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. 2024 Jun;68(6):517-526.
doi: 10.4103/ija.ija_149_24. Epub 2024 May 8.

Effect of prophylactic corticosteroids on postoperative neurocognitive dysfunction in the adult population: An updated systematic review, meta-analysis, and trial sequential analysis of randomised controlled trials

Narinder P Singh  1 , Jeetinder K Makkar  2 , Nitika Goel  2 , Kunal Karamchandani  3 , Mandeep Singh  4 , Preet M Singh  5
Affiliations

Effect of prophylactic corticosteroids on postoperative neurocognitive dysfunction in the adult population: An updated systematic review, meta-analysis, and trial sequential analysis of randomised controlled trials

Narinder P Singh et al. Indian J Anaesth. 2024 Jun.

Abstract

Background and aims: Postoperative neurocognitive dysfunction (PNCD) commonly occurs after surgery and prolongs hospital stays. Both direct noxious stimuli to the central nervous system and systemic inflammation have been implicated. Due to their potent anti-inflammatory effects, corticosteroids have been utilised to attenuate the incidence and severity of PNCD. This systematic review and meta-analysis strived to evaluate the prophylactic role of perioperative corticosteroids for PNCD.

Methods: A search was run in pre-defined databases for randomised controlled trials (RCTs) assessing the role of corticosteroids in preventing PNCD. The incidence of PNCD within 1 month was the primary outcome. Secondary outcomes included the use of antipsychotic medications for the treatment, postoperative infection, and hospital length of stay. The results are exhibited as odds ratio (OR) and the mean difference (MD) with 95% confidence interval (CI).

Results: Fifteen RCTs comprising 15,398 patients were included. The incidence of PNCD was significantly lower in the corticosteroid group than in the control group, with a pooled OR of 0.75 (95% CI 0.58, 0.96; P = 0.02; I2 = 66%). Trial sequential analysis showed the clinical benefit of corticosteroids in preventing PNCD; however, the requisite information size is still inadequate. The sub-group analysis supported the prophylactic effect of corticosteroids on delirium prevention but not on delayed neurocognitive recovery.

Conclusions: Our meta-analysis revealed statistically significant protective effects of corticosteroids on the incidence of PNCD. However, further studies are still needed to confirm the protective role of this commonly used and relatively safe strategy for preventing PNCD.

Keywords: Corticosteroids; delayed neurocognitive recovery; delirium; dexamethasone; meta-analysis; post-operative neurocognitive dysfunction; postoperative cognitive dysfunction; systematic review; trial sequential analysis.

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Conflict of interest statement

There are no conflicts of interest.

Figures

Figure 1
Figure 1
Flow diagram of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines showing the literature search results
Figure 2
Figure 2
(a) Risk of bias summary of the included studies according to the Cochrane Collaboration guidelines. Green, red, and yellow circles indicate low, high, and unclear risk of bias, respectively. (b) Funnel plot for publication bias for postoperative neurocognitive dysfunction
Figure 3
Figure 3
(a) Forest plot showing the effect of corticosteroids on postoperative neurocognitive dysfunction. (b) Trial sequential analysis (TSA) for intraoperative analgesic supplementation. The lower half of the graph below the zero axis represents the area of advantage with respect to the control group, and the upper half represents the advantage area with respect to the steroid group. The solid black squares indicate the cumulative z score with the addition of each of the seven trials in chronological order. The brown lines on the Y-axis represent the conventional model boundaries for TSA with an alpha error of 5%. The red lines represent the alpha-spending boundary (upper O’Brien Fleming, with an alpha of 5% and a low risk of bias). The minimum required IS for the alpha-spending boundary model is 18,445 (vertical line intersecting the X-axis in red)
Figure 4
Figure 4
(a) Subgroup analysis for the incidence of postoperative delirium and delayed neurocognitive recovery with corticosteroids. (b) Subgroup analysis of the effect of the type of surgery on the incidence of postoperative neurocognitive dysfunction. dNCR=Delayed neurocognitive recovery, POCD=Postoperative cognitive dysfunction, CI=Confidence interval
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Comment in

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