European Society of Anaesthesiology evidence-based and consensus-based guideline on postoperative delirium

Protocol for evaluation of perioperative risk in patients aged over 75 years: Aged Patient Perioperative Longitudinal Evaluation-Multidisciplinary Trial (APPLE-MDT study)

BACKGROUND

With the extended life expectancy of the Chinese population and improvements in surgery and anesthesia techniques, the number of aged patients undergoing surgery has been increasing annually. However, safety, effectiveness, and quality of life of aged patients undergoing surgery are facing major challenges. In order to standardize the perioperative assessment and procedures, we have developed a perioperative evaluation and auxiliary decision-making system named "Aged Patient Perioperative Longitudinal Evaluation-Multidisciplinary Trial (APPLE-MDT)".

METHODS

We will conduct a perioperative risk evaluation and targeted intervention, with follow-ups at 1, 3, and 6 months after surgery. The primary objective of the study is to evaluate the effectiveness of the "Aged Patient Perioperative Longitudinal Evaluation-Multiple Disciplinary Trial Path" (hereinafter referred to as the APPLE-MDT path) in surgical decision-making for aged patients (≥75 years) undergoing elective surgery under non-local anesthesia in the operating room. The secondary objectives of the study are to evaluate the postoperative outcome and health economics of the APPLE-MDT path applied to the surgical decision-making of aged patients (≥75 years) undergoing elective surgery under non-local anesthesia and to optimize intervention strategies for aged patients undergoing surgery to reduce the occurrence of postoperative complications and improve the quality of life after surgery.

DISCUSSION

It is necessary to formulate a reliable, effective, and concise evaluation tool, which can effectively predict the perioperative complications and mortality of aged patients, support targeted intervention strategies, and allow for a more comprehensive risk and benefit analysis, thereby forming an effective senile perioperative surgery management path. It is expected that the implementation of this protocol can reduce the occurrence of postoperative complications, improve the postoperative quality of life, shorten hospital stay, reduce hospitalization expenses, reduce social burden, and allow the elderly to have a good quality of life after surgery.

TRIAL REGISTRATION

ChiCTR, ChiCTR1800020363 , Registered 15 December 2018.

Improving perioperative brain health: an expert consensus review of key actions for the perioperative care team

Delirium and postoperative neurocognitive disorder are the commonest perioperative complications in patients more than 65 yr of age. However, data suggest that we often fail to screen patients for preoperative cognitive impairment, to warn patients and families of risk, and to take preventive measures to reduce the incidence of perioperative neurocognitive disorders. As part of the American Society of Anesthesiologists (ASA) Perioperative Brain Health Initiative, an international group of experts was invited to review published best practice statements and guidelines. The expert group aimed to achieve consensus on a small number of practical recommendations that could be implemented by anaesthetists and their partners to reduce the incidence of perioperative neurocognitive disorders. Six statements were selected based not only on the strength of the evidence, but also on the potential for impact and the feasibility of widespread implementation. The actions focus on education, cognitive and delirium screening, non-pharmacologic interventions, pain control, and avoidance of antipsychotics. Strategies for effective implementation are discussed. Anaesthetists should be key members of multidisciplinary perioperative care teams to implement these recommendations.

Intraoperative dexmedetomidine for prevention of postoperative delirium in elderly patients with mild cognitive impairment

OBJECTIVES

Delirium is the most common postoperative neurological complication and some evidence suggests that dexmedetomidine is associated with a decreased incidence of delirium. This study is designed to assess the effect of dexmedetomidine on postoperative delirium (POD) in elderly patients with mild cognitive impairment (MCI).

METHODS

Sixty geriatric patients with MCI were enrolled and ramdomly divided into two groups by a computer-generated randomisation sequence: dexmedetomidine group (D group) and normal saline group (C group). Patients in D group received a loading dose of 0.5 μg/kg dexmedetomidine over 10 minutes before anesthesia induction, followed by a continuous infusion of 0.4 μg·kg^-1·h^-1 until 30 minutes before the end of surgery; equal volume of normal saline was given in C group. Blood samples were extracted to detect the concentration of cytokines, including tumor necrosis factor-α (TNF-α), interleukin-10 (IL-10), heme oxygenase-1 (HO-1), matrix metalloproteinase-9 (MMP-9), and glial fibrillary acidic protein (GFAP) before anesthesia induction (T₁), before suture (T₂), and 30 minutes after surgery (T₃). Postoperative recovery times were recorded. Delirium was assessed with the 3-Minute Diagnostic Interview for confusion assessment method during the first 7 days postoperatively.

RESULTS

POD occurred in 10 (33.3%) of 30 patients in C group, and in 3 (10%) of 30 patients given dexmedetomidine (odds ratio [OR] 0.222, 95% CI 0.054-0.914; P = 0.028). The serum concentrations of TNF-α, MMP-9, and GFAP were significantly increased and IL-10 was decreased in the C group than in the D group at T₂ and T₃. No differences were observed between groups in the level of HO-1. Analysis using random-effect multivariable logistic regression indicated that POD was associated with GFAP (odds ratio [OR] 16.691, 95% CI 2.288-121.746; P = 0.005). The positive predictive ability of the multivariate logistic regression model tested by ROC analysis showed an area under the curve of 0.713 (95% CI, 0.584-0.842).

CONCLUSIONS

Dexmedetomidine can alleviate POD in elderly patients with MCI and may be related to reduce the neuroinflammation by lowering the permeability of blood-brain barrier.

Course and Recognition of Poststroke Delirium: A Prospective Noninferiority Trial of Delirium Screening Tools

BACKGROUND AND PURPOSE

Poststroke delirium (PSD) is an independent predictor of unfavorable outcome. Despite its individual and socioeconomic burden, its frequency, clinical course, and routine detection remain unresolved. This study aimed to assess psychometric properties of established delirium screening tools and investigate the natural course of PSD.

METHODS

This study investigated patients presenting with high-risk transient ischemic attacks or ischemic stroke within 24 hours during a 3-month period. Twice-daily screenings for PSD were done using the confusion assessment method, nursing delirium scale, and rapid delirium assessment, and evaluated for noninferiority against Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria. We investigated demographic and stroke characteristics as predictors of PSD, neurological deficits as predictors of false screening results, and conducted a simulation study to estimate the best timing to identify PSD.

RESULTS

We enrolled 141 patients (73.8±10.4 years of age, 61 female) with a mean National Institutes of Health Stroke Scale score of 6.4±6.5. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition based PSD incidence was 39%, which manifested within 24 hours in 25% and 72 hours in almost all cases. The confusion assessment method was the only screening tool noninferior to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition ratings providing a sensitivity of 82% and specificity of 80%. Age (odds ratio, 1.07 [1.02-1.13] per year, P=0.004) and National Institutes of Health Stroke Scale (odds ratio, 1.24 [1.15-1.34] per point, P<0.001) were predictors of PSD. False-positive screening results were associated with stroke-induced disorientation (odds ratio, 6.1 [3.2-11.61], P<0.001) and neglect (odds ratio, 2.17 [1.22-3.87], P=0.008). Simulations revealed that one in 4 cases is missed with less than daily screenings.

CONCLUSIONS

PSD is a common complication of stroke and transient ischemic attack. Detection is challenged by confounding effects such as focal neurological deficits and the necessity for at least daily screenings. Future studies are required to investigate implementation of these findings in clinical routine. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT03930719.

An Implementation-Effectiveness Study of a Perioperative Delirium Prevention Initiative for Older Adults

BACKGROUND

Postoperative delirium is a common and serious problem for older adults. To better align local practices with delirium prevention consensus guidelines, we implemented a 5-component intervention followed by a quality improvement (QI) project at our institution.

METHODS

This hybrid implementation-effectiveness study took place at 2 adult hospitals within a tertiary care academic health care system. We implemented a 5-component intervention: preoperative delirium risk stratification, multidisciplinary education, written memory aids, delirium prevention postanesthesia care unit (PACU) orderset, and electronic health record enhancements between December 1, 2017 and June 30, 2018. This was followed by a department-wide QI project to increase uptake of the intervention from July 1, 2018 to June 30, 2019. We tracked process outcomes during the QI period, including frequency of preoperative delirium risk screening, percentage of "high-risk" screens, and frequency of appropriate PACU orderset use. We measured practice change after the interventions using interrupted time series analysis of perioperative medication prescribing practices during baseline (December 1, 2016 to November 30, 2017), intervention (December 1, 2017 to June 30, 2018), and QI (July 1, 2018 to June 30, 2019) periods. Participants were consecutive older patients (≥65 years of age) who underwent surgery during the above timeframes and received care in the PACU, compared to a concurrent control group <65 years of age. The a priori primary outcome was a composite of perioperative American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication Use (Beers PIM) medications. The secondary outcome, delirium incidence, was measured in the subset of older patients who were admitted to the hospital for at least 1 night.

RESULTS

During the 12-month QI period, preoperative delirium risk stratification improved from 67% (714 of 1068 patients) in month 1 to 83% in month 12 (776 of 931 patients). Forty percent of patients were stratified as "high risk" during the 12-month period (4246 of 10,494 patients). Appropriate PACU orderset use in high-risk patients increased from 19% in month 1 to 85% in month 12. We analyzed medication use in 7212, 4416, and 8311 PACU care episodes during the baseline, intervention, and QI periods, respectively. Beers PIM administration decreased from 33% to 27% to 23% during the 3 time periods, with adjusted odds ratio (aOR) 0.97 (95% confidence interval [CI], 0.95-0.998; P = .03) per month during the QI period in comparison to baseline. Delirium incidence was 7.5%, 9.2%, and 8.5% during the 3 time periods with aOR of delirium of 0.98 (95% CI, 0.91-1.05, P = .52) per month during the QI period in comparison to baseline.

CONCLUSIONS

A perioperative delirium prevention intervention was associated with reduced administration of Beers PIMs to older adults.

[Expert consensus on the implementation of enhanced recovery after surgery in percutaneous endoscopic interlaminar lumbar decompression/discectomy (2020)]

In recent years, enhanced recovery after surgery (ERAS) has been widely used in spine surgery and achieved satisfactory results. In order to standardize the ERAS implementation process and application in percutaneous endoscopic interlaminar lumbar decompression/discectomy (PEID), we reviewed the literatures and cited evidence-based medicine data, and had a national comprehensive discussion among experts of the Group of Minimally Invasive Spinal Surgery and Enhanced Recovery, Professional Committee of Orthopedic Surgery and Enhanced Recovery, Association of China Rehabilitation Technology Transformation and Promotion. Altogether, the up-to-date expert consensus have been achieved. The consensus may provide the reference for clinical treatment in aspect of the standardization of surgical operations, the reduction of surgical trauma and complications, the optimization of perioperative pain and sleep management, the prevention of venous thrombosis, and the guidance of patients' functional training and perioperative education.

Development and validation of a delirium risk prediction preoperative model for cardiac surgery patients (DELIPRECAS): An observational multicentre study

STUDY OBJECTIVE

To develop and validate a delirium risk prediction preoperative model for patients undergoing cardiac surgery.

DESIGN

Observational prospective multicentre study.

SETTING

Six intensive care units in Spain.

PATIENTS

689 patients undergoing cardiac surgery consecutively, aged ≥18 years.

MEASUREMENTS

The primary outcome measure was the development of delirium, diagnosed using the Confusion Assessment Method in Intensive Care Units (CAM-ICU), during the stay in the intensive care unit after cardiac surgery.

MAIN RESULTS

The model was developed with 345 consecutive patients undergoing cardiac surgery at six hospitals and validated with another 344 patients from the same hospitals. The prediction model contained four preoperative risk factors: age over 65 years, Mini-Mental State Examination (MMSE) score of 25-26 points (possible impairment of cognitive function) or < 25 (impairment of cognitive function), insomnia needing medical treatment and low physical activity (walk less than 30 min a day). The model had an area under the receiver operating characteristics curve of 0.825 (95% confidence interval: 0.76-0.89). The validation resulted in an area under the curve of 0.79 (0.73-0.85) and the pooled area under the receiver operating characteristics curve (n = 689) was 0.81 (0.76-0.85). We stratified patients in groups of low (0%-20%), moderate (> 20%-40%), high (> 40%-60%) and very high (> 60%) risk of developing delirium, with a positive and negative predictive value for the very high risk group of 70.97% and 85.56%, respectively.

CONCLUSION

The DELIPRECAS model (DELIrium PREvention CArdiac Surgery), consisting of four well-defined clinical risk factors, can predict in the preoperative period the risk of developing postoperative delirium in patients undergoing cardiac surgery. An automatic version of the risk calculator is available.

BIS index monitoring and perioperative neurocognitive disorders in older adults: a systematic review and meta-analysis

BACKGROUND AND AIMS

Perioperative neurocognitive disorders (PND) are common in elderly patients after surgery. It has been reported that BIS-guided anesthesia potentially influenced the occurrence of PND. Therefore, we conducted this systematic review and meta-analysis to explore the associations between bispectral index (BIS) monitoring and PND.

METHODS

Two researchers independently searched for relevant randomized controlled trials (RCTs) in PubMed, EMBASE, and the Cochrane Library (CENTRAL) using keywords related to the BIS and PND from inception to April 22, 2019. Odds ratios (OR) with 95% CI were calculated using a random effects model.

RESULTS

Nine RCTs involving 4023 participants aged 60 years or older were included into this meta-analysis. BIS-guided anesthesia was not associated with lower incidence of POD (random effects; OR: 0.69; 95% CI 0.48, 1.01), delayed neurocognitive recovery (DNR) at 1 day, 7 days (random effects; OR: 0.14; 95% CI 0.02, 1.23; random effects; OR: 0.97; 95% CI 0.57, 1.63), and postoperative neurocognitive disorder (NCD) at 90 days and 1 year after surgery in older adults (random effects; OR:0.72; 95% CI 0.52, 1.00; random effects; OR: 0.26; 95% CI 0.03, 2.47).

CONCLUSIONS

No definite evidence demonstrated that BIS-guided anesthesia decreased the incidence of POD, DNR and postoperative NCD in older patients. More homogeneous RCTs assessing the efficacy of BIS monitoring on reducing the occurrence of these perioperative cognitive disorders are needed.

Recommendations from the Italian intersociety consensus on Perioperative Anesthesia Care in Thoracic surgery (PACTS) part 1: preadmission and preoperative care

INTRODUCTION

Anesthetic care in patients undergoing thoracic surgery presents specific challenges that necessitate standardized, multidisciplionary, and continuously updated guidelines for perioperative care.

METHODS

A multidisciplinary expert group, the Perioperative Anesthesia in Thoracic Surgery (PACTS) group, comprising 24 members from 19 Italian centers, was established to develop recommendations for anesthesia practice in patients undergoing thoracic surgery (specifically lung resection for cancer). The project focused on preoperative patient assessment and preparation, intraoperative management (surgical and anesthesiologic care), and postoperative care and discharge. A series of clinical questions was developed, and PubMed and Embase literature searches were performed to inform discussions around these areas, leading to the development of 69 recommendations. The quality of evidence and strength of recommendations were graded using the United States Preventative Services Task Force criteria.

RESULTS

Recommendations for preoperative care focus on risk assessment, patient preparation (prehabilitation), and the choice of procedure (open thoracotomy vs. video-assisted thoracic surgery).

CONCLUSIONS

These recommendations should help pulmonologists to improve preoperative management in thoracic surgery patients. Further refinement of the recommendations can be anticipated as the literature continues to evolve.

Brief Preoperative Screening for Frailty and Cognitive Impairment Predicts Delirium after Spine Surgery

BACKGROUND

Frailty and cognitive impairment are associated with postoperative delirium, but are rarely assessed preoperatively. The study was designed to test the hypothesis that preoperative screening for frailty or cognitive impairment identifies patients at risk for postoperative delirium (primary outcome).

METHODS

In this prospective cohort study, the authors administered frailty and cognitive screening instruments to 229 patients greater than or equal to 70 yr old presenting for elective spine surgery. Screening for frailty (five-item FRAIL scale [measuring fatigue, resistance, ambulation, illness, and weight loss]) and cognition (Mini-Cog, Animal Verbal Fluency) were performed at the time of the preoperative evaluation. Demographic data, perioperative variables, and postoperative outcomes were gathered. Delirium was the primary outcome detected by either the Confusion Assessment Method, assessed daily from postoperative day 1 to 3 or until discharge, if patient was discharged sooner, or comprehensive chart review. Secondary outcomes were all other-cause complications, discharge not to home, and hospital length of stay.

RESULTS

The cohort was 75 [73 to 79 yr] years of age, 124 of 219 (57%) were male. Many scored positive for prefrailty (117 of 218; 54%), frailty (53 of 218; 24%), and cognitive impairment (50 to 82 of 219; 23 to 37%). Fifty-five patients (25%) developed delirium postoperatively. On multivariable analysis, frailty (scores 3 to 5 [odds ratio, 6.6; 95% CI, 1.96 to 21.9; P = 0.002]) versus robust (score 0) on the FRAIL scale, lower animal fluency scores (odds ratio, 1.08; 95% CI, 1.01 to 1.51; P = 0.036) for each point decrease in the number of animals named, and more invasive surgical procedures (odds ratio, 2.69; 95% CI, 1.31 to 5.50; P = 0.007) versus less invasive procedures were associated with postoperative delirium.

CONCLUSIONS

Screening for frailty and cognitive impairment preoperatively using the FRAIL scale and the Animal Verbal Fluency test in older elective spine surgery patients identifies those at high risk for the development of postoperative delirium.

EDITOR’S PERSPECTIVE

[Multidisciplinary team model for patients with oral cancer and systemic diseases: an expert consensus]

Large general hospitals currently play an increasingly important role in the diagnosis and treatment for acute critical patients and difficult diseases because of the development of dual referral system and hierarchical diagnosis, as well as the formation of medical treatment alliance. Patients with oral cancers are often associated with systemic diseases, which increases the complexity of the condition. Thus, meeting the demand through the traditional single medical model is difficult. As such, a multidisciplinary team (MDT) model has been proposed and has achieved a good clinical effect. To standardize the application of this model, we organized an event in which relevant experts discussed and formulated a consensus to provide standardized suggestions on the MDT process and the diagnosis and treatment of common systemic diseases as reference for clinical practice.

Dexmedetomidine for the prevention of postoperative delirium in patients after intracranial operation for brain tumours (DEPOD study): a study protocol and statistical plan for a multicentre randomised controlled trial

INTRODUCTION

Postoperative delirium (POD) is prevalent in patients after major surgery and is associated with adverse outcomes. Several studies have reported that dexmedetomidine, a highly selective α2-adrenergic receptor agonist, can decrease the incidence of POD. However, neurosurgical patients are usually excluded from previous studies. The present study was designed to investigate the impact of prophylactic use of low-dose dexmedetomidine on the incidence of POD in patients after intracranial operation.

METHODS AND ANALYSIS

This is a multicentre, randomised, double-blinded and placebo-controlled trial. Seven hundred intensive care unit admitted patients after elective intracranial operation for brain tumours under general anaesthesia are randomly assigned to the dexmedetomidine group or the placebo group with a 1:1 ratio. For patients in the dexmedetomidine group, a continuous infusion of dexmedetomidine will be started at a rate of 0.1 μg/kg/hour immediately after enrolment on the day of operation and continued until 08:00 on postoperative day 1. For patients in the placebo group, normal saline will be administered at the same rate as in the dexmedetomidine group. The patients will be followed up for 28 days after enrolment. The primary endpoint is the incidence of POD, which is assessed two times per day using the Confusion Assessment Method for the intensive care unit (ICU), during the first 5 postoperative days. The secondary endpoints include the incidence of dexmedetomidine-related adverse events and non-delirium complications, the length of stay in the ICU and hospital and all-cause 28-day mortality after the operation.

ETHICS AND DISSEMINATION

The study protocol was approved by the Institutional Review Board of Beijing Tiantan Hospital Affiliated to Capital Medical University (No KY2019-091-02) and registered at ClinicalTrials.gov. The results of the trial will be presented at national and international conferences relevant to subject fields and submitted to international peer-reviewed journals.

TRIAL REGISTRATION NUMBER

Trial registration number: NCT04399343; Pre-results.

Mortality and morbidity following postoperative use of short-term, low-dose quetiapine vs risperidone in patients with diabetes: Analysis using a national inpatient database

PURPOSE

Short-term, low-dose quetiapine is used to treat postoperative delirium and insomnia. Quetiapine is contraindicated for patients with diabetes in Japan because there have been several case reports of diabetic ketoacidosis (DKA) in patients receiving long-term, high-dose quetiapine. However, because safety of short-term, low-dose quetiapine remains controversial, it is prescribed for patients with diabetes in real-world clinical practice. The present study aimed to compare in-hospital mortality and morbidity between short-term, low-dose quetiapine and risperidone in postoperative patients with diabetes.

METHODS

We used a national inpatient database in Japan to perform a retrospective cohort study. We identified hospitalized patients with diabetes who underwent scheduled elective surgery and received oral quetiapine 200 mg/d or less or oral risperidone 4 mg/d or less within 7 days of surgery between July 2010 and March 2018. We performed one-to-one propensity score-matched analyses to compare outcomes between patients with quetiapine and risperidone. The primary outcome was in-hospital mortality. The secondary outcome was infectious complications (pneumonia, urinary tract infection, surgical site infection, and sepsis).

RESULTS

Propensity score matching created 665 pairs of patients who received quetiapine or risperidone. The primary outcome was observed in 19 (2.9%) of the quetiapine group and 11 (1.7%) of the risperidone group (relative risk, 1.27; 95% confidence interval, 0.97-1.68; P = .14). The secondary outcome did not differ significantly between the groups.

CONCLUSION

In terms of mortality and infectious outcomes, safety of quetiapine and risperidone may be comparable.

Recommendations from the Italian intersociety consensus on Perioperative Anesthesa Care in Thoracic surgery (PACTS) part 2: intraoperative and postoperative care

Introduction

Anesthetic care in patients undergoing thoracic surgery presents specific challenges that require a multidisciplinary approach to management. There remains a need for standardized, evidence-based, continuously updated guidelines for perioperative care in these patients.

Methods

A multidisciplinary expert group, the Perioperative Anesthesia in Thoracic Surgery (PACTS) group, was established to develop recommendations for anesthesia practice in patients undergoing elective lung resection for lung cancer. The project addressed three key areas: preoperative patient assessment and preparation, intraoperative management (surgical and anesthesiologic care), and postoperative care and discharge. A series of clinical questions was developed, and literature searches were performed to inform discussions around these areas, leading to the development of 69 recommendations. The quality of evidence and strength of recommendations were graded using the United States Preventive Services Task Force criteria.

Results

Recommendations for intraoperative care focus on airway management, and monitoring of vital signs, hemodynamics, blood gases, neuromuscular blockade, and depth of anesthesia. Recommendations for postoperative care focus on the provision of multimodal analgesia, intensive care unit (ICU) care, and specific measures such as chest drainage, mobilization, noninvasive ventilation, and atrial fibrillation prophylaxis.

Conclusions

These recommendations should help clinicians to improve intraoperative and postoperative management, and thereby achieve better postoperative outcomes in thoracic surgery patients. Further refinement of the recommendations can be anticipated as the literature continues to evolve.

Use of Processed Electroencephalography in the Clinical Setting

Purpose of Review

Processed electroencephalography (pEEG) is widely used in clinical practice. Few clinicians utilize the full potential of these devices. This brief review will address the improvements in patient management available from the utilization of all pEEG data.

Recent Findings

Anesthesiologists easily learn to recognize raw pEEG patterns that are consistent with an appropriate level of hypnotic effect. Power distribution within the waveform can be displayed in a visual format that identifies signatures of the principal anesthetic hypnotics. Opinion on the benefit of pEEG data in the mitigation of postoperative neurological impairment remains divided.

Summary

Looking beyond the index number can aid clinical decision making and improve confidence in the benefits of this monitoring modality.

Metabolomic and Lipidomic Profiling of Preoperative CSF in Elderly Hip Fracture Patients With Postoperative Delirium

Objective

To investigate dysregulated molecules in preoperative cerebrospinal fluid (CSF) of elderly hip fracture patients with postoperative delirium (POD), in order to identify potential pathological mechanisms and biomarkers for pre-stage POD.

Materials and Methods

This nested case control study used untargeted metabolomic and lipidomic analysis to profile the preoperative CSF of patients (n = 40) who developed POD undergone hip fracture surgery (n = 10) and those who did not (n = 30). Thirty Non-POD patients were matched to 10 POD patients by age (± 2 years) and Mini Mental State Examination score (± 2 points). CSF was collected after successful spinal anesthesia and banked for subsequent analysis. On the first two postoperative days, patients were assessed twice daily using the Confusion Assessment Method-Chinese Revision. CSF samples from the two groups were analyzed to investigate possible relevant pathological mechanisms and identify candidate biomarkers.

Results

Demographic characteristics of the groups were matched. Eighteen metabolites and thirty-three lipids were dysregulated in the preoperative CSF of POD patients. Pathway enrichment analysis revealed perturbations in D-glutamine and D-glutamate metabolism; glycerophospholipid metabolism; alanine, aspartate and glutamate metabolism; sphingolipid metabolism; histidine metabolism; and arginine biosynthesis at the pre-delirium stage. Receiver operating characteristic curve analysis indicated that phosphatidylethanolamine (PE, 40:7e), with an area under the curve value of 0.92, is a potential biomarker for POD.

Conclusion

Multiple pathological mechanisms in the POD group were involved before surgery, including neuroinflammation, oxidative stress, and energy metabolism disorders induced by hypoxia, as well as neurotransmitter imbalances such as increased dopamine and glutamate, and decreased glutamine. These metabolic abnormalities potentially increase the fragility of the brain, thus contributing to POD. PE (40:7e) might be a potential biomarker for POD. Not only do our results provide potential biomarkers for POD, but also provide information for deep pathological research.

Clinical Trial Registration

www.ClinicalTrials.gov, identifier ChiCTR1900021533.

Ketamine vs. haloperidol for prevention of cognitive dysfunction and postoperative delirium: A phase IV multicentre randomised placebo-controlled double-blind clinical trial

STUDY OBJECTIVE

Delirium is frequently observed in the postoperative and intensive care unit (ICU) population. Due to the multifactorial origin of delirium and according to international guidelines (e.g., American Geriatrics Society; Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption (PADIS) guideline), there are several but no incontestable options for prevention and symptomatic treatment. The purpose of the Baden PRIDe (Prevention and Reduction of Incidence of postoperative Delirium) trial was to determine whether postoperative cognitive dysfunction and delirium could be prevented by the combination of possible preventive agents such as haloperidol and ketamine. In addition, pre- and postoperative levels of the biomarkers cortisol, neuron specific enolase (NSE) and S100β were measured to investigate their dynamics in delirious and non-delirious patients after surgery.

DESIGN

The Baden PRIDe Trial was an investigator-initiated, phase IV, two-centre, randomised, placebo-controlled, double-blind clinical trial.

SETTING

Perioperative care.

PATIENTS

182 adult patients that underwent elective or emergency surgery under general or combined (i.e., general and regional) anaesthesia.

INTERVENTIONS

Pre-anaesthetic, pharmacologic prevention of postoperative brain dysfunction with haloperidol, ketamine, and the combination of both vs. placebo.

MEASUREMENTS

Assessment of cognitive performance pre- and postoperatively with the MMSE, the DOS, the Nursing Delirium Screening Scale (Nu-DESC) or the Intensive Care Delirium Screening Checklist (ICDSC) during ICU stay.

MAIN RESULTS

None of the three study arms - haloperidol, ketamine, or both drugs combined - was significantly superior to placebo for prevention of postoperative brain dysfunction and delirium (P = 0.39). Measured levels of postoperative cortisol were significantly higher in delirious patients. S-100β levels were significantly higher in all postoperative outcome groups (cognitive impairment, delirium, no cognitive decline), whereas postoperative NSE levels declined in all groups.

CONCLUSIONS

The study results offer no possibility for a novel recommendation for prevention of postoperative cognitive decline including delirium. Perioperative S-100β trajectories in patients with cognitive deterioration suggest affection of glial cells in particular.

TRIAL REGISTRATION

ClinicalTrials.govNCT02433041; registered on April 7, 2015.

Preoperative serum biomarkers in the prediction of postoperative delirium following abdominal surgery

AIM

Elderly patients undergoing abdominal surgery have a high risk of developing postoperative delirium. This study aimed to explore risk factors for postoperative delirium by focusing on preoperative hematologic markers, and to develop a model that would be useful in predicting the occurrence of postoperative delirium.

METHODS

This retrospective study included patients aged ≥65 years who underwent elective abdominal surgery under general anesthesia from January 2017 to May 2019. Patients' demographics, hematologic data and intraoperative data were recorded. Neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, platelet-to-white blood cell ratio and prognostic nutritional index were calculated. We evaluated risk factors of postoperative delirium assessed using a chart-based method for identification of delirium and developed a predictive model using preoperative and intraoperative data.

RESULTS

Of 931 eligible patients, 833 with a mean age of 73.9 years were included in the analysis. The rate of incidence of postoperative delirium was 7.3%. Age, duration of surgery and preoperative platelet-to-lymphocyte ratio or platelet-to-white blood cell ratio were statistically significant risk factors. The predictive model, which included age, duration of surgery and platelet-to-lymphocyte ratio, had the largest area under the curve of 0.77.

CONCLUSIONS

Age, duration of surgery and preoperative platelet-to-white blood cell ratio or platelet-to-lymphocyte ratio are associated with the development of postoperative delirium. A predictive model, which includes age, duration of surgery and preoperative platelet-to-lymphocyte ratio, is useful in predicting the development of postoperative delirium after elective abdominal surgery. Geriatr Gerontol Int 2020; 20: 1208-1212.

Management of Ambulatory Anesthesia in Older Adults

The number of older patients is increasing globally. Combined with the growing number of ambulatory surgeries, many older patients will undergo ambulatory surgery in the future. The ambulatory setting offers many advantages: early mobilization, higher patient satisfaction, lower costs, and a low incidence of several complications such as infections and thromboembolic events. Moreover, cognitive recovery seems to be enhanced compared with in-hospital surgery, and both frail patients and patients with dementia can benefit from ambulatory surgery. This review provides suggestions for managing perioperative anesthesia for older patients in the ambulatory setting. Not all older patients are eligible for ambulatory surgery, and clinicians must be aware of risk factors for complications, especially frailty. Most anesthesia techniques and agents can be used in the ambulatory setting, but short-acting agents are preferred to ensure fast recovery. Both regional and general anesthesia are useful, but clinicians must be familiar with the physiological changes and specific implications in the older population. The older patients are more sensitive to anesthetic agents, meaning that a lower dose is needed to obtain the desired effect. However, they exhibit huge variation in pharmacodynamics and pharmacokinetics. Prolonged onset time may lead to overdosing and extended recovery. After surgery, effective pain management with opioid minimization is essential to ensure rapid recovery.

Predictors of Delirium in Octogenarian Patients Hospitalized for a Hip Fracture

INTRODUCTION

Since delirium is a major complication that can arise after a patient with a hip fracture has been hospitalized, it is considered to be one of the most common geriatric conditions. Therefore, its prevention and early detection are essential for reducing both the length of the patient's stay in the hospital and complications during the hospitalization process.

OBJECTIVE

To identify and analyze the predictors for developing delirium in octogenarians who were admitted to hospital for a hip fracture.

METHODOLOGY

A prospective study conducted with a sample of 287 patients aged 80 years and older (mean age 87.2 ± 3.2 years; 215 women, 72 men), recruited from the Trauma Unit of the University Hospital of León (Spain). Further, 71.1% of the patients lived in a family member's home, while the other 28.9% lived in a nursing home. After observing each patient's interactions with their doctor in a clinical setting, the data for this study were obtained by reviewing the selected patients' charts. The variables analyzed were sociodemographic information (age, sex, and place of residence), medical information (type of hip break and surgical intervention), cognitive impairment (MMSE score), functional level (Barthel Index score), and clinical information (pharmacological, comorbidities, complications, and the diagnosis and assessment of the severity of delirium in a patient). The univariate and multivariate logistic regression analysis showed a significant relationship between acute confusional state and the following variables: anemia, American Society of Anesthesiologists (ASA) III and IV patients, state of cognitive frailty and functional level, a urinary tract infection, changes in the visual field, renal arterial occlusion, and the type and dosage of drugs administered (this variable was identified in the multivariate model). The inverse relationship between anemia and acute confusional state is surprising.

CONCLUSION

This research shows that clinical observation of acute confusional state is necessary but not sufficient for addressing this condition early and adequately in older adults who have been hospitalized for a hip fracture.

Dexmedetomidine use in pediatric strabismus surgery: A systematic review and meta-analysis

BACKGROUND

Common complications of pediatric strabismus surgery, including emergence agitation (EA), postoperative nausea and vomiting (PONV), and postoperative pain, may be prevented using dexmedetomidine, which is an anxiolytic and analgesic. This systematic review and meta-analysis assessed the effects of dexmedetomidine in patients who had undergone pediatric strabismus surgery.

METHOD

Five databases were searched for randomized controlled trials published from database inception to April 2020 that compared dexmedetomidine use with placebo or active comparator use and evaluated EA, PONV, or postoperative pain incidence (main outcomes) in patients who had undergone pediatric strabismus surgery. Oculocardiac reflex (OCR) incidence and postanesthesia care unit (PACU) stay duration were considered as safety outcomes. All meta-analyses were performed using a random-effects model.

RESULTS

In the nine studies meeting our inclusion criteria, compared with placebo use, dexmedetomidine use reduced EA incidence [risk ratio (RR): 0.39; 95% confidence interval (CI): 0.25-0.62, I2 = 66%], severe EA incidence (RR: 0.27, 95% CI: 0.17-0.43, I2 = 0%), PONV incidence (RR: 0.33, 95% CI: 0.21-0.54, I2 = 0%), analgesia requirement (RR: 0.38, 95% CI: 0.25-0.57, I2 = 0%), and pain scores (standardized mean difference: -1.02, 95% CI: -1.44 to -0.61, I2 = 75%). Dexmedetomidine also led to lower EA incidence in the sevoflurane group than in the desflurane group (RR: 0.26 for sevoflurane vs. 0.45 for desflurane). Continuous dexmedetomidine infusion (RR: 0.19) led to better EA incidence reduction than did bolus dexmedetomidine infusion at the end of surgery (RR: 0.26) or during the peri-induction period (RR: 0.36). Compared with placebo use, dexmedetomidine use reduced OCR incidence (RR: 0.63; I2 = 40%). No significant between-group differences were noted for PACU stay duration.

CONCLUSION

In patients who have undergone pediatric strabismus surgery, dexmedetomidine use may alleviate EA, PONV, and postoperative pain and reduce OCR incidence. Moreover, dexmedetomidine use does not affect the PACU stay duration.

Brain Aging and Anesthesia

Herein, the authors review the neuroanatomical and the neurophysiological aspects of the normal aging evolution based on the recent literature and briefly describe the difference between physiological and pathological brain aging, with consideration of the currently recommended anesthesia management of older patients. The population of elderly patients is growing drastically with advances in medicine that have prolonged the life span. One of the direct consequence has been a significant increase in the request for anesthesia care for older patients despite the type of surgery (cardiac vs noncardiac and mainly orthopedic). Because the brain of this category of patients undergoes a specific triple influence (immune, metabolic, and inflammatory), some particular physiological, anatomical, and structural modifications must be taken into account because they expose these patients more specifically to postoperative cognitive disturbances. To prevent type of adverse outcome, a better knowledge and understanding of these neurosciences must be promoted. The strategies developed to prevent such adverse outcomes include the determination and detection of significant at-risk patients and improvement in the titration of anesthesia to reduce exposure of anesthesia to these patients through an adapted anesthesia-induced unconsciousness that avoids, as much as possible, the risk of toxic overdose with an overly deep brain depression. To accomplish this, the unprocessed electroencephalogram (EEG) and its spectrogram may represent a significant improvement in monitoring, first by allowing for the rapid recognition of repetitive or persistent EEG suppression by the on-line reading of the raw EEG trace and second by allowing for the accurate determination of the adequate anesthetic-induced state, obtained in general in this category of patients by substantially lowered doses of anesthetic agents. This represents a new methodology for anesthesia titration that is adjusted on a more case-by-case basis and is related to the physiology of individual patients. A better understanding of aging-induced brain transformations remains the key regarding the improvement of the anesthetic management of the always growing population of elderly patients. The promotion of the unprocessed EEG may represent the best method of preventing the risk of anesthetic toxicity, including postoperative cognitive dysfunctions.

Downregulation of synapse-associated protein expression and loss of homeostatic microglial control in cerebrospinal fluid of infectious patients with delirium and patients with Alzheimer's disease

Delirium is a complex and multifactorial condition associated with long-term cognitive decline. Due to the strong links between systemic inflammation, delirium and dementia we hypothesized that responses within the brain in patients who develop delirium could show biochemical overlap with patients with Alzheimer's disease (AD). In this observational study we analyzed protein expression signatures in cerebrospinal fluid (CSF) from 15 patients with infectious delirium and compared these to 29 patients with AD, 30 infectious patients without delirium and 15 non-infectious controls free of neurological disease. A proximity extension assay was performed measuring a total of 184 inflammatory and neurology-related proteins. Eight inflammatory proteins (4%), including the key neuron-microglia communication marker CX3CL1 (fractalkine), were significantly upregulated in both delirium and AD, compared to infectious patients without delirium. Likewise, 23 proteins (13%) showed downregulation in both delirium and AD, relative to infectious patients without delirium, which interestingly included CD200R1, another neuron-microglia communication marker, as well as a cluster of proteins related to synapse formation and function. Synaptopathy is an early event in AD and correlates strongly with cognitive dysfunction. These results were partially mediated by aging, which is an important predisposing risk factor among many others for both conditions. Within this study we report the first in vivo human evidence suggesting that synapse pathology and loss of homeostatic microglial control is involved in the pathophysiology of both infectious delirium and AD and thus may provide a link for the association between infections, delirium and long-term cognitive decline.

Estimates of Geriatric Delirium Frequency in Noncardiac Surgeries and Its Evaluation Across the Years: A Systematic Review and Meta-analysis

OBJECTIVES

Delirium is an acute neuropsychiatric syndrome associated with poor outcomes. Older adults undergoing surgery have a higher risk of manifesting perioperative delirium, particularly those having associated comorbidities. It remains unclear whether delirium frequency varies across surgical settings and if it has remained stable across the years. We conducted a systematic review to (1) determine the overall frequency of delirium in older people undergoing noncardiac surgery; (2) explore factors explaining the variability of the estimates; and (3) determine the changing of the estimates over the past 2 decades.

DESIGN

Systematic review and meta-analysis. Literature search was performed in MEDLINE, PubMed, ISI Web of Science, EBSCO, ISRCTN registry, ScienceDirect, and Embase in January 2020 for studies published from 1995 to 2020.

SETTING

Noncardiac surgical settings.

PARTICIPANTS

Forty-nine studies were included with a total of 26,865 patients screened for delirium.

METHODS

We included observational and controlled trials reporting incidence, prevalence, or proportion of delirium in adults aged ≥60 years undergoing any noncardiac surgery requiring hospitalization. Data extracted included sample size, reported delirium frequencies, surgery type, anesthesia type, delirium diagnosis method, length of hospitalization, and year of assessment. (PROSPERO registration no.: CRD42020160045).

RESULTS

We found an overall pooled frequency of preoperative delirium of 17.9% and postoperative delirium (POD) of 23.8%. The POD estimates increased between 1995 and 2020 at an average rate of 3% per year. Pooled estimates of POD were significantly higher in studies not excluding patients with lower cognitive performance before surgery (28% vs 16%) and when general anesthesia was used in comparison to local, spinal, or epidural anesthesia (28% vs 20%).

CONCLUSIONS AND IMPLICATIONS

Type of anesthesia and preoperative cognitive status were significant moderators of delirium frequency. POD in noncardiac surgery has been increasing across the years, suggesting that more resources should be allocated to delirium prevention and management.

Effect of Tropisetron on Prevention of Emergence Delirium in Patients After Noncardiac Surgery: A Trial Protocol

IMPORTANCE

Postoperative delirium is a frequent disorder for patients undergoing surgery and is associated with poor outcomes. Delirium may occur in the immediate period after anesthesia administration and surgery. Tropisetron, which is frequently administrated for postoperative nausea and vomiting, is also a partial agonist of α7 nicotinic acetylcholine receptors associated with neuroprotective effects. Tropisetron may be the potential pharmacological treatment to decrease delirium after noncardiac surgery.

OBJECTIVE

To perform a randomized clinical trial to determine the efficacy and safety of tropisetron for prevention of emergence delirium in patients undergoing noncardiac surgery.

DESIGN, SETTING, AND PARTICIPANTS

This single-center, 2-arm randomized, double-blind, placebo-controlled trial will include 1508 patients undergoing noncardiac surgery. The intervention group will receive 5 mg of intravenous tropisetron before anesthesia induction, and patients in the control group will receive a placebo. The primary end point is the incidence of emergence delirium within 1 hour after tracheal tube removal, measured by the Confusion Assessment Method for the Intensive Care Unit score. The main secondary outcome is the incidence of postoperative delirium measured at 3 days of follow-up. An intention-to-treat principle will be used for all analyses.

DISCUSSION

Delirium remains the most common neuropsychiatric complication for patients after surgery. This will be the first randomized clinical study to evaluate whether tropisetron is effective in preventing emergence delirium. Results from this study will provide evidence for alteration of daily practice.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04027751.

Postoperative delirium: why, what, and how to confront it at your institution

PURPOSE OF REVIEW

The current article reviews the importance of postoperative delirium (POD), focusing on the older surgical population, and summarizes the best-practice guidelines about POD prevention and treatment which have been published within the last several years. We also describe our local experience with implementing a perioperative delirium risk stratification and prevention pathway, and review implementation science principles which others may find useful as they move toward risk stratification and prevention in their own institutions.

RECENT FINDINGS

There are few areas of consensus, backed by strong experimental data, in POD best-practice guidelines. Most guidelines recommend preoperative cognitive screening, nonpharmacologic delirium prevention measures, and avoidance of deliriogenic medications. The field of implementation science offers strategies for closing the evidence-practice gap, which we supplement with lessons learned from our own experience implementing a perioperative delirium risk stratification and prevention pathway.

SUMMARY

POD continues to be a serious perioperative complication commonly experienced by older adults. Growing appreciation of its prognostic implications and evidence behind multidisciplinary, collaborative, and focused prevention strategies rooted in implementation science have prompted several major groups to issue consensus guidelines. Adopting best practices POD risk stratification and prevention pathways will improve perioperative care for older adults.

Dexmedetomidine improves early postoperative neurocognitive disorder in elderly male patients undergoing thoracoscopic lobectomy

Perioperative neurocognitive disorder (PND) is a common complication following thoracic surgery that frequently occurs in patients ≥65 years. PND includes postoperative cognitive dysfunction (POCD) and postoperative delirium (POD). To investigate whether intravenous dexmedetomidine (DEX) is able to improve neurocognitive function in elderly male patients following thoracoscopic lobectomy, a randomized, double-blinded, placebo-controlled trial was performed at the Affiliated Hospital of Inner Mongolia Medical University (Hohhot, China). Patients aged ≥65 years were enrolled and were subjected to thoracic surgery under general anesthesia. A computer-generated randomization sequence was used to randomly assign patients (at a 1:1 ratio) to receive either intravenous DEX (0.5 µg/kg per h, from induction until chest closure) or placebo (intravenous normal saline). The primary endpoint was the result of the Mini-Mental State Examination (MMSE). The secondary endpoints were the results of the Montreal Cognitive Assessment (MoCA) and those obtained with the Confusion Assessment Method (CAM), as well as the incidence of POCD and POD during the first 7 postoperative days. Other observational indexes included sleep quality at night, self-anxiety scale prior to the operation and 7 days following the operation and the visual analogue scale (VAS) score at rest and during movement on the first and third day following the operation. Furthermore, at 6 h following surgery, the MMSE score in the DEX group was significantly higher than that in the saline group. At 6 h and on the first day postoperatively, the MoCA score in the DEX group was significantly higher than that in the saline group. The incidence of POCD and POD in the DEX group was 13.2 and 7.5%, respectively, while that in the saline group was 35.8 and 11.3%, respectively. There was a significant difference in the incidence of POCD between the two groups (P<0.01). In the DEX group, mean sleep quality was increased, whereas the mean VAS was decreased compared with the corresponding values in the saline group. In conclusion, elderly male patients who underwent thoracoscopic lobectomy under continuous infusion of DEX (0.5 µg/kg/h) exhibited a reduced incidence of POCD during the first 7 postoperative days as compared with the placebo group. Furthermore, DEX improved the subjective sleep quality in the first postoperative night, reduced anxiety and alleviated postoperative pain. In addition, it increased the incidence of bradycardia. The present study was registered in the Chinese Clinical Trial Registry (www.chictr.org.cn; registration no. ChiCTR-IPR-17010958).

Noninvasive neuromonitoring in the operating room and its role in the prevention of delirium

Delirium is a frequent and serious complication after surgery. It has a variable incidence between 20% and 40% with the highest incidence in elderly people undergoing major or cardiac surgery. The development of postoperative delirium (POD) is associated with increased hospital stay lengths, morbidity, the need for home care, and mortality. Studies have appeared in the last decade that evaluate the use of noninvasive monitoring to prevent its development. The evaluation of the depth of anesthesia with processed EEG allows to avoid awareness and burst suppression events. The cessation of brain activity is associated with the development of delirium. Another noninvasive monitoring technique is NIRS for cerebral tissue hypoxia detection by measuring regional oxygen saturation. The reduction of this parameter does not seem to be associated with the development of POD but with postoperative cognitive dysfunction. There are few studies in the literature and with conflicting results on the use of the pupillometer and transcranial Doppler in predicting the development of postoperative delirium.

Current Evidence Regarding Biomarkers Used to Aid Postoperative Delirium Diagnosis in the Field of Cardiac Surgery-Review

Postoperative cognitive disorders after cardiac surgery may manifest as postoperative delirium (POD) or later as postoperative cognitive dysfunction (POCD). The incidence of POD after cardiac surgery ranges from 16% to 73%. In contrast to POD, POCD is usually diagnosed after the discharge from hospital, with an incidence of 30 to 70% of cases, very often noticed only by close relative or friends, decreasing after six (20–30%) and twelve (15–25%) months after surgery. Perioperative cognitive disorders are associated with adverse short- and long-term effects, including increased morbidity and mortality. Due to the complexity of delirium pathomechanisms and the difficulties in the diagnosis, researchers have not yet found a clear answer to the question of which patient will be at a higher risk of developing delirium. The risk for POD and POCD in older patients with numerous comorbidities like hypertension, diabetes, and previous ischemic stroke is relatively high, and the predisposing cognitive profile for both conditions is important. The aim of this narrative review was to identify and describe biomarkers used in the diagnosis of delirium after cardiac surgery by presenting a search through studies regarding this subject, which have been published during the last ten years. The authors discussed brain-derived biomarkers, inflammation-related biomarkers, neurotransmitter-based biomarkers, and others. Work based on inflammation-related biomarkers, which are characterized by the low cost of implementation and the effectiveness of delirium diagnosis, seems to be the closest to the goal of discovering an inexpensive and effective marker. Currently, the use of a panel of tests, and not a single biomarker, brings us closer to the discovery of a test, or rather a set of tests ideal for the diagnosis of delirium after cardiac surgery.

Emergence delirium in children undergoing dental surgery under general anesthesia

BACKGROUND

Emergence delirium is a well-described complication in pediatric anesthesia, occurring more often following short surgical procedures using volatile anesthetics with a rapid recovery profile. Dental extractions and conservation dentistry are commonly performed in children and are not painful postoperatively. The use of nerve blocks and local anesthetic infiltration intraoperatively limits nociception and obviates the need for opioids, allowing for more objective assessment of emergence delirium.

AIM

The purpose of this preliminary study was to describe the incidence of emergence delirium and the associated risk factors in children undergoing elective dental surgery under general anesthesia at a regional academic hospital in South Africa.

METHODS

A prospective, descriptive study of healthy children aged 2-6 years was undertaken. Patients were anesthetized using standardized protocols. Assessments included demographics of the child and caregiver, child anxiety at induction using the modified Yale Preoperative Anxiety Scale, intraoperative events, and Paediatric Anaesthesia Emergence Delirium score in the recovery room. Data were assessed for associations and correlations.

RESULTS

Ninety-one children with a mean age of 3.9 (SD = 0.9) years were included. Anxiety was present in 69.2% at induction and emergence delirium occurred in 51.6% of the patients. The mean (SD, range) Paediatric Anaesthesia Emergence Delirium score in the patients without emergence delirium was 7 (2.65, 0-9) and in patients with emergence delirium was 14 (2.52, 10-18). Children with emergence delirium required more interventions in the recovery room but few required pharmacological treatment.

CONCLUSIONS

Emergence delirium occurs commonly after dental surgery, and the majority of the children presenting for dental surgery are anxious at induction. Children with emergence delirium require more interventions in the recovery room but few require pharmacological treatment.

Perioperative Management of Elderly patients (PriME): recommendations from an Italian intersociety consensus

BACKGROUND

Surgical outcomes in geriatric patients may be complicated by factors such as multiple comorbidities, low functional performance, frailty, reduced homeostatic capacity, and cognitive impairment. An integrated multidisciplinary approach to management is, therefore, essential in this population, but at present, the use of such an approach is uncommon. The Perioperative Management of Elderly patients (PriME) project has been established to address this issue.

AIMS

To develop evidence-based recommendations for the integrated care of geriatric surgical patients.

METHODS

A 14-member Expert Task Force of surgeons, anesthetists, and geriatricians was established to develop evidence-based recommendations for the pre-, intra-, and postoperative care of hospitalized older patients (≥ 65 years) undergoing elective surgery. A modified Delphi approach was used to achieve consensus, and the strength of recommendations and quality of evidence was rated using the U.S. Preventative Services Task Force criteria.

RESULTS

A total of 81 recommendations were proposed, covering preoperative evaluation and care (30 items), intraoperative management (19 items), and postoperative care and discharge (32 items).

CONCLUSIONS

These recommendations should facilitate the multidisciplinary management of older surgical patients, integrating the expertise of the surgeon, the anesthetist, the geriatrician, and other specialists and health care professionals (where available) as needed. These roles may vary according to the phase and setting of care and the patient's conditions.

Ultrabrief Screens for Detecting Delirium in Postoperative Cognitively Intact Older Adults

The authors' sought to develop an ultrabrief screen for postoperative delirium in cognitively intact patients older than 70 years undergoing major elective surgery. All possible combinations of one-, two- and three-item screens and their sensitivities, specificities, and 95% confidence intervals were calculated and compared with the delirium reference standard Confusion Assessment Method (CAM). Among the 560 participants (mean age, 77 years; 58% women), delirium occurred in 134 (24%). We considered 1,100 delirium assessments from postoperative days 1 and 2. The screen with the best overall performance consisted of three items: (1) Patient reports feeling confused, (2) Months of the year backward, and (3) "Does the patient appear sleepy?" with sensitivity of 92% and specificity of 72%. This brief, three-item screen rules out delirium quickly, identifies a subset of patients who require further testing, and may be an important tool to improve recognition of postoperative delirium.

Noninvasive ventilation during left atrial appendage closure under sedation: Preliminary experience with the Janus Mask

Background:

Percutaneous left atrial appendage occlusion (LAAO) is indicated in subjects with atrial fibrillation who cannot receive oral anticoagulants. This procedure requires transesophageal echocardiography guidance and is usually performed under general anesthesia. The Janus Mask is a new device designed to allow upper endoscopic procedures during noninvasive ventilation (NIV).

Aims:

This study aims to assess the possibility of performing LAAO under sedation and NIV.

Setting:

Cardiac electrophysiology laboratory.

Design:

Case–control study.

Materials and Methods:

Data from 11 subjects undergoing LAAO under sedation and NIV with the Janus Mask were retrospectively collected. Procedure duration, outcomes, and physicians' satisfaction were compared with those of 11 subjects who underwent LAAO under general anesthesia in the same period.

Statistical Analysis:

Univariate analysis and analysis of variance for between-groups comparison.

Results:

The 11 subjects treated with sedation experienced a good outcome, with a high degree of satisfaction from the medical team. An increase in arterial partial pressure of carbon dioxide in the Janus group (45 [43–62] mmHg vs. 33 [30–35] mmHg in the general anesthesia group, P < 0.001) led to a transient pH decrease 45 min after the beginning of the procedure (7.30 [7.18–7.36] vs. 7.40 [7.39–7.46], P = 0.014). No differences in arterial partial pressure of oxygen, FiO₂, and hemodynamic parameters were observed. The subjects' conditions at discharge from the recovery room were comparable. No difference in procedure duration was registered.

Conclusions:

LAAO procedure under sedation and NIV through the Janus Mask is safe and feasible. This strategy might represent a valuable alternative to manage such a compromised and fragile population.

Effects of preconditioning by nasal splint and mouth breathing on emergence delirium after functional endoscopic sinus surgery in Chinese adults: a study protocol for a randomised controlled trial

INTRODUCTION

Emergence delirium (ED) is a common adverse manifestation after general anaesthesia and may result in undesirable consequences. Its causes and mechanisms are diverse and complex, and it is still unavoidable in clinical work. There is a high incidence of ED after otorhinolaryngology surgery, which may result from the sudden loss of functional senses and discomfort of surgical organs. This study aims to test a non-invasive, non-drug treatment modality of nose clamping and mouth-breathing training before surgery to reduce ED.

METHODS AND ANALYSIS

This prospective randomised controlled trial (RCT) will include 200 patients who undergo functional endoscopic sinus surgery (FESS) at Shanghai General Hospital, China. Study participants will be randomly assigned in two groups with a 1:1 ratio. The pretreatment group (P-group) will receive an intervention by nasal splint and mouth-breathing training before surgery, while the control group (C-group) will not receive any intervention; following which both groups will undergo FESS under general anaesthesia in accordance with the same anaesthesia scheme. After surgery, we will perform a single-blinded assessment of ED occurrence with stratification. IBM SPSS Statistics V.20 statistical software will be used for statistical analyses. A X² test will be used to compare the two groups, and t-tests will determine the statistical significance of continuous variables.

ETHICS AND DISSEMINATION

This RCT was designed in accordance with the principles of the Declaration of Helsinki and has been approved by the Ethics Committee of Shanghai General Hospital, ID: 2019KY039.We expect to release the original data in February 2022 on the ResMan original data sharing platform (IPD sharing platform) of the China clinical trial registry, which can be viewed at the following website:http://www.medresman.org.cn/pub/cn/proj/projectshow.aspx?proj=6293.

TRIAL REGISTRATION NUMBER

ChiCTR1900024925.

Technical considerations when using the EEG export of the SEDLine Root device

Electroencephalographic (EEG) patient monitoring during general anesthesia can help to assess the real-time neurophysiology of unconscious states. Some monitoring systems like the SEDLine Root allow export of the EEG to be used for retrospective analysis. We show that changes made to the SEDLine display during recording affected the recorded EEG. These changes can strongly impact retrospective analysis of EEG signals. Real-time changes of the feed speed in the SEDLine Root device display modifies the sampling rate of the exported EEG. We used a patient as well as a simulated EEG recording to highlight the effects of the display settings on the extracted EEG. Therefore, we changed EEG feed and amplitude resolution on the display in a systematic manner. To visualize the effects of these changes, we present raw EEG segments and the density spectral array of the recording. Changing the display’s amplitude resolution affects the amplitudes. If the amplitude resolution is too fine, the exported EEG contains clipped amplitudes. If the resolution is too coarse, the EEG resolution becomes too low leading to a low-quality signal making frequency analysis impossible. The proportion of clipped or zero-line data caused by the amplitude setting was > 60% in our sedated patient. Changing the display settings results in undocumented changes in EEG amplitude, sampling rate, and signal quality. The occult nature of these changes could make the analysis of data sets difficult if not invalid. We strongly suggest researchers adequately define and keep the EEG display settings to export good quality EEG and to ensure comparability among patients.

Perioperative management of patients with undergoing durable mechanical circulatory support

Durable mechanical circulatory support (MCS) devices revolutionized the treatment options for patients with end-stage heart failure (HF). Implantation of durable mechanical support has become an integral treatment modality in end-stage HF patients and it is associated with improved quality of life and survival. There is no doubt that this needs an interdisciplinary and interprofessional approach of cardiac surgeons, cardiologists, cardiac anesthesiologists, perfusionists, intensivists, psychologists, assist device coordinators as well as physiotherapists and intensive care. Implantation of durable MCS is a challenging procedure for the anesthesiologist due to the patient’s characteristics and comorbid diseases. It demands comprehensive training, high vigilance and quick response during the acute hemodynamic changes occurring during the surgery. Preoperative risk stratification is of major importance to guide perioperative medical treatment strategies. Most of these patients have several comorbidities and multiple medications. Therefore, to anticipate postoperative end-organ dysfunction such as cognitive dysfunction, pulmonary or renal failure, an interdisciplinary approach is necessary to optimize patient’s prior surgery. Transthoracic and transesophageal echocardiography (TTE and TEE), both play an invaluable role in diagnosing the cause and guiding the management in different unstable clinical situations. Especially prevention of postoperative right HF with subsequent necessity of temporary MCS is important as it is associated with higher mortality. The aim of this review is to provide an overview about the current concepts of perioperative management for durable MCS. A multimodal standard operating procedure supports early recovery after surgery and intensive care stay. Standardized perioperative care helps to ensure optimal medical treatment. This review focusses on several major skills of perioperative management of these high-risk surgical patients.

Interventions to improve perioperative neurologic outcomes

PURPOSE OF REVIEW

Few outcomes in surgery are as important to patients as that of their neurologic status. The purpose of this review is to discuss and categorize the most common perioperative neurologic complications. We will also discuss strategies to help prevent and mitigate these complications for our patients.

RECENT FINDINGS

There are several strategies the anesthesiologist can undertake to prevent or treat conditions, such as perioperative neurocognitive disorders, spinal cord ischemia, perioperative stroke, and postoperative visual loss.

SUMMARY

A thorough understanding of threats to patients' neurologic well-being is essential to excellent clinical practice.

The correlation of intraoperative hypotension and postoperative cognitive impairment: a meta-analysis of randomized controlled trials

BACKGROUND

There is no consensus on whether intraoperative hypotension is associated with postoperative cognitive impairment. Hence, we performed a meta-analysis to evaluate the correlation of intraoperative hypotension and the incidence of postoperative delirium (POD) or postoperative cognitive dysfunction (POCD).

METHODS

We searched PubMed, Embase, and Cochrane Library databases to find randomized controlled trials (RCTs) in which reported the relationship between intraoperative hypotension and POD or POCD. The retrieval time is up to January 2020, without language restrictions. Quality assessment of the eligible studies was conducted by two researchers independently with the Cochrane evaluation system.

RESULTS

We analyzed five eligible RCTs. Based on the relative mean arterial pressure (MAP), participants were divided into low-target and high-target groups. For the incidence of POD, there were two studies with 99 participants in the low-target group and 94 participants in the high-target pressure group. For the incidence of POCD, there were four studies involved 360 participants in the low-target group and 341 participants in the high-target group, with a study assessed both POD and POCD. No significant difference between the low-target and the high-target group was observed in the incidence of POD (RR = 3.30, 95% CI 0.80 to 13.54, P = 0.10), or POCD (RR = 1.26, 95% CI 0.76 to 2.08, P = 0.37). Furthermore, it also demonstrates that intraoperative hypotension prolonged the length of ICU stay, but did not increased the mortality, the length of hospital stay, and mechanical ventilation (MV) time.

CONCLUSIONS

There is no significant correlation between intraoperative hypotension and the incidence of POD or POCD.

Multi-disciplinary and pharmacological interventions to reduce post-operative delirium in elderly patients: A systematic review and meta-analysis

STUDY OBJECTIVE

An estimated 80% of older people undergoing surgery develop postoperative delirium (POD) making them a high-risk group. Research in this area is growing fast but there is no established consensus on strategies for POD prevention or management. A systematic review and meta-analysis were conducted to synthesise data on clinical interventions used to reduce POD among older people undergoing elective and emergency surgery.

METHODS

A range of database searches generated 336 papers. A total of 25 studies met the inclusion criteria and were assessed using the Joanna Briggs Institute Critical Appraisal Checklist. The studies were undertaken across the world.

RESULTS

This review identified a range of intervention approaches: comparisons between anaesthetic and sedatives agents, medication-specific interventions and multidisciplinary models of care. Results found more consistencies across multidisciplinary interventions than the pharmacological interventions. In pooled analyses, haloperidol (OR 0.74; 95% CI (confidence interval) 0.44, 1.26) was not statistically significantly associated with reduced POD incidence any more than a placebo.

CONCLUSION

There is a need to implement multidisciplinary interventions, as well as collaboration between clinicians on pre- and postoperative care practices regarding pharmacological interventions to more effectively reduce and manage POD in older people.

The concept of peri-operative medicine to prevent major adverse events and improve outcome in surgical patients: A narrative review

: Peri-operative Medicine is the patient-centred and value-based multidisciplinary peri-operative care of surgical patients. Peri-operative stress, that is the collective response to stimuli occurring before, during and after surgery, is, together with pre-existing comorbidities, the pathophysiological basis of major adverse events. The ultimate goal of Peri-operative Medicine is to promote high quality recovery after surgery. Clinical scores and/or biomarkers should be used to identify patients at high risk of developing major adverse events throughout the peri-operative period. Allocation of high-risk patients to specific care pathways with peri-operative organ protection, close surveillance and specific early interventions is likely to improve patient-relevant outcomes, such as disability, health-related quality of life and mortality.

Postoperative neurocognitive disorders

A decline in cognitive function is a frequent complication of major surgery. Postoperative cognitive impairments have generally been divided into short- (postoperative delirium) and long-term disturbances (postoperative cognitive dysfunction [POCD]). Long-term impairments are often subtle and overlooked. They need to be objectively assessed using neuropsychological tests to be diagnosed. Although POCD has been the subject of considerable research over the past decades, it remains uncertain why some patients do not return to preoperative levels of cognitive function. Surgery and anesthesia have both been implicated to play a role in POCD development, and certain patient-related factors, such as advanced age and low preoperative baseline cognitive function, have consistently been found to predict postoperative cognitive decline. This article will present an overview of POCD and its etiology and provide advice on possible strategies on its prevention.

American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Postoperative Delirium Prevention

Postoperative delirium is a geriatric syndrome that manifests as changes in cognition, attention, and levels of consciousness after surgery. It occurs in up to 50% of patients after major surgery and is associated with adverse outcomes, including increased hospital length of stay, higher cost of care, higher rates of institutionalization after discharge, and higher rates of readmission. Furthermore, it is associated with functional decline and cognitive impairments after surgery. As the age and medical complexity of our surgical population increases, practitioners need the skills to identify and prevent delirium in this high-risk population. Because delirium is a common and consequential postoperative complication, there has been an abundance of recent research focused on delirium, conducted by clinicians from a variety of specialties. There have also been several reviews and recommendation statements; however, these have not been based on robust evidence. The Sixth Perioperative Quality Initiative (POQI-6) consensus conference brought together a team of multidisciplinary experts to formally survey and evaluate the literature on postoperative delirium prevention and provide evidence-based recommendations using an iterative Delphi process and Grading of Recommendations Assessment, Development and Evaluation (GRADE) Criteria for evaluating biomedical literature.