Perioperative management in order to minimise postoperative delirium and postoperative cognitive dysfunction: Results from a Swedish web-based survey

National survey on perioperative cognitive dysfunction

BACKGROUND

Perioperative cognitive dysfunction (PCD) is a very prevalent clinical syndrome due to the progressive aging of the surgical population.The aim of our study is to evaluate the clinical practice of Spanish anesthesiologists surveyed regarding this entity.

MATERIAL AND METHODS

Prospective online survey conducted by the Neurosciences Section and distributed by SEDAR.

RESULTS

544 responses were obtained, with a participation rate of 17%. 54.4% of respondents never make a preoperative assessment of cognitive impairment, only 7.5% always do it. 79.6% lack an intraoperative management protocol for the patient at risk of PCD. In the anesthetic planning, only 23.3% of the patients was kept in mind. Eighty-nine percent considered regional anesthesia with or without sedation preferable to general anesthesia for the prevention of PCD. 88.8% considered benzodiazepines to present a high risk of PCD. 71.7% considered that anesthetic depth monitoring could prevent postoperative cognitive deficit. Routine evaluation of postoperative delirium is low, only 14%. More than 80% recognize that PCD is underdiagnosed.

CONCLUSIONS

Among Spanish anesthesiologists surveyed, PCD is still a little known and underappreciated entity. It is necessary to raise awareness of the need to detect risk factors for PCD, as well as postoperative assessment and diagnosis. Therefore, the development of guidelines and protocols and the implementation of continuing education programs in which anesthesiologists should be key members of multidisciplinary teams in charge of perioperative care are suggested.

Depth of anesthesia monitoring in Norway-A web-based survey

BACKGROUND

The bispectral index (BIS) monitor is the most frequently used electroencephalogram (EEG)-based depth of anesthesia (DoA) technology in Norwegian hospitals. However, there is limited knowledge regarding the extent and clinical impact of its use and how anesthesiologists and nurse anesthetists use the information provided by the DoA monitors in their clinical practice.

METHODS

This cross-sectional survey on the use of DoA monitors in Norway used a web-based questionnaire distributed to anesthesia personnel in all hospitals in Norway. Participation was voluntary and anonymized, and the web form could not track IP sources or respondents' locations.

RESULTS

Three hundred and ninety-one nurse anesthetists (n = 324) and anesthesiologists (n = 67) responded. Among the EEG-based DoA monitoring tools, BIS was most often used to observe and assess patients' DoA (98%). Raw EEG waveform analysis (10%), EEG-spectrogram (9%), and suppression rate (10%) were seldom used. Twenty-seven percent of the anesthesia personnel were able to recognize a burst suppression pattern on EEG and its significance. Fifty-eight percent of the respondents considered clinical observations more reliable than BIS. Almost all respondents reported adjusting anesthetic dosage based on the BIS index values (80%). However, the anesthetic dose was more often increased (90%) because of high BIS index values than lowered (55%) because of low BIS index values.

CONCLUSION

Despite our respondents' extensive use of DoA monitoring, the anesthesia personnel in our survey did not use all the information and the potential to guide the titration of anesthetics the DoA monitors provide. Thus, anesthesia personnel could generally benefit from increased knowledge of how EEG-based DoA monitoring can be used to assess and determine individual patients' need for anesthetic medication.

Knowledge, attitudes, and practice toward postoperative cognitive dysfunction among anesthesiologists in China: a cross-sectional study

BACKGROUND

To investigate the knowledge, attitudes, and practice (KAP) toward postoperative cognitive dysfunction (POCD) among anesthesiologists in China.

METHODS

This cross-sectional study was conducted nationwide among Chinese anesthesiologists between December 2022 and January 2023. The demographic information and KAP scores of the respondents were collected using a web-based questionnaire. The mean KAP dimension scores ≥ 60% were considered good.

RESULTS

This study enrolled 1032 anesthesiologists (51.2% male). The mean total scores of knowledge, positive attitude, and positive practice were 9.3 ± 1.2 (max 12), 34.8 ± 3.3 (max 40), and 30.6 ± 6.7 (max 40), respectively. The knowledge items with correctness scores < 60% were "the anesthetic drugs that tend to cause POCD" (23.3%) and "Treatment of POCD" (40.3%). Multivariable analysis showed that ≥ 40 years old, master's degree or above, intermediate professional title (i.e., attending physician), senior professional title (i.e., chief physician), and working in tertiary hospitals were independently associated with adequate knowledge. Multivariable analysis showed that the attitude scores, middle professional title, and ≥ 16 years of experience were independently associated with good practice.

CONCLUSIONS

These results suggest that Chinese anesthesiologists have good knowledge, favorable attitudes, and good practice toward POCD. Still, some points remain to be improved (e.g., the drugs causing POCD and managing POCD) and should be emphasized in training and continuing education.

TRIAL REGISTRATION

ChiCTR2200066749.

Preoperative assessment of postoperative delirium: a cross-sectional study of patients and anesthesiologists in Canada

PURPOSE

We sought to evaluate 1) patient- and anesthesiologist-reported rates of postoperative delirium (POD) risk discussion during preoperative meetings, 2) patients' and anesthesiologists' ratings of the importance of POD, and 3) predictors of patient-reported discussion of POD risk during preoperative meetings.

METHODS

In this multicentre two-part cross-sectional survey study, patients ≥ 65 yr scheduled to undergo elective noncardiac surgery completed a five-minute survey after preoperative anesthesia consultation. Patients were asked about their perception of POD importance, and whether they discussed or were assessed for POD risk. Anesthesiologists were surveyed using self-administered surveys circulated via institutional email lists. Anesthesiologists were asked about the frequency of POD risk assessment and discussion in older adults, tools used, and perception of POD-screening barriers.

RESULTS

Four hundred and twelve (of 510 approached) patients (50% male; mean age, 73 yr) and 267 anesthesiologists (of 1,205 invited via e-mail) participated in this study conducted in five Canadian hospitals. Postoperative delirium screening and discussion was reported by 88/412 (22%) patients and 229/267 (86%) anesthesiologists. Postoperative delirium was rated as "somewhat-extremely" important by 64% of patients. A previous history of delirium, higher education, the number of daily medications, and longer surgical duration were associated with POD discussion. On average, anesthesiologists rated the importance of POD at 8/10, and 42% ranked "patient risk factors" as the top reason prompting discussion.

CONCLUSION

The combined evaluation of patients' and anesthesiologists' perspectives provides valuable information on preoperative POD screening and risk assessment, and highlights areas for improvement in the current practice. Most factors we identified to be associated with higher odds of POD discussion are recognized risk factors of POD.

Delirium education and post-anaesthetics care unit nurses' knowledge on recognising and managing delirium in older patients

BACKGROUND

Postoperative delirium (POD) is a major complication following a surgical procedure. There is evidence that improving knowledge about POD could enhance POD care and patient outcomes.

AIM

The study aimed to evaluate whether the amount of delirium education among registered nurses working in post-anaesthetics care units (PACU) impacts on their self-reported confidence and competence in recognising and managing delirium as well as prior knowledge on factors that influence the risk of delirium onset for older people.

METHOD

The current study utilised an online survey on delirium care practice among registered nurses in PACUs. The survey consisted of 27 items. There were questions about confidence and competence in delirium care, knowledge about delirium risk factors, and ranked responses to two case scenario questions to evaluate the application of POD care. There were also demographic questions, including previous experience with delirium care education.

RESULTS

A total of 336 responses were generated from registered nurses working in PACU. Our findings found substantial variability among the respondents about their delirium care education. The amount of delirium education did not influence the PACU registered nurses' confidence or competence in delirium care. In addition, previous education did not have an impact on their knowledge about delirium risk factors.

DISCUSSION AND CONCLUSION

These findings suggested that the quantity of prior education about delirium did not improve the confidence, competence, knowledge, or case scenario questions of PACU registered nurses. Thus, delirium care education needs to be transformed to ensure it has a positive effect on delirium care clinical practice by registered nurses in PACU.

Prevention of Dexmedetomidine on Postoperative Delirium and Early Postoperative Cognitive Dysfunction in Elderly Patients Undergoing Thoracoscopic Lobectomy

Objective

To investigate the effect of dexmedetomidine on postoperative cognitive function and delirium in elderly patients undergoing thoracoscopic lobectomy.

Methods

109 elderly patients (age is more than 65 years) who underwent thoracoscopic lobectomy in our hospital from June 2020 to Feb 2022 were randomly divided into the dexmedetomidine (DEX) group (n = 54) and the control group (n = 55). The patients in the experimental group were given dexmedetomidine by intravenous pump, intravenous pump 0.5 μg/kg within 10 minutes, and maintained the speed of 0.5 μg/(kg. h) to 30 min before the operation was ended. The control group was given the same amount of normal saline. Delirium assessment-severity (CAM-S) assessment and Mini-Cog were used to assess the severity levels of POD and POCD 24 h before, 6 hours after, one day after the operation, three days after the operation, and 1 week after the operation. Serum TNF-αα and NSE levels were assessed by using enzyme-linked immunosorbent assay. NRS pain marks were assessed in the DEX group at postanesthesia care unit (PACU) and 24 postoperation. Surgical pierhysmographic index (SPI) evaluation was performed at five time points.

Results

The Mini-Cog scores in the DEX group were markedly enhanced compared with those in the saline group 6 and 24 hours after the operation. The SPI values in the DEX group were markedly reduced within 2 min after intubation and at surgical sutures. Moreover, the CAM scores in the DEX group were markedly reduced 24 hours after the operation. Tumor necrosis factor-α (TNF-α) and neuron-specific enolase (NSE) levels were significantly decreased in the DEX group at T1∼T3.

Conclusion

The use of dexmedetomidine in the thoracoscopic lobectomy in elderly patients could reduce the occurrence and severity of postoperative cognitive dysfunction and delirium.

Spectral edge frequency during general anaesthesia: A narrative literature review

Previous studies have attempted to determine the depth of anaesthesia with different anaesthetic agents using electroencephalogram (EEG) measurements with variable success. Measuring depth of anaesthesia is confounded by the complexity of the EEG and the fact that different agents create different pattens. A narrative review was undertaken to examine the available research evidence on the effect and reliability of spectral edge frequency (SEF) for assessing the depth of anaesthesia in adult patients under general anaesthesia. A systematic search of the PubMed®, Scopus®, CINAHL and Cochrane databases identified six randomized controlled trials and five observational studies. The findings of these studies suggest that SEF varies according to the anaesthetic drugs used. Remifentanil and age are two factors that can affect SEF, while other opioids and benzodiazepine (administered separately) seem to have no effect. No patients experienced intraoperative awareness. However, this does not indicate that SEF can provide full protection against it and the number of articles in which intraoperative awareness was studied was too small to afford any certainty. None of the studies demonstrated a reliable SEF interval associated with adequate general anaesthesia. SEF must be adapted to the anaesthetic drug used, the patient’s age and state while under general anaesthesia.

Comparison of the '4-item assessment test' and 'nursing delirium screening scale' delirium screening tools on non-intensive care unit wards: A prospective mixed-method approach

BACKGROUND

In elderly patients following surgery, postoperative delirium (POD) is the most frequent complication and is associated with negative outcomes. The 2017 European Society of Anaesthesiology guideline on POD aims to improve patient care by implementing structured delirium prevention, diagnosis and treatment. However, these recommendations, especially systematic delirium screening, are still incompletely adopted in clinical practice. The aim of this study was to evaluate the feasibility and acceptance of validated delirium screening tools and to identify barriers to their implementation on nonintensive care unit wards.

METHODS

Screening rates, as well as practicability, acceptance and the interprofessional handling of positive results, were assessed for each group. Screening rates were calculated as a percentage of the total potential testing episodes completed (up to 15 per patient). Patients were considered eligible when aged 65 years and above. Barriers and motivating factors were assessed in a mixed method approach by utilising questionnaires and focus group discussions.

INTERVENTION

In a 3-month phase, a guideline-compliant screening protocol involving screening for POD three times daily for 5 days following surgery was introduced in five wards: both the 4-item assessment test (4AT) and the nursing delirium screening scale (NuDESC) were used. Before commencing the study and again after 6 weeks, medical staff of the respective wards underwent a 45 min training session.

RESULTS

Of a total of 3183 potential testing episodes, 999 (31.4%) were completed, with more NuDESC observational tests (43%) than 4AT bedside tests completed (20%). The 4AT was considered more difficult to integrate into daily working routines, it took longer to administer, and nurses felt uncomfortable conducting the screening (53 vs. 13%). Screening results indicating delirium were often not discussed within the team (47%), and nurses felt that often such results were not taken seriously by physicians (54%).

CONCLUSION

The observational NuDESC showed a higher completion rate than the bedside 4AT, although overall testing rates were low. The necessary time needed to conduct the screening, the negative reactions by patients, insufficient team communication and a lack of initiation of any therapy were identified as major barriers in the implementation of the guideline-compliant screening protocol. For all staff, further education and awareness of the importance of POD diagnosis and treatment might improve the screening rates. The NuDesc received better results concerning acceptance, practicability and introduction into daily work routine, leading to higher screening rates compared with the 4AT. The latter instrument, which was intended to be used rather selectively or when POD is suspected, might therefore not be suitable for guideline-compliant regular and repeated screening for POD.

Experiences of paediatric emergence delirium - from parents' and a child's perspective

BACKGROUND

Emergence delirium is a complex behaviour of perceptual disturbances that may occur after general anaesthesia in children. These children often exhibit delusions, confusion, restlessness and involuntary physical activity. They cry and are almost impossible to console. Research has mainly focused on comparing different medication agents in the occurrence of and dealing with emergence delirium. However, less is known about parents' experiences of emergence delirium during the recovery process, and there is hardly any research concerning the children's experiences.

AIMS

The primary aim of this study was to describe parents' experiences and reflections during their child's emergence delirium behaviour when recovering from anaesthesia. A secondary aim was to describe children's experiences of having been in this condition.

METHOD

A qualitative research approach with thematic analysis was applied. The study was conducted at two county hospitals in southern Sweden. A total of 16 parents and one child were interviewed.

RESULTS

Watching their child demonstrate emergence delirium made parents feel as if they were encountering an incomprehensible scenario. They experienced fear and insecurity and had feelings of powerlessness and guilt. Information and previous experience turned out to offer relief, and being seen by the healthcare staff when they, in their vulnerability, failed to reach or console their child, gave hope and energy. The child confirmed the unexpected and uncontrolled behaviour described by parents. She clearly remembered being 'wild' and out of control.

CONCLUSION

Emergence delirium must be extensively considered in children undergoing general anaesthesia. It is of great importance for healthcare staff to be aware of the parental difficulties it may cause and what is experienced as relieving, such as receiving information and staff members being available, responsive and supportive during the wake-up period.

A survey about postoperative delirium in older patients among nurses and anaesthetists: implications for future practice and policy

BACKGROUND

Postoperative delirium is a major complication associated with anaesthesia and surgery, more commonly seen in older people.

AIMS

The aims of this study were to explore the knowledge and understanding of anaesthetists and nurses involved in anaesthesia through their responses to two case scenarios of postoperative delirium experienced by older people.

METHODS

A 30-item online survey was sent to 500 potential respondents.

RESULTS

Two hundred and twenty-six practitioners from Australia, New Zealand and Scotland responded. Most had no workplace protocols for anaesthesia planning in older people. There was substantial variability in practice in relation to postoperative delirium screening, detection, prevention and management.

CONCLUSIONS

Improvements in education and awareness, together with a more coherent approach, for example, as recommended in the European Society of Anaesthesiology Guidelines, could help to reduce the impact of postoperative delirium in older people. This should be combined with ongoing research into perioperative optimisation of detection, prevention and management of postoperative delirium.

Cognitive Outcomes after DEXmedetomidine sedation in cardiac surgery: CODEX randomised controlled trial protocol

INTRODUCTION

Older patients undergoing cardiac surgery carry the highest risk for developing major postoperative neurocognitive disorder (postoperative NCD or P-NCD) with up to 25% incidence 3 months after surgery. P-NCD is associated with significant morbidity, mortality, loss of independence, premature retirement and increased healthcare costs. This multicentre randomised trial is investigating the efficacy of postoperative dexmedetomidine sedation in reducing the incidence of major P-NCD after cardiac surgery compared with standard protocols. CODEX will be the largest interventional trial with major P-NCD as the primary outcome.

METHODS AND ANALYSIS

CODEX is recruiting patients ≥60 years old, undergoing elective cardiac surgery and without pre-existing major cognitive dysfunction or dementia. Eligible participants are randomised to receive postoperative dexmedetomidine or standard institutional sedation protocols in the intensive care unit. Baseline preoperative cognitive function is assessed with the computer-based Cogstate Brief Battery. The primary outcome, major P-NCD, 3 months after surgery is defined as a decrease in cognitive function ≥1.96 SD below age-matched, non-operative controls. Secondary outcomes include delirium, major P-NCD at 6/12 months, depressive symptoms, mild P-NCD and quality of surgical recovery at 3/6/12 months. The specific diagnostic criteria used in this protocol are consistent with the recommendations for clinical assessment and management of NCD from the Nomenclature Consensus Working Group on perioperative cognitive changes. Intention-to-treat analysis will compare major P-NCD at 3 months between study groups.

ETHICS AND DISSEMINATION

CODEX was approved by Sunnybrook Health Sciences Centre Research Ethics Board (REB) (Project ID 1743). This will be the first multicentre, randomised controlled trial to assess the efficacy of a pharmacological intervention to reduce the incidence of major P-NCD after cardiac surgery in patients ≥60 years old. Dissemination of the study results will include briefings of key findings and interpretation, conference presentations and peer-reviewed publications.

TRIAL REGISTRATION NUMBER

NCT04289142.

The 4 'A's test for detecting delirium in acute medical patients: a diagnostic accuracy study

BACKGROUND

Delirium is a common and serious neuropsychiatric syndrome, usually triggered by illness or drugs. It remains underdetected. One reason for this is a lack of brief, pragmatic assessment tools. The 4 'A's test (Arousal, Attention, Abbreviated Mental Test - 4, Acute change) (4AT) is a screening tool designed for routine use. This project evaluated its usability, diagnostic accuracy and cost.

METHODS

Phase 1 - the usability of the 4AT in routine practice was measured with two surveys and two qualitative studies of health-care professionals, and a review of current clinical use of the 4AT as well as its presence in guidelines and reports. Phase 2 - the 4AT's diagnostic accuracy was assessed in newly admitted acute medical patients aged ≥ 70 years. Its performance was compared with that of the Confusion Assessment Method (CAM; a longer screening tool). The performance of individual 4AT test items was related to cognitive status, length of stay, new institutionalisation, mortality at 12 weeks and outcomes. The method used was a prospective, double-blind diagnostic test accuracy study in emergency departments or in acute general medical wards in three UK sites. Each patient underwent a reference standard delirium assessment and was also randomised to receive an assessment with either the 4AT (n = 421) or the CAM (n = 420). A health economics analysis was also conducted.

RESULTS

Phase 1 found evidence that delirium awareness is increasing, but also that there is a need for education on delirium in general and on the 4AT in particular. Most users reported that the 4AT was useful, and it was in widespread use both in the UK and beyond. No changes to the 4AT were considered necessary. Phase 2 involved 785 individuals who had data for analysis; their mean age was 81.4 (standard deviation 6.4) years, 45% were male, 99% were white and 9% had a known dementia diagnosis. The 4AT (n = 392) had an area under the receiver operating characteristic curve of 0.90. A positive 4AT score (> 3) had a specificity of 95% [95% confidence interval (CI) 92% to 97%] and a sensitivity of 76% (95% CI 61% to 87%) for reference standard delirium. The CAM (n = 382) had a specificity of 100% (95% CI 98% to 100%) and a sensitivity of 40% (95% CI 26% to 57%) in the subset of participants whom it was possible to assess using this. Patients with positive 4AT scores had longer lengths of stay (median 5 days, interquartile range 2.0-14.0 days) than did those with negative 4AT scores (median 2 days, interquartile range 1.0-6.0 days), and they had a higher 12-week mortality rate (16.1% and 9.2%, respectively). The estimated 12-week costs of an initial inpatient stay for patients with delirium were more than double the costs of an inpatient stay for patients without delirium (e.g. in Scotland, £7559, 95% CI £7362 to £7755, vs. £4215, 95% CI £4175 to £4254). The estimated cost of false-positive cases was £4653, of false-negative cases was £8956, and of a missed diagnosis was £2067.

LIMITATIONS

Patients were aged ≥ 70 years and were assessed soon after they were admitted, limiting generalisability. The treatment of patients in accordance with reference standard diagnosis limited the ability to assess comparative cost-effectiveness.

CONCLUSIONS

These findings support the use of the 4AT as a rapid delirium assessment instrument. The 4AT has acceptable diagnostic accuracy for acute older patients aged > 70 years.

FUTURE WORK

Further research should address the real-world implementation of delirium assessment. The 4AT should be tested in other populations.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN53388093.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 40. See the NIHR Journals Library website for further project information. The funder specified that any new delirium assessment tool should be compared against the CAM, but had no other role in the study design or conduct of the study.

Assessment of Postoperative Cognitive Dysfunction: Results From a Survey of Turkish Anaesthesiologists

Objective

Postoperative cognitive dysfunction (POCD) is one of the most common complications in elderly surgical patients. We conducted a survey study to evaluate the perspectives of Turkish anaesthesiologists on postoperative cognitive disorders.

Methods

We conducted a prospective online survey with questions and answers were recorded either in a Likert scale from 1 to 5 (completely disagree to completely agree) or as yes/no/do not know types of answers. Potential participants were contacted through an e-mail that included a brief introductory note, instructions, a link to the survey and the authors' contact information.

Results

We analysed 129 surveys (9.9% of total potential respondents). The majority believed that the risk of cognitive side effects should be considered when choosing the type of anaesthesia (87.6%) and that preoperative cognitive function should be routinely assessed (74.4%). When caring for an agitated and confused patient postoperatively, 56.6%, protocols to screen and manage postoperative cognitive disorders were rarely used. Nearly all respondents believe that postoperative delirium and POCD are neglected areas in anaesthesiology.

Conclusion

Overall, participants perceive postoperative cognitive disorders as important adverse outcomes following surgery and anaesthesia. They are aware of the main risk factors for their development but may lack information on the prevention and management postoperatively.

Clinical practice in the management of postoperative delirium by Chinese anesthesiologists: a cross-sectional survey designed by the European Society of Anaesthesiology

OBJECTIVE

In this survey, we assessed the current clinical management of postoperative delirium (POD) among Chinese anesthesiologists, after publishing the European POD guideline.

METHODS

We administered an electronic survey, designed according to the European POD guideline. The survey was completed using mobile devices.

RESULTS

In total, 1,514 respondents from China participated in the survey. Overall, 74.4% of participants reported that delirium is very important. More than 95% of participants stated that they routinely assessed POD. In total, 61.4% screened for POD using clinical observation and 37.6% used a delirium screening tool. Although the depth of anesthesia (a POD risk factor) was monitored, electroencephalogram monitoring was unavailable to 30.6% of respondents. Regarding treatment, only 24.1% of respondents used a standard algorithm; 58.5% used individualized treatment.

CONCLUSION

Our survey showed that there are high awareness levels among Chinese anesthesiologists regarding the importance of POD. However, routine assessment and monitoring of all patients, including perioperative anesthesia depth monitoring, and a treatment algorithm need to be implemented on a larger scale. According to the results, efforts should be made to improve the knowledge of POD among Chinese anesthesiologists.

Routine management of postoperative delirium outside the ICU: Results of an international survey among anaesthesiologists

BACKGROUND

Postoperative delirium (POD) is a severe brain dysfunction. Although data indicate a high relevance, no survey has investigated the routine practice to monitor delirium outside the ICU setting after surgery. Prior to publishing of the new European Society of Anaesthesiology (ESA) guidelines on POD, an international survey was conducted to assess current practice.

METHODS

European Society of Anaesthesiology-endorsed online survey; Trial Registration: NCT-identifier: 02513537.

RESULTS

In total, 566 respondents from 62 countries accessed, and 564 (99.6%) completed the survey (completion rate). Overall, 385 (68%) of the respondents reported that delirium is either "very relevant" or "relevant" for their daily clinical practice. In all, 38 (7%) of the respondents routinely monitor for delirium in >50% of all patients. Asked on the monitoring time point, more than half (n = 308, 55%) indicated to screen before or at recovery room discharge, 235 (42%) up to the first postoperative day, 143 (25%) up to 3 days, and 77 (14%) up to 5 postoperative days. Although there is a lack of long-term monitoring, nearly all respondents (n = 530, 94%) reported to treat delirium. Availability of EEG/EMG-based monitoring to assess the depth of anaesthesia was high in the study group (n = 547, 97%) and was used by more than one-third of the respondents to reduce risk of burst suppression (n = 189, 34%).

CONCLUSION

Although delirium is perceived as a relevant condition among anaesthesiologists, there is a high demand for implementing monitoring strategies after publishing of the POD Guideline. The survey shows that tools necessary for POD Guideline implementation are available in the centres represented by the respondents.

Diverging Awareness of Postoperative Delirium and Cognitive Dysfunction in German Health Care Providers

PURPOSE

Postoperative cognitive dysfunction (POCD) appears in up to 30% of patients suffering from postoperative delirium (POD). Both are associated with higher mortality and postoperative complications, prolonged hospital stays, and increased costs. Multi-modal models with pre-admission risk reduction counselling, perioperative monitoring, and training of multidisciplinary patient care providers have been shown to decrease the prevalence of both. The aim of our study is to understand how far those measures are known and implemented in routine care and to detect potential gaps in the current practice regarding risk communication and information flow between involved caregivers for patients at risk for POD/POCD.

PATIENTS AND METHODS

As part of a multicenter study, seven semi-structured focus group (FG) discussions with nurses and physicians from tertiary care hospitals (surgery, anesthesiology, and orthopedics, n=31) and general practitioners (GPs) in private practice (n=7) were performed. Transcribed discussions were analyzed using qualitative content analysis.

RESULTS

POD is present above all in the daily work of nurses, whereas physicians do not perceive it as a relevant problem. Physicians report that no regular risk assessment or risk communication was performed prior to elective surgery. Information about POD often gets lost during hand-offs and is not regularly reported in discharge letters. Thus, persisting cognitive dysfunction is often missed. The importance of standardized documentation and continuous education concerning risks, screening, and treatment was emphasized. The often-suggested pre-OP medication adjustment was seen as less important; in contrast, avoiding withdrawal was regarded as far more important.

CONCLUSION

Altogether, it seems that standards and available best practice concepts are rarely implemented. In contrast to physicians, nurses are highly aware of delirium and ask for standardized procedures and more responsibility. Therefore, raising awareness regarding risks, screening tools, and effective preventive measures for POD/POCD seems an urgent goal. Nurses should have a central role in coordination and care of POD to prevent the risk for POCD.

Adverse postoperative cognitive disorders: a national survey of portuguese anesthesiologists

Background and objectives

Postoperative delirium and postoperative cognitive dysfunction are some of the most common complications in older surgical patients and are associated with adverse outcomes. The aim of this study was to evaluate portuguese anesthesiologists’ perspectives and knowledge about adverse postoperative cognitive disorders, and routine clinical practice when caring for older surgical patients.

Methods

We used a prospective online survey with questions using a Likert scale from 1 to 5 (completely disagree to completely agree), or yes/no/don’t know answer types. Potential participants were portuguese anesthesiologists working in hospitals affiliated with the portuguese national health system and private hospitals.

Results

We analyzed 234 surveys (17.7% of total potential respondents). The majority believed that the risk of cognitive side effects should be considered when choosing the type of anesthesia (87.6%) and that preoperative cognitive function should be routinely assessed (78.6%). When caring for an agitated and confused patient postoperatively, 62.4% would first administer an analgesic and 11.1% an anxiolytic. Protocols to screen and manage postoperative cognitive disorders are rarely used. Nearly all respondents believe that postoperative delirium and postoperative cognitive dysfunction are neglected areas in anesthesiology.

Conclusions

Overall, participants perceive postoperative cognitive disorders as important adverse outcomes following surgery and anesthesia are aware of the main risk factors for their development but may lack information on prevention and management of postoperative delirium. The majority of hospitals do not have protocols regarding preoperative cognitive assessment, diagnosis, management or follow-up of patients with delirium and postoperative cognitive dysfunction.

Anesthesia and surgery induce delirium-like behavior in susceptible mice: the role of oxidative stress

Anesthesia and surgery (A + S) are risk factors for patients to develop postoperative delirium (POD). However, the pathogenesis of POD remains largely to be determined. We employed battery of behavioral tests including open-filed test (OFT), elevated plus maze test (EPMT) and buried food test (BFT) to investigate the role of oxidative stress in the development of POD and to explore the therapeutic target for POD in mice after A + S (simple laparotomy under 1.4% isoflurane anesthesia). We initially found that 6 hours after A + S, mice failed to alter the behavioral changes in OFT and the adenosine triphosphate (ATP) level in hippocampus. After hierarchical cluster analysis, however, there was a significant change in the behavior tests between POD unsusceptible (non-POD) and susceptible (POD-like) mice. Interestingly, cyclosporine A, an inhibitor of mitochondrial permeability transition pore (mPTP) opening, exerted pharmacologically beneficial effects on symptoms, decreased reactive oxygen species (ROS) and ATP, and increased superoxide dismutase (SOD), glutathione peroxidase (GSH-Px) and catalase (CAT) levels in the hippocampus of POD-like mice. These findings suggest that abnormally activated oxidative stress might be involved in the underlying mechanisms of POD. Novel therapeutic agents targeting inhibition of oxidative stress would provide an available strategy for POD treatment.

[Adverse postoperative cognitive disorders: a national survey of portuguese anesthesiologists]

BACKGROUND AND OBJECTIVES

Postoperative delirium and postoperative cognitive dysfunction are some of the most common complications in older surgical patients and are associated with adverse outcomes. The aim of this study was to evaluate portuguese anesthesiologists' perspectives and knowledge about adverse postoperative cognitive disorders, and routine clinical practice when caring for older surgical patients.

METHODS

We used a prospective online survey with questions using a Likert scale from 1 to 5 (completely disagree to completely agree), or yes/no/don't know answer types. Potential participants were portuguese anesthesiologists working in hospitals affiliated with the portuguese national health system and private hospitals.

RESULTS

We analyzed 234 surveys (17.7% of total potential respondents). The majority believed that the risk of cognitive side effects should be considered when choosing the type of anesthesia (87.6%) and that preoperative cognitive function should be routinely assessed (78.6%). When caring for an agitated and confused patient postoperatively, 62.4% would first administer an analgesic and 11.1% an anxiolytic. Protocols to screen and manage postoperative cognitive disorders are rarely used. Nearly all respondents believe that postoperative delirium and postoperative cognitive dysfunction are neglected areas in anesthesiology.

CONCLUSIONS

Overall, participants perceive postoperative cognitive disorders as important adverse outcomes following surgery and anesthesia are aware of the main risk factors for their development but may lack information on prevention and management of postoperative delirium. The majority of hospitals do not have protocols regarding preoperative cognitive assessment, diagnosis, management or follow-up of patients with delirium and postoperative cognitive dysfunction.

Effects of intravenous anesthetics on the phosphorylation of cAMP response element‑binding protein in hippocampal slices of adult mice

cAMP response‑element binding protein (CREB) functions in hippocampal synaptic plasticity and memory formation. However, it remains unknown whether intravenous anesthetics modulate CREB. The present study aimed to examine the effects of intravenous anesthetics on CREB phosphorylation in the mouse hippocampus. CREB phosphorylation was examined in hippocampal slices with and without pharmacological or intravenous anesthetics via immunoblotting. In a dose‑response experiment, the concentrations of intravenous anesthetics ranged from 10‑9 to 10‑4 mol/l for 1 h. For the time‑response experiment, these slices were incubated with 5x10‑6 mol/l of propofol for 0, 1, 2, 5, 7, 9, 12, 15, 30 and 60 min. In order to examine whether CREB phosphorylation could be recovered following washing out the propofol, the slices were incubated in plain artificial cerebrospinal fluid at different time durations following 5 min incubation with propofol. Propofol, etomidate, ketamine and midazolam inhibited CREB phosphorylation (P<0.05) in a time‑ and dose‑dependent manner. This inhibition was reversible following the removal of propofol, and was rescued by CREB phosphorylation (P<0.05). The decrease in CREB phosphorylation revealed additive effects with 100 µM of chelerythrine and 20 µM of PD‑98059, and the etomidate‑induced decrease in CREB phosphorylation was blocked by 1 mM of NMDA. However, 0.1 µM of phorbol 12‑myristate 13‑acetate, 50 µM of U 73122, 100 µM of carbachol and 10 µM of MK801 were ineffective in the anesthetic‑induced decrease in CREB phosphorylation. Intravenous anesthetics markedly decreased CREB phosphorylation in the mouse hippocampus, which was most likely via the protein kinase C and mitogen activated protein kinase pathways. This suggests that CREB represents a target for anesthetic action in the brain.

Haloperidol Versus 5-HT3 Receptor Antagonists for Postoperative Vomiting and QTc Prolongation: A Noninferiority Meta-Analysis and Trial Sequential Analysis of Randomized Controlled Trials

Haloperidol is an antipsychotic with well-known antiemetic potential. It is underutilized for postoperative nausea vomiting due to reported corrected QT interval (QTc) prolongation. This meta-analysis evaluates its safety and efficacy as an antiemetic in the perioperative period. Trials comparing haloperidol to 5-HT₃ -receptor antagonists (5-HT₃ -RA) for 24 postoperative vomiting incidences published up to May 2017 were searched in the medical database. Comparisons were made for antiemetic efficiency variables (vomiting incidence, rescue antiemetic need, and patients with complete response) during early (until 6 hours) and late postoperative phases. Eight randomized controlled double-blinded trials were included in the final analysis. Twenty-four-hour vomiting incidence was similar in groups (fixed effects, P = 0.52, I² = 0%). Trial-sequential analysis confirmed noninferiority of haloperidol over 5-HT₃ -RAs (α = 5%, β = 20%, δ = 10%), with "information size" being 859 (required > 812). Pooled results did not demonstrate superiority/inferiority of 5-HT₃ -RAs over haloperidol in all other antiemetic efficacy variables (early and delayed). Negligible heterogeneity was found in all the comparisons made. Pooled Mantel Haenszel odds ratio for QTc prolongation was equivalent in both groups (fixed effects, P = 0.23, I² = 0%). The mean dose of haloperidol used was 1.34 mg, and no trial reported extrapyramidal side effects. Trial-sequential analysis showed statistical equivalence (α = 5%, β = 20%, δ = 10%), with information size being 745 (required > 591). Publication bias was unlikely (Egger test, X-intercept = 2.07, P = 0.10). We conclude that haloperidol is equivalent to the well-established 5-HT₃ -RAs in preventing vomiting during the first day after surgery. The incidence of QTc prolongation with haloperidol is statistically equivalent to 5-HT₃ -RAs and thus should not be the factor that discourages its use for treatment/prophylaxis of postoperative nausea vomiting.

Dexmedetomidine protects against learning and memory impairments caused by electroconvulsive shock in depressed rats: Involvement of the NMDA receptor subunit 2B (NR2B)-ERK signaling pathway

Cognitive impairment is a common adverse effect of electroconvulsive therapy (ECT) during treatment for severe depression. Dexmedetomidine (DEX), a sedative-anesthetic drug, is used to treat post-ECT agitation. However, it is not known if DEX can protect against ECT-induced cognitive impairments. To address this, we used chronic unpredictable mild stress (CUMS) to establish a model of depression for ECT treatment. Our Morris water maze and sucrose preference test results suggest that DEX alleviates ECT-induced learning and memory impairments without altering the antidepressant efficacy of ECT. To further investigate the underlying mechanisms of DEX, hippocampal expression of NR2B, p-ERK/ERK, p-CREB/CREB, and BDNF were quantified by western blotting. These results show that DEX suppresses over-activation of NR2B and enhances phosphorylation of ERK1/2 in the hippocampus of ECT-treated depressed rats. Furthermore, DEX had no significant effect on ECT-induced increases in p-CREB and BDNF. Overall, our findings suggest that DEX ameliorates ECT-induced learning and memory impairments in depressed rats via the NR2B-ERK signaling cascade. Moreover, CREB/BDNF seems not appear to participate in the cognitive protective mechanisms of DEX during ECT treatment.