Beyond drug rankings in cardiac surgical delirium prevention.
Journal
Anaesthesia
Journal Volume
81
Journal Issue
3
Start Page
454
End Page
454
ISSN
1365-2044
Date Issued
2026-03
Author(s)
Abstract
We read with interest the systematic review and Bayesian network meta-analysis by Queiroz et al. [1], which compared peri-operative pharmacological interventions to prevent postoperative delirium in patients undergoing cardiac surgery. Their work provides a valuable synthesis of available evidence, and their conclusion is timely and clinically relevant. The real-world feasibility of combining dexmedetomidine and melatonin remains uncertain. While the ranking is compelling, melatonin is not administered routinely in many countries and is unlicensed for clinical use in others. Available formulations vary widely in dose, purity and release characteristics [2]. The authors acknowledge heterogeneity in dosing regimens and intervention timing as key limitations, yet the practical barriers of drug accessibility and standardisation pose substantial challenges to implementation. The haemodynamic profile of dexmedetomidine warrants closer scrutiny. The meta-analysis highlights reductions in postoperative delirium and duration of ICU stay but pays limited attention to the risk of bradycardia and/or hypotension [3]. In patients who are vulnerable and having cardiac surgery, many of whom are older or have impaired ventricular function, haemodynamic instability may outweigh the benefit of delirium prevention. Furthermore, the exclusive focus on pharmacological interventions overlooks the multidimensional nature of postoperative delirium [4]. The authors note that delirium is influenced by factors such as pain, anxiety, stress and peri-operative sleep disruption, yet non-pharmacological strategies such as early mobilisation, optimising the ICU environment, structured sleep promotion and effective analgesia were not considered [5]. A multimodal strategy integrating pharmacological and non-pharmacological measures may provide the most comprehensive protection. Beyond knowing which combination ranks highest, we do not yet know which patient groups stand to benefit the most. The authors' call for standardised protocols and clearly defined outcomes is welcome, yet practical, patient-centred guidance on dosing and timing is still lacking. While this new study advances our understanding of pharmacological prophylaxis for postoperative delirium, the path to clinical translation requires more than drug rankings alone. Consideration of drug accessibility, haemodynamic safety, integration with non-pharmacological care and answers to bedside clinical questions will be essential to guide anaesthetists in balancing efficacy with patient safety.
SDGs
Type
letter