Vasopressor Selection and Postoperative Delirium in Older Adults: A Propensity-Matched Database Analysis

Objectives Vasopressor choice potentially contributes to postoperative delirium due to differences in end-organ perfusion. This study seeks to determine the rates of postoperative delirium after perioperative phenylephrine, ephedrine, or norepinephrine administration. Design Retrospective, propensity-score matched multicenter database study. Participants Patients aged 60 and older undergoing surgery of the integumentary, musculoskeletal, respiratory, hematologic/lymphatic, gastrointestinal, genitourinary/reproductive, endocrine, or sensory organ systems. Interventions Perioperative vasopressor administration (phenylephrine, ephedrine, norepinephrine). Measurements and Main Results The primary outcome was the incidence of postoperative delirium based on ICD-10 diagnostic codes within seven days of surgery. After propensity score matching, there was no difference in the rate of postoperative delirium between phenylephrine and norepinephrine (OR 0.97; 95% CI 0.61–1.54; P = .9065) or between ephedrine and norepinephrine (OR 0.74; 95% CI 0.41-1.32; P = .3062). Phenylephrine was associated with a higher rate of postoperative delirium when compared to ephedrine (OR 1.30; 95% CI 1.05–1.60; P = .0162), although absolute risk difference was small (0.05%). Conclusions This study highlights the potential influence of vasopressor selection on postoperative neurocognitive outcomes in older adults. Understanding the physiologic and pharmacologic mechanisms underlying these associations may help guide individualized intraoperative management and reduce delirium risk in clinical practice.