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Varpaei HA, Farhadi K, Mohammadi M, Khafaee Pour Khamseh A, Mokhtari T. Postoperative cognitive dysfunction: a concept analysis. Aging Clin Exp Res 2024; 36:133. [PMID: 38902462 PMCID: PMC11189971 DOI: 10.1007/s40520-024-02779-7] [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: 10/28/2023] [Accepted: 02/17/2024] [Indexed: 06/22/2024]
Abstract
BACKGROUND Post-operative cognitive dysfunction (POCD) is a concern for clinicians that often presents post-surgery where generalized anesthesia has been used. Its prevalence ranges from 36.6% in young adults to 42.4% in older individuals. Conceptual clarity for POCD is lacking in the currently body literature. Our two-fold purpose of this concept analysis was to (1) critically appraise the various definitions, while also providing the best definition, of POCD and (2) narratively synthesize the attributes, surrogate or related terms, antecedents (risk factors), and consequences of the concept. METHOD The reporting of our review was guided by the PRISMA statement and the 6-step evolutionary approach to concept analysis developed by Rodgers. Three databases, including Medline, CINAHL, and Web of Science, were searched to retrieve relevant literature on the concept of POCD. Two independent reviewers conducted abstract and full-text screening, data extraction, and appraisal. The review process yielded a final set of 86 eligible articles. RESULT POCD was defined with varying severities ranging from subtle-to-extensive cognitive changes (1) affecting single or multiple cognitive domains that manifest following major surgery (2), is transient and reversible, and (3) may last for several weeks to years. The consequences of POCD may include impaired quality of life, resulting from withdrawal from the labor force, increased patients' dependencies, cognitive decline, an elevated risk of dementia, rising healthcare costs, and eventual mortality. CONCLUSION This review resulted in a refined definition and comprehensive analysis of POCD that can be useful to both researchers and clinicians. Future research is needed to refine the operational definitions of POCD so that they better represent the defining attributes of the concept.
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Affiliation(s)
| | - Kousha Farhadi
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mostafa Mohammadi
- Department of Critical Care, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Tahereh Mokhtari
- Department of Gynecology, School of Medicine, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Han C, Kim HI, Soh S, Choi JW, Song JW, Yoon D. Machine learning with clinical and intraoperative biosignal data for predicting postoperative delirium after cardiac surgery. iScience 2024; 27:109932. [PMID: 38799563 PMCID: PMC11126810 DOI: 10.1016/j.isci.2024.109932] [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: 10/24/2023] [Revised: 02/25/2024] [Accepted: 05/05/2024] [Indexed: 05/29/2024] Open
Abstract
Early identification of patients at high risk of delirium is crucial for its prevention. Our study aimed to develop machine learning models to predict delirium after cardiac surgery using intraoperative biosignals and clinical data. We introduced a novel approach to extract relevant features from continuously measured intraoperative biosignals. These features reflect the patient's overall or baseline status, the extent of unfavorable conditions encountered intraoperatively, and beat-to-beat variability within the data. We developed a soft voting ensemble machine learning model using retrospective data from 1,912 patients. The model was then prospectively validated with data from 202 additional patients, achieving a high performance with an area under the receiver operating characteristic curve of 0.887 and an accuracy of 0.881. According to the SHapley Additive exPlanation method, several intraoperative biosignal features had high feature importance, suggesting that intraoperative patient management plays a crucial role in preventing delirium after cardiac surgery.
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Affiliation(s)
- Changho Han
- Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Yongin, Republic of Korea
| | - Hyun Il Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sarah Soh
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ja Woo Choi
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jong Wook Song
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dukyong Yoon
- Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Yongin, Republic of Korea
- Center for Digital Health, Yongin Severance Hospital, Yonsei University Health System, Yongin, Republic of Korea
- Institute for Innovation in Digital Healthcare (IIDH), Severance Hospital, Seoul, Republic of Korea
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Tsolaki M, Sia E, Giannouli V. Anesthesia and dementia: An up-to-date review of the existing literature. APPLIED NEUROPSYCHOLOGY. ADULT 2024; 31:181-190. [PMID: 35981552 DOI: 10.1080/23279095.2022.2110871] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Concerns around the impact of anesthesia on cognitive decline and dementia, including Alzheimer's Disease (AD), have been increasing and recently attracting considerable attention in the research community. One unanswered question is whether anesthesia is a risk factor of dementia, specifically AD type dementia. A large body of evidence, coming from in vivo and in vitro models, suggests that exposure to anesthetic agents may increase the risk of AD through mechanisms of action similar to AD's neuropathology. In terms of clinical studies, our knowledge of the relationship between anesthesia and dementia is based on limited data, with most studies suggesting that there is no association. The aim of this paper was therefore to outline recent clinical studies exploring this controversial relationship and discuss future directions in terms of study design and potential areas of study. As the aging population and the prevalence of dementia and AD increases, we need a better understanding of anesthesia as a risk factor for neurodegeneration through well-designed studies. Despite the controversy, there seems to be little evidence to support that anesthesia itself or other surgical and patient factors can cause or accelerate AD.
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Affiliation(s)
- Magda Tsolaki
- 1st Department of Neurology, Medical School, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Greek Association of Alzheimer's Disease and Related Disorders, Thessaloniki, Greece
- Laboratory of Neurodegenerative Diseases, Center for Interdisciplinary Research and Innovation (CIRI - AUTh), Thessaloniki, Greece
| | - Eleni Sia
- Greek Association of Alzheimer's Disease and Related Disorders, Thessaloniki, Greece
- Laboratory of Neurodegenerative Diseases, Center for Interdisciplinary Research and Innovation (CIRI - AUTh), Thessaloniki, Greece
| | - Vaitsa Giannouli
- 1st Department of Neurology, Medical School, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Greek Association of Alzheimer's Disease and Related Disorders, Thessaloniki, Greece
- Laboratory of Neurodegenerative Diseases, Center for Interdisciplinary Research and Innovation (CIRI - AUTh), Thessaloniki, Greece
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Wang Y, Zhu H, Xu F, Ding Y, Zhao S, Chen X. The effect of anesthetic depth on postoperative delirium in older adults: a systematic review and meta-analysis. BMC Geriatr 2023; 23:719. [PMID: 37932677 PMCID: PMC10629190 DOI: 10.1186/s12877-023-04432-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 10/27/2023] [Indexed: 11/08/2023] Open
Abstract
BACKGROUND Postoperative delirium (POD) is an important complication for older patients and recent randomised controlled trials have showed a conflicting result of the effect of deep and light anesthesia. METHODS We included randomised controlled trials including older adults that evaluated the effect of anesthetic depth on postoperative delirium from PubMed, Embase, Web of Science and Cochrane Library. We considered deep anesthesia as observer's assessment of the alertness/ sedation scale (OAA/S) of 0-2 or targeted bispectral (BIS) < 45 and the light anesthesia was considered OAA/S 3-5 or targeted BIS > 50. The primary outcome was incidence of POD within 7 days after surgery. And the secondary outcomes were mortality and cognitive function 3 months or more after surgery. The quality of evidence was assessed via the grading of recommendations assessment, development, and evaluation approach. RESULTS We included 6 studies represented 7736 patients aged 60 years and older. We observed that the deep anesthesia would not increase incidence of POD when compared with the light anesthesia when 4 related studies were pooled (OR, 1.40; 95% CI, 0.63-3.08, P = 0.41, I2 = 82%, low certainty). And no significant was found in mortality (OR, 1.12; 95% CI, 0.93-1.35, P = 0.23, I2 = 0%, high certainty) and cognitive function (OR, 1.13; 95% CI, 0.67-1.91, P = 0.64, I2 = 13%, high certainty) 3 months or more after surgery between deep anesthesia and light anesthesia. CONCLUSIONS Low-quality evidence suggests that light general anesthesia was not associated with lower POD incidence than deep general anesthesia. And High-quality evidence showed that anesthetic depth did not affect the long-term mortality and cognitive function. SYSTEMATIC REVIEW REGISTRATION CRD42022300829 (PROSPERO).
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Affiliation(s)
- Yafeng Wang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Key Laboratory of Anesthesiology and Resuscitation, Huazhong University of Science and Technology, Ministry of Education, Wuhan, China
| | - Hongyu Zhu
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Key Laboratory of Anesthesiology and Resuscitation, Huazhong University of Science and Technology, Ministry of Education, Wuhan, China
- Department of Anesthesiology, Linhe District People's Hospital, Bayannur City, 015000, China
| | - Feng Xu
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Key Laboratory of Anesthesiology and Resuscitation, Huazhong University of Science and Technology, Ministry of Education, Wuhan, China
| | - Yuanyuan Ding
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Key Laboratory of Anesthesiology and Resuscitation, Huazhong University of Science and Technology, Ministry of Education, Wuhan, China
| | - Shuai Zhao
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Key Laboratory of Anesthesiology and Resuscitation, Huazhong University of Science and Technology, Ministry of Education, Wuhan, China
| | - Xiangdong Chen
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
- Key Laboratory of Anesthesiology and Resuscitation, Huazhong University of Science and Technology, Ministry of Education, Wuhan, China.
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Chen YC, Hung IY, Hung KC, Chang YJ, Chu CC, Chen JY, Ho CH, Yu CH. Incidence change of postoperative delirium after implementation of processed electroencephalography monitoring during surgery: a retrospective evaluation study. BMC Anesthesiol 2023; 23:330. [PMID: 37794315 PMCID: PMC10548752 DOI: 10.1186/s12871-023-02293-9] [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: 03/21/2023] [Accepted: 09/26/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND Postoperative delirium (POD) is a common complication in the elderly, which is associated with poor outcomes after surgery. Recognized as predisposing factors for POD, anesthetic exposure and burst suppression during general anesthesia can be minimized with intraoperative processed electroencephalography (pEEG) monitoring. In this study, we aimed to evaluate whether implementation of intraoperative pEEG-guided anesthesia is associated with incidence change of POD. METHODS In this retrospective evaluation study, we analyzed intravenous patient-controlled analgesia (IVPCA) dataset from 2013 to 2017. There were 7425 patients using IVPCA after a noncardiac procedure under general anesthesia. Patients incapable of operating the device independently, such as cognitive dysfunction or prolonged sedation, were declined and not involved in the dataset. After excluding patients who opted out within three days (N = 110) and those with missing data (N = 24), 7318 eligible participants were enrolled. Intraoperative pEEG has been implemented since July 2015. Participants having surgery after this time point had intraoperative pEEG applied before induction until full recovery. All related staff had been trained in the application of pEEG-guided anesthesia and the assessment of POD. Patients were screened twice daily for POD within 3 days after surgery by staff in the pain management team. In the first part of this study, we compared the incidence of POD and its trend from 2013 January-2015 July with 2015 July-2017 December. In the second part, we estimated odds ratios of risk factors for POD using multivariable logistic regression in case-control setting. RESULTS The incidence of POD decreased from 1.18 to 0.41% after the administration of intraoperative pEEG. For the age group ≧ 75 years, POD incidence decreased from 5.1 to 1.56%. Further analysis showed that patients with pEEG-guided anesthesia were associated with a lower odd of POD (aOR 0.33; 95% CI 0.18-0.60) than those without after adjusting for other covariates. CONCLUSIONS Implementation of intraoperative pEEG was associated with a lower incidence of POD within 3 days after surgery, particularly in the elderly. Intraoperative pEEG might be reasonably considered as part of the strategy to prevent POD in the elder population. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Yi-Chen Chen
- Department of Medical Research, Chi Mei Medical Center, 901 Zhonghua Road, Yongkang District, Tainan, Taiwan
| | - I-Yin Hung
- Department of Anesthesiology, Chi Mei Medical Center, 901 Zhonghua Road, Yongkang District, Tainan, Taiwan
| | - Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical Center, 901 Zhonghua Road, Yongkang District, Tainan, Taiwan
- Department of Hospital and Health Care Administration, College of Recreation and Health Management, Chia Nan University of Pharmacy and Science, 60 Erren Road, Rende District, Tainan, Taiwan
| | - Ying-Jen Chang
- Department of Anesthesiology, Chi Mei Medical Center, 901 Zhonghua Road, Yongkang District, Tainan, Taiwan
- Department of Recreation and Health Care Management, College of Recreation and Health Management, Chia Nan University of Pharmacy and Science, 60 Erren Road, Rende District, Tainan, Taiwan
| | - Chin-Chen Chu
- Department of Anesthesiology, Chi Mei Medical Center, 901 Zhonghua Road, Yongkang District, Tainan, Taiwan
| | - Jen-Yin Chen
- Department of Anesthesiology, Chi Mei Medical Center, 901 Zhonghua Road, Yongkang District, Tainan, Taiwan
| | - Chung-Han Ho
- Department of Medical Research, Chi Mei Medical Center, 901 Zhonghua Road, Yongkang District, Tainan, Taiwan
- Department of Information Management, Southern Taiwan University of Science and Technology, 1 Nantai St, Yongkang District, Tainan, Taiwan
| | - Chia-Hung Yu
- Department of Anesthesiology, Chi Mei Medical Center, 901 Zhonghua Road, Yongkang District, Tainan, Taiwan.
- Department of Computer Science and Information Engineering, Southern Taiwan University of Science and Technology, 1 Nantai St, Yongkang District, Tainan, Taiwan.
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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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Li Z, Zhu Y, Qin S, Gao X, Kang Y, Li S, Chai J. Effects of permissive hypercapnia on intraoperative cerebral oxygenation and early postoperative cognitive function in older patients with non-acute fragile brain function undergoing laparoscopic colorectal surgery: protocol study. BMC Geriatr 2023; 23:581. [PMID: 37735369 PMCID: PMC10512528 DOI: 10.1186/s12877-023-04125-4] [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: 10/24/2022] [Accepted: 06/21/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND Perioperative brain protection in older patients has been the focus of research recently; meanwhile, exploring the relationship between regional cerebral oxygen saturation (rSO2) and brain function in the perioperative period has been an emerging and challenging area-the difficulties related to the real-time monitoring of rSO2 and the choice of feasible interventions. As an advanced instrument for intraoperative rSO2 monitoring, the clinical application of near-infrared spectrum (NIRS) cerebral oxygen monitoring has gradually increased in popularity and is being recognized for its beneficial clinical outcomes in patients undergoing cardiac and noncardiac surgery. In addition, although sufficient evidence to support this hypothesis is still lacking, the effect of permissive hypercapnia (PHC) on rSO2 has expanded from basic research to clinical exploration. Therefore, monitoring intraoperative rSO2 in older patients with NIRS technology and exploring possible interventions that may change rSO2 and even improve postoperative cognitive performance is significant and clinically valuable. METHODS This study is a single-center randomized controlled trial (RCT). 76 older patients are enrolled as subjects. Patients who meet the screening criteria will be randomly assigned 1:1 to the control and intervention groups. PHC-based mechanical ventilation will be regarded as an intervention. The primary outcome is the absolute change in the percent change in rSO2 from baseline to the completion of surgery in the intervention and control groups. Secondary outcomes mainly include observations of intraoperative cerebral oxygenation and metabolism, markers of brain injury, and assessments of patients' cognitive function using scale through postoperative follow-up. DISCUSSION The findings of this RCT will reveal the effect of PHC on intraoperative rSO2 in older patients with nonacute fragile brain function (NFBF) and the approximate trends over time, and differences in postoperative cognitive function outcomes. We anticipate that the trial results will inform clinical policy decision-makers in clinical practice, enhance the management of intraoperative cerebral oxygen monitoring in older patients with comorbid NFBF, and provide guidance for clinical brain protection and improved postoperative cognitive function outcomes. TRIAL REGISTRATION ChiCTR, ChiCTR2200062093, Registered 9/15/2022.
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Affiliation(s)
- Zhichao Li
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Youzhuang Zhu
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Shangyuan Qin
- Department of Anesthesiology, Liaoning Cancer Hospital & Institute, Shenyang, China
| | - Xin Gao
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yihan Kang
- Department of Anesthesiology, The First Hospital of China Medical University, Shenyang, China
| | - Si Li
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Jun Chai
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, China.
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Ramirez MF, Gan TJ. Total intravenous anesthesia versus inhalation anesthesia: how do outcomes compare? Curr Opin Anaesthesiol 2023; 36:399-406. [PMID: 37338939 DOI: 10.1097/aco.0000000000001274] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
RECENT FINDINGS Surgical procedures that involve general anesthesia are performed with either volatile anesthetics or propofol-based total intravenous anesthesia. Both techniques are safe and provide appropriate conditions for surgery. Despite being a well established anesthetic, the use of propofol-based total intravenous anesthesia (TIVA) remains low. Possible explanations include the perceived increase risk of awareness, lack of target controlled infusion devices, increased turnover time for device set up and individual preference. SUMMARY There are some scenarios where patients could potentially benefit from propofol-based TIVA rather than a volatile anesthetic (e.g. postoperative nausea and vomiting) and some other clinical scenarios where the use of propofol-based anesthesia remains controversial since the strength of the evidence remains low. PURPOSE In this review we will summarize the clinical evidence comparing the effect of propofol-based TIVA and volatile anesthetic on postoperative outcomes such as postoperative nausea and vomiting, postoperative pain, quality of recovery, postoperative cognitive dysfunction and cancer outcomes.
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Affiliation(s)
- Maria F Ramirez
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Rose KM, Narang G, Rosen G, Labatte C, Dumitrascu CI, Campagna J, Yu A, Manley BJ, Spiess PE, Li R, Adibi M, Murray KS, Sexton WJ, Humphreys MR. Antegrade administration of mitomycin gel for upper tract urothelial carcinoma via percutaneous nephrostomy tube: a multi-institutional retrospective cohort study. BJU Int 2023; 131:471-476. [PMID: 36285629 DOI: 10.1111/bju.15925] [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] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To assess the safety profile of antegrade mitomycin gel instillation through a percutaneous nephrostomy tube (PCNT) for upper tract urothelial carcinoma (UTUC) with the aim of decreasing morbidity associated with therapy. PATIENTS AND METHODS Patients undergoing antegrade administration of mitomycin gel via PCNT were retrospectively included for analysis from four tertiary referral centres between 2020 and 2022. The primary outcome was safety profile, as graded by Common Terminology Criteria for Adverse Events (v5.0). Post-therapy disease burden was assessed by primary disease evaluation (PDE) via ureteroscopy. RESULTS Thirty-two patients received at least one dose of mitomycin gel via PCNT for UTUC, 29 of whom completed induction and underwent PDE. Thirteen patients (41%) had residual tumour present prior to induction therapy. At a median of 15.0 months following first dose of induction therapy, ureteric stenosis occurred in three patients (9%), all of whom were treated without later recurrence or chronic stenosis. Other adverse events included fatigue (27%), flank pain (19%), urinary tract infection (12%), sepsis (8%) and haematuria (8%). No patients had impaired renal function during follow-up and there were no treatment-related deaths. Seventeen patients (59%) had no evidence of disease at PDE and have not experienced recurrence at a median follow-up of 13.0 months post induction. CONCLUSIONS Administration of mitomycin gel via a PCNT offers a low rate of ureteric stenosis, demonstrates a favourable safety profile, and is administered without general anaesthesia.
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Affiliation(s)
- Kyle M Rose
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Gopal Narang
- Department of Urology, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Geoffrey Rosen
- Division of Urology, Department of Surgery, University of Missouri, Columbia, MO, USA
| | - Craig Labatte
- Department of Urologic Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | | | - Justin Campagna
- Department of Urology, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Alice Yu
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Brandon J Manley
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Phillippe E Spiess
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Roger Li
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Mehrad Adibi
- Department of Urologic Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - Katie S Murray
- Division of Urology, Department of Surgery, University of Missouri, Columbia, MO, USA
| | - Wade J Sexton
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
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Effects of anesthetic depth on postoperative pain and delirium: a meta-analysis of randomized controlled trials with trial sequential analysis. Chin Med J (Engl) 2022; 135:2805-2814. [PMID: 36728598 PMCID: PMC9944713 DOI: 10.1097/cm9.0000000000002449] [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: 03/02/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Whether anesthetic depth affects postoperative outcomes remains controversial. This meta-analysis aimed to evaluate the effects of deep vs. light anesthesia on postoperative pain, cognitive function, recovery from anesthesia, complications, and mortality. METHODS PubMed, EMBASE, and Cochrane CENTRAL databases were searched until January 2022 for randomized controlled trials comparing deep and light anesthesia in adult surgical patients. The co-primary outcomes were postoperative pain and delirium (assessed using the confusion assessment method). We conducted a meta-analysis using a random-effects model. We assessed publication bias using the Begg's rank correlation test and Egger's linear regression. We evaluated the evidence using the trial sequential analysis and Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. We conducted subgroup analyses for pain scores at different postoperative time points and delirium according to cardiac or non-cardiac surgery. RESULTS A total of 26 trials with 10,743 patients were included. Deep anesthesia compared with light anesthesia (a mean difference in bispectral index of -12 to -11) was associated with lower pain scores at rest at 0 to 1 h postoperatively (weighted mean difference = -0.72, 95% confidence interval [CI] = -1.25 to -0.18, P = 0.009; moderate-quality evidence) and an increased incidence of postoperative delirium (24.95% vs. 15.92%; risk ratio = 1.57, 95% CI = 1.28-1.91, P < 0.0001; high-quality evidence). No publication bias was detected. For the exploratory secondary outcomes, deep anesthesia was associated with prolonged postoperative recovery, without affecting neurocognitive outcomes, major complications, or mortality. In the subgroup analyses, the deep anesthesia group had lower pain scores at rest and on movement during 24 h postoperatively, without statistically significant subgroup differences, and deep anesthesia was associated with an increased incidence of delirium after non-cardiac and cardiac surgeries, without statistically significant subgroup differences. CONCLUSIONS Deep anesthesia reduced early postoperative pain but increased postoperative delirium. The current evidence does not support the use of deep anesthesia in clinical practice.
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Chew WZ, Teoh WY, Sivanesan N, Loh PS, Shariffuddin II, Ti LK, Ng KT. Bispectral Index (BIS) Monitoring and Postoperative Delirium in Elderly Patients Undergoing Surgery: A Systematic Review and Meta-Analysis With Trial Sequential Analysis. J Cardiothorac Vasc Anesth 2022; 36:4449-4459. [PMID: 36038444 DOI: 10.1053/j.jvca.2022.07.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 06/20/2022] [Accepted: 07/04/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To examine the effect of bispectral index (BIS)-guided anesthesia on the incidence of postoperative delirium (POD) in elderly patients undergoing surgery. DESIGN A systematic review, meta-analysis, and trial sequential analysis (TSA). SETTING In the operating room, postoperative anesthesia care units (PACU), and ward. PARTICIPANTS Elderly patients (>60 years old) undergoing surgery. INTERVENTIONS The EMBASE, MEDLINE, and CENTRAL databases were searched systematically from their inception until December 2020 for randomized controlled trials comparing BIS and usual care or blinded BIS. MEASUREMENTS AND MAIN RESULTS Ten trials (N = 3,891) were included for quantitative meta-analysis. In comparison to the control group, there was no significant difference in the incidence of POD in elderly patients randomized to BIS-guided anesthesia (odds ratio [OR] 0.71, 95% CI 0.47-1.08, I2 = 76%, p = 0.11, level of evidence = very low, TSA = inconclusive). The authors' review demonstrated that elderly patients with BIS-guided anesthesia were significantly associated with a lower incidence of postoperative cognitive dysfunction (POCD) (OR 0.64, 95% CI 0.46-0.88, p = 0.006), extubation time (mean difference [MD] -3.38 minutes, 95% CI -4.38 to -2.39, p < 0.00001), time to eye opening (MD -2.17 minutes, 95% CI -4.21 to -0.14, p = 0.04), and time to discharge from the PACU (MD -10.77 minutes, 95% CI -11.31 to - 10.23, p < 0.00001). CONCLUSION The authors' meta-analysis demonstrated that BIS-guided anesthesia was not associated with a reduced incidence of POD, but it was associated with a reduced incidence of POCD and improved recovery parameters.
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Affiliation(s)
- Wei Zhuen Chew
- Faculty of Medicine, University of Glasgow, Glasgow, Scotland
| | - Wan Yi Teoh
- Faculty of Medicine, University of Liverpool, Liverpool, United Kingdom
| | | | - Pui San Loh
- Department of Anaesthesiology, Faculty of Medicine, Universiti Malaya, Jalan Universiti, Kuala Lumpur, Malaysia
| | - Ina Ismiarti Shariffuddin
- Department of Anaesthesiology, Faculty of Medicine, Universiti Malaya, Jalan Universiti, Kuala Lumpur, Malaysia
| | - Lian Kah Ti
- Department of Anaesthesia, National University Hospital, Singapore
| | - Ka Ting Ng
- Department of Anaesthesiology, Faculty of Medicine, Universiti Malaya, Jalan Universiti, Kuala Lumpur, Malaysia.
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Ling L, Yang TX, Lee SWK. Effect of Anaesthesia Depth on Postoperative Delirium and Postoperative Cognitive Dysfunction in High-Risk Patients: A Systematic Review and Meta-Analysis. Cureus 2022; 14:e30120. [DOI: 10.7759/cureus.30120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2022] [Indexed: 11/07/2022] Open
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Han Y, Miao M, Li P, Yang Y, Zhang H, Zhang B, Sun M, Zhang J. EEG-Parameter-Guided Anesthesia for Prevention of Emergence Delirium in Children. Brain Sci 2022; 12:brainsci12091195. [PMID: 36138931 PMCID: PMC9496666 DOI: 10.3390/brainsci12091195] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 08/27/2022] [Accepted: 08/29/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Emergence delirium (ED) usually occurs in children after surgery with an incidence of 10−80%. Though ED is mostly self-limited, its potential injuries cannot be ignored. Whether electroencephalography (EEG)-parameter-guided anesthesia could reduce the incidence of ED in pediatric surgery has not been fully discussed to date. Methods: Fifty-four boys aged 2−12 years undergoing elective hypospadias surgery under sevoflurane anesthesia were selected. In the EEG-parameter-guided group (E group), sevoflurane was used for anesthesia induction and was maintained by titrating the spectral edge frequency (SEF) to 10−15 and combining the monitoring of density spectral array (DSA) power spectra and raw EEG. While in the control group (C group), anesthesiologists were blinded to the SedLine screen (including SEF, DSA, and raw EEG) and adjusted the intraoperative drug usage according to their experience. Patients with a Pediatric Anesthesia Emergence Delirium (PAED) score > 10 were diagnosed with ED, while patients with a PAED score > 2 were diagnosed with emergence agitation (EA). Results: Finally, a total of 37 patients were included in this trial. The incidence of ED in the E group was lower than in the C group (5.6% vs. 36.8%; p = 0.04), while the incidence of EA was similar in the two groups (61% vs. 78.9%; p = 0.48). Intraoperative parameters including remifentanil dosage and the decrease in mean arterial pressure (MAP) were not different between the two groups (p > 0.05), but the mean end-tidal sevoflurane concentration (EtSevo) was lower in the E group than in the C group (p > 0.05). Moreover, during PACU stay, the extubation time and discharge time of the groups were similar, while the PAED scores within 5 min from extubation and the Face, Legs, Activity, Cry, and Consolability (FLACC) scores within 30 min from extubation were lower in the E group than in the C group. Conclusion: EEG-parameter-guided anesthesia management reduced the incidence of ED in children. Studies with larger sample sizes are needed to obtain more convincing results.
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Affiliation(s)
- Yaqian Han
- Department of Anesthesiology and Perioperative Medicine, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Zhengzhou 450003, China
- Department of Anesthesiology and Perioperative Medicine, People’s Hospital of Zhengzhou University, Zhengzhou 450003, China
| | - Mengrong Miao
- Department of Anesthesiology and Perioperative Medicine, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Zhengzhou 450003, China
- Department of Anesthesiology and Perioperative Medicine, People’s Hospital of Zhengzhou University, Zhengzhou 450003, China
| | - Pule Li
- Department of Anesthesiology, Tengzhou Central People’s Hospital, Jining Medical College, Tengzhou 277522, China
| | - Yitian Yang
- Department of Anesthesiology and Perioperative Medicine, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Zhengzhou 450003, China
- Department of Anesthesiology and Perioperative Medicine, People’s Hospital of Zhengzhou University, Zhengzhou 450003, China
| | - Hui Zhang
- Department of Anesthesiology and Perioperative Medicine, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Zhengzhou 450003, China
- Department of Anesthesiology and Perioperative Medicine, People’s Hospital of Zhengzhou University, Zhengzhou 450003, China
| | - Beibei Zhang
- Department of Anesthesiology and Perioperative Medicine, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Zhengzhou 450003, China
- Department of Anesthesiology and Perioperative Medicine, People’s Hospital of Zhengzhou University, Zhengzhou 450003, China
| | - Mingyang Sun
- Department of Anesthesiology and Perioperative Medicine, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Zhengzhou 450003, China
- Correspondence: (M.S.); (J.Z.); Tel.: +86-0371-65580728 (M.S. & J.Z.)
| | - Jiaqiang Zhang
- Department of Anesthesiology and Perioperative Medicine, People’s Hospital of Zhengzhou University, Zhengzhou 450003, China
- Correspondence: (M.S.); (J.Z.); Tel.: +86-0371-65580728 (M.S. & J.Z.)
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Chen D, Fang X, Zhu Z. Progress in the correlation of postoperative cognitive dysfunction and Alzheimer's disease and the potential therapeutic drug exploration. IBRAIN 2022; 9:446-462. [PMID: 38680509 PMCID: PMC11045201 DOI: 10.1002/ibra.12040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 04/27/2022] [Accepted: 05/02/2022] [Indexed: 05/01/2024]
Abstract
Postoperative cognitive dysfunction (POCD) is a decrease in mental capacity that can occur days to weeks after a medical procedure and may become permanent and rarely lasts for a longer period of time. With the continuous development of research, various viewpoints in academic circles have undergone subtle changes, and the role of anesthesia depth and anesthesia type seems to be gradually weakened; Alzheimer's disease (AD) is a latent and progressive neurodegenerative disease in the elderly. The protein hypothesis and the synaptic hypothesis are well-known reasons. These changes will also lead to the occurrence of an inflammatory cascade. The exact etiology and pathogenesis need to be studied. The reasonable biological mechanism affecting brain protein deposition, neuroinflammation, and acetylcholine-like effect has a certain relationship between AD and POCD. Whereas there is still further uncertainty about the mechanism and treatment, and it is elusive whether POCD is a link in the continuous progress of AD or a separate entity, which has doubts about the diagnosis and treatment of the disease. Therefore, this review is based on the current common clinical characteristics of AD and POCD, and pathophysiological research, to search for their common points and explore the direction and new strategies for future treatment.
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Affiliation(s)
- Dong‐Qin Chen
- Department of AnesthesiologyAffiliated Hospital of Zunyi Medical UniversityZunyiChina
- College of AnesthesiologyZunyi Medical UniversityZunyiChina
| | - Xu Fang
- Department of AnesthesiologyAffiliated Hospital of Zunyi Medical UniversityZunyiChina
- College of AnesthesiologyZunyi Medical UniversityZunyiChina
| | - Zhao‐Qiong Zhu
- Department of AnesthesiologyAffiliated Hospital of Zunyi Medical UniversityZunyiChina
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15
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Zhu Z, Ma L. Sevoflurane induces inflammation in primary hippocampal neurons by regulating Hoxa5/Gm5106/miR-27b-3p positive feedback loop. Bioengineered 2021; 12:12215-12226. [PMID: 34783294 PMCID: PMC8810152 DOI: 10.1080/21655979.2021.2005927] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 11/08/2021] [Accepted: 11/09/2021] [Indexed: 10/27/2022] Open
Abstract
Postoperative cognitive dysfunction (POCD) is a normal condition that develops after surgery with anesthesia, leading to deterioration of cognitive functions. However, the mechanism of POCD still remains unknown. To elucidate the POCD molecular mechanism, sevoflurane was employed in the present study to generate neuroinflammation mice model. Sevoflurane treatment caused inflammatory markers IL6, IL-10 and TNF-α high expression in primary hippocampal neurons and blood samples. Long non-coding RNA Gm5106 was found to be increased after being stimulated with sevoflurane. Silencing Gm5106 inhibited neuron inflammation. In the meanwhile, Gm5106 was identified as a direct target of miR-27b-3p that was inhibited by sevoflurane and related to inflammation suppression. In addition, transcription factor (TF) Hoxa5 was validated to activate Gm5106 through two binding motifs in the promoter region after sevoflurane exposure. Furthermore, miR-27b-3p also directly targeted Hoxa5 3'UTR, which affected nuclear Hoxa5 protein served as TF. Hoxa5 protein instead of 3'UTR reduced miR-27b-3p, in which Gm5106 knocking down abrogated this effect. In conclusion, sevoflurane induces neuroinflammation through increasing long non-coding RNA Gm5106, which is transcriptionally activated by Hoxa5 and directly targeted by miR-27-3p. Apart from that, Hoxa5, Gm5106, and miR-27b-3p form a positive feedback loop in sevoflurane stimulation.
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Affiliation(s)
- Zifu Zhu
- Huizhou Municipal Central Hospital, Huizhou, Guangdong, PR China
| | - Li Ma
- First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, PR China
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16
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Shalev S, Ben-Sira L, Wasserzug O, Shaylor R, Shiran SI, Ekstein M. Utility of three-dimensional modeling of the fetal airway for ex utero intrapartum treatment. J Anesth 2021; 35:595-598. [PMID: 34075478 DOI: 10.1007/s00540-021-02950-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 05/22/2021] [Indexed: 11/24/2022]
Abstract
Recent technological developments in three-dimensional (3D) printing have created new opportunities for applications in clinical medicine. 3D printing has been adopted for teaching and planning complicated surgeries, including maxillofacial, orthopedic reconstructions, and airway manipulation for one-lung ventilation or airway stenting. We present here the first use of such technology to print a model from in utero imaging for intrapartum treatment planning. A 32-week fetus presented with congenital high airway obstruction syndrome (CHAOS) due to a large cervical lymphatic malformation. An ex utero intrapartum treatment (EXIT) procedure was planned to allow delivery of a viable infant. We printed a 3D model of the fetal airway by printing separate elements: mandible, tongue, mass, larynx, and trachea from the fetal MRI. The elements were stuck together maintaining correct anatomical relationships. Airway planning was then performed in consultation with a pediatric ear nose and throat (ENT) surgeon. 3D modeling in utero presents many challenges: the resolution of the 3D model generated from a fetal MRI is less crisp than from CT images, fetal position may be variable and not in a defined anatomical plane, movement artifact occurs. Nevertheless, pre-procedure simulations with the aid of 3D modeling promoted team cooperation and well-prepared management of the fetus during EXIT.
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Affiliation(s)
- Shahar Shalev
- Division of Anesthesiology, Intensive Care, and Pain Medicine, Tel-Aviv Medical Center, affiliated with the Sackler Faculty of Medicine, 6 Weizmann Street, 6423906, Tel-Aviv, Israel
| | - Liat Ben-Sira
- Department of Radiology, Tel-Aviv Medical Center, The Dana-Dwek Children's Hospital, affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Oshri Wasserzug
- Department of Pediatric Otolaryngology, Tel-Aviv Medical Center, The Dana-Dwek Children's Hospital, affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Ruth Shaylor
- Division of Anesthesiology, Intensive Care, and Pain Medicine, Tel-Aviv Medical Center, affiliated with the Sackler Faculty of Medicine, 6 Weizmann Street, 6423906, Tel-Aviv, Israel
| | - Shelly I Shiran
- Department of Radiology, Tel-Aviv Medical Center, The Dana-Dwek Children's Hospital, affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Margaret Ekstein
- Division of Anesthesiology, Intensive Care, and Pain Medicine, Tel-Aviv Medical Center, affiliated with the Sackler Faculty of Medicine, 6 Weizmann Street, 6423906, Tel-Aviv, Israel.
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Intravenous versus Volatile Anesthetic Effects on Postoperative Cognition in Elderly Patients Undergoing Laparoscopic Abdominal Surgery. Anesthesiology 2021; 134:381-394. [PMID: 33439974 DOI: 10.1097/aln.0000000000003680] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Delayed neurocognitive recovery after surgery is associated with poor outcome. Most surgeries require general anesthesia, of which sevoflurane and propofol are the most commonly used inhalational and intravenous anesthetics. The authors tested the primary hypothesis that patients with laparoscopic abdominal surgery under propofol-based anesthesia have a lower incidence of delayed neurocognitive recovery than patients under sevoflurane-based anesthesia. A second hypothesis is that there were blood biomarkers for predicting delayed neurocognitive recovery to occur. METHODS A randomized, double-blind, parallel, controlled study was performed at four hospitals in China. Elderly patients (60 yr and older) undergoing laparoscopic abdominal surgery that was likely longer than 2 h were randomized to a propofol- or sevoflurane-based regimen to maintain general anesthesia. A minimum of 221 patients was planned for each group to detect a one-third decrease in delayed neurocognitive recovery incidence in propofol group compared with sevoflurane group. The primary outcome was delayed neurocognitive recovery incidence 5 to 7 days after surgery. RESULTS A total of 544 patients were enrolled, with 272 patients in each group. Of these patients, 226 in the propofol group and 221 in the sevoflurane group completed the needed neuropsychological tests for diagnosing delayed neurocognitive recovery, and 46 (20.8%) in the sevoflurane group and 38 (16.8%) in the propofol group met the criteria for delayed neurocognitive recovery (odds ratio, 0.77; 95% CI, 0.48 to 1.24; P = 0.279). A high blood interleukin-6 concentration at 1 h after skin incision was associated with an increased likelihood of delayed neurocognitive recovery (odds ratio, 1.04; 95% CI, 1.01 to 1.07; P = 0.007). Adverse event incidences were similar in both groups. CONCLUSIONS Anesthetic choice between propofol and sevoflurane did not appear to affect the incidence of delayed neurocognitive recovery 5 to 7 days after laparoscopic abdominal surgery. A high blood interleukin-6 concentration after surgical incision may be an independent risk factor for delayed neurocognitive recovery. EDITOR’S PERSPECTIVE
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Brodier E, Cibelli M. Postoperative cognitive dysfunction in clinical practice. BJA Educ 2021; 21:75-82. [PMID: 33889433 PMCID: PMC7810820 DOI: 10.1016/j.bjae.2020.10.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2020] [Indexed: 12/13/2022] Open
Affiliation(s)
- E.A. Brodier
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - M. Cibelli
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Montupil J, Defresne A, Bonhomme V. The Raw and Processed Electroencephalogram as a Monitoring and Diagnostic Tool. J Cardiothorac Vasc Anesth 2020; 33 Suppl 1:S3-S10. [PMID: 31279351 DOI: 10.1053/j.jvca.2019.03.038] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
In this narrative review, different aspects of electroencephalogram (EEG) monitoring during anesthesia are approached, with a special focus on cardiothoracic and vascular anesthesia, from the basic principles to more sophisticated diagnosis and monitoring utilities. The available processed EEG-derived indexes of the depth of the hypnotic component of anesthesia have well-defined limitations and usefulness. They prevent intraoperative awareness with recall in specific patient populations and under a specific anesthetic regimen. They prevent intraoperative overdose, and they shorten recovery times. They also help to avoid lengthy intraoperative periods of suppression activity, which are known to be deleterious in terms of outcome. Other than those available indexes, the huge amount of information contained in the EEG currently is being used only partially. Several other areas of interest regarding EEG during anesthesia have emerged in terms of anesthesia mechanisms elucidation, nociception monitoring, and diagnosis or prevention of brain insults.
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Affiliation(s)
- Javier Montupil
- University Department of Anesthesia and Intensive Care Medicine, CHR Citadelle, Liège, Belgium
| | - Aline Defresne
- Department of Anesthesia and Intensive Care Medicine, CHU Liege, Liège, Belgium
| | - Vincent Bonhomme
- Anesthesia and Intensive Care Laboratory, GIGA-Consciousness Thematic Unit, GIGA Research, Liege University, Liège, Belgium.
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Zugni N, Guadrini L, Rasulo F. Noninvasive neuromonitoring in the operating room and its role in the prevention of delirium. Best Pract Res Clin Anaesthesiol 2020; 35:191-206. [PMID: 34030804 DOI: 10.1016/j.bpa.2020.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 09/20/2020] [Accepted: 09/25/2020] [Indexed: 01/16/2023]
Abstract
Delirium is a frequent and serious complication after surgery. It has a variable incidence between 20% and 40% with the highest incidence in elderly people undergoing major or cardiac surgery. The development of postoperative delirium (POD) is associated with increased hospital stay lengths, morbidity, the need for home care, and mortality. Studies have appeared in the last decade that evaluate the use of noninvasive monitoring to prevent its development. The evaluation of the depth of anesthesia with processed EEG allows to avoid awareness and burst suppression events. The cessation of brain activity is associated with the development of delirium. Another noninvasive monitoring technique is NIRS for cerebral tissue hypoxia detection by measuring regional oxygen saturation. The reduction of this parameter does not seem to be associated with the development of POD but with postoperative cognitive dysfunction. There are few studies in the literature and with conflicting results on the use of the pupillometer and transcranial Doppler in predicting the development of postoperative delirium.
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Affiliation(s)
- Nicola Zugni
- Division of Anesthesiology, Intensive Care, and Emergency Medicine, University of Brescia at Spedali Civili Hospital, Brescia, Italy.
| | - Lucrezia Guadrini
- Division of Anesthesiology, Intensive Care, and Emergency Medicine, University of Brescia at Spedali Civili Hospital, Brescia, Italy.
| | - Frank Rasulo
- Division of Anesthesiology, Intensive Care, and Emergency Medicine, University of Brescia at Spedali Civili Hospital, Brescia, Italy; Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, Division of Anesthesiology, Intensive Care and Emergency Medicine, University of Brescia at Spedali Civili Hospital, Brescia, Italy.
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21
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Ding L, Chen DX, Li Q. Effects of electroencephalography and regional cerebral oxygen saturation monitoring on perioperative neurocognitive disorders: a systematic review and meta-analysis. BMC Anesthesiol 2020; 20:254. [PMID: 32998697 PMCID: PMC7526409 DOI: 10.1186/s12871-020-01163-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 09/16/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Perioperative neurocognitive disorders (PND) is a common postoperative complication including postoperative delirium (POD), postoperative cognitive decline (POCD) or delayed neurocognitive recovery. It is still controversial whether the use of intraoperative cerebral function monitoring can decrease the incidence of PND. The purpose of this study was to evaluate the effects of different cerebral function monitoring (electroencephalography (EEG) and regional cerebral oxygen saturation (rSO2) monitoring) on PND based on the data from randomized controlled trials (RCTs). METHODS The electronic databases of Ovid MEDLINE, PubMed, EMBASE, Cochrane Library database were systematically searched using the indicated keywords from their inception to April 2020. The odds ratio (OR) or mean difference (MD) with 95% confidence interval (CI) were employed to analyze the data. Heterogeneity across analyzed studies was assessed with chi-square test and I2 test. RESULTS Twenty two RCTs with 6356 patients were included in the final analysis. Data from 12 studies including 4976 patients were analyzed to assess the association between the EEG-guided anesthesia and PND. The results showed that EEG-guided anesthesia could reduce the incidence of POD in patients undergoing non-cardiac surgery (OR: 0.73; 95% CI: 0.57-0.95; P = 0.02), but had no effect on patients undergoing cardiac surgery (OR: 0.44; 95% CI: 0.05-3.54; P = 0.44). The use of intraoperative EEG monitoring reduced the incidence of POCD up to 3 months after the surgery (OR: 0.69; 95% CI: 0.49-0.96; P = 0.03), but the incidence of early POCD remained unaffected (OR: 0.61; 95% CI: 0.35-1.07; P = 0.09). The remaining 10 studies compared the effect of rSO2 monitoring to routine care in a total of 1380 participants on the incidence of PND. The results indicated that intraoperative monitoring of rSO2 could reduce the incidence of POCD (OR 0.53, 95% CI 0.39-0.73; P < 0.0001), whereas no significant difference was found regarding the incidence of POD (OR: 0.74; 95% CI: 0.48-1.14; P = 0.17). CONCLUSIONS The findings in the present study indicated that intraoperative use of EEG or/and rSO2 monitor could decrease the risk of PND. TRIAL REGISTRATION PROSPREO registration number: CRD42019130512 .
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Affiliation(s)
- Lin Ding
- National Clinical Research Center for Geriatrics and department of Anesthesiology, West China Hospital of Sichuan University & The Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, Chengdu, 610041, China
| | - Dong Xu Chen
- National Clinical Research Center for Geriatrics and department of Anesthesiology, West China Hospital of Sichuan University & The Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, Chengdu, 610041, China
| | - Qian Li
- National Clinical Research Center for Geriatrics and department of Anesthesiology, West China Hospital of Sichuan University & The Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, Chengdu, 610041, China.
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Li Y, Zhang B. Effects of anesthesia depth on postoperative cognitive function and inflammation: a systematic review and meta-analysis. Minerva Anestesiol 2020; 86:965-973. [DOI: 10.23736/s0375-9393.20.14251-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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23
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Tasbihgou SR, Absalom AR. Postoperative neurocognitive disorders. Korean J Anesthesiol 2020; 74:15-22. [PMID: 32623846 PMCID: PMC7862941 DOI: 10.4097/kja.20294] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 07/01/2020] [Indexed: 12/16/2022] Open
Abstract
A decline in cognitive function is a frequent complication of major surgery. Postoperative cognitive impairments have generally been divided into short- (postoperative delirium) and long-term disturbances (postoperative cognitive dysfunction [POCD]). Long-term impairments are often subtle and overlooked. They need to be objectively assessed using neuropsychological tests to be diagnosed. Although POCD has been the subject of considerable research over the past decades, it remains uncertain why some patients do not return to preoperative levels of cognitive function. Surgery and anesthesia have both been implicated to play a role in POCD development, and certain patient-related factors, such as advanced age and low preoperative baseline cognitive function, have consistently been found to predict postoperative cognitive decline. This article will present an overview of POCD and its etiology and provide advice on possible strategies on its prevention.
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Affiliation(s)
- Setayesh Reza Tasbihgou
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Anthony Ray Absalom
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Xu X, Hu X, Wu Y, Li Y, Zhang Y, Zhang M, Yang Q. Effects of different BP management strategies on postoperative delirium in elderly patients undergoing hip replacement: A single center randomized controlled trial. J Clin Anesth 2020; 62:109730. [DOI: 10.1016/j.jclinane.2020.109730] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 12/17/2019] [Accepted: 01/18/2020] [Indexed: 12/19/2022]
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Zdravkovic M, Kamenik M. A prospective randomized controlled study of combined spinal-general anesthesia vs. general anesthesia for laparoscopic gynecological surgery: Opioid sparing properties. J Clin Anesth 2020; 64:109808. [PMID: 32305787 DOI: 10.1016/j.jclinane.2020.109808] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 02/20/2020] [Accepted: 04/04/2020] [Indexed: 12/11/2022]
Abstract
STUDY OBJECTIVE We aimed to determine the magnitude of peri-operative opioid sparing effect when general anesthesia is combined with spinal analgesia for laparoscopic gynecological surgery. DESIGN A prospective randomized controlled study; a three-group trial with two comparisons (each intervention group to control). SETTING Operating room and postoperative recovery area. PATIENTS Patients aged between 18 and 65 years with American Society of Anesthesiologists physical status 1 or 2 who were scheduled for inpatient elective laparoscopic gynecological surgery with expected pneumoperitoneum duration of at least 20 min. Of 102 randomized patients, 99 completed the study. INTERVENTIONS Patients were randomized to general anesthesia alone (control group) or combined with very-low-dose (levobupivacaine 3.75 mg; sufentanil 2.5 μg) or low-dose (levobupivacaine 7.5 mg; sufentanil 2.5 μg) spinal analgesia. MEASUREMENTS Primary endpoints were perioperative opioid consumption and pain scores (11-point numeric rating scale) at 30 min, 1 h, 2 h, 4 h and 24 h post-surgery. Secondary endpoints were patient satisfaction with anesthetic care and participation in research, sevoflurane consumption and adverse effects. MAIN RESULTS Intra-operative sufentanil (median [95% CI]) consumption was 16.1 (10.5-22.6) μg/h in the control group versus 4.7 (3.2-9.2) μg/h in the very-low-dose and versus 2.9 (0.0-4.0) μg/h in the low-dose spinal analgesia groups (p < 0.001, for both comparisons). Median (95% CI) piritramide consumption at 24 h post-surgery was 7.5 (3-8) mg in the control group versus 5 (0-7.5) mg in the very-low dose spinal analgesia group (p = 0.182) and versus 2 (0-2.5) mg in the low-dose spinal analgesia group (p = 0.001). Postoperative pain scores were consistently <3 only in the low dose spinal analgesia group. Patient satisfaction with anesthetic care and participation in research was very high in all groups. CONCLUSIONS Low-dose spinal analgesia in combination with general anesthesia reduces peri-operative opioid consumption in laparoscopic gynecological surgery in immediate postoperative period.
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Affiliation(s)
- Marko Zdravkovic
- Department of Anaesthesiology, Intensive Care and Pain Management, University Medical Centre Maribor, Ljubljanska ulica 5, 2000 Maribor, Slovenia; Faculty of Medicine, University of Maribor, Taborska ulica 8, 2000 Maribor, Slovenia.
| | - Mirt Kamenik
- Department of Anaesthesiology, Intensive Care and Pain Management, University Medical Centre Maribor, Ljubljanska ulica 5, 2000 Maribor, Slovenia; Faculty of Medicine, University of Maribor, Taborska ulica 8, 2000 Maribor, Slovenia
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Abstract
PURPOSE OF REVIEW Cognitive decline is frequently reported after hospitalisation in the contexts of surgery, delirium and critical care. The question not adequately addressed is whether all types of acute hospitalisations increase the risk of cognitive decline. As acute hospitalisations are common in the elderly, who are also vulnerable to cognitive decline, this possible association is of significant concern. RECENT FINDINGS This review summarises cognitive outcomes from recent observational studies investigating acute hospitalisation (emergent and elective) in older age adults. Studies were identified from searching Medline, Embase and PsycINFO databases and citations lists. The highest incidence of cognitive decline has been reported following critical care admissions and admissions complicated by delirium, although all types of acute hospitalisations are implicated. Age is the most consistent risk factor for cognitive decline. Several etiological and therapeutic aspects are being investigated, particularly the measurement of inflammatory biomarkers and treatment with anti-inflammatory medications. SUMMARY Acute hospitalisation for any reason appears to increase the risk of cognitive decline in older adults, but the cause remains elusive. Future research must clarify the nature and modifiers of posthospitalisation cognitive change, a priority in the face of an ageing population.
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Bocskai T, Kovács M, Szakács Z, Gede N, Hegyi P, Varga G, Pap I, Tóth I, Révész P, Szanyi I, Németh A, Gerlinger I, Karádi K, Lujber L. Is the bispectral index monitoring protective against postoperative cognitive decline? A systematic review with meta-analysis. PLoS One 2020; 15:e0229018. [PMID: 32053678 PMCID: PMC7018011 DOI: 10.1371/journal.pone.0229018] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 01/28/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Several studies have suggested that monitoring the depth of anaesthesia might prevent the development of postoperative cognitive decline. We aimed to conduct a meta-analysis to investigate the effects of bispectral index (BIS) monitoring in anaesthesia. METHODS We searched in six major electronic databases. Trials were included if they discussed anaesthesia with and without BIS monitoring or low (<50) and high (≥50) BIS levels and which measured the risk of postoperative delirium (POD) and/or postoperative cognitive dysfunction (POCD). RESULTS We included fourteen studies in the systematic review, eight of which were eligible for meta-analysis. BIS proved to be protective against POD at 1 day postoperatively in a cohort of 2138 patients (16.1% vs. 22.8% for BIS vs. no BIS groups, respectively; relative risk [RR] 0.71; 95% confidence interval [CI] 0.59 to 0.85, without significant between-study heterogeneity I2 = 0.0%, P = 0.590). The use of BIS was neutral for POCD at 1 week but protective for POCD at 12 weeks (15.8% vs. 18.8% for BIS vs. no BIS groups, respectively; RR = 0.84, CI: 0.66 to 1.08), without significant between-study heterogeneity (I2 = 25.8%, P = 0.260). The neutral association at 1 week proved to be underpowered with trial sequential analysis. In the comparison of low BIS versus high BIS, the incidence of POD at 1 day was similar in the groups. CONCLUSION Our findings suggest a protective effect of BIS compared to not using BIS regarding the incidence of POD at 1 day and POCD at 12 weeks. However, limitations of the evidence warrant further investigation to identify those groups of patients by age, comorbid conditions and other individual variables who would benefit the most from the use of BIS monitoring.
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Affiliation(s)
- Timea Bocskai
- Department of Anaesthesiology and Intensive Care, Medical School, University of Pécs, Pécs, Hungary
| | - Márton Kovács
- Department of Otorhinolaryngology (ENT), Medical School, University of Pécs, Pécs, Hungary
| | - Zsolt Szakács
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
- János Szentágothai Research Center, University of Pécs, Pécs, Hungary
| | - Noémi Gede
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Péter Hegyi
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
- János Szentágothai Research Center, University of Pécs, Pécs, Hungary
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
- Hungarian Academy of Sciences–University of Szeged, Momentum Gastroenterology Multidisciplinary Research Group, Szeged, Hungary
| | - Gábor Varga
- Department of Oral Biology, Semmelweis University, Budapest, Hungary
| | - István Pap
- Department of Otorhinolaryngology (ENT), Medical School, University of Pécs, Pécs, Hungary
| | - István Tóth
- Department of Otorhinolaryngology (ENT), Medical School, University of Pécs, Pécs, Hungary
| | - Péter Révész
- Department of Otorhinolaryngology (ENT), Medical School, University of Pécs, Pécs, Hungary
| | - István Szanyi
- Department of Otorhinolaryngology (ENT), Medical School, University of Pécs, Pécs, Hungary
| | - Adrienne Németh
- Department of Otorhinolaryngology (ENT), Medical School, University of Pécs, Pécs, Hungary
| | - Imre Gerlinger
- Department of Otorhinolaryngology (ENT), Medical School, University of Pécs, Pécs, Hungary
| | - Kázmér Karádi
- Institute of Behavioral Sciences, Medical School, University of Pécs, Pécs, Hungary
| | - László Lujber
- Department of Otorhinolaryngology (ENT), Medical School, University of Pécs, Pécs, Hungary
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Belrose JC, Noppens RR. Anesthesiology and cognitive impairment: a narrative review of current clinical literature. BMC Anesthesiol 2019; 19:241. [PMID: 31881996 PMCID: PMC6933922 DOI: 10.1186/s12871-019-0903-7] [Citation(s) in RCA: 102] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 12/03/2019] [Indexed: 12/14/2022] Open
Abstract
Background The impact of general anesthesia on cognitive impairment is controversial and complex. A large body of evidence supports the association between exposure to surgery under general anesthesia and development of delayed neurocognitive recovery in a subset of patients. Existing literature continues to debate whether these short-term effects on cognition can be attributed to anesthetic agents themselves, or whether other variables are causative of the observed changes in cognition. Furthermore, there is conflicting data on the relationship between anesthesia exposure and the development of long-term neurocognitive disorders, or development of incident dementia in the patient population with normal preoperative cognitive function. Patients with pre-existing cognitive impairment present a unique set of anesthetic considerations, including potential medication interactions, challenges with cooperation during assessment and non-general anesthesia techniques, and the possibility that pre-existing cognitive impairment may impart a susceptibility to further cognitive dysfunction. Main body This review highlights landmark and recent studies in the field, and explores potential mechanisms involved in perioperative cognitive disorders (also known as postoperative cognitive dysfunction, POCD). Specifically, we will review clinical and preclinical evidence which implicates alterations to tau protein, inflammation, calcium dysregulation, and mitochondrial dysfunction. As our population ages and the prevalence of Alzheimer’s disease and other forms of dementia continues to increase, we require a greater understanding of potential modifiable factors that impact perioperative cognitive impairment. Conclusions Future research should aim to further characterize the associated risk factors and determine whether certain anesthetic approaches or other interventions may lower the potential risk which may be conferred by anesthesia and/or surgery in susceptible individuals.
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Affiliation(s)
- Jillian C Belrose
- Department of Anesthesia & Perioperative Medicine, Western University, London Health Sciences Center, 339 Windermere Rd, London, ON, N6A 5A5, Canada
| | - Ruediger R Noppens
- Department of Anesthesia & Perioperative Medicine, Western University, London Health Sciences Center, 339 Windermere Rd, London, ON, N6A 5A5, Canada.
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Lin X, Chen Y, Zhang P, Chen G, Zhou Y, Yu X. The potential mechanism of postoperative cognitive dysfunction in older people. Exp Gerontol 2019; 130:110791. [PMID: 31765741 DOI: 10.1016/j.exger.2019.110791] [Citation(s) in RCA: 148] [Impact Index Per Article: 29.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 10/18/2019] [Accepted: 11/21/2019] [Indexed: 02/08/2023]
Abstract
Postoperative cognitive dysfunction (POCD) is a common disorder following surgery, which seriously threatens the quality of patients' life, especially the older people. Accumulating attention has been paid to POCD worldwide in pace with the popularization of anesthesia/surgery. The development of medical humanities and rehabilitation medicine sets higher demands on accurate diagnosis and safe treatment system of POCD. Although the research on POCD is in full swing, underlying pathogenesis is still inconclusive due to these conflicting results and controversial evidence. Generally, POCD is closely related to neuropsychiatric diseases such as dementia, depression and Alzheimer's disease in molecular pathways. Researchers have come up with various hypotheses to reveal the mechanisms of POCD, including neuroinflammation, oxidative stress, autophagy disorder, impaired synaptic function, lacking neurotrophic support, etc. Recent work focused on molecular mechanism of POCD in older people has been thoroughly reviewed and summed up here, concerning the changes of peripheral circulation, pathological pathways of central nervous system (CNS), the microbiota-gut-brain axis and the related brain regions. Accordingly, this article provides a better perspective to understand the development situation of POCD in older people, which is conductive to uncover the pathological mechanism and exploit reasonable treatment strategy of POCD.
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Affiliation(s)
- Xianyi Lin
- Department of Anesthesiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China
| | - Yeru Chen
- Department of Anesthesiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China
| | - Piao Zhang
- Department of Anesthesiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China
| | - Gang Chen
- Department of Anesthesiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China.
| | - Youfa Zhou
- Department of Anesthesiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China
| | - Xin Yu
- Department of Anesthesiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China
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Impact of thoracic paravertebral block combined with general anesthesia on postoperative cognitive function and serum adiponectin levels in elderly patients undergoing lobectomy. Wideochir Inne Tech Maloinwazyjne 2019; 14:538-544. [PMID: 31908700 PMCID: PMC6939210 DOI: 10.5114/wiitm.2019.84742] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 03/02/2019] [Indexed: 11/25/2022] Open
Abstract
Introduction Thoracic paravertebral block (TPVB) can improve postoperative analgesia, inhibiting perioperative stress and the inflammatory response. However, whether it can improve early postoperative cognitive dysfunction (POCD) by altering the secretion and expression of serum ADP remains unclear. Aim To investigate the impact of thoracic paravertebral block combined with general anesthesia (TPVB-GA) on postoperative cognitive function and serum adiponectin (ADP) levels in elderly patients undergoing lobectomy. Material and methods A total of 120 elderly patients undergoing elective lobectomy were randomly divided into three groups: general anesthesia (GA); TPVB-GA (PG); epidural block combined with general anesthesia (EG). Cognitive function in the three groups was evaluated 1 day before and 7 days after surgery. The serum levels of ADP and S-100β protein were evaluated before anesthesia (T0), 15 min after skin incision (T3), and 7 days after surgery (T5). Results Cognitive function scores in the three groups decreased by different extents at T5 (p < 0.05); scores in groups PG and EG were higher than those in group GA (p < 0.05). The serum levels of S-100β protein in the three groups at T3 were higher than those at T0 (p < 0.05); however, serum ADP concentrations were reduced (p < 0.05); the serum levels of S-100β protein in groups PG and EG were lower than those in group GA at T3, while serum ADP levels were higher. Conclusions Thoracic paravertebral block or epidural block combined with general anesthesia can improve early postoperative cognitive function in elderly patients undergoing lobectomy. TPVB-GA demonstrated better effects, which may be related to the secretion of ADP.
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Delayed recovery following thoracic surgery: persistent issues and potential interventions. Curr Opin Anaesthesiol 2019; 32:3-9. [PMID: 30507683 DOI: 10.1097/aco.0000000000000669] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW Lung and esophageal surgery remain a curative option for resectable cancers. However, despite advances in surgical and anesthesia practices, the inclusion of patients with comorbidities that would have previously not been offered curative resection presents additional concerns and challenges. RECENT FINDINGS Perioperative complication rates remain high and prolonged and/or painful recovery are common. Further, many patients face a permanent decline in their functional status, which negatively affects their quality of life. Examination of the variables associated with high complications following thoracic surgery reveals patient, physician, and institutional factors in the forefront. Anesthesiologist training, Enhanced Recovery After Surgery protocols, and preparations to minimize "failure to rescue" when a complication does arise are key strategies to address adverse outcomes. SUMMARY Delayed and complicated recovery after thoracic noncardiac surgery persist in current practice. This review analyzes the diverse factors that can impact complications and quality of life after lung surgery and the interventions that can help decrease length of stay and improve return to baseline conditions.
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Abstract
PURPOSE OF REVIEW This article reviews the recent clinical evidence published between January 2017 and June 2018 - related to perioperative cognitive evaluation. Namely, new insights into risk factors, prevention, diagnosis and diagnostic tools and treatment. RECENT FINDINGS Several risk factors (preoperative, intraoperative and postoperative) have been found to be associated with the development of postoperative delirium (POD) and/or postoperative cognitive dysfunction (POCD). Short-term and long-term postoperative consequences can be reduced by targeting risk factors, introducing preventive strategies and including frequent cognitive monitoring. Administration of medications such as ketamine, opioids and benzodiazepines are associated with increased cognitive dysfunction. Prevention of POD/POCD starts with creating an environment, which promotes return to preoperative baseline functioning. This includes frequent monitoring of cognitive status, access to rehabilitation and psychological and social supports, and avoiding polypharmacy. In addition, patients should have early access to their sensory aids and maintain normal circadian rhythm. Treatment of POD/POCD has pharmacological and nonpharmacological approaches. SUMMARY Clinical evidence on POD/POCD is continuously evolving, which is essential in guiding clinical management to provide the highest quality of clinical care.
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Processed Electroencephalogram Monitoring and Postoperative Delirium: A Systematic Review and Meta-analysis. Anesthesiology 2019; 129:417-427. [PMID: 29912008 DOI: 10.1097/aln.0000000000002323] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
WHAT WE ALREADY KNOW ABOUT THIS TOPIC WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Postoperative delirium complicates approximately 15 to 20% of major operations in patients at least 65 yr old and is associated with adverse outcomes and increased resource utilization. Furthermore, patients with postoperative delirium might also be at risk of developing long-term postoperative cognitive dysfunction. One potentially modifiable variable is use of intraoperative processed electroencephalogram to guide anesthesia. This systematic review and meta-analysis examines the relationship between processed electroencephalogram monitoring and postoperative delirium and cognitive dysfunction. METHODS A systematic search for randomized controlled trials was conducted using Ovid MEDLINE, PubMed, EMBASE, Cochrane Library, and Google search using the keywords processed electroencephalogram, Bispectral Index, postoperative delirium, postoperative cognitive dysfunction. Screening and data extraction were conducted by two independent reviewers, and risk of bias was assessed. Postoperative delirium combined-effect estimates calculated with a fixed-effects model were expressed as odds ratios with 95% CIs. RESULTS Thirteen of 369 search results met inclusion criteria. Postoperative cognitive dysfunction data were excluded in meta-analysis because of heterogeneity of outcome measurements; results were discussed descriptively. Five studies were included in the quantitative postoperative delirium analysis, with data pooled from 2,654 patients. The risk of bias was low in three studies and unclear for the other two. The use of processed electroencephalogram-guided anesthesia was associated with a 38% reduction in odds for developing postoperative delirium (odds ratio = 0.62; P < 0.001; 95% CI, 0.51 to 0.76). CONCLUSIONS Processed electroencephalogram-guided anesthesia was associated with a decrease in postoperative delirium. The mechanism explaining this association, however, is yet to be determined. The data are insufficient to assess the relationship between processed electroencephalogram monitoring and postoperative cognitive dysfunction.
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