Cisatracurium Compared to Atracurium for the Prevention of Postoperative Delirium in Colorectal Cancer Surgery: Protocol of a Double-Blind, Randomized, Clinical Trial
-
Kousha Farhadi
,
Mohammadreza Neishaboury
,
Farhad Etezadi
,
Hesam Varpaei
,
Erta Rajabi
,
Mohammad Reza Khajavi
,
Mahsa Arab Mohammadi
,
Reza Shariat Moharari
,
Atabak Najafi
,
Reza Bahman
,
Hamidreza Sharifnia
,
Pejman Pourfakhr
Abstract
Background: Non-depolarizing neuromuscular blocking agents have been shown to play a role in postoperative delirium (POD) and postoperative cognitive dysfunction (POCD). Cisatracurium is known for its higher potency, lower induction dose, anti-inflammatory activity, lower histamine release, and better hemodynamic stability compared to atracurium, all of which may benefit postoperative cognitive function. This study aims to assess the preventive effects of cisatracurium compared with atracurium on POD incidence in patients undergoing colorectal surgery.
Methods: This single-center, randomized, controlled trial will be conducted at a tertiary care hospital of Sina (Tehran, Iran) from November 2025, assessing the preventive effects on POD of 0.2 mg/kg cisatracurium compared to 0.5 mg/kg atracurium induction dose with subsequent similar drug maintenance on a total of 200 patients undergoing mass resection surgery of colorectal cancers. Patients will be randomly assigned to a 1:1 allocation to each group. The primary outcome will be the prevalence of POD, assessed twice daily from the night after surgery until day 5, using the intensive care delirium screening checklist (ICDSC). The secondary aims are clinically relevant outcomes, including POCD, as measured by the Montreal Cognitive Assessment (MoCA), postoperative pain using a visual analogue scale (VAS), POD severity using the ICDSC, and duration of hospitalization.
Conclusion: This paper provides the protocol for the study comparing the activity of two neuromuscular blocking agents in preventing POD in colorectal cancer surgeries based on the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) guideline.
[1] Fong TG, Inouye SK. The inter-relationship between delirium and dementia: the importance of delirium prevention. Nat Rev Neurol. 2022; 18(10):579-96.
[2] Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. American Psychiatric Association Publishing, Washington, DC. 2013.
[3] Ramírez Echeverría MDL, Schoo C, Paul M. Delirium. 2022 Nov 19. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025.
[4] Mei X, Liu YH, Han YQ, Zheng CY. Risk factors, preventive interventions, overlapping symptoms, and clinical measures of delirium in elderly patients. World J Psychiatry. 2023; 13(12):973-84.
[5] Lee SH, Lim SW. Risk factors for postoperative delirium after colorectal surgery: a systematic review and meta-analysis. Int J Colorectal Dis. 2020; 35(3):433-44.
[6] Varpaei HA, Robbins LB, Ling J, Lehto RH, Bender CM. Anaesthesia-related cognitive dysfunction following cardiothoracic surgery in late middle-age and younger adults: A scoping review. Nurs Crit Care. 2024; 29(3):457-65.
[7] Mevorach L, Forookhi A, Farcomeni A, Romagnoli S, Bilotta F. Perioperative risk factors associated with increased incidence of postoperative delirium: systematic review, meta-analysis, and Grading of Recommendations Assessment, Development, and Evaluation system report of clinical literature. Br J Anaesth. 2023; 130(2):e254-e62.
[8] Varpaei HA, Farhadi K, Mohammadi M, Khafaee Pour Khamseh A, Mokhtari T. Postoperative cognitive dysfunction: a concept analysis. Aging Clin Exp Res. 2024; 36(1):133.
[9] Liu Y, Li XJ, Liang Y, Kang Y. Pharmacological Prevention of Postoperative Delirium: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Evid Based Complement Alternat Med. 2019; 2019:9607129.
[10] Hsiao CC, Lin CJ, Hasan F, Romadlon DS, Traynor V, Hulu SRK, et al. Comparative efficacy of nonpharmacological interventions for preventing postoperative delirium in hospitalized older adults: a systematic review and network meta-analysis. Age Ageing. 2025; 54(9):afaf264.
[11] Méndez-Martínez C, Fernández-Martínez MN, García-Suárez M, Martínez-Isasi S, Fernández-Fernández JA, Fernández-García D. Related Factors and Treatment of Postoperative Delirium in Old Adult Patients: An Integrative Review. Healthcare (Basel). 2021; 9(9):1103.
[12] O'Gara BP, Gao L, Marcantonio ER, Subramaniam B. Sleep, Pain, and Cognition: Modifiable Targets for Optimal Perioperative Brain Health. Anesthesiology. 2021; 135(6):1132-52.
[13] Bramley P, McArthur K, Blayney A, McCullagh I. Risk factors for postoperative delirium: An umbrella review of systematic reviews. Int J Surg. 2021; 93:106063.
[14] Yan F, Chen B, Ma Z, Chen Q, Jin Z, Wang Y, et al. Exploring molecular mechanisms of postoperative delirium through multi-omics strategies in plasma exosomes. Sci Rep. 2024; 14(1):29466.
[15] Li W, Shi Q, Bai R, Zeng J, Lin L, Dai X, et al. Advances in research on the pathogenesis and signaling pathways associated with postoperative delirium (Review). Mol Med Rep. 2025; 32(2):220.
[16] Li T, Lu Z, Qin T, Liu L, Zhang J. Pathomechanism of postoperative delirium: Systemic inflammatory response and neuroinflammation following anesthesia/surgery. Neuroscience. 2025; 581:40-9.
[17] Mulkey MA, Hardin SR, Olson DM, Munro CL. Pathophysiology Review: Seven Neurotransmitters Associated With Delirium. Clin Nurse Spec. 2018; 32(4):195-211.
[18] Geßele C, Rémi C, Smolka V, Dimitriadis K, Amann U, Saller T, et al. Anticholinergic Exposure, Drug Dose and Postoperative Delirium: Comparison of Dose-Related and Non-Dose-Related Anticholinergic Burden Scores in a Retrospective Cohort Study of Older Orthopaedic and Trauma Surgery Patients. Drugs Aging. 2025; 42(2):177-8.
[19] Ieong C, Chen T, Chen S, Gao X, Yan K, He W, et al. Differences of anticholinergic drug burden between older hospitalized patients with and without delirium: a systematic review and meta-analysis based on prospective cohort studies. BMC Geriatr. 2024; 24(1):599.
[20] Moellmann HL, Boulghoudan S, Kuhlmann J, Rahm L, Frohnhofen H. Polypharmacy and anticholinergic burden as risk factors for postoperative delirium in surgical medicine. Z Gerontol Geriatr. 2025; 58(3):203-8.
[21] Shen QH, Li HF, Zhou XY, Lu YP, Yuan XZ. Relation of serum melatonin levels to postoperative delirium in older patients undergoing major abdominal surgery. J Int Med Res. 2020; 48(3):300060520910642.
[22] Farhadi K, Rahimi M, Varpaei H, Rajabi E, Tafreshi SMMT, Mohammadi P, et al. Ketamine and melatonin for the prevention of postoperative delirium in patients with colorectal cancer: a feasibility study. Perioper Med (Lond). 2025; 14(1):90.
[23] Queiroz I, Barbosa LM, Gallo Ruelas M, Araújo B, Defante MLR, Tavares AH, et al. Effect of peri-operative pharmacological interventions on postoperative delirium in patients having cardiac surgery: a systematic review and Bayesian network meta-analysis. Anaesthesia. 2025 Sep 1. Epub ahead of print.
[24] Haque N, Naqvi RM, Dasgupta M. Efficacy of Ondansetron in the Prevention or Treatment of Post-operative Delirium-a Systematic Review. Can Geriatr J. 2019; 22(1):1-6.
[25] Kotake K, Matsunuma S, Kitamura N, Noritake Y, Kawakami Y. Preventive effects of first-generation antihistamine on emergence agitation or delirium: a systematic review. Eur J Clin Pharmacol. 2024; 80(12):1883-92.
[26] Kikkawa N, Sogawa R, Monji A, Sumi S, Murakawa-Hirachi T, Kubo T, et al. Delirium risk of histamine-2 receptor antagonists and proton pump inhibitors: A study based on the adverse drug event reporting database in Japan. Gen Hosp Psychiatry. 2021; 72:88-91.
[27] Shiddapur A, Kistler CE, Busby-Whitehead J, Austin CA. Association of Histamine-2 Blockers and Proton-Pump Inhibitors With Delirium Development in Critically Ill Adults: A Retrospective Cohort Study. Crit Care Explor. 2021; 3(8):e0507.
[28] Orzechowski RF, Currie DS, Valancius CA. Comparative anticholinergic activities of 10 histamine H1 receptor antagonists in two functional models. Eur J Pharmacol. 2005; 506(3):257-64.
[29] Clar DT, Liu M. Nondepolarizing Neuromuscular Blockers. 2024 Oct 18. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025.
[30] Ritz ML, Derian A. Atracurium. 2025 Feb 6. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025.
[31] Strawbridge AD, Khanna NR, Patel P, Hauser JM. Cisatracurium. 2023 Oct 24. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025.
[32] Roy VC, Mehta S, Bala R. The Use of Cisatracurium in Cardiac Surgery. Turk J Anaesthesiol Reanim. 2025; 53(6):293-300.
[33] He T, Tao J, Wang X, Wang X. Effects of cisatracurium in combination with ventilation on inflammatory factors and immune variations in sepsis rats. Exp Ther Med. 2018; 15(5):4414-8.
[34] Ghorbanlo M, Mohaghegh MR, Yazdanian F, Mesbah M, Totonchi Z. A Comparison Between the Hemodynamic Effects of Cisatracurium and Atracurium in Patient with Low Function of Left Ventricle who are Candidate for Open Heart Surgery. Med Arch. 2016; 70(4):265-8.
[35] Cao Q, Tian X, Dong C, Bu H, Cheng Y. Effects of different doses of cisatracurium besilate on hemodynamics and postoperative cognitive function in patients undergoing radical resection of lung cancer. Oncol Lett. 2019; 18(2):1761-6.
[36] Hopewell S, Chan AW, Collins GS, Hróbjartsson A, Moher D, Schulz KF, et al. CONSORT 2025 statement: updated guideline for reporting randomised trials. BMJ. 2025; 389:e081123.
[37] Chan AW, Boutron I, Hopewell S, Moher D, Schulz KF, Collins GS, et al. SPIRIT 2025 statement: updated guideline for protocols of randomised trials. BMJ. 2025; 389:e081477.
[38] Abouleish AE, Leib ML, Cohen NH. ASA Provides Examples to Each ASA Physical Status Class. ASA Monitor. 2015; 79(6):38-49.
[39] Bergeron N, Dubois MJ, Dumont M, Dial S, Skrobik Y. Intensive Care Delirium Screening Checklist: evaluation of a new screening tool. Intensive Care Med. 2001; 27(5):859-64.
[40] Nasreddine ZS, Phillips NA, Bédirian V, Charbonneau S, Whitehead V, Collin I, et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2019; 67(9):1991.
[41] Aitken RC. Measurement of feelings using visual analogue scales. Proc R Soc Med. 1969; 62(10):989-93.
[42] Wada S, Sadahiro R, Matsuoka YJ, Uchitomi Y, Yamaguchi T, Sato T, et al. Yokukansan for Treatment of Preoperative Anxiety and Prevention of Postoperative Delirium in Cancer Patients Undergoing Highly Invasive Surgery. J Pain Symptom Manage. 2021; 61(1):71-80.
[43] Sessler CN, Gosnell MS, Grap MJ, Brophy GM, O'Neal PV, Keane KA, et al. The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med. 2002; 166(10):1338-44.
[44] Ely EW, Truman B, Shintani A, Thomason JW, Wheeler AP, Gordon S, et al. Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS). JAMA. 2003; 289(22):2983-91.
[45] Grossmann FF, Hasemann W, Kressig RW, Bingisser R, Nickel CH. Performance of the modified Richmond Agitation Sedation Scale in identifying delirium in older ED patients. Am J Emerg Med. 2017; 35(9):1324-6.
[46] Chen TJ, Chung YW, Chang HR, Chen PY, Wu CR, Hsieh SH, et al. Diagnostic accuracy of the CAM-ICU and ICDSC in detecting intensive care unit delirium: A bivariate meta-analysis. Int J Nurs Stud. 2021; 113:103782.
[47] Torshizi M, Hekmatpou D, Sharbafchi MR, Afshar H, Ayati MM. Reliability and Validity of the Persian Version of Intensive Care Delirium Screening Checklist in detection of delirium in Intensive Care Units. J Isfahan Med Sch. 2016; 34(383):536-46.
[48] Little RJ. A test of missing completely at random for multivariate data with missing values. J Am Stat Assoc. 1988; 83(404):1198-202.
[49] Karimi M, Ghaheri A, Saleh K, Cheraghi Z, Farahanchi A. Effect of Atracurium versus Cisatracurium on QT interval changes in patients undergoing cataract surgery: a randomized clinical trial. BMC Anesthesiol. 2024; 24(1):431.
[50] Wachtendorf LJ, Azimaraghi O, Santer P, Linhardt FC, Blank M, Suleiman A, et al. Association Between Intraoperative Arterial Hypotension and Postoperative Delirium After Noncardiac Surgery: A Retrospective Multicenter Cohort Study. Anesth Analg. 2022; 134(4):822-33.
[51] Mohammadi M, Ahmadi M, Khalili H, Cheraghchi H, Arbabi M. Cyproheptadine for the Prevention of Postoperative Delirium: A Pilot Study. Ann Pharmacother. 2016; 50(3):180-7.
[52] Devlin JW, Sieber F, Akeju O, Khan BA, MacLullich AMJ, Marcantonio ER, et al. Advancing Delirium Treatment Trials in Older Adults: Recommendations for Future Trials From the Network for Investigation of Delirium: Unifying Scientists (NIDUS). Crit Care Med. 2025; 53(1):e15-28.
[2] Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. American Psychiatric Association Publishing, Washington, DC. 2013.
[3] Ramírez Echeverría MDL, Schoo C, Paul M. Delirium. 2022 Nov 19. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025.
[4] Mei X, Liu YH, Han YQ, Zheng CY. Risk factors, preventive interventions, overlapping symptoms, and clinical measures of delirium in elderly patients. World J Psychiatry. 2023; 13(12):973-84.
[5] Lee SH, Lim SW. Risk factors for postoperative delirium after colorectal surgery: a systematic review and meta-analysis. Int J Colorectal Dis. 2020; 35(3):433-44.
[6] Varpaei HA, Robbins LB, Ling J, Lehto RH, Bender CM. Anaesthesia-related cognitive dysfunction following cardiothoracic surgery in late middle-age and younger adults: A scoping review. Nurs Crit Care. 2024; 29(3):457-65.
[7] Mevorach L, Forookhi A, Farcomeni A, Romagnoli S, Bilotta F. Perioperative risk factors associated with increased incidence of postoperative delirium: systematic review, meta-analysis, and Grading of Recommendations Assessment, Development, and Evaluation system report of clinical literature. Br J Anaesth. 2023; 130(2):e254-e62.
[8] Varpaei HA, Farhadi K, Mohammadi M, Khafaee Pour Khamseh A, Mokhtari T. Postoperative cognitive dysfunction: a concept analysis. Aging Clin Exp Res. 2024; 36(1):133.
[9] Liu Y, Li XJ, Liang Y, Kang Y. Pharmacological Prevention of Postoperative Delirium: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Evid Based Complement Alternat Med. 2019; 2019:9607129.
[10] Hsiao CC, Lin CJ, Hasan F, Romadlon DS, Traynor V, Hulu SRK, et al. Comparative efficacy of nonpharmacological interventions for preventing postoperative delirium in hospitalized older adults: a systematic review and network meta-analysis. Age Ageing. 2025; 54(9):afaf264.
[11] Méndez-Martínez C, Fernández-Martínez MN, García-Suárez M, Martínez-Isasi S, Fernández-Fernández JA, Fernández-García D. Related Factors and Treatment of Postoperative Delirium in Old Adult Patients: An Integrative Review. Healthcare (Basel). 2021; 9(9):1103.
[12] O'Gara BP, Gao L, Marcantonio ER, Subramaniam B. Sleep, Pain, and Cognition: Modifiable Targets for Optimal Perioperative Brain Health. Anesthesiology. 2021; 135(6):1132-52.
[13] Bramley P, McArthur K, Blayney A, McCullagh I. Risk factors for postoperative delirium: An umbrella review of systematic reviews. Int J Surg. 2021; 93:106063.
[14] Yan F, Chen B, Ma Z, Chen Q, Jin Z, Wang Y, et al. Exploring molecular mechanisms of postoperative delirium through multi-omics strategies in plasma exosomes. Sci Rep. 2024; 14(1):29466.
[15] Li W, Shi Q, Bai R, Zeng J, Lin L, Dai X, et al. Advances in research on the pathogenesis and signaling pathways associated with postoperative delirium (Review). Mol Med Rep. 2025; 32(2):220.
[16] Li T, Lu Z, Qin T, Liu L, Zhang J. Pathomechanism of postoperative delirium: Systemic inflammatory response and neuroinflammation following anesthesia/surgery. Neuroscience. 2025; 581:40-9.
[17] Mulkey MA, Hardin SR, Olson DM, Munro CL. Pathophysiology Review: Seven Neurotransmitters Associated With Delirium. Clin Nurse Spec. 2018; 32(4):195-211.
[18] Geßele C, Rémi C, Smolka V, Dimitriadis K, Amann U, Saller T, et al. Anticholinergic Exposure, Drug Dose and Postoperative Delirium: Comparison of Dose-Related and Non-Dose-Related Anticholinergic Burden Scores in a Retrospective Cohort Study of Older Orthopaedic and Trauma Surgery Patients. Drugs Aging. 2025; 42(2):177-8.
[19] Ieong C, Chen T, Chen S, Gao X, Yan K, He W, et al. Differences of anticholinergic drug burden between older hospitalized patients with and without delirium: a systematic review and meta-analysis based on prospective cohort studies. BMC Geriatr. 2024; 24(1):599.
[20] Moellmann HL, Boulghoudan S, Kuhlmann J, Rahm L, Frohnhofen H. Polypharmacy and anticholinergic burden as risk factors for postoperative delirium in surgical medicine. Z Gerontol Geriatr. 2025; 58(3):203-8.
[21] Shen QH, Li HF, Zhou XY, Lu YP, Yuan XZ. Relation of serum melatonin levels to postoperative delirium in older patients undergoing major abdominal surgery. J Int Med Res. 2020; 48(3):300060520910642.
[22] Farhadi K, Rahimi M, Varpaei H, Rajabi E, Tafreshi SMMT, Mohammadi P, et al. Ketamine and melatonin for the prevention of postoperative delirium in patients with colorectal cancer: a feasibility study. Perioper Med (Lond). 2025; 14(1):90.
[23] Queiroz I, Barbosa LM, Gallo Ruelas M, Araújo B, Defante MLR, Tavares AH, et al. Effect of peri-operative pharmacological interventions on postoperative delirium in patients having cardiac surgery: a systematic review and Bayesian network meta-analysis. Anaesthesia. 2025 Sep 1. Epub ahead of print.
[24] Haque N, Naqvi RM, Dasgupta M. Efficacy of Ondansetron in the Prevention or Treatment of Post-operative Delirium-a Systematic Review. Can Geriatr J. 2019; 22(1):1-6.
[25] Kotake K, Matsunuma S, Kitamura N, Noritake Y, Kawakami Y. Preventive effects of first-generation antihistamine on emergence agitation or delirium: a systematic review. Eur J Clin Pharmacol. 2024; 80(12):1883-92.
[26] Kikkawa N, Sogawa R, Monji A, Sumi S, Murakawa-Hirachi T, Kubo T, et al. Delirium risk of histamine-2 receptor antagonists and proton pump inhibitors: A study based on the adverse drug event reporting database in Japan. Gen Hosp Psychiatry. 2021; 72:88-91.
[27] Shiddapur A, Kistler CE, Busby-Whitehead J, Austin CA. Association of Histamine-2 Blockers and Proton-Pump Inhibitors With Delirium Development in Critically Ill Adults: A Retrospective Cohort Study. Crit Care Explor. 2021; 3(8):e0507.
[28] Orzechowski RF, Currie DS, Valancius CA. Comparative anticholinergic activities of 10 histamine H1 receptor antagonists in two functional models. Eur J Pharmacol. 2005; 506(3):257-64.
[29] Clar DT, Liu M. Nondepolarizing Neuromuscular Blockers. 2024 Oct 18. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025.
[30] Ritz ML, Derian A. Atracurium. 2025 Feb 6. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025.
[31] Strawbridge AD, Khanna NR, Patel P, Hauser JM. Cisatracurium. 2023 Oct 24. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025.
[32] Roy VC, Mehta S, Bala R. The Use of Cisatracurium in Cardiac Surgery. Turk J Anaesthesiol Reanim. 2025; 53(6):293-300.
[33] He T, Tao J, Wang X, Wang X. Effects of cisatracurium in combination with ventilation on inflammatory factors and immune variations in sepsis rats. Exp Ther Med. 2018; 15(5):4414-8.
[34] Ghorbanlo M, Mohaghegh MR, Yazdanian F, Mesbah M, Totonchi Z. A Comparison Between the Hemodynamic Effects of Cisatracurium and Atracurium in Patient with Low Function of Left Ventricle who are Candidate for Open Heart Surgery. Med Arch. 2016; 70(4):265-8.
[35] Cao Q, Tian X, Dong C, Bu H, Cheng Y. Effects of different doses of cisatracurium besilate on hemodynamics and postoperative cognitive function in patients undergoing radical resection of lung cancer. Oncol Lett. 2019; 18(2):1761-6.
[36] Hopewell S, Chan AW, Collins GS, Hróbjartsson A, Moher D, Schulz KF, et al. CONSORT 2025 statement: updated guideline for reporting randomised trials. BMJ. 2025; 389:e081123.
[37] Chan AW, Boutron I, Hopewell S, Moher D, Schulz KF, Collins GS, et al. SPIRIT 2025 statement: updated guideline for protocols of randomised trials. BMJ. 2025; 389:e081477.
[38] Abouleish AE, Leib ML, Cohen NH. ASA Provides Examples to Each ASA Physical Status Class. ASA Monitor. 2015; 79(6):38-49.
[39] Bergeron N, Dubois MJ, Dumont M, Dial S, Skrobik Y. Intensive Care Delirium Screening Checklist: evaluation of a new screening tool. Intensive Care Med. 2001; 27(5):859-64.
[40] Nasreddine ZS, Phillips NA, Bédirian V, Charbonneau S, Whitehead V, Collin I, et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2019; 67(9):1991.
[41] Aitken RC. Measurement of feelings using visual analogue scales. Proc R Soc Med. 1969; 62(10):989-93.
[42] Wada S, Sadahiro R, Matsuoka YJ, Uchitomi Y, Yamaguchi T, Sato T, et al. Yokukansan for Treatment of Preoperative Anxiety and Prevention of Postoperative Delirium in Cancer Patients Undergoing Highly Invasive Surgery. J Pain Symptom Manage. 2021; 61(1):71-80.
[43] Sessler CN, Gosnell MS, Grap MJ, Brophy GM, O'Neal PV, Keane KA, et al. The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med. 2002; 166(10):1338-44.
[44] Ely EW, Truman B, Shintani A, Thomason JW, Wheeler AP, Gordon S, et al. Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS). JAMA. 2003; 289(22):2983-91.
[45] Grossmann FF, Hasemann W, Kressig RW, Bingisser R, Nickel CH. Performance of the modified Richmond Agitation Sedation Scale in identifying delirium in older ED patients. Am J Emerg Med. 2017; 35(9):1324-6.
[46] Chen TJ, Chung YW, Chang HR, Chen PY, Wu CR, Hsieh SH, et al. Diagnostic accuracy of the CAM-ICU and ICDSC in detecting intensive care unit delirium: A bivariate meta-analysis. Int J Nurs Stud. 2021; 113:103782.
[47] Torshizi M, Hekmatpou D, Sharbafchi MR, Afshar H, Ayati MM. Reliability and Validity of the Persian Version of Intensive Care Delirium Screening Checklist in detection of delirium in Intensive Care Units. J Isfahan Med Sch. 2016; 34(383):536-46.
[48] Little RJ. A test of missing completely at random for multivariate data with missing values. J Am Stat Assoc. 1988; 83(404):1198-202.
[49] Karimi M, Ghaheri A, Saleh K, Cheraghi Z, Farahanchi A. Effect of Atracurium versus Cisatracurium on QT interval changes in patients undergoing cataract surgery: a randomized clinical trial. BMC Anesthesiol. 2024; 24(1):431.
[50] Wachtendorf LJ, Azimaraghi O, Santer P, Linhardt FC, Blank M, Suleiman A, et al. Association Between Intraoperative Arterial Hypotension and Postoperative Delirium After Noncardiac Surgery: A Retrospective Multicenter Cohort Study. Anesth Analg. 2022; 134(4):822-33.
[51] Mohammadi M, Ahmadi M, Khalili H, Cheraghchi H, Arbabi M. Cyproheptadine for the Prevention of Postoperative Delirium: A Pilot Study. Ann Pharmacother. 2016; 50(3):180-7.
[52] Devlin JW, Sieber F, Akeju O, Khan BA, MacLullich AMJ, Marcantonio ER, et al. Advancing Delirium Treatment Trials in Older Adults: Recommendations for Future Trials From the Network for Investigation of Delirium: Unifying Scientists (NIDUS). Crit Care Med. 2025; 53(1):e15-28.
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How to Cite
1.
Farhadi K, Neishaboury M, Etezadi F, Varpaei H, Rajabi E, Khajavi MR, Arab Mohammadi M, Moharari RS, Najafi A, Bahman R, Sharifnia H, Pourfakhr P. Cisatracurium Compared to Atracurium for the Prevention of Postoperative Delirium in Colorectal Cancer Surgery: Protocol of a Double-Blind, Randomized, Clinical Trial. Arch Anesth & Crit Care. 2026;.
