442Q401 442 415 440T441 433T460 423T475 411T485 398T493 385T497 373T500 364T502 357L510 367Q573 442 659 442Q713 442 746 415T780 336Q780 285 742 178T704 50Q705 36 709 31T724 26Q752 26 776 56T815 138Q818 149 821 151T837 153Q857 153 857 145Q857 144 853 130Q845 101 831 73T785 17T716 -10Q669 -10 648 17T627 73Q627 92 663 193T700 345Q700 404 656 404H651Q565 404 506 303L499 291L466 157Q433 26 428 16Q415 -11 385 -11Q372 -11 364 -4T353 8T350 18Q350 29 384 161L420 307Q423 322 423 345Q423 404 379 404H374Q288 404 229 303L222 291L189 157Q156 26 151 16Q138 -11 108 -11Q95 -11 87 -5T76 7T74 17Q74 30 112 181Q151 335 151 342Q154 357 154 369Q154 405 129 405Q107 405 92 377T69 316T57 280Q55 278 41 278H27Q21 284 21 287Z"></path></g><g data-mml-node="mi" transform="translate(2433.8,0)"><path data-c="1D454" d="M311 43Q296 30 267 15T206 0Q143 0 105 45T66 160Q66 265 143 353T314 442Q361 442 401 394L404 398Q406 401 409 404T418 412T431 419T447 422Q461 422 470 413T480 394Q480 379 423 152T363 -80Q345 -134 286 -169T151 -205Q10 -205 10 -137Q10 -111 28 -91T74 -71Q89 -71 102 -80T116 -111Q116 -121 114 -130T107 -144T99 -154T92 -162L90 -164H91Q101 -167 151 -167Q189 -167 211 -155Q234 -144 254 -122T282 -75Q288 -56 298 -13Q311 35 311 43ZM384 328L380 339Q377 350 375 354T369 368T359 382T346 393T328 402T306 405Q262 405 221 352Q191 313 171 233T151 117Q151 38 213 38Q269 38 323 108L331 118L384 328Z"></path></g><g data-mml-node="TeXAtom" data-mjx-texclass="ORD" transform="translate(2910.8,0)"><g data-mml-node="mo"><path data-c="2F" d="M423 750Q432 750 438 744T444 730Q444 725 271 248T92 -240Q85 -250 75 -250Q68 -250 62 -245T56 -231Q56 -221 230 257T407 740Q411 750 423 750Z"></path></g></g><g data-mml-node="mi" transform="translate(3410.8,0)"><path data-c="1D451" d="M366 683Q367 683 438 688T511 694Q523 694 523 686Q523 679 450 384T375 83T374 68Q374 26 402 26Q411 27 422 35Q443 55 463 131Q469 151 473 152Q475 153 483 153H487H491Q506 153 506 145Q506 140 503 129Q490 79 473 48T445 8T417 -8Q409 -10 393 -10Q359 -10 336 5T306 36L300 51Q299 52 296 50Q294 48 292 46Q233 -10 172 -10Q117 -10 75 30T33 157Q33 205 53 255T101 341Q148 398 195 420T280 442Q336 442 364 400Q369 394 369 396Q370 400 396 505T424 616Q424 629 417 632T378 637H357Q351 643 351 645T353 664Q358 683 366 683ZM352 326Q329 405 277 405Q242 405 210 374T160 293Q131 214 119 129Q119 126 119 118T118 106Q118 61 136 44T179 26Q233 26 290 98L298 109L352 326Z"></path></g><g data-mml-node="mi" transform="translate(3930.8,0)"><path data-c="1D43F" d="M228 637Q194 637 192 641Q191 643 191 649Q191 673 202 682Q204 683 217 683Q271 680 344 680Q485 680 506 683H518Q524 677 524 674T522 656Q517 641 513 637H475Q406 636 394 628Q387 624 380 600T313 336Q297 271 279 198T252 88L243 52Q243 48 252 48T311 46H328Q360 46 379 47T428 54T478 72T522 106T564 161Q580 191 594 228T611 270Q616 273 628 273H641Q647 264 647 262T627 203T583 83T557 9Q555 4 553 3T537 0T494 -1Q483 -1 418 -1T294 0H116Q32 0 32 10Q32 17 34 24Q39 43 44 45Q48 46 59 46H65Q92 46 125 49Q139 52 144 61Q147 65 216 339T285 628Q285 635 228 637Z"></path></g></g></g></svg></mjx-container></span>, liver dysfunction, recent history of alcohol abuse, English language limitations, hypersensitivity to study medications, and undergoing emergent surgery</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Study Design</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Single center, randomized, triple blind, placebo controlled, factorial design clinical trial</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; " class="_empty"></td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Patients were randomized to one of four factorial groups which included randomization to receive postoperative analgesia with intravenous acetaminophen or placebo every 6 hours for 48 hours. In addition, patients were randomized to receive postoperative sedation starting at chest closure and continued for up to 6 hours postoperatively or until extubation with intravenous dexmedetomidine or propofol.</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; " class="_empty"></td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">The incidence of postoperative in-hospital delirium was assessed daily using the CAM or CAM-ICU during the patient's hospitalization. In addition, follow up assessments were conducted at one month and one year.</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Study Discontinuation</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Patient request or any serious adverse event thought to be related to study procedures</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Key Roles</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Principal Investigator: Balachundhar Subramaniam, MD MPH</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; " class="_empty"></td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Institution: Beth Israel Deaconess Medical Center, Boston MA</td> |
| </tr> |
| </tbody> |
| </table> |
| </div></div> |
| <div>Effect of Postoperative Intravenous Acetaminophen versus Placebo, Combined with Propofol or Dexmedetomidine, on Postoperative In-Hospital Delirium Among Older Patients Following Cardiac Surgery: The DEXACET Randomized Clinical Trial</div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="significance-and-background"> |
| Significance and Background</h2> |
| <div>Approximately <span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.127ex;" xmlns="http://www.w3.org/2000/svg" width="4.147ex" height="1.824ex" role="img" focusable="false" viewBox="0 -750 1833 806"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mn"><path data-c="35" d="M164 157Q164 133 148 117T109 101H102Q148 22 224 22Q294 22 326 82Q345 115 345 210Q345 313 318 349Q292 382 260 382H254Q176 382 136 314Q132 307 129 306T114 304Q97 304 95 310Q93 314 93 485V614Q93 664 98 664Q100 666 102 666Q103 666 123 658T178 642T253 634Q324 634 389 662Q397 666 402 666Q410 666 410 648V635Q328 538 205 538Q174 538 149 544L139 546V374Q158 388 169 396T205 412T256 420Q337 420 393 355T449 201Q449 109 385 44T229 -22Q148 -22 99 32T50 154Q50 178 61 192T84 210T107 214Q132 214 148 197T164 157Z"></path><path data-c="30" d="M96 585Q152 666 249 666Q297 666 345 640T423 548Q460 465 460 320Q460 165 417 83Q397 41 362 16T301 -15T250 -22Q224 -22 198 -16T137 16T82 83Q39 165 39 320Q39 494 96 585ZM321 597Q291 629 250 629Q208 629 178 597Q153 571 145 525T137 333Q137 175 145 125T181 46Q209 16 250 16Q290 16 318 46Q347 76 354 130T362 333Q362 478 354 524T321 597Z" transform="translate(500,0)"></path></g><g data-mml-node="mi" transform="translate(1000,0)"><path data-c="25" d="M465 605Q428 605 394 614T340 632T319 641Q332 608 332 548Q332 458 293 403T202 347Q145 347 101 402T56 548Q56 637 101 693T202 750Q241 750 272 719Q359 642 464 642Q580 642 650 732Q662 748 668 749Q670 750 673 750Q682 750 688 743T693 726Q178 -47 170 -52Q166 -56 160 -56Q147 -56 142 -45Q137 -36 142 -27Q143 -24 363 304Q469 462 525 546T581 630Q528 605 465 605ZM207 385Q235 385 263 427T292 548Q292 617 267 664T200 712Q193 712 186 709T167 698T147 668T134 615Q132 595 132 548V527Q132 436 165 403Q183 385 203 385H207ZM500 146Q500 234 544 290T647 347Q699 347 737 292T776 146T737 0T646 -56Q590 -56 545 0T500 146ZM651 -18Q679 -18 707 24T736 146Q736 215 711 262T644 309Q637 309 630 306T611 295T591 265T578 212Q577 200 577 146V124Q577 -18 647 -18H651Z"></path></g></g></g></svg></mjx-container></span> of patients have postoperative delirium following cardiac surgery <span class="math-inline " data-overflow="visible"> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: 0;" xmlns="http://www.w3.org/2000/svg" width="0.988ex" height="1.887ex" role="img" focusable="false" viewBox="0 -833.9 436.6 833.9"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="msup"><g data-mml-node="TeXAtom" data-mjx-texclass="ORD"></g><g data-mml-node="TeXAtom" transform="translate(33,363) scale(0.707)" data-mjx-texclass="ORD"><g data-mml-node="mn"><path data-c="31" d="M213 578L200 573Q186 568 160 563T102 556H83V602H102Q149 604 189 617T245 641T273 663Q275 666 285 666Q294 666 302 660V361L303 61Q310 54 315 52T339 48T401 46H427V0H416Q395 3 257 3Q121 3 100 0H88V46H114Q136 46 152 46T177 47T193 50T201 52T207 57T213 61V578Z"></path></g></g></g></g></g></svg></mjx-container></span>. The growing body of evidence suggests that in-hospital delirium is associated with poor hospital outcomes, including a tenfold increased risk of death, and a fivefold increased risk of nosocomial related complications <span class="math-inline " data-overflow="visible"> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: 0;" xmlns="http://www.w3.org/2000/svg" width="0.988ex" height="1.887ex" role="img" focusable="false" viewBox="0 -833.9 436.6 833.9"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="msup"><g data-mml-node="TeXAtom" data-mjx-texclass="ORD"></g><g data-mml-node="TeXAtom" transform="translate(33,363) scale(0.707)" data-mjx-texclass="ORD"><g data-mml-node="mn"><path data-c="32" d="M109 429Q82 429 66 447T50 491Q50 562 103 614T235 666Q326 666 387 610T449 465Q449 422 429 383T381 315T301 241Q265 210 201 149L142 93L218 92Q375 92 385 97Q392 99 409 186V189H449V186Q448 183 436 95T421 3V0H50V19V31Q50 38 56 46T86 81Q115 113 136 137Q145 147 170 174T204 211T233 244T261 278T284 308T305 340T320 369T333 401T340 431T343 464Q343 527 309 573T212 619Q179 619 154 602T119 569T109 550Q109 549 114 549Q132 549 151 535T170 489Q170 464 154 447T109 429Z"></path></g></g></g></g></g></svg></mjx-container></span>. Delirium has also been associated with serious longer term outcomes such as poor functional recovery, and most recently, impaired cognitive function for up to one year after cardiac surgery <span class="math-inline " data-overflow="visible"> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: 0;" xmlns="http://www.w3.org/2000/svg" width="0.988ex" height="1.885ex" role="img" focusable="false" viewBox="0 -833.2 436.6 833.2"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="msup"><g data-mml-node="TeXAtom" data-mjx-texclass="ORD"></g><g data-mml-node="TeXAtom" transform="translate(33,363) scale(0.707)" data-mjx-texclass="ORD"><g data-mml-node="mn"><path data-c="33" d="M127 463Q100 463 85 480T69 524Q69 579 117 622T233 665Q268 665 277 664Q351 652 390 611T430 522Q430 470 396 421T302 350L299 348Q299 347 308 345T337 336T375 315Q457 262 457 175Q457 96 395 37T238 -22Q158 -22 100 21T42 130Q42 158 60 175T105 193Q133 193 151 175T169 130Q169 119 166 110T159 94T148 82T136 74T126 70T118 67L114 66Q165 21 238 21Q293 21 321 74Q338 107 338 175V195Q338 290 274 322Q259 328 213 329L171 330L168 332Q166 335 166 348Q166 366 174 366Q202 366 232 371Q266 376 294 413T322 525V533Q322 590 287 612Q265 626 240 626Q208 626 181 615T143 592T132 580H135Q138 579 143 578T153 573T165 566T175 555T183 540T186 520Q186 498 172 481T127 463Z"></path></g></g></g></g></g></svg></mjx-container></span>. Importantly, intervenable factors, such as perioperative sedation and analgesia with opioids may contribute to the etiology of delirium. In the setting of cardiac surgery done increasingly in older patients, there is an urgent need to test alternative sedation and complementary analgesic techniques.</div> |
| <div>Dexmedetomidine, a selective alpha-2 receptor agonist, provides sedation without causing respiratory depression. Dexmedetomidine is also suggested to have an opioid sparing effect that makes it a unique sedative drug. Currently used sedation drugs (midazolam) release deliriogenic mediators through binding of Gamma-aminobutyric Acid (GABA) receptors. Dexmedetomidine has no effect on the GABA receptors. Although these characteristics suggest dexmedetomidine to be a unique and promising drug for sedation following cardiac surgery, its efficacy on reducing the incidence, duration and long term effects of delirium has not been studied thoroughly.</div> |
| <div>Studies involving use of dexmedetomidine in an attempt to reduce the incidence of delirium in cardiac surgical patients provide conflicting results. One meta-analysis concluded that dexmedetomidine in cardiac surgery shortened the ventilator time (but not the Intensive Care Unit (ICU) or hospital length of stay), reduced the incidence of postoperative ventricular arrhythmias and delirium in cardiac surgical patients <span class="math-inline " data-overflow="visible"> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: 0;" xmlns="http://www.w3.org/2000/svg" width="0.988ex" height="1.904ex" role="img" focusable="false" viewBox="0 -841.7 436.6 841.7"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="msup"><g data-mml-node="TeXAtom" data-mjx-texclass="ORD"></g><g data-mml-node="TeXAtom" transform="translate(33,363) scale(0.707)" data-mjx-texclass="ORD"><g data-mml-node="mn"><path data-c="34" d="M462 0Q444 3 333 3Q217 3 199 0H190V46H221Q241 46 248 46T265 48T279 53T286 61Q287 63 287 115V165H28V211L179 442Q332 674 334 675Q336 677 355 677H373L379 671V211H471V165H379V114Q379 73 379 66T385 54Q393 47 442 46H471V0H462ZM293 211V545L74 212L183 211H293Z"></path></g></g></g></g></g></svg></mjx-container></span>. However, there are several issues with this meta-analysis, particularly for the systematic assessment of postoperative delirium. The problems with the four studies that formed the basis of this meta-analysis are explained in the next few paragraphs.</div> |
| <div>In a retrospective study <span class="math-inline " data-overflow="visible"> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: 0;" xmlns="http://www.w3.org/2000/svg" width="0.988ex" height="1.887ex" role="img" focusable="false" viewBox="0 -833.9 436.6 833.9"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="msup"><g data-mml-node="TeXAtom" data-mjx-texclass="ORD"></g><g data-mml-node="TeXAtom" transform="translate(33,363) scale(0.707)" data-mjx-texclass="ORD"><g data-mml-node="mn"><path data-c="35" d="M164 157Q164 133 148 117T109 101H102Q148 22 224 22Q294 22 326 82Q345 115 345 210Q345 313 318 349Q292 382 260 382H254Q176 382 136 314Q132 307 129 306T114 304Q97 304 95 310Q93 314 93 485V614Q93 664 98 664Q100 666 102 666Q103 666 123 658T178 642T253 634Q324 634 389 662Q397 666 402 666Q410 666 410 648V635Q328 538 205 538Q174 538 149 544L139 546V374Q158 388 169 396T205 412T256 420Q337 420 393 355T449 201Q449 109 385 44T229 -22Q148 -22 99 32T50 154Q50 178 61 192T84 210T107 214Q132 214 148 197T164 157Z"></path></g></g></g></g></g></svg></mjx-container></span> of administrative database from 250 hospitals, the incidence of postoperative delirium following cardiac surgery was significantly decreased with associated cost savings in the dexmedetomidine group. This study compared two regimens (dexmedetomidine, propofol plus narcotics vs. propofol vs. narcotics). Propofol was used in the dexmedetomidine group as well. This trial specifically does not mention how delirium was assessed in individual hospitals.</div> |
| <div>A randomized controlled trial <span class="math-inline " data-overflow="visible"> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: 0;" xmlns="http://www.w3.org/2000/svg" width="0.988ex" height="1.887ex" role="img" focusable="false" viewBox="0 -833.9 436.6 833.9"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="msup"><g data-mml-node="TeXAtom" data-mjx-texclass="ORD"></g><g data-mml-node="TeXAtom" transform="translate(33,363) scale(0.707)" data-mjx-texclass="ORD"><g data-mml-node="mn"><path data-c="36" d="M42 313Q42 476 123 571T303 666Q372 666 402 630T432 550Q432 525 418 510T379 495Q356 495 341 509T326 548Q326 592 373 601Q351 623 311 626Q240 626 194 566Q147 500 147 364L148 360Q153 366 156 373Q197 433 263 433H267Q313 433 348 414Q372 400 396 374T435 317Q456 268 456 210V192Q456 169 451 149Q440 90 387 34T253 -22Q225 -22 199 -14T143 16T92 75T56 172T42 313ZM257 397Q227 397 205 380T171 335T154 278T148 216Q148 133 160 97T198 39Q222 21 251 21Q302 21 329 59Q342 77 347 104T352 209Q352 289 347 316T329 361Q302 397 257 397Z"></path></g></g></g></g></g></svg></mjx-container></span> comparing dexmedetomidine/propofol to morphine/propofol in cardiac surgery patients showed a decreased duration of delirium ( 5 days to 2 days) in the dexmedetomidine group. This study found a similar incidence of delirium in both the groups. Propofol was used as a sedative in both the groups and this could have attributed to similar incidences of delirium in both the groups. There is a possibility the study was not powered adequately as the baseline incidence of delirium in the control group was a surprisingly low <span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.127ex;" xmlns="http://www.w3.org/2000/svg" width="4.147ex" height="1.824ex" role="img" focusable="false" viewBox="0 -750 1833 806"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mn"><path data-c="31" d="M213 578L200 573Q186 568 160 563T102 556H83V602H102Q149 604 189 617T245 641T273 663Q275 666 285 666Q294 666 302 660V361L303 61Q310 54 315 52T339 48T401 46H427V0H416Q395 3 257 3Q121 3 100 0H88V46H114Q136 46 152 46T177 47T193 50T201 52T207 57T213 61V578Z"></path><path data-c="35" d="M164 157Q164 133 148 117T109 101H102Q148 22 224 22Q294 22 326 82Q345 115 345 210Q345 313 318 349Q292 382 260 382H254Q176 382 136 314Q132 307 129 306T114 304Q97 304 95 310Q93 314 93 485V614Q93 664 98 664Q100 666 102 666Q103 666 123 658T178 642T253 634Q324 634 389 662Q397 666 402 666Q410 666 410 648V635Q328 538 205 538Q174 538 149 544L139 546V374Q158 388 169 396T205 412T256 420Q337 420 393 355T449 201Q449 109 385 44T229 -22Q148 -22 99 32T50 154Q50 178 61 192T84 210T107 214Q132 214 148 197T164 157Z" transform="translate(500,0)"></path></g><g data-mml-node="mi" transform="translate(1000,0)"><path data-c="25" d="M465 605Q428 605 394 614T340 632T319 641Q332 608 332 548Q332 458 293 403T202 347Q145 347 101 402T56 548Q56 637 101 693T202 750Q241 750 272 719Q359 642 464 642Q580 642 650 732Q662 748 668 749Q670 750 673 750Q682 750 688 743T693 726Q178 -47 170 -52Q166 -56 160 -56Q147 -56 142 -45Q137 -36 142 -27Q143 -24 363 304Q469 462 525 546T581 630Q528 605 465 605ZM207 385Q235 385 263 427T292 548Q292 617 267 664T200 712Q193 712 186 709T167 698T147 668T134 615Q132 595 132 548V527Q132 436 165 403Q183 385 203 385H207ZM500 146Q500 234 544 290T647 347Q699 347 737 292T776 146T737 0T646 -56Q590 -56 545 0T500 146ZM651 -18Q679 -18 707 24T736 146Q736 215 711 262T644 309Q637 309 630 306T611 295T591 265T578 212Q577 200 577 146V124Q577 -18 647 -18H651Z"></path></g></g></g></svg></mjx-container></span>, much lower than other cardiac surgery studies that have employed state-ofthe art delirium measures. This study used CAM-ICU for assessing delirium both in intubated and extubated patients. While the CAM-ICU, a delirium assessment that does not require any verbal responses by the patient, is state-of-the-art for intubated patients, it has reduced sensitivity for delirium in verbal patients. This design could have underestimated the incidence of delirium.</div> |
| <div>The third study <span class="math-inline " data-overflow="visible"> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: 0;" xmlns="http://www.w3.org/2000/svg" width="0.988ex" height="1.903ex" role="img" focusable="false" viewBox="0 -841 436.6 841"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="msup"><g data-mml-node="TeXAtom" data-mjx-texclass="ORD"></g><g data-mml-node="TeXAtom" transform="translate(33,363) scale(0.707)" data-mjx-texclass="ORD"><g data-mml-node="mn"><path data-c="37" d="M55 458Q56 460 72 567L88 674Q88 676 108 676H128V672Q128 662 143 655T195 646T364 644H485V605L417 512Q408 500 387 472T360 435T339 403T319 367T305 330T292 284T284 230T278 162T275 80Q275 66 275 52T274 28V19Q270 2 255 -10T221 -22Q210 -22 200 -19T179 0T168 40Q168 198 265 368Q285 400 349 489L395 552H302Q128 552 119 546Q113 543 108 522T98 479L95 458V455H55V458Z"></path></g></g></g></g></g></svg></mjx-container></span> included in the meta-analysis was a prospective, randomized, open labeled trial comparing three groups (dexmedetomidine, midazolam, and propofol). This study reported a dramatically decreased incidence of delirium in the dexmedetomidine group, <span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.127ex;" xmlns="http://www.w3.org/2000/svg" width="3.016ex" height="1.824ex" role="img" focusable="false" viewBox="0 -750 1333 806"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mn"><path data-c="33" d="M127 463Q100 463 85 480T69 524Q69 579 117 622T233 665Q268 665 277 664Q351 652 390 611T430 522Q430 470 396 421T302 350L299 348Q299 347 308 345T337 336T375 315Q457 262 457 175Q457 96 395 37T238 -22Q158 -22 100 21T42 130Q42 158 60 175T105 193Q133 193 151 175T169 130Q169 119 166 110T159 94T148 82T136 74T126 70T118 67L114 66Q165 21 238 21Q293 21 321 74Q338 107 338 175V195Q338 290 274 322Q259 328 213 329L171 330L168 332Q166 335 166 348Q166 366 174 366Q202 366 232 371Q266 376 294 413T322 525V533Q322 590 287 612Q265 626 240 626Q208 626 181 615T143 592T132 580H135Q138 579 143 578T153 573T165 566T175 555T183 540T186 520Q186 498 172 481T127 463Z"></path></g><g data-mml-node="mi" transform="translate(500,0)"><path data-c="25" d="M465 605Q428 605 394 614T340 632T319 641Q332 608 332 548Q332 458 293 403T202 347Q145 347 101 402T56 548Q56 637 101 693T202 750Q241 750 272 719Q359 642 464 642Q580 642 650 732Q662 748 668 749Q670 750 673 750Q682 750 688 743T693 726Q178 -47 170 -52Q166 -56 160 -56Q147 -56 142 -45Q137 -36 142 -27Q143 -24 363 304Q469 462 525 546T581 630Q528 605 465 605ZM207 385Q235 385 263 427T292 548Q292 617 267 664T200 712Q193 712 186 709T167 698T147 668T134 615Q132 595 132 548V527Q132 436 165 403Q183 385 203 385H207ZM500 146Q500 234 544 290T647 347Q699 347 737 292T776 146T737 0T646 -56Q590 -56 545 0T500 146ZM651 -18Q679 -18 707 24T736 146Q736 215 711 262T644 309Q637 309 630 306T611 295T591 265T578 212Q577 200 577 146V124Q577 -18 647 -18H651Z"></path></g></g></g></svg></mjx-container></span>, compared to <span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.127ex;" xmlns="http://www.w3.org/2000/svg" width="4.147ex" height="1.824ex" role="img" focusable="false" viewBox="0 -750 1833 806"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mn"><path data-c="35" d="M164 157Q164 133 148 117T109 101H102Q148 22 224 22Q294 22 326 82Q345 115 345 210Q345 313 318 349Q292 382 260 382H254Q176 382 136 314Q132 307 129 306T114 304Q97 304 95 310Q93 314 93 485V614Q93 664 98 664Q100 666 102 666Q103 666 123 658T178 642T253 634Q324 634 389 662Q397 666 402 666Q410 666 410 648V635Q328 538 205 538Q174 538 149 544L139 546V374Q158 388 169 396T205 412T256 420Q337 420 393 355T449 201Q449 109 385 44T229 -22Q148 -22 99 32T50 154Q50 178 61 192T84 210T107 214Q132 214 148 197T164 157Z"></path><path data-c="30" d="M96 585Q152 666 249 666Q297 666 345 640T423 548Q460 465 460 320Q460 165 417 83Q397 41 362 16T301 -15T250 -22Q224 -22 198 -16T137 16T82 83Q39 165 39 320Q39 494 96 585ZM321 597Q291 629 250 629Q208 629 178 597Q153 571 145 525T137 333Q137 175 145 125T181 46Q209 16 250 16Q290 16 318 46Q347 76 354 130T362 333Q362 478 354 524T321 597Z" transform="translate(500,0)"></path></g><g data-mml-node="mi" transform="translate(1000,0)"><path data-c="25" d="M465 605Q428 605 394 614T340 632T319 641Q332 608 332 548Q332 458 293 403T202 347Q145 347 101 402T56 548Q56 637 101 693T202 750Q241 750 272 719Q359 642 464 642Q580 642 650 732Q662 748 668 749Q670 750 673 750Q682 750 688 743T693 726Q178 -47 170 -52Q166 -56 160 -56Q147 -56 142 -45Q137 -36 142 -27Q143 -24 363 304Q469 462 525 546T581 630Q528 605 465 605ZM207 385Q235 385 263 427T292 548Q292 617 267 664T200 712Q193 712 186 709T167 698T147 668T134 615Q132 595 132 548V527Q132 436 165 403Q183 385 203 385H207ZM500 146Q500 234 544 290T647 347Q699 347 737 292T776 146T737 0T646 -56Q590 -56 545 0T500 146ZM651 -18Q679 -18 707 24T736 146Q736 215 711 262T644 309Q637 309 630 306T611 295T591 265T578 212Q577 200 577 146V124Q577 -18 647 -18H651Z"></path></g></g></g></svg></mjx-container></span> in propofol and midazolam groups. This was a small study, with only 118 patients were recruited and only 90 patients finally analyzed,</div> |
| <div>Effect of Postoperative Intravenous Acetaminophen versus Placebo, Combined with Propofol or Dexmedetomidine, on Postoperative In-Hospital Delirium Among Older Patients Following Cardiac Surgery: The DEXACET Randomized Clinical Trial with 28 patients randomized patients excluded for protocol violations. This introduces a significant selection bias. Furthermore, a <span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.127ex;" xmlns="http://www.w3.org/2000/svg" width="4.147ex" height="1.824ex" role="img" focusable="false" viewBox="0 -750 1833 806"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mn"><path data-c="39" d="M352 287Q304 211 232 211Q154 211 104 270T44 396Q42 412 42 436V444Q42 537 111 606Q171 666 243 666Q245 666 249 666T257 665H261Q273 665 286 663T323 651T370 619T413 560Q456 472 456 334Q456 194 396 97Q361 41 312 10T208 -22Q147 -22 108 7T68 93T121 149Q143 149 158 135T173 96Q173 78 164 65T148 49T135 44L131 43Q131 41 138 37T164 27T206 22H212Q272 22 313 86Q352 142 352 280V287ZM244 248Q292 248 321 297T351 430Q351 508 343 542Q341 552 337 562T323 588T293 615T246 625Q208 625 181 598Q160 576 154 546T147 441Q147 358 152 329T172 282Q197 248 244 248Z"></path><path data-c="34" d="M462 0Q444 3 333 3Q217 3 199 0H190V46H221Q241 46 248 46T265 48T279 53T286 61Q287 63 287 115V165H28V211L179 442Q332 674 334 675Q336 677 355 677H373L379 671V211H471V165H379V114Q379 73 379 66T385 54Q393 47 442 46H471V0H462ZM293 211V545L74 212L183 211H293Z" transform="translate(500,0)"></path></g><g data-mml-node="mi" transform="translate(1000,0)"><path data-c="25" d="M465 605Q428 605 394 614T340 632T319 641Q332 608 332 548Q332 458 293 403T202 347Q145 347 101 402T56 548Q56 637 101 693T202 750Q241 750 272 719Q359 642 464 642Q580 642 650 732Q662 748 668 749Q670 750 673 750Q682 750 688 743T693 726Q178 -47 170 -52Q166 -56 160 -56Q147 -56 142 -45Q137 -36 142 -27Q143 -24 363 304Q469 462 525 546T581 630Q528 605 465 605ZM207 385Q235 385 263 427T292 548Q292 617 267 664T200 712Q193 712 186 709T167 698T147 668T134 615Q132 595 132 548V527Q132 436 165 403Q183 385 203 385H207ZM500 146Q500 234 544 290T647 347Q699 347 737 292T776 146T737 0T646 -56Q590 -56 545 0T500 146ZM651 -18Q679 -18 707 24T736 146Q736 215 711 262T644 309Q637 309 630 306T611 295T591 265T578 212Q577 200 577 146V124Q577 -18 647 -18H651Z"></path></g></g></g></svg></mjx-container></span> reduction in the incidence of delirium was seen in this study. This effect size is almost implausibly large and has not been seen in other studies. Nevertheless, this study can provide a framework for sample size for future studies assuming the best case scenario.</div> |
| <div>The final study <span class="math-inline " data-overflow="visible"> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: 0;" xmlns="http://www.w3.org/2000/svg" width="0.988ex" height="1.887ex" role="img" focusable="false" viewBox="0 -833.9 436.6 833.9"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="msup"><g data-mml-node="TeXAtom" data-mjx-texclass="ORD"></g><g data-mml-node="TeXAtom" transform="translate(33,363) scale(0.707)" data-mjx-texclass="ORD"><g data-mml-node="mn"><path data-c="38" d="M70 417T70 494T124 618T248 666Q319 666 374 624T429 515Q429 485 418 459T392 417T361 389T335 371T324 363L338 354Q352 344 366 334T382 323Q457 264 457 174Q457 95 399 37T249 -22Q159 -22 101 29T43 155Q43 263 172 335L154 348Q133 361 127 368Q70 417 70 494ZM286 386L292 390Q298 394 301 396T311 403T323 413T334 425T345 438T355 454T364 471T369 491T371 513Q371 556 342 586T275 624Q268 625 242 625Q201 625 165 599T128 534Q128 511 141 492T167 463T217 431Q224 426 228 424L286 386ZM250 21Q308 21 350 55T392 137Q392 154 387 169T375 194T353 216T330 234T301 253T274 270Q260 279 244 289T218 306L210 311Q204 311 181 294T133 239T107 157Q107 98 150 60T250 21Z"></path></g></g></g></g></g></svg></mjx-container></span> included in the meta-analysis was a prospective randomized control trial of 89 patients undergoing non emergent CABG. In this study, a patient satisfaction questionnaire was used to assess pain, comfort and extubation process between intravenous dexmedetomidine and propofol groups. One patient in each group was reported to have delirium. This study was not designed to identify patients with delirium with any specific tools such as CAM and thus could have grossly underestimated delirium incidence. Thus, the meta-analysis represents a combination of poorly designed studies with differing measurements, and is extremely unlikely to create a significant impact or practice change among clinicians. Therefore, these findings will not result in a practice change in cardiac surgical intensive care units.</div> |
| <div>Postoperative pain following cardiac surgery can be due to the sternal incision, chest tube sites and leg incisions. Current pain relief strategy includes postoperative opioid administration (IV morphine or hydromorphone). While, inadequate pain relief increases the risk of postoperative delirium, opioids with their psychoactive properties also increase the risk of postoperative delirium, especially in elderly patients. A multimodal balanced postoperative pain management is advantageous and provides several beneficial effects. The options in cardiac surgery would include nonsteroidal anti-inflammatory drugs and acetaminophen. Their postoperative use decreases the exposure of older patients to opioids and can be an effective delirium prevention strategy. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) have contraindications after many kinds of surgery, including cardiac surgery, which include their deleterious effects on the gastrointestinal tract and renal function.</div> |
| <div>Acetaminophen has no psychoactive properties and is an attractive option as it lacks bleeding risks associated with nonsteroidal agents. Acetaminophen is for the most part safe but could cause liver dysfunction in rare instances. Oral administration of acetaminophen achieves limited blood levels in critically ill patients and therefore has limited efficacy. IV acetaminophen addresses this by allowing administration in critically ill patients and providing superior bioavailability to oral preparations <span class="math-inline " data-overflow="visible"> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: 0;" xmlns="http://www.w3.org/2000/svg" width="0.988ex" height="1.887ex" role="img" focusable="false" viewBox="0 -833.9 436.6 833.9"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="msup"><g data-mml-node="TeXAtom" data-mjx-texclass="ORD"></g><g data-mml-node="TeXAtom" transform="translate(33,363) scale(0.707)" data-mjx-texclass="ORD"><g data-mml-node="mn"><path data-c="39" d="M352 287Q304 211 232 211Q154 211 104 270T44 396Q42 412 42 436V444Q42 537 111 606Q171 666 243 666Q245 666 249 666T257 665H261Q273 665 286 663T323 651T370 619T413 560Q456 472 456 334Q456 194 396 97Q361 41 312 10T208 -22Q147 -22 108 7T68 93T121 149Q143 149 158 135T173 96Q173 78 164 65T148 49T135 44L131 43Q131 41 138 37T164 27T206 22H212Q272 22 313 86Q352 142 352 280V287ZM244 248Q292 248 321 297T351 430Q351 508 343 542Q341 552 337 562T323 588T293 615T246 625Q208 625 181 598Q160 576 154 546T147 441Q147 358 152 329T172 282Q197 248 244 248Z"></path></g></g></g></g></g></svg></mjx-container></span>. This approach has been shown to reduce pain intensity and also decrease the rescue intravenous morphine used during the postoperative period.</div> |
| <div>IV acetaminophen has never been studied in the context of cardiac surgery and delirium prevention. Additionally, comparing IV acetaminophen as an adjuvant analgesic in combination with IV propofol or IV dexmedetomidine may ascertain additive or synergistic effects on delirium prevention. Our randomized, single-blind, pre-pilot study with 12 patients showed that in patients who received IV acetaminophen as adjuvant analgesic <span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.566ex;" xmlns="http://www.w3.org/2000/svg" width="7.918ex" height="2.262ex" role="img" focusable="false" viewBox="0 -750 3499.6 1000"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mo"><path data-c="28" d="M94 250Q94 319 104 381T127 488T164 576T202 643T244 695T277 729T302 750H315H319Q333 750 333 741Q333 738 316 720T275 667T226 581T184 443T167 250T184 58T225 -81T274 -167T316 -220T333 -241Q333 -250 318 -250H315H302L274 -226Q180 -141 137 -14T94 250Z"></path></g><g data-mml-node="mi" transform="translate(389,0)"><path data-c="1D441" d="M234 637Q231 637 226 637Q201 637 196 638T191 649Q191 676 202 682Q204 683 299 683Q376 683 387 683T401 677Q612 181 616 168L670 381Q723 592 723 606Q723 633 659 637Q635 637 635 648Q635 650 637 660Q641 676 643 679T653 683Q656 683 684 682T767 680Q817 680 843 681T873 682Q888 682 888 672Q888 650 880 642Q878 637 858 637Q787 633 769 597L620 7Q618 0 599 0Q585 0 582 2Q579 5 453 305L326 604L261 344Q196 88 196 79Q201 46 268 46H278Q284 41 284 38T282 19Q278 6 272 0H259Q228 2 151 2Q123 2 100 2T63 2T46 1Q31 1 31 10Q31 14 34 26T39 40Q41 46 62 46Q130 49 150 85Q154 91 221 362L289 634Q287 635 234 637Z"></path></g><g data-mml-node="mo" transform="translate(1554.8,0)"><path data-c="3D" d="M56 347Q56 360 70 367H707Q722 359 722 347Q722 336 708 328L390 327H72Q56 332 56 347ZM56 153Q56 168 72 173H708Q722 163 722 153Q722 140 707 133H70Q56 140 56 153Z"></path></g><g data-mml-node="mn" transform="translate(2610.6,0)"><path data-c="36" d="M42 313Q42 476 123 571T303 666Q372 666 402 630T432 550Q432 525 418 510T379 495Q356 495 341 509T326 548Q326 592 373 601Q351 623 311 626Q240 626 194 566Q147 500 147 364L148 360Q153 366 156 373Q197 433 263 433H267Q313 433 348 414Q372 400 396 374T435 317Q456 268 456 210V192Q456 169 451 149Q440 90 387 34T253 -22Q225 -22 199 -14T143 16T92 75T56 172T42 313ZM257 397Q227 397 205 380T171 335T154 278T148 216Q148 133 160 97T198 39Q222 21 251 21Q302 21 329 59Q342 77 347 104T352 209Q352 289 347 316T329 361Q302 397 257 397Z"></path></g><g data-mml-node="mo" transform="translate(3110.6,0)"><path data-c="29" d="M60 749L64 750Q69 750 74 750H86L114 726Q208 641 251 514T294 250Q294 182 284 119T261 12T224 -76T186 -143T145 -194T113 -227T90 -246Q87 -249 86 -250H74Q66 -250 63 -250T58 -247T55 -238Q56 -237 66 -225Q221 -64 221 250T66 725Q56 737 55 738Q55 746 60 749Z"></path></g></g></g></svg></mjx-container></span>, the incidence of delirium was <span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.566ex;" xmlns="http://www.w3.org/2000/svg" width="9.301ex" height="2.262ex" role="img" focusable="false" viewBox="0 -750 4111 1000"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mn"><path data-c="31" d="M213 578L200 573Q186 568 160 563T102 556H83V602H102Q149 604 189 617T245 641T273 663Q275 666 285 666Q294 666 302 660V361L303 61Q310 54 315 52T339 48T401 46H427V0H416Q395 3 257 3Q121 3 100 0H88V46H114Q136 46 152 46T177 47T193 50T201 52T207 57T213 61V578Z"></path><path data-c="37" d="M55 458Q56 460 72 567L88 674Q88 676 108 676H128V672Q128 662 143 655T195 646T364 644H485V605L417 512Q408 500 387 472T360 435T339 403T319 367T305 330T292 284T284 230T278 162T275 80Q275 66 275 52T274 28V19Q270 2 255 -10T221 -22Q210 -22 200 -19T179 0T168 40Q168 198 265 368Q285 400 349 489L395 552H302Q128 552 119 546Q113 543 108 522T98 479L95 458V455H55V458Z" transform="translate(500,0)"></path></g><g data-mml-node="mi" transform="translate(1000,0)"><path data-c="25" d="M465 605Q428 605 394 614T340 632T319 641Q332 608 332 548Q332 458 293 403T202 347Q145 347 101 402T56 548Q56 637 101 693T202 750Q241 750 272 719Q359 642 464 642Q580 642 650 732Q662 748 668 749Q670 750 673 750Q682 750 688 743T693 726Q178 -47 170 -52Q166 -56 160 -56Q147 -56 142 -45Q137 -36 142 -27Q143 -24 363 304Q469 462 525 546T581 630Q528 605 465 605ZM207 385Q235 385 263 427T292 548Q292 617 267 664T200 712Q193 712 186 709T167 698T147 668T134 615Q132 595 132 548V527Q132 436 165 403Q183 385 203 385H207ZM500 146Q500 234 544 290T647 347Q699 347 737 292T776 146T737 0T646 -56Q590 -56 545 0T500 146ZM651 -18Q679 -18 707 24T736 146Q736 215 711 262T644 309Q637 309 630 306T611 295T591 265T578 212Q577 200 577 146V124Q577 -18 647 -18H651Z"></path></g><g data-mml-node="mo" transform="translate(1833,0)"><path data-c="28" d="M94 250Q94 319 104 381T127 488T164 576T202 643T244 695T277 729T302 750H315H319Q333 750 333 741Q333 738 316 720T275 667T226 581T184 443T167 250T184 58T225 -81T274 -167T316 -220T333 -241Q333 -250 318 -250H315H302L274 -226Q180 -141 137 -14T94 250Z"></path></g><g data-mml-node="mn" transform="translate(2222,0)"><path data-c="31" d="M213 578L200 573Q186 568 160 563T102 556H83V602H102Q149 604 189 617T245 641T273 663Q275 666 285 666Q294 666 302 660V361L303 61Q310 54 315 52T339 48T401 46H427V0H416Q395 3 257 3Q121 3 100 0H88V46H114Q136 46 152 46T177 47T193 50T201 52T207 57T213 61V578Z"></path></g><g data-mml-node="TeXAtom" data-mjx-texclass="ORD" transform="translate(2722,0)"><g data-mml-node="mo"><path data-c="2F" d="M423 750Q432 750 438 744T444 730Q444 725 271 248T92 -240Q85 -250 75 -250Q68 -250 62 -245T56 -231Q56 -221 230 257T407 740Q411 750 423 750Z"></path></g></g><g data-mml-node="mn" transform="translate(3222,0)"><path data-c="36" d="M42 313Q42 476 123 571T303 666Q372 666 402 630T432 550Q432 525 418 510T379 495Q356 495 341 509T326 548Q326 592 373 601Q351 623 311 626Q240 626 194 566Q147 500 147 364L148 360Q153 366 156 373Q197 433 263 433H267Q313 433 348 414Q372 400 396 374T435 317Q456 268 456 210V192Q456 169 451 149Q440 90 387 34T253 -22Q225 -22 199 -14T143 16T92 75T56 172T42 313ZM257 397Q227 397 205 380T171 335T154 278T148 216Q148 133 160 97T198 39Q222 21 251 21Q302 21 329 59Q342 77 347 104T352 209Q352 289 347 316T329 361Q302 397 257 397Z"></path></g><g data-mml-node="mo" transform="translate(3722,0)"><path data-c="29" d="M60 749L64 750Q69 750 74 750H86L114 726Q208 641 251 514T294 250Q294 182 284 119T261 12T224 -76T186 -143T145 -194T113 -227T90 -246Q87 -249 86 -250H74Q66 -250 63 -250T58 -247T55 -238Q56 -237 66 -225Q221 -64 221 250T66 725Q56 737 55 738Q55 746 60 749Z"></path></g></g></g></svg></mjx-container></span> compared to <span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.566ex;" xmlns="http://www.w3.org/2000/svg" width="9.301ex" height="2.262ex" role="img" focusable="false" viewBox="0 -750 4111 1000"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mn"><path data-c="36" d="M42 313Q42 476 123 571T303 666Q372 666 402 630T432 550Q432 525 418 510T379 495Q356 495 341 509T326 548Q326 592 373 601Q351 623 311 626Q240 626 194 566Q147 500 147 364L148 360Q153 366 156 373Q197 433 263 433H267Q313 433 348 414Q372 400 396 374T435 317Q456 268 456 210V192Q456 169 451 149Q440 90 387 34T253 -22Q225 -22 199 -14T143 16T92 75T56 172T42 313ZM257 397Q227 397 205 380T171 335T154 278T148 216Q148 133 160 97T198 39Q222 21 251 21Q302 21 329 59Q342 77 347 104T352 209Q352 289 347 316T329 361Q302 397 257 397Z"></path><path data-c="37" d="M55 458Q56 460 72 567L88 674Q88 676 108 676H128V672Q128 662 143 655T195 646T364 644H485V605L417 512Q408 500 387 472T360 435T339 403T319 367T305 330T292 284T284 230T278 162T275 80Q275 66 275 52T274 28V19Q270 2 255 -10T221 -22Q210 -22 200 -19T179 0T168 40Q168 198 265 368Q285 400 349 489L395 552H302Q128 552 119 546Q113 543 108 522T98 479L95 458V455H55V458Z" transform="translate(500,0)"></path></g><g data-mml-node="mi" transform="translate(1000,0)"><path data-c="25" d="M465 605Q428 605 394 614T340 632T319 641Q332 608 332 548Q332 458 293 403T202 347Q145 347 101 402T56 548Q56 637 101 693T202 750Q241 750 272 719Q359 642 464 642Q580 642 650 732Q662 748 668 749Q670 750 673 750Q682 750 688 743T693 726Q178 -47 170 -52Q166 -56 160 -56Q147 -56 142 -45Q137 -36 142 -27Q143 -24 363 304Q469 462 525 546T581 630Q528 605 465 605ZM207 385Q235 385 263 427T292 548Q292 617 267 664T200 712Q193 712 186 709T167 698T147 668T134 615Q132 595 132 548V527Q132 436 165 403Q183 385 203 385H207ZM500 146Q500 234 544 290T647 347Q699 347 737 292T776 146T737 0T646 -56Q590 -56 545 0T500 146ZM651 -18Q679 -18 707 24T736 146Q736 215 711 262T644 309Q637 309 630 306T611 295T591 265T578 212Q577 200 577 146V124Q577 -18 647 -18H651Z"></path></g><g data-mml-node="mo" transform="translate(1833,0)"><path data-c="28" d="M94 250Q94 319 104 381T127 488T164 576T202 643T244 695T277 729T302 750H315H319Q333 750 333 741Q333 738 316 720T275 667T226 581T184 443T167 250T184 58T225 -81T274 -167T316 -220T333 -241Q333 -250 318 -250H315H302L274 -226Q180 -141 137 -14T94 250Z"></path></g><g data-mml-node="mn" transform="translate(2222,0)"><path data-c="34" d="M462 0Q444 3 333 3Q217 3 199 0H190V46H221Q241 46 248 46T265 48T279 53T286 61Q287 63 287 115V165H28V211L179 442Q332 674 334 675Q336 677 355 677H373L379 671V211H471V165H379V114Q379 73 379 66T385 54Q393 47 442 46H471V0H462ZM293 211V545L74 212L183 211H293Z"></path></g><g data-mml-node="TeXAtom" data-mjx-texclass="ORD" transform="translate(2722,0)"><g data-mml-node="mo"><path data-c="2F" d="M423 750Q432 750 438 744T444 730Q444 725 271 248T92 -240Q85 -250 75 -250Q68 -250 62 -245T56 -231Q56 -221 230 257T407 740Q411 750 423 750Z"></path></g></g><g data-mml-node="mn" transform="translate(3222,0)"><path data-c="36" d="M42 313Q42 476 123 571T303 666Q372 666 402 630T432 550Q432 525 418 510T379 495Q356 495 341 509T326 548Q326 592 373 601Q351 623 311 626Q240 626 194 566Q147 500 147 364L148 360Q153 366 156 373Q197 433 263 433H267Q313 433 348 414Q372 400 396 374T435 317Q456 268 456 210V192Q456 169 451 149Q440 90 387 34T253 -22Q225 -22 199 -14T143 16T92 75T56 172T42 313ZM257 397Q227 397 205 380T171 335T154 278T148 216Q148 133 160 97T198 39Q222 21 251 21Q302 21 329 59Q342 77 347 104T352 209Q352 289 347 316T329 361Q302 397 257 397Z"></path></g><g data-mml-node="mo" transform="translate(3722,0)"><path data-c="29" d="M60 749L64 750Q69 750 74 750H86L114 726Q208 641 251 514T294 250Q294 182 284 119T261 12T224 -76T186 -143T145 -194T113 -227T90 -246Q87 -249 86 -250H74Q66 -250 63 -250T58 -247T55 -238Q56 -237 66 -225Q221 -64 221 250T66 725Q56 737 55 738Q55 746 60 749Z"></path></g></g></g></svg></mjx-container></span> in those who did not. The total incidence was <span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.566ex;" xmlns="http://www.w3.org/2000/svg" width="10.432ex" height="2.262ex" role="img" focusable="false" viewBox="0 -750 4611 1000"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mn"><path data-c="34" d="M462 0Q444 3 333 3Q217 3 199 0H190V46H221Q241 46 248 46T265 48T279 53T286 61Q287 63 287 115V165H28V211L179 442Q332 674 334 675Q336 677 355 677H373L379 671V211H471V165H379V114Q379 73 379 66T385 54Q393 47 442 46H471V0H462ZM293 211V545L74 212L183 211H293Z"></path><path data-c="32" d="M109 429Q82 429 66 447T50 491Q50 562 103 614T235 666Q326 666 387 610T449 465Q449 422 429 383T381 315T301 241Q265 210 201 149L142 93L218 92Q375 92 385 97Q392 99 409 186V189H449V186Q448 183 436 95T421 3V0H50V19V31Q50 38 56 46T86 81Q115 113 136 137Q145 147 170 174T204 211T233 244T261 278T284 308T305 340T320 369T333 401T340 431T343 464Q343 527 309 573T212 619Q179 619 154 602T119 569T109 550Q109 549 114 549Q132 549 151 535T170 489Q170 464 154 447T109 429Z" transform="translate(500,0)"></path></g><g data-mml-node="mi" transform="translate(1000,0)"><path data-c="25" d="M465 605Q428 605 394 614T340 632T319 641Q332 608 332 548Q332 458 293 403T202 347Q145 347 101 402T56 548Q56 637 101 693T202 750Q241 750 272 719Q359 642 464 642Q580 642 650 732Q662 748 668 749Q670 750 673 750Q682 750 688 743T693 726Q178 -47 170 -52Q166 -56 160 -56Q147 -56 142 -45Q137 -36 142 -27Q143 -24 363 304Q469 462 525 546T581 630Q528 605 465 605ZM207 385Q235 385 263 427T292 548Q292 617 267 664T200 712Q193 712 186 709T167 698T147 668T134 615Q132 595 132 548V527Q132 436 165 403Q183 385 203 385H207ZM500 146Q500 234 544 290T647 347Q699 347 737 292T776 146T737 0T646 -56Q590 -56 545 0T500 146ZM651 -18Q679 -18 707 24T736 146Q736 215 711 262T644 309Q637 309 630 306T611 295T591 265T578 212Q577 200 577 146V124Q577 -18 647 -18H651Z"></path></g><g data-mml-node="mo" transform="translate(1833,0)"><path data-c="28" d="M94 250Q94 319 104 381T127 488T164 576T202 643T244 695T277 729T302 750H315H319Q333 750 333 741Q333 738 316 720T275 667T226 581T184 443T167 250T184 58T225 -81T274 -167T316 -220T333 -241Q333 -250 318 -250H315H302L274 -226Q180 -141 137 -14T94 250Z"></path></g><g data-mml-node="mn" transform="translate(2222,0)"><path data-c="35" d="M164 157Q164 133 148 117T109 101H102Q148 22 224 22Q294 22 326 82Q345 115 345 210Q345 313 318 349Q292 382 260 382H254Q176 382 136 314Q132 307 129 306T114 304Q97 304 95 310Q93 314 93 485V614Q93 664 98 664Q100 666 102 666Q103 666 123 658T178 642T253 634Q324 634 389 662Q397 666 402 666Q410 666 410 648V635Q328 538 205 538Q174 538 149 544L139 546V374Q158 388 169 396T205 412T256 420Q337 420 393 355T449 201Q449 109 385 44T229 -22Q148 -22 99 32T50 154Q50 178 61 192T84 210T107 214Q132 214 148 197T164 157Z"></path></g><g data-mml-node="TeXAtom" data-mjx-texclass="ORD" transform="translate(2722,0)"><g data-mml-node="mo"><path data-c="2F" d="M423 750Q432 750 438 744T444 730Q444 725 271 248T92 -240Q85 -250 75 -250Q68 -250 62 -245T56 -231Q56 -221 230 257T407 740Q411 750 423 750Z"></path></g></g><g data-mml-node="mn" transform="translate(3222,0)"><path data-c="31" d="M213 578L200 573Q186 568 160 563T102 556H83V602H102Q149 604 189 617T245 641T273 663Q275 666 285 666Q294 666 302 660V361L303 61Q310 54 315 52T339 48T401 46H427V0H416Q395 3 257 3Q121 3 100 0H88V46H114Q136 46 152 46T177 47T193 50T201 52T207 57T213 61V578Z"></path><path data-c="32" d="M109 429Q82 429 66 447T50 491Q50 562 103 614T235 666Q326 666 387 610T449 465Q449 422 429 383T381 315T301 241Q265 210 201 149L142 93L218 92Q375 92 385 97Q392 99 409 186V189H449V186Q448 183 436 95T421 3V0H50V19V31Q50 38 56 46T86 81Q115 113 136 137Q145 147 170 174T204 211T233 244T261 278T284 308T305 340T320 369T333 401T340 431T343 464Q343 527 309 573T212 619Q179 619 154 602T119 569T109 550Q109 549 114 549Q132 549 151 535T170 489Q170 464 154 447T109 429Z" transform="translate(500,0)"></path></g><g data-mml-node="mo" transform="translate(4222,0)"><path data-c="29" d="M60 749L64 750Q69 750 74 750H86L114 726Q208 641 251 514T294 250Q294 182 284 119T261 12T224 -76T186 -143T145 -194T113 -227T90 -246Q87 -249 86 -250H74Q66 -250 63 -250T58 -247T55 -238Q56 -237 66 -225Q221 -64 221 250T66 725Q56 737 55 738Q55 746 60 749Z"></path></g></g></g></svg></mjx-container></span>. Despite the small sample size, this provocative finding suggests that IV acetaminophen with propofol or dexmedetomidine may offer a significant benefit in reducing the incidence of delirium following cardiac surgery. If this benefit is proved in a larger study as proposed, this will have a significant impact in patient care and satisfaction.</div> |
| <div>Effect of Postoperative Intravenous Acetaminophen versus Placebo, Combined with Propofol or Dexmedetomidine, on Postoperative In-Hospital Delirium Among Older Patients Following Cardiac Surgery: The DEXACET Randomized Clinical Trial</div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="subject-recruitment"> |
| Subject Recruitment</h2> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="screening"> |
| Screening</h2> |
| <div>Eligible participants will be identified at preadmission testing clinic appointments, in the cardiac catheterization lab or on the medical floors. At this time all inclusion and exclusion criteria will be assessed.</div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="inclusion-criteria"> |
| Inclusion Criteria</h2> |
| <div>Adult patients <span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.312ex;" xmlns="http://www.w3.org/2000/svg" width="4.651ex" height="1.819ex" role="img" focusable="false" viewBox="0 -666 2055.8 804"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mo"><path data-c="2265" d="M83 616Q83 624 89 630T99 636Q107 636 253 568T543 431T687 361Q694 356 694 346T687 331Q685 329 395 192L107 56H101Q83 58 83 76Q83 77 83 79Q82 86 98 95Q117 105 248 167Q326 204 378 228L626 346L360 472Q291 505 200 548Q112 589 98 597T83 616ZM84 -118Q84 -108 99 -98H678Q694 -104 694 -118Q694 -130 679 -138H98Q84 -131 84 -118Z"></path></g><g data-mml-node="mn" transform="translate(1055.8,0)"><path data-c="36" d="M42 313Q42 476 123 571T303 666Q372 666 402 630T432 550Q432 525 418 510T379 495Q356 495 341 509T326 548Q326 592 373 601Q351 623 311 626Q240 626 194 566Q147 500 147 364L148 360Q153 366 156 373Q197 433 263 433H267Q313 433 348 414Q372 400 396 374T435 317Q456 268 456 210V192Q456 169 451 149Q440 90 387 34T253 -22Q225 -22 199 -14T143 16T92 75T56 172T42 313ZM257 397Q227 397 205 380T171 335T154 278T148 216Q148 133 160 97T198 39Q222 21 251 21Q302 21 329 59Q342 77 347 104T352 209Q352 289 347 316T329 361Q302 397 257 397Z"></path><path data-c="30" d="M96 585Q152 666 249 666Q297 666 345 640T423 548Q460 465 460 320Q460 165 417 83Q397 41 362 16T301 -15T250 -22Q224 -22 198 -16T137 16T82 83Q39 165 39 320Q39 494 96 585ZM321 597Q291 629 250 629Q208 629 178 597Q153 571 145 525T137 333Q137 175 145 125T181 46Q209 16 250 16Q290 16 318 46Q347 76 354 130T362 333Q362 478 354 524T321 597Z" transform="translate(500,0)"></path></g></g></g></svg></mjx-container></span> years of age who are undergoing CABG with/without valve (aortic and/or mitral) procedure requiring bypass.</div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="exclusion-criteria"> |
| Exclusion Criteria</h2> |
| <div>Patients will be excluded if they had a preoperative LVEF <span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.127ex;" xmlns="http://www.w3.org/2000/svg" width="6.536ex" height="1.824ex" role="img" focusable="false" viewBox="0 -750 2888.8 806"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mo"><path data-c="3C" d="M694 -11T694 -19T688 -33T678 -40Q671 -40 524 29T234 166L90 235Q83 240 83 250Q83 261 91 266Q664 540 678 540Q681 540 687 534T694 519T687 505Q686 504 417 376L151 250L417 124Q686 -4 687 -5Q694 -11 694 -19Z"></path></g><g data-mml-node="mn" transform="translate(1055.8,0)"><path data-c="33" d="M127 463Q100 463 85 480T69 524Q69 579 117 622T233 665Q268 665 277 664Q351 652 390 611T430 522Q430 470 396 421T302 350L299 348Q299 347 308 345T337 336T375 315Q457 262 457 175Q457 96 395 37T238 -22Q158 -22 100 21T42 130Q42 158 60 175T105 193Q133 193 151 175T169 130Q169 119 166 110T159 94T148 82T136 74T126 70T118 67L114 66Q165 21 238 21Q293 21 321 74Q338 107 338 175V195Q338 290 274 322Q259 328 213 329L171 330L168 332Q166 335 166 348Q166 366 174 366Q202 366 232 371Q266 376 294 413T322 525V533Q322 590 287 612Q265 626 240 626Q208 626 181 615T143 592T132 580H135Q138 579 143 578T153 573T165 566T175 555T183 540T186 520Q186 498 172 481T127 463Z"></path><path data-c="30" d="M96 585Q152 666 249 666Q297 666 345 640T423 548Q460 465 460 320Q460 165 417 83Q397 41 362 16T301 -15T250 -22Q224 -22 198 -16T137 16T82 83Q39 165 39 320Q39 494 96 585ZM321 597Q291 629 250 629Q208 629 178 597Q153 571 145 525T137 333Q137 175 145 125T181 46Q209 16 250 16Q290 16 318 46Q347 76 354 130T362 333Q362 478 354 524T321 597Z" transform="translate(500,0)"></path></g><g data-mml-node="mi" transform="translate(2055.8,0)"><path data-c="25" d="M465 605Q428 605 394 614T340 632T319 641Q332 608 332 548Q332 458 293 403T202 347Q145 347 101 402T56 548Q56 637 101 693T202 750Q241 750 272 719Q359 642 464 642Q580 642 650 732Q662 748 668 749Q670 750 673 750Q682 750 688 743T693 726Q178 -47 170 -52Q166 -56 160 -56Q147 -56 142 -45Q137 -36 142 -27Q143 -24 363 304Q469 462 525 546T581 630Q528 605 465 605ZM207 385Q235 385 263 427T292 548Q292 617 267 664T200 712Q193 712 186 709T167 698T147 668T134 615Q132 595 132 548V527Q132 436 165 403Q183 385 203 385H207ZM500 146Q500 234 544 290T647 347Q699 347 737 292T776 146T737 0T646 -56Q590 -56 545 0T500 146ZM651 -18Q679 -18 707 24T736 146Q736 215 711 262T644 309Q637 309 630 306T611 295T591 265T578 212Q577 200 577 146V124Q577 -18 647 -18H651Z"></path></g></g></g></svg></mjx-container></span> emergent procedure, isolated aortic surgery, pre-existing cognitive impairment, Parkinson's disease, Alzheimer's disease, prophylactic medications for cognitive decline, active history of drug or alcohol abuse, serum creatinine <span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.566ex;" xmlns="http://www.w3.org/2000/svg" width="10.434ex" height="2.262ex" role="img" focusable="false" viewBox="0 -750 4611.8 1000"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mo"><path data-c="3E" d="M84 520Q84 528 88 533T96 539L99 540Q106 540 253 471T544 334L687 265Q694 260 694 250T687 235Q685 233 395 96L107 -40H101Q83 -38 83 -20Q83 -19 83 -17Q82 -10 98 -1Q117 9 248 71Q326 108 378 132L626 250L378 368Q90 504 86 509Q84 513 84 520Z"></path></g><g data-mml-node="mn" transform="translate(1055.8,0)"><path data-c="32" d="M109 429Q82 429 66 447T50 491Q50 562 103 614T235 666Q326 666 387 610T449 465Q449 422 429 383T381 315T301 241Q265 210 201 149L142 93L218 92Q375 92 385 97Q392 99 409 186V189H449V186Q448 183 436 95T421 3V0H50V19V31Q50 38 56 46T86 81Q115 113 136 137Q145 147 170 174T204 211T233 244T261 278T284 308T305 340T320 369T333 401T340 431T343 464Q343 527 309 573T212 619Q179 619 154 602T119 569T109 550Q109 549 114 549Q132 549 151 535T170 489Q170 464 154 447T109 429Z"></path></g><g data-mml-node="mi" transform="translate(1555.8,0)"><path data-c="1D45A" d="M21 287Q22 293 24 303T36 341T56 388T88 425T132 442T175 435T205 417T221 395T229 376L231 369Q231 367 232 367L243 378Q303 442 384 442Q401 442 415 440T441 433T460 423T475 411T485 398T493 385T497 373T500 364T502 357L510 367Q573 442 659 442Q713 442 746 415T780 336Q780 285 742 178T704 50Q705 36 709 31T724 26Q752 26 776 56T815 138Q818 149 821 151T837 153Q857 153 857 145Q857 144 853 130Q845 101 831 73T785 17T716 -10Q669 -10 648 17T627 73Q627 92 663 193T700 345Q700 404 656 404H651Q565 404 506 303L499 291L466 157Q433 26 428 16Q415 -11 385 -11Q372 -11 364 -4T353 8T350 18Q350 29 384 161L420 307Q423 322 423 345Q423 404 379 404H374Q288 404 229 303L222 291L189 157Q156 26 151 16Q138 -11 108 -11Q95 -11 87 -5T76 7T74 17Q74 30 112 181Q151 335 151 342Q154 357 154 369Q154 405 129 405Q107 405 92 377T69 316T57 280Q55 278 41 278H27Q21 284 21 287Z"></path></g><g data-mml-node="mi" transform="translate(2433.8,0)"><path data-c="1D454" d="M311 43Q296 30 267 15T206 0Q143 0 105 45T66 160Q66 265 143 353T314 442Q361 442 401 394L404 398Q406 401 409 404T418 412T431 419T447 422Q461 422 470 413T480 394Q480 379 423 152T363 -80Q345 -134 286 -169T151 -205Q10 -205 10 -137Q10 -111 28 -91T74 -71Q89 -71 102 -80T116 -111Q116 -121 114 -130T107 -144T99 -154T92 -162L90 -164H91Q101 -167 151 -167Q189 -167 211 -155Q234 -144 254 -122T282 -75Q288 -56 298 -13Q311 35 311 43ZM384 328L380 339Q377 350 375 354T369 368T359 382T346 393T328 402T306 405Q262 405 221 352Q191 313 171 233T151 117Q151 38 213 38Q269 38 323 108L331 118L384 328Z"></path></g><g data-mml-node="TeXAtom" data-mjx-texclass="ORD" transform="translate(2910.8,0)"><g data-mml-node="mo"><path data-c="2F" d="M423 750Q432 750 438 744T444 730Q444 725 271 248T92 -240Q85 -250 75 -250Q68 -250 62 -245T56 -231Q56 -221 230 257T407 740Q411 750 423 750Z"></path></g></g><g data-mml-node="mi" transform="translate(3410.8,0)"><path data-c="1D451" d="M366 683Q367 683 438 688T511 694Q523 694 523 686Q523 679 450 384T375 83T374 68Q374 26 402 26Q411 27 422 35Q443 55 463 131Q469 151 473 152Q475 153 483 153H487H491Q506 153 506 145Q506 140 503 129Q490 79 473 48T445 8T417 -8Q409 -10 393 -10Q359 -10 336 5T306 36L300 51Q299 52 296 50Q294 48 292 46Q233 -10 172 -10Q117 -10 75 30T33 157Q33 205 53 255T101 341Q148 398 195 420T280 442Q336 442 364 400Q369 394 369 396Q370 400 396 505T424 616Q424 629 417 632T378 637H357Q351 643 351 645T353 664Q358 683 366 683ZM352 326Q329 405 277 405Q242 405 210 374T160 293Q131 214 119 129Q119 126 119 118T118 106Q118 61 136 44T179 26Q233 26 290 98L298 109L352 326Z"></path></g><g data-mml-node="mi" transform="translate(3930.8,0)"><path data-c="1D43F" d="M228 637Q194 637 192 641Q191 643 191 649Q191 673 202 682Q204 683 217 683Q271 680 344 680Q485 680 506 683H518Q524 677 524 674T522 656Q517 641 513 637H475Q406 636 394 628Q387 624 380 600T313 336Q297 271 279 198T252 88L243 52Q243 48 252 48T311 46H328Q360 46 379 47T428 54T478 72T522 106T564 161Q580 191 594 228T611 270Q616 273 628 273H641Q647 264 647 262T627 203T583 83T557 9Q555 4 553 3T537 0T494 -1Q483 -1 418 -1T294 0H116Q32 0 32 10Q32 17 34 24Q39 43 44 45Q48 46 59 46H65Q92 46 125 49Q139 52 144 61Q147 65 216 339T285 628Q285 635 228 637Z"></path></g></g></g></svg></mjx-container></span>, liver dysfunction, non-English speaking, seizures in the last three months, emergent procedure or hypersensitivity to study drugs or procedures.</div> |
| <div>Adult patients unqualified or incapable of giving legal consent will be excluded.</div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="informed-consent"> |
| Informed Consent</h2> |
| <div>Written informed consent will be obtained prior to initiation of any study-specific procedures. Consent will be obtained by one of the participating researchers of the study. At the time of consent, all study procedures will be explained in detail, including the associated risks and benefits. The subjects will have the opportunity to ask any and all questions, and will be reminded that participation is voluntarily. All subjects will be consented with curtains drawn or the door closed, assuring patient privacy. Written informed consent will then be obtained from interested participants. The original signed form will remain with the investigator in the study file. Copies will be given to the patient and filed in the official medical record as well.</div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="randomization-and-blinding"> |
| Randomization and Blinding</h2> |
| <div>After obtaining written informed consent, participants will be randomized to one of four groups by the research pharmacy using a sequence of computer -generated random numbers. Blocked randomization will be used to assign recruited participants to one of four combinations of analgesics and sedatives in a 1:1:1:1 allocation: (1) acetaminophen and dexmedetomidine, (2) acetaminophen and propofol, (3) placebo and dexmedetomidine, or (4) placebo and propofol. In order to blind the patient, the care team, and the research staff assessing outcomes to the analgesia group, 1 gram of IV acetaminophen and placebo ( <span class="math-inline "> |
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| <h2 type="section" data-unnumbered="true" class="section-title" id="study-procedures"> |
| Study Procedures</h2> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="overview"> |
| Overview</h2> |
| <div>The proposed study is a randomized, placebo controlled, factorial design, triple blind, clinical trial designed to evaluate the effect of postoperative IV acetaminophen versus placebo, combined with IV propofol versus dexmedetomidine, on postoperative delirium among older patients undergoing cardiac surgery. Patients will be randomized to one of four groups (1) acetaminophen and dexmedetomidine, (2) acetaminophen and propofol, (3) placebo and dexmedetomidine, or (4) placebo and propofol. It is possible that the participants who receive acetaminophen and dexmedetomidine may benefit from the study as their incidence of delirium could possibly be reduced, however we cannot guarantee this.</div> |
| <div>Effect of Postoperative Intravenous Acetaminophen versus Placebo, Combined with Propofol or Dexmedetomidine, on Postoperative In-Hospital Delirium Among Older Patients Following Cardiac Surgery: The DEXACET Randomized Clinical Trial<br> |
| Study Groups<br> |
| The four treatment arms will be:</div> |
| <ol> |
| <li>Acetaminophen and dexmedetomidine</li> |
| <li>Acetaminophen and propofol</li> |
| <li>Placebo and dexmedetomidine</li> |
| <li>Placebo and propofol</li> |
| </ol> |
| <div>All study medications will be administered intravenously and doses will be weight-based. Acetaminophen/placebo will be administered on ICU transfer and thereafter every six hours for a total of eight doses. Volume of the placebo (saline) will match that of IV acetaminophen at <span class="math-inline "> |
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Acetaminophen administration in any form other than the blinded study medication during this time was not allowed. Propofol or dexmedetomidine was started during chest closure and continued for up to six hours postoperatively or until extubation, whichever occurred first. Participants in the dexmedetomidine groups will get a bolus dose of <span class="math-inline "> |
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Propofol infusions will be avoided in these participants. Patients in the propofol groups will receive propofol at a dose of <span class="math-inline "> |
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-11Q129 -11 102 10T74 74Q74 91 79 106T122 220Q160 321 166 341T173 380Q173 404 156 404H154Q124 404 99 371T61 287Q60 286 59 284T58 281T56 279T53 278T49 278T41 278H27Q21 284 21 287Z"></path></g><g data-mml-node="mi" transform="translate(8731.4,0)"><path data-c="1D45B" d="M21 287Q22 293 24 303T36 341T56 388T89 425T135 442Q171 442 195 424T225 390T231 369Q231 367 232 367L243 378Q304 442 382 442Q436 442 469 415T503 336T465 179T427 52Q427 26 444 26Q450 26 453 27Q482 32 505 65T540 145Q542 153 560 153Q580 153 580 145Q580 144 576 130Q568 101 554 73T508 17T439 -10Q392 -10 371 17T350 73Q350 92 386 193T423 345Q423 404 379 404H374Q288 404 229 303L222 291L189 157Q156 26 151 16Q138 -11 108 -11Q95 -11 87 -5T76 7T74 17Q74 30 112 180T152 343Q153 348 153 366Q153 405 129 405Q91 405 66 305Q60 285 60 284Q58 278 41 278H27Q21 284 21 287Z"></path></g></g></g></svg></mjx-container></span> and dexmedetomidine infusions will be avoided in these patients.</div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="pharmacy"> |
| Pharmacy</h2> |
| <div>Once a participant is enrolled, the study team will contact the research pharmacy to randomize the subject. The research pharmacy at Beth Israel Deaconess Medical Center will be responsible for preparation and distribution of study medications. Study team members will physically deliver the first dose of the acetaminophen/placebo (saline) medication. Subsequently the research pharmacy will be responsible for delivering the study medication to the ICU. Any unused drug will be returned to the research pharmacy for disposal.</div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="study-assessments"> |
| Study Assessments</h2> |
| <div>The assessments will be completed at specific time points. Once consent is obtained, a trained study team member blinded to treatment allocation will proceed with a baseline cognitive and delirium assessment. This will include the assessment of cognitive function using the Montreal Cognitive Assessment (MoCA), supplemented with days of the week backwards (DOWB) and months of the year backwards (MOYB) for additional attention testing, the Delirium Symptom Interview (DSI) to capture symptoms of delirium and the Geriatric Depression Scale (GDS) to assess for baseline depression. Using data from the cognitive testing and DSI, a study team member will complete the Confusion Assessment Method (CAM), which includes a diagnosis of delirium using the CAM diagnostic algorithm. This detailed assessment will take no more than 20-30 minutes. Every day, a study team member will administer a standard cognitive assessment and the CAM. These daily assessments will take approximately <span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.186ex;" xmlns="http://www.w3.org/2000/svg" width="7.291ex" height="1.692ex" role="img" focusable="false" viewBox="0 -666 3222.4 748"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mn"><path data-c="31" d="M213 578L200 573Q186 568 160 563T102 556H83V602H102Q149 604 189 617T245 641T273 663Q275 666 285 666Q294 666 302 660V361L303 61Q310 54 315 52T339 48T401 46H427V0H416Q395 3 257 3Q121 3 100 0H88V46H114Q136 46 152 46T177 47T193 50T201 52T207 57T213 61V578Z"></path><path data-c="30" d="M96 585Q152 666 249 666Q297 666 345 640T423 548Q460 465 460 320Q460 165 417 83Q397 41 362 16T301 -15T250 -22Q224 -22 198 -16T137 16T82 83Q39 165 39 320Q39 494 96 585ZM321 597Q291 629 250 629Q208 629 178 597Q153 571 145 525T137 333Q137 175 145 125T181 46Q209 16 250 16Q290 16 318 46Q347 76 354 130T362 333Q362 478 354 524T321 597Z" transform="translate(500,0)"></path></g><g data-mml-node="mo" transform="translate(1222.2,0)"><path data-c="2212" d="M84 237T84 250T98 270H679Q694 262 694 250T679 230H98Q84 237 84 250Z"></path></g><g data-mml-node="mn" transform="translate(2222.4,0)"><path data-c="31" d="M213 578L200 573Q186 568 160 563T102 556H83V602H102Q149 604 189 617T245 641T273 663Q275 666 285 666Q294 666 302 660V361L303 61Q310 54 315 52T339 48T401 46H427V0H416Q395 3 257 3Q121 3 100 0H88V46H114Q136 46 152 46T177 47T193 50T201 52T207 57T213 61V578Z"></path><path data-c="35" d="M164 157Q164 133 148 117T109 101H102Q148 22 224 22Q294 22 326 82Q345 115 345 210Q345 313 318 349Q292 382 260 382H254Q176 382 136 314Q132 307 129 306T114 304Q97 304 95 310Q93 314 93 485V614Q93 664 98 664Q100 666 102 666Q103 666 123 658T178 642T253 634Q324 634 389 662Q397 666 402 666Q410 666 410 648V635Q328 538 205 538Q174 538 149 544L139 546V374Q158 388 169 396T205 412T256 420Q337 420 393 355T449 201Q449 109 385 44T229 -22Q148 -22 99 32T50 154Q50 178 61 192T84 210T107 214Q132 214 148 197T164 157Z" transform="translate(500,0)"></path></g></g></g></svg></mjx-container></span> minutes. On the day of discharge, the MoCA with DOW and MOY, the DSI, and CAM will be completed. (If the discharge assessment was performed in anticipation of discharge on a specific day but the discharge was delayed (i.e. logistical reasons, clinical reasons), this will not be considered a protocol deviation.) A follow-up assessment will be administered at 1 month and 1 year post-discharge over the telephone and will include a telephone version of the MoCA known as the T-MoCA, DSI, GDS, and CAM. Assessments will be administered and scored by trained study team members.</div> |
| <div>If daily assessments are negative for three consecutive days (i.e. days <span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.439ex;" xmlns="http://www.w3.org/2000/svg" width="6.16ex" height="2.059ex" role="img" focusable="false" viewBox="0 -716 2722.7 910"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mn"><path data-c="35" d="M164 157Q164 133 148 117T109 101H102Q148 22 224 22Q294 22 326 82Q345 115 345 210Q345 313 318 349Q292 382 260 382H254Q176 382 136 314Q132 307 129 306T114 304Q97 304 95 310Q93 314 93 485V614Q93 664 98 664Q100 666 102 666Q103 666 123 658T178 642T253 634Q324 634 389 662Q397 666 402 666Q410 666 410 648V635Q328 538 205 538Q174 538 149 544L139 546V374Q158 388 169 396T205 412T256 420Q337 420 393 355T449 201Q449 109 385 44T229 -22Q148 -22 99 32T50 154Q50 178 61 192T84 210T107 214Q132 214 148 197T164 157Z"></path></g><g data-mml-node="mo" transform="translate(500,0)"><path data-c="2C" d="M78 35T78 60T94 103T137 121Q165 121 187 96T210 8Q210 -27 201 -60T180 -117T154 -158T130 -185T117 -194Q113 -194 104 -185T95 -172Q95 -168 106 -156T131 -126T157 -76T173 -3V9L172 8Q170 7 167 6T161 3T152 1T140 0Q113 0 96 17Z"></path></g><g data-mml-node="mn" transform="translate(944.7,0)"><path data-c="36" d="M42 313Q42 476 123 571T303 666Q372 666 402 630T432 550Q432 525 418 510T379 495Q356 495 341 509T326 548Q326 592 373 601Q351 623 311 626Q240 626 194 566Q147 500 147 364L148 360Q153 366 156 373Q197 433 263 433H267Q313 433 348 414Q372 400 396 374T435 317Q456 268 456 210V192Q456 169 451 149Q440 90 387 34T253 -22Q225 -22 199 -14T143 16T92 75T56 172T42 313ZM257 397Q227 397 205 380T171 335T154 278T148 216Q148 133 160 97T198 39Q222 21 251 21Q302 21 329 59Q342 77 347 104T352 209Q352 289 347 316T329 361Q302 397 257 397Z"></path></g><g data-mml-node="mi" transform="translate(1444.7,0)"><path data-c="26" d="M156 540Q156 620 201 668T302 716Q354 716 377 671T401 578Q401 505 287 386L274 373Q309 285 416 148L429 132L437 142Q474 191 543 309L562 341V349Q562 368 541 376T498 385H493V431H502L626 428Q709 428 721 431H727V385H712Q688 384 669 379T639 369T618 354T603 337T591 316T578 295Q537 223 506 176T464 117T454 104Q454 102 471 85T497 62Q543 24 585 24Q618 24 648 48T682 113V121H722V112Q721 94 714 75T692 32T646 -7T574 -22Q491 -19 414 42L402 51L391 42Q312 -22 224 -22Q144 -22 93 25T42 135Q42 153 46 169T55 197T74 225T96 249T125 278T156 308L195 347L190 360Q185 372 182 382T174 411T165 448T159 491T156 540ZM361 576Q361 613 348 646T305 679Q272 679 252 649T232 572Q232 497 255 426L259 411L267 420Q361 519 361 576ZM140 164Q140 103 167 64T240 24Q271 24 304 36T356 61T374 77Q295 156 235 262L220 292L210 310L193 293Q177 277 169 268T151 229T140 164Z"></path></g><g data-mml-node="mn" transform="translate(2222.7,0)"><path data-c="37" d="M55 458Q56 460 72 567L88 674Q88 676 108 676H128V672Q128 662 143 655T195 646T364 644H485V605L417 512Q408 500 387 472T360 435T339 403T319 367T305 330T292 284T284 230T278 162T275 80Q275 66 275 52T274 28V19Q270 2 255 -10T221 -22Q210 -22 200 -19T179 0T168 40Q168 198 265 368Q285 400 349 489L395 552H302Q128 552 119 546Q113 543 108 522T98 479L95 458V455H55V458Z"></path></g></g></g></svg></mjx-container></span> ), they will then be completed every other day until date of discharge. In addition, these assessments will be done at the patient's convenience to ensure ability to finish the evaluations. The table below outlines the assessments at various time points.</div> |
| <div>Effect of Postoperative Intravenous Acetaminophen versus Placebo, Combined with Propofol or Dexmedetomidine, on Postoperative In-Hospital Delirium Among Older Patients Following Cardiac Surgery: The DEXACET Randomized Clinical Trial</div> |
| <div class="table_tabular" style="text-align: center"> |
| <div class="inline-tabular"><table class="tabular"> |
| <tbody> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom: none !important; border-top: none !important; vertical-align: bottom; width: auto; border-top-style: solid !important; border-top-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; " rowspan="2">Assessments</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top-style: solid !important; border-top-width: 1px !important; width: auto; vertical-align: middle; ">Baseline</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top-style: solid !important; border-top-width: 1px !important; width: auto; vertical-align: middle; ">Daily</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top-style: solid !important; border-top-width: 1px !important; width: auto; vertical-align: middle; ">Discharge</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top-style: solid !important; border-top-width: 1px !important; width: auto; vertical-align: middle; ">1 month</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top-style: solid !important; border-top-width: 1px !important; width: auto; vertical-align: middle; ">1 year</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; " class="_empty"></td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; " class="_empty"></td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; " class="_empty"></td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; " class="_empty"></td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; " class="_empty"></td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Montreal Cognitive Assessment (MoCA) with Days of the week (DOW) & Months of the year (MOY)</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">X</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; " class="_empty"></td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">X</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; " class="_empty"></td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; " class="_empty"></td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Delirium Symptom Interview (DSI)</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">X</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">X</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">X</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">X</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">X</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Geriatric Depression Scale (GDS)</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">X</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; " class="_empty"></td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; " class="_empty"></td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">X</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">X</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Confusion Assessment Method (CAM)</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">X</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">X</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">X</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">X</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">X</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Standard Cognitive Assessment</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; " class="_empty"></td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">X</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; " class="_empty"></td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; " class="_empty"></td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; " class="_empty"></td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Telephone Montreal Cognitive Assessment (t-MoCA) with DOW and MOY</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; " class="_empty"></td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; " class="_empty"></td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; " class="_empty"></td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">X</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">X</td> |
| </tr> |
| </tbody> |
| </table> |
| </div></div> |
| <div>The delirium research assessments will not be provided to the treating clinicians. Treating clinicians will assess and treat delirium as usual, including assessment and correction of reversible causes, behavioral management and use of IV haloperidol for agitation, if needed. Rescue doses of haloperidol will be recorded in the study.</div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="blood-acquisition"> |
| Blood Acquisition</h2> |
| <div>Blood will be collected at four times points 1) Baseline: at the time of the pre-operative study assessments or on day of surgery; 2) on POD 1 while in the intensive care unit; 3) on POD 2 while in the intensive care unit; and 4 ) within 48 hours prior to discharge or days <span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.186ex;" xmlns="http://www.w3.org/2000/svg" width="6.159ex" height="1.692ex" role="img" focusable="false" viewBox="0 -666 2722.4 748"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mn"><path data-c="38" d="M70 417T70 494T124 618T248 666Q319 666 374 624T429 515Q429 485 418 459T392 417T361 389T335 371T324 363L338 354Q352 344 366 334T382 323Q457 264 457 174Q457 95 399 37T249 -22Q159 -22 101 29T43 155Q43 263 172 335L154 348Q133 361 127 368Q70 417 70 494ZM286 386L292 390Q298 394 301 396T311 403T323 413T334 425T345 438T355 454T364 471T369 491T371 513Q371 556 342 586T275 624Q268 625 242 625Q201 625 165 599T128 534Q128 511 141 492T167 463T217 431Q224 426 228 424L286 386ZM250 21Q308 21 350 55T392 137Q392 154 387 169T375 194T353 216T330 234T301 253T274 270Q260 279 244 289T218 306L210 311Q204 311 181 294T133 239T107 157Q107 98 150 60T250 21Z"></path></g><g data-mml-node="mo" transform="translate(722.2,0)"><path data-c="2212" d="M84 237T84 250T98 270H679Q694 262 694 250T679 230H98Q84 237 84 250Z"></path></g><g data-mml-node="mn" transform="translate(1722.4,0)"><path data-c="31" d="M213 578L200 573Q186 568 160 563T102 556H83V602H102Q149 604 189 617T245 641T273 663Q275 666 285 666Q294 666 302 660V361L303 61Q310 54 315 52T339 48T401 46H427V0H416Q395 3 257 3Q121 3 100 0H88V46H114Q136 46 152 46T177 47T193 50T201 52T207 57T213 61V578Z"></path><path data-c="30" d="M96 585Q152 666 249 666Q297 666 345 640T423 548Q460 465 460 320Q460 165 417 83Q397 41 362 16T301 -15T250 -22Q224 -22 198 -16T137 16T82 83Q39 165 39 320Q39 494 96 585ZM321 597Q291 629 250 629Q208 629 178 597Q153 571 145 525T137 333Q137 175 145 125T181 46Q209 16 250 16Q290 16 318 46Q347 76 354 130T362 333Q362 478 354 524T321 597Z" transform="translate(500,0)"></path></g></g></g></svg></mjx-container></span>, at the latest. A total of 80 ccs of blood will be collected. Blood samples will be collected into sterile vacuum tubes using either a vacutainer or butterfly system, at the preference of the phlebotomist. All samples will be centrifuged. The plasma and buffy coat will be separated from red blood cells, aliquoted into small samples, labelled and frozen at -80 Celsius for future use. Blood samples will be stored in a biomarker bank for further analysis.</div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="blood-storage"> |
| Blood Storage</h2> |
| <div>Using all blood samples from our participants, we will create a bio-repository of genetic material and plasma, a resource for future biomarker discovery studies. The banked specimens will be coded and stored in a 80 Celsius freezer at a BIDMC facility. A list linking study numbers to participants will be kept in a secure computer database. In the future, the frozen plasma or DNA may be shared with other scientists studying a similar relationship between delirium and genetic factors after a formal application procedure and scientific review process approved by the IRB. Information including contact information, rationale for studying data and intended use of data may need to be approved by CCI/IRB prior to sharing data. All such studies will be carried out under controlled access and under the close supervision of the study team. In these cases, the study investigators will maintain confidentiality of the specimens by maintaining the de-identification of</div> |
| <div>Effect of Postoperative Intravenous Acetaminophen versus Placebo, Combined with Propofol or Dexmedetomidine, on Postoperative In-Hospital Delirium Among Older Patients Following Cardiac Surgery: The DEXACET Randomized Clinical Trial patient information to the other scientists. We plan to store these specimens indefinitely. None of the results from these studies will be shared with participants or their family members and none of the genetic information obtained will be included in the patient's medical records. All patients approached for participation in study will also need to agree to participation in blood collection/storage as noted in informed consent.</div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="follow-up"> |
| Follow Up</h2> |
| <div>A follow-up assessment will be administered at 1 month and 1 year post-discharge over the telephone and will include a telephone version of the MoCA known as the T-MoCA, DSI, GDS, and CAM.</div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="study-outcomes"> |
| Study Outcomes</h2> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="primary-outcome"> |
| Primary Outcome</h2> |
| <div>The primary objective of this study was the incidence of in-hospital delirium at any time during a patients' hospital stay.</div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="secondary-outcomes"> |
| Secondary Outcomes</h2> |
| <div>The secondary outcomes included duration of delirium, postoperative neurocognition at discharge, 48hour breakthrough analgesic requirements, and ICU and hospital lengths of stay.</div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="data-collection"> |
| Data Collection</h2> |
| <div>The participant's demographic data such as age, sex, ethnicity, race and body mass index will be recorded. Patient comorbid conditions, surgery and anesthetic drugs used will be obtained from Society of Thoracic Surgery database and Anesthesia Information Management System, which is a clinical outcomes registry that records and assesses the care of adult patients undergoing cardiac procedures at participating hospitals. Pertinent characteristics include: preoperative medications, comorbidities, surgical characteristics, and postoperative outcomes, including 30 day mortality and major adverse events like renal failure during hospital admission. Information on the sedatives and analgesics given within six hours prior to initiation of the cognitive assessment will be recorded, as to determine whether there is an effect on performance. The total opioid dosage administered during the first 48 hours post operatively, pain scores and patient delirium assessment data will be collected using REDCap. REDCap is a web-based application that allows customized data collection and entry. The study team will build and maintain the case report form electronically. Additionally, internal audits will be conducted to ensure data completion and data quality. Data will be kept secure in computers with password protection. All data will be analyzed with modified intention to treat basis, in which all subjects who receive at least one dose of a study medication will be included.</div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="data-security-and-storage"> |
| Data Security and Storage</h2> |
| <div>All data will be kept secure in the password-protected BIDMC network servers. The paper format will be stored in locked file cabinets during the study period. Study data will be entered in datasheets and stored on a secure password-protected computer on the BIDMC network. Each patient will be assigned a studyspecific ID number. The data will have all HIPAA identifiers removed and a random study number assigned to each patient.</div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="safety-reporting"> |
| Safety Reporting</h2> |
| <div>Our patient population is by definition undergoing high risk surgery and is critically ill. It is expected that they will have a number of unrelated adverse health events during the course of their hospital stay. The potential adverse effects such as the number of episodes of hypotension (predefined as <span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.09ex;" xmlns="http://www.w3.org/2000/svg" width="8.624ex" height="1.597ex" role="img" focusable="false" viewBox="0 -666 3811.8 706"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mo"><path data-c="3C" d="M694 -11T694 -19T688 -33T678 -40Q671 -40 524 29T234 166L90 235Q83 240 83 250Q83 261 91 266Q664 540 678 540Q681 540 687 534T694 519T687 505Q686 504 417 376L151 250L417 124Q686 -4 687 -5Q694 -11 694 -19Z"></path></g><g data-mml-node="mn" transform="translate(1055.8,0)"><path data-c="39" d="M352 287Q304 211 232 211Q154 211 104 270T44 396Q42 412 42 436V444Q42 537 111 606Q171 666 243 666Q245 666 249 666T257 665H261Q273 665 286 663T323 651T370 619T413 560Q456 472 456 334Q456 194 396 97Q361 41 312 10T208 -22Q147 -22 108 7T68 93T121 149Q143 149 158 135T173 96Q173 78 164 65T148 49T135 44L131 43Q131 41 138 37T164 27T206 22H212Q272 22 313 86Q352 142 352 280V287ZM244 248Q292 248 321 297T351 430Q351 508 343 542Q341 552 337 562T323 588T293 615T246 625Q208 625 181 598Q160 576 154 546T147 441Q147 358 152 329T172 282Q197 248 244 248Z"></path><path data-c="30" d="M96 585Q152 666 249 666Q297 666 345 640T423 548Q460 465 460 320Q460 165 417 83Q397 41 362 16T301 -15T250 -22Q224 -22 198 -16T137 16T82 83Q39 165 39 320Q39 494 96 585ZM321 597Q291 629 250 629Q208 629 178 597Q153 571 145 525T137 333Q137 175 145 125T181 46Q209 16 250 16Q290 16 318 46Q347 76 354 130T362 333Q362 478 354 524T321 597Z" transform="translate(500,0)"></path></g><g data-mml-node="mi" transform="translate(2055.8,0)"><path data-c="1D45A" d="M21 287Q22 293 24 303T36 341T56 388T88 425T132 442T175 435T205 417T221 395T229 376L231 369Q231 367 232 367L243 378Q303 442 384 442Q401 442 415 440T441 433T460 423T475 411T485 398T493 385T497 373T500 364T502 357L510 367Q573 442 659 442Q713 442 746 415T780 336Q780 285 742 178T704 50Q705 36 709 31T724 26Q752 26 776 56T815 138Q818 149 821 151T837 153Q857 153 857 145Q857 144 853 130Q845 101 831 73T785 17T716 -10Q669 -10 648 17T627 73Q627 92 663 193T700 345Q700 404 656 404H651Q565 404 506 303L499 291L466 157Q433 26 428 16Q415 -11 385 -11Q372 -11 364 -4T353 8T350 18Q350 29 384 161L420 307Q423 322 423 345Q423 404 379 404H374Q288 404 229 303L222 291L189 157Q156 26 151 16Q138 -11 108 -11Q95 -11 87 -5T76 7T74 17Q74 30 112 181Q151 335 151 342Q154 357 154 369Q154 405 129 405Q107 405 92 377T69 316T57 280Q55 278 41 278H27Q21 284 21 287Z"></path></g><g data-mml-node="mi" transform="translate(2933.8,0)"><path data-c="1D45A" d="M21 287Q22 293 24 303T36 341T56 388T88 425T132 442T175 435T205 417T221 395T229 376L231 369Q231 367 232 367L243 378Q303 442 384 442Q401 442 415 440T441 433T460 423T475 411T485 398T493 385T497 373T500 364T502 357L510 367Q573 442 659 442Q713 442 746 415T780 336Q780 285 742 178T704 50Q705 36 709 31T724 26Q752 26 776 56T815 138Q818 149 821 151T837 153Q857 153 857 145Q857 144 853 130Q845 101 831 73T785 17T716 -10Q669 -10 648 17T627 73Q627 92 663 193T700 345Q700 404 656 404H651Q565 404 506 303L499 291L466 157Q433 26 428 16Q415 -11 385 -11Q372 -11 364 -4T353 8T350 18Q350 29 384 161L420 307Q423 322 423 345Q423 404 379 404H374Q288 404 229 303L222 291L189 157Q156 26 151 16Q138 -11 108 -11Q95 -11 87 -5T76 7T74 17Q74 30 112 181Q151 335 151 342Q154 357 154 369Q154 405 129 405Q107 405 92 377T69 316T57 280Q55 278 41 278H27Q21 284 21 287Z"></path></g></g></g></svg></mjx-container></span> systolic for 5 minutes or more), and bradycardia (predefined as <40 beats per minute), will be collected from the ICU charts.</div> |
| <div>Effect of Postoperative Intravenous Acetaminophen versus Placebo, Combined with Propofol or Dexmedetomidine, on Postoperative In-Hospital Delirium Among Older Patients Following Cardiac Surgery: The DEXACET Randomized Clinical Trial<br> |
| Therefore, we will limit the scope of our AE monitoring and reporting to the following:</div> |
| <ul> |
| <li>All Serious Adverse Events, including an unexpected death, believed to be related to the study</li> |
| <li>Unexpected, non-serious Adverse Events believed to be possibly or probably related to the intervention</li> |
| </ul> |
| <div>Evidence for adverse events will be assessed daily during the hospital stay, for a maximum of 10 days.</div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="statistical-analysis"> |
| Statistical Analysis</h2> |
| <div>Please refer to the Statistical Analysis Plan (SAP) for details of the power calculation and analyses.</div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="benefits-to-the-subject"> |
| Benefits to the Subject</h2> |
| <div>There is a possible benefit to those enrolled in the dexmedetomidine and acetaminophen group, as their incidence of delirium can possibly be reduced, however we cannot guarantee this. Society as a whole will benefit in the future as a result of knowledge gained from the research.</div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="risks-to-the-subject"> |
| Risks to the Subject</h2> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="risk-of-the-drugs-used"> |
| Risk of the Drugs Used</h2> |
| <div>The drugs dexmedetomidine and acetaminophen are FDA approved for sedation and analgesic purposes. Bradycardia and hypotension are less common side effects with dexmedetomidine and in an intensively monitored setting of cardiac surgical ICU, the risks of bradycardia and hypotension can be managed effectively. Liver dysfunction is a rare side effect associated with IV acetaminophen. However, the drug is commonly used already in the perioperative setting routinely as the benefits seem to outweigh the risks. No routine monitoring is done for liver dysfunction in the current standard of care.</div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="risk-associated-with-blood-draw"> |
| Risk Associated with Blood Draw</h2> |
| <div>There is a small risk of phlebotomy to obtain serum for the serum biomarker assays at four time points during the study. Wherever possible, the serum collection will be obtained at the same time as phlebotomy and other labs for routine clinical laboratory work, thereby eliminating an additional risk imposed by a separate phlebotomy for study purposes. However, in rare cases such as at the time of discharge, patients may require a separate lab draw. The risks of the phlebotomy procedure itself are minimal and are primarily related to pain or bruising at the needle puncture site. Since the amount of blood required at each time point is small the risks from anemia or blood loss are negligible. The blood draws will total only 80 cc's over a maximum of four weeks, which is considered minimal risk.</div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="risk-of-breach-of-confidentiality"> |
| Risk of Breach of Confidentiality</h2> |
| <div>Patients will be referred to by a study number, and records will be password protected on BIDMC network servers. No identifiable data will be shared with the funding agency, or across institutions. The information that we collect from this research project will be kept confidential. All information will be stored in a HIPAA compliant database.</div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="risk%2Fbenefit-ratio"> |
| Risk/Benefit Ratio</h2> |
| <div>The drugs used for this study are approved by the FDA for sedation and analgesic purposes. When monitored in the intensive care setting, the risks of lower blood pressures or heart rates are far too small compared to the benefits of decreased delirium following cardiac surgery.</div> |
| <div>Effect of Postoperative Intravenous Acetaminophen versus Placebo, Combined with Propofol or Dexmedetomidine, on Postoperative In-Hospital Delirium Among Older Patients Following Cardiac Surgery: The DEXACET Randomized Clinical Trial</div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="inducements"> |
| Inducements</h2> |
| <div>No inducements will be offered. Neither patients nor healthcare providers will be paid as part of their participation in the study.</div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="participant-withdrawals"> |
| Participant Withdrawals</h2> |
| <div>Throughout the study participants will be reminded that participation is entirely voluntary and that they have the option to withdraw at any time, for any reason.</div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="subject-protection"> |
| Subject Protection</h2> |
| <div>Patients will be contacted directly for this study. The informed consent will be explained and obtained in a secure and private location such as the preadmission testing clinic, cardiac catheterization holding areas, cardiac surgery clinic, and/or in the pre-operative holding area. Patients will be informed that their decision to participate or not to participate will in no way affect their relationship with their health care provider. Furthermore they will still receive all information about their analgesic management, as is the standard of care. Patients will also have the ability to discontinue their participation at any time.</div> |
| <div>Effect of Postoperative Intravenous Acetaminophen versus Placebo, Combined with Propofol or Dexmedetomidine, on Postoperative In-Hospital Delirium Among Older Patients Following Cardiac Surgery: The DEXACET Randomized Clinical Trial</div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="statistical-analysis-plan"> |
| STATISTICAL ANALYSIS PLAN</h2> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="introduction"> |
| Introduction</h2> |
| <div>This Statistical Analysis Plan describes the analysis of the prospective randomized controlled trial that has been reviewed and approved by the Committee on Clinical Investigations at Beth Israel Deaconess Medical Center (2014P000413) and will be conducted in accordance with all applicable human subjects' research requirements and applicable federal regulations.</div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="study-aims"> |
| Study Aims</h2> |
| <div>Briefly, this randomized, factorial clinical trial evaluates the effect of intravenous acetaminophen versus placebo, combined with intravenous propofol versus dexmedetomidine, for postoperative sedation and analgesia respectively, in adult patients 60 years or older undergoing coronary artery bypass grafting (CABG) or combined CABG/valve surgeries to assess the incidence and duration of postoperative delirium.</div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="study-design"> |
| Study Design</h2> |
| <div>This is a single-center randomized controlled factorial trial of two sedative and two analgesic regimens.</div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="study-population-and-sites"> |
| Study Population and Sites</h2> |
| <div>The study will prospectively enroll patients undergoing cardiac surgery at Beth Israel Deaconess Medical Center in Boston, Massachusetts. This includes patients enrolled between September 2015 and April 2018.</div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="randomization"> |
| Randomization</h2> |
| <div>Randomization will be by pre-prepared using a computer generated block randomization in SAS 9.3. Details of the block size are kept confidential until the completion of study enrollment. This schema will be created by the unblinded statistician (Ariel Mueller, MA) and sent to the research pharmacy. Members of the research pharmacy will be responsible for preparing and dispensing the study medications following an active order for study medications. Specifically this includes preparation and blinding of the placebo in accordance with the study randomization schema.</div> |
| <div>Patients will be randomized to one of four groups in a <span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: 0;" xmlns="http://www.w3.org/2000/svg" width="10.183ex" height="1.507ex" role="img" focusable="false" viewBox="0 -666 4500.7 666"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mn"><path data-c="31" d="M213 578L200 573Q186 568 160 563T102 556H83V602H102Q149 604 189 617T245 641T273 663Q275 666 285 666Q294 666 302 660V361L303 61Q310 54 315 52T339 48T401 46H427V0H416Q395 3 257 3Q121 3 100 0H88V46H114Q136 46 152 46T177 47T193 50T201 52T207 57T213 61V578Z"></path></g><g data-mml-node="mo" transform="translate(777.8,0)"><path data-c="3A" d="M78 370Q78 394 95 412T138 430Q162 430 180 414T199 371Q199 346 182 328T139 310T96 327T78 370ZM78 60Q78 84 95 102T138 120Q162 120 180 104T199 61Q199 36 182 18T139 0T96 17T78 60Z"></path></g><g data-mml-node="mn" transform="translate(1333.6,0)"><path data-c="31" d="M213 578L200 573Q186 568 160 563T102 556H83V602H102Q149 604 189 617T245 641T273 663Q275 666 285 666Q294 666 302 660V361L303 61Q310 54 315 52T339 48T401 46H427V0H416Q395 3 257 3Q121 3 100 0H88V46H114Q136 46 152 46T177 47T193 50T201 52T207 57T213 61V578Z"></path></g><g data-mml-node="mo" transform="translate(2111.3,0)"><path data-c="3A" d="M78 370Q78 394 95 412T138 430Q162 430 180 414T199 371Q199 346 182 328T139 310T96 327T78 370ZM78 60Q78 84 95 102T138 120Q162 120 180 104T199 61Q199 36 182 18T139 0T96 17T78 60Z"></path></g><g data-mml-node="mn" transform="translate(2667.1,0)"><path data-c="31" d="M213 578L200 573Q186 568 160 563T102 556H83V602H102Q149 604 189 617T245 641T273 663Q275 666 285 666Q294 666 302 660V361L303 61Q310 54 315 52T339 48T401 46H427V0H416Q395 3 257 3Q121 3 100 0H88V46H114Q136 46 152 46T177 47T193 50T201 52T207 57T213 61V578Z"></path></g><g data-mml-node="mo" transform="translate(3444.9,0)"><path data-c="3A" d="M78 370Q78 394 95 412T138 430Q162 430 180 414T199 371Q199 346 182 328T139 310T96 327T78 370ZM78 60Q78 84 95 102T138 120Q162 120 180 104T199 61Q199 36 182 18T139 0T96 17T78 60Z"></path></g><g data-mml-node="mn" transform="translate(4000.7,0)"><path data-c="31" d="M213 578L200 573Q186 568 160 563T102 556H83V602H102Q149 604 189 617T245 641T273 663Q275 666 285 666Q294 666 302 660V361L303 61Q310 54 315 52T339 48T401 46H427V0H416Q395 3 257 3Q121 3 100 0H88V46H114Q136 46 152 46T177 47T193 50T201 52T207 57T213 61V578Z"></path></g></g></g></svg></mjx-container></span> fashion. This includes:</div> |
| <ul> |
| <li>Acetaminophen and Dexmedetomidine</li> |
| <li>Acetaminophen and Propofol</li> |
| <li>Placebo and Dexmedetomidine</li> |
| <li>Placebo and Propofol</li> |
| </ul> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="primary-endpoints"> |
| Primary Endpoints</h2> |
| <div>The primary endpoint will be the incidence of in-hospital delirium. This is assessed via the Confusion Assessment Method (or CAM-ICU for intubated patients) daily postoperatively, as specified in the study protocol. If a patient is noted to be positive for delirium on any postoperative day, they will have been documented as achieving the primary study endpoint.</div> |
| <div>Our pre-specified primary analysis will assess the incidence of delirium between patients receiving IV acetaminophen versus placebo.</div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="secondary-endpoints"> |
| Secondary Endpoints</h2> |
| <div>Secondary outcomes for this study include:</div> |
| <ul> |
| <li>Duration of delirium</li> |
| </ul> |
| <div>Effect of Postoperative Intravenous Acetaminophen versus Placebo, Combined with Propofol or Dexmedetomidine, on Postoperative In-Hospital Delirium Among Older Patients Following Cardiac Surgery: The DEXACET Randomized Clinical Trial</div> |
| <ul> |
| <li>Definition: The number of days of being positive for delirium on the CAM or CAM-ICU instruments will be recorded and assessed. This will be assessed as a continuous variable.</li> |
| <li>Postoperative cognitive decline at discharge, one month and one year postoperatively</li> |
| <li>Definition: This will be assessed by using the change in Montreal Cognitive Assessment score at this time point since baseline. This will be assessed as a continuous variable.</li> |
| <li>Breakthrough analgesic requirements within the first 48 hours postoperatively</li> |
| <li>Definition: This will be assessed by calculating the total morphine equivalent administered in the first 48 hours postoperatively, with time zero starting at ICU admission. This will be assessed as a continuous variable.</li> |
| <li>Intensive care unit (ICU) length of stay</li> |
| <li>Definition: This will be defined as the number of hours admitted in the ICU prior to transfer to the general floor. This will be assessed as a continuous variable and reported in hours.</li> |
| <li>Hospital length of stay</li> |
| <li>Definition: This will be calculated as the day of hospital discharge minus the day of surgery plus one. This will be assessed as a continuous variable and reported in days.</li> |
| <li>Predefined potential adverse effects of the study drugs including:</li> |
| <li>Number and duration of episodes of hypotension</li> |
| <li>Definition: This is predefined as less than 90 mm Hg systolic blood pressure for five minutes or more</li> |
| <li>Number and duration of episodes of bradycardia</li> |
| <li>Definition: This is predefined as less than 40 beats per minute.</li> |
| <li>The proportion of patients who complete the protocol successfully will be measured.</li> |
| <li>If this sedation and analgesic regimen is abandoned by the clinicians, the reason will be qualitatively described at the end of the study.</li> |
| <li>Levels of inflammatory biomarkers</li> |
| </ul> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="covariates"> |
| Covariates</h2> |
| <div>Trial data will be collected managed using REDCap electronic data capture tools hosted at Beth Israel Deaconess Medical Center. REDCap (Research Electronic Data Capture) is a secure, web-based application designed to support data capture for research studies, providing 1) an intuitive interface for validated data entry; 2) audit trails for tracking data manipulation and export procedures; 3) automated export procedures for seamless data downloads to common statistical packages; and 4) procedures for importing data from external sources. The REDCap system includes validation rules for data entry to help ensure data accuracy, and has a full audit trail of data entry and changes.</div> |
| <div>Data collection includes the participant's demographic data such as age, sex, ethnicity, race and body mass index will be recorded. Patient comorbid conditions, surgery and anesthetic drugs used will be obtained from Society of Thoracic Surgery database and Anesthesia Information Management System, which is a clinical outcomes registry that records and assesses the care of adult patients undergoing cardiac procedures at participating hospitals. Pertinent characteristics include preoperative medications, comorbidities, surgical characteristics, and postoperative outcomes, including 30 day mortality and major adverse events like renal failure during hospital admission. Information on the sedatives and analgesics given within six hours prior to initiation of the cognitive assessment will be recorded, as to determine whether there is an effect on performance. The total opioid dosage administered during the first 48 hours post operatively, pain scores and patient delirium assessment data will be collected using REDCap.</div> |
| <div>The overall flow and reporting of study recruitment, enrollment and follow up will follow the CONSORT recommendations for the reporting of randomized controlled trials.</div> |
| <div>Effect of Postoperative Intravenous Acetaminophen versus Placebo, Combined with Propofol or Dexmedetomidine, on Postoperative In-Hospital Delirium Among Older Patients Following Cardiac Surgery: The DEXACET Randomized Clinical Trial</div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="sample-size-estimation"> |
| Sample Size Estimation</h2> |
| <div>This is a prospective, randomized, placebo controlled, double-blinded, factorial design study consisting of 120 patients to assess the incidence and duration of postoperative delirium following cardiac surgery. From the previous delirium studies conducted at our institution, the baseline delirium incidence was <span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.127ex;" xmlns="http://www.w3.org/2000/svg" width="4.147ex" height="1.824ex" role="img" focusable="false" viewBox="0 -750 1833 806"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mn"><path data-c="35" d="M164 157Q164 133 148 117T109 101H102Q148 22 224 22Q294 22 326 82Q345 115 345 210Q345 313 318 349Q292 382 260 382H254Q176 382 136 314Q132 307 129 306T114 304Q97 304 95 310Q93 314 93 485V614Q93 664 98 664Q100 666 102 666Q103 666 123 658T178 642T253 634Q324 634 389 662Q397 666 402 666Q410 666 410 648V635Q328 538 205 538Q174 538 149 544L139 546V374Q158 388 169 396T205 412T256 420Q337 420 393 355T449 201Q449 109 385 44T229 -22Q148 -22 99 32T50 154Q50 178 61 192T84 210T107 214Q132 214 148 197T164 157Z"></path><path data-c="30" d="M96 585Q152 666 249 666Q297 666 345 640T423 548Q460 465 460 320Q460 165 417 83Q397 41 362 16T301 -15T250 -22Q224 -22 198 -16T137 16T82 83Q39 165 39 320Q39 494 96 585ZM321 597Q291 629 250 629Q208 629 178 597Q153 571 145 525T137 333Q137 175 145 125T181 46Q209 16 250 16Q290 16 318 46Q347 76 354 130T362 333Q362 478 354 524T321 597Z" transform="translate(500,0)"></path></g><g data-mml-node="mi" transform="translate(1000,0)"><path data-c="25" d="M465 605Q428 605 394 614T340 632T319 641Q332 608 332 548Q332 458 293 403T202 347Q145 347 101 402T56 548Q56 637 101 693T202 750Q241 750 272 719Q359 642 464 642Q580 642 650 732Q662 748 668 749Q670 750 673 750Q682 750 688 743T693 726Q178 -47 170 -52Q166 -56 160 -56Q147 -56 142 -45Q137 -36 142 -27Q143 -24 363 304Q469 462 525 546T581 630Q528 605 465 605ZM207 385Q235 385 263 427T292 548Q292 617 267 664T200 712Q193 712 186 709T167 698T147 668T134 615Q132 595 132 548V527Q132 436 165 403Q183 385 203 385H207ZM500 146Q500 234 544 290T647 347Q699 347 737 292T776 146T737 0T646 -56Q590 -56 545 0T500 146ZM651 -18Q679 -18 707 24T736 146Q736 215 711 262T644 309Q637 309 630 306T611 295T591 265T578 212Q577 200 577 146V124Q577 -18 647 -18H651Z"></path></g></g></g></svg></mjx-container></span>. The pilot study showed a 66% reduction in the incidence of delirium. For the power calculation, a 50% reduction in the delirium incidence was used. Each group needed 56 patients (alpha <span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.186ex;" xmlns="http://www.w3.org/2000/svg" width="6.411ex" height="1.692ex" role="img" focusable="false" viewBox="0 -666 2833.8 748"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mo"><path data-c="3D" d="M56 347Q56 360 70 367H707Q722 359 722 347Q722 336 708 328L390 327H72Q56 332 56 347ZM56 153Q56 168 72 173H708Q722 163 722 153Q722 140 707 133H70Q56 140 56 153Z"></path></g><g data-mml-node="mn" transform="translate(1055.8,0)"><path data-c="30" d="M96 585Q152 666 249 666Q297 666 345 640T423 548Q460 465 460 320Q460 165 417 83Q397 41 362 16T301 -15T250 -22Q224 -22 198 -16T137 16T82 83Q39 165 39 320Q39 494 96 585ZM321 597Q291 629 250 629Q208 629 178 597Q153 571 145 525T137 333Q137 175 145 125T181 46Q209 16 250 16Q290 16 318 46Q347 76 354 130T362 333Q362 478 354 524T321 597Z"></path><path data-c="2E" d="M78 60Q78 84 95 102T138 120Q162 120 180 104T199 61Q199 36 182 18T139 0T96 17T78 60Z" transform="translate(500,0)"></path><path data-c="30" d="M96 585Q152 666 249 666Q297 666 345 640T423 548Q460 465 460 320Q460 165 417 83Q397 41 362 16T301 -15T250 -22Q224 -22 198 -16T137 16T82 83Q39 165 39 320Q39 494 96 585ZM321 597Q291 629 250 629Q208 629 178 597Q153 571 145 525T137 333Q137 175 145 125T181 46Q209 16 250 16Q290 16 318 46Q347 76 354 130T362 333Q362 478 354 524T321 597Z" transform="translate(778,0)"></path><path data-c="35" d="M164 157Q164 133 148 117T109 101H102Q148 22 224 22Q294 22 326 82Q345 115 345 210Q345 313 318 349Q292 382 260 382H254Q176 382 136 314Q132 307 129 306T114 304Q97 304 95 310Q93 314 93 485V614Q93 664 98 664Q100 666 102 666Q103 666 123 658T178 642T253 634Q324 634 389 662Q397 666 402 666Q410 666 410 648V635Q328 538 205 538Q174 538 149 544L139 546V374Q158 388 169 396T205 412T256 420Q337 420 393 355T449 201Q449 109 385 44T229 -22Q148 -22 99 32T50 154Q50 178 61 192T84 210T107 214Q132 214 148 197T164 157Z" transform="translate(1278,0)"></path></g></g></g></svg></mjx-container></span> and 1 -Beta <span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.186ex;" xmlns="http://www.w3.org/2000/svg" width="6.411ex" height="1.692ex" role="img" focusable="false" viewBox="0 -666 2833.8 748"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mo"><path data-c="3D" d="M56 347Q56 360 70 367H707Q722 359 722 347Q722 336 708 328L390 327H72Q56 332 56 347ZM56 153Q56 168 72 173H708Q722 163 722 153Q722 140 707 133H70Q56 140 56 153Z"></path></g><g data-mml-node="mn" transform="translate(1055.8,0)"><path data-c="30" d="M96 585Q152 666 249 666Q297 666 345 640T423 548Q460 465 460 320Q460 165 417 83Q397 41 362 16T301 -15T250 -22Q224 -22 198 -16T137 16T82 83Q39 165 39 320Q39 494 96 585ZM321 597Q291 629 250 629Q208 629 178 597Q153 571 145 525T137 333Q137 175 145 125T181 46Q209 16 250 16Q290 16 318 46Q347 76 354 130T362 333Q362 478 354 524T321 597Z"></path><path data-c="2E" d="M78 60Q78 84 95 102T138 120Q162 120 180 104T199 61Q199 36 182 18T139 0T96 17T78 60Z" transform="translate(500,0)"></path><path data-c="38" d="M70 417T70 494T124 618T248 666Q319 666 374 624T429 515Q429 485 418 459T392 417T361 389T335 371T324 363L338 354Q352 344 366 334T382 323Q457 264 457 174Q457 95 399 37T249 -22Q159 -22 101 29T43 155Q43 263 172 335L154 348Q133 361 127 368Q70 417 70 494ZM286 386L292 390Q298 394 301 396T311 403T323 413T334 425T345 438T355 454T364 471T369 491T371 513Q371 556 342 586T275 624Q268 625 242 625Q201 625 165 599T128 534Q128 511 141 492T167 463T217 431Q224 426 228 424L286 386ZM250 21Q308 21 350 55T392 137Q392 154 387 169T375 194T353 216T330 234T301 253T274 270Q260 279 244 289T218 306L210 311Q204 311 181 294T133 239T107 157Q107 98 150 60T250 21Z" transform="translate(778,0)"></path><path data-c="30" d="M96 585Q152 666 249 666Q297 666 345 640T423 548Q460 465 460 320Q460 165 417 83Q397 41 362 16T301 -15T250 -22Q224 -22 198 -16T137 16T82 83Q39 165 39 320Q39 494 96 585ZM321 597Q291 629 250 629Q208 629 178 597Q153 571 145 525T137 333Q137 175 145 125T181 46Q209 16 250 16Q290 16 318 46Q347 76 354 130T362 333Q362 478 354 524T321 597Z" transform="translate(1278,0)"></path></g></g></g></svg></mjx-container></span> ). This study will not be powered for secondary outcomes.</div> |
| <div>Because complete data from 112 patients is required in order for analysis, we plan to enroll enough patients to obtain data from 120 patients who received the study intervention ( 60 patients per group - acetaminophen vs. no acetaminophen). We estimate that approximately 150 patients will be enrolled (consented) in order to achieve this sample size. This increase is required because it is possible that patients can be withdrawn both before randomization (i.e. cancelled surgery) as well as after randomization but before receiving the study intervention (i.e. change in surgery type intraoperatively). Enrollment will be stopped once a total of 120 randomized patients have undergone surgery and received the study medications.</div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="general-approach-to-statistical-analyses"> |
| General Approach to Statistical Analyses</h2> |
| <div>Baseline and demographic characteristics will be summarized and presented using descriptive statistics. Continuous data will be presented as means ± standard deviations or medians (interquartile range) depending on the distribution of the data. The Shapiro-Wilk test will be utilized in order to determine whether or not the data follows a Gaussian distribution. Differences in continuous data between study groups will be assessed using a parametric t-tests or Wilcoxon Rank-Sum tests as appropriate. Categorical data will be presented as frequencies and proportions and assessed with a chi-square test. In the event that cell counts are small (less than 5), we will employ the use of a Fisher's Exact test. For all analyses two-sided p-values less than 0.05 will be considered statistically significant. SAS 9.3 (SAS Institute Inc., Cary, NC) or later will be utilized for all analyses.</div> |
| <div>Analyses will be performed on a modified intention to treat basis, in which all patient who receive at least one dose of any of the four study medications will be included.</div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="analysis-of-the-primary-and-secondary-outcomes"> |
| Analysis of the Primary and Secondary Outcomes</h2> |
| <div>The DEXACET trial has been designed as a factorial, randomized controlled trial with four treatment groups. We will therefore aim to test 1) the effect of acetaminophen versus placebo and 2) the effect of dexmedetomidine in comparison to propofol in the event that there is no interaction between treatment effects. However, the first of these (the effect of acetaminophen) is considered the most interesting and the study has been powered to answer this question using an unadjusted chi-squared test.</div> |
| <div>To test whether or not there is an interaction we will compose a logistic regression model include indicator variables for the acetaminophen group as well as the dexmedetomidine group. We will further include an interaction term in this model composed of the indicator variables multiplied together. If there is a significant interaction between groups when assessing the incidence of in-hospital delirium, we will interpret the results stratified by all four groups, presenting the main effects only after taking into account the other factor, in a 'inside the table analysis'. If the interaction term is not significant we will present the main effects by pooling data across the other factor.</div> |
| <div>Kaplan Meier curves and a Cox proportional hazards model was used to compare time to experiencing delirium, after confirming the proportional hazards assumption is met. To test whether the Proportional</div> |
| <div>Effect of Postoperative Intravenous Acetaminophen versus Placebo, Combined with Propofol or Dexmedetomidine, on Postoperative In-Hospital Delirium Among Older Patients Following Cardiac Surgery: The DEXACET Randomized Clinical Trial<br> |
| Hazards (PH) assumption holds, we will include a time varying covariate with group in the model. Given the factorial design this approach will be replicated in models for all four factorial groups, as well as the pairwise comparisons (dexmedetomidine vs propofol; acetaminophen vs placebo) to ensure this assumption remains valid. In the event that this assumption is not valid, we will include a time-varying covariate in the model. Hazards ratios and their associated <span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.127ex;" xmlns="http://www.w3.org/2000/svg" width="4.147ex" height="1.824ex" role="img" focusable="false" viewBox="0 -750 1833 806"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mn"><path data-c="39" d="M352 287Q304 211 232 211Q154 211 104 270T44 396Q42 412 42 436V444Q42 537 111 606Q171 666 243 666Q245 666 249 666T257 665H261Q273 665 286 663T323 651T370 619T413 560Q456 472 456 334Q456 194 396 97Q361 41 312 10T208 -22Q147 -22 108 7T68 93T121 149Q143 149 158 135T173 96Q173 78 164 65T148 49T135 44L131 43Q131 41 138 37T164 27T206 22H212Q272 22 313 86Q352 142 352 280V287ZM244 248Q292 248 321 297T351 430Q351 508 343 542Q341 552 337 562T323 588T293 615T246 625Q208 625 181 598Q160 576 154 546T147 441Q147 358 152 329T172 282Q197 248 244 248Z"></path><path data-c="35" d="M164 157Q164 133 148 117T109 101H102Q148 22 224 22Q294 22 326 82Q345 115 345 210Q345 313 318 349Q292 382 260 382H254Q176 382 136 314Q132 307 129 306T114 304Q97 304 95 310Q93 314 93 485V614Q93 664 98 664Q100 666 102 666Q103 666 123 658T178 642T253 634Q324 634 389 662Q397 666 402 666Q410 666 410 648V635Q328 538 205 538Q174 538 149 544L139 546V374Q158 388 169 396T205 412T256 420Q337 420 393 355T449 201Q449 109 385 44T229 -22Q148 -22 99 32T50 154Q50 178 61 192T84 210T107 214Q132 214 148 197T164 157Z" transform="translate(500,0)"></path></g><g data-mml-node="mi" transform="translate(1000,0)"><path data-c="25" d="M465 605Q428 605 394 614T340 632T319 641Q332 608 332 548Q332 458 293 403T202 347Q145 347 101 402T56 548Q56 637 101 693T202 750Q241 750 272 719Q359 642 464 642Q580 642 650 732Q662 748 668 749Q670 750 673 750Q682 750 688 743T693 726Q178 -47 170 -52Q166 -56 160 -56Q147 -56 142 -45Q137 -36 142 -27Q143 -24 363 304Q469 462 525 546T581 630Q528 605 465 605ZM207 385Q235 385 263 427T292 548Q292 617 267 664T200 712Q193 712 186 709T167 698T147 668T134 615Q132 595 132 548V527Q132 436 165 403Q183 385 203 385H207ZM500 146Q500 234 544 290T647 347Q699 347 737 292T776 146T737 0T646 -56Q590 -56 545 0T500 146ZM651 -18Q679 -18 707 24T736 146Q736 215 711 262T644 309Q637 309 630 306T611 295T591 265T578 212Q577 200 577 146V124Q577 -18 647 -18H651Z"></path></g></g></g></svg></mjx-container></span> confidence intervals will be reported.</div> |
| <div>Repeated measures analyses including generalized estimating equations with robust variance will be employed to assess for differences in continuous variables that are measured at multiple time points over time between groups using mixed model regression.</div> |
| <div>Interrater reliability assessments of delirium will be assessed for approximately <span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.127ex;" xmlns="http://www.w3.org/2000/svg" width="4.147ex" height="1.824ex" role="img" focusable="false" viewBox="0 -750 1833 806"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mn"><path data-c="31" d="M213 578L200 573Q186 568 160 563T102 556H83V602H102Q149 604 189 617T245 641T273 663Q275 666 285 666Q294 666 302 660V361L303 61Q310 54 315 52T339 48T401 46H427V0H416Q395 3 257 3Q121 3 100 0H88V46H114Q136 46 152 46T177 47T193 50T201 52T207 57T213 61V578Z"></path><path data-c="30" d="M96 585Q152 666 249 666Q297 666 345 640T423 548Q460 465 460 320Q460 165 417 83Q397 41 362 16T301 -15T250 -22Q224 -22 198 -16T137 16T82 83Q39 165 39 320Q39 494 96 585ZM321 597Q291 629 250 629Q208 629 178 597Q153 571 145 525T137 333Q137 175 145 125T181 46Q209 16 250 16Q290 16 318 46Q347 76 354 130T362 333Q362 478 354 524T321 597Z" transform="translate(500,0)"></path></g><g data-mml-node="mi" transform="translate(1000,0)"><path data-c="25" d="M465 605Q428 605 394 614T340 632T319 641Q332 608 332 548Q332 458 293 403T202 347Q145 347 101 402T56 548Q56 637 101 693T202 750Q241 750 272 719Q359 642 464 642Q580 642 650 732Q662 748 668 749Q670 750 673 750Q682 750 688 743T693 726Q178 -47 170 -52Q166 -56 160 -56Q147 -56 142 -45Q137 -36 142 -27Q143 -24 363 304Q469 462 525 546T581 630Q528 605 465 605ZM207 385Q235 385 263 427T292 548Q292 617 267 664T200 712Q193 712 186 709T167 698T147 668T134 615Q132 595 132 548V527Q132 436 165 403Q183 385 203 385H207ZM500 146Q500 234 544 290T647 347Q699 347 737 292T776 146T737 0T646 -56Q590 -56 545 0T500 146ZM651 -18Q679 -18 707 24T736 146Q736 215 711 262T644 309Q637 309 630 306T611 295T591 265T578 212Q577 200 577 146V124Q577 -18 647 -18H651Z"></path></g></g></g></svg></mjx-container></span> of patients. This includes assessment of both for the presence of delirium, and for key features including acute change, inattention, disorganized thinking and an altered level of consciousness. Percent agreement, kappa and weighted kappa will be reported.</div> |
| <div>Given the nature of a randomized controlled trial, we do not anticipate seeing differences between groups in baseline characteristics; however, we will perform a secondary analysis, adjusting for any differences observed between groups and presenting adjusted odds ratios and their associated <span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.127ex;" xmlns="http://www.w3.org/2000/svg" width="4.147ex" height="1.824ex" role="img" focusable="false" viewBox="0 -750 1833 806"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mn"><path data-c="39" d="M352 287Q304 211 232 211Q154 211 104 270T44 396Q42 412 42 436V444Q42 537 111 606Q171 666 243 666Q245 666 249 666T257 665H261Q273 665 286 663T323 651T370 619T413 560Q456 472 456 334Q456 194 396 97Q361 41 312 10T208 -22Q147 -22 108 7T68 93T121 149Q143 149 158 135T173 96Q173 78 164 65T148 49T135 44L131 43Q131 41 138 37T164 27T206 22H212Q272 22 313 86Q352 142 352 280V287ZM244 248Q292 248 321 297T351 430Q351 508 343 542Q341 552 337 562T323 588T293 615T246 625Q208 625 181 598Q160 576 154 546T147 441Q147 358 152 329T172 282Q197 248 244 248Z"></path><path data-c="35" d="M164 157Q164 133 148 117T109 101H102Q148 22 224 22Q294 22 326 82Q345 115 345 210Q345 313 318 349Q292 382 260 382H254Q176 382 136 314Q132 307 129 306T114 304Q97 304 95 310Q93 314 93 485V614Q93 664 98 664Q100 666 102 666Q103 666 123 658T178 642T253 634Q324 634 389 662Q397 666 402 666Q410 666 410 648V635Q328 538 205 538Q174 538 149 544L139 546V374Q158 388 169 396T205 412T256 420Q337 420 393 355T449 201Q449 109 385 44T229 -22Q148 -22 99 32T50 154Q50 178 61 192T84 210T107 214Q132 214 148 197T164 157Z" transform="translate(500,0)"></path></g><g data-mml-node="mi" transform="translate(1000,0)"><path data-c="25" d="M465 605Q428 605 394 614T340 632T319 641Q332 608 332 548Q332 458 293 403T202 347Q145 347 101 402T56 548Q56 637 101 693T202 750Q241 750 272 719Q359 642 464 642Q580 642 650 732Q662 748 668 749Q670 750 673 750Q682 750 688 743T693 726Q178 -47 170 -52Q166 -56 160 -56Q147 -56 142 -45Q137 -36 142 -27Q143 -24 363 304Q469 462 525 546T581 630Q528 605 465 605ZM207 385Q235 385 263 427T292 548Q292 617 267 664T200 712Q193 712 186 709T167 698T147 668T134 615Q132 595 132 548V527Q132 436 165 403Q183 385 203 385H207ZM500 146Q500 234 544 290T647 347Q699 347 737 292T776 146T737 0T646 -56Q590 -56 545 0T500 146ZM651 -18Q679 -18 707 24T736 146Q736 215 711 262T644 309Q637 309 630 306T611 295T591 265T578 212Q577 200 577 146V124Q577 -18 647 -18H651Z"></path></g></g></g></svg></mjx-container></span> confidence intervals.</div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="interim-analyses"> |
| Interim Analyses</h2> |
| <div>There will be no interim analysis.</div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="missing-data"> |
| Missing Data</h2> |
| <div>The frequency and percentage of missing values for each variable will be collected, analyzed and reported as necessary. If there are missing values for the outcome variable(s), individual patients will be excluded. Highly incomplete covariates (>33% of observations missing) will be excluded from analyses. In the event that a variable is missing more than <span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.127ex;" xmlns="http://www.w3.org/2000/svg" width="4.147ex" height="1.824ex" role="img" focusable="false" viewBox="0 -750 1833 806"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mn"><path data-c="31" d="M213 578L200 573Q186 568 160 563T102 556H83V602H102Q149 604 189 617T245 641T273 663Q275 666 285 666Q294 666 302 660V361L303 61Q310 54 315 52T339 48T401 46H427V0H416Q395 3 257 3Q121 3 100 0H88V46H114Q136 46 152 46T177 47T193 50T201 52T207 57T213 61V578Z"></path><path data-c="30" d="M96 585Q152 666 249 666Q297 666 345 640T423 548Q460 465 460 320Q460 165 417 83Q397 41 362 16T301 -15T250 -22Q224 -22 198 -16T137 16T82 83Q39 165 39 320Q39 494 96 585ZM321 597Q291 629 250 629Q208 629 178 597Q153 571 145 525T137 333Q137 175 145 125T181 46Q209 16 250 16Q290 16 318 46Q347 76 354 130T362 333Q362 478 354 524T321 597Z" transform="translate(500,0)"></path></g><g data-mml-node="mi" transform="translate(1000,0)"><path data-c="25" d="M465 605Q428 605 394 614T340 632T319 641Q332 608 332 548Q332 458 293 403T202 347Q145 347 101 402T56 548Q56 637 101 693T202 750Q241 750 272 719Q359 642 464 642Q580 642 650 732Q662 748 668 749Q670 750 673 750Q682 750 688 743T693 726Q178 -47 170 -52Q166 -56 160 -56Q147 -56 142 -45Q137 -36 142 -27Q143 -24 363 304Q469 462 525 546T581 630Q528 605 465 605ZM207 385Q235 385 263 427T292 548Q292 617 267 664T200 712Q193 712 186 709T167 698T147 668T134 615Q132 595 132 548V527Q132 436 165 403Q183 385 203 385H207ZM500 146Q500 234 544 290T647 347Q699 347 737 292T776 146T737 0T646 -56Q590 -56 545 0T500 146ZM651 -18Q679 -18 707 24T736 146Q736 215 711 262T644 309Q637 309 630 306T611 295T591 265T578 212Q577 200 577 146V124Q577 -18 647 -18H651Z"></path></g></g></g></svg></mjx-container></span> of the time we will consider imputation. If missing values are missing at random (MAR) or not at random (MNAR), multiple imputation will be performed. Missing values, selection or exclusion of observations and variables and handling of missing values in the statistical analysis will be describes carefully and sensitivity analysis will be provided in the manuscript.</div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="statistical-analytical-issues"> |
| Statistical Analytical Issues</h2> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="adjustments-for-covariates"> |
| Adjustments for Covariates</h2> |
| <div>Given the randomized nature of this study, there will be no covariate adjustment in the primary analysis. If differences between groups persist after randomization we will perform a post hoc analysis including variables that are significantly differ between groups.</div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="multiple-comparisons"> |
| Multiple Comparisons</h2> |
| <div>There will be no adjustment for multiple testing. Results of secondary outcomes and post hoc analyses will therefore be considered exploratory.</div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="examination-of-subgroups"> |
| Examination of Subgroups</h2> |
| <div>Our pre-specified primary analysis will assess the incidence of delirium between patients receiving intravenous acetaminophen versus placebo. Predefined subgroup analyses will be performed for our primary and secondary outcomes for the following groups:</div> |
| <ul> |
| <li>Two sedative groups: dexmedetomidine versus propofol</li> |
| </ul> |
| <div>Effect of Postoperative Intravenous Acetaminophen versus Placebo, Combined with Propofol or Dexmedetomidine, on Postoperative In-Hospital Delirium Among Older Patients Following Cardiac Surgery: The DEXACET Randomized Clinical Trial</div> |
| <ul> |
| <li>All four factorial groups including both sedatives (dexmedetomidine and propofol) and analgesics (acetaminophen and placebo).</li> |
| </ul> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="post-hoc-analyses"> |
| Post-hoc Analyses</h2> |
| <div>Post-hoc data driven analyses are allowed after the following are undertaken:<br> |
| (a) Document which analyses were conducted after the results for the Primary and Secondary Aims are analyzed.<br> |
| (b) Document the rationale for these analyses.<br> |
| (c) Pre-specify their interpretation in the context of the primary and secondary results and their impact on the overall trial conclusions.</div> |
| <div>Effect of Postoperative Intravenous Acetaminophen versus Placebo, Combined with Propofol or Dexmedetomidine, on Postoperative In-Hospital Delirium Among Older Patients Following Cardiac Surgery: The DEXACET Randomized Clinical Trial<br> |
| eAPPENDIX 2. FAST TRACK PROTOCOL AND INTRAVENOUS DRUG ADMINISTRATION GUIDELINES</div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="fast-track-protocol-for-cardiac-surgery"> |
| FAST TRACK PROTOCOL FOR CARDIAC SURGERY</h2> |
| <div>Version:<br> |
| Institutional Authors:</div> |
| <div>12/2015<br> |
| BIDMC Perioperative Cardiovascular Intensive Care Unit Committee</div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="cardiac-surgery-fast-track-ventilator-weaning-guideline"> |
| Cardiac Surgery Fast Track Ventilator Weaning Guideline</h2> |
| <div>Purpose: Patients who have undergone an uncomplicated cardiac surgical procedure should be able to wean quickly from the ventilator, fostering a more rapid recovery. The fast track weaning guideline provides a decision-making framework that will expedite the process of weaning most efficiently</div> |
| <div>Patient Selection: Selection of patients for fast track ventilator weaning will be made at time of handoff in Cardiovascular Intensive Care Unit (CVICU). It is a collaborative decision by the healthcare team at which time an order is placed in the system.</div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="ventilator-settings-on-arrival"> |
| Ventilator Settings on Arrival</h2> |
| <div>All patients are placed on: assist control positive end expiratory pressure (PEEP) 5, fraction of inspired oxygen (FiO2) <span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.127ex;" xmlns="http://www.w3.org/2000/svg" width="5.278ex" height="1.824ex" role="img" focusable="false" viewBox="0 -750 2333 806"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mn"><path data-c="31" d="M213 578L200 573Q186 568 160 563T102 556H83V602H102Q149 604 189 617T245 641T273 663Q275 666 285 666Q294 666 302 660V361L303 61Q310 54 315 52T339 48T401 46H427V0H416Q395 3 257 3Q121 3 100 0H88V46H114Q136 46 152 46T177 47T193 50T201 52T207 57T213 61V578Z"></path><path data-c="30" d="M96 585Q152 666 249 666Q297 666 345 640T423 548Q460 465 460 320Q460 165 417 83Q397 41 362 16T301 -15T250 -22Q224 -22 198 -16T137 16T82 83Q39 165 39 320Q39 494 96 585ZM321 597Q291 629 250 629Q208 629 178 597Q153 571 145 525T137 333Q137 175 145 125T181 46Q209 16 250 16Q290 16 318 46Q347 76 354 130T362 333Q362 478 354 524T321 597Z" transform="translate(500,0)"></path><path data-c="30" d="M96 585Q152 666 249 666Q297 666 345 640T423 548Q460 465 460 320Q460 165 417 83Q397 41 362 16T301 -15T250 -22Q224 -22 198 -16T137 16T82 83Q39 165 39 320Q39 494 96 585ZM321 597Q291 629 250 629Q208 629 178 597Q153 571 145 525T137 333Q137 175 145 125T181 46Q209 16 250 16Q290 16 318 46Q347 76 354 130T362 333Q362 478 354 524T321 597Z" transform="translate(1000,0)"></path></g><g data-mml-node="mi" transform="translate(1500,0)"><path data-c="25" d="M465 605Q428 605 394 614T340 632T319 641Q332 608 332 548Q332 458 293 403T202 347Q145 347 101 402T56 548Q56 637 101 693T202 750Q241 750 272 719Q359 642 464 642Q580 642 650 732Q662 748 668 749Q670 750 673 750Q682 750 688 743T693 726Q178 -47 170 -52Q166 -56 160 -56Q147 -56 142 -45Q137 -36 142 -27Q143 -24 363 304Q469 462 525 546T581 630Q528 605 465 605ZM207 385Q235 385 263 427T292 548Q292 617 267 664T200 712Q193 712 186 709T167 698T147 668T134 615Q132 595 132 548V527Q132 436 165 403Q183 385 203 385H207ZM500 146Q500 234 544 290T647 347Q699 347 737 292T776 146T737 0T646 -56Q590 -56 545 0T500 146ZM651 -18Q679 -18 707 24T736 146Q736 215 711 262T644 309Q637 309 630 306T611 295T591 265T578 212Q577 200 577 146V124Q577 -18 647 -18H651Z"></path></g></g></g></svg></mjx-container></span>, tidal volume (vT) <span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.566ex;" xmlns="http://www.w3.org/2000/svg" width="12.209ex" height="2.262ex" role="img" focusable="false" viewBox="0 -750 5396.4 1000"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mn"><path data-c="36" d="M42 313Q42 476 123 571T303 666Q372 666 402 630T432 550Q432 525 418 510T379 495Q356 495 341 509T326 548Q326 592 373 601Q351 623 311 626Q240 626 194 566Q147 500 147 364L148 360Q153 366 156 373Q197 433 263 433H267Q313 433 348 414Q372 400 396 374T435 317Q456 268 456 210V192Q456 169 451 149Q440 90 387 34T253 -22Q225 -22 199 -14T143 16T92 75T56 172T42 313ZM257 397Q227 397 205 380T171 335T154 278T148 216Q148 133 160 97T198 39Q222 21 251 21Q302 21 329 59Q342 77 347 104T352 209Q352 289 347 316T329 361Q302 397 257 397Z"></path></g><g data-mml-node="mo" transform="translate(722.2,0)"><path data-c="2212" d="M84 237T84 250T98 270H679Q694 262 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440T441 433T460 423T475 411T485 398T493 385T497 373T500 364T502 357L510 367Q573 442 659 442Q713 442 746 415T780 336Q780 285 742 178T704 50Q705 36 709 31T724 26Q752 26 776 56T815 138Q818 149 821 151T837 153Q857 153 857 145Q857 144 853 130Q845 101 831 73T785 17T716 -10Q669 -10 648 17T627 73Q627 92 663 193T700 345Q700 404 656 404H651Q565 404 506 303L499 291L466 157Q433 26 428 16Q415 -11 385 -11Q372 -11 364 -4T353 8T350 18Q350 29 384 161L420 307Q423 322 423 345Q423 404 379 404H374Q288 404 229 303L222 291L189 157Q156 26 151 16Q138 -11 108 -11Q95 -11 87 -5T76 7T74 17Q74 30 112 181Q151 335 151 342Q154 357 154 369Q154 405 129 405Q107 405 92 377T69 316T57 280Q55 278 41 278H27Q21 284 21 287Z"></path></g><g data-mml-node="mi" transform="translate(3600.4,0)"><path data-c="1D459" d="M117 59Q117 26 142 26Q179 26 205 131Q211 151 215 152Q217 153 225 153H229Q238 153 241 153T246 151T248 144Q247 138 245 128T234 90T214 43T183 6T137 -11Q101 -11 70 11T38 85Q38 97 39 102L104 360Q167 615 167 623Q167 626 166 628T162 632T157 634T149 635T141 636T132 637T122 637Q112 637 109 637T101 638T95 641T94 647Q94 649 96 661Q101 680 107 682T179 688Q194 689 213 690T243 693T254 694Q266 694 266 686Q266 675 193 386T118 83Q118 81 118 75T117 65V59Z"></path></g><g data-mml-node="TeXAtom" data-mjx-texclass="ORD" transform="translate(3898.4,0)"><g data-mml-node="mo"><path data-c="2F" d="M423 750Q432 750 438 744T444 730Q444 725 271 248T92 -240Q85 -250 75 -250Q68 -250 62 -245T56 -231Q56 -221 230 257T407 740Q411 750 423 750Z"></path></g></g><g data-mml-node="mi" transform="translate(4398.4,0)"><path data-c="1D458" d="M121 647Q121 657 125 670T137 683Q138 683 209 688T282 694Q294 694 294 686Q294 679 244 477Q194 279 194 272Q213 282 223 291Q247 309 292 354T362 415Q402 442 438 442Q468 442 485 423T503 369Q503 344 496 327T477 302T456 291T438 288Q418 288 406 299T394 328Q394 353 410 369T442 390L458 393Q446 405 434 405H430Q398 402 367 380T294 316T228 255Q230 254 243 252T267 246T293 238T320 224T342 206T359 180T365 147Q365 130 360 106T354 66Q354 26 381 26Q429 26 459 145Q461 153 479 153H483Q499 153 499 144Q499 139 496 130Q455 -11 378 -11Q333 -11 305 15T277 90Q277 108 280 121T283 145Q283 167 269 183T234 206T200 217T182 220H180Q168 178 159 139T145 81T136 44T129 20T122 7T111 -2Q98 -11 83 -11Q66 -11 57 -1T48 16Q48 26 85 176T158 471L195 616Q196 629 188 632T149 637H144Q134 637 131 637T124 640T121 647Z"></path></g><g data-mml-node="mi" transform="translate(4919.4,0)"><path data-c="1D454" d="M311 43Q296 30 267 15T206 0Q143 0 105 45T66 160Q66 265 143 353T314 442Q361 442 401 394L404 398Q406 401 409 404T418 412T431 419T447 422Q461 422 470 413T480 394Q480 379 423 152T363 -80Q345 -134 286 -169T151 -205Q10 -205 10 -137Q10 -111 28 -91T74 -71Q89 -71 102 -80T116 -111Q116 -121 114 -130T107 -144T99 -154T92 -162L90 -164H91Q101 -167 151 -167Q189 -167 211 -155Q234 -144 254 -122T282 -75Q288 -56 298 -13Q311 35 311 43ZM384 328L380 339Q377 350 375 354T369 368T359 382T346 393T328 402T306 405Q262 405 221 352Q191 313 171 233T151 117Q151 38 213 38Q269 38 323 108L331 118L384 328Z"></path></g></g></g></svg></mjx-container></span> (ideal body weight) and respiratory rate <span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.186ex;" xmlns="http://www.w3.org/2000/svg" width="7.291ex" height="1.717ex" role="img" focusable="false" viewBox="0 -677 3222.4 759"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mn"><path data-c="31" d="M213 578L200 573Q186 568 160 563T102 556H83V602H102Q149 604 189 617T245 641T273 663Q275 666 285 666Q294 666 302 660V361L303 61Q310 54 315 52T339 48T401 46H427V0H416Q395 3 257 3Q121 3 100 0H88V46H114Q136 46 152 46T177 47T193 50T201 52T207 57T213 61V578Z"></path><path data-c="32" d="M109 429Q82 429 66 447T50 491Q50 562 103 614T235 666Q326 666 387 610T449 465Q449 422 429 383T381 315T301 241Q265 210 201 149L142 93L218 92Q375 92 385 97Q392 99 409 186V189H449V186Q448 183 436 95T421 3V0H50V19V31Q50 38 56 46T86 81Q115 113 136 137Q145 147 170 174T204 211T233 244T261 278T284 308T305 340T320 369T333 401T340 431T343 464Q343 527 309 573T212 619Q179 619 154 602T119 569T109 550Q109 549 114 549Q132 549 151 535T170 489Q170 464 154 447T109 429Z" transform="translate(500,0)"></path></g><g data-mml-node="mo" transform="translate(1222.2,0)"><path data-c="2212" d="M84 237T84 250T98 270H679Q694 262 694 250T679 230H98Q84 237 84 250Z"></path></g><g data-mml-node="mn" transform="translate(2222.4,0)"><path data-c="31" d="M213 578L200 573Q186 568 160 563T102 556H83V602H102Q149 604 189 617T245 641T273 663Q275 666 285 666Q294 666 302 660V361L303 61Q310 54 315 52T339 48T401 46H427V0H416Q395 3 257 3Q121 3 100 0H88V46H114Q136 46 152 46T177 47T193 50T201 52T207 57T213 61V578Z"></path><path data-c="34" d="M462 0Q444 3 333 3Q217 3 199 0H190V46H221Q241 46 248 46T265 48T279 53T286 61Q287 63 287 115V165H28V211L179 442Q332 674 334 675Q336 677 355 677H373L379 671V211H471V165H379V114Q379 73 379 66T385 54Q393 47 442 46H471V0H462ZM293 211V545L74 212L183 211H293Z" transform="translate(500,0)"></path></g></g></g></svg></mjx-container></span> (or per anesthesia)</div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="extubation-goal-(4-hours-for-fast-track)"> |
| Extubation Goal (4 hours for Fast Track)</h2> |
| <ul> |
| <li>Nurse will write time of arrival on White Board</li> |
| <li>This allows all members of the team to know when 23 hours is up to prevent Society of Thoracic Surgeons (STS) designation of prolonged ventilation</li> |
| </ul> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="pre-extubation"> |
| PRE-EXTUBATION</h2> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="i.-hand-off"> |
| I. Hand Off</h2> |
| <ul> |
| <li>Patient designated as appropriate for fast track wean</li> |
| <li>CVICU Nurse</li> |
| <li>Anesthesia</li> |
| <li>Intensive Care Unit (ICU) Provider</li> |
| <li>CVICU Respiratory Therapist (RT)</li> |
| </ul> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="ii.-difficult-airway"> |
| II. Difficult Airway</h2> |
| <ul> |
| <li>ICU Provider, Intensivist, Registered Nurse (RN), and RT discuss plan in detail</li> |
| <li>Who needs to be notified when patient ready to extubated?</li> |
| <li>Does ICU Provider or Intensivist want to be present for extubation?</li> |
| <li>What additional equipment is needed at the bedside?</li> |
| </ul> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="iii.-rewarming-guidelines"> |
| III. Rewarming Guidelines</h2> |
| <div>Effect of Postoperative Intravenous Acetaminophen versus Placebo, Combined with Propofol or Dexmedetomidine, on Postoperative In-Hospital Delirium Among Older Patients Following Cardiac Surgery: The DEXACET Randomized Clinical Trial</div> |
| <ul> |
| <li>All Patients on arrival</li> |
| <li>Change intravenous fluid (IVF) to warmed IVF</li> |
| <li>Warmed blankets</li> |
| <li>Hourly temperature for the first 4 hours postoperatively</li> |
| <li>Record temperature prior to administration of reversal agents</li> |
| <li>If Temperature <span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.566ex;" xmlns="http://www.w3.org/2000/svg" width="16.2ex" height="2.262ex" role="img" focusable="false" viewBox="0 -750 7160.6 1000"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mo"><path data-c="2264" d="M674 636Q682 636 688 630T694 615T687 601Q686 600 417 472L151 346L399 228Q687 92 691 87Q694 81 694 76Q694 58 676 56H670L382 192Q92 329 90 331Q83 336 83 348Q84 359 96 365Q104 369 382 500T665 634Q669 636 674 636ZM84 -118Q84 -108 99 -98H678Q694 -104 694 -118Q694 -130 679 -138H98Q84 -131 84 -118Z"></path></g><g data-mml-node="msup" transform="translate(1055.8,0)"><g data-mml-node="mn"><path data-c="33" d="M127 463Q100 463 85 480T69 524Q69 579 117 622T233 665Q268 665 277 664Q351 652 390 611T430 522Q430 470 396 421T302 350L299 348Q299 347 308 345T337 336T375 315Q457 262 457 175Q457 96 395 37T238 -22Q158 -22 100 21T42 130Q42 158 60 175T105 193Q133 193 151 175T169 130Q169 119 166 110T159 94T148 82T136 74T126 70T118 67L114 66Q165 21 238 21Q293 21 321 74Q338 107 338 175V195Q338 290 274 322Q259 328 213 329L171 330L168 332Q166 335 166 348Q166 366 174 366Q202 366 232 371Q266 376 294 413T322 525V533Q322 590 287 612Q265 626 240 626Q208 626 181 615T143 592T132 580H135Q138 579 143 578T153 573T165 566T175 555T183 540T186 520Q186 498 172 481T127 463Z"></path><path data-c="36" d="M42 313Q42 476 123 571T303 666Q372 666 402 630T432 550Q432 525 418 510T379 495Q356 495 341 509T326 548Q326 592 373 601Q351 623 311 626Q240 626 194 566Q147 500 147 364L148 360Q153 366 156 373Q197 433 263 433H267Q313 433 348 414Q372 400 396 374T435 317Q456 268 456 210V192Q456 169 451 149Q440 90 387 34T253 -22Q225 -22 199 -14T143 16T92 75T56 172T42 313ZM257 397Q227 397 205 380T171 335T154 278T148 216Q148 133 160 97T198 39Q222 21 251 21Q302 21 329 59Q342 77 347 104T352 209Q352 289 347 316T329 361Q302 397 257 397Z" transform="translate(500,0)"></path></g><g data-mml-node="TeXAtom" transform="translate(1033,393.1) scale(0.707)" data-mjx-texclass="ORD"><g data-mml-node="mo"><path data-c="2218" d="M55 251Q55 328 112 386T249 444T386 388T444 249Q444 171 388 113T250 55Q170 55 113 112T55 251ZM245 403Q188 403 142 361T96 250Q96 183 141 140T250 96Q284 96 313 109T354 135T375 160Q403 197 403 250Q403 313 360 358T245 403Z"></path></g></g></g><g data-mml-node="mi" transform="translate(2492.3,0)"><path data-c="1D436" d="M50 252Q50 367 117 473T286 641T490 704Q580 704 633 653Q642 643 648 636T656 626L657 623Q660 623 684 649Q691 655 699 663T715 679T725 690L740 705H746Q760 705 760 698Q760 694 728 561Q692 422 692 421Q690 416 687 415T669 413H653Q647 419 647 422Q647 423 648 429T650 449T651 481Q651 552 619 605T510 659Q484 659 454 652T382 628T299 572T226 479Q194 422 175 346T156 222Q156 108 232 58Q280 24 350 24Q441 24 512 92T606 240Q610 253 612 255T628 257Q648 257 648 248Q648 243 647 239Q618 132 523 55T319 -22Q206 -22 128 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248 244 248Z"></path><path data-c="36" d="M42 313Q42 476 123 571T303 666Q372 666 402 630T432 550Q432 525 418 510T379 495Q356 495 341 509T326 548Q326 592 373 601Q351 623 311 626Q240 626 194 566Q147 500 147 364L148 360Q153 366 156 373Q197 433 263 433H267Q313 433 348 414Q372 400 396 374T435 317Q456 268 456 210V192Q456 169 451 149Q440 90 387 34T253 -22Q225 -22 199 -14T143 16T92 75T56 172T42 313ZM257 397Q227 397 205 380T171 335T154 278T148 216Q148 133 160 97T198 39Q222 21 251 21Q302 21 329 59Q342 77 347 104T352 209Q352 289 347 316T329 361Q302 397 257 397Z" transform="translate(500,0)"></path><path data-c="2E" d="M78 60Q78 84 95 102T138 120Q162 120 180 104T199 61Q199 36 182 18T139 0T96 17T78 60Z" transform="translate(1000,0)"></path><path data-c="38" d="M70 417T70 494T124 618T248 666Q319 666 374 624T429 515Q429 485 418 459T392 417T361 389T335 371T324 363L338 354Q352 344 366 334T382 323Q457 264 457 174Q457 95 399 37T249 -22Q159 -22 101 29T43 155Q43 263 172 335L154 348Q133 361 127 368Q70 417 70 494ZM286 386L292 390Q298 394 301 396T311 403T323 413T334 425T345 438T355 454T364 471T369 491T371 513Q371 556 342 586T275 624Q268 625 242 625Q201 625 165 599T128 534Q128 511 141 492T167 463T217 431Q224 426 228 424L286 386ZM250 21Q308 21 350 55T392 137Q392 154 387 169T375 194T353 216T330 234T301 253T274 270Q260 279 244 289T218 306L210 311Q204 311 181 294T133 239T107 157Q107 98 150 60T250 21Z" transform="translate(1278,0)"></path></g><g data-mml-node="TeXAtom" transform="translate(1811,393.1) scale(0.707)" data-mjx-texclass="ORD"><g data-mml-node="mo"><path data-c="2218" d="M55 251Q55 328 112 386T249 444T386 388T444 249Q444 171 388 113T250 55Q170 55 113 112T55 251ZM245 403Q188 403 142 361T96 250Q96 183 141 140T250 96Q284 96 313 109T354 135T375 160Q403 197 403 250Q403 313 360 358T245 403Z"></path></g></g></g><g data-mml-node="mi" transform="translate(2603.6,0)"><path data-c="1D439" d="M48 1Q31 1 31 11Q31 13 34 25Q38 41 42 43T65 46Q92 46 125 49Q139 52 144 61Q146 66 215 342T285 622Q285 629 281 629Q273 632 228 634H197Q191 640 191 642T193 659Q197 676 203 680H742Q749 676 749 669Q749 664 736 557T722 447Q720 440 702 440H690Q683 445 683 453Q683 454 686 477T689 530Q689 560 682 579T663 610T626 626T575 633T503 634H480Q398 633 393 631Q388 629 386 623Q385 622 352 492L320 363H375Q378 363 398 363T426 364T448 367T472 374T489 386Q502 398 511 419T524 457T529 475Q532 480 548 480H560Q567 475 567 470Q567 467 536 339T502 207Q500 200 482 200H470Q463 206 463 212Q463 215 468 234T473 274Q473 303 453 310T364 317H309L277 190Q245 66 245 60Q245 46 334 46H359Q365 40 365 39T363 19Q359 6 353 0H336Q295 2 185 2Q120 2 86 2T48 1Z"></path></g><g data-mml-node="mo" transform="translate(3352.6,0)"><path data-c="29" d="M60 749L64 750Q69 750 74 750H86L114 726Q208 641 251 514T294 250Q294 182 284 119T261 12T224 -76T186 -143T145 -194T113 -227T90 -246Q87 -249 86 -250H74Q66 -250 63 -250T58 -247T55 -238Q56 -237 66 -225Q221 -64 221 250T66 725Q56 737 55 738Q55 746 60 749Z"></path></g></g></g></g></svg></mjx-container></span></li> |
| <li>Bair Hugger set at <span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.05ex;" xmlns="http://www.w3.org/2000/svg" width="4.97ex" height="1.674ex" role="img" focusable="false" viewBox="0 -718 2196.6 740"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="msup"><g data-mml-node="mn"><path data-c="34" d="M462 0Q444 3 333 3Q217 3 199 0H190V46H221Q241 46 248 46T265 48T279 53T286 61Q287 63 287 115V165H28V211L179 442Q332 674 334 675Q336 677 355 677H373L379 671V211H471V165H379V114Q379 73 379 66T385 54Q393 47 442 46H471V0H462ZM293 211V545L74 212L183 211H293Z"></path><path data-c="32" d="M109 429Q82 429 66 447T50 491Q50 562 103 614T235 666Q326 666 387 610T449 465Q449 422 429 383T381 315T301 241Q265 210 201 149L142 93L218 92Q375 92 385 97Q392 99 409 186V189H449V186Q448 183 436 95T421 3V0H50V19V31Q50 38 56 46T86 81Q115 113 136 137Q145 147 170 174T204 211T233 244T261 278T284 308T305 340T320 369T333 401T340 431T343 464Q343 527 309 573T212 619Q179 619 154 602T119 569T109 550Q109 549 114 549Q132 549 151 535T170 489Q170 464 154 447T109 429Z" transform="translate(500,0)"></path></g><g data-mml-node="TeXAtom" transform="translate(1033,404.1) scale(0.707)" data-mjx-texclass="ORD"><g data-mml-node="mo"><path data-c="2218" d="M55 251Q55 328 112 386T249 444T386 388T444 249Q444 171 388 113T250 55Q170 55 113 112T55 251ZM245 403Q188 403 142 361T96 250Q96 183 141 140T250 96Q284 96 313 109T354 135T375 160Q403 197 403 250Q403 313 360 358T245 403Z"></path></g></g></g><g data-mml-node="mi" transform="translate(1436.6,0)"><path data-c="1D436" d="M50 252Q50 367 117 473T286 641T490 704Q580 704 633 653Q642 643 648 636T656 626L657 623Q660 623 684 649Q691 655 699 663T715 679T725 690L740 705H746Q760 705 760 698Q760 694 728 561Q692 422 692 421Q690 416 687 415T669 413H653Q647 419 647 422Q647 423 648 429T650 449T651 481Q651 552 619 605T510 659Q484 659 454 652T382 628T299 572T226 479Q194 422 175 346T156 222Q156 108 232 58Q280 24 350 24Q441 24 512 92T606 240Q610 253 612 255T628 257Q648 257 648 248Q648 243 647 239Q618 132 523 55T319 -22Q206 -22 128 53T50 252Z"></path></g></g></g></svg></mjx-container></span></li> |
| <li>May remove when temp <span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.566ex;" xmlns="http://www.w3.org/2000/svg" width="16.2ex" height="2.262ex" role="img" focusable="false" viewBox="0 -750 7160.6 1000"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mo"><path data-c="3E" d="M84 520Q84 528 88 533T96 539L99 540Q106 540 253 471T544 334L687 265Q694 260 694 250T687 235Q685 233 395 96L107 -40H101Q83 -38 83 -20Q83 -19 83 -17Q82 -10 98 -1Q117 9 248 71Q326 108 378 132L626 250L378 368Q90 504 86 509Q84 513 84 520Z"></path></g><g data-mml-node="msup" transform="translate(1055.8,0)"><g data-mml-node="mn"><path data-c="33" d="M127 463Q100 463 85 480T69 524Q69 579 117 622T233 665Q268 665 277 664Q351 652 390 611T430 522Q430 470 396 421T302 350L299 348Q299 347 308 345T337 336T375 315Q457 262 457 175Q457 96 395 37T238 -22Q158 -22 100 21T42 130Q42 158 60 175T105 193Q133 193 151 175T169 130Q169 119 166 110T159 94T148 82T136 74T126 70T118 67L114 66Q165 21 238 21Q293 21 321 74Q338 107 338 175V195Q338 290 274 322Q259 328 213 329L171 330L168 332Q166 335 166 348Q166 366 174 366Q202 366 232 371Q266 376 294 413T322 525V533Q322 590 287 612Q265 626 240 626Q208 626 181 615T143 592T132 580H135Q138 579 143 578T153 573T165 566T175 555T183 540T186 520Q186 498 172 481T127 463Z"></path><path data-c="36" d="M42 313Q42 476 123 571T303 666Q372 666 402 630T432 550Q432 525 418 510T379 495Q356 495 341 509T326 548Q326 592 373 601Q351 623 311 626Q240 626 194 566Q147 500 147 364L148 360Q153 366 156 373Q197 433 263 433H267Q313 433 348 414Q372 400 396 374T435 317Q456 268 456 210V192Q456 169 451 149Q440 90 387 34T253 -22Q225 -22 199 -14T143 16T92 75T56 172T42 313ZM257 397Q227 397 205 380T171 335T154 278T148 216Q148 133 160 97T198 39Q222 21 251 21Q302 21 329 59Q342 77 347 104T352 209Q352 289 347 316T329 361Q302 397 257 397Z" transform="translate(500,0)"></path></g><g data-mml-node="TeXAtom" transform="translate(1033,393.1) scale(0.707)" data-mjx-texclass="ORD"><g data-mml-node="mo"><path data-c="2218" d="M55 251Q55 328 112 386T249 444T386 388T444 249Q444 171 388 113T250 55Q170 55 113 112T55 251ZM245 403Q188 403 142 361T96 250Q96 183 141 140T250 96Q284 96 313 109T354 135T375 160Q403 197 403 250Q403 313 360 358T245 403Z"></path></g></g></g><g data-mml-node="mi" transform="translate(2492.3,0)"><path data-c="1D436" d="M50 252Q50 367 117 473T286 641T490 704Q580 704 633 653Q642 643 648 636T656 626L657 623Q660 623 684 649Q691 655 699 663T715 679T725 690L740 705H746Q760 705 760 698Q760 694 728 561Q692 422 692 421Q690 416 687 415T669 413H653Q647 419 647 422Q647 423 648 429T650 449T651 481Q651 552 619 605T510 659Q484 659 454 652T382 628T299 572T226 479Q194 422 175 346T156 222Q156 108 232 58Q280 24 350 24Q441 24 512 92T606 240Q610 253 612 255T628 257Q648 257 648 248Q648 243 647 239Q618 132 523 55T319 -22Q206 -22 128 53T50 252Z"></path></g><g data-mml-node="mrow" transform="translate(3419,0)"><g data-mml-node="mo"><path data-c="28" d="M94 250Q94 319 104 381T127 488T164 576T202 643T244 695T277 729T302 750H315H319Q333 750 333 741Q333 738 316 720T275 667T226 581T184 443T167 250T184 58T225 -81T274 -167T316 -220T333 -241Q333 -250 318 -250H315H302L274 -226Q180 -141 137 -14T94 250Z"></path></g><g data-mml-node="msup" transform="translate(389,0)"><g data-mml-node="mn"><path data-c="39" d="M352 287Q304 211 232 211Q154 211 104 270T44 396Q42 412 42 436V444Q42 537 111 606Q171 666 243 666Q245 666 249 666T257 665H261Q273 665 286 663T323 651T370 619T413 560Q456 472 456 334Q456 194 396 97Q361 41 312 10T208 -22Q147 -22 108 7T68 93T121 149Q143 149 158 135T173 96Q173 78 164 65T148 49T135 44L131 43Q131 41 138 37T164 27T206 22H212Q272 22 313 86Q352 142 352 280V287ZM244 248Q292 248 321 297T351 430Q351 508 343 542Q341 552 337 562T323 588T293 615T246 625Q208 625 181 598Q160 576 154 546T147 441Q147 358 152 329T172 282Q197 248 244 248Z"></path><path data-c="36" d="M42 313Q42 476 123 571T303 666Q372 666 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454T364 471T369 491T371 513Q371 556 342 586T275 624Q268 625 242 625Q201 625 165 599T128 534Q128 511 141 492T167 463T217 431Q224 426 228 424L286 386ZM250 21Q308 21 350 55T392 137Q392 154 387 169T375 194T353 216T330 234T301 253T274 270Q260 279 244 289T218 306L210 311Q204 311 181 294T133 239T107 157Q107 98 150 60T250 21Z" transform="translate(1278,0)"></path></g><g data-mml-node="TeXAtom" transform="translate(1811,393.1) scale(0.707)" data-mjx-texclass="ORD"><g data-mml-node="mo"><path data-c="2218" d="M55 251Q55 328 112 386T249 444T386 388T444 249Q444 171 388 113T250 55Q170 55 113 112T55 251ZM245 403Q188 403 142 361T96 250Q96 183 141 140T250 96Q284 96 313 109T354 135T375 160Q403 197 403 250Q403 313 360 358T245 403Z"></path></g></g></g><g data-mml-node="mi" transform="translate(2603.6,0)"><path data-c="1D439" d="M48 1Q31 1 31 11Q31 13 34 25Q38 41 42 43T65 46Q92 46 125 49Q139 52 144 61Q146 66 215 342T285 622Q285 629 281 629Q273 632 228 634H197Q191 640 191 642T193 659Q197 676 203 680H742Q749 676 749 669Q749 664 736 557T722 447Q720 440 702 440H690Q683 445 683 453Q683 454 686 477T689 530Q689 560 682 579T663 610T626 626T575 633T503 634H480Q398 633 393 631Q388 629 386 623Q385 622 352 492L320 363H375Q378 363 398 363T426 364T448 367T472 374T489 386Q502 398 511 419T524 457T529 475Q532 480 548 480H560Q567 475 567 470Q567 467 536 339T502 207Q500 200 482 200H470Q463 206 463 212Q463 215 468 234T473 274Q473 303 453 310T364 317H309L277 190Q245 66 245 60Q245 46 334 46H359Q365 40 365 39T363 19Q359 6 353 0H336Q295 2 185 2Q120 2 86 2T48 1Z"></path></g><g data-mml-node="mo" transform="translate(3352.6,0)"><path data-c="29" d="M60 749L64 750Q69 750 74 750H86L114 726Q208 641 251 514T294 250Q294 182 284 119T261 12T224 -76T186 -143T145 -194T113 -227T90 -246Q87 -249 86 -250H74Q66 -250 63 -250T58 -247T55 -238Q56 -237 66 -225Q221 -64 221 250T66 725Q56 737 55 738Q55 746 60 749Z"></path></g></g></g></g></svg></mjx-container></span> for at least one hour</li> |
| <li>Suggest defer bath until <span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.09ex;" xmlns="http://www.w3.org/2000/svg" width="7.358ex" height="1.69ex" role="img" focusable="false" viewBox="0 -707 3252.3 747"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mo"><path data-c="3E" d="M84 520Q84 528 88 533T96 539L99 540Q106 540 253 471T544 334L687 265Q694 260 694 250T687 235Q685 233 395 96L107 -40H101Q83 -38 83 -20Q83 -19 83 -17Q82 -10 98 -1Q117 9 248 71Q326 108 378 132L626 250L378 368Q90 504 86 509Q84 513 84 520Z"></path></g><g data-mml-node="msup" transform="translate(1055.8,0)"><g data-mml-node="mn"><path data-c="33" d="M127 463Q100 463 85 480T69 524Q69 579 117 622T233 665Q268 665 277 664Q351 652 390 611T430 522Q430 470 396 421T302 350L299 348Q299 347 308 345T337 336T375 315Q457 262 457 175Q457 96 395 37T238 -22Q158 -22 100 21T42 130Q42 158 60 175T105 193Q133 193 151 175T169 130Q169 119 166 110T159 94T148 82T136 74T126 70T118 67L114 66Q165 21 238 21Q293 21 321 74Q338 107 338 175V195Q338 290 274 322Q259 328 213 329L171 330L168 332Q166 335 166 348Q166 366 174 366Q202 366 232 371Q266 376 294 413T322 525V533Q322 590 287 612Q265 626 240 626Q208 626 181 615T143 592T132 580H135Q138 579 143 578T153 573T165 566T175 555T183 540T186 520Q186 498 172 481T127 463Z"></path><path data-c="36" d="M42 313Q42 476 123 571T303 666Q372 666 402 630T432 550Q432 525 418 510T379 495Q356 495 341 509T326 548Q326 592 373 601Q351 623 311 626Q240 626 194 566Q147 500 147 364L148 360Q153 366 156 373Q197 433 263 433H267Q313 433 348 414Q372 400 396 374T435 317Q456 268 456 210V192Q456 169 451 149Q440 90 387 34T253 -22Q225 -22 199 -14T143 16T92 75T56 172T42 313ZM257 397Q227 397 205 380T171 335T154 278T148 216Q148 133 160 97T198 39Q222 21 251 21Q302 21 329 59Q342 77 347 104T352 209Q352 289 347 316T329 361Q302 397 257 397Z" transform="translate(500,0)"></path></g><g data-mml-node="TeXAtom" transform="translate(1033,393.1) scale(0.707)" data-mjx-texclass="ORD"><g data-mml-node="mo"><path data-c="2218" d="M55 251Q55 328 112 386T249 444T386 388T444 249Q444 171 388 113T250 55Q170 55 113 112T55 251ZM245 403Q188 403 142 361T96 250Q96 183 141 140T250 96Q284 96 313 109T354 135T375 160Q403 197 403 250Q403 313 360 358T245 403Z"></path></g></g></g><g data-mml-node="mi" transform="translate(2492.3,0)"><path data-c="1D436" d="M50 252Q50 367 117 473T286 641T490 704Q580 704 633 653Q642 643 648 636T656 626L657 623Q660 623 684 649Q691 655 699 663T715 679T725 690L740 705H746Q760 705 760 698Q760 694 728 561Q692 422 692 421Q690 416 687 415T669 413H653Q647 419 647 422Q647 423 648 429T650 449T651 481Q651 552 619 605T510 659Q484 659 454 652T382 628T299 572T226 479Q194 422 175 346T156 222Q156 108 232 58Q280 24 350 24Q441 24 512 92T606 240Q610 253 612 255T628 257Q648 257 648 248Q648 243 647 239Q618 132 523 55T319 -22Q206 -22 128 53T50 252Z"></path></g></g></g></svg></mjx-container></span> for at least one hour</li> |
| <li>Nasal Thermometer Probes</li> |
| <li>May be used if still in place from Operating Room (OR)</li> |
| <li>Should be removed when reversal agents are administered or at 8 hours, whichever comes first</li> |
| <li>If accuracy is being questioned, switch to oral temperatures</li> |
| </ul> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="iv.-weaning-criteria"> |
| IV. Weaning Criteria</h2> |
| <div class="table_tabular" style="text-align: center"> |
| <div class="inline-tabular"><table class="tabular"> |
| <tbody> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom: none !important; border-top: none !important; border-top-style: solid !important; border-top-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; " colspan="2">Patient Criteria for Ventilator Weaning</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Parameter</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Criteria</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Richmond Agitation-Sedation Scale (RASS)</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">+1 thru -1</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Cardiac Index</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; "><span class="math-inline "> |
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| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Mean Arterial Pressure (MAP)</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; "><span class="math-inline "> |
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| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Cardiac Rhythm</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Stable</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Inotropic Support</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">No more than one inotropic drip</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Chest Tube Drainage</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; "><span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.566ex;" xmlns="http://www.w3.org/2000/svg" width="9.574ex" height="2.262ex" role="img" focusable="false" viewBox="0 -750 4231.8 1000"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mo"><path data-c="3C" d="M694 -11T694 -19T688 -33T678 -40Q671 -40 524 29T234 166L90 235Q83 240 83 250Q83 261 91 266Q664 540 678 540Q681 540 687 534T694 519T687 505Q686 504 417 376L151 250L417 124Q686 -4 687 -5Q694 -11 694 -19Z"></path></g><g data-mml-node="mn" transform="translate(1055.8,0)"><path data-c="31" d="M213 578L200 573Q186 568 160 563T102 556H83V602H102Q149 604 189 617T245 641T273 663Q275 666 285 666Q294 666 302 660V361L303 61Q310 54 315 52T339 48T401 46H427V0H416Q395 3 257 3Q121 3 100 0H88V46H114Q136 46 152 46T177 47T193 50T201 52T207 57T213 61V578Z"></path><path data-c="30" d="M96 585Q152 666 249 666Q297 666 345 640T423 548Q460 465 460 320Q460 165 417 83Q397 41 362 16T301 -15T250 -22Q224 -22 198 -16T137 16T82 83Q39 165 39 320Q39 494 96 585ZM321 597Q291 629 250 629Q208 629 178 597Q153 571 145 525T137 333Q137 175 145 125T181 46Q209 16 250 16Q290 16 318 46Q347 76 354 130T362 333Q362 478 354 524T321 597Z" transform="translate(500,0)"></path><path data-c="30" d="M96 585Q152 666 249 666Q297 666 345 640T423 548Q460 465 460 320Q460 165 417 83Q397 41 362 16T301 -15T250 -22Q224 -22 198 -16T137 16T82 83Q39 165 39 320Q39 494 96 585ZM321 597Q291 629 250 629Q208 629 178 597Q153 571 145 525T137 333Q137 175 145 125T181 46Q209 16 250 16Q290 16 318 46Q347 76 354 130T362 333Q362 478 354 524T321 597Z" transform="translate(1000,0)"></path></g><g data-mml-node="mi" transform="translate(2555.8,0)"><path data-c="1D45A" d="M21 287Q22 293 24 303T36 341T56 388T88 425T132 442T175 435T205 417T221 395T229 376L231 369Q231 367 232 367L243 378Q303 442 384 442Q401 442 415 440T441 433T460 423T475 411T485 398T493 385T497 373T500 364T502 357L510 367Q573 442 659 442Q713 442 746 415T780 336Q780 285 742 178T704 50Q705 36 709 31T724 26Q752 26 776 56T815 138Q818 149 821 151T837 153Q857 153 857 145Q857 144 853 130Q845 101 831 73T785 17T716 -10Q669 -10 648 17T627 73Q627 92 663 193T700 345Q700 404 656 404H651Q565 404 506 303L499 291L466 157Q433 26 428 16Q415 -11 385 -11Q372 -11 364 -4T353 8T350 18Q350 29 384 161L420 307Q423 322 423 345Q423 404 379 404H374Q288 404 229 303L222 291L189 157Q156 26 151 16Q138 -11 108 -11Q95 -11 87 -5T76 7T74 17Q74 30 112 181Q151 335 151 342Q154 357 154 369Q154 405 129 405Q107 405 92 377T69 316T57 280Q55 278 41 278H27Q21 284 21 287Z"></path></g><g data-mml-node="mi" transform="translate(3433.8,0)"><path data-c="1D459" d="M117 59Q117 26 142 26Q179 26 205 131Q211 151 215 152Q217 153 225 153H229Q238 153 241 153T246 151T248 144Q247 138 245 128T234 90T214 43T183 6T137 -11Q101 -11 70 11T38 85Q38 97 39 102L104 360Q167 615 167 623Q167 626 166 628T162 632T157 634T149 635T141 636T132 637T122 637Q112 637 109 637T101 638T95 641T94 647Q94 649 96 661Q101 680 107 682T179 688Q194 689 213 690T243 693T254 694Q266 694 266 686Q266 675 193 386T118 83Q118 81 118 75T117 65V59Z"></path></g><g data-mml-node="TeXAtom" data-mjx-texclass="ORD" transform="translate(3731.8,0)"><g data-mml-node="mo"><path data-c="2F" d="M423 750Q432 750 438 744T444 730Q444 725 271 248T92 -240Q85 -250 75 -250Q68 -250 62 -245T56 -231Q56 -221 230 257T407 740Q411 750 423 750Z"></path></g></g></g></g></svg></mjx-container></span> hour</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Core Temperature</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; "><span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.312ex;" xmlns="http://www.w3.org/2000/svg" width="7.358ex" height="1.912ex" role="img" focusable="false" viewBox="0 -707 3252.3 845"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mo"><path data-c="2265" d="M83 616Q83 624 89 630T99 636Q107 636 253 568T543 431T687 361Q694 356 694 346T687 331Q685 329 395 192L107 56H101Q83 58 83 76Q83 77 83 79Q82 86 98 95Q117 105 248 167Q326 204 378 228L626 346L360 472Q291 505 200 548Q112 589 98 597T83 616ZM84 -118Q84 -108 99 -98H678Q694 -104 694 -118Q694 -130 679 -138H98Q84 -131 84 -118Z"></path></g><g data-mml-node="msup" transform="translate(1055.8,0)"><g data-mml-node="mn"><path data-c="33" d="M127 463Q100 463 85 480T69 524Q69 579 117 622T233 665Q268 665 277 664Q351 652 390 611T430 522Q430 470 396 421T302 350L299 348Q299 347 308 345T337 336T375 315Q457 262 457 175Q457 96 395 37T238 -22Q158 -22 100 21T42 130Q42 158 60 175T105 193Q133 193 151 175T169 130Q169 119 166 110T159 94T148 82T136 74T126 70T118 67L114 66Q165 21 238 21Q293 21 321 74Q338 107 338 175V195Q338 290 274 322Q259 328 213 329L171 330L168 332Q166 335 166 348Q166 366 174 366Q202 366 232 371Q266 376 294 413T322 525V533Q322 590 287 612Q265 626 240 626Q208 626 181 615T143 592T132 580H135Q138 579 143 578T153 573T165 566T175 555T183 540T186 520Q186 498 172 481T127 463Z"></path><path data-c="35" d="M164 157Q164 133 148 117T109 101H102Q148 22 224 22Q294 22 326 82Q345 115 345 210Q345 313 318 349Q292 382 260 382H254Q176 382 136 314Q132 307 129 306T114 304Q97 304 95 310Q93 314 93 485V614Q93 664 98 664Q100 666 102 666Q103 666 123 658T178 642T253 634Q324 634 389 662Q397 666 402 666Q410 666 410 648V635Q328 538 205 538Q174 538 149 544L139 546V374Q158 388 169 396T205 412T256 420Q337 420 393 355T449 201Q449 109 385 44T229 -22Q148 -22 99 32T50 154Q50 178 61 192T84 210T107 214Q132 214 148 197T164 157Z" transform="translate(500,0)"></path></g><g data-mml-node="TeXAtom" transform="translate(1033,393.1) scale(0.707)" data-mjx-texclass="ORD"><g data-mml-node="mo"><path data-c="2218" d="M55 251Q55 328 112 386T249 444T386 388T444 249Q444 171 388 113T250 55Q170 55 113 112T55 251ZM245 403Q188 403 142 361T96 250Q96 183 141 140T250 96Q284 96 313 109T354 135T375 160Q403 197 403 250Q403 313 360 358T245 403Z"></path></g></g></g><g data-mml-node="mi" transform="translate(2492.3,0)"><path data-c="1D436" d="M50 252Q50 367 117 473T286 641T490 704Q580 704 633 653Q642 643 648 636T656 626L657 623Q660 623 684 649Q691 655 699 663T715 679T725 690L740 705H746Q760 705 760 698Q760 694 728 561Q692 422 692 421Q690 416 687 415T669 413H653Q647 419 647 422Q647 423 648 429T650 449T651 481Q651 552 619 605T510 659Q484 659 454 652T382 628T299 572T226 479Q194 422 175 346T156 222Q156 108 232 58Q280 24 350 24Q441 24 512 92T606 240Q610 253 612 255T628 257Q648 257 648 248Q648 243 647 239Q618 132 523 55T319 -22Q206 -22 128 53T50 252Z"></path></g></g></g></svg></mjx-container></span></td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">pH</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; "><span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.312ex;" xmlns="http://www.w3.org/2000/svg" width="6.411ex" height="1.842ex" role="img" focusable="false" viewBox="0 -676 2833.8 814"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mo"><path data-c="2265" d="M83 616Q83 624 89 630T99 636Q107 636 253 568T543 431T687 361Q694 356 694 346T687 331Q685 329 395 192L107 56H101Q83 58 83 76Q83 77 83 79Q82 86 98 95Q117 105 248 167Q326 204 378 228L626 346L360 472Q291 505 200 548Q112 589 98 597T83 616ZM84 -118Q84 -108 99 -98H678Q694 -104 694 -118Q694 -130 679 -138H98Q84 -131 84 -118Z"></path></g><g data-mml-node="mn" transform="translate(1055.8,0)"><path data-c="37" d="M55 458Q56 460 72 567L88 674Q88 676 108 676H128V672Q128 662 143 655T195 646T364 644H485V605L417 512Q408 500 387 472T360 435T339 403T319 367T305 330T292 284T284 230T278 162T275 80Q275 66 275 52T274 28V19Q270 2 255 -10T221 -22Q210 -22 200 -19T179 0T168 40Q168 198 265 368Q285 400 349 489L395 552H302Q128 552 119 546Q113 543 108 522T98 479L95 458V455H55V458Z"></path><path data-c="2E" d="M78 60Q78 84 95 102T138 120Q162 120 180 104T199 61Q199 36 182 18T139 0T96 17T78 60Z" transform="translate(500,0)"></path><path data-c="33" d="M127 463Q100 463 85 480T69 524Q69 579 117 622T233 665Q268 665 277 664Q351 652 390 611T430 522Q430 470 396 421T302 350L299 348Q299 347 308 345T337 336T375 315Q457 262 457 175Q457 96 395 37T238 -22Q158 -22 100 21T42 130Q42 158 60 175T105 193Q133 193 151 175T169 130Q169 119 166 110T159 94T148 82T136 74T126 70T118 67L114 66Q165 21 238 21Q293 21 321 74Q338 107 338 175V195Q338 290 274 322Q259 328 213 329L171 330L168 332Q166 335 166 348Q166 366 174 366Q202 366 232 371Q266 376 294 413T322 525V533Q322 590 287 612Q265 626 240 626Q208 626 181 615T143 592T132 580H135Q138 579 143 578T153 573T165 566T175 555T183 540T186 520Q186 498 172 481T127 463Z" transform="translate(778,0)"></path><path data-c="32" d="M109 429Q82 429 66 447T50 491Q50 562 103 614T235 666Q326 666 387 610T449 465Q449 422 429 383T381 315T301 241Q265 210 201 149L142 93L218 92Q375 92 385 97Q392 99 409 186V189H449V186Q448 183 436 95T421 3V0H50V19V31Q50 38 56 46T86 81Q115 113 136 137Q145 147 170 174T204 211T233 244T261 278T284 308T305 340T320 369T333 401T340 431T343 464Q343 527 309 573T212 619Q179 619 154 602T119 569T109 550Q109 549 114 549Q132 549 151 535T170 489Q170 464 154 447T109 429Z" transform="translate(1278,0)"></path></g></g></g></svg></mjx-container></span></td> |
| </tr> |
| </tbody> |
| </table> |
| </div></div> |
| <div>V. Page ICU Provider at time patient placed on Continuous Positive Airway Pressure (CPAP) 5/5</div> |
| <ul> |
| <li>Notify provider if cuff leak present or not<br> |
| VI. Arterial Blood Gas (ABG) should be obtained 30 minutes after placed on CPAP</li> |
| <li>Patient condition may warrant earlier sampling to expedite extubation</li> |
| <li>Should discuss with team</li> |
| </ul> |
| <div>Effect of Postoperative Intravenous Acetaminophen versus Placebo, Combined with Propofol or Dexmedetomidine, on Postoperative In-Hospital Delirium Among Older Patients Following Cardiac Surgery: The DEXACET Randomized Clinical Trial</div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="extubation"> |
| EXTUBATION</h2> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="vii.-extubation-criteria"> |
| VII. Extubation Criteria</h2> |
| <div class="table_tabular" style="text-align: center"> |
| <div class="inline-tabular"><table class="tabular"> |
| <tbody> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom: none !important; border-top: none !important; border-top-style: solid !important; border-top-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; " colspan="2">Patient Criteria for Extubation</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Parameter</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Criteria</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Strength</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Able to lift and hold head for <span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.312ex;" xmlns="http://www.w3.org/2000/svg" width="6.615ex" height="1.819ex" role="img" focusable="false" viewBox="0 -666 2923.8 804"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mo"><path data-c="2265" d="M83 616Q83 624 89 630T99 636Q107 636 253 568T543 431T687 361Q694 356 694 346T687 331Q685 329 395 192L107 56H101Q83 58 83 76Q83 77 83 79Q82 86 98 95Q117 105 248 167Q326 204 378 228L626 346L360 472Q291 505 200 548Q112 589 98 597T83 616ZM84 -118Q84 -108 99 -98H678Q694 -104 694 -118Q694 -130 679 -138H98Q84 -131 84 -118Z"></path></g><g data-mml-node="mn" transform="translate(1055.8,0)"><path data-c="35" d="M164 157Q164 133 148 117T109 101H102Q148 22 224 22Q294 22 326 82Q345 115 345 210Q345 313 318 349Q292 382 260 382H254Q176 382 136 314Q132 307 129 306T114 304Q97 304 95 310Q93 314 93 485V614Q93 664 98 664Q100 666 102 666Q103 666 123 658T178 642T253 634Q324 634 389 662Q397 666 402 666Q410 666 410 648V635Q328 538 205 538Q174 538 149 544L139 546V374Q158 388 169 396T205 412T256 420Q337 420 393 355T449 201Q449 109 385 44T229 -22Q148 -22 99 32T50 154Q50 178 61 192T84 210T107 214Q132 214 148 197T164 157Z"></path></g><g data-mml-node="mi" transform="translate(1555.8,0)"><path data-c="1D460" d="M131 289Q131 321 147 354T203 415T300 442Q362 442 390 415T419 355Q419 323 402 308T364 292Q351 292 340 300T328 326Q328 342 337 354T354 372T367 378Q368 378 368 379Q368 382 361 388T336 399T297 405Q249 405 227 379T204 326Q204 301 223 291T278 274T330 259Q396 230 396 163Q396 135 385 107T352 51T289 7T195 -10Q118 -10 86 19T53 87Q53 126 74 143T118 160Q133 160 146 151T160 120Q160 94 142 76T111 58Q109 57 108 57T107 55Q108 52 115 47T146 34T201 27Q237 27 263 38T301 66T318 97T323 122Q323 150 302 164T254 181T195 196T148 231Q131 256 131 289Z"></path></g><g data-mml-node="mi" transform="translate(2024.8,0)"><path data-c="1D452" d="M39 168Q39 225 58 272T107 350T174 402T244 433T307 442H310Q355 442 388 420T421 355Q421 265 310 237Q261 224 176 223Q139 223 138 221Q138 219 132 186T125 128Q125 81 146 54T209 26T302 45T394 111Q403 121 406 121Q410 121 419 112T429 98T420 82T390 55T344 24T281 -1T205 -11Q126 -11 83 42T39 168ZM373 353Q367 405 305 405Q272 405 244 391T199 357T170 316T154 280T149 261Q149 260 169 260Q282 260 327 284T373 353Z"></path></g><g data-mml-node="mi" transform="translate(2490.8,0)"><path data-c="1D450" d="M34 159Q34 268 120 355T306 442Q362 442 394 418T427 355Q427 326 408 306T360 285Q341 285 330 295T319 325T330 359T352 380T366 386H367Q367 388 361 392T340 400T306 404Q276 404 249 390Q228 381 206 359Q162 315 142 235T121 119Q121 73 147 50Q169 26 205 26H209Q321 26 394 111Q403 121 406 121Q410 121 419 112T429 98T420 83T391 55T346 25T282 0T202 -11Q127 -11 81 37T34 159Z"></path></g></g></g></svg></mjx-container></span></td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">RASS</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">+1 to -1</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Heart Rate</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">60-100</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Cardiac Index</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; "><span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.566ex;" xmlns="http://www.w3.org/2000/svg" width="16.182ex" height="2.452ex" role="img" focusable="false" viewBox="0 -833.9 7152.3 1083.9"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mo"><path data-c="2265" d="M83 616Q83 624 89 630T99 636Q107 636 253 568T543 431T687 361Q694 356 694 346T687 331Q685 329 395 192L107 56H101Q83 58 83 76Q83 77 83 79Q82 86 98 95Q117 105 248 167Q326 204 378 228L626 346L360 472Q291 505 200 548Q112 589 98 597T83 616ZM84 -118Q84 -108 99 -98H678Q694 -104 694 -118Q694 -130 679 -138H98Q84 -131 84 -118Z"></path></g><g data-mml-node="mn" transform="translate(1055.8,0)"><path data-c="32" d="M109 429Q82 429 66 447T50 491Q50 562 103 614T235 666Q326 666 387 610T449 465Q449 422 429 383T381 315T301 241Q265 210 201 149L142 93L218 92Q375 92 385 97Q392 99 409 186V189H449V186Q448 183 436 95T421 3V0H50V19V31Q50 38 56 46T86 81Q115 113 136 137Q145 147 170 174T204 211T233 244T261 278T284 308T305 340T320 369T333 401T340 431T343 464Q343 527 309 573T212 619Q179 619 154 602T119 569T109 550Q109 549 114 549Q132 549 151 535T170 489Q170 464 154 447T109 429Z"></path><path data-c="2E" d="M78 60Q78 84 95 102T138 120Q162 120 180 104T199 61Q199 36 182 18T139 0T96 17T78 60Z" transform="translate(500,0)"></path><path data-c="30" d="M96 585Q152 666 249 666Q297 666 345 640T423 548Q460 465 460 320Q460 165 417 83Q397 41 362 16T301 -15T250 -22Q224 -22 198 -16T137 16T82 83Q39 165 39 320Q39 494 96 585ZM321 597Q291 629 250 629Q208 629 178 597Q153 571 145 525T137 333Q137 175 145 125T181 46Q209 16 250 16Q290 16 318 46Q347 76 354 130T362 333Q362 478 354 524T321 597Z" transform="translate(778,0)"></path></g><g data-mml-node="mi" transform="translate(2333.8,0)"><path data-c="1D43F" d="M228 637Q194 637 192 641Q191 643 191 649Q191 673 202 682Q204 683 217 683Q271 680 344 680Q485 680 506 683H518Q524 677 524 674T522 656Q517 641 513 637H475Q406 636 394 628Q387 624 380 600T313 336Q297 271 279 198T252 88L243 52Q243 48 252 48T311 46H328Q360 46 379 47T428 54T478 72T522 106T564 161Q580 191 594 228T611 270Q616 273 628 273H641Q647 264 647 262T627 203T583 83T557 9Q555 4 553 3T537 0T494 -1Q483 -1 418 -1T294 0H116Q32 0 32 10Q32 17 34 24Q39 43 44 45Q48 46 59 46H65Q92 46 125 49Q139 52 144 61Q147 65 216 339T285 628Q285 635 228 637Z"></path></g><g data-mml-node="TeXAtom" data-mjx-texclass="ORD" transform="translate(3014.8,0)"><g data-mml-node="mo"><path data-c="2F" d="M423 750Q432 750 438 744T444 730Q444 725 271 248T92 -240Q85 -250 75 -250Q68 -250 62 -245T56 -231Q56 -221 230 257T407 740Q411 750 423 750Z"></path></g></g><g data-mml-node="mi" transform="translate(3514.8,0)"><path data-c="1D45A" d="M21 287Q22 293 24 303T36 341T56 388T88 425T132 442T175 435T205 417T221 395T229 376L231 369Q231 367 232 367L243 378Q303 442 384 442Q401 442 415 440T441 433T460 423T475 411T485 398T493 385T497 373T500 364T502 357L510 367Q573 442 659 442Q713 442 746 415T780 336Q780 285 742 178T704 50Q705 36 709 31T724 26Q752 26 776 56T815 138Q818 149 821 151T837 153Q857 153 857 145Q857 144 853 130Q845 101 831 73T785 17T716 -10Q669 -10 648 17T627 73Q627 92 663 193T700 345Q700 404 656 404H651Q565 404 506 303L499 291L466 157Q433 26 428 16Q415 -11 385 -11Q372 -11 364 -4T353 8T350 18Q350 29 384 161L420 307Q423 322 423 345Q423 404 379 404H374Q288 404 229 303L222 291L189 157Q156 26 151 16Q138 -11 108 -11Q95 -11 87 -5T76 7T74 17Q74 30 112 181Q151 335 151 342Q154 357 154 369Q154 405 129 405Q107 405 92 377T69 316T57 280Q55 278 41 278H27Q21 284 21 287Z"></path></g><g data-mml-node="mi" transform="translate(4392.8,0)"><path data-c="1D456" d="M184 600Q184 624 203 642T247 661Q265 661 277 649T290 619Q290 596 270 577T226 557Q211 557 198 567T184 600ZM21 287Q21 295 30 318T54 369T98 420T158 442Q197 442 223 419T250 357Q250 340 236 301T196 196T154 83Q149 61 149 51Q149 26 166 26Q175 26 185 29T208 43T235 78T260 137Q263 149 265 151T282 153Q302 153 302 143Q302 135 293 112T268 61T223 11T161 -11Q129 -11 102 10T74 74Q74 91 79 106T122 220Q160 321 166 341T173 380Q173 404 156 404H154Q124 404 99 371T61 287Q60 286 59 284T58 281T56 279T53 278T49 278T41 278H27Q21 284 21 287Z"></path></g><g data-mml-node="mi" transform="translate(4737.8,0)"><path data-c="1D45B" d="M21 287Q22 293 24 303T36 341T56 388T89 425T135 442Q171 442 195 424T225 390T231 369Q231 367 232 367L243 378Q304 442 382 442Q436 442 469 415T503 336T465 179T427 52Q427 26 444 26Q450 26 453 27Q482 32 505 65T540 145Q542 153 560 153Q580 153 580 145Q580 144 576 130Q568 101 554 73T508 17T439 -10Q392 -10 371 17T350 73Q350 92 386 193T423 345Q423 404 379 404H374Q288 404 229 303L222 291L189 157Q156 26 151 16Q138 -11 108 -11Q95 -11 87 -5T76 7T74 17Q74 30 112 180T152 343Q153 348 153 366Q153 405 129 405Q91 405 66 305Q60 285 60 284Q58 278 41 278H27Q21 284 21 287Z"></path></g><g data-mml-node="TeXAtom" data-mjx-texclass="ORD" transform="translate(5337.8,0)"><g data-mml-node="mo"><path data-c="2F" d="M423 750Q432 750 438 744T444 730Q444 725 271 248T92 -240Q85 -250 75 -250Q68 -250 62 -245T56 -231Q56 -221 230 257T407 740Q411 750 423 750Z"></path></g></g><g data-mml-node="msup" transform="translate(5837.8,0)"><g data-mml-node="mi"><path data-c="1D45A" d="M21 287Q22 293 24 303T36 341T56 388T88 425T132 442T175 435T205 417T221 395T229 376L231 369Q231 367 232 367L243 378Q303 442 384 442Q401 442 415 440T441 433T460 423T475 411T485 398T493 385T497 373T500 364T502 357L510 367Q573 442 659 442Q713 442 746 415T780 336Q780 285 742 178T704 50Q705 36 709 31T724 26Q752 26 776 56T815 138Q818 149 821 151T837 153Q857 153 857 145Q857 144 853 130Q845 101 831 73T785 17T716 -10Q669 -10 648 17T627 73Q627 92 663 193T700 345Q700 404 656 404H651Q565 404 506 303L499 291L466 157Q433 26 428 16Q415 -11 385 -11Q372 -11 364 -4T353 8T350 18Q350 29 384 161L420 307Q423 322 423 345Q423 404 379 404H374Q288 404 229 303L222 291L189 157Q156 26 151 16Q138 -11 108 -11Q95 -11 87 -5T76 7T74 17Q74 30 112 181Q151 335 151 342Q154 357 154 369Q154 405 129 405Q107 405 92 377T69 316T57 280Q55 278 41 278H27Q21 284 21 287Z"></path></g><g data-mml-node="TeXAtom" transform="translate(911,363) scale(0.707)" data-mjx-texclass="ORD"><g data-mml-node="mn"><path data-c="32" d="M109 429Q82 429 66 447T50 491Q50 562 103 614T235 666Q326 666 387 610T449 465Q449 422 429 383T381 315T301 241Q265 210 201 149L142 93L218 92Q375 92 385 97Q392 99 409 186V189H449V186Q448 183 436 95T421 3V0H50V19V31Q50 38 56 46T86 81Q115 113 136 137Q145 147 170 174T204 211T233 244T261 278T284 308T305 340T320 369T333 401T340 431T343 464Q343 527 309 573T212 619Q179 619 154 602T119 569T109 550Q109 549 114 549Q132 549 151 535T170 489Q170 464 154 447T109 429Z"></path></g></g></g></g></g></svg></mjx-container></span></td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">MAP</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; "><span class="math-inline "> |
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-111Q116 -121 114 -130T107 -144T99 -154T92 -162L90 -164H91Q101 -167 151 -167Q189 -167 211 -155Q234 -144 254 -122T282 -75Q288 -56 298 -13Q311 35 311 43ZM384 328L380 339Q377 350 375 354T369 368T359 382T346 393T328 402T306 405Q262 405 221 352Q191 313 171 233T151 117Q151 38 213 38Q269 38 323 108L331 118L384 328Z"></path></g></g></g></svg></mjx-container></span></td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Cardiac Rhythm</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Stable</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Inotropic Support</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">No increase</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Chest Tube Drainage</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; "><span class="math-inline "> |
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| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Core Temperature</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; "><span class="math-inline "> |
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248 244 248Z"></path><path data-c="36" d="M42 313Q42 476 123 571T303 666Q372 666 402 630T432 550Q432 525 418 510T379 495Q356 495 341 509T326 548Q326 592 373 601Q351 623 311 626Q240 626 194 566Q147 500 147 364L148 360Q153 366 156 373Q197 433 263 433H267Q313 433 348 414Q372 400 396 374T435 317Q456 268 456 210V192Q456 169 451 149Q440 90 387 34T253 -22Q225 -22 199 -14T143 16T92 75T56 172T42 313ZM257 397Q227 397 205 380T171 335T154 278T148 216Q148 133 160 97T198 39Q222 21 251 21Q302 21 329 59Q342 77 347 104T352 209Q352 289 347 316T329 361Q302 397 257 397Z" transform="translate(500,0)"></path><path data-c="2E" d="M78 60Q78 84 95 102T138 120Q162 120 180 104T199 61Q199 36 182 18T139 0T96 17T78 60Z" transform="translate(1000,0)"></path><path data-c="38" d="M70 417T70 494T124 618T248 666Q319 666 374 624T429 515Q429 485 418 459T392 417T361 389T335 371T324 363L338 354Q352 344 366 334T382 323Q457 264 457 174Q457 95 399 37T249 -22Q159 -22 101 29T43 155Q43 263 172 335L154 348Q133 361 127 368Q70 417 70 494ZM286 386L292 390Q298 394 301 396T311 403T323 413T334 425T345 438T355 454T364 471T369 491T371 513Q371 556 342 586T275 624Q268 625 242 625Q201 625 165 599T128 534Q128 511 141 492T167 463T217 431Q224 426 228 424L286 386ZM250 21Q308 21 350 55T392 137Q392 154 387 169T375 194T353 216T330 234T301 253T274 270Q260 279 244 289T218 306L210 311Q204 311 181 294T133 239T107 157Q107 98 150 60T250 21Z" transform="translate(1278,0)"></path></g><g data-mml-node="TeXAtom" transform="translate(1811,393.1) scale(0.707)" data-mjx-texclass="ORD"><g data-mml-node="mo"><path data-c="2218" d="M55 251Q55 328 112 386T249 444T386 388T444 249Q444 171 388 113T250 55Q170 55 113 112T55 251ZM245 403Q188 403 142 361T96 250Q96 183 141 140T250 96Q284 96 313 109T354 135T375 160Q403 197 403 250Q403 313 360 358T245 403Z"></path></g></g></g><g data-mml-node="mi" transform="translate(2603.6,0)"><path data-c="1D439" d="M48 1Q31 1 31 11Q31 13 34 25Q38 41 42 43T65 46Q92 46 125 49Q139 52 144 61Q146 66 215 342T285 622Q285 629 281 629Q273 632 228 634H197Q191 640 191 642T193 659Q197 676 203 680H742Q749 676 749 669Q749 664 736 557T722 447Q720 440 702 440H690Q683 445 683 453Q683 454 686 477T689 530Q689 560 682 579T663 610T626 626T575 633T503 634H480Q398 633 393 631Q388 629 386 623Q385 622 352 492L320 363H375Q378 363 398 363T426 364T448 367T472 374T489 386Q502 398 511 419T524 457T529 475Q532 480 548 480H560Q567 475 567 470Q567 467 536 339T502 207Q500 200 482 200H470Q463 206 463 212Q463 215 468 234T473 274Q473 303 453 310T364 317H309L277 190Q245 66 245 60Q245 46 334 46H359Q365 40 365 39T363 19Q359 6 353 0H336Q295 2 185 2Q120 2 86 2T48 1Z"></path></g><g data-mml-node="mo" transform="translate(3352.6,0)"><path data-c="29" d="M60 749L64 750Q69 750 74 750H86L114 726Q208 641 251 514T294 250Q294 182 284 119T261 12T224 -76T186 -143T145 -194T113 -227T90 -246Q87 -249 86 -250H74Q66 -250 63 -250T58 -247T55 -238Q56 -237 66 -225Q221 -64 221 250T66 725Q56 737 55 738Q55 746 60 749Z"></path></g></g></g></g></svg></mjx-container></span></td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Respiratory Rate</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; "><span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.439ex;" xmlns="http://www.w3.org/2000/svg" width="11.386ex" height="2.009ex" role="img" focusable="false" viewBox="0 -694 5032.4 888"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mn"><path data-c="31" d="M213 578L200 573Q186 568 160 563T102 556H83V602H102Q149 604 189 617T245 641T273 663Q275 666 285 666Q294 666 302 660V361L303 61Q310 54 315 52T339 48T401 46H427V0H416Q395 3 257 3Q121 3 100 0H88V46H114Q136 46 152 46T177 47T193 50T201 52T207 57T213 61V578Z"></path><path data-c="30" d="M96 585Q152 666 249 666Q297 666 345 640T423 548Q460 465 460 320Q460 165 417 83Q397 41 362 16T301 -15T250 -22Q224 -22 198 -16T137 16T82 83Q39 165 39 320Q39 494 96 585ZM321 597Q291 629 250 629Q208 629 178 597Q153 571 145 525T137 333Q137 175 145 125T181 46Q209 16 250 16Q290 16 318 46Q347 76 354 130T362 333Q362 478 354 524T321 597Z" transform="translate(500,0)"></path></g><g data-mml-node="mo" transform="translate(1222.2,0)"><path data-c="2212" d="M84 237T84 250T98 270H679Q694 262 694 250T679 230H98Q84 237 84 250Z"></path></g><g data-mml-node="mn" transform="translate(2222.4,0)"><path data-c="32" d="M109 429Q82 429 66 447T50 491Q50 562 103 614T235 666Q326 666 387 610T449 465Q449 422 429 383T381 315T301 241Q265 210 201 149L142 93L218 92Q375 92 385 97Q392 99 409 186V189H449V186Q448 183 436 95T421 3V0H50V19V31Q50 38 56 46T86 81Q115 113 136 137Q145 147 170 174T204 211T233 244T261 278T284 308T305 340T320 369T333 401T340 431T343 464Q343 527 309 573T212 619Q179 619 154 602T119 569T109 550Q109 549 114 549Q132 549 151 535T170 489Q170 464 154 447T109 429Z"></path><path data-c="34" d="M462 0Q444 3 333 3Q217 3 199 0H190V46H221Q241 46 248 46T265 48T279 53T286 61Q287 63 287 115V165H28V211L179 442Q332 674 334 675Q336 677 355 677H373L379 671V211H471V165H379V114Q379 73 379 66T385 54Q393 47 442 46H471V0H462ZM293 211V545L74 212L183 211H293Z" transform="translate(500,0)"></path></g><g data-mml-node="mi" transform="translate(3222.4,0)"><path data-c="1D44F" d="M73 647Q73 657 77 670T89 683Q90 683 161 688T234 694Q246 694 246 685T212 542Q204 508 195 472T180 418L176 399Q176 396 182 402Q231 442 283 442Q345 442 383 396T422 280Q422 169 343 79T173 -11Q123 -11 82 27T40 150V159Q40 180 48 217T97 414Q147 611 147 623T109 637Q104 637 101 637H96Q86 637 83 637T76 640T73 647ZM336 325V331Q336 405 275 405Q258 405 240 397T207 376T181 352T163 330L157 322L136 236Q114 150 114 114Q114 66 138 42Q154 26 178 26Q211 26 245 58Q270 81 285 114T318 219Q336 291 336 325Z"></path></g><g data-mml-node="mi" transform="translate(3651.4,0)"><path data-c="1D45D" d="M23 287Q24 290 25 295T30 317T40 348T55 381T75 411T101 433T134 442Q209 442 230 378L240 387Q302 442 358 442Q423 442 460 395T497 281Q497 173 421 82T249 -10Q227 -10 210 -4Q199 1 187 11T168 28L161 36Q160 35 139 -51T118 -138Q118 -144 126 -145T163 -148H188Q194 -155 194 -157T191 -175Q188 -187 185 -190T172 -194Q170 -194 161 -194T127 -193T65 -192Q-5 -192 -24 -194H-32Q-39 -187 -39 -183Q-37 -156 -26 -148H-6Q28 -147 33 -136Q36 -130 94 103T155 350Q156 355 156 364Q156 405 131 405Q109 405 94 377T71 316T59 280Q57 278 43 278H29Q23 284 23 287ZM178 102Q200 26 252 26Q282 26 310 49T356 107Q374 141 392 215T411 325V331Q411 405 350 405Q339 405 328 402T306 393T286 380T269 365T254 350T243 336T235 326L232 322Q232 321 229 308T218 264T204 212Q178 106 178 102Z"></path></g><g data-mml-node="mi" transform="translate(4154.4,0)"><path data-c="1D45A" d="M21 287Q22 293 24 303T36 341T56 388T88 425T132 442T175 435T205 417T221 395T229 376L231 369Q231 367 232 367L243 378Q303 442 384 442Q401 442 415 440T441 433T460 423T475 411T485 398T493 385T497 373T500 364T502 357L510 367Q573 442 659 442Q713 442 746 415T780 336Q780 285 742 178T704 50Q705 36 709 31T724 26Q752 26 776 56T815 138Q818 149 821 151T837 153Q857 153 857 145Q857 144 853 130Q845 101 831 73T785 17T716 -10Q669 -10 648 17T627 73Q627 92 663 193T700 345Q700 404 656 404H651Q565 404 506 303L499 291L466 157Q433 26 428 16Q415 -11 385 -11Q372 -11 364 -4T353 8T350 18Q350 29 384 161L420 307Q423 322 423 345Q423 404 379 404H374Q288 404 229 303L222 291L189 157Q156 26 151 16Q138 -11 108 -11Q95 -11 87 -5T76 7T74 17Q74 30 112 181Q151 335 151 342Q154 357 154 369Q154 405 129 405Q107 405 92 377T69 316T57 280Q55 278 41 278H27Q21 284 21 287Z"></path></g></g></g></svg></mjx-container></span></td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">ABG on following settings: CPAP FiO2 <span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.312ex;" xmlns="http://www.w3.org/2000/svg" width="6.536ex" height="2.009ex" role="img" focusable="false" viewBox="0 -750 2888.8 888"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mo"><path data-c="2264" d="M674 636Q682 636 688 630T694 615T687 601Q686 600 417 472L151 346L399 228Q687 92 691 87Q694 81 694 76Q694 58 676 56H670L382 192Q92 329 90 331Q83 336 83 348Q84 359 96 365Q104 369 382 500T665 634Q669 636 674 636ZM84 -118Q84 -108 99 -98H678Q694 -104 694 -118Q694 -130 679 -138H98Q84 -131 84 -118Z"></path></g><g data-mml-node="mn" transform="translate(1055.8,0)"><path data-c="35" d="M164 157Q164 133 148 117T109 101H102Q148 22 224 22Q294 22 326 82Q345 115 345 210Q345 313 318 349Q292 382 260 382H254Q176 382 136 314Q132 307 129 306T114 304Q97 304 95 310Q93 314 93 485V614Q93 664 98 664Q100 666 102 666Q103 666 123 658T178 642T253 634Q324 634 389 662Q397 666 402 666Q410 666 410 648V635Q328 538 205 538Q174 538 149 544L139 546V374Q158 388 169 396T205 412T256 420Q337 420 393 355T449 201Q449 109 385 44T229 -22Q148 -22 99 32T50 154Q50 178 61 192T84 210T107 214Q132 214 148 197T164 157Z"></path><path data-c="30" d="M96 585Q152 666 249 666Q297 666 345 640T423 548Q460 465 460 320Q460 165 417 83Q397 41 362 16T301 -15T250 -22Q224 -22 198 -16T137 16T82 83Q39 165 39 320Q39 494 96 585ZM321 597Q291 629 250 629Q208 629 178 597Q153 571 145 525T137 333Q137 175 145 125T181 46Q209 16 250 16Q290 16 318 46Q347 76 354 130T362 333Q362 478 354 524T321 597Z" transform="translate(500,0)"></path></g><g data-mml-node="mi" transform="translate(2055.8,0)"><path data-c="25" d="M465 605Q428 605 394 614T340 632T319 641Q332 608 332 548Q332 458 293 403T202 347Q145 347 101 402T56 548Q56 637 101 693T202 750Q241 750 272 719Q359 642 464 642Q580 642 650 732Q662 748 668 749Q670 750 673 750Q682 750 688 743T693 726Q178 -47 170 -52Q166 -56 160 -56Q147 -56 142 -45Q137 -36 142 -27Q143 -24 363 304Q469 462 525 546T581 630Q528 605 465 605ZM207 385Q235 385 263 427T292 548Q292 617 267 664T200 712Q193 712 186 709T167 698T147 668T134 615Q132 595 132 548V527Q132 436 165 403Q183 385 203 385H207ZM500 146Q500 234 544 290T647 347Q699 347 737 292T776 146T737 0T646 -56Q590 -56 545 0T500 146ZM651 -18Q679 -18 707 24T736 146Q736 215 711 262T644 309Q637 309 630 306T611 295T591 265T578 212Q577 200 577 146V124Q577 -18 647 -18H651Z"></path></g></g></g></svg></mjx-container></span> PEEP 5 PS 5</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">pH 7.34-7.45; pCO2 35-45; <span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.312ex;" xmlns="http://www.w3.org/2000/svg" width="11.033ex" height="1.905ex" role="img" focusable="false" viewBox="0 -704 4876.6 842"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mi"><path data-c="1D443" d="M287 628Q287 635 230 637Q206 637 199 638T192 648Q192 649 194 659Q200 679 203 681T397 683Q587 682 600 680Q664 669 707 631T751 530Q751 453 685 389Q616 321 507 303Q500 302 402 301H307L277 182Q247 66 247 59Q247 55 248 54T255 50T272 48T305 46H336Q342 37 342 35Q342 19 335 5Q330 0 319 0Q316 0 282 1T182 2Q120 2 87 2T51 1Q33 1 33 11Q33 13 36 25Q40 41 44 43T67 46Q94 46 127 49Q141 52 146 61Q149 65 218 339T287 628ZM645 554Q645 567 643 575T634 597T609 619T560 635Q553 636 480 637Q463 637 445 637T416 636T404 636Q391 635 386 627Q384 621 367 550T332 412T314 344Q314 342 395 342H407H430Q542 342 590 392Q617 419 631 471T645 554Z"></path></g><g data-mml-node="mi" transform="translate(751,0)"><path data-c="1D44E" d="M33 157Q33 258 109 349T280 441Q331 441 370 392Q386 422 416 422Q429 422 439 414T449 394Q449 381 412 234T374 68Q374 43 381 35T402 26Q411 27 422 35Q443 55 463 131Q469 151 473 152Q475 153 483 153H487Q506 153 506 144Q506 138 501 117T481 63T449 13Q436 0 417 -8Q409 -10 393 -10Q359 -10 336 5T306 36L300 51Q299 52 296 50Q294 48 292 46Q233 -10 172 -10Q117 -10 75 30T33 157ZM351 328Q351 334 346 350T323 385T277 405Q242 405 210 374T160 293Q131 214 119 129Q119 126 119 118T118 106Q118 61 136 44T179 26Q217 26 254 59T298 110Q300 114 325 217T351 328Z"></path></g><g data-mml-node="mi" transform="translate(1280,0)"><path data-c="1D442" d="M740 435Q740 320 676 213T511 42T304 -22Q207 -22 138 35T51 201Q50 209 50 244Q50 346 98 438T227 601Q351 704 476 704Q514 704 524 703Q621 689 680 617T740 435ZM637 476Q637 565 591 615T476 665Q396 665 322 605Q242 542 200 428T157 216Q157 126 200 73T314 19Q404 19 485 98T608 313Q637 408 637 476Z"></path></g><g data-mml-node="mn" transform="translate(2043,0)"><path data-c="32" d="M109 429Q82 429 66 447T50 491Q50 562 103 614T235 666Q326 666 387 610T449 465Q449 422 429 383T381 315T301 241Q265 210 201 149L142 93L218 92Q375 92 385 97Q392 99 409 186V189H449V186Q448 183 436 95T421 3V0H50V19V31Q50 38 56 46T86 81Q115 113 136 137Q145 147 170 174T204 211T233 244T261 278T284 308T305 340T320 369T333 401T340 431T343 464Q343 527 309 573T212 619Q179 619 154 602T119 569T109 550Q109 549 114 549Q132 549 151 535T170 489Q170 464 154 447T109 429Z"></path></g><g data-mml-node="mo" transform="translate(2820.8,0)"><path data-c="2265" d="M83 616Q83 624 89 630T99 636Q107 636 253 568T543 431T687 361Q694 356 694 346T687 331Q685 329 395 192L107 56H101Q83 58 83 76Q83 77 83 79Q82 86 98 95Q117 105 248 167Q326 204 378 228L626 346L360 472Q291 505 200 548Q112 589 98 597T83 616ZM84 -118Q84 -108 99 -98H678Q694 -104 694 -118Q694 -130 679 -138H98Q84 -131 84 -118Z"></path></g><g data-mml-node="mn" transform="translate(3876.6,0)"><path data-c="38" d="M70 417T70 494T124 618T248 666Q319 666 374 624T429 515Q429 485 418 459T392 417T361 389T335 371T324 363L338 354Q352 344 366 334T382 323Q457 264 457 174Q457 95 399 37T249 -22Q159 -22 101 29T43 155Q43 263 172 335L154 348Q133 361 127 368Q70 417 70 494ZM286 386L292 390Q298 394 301 396T311 403T323 413T334 425T345 438T355 454T364 471T369 491T371 513Q371 556 342 586T275 624Q268 625 242 625Q201 625 165 599T128 534Q128 511 141 492T167 463T217 431Q224 426 228 424L286 386ZM250 21Q308 21 350 55T392 137Q392 154 387 169T375 194T353 216T330 234T301 253T274 270Q260 279 244 289T218 306L210 311Q204 311 181 294T133 239T107 157Q107 98 150 60T250 21Z"></path><path data-c="30" d="M96 585Q152 666 249 666Q297 666 345 640T423 548Q460 465 460 320Q460 165 417 83Q397 41 362 16T301 -15T250 -22Q224 -22 198 -16T137 16T82 83Q39 165 39 320Q39 494 96 585ZM321 597Q291 629 250 629Q208 629 178 597Q153 571 145 525T137 333Q137 175 145 125T181 46Q209 16 250 16Q290 16 318 46Q347 76 354 130T362 333Q362 478 354 524T321 597Z" transform="translate(500,0)"></path></g></g></g></svg></mjx-container></span></td> |
| </tr> |
| </tbody> |
| </table> |
| </div></div> |
| <div>VIII. If not within fast track criteria then page the ICU provider immediately to discuss plan of action and if not ready for extubation return to step IV.</div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="ix.-meets-extubation-criteria"> |
| IX. Meets Extubation Criteria</h2> |
| <ul> |
| <li>Decision to proceed with extubation may be made by the CVICU RN, in coordination with the CVICU RT</li> |
| <li>For patients with a difficult airway, the plan to extubate should be discussed with the intensivist and ICU provider, prior to extubation</li> |
| </ul> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="x.-extubate"> |
| X. Extubate</h2> |
| <ul> |
| <li>Head of Bed (HOB) should be elevated at least <span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.05ex;" xmlns="http://www.w3.org/2000/svg" width="3.25ex" height="1.649ex" role="img" focusable="false" viewBox="0 -707 1436.6 729"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="msup"><g data-mml-node="mn"><path data-c="36" d="M42 313Q42 476 123 571T303 666Q372 666 402 630T432 550Q432 525 418 510T379 495Q356 495 341 509T326 548Q326 592 373 601Q351 623 311 626Q240 626 194 566Q147 500 147 364L148 360Q153 366 156 373Q197 433 263 433H267Q313 433 348 414Q372 400 396 374T435 317Q456 268 456 210V192Q456 169 451 149Q440 90 387 34T253 -22Q225 -22 199 -14T143 16T92 75T56 172T42 313ZM257 397Q227 397 205 380T171 335T154 278T148 216Q148 133 160 97T198 39Q222 21 251 21Q302 21 329 59Q342 77 347 104T352 209Q352 289 347 316T329 361Q302 397 257 397Z"></path><path data-c="30" d="M96 585Q152 666 249 666Q297 666 345 640T423 548Q460 465 460 320Q460 165 417 83Q397 41 362 16T301 -15T250 -22Q224 -22 198 -16T137 16T82 83Q39 165 39 320Q39 494 96 585ZM321 597Q291 629 250 629Q208 629 178 597Q153 571 145 525T137 333Q137 175 145 125T181 46Q209 16 250 16Q290 16 318 46Q347 76 354 130T362 333Q362 478 354 524T321 597Z" transform="translate(500,0)"></path></g><g data-mml-node="TeXAtom" transform="translate(1033,393.1) scale(0.707)" data-mjx-texclass="ORD"><g data-mml-node="mo"><path data-c="2218" d="M55 251Q55 328 112 386T249 444T386 388T444 249Q444 171 388 113T250 55Q170 55 113 112T55 251ZM245 403Q188 403 142 361T96 250Q96 183 141 140T250 96Q284 96 313 109T354 135T375 160Q403 197 403 250Q403 313 360 358T245 403Z"></path></g></g></g></g></g></svg></mjx-container></span> unless contraindicated</li> |
| <li>Endotracheal Tube (ETT) should be suctioned prior to extubation, with hyperoxygenation of the patient before and after suctioning (use the Suction 100% function on ventilator).</li> |
| <li>Suction mouth with Yankauer immediately prior to extubation.</li> |
| <li>Nasogastric tube, if present, should be aspirated and discontinued.</li> |
| <li>Explain procedure to patient, informing them that a strong cough will be necessary as the ETT is withdrawn; explain that patient may be unable to speak for a time.</li> |
| <li>Patient to be placed on face tent/nasal cannula to provide adequate <span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.439ex;" xmlns="http://www.w3.org/2000/svg" width="12.475ex" height="2.136ex" role="img" focusable="false" viewBox="0 -750 5514.1 944"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mi"><path data-c="1D446" d="M308 24Q367 24 416 76T466 197Q466 260 414 284Q308 311 278 321T236 341Q176 383 176 462Q176 523 208 573T273 648Q302 673 343 688T407 704H418H425Q521 704 564 640Q565 640 577 653T603 682T623 704Q624 704 627 704T632 705Q645 705 645 698T617 577T585 459T569 456Q549 456 549 465Q549 471 550 475Q550 478 551 494T553 520Q553 554 544 579T526 616T501 641Q465 662 419 662Q362 662 313 616T263 510Q263 480 278 458T319 427Q323 425 389 408T456 390Q490 379 522 342T554 242Q554 216 546 186Q541 164 528 137T492 78T426 18T332 -20Q320 -22 298 -22Q199 -22 144 33L134 44L106 13Q83 -14 78 -18T65 -22Q52 -22 52 -14Q52 -11 110 221Q112 227 130 227H143Q149 221 149 216Q149 214 148 207T144 186T142 153Q144 114 160 87T203 47T255 29T308 24Z"></path></g><g data-mml-node="mi" transform="translate(645,0)"><path data-c="1D45D" d="M23 287Q24 290 25 295T30 317T40 348T55 381T75 411T101 433T134 442Q209 442 230 378L240 387Q302 442 358 442Q423 442 460 395T497 281Q497 173 421 82T249 -10Q227 -10 210 -4Q199 1 187 11T168 28L161 36Q160 35 139 -51T118 -138Q118 -144 126 -145T163 -148H188Q194 -155 194 -157T191 -175Q188 -187 185 -190T172 -194Q170 -194 161 -194T127 -193T65 -192Q-5 -192 -24 -194H-32Q-39 -187 -39 -183Q-37 -156 -26 -148H-6Q28 -147 33 -136Q36 -130 94 103T155 350Q156 355 156 364Q156 405 131 405Q109 405 94 377T71 316T59 280Q57 278 43 278H29Q23 284 23 287ZM178 102Q200 26 252 26Q282 26 310 49T356 107Q374 141 392 215T411 325V331Q411 405 350 405Q339 405 328 402T306 393T286 380T269 365T254 350T243 336T235 326L232 322Q232 321 229 308T218 264T204 212Q178 106 178 102Z"></path></g><g data-mml-node="msub" transform="translate(1148,0)"><g data-mml-node="mi"><path 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| </ul> |
| <div>Effect of Postoperative Intravenous Acetaminophen versus Placebo, Combined with Propofol or Dexmedetomidine, on Postoperative In-Hospital Delirium Among Older Patients Following Cardiac Surgery: The DEXACET Randomized Clinical Trial</div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="post-extubation-care"> |
| POST-EXTUBATION CARE</h2> |
| <div>Over the next several hours, oxygen should be weaned to maintain peripheral capillary oxygen saturation <span class="math-inline "> |
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| <div class="table_tabular" style="text-align: center"> |
| <div class="inline-tabular"><table class="tabular"> |
| <tbody> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: center; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom: none !important; border-top: none !important; border-top-style: solid !important; border-top-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; " colspan="2">Nasal Cannula <span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.339ex;" xmlns="http://www.w3.org/2000/svg" width="2.714ex" height="1.932ex" role="img" focusable="false" viewBox="0 -704 1199.6 854"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="msub"><g data-mml-node="mi"><path data-c="1D442" d="M740 435Q740 320 676 213T511 42T304 -22Q207 -22 138 35T51 201Q50 209 50 244Q50 346 98 438T227 601Q351 704 476 704Q514 704 524 703Q621 689 680 617T740 435ZM637 476Q637 565 591 615T476 665Q396 665 322 605Q242 542 200 428T157 216Q157 126 200 73T314 19Q404 19 485 98T608 313Q637 408 637 476Z"></path></g><g data-mml-node="TeXAtom" transform="translate(796,-150) scale(0.707)" data-mjx-texclass="ORD"><g data-mml-node="mn"><path data-c="32" d="M109 429Q82 429 66 447T50 491Q50 562 103 614T235 666Q326 666 387 610T449 465Q449 422 429 383T381 315T301 241Q265 210 201 149L142 93L218 92Q375 92 385 97Q392 99 409 186V189H449V186Q448 183 436 95T421 3V0H50V19V31Q50 38 56 46T86 81Q115 113 136 137Q145 147 170 174T204 211T233 244T261 278T284 308T305 340T320 369T333 401T340 431T343 464Q343 527 309 573T212 619Q179 619 154 602T119 569T109 550Q109 549 114 549Q132 549 151 535T170 489Q170 464 154 447T109 429Z"></path></g></g></g></g></g></svg></mjx-container></span> Flow / FiO <span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.339ex;" xmlns="http://www.w3.org/2000/svg" width="2.119ex" height="1.846ex" role="img" focusable="false" viewBox="0 -666 936.6 816"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="msub"><g data-mml-node="mn"><path data-c="32" d="M109 429Q82 429 66 447T50 491Q50 562 103 614T235 666Q326 666 387 610T449 465Q449 422 429 383T381 315T301 241Q265 210 201 149L142 93L218 92Q375 92 385 97Q392 99 409 186V189H449V186Q448 183 436 95T421 3V0H50V19V31Q50 38 56 46T86 81Q115 113 136 137Q145 147 170 174T204 211T233 244T261 278T284 308T305 340T320 369T333 401T340 431T343 464Q343 527 309 573T212 619Q179 619 154 602T119 569T109 550Q109 549 114 549Q132 549 151 535T170 489Q170 464 154 447T109 429Z"></path></g><g data-mml-node="TeXAtom" transform="translate(533,-150) scale(0.707)" data-mjx-texclass="ORD"><g data-mml-node="mn"><path data-c="32" d="M109 429Q82 429 66 447T50 491Q50 562 103 614T235 666Q326 666 387 610T449 465Q449 422 429 383T381 315T301 241Q265 210 201 149L142 93L218 92Q375 92 385 97Q392 99 409 186V189H449V186Q448 183 436 95T421 3V0H50V19V31Q50 38 56 46T86 81Q115 113 136 137Q145 147 170 174T204 211T233 244T261 278T284 308T305 340T320 369T333 401T340 431T343 464Q343 527 309 573T212 619Q179 619 154 602T119 569T109 550Q109 549 114 549Q132 549 151 535T170 489Q170 464 154 447T109 429Z"></path></g></g></g></g></g></svg></mjx-container></span></td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Oxygen Flow L/min</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Approximate <span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.339ex;" xmlns="http://www.w3.org/2000/svg" width="5.189ex" height="1.932ex" role="img" focusable="false" viewBox="0 -704 2293.6 854"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mi"><path data-c="1D439" d="M48 1Q31 1 31 11Q31 13 34 25Q38 41 42 43T65 46Q92 46 125 49Q139 52 144 61Q146 66 215 342T285 622Q285 629 281 629Q273 632 228 634H197Q191 640 191 642T193 659Q197 676 203 680H742Q749 676 749 669Q749 664 736 557T722 447Q720 440 702 440H690Q683 445 683 453Q683 454 686 477T689 530Q689 560 682 579T663 610T626 626T575 633T503 634H480Q398 633 393 631Q388 629 386 623Q385 622 352 492L320 363H375Q378 363 398 363T426 364T448 367T472 374T489 386Q502 398 511 419T524 457T529 475Q532 480 548 480H560Q567 475 567 470Q567 467 536 339T502 207Q500 200 482 200H470Q463 206 463 212Q463 215 468 234T473 274Q473 303 453 310T364 317H309L277 190Q245 66 245 60Q245 46 334 46H359Q365 40 365 39T363 19Q359 6 353 0H336Q295 2 185 2Q120 2 86 2T48 1Z"></path></g><g data-mml-node="mi" transform="translate(749,0)"><path data-c="1D456" d="M184 600Q184 624 203 642T247 661Q265 661 277 649T290 619Q290 596 270 577T226 557Q211 557 198 567T184 600ZM21 287Q21 295 30 318T54 369T98 420T158 442Q197 442 223 419T250 357Q250 340 236 301T196 196T154 83Q149 61 149 51Q149 26 166 26Q175 26 185 29T208 43T235 78T260 137Q263 149 265 151T282 153Q302 153 302 143Q302 135 293 112T268 61T223 11T161 -11Q129 -11 102 10T74 74Q74 91 79 106T122 220Q160 321 166 341T173 380Q173 404 156 404H154Q124 404 99 371T61 287Q60 286 59 284T58 281T56 279T53 278T49 278T41 278H27Q21 284 21 287Z"></path></g><g data-mml-node="msub" transform="translate(1094,0)"><g data-mml-node="mi"><path data-c="1D442" d="M740 435Q740 320 676 213T511 42T304 -22Q207 -22 138 35T51 201Q50 209 50 244Q50 346 98 438T227 601Q351 704 476 704Q514 704 524 703Q621 689 680 617T740 435ZM637 476Q637 565 591 615T476 665Q396 665 322 605Q242 542 200 428T157 216Q157 126 200 73T314 19Q404 19 485 98T608 313Q637 408 637 476Z"></path></g><g data-mml-node="TeXAtom" transform="translate(796,-150) scale(0.707)" data-mjx-texclass="ORD"><g data-mml-node="mn"><path data-c="32" d="M109 429Q82 429 66 447T50 491Q50 562 103 614T235 666Q326 666 387 610T449 465Q449 422 429 383T381 315T301 241Q265 210 201 149L142 93L218 92Q375 92 385 97Q392 99 409 186V189H449V186Q448 183 436 95T421 3V0H50V19V31Q50 38 56 46T86 81Q115 113 136 137Q145 147 170 174T204 211T233 244T261 278T284 308T305 340T320 369T333 401T340 431T343 464Q343 527 309 573T212 619Q179 619 154 602T119 569T109 550Q109 549 114 549Q132 549 151 535T170 489Q170 464 154 447T109 429Z"></path></g></g></g></g></g></svg></mjx-container></span></td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">Room Air</td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">21%</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; "><span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.566ex;" xmlns="http://www.w3.org/2000/svg" width="7.928ex" height="2.262ex" role="img" focusable="false" viewBox="0 -750 3504 1000"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mn"><path data-c="31" d="M213 578L200 573Q186 568 160 563T102 556H83V602H102Q149 604 189 617T245 641T273 663Q275 666 285 666Q294 666 302 660V361L303 61Q310 54 315 52T339 48T401 46H427V0H416Q395 3 257 3Q121 3 100 0H88V46H114Q136 46 152 46T177 47T193 50T201 52T207 57T213 61V578Z"></path></g><g data-mml-node="mi" transform="translate(500,0)"><path data-c="1D43F" d="M228 637Q194 637 192 641Q191 643 191 649Q191 673 202 682Q204 683 217 683Q271 680 344 680Q485 680 506 683H518Q524 677 524 674T522 656Q517 641 513 637H475Q406 636 394 628Q387 624 380 600T313 336Q297 271 279 198T252 88L243 52Q243 48 252 48T311 46H328Q360 46 379 47T428 54T478 72T522 106T564 161Q580 191 594 228T611 270Q616 273 628 273H641Q647 264 647 262T627 203T583 83T557 9Q555 4 553 3T537 0T494 -1Q483 -1 418 -1T294 0H116Q32 0 32 10Q32 17 34 24Q39 43 44 45Q48 46 59 46H65Q92 46 125 49Q139 52 144 61Q147 65 216 339T285 628Q285 635 228 637Z"></path></g><g data-mml-node="TeXAtom" data-mjx-texclass="ORD" transform="translate(1181,0)"><g data-mml-node="mo"><path data-c="2F" d="M423 750Q432 750 438 744T444 730Q444 725 271 248T92 -240Q85 -250 75 -250Q68 -250 62 -245T56 -231Q56 -221 230 257T407 740Q411 750 423 750Z"></path></g></g><g data-mml-node="mi" transform="translate(1681,0)"><path data-c="1D45A" d="M21 287Q22 293 24 303T36 341T56 388T88 425T132 442T175 435T205 417T221 395T229 376L231 369Q231 367 232 367L243 378Q303 442 384 442Q401 442 415 440T441 433T460 423T475 411T485 398T493 385T497 373T500 364T502 357L510 367Q573 442 659 442Q713 442 746 415T780 336Q780 285 742 178T704 50Q705 36 709 31T724 26Q752 26 776 56T815 138Q818 149 821 151T837 153Q857 153 857 145Q857 144 853 130Q845 101 831 73T785 17T716 -10Q669 -10 648 17T627 73Q627 92 663 193T700 345Q700 404 656 404H651Q565 404 506 303L499 291L466 157Q433 26 428 16Q415 -11 385 -11Q372 -11 364 -4T353 8T350 18Q350 29 384 161L420 307Q423 322 423 345Q423 404 379 404H374Q288 404 229 303L222 291L189 157Q156 26 151 16Q138 -11 108 -11Q95 -11 87 -5T76 7T74 17Q74 30 112 181Q151 335 151 342Q154 357 154 369Q154 405 129 405Q107 405 92 377T69 316T57 280Q55 278 41 278H27Q21 284 21 287Z"></path></g><g data-mml-node="mi" transform="translate(2559,0)"><path data-c="1D456" d="M184 600Q184 624 203 642T247 661Q265 661 277 649T290 619Q290 596 270 577T226 557Q211 557 198 567T184 600ZM21 287Q21 295 30 318T54 369T98 420T158 442Q197 442 223 419T250 357Q250 340 236 301T196 196T154 83Q149 61 149 51Q149 26 166 26Q175 26 185 29T208 43T235 78T260 137Q263 149 265 151T282 153Q302 153 302 143Q302 135 293 112T268 61T223 11T161 -11Q129 -11 102 10T74 74Q74 91 79 106T122 220Q160 321 166 341T173 380Q173 404 156 404H154Q124 404 99 371T61 287Q60 286 59 284T58 281T56 279T53 278T49 278T41 278H27Q21 284 21 287Z"></path></g><g data-mml-node="mi" transform="translate(2904,0)"><path data-c="1D45B" d="M21 287Q22 293 24 303T36 341T56 388T89 425T135 442Q171 442 195 424T225 390T231 369Q231 367 232 367L243 378Q304 442 382 442Q436 442 469 415T503 336T465 179T427 52Q427 26 444 26Q450 26 453 27Q482 32 505 65T540 145Q542 153 560 153Q580 153 580 145Q580 144 576 130Q568 101 554 73T508 17T439 -10Q392 -10 371 17T350 73Q350 92 386 193T423 345Q423 404 379 404H374Q288 404 229 303L222 291L189 157Q156 26 151 16Q138 -11 108 -11Q95 -11 87 -5T76 7T74 17Q74 30 112 180T152 343Q153 348 153 366Q153 405 129 405Q91 405 66 305Q60 285 60 284Q58 278 41 278H27Q21 284 21 287Z"></path></g></g></g></svg></mjx-container></span></td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">24%</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; "><span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.566ex;" xmlns="http://www.w3.org/2000/svg" width="7.928ex" height="2.262ex" role="img" focusable="false" viewBox="0 -750 3504 1000"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mn"><path data-c="32" d="M109 429Q82 429 66 447T50 491Q50 562 103 614T235 666Q326 666 387 610T449 465Q449 422 429 383T381 315T301 241Q265 210 201 149L142 93L218 92Q375 92 385 97Q392 99 409 186V189H449V186Q448 183 436 95T421 3V0H50V19V31Q50 38 56 46T86 81Q115 113 136 137Q145 147 170 174T204 211T233 244T261 278T284 308T305 340T320 369T333 401T340 431T343 464Q343 527 309 573T212 619Q179 619 154 602T119 569T109 550Q109 549 114 549Q132 549 151 535T170 489Q170 464 154 447T109 429Z"></path></g><g data-mml-node="mi" transform="translate(500,0)"><path data-c="1D43F" d="M228 637Q194 637 192 641Q191 643 191 649Q191 673 202 682Q204 683 217 683Q271 680 344 680Q485 680 506 683H518Q524 677 524 674T522 656Q517 641 513 637H475Q406 636 394 628Q387 624 380 600T313 336Q297 271 279 198T252 88L243 52Q243 48 252 48T311 46H328Q360 46 379 47T428 54T478 72T522 106T564 161Q580 191 594 228T611 270Q616 273 628 273H641Q647 264 647 262T627 203T583 83T557 9Q555 4 553 3T537 0T494 -1Q483 -1 418 -1T294 0H116Q32 0 32 10Q32 17 34 24Q39 43 44 45Q48 46 59 46H65Q92 46 125 49Q139 52 144 61Q147 65 216 339T285 628Q285 635 228 637Z"></path></g><g data-mml-node="TeXAtom" data-mjx-texclass="ORD" transform="translate(1181,0)"><g data-mml-node="mo"><path data-c="2F" d="M423 750Q432 750 438 744T444 730Q444 725 271 248T92 -240Q85 -250 75 -250Q68 -250 62 -245T56 -231Q56 -221 230 257T407 740Q411 750 423 750Z"></path></g></g><g data-mml-node="mi" transform="translate(1681,0)"><path data-c="1D45A" d="M21 287Q22 293 24 303T36 341T56 388T88 425T132 442T175 435T205 417T221 395T229 376L231 369Q231 367 232 367L243 378Q303 442 384 442Q401 442 415 440T441 433T460 423T475 411T485 398T493 385T497 373T500 364T502 357L510 367Q573 442 659 442Q713 442 746 415T780 336Q780 285 742 178T704 50Q705 36 709 31T724 26Q752 26 776 56T815 138Q818 149 821 151T837 153Q857 153 857 145Q857 144 853 130Q845 101 831 73T785 17T716 -10Q669 -10 648 17T627 73Q627 92 663 193T700 345Q700 404 656 404H651Q565 404 506 303L499 291L466 157Q433 26 428 16Q415 -11 385 -11Q372 -11 364 -4T353 8T350 18Q350 29 384 161L420 307Q423 322 423 345Q423 404 379 404H374Q288 404 229 303L222 291L189 157Q156 26 151 16Q138 -11 108 -11Q95 -11 87 -5T76 7T74 17Q74 30 112 181Q151 335 151 342Q154 357 154 369Q154 405 129 405Q107 405 92 377T69 316T57 280Q55 278 41 278H27Q21 284 21 287Z"></path></g><g data-mml-node="mi" transform="translate(2559,0)"><path data-c="1D456" d="M184 600Q184 624 203 642T247 661Q265 661 277 649T290 619Q290 596 270 577T226 557Q211 557 198 567T184 600ZM21 287Q21 295 30 318T54 369T98 420T158 442Q197 442 223 419T250 357Q250 340 236 301T196 196T154 83Q149 61 149 51Q149 26 166 26Q175 26 185 29T208 43T235 78T260 137Q263 149 265 151T282 153Q302 153 302 143Q302 135 293 112T268 61T223 11T161 -11Q129 -11 102 10T74 74Q74 91 79 106T122 220Q160 321 166 341T173 380Q173 404 156 404H154Q124 404 99 371T61 287Q60 286 59 284T58 281T56 279T53 278T49 278T41 278H27Q21 284 21 287Z"></path></g><g data-mml-node="mi" transform="translate(2904,0)"><path data-c="1D45B" d="M21 287Q22 293 24 303T36 341T56 388T89 425T135 442Q171 442 195 424T225 390T231 369Q231 367 232 367L243 378Q304 442 382 442Q436 442 469 415T503 336T465 179T427 52Q427 26 444 26Q450 26 453 27Q482 32 505 65T540 145Q542 153 560 153Q580 153 580 145Q580 144 576 130Q568 101 554 73T508 17T439 -10Q392 -10 371 17T350 73Q350 92 386 193T423 345Q423 404 379 404H374Q288 404 229 303L222 291L189 157Q156 26 151 16Q138 -11 108 -11Q95 -11 87 -5T76 7T74 17Q74 30 112 180T152 343Q153 348 153 366Q153 405 129 405Q91 405 66 305Q60 285 60 284Q58 278 41 278H27Q21 284 21 287Z"></path></g></g></g></svg></mjx-container></span></td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">28%</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; "><span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.566ex;" xmlns="http://www.w3.org/2000/svg" width="7.928ex" height="2.262ex" role="img" focusable="false" viewBox="0 -750 3504 1000"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mn"><path data-c="33" d="M127 463Q100 463 85 480T69 524Q69 579 117 622T233 665Q268 665 277 664Q351 652 390 611T430 522Q430 470 396 421T302 350L299 348Q299 347 308 345T337 336T375 315Q457 262 457 175Q457 96 395 37T238 -22Q158 -22 100 21T42 130Q42 158 60 175T105 193Q133 193 151 175T169 130Q169 119 166 110T159 94T148 82T136 74T126 70T118 67L114 66Q165 21 238 21Q293 21 321 74Q338 107 338 175V195Q338 290 274 322Q259 328 213 329L171 330L168 332Q166 335 166 348Q166 366 174 366Q202 366 232 371Q266 376 294 413T322 525V533Q322 590 287 612Q265 626 240 626Q208 626 181 615T143 592T132 580H135Q138 579 143 578T153 573T165 566T175 555T183 540T186 520Q186 498 172 481T127 463Z"></path></g><g data-mml-node="mi" transform="translate(500,0)"><path data-c="1D43F" d="M228 637Q194 637 192 641Q191 643 191 649Q191 673 202 682Q204 683 217 683Q271 680 344 680Q485 680 506 683H518Q524 677 524 674T522 656Q517 641 513 637H475Q406 636 394 628Q387 624 380 600T313 336Q297 271 279 198T252 88L243 52Q243 48 252 48T311 46H328Q360 46 379 47T428 54T478 72T522 106T564 161Q580 191 594 228T611 270Q616 273 628 273H641Q647 264 647 262T627 203T583 83T557 9Q555 4 553 3T537 0T494 -1Q483 -1 418 -1T294 0H116Q32 0 32 10Q32 17 34 24Q39 43 44 45Q48 46 59 46H65Q92 46 125 49Q139 52 144 61Q147 65 216 339T285 628Q285 635 228 637Z"></path></g><g data-mml-node="TeXAtom" data-mjx-texclass="ORD" transform="translate(1181,0)"><g data-mml-node="mo"><path data-c="2F" d="M423 750Q432 750 438 744T444 730Q444 725 271 248T92 -240Q85 -250 75 -250Q68 -250 62 -245T56 -231Q56 -221 230 257T407 740Q411 750 423 750Z"></path></g></g><g data-mml-node="mi" transform="translate(1681,0)"><path data-c="1D45A" d="M21 287Q22 293 24 303T36 341T56 388T88 425T132 442T175 435T205 417T221 395T229 376L231 369Q231 367 232 367L243 378Q303 442 384 442Q401 442 415 440T441 433T460 423T475 411T485 398T493 385T497 373T500 364T502 357L510 367Q573 442 659 442Q713 442 746 415T780 336Q780 285 742 178T704 50Q705 36 709 31T724 26Q752 26 776 56T815 138Q818 149 821 151T837 153Q857 153 857 145Q857 144 853 130Q845 101 831 73T785 17T716 -10Q669 -10 648 17T627 73Q627 92 663 193T700 345Q700 404 656 404H651Q565 404 506 303L499 291L466 157Q433 26 428 16Q415 -11 385 -11Q372 -11 364 -4T353 8T350 18Q350 29 384 161L420 307Q423 322 423 345Q423 404 379 404H374Q288 404 229 303L222 291L189 157Q156 26 151 16Q138 -11 108 -11Q95 -11 87 -5T76 7T74 17Q74 30 112 181Q151 335 151 342Q154 357 154 369Q154 405 129 405Q107 405 92 377T69 316T57 280Q55 278 41 278H27Q21 284 21 287Z"></path></g><g data-mml-node="mi" transform="translate(2559,0)"><path data-c="1D456" d="M184 600Q184 624 203 642T247 661Q265 661 277 649T290 619Q290 596 270 577T226 557Q211 557 198 567T184 600ZM21 287Q21 295 30 318T54 369T98 420T158 442Q197 442 223 419T250 357Q250 340 236 301T196 196T154 83Q149 61 149 51Q149 26 166 26Q175 26 185 29T208 43T235 78T260 137Q263 149 265 151T282 153Q302 153 302 143Q302 135 293 112T268 61T223 11T161 -11Q129 -11 102 10T74 74Q74 91 79 106T122 220Q160 321 166 341T173 380Q173 404 156 404H154Q124 404 99 371T61 287Q60 286 59 284T58 281T56 279T53 278T49 278T41 278H27Q21 284 21 287Z"></path></g><g data-mml-node="mi" transform="translate(2904,0)"><path data-c="1D45B" d="M21 287Q22 293 24 303T36 341T56 388T89 425T135 442Q171 442 195 424T225 390T231 369Q231 367 232 367L243 378Q304 442 382 442Q436 442 469 415T503 336T465 179T427 52Q427 26 444 26Q450 26 453 27Q482 32 505 65T540 145Q542 153 560 153Q580 153 580 145Q580 144 576 130Q568 101 554 73T508 17T439 -10Q392 -10 371 17T350 73Q350 92 386 193T423 345Q423 404 379 404H374Q288 404 229 303L222 291L189 157Q156 26 151 16Q138 -11 108 -11Q95 -11 87 -5T76 7T74 17Q74 30 112 180T152 343Q153 348 153 366Q153 405 129 405Q91 405 66 305Q60 285 60 284Q58 278 41 278H27Q21 284 21 287Z"></path></g></g></g></svg></mjx-container></span></td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">32%</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; "><span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.566ex;" xmlns="http://www.w3.org/2000/svg" width="7.928ex" height="2.262ex" role="img" focusable="false" viewBox="0 -750 3504 1000"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mn"><path data-c="34" d="M462 0Q444 3 333 3Q217 3 199 0H190V46H221Q241 46 248 46T265 48T279 53T286 61Q287 63 287 115V165H28V211L179 442Q332 674 334 675Q336 677 355 677H373L379 671V211H471V165H379V114Q379 73 379 66T385 54Q393 47 442 46H471V0H462ZM293 211V545L74 212L183 211H293Z"></path></g><g data-mml-node="mi" transform="translate(500,0)"><path data-c="1D43F" d="M228 637Q194 637 192 641Q191 643 191 649Q191 673 202 682Q204 683 217 683Q271 680 344 680Q485 680 506 683H518Q524 677 524 674T522 656Q517 641 513 637H475Q406 636 394 628Q387 624 380 600T313 336Q297 271 279 198T252 88L243 52Q243 48 252 48T311 46H328Q360 46 379 47T428 54T478 72T522 106T564 161Q580 191 594 228T611 270Q616 273 628 273H641Q647 264 647 262T627 203T583 83T557 9Q555 4 553 3T537 0T494 -1Q483 -1 418 -1T294 0H116Q32 0 32 10Q32 17 34 24Q39 43 44 45Q48 46 59 46H65Q92 46 125 49Q139 52 144 61Q147 65 216 339T285 628Q285 635 228 637Z"></path></g><g data-mml-node="TeXAtom" data-mjx-texclass="ORD" transform="translate(1181,0)"><g data-mml-node="mo"><path data-c="2F" d="M423 750Q432 750 438 744T444 730Q444 725 271 248T92 -240Q85 -250 75 -250Q68 -250 62 -245T56 -231Q56 -221 230 257T407 740Q411 750 423 750Z"></path></g></g><g data-mml-node="mi" transform="translate(1681,0)"><path data-c="1D45A" d="M21 287Q22 293 24 303T36 341T56 388T88 425T132 442T175 435T205 417T221 395T229 376L231 369Q231 367 232 367L243 378Q303 442 384 442Q401 442 415 440T441 433T460 423T475 411T485 398T493 385T497 373T500 364T502 357L510 367Q573 442 659 442Q713 442 746 415T780 336Q780 285 742 178T704 50Q705 36 709 31T724 26Q752 26 776 56T815 138Q818 149 821 151T837 153Q857 153 857 145Q857 144 853 130Q845 101 831 73T785 17T716 -10Q669 -10 648 17T627 73Q627 92 663 193T700 345Q700 404 656 404H651Q565 404 506 303L499 291L466 157Q433 26 428 16Q415 -11 385 -11Q372 -11 364 -4T353 8T350 18Q350 29 384 161L420 307Q423 322 423 345Q423 404 379 404H374Q288 404 229 303L222 291L189 157Q156 26 151 16Q138 -11 108 -11Q95 -11 87 -5T76 7T74 17Q74 30 112 181Q151 335 151 342Q154 357 154 369Q154 405 129 405Q107 405 92 377T69 316T57 280Q55 278 41 278H27Q21 284 21 287Z"></path></g><g data-mml-node="mi" transform="translate(2559,0)"><path data-c="1D456" d="M184 600Q184 624 203 642T247 661Q265 661 277 649T290 619Q290 596 270 577T226 557Q211 557 198 567T184 600ZM21 287Q21 295 30 318T54 369T98 420T158 442Q197 442 223 419T250 357Q250 340 236 301T196 196T154 83Q149 61 149 51Q149 26 166 26Q175 26 185 29T208 43T235 78T260 137Q263 149 265 151T282 153Q302 153 302 143Q302 135 293 112T268 61T223 11T161 -11Q129 -11 102 10T74 74Q74 91 79 106T122 220Q160 321 166 341T173 380Q173 404 156 404H154Q124 404 99 371T61 287Q60 286 59 284T58 281T56 279T53 278T49 278T41 278H27Q21 284 21 287Z"></path></g><g data-mml-node="mi" transform="translate(2904,0)"><path data-c="1D45B" d="M21 287Q22 293 24 303T36 341T56 388T89 425T135 442Q171 442 195 424T225 390T231 369Q231 367 232 367L243 378Q304 442 382 442Q436 442 469 415T503 336T465 179T427 52Q427 26 444 26Q450 26 453 27Q482 32 505 65T540 145Q542 153 560 153Q580 153 580 145Q580 144 576 130Q568 101 554 73T508 17T439 -10Q392 -10 371 17T350 73Q350 92 386 193T423 345Q423 404 379 404H374Q288 404 229 303L222 291L189 157Q156 26 151 16Q138 -11 108 -11Q95 -11 87 -5T76 7T74 17Q74 30 112 180T152 343Q153 348 153 366Q153 405 129 405Q91 405 66 305Q60 285 60 284Q58 278 41 278H27Q21 284 21 287Z"></path></g></g></g></svg></mjx-container></span></td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">36%</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; "><span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.566ex;" xmlns="http://www.w3.org/2000/svg" width="7.928ex" height="2.262ex" role="img" focusable="false" viewBox="0 -750 3504 1000"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mn"><path data-c="35" d="M164 157Q164 133 148 117T109 101H102Q148 22 224 22Q294 22 326 82Q345 115 345 210Q345 313 318 349Q292 382 260 382H254Q176 382 136 314Q132 307 129 306T114 304Q97 304 95 310Q93 314 93 485V614Q93 664 98 664Q100 666 102 666Q103 666 123 658T178 642T253 634Q324 634 389 662Q397 666 402 666Q410 666 410 648V635Q328 538 205 538Q174 538 149 544L139 546V374Q158 388 169 396T205 412T256 420Q337 420 393 355T449 201Q449 109 385 44T229 -22Q148 -22 99 32T50 154Q50 178 61 192T84 210T107 214Q132 214 148 197T164 157Z"></path></g><g data-mml-node="mi" transform="translate(500,0)"><path data-c="1D43F" d="M228 637Q194 637 192 641Q191 643 191 649Q191 673 202 682Q204 683 217 683Q271 680 344 680Q485 680 506 683H518Q524 677 524 674T522 656Q517 641 513 637H475Q406 636 394 628Q387 624 380 600T313 336Q297 271 279 198T252 88L243 52Q243 48 252 48T311 46H328Q360 46 379 47T428 54T478 72T522 106T564 161Q580 191 594 228T611 270Q616 273 628 273H641Q647 264 647 262T627 203T583 83T557 9Q555 4 553 3T537 0T494 -1Q483 -1 418 -1T294 0H116Q32 0 32 10Q32 17 34 24Q39 43 44 45Q48 46 59 46H65Q92 46 125 49Q139 52 144 61Q147 65 216 339T285 628Q285 635 228 637Z"></path></g><g data-mml-node="TeXAtom" data-mjx-texclass="ORD" transform="translate(1181,0)"><g data-mml-node="mo"><path data-c="2F" d="M423 750Q432 750 438 744T444 730Q444 725 271 248T92 -240Q85 -250 75 -250Q68 -250 62 -245T56 -231Q56 -221 230 257T407 740Q411 750 423 750Z"></path></g></g><g data-mml-node="mi" transform="translate(1681,0)"><path data-c="1D45A" d="M21 287Q22 293 24 303T36 341T56 388T88 425T132 442T175 435T205 417T221 395T229 376L231 369Q231 367 232 367L243 378Q303 442 384 442Q401 442 415 440T441 433T460 423T475 411T485 398T493 385T497 373T500 364T502 357L510 367Q573 442 659 442Q713 442 746 415T780 336Q780 285 742 178T704 50Q705 36 709 31T724 26Q752 26 776 56T815 138Q818 149 821 151T837 153Q857 153 857 145Q857 144 853 130Q845 101 831 73T785 17T716 -10Q669 -10 648 17T627 73Q627 92 663 193T700 345Q700 404 656 404H651Q565 404 506 303L499 291L466 157Q433 26 428 16Q415 -11 385 -11Q372 -11 364 -4T353 8T350 18Q350 29 384 161L420 307Q423 322 423 345Q423 404 379 404H374Q288 404 229 303L222 291L189 157Q156 26 151 16Q138 -11 108 -11Q95 -11 87 -5T76 7T74 17Q74 30 112 181Q151 335 151 342Q154 357 154 369Q154 405 129 405Q107 405 92 377T69 316T57 280Q55 278 41 278H27Q21 284 21 287Z"></path></g><g data-mml-node="mi" transform="translate(2559,0)"><path data-c="1D456" d="M184 600Q184 624 203 642T247 661Q265 661 277 649T290 619Q290 596 270 577T226 557Q211 557 198 567T184 600ZM21 287Q21 295 30 318T54 369T98 420T158 442Q197 442 223 419T250 357Q250 340 236 301T196 196T154 83Q149 61 149 51Q149 26 166 26Q175 26 185 29T208 43T235 78T260 137Q263 149 265 151T282 153Q302 153 302 143Q302 135 293 112T268 61T223 11T161 -11Q129 -11 102 10T74 74Q74 91 79 106T122 220Q160 321 166 341T173 380Q173 404 156 404H154Q124 404 99 371T61 287Q60 286 59 284T58 281T56 279T53 278T49 278T41 278H27Q21 284 21 287Z"></path></g><g data-mml-node="mi" transform="translate(2904,0)"><path data-c="1D45B" d="M21 287Q22 293 24 303T36 341T56 388T89 425T135 442Q171 442 195 424T225 390T231 369Q231 367 232 367L243 378Q304 442 382 442Q436 442 469 415T503 336T465 179T427 52Q427 26 444 26Q450 26 453 27Q482 32 505 65T540 145Q542 153 560 153Q580 153 580 145Q580 144 576 130Q568 101 554 73T508 17T439 -10Q392 -10 371 17T350 73Q350 92 386 193T423 345Q423 404 379 404H374Q288 404 229 303L222 291L189 157Q156 26 151 16Q138 -11 108 -11Q95 -11 87 -5T76 7T74 17Q74 30 112 180T152 343Q153 348 153 366Q153 405 129 405Q91 405 66 305Q60 285 60 284Q58 278 41 278H27Q21 284 21 287Z"></path></g></g></g></svg></mjx-container></span></td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">40%</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; "><span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.566ex;" xmlns="http://www.w3.org/2000/svg" width="7.928ex" height="2.262ex" role="img" focusable="false" viewBox="0 -750 3504 1000"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mn"><path data-c="36" d="M42 313Q42 476 123 571T303 666Q372 666 402 630T432 550Q432 525 418 510T379 495Q356 495 341 509T326 548Q326 592 373 601Q351 623 311 626Q240 626 194 566Q147 500 147 364L148 360Q153 366 156 373Q197 433 263 433H267Q313 433 348 414Q372 400 396 374T435 317Q456 268 456 210V192Q456 169 451 149Q440 90 387 34T253 -22Q225 -22 199 -14T143 16T92 75T56 172T42 313ZM257 397Q227 397 205 380T171 335T154 278T148 216Q148 133 160 97T198 39Q222 21 251 21Q302 21 329 59Q342 77 347 104T352 209Q352 289 347 316T329 361Q302 397 257 397Z"></path></g><g data-mml-node="mi" transform="translate(500,0)"><path data-c="1D43F" d="M228 637Q194 637 192 641Q191 643 191 649Q191 673 202 682Q204 683 217 683Q271 680 344 680Q485 680 506 683H518Q524 677 524 674T522 656Q517 641 513 637H475Q406 636 394 628Q387 624 380 600T313 336Q297 271 279 198T252 88L243 52Q243 48 252 48T311 46H328Q360 46 379 47T428 54T478 72T522 106T564 161Q580 191 594 228T611 270Q616 273 628 273H641Q647 264 647 262T627 203T583 83T557 9Q555 4 553 3T537 0T494 -1Q483 -1 418 -1T294 0H116Q32 0 32 10Q32 17 34 24Q39 43 44 45Q48 46 59 46H65Q92 46 125 49Q139 52 144 61Q147 65 216 339T285 628Q285 635 228 637Z"></path></g><g data-mml-node="TeXAtom" data-mjx-texclass="ORD" transform="translate(1181,0)"><g data-mml-node="mo"><path data-c="2F" d="M423 750Q432 750 438 744T444 730Q444 725 271 248T92 -240Q85 -250 75 -250Q68 -250 62 -245T56 -231Q56 -221 230 257T407 740Q411 750 423 750Z"></path></g></g><g data-mml-node="mi" transform="translate(1681,0)"><path data-c="1D45A" d="M21 287Q22 293 24 303T36 341T56 388T88 425T132 442T175 435T205 417T221 395T229 376L231 369Q231 367 232 367L243 378Q303 442 384 442Q401 442 415 440T441 433T460 423T475 411T485 398T493 385T497 373T500 364T502 357L510 367Q573 442 659 442Q713 442 746 415T780 336Q780 285 742 178T704 50Q705 36 709 31T724 26Q752 26 776 56T815 138Q818 149 821 151T837 153Q857 153 857 145Q857 144 853 130Q845 101 831 73T785 17T716 -10Q669 -10 648 17T627 73Q627 92 663 193T700 345Q700 404 656 404H651Q565 404 506 303L499 291L466 157Q433 26 428 16Q415 -11 385 -11Q372 -11 364 -4T353 8T350 18Q350 29 384 161L420 307Q423 322 423 345Q423 404 379 404H374Q288 404 229 303L222 291L189 157Q156 26 151 16Q138 -11 108 -11Q95 -11 87 -5T76 7T74 17Q74 30 112 181Q151 335 151 342Q154 357 154 369Q154 405 129 405Q107 405 92 377T69 316T57 280Q55 278 41 278H27Q21 284 21 287Z"></path></g><g data-mml-node="mi" transform="translate(2559,0)"><path data-c="1D456" d="M184 600Q184 624 203 642T247 661Q265 661 277 649T290 619Q290 596 270 577T226 557Q211 557 198 567T184 600ZM21 287Q21 295 30 318T54 369T98 420T158 442Q197 442 223 419T250 357Q250 340 236 301T196 196T154 83Q149 61 149 51Q149 26 166 26Q175 26 185 29T208 43T235 78T260 137Q263 149 265 151T282 153Q302 153 302 143Q302 135 293 112T268 61T223 11T161 -11Q129 -11 102 10T74 74Q74 91 79 106T122 220Q160 321 166 341T173 380Q173 404 156 404H154Q124 404 99 371T61 287Q60 286 59 284T58 281T56 279T53 278T49 278T41 278H27Q21 284 21 287Z"></path></g><g data-mml-node="mi" transform="translate(2904,0)"><path data-c="1D45B" d="M21 287Q22 293 24 303T36 341T56 388T89 425T135 442Q171 442 195 424T225 390T231 369Q231 367 232 367L243 378Q304 442 382 442Q436 442 469 415T503 336T465 179T427 52Q427 26 444 26Q450 26 453 27Q482 32 505 65T540 145Q542 153 560 153Q580 153 580 145Q580 144 576 130Q568 101 554 73T508 17T439 -10Q392 -10 371 17T350 73Q350 92 386 193T423 345Q423 404 379 404H374Q288 404 229 303L222 291L189 157Q156 26 151 16Q138 -11 108 -11Q95 -11 87 -5T76 7T74 17Q74 30 112 180T152 343Q153 348 153 366Q153 405 129 405Q91 405 66 305Q60 285 60 284Q58 278 41 278H27Q21 284 21 287Z"></path></g></g></g></svg></mjx-container></span></td> |
| <td style="text-align: left; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; ">44%</td> |
| </tr> |
| </tbody> |
| </table> |
| </div></div> |
| <ul> |
| <li>ABG 30 minutes after extubation only if clinical suspicion of poor respiratory function</li> |
| <li>Continuous SpO2 Monitoring</li> |
| <li>Observation and assessment of patient for respiratory distress or increased work of breathing</li> |
| <li>Incentive Spirometry (IS) every <span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.05ex;" xmlns="http://www.w3.org/2000/svg" width="10.284ex" height="1.581ex" role="img" focusable="false" viewBox="0 -677 4545.4 699"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mn"><path data-c="33" d="M127 463Q100 463 85 480T69 524Q69 579 117 622T233 665Q268 665 277 664Q351 652 390 611T430 522Q430 470 396 421T302 350L299 348Q299 347 308 345T337 336T375 315Q457 262 457 175Q457 96 395 37T238 -22Q158 -22 100 21T42 130Q42 158 60 175T105 193Q133 193 151 175T169 130Q169 119 166 110T159 94T148 82T136 74T126 70T118 67L114 66Q165 21 238 21Q293 21 321 74Q338 107 338 175V195Q338 290 274 322Q259 328 213 329L171 330L168 332Q166 335 166 348Q166 366 174 366Q202 366 232 371Q266 376 294 413T322 525V533Q322 590 287 612Q265 626 240 626Q208 626 181 615T143 592T132 580H135Q138 579 143 578T153 573T165 566T175 555T183 540T186 520Q186 498 172 481T127 463Z"></path><path data-c="30" d="M96 585Q152 666 249 666Q297 666 345 640T423 548Q460 465 460 320Q460 165 417 83Q397 41 362 16T301 -15T250 -22Q224 -22 198 -16T137 16T82 83Q39 165 39 320Q39 494 96 585ZM321 597Q291 629 250 629Q208 629 178 597Q153 571 145 525T137 333Q137 175 145 125T181 46Q209 16 250 16Q290 16 318 46Q347 76 354 130T362 333Q362 478 354 524T321 597Z" transform="translate(500,0)"></path></g><g data-mml-node="mi" transform="translate(1000,0)"><path data-c="1D45A" d="M21 287Q22 293 24 303T36 341T56 388T88 425T132 442T175 435T205 417T221 395T229 376L231 369Q231 367 232 367L243 378Q303 442 384 442Q401 442 415 440T441 433T460 423T475 411T485 398T493 385T497 373T500 364T502 357L510 367Q573 442 659 442Q713 442 746 415T780 336Q780 285 742 178T704 50Q705 36 709 31T724 26Q752 26 776 56T815 138Q818 149 821 151T837 153Q857 153 857 145Q857 144 853 130Q845 101 831 73T785 17T716 -10Q669 -10 648 17T627 73Q627 92 663 193T700 345Q700 404 656 404H651Q565 404 506 303L499 291L466 157Q433 26 428 16Q415 -11 385 -11Q372 -11 364 -4T353 8T350 18Q350 29 384 161L420 307Q423 322 423 345Q423 404 379 404H374Q288 404 229 303L222 291L189 157Q156 26 151 16Q138 -11 108 -11Q95 -11 87 -5T76 7T74 17Q74 30 112 181Q151 335 151 342Q154 357 154 369Q154 405 129 405Q107 405 92 377T69 316T57 280Q55 278 41 278H27Q21 284 21 287Z"></path></g><g data-mml-node="mi" transform="translate(1878,0)"><path data-c="1D456" d="M184 600Q184 624 203 642T247 661Q265 661 277 649T290 619Q290 596 270 577T226 557Q211 557 198 567T184 600ZM21 287Q21 295 30 318T54 369T98 420T158 442Q197 442 223 419T250 357Q250 340 236 301T196 196T154 83Q149 61 149 51Q149 26 166 26Q175 26 185 29T208 43T235 78T260 137Q263 149 265 151T282 153Q302 153 302 143Q302 135 293 112T268 61T223 11T161 -11Q129 -11 102 10T74 74Q74 91 79 106T122 220Q160 321 166 341T173 380Q173 404 156 404H154Q124 404 99 371T61 287Q60 286 59 284T58 281T56 279T53 278T49 278T41 278H27Q21 284 21 287Z"></path></g><g data-mml-node="mi" transform="translate(2223,0)"><path data-c="1D45B" d="M21 287Q22 293 24 303T36 341T56 388T89 425T135 442Q171 442 195 424T225 390T231 369Q231 367 232 367L243 378Q304 442 382 442Q436 442 469 415T503 336T465 179T427 52Q427 26 444 26Q450 26 453 27Q482 32 505 65T540 145Q542 153 560 153Q580 153 580 145Q580 144 576 130Q568 101 554 73T508 17T439 -10Q392 -10 371 17T350 73Q350 92 386 193T423 345Q423 404 379 404H374Q288 404 229 303L222 291L189 157Q156 26 151 16Q138 -11 108 -11Q95 -11 87 -5T76 7T74 17Q74 30 112 180T152 343Q153 348 153 366Q153 405 129 405Q91 405 66 305Q60 285 60 284Q58 278 41 278H27Q21 284 21 287Z"></path></g><g data-mml-node="mo" transform="translate(3045.2,0)"><path data-c="D7" d="M630 29Q630 9 609 9Q604 9 587 25T493 118L389 222L284 117Q178 13 175 11Q171 9 168 9Q160 9 154 15T147 29Q147 36 161 51T255 146L359 250L255 354Q174 435 161 449T147 471Q147 480 153 485T168 490Q173 490 175 489Q178 487 284 383L389 278L493 382Q570 459 587 475T609 491Q630 491 630 471Q630 464 620 453T522 355L418 250L522 145Q606 61 618 48T630 29Z"></path></g><g data-mml-node="mn" transform="translate(4045.4,0)"><path data-c="34" d="M462 0Q444 3 333 3Q217 3 199 0H190V46H221Q241 46 248 46T265 48T279 53T286 61Q287 63 287 115V165H28V211L179 442Q332 674 334 675Q336 677 355 677H373L379 671V211H471V165H379V114Q379 73 379 66T385 54Q393 47 442 46H471V0H462ZM293 211V545L74 212L183 211H293Z"></path></g></g></g></svg></mjx-container></span>, every 1 hour <span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: 0;" xmlns="http://www.w3.org/2000/svg" width="2.891ex" height="1.532ex" role="img" focusable="false" viewBox="0 -677 1278 677"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mo"><path data-c="D7" d="M630 29Q630 9 609 9Q604 9 587 25T493 118L389 222L284 117Q178 13 175 11Q171 9 168 9Q160 9 154 15T147 29Q147 36 161 51T255 146L359 250L255 354Q174 435 161 449T147 471Q147 480 153 485T168 490Q173 490 175 489Q178 487 284 383L389 278L493 382Q570 459 587 475T609 491Q630 491 630 471Q630 464 620 453T522 355L418 250L522 145Q606 61 618 48T630 29Z"></path></g><g data-mml-node="mn" transform="translate(778,0)"><path data-c="34" d="M462 0Q444 3 333 3Q217 3 199 0H190V46H221Q241 46 248 46T265 48T279 53T286 61Q287 63 287 115V165H28V211L179 442Q332 674 334 675Q336 677 355 677H373L379 671V211H471V165H379V114Q379 73 379 66T385 54Q393 47 442 46H471V0H462ZM293 211V545L74 212L183 211H293Z"></path></g></g></g></svg></mjx-container></span>; then hourly while awake or more often, as indicated</li> |
| <li>Dangling on edge of bed within 2 hours should be performed unless contraindicated</li> |
| <li>Patient/Family instruction in use of splint pillow during coughing and deep breathing</li> |
| <li>Patient instruction in pain control as an important part of improved ventilation</li> |
| <li>Position with HOB <span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.09ex;" xmlns="http://www.w3.org/2000/svg" width="4.651ex" height="1.622ex" role="img" focusable="false" viewBox="0 -677 2055.8 717"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mo"><path data-c="3E" d="M84 520Q84 528 88 533T96 539L99 540Q106 540 253 471T544 334L687 265Q694 260 694 250T687 235Q685 233 395 96L107 -40H101Q83 -38 83 -20Q83 -19 83 -17Q82 -10 98 -1Q117 9 248 71Q326 108 378 132L626 250L378 368Q90 504 86 509Q84 513 84 520Z"></path></g><g data-mml-node="mn" transform="translate(1055.8,0)"><path data-c="34" d="M462 0Q444 3 333 3Q217 3 199 0H190V46H221Q241 46 248 46T265 48T279 53T286 61Q287 63 287 115V165H28V211L179 442Q332 674 334 675Q336 677 355 677H373L379 671V211H471V165H379V114Q379 73 379 66T385 54Q393 47 442 46H471V0H462ZM293 211V545L74 212L183 211H293Z"></path><path data-c="35" d="M164 157Q164 133 148 117T109 101H102Q148 22 224 22Q294 22 326 82Q345 115 345 210Q345 313 318 349Q292 382 260 382H254Q176 382 136 314Q132 307 129 306T114 304Q97 304 95 310Q93 314 93 485V614Q93 664 98 664Q100 666 102 666Q103 666 123 658T178 642T253 634Q324 634 389 662Q397 666 402 666Q410 666 410 648V635Q328 538 205 538Q174 538 149 544L139 546V374Q158 388 169 396T205 412T256 420Q337 420 393 355T449 201Q449 109 385 44T229 -22Q148 -22 99 32T50 154Q50 178 61 192T84 210T107 214Q132 214 148 197T164 157Z" transform="translate(500,0)"></path></g></g></g></svg></mjx-container></span>, or up in chair, for enhanced respiratory pattern/coughing</li> |
| <li>Weaning of FiO 2 as tolerated to <span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.439ex;" xmlns="http://www.w3.org/2000/svg" width="12.475ex" height="2.136ex" role="img" focusable="false" viewBox="0 -750 5514.1 944"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mi"><path data-c="1D446" d="M308 24Q367 24 416 76T466 197Q466 260 414 284Q308 311 278 321T236 341Q176 383 176 462Q176 523 208 573T273 648Q302 673 343 688T407 704H418H425Q521 704 564 640Q565 640 577 653T603 682T623 704Q624 704 627 704T632 705Q645 705 645 698T617 577T585 459T569 456Q549 456 549 465Q549 471 550 475Q550 478 551 494T553 520Q553 554 544 579T526 616T501 641Q465 662 419 662Q362 662 313 616T263 510Q263 480 278 458T319 427Q323 425 389 408T456 390Q490 379 522 342T554 242Q554 216 546 186Q541 164 528 137T492 78T426 18T332 -20Q320 -22 298 -22Q199 -22 144 33L134 44L106 13Q83 -14 78 -18T65 -22Q52 -22 52 -14Q52 -11 110 221Q112 227 130 227H143Q149 221 149 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| </ul> |
| <div>Effect of Postoperative Intravenous Acetaminophen versus Placebo, Combined with Propofol or Dexmedetomidine, on Postoperative In-Hospital Delirium Among Older Patients Following Cardiac Surgery: The DEXACET Randomized Clinical Trial</div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="institutional-intravenous-drug-administration-guidelines"> |
| INSTITUTIONAL INTRAVENOUS DRUG ADMINISTRATION GUIDELINES</h2> |
| <div class="table_tabular" style="text-align: center"> |
| <div class="inline-tabular"><table class="tabular"> |
| <tbody> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left: none !important; border-right: none !important; border-bottom: none !important; border-top: none !important; width: auto; vertical-align: middle; ">Version Date:</td> |
| <td style="text-align: left; border-bottom: none !important; border-top: none !important; width: auto; vertical-align: middle; "><span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.566ex;" xmlns="http://www.w3.org/2000/svg" width="7.919ex" height="2.262ex" role="img" focusable="false" viewBox="0 -750 3500 1000"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mn"><path data-c="30" d="M96 585Q152 666 249 666Q297 666 345 640T423 548Q460 465 460 320Q460 165 417 83Q397 41 362 16T301 -15T250 -22Q224 -22 198 -16T137 16T82 83Q39 165 39 320Q39 494 96 585ZM321 597Q291 629 250 629Q208 629 178 597Q153 571 145 525T137 333Q137 175 145 125T181 46Q209 16 250 16Q290 16 318 46Q347 76 354 130T362 333Q362 478 354 524T321 597Z"></path><path data-c="31" d="M213 578L200 573Q186 568 160 563T102 556H83V602H102Q149 604 189 617T245 641T273 663Q275 666 285 666Q294 666 302 660V361L303 61Q310 54 315 52T339 48T401 46H427V0H416Q395 3 257 3Q121 3 100 0H88V46H114Q136 46 152 46T177 47T193 50T201 52T207 57T213 61V578Z" transform="translate(500,0)"></path></g><g data-mml-node="TeXAtom" data-mjx-texclass="ORD" transform="translate(1000,0)"><g data-mml-node="mo"><path data-c="2F" d="M423 750Q432 750 438 744T444 730Q444 725 271 248T92 -240Q85 -250 75 -250Q68 -250 62 -245T56 -231Q56 -221 230 257T407 740Q411 750 423 750Z"></path></g></g><g data-mml-node="mn" transform="translate(1500,0)"><path data-c="32" d="M109 429Q82 429 66 447T50 491Q50 562 103 614T235 666Q326 666 387 610T449 465Q449 422 429 383T381 315T301 241Q265 210 201 149L142 93L218 92Q375 92 385 97Q392 99 409 186V189H449V186Q448 183 436 95T421 3V0H50V19V31Q50 38 56 46T86 81Q115 113 136 137Q145 147 170 174T204 211T233 244T261 278T284 308T305 340T320 369T333 401T340 431T343 464Q343 527 309 573T212 619Q179 619 154 602T119 569T109 550Q109 549 114 549Q132 549 151 535T170 489Q170 464 154 447T109 429Z"></path><path data-c="30" d="M96 585Q152 666 249 666Q297 666 345 640T423 548Q460 465 460 320Q460 165 417 83Q397 41 362 16T301 -15T250 -22Q224 -22 198 -16T137 16T82 83Q39 165 39 320Q39 494 96 585ZM321 597Q291 629 250 629Q208 629 178 597Q153 571 145 525T137 333Q137 175 145 125T181 46Q209 16 250 16Q290 16 318 46Q347 76 354 130T362 333Q362 478 354 524T321 597Z" transform="translate(500,0)"></path><path data-c="30" d="M96 585Q152 666 249 666Q297 666 345 640T423 548Q460 465 460 320Q460 165 417 83Q397 41 362 16T301 -15T250 -22Q224 -22 198 -16T137 16T82 83Q39 165 39 320Q39 494 96 585ZM321 597Q291 629 250 629Q208 629 178 597Q153 571 145 525T137 333Q137 175 145 125T181 46Q209 16 250 16Q290 16 318 46Q347 76 354 130T362 333Q362 478 354 524T321 597Z" transform="translate(1000,0)"></path><path data-c="32" d="M109 429Q82 429 66 447T50 491Q50 562 103 614T235 666Q326 666 387 610T449 465Q449 422 429 383T381 315T301 241Q265 210 201 149L142 93L218 92Q375 92 385 97Q392 99 409 186V189H449V186Q448 183 436 95T421 3V0H50V19V31Q50 38 56 46T86 81Q115 113 136 137Q145 147 170 174T204 211T233 244T261 278T284 308T305 340T320 369T333 401T340 431T343 464Q343 527 309 573T212 619Q179 619 154 602T119 569T109 550Q109 549 114 549Q132 549 151 535T170 489Q170 464 154 447T109 429Z" transform="translate(1500,0)"></path></g></g></g></svg></mjx-container></span></td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left: none !important; border-right: none !important; border-bottom: none !important; border-top: none !important; width: auto; vertical-align: middle; ">Revision Date:</td> |
| <td style="text-align: left; border-bottom: none !important; border-top: none !important; width: auto; vertical-align: middle; "><span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.566ex;" xmlns="http://www.w3.org/2000/svg" width="7.919ex" height="2.262ex" role="img" focusable="false" viewBox="0 -750 3500 1000"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mn"><path data-c="31" d="M213 578L200 573Q186 568 160 563T102 556H83V602H102Q149 604 189 617T245 641T273 663Q275 666 285 666Q294 666 302 660V361L303 61Q310 54 315 52T339 48T401 46H427V0H416Q395 3 257 3Q121 3 100 0H88V46H114Q136 46 152 46T177 47T193 50T201 52T207 57T213 61V578Z"></path><path data-c="31" d="M213 578L200 573Q186 568 160 563T102 556H83V602H102Q149 604 189 617T245 641T273 663Q275 666 285 666Q294 666 302 660V361L303 61Q310 54 315 52T339 48T401 46H427V0H416Q395 3 257 3Q121 3 100 0H88V46H114Q136 46 152 46T177 47T193 50T201 52T207 57T213 61V578Z" transform="translate(500,0)"></path></g><g data-mml-node="TeXAtom" data-mjx-texclass="ORD" transform="translate(1000,0)"><g data-mml-node="mo"><path data-c="2F" d="M423 750Q432 750 438 744T444 730Q444 725 271 248T92 -240Q85 -250 75 -250Q68 -250 62 -245T56 -231Q56 -221 230 257T407 740Q411 750 423 750Z"></path></g></g><g data-mml-node="mn" transform="translate(1500,0)"><path data-c="32" d="M109 429Q82 429 66 447T50 491Q50 562 103 614T235 666Q326 666 387 610T449 465Q449 422 429 383T381 315T301 241Q265 210 201 149L142 93L218 92Q375 92 385 97Q392 99 409 186V189H449V186Q448 183 436 95T421 3V0H50V19V31Q50 38 56 46T86 81Q115 113 136 137Q145 147 170 174T204 211T233 244T261 278T284 308T305 340T320 369T333 401T340 431T343 464Q343 527 309 573T212 619Q179 619 154 602T119 569T109 550Q109 549 114 549Q132 549 151 535T170 489Q170 464 154 447T109 429Z"></path><path data-c="30" d="M96 585Q152 666 249 666Q297 666 345 640T423 548Q460 465 460 320Q460 165 417 83Q397 41 362 16T301 -15T250 -22Q224 -22 198 -16T137 16T82 83Q39 165 39 320Q39 494 96 585ZM321 597Q291 629 250 629Q208 629 178 597Q153 571 145 525T137 333Q137 175 145 125T181 46Q209 16 250 16Q290 16 318 46Q347 76 354 130T362 333Q362 478 354 524T321 597Z" transform="translate(500,0)"></path><path data-c="31" d="M213 578L200 573Q186 568 160 563T102 556H83V602H102Q149 604 189 617T245 641T273 663Q275 666 285 666Q294 666 302 660V361L303 61Q310 54 315 52T339 48T401 46H427V0H416Q395 3 257 3Q121 3 100 0H88V46H114Q136 46 152 46T177 47T193 50T201 52T207 57T213 61V578Z" transform="translate(1000,0)"></path><path data-c="34" d="M462 0Q444 3 333 3Q217 3 199 0H190V46H221Q241 46 248 46T265 48T279 53T286 61Q287 63 287 115V165H28V211L179 442Q332 674 334 675Q336 677 355 677H373L379 671V211H471V165H379V114Q379 73 379 66T385 54Q393 47 442 46H471V0H462ZM293 211V545L74 212L183 211H293Z" transform="translate(1500,0)"></path></g></g></g></svg></mjx-container></span></td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left: none !important; border-right: none !important; border-bottom: none !important; border-top: none !important; width: auto; vertical-align: middle; ">Medication:</td> |
| <td style="text-align: left; border-bottom: none !important; border-top: none !important; width: auto; vertical-align: middle; ">Dexmedetomidine Hydrochloride (PRECEDEX)</td> |
| </tr> |
| </tbody> |
| </table> |
| </div></div> |
| <div>Effect of Postoperative Intravenous Acetaminophen versus Placebo, Combined with Propofol or Dexmedetomidine, on Postoperative In-Hospital Delirium Among Older Patients Following Cardiac Surgery: The DEXACET Randomized Clinical Trial</div> |
| <div class="table_tabular" style="text-align: center"> |
| <div class="inline-tabular"><table class="tabular"> |
| <tbody> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top-style: solid !important; border-top-width: 1px !important; width: auto; vertical-align: middle; "><figure style="text-align: center"><img src="https://cdn.mathpix.com/cropped/6c46927b-ae99-4127-9213-1a3afb06732f-22.jpg?height=133&width=104&top_left_y=308&top_left_x=390" alt="" data-align="center"></figure></td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; "><div class="inline-tabular sub-table"><table class="tabular"> |
| <tbody> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left: none !important; border-bottom: none !important; border-top: none !important; width: auto; vertical-align: middle; ">Therapeutic category: Alpha 2-Adrenergic Agonist Sedative</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left: none !important; border-bottom: none !important; border-top: none !important; width: auto; vertical-align: middle; ">Therapeutic Use: Short term sedation of mechanically ventilated patients, or selected non-intubated patients in the intensive care setting, adjunct treatment for alcohol withdrawal in the intensive care setting.</td> |
| </tr> |
| </tbody> |
| </table> |
| </div></td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; "><div class="inline-tabular sub-table"><table class="tabular"> |
| <tbody> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left: none !important; border-bottom: none !important; border-top: none !important; width: auto; vertical-align: middle; ">IV PUSH</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left: none !important; border-bottom: none !important; border-top: none !important; width: auto; vertical-align: middle; ">Not recommended</td> |
| </tr> |
| </tbody> |
| </table> |
| </div></td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; " class="_empty"></td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; "><div class="inline-tabular sub-table"><table class="tabular"> |
| <tbody> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left: none !important; border-bottom: none !important; border-top: none !important; width: auto; vertical-align: middle; ">INTERMITTENT INFUSION</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left: none !important; border-bottom: none !important; border-top: none !important; width: auto; vertical-align: middle; ">Not recommended</td> |
| </tr> |
| </tbody> |
| </table> |
| </div></td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; "><div class="inline-tabular sub-table"><table class="tabular"> |
| <tbody> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left: none !important; border-bottom: none !important; border-top: none !important; width: auto; vertical-align: middle; ">CLINICAL CONSIDERATIONS</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left: none !important; border-bottom: none !important; border-top: none !important; width: auto; vertical-align: middle; ">- IV access: May be administered peripherally or centrally</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left: none !important; border-bottom: none !important; border-top: none !important; width: auto; vertical-align: middle; ">- IV infusion device: Sigma infusion pump required</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left: none !important; border-bottom: none !important; border-top: none !important; width: auto; vertical-align: middle; ">- Infusion related considerations:</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left: none !important; border-bottom: none !important; border-top: none !important; width: auto; vertical-align: middle; ">- Continuous infusion should be titrated in <span class="math-inline "> |
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| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left: none !important; border-bottom: none !important; border-top: none !important; width: auto; vertical-align: middle; ">- Acute agitation while titrating infusion should be managed with either midazolam or fentanyl bolus dosing -Do not bolus dose dexmedetomidine for ICU sedation</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left: none !important; border-bottom: none !important; border-top: none !important; width: auto; vertical-align: middle; ">- When converting a patient from other continuous sedation, dexmedetomidine should be initiated at 0.4 <span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.566ex;" xmlns="http://www.w3.org/2000/svg" width="10.889ex" height="2.262ex" role="img" focusable="false" viewBox="0 -750 4813 1000"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mi"><path data-c="1D45A" d="M21 287Q22 293 24 303T36 341T56 388T88 425T132 442T175 435T205 417T221 395T229 376L231 369Q231 367 232 367L243 378Q303 442 384 442Q401 442 415 440T441 433T460 423T475 411T485 398T493 385T497 373T500 364T502 357L510 367Q573 442 659 442Q713 442 746 415T780 336Q780 285 742 178T704 50Q705 36 709 31T724 26Q752 26 776 56T815 138Q818 149 821 151T837 153Q857 153 857 145Q857 144 853 130Q845 101 831 73T785 17T716 -10Q669 -10 648 17T627 73Q627 92 663 193T700 345Q700 404 656 404H651Q565 404 506 303L499 291L466 157Q433 26 428 16Q415 -11 385 -11Q372 -11 364 -4T353 8T350 18Q350 29 384 161L420 307Q423 322 423 345Q423 404 379 404H374Q288 404 229 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| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.186ex;" xmlns="http://www.w3.org/2000/svg" width="5.028ex" height="1.692ex" role="img" focusable="false" viewBox="0 -666 2222.4 748"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mn"><path data-c="31" d="M213 578L200 573Q186 568 160 563T102 556H83V602H102Q149 604 189 617T245 641T273 663Q275 666 285 666Q294 666 302 660V361L303 61Q310 54 315 52T339 48T401 46H427V0H416Q395 3 257 3Q121 3 100 0H88V46H114Q136 46 152 46T177 47T193 50T201 52T207 57T213 61V578Z"></path></g><g data-mml-node="mo" transform="translate(722.2,0)"><path data-c="2212" d="M84 237T84 250T98 270H679Q694 262 694 250T679 230H98Q84 237 84 250Z"></path></g><g data-mml-node="mn" transform="translate(1722.4,0)"><path data-c="32" d="M109 429Q82 429 66 447T50 491Q50 562 103 614T235 666Q326 666 387 610T449 465Q449 422 429 383T381 315T301 241Q265 210 201 149L142 93L218 92Q375 92 385 97Q392 99 409 186V189H449V186Q448 183 436 95T421 3V0H50V19V31Q50 38 56 46T86 81Q115 113 136 137Q145 147 170 174T204 211T233 244T261 278T284 308T305 340T320 369T333 401T340 431T343 464Q343 527 309 573T212 619Q179 619 154 602T119 569T109 550Q109 549 114 549Q132 549 151 535T170 489Q170 464 154 447T109 429Z"></path></g></g></g></svg></mjx-container></span> hours before attempting weaning of other sedative agents.</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left: none !important; border-bottom: none !important; border-top: none !important; width: auto; vertical-align: middle; ">- Patients may remain on dexmedetomidine after extubation, (or to avoid intubation in alcohol withdrawal) but care should be taken to monitor hemodynamics and respiratory status (as below)</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left: none !important; border-bottom: none !important; border-top: none !important; width: auto; vertical-align: middle; ">- Monitoring:</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left: none !important; border-bottom: none !important; border-top: none !important; width: auto; vertical-align: middle; ">- Patient should be continuously monitored for heart rate and blood pressure</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left: none !important; border-bottom: none !important; border-top: none !important; width: auto; vertical-align: middle; ">- Dexmedetomidine may prolong PR interval.</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left: none !important; border-bottom: none !important; border-top: none !important; width: auto; vertical-align: middle; ">- While dexmedetomidine does not cause respiratory depression, cases of obstructive apnea have been reported with high doses. Monitor continuous oxygen saturation while infusing</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left: none !important; border-bottom: none !important; border-top: none !important; width: auto; vertical-align: middle; ">- Level of sedation. (RASS) should be monitored at least every 4 hours</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left: none !important; border-bottom: none !important; border-top: none !important; width: auto; vertical-align: middle; ">- Common adverse effects include bradycardia and hypotension.</td> |
| </tr> |
| </tbody> |
| </table> |
| </div></td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; "><div class="inline-tabular sub-table"><table class="tabular"> |
| <tbody> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left: none !important; border-bottom: none !important; border-top: none !important; width: auto; vertical-align: middle; ">COMPATIBILITY</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left: none !important; border-bottom: none !important; border-top: none !important; width: auto; vertical-align: middle; ">- Compatible with <span class="math-inline "> |
| <mjx-container class="MathJax" jax="SVG"><svg style="vertical-align: -0.127ex;" xmlns="http://www.w3.org/2000/svg" width="4.776ex" height="1.824ex" role="img" focusable="false" viewBox="0 -750 2111 806"><g stroke="currentColor" fill="currentColor" stroke-width="0" transform="scale(1,-1)"><g data-mml-node="math"><g data-mml-node="mn"><path data-c="30" d="M96 585Q152 666 249 666Q297 666 345 640T423 548Q460 465 460 320Q460 165 417 83Q397 41 362 16T301 -15T250 -22Q224 -22 198 -16T137 16T82 83Q39 165 39 320Q39 494 96 585ZM321 597Q291 629 250 629Q208 629 178 597Q153 571 145 525T137 333Q137 175 145 125T181 46Q209 16 250 16Q290 16 318 46Q347 76 354 130T362 333Q362 478 354 524T321 597Z"></path><path data-c="2E" d="M78 60Q78 84 95 102T138 120Q162 120 180 104T199 61Q199 36 182 18T139 0T96 17T78 60Z" transform="translate(500,0)"></path><path data-c="39" d="M352 287Q304 211 232 211Q154 211 104 270T44 396Q42 412 42 436V444Q42 537 111 606Q171 666 243 666Q245 666 249 666T257 665H261Q273 665 286 663T323 651T370 619T413 560Q456 472 456 334Q456 194 396 97Q361 41 312 10T208 -22Q147 -22 108 7T68 93T121 149Q143 149 158 135T173 96Q173 78 164 65T148 49T135 44L131 43Q131 41 138 37T164 27T206 22H212Q272 22 313 86Q352 142 352 280V287ZM244 248Q292 248 321 297T351 430Q351 508 343 542Q341 552 337 562T323 588T293 615T246 625Q208 625 181 598Q160 576 154 546T147 441Q147 358 152 329T172 282Q197 248 244 248Z" transform="translate(778,0)"></path></g><g data-mml-node="mi" transform="translate(1278,0)"><path data-c="25" d="M465 605Q428 605 394 614T340 632T319 641Q332 608 332 548Q332 458 293 403T202 347Q145 347 101 402T56 548Q56 637 101 693T202 750Q241 750 272 719Q359 642 464 642Q580 642 650 732Q662 748 668 749Q670 750 673 750Q682 750 688 743T693 726Q178 -47 170 -52Q166 -56 160 -56Q147 -56 142 -45Q137 -36 142 -27Q143 -24 363 304Q469 462 525 546T581 630Q528 605 465 605ZM207 385Q235 385 263 427T292 548Q292 617 267 664T200 712Q193 712 186 709T167 698T147 668T134 615Q132 595 132 548V527Q132 436 165 403Q183 385 203 385H207ZM500 146Q500 234 544 290T647 347Q699 347 737 292T776 146T737 0T646 -56Q590 -56 545 0T500 146ZM651 -18Q679 -18 707 24T736 146Q736 215 711 262T644 309Q637 309 630 306T611 295T591 265T578 212Q577 200 577 146V124Q577 -18 647 -18H651Z"></path></g></g></g></svg></mjx-container></span> Sodium Chloride</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left: none !important; border-bottom: none !important; border-top: none !important; width: auto; vertical-align: middle; ">- Dexmedetomidine standard concentration: <span class="math-inline "> |
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| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left: none !important; border-bottom: none !important; border-top: none !important; width: auto; vertical-align: middle; ">- Stable for 48 hours at room temperature. Do not refrigerate</td> |
| </tr> |
| </tbody> |
| </table> |
| </div></td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left-style: solid !important; border-left-width: 1px !important; border-right-style: solid !important; border-right-width: 1px !important; border-bottom-style: solid !important; border-bottom-width: 1px !important; border-top: none !important; width: auto; vertical-align: middle; "><div class="inline-tabular sub-table"><table class="tabular"> |
| <tbody> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left: none !important; border-bottom: none !important; border-top: none !important; width: auto; vertical-align: middle; ">WRITTEN BY: John Marshall, PharmD</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left: none !important; border-bottom: none !important; border-top: none !important; width: auto; vertical-align: middle; ">APPROVED: Pharmacy and Therapeutics Committee</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left: none !important; border-bottom: none !important; border-top: none !important; width: auto; vertical-align: middle; ">DATE: January 2002</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left: none !important; border-bottom: none !important; border-top: none !important; width: auto; vertical-align: middle; ">REVISED: November 2014</td> |
| </tr> |
| <tr style="border-top: none !important; border-bottom: none !important;"> |
| <td style="text-align: left; border-left: none !important; border-bottom: none !important; border-top: none !important; width: auto; vertical-align: middle; ">STATUS: Formulary</td> |
| </tr> |
| </tbody> |
| </table> |
| </div></td> |
| </tr> |
| </tbody> |
| </table> |
| </div></div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="references%3A"> |
| References:</h2> |
| <div>Shehabi Y et al. Clinical Application, The Use of Dexmedetomidine in Intensive Care Sedation. Crit Care & Shock 2010 Vol.13:(2); 40-50</div> |
| <div>Effect of Postoperative Intravenous Acetaminophen versus Placebo, Combined with Propofol or Dexmedetomidine, on Postoperative In-Hospital Delirium Among Older Patients Following Cardiac Surgery: The DEXACET Randomized Clinical Trial</div> |
| <h2 type="section" data-unnumbered="true" class="section-title" id="references"> |
| REFERENCES</h2> |
| <ol> |
| <li>Rudolph JL, Jones RN, Levkoff SE, et al. Derivation and validation of a preoperative prediction rule for delirium after cardiac surgery. Circulation. 2009;119(2):229-236.</li> |
| <li>Inouye SK. Delirium in older persons. N Engl J Med. 2006;354(11):1157-1165.</li> |
| <li>Saczynski JS, Marcantonio ER, Quach L, et al. Cognitive trajectories after postoperative delirium. N Engl J Med. 2012;367(1):30-39.</li> |
| <li>Lin YY, He B, Chen J, Wang ZN. Can dexmedetomidine be a safe and efficacious sedative agent in post-cardiac surgery patients? a meta-analysis. Crit Care. 2012;16(5):R169.</li> |
| <li>Dasta JF, Jacobi J, Sesti AM, McLaughlin TP. Addition of dexmedetomidine to standard sedation regimens after cardiac surgery: an outcomes analysis. Pharmacotherapy. 2006;26(6):798-805.</li> |
| <li>Shehabi Y, Grant P, Wolfenden H, et al. Prevalence of delirium with dexmedetomidine compared with morphine based therapy after cardiac surgery: a randomized controlled trial (DEXmedetomidine COmpared to Morphine-DEXCOM Study). Anesthesiology. 2009;111(5):1075-1084.</li> |
| <li>Maldonado JR, Wysong A, van der Starre PJ, Block T, Miller C, Reitz BA. Dexmedetomidine and the reduction of postoperative delirium after cardiac surgery. Psychosomatics. 2009;50(3):206-217.</li> |
| <li>Corbett SM, Rebuck JA, Greene CM, et al. Dexmedetomidine does not improve patient satisfaction when compared with propofol during mechanical ventilation. Crit Care Med. 2005;33(5):940-945.</li> |
| <li>Holmer Pettersson P, Jakobsson J, Owall A. Plasma concentrations following repeated rectal or intravenous administration of paracetamol after heart surgery. Acta Anaesthesiol Scand. 2006;50(6):673-677.</li> |
| </ol> |
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