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Peng Z, Wu J, Wang Z, Xie H, Wang J, Zhang P, Yang Q, Luo Y. Incidence and related risk factors for postoperative delirium following revision total knee arthroplasty: a retrospective nationwide inpatient sample database study. BMC Musculoskelet Disord 2024; 25:633. [PMID: 39118027 PMCID: PMC11313129 DOI: 10.1186/s12891-024-07757-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 08/05/2024] [Indexed: 08/10/2024] Open
Abstract
BACKGROUND Postoperative delirium (POD) is a common surgical complication. However, the incidence and risk factors associated with postoperative delirium after revision total knee arthroplasty (rTKA) have not been comprehensively explored through extensive national databases. METHODS Utilizing the National Inpatient Sample (NIS), the largest comprehensive U.S. hospital healthcare database, we undertook a retrospective investigation involving 127,400 patients who underwent rTKA between 2010 and 2019. We assessed various aspects, including patient demographics, hospital characteristics, pre-existing medical conditions, and perioperative complications. RESULTS The overall incidence of postoperative delirium (POD) in patients undergoing rTKA between 2010 and 2019 was 0.97%. The highest incidence rate of 1.31% was recorded in 2013. Notably, this patient cohort demonstrated advanced age, increased burden of co-morbidities, prolonged hospital stays, increased hospitalization costs, and elevated in-hospital mortality rates (P < 0.001). Moreover, non-elective admissions, non-private insurance payments, and a preference for teaching hospitals were commonly observed among these patients. During their hospitalization, individuals who developed delirium subsequent to rTKA were more prone to experiencing certain perioperative complications. These complications encompassed medical issues like acute myocardial infarction, continuous invasive mechanical ventilation, postoperative shock, sepsis, stroke and other medical problems. Additionally, surgical complications including hemorrhage / seroma / hematoma, irrigation and debridement, prosthetic joint infection, periprosthetic fracture, and wound dehiscence / nonunion were noted. Several risk factors were found to be linked with the development of POD. These included advanced age (≥ 75 years), alcohol abuse, coagulation disorders, congestive heart failure, depression, fluid and electrolyte imbalances, and more. Conversely, female sex, having private insurance, and undergoing elective hospitalization emerged as protective factors against POD. CONCLUSION Our findings suggest that the general prevalence of POD in rTKA is relatively low according to NIS. There was a significant connection between the POD of rTKA and advanced age, prolonged length of stay (LOS), more in-patients' costs, higher in-hospital mortality rate, increased comorbidities, postoperative medical complications and postoperative surgical complications. This study helps to understand the risk factors associated with POD to improve poor outcomes.
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Affiliation(s)
- Zikai Peng
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, 510515, China
| | - Jingyi Wu
- Department of Orthopedics, General Hospital of Southern Theater Command, The First School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Zhennan Wang
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Hao Xie
- Division of Orthopaedic Surgery, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, 510515, China
| | - Jian Wang
- Division of Orthopaedic Surgery, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, 510515, China
| | - Ping Zhang
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, 510515, China.
| | - Qinfeng Yang
- Division of Orthopaedic Surgery, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, 510515, China.
| | - Ya Luo
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, 510515, China.
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Mehler DM, Kreuzer M, Obert DP, Cardenas LF, Barra I, Zurita F, Lobo FA, Kratzer S, Schneider G, Sepúlveda PO. Electroencephalographic guided propofol-remifentanil TCI anesthesia with and without dexmedetomidine in a geriatric population: electroencephalographic signatures and clinical evaluation. J Clin Monit Comput 2024; 38:803-815. [PMID: 38451341 DOI: 10.1007/s10877-024-01127-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 01/17/2024] [Indexed: 03/08/2024]
Abstract
Elderly and multimorbid patients are at high risk for developing unfavorable postoperative neurocognitive outcomes; however, well-adjusted and EEG-guided anesthesia may help titrate anesthesia and improve postoperative outcomes. Over the last decade, dexmedetomidine has been increasingly used as an adjunct in the perioperative setting. Its synergistic effect with propofol decreases the dose of propofol needed to induce and maintain general anesthesia. In this pilot study, we evaluate two highly standardized anesthetic regimens for their potential to prevent burst suppression and postoperative neurocognitive dysfunction in a high-risk population. Prospective, randomized clinical trial with non-blinded intervention. Operating room and post anesthesia care unit at Hospital Base San José, Osorno/Universidad Austral, Valdivia, Chile. 23 patients with scheduled non-neurologic, non-cardiac surgeries with age > 69 years and a planned intervention time > 60 min. Patients were randomly assigned to receive either a propofol-remifentanil based anesthesia or an anesthetic regimen with dexmedetomidine-propofol-remifentanil. All patients underwent a slow titrated induction, followed by a target controlled infusion (TCI) of propofol and remifentanil (n = 10) or propofol, remifentanil and continuous dexmedetomidine infusion (n = 13). We compared the perioperative EEG signatures, drug-induced changes, and neurocognitive outcomes between two anesthetic regimens in geriatric patients. We conducted a pre- and postoperative Montreal Cognitive Assessment (MoCa) test and measured the level of alertness postoperatively using a sedation agitation scale to assess neurocognitive status. During slow induction, maintenance, and emergence, burst suppression was not observed in either group; however, EEG signatures differed significantly between the two groups. In general, EEG activity in the propofol group was dominated by faster rhythms than in the dexmedetomidine group. Time to responsiveness was not significantly different between the two groups (p = 0.352). Finally, no significant differences were found in postoperative cognitive outcomes evaluated by the MoCa test nor sedation agitation scale up to one hour after extubation. This pilot study demonstrates that the two proposed anesthetic regimens can be safely used to slowly induce anesthesia and avoid EEG burst suppression patterns. Despite the patients being elderly and at high risk, we did not observe postoperative neurocognitive deficits. The reduced alpha power in the dexmedetomidine-treated group was not associated with adverse neurocognitive outcomes.
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Affiliation(s)
- Dominik M Mehler
- Department of Anesthesiology and Intensive Care, School of Medicine, Technical University of Munich, Munich, Germany
| | - Matthias Kreuzer
- Department of Anesthesiology and Intensive Care, School of Medicine, Technical University of Munich, Munich, Germany
| | - David P Obert
- Department of Anesthesiology and Intensive Care, School of Medicine, Technical University of Munich, Munich, Germany
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts's General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Luis F Cardenas
- Department of Anesthesiology, Hospital Base San José, Osorno/Universidad Austral, Valdivia, Chile
| | - Ignacio Barra
- Department of Anesthesiology, Hospital Base San José, Osorno/Universidad Austral, Valdivia, Chile
| | - Fernando Zurita
- Department of Anesthesiology, Hospital Base San José, Osorno/Universidad Austral, Valdivia, Chile
| | - Francisco A Lobo
- Anesthesiology Institute, Cleveland Clinic Abu Dhabi, United Arab Emirates, Abu Dhabi, UAE
| | - Stephan Kratzer
- Department of Anesthesiology and Intensive Care, School of Medicine, Technical University of Munich, Munich, Germany
| | - Gerhard Schneider
- Department of Anesthesiology and Intensive Care, School of Medicine, Technical University of Munich, Munich, Germany
| | - Pablo O Sepúlveda
- Department of Anesthesiology, Hospital Base San José, Osorno/Universidad Austral, Valdivia, Chile.
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Yan E, Butris N, Alhamdah Y, Kapoor P, Lovblom LE, Islam S, Saripella A, Wong J, Tang-Wai DF, Mah L, Alibhai SMH, Tartaglia MC, He D, Chung F. The utility of remote cognitive screening tools in identifying cognitive impairment in older surgical patients: An observational cohort study. J Clin Anesth 2024; 97:111557. [PMID: 39047531 DOI: 10.1016/j.jclinane.2024.111557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 05/13/2024] [Accepted: 07/17/2024] [Indexed: 07/27/2024]
Abstract
STUDY OBJECTIVES To determine the prevalence of suspected cognitive impairment using the Centers for Disease Control and Prevention (CDC) cognitive question, Ascertain Dementia Eight-item Questionnaire (AD8), Modified Telephone Interview for Cognitive Status (TICS-M), and Telephone Montreal Cognitive Assessment (T-MoCA), the agreement between each tool beyond chance, and the risk factors associated with a positive screen. DESIGN Multicenter prospective study. SETTING Remote preoperative assessments. PATIENTS 307 non-cardiac surgical patients aged ≥65 years. MEASUREMENTS Prevalence, Cohen's kappa (κ). MAIN RESULTS The T-MoCA detected the highest prevalence of suspected cognitive impairment (28%), followed by the AD8 (17%), CDC cognitive question (9%), and TICS-M (6%). The four screening tools showed poor agreement beyond chance with one another, with the CDC cognitive question and AD8 approaching the threshold for weak agreement (κ = 0.39). Depression was associated with screening positive on the CDC cognitive question (OR: 2.81; 95% CI: 1.04, 7.68). Obstructive sleep apnea (OSA) (OR: 3.10; 95% CI: 1.26, 7.71) and functional disability (OR: 3.74; 95% CI: 1.34, 11.11) were associated with a positive AD8 screen. Older age (OR: 1.56; 95% CI: 1.01, 2.41), male sex (OR: 3.08; 95% CI: 1.09, 9.40), and higher pain level (OR: 1.21; 95% CI: 1.01, 1.47) were associated with a positive TICS-M screen. Similarly, older age (OR: 1.33; 95% CI: 1.03, 1.73), male sex (OR: 2.02; 95% CI: 1.09, 3.83), and higher pain level (OR: 1.15; 95% CI: 1.02, 1.30) were associated with a positive T-MoCA screen. CONCLUSIONS The CDC cognitive question, AD8, TICS-M, and T-MoCA were easily implemented during preoperative assessment among older surgical patients. OSA, functional disability, and depression were associated with complaints on the CDC cognitive question and AD8. Older age, male sex, and higher pain level were associated with screening positive on the TICS-M and T-MoCA. Early remote cognitive screening may enhance risk stratification of vulnerable patients.
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Affiliation(s)
- Ellene Yan
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Temerty Faculty of Medicine, University of Toronto, ON, Canada
| | - Nina Butris
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Temerty Faculty of Medicine, University of Toronto, ON, Canada
| | - Yasmin Alhamdah
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Temerty Faculty of Medicine, University of Toronto, ON, Canada
| | - Paras Kapoor
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Temerty Faculty of Medicine, University of Toronto, ON, Canada
| | - Leif Erik Lovblom
- Biostatistics Department, University Health Network, Toronto, ON, Canada
| | - Sazzadul Islam
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Aparna Saripella
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Jean Wong
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Temerty Faculty of Medicine, University of Toronto, ON, Canada; Women's College Hospital, Toronto, ON, Canada
| | - David F Tang-Wai
- Temerty Faculty of Medicine, University of Toronto, ON, Canada; Division of Neurology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Linda Mah
- Temerty Faculty of Medicine, University of Toronto, ON, Canada; Division of Geriatric Psychiatry, Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Rotman Research Institute, Baycrest Health Sciences Centre, Toronto, ON, Canada
| | - Shabbir M H Alibhai
- Temerty Faculty of Medicine, University of Toronto, ON, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
| | - Maria Carmela Tartaglia
- Temerty Faculty of Medicine, University of Toronto, ON, Canada; Division of Neurology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - David He
- Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Frances Chung
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Temerty Faculty of Medicine, University of Toronto, ON, Canada.
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Yin S, Dai J, Lu L. Summary of the Clinical Evidence for Non-Pharmacological Management of Postoperative Delirium in Adults: An Evidence Synthesis. J Multidiscip Healthc 2024; 17:3427-3438. [PMID: 39056091 PMCID: PMC11269450 DOI: 10.2147/jmdh.s469157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 06/24/2024] [Indexed: 07/28/2024] Open
Abstract
Objective To retrieve, evaluate, and summarise the clinical evidence for non-pharmacological interventions in adult postoperative delirium (POD), encompassing the preoperative, intraoperative, and postoperative phases. Methods The methods included conducting searches on UpToDate Clinical Consultants, the Scottish Intercollegiate Guidelines Network, the National Institute for Health and Care Excellence, the Registered Nurses' Association of Ontario, BMJ Best Practice, the Cochrane Library, Web of Science, PubMed, China National Knowledge Infrastructure, Wanfang, VIP, and the Chinese Biomedical Literature Service System. Clinical practice guidelines, clinical decision-making, evidence summaries, evidence synthesis, expert consensus, systematic reviews, and meta-analyses on non-pharmacological interventions for adult POD were examined, and the search period spanned between the establishment of each database and 30 October 2023. Results A total of 17 documents were included, comprising three guidelines, one expert consensus, one clinical decision-making article, four evidence summaries, three systematic reviews, and five meta-analyses. These documents primarily focused on the following three aspects: preoperative, intraoperative, and postoperative care. In total, 30 "best evidence" instances were compiled. Conclusion Considering the complexity and potential harm of adult POD, an accurate and timely evaluation of high-risk factors, alongside effective medical nursing strategies, is vital in its prevention and treatment. Non-pharmacological interventions remain the preferred choice for preventing and treating POD. Medical institutions should establish standardised processes for non-pharmacological intervention in adult POD, based on evidence-based medicine, to enhance the level of clinical care in this field.
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Affiliation(s)
- Sujin Yin
- Department of General Surgery, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Gusu School, Nanjing Medical University, Suzhou, 215000, People’s Republic of China
| | - Jingen Dai
- Department of General Surgery, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Gusu School, Nanjing Medical University, Suzhou, 215000, People’s Republic of China
| | - Lingling Lu
- Department of General Surgery, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Gusu School, Nanjing Medical University, Suzhou, 215000, People’s Republic of China
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Meco BC, Jakobsen K, De Robertis E, Buhre W, Alkış N, Kirkegaard PR, Hägi-Pedersen D, Bubser F, Koch S, Evered LA, Saunders SJ, Caterino M, Paolini F, Berger-Estilita J, Radtke FM. A first assessment of the safe brain initiative care bundle for addressing postoperative delirium in the postanesthesia care unit. J Clin Anesth 2024; 97:111506. [PMID: 38972091 DOI: 10.1016/j.jclinane.2024.111506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 05/27/2024] [Accepted: 05/29/2024] [Indexed: 07/09/2024]
Abstract
BACKGROUND Postoperative delirium (POD) following surgery is a prevalent and distressing condition associated with adverse patient outcomes and an increased healthcare burden. OBJECTIVES To assess the effectiveness of the Safe Brain Initiative care bundle (SBI-CB) in reducing POD in the postanesthesia care unit (PACU). DESIGN A multicenter, quality-improvement initiative with retrospective analysis of collected data. SETTING The study was conducted in the operating rooms and postanesthesia care units (PACUs) of four hospitals across Denmark and Turkey. PATIENTS The convenience sample of patients were aged ≥18 years, scheduled for surgery, and could communicate verbally. Age, sex, preoperative delirium, and the American Society for Anesthesiology physical status classification were used in statistical methods to control for potential confounding influences. INTERVENTION The SBI-CB, 18 delirium-reducing recommendations aligned with international guidelines. The intervention included patient education, staff training, coordination meetings across centers, and a dashboard for the monitoring of outcomes in the PACU. MAIN OUTCOME MEASURES The primary outcome was the POD trend in the PACU during implementation months, assessed through Nu-DESC screening at up to three time points in the PACU. We also examined the length of hospital stay. RESULTS Data were collected from 18,697 adult patients across four hospitals. Initial POD incidence in the PACU after the first three months was 16.36% across all sites (n = 1021). POD in the PACU was observed across all age groups, with peak incidence in younger (18-35 years) and older (>75 years) patients. General anesthesia and longer surgical duration (>1 h) were identified as significant risk factors for POD in the PACU. Matched patients who experienced POD in the PACU had longer stays in hospital, with a mean increase from 35 to 69 h (p < 0.001). Implementation of the SBI-CB was associated with a decreased risk of POD in the PACU for each month of SBI-CB implementation (adjusted odds ratio 0.96, 95% confidence interval: [0.94, 0.97], p < 0.001). CONCLUSIONS The presented pragmatic implementation of a multidisciplinary care bundle, encompassing pre-, intra-, and postoperative measures alongside outcome monitoring, has the potential to significantly reduce the incidence of POD in the PACU. Improved patient outcomes may be achieved for general surgical departments with patient cohorts not typically considered at risk for developing POD. TRIAL REGISTRATION Clinicaltrials.gov, identifier NCT05765162.
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Affiliation(s)
- Basak Ceyda Meco
- Department of Anaesthesiology and Intensive Care, Ankara University Faculty of Medicine, Ibni Sina Hospital, Ankara, Turkey; Ankara University Brain Research Center (AÜBAUM), Ankara, Turkey
| | - Karina Jakobsen
- Department of Anesthesia and Intensive Care, Hospital of Nykøbing Falster, Nykøbing Falster, Denmark
| | - Edoardo De Robertis
- Division of Anesthesia, Analgesia, and Intensive Care, Department of Medicine and Surgery, University of Perugia, Italy
| | - Wolfgang Buhre
- Division of Anesthesiology, Perioperative Medicine, Emergency and Critical Care Medicine, Maastricht University Medical Center, Research School, Mental Health and Neuroscience (MhenS), Maastricht University, Maastricht, the Netherlands
| | - Neslihan Alkış
- Department of Anaesthesiology and Intensive Care, Ankara University Faculty of Medicine, Ibni Sina Hospital, Ankara, Turkey
| | - Peter Roy Kirkegaard
- Department of Anesthesia and Intensive Care, Hospital of Nykøbing Falster, Nykøbing Falster, Denmark
| | - Daniel Hägi-Pedersen
- Department of Anesthesia, Research Center of Anaesthesiology and Intensive Care Medicine, NSR Hospitals (Næstved, Slagelse, Ringsted) Næstved and Ringsted Hospital, Denmark; Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Florian Bubser
- Department of Anesthesia and Intensive Care, Hospital of Nykøbing Falster, Nykøbing Falster, Denmark
| | - Susanne Koch
- Department of Anesthesia and Intensive Care, Hospital of Nykøbing Falster, Nykøbing Falster, Denmark; Charité, Universitätsmedizin Berlin, Berlin, Germany
| | - Lisbeth A Evered
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA; Department of Anesthesia and Acute Pain Medicine, St Vincent's Hospital, Melbourne, VIC, Australia; Department of Critical Care Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Sita J Saunders
- Evaluate Healthcare, Königswinter, Germany; Coreva Scientific, Königswinter, Germany
| | | | | | - Joana Berger-Estilita
- Institute of Anaesthesiology and Intensive Care, Salemspital, Hirslanden Medical Group, Schänzlistrasse 39, 3013 Bern, Switzerland; Institute for Medical Education, University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland; CINTESIS, Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Finn M Radtke
- Department of Anesthesia and Intensive Care, Hospital of Nykøbing Falster, Nykøbing Falster, Denmark; Charité, Universitätsmedizin Berlin, Berlin, Germany.
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Aldana EM, Pérez de Arriba N, Valverde JL, Aldecoa C, Fábregas N, Fernández-Candil JL. National survey on perioperative cognitive dysfunction. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024:S2341-1929(24)00122-7. [PMID: 38972351 DOI: 10.1016/j.redare.2024.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 11/29/2023] [Accepted: 02/15/2024] [Indexed: 07/09/2024]
Abstract
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.
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Affiliation(s)
- E M Aldana
- Anestesiología y Reanimación, Hospital Vithas Xanit Internacional, Benalmádena, Málaga, Spain.
| | - N Pérez de Arriba
- Anestesiología y Reanimación, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - J L Valverde
- Anestesiología y Reanimación, Hospital Vithas Xanit Internacional, Benalmádena, Málaga, Spain
| | - C Aldecoa
- Anestesiología y Reanimación, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - N Fábregas
- Anestesiología y Reanimación, Hospital Clínic, Universidad de Barcelona, Barcelona, Spain
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Thedim M, Vacas S. Postoperative Delirium and the Older Adult: Untangling the Confusion. J Neurosurg Anesthesiol 2024; 36:184-189. [PMID: 38683185 DOI: 10.1097/ana.0000000000000971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 04/01/2024] [Indexed: 05/01/2024]
Abstract
Postoperative delirium is one of the most prevalent postoperative complications, affecting mostly older adults. Its incidence is expected to rise because of surgical advances, shifting demographics, and increased life expectancy. Although an acute alteration in brain function, postoperative delirium is associated with adverse outcomes, including progressive cognitive decline and dementia, that place significant burdens on patients' lives and healthcare systems. This has prompted efforts to understand the mechanisms of postoperative delirium to provide effective prevention and treatment. There are multiple mechanisms involved in the etiology of postoperative delirium that share similarities with the physiological changes associated with the aging brain. In addition, older patients often have multiple comorbidities including increased cognitive impairment that is also implicated in the genesis of delirium. These tangled connections pinpointed a shift toward creation of a holistic model of the pathophysiology of postoperative delirium. Scientific advancements integrating clinical risk factors, possible postoperative delirium biomarkers, genetic features, digital platforms, and other biotechnical and information technological innovations, will become available in the near future. Advances in artificial intelligence, for example, will aggregate cognitive testing platforms with patient-specific postoperative delirium risk stratification studies, panels of serum and cerebrospinal fluid molecules, electroencephalogram signatures, and gut microbiome features, along with the integration of novel polygenetic variants of sleep and cognition. These advances will allow for the enrollment of high-risk patients into prevention programs and help uncover new pharmacologic targets.
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Affiliation(s)
- Mariana Thedim
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Serviço de Anestesiologia, Unidade Local de Saúde Gaia e Espinho, Vila Nova de Gaia, Portugal
| | - Susana Vacas
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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8
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Zhu W, Shen Y, Zhao H, Tang Y, Wang X, Li S. Predicting postoperative delirium after percutaneous transluminal angioplasty and stenting in patients with intracranial atherosclerotic stenosis. Neurol Res 2024:1-9. [PMID: 38909321 DOI: 10.1080/01616412.2024.2370730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 06/17/2024] [Indexed: 06/24/2024]
Abstract
OBJECTIVE Known as a major surgical complication, postoperative delirium (POD) has not been well studied in patients with intracranial atherosclerotic stenosis (ICAS). This study aimed to investigate the correlation between perioperative clinical characteristics and the occurrence of POD. METHODS Patients' demographic characteristics and perioperative testing data were collected. Binary logistic regression was conducted for assessing related risk factors. A nomogram was developed to predict the occurrence of POD after percutaneous transluminal angioplasty and stenting (PTAS) in patients with ICAS. RESULTS The occurrence of POD in this study was 30.67%. Among all the clinical and laboratory characteristics in patients, age (OR = 1.234, 95%CI = 1.004-1.517, p = 0.046), gender (OR = 5.676, 95%CI = 1.028-31.334, p = 0.046), preoperative MMSE scores (OR = 2.298, 95%CI = 1.005-5.259, p = 0.049), the degree of stenosis (OR = 6.294, 95%CI = 1.043-37.974, p = 0.045), operating time (OR = 1.088, 95%CI = 1.023-1.157, p = 0.006), and HbA1c levels (OR = 2.226, 95%CI = 1.199-4.130, p = 0.011) were the independent risk factors. CONCLUSION Male patients with advanced-age, lower preoperative MMSE scores, severe stenosis, longer operating time, and higher HbA1c levels are closely related to POD after PTAS. Fully perioperative assessments may play an important role in predicting the occurrence of POD.
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Affiliation(s)
- Wanchun Zhu
- Department of Neurosurgery, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yiman Shen
- Department of Neurosurgery, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Hua Zhao
- Department of Neurosurgery, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yinda Tang
- Department of Neurosurgery, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xuhui Wang
- Department of Neurosurgery, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Shiting Li
- Department of Neurosurgery, Shanghai Jiaotong University School of Medicine, Shanghai, China
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Wang Y, Ma B, Wang C, Wang Y, Liu A, Hang L. The influence of low-dose s-ketamine on postoperative delirium and cognitive function in older adults undergoing thoracic surgery. J Cardiothorac Surg 2024; 19:324. [PMID: 38849859 PMCID: PMC11157807 DOI: 10.1186/s13019-024-02811-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Accepted: 05/25/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND Postoperative delirium (POD) and cognitive dysfunction (POCD) are common complications following thoracic surgery, particularly in patients aged 65 years and above. These complications can significantly affect recovery and increase healthcare costs. This study investigates the effects of low-dose S-ketamine on reducing POD and POCD in this patient demographic. METHODS In this retrospective cohort study, medical records of patients aged ≥ 65 years who underwent elective thoracic surgery from January 2019 to August 2023 were reviewed. Patients were categorized into S-ketamine and Control groups based on intraoperative S-ketamine exposure. POD was assessed using the Confusion Assessment Method (CAM), while cognitive function was evaluated using the Montreal Cognitive Assessment (MoCA) at baseline, 1 week, 1 month, and 6 months post-surgery. Intraoperative and postoperative parameters, including hemodynamic stability, blood loss, pain scores, and ICU stay length, were also recorded. RESULTS The study comprised 140 participants, with 70 in each group. The S-ketamine group demonstrated a significantly lower incidence of POD at 7 days post-surgery (12.0% vs. 26.7%, P < 0.001), and reduced POCD at 1 month (18.7% vs. 36.0%, P < 0.05) and 6 months (10.7% vs. 21.3%, P < 0.05). The Ketamine group had a significantly higher median MoCA score compared to the Control group both at 1 month (P = 0.021) and 6 months (P = 0.007). Adverse events, such as infection, bleeding, and respiratory failure, showed no significant differences between the groups, suggesting a safe profile for S-ketamine. CONCLUSION Administering low-dose S-ketamine during thoracic surgery in patients aged 65 years and above significantly reduces the incidence of POD and POCD, highlighting its neuroprotective potential. These findings advocate for the inclusion of S-ketamine in anesthetic protocols to improve postoperative outcomes and reduce healthcare costs in this patient population.
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Affiliation(s)
- Yujia Wang
- Department of Anesthesiology, Kunshan First People's Hospital, Kunshan Hospital Affiliated to Jiangsu University, No.566 Qianjin East Road, Kunshan, 215300, China.
| | - Bingqiang Ma
- Department of Anesthesiology, Kunshan First People's Hospital, Kunshan Hospital Affiliated to Jiangsu University, No.566 Qianjin East Road, Kunshan, 215300, China
| | - Chaochang Wang
- Department of Anesthesiology, Kunshan First People's Hospital, Kunshan Hospital Affiliated to Jiangsu University, No.566 Qianjin East Road, Kunshan, 215300, China
| | - Yingqi Wang
- Department of Anesthesiology, Kunshan First People's Hospital, Kunshan Hospital Affiliated to Jiangsu University, No.566 Qianjin East Road, Kunshan, 215300, China
| | - Aijia Liu
- Department of Anesthesiology, Kunshan First People's Hospital, Kunshan Hospital Affiliated to Jiangsu University, No.566 Qianjin East Road, Kunshan, 215300, China
| | - Lihua Hang
- Department of Anesthesiology, Kunshan First People's Hospital, Kunshan Hospital Affiliated to Jiangsu University, No.566 Qianjin East Road, Kunshan, 215300, China
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10
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Singh NP, Makkar JK, Goel N, Karamchandani K, Singh M, Singh PM. Effect of prophylactic corticosteroids on postoperative neurocognitive dysfunction in the adult population: An updated systematic review, meta-analysis, and trial sequential analysis of randomised controlled trials. Indian J Anaesth 2024; 68:517-526. [PMID: 38903252 PMCID: PMC11186528 DOI: 10.4103/ija.ija_149_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 03/15/2024] [Accepted: 03/20/2024] [Indexed: 06/22/2024] Open
Abstract
Background and Aims Postoperative neurocognitive dysfunction (PNCD) commonly occurs after surgery and prolongs hospital stays. Both direct noxious stimuli to the central nervous system and systemic inflammation have been implicated. Due to their potent anti-inflammatory effects, corticosteroids have been utilised to attenuate the incidence and severity of PNCD. This systematic review and meta-analysis strived to evaluate the prophylactic role of perioperative corticosteroids for PNCD. Methods A search was run in pre-defined databases for randomised controlled trials (RCTs) assessing the role of corticosteroids in preventing PNCD. The incidence of PNCD within 1 month was the primary outcome. Secondary outcomes included the use of antipsychotic medications for the treatment, postoperative infection, and hospital length of stay. The results are exhibited as odds ratio (OR) and the mean difference (MD) with 95% confidence interval (CI). Results Fifteen RCTs comprising 15,398 patients were included. The incidence of PNCD was significantly lower in the corticosteroid group than in the control group, with a pooled OR of 0.75 (95% CI 0.58, 0.96; P = 0.02; I2 = 66%). Trial sequential analysis showed the clinical benefit of corticosteroids in preventing PNCD; however, the requisite information size is still inadequate. The sub-group analysis supported the prophylactic effect of corticosteroids on delirium prevention but not on delayed neurocognitive recovery. Conclusions Our meta-analysis revealed statistically significant protective effects of corticosteroids on the incidence of PNCD. However, further studies are still needed to confirm the protective role of this commonly used and relatively safe strategy for preventing PNCD.
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Affiliation(s)
- Narinder P. Singh
- Department of Anesthesia and Pain Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Jeetinder K. Makkar
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Nitika Goel
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Kunal Karamchandani
- Department of Anesthesiology and Pain Management, Division of Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, USA
| | - Mandeep Singh
- Department of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Preet M. Singh
- Department of Anesthesia, Washington University in Saint Louis, MO, USA
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11
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Lu N, Chi Y, Liu M. Relationship Between Coronary Artery Revascularization and Postoperative Delirium: Progress and Perspectives. Angiology 2024:33197241252467. [PMID: 38712998 DOI: 10.1177/00033197241252467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
Brain dysfunction resulting from damage to the heart-brain link leads to a decline in cognitive function. This, in turn, gives rise to the clinical symptom of perioperative delirium in patients undergoing coronary artery revascularization. Those affected are provided symptomatic treatment, but many do not recover fully. Thus, medium- and long-term mortality and adverse event rates remain relatively high in patients with perioperative delirium. Despite the relatively high incidence of perioperative delirium in patients undergoing coronary artery revascularization, it has not been systematically investigated. Inflammation, vascular damage, neuronal damage, and embolism are all involved in the injury process. Here, we discuss the incidence rate, pathological mechanisms, and prognosis of delirium after coronary artery revascularization. We also discuss in detail the risk factors for delirium after coronary artery revascularization, such as anxiety, depression, mode of operation, and drug use. We hope that prevention, early diagnosis, assessment, and potential treatment can be achieved by cardiologists to improve patient prognosis.
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Affiliation(s)
- Nan Lu
- Department of Psycho-cardiology, Beijing Anzhen Hospital Affiliated to Capital Medical University, Beijing, People's Republic of China
| | - Yunpeng Chi
- Department of Psycho-cardiology, Beijing Anzhen Hospital Affiliated to Capital Medical University, Beijing, People's Republic of China
| | - Meiyan Liu
- Department of Psycho-cardiology, Beijing Anzhen Hospital Affiliated to Capital Medical University, Beijing, People's Republic of China
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12
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Sugg E, Gleeson E, Baker SN, Li P, Gao C, Mueller A, Deng H, Shen S, Franco-Garcia E, Saxena R, Musiek ES, Akeju O, Xie Z, Hu K, Gao L. Sleep and circadian biomarkers of postoperative delirium (SLEEP-POD): protocol for a prospective and observational cohort study. BMJ Open 2024; 14:e080796. [PMID: 38643014 PMCID: PMC11033637 DOI: 10.1136/bmjopen-2023-080796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 03/06/2024] [Indexed: 04/22/2024] Open
Abstract
INTRODUCTION Surgical patients over 70 experience postoperative delirium (POD) complications in up to 50% of procedures. Sleep/circadian disruption has emerged as a potential risk factor for POD in epidemiological studies. This protocol presents a single-site, prospective observational study designed to examine the relationship between sleep/circadian regulation and POD and how this association could be moderated or mediated by Alzheimer's disease (AD) pathology and genetic risk for AD. METHODS AND ANALYSIS Study staff members will screen for eligible patients (age ≥70) seeking joint replacement or spinal surgery at Massachusetts General Hospital (MGH). At the inclusion visit, patients will be asked a series of questionnaires related to sleep and cognition, conduct a four-lead ECG recording and be fitted for an actigraphy watch to wear for 7 days before surgery. Blood samples will be collected preoperatively and postoperatively and will be used to gather information about AD variant genes (APOE-ε4) and AD-related pathology (total and phosphorylated tau). Confusion Assessment Method-Scale and Montreal Cognitive Assessment will be completed twice daily for 3 days after surgery. Seven-day actigraphy assessments and Patient-Reported Outcomes Measurement Information System questionnaires will be performed 1, 3 and 12 months after surgery. Relevant patient clinical data will be monitored and recorded throughout the study. ETHICS AND DISSEMINATION This study is approved by the IRB at MGH, Boston, and it is registered with the US National Institutes of Health on ClinicalTrials.gov (NCT06052397). Plans for dissemination include conference presentations at a variety of scientific institutions. Results from this study are intended to be published in peer-reviewed journals. Relevant updates will be made available on ClinicalTrials.gov. TRIAL REGISTRATION NUMBER NCT06052397.
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Affiliation(s)
- Elizabeth Sugg
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Medical Biodynamics Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Elizabeth Gleeson
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sarah N Baker
- Hackensack Meridian School of Medicine, Nutley, New Jersey, USA
| | - Peng Li
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Medical Biodynamics Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Chenlu Gao
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Medical Biodynamics Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ariel Mueller
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Hao Deng
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Shiqian Shen
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Esteban Franco-Garcia
- Department of Internal Medicine, Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Richa Saxena
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Erik S Musiek
- Department of Neurology, Washington University School of Medicine, St Louis, Missouri, USA
- Center on Biological Rhythms and Sleep (COBRAS), Washington University School of Medicine, St Louis, Missouri, USA
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Oluwaseun Akeju
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Zhongcong Xie
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kun Hu
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Medical Biodynamics Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Lei Gao
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Medical Biodynamics Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, Massachusetts, USA
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13
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Van Wicklin SA. Fundamentals of Plastic and Aesthetic Nursing: Postoperative Management of Older Adult Patients Undergoing Plastic Surgical Procedures. Pediatr Phys Ther 2024; 44:99-115. [PMID: 38639967 DOI: 10.1097/psn.0000000000000561] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Affiliation(s)
- Sharon Ann Van Wicklin
- Sharon Ann Van Wicklin, PhD, RN, CNOR, CRNFA(E), CPSN-R, PLNC, ISPAN-F, FAORN, FAAN, is Editor in Chief, Plastic and Aesthetic Nursing, and is a Perioperative and Legal Nurse Consultant, Aurora, CO
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14
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Singh NP, Makkar JK, Borle A, Singh PM. Role of supplemental regional blocks on postoperative neurocognitive dysfunction after major non-cardiac surgeries: a systematic review and meta-analysis of randomized controlled trials. Reg Anesth Pain Med 2024; 49:49-58. [PMID: 36535728 DOI: 10.1136/rapm-2022-104095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 12/09/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND/IMPORTANCE Postoperative neurocognitive dysfunction (PNCD) is a frequent and preventable complication after surgery. The large high-quality evidence for the efficacy of supplemental regional analgesia blocks (RAB) for preventing PNCD is still elusive. OBJECTIVE The objective of this meta-analysis was to evaluate the effect of RAB versus standard anesthesia care on the incidence of PNCD in adult patients undergoing major non-cardiac surgery. EVIDENCE REVIEW PubMed, EMBASE, Scopus, and the Cochrane Central Registers of Controlled Trials (CENTRAL) were searched for randomized controlled trials (RCTs) from 2017 until June 2022. The primary outcome was the incidence of PNCD within 1 month of surgery. A random-effects model with an inverse variance method was used to pool results, and OR and mean differences were calculated for dichotomous and continuous outcomes. Various exploratory subgroup analyses were performed to explore the possibility of the association between the various patient, technique, and surgery-related factors. Grading of Recommendation, Assessment, Development, and Evaluation guidelines were used to determine the certainty of evidence. FINDINGS Twenty-six RCTs comprizing 4414 patients were included. The RAB group was associated with a significant reduction in the incidence of PNCD with an OR of 0.46 (95% CI 0.35 to 0.59; p<0.00001; I2=28%) compared with the control group (moderate certainty). Subgroup analysis exhibited that the prophylactic efficacy of RAB persisted for both delirium and delayed neurocognitive recovery. CONCLUSIONS Current evidence suggests that supplemental RAB are beneficial in preventing PNCD in patients after major non-cardiac surgery. PROSPERO REGISTRATION NUMBER CRD42022338820.
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Affiliation(s)
- Narinder P Singh
- Department of Anesthesiology, Maharishi Markandeshwar Institute of Medical Sciences and Research, Ambala, Haryana, India
| | - Jeetinder Kaur Makkar
- Department of Anaesthesia and Intensive care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Anuradha Borle
- Department of Anesthesiology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Preet Mohinder Singh
- Department of Anesthesiology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
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15
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Lai YH, Latmore M, Joo SS, Hong J. Regional anesthesia for the geriatric patient: a narrative review and update on hip fracture repair. Int Anesthesiol Clin 2024; 62:79-85. [PMID: 37955145 DOI: 10.1097/aia.0000000000000422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Affiliation(s)
- Yan H Lai
- Department of Anesthesiology, Pain, and Perioperative Medicine, Mount Sinai West and Morningside Hospitals, Icahn School of Medicine, New York, NY
| | - Malikah Latmore
- Department of Anesthesiology, Pain, and Perioperative Medicine, Mount Sinai West and Morningside Hospitals, Icahn School of Medicine, New York, NY
| | - Sarah S Joo
- Department of Anesthesiology, Pain, and Perioperative Medicine, Mount Sinai West and Morningside Hospitals, Icahn School of Medicine, New York, NY
| | - Janet Hong
- Department of Anesthesiology, Pain, and Perioperative Medicine, Mount Sinai West and Morningside Hospitals, Icahn School of Medicine, New York, NY
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Tian L, Wang H, Jia Y, Jin L, Zhou C, Zhou H, Yuan S. Effect of percutaneous cerebral oximetry-guided anaesthetic management on postoperative delirium in older adults undergoing off-pump coronary artery bypass grafting: study protocol for a single-centre prospective randomised controlled trial in a tertiary academic hospital in China. BMJ Open 2023; 13:e076419. [PMID: 38070897 PMCID: PMC10729170 DOI: 10.1136/bmjopen-2023-076419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 11/21/2023] [Indexed: 12/18/2023] Open
Abstract
INTRODUCTION Postoperative delirium is a prominent and clinically important complication in older adults after coronary artery bypass grafting (CABG) surgery, resulting in prolonged hospital stay, long-term cognitive impairment and increased morbidity and mortality. Many studies have shown that cerebral desaturation is associated with increased risk of postoperative delirium during on-pump cardiac surgery. However, few studies have focused on the effect of optimising regional cerebral oxygen saturation (rSO2) on postoperative delirium during off-pump CABG. The purpose of this study is to investigate whether intraoperative anaesthetic management based on percutaneous cerebral oximetry monitoring decreases the incidence of postoperative delirium in older adults undergoing off-pump CABG. METHODS This single-centre randomised controlled trial will randomly assign 200 patients to the intervention group or the control group at a ratio of 1:1. The patients in the intervention group will be observed by percutaneous cerebral oximetry monitoring that the desaturation (a drop of more than 20% from baseline value or rSO2 less than 55% for >60 consecutive seconds at either probe) during the procedure triggered the intervention strategies, while the cerebral oximetry data of the control group will be hidden from the clinical team and patients will be anaesthetised by the usual anaesthetic management. The primary outcome will be the incidence of postoperative delirium during the first 7 days after off-pump CABG. Delirium will be comprehensively evaluated by the combination of the Richmond Agitation Sedation Scale and the Confusion Assessment Method for the intensive care unit. The secondary outcomes will include the incidence of postoperative acute kidney injury and myocardial infarction during the hospital stay, as well as the intensive care unit and hospital length of stay. ETHICS AND DISSEMINATION This study was approved by the Ethics Committee of the Chinese Academy of Medical Sciences, Fuwai Hospital (No 2022-1824). Written informed consent will be obtained from each patient or their legal representatives before enrolment. The results of this trial will be published in an international peer-reviewed scientific journal. TRIAL REGISTRATION NUMBER ChiCTR2300068537.
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Affiliation(s)
- Lijuan Tian
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Hongbai Wang
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yuan Jia
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Lei Jin
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Chenghui Zhou
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Hongyan Zhou
- Department of Intensive Care Unit, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Su Yuan
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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Hunter CL, Ni Chroinin D, McEvoy L, Chuan A. Poorer outcomes in patients with early postoperative delirium: 120-day follow-up of the Delirium Reduction by Analgesia Management in Hip Fracture (DRAM-HF) study. Australas J Ageing 2023; 42:736-741. [PMID: 37708340 DOI: 10.1111/ajag.13239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 07/25/2023] [Accepted: 08/15/2023] [Indexed: 09/16/2023]
Abstract
OBJECTIVES The Delirium Reduction by Analgesia Management-Hip Fracture (DRAM-HF) model of care, which incorporated a multicomponent intervention focussing on perioperative analgesia and medication optimisation, was associated with reduced Day 3 postoperative delirium (POD) amongst hip fracture patients. We investigated whether this effect was seen at 120 days postoperatively. METHODS We assessed 120-day outcomes in all patients who were included in the DRAM-HF study, by telephone, supplemented by electronic medical records, to include death (primary outcome), residential aged care facility (RACF) residence, patient/carer-reported frailty, hospital readmission and new dementia diagnosis. RESULTS Amongst 300 patients (mean age 81.1, 70% female, none lost to follow-up), by 120 days, 8% (n = 24) had died; 25% of survivors (n = 68/276) were RACF residents. Twenty-two per cent were readmitted (n = 61/281). A new dementia diagnosis was reported by 6% (n = 17/281). Intervention status in the DRAM-HF trial (intervention/control) was not associated with death by 120 days (OR 0.83, 95% CI 0.36-1.93, p = 0.67) or other outcomes assessed. POD was independently associated with 120-day death (aOR 3.3, 95% CI 1.2-9.2, p = 0.02), RACF residence (aOR 2.2, 95% CI 1.1-4.7, p = 0.03) and patient/carer-reported frailty (aOR 5.6, 95% CI 1.0-30.7, p = 0.05), but not readmission (p = 0.21) or new diagnosis of dementia (p = 0.08). CONCLUSIONS In this cohort, while the DRAM-HF bundle of care did not influence 120-day outcomes, patients who experienced POD had poorer clinical outcomes 120-day postfracture. Given that delirium was associated with death, RACF residence and frailty, models of care which have the potential to reduce POD may have benefits beyond the acute admission, and further investigation is needed.
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Affiliation(s)
- Carol Lu Hunter
- Department of Geriatric Medicine, Liverpool Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine, UNSW Sydney, Sydney, New South Wales, Australia
| | - Danielle Ni Chroinin
- Department of Geriatric Medicine, Liverpool Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine, UNSW Sydney, Sydney, New South Wales, Australia
| | - Lynette McEvoy
- Department of Orthopaedic Surgery, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Alwin Chuan
- Faculty of Medicine, UNSW Sydney, Sydney, New South Wales, Australia
- Department of Anaesthetics, Liverpool Hospital, Sydney, New South Wales, Australia
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Song AL, Li YJ, Liang H, Sun YZ, Shu X, Huang JH, Yang ZY, He WQ, Zhao L, Zhu T, Zhong KH, Chen YW, Lu KZ, Yi B. Dynamic Nomogram for Predicting the Risk of Perioperative Neurocognitive Disorders in Adults. Anesth Analg 2023; 137:1257-1269. [PMID: 37973132 PMCID: PMC10629609 DOI: 10.1213/ane.0000000000006746] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Simple and rapid tools for screening high-risk patients for perioperative neurocognitive disorders (PNDs) are urgently needed to improve patient outcomes. We developed an online tool with machine-learning algorithms using routine variables based on multicenter data. METHODS The entire dataset was composed of 49,768 surgical patients from 3 representative academic hospitals in China. Surgical patients older than 45 years, those undergoing general anesthesia, and those without a history of PND were enrolled. When the patient's discharge diagnosis was PND, the patient was in the PND group. Patients in the non-PND group were randomly extracted from the big data platform according to the surgical type, age, and source of data in the PND group with a ratio of 3:1. After data preprocessing and feature selection, general linear model (GLM), artificial neural network (ANN), and naive Bayes (NB) were used for model development and evaluation. Model performance was evaluated by the area under the receiver operating characteristic curve (ROCAUC), the area under the precision-recall curve (PRAUC), the Brier score, the index of prediction accuracy (IPA), sensitivity, specificity, etc. The model was also externally validated on the multiparameter intelligent monitoring in intensive care (MIMIC) Ⅳ database. Afterward, we developed an online visualization tool to preoperatively predict patients' risk of developing PND based on the models with the best performance. RESULTS A total of 1051 patients (242 PND and 809 non-PND) and 2884 patients (6.2% patients with PND) were analyzed on multicenter data (model development, test [internal validation], external validation-1) and MIMIC Ⅳ dataset (external validation-2). The model performance based on GLM was much better than that based on ANN and NB. The best-performing GLM model on validation-1 dataset achieved ROCAUC (0.874; 95% confidence interval [CI], 0.833-0.915), PRAUC (0.685; 95% CI, 0.584-0.786), sensitivity (72.6%; 95% CI, 61.4%-81.5%), specificity (84.4%; 95% CI, 79.3%-88.4%), Brier score (0.131), and IPA (44.7%), and of which the ROCAUC (0.761, 95% CI, 0.712-0.809), the PRAUC (0.475, 95% CI, 0.370-0.581), Brier score (0.053), and IPA (76.8%) on validation-2 dataset. Afterward, we developed an online tool (https://pnd-predictive-model-dynnom.shinyapps.io/ DynNomapp/) with 10 routine variables for preoperatively screening high-risk patients. CONCLUSIONS We developed a simple and rapid online tool to preoperatively screen patients' risk of PND using GLM based on multicenter data, which may help medical staff's decision-making regarding perioperative management strategies to improve patient outcomes.
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Affiliation(s)
- Ai-lin Song
- From the Department of Anesthesiology, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Yu-jie Li
- From the Department of Anesthesiology, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Hao Liang
- From the Department of Anesthesiology, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Yi-zhu Sun
- From the Department of Anesthesiology, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Xin Shu
- From the Department of Anesthesiology, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Jia-hao Huang
- From the Department of Anesthesiology, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Zhi-yong Yang
- From the Department of Anesthesiology, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Wen-quan He
- From the Department of Anesthesiology, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Lei Zhao
- Department of Anesthesiology, Xuan Wu Hospital, Capital Medical University, Beijing, China
| | - Tao Zhu
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
| | - Kun-hua Zhong
- Electronic Information Technology Research Institute, Chongqing Institute of Green and Intelligent Technology, Chinese Academy of Science, Chongqing, China
| | - Yu-wen Chen
- Electronic Information Technology Research Institute, Chongqing Institute of Green and Intelligent Technology, Chinese Academy of Science, Chongqing, China
| | - Kai-zhi Lu
- From the Department of Anesthesiology, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Bin Yi
- From the Department of Anesthesiology, Southwest Hospital, Third Military Medical University, Chongqing, China
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Kim DH, Lee H, Pawar A, Lee SB, Park CM, Levin R, Metzger E, Bateman BT, Ely EW, Pandharipande PP, Pisani MA, Hohmann SF, Marcantonio ER, Inouye SK. Trends in use of antipsychotics and psychoactive drugs in older patients after major surgery. J Am Geriatr Soc 2023; 71:3755-3767. [PMID: 37676699 PMCID: PMC10841351 DOI: 10.1111/jgs.18580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 07/05/2023] [Accepted: 07/13/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Professional society guidelines recommend limiting the use of antipsychotics in older patients with postoperative delirium. How these recommendations affected the use of antipsychotics and other psychoactive drugs in the postoperative period has not been studied. METHODS This retrospective cohort study included patients 65 years or older without psychiatric diagnoses who underwent major surgery in community hospitals (CHs) and academic medical centers (AMCs) in the United States. The outcome was the rate of hospital days exposed to antipsychotics, antidepressants, antiepileptics, benzodiazepines, hypnotics, and selective alpha-2 receptor agonist dexmedetomidine in the postoperative period by hospital type. RESULTS The study included 4,098,431 surgical admissions from CHs (mean age 75.0 [standard deviation, 7.1] years; 50.8% female) during 2008-2018 and 2,310,529 surgical admissions from AMCs (75.0 [7.4] years; 49.4% female) during 2009-2018. In the intensive care unit (ICU) setting, the number of exposed days per 1000 hospital-days declined for haloperidol (CHs: 33-21 days [p < 0.01]; AMCs: 24-15 days [p < 0.01]) and benzodiazepines (CHs: 261-136 days [p < 0.01]; AMCs: 150-77 days [p < 0.01]). The use of atypical antipsychotics, antidepressants, antiepileptics, and dexmedetomidine increased, while hypnotic use varied by the hospital type. In the non-ICU setting, the rate declined for haloperidol in CHs but not in AMCs (CHs: 10-6 days [p < 0.01]; AMCs: 4-3 days [p = 0.52]) and for benzodiazepines in both settings (CHs: 126-56 days [p < 0.01]; AMCs: 30-27 days [p < 0.01]). The use of antiepileptics and antidepressants increased, while the use of atypical antipsychotics and hypnotics varied by the hospital type. CONCLUSIONS The use of haloperidol and benzodiazepines in the postoperative period declined at both CHs and AMCs. These trends coincided with the increasing use of other psychoactive drugs.
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Affiliation(s)
- Dae Hyun Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, MA
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Hemin Lee
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, MA
| | - Ajinkya Pawar
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, MA
| | - Su Been Lee
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, MA
| | - Chan Mi Park
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | - Raisa Levin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, MA
| | - Eran Metzger
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
- Harvard Medical School, Boston, MA
| | - Brian T. Bateman
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - E. Wesley Ely
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN
| | - Pratik P. Pandharipande
- Departments of Anesthesiology and Surgery, Division of Anesthesiology Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Margaret A. Pisani
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT
| | - Samuel F. Hohmann
- Vizient, Inc. and Department of Health Systems Management, Rush University, Chicago, IL
| | - Edward R. Marcantonio
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Sharon K. Inouye
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
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20
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Choi JY, Yoo S, Song W, Kim S, Baek H, Lee JS, Yoon YS, Yoon S, Lee HY, Kim KI. Development and Validation of a Prognostic Classification Model Predicting Postoperative Adverse Outcomes in Older Surgical Patients Using a Machine Learning Algorithm: Retrospective Observational Network Study. J Med Internet Res 2023; 25:e42259. [PMID: 37955965 PMCID: PMC10682929 DOI: 10.2196/42259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 03/08/2023] [Accepted: 10/11/2023] [Indexed: 11/14/2023] Open
Abstract
BACKGROUND Older adults are at an increased risk of postoperative morbidity. Numerous risk stratification tools exist, but effort and manpower are required. OBJECTIVE This study aimed to develop a predictive model of postoperative adverse outcomes in older patients following general surgery with an open-source, patient-level prediction from the Observational Health Data Sciences and Informatics for internal and external validation. METHODS We used the Observational Medical Outcomes Partnership common data model and machine learning algorithms. The primary outcome was a composite of 90-day postoperative all-cause mortality and emergency department visits. Secondary outcomes were postoperative delirium, prolonged postoperative stay (≥75th percentile), and prolonged hospital stay (≥21 days). An 80% versus 20% split of the data from the Seoul National University Bundang Hospital (SNUBH) and Seoul National University Hospital (SNUH) common data model was used for model training and testing versus external validation. Model performance was evaluated using the area under the receiver operating characteristic curve (AUC) with a 95% CI. RESULTS Data from 27,197 (SNUBH) and 32,857 (SNUH) patients were analyzed. Compared to the random forest, Adaboost, and decision tree models, the least absolute shrinkage and selection operator logistic regression model showed good internal discriminative accuracy (internal AUC 0.723, 95% CI 0.701-0.744) and transportability (external AUC 0.703, 95% CI 0.692-0.714) for the primary outcome. The model also possessed good internal and external AUCs for postoperative delirium (internal AUC 0.754, 95% CI 0.713-0.794; external AUC 0.750, 95% CI 0.727-0.772), prolonged postoperative stay (internal AUC 0.813, 95% CI 0.800-0.825; external AUC 0.747, 95% CI 0.741-0.753), and prolonged hospital stay (internal AUC 0.770, 95% CI 0.749-0.792; external AUC 0.707, 95% CI 0.696-0.718). Compared with age or the Charlson comorbidity index, the model showed better prediction performance. CONCLUSIONS The derived model shall assist clinicians and patients in understanding the individualized risks and benefits of surgery.
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Affiliation(s)
- Jung-Yeon Choi
- Departmentof Internal Medicine, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea
| | - Sooyoung Yoo
- Office of eHealth Research and Business, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea
| | - Wongeun Song
- Office of eHealth Research and Business, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea
- Department of Health Science and Technology, Graduate School of Convergence Science and Technology, Seoul National University, Seongnam-si, Republic of Korea
| | - Seok Kim
- Office of eHealth Research and Business, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea
| | - Hyunyoung Baek
- Office of eHealth Research and Business, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea
| | - Jun Suh Lee
- Department of Surgery, G Sam Hospital, Gunpo, Republic of Korea
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Seonghae Yoon
- Department of Clinical Pharmacology and Therapeutic, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea
| | - Hae-Young Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kwang-Il Kim
- Departmentof Internal Medicine, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
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21
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Anesthesia in Outpatient Facilities. J Oral Maxillofac Surg 2023; 81:E35-E50. [PMID: 37833028 DOI: 10.1016/j.joms.2023.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
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22
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Hao D, Fritz BA, Saddawi-Konefka D, Palanca BJA. Pro-Con Debate: Electroencephalography-Guided Anesthesia for Reducing Postoperative Delirium. Anesth Analg 2023; 137:976-982. [PMID: 37862399 DOI: 10.1213/ane.0000000000006399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2023]
Abstract
Postoperative delirium (POD) has significant implications on morbidity, mortality, and health care expenditures. Monitoring electroencephalography (EEG) to adjust anesthetic management has gained interest as a strategy to mitigate POD. In this Pro-Con commentary article, the pro side supports the use of EEG to reduce POD, citing an empiric reduction in POD with processed EEG (pEEG)-guided general anesthesia found in several studies and recent meta-analysis. The Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes (ENGAGES) trial is the exception to this, and issues with methods and achieved depths are discussed. Meanwhile, the Con side advocates that the use of EEG to reduce POD is not yet certain, citing that there is a lack of evidence that associations between anesthetic depth and POD represent causal relationships. The Con side also contends that the ideal EEG signatures to guide anesthetic titration are currently unknown, and the potential benefits of reduced anesthesia levels may be outweighed by the risks of potentially insufficient anesthetic administration. As the public health burden of POD increases, anesthesia clinicians will be tasked to consider interventions to mitigate risk such as EEG. This Pro-Con debate will provide 2 perspectives on the evidence and rationales for using EEG to mitigate POD.
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Affiliation(s)
- David Hao
- From the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Bradley A Fritz
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Daniel Saddawi-Konefka
- From the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ben Julian A Palanca
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
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23
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Yan E, Veitch M, Saripella A, Alhamdah Y, Butris N, Tang-Wai DF, Tartaglia MC, Nagappa M, Englesakis M, He D, Chung F. Association between postoperative delirium and adverse outcomes in older surgical patients: A systematic review and meta-analysis. J Clin Anesth 2023; 90:111221. [PMID: 37515876 DOI: 10.1016/j.jclinane.2023.111221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 07/10/2023] [Accepted: 07/19/2023] [Indexed: 07/31/2023]
Abstract
STUDY OBJECTIVE To assess the incidence of postoperative delirium and its outcomes in older non-cardiac surgical patients. DESIGN A systematic review and meta-analysis with multiple databases searched from inception to February 22, 2022. SETTING Postoperative assessments. PATIENTS Non-cardiac and non-neurological surgical patients aged ≥60 years with and without postoperative delirium. Included studies must report ≥1 postoperative outcome. Studies with a small sample size (N < 100 subjects) were excluded. MEASUREMENTS Outcomes comprised the pooled incidence of postoperative delirium and its postoperative outcomes, including mortality, complications, unplanned intensive care unit admissions, length of stay, and non-home discharge. For dichotomous and continuous outcomes, OR and difference in means were computed, respectively, with a 95% CI. MAIN RESULTS Fifty-four studies (20,988 patients, 31 elective studies, 23 emergency studies) were included. The pooled incidence of postoperative delirium was 19% (95% CI: 16%, 23%) after elective surgery and 32% (95% CI: 25%, 39%) after emergency surgery. In elective surgery, postoperative delirium was associated with increased mortality at 1-month (OR: 6.60; 95% CI: 1.58, 27.66), 6-month (OR: 5.69; 95% CI: 2.33, 13.88), and 1-year (OR: 2.87; 95% CI: 1.63, 5.06). The odds of postoperative complications, unplanned intensive care unit admissions, prolonged length of hospital stay, and non-home discharge were also higher in delirium cases. In emergency surgery, patients with postoperative delirium had greater odds of mortality at 1-month (OR: 3.56; 95% CI: 1.77, 7.15), 6-month (OR: 2.60; 95% CI: 1.88, 3.61), and 1-year (OR: 2.30; 95% CI: 1.77, 3.00). CONCLUSIONS Postoperative delirium was associated with higher odds of mortality, postoperative complications, unplanned intensive care unit admissions, length of hospital stay, and non-home discharge. Prevention and perioperative management of delirium may optimize surgical outcomes.
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Affiliation(s)
- Ellene Yan
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, ON, Canada
| | - Matthew Veitch
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Aparna Saripella
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Yasmin Alhamdah
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, ON, Canada
| | - Nina Butris
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, ON, Canada
| | - David F Tang-Wai
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Maria Carmela Tartaglia
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, ON, Canada; Division of Neurology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Mahesh Nagappa
- Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Marina Englesakis
- Library & Information Services, University Health Network, Toronto, ON, Canada
| | - David He
- Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Frances Chung
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, ON, Canada.
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24
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Kubo T, Sogawa R, Tsuruhashi S, Murakawa-Hirachi T, Matsuoka A, Mizoguchi Y, Monji A, Shimanoe C. Risk of delirium with antiepileptic drug use: a study based on the Japanese Adverse Drug Event Report database. Int J Clin Pharm 2023; 45:1260-1266. [PMID: 36977859 DOI: 10.1007/s11096-023-01564-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 02/24/2023] [Indexed: 03/30/2023]
Abstract
BACKGROUND Antiepileptic drugs may cause delirium, and the risk may vary with each drug. However, related studies have provided inconsistent results. AIM The aim of this study was to investigate whether the use of antiepileptic drugs is a risk factor for delirium development. METHOD Using the Japanese Adverse Drug Event Report database, we analysed 573,316 reports pertaining to the period from 2004 to 2020. Reporting odds ratios and 95% confidence intervals of delirium associated with use of antiepileptic drugs were calculated after adjusting for potential confounders. Furthermore, for each antiepileptic drug, we performed an analysis stratified based on older age and benzodiazepine receptor agonist usage. RESULTS There were 27,439 reports of antiepileptic drug-related adverse events. Of these, 191 reports were associated with antiepileptic drugs and delirium (crude reporting odds ratio [cROR], 1.66; 95% confidence interval [CI], 1.43-1.93). The use of lacosamide (adjusted reporting odds ratio [aROR], 2.44; 95% CI, 1.24-4.80), lamotrigine (aROR, 1.54; 95% CI, 1.05-2.26), levetiracetam (aROR, 1.91; 95% CI, 1.35-2.71), and valproic acid (aROR, 1.49; 95% CI, 1.16-1.91) was related to a significantly higher reporting odds ratio for delirium, even after adjustment for possible confounding factors. However, when used in combination with benzodiazepine receptor agonists, none of the antiepileptic drugs were found to be associated with delirium. CONCLUSION Our study's findings suggest that antiepileptic drug usage may be associated with delirium development.
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Affiliation(s)
- Toshiki Kubo
- Department of Pharmacy, Saga University Hospital, 5-1-1 Nabeshima, Saga, 849-8501, Japan
| | - Rintaro Sogawa
- Department of Pharmacy, Saga University Hospital, 5-1-1 Nabeshima, Saga, 849-8501, Japan.
| | - Satoko Tsuruhashi
- Department of Pharmacy, Saga University Hospital, 5-1-1 Nabeshima, Saga, 849-8501, Japan
| | - Toru Murakawa-Hirachi
- Department of Psychiatry, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan
| | - Ayaka Matsuoka
- Department of Emergency and Critical Care Medicine, Saga University Hospital, 5-1-1 Nabeshima, Saga, 849-8501, Japan
| | - Yoshito Mizoguchi
- Department of Psychiatry, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan
| | - Akira Monji
- Department of Psychiatry, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan
| | - Chisato Shimanoe
- Department of Pharmacy, Saga University Hospital, 5-1-1 Nabeshima, Saga, 849-8501, Japan
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Almuzayyen HA, Chowdhury T, Alghamdi AS. Postoperative cognitive recovery and prevention of postoperative cognitive complications in the elderly patient. Saudi J Anaesth 2023; 17:550-556. [PMID: 37779573 PMCID: PMC10540994 DOI: 10.4103/sja.sja_529_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 06/25/2023] [Accepted: 06/26/2023] [Indexed: 10/03/2023] Open
Abstract
Elderly patients undergoing surgery are at higher risk of life-altering and costly complications. This challenge is increasingly recognized with the growing geriatric surgical population. Advanced age and comorbid conditions, such as disability and frailty that often develop with age, are all independent risk factors of postoperative morbidity and mortality. A common factor in this age group is cognitive impairment, which poses a challenge for the patient and clinician in the perioperative setting. It affects the capacity for informed consent and limits optimization before surgery; furthermore, an existing impairment may progress in severity during the perioperative period, and new onset of signs of delirium or postoperative cognitive dysfunction may arise during postoperative recovery. In this article, we aim to review the current literature examining the latest definitions, diagnostic criteria, and preventive strategies that may ameliorate postoperative cognitive complications.
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Affiliation(s)
- Hisham A. Almuzayyen
- Department of Anesthesiology, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
- King Fahad Hospital of University, Imam Abdulrahman Bin Faisal University, Khobar, Saudi Arabia
| | - Tumul Chowdhury
- Department of Anesthesia, Toronto Western Hospital, Clinical Investigator, UHN, University of Toronto, Toronto, Canada
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Gaba A, Li P, Xi Z, Gao C, Ruixue C, Hu K, Gao L. Associations between depression symptom burden and delirium risk: a prospective cohort study. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.09.21.23295926. [PMID: 37790485 PMCID: PMC10543040 DOI: 10.1101/2023.09.21.23295926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
BACKGROUND AND OBJECTIVES Delirium and depression are increasingly common in aging. There is considerable clinical overlap, including shared symptoms and comorbid conditions, including Alzheimer's disease (AD), functional decline, and mortality. Despite this, the long-term relationship between depression and delirium remains unclear. This study assessed the associations of depression symptom burden and its trajectory with delirium risk in a 12-year prospective study of older individuals during hospitalization. RESEARCH DESIGN AND METHODS 319,141 UK biobank participants between 2006-2010 (mean 58y [range 37-74, SD=8], 54% female) reported frequency (0-3) of four depressive symptoms (mood, disinterest, tenseness, or lethargy) in the preceding 2 weeks, and aggregated into a depressive symptom burden score (0-12). New-onset delirium was obtained from hospitalization records during 12y median follow-up. 40,451 (mean age 57±8; range 40-74y) had repeat assessment on average 8y after their first. Cox proportional hazard models examined whether depression symptom burden and trajectory predicted incident delirium during hospitalization. RESULTS 5,753 (15 per 1000) newly developed delirium during follow-up. Increased risk for delirium was seen for mild (aggregated scores 1-2, hazards ratio, HR=1.16, [95% confidence interval 1.08-1.25], p<0.001), modest (scores 3-5, 1.30 [1.19-1.43], p<0.001) and severe (scores ≥ 5, 1.38 [1.24-1.55], p<0.001) depressive symptoms, versus none in the fully adjusted model. These findings were independent of the number of hospitalizations and consistent across hospitalization settings (e.g., surgical, medical, or critical care) and specialty (e.g., neuropsychiatric, cardiorespiratory or other). Worsening depression symptoms (≥1 point increase), compared to no change/improved score, were associated with an additional 39% increased risk (1.39 [1.03-1.88], p=0.03) independent of baseline depression burden. The association was strongest in those over 65y at baseline (p for interaction <0.001). DISCUSSION AND IMPLICATIONS Depression symptom burden and worsening trajectory predicted delirium risk during hospitalization. Increased awareness of subclinical depression symptoms may be warranted for delirium prevention.
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Affiliation(s)
- Arlen Gaba
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, MA, USA
- Wake Forest University School of Medicine, Winston Salem, NC, USA
| | - Peng Li
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, MA, USA
- Division of Sleep Medicine, Harvard Medical School, Boston, MA, USA
| | - Zheng Xi
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, MA, USA
| | - Chenlu Gao
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, MA, USA
- Division of Sleep Medicine, Harvard Medical School, Boston, MA, USA
| | - Cai Ruixue
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, MA, USA
| | - Kun Hu
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, MA, USA
- Division of Sleep Medicine, Harvard Medical School, Boston, MA, USA
| | - Lei Gao
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, MA, USA
- Division of Sleep Medicine, Harvard Medical School, Boston, MA, USA
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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27
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Zhou Y, Wang X, Li Z, Ma Y, Yu C, Chen Y, Ding J, Yu J, Zhou R, Yang N, Liu T, Guo X, Fan T, Shi C. Development of a Brief Cognitive Screening Tool for Predicting Postoperative Delirium in Patients with Parkinson's Disease: A Secondary Analysis. Clin Interv Aging 2023; 18:1555-1564. [PMID: 37727451 PMCID: PMC10506594 DOI: 10.2147/cia.s410687] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 09/04/2023] [Indexed: 09/21/2023] Open
Abstract
Background A simple, rapid, and effective cognitive screening test appropriate for fast-paced settings with limited resources and staff is essential, especially preoperatively. This study aimed to develop and validate the short versions of Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) for predicting postoperative delirium (POD) in patients with Parkinson's disease (PD) who were scheduled for surgery. Methods The current study was a secondary analysis of data collected from 128 inpatients scheduled for deep brain stimulation of the subthalamic nuclei (STN-DBS) lasting >60 min, at Tsinghua University Yuquan Hospital, China. Preoperative cognitive screening was performed during the preoperative visit using the MMSE and MoCA. The optimal MMSE and MoCA cut-off scores for detecting PD-MCI was 27 and 23 respectively. The POD was assessed twice a day on the first postoperative day until discharge by the confusion assessment method. The backward conditional logistic regression analysis was used to organize the reduced versions of the MMSE or MoCA. Also, the areas under the receiver operating characteristic curves (AUCs) were examined using the DeLong test. Results 125/128 PD patients were included in the analysis, and 27 (21.6%) developed POD. The MMSE reduced version (orientation to time, attention and calculation, and comprehension) demonstrated performance similar to the original MMSE in predicting POD (z=0.820, p=0.412). The AUC of the original MoCA and the short MoCA (visuospatial and executive attention and orientation) were 0.808 and 0.826, respectively. There was no significantly difference in the AUC values between the tests (z=0.561, p=0.575). Conclusion Our simplified MMSE and MoCA could be efficiently used to identify patients at risk for POD. Also, short cognitive tests could be considered while predicting POD in fast-paced preoperative settings with limited resources and staff.
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Affiliation(s)
- Yongde Zhou
- Department of Anesthesiology, Tsinghua University Yuquan Hospital, Beijing, 100040, People’s Republic of China
| | - Xiaoxiao Wang
- Department of Anesthesiology, Peking University Third Hospital, Beijing, 100191, People’s Republic of China
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing, 100191, People’s Republic of China
| | - Zhengqian Li
- Department of Anesthesiology, Peking University Third Hospital, Beijing, 100191, People’s Republic of China
- Beijing Center of Quality Control and Improvement on Clinical Anesthesia, Beijing, 100191, People’s Republic of China
| | - Yu Ma
- Department of Neurosurgery, Tsinghua University Yuquan Hospital, Beijing, 100040, People’s Republic of China
| | - Cuiping Yu
- Department of Anesthesiology, Tsinghua University Yuquan Hospital, Beijing, 100040, People’s Republic of China
| | - Yao Chen
- Department of Anesthesiology, Tsinghua University Yuquan Hospital, Beijing, 100040, People’s Republic of China
| | - Jian Ding
- Department of Anesthesiology, Tsinghua University Yuquan Hospital, Beijing, 100040, People’s Republic of China
| | - Jianfeng Yu
- Department of Anesthesiology, Tsinghua University Yuquan Hospital, Beijing, 100040, People’s Republic of China
| | - Rongsong Zhou
- Department of Neurosurgery, Tsinghua University Yuquan Hospital, Beijing, 100040, People’s Republic of China
| | - Ning Yang
- Department of Anesthesiology, Peking University Third Hospital, Beijing, 100191, People’s Republic of China
- Beijing Center of Quality Control and Improvement on Clinical Anesthesia, Beijing, 100191, People’s Republic of China
| | - Taotao Liu
- Department of Anesthesiology, Peking University Third Hospital, Beijing, 100191, People’s Republic of China
- Beijing Center of Quality Control and Improvement on Clinical Anesthesia, Beijing, 100191, People’s Republic of China
| | - Xiangyang Guo
- Department of Anesthesiology, Peking University Third Hospital, Beijing, 100191, People’s Republic of China
- Beijing Center of Quality Control and Improvement on Clinical Anesthesia, Beijing, 100191, People’s Republic of China
| | - Ting Fan
- Department of Anesthesiology, Tsinghua University Yuquan Hospital, Beijing, 100040, People’s Republic of China
| | - Chengmei Shi
- Department of Anesthesiology, Peking University Third Hospital, Beijing, 100191, People’s Republic of China
- Beijing Center of Quality Control and Improvement on Clinical Anesthesia, Beijing, 100191, People’s Republic of China
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28
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Sandhu MRS, Tickoo M, Bardia A. Data Science and Geriatric Anesthesia Research: Opportunity and Challenges. Anesthesiol Clin 2023; 41:631-646. [PMID: 37516499 DOI: 10.1016/j.anclin.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2023]
Abstract
With an increase in geriatric population undergoing surgical procedures, research focused on enhancing their perioperative outcomes is of paramount importance. Currently, most of the evidence-based medicine protocols are driven by studies concentrating on adults encompassing all adult age groups. Given the alterations in physiology with aging, geriatric patients respond differently to anesthetics and, therefore, require specific research initiatives to further expound on the same. Large databases and the development of sophisticated analytic tools can provide meaningful insights into this. Here, we discuss a few research opportunities and challenges that data scientists face when focusing on geriatric perioperative research.
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Affiliation(s)
- Mani Ratnesh S Sandhu
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Mayanka Tickoo
- Division of Pulmonary, Department of Medicine, Critical Care and Sleep Medicine, Tufts Medical Center, Biewend Building, 3Road Floor, 260 Tremont Street, Boston, MA 02118, USA
| | - Amit Bardia
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA 06520, USA.
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29
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Lersch F, Zingg TJG, Knapp J, Stüber F, Hight D, Kaiser HA. [Processed EEG for personalized dosing of anesthetics during general anesthesia]. DIE ANAESTHESIOLOGIE 2023; 72:662-676. [PMID: 37552241 PMCID: PMC10457248 DOI: 10.1007/s00101-023-01313-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/26/2023] [Indexed: 08/09/2023]
Abstract
Electroencephalogram (EEG)-guided anesthesia is indispensable in modern operating rooms and has become established as the standard form of monitoring. Many anesthesiologists rely on processed EEG indices in the hope of averting anesthesia-related complications, such as intraoperative awareness, postoperative delirium and other cognitive complications in their patients. This educational review aims to provide information on the five most prevalent monitors used to guide depth of sedation during general anesthesia. This article elucidates the principles underpinning the application of these monitors where known, which are generally based on power in various EEG frequency bands and on the burst suppression pattern. Convinced that EEG-guided anesthesia has the potential of benefitting many surgical patients, it is felt that many basic principles and shortcomings of processed EEG indices need to be better understood in the clinical practice. After discussing the different monitors and clinically relevant data from the literature, the article gives a short practical guidance on how to critically interpret processed EEG information and troubleshooting of confounded indices in the context of clinical situations.
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Affiliation(s)
- F Lersch
- Universitätsklinik für Anästhesiologie und Schmerzmedizin, Inselspital, Universitätsspital Bern, Universität Bern, Freiburgstrasse, 3010, Bern, Schweiz
| | - T J G Zingg
- Universitätsklinik für Anästhesiologie und Schmerzmedizin, Inselspital, Universitätsspital Bern, Universität Bern, Freiburgstrasse, 3010, Bern, Schweiz
| | - J Knapp
- Universitätsklinik für Anästhesiologie und Schmerzmedizin, Inselspital, Universitätsspital Bern, Universität Bern, Freiburgstrasse, 3010, Bern, Schweiz
| | - F Stüber
- Universitätsklinik für Anästhesiologie und Schmerzmedizin, Inselspital, Universitätsspital Bern, Universität Bern, Freiburgstrasse, 3010, Bern, Schweiz
| | - D Hight
- Universitätsklinik für Anästhesiologie und Schmerzmedizin, Inselspital, Universitätsspital Bern, Universität Bern, Freiburgstrasse, 3010, Bern, Schweiz
| | - H A Kaiser
- Universitätsklinik für Anästhesiologie und Schmerzmedizin, Inselspital, Universitätsspital Bern, Universität Bern, Freiburgstrasse, 3010, Bern, Schweiz.
- Zentrum für Anästhesiologie und Intensivmedizin, Hirslanden Klinik Aarau, Hirslanden AG, Schänisweg, 5001, Aarau, Schweiz.
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30
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Spence J, Belley-Côté E, Jacobsohn E, Lee SF, D’Aragon F, Avidan M, Mazer CD, Rousseau-Saine N, Rajamohan R, Pryor K, Klein R, Tan E(CH, Cameron M, Di Sante E, DeBorba E, Mustard M, Couture E, Zamper R, Law M, Djaiani G, Saha T, Choi S, Hedlin P, Pikaluk R, Lam WY, Deschamps A, Whitlock R, Dulong B, Devereaux P, Beaver C, Kloppenburg S, Oczkowski S, McIntyre WF, McFarling M, Lamy A, Vincent J, Connolly S. Benzodiazepine-Free Cardiac Anesthesia for Reduction of Postoperative Delirium (B-Free): A Protocol for a Multi-centre Randomized Cluster Crossover Trial. CJC Open 2023; 5:691-699. [PMID: 37744662 PMCID: PMC10516716 DOI: 10.1016/j.cjco.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 06/01/2023] [Indexed: 09/26/2023] Open
Abstract
Delirium is common after cardiac surgery and is associated with adverse outcomes. Administration of benzodiazepines before and after cardiac surgery is associated with delirium; guidelines recommend minimizing their use. Benzodiazepine administration during cardiac surgery remains common because of its recognized benefits. The Benzodiazepine-Free Cardiac Anesthesia for Reduction of Postoperative Delirium (B-Free) trial is a randomized cluster crossover trial evaluating whether an institutional policy of restricting intraoperative benzodiazepine administration (ie, ≥ 90% of patients do not receive benzodiazepines during cardiac surgery), as compared with a policy of liberal intraoperative benzodiazepine administration (ie, ≥ 90% of patients receive ≥ 0.03 mg/kg midazolam equivalent), reduces delirium. Hospitals performing ≥ 250 cardiac surgeries a year are included if their cardiac anesthesia group agrees to apply both benzodiazepine policies per their randomization, and patients are assessed for postoperative delirium every 12 hours in routine clinical care. Hospitals apply the restricted or liberal benzodiazepine policy during 12 to 18 crossover periods of 4 weeks each. Randomization for all periods takes place in advance of site startup; sites are notified of their allocated policy during the last week of each crossover period. Policies are applied to all patients undergoing cardiac surgery during the trial period. The primary outcome is the incidence of delirium at up to 72 hours after surgery. The B-Free trial will enroll ≥ 18,000 patients undergoing cardiac surgery at 20 hospitals across North America. Delirium is common after cardiac surgery, and benzodiazepines are associated with the occurrence of delirium. The B-Free trial will determine whether an institutional policy restricting the administration of benzodiazepines during cardiac surgery reduces the incidence of delirium after cardiac surgery. Clinicaltrials.gov registration number: NCT03928236 (First registered April 26, 2019).
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Affiliation(s)
- Jessica Spence
- Departments of Anesthesia and Critical Care and Health Research Methods, Evaluation, and Impact, McMaster University; and Perioperative Research Division, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Emilie Belley-Côté
- Departments of Medicine (Cardiology and Critical Care), and Health Research Methods, Evaluation, and Impact, McMaster University, and Perioperative Research Division, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Eric Jacobsohn
- Departments of Anesthesia and Perioperative Medicine and Medicine (Critical Care), University of Manitoba, Winnipeg, Manitoba, Canada
| | - Shun Fu Lee
- Department of Health Research Methods, Evaluation, and Impact, McMaster University, and Population Health Research Institute, Hamilton, Ontario, Canada
| | - Frederick D’Aragon
- Département d'anesthésiologie, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Michael Avidan
- Department of Anesthesia, Washington University at St. Louis, St. Louis, Missouri, USA
| | - C. David Mazer
- Department of Anesthesia and Li Ka Shing Knowledge Institute, St. Michael’s Hospital, and Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Raja Rajamohan
- Department of Anesthesia, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kane Pryor
- Department of Anesthesiology, Weill Cornell Medical College, New York, New York, USA
| | - Rael Klein
- Department of Anesthesia, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Matthew Cameron
- Department of Anesthesia, McGill University, Montreal, Quebec, Canada
| | - Emily Di Sante
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Erin DeBorba
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Mary Mustard
- St. Michael's Hospital, Toronto, Ontario, Canada
| | - Etienne Couture
- Département d'anesthésiologie, Université Laval, Quebec City, Quebec, Canada
| | - Raffael Zamper
- Department of Anesthesia, University of Western Ontario, London, Ontario, Canada
| | - Michael Law
- Department of Anesthesia, University of British Columbia, Vancouver, British Columbia, Canada
| | - George Djaiani
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Tarit Saha
- Department of Anesthesia, Queen's University, Kingston, Ontario, Canada
| | - Stephen Choi
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Peter Hedlin
- Department of Anesthesia, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Ryan Pikaluk
- Department of Anesthesia, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Wing Ying Lam
- Department of Anesthesia, University of Alberta, Edmonton, Alberta, Canada
| | - Alain Deschamps
- Département d'anesthésiologie, Université de Montréal, Montréal, Quebec, Canada
| | - Richard Whitlock
- Departments of Surgery (Cardiac Surgery) and Health Research Methods, Evaluation, and Impact, McMaster University, and Perioperative Research Division, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Braden Dulong
- Department of Anesthesia, Dalhousie University, Halifax, Nova Scotia, Canada
| | - P.J. Devereaux
- Departments of Medicine (Cardiology and Critical Care), and Health Research Methods, Evaluation, and Impact, McMaster University, and Perioperative Research Division, Population Health Research Institute, Hamilton, Ontario, Canada
| | | | | | - Simon Oczkowski
- Department of Medicine (Critical Care), McMaster University, Hamilton, Ontario, Canada
| | - William Finlay McIntyre
- Department of Medicine (Cardiology), McMaster University, and Perioperative Research Division, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Matthew McFarling
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Andre Lamy
- Departments of Surgery (Cardiac Surgery) and Health Research Methods, Evaluation, and Impact, McMaster University, Perioperative Research Division, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Jessica Vincent
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Stuart Connolly
- Department of Medicine (Cardiology), McMaster University, and Population Health Research Institute, Hamilton, Ontario, Canada
| | - B-Free Investigators∗
- Departments of Anesthesia and Critical Care and Health Research Methods, Evaluation, and Impact, McMaster University; and Perioperative Research Division, Population Health Research Institute, Hamilton, Ontario, Canada
- Departments of Medicine (Cardiology and Critical Care), and Health Research Methods, Evaluation, and Impact, McMaster University, and Perioperative Research Division, Population Health Research Institute, Hamilton, Ontario, Canada
- Departments of Anesthesia and Perioperative Medicine and Medicine (Critical Care), University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Health Research Methods, Evaluation, and Impact, McMaster University, and Population Health Research Institute, Hamilton, Ontario, Canada
- Département d'anesthésiologie, Université de Sherbrooke, Sherbrooke, Quebec, Canada
- Department of Anesthesia, Washington University at St. Louis, St. Louis, Missouri, USA
- Department of Anesthesia and Li Ka Shing Knowledge Institute, St. Michael’s Hospital, and Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Département d'anesthésiologie, Université de Montréal, Montréal, Quebec, Canada
- Department of Anesthesia, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Anesthesiology, Weill Cornell Medical College, New York, New York, USA
- Department of Anesthesia, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Anesthesia, McGill University, Montreal, Quebec, Canada
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
- St. Michael's Hospital, Toronto, Ontario, Canada
- Département d'anesthésiologie, Université Laval, Quebec City, Quebec, Canada
- Department of Anesthesia, University of Western Ontario, London, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia, Queen's University, Kingston, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
- Department of Anesthesia, University of Alberta, Edmonton, Alberta, Canada
- Departments of Surgery (Cardiac Surgery) and Health Research Methods, Evaluation, and Impact, McMaster University, and Perioperative Research Division, Population Health Research Institute, Hamilton, Ontario, Canada
- Sheridan College, Brampton, Ontario, Canada
- Population Health Research Institute, Hamilton, Ontario, Canada
- Department of Medicine (Critical Care), McMaster University, Hamilton, Ontario, Canada
- Department of Medicine (Cardiology), McMaster University, and Perioperative Research Division, Population Health Research Institute, Hamilton, Ontario, Canada
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
- Departments of Surgery (Cardiac Surgery) and Health Research Methods, Evaluation, and Impact, McMaster University, Perioperative Research Division, Population Health Research Institute, Hamilton, Ontario, Canada
- Department of Medicine (Cardiology), McMaster University, and Population Health Research Institute, Hamilton, Ontario, Canada
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31
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Rhee J, Vazquez R, Ma H. Pro-Con Debate: Judicious Benzodiazepine Administration for Preoperative Anxiolysis in Older Patients. Anesth Analg 2023; 137:280-288. [PMID: 37450906 PMCID: PMC10358369 DOI: 10.1213/ane.0000000000006337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
In this Pro-Con commentary article, we discuss the risks and benefits of administering preoperative benzodiazepines to older patients to decrease preoperative anxiety. The Pro side first focuses on the critical importance of treating preoperative anxiety and that benzodiazepines are the best tool to achieve that goal. The competing argument presented by the Con side is that myriad options exist to treat preoperative anxiety without simultaneously increasing the risk for devastating complications such as postoperative delirium. Both sides call for more high-quality investigations to determine the most effective strategies for decreasing preoperative anxiety in older adults while improving outcomes and reducing morbidity.
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Affiliation(s)
- James Rhee
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Rafael Vazquez
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Haobo Ma
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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32
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Wang E, Belley-Côté EP, Young J, He H, Saud H, D'Aragon F, Um K, Alhazzani W, Piticaru J, Hedden M, Whitlock R, Mazer CD, Kashani HH, Zhang SY, Lucas A, Timmerman N, Nishi C, Jain D, Kugler A, Beaver C, Kloppenburg S, Schulman S, Borges FK, Kavosh M, Wada C, Lin S, Sibilio S, Lauw M, Benz A, Szczeklik W, Mokhtari A, Jacobsohn E, Spence J. Effect of perioperative benzodiazepine use on intraoperative awareness and postoperative delirium: a systematic review and meta-analysis of randomised controlled trials and observational studies. Br J Anaesth 2023; 131:302-313. [PMID: 36621439 DOI: 10.1016/j.bja.2022.12.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 11/07/2022] [Accepted: 12/02/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Benzodiazepine use is associated with delirium, and guidelines recommend avoiding them in older and critically ill patients. Their perioperative use remains common because of perceived benefits. METHODS We searched CENTRAL, MEDLINE, CINAHL, PsycInfo, and Web of Science from inception to June 2021. Pairs of reviewers identified randomised controlled trials and prospective observational studies comparing perioperative use of benzodiazepines with other agents or placebo in patients undergoing surgery. Two reviewers independently abstracted data, which we combined using a random-effects model. Our primary outcomes were delirium, intraoperative awareness, and mortality. RESULTS We included 34 randomised controlled trials (n=4354) and nine observational studies (n=3309). Observational studies were considered separately. Perioperative benzodiazepines did not increase the risk of delirium (n=1352; risk ratio [RR] 1.43; 95% confidence interval [CI]: 0.9-2.27; I2=72%; P=0.13; very low-quality evidence). Use of benzodiazepines instead of dexmedetomidine did, however, increase the risk of delirium (five studies; n=429; RR 1.83; 95% CI: 1.24-2.72; I2=13%; P=0.002). Perioperative benzodiazepine use decreased the risk of intraoperative awareness (n=2245; RR 0.26; 95% CI: 0.12-0.58; I2=35%; P=0.001; very low-quality evidence). When considering non-events, perioperative benzodiazepine use increased the probability of not having intraoperative awareness (RR 1.07; 95% CI: 1.01-1.13; I2=98%; P=0.03; very low-quality evidence). Mortality was reported by one randomised controlled trial (n=800; RR 0.90; 95% CI: 0.20-3.1; P=0.80; very low quality). CONCLUSIONS In this systematic review and meta-analysis, perioperative benzodiazepine use did not increase postoperative delirium and decreased intraoperative awareness. Previously observed relationships of benzodiazepine use with delirium could be explained by comparisons with dexmedetomidine. SYSTEMATIC REVIEW PROTOCOL PROSPERO CRD42019128144.
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Affiliation(s)
- Eugene Wang
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Emilie P Belley-Côté
- Departments of Medicine (Cardiology and Critical Care), McMaster University, Hamilton, ON, Canada; Perioperative Research Division, Population Health Research Institute, Hamilton, ON, Canada
| | - Jack Young
- Health Sciences Library, McMaster University, Hamilton, ON, Canada
| | - Henry He
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Haris Saud
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Frederick D'Aragon
- Départment d'anesthésiologie, Université de Sherbrooke, Quebec, QU, Canada
| | - Kevin Um
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Waleed Alhazzani
- Departments of Critical Care, Medicine (Gastroenterology), and Health Research Methods, Evaluation, and Impact, McMaster University, Hamilton, ON, Canada
| | - Joshua Piticaru
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Matthew Hedden
- Faculty of Arts and Science, Queen's University, Kingston, ON, Canada
| | - Richard Whitlock
- Perioperative Research Division, Population Health Research Institute, Hamilton, ON, Canada; Departments of Surgery (Cardiac Surgery) and Health Research Methods, Evaluation, and Impact, McMaster University, Hamilton, ON, Canada
| | - C David Mazer
- Department of Anesthesia and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Hessam H Kashani
- Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada
| | | | - Amanda Lucas
- Department of Health Research Methods, Evaluation, and Impact; McMaster University, Hamilton, ON, Canada
| | | | - Cameron Nishi
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Davinder Jain
- Department of Anesthesiology, Trillium Health Partners, Toronto, ON, Canada
| | - Aaron Kugler
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | | | | | - Sam Schulman
- Department of Medicine (Hematology), McMaster University, Hamilton, ON, Canada; Thrombosis and Atherosclerosis Research Institute, Population Health Research Institute, Hamilton, ON, Canada; Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Flavia K Borges
- Perioperative Research Division, Population Health Research Institute, Hamilton, ON, Canada; Departments of Medicine and Health Research Methods, Evaluation, and Impact, McMaster University, Hamilton, ON, Canada
| | - Morvarid Kavosh
- Department of Medicine, Coney Island Hospital, Brooklyn, NY, USA
| | - Chihiro Wada
- Faculty of Arts, Waseda University, Tokyo, Japan
| | - Sabrina Lin
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Serena Sibilio
- Division of Cardiac Surgery, Instituto Clinico Sant'Ambrogio, Milan, Italy; Division of Cardiac Surgery, Centre Hospitalière Universitaire de Lille, Lille, France
| | - Mandy Lauw
- Population Health Research Institute, Hamilton, ON, Canada
| | - Alexander Benz
- Population Health Research Institute, Hamilton, ON, Canada
| | - Wojciech Szczeklik
- Center for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Arastoo Mokhtari
- Department of Medicine (Cardiology), McMaster University, Hamilton, ON, Canada
| | - Eric Jacobsohn
- Departments of Anesthesia and Perioperative Medicine and Medicine (Critical Care), University of Manitoba, Winnipeg, MB, Canada
| | - Jessica Spence
- Perioperative Research Division, Population Health Research Institute, Hamilton, ON, Canada; Departments of Anesthesia and Critical Care and Health Research Methods, Evaluation, and Impact, McMaster University, Hamilton, ON, Canada.
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Deng Y, Hong JS, Cao YY, Kang N, Han DY, Li YT, Chen L, Li ZQ, Zhan R, Guo XY, Yang N, Shi CM. Specific antagonist of receptor for advanced glycation end‑products attenuates delirium‑like behaviours induced by sevoflurane anaesthesia with surgery in aged mice partially by improving damage to the blood‑brain barrier. Exp Ther Med 2023; 26:317. [PMID: 38895540 PMCID: PMC11184639 DOI: 10.3892/etm.2023.12016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 02/16/2023] [Indexed: 06/21/2024] Open
Abstract
Postoperative delirium (POD), which occurs in hospital up to 1-week post-procedure or until discharge, is a common complication, especially in older adult patients. However, the pathogenesis of POD remains unclear. Although damage to blood-brain barrier (BBB) integrity is involved in the neuropathogenesis of POD, the specific role of the BBB in POD requires further elucidation. Anaesthesia using 2% isoflurane for 4 h results in the upregulation of hippocampal receptor for advanced glycation end-products (RAGE) expression and β-amyloid accumulation in aged rats. The present study investigated the role of RAGE in BBB integrity and its mechanisms in POD-like behaviours. The buried food, open field and Y maze tests were used to evaluate neurobehavioural changes in aged mice following 2.5% sevoflurane anaesthesia administration with exploratory laparotomy. Levels of tight junction proteins were assessed by western blotting. Multiphoton in vivo microscopy was used to observe the ultrastructural changes in the BBB in the hippocampal CA1 region. Anaesthesia with surgery decreased the levels of tight junction proteins occludin and claudin 5, increased matrix metalloproteinases (MMPs) 2 and 9, damaged the ultrastructure of the BBB and induced POD-like behaviour. FPS-ZM1, a specific RAGE antagonist, ameliorated POD-like behaviour induced by anaesthesia and surgery in aged mice. Furthermore, FPS-ZM1 also restored decreased levels of occludin and claudin 5 as well as increased levels of MMP2 and MMP9. The present findings suggested that RAGE signalling was involved in BBB damage following anaesthesia with surgery. Thus, RAGE has potential as a novel therapeutic intervention for the prevention of POD.
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Affiliation(s)
- Ying Deng
- Department of Anaesthesiology, Peking University Third Hospital, Beijing 100191, P.R. China
| | - Jing-Shu Hong
- Department of Anaesthesiology, Peking University Third Hospital, Beijing 100191, P.R. China
| | - Yi-Yun Cao
- Department of Anaesthesiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200233, P.R. China
| | - Ning Kang
- Department of Anaesthesiology, Peking University Third Hospital, Beijing 100191, P.R. China
| | - Deng-Yang Han
- Department of Anaesthesiology, Peking University Third Hospital, Beijing 100191, P.R. China
| | - Yi-Tong Li
- Department of Anaesthesiology, Peking University Third Hospital, Beijing 100191, P.R. China
| | - Lei Chen
- Department of Anaesthesiology, Peking University Third Hospital, Beijing 100191, P.R. China
| | - Zheng-Qian Li
- Department of Anaesthesiology, Peking University Third Hospital, Beijing 100191, P.R. China
- Beijing Center of Quality Control and Improvement on Clinical Anesthesia, Beijing 100191, P.R. China
| | - Rui Zhan
- The Institute of Cardiovascular Sciences and Institute of Systems Biomedicine, School of Basic Medical Sciences, Key Laboratory of Molecular Cardiovascular Science of Ministry of Education, NHC Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Beijing Key Laboratory of Cardiovascular Receptors Research, Health Science Center, Peking University, Beijing 100191, P.R. China
| | - Xiang-Yang Guo
- Department of Anaesthesiology, Peking University Third Hospital, Beijing 100191, P.R. China
- Beijing Center of Quality Control and Improvement on Clinical Anesthesia, Beijing 100191, P.R. China
| | - Ning Yang
- Department of Anaesthesiology, Peking University Third Hospital, Beijing 100191, P.R. China
| | - Cheng-Mei Shi
- Department of Anaesthesiology, Peking University Third Hospital, Beijing 100191, P.R. China
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34
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Tian BWCA, Stahel PF, Picetti E, Campanelli G, Di Saverio S, Moore E, Bensard D, Sakakushev B, Galante J, Fraga GP, Koike K, Di Carlo I, Tebala GD, Leppaniemi A, Tan E, Damaskos D, De'Angelis N, Hecker A, Pisano M, Maier RV, De Simone B, Amico F, Ceresoli M, Pikoulis M, Weber DG, Biffl W, Beka SG, Abu-Zidan FM, Valentino M, Coccolini F, Kluger Y, Sartelli M, Agnoletti V, Chirica M, Bravi F, Sall I, Catena F. Assessing and managing frailty in emergency laparotomy: a WSES position paper. World J Emerg Surg 2023; 18:38. [PMID: 37355698 DOI: 10.1186/s13017-023-00506-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/27/2023] [Indexed: 06/26/2023] Open
Abstract
Many countries are facing an aging population. As people live longer, surgeons face the prospect of operating on increasingly older patients. Traditional teaching is that with older age, these patients face an increased risk of mortality and morbidity, even to a level deemed too prohibitive for surgery. However, this is not always true. An active 90-year-old patient can be much fitter than an overweight, sedentary 65-year-old patient with comorbidities. Recent literature shows that frailty-an age-related cumulative decline in multiple physiological systems, is therefore a better predictor of mortality and morbidity than chronological age alone. Despite recognition of frailty as an important tool in identifying vulnerable surgical patients, many surgeons still shun objective tools. The aim of this position paper was to perform a review of the existing literature and to provide recommendations on emergency laparotomy and in frail patients. This position paper was reviewed by an international expert panel composed of 37 experts who were asked to critically revise the manuscript and position statements. The position paper was conducted according to the WSES methodology. We shall present the derived statements upon which a consensus was reached, specifying the quality of the supporting evidence and suggesting future research directions.
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Affiliation(s)
- Brian W C A Tian
- Department of General Surgery, Singapore General Hospital, Singapore, Singapore
| | - Philip F Stahel
- Department of Orthopedic Surgery and Department of Neurosurgery, Denver Health Medical Center and University of Colorado School of Medicine, Denver, CO, USA
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Parma, Parma, Italy
| | | | - Salomone Di Saverio
- Unit of General Surgery, San Benedetto del Tronto Hospital, av5 Asur Marche, San Benedetto del Tronto, Italy
| | - Ernest Moore
- Department of Surgery, Denver Health Medical Center, Denver, CO, USA
| | - Denis Bensard
- Department of Surgery, Denver Health Medical Center, Denver, CO, USA
| | - Boris Sakakushev
- Research Institute of Medical University Plovdiv/University Hospital St George Plovdiv, Plovdiv, Bulgaria
| | - Joseph Galante
- Trauma Department, University of California, Davis, Sacramento, CA, USA
| | - Gustavo P Fraga
- Faculdade de Ciências Médicas (FCM), Unicamp Campinas, Campinas, SP, Brazil
| | - Kaoru Koike
- Department of Primary Care and Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Isidoro Di Carlo
- Department of Surgical Sciences and Advanced Technologies "GF Ingrassia", University of Catania, Cannizzaro Hospital, Via Messina 829, 95126, Catania, Italy
| | - Giovanni D Tebala
- Oxford University Hospitals NHSFT John Radcliffe Hospital, Headley Way, HeadingtonOxford, OX3 9DU, UK
| | - Ari Leppaniemi
- General Surgery Department, Helsinki University Hospital, Helsinki, Finland
| | - Edward Tan
- Department of Surgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - Dimitris Damaskos
- General and Emergency Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Nicola De'Angelis
- Hôpital Henri Mondor, Université Paris Est, Service de Chirurgie Digestive et Hépato-Bilio-Pancréatique, Créteil, France
| | - Andreas Hecker
- Department of General and Thoracic Surgery, University Hospital, Giessen, Germany
| | - Michele Pisano
- General and Emergency Surgery, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Ron V Maier
- Department of Surgery, Harborview Medical Centre, University of Washington, Seattle, USA
| | - Belinda De Simone
- Department of Emergency Surgery, Centre Hospitalier Intercommunal de Villeneuve-Saint-Georges, Villeneuve-Saint-Georges, France
| | - Francesco Amico
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Marco Ceresoli
- General Surgery, Monza University Hospital, Monza, Italy
| | - Manos Pikoulis
- 3Rd Department of Surgery, Attikon General Hospital, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | - Dieter G Weber
- Department of General Surgery, Royal Perth Hospital, University of Western Australia, Perth, Australia
| | - Walt Biffl
- Department of Trauma and Acute Care Surgery, Scripps Memorial Hospital La Jolla, La Jolla, San Diego, CA, USA
| | - Solomon Gurmu Beka
- School of Medicine and Health Science, University of Otago, Wellington Campus, Wellington, New Zealand
| | - Fikri M Abu-Zidan
- The Research Office, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, UAE
| | | | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | | | - Vanni Agnoletti
- Anesthesia and Intensive Care Unit, AUSL Romagna, M. Bufalini Hospital, Cesena, Italy
| | - Mircea Chirica
- Service de Chirurgie Digestive, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Francesca Bravi
- Healthcare Administration, Santa Maria Delle Croci Hospital, Ravenna, Italy
| | - Ibrahima Sall
- Department of General Surgery, Military Teaching Hospital, Hôpital Principal Dakar, Dakar, Senegal.
| | - Fausto Catena
- Department of Emergency and Trauma Surgery, Bufalini Hospital, Cesena, Italy
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Gao L, Li P, Gaykova N, Zheng X, Gao C, Lane JM, Saxena R, Scheer FAJL, Rutter MK, Akeju O, Hu K. Circadian Rest-Activity Rhythms, Delirium Risk, and Progression to Dementia. Ann Neurol 2023; 93:1145-1157. [PMID: 36808743 PMCID: PMC10247440 DOI: 10.1002/ana.26617] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 02/13/2023] [Accepted: 02/16/2023] [Indexed: 02/22/2023]
Abstract
OBJECTIVE Delirium is a complex neurocognitive syndrome suspected to be bidirectionally linked to dementia. Circadian rhythm disturbances likely contribute to dementia pathogenesis, but whether these disturbances are related to delirium risk and progression to all-cause dementia is unknown. METHODS We analyzed continuous actigraphy data from 53,417 middle-aged or older UK Biobank participants during a median 5 years of follow-up. Four measures were used to characterize the 24-hour daily rest-activity rhythms (RARs): normalized amplitude, acrophase representing the peak activity time, interdaily stability, and intradaily variability (IV) for fragmentation of the rhythm. Cox proportional hazards models examined whether RARs predicted incident delirium (n = 551) and progression to dementia (n = 61). RESULTS Suppressed 24-hour amplitude, lowest (Q1) versus highest (Q4) quartile (hazard ratio [HR]Q1 vs Q4 = 1.94, 95% confidence interval [CI] = 1.53-2.46, p < 0.001), and more fragmented (higher IV: HRQ4 vs Q1 = 1.49, 95% CI = 1.18-1.88, p < 0.001) rhythms predicted higher delirium risk, after adjusting for age, sex, education, cognitive performance, sleep duration/disturbances, and comorbidities. In those free from dementia, each hour of delayed acrophase was associated with delirium risk (HR = 1.13, 95% CI = 1.04-1.23, p = 0.003). Suppressed 24-hour amplitude was associated with increased risk of progression from delirium to new onset dementia (HR = 1.31, 95% CI = 1.03-1.67, p = 0.03 for each 1-standard deviation decrease). INTERPRETATION Twenty-four-hour daily RAR suppression, fragmentation, and potentially delayed acrophase were associated with delirium risk. Subsequent progression to dementia was more likely in delirium cases with suppressed rhythms. The presence of RAR disturbances before delirium and prior to progression to dementia suggests that these disturbances may predict higher risk and be involved in early disease pathogenesis. ANN NEUROL 2023;93:1145-1157.
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Affiliation(s)
- Lei Gao
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, MA, USA
- Division of Sleep Medicine, Harvard Medical School, Boston, MA, USA
- Broad Institute of Massachusetts Institute of Technology and Harvard University, Cambridge, MA, USA
| | - Peng Li
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, MA, USA
- Division of Sleep Medicine, Harvard Medical School, Boston, MA, USA
- Broad Institute of Massachusetts Institute of Technology and Harvard University, Cambridge, MA, USA
| | - Nicole Gaykova
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, MA, USA
| | - Xi Zheng
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, MA, USA
| | - Chenlu Gao
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, MA, USA
- Division of Sleep Medicine, Harvard Medical School, Boston, MA, USA
| | - Jacqueline M Lane
- Division of Sleep Medicine, Harvard Medical School, Boston, MA, USA
- Broad Institute of Massachusetts Institute of Technology and Harvard University, Cambridge, MA, USA
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Richa Saxena
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Broad Institute of Massachusetts Institute of Technology and Harvard University, Cambridge, MA, USA
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Frank A J L Scheer
- Division of Sleep Medicine, Harvard Medical School, Boston, MA, USA
- Broad Institute of Massachusetts Institute of Technology and Harvard University, Cambridge, MA, USA
- Medical Chronobiology Program, Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, MA, USA
| | - Martin K Rutter
- Division of Diabetes, Endocrinology, and Gastroenterology, University of Manchester, Manchester, UK
- Diabetes Endocrinology and Metabolism Centre, Manchester University National Health Service Foundation Trust, Manchester, UK
| | - Oluwaseun Akeju
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kun Hu
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, MA, USA
- Division of Sleep Medicine, Harvard Medical School, Boston, MA, USA
- Broad Institute of Massachusetts Institute of Technology and Harvard University, Cambridge, MA, USA
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Bao L, Liu T, Zhang Z, Pan Q, Wang L, Fan G, Li Z, Yin Y. The prediction of postoperative delirium with the preoperative bispectral index in older aged patients: a cohort study. Aging Clin Exp Res 2023:10.1007/s40520-023-02408-9. [PMID: 37204755 DOI: 10.1007/s40520-023-02408-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 04/05/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Postoperative delirium (POD) is the most common postoperative complication in elderly patients, especially in older aged patients (aged 75 years or over). The development of electroencephalography analysis could provide indicators for early detection, intervention, and evaluation. If there are pathophysiological changes in the brain, the BIS value will also change accordingly. In this study, we investigated the predictive value of the preoperative bispectral (BIS) index in POD for patients aged over 75 years. METHODS In this prospective study, patients (≥ 75 years) undergoing elective non-neurosurgery and non-cardiac surgery under general anesthesia were included (n = 308). Informed consent was obtained from all involved patients. Before the operation and during the first 5 postoperative days, delirium was assessed with the confusion assessment method by trained researchers twice every day. Thereafter, the preoperative bedside BIS of each patient was dynamically acquired by the BIS VISTA monitoring system and the BIS monitoring of electrodes. A series of evaluation scales were assessed before and after surgery. A preoperative predictive score was generated according to the results of multivariable logistic regression. The receiver operating characteristic curves were drawn and the area under the curves was estimated to evaluate the perioperative diagnostic values of BIS and preoperative predictive score for POD. The specificity, sensitivity, positive predictive value (PPV), and negative predictive (NPV) value were calculated. RESULTS Delirium occurred in 50 of 308 (16.2%) patients. The median BIS of delirious patients was 86.7 (interquartile range [IQR] 80.0-94.0), lower than that of the non-delirious 91.9 (IQR 89.7-95.4, P < 0.001). According to the ROC curve of the BIS index, the optimal cut-off value was 84, with a sensitivity of 48%, specificity of 87%, PPV 43%, NPV 89% for forecasting POD and the area under curves was 0.67. While integrating BIS, mini-mental state examination, anemia, activities of daily living, and blood urea nitrogen, the model had a sensitivity of 78%, specificity of 74%, PPV of 0.37%, and NPV of 95% for forecasting POD, and the area under curves was 0.83. CONCLUSIONS Preoperative bedside BIS in delirium patients was lower than that in non-delirium patients when undergoing non-neurosurgery and non-cardiac surgery in patients aged over 75. The model of integrating BIS, mini-mental state examination, anemia, activities of daily living, and blood urea nitrogen is a promising tool for predicting postoperative delirium in patients aged over 75.
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Affiliation(s)
- Lin Bao
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
- Beijing Center of Quality Control and Improvement on Clinical Anesthesia, Beijing, China
| | - Taotao Liu
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
- Beijing Center of Quality Control and Improvement on Clinical Anesthesia, Beijing, China
| | - Zhenzhen Zhang
- Department of Anesthesiology, Capital Medical University Affiliated Beijing Shijitan Hospital, Beijing, China
| | - Qian Pan
- Department of Anesthesiology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin, China
- Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
- Tianjin's Clinical Research Center for Cancer, Tianjin, China
| | - Lifang Wang
- Department of Anesthesiology, China-Japan Friendship Hospital, Beijing, China
| | - Guohui Fan
- Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, China
| | - Zhengqian Li
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China.
- Beijing Center of Quality Control and Improvement on Clinical Anesthesia, Beijing, China.
| | - Yiqing Yin
- Department of Anesthesiology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin, China.
- Key Laboratory of Cancer Prevention and Therapy, Tianjin, China.
- Tianjin's Clinical Research Center for Cancer, Tianjin, China.
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Wakabayashi R. Anesthetic management of a patient with an electroencephalogram phenotype for a "vulnerable brain": a case report. JA Clin Rep 2023; 9:25. [PMID: 37193855 DOI: 10.1186/s40981-023-00616-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 04/28/2023] [Accepted: 05/06/2023] [Indexed: 05/18/2023] Open
Abstract
BACKGROUND Low frontal alpha power is an electroencephalogram phenotype suggesting vulnerability to anesthetics. This phenotype for a "vulnerable brain" carries risks for burst suppression at lower-than-expected anesthetic concentrations and therefore for postoperative delirium. CASE PRESENTATION A 73-year-old man underwent a laparoscopic Miles' operation. He was monitored with a bispectral index monitor. Before the skin incision, the fraction of age-adjusted minimum alveolar concentration of desflurane was 0.48, and a spectrogram showed slow-delta oscillation despite a bispectral index value of 38-48. Although the fraction of age-adjusted minimum alveolar concentration of desflurane decreased to 0.33, the EEG signature remained unchanged, along with a similar bispectral index value. No burst suppression patterns were observed throughout the whole procedure, and he did not experience postoperative delirium. CONCLUSIONS This case suggests that monitoring of electroencephalogram signatures is helpful for detecting patients with a "vulnerable brain" and for providing optimal anesthetic depth in such patients.
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Affiliation(s)
- Ryo Wakabayashi
- Department of Anesthesia, Nagano Red Cross Hospital, 5-22-1, Wakasato, Nagano, 380-8582, Japan.
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Igwe EO, Nealon J, O'Shaughnessy P, Bowden A, Chang HCR, Ho MH, Montayre J, Montgomery A, Rolls K, Chou KR, Chen KH, Traynor V, Smerdely P. Incidence of postoperative delirium in older adults undergoing surgical procedures: A systematic literature review and meta-analysis. Worldviews Evid Based Nurs 2023. [PMID: 37128953 DOI: 10.1111/wvn.12649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 03/05/2023] [Accepted: 03/11/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND With the increase in life expectancy around the globe, the incidence of postoperative delirium (POD) among older people (≥65 years) is growing. Previous studies showed a wide variation in the incidence of POD, from 4% to 53%, with a lack of specific evidence about the incidence of POD by specific surgery type among older people. The aim of this systematic review and meta-analysis was to determine the incidence of POD by surgery type within populations 65 years and over. METHODS Databases including PubMed, Cochrane library, Embase, and CINAHL were searched until October 2020. Due to the relatively higher number of meta-analyses undertaken in this area of research, a streamlined systematic meta-analysis was proposed. RESULTS A total of 28 meta-analyses (comprising 284 individual studies) were reviewed. Data from relevant individual studies (n = 90) were extracted and included in the current study. Studies were grouped into eight surgery types and the incidence of POD for orthopedic, vascular, spinal, cardiac, colorectal, abdominal, urologic, and mixed surgeries was 20%, 14%, 13%, 32%, 14%, 30%, 10%, and 26%, respectively. POD detection instruments were different across the studies, with Confusion Assessment Method (CAM & CAM-ICU) being the most frequently adopted. LINKING EVIDENCE TO ACTION This study showed that POD incidence in older people undergoing surgery varied widely across surgery type. The more complex surgeries like cardiac and abdominal surgeries were associated with a higher risk of POD. This highlights the need to include the level of surgery complexity as a risk factor in preoperative assessments.
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Affiliation(s)
- Ezinne Oyidia Igwe
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
- Illawarra Health and Medical Research Institute (IHMRI), Wollongong, New South Wales, Australia
| | - Jessica Nealon
- Illawarra Health and Medical Research Institute (IHMRI), Wollongong, New South Wales, Australia
- School of Medicine, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - Pauline O'Shaughnessy
- School of Mathematics and Applied Statistics, Faculty of Engineering and Information Sciences, University of Wollongong, Wollongong, New South Wales, Australia
| | - Alera Bowden
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
- Illawarra Health and Medical Research Institute (IHMRI), Wollongong, New South Wales, Australia
- Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia
| | - Hui-Chen Rita Chang
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
- Illawarra Health and Medical Research Institute (IHMRI), Wollongong, New South Wales, Australia
- School of Nursing and Midwifery, Western Sydney University, Penrith, New South Wales, Australia
| | - Mu-Hsing Ho
- School of Nursing, LKS Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Jed Montayre
- School of Nursing, Hong Kong Polytechnic University, Hung Hom, Hong Kong SAR
| | - Amy Montgomery
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
- Illawarra Health and Medical Research Institute (IHMRI), Wollongong, New South Wales, Australia
| | - Kaye Rolls
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - Kuei-Ru Chou
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
- Center for Nursing and Healthcare Research in Clinical Practice Application, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Department of Nursing, Taipei Medical University-Shuang Ho Hospital, New Taipei, Taiwan
- Psychiatric Research Center, Taipei Medical University Hospital, Taipei, Taiwan
| | - Kee-Hsin Chen
- Post-Baccalaureate Program in Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
- Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan
- Center for Nursing and Healthcare Research in Clinical Practice Application, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Evidence-based Knowledge Translation Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Victoria Traynor
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
- Illawarra Health and Medical Research Institute (IHMRI), Wollongong, New South Wales, Australia
| | - Peter Smerdely
- School of Population Health, UNSW Medicine, Sydney, New South Wales, Australia
- St George Hospital, Kogarah, New South Wales, Australia
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Yan E, He D, Rajji TK, Chung F. Cognitive impairment and its adverse outcomes in older surgical patients: an under-recognized problem! Int Anesthesiol Clin 2023; 61:23-28. [PMID: 36735463 DOI: 10.1097/aia.0000000000000392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Ellene Yan
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Ontario, Canada
| | - David He
- Department of Anesthesia and Pain Management, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Tarek K Rajji
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Ontario, Canada
- Department of Adult Neurodevelopment and Geriatric Psychiatry, Centre for Addictions and Mental Health, Toronto, Ontario, Canada
- Toronto Dementia Research Alliance, University of Toronto, Toronto, Ontario, Canada
| | - Frances Chung
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Ontario, Canada
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Yang KL, Detroyer E, Van Grootven B, Tuand K, Zhao DN, Rex S, Milisen K. Association between preoperative anxiety and postoperative delirium in older patients: a systematic review and meta-analysis. BMC Geriatr 2023; 23:198. [PMID: 36997928 PMCID: PMC10064748 DOI: 10.1186/s12877-023-03923-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 03/24/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND Postoperative delirium (POD) is a common postoperative complication associated with multiple adverse consequences on patient outcomes and higher medical expenses. Preoperative anxiety has been suggested as a possible precipitating factor for the development of POD. As such, we aimed to explore the association between preoperative anxiety and POD in older surgical patients. METHODS Electronic databases including MEDLINE (via PubMed), EMBASE (via Embase.com), Web of Science Core Collection, Cumulative Index to Nursing and Allied Health Literature (CINAHL Complete; via EBSCOhost) and clinical trial registries were systematically searched to identify prospective studies examining preoperative anxiety as a risk factor for POD in older surgical patients. We used Joanna Briggs Institute Critical Appraisal Checklist for Cohort Studies to assess the quality of included studies. The association between preoperative anxiety and POD was summarized with odds ratios (ORs) and 95% confidence intervals (CIs) using DerSimonian-Laird random-effects meta-analysis. RESULTS Eleven studies were included (1691 participants; mean age ranging between 63.1-82.3 years). Five studies used a theoretical definition for preoperative anxiety, with the Anxiety subscale of Hospital Anxiety and Depression Scale (HADS-A) as the instrument being most often used. When using dichotomized measures and within the HADS-A subgroup analysis, preoperative anxiety was significantly associated with POD (OR = 2.17, 95%CI: 1.01-4.68, I2 = 54%, Tau2 = 0.4, n = 5; OR = 3.23, 95%CI: 1.70-6.13, I2 = 0, Tau2 = 0, n = 4; respectively). No association was observed when using continuous measurements (OR = 0.99, 95%CI: 0.93-1.05, I2 = 0, Tau2 = 0, n = 4), nor in the subgroup analysis of STAI-6 (six-item version of state scale of Spielberger State-Trait Anxiety Inventory, OR = 1.07, 95%CI: 0.93-1.24, I2 = 0, Tau2 = 0, n = 2). We found the overall quality of included studies to be moderate to good. CONCLUSIONS An unclear association between preoperative anxiety and POD in older surgical patients was found in our study. Given the ambiguity in conceptualization and measurement instruments used for preoperative anxiety, more research is warranted in which a greater emphasis should be placed on how preoperative anxiety is operationalized and measured.
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Affiliation(s)
- Ke-Lu Yang
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven - University of Leuven, Kapucijnenvoer 35/4, B-3000, Leuven, Belgium
| | - Elke Detroyer
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven - University of Leuven, Kapucijnenvoer 35/4, B-3000, Leuven, Belgium
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Bastiaan Van Grootven
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven - University of Leuven, Kapucijnenvoer 35/4, B-3000, Leuven, Belgium
| | - Krizia Tuand
- KU Leuven Libraries - 2Bergen - Learning Centre Désiré Collen, Leuven, Belgium
| | - Dan-Ni Zhao
- The Second Clinic School, Lanzhou University, Lanzhou, China
| | - Steffen Rex
- Department of Anesthesiology, University Hospitals of Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, KU Leuven - University of Leuven, Leuven, Belgium
| | - Koen Milisen
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven - University of Leuven, Kapucijnenvoer 35/4, B-3000, Leuven, Belgium.
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium.
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Kiani SN, Maron SZ, Rao MG, Zubizarreta N, Mazumdar M, Galatz LM, Poeran J, Cagle PJ. The Burden of Postoperative Delirium After Shoulder Arthroplasty and Modifiable Pharmacological Perioperative Risk Factors: A Retrospective Nationwide Cohort Study. HSS J 2023; 19:13-21. [PMID: 36761234 PMCID: PMC9837409 DOI: 10.1177/15563316221134244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 08/21/2022] [Indexed: 12/13/2022]
Abstract
Background: Increasing demand for shoulder arthroplasty and an aging population may increase the rate of complications associated with advanced age such as postoperative delirium, but little is known on its burden in this cohort. Purpose: We sought to answer the following questions: (1) What is the epidemiology of postoperative delirium after shoulder arthroplasty? (2) What modifiable risk factors can be identified for postoperative delirium after shoulder arthroplasty? (3) Do risk factors differ in those younger than and in those older than 70 years of age? Methods: In a retrospective nationwide cohort study, we extracted data from the Premier Healthcare database on inpatient total and reverse shoulder arthroplasties from 2006 to 2016. The primary outcome was postoperative delirium; modifiable risk factors of interest were perioperative opioid use (high, medium, or low), peripheral nerve block use, and perioperative prescription medications. Mixed-effects models assessed associations between risk factors and postoperative delirium. Odds ratios and confidence intervals are reported. We applied a cutoff of 70 years of age because it was the median age of the cohort, as well as the age at which we observed that delirium prevalence increased. Results: A total of 92,429 total and reverse shoulder arthroplasties were identified (age range: 14-89 years). Overall delirium prevalence was 3.1% (n = 2909). Age-specific prevalence of postoperative delirium was lower in patients aged 50 to 70 years and higher in those aged 70 years and older, up to 8% among those older than 88 years. After adjusting for relevant covariates, only long-acting and combined short-acting and long-acting benzodiazepines (compared with no benzodiazepines) were associated with increased odds of postoperative delirium. Corticosteroids were associated with decreased odds of postoperative delirium. Conclusion: Our retrospective cohort study demonstrated that benzodiazepine use and older patient age were significantly associated with postoperative delirium in shoulder arthroplasty patients. The relationship between benzodiazepine use and delirium was particularly notable among those 70 years of age and older. Further investigation is indicated, given the known adverse effects of benzodiazepines in older adults and our findings of higher than expected use of these medications in this surgical cohort.
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Affiliation(s)
- Sara N. Kiani
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, NY, USA,Leni and Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA,Sara N. Kiani, MPH, Leni and Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, New York, NY 10029-6574, USA.
| | - Samuel Z. Maron
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, NY, USA,Leni and Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Manasa G. Rao
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, NY, USA,Leni and Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nicole Zubizarreta
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Madhu Mazumdar
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Leesa M. Galatz
- Leni and Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jashvant Poeran
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Paul J. Cagle
- Leni and Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Aoki Y, Kurita T, Nakajima M, Imai R, Suzuki Y, Makino H, Kinoshita H, Doi M, Nakajima Y. Association between remimazolam and postoperative delirium in older adults undergoing elective cardiovascular surgery: a prospective cohort study. J Anesth 2023; 37:13-22. [PMID: 36220948 DOI: 10.1007/s00540-022-03119-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 10/05/2022] [Indexed: 01/26/2023]
Abstract
PURPOSE Postoperative delirium is one of the most common complications after cardiovascular surgery in older adults. Benzodiazepines are a reported risk factor for delirium; however, there are no studies investigating remimazolam, a novel anesthetic agent. Therefore, we prospectively investigated the effect of remimazolam on postoperative delirium. METHODS We included elective cardiovascular surgery patients aged ≥ 65 years at Hamamatsu University Hospital between August 2020 and February 2022. Patients who received general anesthesia with remimazolam were compared with those who received other anesthetics (control group). The primary outcome was delirium within 5 days after surgery. Secondary outcomes were delirium during intensive care unit stay and hospitalization, total duration of delirium, subsyndromal delirium, and differences in the Mini-Mental State Examination scores from preoperative to postoperative days 2 and 5. To adjust for differences in the groups' baseline covariates, we used stabilized inverse probability weighting as the primary analysis and propensity score matching as the sensitivity analysis. RESULTS We enrolled 200 patients; 78 in the remimazolam group and 122 in the control group. After stabilized inverse probability weighting, 30.3% of the remimazolam group patients and 26.6% of the control group patients developed delirium within 5 days (risk difference, 3.8%; 95% confidence interval -11.5% to 19.1%; p = 0.63). The secondary outcomes did not differ significantly between the groups, and the sensitivity analysis results were similar to those for the primary analysis. CONCLUSION Remimazolam was not significantly associated with postoperative delirium when compared with other anesthetic agents.
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Affiliation(s)
- Yoshitaka Aoki
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, Shizuoka, 431-3192, Japan.
| | - Tadayoshi Kurita
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Mikio Nakajima
- Emergency Life-Saving Technique Academy of Tokyo, Foundation for Ambulance Service Development, Tokyo, Japan.,Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Ryo Imai
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Yuji Suzuki
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Hiroshi Makino
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Hiroyuki Kinoshita
- Department of Anesthesiology, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Matsuyuki Doi
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Yoshiki Nakajima
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, Shizuoka, 431-3192, Japan
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Ma X, Chu H, Han K, Shao Q, Yu Y, Jia S, Wang D, Wang Z, Zhou Y. Postoperative delirium after transcatheter aortic valve replacement: An updated systematic review and meta-analysis. J Am Geriatr Soc 2023; 71:646-660. [PMID: 36419366 DOI: 10.1111/jgs.18104] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 08/19/2022] [Accepted: 09/24/2022] [Indexed: 11/25/2022]
Abstract
AIMS To perform an updated systematic review and meta-analysis of postoperative delirium (POD) after transcatheter aortic valve replacement (TAVR). METHODS We conducted a systematic literature search of PubMed, Embase, and Cochrane Library databases from the time of the first human TAVR procedure in 2002 until December 24, 2021, which was supplemented by manual searches of bibliographies. Data were collected on incidence rates, risk factors, and/or associated mortality of POD after TAVR. Pooled analyses were conducted using random effects models to yield mean differences, odds ratios, hazard ratios, and risk ratios, with 95% confidence intervals. RESULTS A total of 70 articles (69 studies) comprising 413,389 patients were included. The study heterogeneity was substantial. The pooled mean incidence of POD after TAVR in all included studies was 9.8% (95% CI: 8.7%-11.0%), whereas that in studies using validated tools to assess for delirium at least once a day for at least 2 consecutive days after TAVR was 20.7% (95% CI: 17.8%-23.7%). According to the level of evidence and results of meta-analysis, independent preoperative risk factors with a high level of evidence included increased age, male sex, prior stroke or transient ischemic attack, atrial fibrillation/flutter, weight loss, electrolyte abnormality, and impaired Instrumental Activities of Daily Living; intraoperative risk factors included non-transfemoral access and general anesthesia; and acute kidney injury was a postoperative risk factor. POD after TAVR was associated with significantly increased mortality (pooled unadjusted RR: 2.20, 95% CI: 1.79-2.71; pooled adjusted RR: 1.62, 95% CI: 1.25-2.10), particularly long-term mortality (pooled unadjusted HR: 2.84, 95% CI: 1.91-4.23; pooled adjusted HR: 1.88, 95% CI: 1.30-2.73). CONCLUSIONS POD after TAVR is common and is associated with an increased risk of mortality. Accurate identification of risk factors for POD after TAVR and implementation of preventive measures are critical to improve prognosis.
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Affiliation(s)
- Xiaoteng Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Huijun Chu
- Department of Anesthesia, Qingdao Women and Children's Hospital, Qingdao University, Qingdao, China
| | - Kangning Han
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Qiaoyu Shao
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yi Yu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Shuo Jia
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Dunliang Wang
- Department of Anesthesia, Qingdao Women and Children's Hospital, Qingdao University, Qingdao, China
| | - Zhijian Wang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yujie Zhou
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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Wilson MP, Hamrick E, Stiebel V, Nordstrom K. Contemporary Practices for Medical Evaluation of the Psychiatric Patient in the Emergency Department. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2023; 21:28-34. [PMID: 37205042 PMCID: PMC10172537 DOI: 10.1176/appi.focus.20220063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Although emergency department (ED) visits for patients with mental illness are frequent, medical evaluation (i.e., "medical screening") of patients presenting with psychiatric complaints is inconsistent. This may largely be related to differing goals for medical screening, which often vary according to specialty. Although emergency physicians typically focus on stabilization of life-threatening diseases, psychiatrists tend to believe that care in the ED is more comprehensive, which often places the two fields at odds. The authors discuss the concept of medical screening, review the literature on this topic, and offer a clinically oriented update to the 2017 American Association for Emergency Psychiatry consensus guidelines on medical evaluation of the adult psychiatric patient in the ED.
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Affiliation(s)
- Michael P Wilson
- Department of Emergency Medicine and Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Wilson); Department of Psychiatry (Hamrick, Stiebel) and Department of Emergency Medicine (Stiebel), West Virginia University, Morgantown; Department of Psychiatry, University of Colorado Denver, Denver (Nordstrom)
| | - Edward Hamrick
- Department of Emergency Medicine and Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Wilson); Department of Psychiatry (Hamrick, Stiebel) and Department of Emergency Medicine (Stiebel), West Virginia University, Morgantown; Department of Psychiatry, University of Colorado Denver, Denver (Nordstrom)
| | - Victor Stiebel
- Department of Emergency Medicine and Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Wilson); Department of Psychiatry (Hamrick, Stiebel) and Department of Emergency Medicine (Stiebel), West Virginia University, Morgantown; Department of Psychiatry, University of Colorado Denver, Denver (Nordstrom)
| | - Kimberly Nordstrom
- Department of Emergency Medicine and Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Wilson); Department of Psychiatry (Hamrick, Stiebel) and Department of Emergency Medicine (Stiebel), West Virginia University, Morgantown; Department of Psychiatry, University of Colorado Denver, Denver (Nordstrom)
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Toda Y, Ishiki H, Machida T, Kawasaki N, Kobayashi E. Pain, Analgesic Use, and Patient Satisfaction With Spinal Versus General Anesthesia for Hip Fracture Surgery. Ann Intern Med 2023; 176:eL220366. [PMID: 36645899 DOI: 10.7326/l22-0366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Affiliation(s)
- Yu Toda
- Department of Palliative Medicine and Department of Musculoskeletal Oncology and Rehabilitation Medicine, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroto Ishiki
- Department of Palliative Medicine, National Cancer Center Hospital, Tokyo, Japan
| | - Taku Machida
- Department of Palliative Medicine, National Cancer Center Hospital, Tokyo, Japan
| | - Naruaki Kawasaki
- Department of Palliative Medicine, National Cancer Center Hospital, Tokyo, Japan
| | - Eisuke Kobayashi
- Department of Musculoskeletal Oncology and Rehabilitation Medicine, National Cancer Center Hospital, Tokyo, Japan
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Delirium Education for Geriatric Patients and their Families: A Quality Improvement Initiative. AGING AND HEALTH RESEARCH 2023. [DOI: 10.1016/j.ahr.2023.100123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
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Saller T, Hubig L, Seibold H, Schroeder Z, Wang B, Groene P, Perneczky R, von Dossow V, Hinske LC. Association between post-operative delirium and use of volatile anesthetics in the elderly: A real-world big data approach. J Clin Anesth 2022; 83:110957. [PMID: 36084424 DOI: 10.1016/j.jclinane.2022.110957] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 08/17/2022] [Accepted: 08/19/2022] [Indexed: 11/19/2022]
Abstract
STUDY OBJECTIVE Early post-operative delirium is a common perioperative complication in the post anesthesia care unit. To date it is unknown if a specific anesthetic regime can affect the incidence of delirium after surgery. Our objective was to examine the effect of volatile anesthetics on post-operative delirium. DESIGN Single Center Observational Study. SETTING Post Anesthesia Care Units at a German tertiary medical center. PATIENTS 30,075 patients receiving general anesthesia for surgery. MEASUREMENTS Delirium was assessed with the Nursing Delirium Screening Scale at the end of the recovery period. Subgroup-specific effects of volatile anesthetics on post-operative delirium were estimated using generalized-linear-model trees with inverse probability of treatment weighting. We further assessed the age-specific effect of volatiles using logistic regression models. MAIN RESULTS Out of 30,075 records, 956 patients (3.2%) developed delirium in the post anesthesia care unit. On average, patients who developed delirium were older than patients without delirium. We found volatile anesthetics to increase the risk (Odds exp. (B) for delirium in the elderly 1.8-fold compared to total intravenous anesthesia. Odds increases with unplanned surgery 3.0-fold. In the very old (87 years or older), the increase in delirium is 6.2-fold. This result was confirmed with internal validation and in a logistic regression model. CONCLUSIONS Our exploratory study indicates that early postoperative delirium is associated with the use of volatile anesthetics especially in the sub-cohort of patients aged 75 years and above. Further studies should include both volatile and intravenous anesthetics to find the ideal anesthetic in elderly patients.
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Affiliation(s)
- Thomas Saller
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany; Scientific Commission on Gerontoanaesthesiology, German Association for Anaesthesiology and Intensive Care Medicine, Roritzer Str. 19, 90419 Nuremberg, Germany.
| | - Lena Hubig
- Institute for Medical Information Processing, Biometry, and Epidemiology (IBE), Faculty of Medicine, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Heidi Seibold
- Institute for Medical Information Processing, Biometry, and Epidemiology (IBE), Faculty of Medicine, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Zoé Schroeder
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Baocheng Wang
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Philipp Groene
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Robert Perneczky
- Department of Psychiatry, University Hospital, LMU Munich, Nussbaumstr. 7, 80336 Munich, Germany; German Center for Neurodegenerative Disorders (DZNE), Munich, Germany; Munich Cluster for Systems Neurology (SyNergy), Feodor-Lynen-Strasse 17, 81377 Munich, Germany; Ageing Epidemiology Research Unit, School of Public Health, Imperial College London, Level 2 Faculty Building South Kensington Campus, London SW7 2AZ, UK; Sheffield Institute for Translational Neuroscience (SITraN), University of Sheffield, 385A Glossop Road, Sheffield S10 2HQ, UK
| | - Vera von Dossow
- Scientific Commission on Gerontoanaesthesiology, German Association for Anaesthesiology and Intensive Care Medicine, Roritzer Str. 19, 90419 Nuremberg, Germany; Institute for Anesthesiology, Heart and Diabetes Center NRW, Ruhr University of Bochum, Georgstr. 11, 32545 Bad Oeynhausen, Germany
| | - Ludwig C Hinske
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany; Institute for Medical Information Processing, Biometry, and Epidemiology (IBE), Faculty of Medicine, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany; Professorship for Data Management und Clinical Decision Support, Faculty of Medicine, Augsburg University, University Hospital, Stenglinstr. 2, 86156 Augsburg, Germany
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Mansutti I, Saiani L, Cargnelutti D, Petrucco S, Giannina V, Di Domenico C, Passadore P, Palese A. Delirium prevalence, risk factors and outcomes among patients with acute stroke: A multi-centre observational study. JOURNAL OF VASCULAR NURSING 2022; 40:172-180. [PMID: 36435600 DOI: 10.1016/j.jvn.2022.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 09/11/2022] [Accepted: 09/16/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Delirium is a frequent and serious acute neuropsychiatric syndrome leading to worse prognosis including mortality. Patients with ischaemic and/or haemorrhagic stroke are vulnerable to delirium. However, predisposing and precipitating factors have not been fully discovered to date, leaving this area of practice under-represented in available guidelines. AIMS To describe the prevalence, associated factors and main in-hospital outcomes of post-stroke delirium. METHODS A multi-centre observational study was conducted from 2019 to 2020 and reported according to the Strengthening the Reporting of Observational Studies in Epidemiology guidelines. Data were collected in stroke units located in two large hospitals in the North-East region of Italy. Consecutive adult patients with ischaemic and/or haemorrhagic stroke with a Glasgow Coma Scale > 5, who were willing to participate, were included. Data at admission, during the in-hospital stay and at discharge were collected by trained nurses, not involved in the care of patients, with (a) validated tools, (b) direct observation, and (c) access of patients' records. RESULTS A total of 78 patients were enrolled (mean 73.1 years; 59% male), and 70.5% of them had suffered an ischaemic stroke. The mean National Institutes of Health Stroke Scale (NIHSS) at admission was 8.2 ± 7.0. A total of 34.6% of patients developed post-stroke delirium; the onset was mainly on the first day of admission (70.4%) and the condition lasted for an average of 3.7 days (SD 2.6). In the multivariate logistic regression, 64.1% of the delirium variance was explained by the NIHSS scores (RR 1.259, 95%CI 1.035-1.533; p = 0.022). Patients with post-stroke delirium reported higher functional dependence at discharge and the need for more delaying of hospital care to be admitted in rehabilitation units. CONCLUSIONS At admission, higher scores in the NIHSS evaluation might suggest which patients are at an increased risk of delirium. Avoiding interventions that could potentially increase this risk, together with continuous surveillance, become imperative for nurses who are constantly and closely present by their patients' side, in order to prevent this serious complication.
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Affiliation(s)
- Irene Mansutti
- Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy.
| | - Luisa Saiani
- Department of Diagnostics and Public Health, University of Verona, Verona, Italy.
| | - Daniela Cargnelutti
- Department of Neurosciences, Stroke Unit/Neurology, Udine University Hospital, Italy.
| | - Stefania Petrucco
- Department of Neurosciences, Stroke Unit/Neurology, Udine University Hospital, Italy.
| | - Viera Giannina
- Department of Medical Sciences, University of Udine, Italy.
| | | | - Paolo Passadore
- Department of Neurosciences, Stroke Unit/Neurology, Pordenone Hospital, Italy.
| | - Alvisa Palese
- Department of Medical Sciences, University of Udine, Italy.
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Poikajärvi S, Rauta S, Salanterä S, Junttila K. Delirium in a surgical context from a nursing perspective: A hybrid concept analysis. INTERNATIONAL JOURNAL OF NURSING STUDIES ADVANCES 2022; 4:100103. [PMID: 38745600 PMCID: PMC11080469 DOI: 10.1016/j.ijnsa.2022.100103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 09/12/2022] [Accepted: 09/26/2022] [Indexed: 10/14/2022] Open
Abstract
Background The term delirium has been defined in medical diagnosis criteria as a multidimensional disorder, and the term acute confusion is included in nursing classifications. Delirium can be a serious complication assessed in a patient after a surgical procedure. Still, the patient's delirium frequently remains unrecognised. Care of patients with delirium after surgical procedure is complex, and it challenges nursing expertise. From the nurses' viewpoint, delirium is associated with ambiguity of concepts and lack of knowledge. Therefore, reseach on how nurses perceive patients with delirium in a surgical context is needed. Objective The aim of this study was to describe the concepts of delirium and acute confusion, as well as the associated dimensions, in adult patients in a surgical context from the nursing perspective. Design The study used Schwartz and Barcott's hybrid concept analysis with theoretical, fieldwork, and final analytical phases. Settings Surgical wards, surgical intensive care units, and post-anaesthesia care units. Data sources A systematic literature search was performed through Pubmed (Medline), Cinahl, PsycInfo, and Embase. Participants Registered nurses and licensed practical nurses (n = 105) participated in the fieldwork phase. Methods In the theoretical phase, the concepts' working definitions were formulated based on a systematic literature search with the year limitations from 2000 until February 2021. At the fieldwork phase, the nurses' descriptions of patients with delirium were analysed using the deductive content analysis method. At the final analytical phase, findings were combined and reported. Results The concepts of delirium, subsyndromal delirium, and acute confusion are well defined in the literature. From the perspective of the nurses in the study, concepts were seen as a continuum not as individual diagnoses. Nurses described the continuum of delirium as a process with acute onset, duration, and recovery with the associated dimensions of symptoms, symptom severity, risk factors, and early signs. The acute phase of delirium was emphasised, and preoperative or prolonged disturbance did not seem to be relevant in the surgical care context. Patients' compliance with care may be decreased with the continuum of delirium, which might challenge both patients' recovery from surgery and the quality of nursing care. Conclusions In clinical practice the nurses used term confusion inaccurately. The term acute confusion might be used when illustrating an early stage of delirium. Nurses could benefit from further education where the theoretical knowledge is combined with the clinical practice. The discussion about the delirium, which covers the time both before surgery and after the acute phase should be increased.
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Affiliation(s)
- Satu Poikajärvi
- Department of Nursing Science, Faculty of Medicine, University of Turku, Turku, Finland
- Department of Perioperative, Intensive Care, and Pain Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Satu Rauta
- Department of Perioperative, Intensive Care, and Pain Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Sanna Salanterä
- Department of Nursing Science, Faculty of Medicine, University of Turku, Turku, Finland
- Turku University Hospital, Turku, Finland
| | - Kristiina Junttila
- Department of Nursing Science, Faculty of Medicine, University of Turku, Turku, Finland
- Nursing Research Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Anada S, Iigaya M, Takahashi M, Soda K, Wada N. Impact of early mobilization on the duration of delirium in elderly hospitalized patients: A retrospective cohort pilot study. Medicine (Baltimore) 2022; 101:e31641. [PMID: 36343083 PMCID: PMC9646638 DOI: 10.1097/md.0000000000031641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Development of delirium during hospitalization impairs the activities of daily living in elderly hospitalized patients. In clinical practice, early mobilization from bed is recommended to reduce delirium incidence and hospitalization stay. However, the effects of early mobilization on elderly inpatients with delirium have not been established yet. The aim of this study was to investigate the association between early mobilization and the duration of delirium in elderly inpatients with delirium. This retrospective cohort pilot study examined 45 participants (23 males, 22 females; mean age: 84.5 ± 6.6 years), who developed delirium during hospitalization. Of the participants, 28 were surgically treated and 17 were non-surgically treated. We classified early or delayed mobilization based on the median number of days until the start of mobilization and compared after propensity score matching to adjust for baseline characteristics. Additionally, we examined the correlation between the number of days until the start of mobilization and the duration of delirium. The duration of delirium was significantly shorter in the early mobilization group, particularly in terms of sitting on the bed and wheelchair use than that in the delayed mobilization group {median: 4.0 [interquartile range (IQR): 2.0-6.0] vs 8.0 [IQR: 7.0-14.5] days, P = .013; median: 3.0 [IQR: 2.0-5.5] vs 11.0 [IQR: 7.5-14.5] days, P = .004, respectively}. Moreover, the duration of delirium significantly positively moderate correlated with the time until the start of sitting on the bed and wheelchair use (Spearman r = 0.527; P = .012, Spearman r = 0.630; P = .002, respectively). The results of this study suggest that early mobilization from sitting on the bed or wheelchair use after hospitalization or surgery may shorten the duration of delirium. Because the sample size of this pilot study is small, careful interpretation is needed, and further research is warranted.
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Affiliation(s)
- Satoshi Anada
- Department of Rehabilitation, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
- *Correspondence: Satoshi Anada, Department of Rehabilitation, Kitasato University Kitasato Institute Hospital, 5-9-1 Shirokane, Minato-ku, Tokyo, 108-8642, Japan (e-mail: )
| | - Miho Iigaya
- Department of Neurology, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Megumi Takahashi
- Department of Psychiatry, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Kazue Soda
- Department of Pharmacy, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Namiko Wada
- Department of Nursing, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
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