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Postoperative cognitive dysfunction is rare after fast-track hip- and knee arthroplasty - But potentially related to opioid use. J Clin Anesth 2019; 57:80-86. [PMID: 30927698 DOI: 10.1016/j.jclinane.2019.03.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 03/19/2019] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE Postoperative cognitive dysfunction (POCD) remains a frequent postoperative complication in non-fast-track surgeries, with negative implications for return to daily activities and work. In fast-track total hip and -knee arthroplasty (THA/TKA) an 8-9% incidence of POCD after 3 months has been reported, but without details on specific perioperative risk factors. Thus, we re-investigated the incidence and role of suggested factors for POCD in a well-controlled patient cohort, to guide future preventive interventions. DESIGN A subanalysis of a prospective study. SETTING Hospital ward, patients own home. PATIENTS One-hundred-and-four patients undergoing elective THA/TKA. INTERVENTIONS A full contextual and validated cognitive test battery pre- and 2-3 weeks postoperatively by interview by research nurse. MEASUREMENTS Results from the cognitive test battery were corrected for learning effect by normative data from an age-matched unoperated control group. Potential perioperative risk factors (age, procedure, gender, inflammation, blood-percentage, opioids etc.) associated with POCD was investigated by univariate and multivariate logistic analysis, with a 5% significance level. MAIN RESULTS Four patients (3.9%) developed POCD. POCD-positive patients consumed higher dose of opioids in the acute postoperative period (postoperative days 0-3: median 214 mg), vs. POCD-negative patients (postoperative days 0-3: median 98 mg, p = 0.008), and during the 2-3-week study period (POCD-positive vs. POCD-negative patients, median 739 mg vs. 208 mg, respectively). Other pre and postoperative factors were non-significant but associated with the development of POCD. CONCLUSION POCD is rare in fast-track THA/TKA patients and may be related to postoperative opioid consumption, supporting the ongoing focus on opioid-sparing analgesia.
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Ayob F, Lam E, Ho G, Chung F, El-Beheiry H, Wong J. Pre-operative biomarkers and imaging tests as predictors of post-operative delirium in non-cardiac surgical patients: a systematic review. BMC Anesthesiol 2019; 19:25. [PMID: 30797230 PMCID: PMC6387490 DOI: 10.1186/s12871-019-0693-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 02/08/2019] [Indexed: 02/06/2023] Open
Abstract
Background Post-operative delirium (POD) is a common post-operative complication in elderly individuals and imposes a significant health and financial burden. Identifying predictive biomarkers may help understand the pathophysiology of POD. Our objective is to summarize the evidence of pre-operative biomarkers and imaging tests to predict POD in patients undergoing non-cardiac surgery. Methods A systematic search of English language articles in MEDLINE, EMBASE, Cochrane Database, PsychINFO, PubMed and ClinicalTrials. Gov up to January 2018 was performed. Studies that used biomarkers or imaging tests to predict POD and a validated POD assessment tool were included. Animal studies, paediatric, cardiac and intracranial surgery were excluded. Risk of bias was assessed using the Quality In Prognosis Study tool. Results Thirty-four prospective cohort studies involving 4424 patients were included. Nineteen studies described serum tests [Interleukin-6, Insulin-like Growth Factor 1, C-Reactive Protein (CRP), cholinesterases, apolipoprotein-E genotype, leptin, hypovitaminosis, hypoalbuminaemia, gamma-amino butyric acid], 10 described cerebral-spinal fluid tests (monoamine precursor, melatonin, acute phase proteins, S100B and neurofibrillary tangles), and 5 described imaging tests. Two studies had high risk of bias due to unclear outcome measurement and study participation. CRP was significantly associated with POD in 5 studies. Other biomarkers were either examined by only a single study or two or more studies with conflicting results. Conclusion CRP is the most promising biomarker associated with POD. However, we are still in the early stages in identifying biomarkers and imaging tests that may further understanding of the pathophysiology of POD. Electronic supplementary material The online version of this article (10.1186/s12871-019-0693-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Farrah Ayob
- Department of Anesthesia, Toronto Western Hospital, University Health Network, 2-434 McLaughlin Wing, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada
| | - Enoch Lam
- Department of Anesthesia, Toronto Western Hospital, University Health Network, 2-434 McLaughlin Wing, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada
| | - George Ho
- Faculty of Medicine, University of Toronto, 1 King's College Circle, Medical Sciences Building, Room 2109, Toronto, ON, M5S 1A8, Canada
| | - Frances Chung
- Department of Anesthesia, Toronto Western Hospital, University Health Network, 2-434 McLaughlin Wing, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada
| | - Hossam El-Beheiry
- Department of Anesthesia, Trillium Health Partners, Mississauga Hospital, 100 Queensway, West, Mississauga, ON, L5B 1B, Canada
| | - Jean Wong
- Department of Anesthesia, Toronto Western Hospital, University Health Network, 2-434 McLaughlin Wing, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada. .,Women's College Hospital, Toronto, Ontario, 76 Grenville St, Toronto, ON, M5S 1B2, Canada.
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Vallet H, Fali T, Sauce D. Le vieillissement du système immunitaire : du fondamental à la clinique. Rev Med Interne 2019; 40:105-111. [DOI: 10.1016/j.revmed.2018.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 06/26/2018] [Accepted: 07/03/2018] [Indexed: 01/08/2023]
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Li QH, Yu L, Yu ZW, Fan XL, Yao WX, Ji C, Deng F, Luo XZ, Sun JL. Relation of postoperative serum S100A12 levels to delirium and cognitive dysfunction occurring after hip fracture surgery in elderly patients. Brain Behav 2019; 9:e01176. [PMID: 30548434 PMCID: PMC6346413 DOI: 10.1002/brb3.1176] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 10/27/2018] [Accepted: 10/30/2018] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE Brain injury is implicated in pathogenesis of postoperative delirium (POD) and cognitive dysfunction (POCD). S100A12 is involved in inflammatory process and is recently known as a biomarker for brain injury. Herein, we clarified whether serum S100A12 levels are related to POD and POCD after hip fracture surgery in elderly patients. MATERIALS AND METHODS In this prospective, observational study, we gauged S100A12 levels in preoperative and postoperative serum from 186 patients and serum from 186 controls. Patients were categorized according to the presence of POD and POCD. RESULTS Postoperative, but not preoperative serum S100A12 levels were significantly higher in patients than in controls. There was a positive and independent correlation between postoperative C-reactive protein and S100A12 levels (t = 8.797, p < 0.001). Postoperative S10012 levels and age were independently associated with the risk of developing POD (S100A12 levels: odds ratio [OR] = 1.166, 95% confidence interval [CI] = 1.045-2.087, p = 0.001; age: OR = 1.243, 95% CI = 1.073-1.419, p = 0.012) and POCD (S100A12: OR = 1.157, 95% CI = 1.030-1.986, p = 0.003; age: OR = 1.228, 95% CI = 1.054-1.387, p = 0.014). In terms of area under receiver operating characteristic curve, postoperative S100A12 levels had a higher predictive ability than age and their combination dramatically exceeded that of each one alone. CONCLUSIONS Postoperative elevated serum S100A12 levels have a strong relation to inflammation and are associated independently with the development of POD and POCD, substantializing serum S100A12 as a potential biomarker for predicting POD and POCD in elderly patients undergoing hip fracture surgery.
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Affiliation(s)
- Qing-Hua Li
- Department of Anesthesia and Pain, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Liang Yu
- Department of Anesthesia and Pain, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zheng-Wei Yu
- Department of Anesthesia and Pain, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiao-Liang Fan
- Department of Orthopedics, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wang-Xiang Yao
- Department of Orthopedics, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Cheng Ji
- Department of Orthopedics, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Fang Deng
- Department of Anesthesia and Pain, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xian-Zhe Luo
- Department of Anesthesia and Pain, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jian-Liang Sun
- Department of Anesthesia and Pain, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Hall RJ, Watne LO, Cunningham E, Zetterberg H, Shenkin SD, Wyller TB, MacLullich AMJ. CSF biomarkers in delirium: a systematic review. Int J Geriatr Psychiatry 2018; 33:1479-1500. [PMID: 28585290 DOI: 10.1002/gps.4720] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 03/16/2017] [Indexed: 12/18/2022]
Abstract
OBJECTIVE In recent years, there has been a blossoming of studies examining cerebrospinal fluid (CSF) as a method of studying the pathophysiology of delirium. We systematically reviewed the literature for CSF studies in delirium and provide here a summary of the implications for our understanding of delirium pathophysiology. We also summarise the methods used for CSF analysis and discuss challenges and implications for future studies. METHODS In this systematic review, we screened MEDLINE, EMBASE, PsycINFO, Web of Science, PubMed and the Cochrane Library for articles on CSF biomarkers in delirium, published on 3 September 2016. Studies were required to use Diagnostic and Statistical Manual of Mental Disorders or International Classification of Diseases criteria for delirium or a validated tool. We excluded case reports. There were no other restrictions on study type. RESULTS We identified 3280 articles from our initial search, and 22 articles were included in this review. All studies were prospective, including over 400 patients with delirium and 700 controls. More than 70 different biomarkers were studied. Studies could not be compared with each other for meta-analysis because of their heterogeneity and varied widely in their risk of bias and quality assessments. CONCLUSIONS The 22 studies identified in this review reveal a small but growing literature, in which many of the important hypotheses in delirium pathogenesis have been examined, but from which few firm conclusions can currently be drawn. Nevertheless, the overall interpretation of the literature supports the vulnerable brain concept, that is, that biomarker evidence of, for example, Alzheimer's disease pathology and/or neuroinflammation, is associated with delirium.
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Affiliation(s)
- Roanna J Hall
- Edinburgh Delirium Research Group, Geriatric Medicine, University of Edinburgh, Edinburgh, UK.,Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, Scotland
| | - Leiv Otto Watne
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Emma Cunningham
- Centre for Public Health, Queen's University of Belfast, Belfast, Ireland
| | - Henrik Zetterberg
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Neuroscience and Physiology, Department of Psychiatry and Neurochemistry, The Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.,Department of Molecular Neuroscience, UCL Institute of Neurology, London, UK
| | - Susan D Shenkin
- Edinburgh Delirium Research Group, Geriatric Medicine, University of Edinburgh, Edinburgh, UK.,Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, Scotland
| | - Torgeir Bruun Wyller
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine, University of Edinburgh, Edinburgh, UK.,Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, Scotland
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Bellelli G, Zambon A, Volpato S, Abete P, Bianchi L, Bo M, Cherubini A, Corica F, Di Bari M, Maggio M, Manca GM, Rizzo MR, Rossi A, Landi F, Brombo G, Ortolani B, Savino E, Maietti E, Fisichella A, Buttò V, Zamboni M, Caliari C, Ferrari E, Orso F, Sacco F, Di Meo ML, Pittella F, Motta M, Massariello F, Fusco S, Schepisi R, Ferro C, Marchese L, Agosta L, Basile C, Coppola C, Dalise AM, Fava I, Catte O, Orru M, Salaris P, Martone AM, Ortolani E, Salini S, dell'Aquila G, Carrieri B. The association between delirium and sarcopenia in older adult patients admitted to acute geriatrics units: Results from the GLISTEN multicenter observational study. Clin Nutr 2018; 37:1498-1504. [DOI: 10.1016/j.clnu.2017.08.027] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Revised: 07/24/2017] [Accepted: 08/30/2017] [Indexed: 12/25/2022]
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Impact of stress on aged immune system compartments: Overview from fundamental to clinical data. Exp Gerontol 2018; 105:19-26. [DOI: 10.1016/j.exger.2018.02.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 02/03/2018] [Accepted: 02/05/2018] [Indexed: 12/12/2022]
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Liu X, Yu Y, Zhu S. Inflammatory markers in postoperative delirium (POD) and cognitive dysfunction (POCD): A meta-analysis of observational studies. PLoS One 2018; 13:e0195659. [PMID: 29641605 PMCID: PMC5895053 DOI: 10.1371/journal.pone.0195659] [Citation(s) in RCA: 121] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 03/27/2018] [Indexed: 11/19/2022] Open
Abstract
Background The aim of this study was to summarize and discuss the similarities and differences in inflammatory biomarkers in postoperative delirium (POD) and cognitive dysfunction (POCD). Methods A systematic retrieval of literature up to June 2017 in PubMed, Embase, the Cochrane Library, the China National Knowledge Infrastructure database, and the Wanfang database was conducted. Extracted data were analyzed with STATA (version 14). The standardized mean difference (SMD) and the 95% confidence interval (95% CI) of each indicator were calculated using a random effect model. We also performed tests of heterogeneity, sensitivity analysis, assessments of bias, and meta-regression in this meta-analysis. Results A total of 54 observational studies were included. By meta-analysis we found significantly increased C-reactive protein (CRP) (9 studies, SMD 0.883, 95% CI 0.130 to 1.637, P = 0.022 in POD; 10 studies, SMD -0.133, 95% CI -0.512 to 0.246, P = 0.429 in POCD) and interleukin (IL)-6 (7 studies, SMD 0.386, 95% CI 0.054 to 0.717, P = 0.022 in POD; 16 studies, SMD 0.089, 95% CI -0.133 to 0.311, P = 0.433 in POCD) concentrations in both POD and POCD patients. We also found that the SMDs of CRP and IL-6 from POCD patients were positively correlated with surgery type in the meta-regression (CRP: Coefficient = 1.555365, P = 0.001, 10 studies; IL-6: Coefficient = -0.6455521, P = 0.086, 16 studies). Conclusion Available evidence from medium-to-high quality observational studies suggests that POD and POCD are indeed correlated with the concentration of peripheral and cerebrospinal fluid (CSF) inflammatory markers. Some of these markers, such as CRP and IL-6, play roles in both POD and POCD, while others are specific to either one of them.
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Affiliation(s)
- Xuling Liu
- Zhejiang University School of Medicine, Hangzhou, Zhejiang, P.R. China
| | - Yang Yu
- Zhejiang University School of Medicine, Hangzhou, Zhejiang, P.R. China
| | - Shengmei Zhu
- Zhejiang University School of Medicine, Hangzhou, Zhejiang, P.R. China
- Department of Anesthesiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, P.R. China
- * E-mail:
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Xiong C, Zhang Z, Baht GS, Terrando N. A Mouse Model of Orthopedic Surgery to Study Postoperative Cognitive Dysfunction and Tissue Regeneration. J Vis Exp 2018. [PMID: 29553500 PMCID: PMC5916114 DOI: 10.3791/56701] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Surgery is commonly used to improve and maintain quality of life. Unfortunately, in vulnerable patients such as the elderly, complications may occur and significantly diminish the outcome. Indeed, after routine orthopedic surgery to repair a fracture, as many as 50% of elderly patients suffer from neurologic complications like delirium. Also, the capacity to heal and regenerate tissue after surgery decreases with age, and can impact the quality of fracture repair and even osseous integration of implants. Thus, a better understanding of mechanisms that drive these age-dependent changes could provide strategic targets to minimize risk for such complications and optimize outcomes. Here, we introduce a clinically relevant mouse model of tibial fracture. The postoperative changes in these mice mimic some of the cognitive impairments commonly observed after routine orthopedic surgery in humans. Briefly, an incision is performed in the right hind limb under strictly aseptic conditions. Muscles are disassociated, and a 0.38-mm stainless steel pin is inserted into the upper crest of the tibia, inside the intramedullary canal. Osteotomy is then performed, and the wound is stapled. We have used this model to investigate the effects of surgical trauma on postoperative neuroinflammation and behavioral changes. By applying this fracture model in combination with parabiosis, a surgical model in which 2 mice are anastomosed, we have studied cells and secreted factors that systemically rejuvenate organ function and tissue regeneration after injury. By following our step-by-step protocol, these models can be reproduced with high fidelity, and can be adapted to interrogate many biologic pathways that are altered by surgical trauma.
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Affiliation(s)
- Chao Xiong
- Department of Anesthesiology, Duke University Medical Center
| | - Zhiquan Zhang
- Department of Anesthesiology, Duke University Medical Center
| | - Gurpreet S Baht
- Department of Orthopaedic Surgery, Duke University Medical Center; Duke Molecular Physiology Institute;
| | - Niccolo Terrando
- Department of Anesthesiology, Duke University Medical Center; Center for Translational Pain Medicine, Duke University Medical Center;
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Sanford AM, Morley JE, McKee A. Editorial: Orthogeriatrics and Hip Fractures. J Nutr Health Aging 2018; 22:457-462. [PMID: 29582883 DOI: 10.1007/s12603-018-1007-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- A M Sanford
- John E. Morley, MB,BCh, Division of Geriatric Medicine, Saint Louis University School of Medicine, 1402 S. Grand Blvd., M238, St. Louis, MO 63104,
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Zhu B, Jiang RY, Yang C. Cognitive Reserve: Predictor of Onset of Postoperative Delirium in Older Adults? J Am Geriatr Soc 2016; 65:659-660. [PMID: 28029707 DOI: 10.1111/jgs.14581] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Bin Zhu
- Department of Critical Care Medicine, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Ri-Yue Jiang
- Department of Radiation Oncology, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Chun Yang
- Department of Anesthesiology, The Third Affiliated Hospital of Soochow University, Changzhou, China
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