Effects of Intranasal Insulin Pretreatment on Preoperative Sleep Quality and Postoperative Delirium in Patients Undergoing Valve Replacement for Rheumatic Heart Disease

Abstract

Background

Postoperative delirium (POD) is a common neurological complication associated with valve replacement. Preoperative sleep disturbance is a risk factor for POD development, and nasal insulin modulates the sleep-wake cycle. This study investigated the beneficial effects of intranasal insulin pretreatment on preoperative sleep quality and reducing POD in patients undergoing valve replacement for rheumatic heart disease.

Patients and Methods

This prospective, single-center, randomized controlled trial (RCT) included 76 adult patients aged 18–65 years undergoing valve surgery with cardiopulmonary bypass who were randomly allocated to receive intranasal insulin or normal saline interventions two days before surgery. POD incidence was on postoperative days 1 (T3), 2 (T4), and 3 (T5). Before the first intervention (T0), 1 d before surgery (T1), and before anesthesia on the day of surgery (T2), sleep quality was assessed and serum cortisol concentrations were measured. At T1 and T2, sleep quality related indicators monitored by sleep monitoring watches from the previous night were recorded.

Results

Compared with the normal saline group, 3 days after surgery, the insulin group showed a significantly reduced incidence of POD; significantly increased deep sleep, REM sleep, deep sleep continuity, and total sleep quality scores at T1 and T2; and significantly reduced serum cortisol concentration, PSQI scale, light sleep ratio, and wakefulness at T1 and T2.

Conclusion

The administration of 20 U of intranasal insulin twice daily, from 2 days preoperatively until 10 minutes preanesthesia on the day of surgery, can improved preoperative sleep quality significantly and reduced POD incidence in patients with rheumatic heart disease undergoing valve replacement.

Clinical Trial Registration

This study was registered with the Chinese Clinical Trial Registry (www.chictr.org.cn, with the unique identifier ChiCTR2100048515; July 9, 2021).

Keywords:

• postoperative delirium
• rheumatic heart disease
• valve replacement
• preoperative sleep quality
• intranasal insulin

Abbreviations

ASA, American Society of Anesthesiologists; BIS, bispectral index; CAM-CR, Delirium Scale Analysis System; CAM-ICU, confusion assessment method for the intensive care unit; CPB, cardiopulmonary bypass; DSMIV, Diagnostic and Statistical Manual of Mental Disorders (4th Edition); HPA, hypothalamic-pituitary-adrenal; FIO₂, concentration of inhaled oxygen; ICU, intensive care unit; INS, insulin; MAP, mean arterial pressure; MMSE, Mini-Mental State Examination; NRS, numerical rating scale; NS, normal saline; PCIA, patient-controlled intravenous analgesia; PCV-VG, pressure control volume guarantee; PETCO₂, partial pressure end-tidal carbon dioxide, POD, postoperative delirium; PSQI, Pittsburgh Sleep Quality Index; RASS, Richmond Agitation Scale; REM, rapid eye movement; SD, standard deviation; T0, before the first intervention; T1, 1 day before surgery; T2, before anesthesia on the day of surgery; T3, postoperative day 1; T4, postoperative day 2; T5, postoperative day 5.

Data Sharing Statement

The raw data for this study have been uploaded to www.medresman.org.cn and are also available from the corresponding author on reasonable request.

Acknowledgments

We thank the medical staff who participated in this study. We would also like to thank the English editor (www.Editage.com).

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors report no conflicts of interest in this work.

Additional information

Funding

This study was supported by the Hospital Management Project of the General Hospital of the Western Theater Command (grant number 2021-XZYG-C25), the Joint key project (grant number 2019LH01) and Sichuan Natural Science Foundation Project (No. 2022NSFSC0746).