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Kong F, Chen S, Cheng Y, Ma L, Lu H, Zhang H, Hu W. Minocycline attenuates cognitive impairment induced by isoflurane anesthesia in aged rats. PLoS One 2013; 8:e61385. [PMID: 23613842 PMCID: PMC3629183 DOI: 10.1371/journal.pone.0061385] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2012] [Accepted: 03/08/2013] [Indexed: 11/18/2022] Open
Abstract
Postoperative cognitive dysfunction (POCD) is a clinical phenomenon characterized by cognitive deficits in patients after anesthesia and surgery, especially in geriatric surgical patients. Although it has been documented that isoflurane exposure impaired cognitive function in several aged animal models, there are few clinical interventions and treatments available to prevent this disorder. Minocycline has been well established to exert neuroprotective effects in various experimental animal models and neurodegenerative diseases. Therefore, we hypothesized that pretreatment with minocycline attenuates isoflurane-induced cognitive decline in aged rats. In the present study, twenty-month-old rats were administered minocycline or an equal volume of saline by intraperitoneal injection 12 h before exposure to isoflurane. Then the rats were exposed to 1.3% isoflurane for 4 h. Two weeks later, spatial learning and memory of the rats were examined using the Morris Water Maze. We found that pretreatment with minocycline mitigated isoflurane-induced cognitive deficits and suppressed the isoflurane-induced excessive release of IL-1β and caspase-3 in the hippocampal CA1 region at 4 h after isoflurane exposure, as well as the number of TUNEL-positive nuclei. In addition, minocycline treatment also prevented the changes of synaptic ultrastructure in the hippocampal CA1 region induced by isoflurane. In conclusion, pretreatment with minocycline attenuated isoflurane-induced cognitive impairment in aged rats.
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Affiliation(s)
- Feijuan Kong
- Department of Anesthesiology, Hangzhou First People's Hospital, Nanjing Medical University, Hangzhou, China
- * E-mail: (FJK); (LLM)
| | - Shuping Chen
- Department of Anesthesiology, Hangzhou First People's Hospital, Nanjing Medical University, Hangzhou, China
| | - Yuan Cheng
- Department of Anesthesiology, Hangzhou First People's Hospital, Nanjing Medical University, Hangzhou, China
| | - Leilei Ma
- Department of Anesthesiology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- * E-mail: (FJK); (LLM)
| | - Huishun Lu
- Department of Anesthesiology, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Honghai Zhang
- Department of Anesthesiology, Hangzhou First People's Hospital, Nanjing Medical University, Hangzhou, China
| | - Wenwen Hu
- Department of Anesthesiology, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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202
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Yang R, Wolfson M, Lewis MC. Unique Aspects of the Elderly Surgical Population: An Anesthesiologist's Perspective. Geriatr Orthop Surg Rehabil 2013; 2:56-64. [PMID: 23569671 DOI: 10.1177/2151458510394606] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Increasing life expectancies paired with age-related comorbidities have resulted in the continued growth of the elderly surgical population. In this group, age-associated changes and decreased physiological reserve impede the body's ability to maintain homeostasis during times of physiological stress, with a subsequent decrease in physiological reserve. This can lead to age-related physiological and cognitive dysfunction resulting in perioperative complications. Changes in the cardiovascular, pulmonary, nervous, hepatorenal, endocrine, skin, and soft tissue systems are discussed as they are connected to the perioperative experience. Alterations affect both the pharmacodynamics and pharmacokinetics of administered drugs. Elderly patients with coexisting diseases are at a greater risk for polypharmacy that can further complicate anesthetic management. Consequently, the importance of conducting a focused preoperative evaluation and identifying potential risk factors is strongly emphasized. Efforts to maintain intraoperative normothermia have been shown to be of great importance. Procedures to maintain stable body temperature throughout the perioperative period are presented. The choice of anesthetic technique, in regard to a regional versus general anesthetic approach, is debated widely in the literature. The type of anesthesia to be administered should be assessed on a case-by-case basis, with special consideration given to the health status of the patient, the type of operation being conducted, and the expertise of the anesthesiologist. Specifically addressed in this article are age-related cognitive issues such as postoperative cognitive dysfunction and postoperative delirium. Strategies are suggested for avoiding these pitfalls.
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Affiliation(s)
- Relin Yang
- Jackson Memorial Hospital, Miami, Florida, USA
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203
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Cegin MB, Goktas U, Katı I, Guzel A, Binici O. Effects of Fentanyl with Levobupivacaine on Cognitive Functions and Cerebral Oxygenation. ELECTRONIC JOURNAL OF GENERAL MEDICINE 2013. [DOI: 10.29333/ejgm/82286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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204
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Evered L. Dissecting the possible influences of anesthesia and surgery on Alzheimer’s disease. Neurodegener Dis Manag 2013. [DOI: 10.2217/nmt.13.8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
SUMMARY Alzheimer’s disease (AD) is a neurodegenerative disease with late onset leading to significant morbidity and, ultimately, mortality. The prevalence of dementia in developed countries for individuals aged 65 years or over is approximately 10% currently, and the number of people with dementia is projected to increase by 350% by 2050. Older people frequently require anesthesia and surgery, such that by 2050 it is anticipated that 50% of all anesthetics will be administered to people aged 65 years or over. Anesthesia is known to be associated with neuropathological changes that mirror AD neuropathology in animal studies, and also with clinical cognitive changes known as postoperative cognitive dysfunction. This article will consider the evidence to date and whether we are able to dissect the possible influences of anesthesia and surgery. Identifying associations between postoperative cognitive dysfunction, dementia and AD is essential for developing strategies that will limit injury, and defer or prevent this disease. As a first step, preoperative cognitive assessment as part of routine perioperative management should become routine practice.
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Affiliation(s)
- Lisbeth Evered
- Centre for Anaesthesia & Cognitive Function, Department of Anaesthesia, St Vincent’s Health, PO Box 2900, 3065 Fitzroy Victoria, Australia
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205
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Abstract
It has long been observed that some patients suffer a significant cognitive impact following anesthesia and surgery. This should not be surprising when considering that not only is the target organ for general anesthetic agents the brain itself but also that the process of anesthesia is a form of deep, pharmacologically induced coma rather than “sleep.” The expectation that such a process should be fully reversible with transient neurophysiological effects contradicts our experience with repeated abuse of other central nervous system depressants such as glue, petrol, and alcohol. Of great concern is that, while approximately 10% of populations in developed countries undergo anesthesia and surgery of some form each year, the proportion of the elderly making up this group is much greater. In addition, it is the elderly who are potentially at a greater risk of cognitive impairment following such procedures because many have decreased cognitive reserve, either due to pre-existing mild cognitive impairment (MCI) or frank dementia, which may be diagnosed or unknown. The impact of anesthesia on these individuals is poorly understood, as are the implications of the emerging laboratory data that suggest an effect of anesthetic agents on the pathological processes of Alzheimer's Disease (AD) itself.
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206
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Li SY, Xia LX, Zhao YL, Yang L, Chen YL, Wang JT, Luo AL. Minocycline mitigates isoflurane-induced cognitive impairment in aged rats. Brain Res 2013; 1496:84-93. [PMID: 23270609 DOI: 10.1016/j.brainres.2012.12.025] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Revised: 12/05/2012] [Accepted: 12/06/2012] [Indexed: 11/16/2022]
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207
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Intracisternal interleukin-1 receptor antagonist prevents postoperative cognitive decline and neuroinflammatory response in aged rats. J Neurosci 2013; 32:14641-8. [PMID: 23077050 DOI: 10.1523/jneurosci.2173-12.2012] [Citation(s) in RCA: 183] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
To investigate the role of the pro-inflammatory cytokine interleukin-1β (IL-1β) in postoperative cognitive dysfunction (POCD) in aged rats, we used laparotomy to mimic human abdominal surgery in adult (3 months) and aged (24 months) F344/BN rats. We demonstrated that memory consolidation of the hippocampal-dependent contextual fear-conditioning task is significantly impaired in aged but not young rats 4 d after surgery. Hippocampal-independent auditory-cued fear memory was not disrupted by laparotomy in either age group. The hippocampal-dependent memory impairment was paralleled by elevations of IL-1β in the hippocampus of aged animals 1 and 4 d after surgery. These findings support our substantial line of previous research showing that aged animals are more vulnerable to cognitive decline after a peripheral immune challenge. In addition, we demonstrated that a single intracisternal administration of interleukin-1 receptor antagonist (IL-1RA; 112 μg) at the time of surgery was sufficient to block both the behavioral deficit and the neuroinflammatory response. Injecting the same dose of IL-1RA peripherally failed to have a protective effect. These data provide strong support for the specific role of central, not peripheral, IL-1β in POCD. Furthermore, the long-lasting presence of IL-1RA in the brain (4 d) compared with in the blood (<24 h) underscores the value of intracisternal administration of IL-1RA for therapeutic purposes.
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208
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Mézière A, Paillaud E, Plaud B. [Anesthesia in the elderly]. Presse Med 2012; 42:197-201. [PMID: 23273508 DOI: 10.1016/j.lpm.2012.07.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2012] [Accepted: 07/17/2012] [Indexed: 11/16/2022] Open
Abstract
A growing number of old or very old patients benefits from a surgical procedure. Age is an independent risk factor of postoperative mortality and postoperative complications including cognitive dysfunction. The choice of anesthetic technique does not significantly modify this risk. Preventive strategies and preoperative procedures can be implemented. A multidisciplinary management involving all care providers around the patient is essential to reduce the risk of dependence after surgery which is higher in this population. Early postoperative rehabilitation is recommended in the elderly to improve the prognosis.
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Affiliation(s)
- Anthony Mézière
- Assistance publique-Hôpitaux de Paris, groupe hospitalier et universitaire Albert-Chenevier-Henri-Mondor, université Paris-Est Créteil, département de gériatrie, 94010 Créteil, France
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209
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Clinical, methodological and theoretical issues in the assessment of cognition after anaesthesia and surgery: a review. Eur J Anaesthesiol 2012; 29:409-22. [PMID: 22828386 DOI: 10.1097/eja.0b013e328356bd6e] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
As people live longer, the burden of cognitive impairment to elderly patients, their families and society becomes increasingly common and important. The loss of independence, a reduction in the quality of life and increased mortality are possible correlates to the mental disintegration. Cognitive dysfunction following major surgery on the elderly is a significant problem which adds to other cognitive impairments caused by neurodegeneration, cerebrovascular impairments and other causes. There are challenges in reviewing the literature because of many methodological concerns. There is no standard definition; the diagnosis is made only by the results of neuropsychological tests which are not standardised for this purpose; test results are analysed by different statistical methods (some of them inappropriate); controls are often absent or poorly matched; and pre-existing mild cognitive impairment, which affects 10 to 20% of people older than 65 years and is similar to the subtle cognitive impairment following surgery, is not sought for and recognised. Reviews of the subject have varied from descriptions such as 'a well recognised and significant problem' to 'a hypothetical phenomenon for which there is no International Statistical Classification of Disease (ICD-9) code, and no Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) code'. This article examines both sides of the spectrum in a detailed review which explains the necessary psychological 'jargon', discusses the methods used and points to areas of future research.
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210
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Abstract
Postoperative cognitive dysfunction (POCD) is a severe long-term complication after surgical procedures. POCD is mainly seen among geriatric patients. Hospitalization, extent of surgery, and systemic inflammatory response might contribute to POCD. The possible influence of the type of anesthesia is discussed. POCD is often not recognized; thus, incidence rates are likely to be underestimated (19-40%). POCD is associated with major consequences for the individual patient, e.g., delayed long-term recovery, reduced quality of life, and an increased mortality rate. Multiple risk factors have been identified over the last decade. However, the exact etiology is still unknown. This mini-review summarizes the recent developments concerning POCD prevention, diagnosis, and treatment.
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211
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He HJ, Wang Y, Le Y, Duan KM, Yan XB, Liao Q, Liao Y, Tong JB, Terrando N, Ouyang W. Surgery upregulates high mobility group box-1 and disrupts the blood-brain barrier causing cognitive dysfunction in aged rats. CNS Neurosci Ther 2012; 18:994-1002. [PMID: 23078219 PMCID: PMC6493557 DOI: 10.1111/cns.12018] [Citation(s) in RCA: 144] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Revised: 09/16/2012] [Accepted: 09/17/2012] [Indexed: 12/19/2022] Open
Abstract
AIM Postoperative cognitive dysfunction (POCD) is a growing and largely underestimated problem without defined etiology. Herein, we sought to determine the relationship between cognitive decline, blood-brain barrier (BBB) permeability, and inflammation, namely high mobility group box-1 (HMGB1), after surgery in aged rats. METHODS Aged rats were randomly assigned as surgery group (n = 45, splenectomy under general anesthesia), anesthesia (n = 45, 2% isoflurane for 2 h), and naïve control (n = 15). Markers of inflammation were measured in plasma and brain. Blood-brain barrier ultrastructure and permeability were measured by transmission electron microscope (TEM) and IgG immunohistochemistry. Cognitive function was assessed in a reversal learning version of the Morris water maze (MWM). RESULTS Surgical trauma under general anesthesia caused distinct changes in systemic and central proinflammatory cytokines. Levels of HMGB1 and the receptor for advanced glycation end products (RAGE) were significantly upregulated in the hippocampus of operated animals. Immunohistochemistry and TEM showed BBB disruption induced by surgery and anesthesia. These molecular changes were associated with cognitive impairment in latency with the MWM up to postoperative day 3. CONCLUSIONS HMGB1 and RAGE signaling appear pivotal mediators of surgery-induced cognitive decline and may contribute to the changes in BBB permeability after peripheral surgical trauma.
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Affiliation(s)
- Hui-Juan He
- Department of Anesthesiology, The Third Xiangya Hospital of Central South University, Changsha, China
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212
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Dexmedetomidine may benefit cognitive function after laparoscopic cholecystectomy in elderly patients. Exp Ther Med 2012; 5:489-494. [PMID: 23403854 PMCID: PMC3570133 DOI: 10.3892/etm.2012.811] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2012] [Accepted: 10/24/2012] [Indexed: 01/18/2023] Open
Abstract
Laparoscopic cholecystectomy is performed with increasing frequency in aging populations. However, in elderly patients, cognitive dysfunction following surgery may impair the outcome of surgical procedures. Dexmedetomidine (DEX) has been demonstrated to have a neuroprotectve effect in animal experiments. However, it is unclear whether DEX also has a neuroprotective effect in human patients. The present study was a randomized, placebo-controlled double-blind trial of 126 patients who had undergone laparoscopic cholecystectomy, using clinical interviews to determine whether intravenously administrated DEX during general anesthesia ameliorates cognitive function impairment. The cognitive deficit of each patient was assessed using the Mini-Mental State Examination (MMSE). The scores on the MMSE for the DEX and control groups one week after surgery (DEX group, 27.6±1.2; control group, 25.7±1.5) were significantly different (P=0.005). The MMSE scores of patients ≤65 years old were significantly higher than those of patients >65 one week after surgery. The MMSE scores were significantly different between the two age groups in the control patients (≤65 years old, 28.3±1.2; >65 years old, 26.6±2.1; P=0.036), while the difference was not statistically significant in the DEX-treated patients. Eight patients in the DEX group and 15 patients in the control group had mild cognitive impairment (26≥ MMSE score ≥21) although the difference was not statistically significant. The findings of the present study support the hypothesis that DEX administration may be an effective method for ameliorating postoperative cognitive impairment in elderly patients who have undergone laparoscopic cholecystectomy. Further research is required to confirm the findings of the present study.
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213
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[Postoperative cognitive dysfunction. Possible neuronal mechanisms and practical consequences for clinical routine]. Anaesthesist 2012; 61:437-43. [PMID: 22618468 DOI: 10.1007/s00101-012-2024-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Postoperative cognitive dysfunction (POCD) presents as a long-lasting decline in cognitive function after a surgical procedure, predominantly occurring in elderly patients. The causes are most likely multifactorial with the exact mechanisms still unknown. Hypotheses of the causes of POCD are based on experimental evidence that anesthetics can impair mechanisms of learning and memory on a neuronal level and might lead to neurodegeneration. Additionally, surgery can result in neuroinflammation which could also underlie POCD. The most important strategy to avoid POCD is to maintain the patient's physiological homeostasis perioperatively. According to the presently available clinical studies recommendations in favor or against certain anesthesiological procedures cannot be given.
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214
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FIDALGO AR, CIBELLI M, WHITE JPM, NAGY I, WAN Y, MA D. Isoflurane causes neocortical but not hippocampal-dependent memory impairment in mice. Acta Anaesthesiol Scand 2012; 56:1052-7. [PMID: 22471713 DOI: 10.1111/j.1399-6576.2012.02691.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2012] [Indexed: 01/08/2023]
Abstract
BACKGROUND The aim of this study is to investigate the effect of general anaesthesia induced by isoflurane with buprenorphine on hippocampus-dependent and neocortex-dependent memory, respectively, in mice, and in addition, to compare the effects of such anaesthesia on these memory processes with the effects induced by lipopolysaccharide (LPS) administration on the same memory processes. METHODS To assess hippocampus-dependent memory, isoflurane (for 15 min) after buprenorphine injection, or LPS 100 μg/kg (intraperitoneally) was administered 24 h before or after fear conditioning. The effect of these treatments on hippocampus-dependent memory was assessed using contextual fear-conditioning tasks at day 4. To assess neocortex-dependent memory, isoflurane anaesthesia or LPS was given 72 h after contextual fear conditioning. Neocortex-dependent memory assessment was performed at day 32. RESULTS Unlike LPS injection, isoflurane with buprenorphine-induced anaesthesia does not impair freezing responses in hippocampus-dependent fear-conditioning memory tasks. On anterograde amnesia assessment: 49.67 ± 6.87% for the anaesthesia group and 54.5 ± 4.12% for the control group. On retrograde amnesia assessment: 47.16 ± 8.71% for the anaesthesia group and 54.5 ± 4.12% for control group; P > 0.05. Thus, neither isoflurane nor buprenorphine impair hippocampus-dependent memory. However, on the neocortex-dependent memory task, both isoflurane-induced anaesthesia and LPS-induced inflammation result in reduced freezing responses: 62.13 ± 5.80% for the anaesthesia group, 74.63 ± 5.69% for the LPS group, and 81.75 ± 3.26% for the control group; P < 0.05 compared with control group. CONCLUSION General anaesthesia induced by isoflurane with buprenorphine may result in impairment of neocortex-dependent memory in mouse. However, general anaesthesia so induced does not impair hippocampus-dependent memory in mouse in our experimental conditions.
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Affiliation(s)
- A. R. FIDALGO
- Pain Medicine and Intensive Care Section, Department of Surgery and Cancer; Chelsea and Westminster Hospital, Imperial College School of Medicine; London; UK
| | | | - J. P. M. WHITE
- Pain Medicine and Intensive Care Section, Department of Surgery and Cancer; Chelsea and Westminster Hospital, Imperial College School of Medicine; London; UK
| | - I. NAGY
- Pain Medicine and Intensive Care Section, Department of Surgery and Cancer; Chelsea and Westminster Hospital, Imperial College School of Medicine; London; UK
| | - Y. WAN
- Department of Anesthesiology; Gongli Hospital; Shanghai; China
| | - D. MA
- Pain Medicine and Intensive Care Section, Department of Surgery and Cancer; Chelsea and Westminster Hospital, Imperial College School of Medicine; London; UK
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215
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Voigt Hansen M, Simon Rasmussen L, Jespersgaard C, Rosenberg J, Gogenur I. There Is No Association Between the Circadian Clock Gene HPER3 and Cognitive Dysfunction After Noncardiac Surgery. Anesth Analg 2012; 115:379-85. [DOI: 10.1213/ane.0b013e318253d6b3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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216
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Ballard C, Jones E, Gauge N, Aarsland D, Nilsen OB, Saxby BK, Lowery D, Corbett A, Wesnes K, Katsaiti E, Arden J, Amoako D, Prophet N, Purushothaman B, Green D. Optimised anaesthesia to reduce post operative cognitive decline (POCD) in older patients undergoing elective surgery, a randomised controlled trial. PLoS One 2012; 7:e37410. [PMID: 22719840 PMCID: PMC3376123 DOI: 10.1371/journal.pone.0037410] [Citation(s) in RCA: 156] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2012] [Accepted: 04/18/2012] [Indexed: 11/19/2022] Open
Abstract
Background The study determined the one year incidence of post operative cognitive decline (POCD) and evaluated the effectiveness of an intra-operative anaesthetic intervention in reducing post-operative cognitive impairment in older adults (over 60 years of age) undergoing elective orthopaedic or abdominal surgery. Methods and Trial Design The design was a prospective cohort study with a nested randomised, controlled intervention trial, using intra-operative BiSpectral index and cerebral oxygen saturation monitoring to enable optimisation of anaesthesia depth and cerebral oxygen saturation in older adults undergoing surgery. Results In the 52 week prospective cohort study (192 surgical patients and 138 controls), mild (χ2 = 17.9 p<0.0001), moderate (χ2 = 7.8 p = 0.005) and severe (χ2 = 5.1 p = 0.02) POCD were all significantly higher after 52 weeks in the surgical patients than among the age matched controls. In the nested RCT, 81 patients were randomized, 73 contributing to the data analysis (34 intervention, 39 control). In the intervention group mild POCD was significantly reduced at 1, 12 and 52 weeks (Fisher’s Exact Test p = 0.018, χ2 = 5.1 p = 0.02 and χ2 = 5.9 p = 0.015), and moderate POCD was reduced at 1 and 52 weeks (χ2 = 4.4 p = 0·037 and χ2 = 5.4 p = 0.02). In addition there was significant improvement in reaction time at all time-points (Vigilance Reaction Time MWU Z = −2.1 p = 0.03, MWU Z = −2.7 p = 0.004, MWU Z = −3.0 p = 0.005), in MMSE at one and 52 weeks (MWU Z = −2.9 p = 0.003, MWU Z = −3.3 p = 0.001), and in executive function at 12 and 52 weeks (Trail Making MWU Z = −2.4 p = .0.018, MWU Z = −2.4 p = 0.019). Conclusion POCD is common and persistent in older adults following surgery. The results of the nested RCT indicate the potential benefits of intra-operative monitoring of anaesthetic depth and cerebral oxygenation as a pragmatic intervention to reduce post-operative cognitive impairment. Trial Registration Controlled-Trials.com ISRCTN39503939
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Affiliation(s)
- Clive Ballard
- Wolfson Centre for Age-Related Diseases, King's College London, London, United Kingdom.
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Grape S, Ravussin P, Rossi A, Kern C, Steiner L. Postoperative cognitive dysfunction. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2012. [DOI: 10.1016/j.tacc.2012.02.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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218
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van Amsterdam JG, van Laar M, Brunt TM, van den Brink W. Risk assessment of gamma-hydroxybutyric acid (GHB) in the Netherlands. Regul Toxicol Pharmacol 2012; 63:55-63. [DOI: 10.1016/j.yrtph.2012.03.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2012] [Revised: 02/22/2012] [Accepted: 03/07/2012] [Indexed: 11/26/2022]
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219
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Post-operative cognitive dysfunction – Lessons from the ISPOCD studies. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2012. [DOI: 10.1016/j.tacc.2012.02.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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220
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Kjølhede P, Borendal Wodlin N, Nilsson L, Fredrikson M, Wijma K. Impact of stress coping capacity on recovery from abdominal hysterectomy in a fast-track programme: a prospective longitudinal study. BJOG 2012; 119:998-1006; discussion 1006-7. [DOI: 10.1111/j.1471-0528.2012.03342.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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221
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The possibility of postoperative cognitive dysfunction in obstetric anaesthesia following caesarean section. Eur J Anaesthesiol 2012; 29:61-3. [PMID: 22237254 DOI: 10.1097/eja.0b013e32834d86bf] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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222
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Radtke FM, Franck M, Herbig TS, Papkalla N, Kleinwaechter R, Kork F, Brockhaus WR, Wernecke KD, Spies CD. Incidence and Risk Factors for Cognitive Dysfunction in Patients with Severe Systemic Disease. J Int Med Res 2012; 40:612-20. [DOI: 10.1177/147323001204000223] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE: To determine the relevance of surgery and other causative factors to the incidence of postoperative cognitive dysfunction (POCD) in patients with severe systemic disease. METHODS: This observational study included 107 noncardiac surgical patients and 26 nonsurgical control subjects, all of whom had an American Society of Anesthesiologists physical classification status of 3. Cognitive assessment was performed preoperatively and 7 days postoperatively, or with a 7-day interval for the control group. POCD was calculated as a combined Z-score. Mini Mental State Examination (MMSE) was used to exclude patients with pre-existing cognitive deficit (MMSE score ≥ 23). Surgical and other factors including duration of surgery/anaesthesia and length of stay in the intensive care unit (ICU) were recorded. RESULTS: After 7 days, POCD was found in 40/107 (37.4%) surgical patients compared with 4/26 (15.4%) nonsurgical controls. Preoperative MMSE score, duration of surgery/anaesthesia, and length of stay in the ICU and hospital were associated with POCD. Logistic regression analysis revealed that preoperative MMSE score was an independent predictor of POCD. CONCLUSION: Lower baseline MMSE score was the only independent predictor for POCD in patients with severe systemic disease.
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Affiliation(s)
- FM Radtke
- Department of Anaesthesia and Surgical Intensive Care, Charité – University of Medicine Berlin, Berlin, Germany
| | - M Franck
- Department of Anaesthesia and Surgical Intensive Care, Charité – University of Medicine Berlin, Berlin, Germany
| | - TS Herbig
- Department of Anaesthesia and Surgical Intensive Care, Charité – University of Medicine Berlin, Berlin, Germany
| | - N Papkalla
- Department of Anaesthesia and Surgical Intensive Care, Charité – University of Medicine Berlin, Berlin, Germany
| | - R Kleinwaechter
- Department of Anaesthesia and Surgical Intensive Care, Charité – University of Medicine Berlin, Berlin, Germany
| | - F Kork
- Department of Anaesthesia and Surgical Intensive Care, Charité – University of Medicine Berlin, Berlin, Germany
| | - WR Brockhaus
- Department of Anaesthesia and Surgical Intensive Care, Charité – University of Medicine Berlin, Berlin, Germany
| | - K-D Wernecke
- Department of Anaesthesia and Surgical Intensive Care, Charité – University of Medicine Berlin, Berlin, Germany
- SoStAna GmbH, Berlin, Germany
| | - CD Spies
- Department of Anaesthesia and Surgical Intensive Care, Charité – University of Medicine Berlin, Berlin, Germany
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White PF, White LM, Monk T, Jakobsson J, Raeder J, Mulroy MF, Bertini L, Torri G, Solca M, Pittoni G, Bettelli G. Perioperative care for the older outpatient undergoing ambulatory surgery. Anesth Analg 2012; 114:1190-215. [PMID: 22467899 DOI: 10.1213/ane.0b013e31824f19b8] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
As the number of ambulatory surgery procedures continues to grow in an aging global society, the implementation of evidence-based perioperative care programs for the elderly will assume increased importance. Given the recent advances in anesthesia, surgery, and monitoring technology, the ambulatory setting offers potential advantages for elderly patients undergoing elective surgery. In this review article we summarize the physiologic and pharmacologic effects of aging and their influence on anesthetic drugs, the important considerations in the preoperative evaluation of elderly outpatients with coexisting diseases, the advantages and disadvantages of different anesthetic techniques on a procedural-specific basis, and offer recommendations regarding the management of common postoperative side effects (including delirium and cognitive dysfunction, fatigue, dizziness, pain, and gastrointestinal dysfunction) after ambulatory surgery. We conclude with a discussion of future challenges related to the growth of ambulatory surgery practice in this segment of our surgical population. When information specifically for the elderly population was not available in the peer-reviewed literature, we drew from relevant information in other ambulatory surgery populations.
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Affiliation(s)
- Paul F White
- Department of Anesthesia, Cedars-Sinai Medical Center, Los Angeles, California, USA.
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224
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Mracek J, Holeckova I, Chytra I, Mork J, Stepanek D, Vesela P. The impact of general versus local anesthesia on early subclinical cognitive function following carotid endarterectomy evaluated using P3 event-related potentials. Acta Neurochir (Wien) 2012; 154:433-8. [PMID: 22245975 DOI: 10.1007/s00701-011-1270-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2011] [Accepted: 12/29/2011] [Indexed: 11/28/2022]
Abstract
BACKGROUND Postoperative cognitive dysfunction (POCD) is detected in 25% of patients undergoing carotid endarterectomy (CEA). The mechanism of POCD is poorly understood, but it is believed that general anesthesia (GA) itself may contribute significantly to POCD. The aim of our prospective study was to compare, with the aid of event-related potentials, the impact of general anesthesia (GA) and local anesthesia (LA) on POCD in patients undergoing CEA. METHODS Sixty patients were included in this study and were divided into two groups: CEA was performed in 30 patients placed under GA (total intravenous anesthesia), herein the GA group, while 30 patients underwent CEA under LA (cervical plexus block), herein LA group. Cognitive outcome was assessed with the use of auditory event-related potentials (ERPs), P3 response. The measurements were taken before surgery (pre-op) and on the first (1.post-op) and the sixth postoperative days (6.post-op). RESULTS Preoperative cognitive functions did not differ significantly between the two groups. A significant decrease in P3 amplitude was found on the first postoperative day (1.post-op) in the GA group (p = 0.0005), but normalization of P3 amplitude was detected at the second postoperative measurement (6.post-op). The patients operated on under local anesthesia (LA group) showed stable P3 amplitudes in all three measurements. No significant changes in P3 latencies were observed in either group. There were no significant differences between the two groups regarding demographic characteristics, preoperative and postoperative clinical condition, percentage significance of carotid artery stenosis, duration of carotid cross-clamping or in the frequency of shunt use (zero frequency for both groups). CONCLUSIONS Our study showed that general anesthesia, used for patients undergoing CEA, negatively influenced cognitive function during the immediate period after surgery (the first postoperative day). However, by the sixth postoperative day, this cognitive impairment was no longer being detected. POCD occurring shortly after carotid endarterectomy is the result of general anesthesia, which is probably an independent evoking factor in itself. The cognitive deficit recorded only during the immediate postoperative period, is not a negative effect of GA but merely a side-effect and thus GA should not be considered inferior to LA for use during CEA.
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Affiliation(s)
- Jan Mracek
- Department of Neurosurgery, University Hospital and Faculty of Medicine in Pilsen, Charles University, Alej Svobody 80, Pilsen, Czech Republic.
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225
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van Harten AE, Scheeren TWL, Absalom AR. A review of postoperative cognitive dysfunction and neuroinflammation associated with cardiac surgery and anaesthesia. Anaesthesia 2012; 67:280-93. [DOI: 10.1111/j.1365-2044.2011.07008.x] [Citation(s) in RCA: 188] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Abstract
Postoperative cognitive dysfunction (POCD) refers to a postoperative decline in cognitive function compared with preoperative cognitive function. Diagnosis requires pre- and postoperative testing, the latter of which is usually performed both 7 days and 3 months postoperatively. Although several risk factors for POCD have been described, age is the only consistently reported risk factor. Postoperative cognitive dysfunction is often transient. It may last several months, and is associated with leaving the labor market prematurely and increased mortality. As the pathophysiology of POCD is still a matter of debate and is likely to be multifactorial, there are no widely accepted prophylactic and therapeutic interventions. In this article, we discuss POCD's definition, risk factors, long-term significance, and pathophysiology. We also present data on prophylactic interventions that have been investigated in clinical trials.
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Affiliation(s)
- Christoph S Burkhart
- Department of Anesthesia and Intensive Care Medicine, University Hospital Basel, Basel, Switzerland.
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227
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Seitz DP, Shah PS, Herrmann N, Beyene J, Siddiqui N. Exposure to general anesthesia and risk of Alzheimer's disease: a systematic review and meta-analysis. BMC Geriatr 2011; 11:83. [PMID: 22168260 PMCID: PMC3258207 DOI: 10.1186/1471-2318-11-83] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2011] [Accepted: 12/14/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Alzheimer's disease (AD) is common among older adults and leads to significant disability. Volatile anesthetic gases administered during general anesthesia (GA) have been hypothesized to be a risk factor for the development of AD. The objective of this study is to systematically review the association between exposure to GA and risk of AD. METHODS We searched electronic databases including MEDLINE, Embase, and Google scholar for observational studies examining the association between exposure to GA and risk of AD. We examined study quality using a modified version of the Newcastle-Ottawa risk of bias assessment for observational studies. We used standard meta-analytic techniques to estimate pooled odds ratios (OR) and 95% confidence intervals (CI). Subgroup and sensitivity analyses were undertaken to evaluate the robustness of the findings. RESULTS A total of 15 case-control studies were included in the review. No cohort studies were identified that met inclusion criteria. There was variation in the methodological quality of included studies. There was no significant association between any exposure to GA and risk of AD (pooled OR: 1.05; 95% CI: 0.93 - 1.19, Z = 0.80, p = 0.43). There was also no significant association between GA and risk of AD in several subgroup and sensitivity analyses. CONCLUSIONS A history of exposure to GA is not associated with an increased risk of AD although there are few high-quality studies in this area. Prospective cohort studies with long-term follow-up or randomized controlled trials are required to further understand the association between GA and AD.
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Affiliation(s)
- Dallas P Seitz
- Department of Psychiatry, Queen's University, Kingston, Ontario, Canada.
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228
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Su D, Zhao Y, Wang B, Xu H, Li W, Chen J, Wang X. Isoflurane-induced spatial memory impairment in mice is prevented by the acetylcholinesterase inhibitor donepezil. PLoS One 2011; 6:e27632. [PMID: 22114680 PMCID: PMC3219671 DOI: 10.1371/journal.pone.0027632] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2011] [Accepted: 10/20/2011] [Indexed: 11/30/2022] Open
Abstract
Although many studies have shown that isoflurane exposure impairs spatial memory in aged animals, there are no clinical treatments available to prevent this memory deficit. The anticholinergic properties of volatile anesthetics are a biologically plausible cause of cognitive dysfunction in elderly subjects. We hypothesized that pretreatment with the acetylcholinesterase inhibitor donepezil, which has been approved by the Food and Drug Administration (FDA) for the treatment of Alzheimer's disease, prevents isoflurane-induced spatial memory impairment in aged mice. In present study, eighteen-month-old mice were administered donepezil (5 mg/kg) or an equal volume of saline by oral gavage with a feeding needle for four weeks. Then the mice were exposed to isoflurane (1.2%) for six hours. Two weeks later, mice were subjected to the Morris water maze to examine the impairment of spatial memory after exposure to isoflurane. After the behavioral test, the mice were sacrificed, and the protein expression level of acetylcholinesterase (AChE), choline acetylase (ChAT) and α7 nicotinic receptor (α7-nAChR) were measured in the brain. Each group consisted of 12 mice. We found that isoflurane exposure for six hours impaired the spatial memory of the mice. Compared with the control group, isoflurane exposure dramatically decreased the protein level of ChAT, but not AChE or α7-nAChR. Donepezil prevented isoflurane-induced spatial memory impairments and increased ChAT levels, which were downregulated by isoflurane. In conclusions, pretreatment with the AChE inhibitor donepezil prevented isoflurane-induced spatial memory impairment in aged mice. The mechanism was associated with the upregulation of ChAT, which was decreased by isoflurane.
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Affiliation(s)
- Diansan Su
- Department of Anesthesiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
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229
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Zhang B, Tian M, Zhen Y, Yue Y, Sherman J, Zheng H, Li S, Tanzi RE, Marcantonio ER, Xie Z. The effects of isoflurane and desflurane on cognitive function in humans. Anesth Analg 2011; 114:410-5. [PMID: 22075020 DOI: 10.1213/ane.0b013e31823b2602] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The etiology of postoperative cognitive decline (POCD) remains to be determined. Anesthetic isoflurane, but not desflurane, may induce neurotoxicity. However, the functional consequences of these effects have not been assessed. We therefore performed a pilot study to determine the effects of isoflurane and desflurane on cognitive function in humans. METHODS The subjects included patients who had lower extremity or abdominal surgery under spinal anesthesia alone (S, n = 15), spinal plus desflurane anesthesia (SD, n = 15), or spinal plus isoflurane anesthesia (SI, n = 15) by randomization. Each of the subjects received cognitive tests immediately before and 1 week after anesthesia and surgery administered by an investigator who was blinded to the anesthesia regimen. POCD was defined using the scores from each of these tests. RESULTS We studied 45 subjects, 24 males and 21 females. The mean age of the subjects was 69.0 ± 1.9 years. There was no significant difference in age and other characteristics among the treatment arms. The mean number of cognitive function declines in the S, SD, and SI groups was 1.13, 1.07, and 1.40, respectively. POCD incidence after SI (27%), but not SD (0%), anesthesia was higher than that after S (0%), P = 0.028 (3-way comparison). CONCLUSION These findings from our pilot study suggest that isoflurane and desflurane may have different effects on postoperative cognitive function, and additional studies with a larger sample size and longer times of follow-up testing are needed.
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Affiliation(s)
- Bin Zhang
- Department of Anesthesia, Capital Medical University, Beijing, People's Republic of China
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230
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Guay J. General anaesthesia does not contribute to long-term post-operative cognitive dysfunction in adults: A meta-analysis. Indian J Anaesth 2011; 55:358-63. [PMID: 22013251 PMCID: PMC3190509 DOI: 10.4103/0019-5049.84850] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
CONTEXT The contribution of anaesthesia itself to post-operative cognitive dysfunction (POCD) or the potential protective effect of one specific type of anaesthesia on the occurrence of POCD is unclear. AIMS This is a meta-analysis evaluating the effects of the anaesthetic technique (regional vs. general anaesthesia) on POCD of patients undergoing non-cardiac surgery. SETTINGS AND DESIGN Meta-analysis performed in a University affiliated hospital. METHODS A search for randomized controlled trials (RCT) comparing regional anaesthesia to general anaesthesia for surgery was done in PUBMED, MEDLINE, EMBASE, EBM Reviews-Cochrane Central Register of Controlled Trials, PsychINFO and Current Contents/all editions in 2009. STATISTICAL ANALYSIS Data were analyzed with comprehensive Meta-analysis Version 2.2.044. RESULTS Twenty-six RCTs including 2365 patients: 1169 for regional anaesthesia and 1196 for general anaesthesia were retained. The standardized difference in means for the tests included in the 26 RCTs was -0.08 (95% confidence interval: -0.17-0.01; P value 0.094; I-squared = 0.00%). The assessor was blinded to the anaesthetic technique for 12 of the RCTs including only 798 patients: 393 for regional anaesthesia and 405 for general anaesthesia. The standardized difference in means for these 12 studies is 0.05 (-0.10-0.20; P=0.51; I-squared = 0.00%). CONCLUSIONS The present meta-analysis does not support the concerns that a single exposure to general anaesthesia in an adult would significantly contribute to permanent POCD after non-cardiac surgery.
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Affiliation(s)
- Joanne Guay
- Department of Anesthesiology, University of Montreal, Montreal, Quebec, Canada
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Abstract
PURPOSE OF REVIEW The elderly are the fastest growing segment of the population and undergo 25-30% of all surgical procedures. Postoperative cognitive problems are common in older patients following major surgery. The socioeconomic implications of these cognitive disorders are profound; cognitive decline is associated with a loss of independence, a reduction in the quality of life, and death. This review will focus on the two most common cognitive problems following surgery: postoperative delirium and postoperative cognitive dysfunction (POCD). RECENT FINDINGS For years, preoperative geriatric consultation/screening was the only intervention proven to decrease postoperative delirium. There are, however, several recent publications indicating that preoperative and postoperative pharmacological and medical (hydration, oxygenation) management can reduce postoperative delirium. Spinal anesthesia with minimal propofol sedation has been shown to decrease the incidence of postoperative delirium in hip-fracture patients. Likewise, dexmedetomidine sedation in mechanically ventilated patients in the ICU is associated with less postoperative delirium and shorter ventilator times. Preoperative levels of education and brain function (cognitive reserve) may predict patients at risk for postoperative cognitive problems. Reduced white matter integrity is reported to place patients at a higher risk for both postoperative delirium and POCD. SUMMARY The etiology of postoperative cognitive problems is unknown, but there is emerging evidence that decreased preoperative cognitive function contributes to the development of postoperative delirium and POCD. There is growing concern that inhalation anesthetics may be neurotoxic to the aging brain, but there are no human data evaluating this hypothesis to date. Randomized controlled trials evaluating interventions to improve long-term cognitive outcomes in elderly patients are urgently needed.
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232
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Vizcaychipi MP, Lloyd DG, Wan Y, Palazzo MG, Maze M, Ma D. Xenon pretreatment may prevent early memory decline after isoflurane anesthesia and surgery in mice. PLoS One 2011; 6:e26394. [PMID: 22073162 PMCID: PMC3207823 DOI: 10.1371/journal.pone.0026394] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2011] [Accepted: 09/26/2011] [Indexed: 11/19/2022] Open
Abstract
Postoperative cognitive decline (POCD) is a common complication following surgery, but its aetiology remains unclear. We hypothesized that xenon pretreatment prevents POCD by suppressing the systemic inflammatory response or through an associated protective signaling pathway involving heat shock protein 72 (Hsp72) and PI3-kinase. Twenty-four hours after establishing long-term memory using fear conditioning training, C57BL/6 adult male mice (n = 12/group) received one of the following treatments: 1) no treatment group (control); 2) 1.8% isoflurane anesthesia; 3) 70% xenon anesthesia; 4) 1.8% isoflurane anesthesia with surgery of the right hind leg tibia that was pinned and fractured; or 5) pretreatment with 70% xenon for 20 minutes followed immediately by 1.8% isoflurane anesthesia with the surgery described above. Assessments of hippocampal-dependent memory were performed on days 1 and 7 after treatment. Hsp72 and PI3-kinase in hippocampus, and plasma IL-1β, were measured using western blotting and ELISA respectively, from different cohorts on day 1 after surgery. Isoflurane induced memory deficit after surgery was attenuated by xenon pretreatment. Xenon pretreatment prevented the memory deficit typically seen on day 1 (P = 0.04) but not on day 7 (P = 0.69) after surgery under isoflurane anesthesia, when compared with animals that underwent surgery without pretreatment. Xenon pretreatment modulated the expression of Hsp72 (P = 0.054) but had no significant effect on PI3-kinase (P = 0.54), when compared to control. Xenon pretreatment also reduced the plasma level increase of IL-1β induced by surgery (P = 0.028). Our data indicated that surgery and/or Isoflurane induced memory deficit was attenuated by xenon pretreatment. This was associated with a reduction in the plasma level of IL-1β and an upregulation of Hsp72 in the hippocampus.
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Affiliation(s)
- Marcela P. Vizcaychipi
- Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Imperial College London, Chelsea and Westminster Hospital, London, United Kingdom
| | - Dafydd G. Lloyd
- Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Imperial College London, Chelsea and Westminster Hospital, London, United Kingdom
| | - Yanjie Wan
- Department of Anesthesiology, Gongli Hospital, Shanghai, China
| | - Mark G. Palazzo
- Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Imperial College London, Chelsea and Westminster Hospital, London, United Kingdom
| | - Mervyn Maze
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, United States of America
| | - Daqing Ma
- Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Imperial College London, Chelsea and Westminster Hospital, London, United Kingdom
- * E-mail:
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233
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Ferré F, Minville V. [Preoperative management to reduce morbidity and mortality of hip fracture]. ACTA ACUST UNITED AC 2011; 30:e45-8. [PMID: 21945704 DOI: 10.1016/j.annfar.2011.08.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Hip femur is extremely common in the elderly and is one of the most common reasons for admission in trauma care. The main reported causes of death after hip fracture were cardiovascular (29%), neurological (20%) and pulmonary. Large epidemiological studies have shown a relatively small decrease in mortality for 20 years despite an active approach to medical and surgical management. Yet 57% of deaths occurring within 30 days post-surgery are preventable because they are not related to a pre-existing disease. Preoperative management to optimize these patients could help to reduce morbidity and mortality and is thus a crucial issue. The anesthesia consultation is used to evaluate the perioperative risk, treat pain, manage treatment and stabilize the patient. An operative delay of more than 48hours after admission increases mortality. This period should not be prolonged by unnecessary investigations that will not change the perioperative management. The preoperative period is a key moment because it allows to choose the anesthetic technique. Even if this choice is controversial, continuous spinal anesthesia (titrated) do not modify the cardiovascular and neurological physiological balance of these precarious patients.
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Affiliation(s)
- F Ferré
- Département D'anesthésie et de Réanimation, Faculté de Médecine Toulouse-Rangueil, Université Toulouse III Paul-Sabatier, CHU de Toulouse, Institut Louis-Bugnard (IFR 150), 31000 Toulouse, France
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234
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[Postoperative cognitive dysfunction (POCD): strategy of prevention, assessment and management]. ACTA ACUST UNITED AC 2011; 30:e49-53. [PMID: 21945705 DOI: 10.1016/j.annfar.2011.08.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The femoral neck fracture is a major cause of morbidity and mortality in the elderly. The etiology of cognitive impairment observed in this population of aged patient seems to be multifactorial. In the strategy of prevention, elderly patient must have the clearer information dealing with the postoperative cognitive dysfunction. This would reduce the incidence of POCD and some cognitive complaints, which often reflect the anxiety of the elderly patient facing the possibility of cognitive impairment. During the anaesthesia consultation, it seems important to assess the cognitive function of this elderly patient (like using neuropsycholgical scale as the MMSE) and to identify associated risk factors of cognitive dysfunction. The management of cognitive disorders should be multidisciplinary, the anesthesiologist being the main referent, in collaboration with the geriatrician and the surgeon. In the clinical setting of femoral neck fracture in the elderly, this multimodal management (pain, nutrition, functional rehabilitation to make these patients autonomous as quickly as possible), seems to improve the functional prognosis and to have the observed POCD decreased.
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235
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Cognitive decline in the elderly: Is anaesthesia implicated? Best Pract Res Clin Anaesthesiol 2011; 25:379-93. [DOI: 10.1016/j.bpa.2011.05.001] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2011] [Accepted: 05/11/2011] [Indexed: 11/19/2022]
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Terrando N, Brzezinski M, Degos V, Eriksson LI, Kramer JH, Leung JM, Miller BL, Seeley WW, Vacas S, Weiner MW, Yaffe K, Young WL, Xie Z, Maze M. Perioperative cognitive decline in the aging population. Mayo Clin Proc 2011; 86:885-93. [PMID: 21878601 PMCID: PMC3257991 DOI: 10.4065/mcp.2011.0332] [Citation(s) in RCA: 124] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Elderly patients who have an acute illness or who undergo surgery often experience cognitive decline. The pathophysiologic mechanisms that cause neurodegeneration resulting in cognitive decline, including protein deposition and neuroinflammation, also play a role in animal models of surgery-induced cognitive decline. With the aging of the population, surgical candidates of advanced age with underlying neurodegeneration are encountered more often, raising concerns that, in patients with this combination, cognitive function will precipitously decline postoperatively. This special article is based on a symposium that the University of California, San Francisco, convened to explore the contributions of surgery and anesthesia to the development of cognitive decline in the aged patient. A road map to further elucidate the mechanisms, diagnosis, risk factors, mitigation, and treatment of postoperative cognitive decline in the elderly is provided.
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Affiliation(s)
- Niccolò Terrando
- Department of Anesthesia and Perioperative Care, San Francisco, CA 94143-0648, USA
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Mandal S, Basu M, Kirtania J, Sarbapalli D, Pal R, Kar S, Kundu KK, Sarkar U, Gupta SD. Impact of general versus epidural anesthesia on early post-operative cognitive dysfunction following hip and knee surgery. J Emerg Trauma Shock 2011; 4:23-8. [PMID: 21633563 PMCID: PMC3097574 DOI: 10.4103/0974-2700.76829] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2009] [Accepted: 09/02/2010] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Post-operative cognitive dysfunction is the subtle cerebral complication temporally seen following surgery. The aim of this study was to compare the influence of either general anesthesia (GA) or epidural anesthesia (EA) on the early post-operative neurocognitive outcome in elderly (>59 years) subjects undergoing hip and knee surgery. METHODS A total of 60 patients were recruited in a prospective, randomized, parallel-group study, comparable by age and sex. They were enrolled and randomized to receive either EA (n = 30) or GA (n = 30). All of them were screened using the Mini Mental State Examination (MMSE), with components of the Kolkata Cognitive Screening Battery. The operated patients were re-evaluated 1 week after surgery using the same scale. The data collected were analyzed to assess statistical significance. RESULTS We observed no statistical difference in cognitive behavior in either group pre-operatively, which were comparable with respect to age, sex and type of surgery. Grossly, a significant difference was seen between the two groups with respect to the perioperative changes in verbal fluency for categories and MMSE scores. However, these differences were not significant after the application of the Bonferroni correction for multiple analyses, except the significant differences observed only in the MMSE scores. CONCLUSIONS We observed a difference in cognitive outcome with GA compared with EA. Certain aspects of the cognition were affected to a greater extent in this group of patients undergoing hip and knee surgery.
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Ramaiah R. What's new in Emergencies, Trauma and Shock? Anesthesia, surgery and postoperative cognition. J Emerg Trauma Shock 2011; 4:1-2. [PMID: 21633558 PMCID: PMC3097556 DOI: 10.4103/0974-2700.76816] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Ramesh Ramaiah
- Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Box 359724, 325 Ninth Avenue, Seattle, WA 98104-8009
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Bilotta F, Doronzio A, Stazi E, Titi L, Zeppa IO, Cianchi A, Rosa G, Paoloni FP, Bergese S, Asouhidou I, Ioannou P, Abramowicz AE, Spinelli A, Delphin E, Ayrian E, Zelman V, Lumb P. Early postoperative cognitive dysfunction and postoperative delirium after anaesthesia with various hypnotics: study protocol for a randomised controlled trial--the PINOCCHIO trial. Trials 2011; 12:170. [PMID: 21733178 PMCID: PMC3155116 DOI: 10.1186/1745-6215-12-170] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2010] [Accepted: 07/06/2011] [Indexed: 11/28/2022] Open
Abstract
Background Postoperative delirium can result in increased postoperative morbidity and mortality, major demand for postoperative care and higher hospital costs. Hypnotics serve to induce and maintain anaesthesia and to abolish patients' consciousness. Their persisting clinical action can delay postoperative cognitive recovery and favour postoperative delirium. Some evidence suggests that these unwanted effects vary according to each hypnotic's specific pharmacodynamic and pharmacokinetic characteristics and its interaction with the individual patient. We designed this study to evaluate postoperative delirium rate after general anaesthesia with various hypnotics in patients undergoing surgical procedures other than cardiac or brain surgery. We also aimed to test whether delayed postoperative cognitive recovery increases the risk of postoperative delirium. Methods/Design After local ethics committee approval, enrolled patients will be randomly assigned to one of three treatment groups. In all patients anaesthesia will be induced with propofol and fentanyl, and maintained with the anaesthetics desflurane, or sevoflurane, or propofol and the analgesic opioid fentanyl. The onset of postoperative delirium will be monitored with the Nursing Delirium Scale every three hours up to 72 hours post anaesthesia. Cognitive function will be evaluated with two cognitive test batteries (the Short Memory Orientation Memory Concentration Test and the Rancho Los Amigos Scale) preoperatively, at baseline, and postoperatively at 20, 40 and 60 min after extubation. Statistical analysis will investigate differences in the hypnotics used to maintain anaesthesia and the odds ratios for postoperative delirium, the relation of early postoperative cognitive recovery and postoperative delirium rate. A subgroup analysis will be used to categorize patients according to demographic variables relevant to the risk of postoperative delirium (age, sex, body weight) and to the preoperative score index for delirium. Discussion The results of this comparative anaesthesiological trial should whether each the three hypnotics tested is related to a significantly different postoperative delirium rate. This information could ultimately allow us to select the most appropriate hypnotic to maintain anaesthesia for specific subgroups of patients and especially for those at high risk of postoperative delirium. Registered at Trial.gov Number ClinicalTrials.gov: NCT00507195
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Affiliation(s)
- Federico Bilotta
- Department of Anaesthesiology, Critical Care and Pain Medicine, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy.
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Fidalgo AR, Cibelli M, White JPM, Nagy I, Noormohamed F, Benzonana L, Maze M, Ma D. Peripheral orthopaedic surgery down-regulates hippocampal brain-derived neurotrophic factor and impairs remote memory in mouse. Neuroscience 2011; 190:194-9. [PMID: 21699962 DOI: 10.1016/j.neuroscience.2011.05.073] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Revised: 05/25/2011] [Accepted: 05/30/2011] [Indexed: 12/22/2022]
Abstract
Peripheral orthopaedic surgery induces a profound inflammatory response. This includes a substantial increase in cytokines and, especially, in the level of interleukin (IL)-1β in the hippocampus, which has been shown to impair hippocampal-dependent memory in mice. We have employed two tests of contextual remote memory to demonstrate that the inflammatory response to surgical insult in mice also results in impairment of remote memory associated with prefrontal cortex (PFC). We have also found that, under the conditions presented in the social interaction test, peripheral orthopaedic surgery does not increase anxiety-like behaviour in our animal model. Although such surgery induces an increase in the level of IL-1β in the hippocampus, it fails to do so in the PFC. Peripheral orthopaedic surgery also results in a reduction in the level of hippocampal brain-derived neurotrophic factor (BDNF) and this may contribute, in part, to the memory impairment found after such surgery. Our data suggest that a reduction in the level of hippocampal BDNF and an increase in the level of hippocampal IL-1β following surgery may affect the transference of fear memory in the mouse brain.
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Affiliation(s)
- A R Fidalgo
- Anaesthesia, Pain Medicine and Intensive Care Section, Department of Surgery and Cancer, Chelsea and Westminster Hospital, Imperial College School of Medicine, 369 Fulham Road, London SW10 9NH, UK
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241
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Heat shock protein 72 overexpression prevents early postoperative memory decline after orthopedic surgery under general anesthesia in mice. Anesthesiology 2011; 114:891-900. [PMID: 21317632 DOI: 10.1097/aln.0b013e31820ad3ce] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Problems with learning and memory are common after surgery in the elderly and are associated with high morbidity. Heat shock protein 72 (Hsp72) confers neuroprotection against acute neurologic injury. We hypothesized that overexpression of Hsp72 would prevent the development of postoperative memory loss. METHODS C57BL/6 wild-type and Hsp72 overexpressing transgenic mice were randomly allocated to the following: control, isoflurane anesthesia alone, or tibial fracture during isoflurane anesthesia. Animals were trained 24 h before surgery using a fear conditioning protocol and assessed in their training environment and in a novel context on posttreatment days 1, 3, and 7. Microglial activation was assessed by immunostaining. RESULTS Adult male C57BL/6 wild-type mice exhibited reduced memory evidenced by a decreased percentage freezing time on days 1 and 3 after anesthesia alone (58.8 ± 5, 46.5 ± 5 mean ± SEM) and after surgery (53.4 ± 6, 44.1 ± 7), compared with controls (78.8 ± 5, 63.4 ± 6; P < 0.05 and P < 0.001, respectively). Hsp72 mice showed no difference by treatment on any day. Similarly, nonhippocampal-dependent memory was significantly impaired on days 1 and 3 after surgery and day 3 after anesthesia. The genotype effect was significant on days 1 and 7. CD68-immunopositive activated microglia in the hippocampus varied modestly with subregion and time; on day 7, there was a significant treatment effect with no genotype effect, with more activated microglia after surgery in all regions. CONCLUSION Hsp72 overexpression is associated with prevention of postoperative hippocampal-dependent and -independent memory deficit induced by anesthesia and/or surgery. Memory deficit is not correlated with numbers of activated hippocampal microglia.
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242
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Evered L, Scott DA, Silbert B, Maruff P. Postoperative Cognitive Dysfunction Is Independent of Type of Surgery and Anesthetic. Anesth Analg 2011; 112:1179-85. [DOI: 10.1213/ane.0b013e318215217e] [Citation(s) in RCA: 262] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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243
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244
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Silbert B, Evered L, Scott DA, Maruff P. Anesthesiology Must Play a Greater Role in Patients with Alzheimer's Disease. Anesth Analg 2011; 112:1242-5. [DOI: 10.1213/ane.0b013e3182147f5b] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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245
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Lin D, Feng C, Cao M, Zuo Z. Volatile Anesthetics May Not Induce Significant Toxicity to Human Neuron-Like Cells. Anesth Analg 2011; 112:1194-8. [DOI: 10.1213/ane.0b013e3181fdf69d] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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246
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Hughes CG, Pandharipande PP. Review articles: the effects of perioperative and intensive care unit sedation on brain organ dysfunction. Anesth Analg 2011; 112:1212-7. [PMID: 21474659 DOI: 10.1213/ane.0b013e318215366d] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Analgesia and sedation are routinely administered to patients in procedural suites, operating rooms, and intensive care units to permit invasive procedures, prevent pain and anxiety, reduce stress and oxygen consumption, allow mechanical ventilation, and for numerous other patient comfort and safety reasons. Increasing research and evidence, however, has implicated commonly prescribed sedative medications as risk factors for untoward events and worse patient outcomes, including brain organ dysfunction manifested as delirium and coma. The effect of sedatives on outcomes is also influenced by the depth of sedation, making it imperative to reduce total exposure to this class of medications. Juxtaposing the widespread necessity and use of sedation with the cost of acute and long-term cognitive dysfunction to patients and society, physicians must now strive to balance patients' demands and requisite for comfort with their own oath to do no harm. Fortunately, our methods of sedation and choice of medications can likely mitigate this cognitive risk. In this review, we detail the effects of perioperative and intensive care unit sedation on the development of delirium and cognitive impairment and provide an evidence-based approach towards analgesia and sedation paradigms to improve patient outcomes.
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Affiliation(s)
- Christopher G Hughes
- Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee 37212, USA
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247
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Su D, Zhao Y, Wang B, Li W, Xiao J, Chen J, Wang X. Repeated but not single isoflurane exposure improved the spatial memory of young adult mice. Acta Anaesthesiol Scand 2011; 55:468-73. [PMID: 21288227 DOI: 10.1111/j.1399-6576.2010.02385.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Exposure to general anesthesia damages the spatial memory of aged rodents, but its role in the young adult has not been well investigated. This study was conducted to determine the effects of single and repeated isoflurane exposure on spatial memory in young adult mice. METHODS The experimental design comprised three series of experiments. In the first series, animals (2 months old) were randomly exposed to 1.4% isoflurane for 2 or 6 h or vehicle gas for 6 h (n=15 in each group). The Morris water maze (MWM) test was performed at 48 h after anesthetic exposure to evaluate spatial memory. In the second part, animals were randomly exposed to 1.4% isoflurane (isoflurane group, n=15) or vehicle gas only (control group, n=15) for 2 h/day on 5 consecutive days. Forty-eight hours later, the MWM was performed. In the third part, animals were randomized into an isoflurane group (n=15) and a control group (n=15) as in the second part of the experiment. Two weeks later, the MWM was performed. RESULTS The mean escape latency time and the mean pathway length measured at 48 h after repeated isoflurane exposure decreased significantly compared with the control. However, there was no difference between the two groups when tested at 2 weeks after repeated isoflurane exposure. A single exposure to isoflurane lasting 2 or 6 h had no effect on the performance of mice in the MWM as compared with the control. CONCLUSION Repeated but not single isoflurane exposure temporarily improved the spatial memory of young adult mice.
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Affiliation(s)
- D Su
- Department of Anesthesiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
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248
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Abstract
Over the last several decades, the average age of patients has steadily increased, whereas the use of general anesthesia and deep sedation has grown largely outside the operating room environment. Currently available general anesthetics and delivery models represent limitations in addressing these trends. At the same time, research has tremendously expanded the knowledge of how general anesthetics produce their beneficial effects and also revealed evidence of previously unappreciated general anesthetic toxicities. The goal of this review is to highlight these important developments and describe translational research on new general anesthetics with the potential to improve and reshape clinical care.
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Affiliation(s)
- Stuart A Forman
- Department of Anesthesia, Critical Care & Pain Medicine, Massachusetts General Hospital, Jackson 4, MGH, 55 Fruit Street, Boston, MA 02114, USA.
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Vanderweyde T, Bednar MM, Forman SA, Wolozin B. Iatrogenic risk factors for Alzheimer's disease: surgery and anesthesia. J Alzheimers Dis 2011; 22 Suppl 3:91-104. [PMID: 20858967 DOI: 10.3233/jad-2010-100843] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Increasing evidence indicates that patients develop post-operative cognitive decline (POCD) following surgery. POCD is characterized by transient short-term decline in cognitive ability evident in the early post-operative period. This initial decline might be associated with increased risk of a delayed cognitive decline associated with dementia 3 to 5 years post-surgery. In some studies, the conversion rates to dementia are up to 70% in patients who are 65 years or older. The factors responsible for the increased risk of dementia are unclear; however, clinical studies investigating the prevalence of POCD and dementia following surgery do not show an association with the type of anesthesia or duration of surgery. Epidemiological studies from our group support this observation. The adjusted Hazard Ratios for developing dementia (or AD specifically) after prostate or hernia surgery were 0.65 (95% CI, 0.51 to 0.83, prostate) and 0.65 (95% CI, 0.49 to 0.85, hernia) for cohorts of subjects exposed to general anesthesia compared to those exposed only to local anesthesia. Animal studies suggest that prolonged exposure to some volatile-inhalational anesthetics increase production of amyloid-β and vulnerability to neurodegeneration, but these results are weakened by the absence of clinical support. Inflammation and a maladaptive stress response might also contribute to the pathophysiology of this disorder. Future research needs to identify predisposing factors, and then strategies to protect against POCD and subsequent dementia. The field also needs to adopt a more rigorous approach to codifying the frequency and extent of early and delayed post-operative cognitive decline.
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Affiliation(s)
- Tara Vanderweyde
- Department of Pharmacology, Boston University School of Medicine, MA 021182526, USA
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Ancelin ML, de Roquefeuil G, Scali J, Bonnel F, Adam JF, Cheminal JC, Cristol JP, Dupuy AM, Carrière I, Ritchie K. Long-term post-operative cognitive decline in the elderly: the effects of anesthesia type, apolipoprotein E genotype, and clinical antecedents. J Alzheimers Dis 2011; 22 Suppl 3:105-13. [PMID: 20858969 DOI: 10.3233/jad-2010-100807] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Cognitive dysfunction in the elderly commonly observed following anesthesia has been attributed to age-related neuronal changes exacerbated by pharmacotoxic effects. However, the extent to which these changes may persist following recovery from surgery is still largely unknown. This study investigates the long-term effects of anesthesia on cognitive functioning after orthopedic surgery in 270 elderly patients over the age of 65 who completed a computerized cognitive battery before and 8 days, 4 and 13 months after surgery. Their performance was compared to those of 310 elderly controls who completed the same neuropsychiatric evaluation at baseline and one-year interval. Multivariate analyses adjusted for socio-demographic variables, depressive symptomatology, vascular pathology as well as baseline cognitive performance. We found early and transient post-operative decline in reaction time and constructional praxis. With regard to long-term changes we observed improvement compared to controls in most verbal tasks (probably due to learning effects). On the other hand, a clear dissociation effect was observed for several areas of visuospatial functioning which persisted up to the 13-month follow-up. This specific pattern of visuospatial deficit was found to be independent of apolipoprotein E genotype and closely resembles what has recently been termed vascular mild cognitive impairment, in turn associated with subtle sub-cortical vascular changes. The observation of only minor differences between persons operated by general and regional anesthesia makes it difficult to attribute these changes directly to the anesthetic agents themselves, suggesting that cognitive dysfunction may be attributable at least in part to peri-operative conditions, notably stress and glucocorticoid exposure.
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