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Meng L, Zhao X, Sun Y, Cheng S, Bao L, Fang K, Yu Q, Zheng Y, Wang J, Luo M, Gunderman D, Vuckovic N, Sidhu AS, Li J, Li G, Wolfe JW, Liu Z, Adams DC. Characteristics associated with effectiveness in postoperative delirium research: a systematic review of randomised controlled trials with meta-regression and meta-analysis. Br J Anaesth 2024; 133:565-583. [PMID: 38969535 DOI: 10.1016/j.bja.2024.05.033] [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: 09/15/2023] [Revised: 05/28/2024] [Accepted: 05/30/2024] [Indexed: 07/07/2024] Open
Abstract
BACKGROUND Postoperative delirium remains prevalent despite extensive research through randomised trials aimed at reducing its incidence. Understanding trial characteristics associated with interventions' effectiveness facilitates data interpretation. METHODS Trial characteristics were extracted from eligible trials identified through two systematic literature searches. Multivariable meta-regression was used to investigate trial characteristics associated with effectiveness estimated using odds ratios. Meta-analysis was used to investigate pooled effectiveness. RESULTS We identified 201 eligible trials. Compared with China, trials from the USA/Canada (ratio of odds ratio, 1.89; 95% confidence interval, 1.45-2.45) and Europe/Australia/New Zealand (1.67; 1.29-2.18) had an 89% and 67% higher odds ratio, respectively, suggesting reduced effectiveness. The effectiveness was enhanced when the incidence of postoperative delirium increased (0.85; 0.79-0.92, per 10% increase). Trials with concerns related to deviations from intended interventions reported increased effectiveness compared with those at low risk (0.69; 0.53-0.90). Compared with usual care, certain interventions appeared to have reduced the incidence of postoperative delirium in low-risk trials with low-to-moderate certainty of evidence. However, these findings should be considered inconclusive because of challenges in grouping heterogeneous interventions, the limited number of eligible trials, the prevalence of small-scale studies, and potential publication bias. CONCLUSIONS The effectiveness of postoperative delirium trials varied based on the region of trial origin, the incidence of delirium, and the risk of bias. The limitations caution against drawing definitive conclusions from different bodies of evidence. These findings highlight the imperative need to improve the quality of research on a global scale. SYSTEMATIC REVIEW PROTOCOL PROSPERO (CRD42023413984).
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Affiliation(s)
- Lingzhong Meng
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Xu Zhao
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yanhua Sun
- Department of Anesthesiology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Shufen Cheng
- Department of Anesthesiology, The Fourth Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Lin Bao
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
| | - Kaiyun Fang
- Department of Anesthesiology, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China
| | - Qiong Yu
- Department of Anesthesiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Yueying Zheng
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jin Wang
- Department of Anesthesiology, The Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Mengqiang Luo
- Department of Anesthesiology, Huashan Hospital, Fudan University, Shanghai, China
| | - David Gunderman
- Indiana University School of Medicine, Indiana University, Indianapolis, IN, USA
| | - Nikola Vuckovic
- Indiana University School of Medicine, Indiana University, Indianapolis, IN, USA
| | - Angad S Sidhu
- Indiana University School of Medicine, Indiana University, Indianapolis, IN, USA
| | - Jian Li
- Department of Anesthesiology, The Fourth Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Gang Li
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
| | - John W Wolfe
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ziyue Liu
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, USA
| | - David C Adams
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN, USA
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Siburian R, Fadillah R, Altobaishat O, Umar TP, Dilawar I, Nugroho DT. Remote ischemic preconditioning and cognitive dysfunction following coronary artery bypass grafting: A systematic review and meta-analysis of randomized controlled trials. Saudi J Anaesth 2024; 18:187-193. [PMID: 38654856 PMCID: PMC11033882 DOI: 10.4103/sja.sja_751_23] [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: 09/08/2023] [Revised: 09/19/2023] [Accepted: 09/19/2023] [Indexed: 04/26/2024] Open
Abstract
Introduction Postoperative cognitive dysfunction (POCD) is a common neurological issue following cardiopulmonary bypass (CPB)-assisted heart surgery. Remote ischemic preconditioning (RIPC) increases the tolerance of vital organs to ischemia/reperfusion injury, leading to reduced brain injury biomarkers and improved cognitive control. However, the exact mechanisms underlying RIPC's neuroprotective effects remain unclear. This systematic review aimed to explore the hypothesis that RIPC lowers neurocognitive dysfunction in patients undergoing CPB surgery. Method All relevant studies were searched in PubMed, ScienceDirect, EBSCOhost, Google Scholar, Semantic Scholar, Scopus, and Cochrane Library database. Assessment of study quality was carried out by two independent reviewers individually using the Cochrane Risk of Bias (RoB-2) tool. Meta-analysis was performed using a fixed-effect model due to low heterogeneity among studies, except for those with substantial heterogeneity. Results A total of five studies with 1,843 participants were included in the meta-analysis. RIPC was not associated with reduced incidence of postoperative cognitive dysfunction (five RCTs, odds ratio [OR:] 0.79, 95% confidence interval [CI]: 0.56-1.11) nor its improvement (three RCTs, OR: 0.80, 95% CI: 0.50-1.27). In addition, the analysis of the effect of RIPC on specific cognitive function tests found that pooled SMD for RAVLT 1-3 and RAVLT LT were -0.07 (95% CI: -0.25,012) and -0.04 (95% CI: -0.25-0.12), respectively, and for VFT semantic and phonetic were -0.15 (95% CI: -0.33-0.04) and 0.11 (95% CI: -0.40-0.62), respectively. Conclusion The effect of RIPC on cognitive performance in CABG patients remained insignificant. Results from previous studies were unable to justify the use of RIPC as a neuroprotective agent in CABG patients.
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Affiliation(s)
| | - Rizki Fadillah
- Department of Medical Profession, Faculty of Medicine, Universitas Sriwijaya, Palembang, Indonesia
| | - Obieda Altobaishat
- Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Tungki Pratama Umar
- UCL Centre for Nanotechnology and Regenerative Medicine, Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Ismail Dilawar
- Division of Cardiothoracic Surgery, Jakarta Heart Center, Jakarta, Indonesia
| | - Dimas Tri Nugroho
- Division of Cardiothoracic Surgery, Jakarta Heart Center, Jakarta, Indonesia
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Han M, Du Y, Li J, Li Y, Han S, Li C. Effect of remote ischemic preconditioning on postoperative cognitive dysfunction in adult patients with general anesthesia: a meta-analysis. J Cardiothorac Surg 2024; 19:68. [PMID: 38321534 PMCID: PMC10848366 DOI: 10.1186/s13019-024-02520-5] [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: 09/17/2022] [Accepted: 01/28/2024] [Indexed: 02/08/2024] Open
Abstract
BACKGROUND Remote ischemic preconditioning (RIPC) is proven to have neuroprotective protective effects. Nevertheless, the impact of RIPC on postoperative cognitive dysfunction (POCD) in patients undergoing general anesthesia is controversial. This meta-analysis of randomized controlled trials (RCTs) aimed to assess the effect of RIPC on POCD in adults after general anesthesia. METHODS Relevant literature was obtained by searching Embase, PubMed, Web of Science, Cochrane Library, Wanfang, and China National Knowledge Infrastructure (CNKI) databases in July 2022. RCTs were included to assess the influences of RIPC on POCD in adults following general anesthesia. Two investigators independently performed literature screening, data extraction, and quality assessment based on the inclusion and exclusion criteria. The incidence of POCD, operation time, and hospital stay were analyzed by Review manager5.4 software. RESULTS Thirteen RCTs with 1122 participants were selected for this meta-analysis. Compared to the control group, RIPC decreased the incidence of POCD (OR = 0.50, 95% CI 0.31-0.82), as well as reduced the duration of hospitalization (MD = - 0.98, 95% CI - 1.69 to - 0.27), but did not prolong operative time (MD = - 2.65, 95% CI - 7.68 to 2.37). CONCLUSION RIPC reduced the incidence of POCD in adult patients after general anesthesia and accelerated their discharge.
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Affiliation(s)
- Mengnan Han
- Department of Anesthesiology, Hebei General Hospital, No 348 West Heping Road, Shijiazhuang, 050051, China
- Graduate Faculty, Hebei North University, Zhangjiakou, China
| | - Yanru Du
- Department of Anesthesiology, Hebei General Hospital, No 348 West Heping Road, Shijiazhuang, 050051, China
| | - Jianli Li
- Department of Anesthesiology, Hebei General Hospital, No 348 West Heping Road, Shijiazhuang, 050051, China.
| | - Yi Li
- Department of Anesthesiology, Hebei General Hospital, No 348 West Heping Road, Shijiazhuang, 050051, China
| | - Shuang Han
- Department of Anesthesiology, Hebei General Hospital, No 348 West Heping Road, Shijiazhuang, 050051, China
| | - Chong Li
- Department of Anesthesiology, Hebei General Hospital, No 348 West Heping Road, Shijiazhuang, 050051, China
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Chang H, Chen E, Zhu T, Liu J, Chen C. Communication Regarding the Myocardial Ischemia/Reperfusion and Cognitive Impairment: A Narrative Literature Review. J Alzheimers Dis 2024; 97:1545-1570. [PMID: 38277294 PMCID: PMC10894588 DOI: 10.3233/jad-230886] [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] [Accepted: 12/07/2023] [Indexed: 01/28/2024]
Abstract
Coronary artery disease is a prevalent ischemic disease that results in insufficient blood supply to the heart muscle due to narrowing or occlusion of the coronary arteries. Various reperfusion strategies, including pharmacological thrombolysis and percutaneous coronary intervention, have been developed to enhance blood flow restoration. However, these interventions can lead to myocardial ischemia/reperfusion injury (MI/RI), which can cause unpredictable complications. Recent research has highlighted a compelling association between MI/RI and cognitive function, revealing pathophysiological mechanisms that may explain altered brain cognition. Manifestations in the brain following MI/RI exhibit pathological features resembling those observed in Alzheimer's disease (AD), implying a potential link between MI/RI and the development of AD. The pro-inflammatory state following MI/RI may induce neuroinflammation via systemic inflammation, while impaired cardiac function can result in cerebral under-perfusion. This review delves into the role of extracellular vesicles in transporting deleterious substances from the heart to the brain during conditions of MI/RI, potentially contributing to impaired cognition. Addressing the cognitive consequence of MI/RI, the review also emphasizes potential neuroprotective interventions and pharmacological treatments within the MI/RI model. In conclusion, the review underscores the significant impact of MI/RI on cognitive function, summarizes potential mechanisms of cardio-cerebral communication in the context of MI/RI, and offers ideas and insights for the prevention and treatment of cognitive dysfunction following MI/RI.
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Affiliation(s)
- Haiqing Chang
- Department of Anesthesiology, West China Hospital, Sichuan University, Sichuan, China
- Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Erya Chen
- Department of Anesthesiology, West China Hospital, Sichuan University, Sichuan, China
- Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Tao Zhu
- Department of Anesthesiology, West China Hospital, Sichuan University, Sichuan, China
- Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jin Liu
- Department of Anesthesiology, West China Hospital, Sichuan University, Sichuan, China
- Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Chan Chen
- Department of Anesthesiology, West China Hospital, Sichuan University, Sichuan, China
- Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Laudanski K, Liu D, Karnatovskaia L, Devang S, Mathew A, Szeto WY. Whole Blood Reactivity to Viral and Bacterial Pathogens after Non-Emergent Cardiac Surgery during the Acute and Convalescence Periods Demonstrates a Distinctive Profile of Cytokines Production Compared to the Preoperative Baseline in Cohort of 108 Patients, Suggesting Immunological Reprogramming during the 28 Days Traditionally Recognized as the Post-Surgical Recovery Period. Biomedicines 2023; 12:28. [PMID: 38275389 PMCID: PMC10812925 DOI: 10.3390/biomedicines12010028] [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: 09/21/2023] [Revised: 11/19/2023] [Accepted: 12/06/2023] [Indexed: 01/27/2024] Open
Abstract
The release of danger signals from tissues in response to trauma during cardiac surgery creates conditions to reprogram the immune system to subsequent challenges posed by pathogens in the postoperative period. To demonstrate this, we tested immunoreactivity before surgery as the baseline (tbaseline), followed by subsequent challenges during the acute phase (t24h), convalescence (t7d), and long-term recovery (t3m). For 108 patients undergoing elective heart surgery, whole blood was stimulated with lipopolysaccharide (LPS), Influenza A virus subtype N2 (H3N2), or the Flublok™ vaccine to represent common pathogenic challenges. Leukocytosis, platelet count, and serum C-reactive protein (CRP) were used to measure non-specific inflammation. Cytokines were measured after 18 h of stimulation to reflect activation of the various cell types (activated neutrophils-IL-8; activated T cells-IL-2, IFNγ, activated monocyte (MO)-TNFα, IL-6, and deactivated or atypically activated MO and/or T cells-M-CSF, IL-10). IL-2 and IL-10 were increased at t7d, while TNFα was suppressed at t24h when LPS was utilized. Interestingly, M-CSF and IL-6 production was elevated at seven days in response to all stimuli compared to baseline. While some non-specific markers of inflammation (white cell count, IL-6, and IL-8) returned to presurgical levels at t3m, CRP and platelet counts remained elevated. We showed that surgical stimulus reprograms leukocyte response to LPS with only partial restoration of non-specific markers of inflammation.
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Affiliation(s)
- Krzysztof Laudanski
- Department of Anesthesiology and Perioperative Care, Mayo Clinic, Rochester, MN 55905, USA
| | - Da Liu
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang 110055, China;
| | - Lioudmila Karnatovskaia
- Division of Pulmonary and Critical Care, Department of Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA;
| | - Sanghavi Devang
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL 32224, USA;
| | - Amal Mathew
- School of Biomedical Engineering, Science and Health Systems, Drexel University, Philadelphia, PA 19104, USA;
| | - Wilson Y. Szeto
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA 19104, USA;
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Kashiwagi S, Mihara T, Yokoi A, Yokoyama C, Nakajima D, Goto T. Effect of remote ischemic preconditioning on lung function after surgery under general anesthesia: a systematic review and meta-analysis. Sci Rep 2023; 13:17720. [PMID: 37853024 PMCID: PMC10584824 DOI: 10.1038/s41598-023-44833-w] [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: 05/19/2023] [Accepted: 10/12/2023] [Indexed: 10/20/2023] Open
Abstract
Remote ischemic preconditioning (RIPC) protects organs from ischemia-reperfusion injury. Recent trials showed that RIPC improved gas exchange in patients undergoing lung or cardiac surgery. We performed a systematic search to identify randomized controlled trials involving RIPC in surgery under general anesthesia. The primary outcome was the PaO2/FIO2 (P/F) ratio at 24 h after surgery. Secondary outcomes were A-a DO2, the respiratory index, duration of postoperative mechanical ventilation (MV), incidence of acute respiratory distress syndrome (ARDS), and serum cytokine levels. The analyses included 71 trials comprising 7854 patients. Patients with RIPC showed higher P/F ratio than controls (mean difference [MD] 36.6, 95% confidence interval (CI) 12.8 to 60.4, I2 = 69%). The cause of heterogeneity was not identified by the subgroup analysis. Similarly, A-a DO2 (MD 15.2, 95% CI - 29.7 to - 0.6, I2 = 87%) and respiratory index (MD - 0.17, 95% CI - 0.34 to - 0.01, I2 = 94%) were lower in the RIPC group. Additionally, the RIPC group was weaned from MV earlier (MD - 0.9 h, 95% CI - 1.4 to - 0.4, I2 = 78%). Furthermore, the incidence of ARDS was lower in the RIPC group (relative risk 0.73, 95% CI 0.60 to 0.89, I2 = 0%). Serum TNFα was lower in the RIPC group (SMD - 0.6, 95%CI - 1.0 to - 0.3 I2 = 87%). No significant difference was observed in interleukin-6, 8 and 10. Our meta-analysis suggested that RIPC improved oxygenation after surgery under general anesthesia.Clinical trial number: This study protocol was registered in the University Hospital Medical Information Network (registration number: UMIN000030918), https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000035305.
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Affiliation(s)
- Shizuka Kashiwagi
- Department of Anesthesiology, Yokohama City University Graduate School of Medicine, Yokohama, Japan.
- Department of Anesthesiology, Yokohama City University Hospital, 3-9 Fukuura, Kanazawa-Ku, Yokohama City, Kanagawa-Ken, 236-0004, Japan.
| | - Takahiro Mihara
- Department of Health Data Science, Yokohama City University Graduate School of Data Science, Yokohama, Japan
| | - Ayako Yokoi
- Department of Anesthesiology and Intensive Care Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Chisaki Yokoyama
- Department of Anesthesia, Chiba Children's Hospital, Chiba, Japan
| | - Daisuke Nakajima
- Department of Anesthesiology, Yokohama City University Medical Center, Yokohama City, Japan
| | - Takahisa Goto
- Department of Anesthesiology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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Mulkey MA, Smith AB, Wion RK, House SL, Wierenga KL. Nonpharmacological Cognitive Impairment Prevention Interventions in Older Adults Undergoing Cardiac Surgery: A Systematic Review. J Cardiovasc Nurs 2023; 38:E165-E177. [PMID: 35953076 PMCID: PMC9899292 DOI: 10.1097/jcn.0000000000000936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND More than 1 million individuals undergo cardiothoracic surgery for coronary artery bypass graft or valve repair/replacement annually in the United States. There is an increased risk of developing serious cognitive impairment post cardiothoracic surgery. Pharmacological interventions and surgical techniques were associated with improvements in cognitive function in previous systematic reviews. However, a gap in the literature exists regarding how nonpharmacological interventions can mitigate cognitive impairment in adults undergoing cardiac surgery. OBJECTIVE The aim of this study was to explore the effectiveness of nonpharmacological interventions to reduce the detrimental effects of cardiac surgery on cognitive function in patients after cardiothoracic surgery. METHODS CINAHL, MEDLINE, PubMed, EMBASE, PsycINFO, and Web of Science databases were searched following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines from January 2011 to February 2022. RESULTS Nineteen studies were included in this review. Researchers defined cognitive impairment differently across studies. Various interventions were used to reduce cognitive impairment post cardiothoracic surgery, with the most common being remote ischemic limb conditioning. The interventions used to reduce cognitive impairment were heterogeneous in outcomes, measurements, and time of assessment, but only 2 interventions were associated with a reduction in cognitive impairment. CONCLUSIONS This review is a unique synthesis of the quality of interventions that address broader components of cognition. Researchers used various interventions to reduce cognitive impairment; the outcomes, instruments, and time interval for measurements were heterogeneous. Researchers should conduct future studies at multiple time intervals, using a comprehensive measure of cognitive impairment to better understand the impact of cognitive impairment interventions postoperatively.
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Han M, Wu X, Li J, Han S, Rong J. Effects of Remote Ischemic Preconditioning on Postoperative Cognitive Dysfunction in Elderly Patients with Laparoscopic Cholecystectomy. Int J Gen Med 2023; 16:961-971. [PMID: 36959973 PMCID: PMC10027852 DOI: 10.2147/ijgm.s401902] [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: 12/23/2022] [Accepted: 03/03/2023] [Indexed: 03/17/2023] Open
Abstract
Purpose We hypothesized that remote ischemic preconditioning (RIPC) could improve postoperative cognitive dysfunction (POCD) in elderly patients following laparoscopic cholecystectomy (LC). Patients and Methods Eighty-eight patients were randomly assigned to either the control or the RIPC group. The RIPC was applied on the right upper limb using a blood pressure cuff inflating 200 mmHg, consisting of 3 cycles of 5 min ischemia and 5 min reperfusion. Serum concentrations of Neuron-specific Enolase (NSE) and Brain-Derived Neurotrophic Factor (BDNF) were collected at one-day preoperative (T0), at the end of the operation (T4) and one-day postoperative (T5). Z score was tested at T0 and 3 days after the operation (T6). POCD was determined if there were two Z scores ≥1.96 at the same time or an average Z score ≥1.96. Results There was no significant difference in the Z score of each test between the two groups at T0 (P > 0.05). Notably, the duration of Stroop test C was significantly shorter in the RIPC group than that in the Control group at T6 (P = 0.01). POCD occurred in 1/44 (2.3%) patients in the RIPC group and 8/44 (18.2%) patients in the control group at T6 (P=0.035). In addition, serum NSE concentration was significantly decreased, but serum BDNF concentration was increased compared with the control group at T4 and T5 (P<0.001). Conclusion RIPC could reduce the incidence of POCD in elderly patients after laparoscopic cholecystectomy.
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Affiliation(s)
- Mengnan Han
- Department of Anesthesiology, Hebei General Hospital, Shijiazhuang, People’s Republic of China
- Graduate Faculty, Hebei North University, Zhangjiakou, People’s Republic of China
| | - Xiaoqian Wu
- Department of Anesthesiology, Hebei General Hospital, Shijiazhuang, People’s Republic of China
| | - Jianli Li
- Department of Anesthesiology, Hebei General Hospital, Shijiazhuang, People’s Republic of China
- Correspondence: Jianli Li, Department of Anesthesiology, Hebei General Hospital, No. 348 West Heping Road, Shijiazhuang, 050051, People’s Republic of China, Tel +86 13785118676, Email
| | - Shuang Han
- Department of Anesthesiology, Hebei General Hospital, Shijiazhuang, People’s Republic of China
| | - Junfang Rong
- Department of Anesthesiology, Hebei General Hospital, Shijiazhuang, People’s Republic of China
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Amorim S, Felício AC, Aagaard P, Suetta C, Blauenfeldt RA, Andersen G. Effects of remote ischemic conditioning on cognitive performance: A systematic review. Physiol Behav 2022; 254:113893. [PMID: 35780946 DOI: 10.1016/j.physbeh.2022.113893] [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: 03/22/2022] [Revised: 06/08/2022] [Accepted: 06/23/2022] [Indexed: 10/17/2022]
Abstract
The aging process leads to subtle decline in cognitive function, and in some overt dementia. Like physical activity Remote Ischemic Conditioning (RIC) may ameliorate these changes on cognitive impairment in humans. The purpose of this study was to compared the effects of single, repeated short-term and long-term treatment RIC, and analyze its effect registered as immediate vs. long-term on cognitive performance in humans. This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and was registered with PROSPERO, number (CRD42021285668). A systematic review was conducted to identify relevant studies through six healthcare science databases (Cochrane, PubMed, EMBASE, EBSCO, Scopus, and Web of Science) up to December 2021. Eligibility criteria included (1) a study sample of participants aged ≥18 years, (2) post-intervention changes on cognitive performance in humans, and (3) this systematic review included only randomized controlled trials of RIC in humans. The quality of the included studies was assessed by GRADEpro tool. A total of 118 articles were initially identified, 35 of which met the inclusion criteria. Based on title/abstract, age and RIC protocol, 14 articles were included in this review: 5 studies investigated the immediate and long-term effect of a single RIC (n = 370 patients), 4 studies examined intermittent short-term RIC (n = 174 patients) and 5 studies evaluated repeated long-term RIC (n = 228 patients). A single pre-operative RIC treatment had an immediate effect that disappeared at one week. Short-term RIC showed either a positive or no effects on cognitive function. The majority of studies examining long-term RIC treatment showed improvements in cognitive performance, particularly in very old adults and older patients with cognitive impairments. Single RIC treatment did not show any persisting effect on cognition. However, repeated short term RIC showed some improvement and long-term RIC may improve cognitive performance after stroke or enhance neuropsychological tests in patients diagnosed with vascular dementia. The mixed results might be explained by different RIC treatment protocols and populations investigated.
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Affiliation(s)
- Samuel Amorim
- Hospital Israelita Albert Einstein, São Paulo, Brazil.
| | | | - Per Aagaard
- Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark
| | - Charlotte Suetta
- Bispebjerg Hospital, Copenhagen University - Department of Geriatrics
| | - Rolf Ankerlund Blauenfeldt
- Danish Stroke Center, Aarhus University Hospital and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Grethe Andersen
- Danish Stroke Center, Aarhus University Hospital and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Zhu S, Zheng Z, Lv W, Ouyang P, Han J, Zhang J, Dong H, Lei C. Neuroprotective effect of remote ischemic preconditioning in patients undergoing cardiac surgery: A randomized controlled trial. Front Cardiovasc Med 2022; 9:952033. [PMID: 36148077 PMCID: PMC9485807 DOI: 10.3389/fcvm.2022.952033] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 08/15/2022] [Indexed: 11/24/2022] Open
Abstract
Background The neuroprotective effect of remote ischemic preconditioning (RIPC) in patients undergoing elective cardiopulmonary bypass (CPB)-assisted coronary artery bypass graft (CABG) or valvular cardiac surgery remains unclear. Methods A randomized, double-blind, placebo-controlled superior clinical trial was conducted in patients undergoing elective on-pump coronary artery bypass surgery or valve surgery. Before anesthesia induction, patients were randomly assigned to RIPC (three 5-min cycles of inflation and deflation of blood pressure cuff on the upper limb) or the control group. The primary endpoint was the changes in S-100 calcium-binding protein β (S100-β) levels at 6 h postoperatively. Secondary endpoints included changes in Neuron-specific enolase (NSE), Mini-mental State Examination (MMSE), and Montreal Cognitive Assessment (MoCA) levels. Results A total of 120 patients [mean age, 48.7 years; 36 women (34.3%)] were randomized at three cardiac surgery centers in China. One hundred and five patients were included in the modified intent-to-treat analysis (52 in the RIPC group and 53 in the control group). The primary result demonstrated that at 6 h after surgery, S100-β levels were lower in the RIPC group than in the control group (50.75; 95% confidence interval, 67.08 to 64.40 pg/ml vs. 70.48; 95% CI, 56.84 to 84.10 pg/ml, P = 0.036). Compared to the control group, the concentrations of S100-β at 24 h and 72 h and the concentration of NSE at 6 h, 24 h, and 72 h postoperatively were significantly lower in the RIPC group. However, neither the MMSE nor the MoCA revealed significant between-group differences in postoperative cognitive performance at 7 days, 3 months, and 6 months after surgery. Conclusion In patients undergoing CPB-assisted cardiac surgery, RIPC attenuated brain damage as indicated with the decreased release of brain damage biomarker S100-β and NSE. Clinical trial registration [ClinicalTrials.gov], identifier [NCT01231789].
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Affiliation(s)
- Shouqiang Zhu
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Air Force Medical University, Xi’an, China
| | - Ziyu Zheng
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Air Force Medical University, Xi’an, China
| | - Wenying Lv
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Air Force Medical University, Xi’an, China
| | - Pengrong Ouyang
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Air Force Medical University, Xi’an, China
| | - Jiange Han
- Department of Anesthesiology, Tianjin Chest Hospital, Tianjin, China
| | - Jiaqiang Zhang
- Department of Anesthesiology and Perioperative Medicine, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Zhengzhou, China
| | - Hailong Dong
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Air Force Medical University, Xi’an, China
- *Correspondence: Hailong Dong,
| | - Chong Lei
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Air Force Medical University, Xi’an, China
- Chong Lei,
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11
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Li Y, Huang P, Huang J, Zhong Z, Zhou S, Dong H, Xie J, Wu Y, Li P. Remote ischemic preconditioning improves cognitive control in healthy adults: Evidence from an event-related potential study. Front Neurosci 2022; 16:936975. [PMID: 36017186 PMCID: PMC9395971 DOI: 10.3389/fnins.2022.936975] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 07/19/2022] [Indexed: 11/13/2022] Open
Abstract
It is suggested that remote ischemic preconditioning (RIPC) may be a promising treatment for improving healthy adults’ cognitive control. However, direct empirical evidence was absent. Therefore, this study aims to provide evidence for the impact of RIPC on cognitive control. Sixty healthy young male volunteers were recruited, and 30 of them received 1-week RIPC treatment (RIPC group), while the rest did not receive RIPC (control group). Their cognitive control before and after RIPC treatment was evaluated using the classic Stroop task, and the scalp electricity activity was recorded by event-related potentials (ERPs). The behavioral results showed a conventional Stroop interference effect of both reaction times (RTs) and the accuracy rate (ACC), but the Stroop interference effect of RTs significantly decreased in the posttest compared to the pretest. Furthermore, at the electrophysiological level, ERP data showed that N450 and SP for incongruent trials were larger than that for congruent trials. Importantly, the SP differential amplitude increased after RIPC treatment, whereas there was no significant change in the control group. These results implied that RIPC treatment could improve cognitive control, especially conflict resolving in the Stroop task.
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Affiliation(s)
- Yaling Li
- Department of High Altitude Operational Medicine, College of High Altitude Military Medicine, Army Medical University, Chongqing, China
- Key Laboratory of Extreme Environmental Medicine, Ministry of Education of China, Army Medical University, Chongqing, China
- Key Laboratory of High Altitude Medicine, Army Medical University, Chongqing, China
| | - Pei Huang
- Department of High Altitude Operational Medicine, College of High Altitude Military Medicine, Army Medical University, Chongqing, China
- Key Laboratory of Extreme Environmental Medicine, Ministry of Education of China, Army Medical University, Chongqing, China
- Key Laboratory of High Altitude Medicine, Army Medical University, Chongqing, China
| | - Jun Huang
- Chongqing Key Laboratory of Psychological Diagnosis and Education Technology for Children With Special Needs, College of Education Science, Chongqing Normal University, Chongqing, China
| | - Zhifeng Zhong
- Department of High Altitude Operational Medicine, College of High Altitude Military Medicine, Army Medical University, Chongqing, China
- Key Laboratory of Extreme Environmental Medicine, Ministry of Education of China, Army Medical University, Chongqing, China
- Key Laboratory of High Altitude Medicine, Army Medical University, Chongqing, China
| | - Simin Zhou
- Department of High Altitude Operational Medicine, College of High Altitude Military Medicine, Army Medical University, Chongqing, China
- Key Laboratory of Extreme Environmental Medicine, Ministry of Education of China, Army Medical University, Chongqing, China
- Key Laboratory of High Altitude Medicine, Army Medical University, Chongqing, China
| | - Huaping Dong
- Department of High Altitude Operational Medicine, College of High Altitude Military Medicine, Army Medical University, Chongqing, China
- Key Laboratory of Extreme Environmental Medicine, Ministry of Education of China, Army Medical University, Chongqing, China
- Key Laboratory of High Altitude Medicine, Army Medical University, Chongqing, China
| | - Jiaxin Xie
- Department of High Altitude Operational Medicine, College of High Altitude Military Medicine, Army Medical University, Chongqing, China
- Key Laboratory of Extreme Environmental Medicine, Ministry of Education of China, Army Medical University, Chongqing, China
- Key Laboratory of High Altitude Medicine, Army Medical University, Chongqing, China
| | - Yu Wu
- Department of High Altitude Operational Medicine, College of High Altitude Military Medicine, Army Medical University, Chongqing, China
- Key Laboratory of Extreme Environmental Medicine, Ministry of Education of China, Army Medical University, Chongqing, China
- Key Laboratory of High Altitude Medicine, Army Medical University, Chongqing, China
- *Correspondence: Yu Wu,
| | - Peng Li
- Department of High Altitude Operational Medicine, College of High Altitude Military Medicine, Army Medical University, Chongqing, China
- Key Laboratory of Extreme Environmental Medicine, Ministry of Education of China, Army Medical University, Chongqing, China
- Key Laboratory of High Altitude Medicine, Army Medical University, Chongqing, China
- Peng Li,
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12
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Jing Y, Gao B, Li X. Influences of remote ischemic preconditioning on postoperative delirium and cognitive dysfunction in adults after cardiac surgery: a meta-analysis of randomized controlled trials. Perioper Med (Lond) 2021; 10:50. [PMID: 34886892 PMCID: PMC8662864 DOI: 10.1186/s13741-021-00216-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 08/25/2021] [Indexed: 01/12/2023] Open
Abstract
Background Remote ischemic preconditioning (RIPC) has been suggested to confer neuroprotective effect. However, influences of RIPC on postoperative delirium (POD) and cognitive dysfunction (POCD) in adults after cardiac surgery are less known. We performed a meta-analysis of randomized controlled trials (RCTs) to evaluate the effects of RIPC on POD and POCD. Methods Relevant studies were obtained by search of PubMed, Embase, and Cochrane’s Library databases. A random-effect model was used to pool the results. Results Ten RCTs including 2303 adults who received cardiac surgery were included. Pooled results showed that RIPC did not significantly affect the incidence of POD (six RCTs, odds ratio [OR] 1.07, 95% confidence interval [CI] 0.81 to 1.40, P = 0.65) with no significant heterogeneity (I2 = 0%). In addition, combined results showed that RIPC did not significantly reduce the incidence of POCD either (six RCTs, OR 0.64, 95% CI 0.37 to 1.11, P = 0.11) with moderate heterogeneity (I2 = 44%). Sensitivity analysis by excluding one RCT at a time showed consistent results (P values all > 0.05). Conclusions Current evidence from RCTs did not support that RIPC could prevent the incidence of POD or POCD in adults after cardiac surgery. Although these findings may be validated in large-scale RCTs, particularly for the results of POCD, based on these findings, RIPC should not be routinely used as a preventative measure for POD and POCD in adult patients after cardiac surgery.
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Affiliation(s)
- Yuchen Jing
- Department of Vascular Surgery, The First Affiliated Hospital of China Medical University, No. 155 Nanjing Bei Street, Heping District, Shenyang, 110001, China
| | - Bai Gao
- Department of Neurology, Shengjing Hospital Affiliated to China Medical University, Shenyang, 110004, China
| | - Xi Li
- Department of Vascular Surgery, The First Affiliated Hospital of China Medical University, No. 155 Nanjing Bei Street, Heping District, Shenyang, 110001, China.
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13
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Burton JK, Craig L, Yong SQ, Siddiqi N, Teale EA, Woodhouse R, Barugh AJ, Shepherd AM, Brunton A, Freeman SC, Sutton AJ, Quinn TJ. Non-pharmacological interventions for preventing delirium in hospitalised non-ICU patients. Cochrane Database Syst Rev 2021; 11:CD013307. [PMID: 34826144 PMCID: PMC8623130 DOI: 10.1002/14651858.cd013307.pub3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Delirium is an acute neuropsychological disorder that is common in hospitalised patients. It can be distressing to patients and carers and it is associated with serious adverse outcomes. Treatment options for established delirium are limited and so prevention of delirium is desirable. Non-pharmacological interventions are thought to be important in delirium prevention. OBJECTIVES: To assess the effectiveness of non-pharmacological interventions designed to prevent delirium in hospitalised patients outside intensive care units (ICU). SEARCH METHODS We searched ALOIS, the specialised register of the Cochrane Dementia and Cognitive Improvement Group, with additional searches conducted in MEDLINE, Embase, PsycINFO, CINAHL, LILACS, Web of Science Core Collection, ClinicalTrials.gov and the World Health Organization Portal/ICTRP to 16 September 2020. There were no language or date restrictions applied to the electronic searches, and no methodological filters were used to restrict the search. SELECTION CRITERIA We included randomised controlled trials (RCTs) of single and multicomponent non-pharmacological interventions for preventing delirium in hospitalised adults cared for outside intensive care or high dependency settings. We only included non-pharmacological interventions which were designed and implemented to prevent delirium. DATA COLLECTION AND ANALYSIS: Two review authors independently examined titles and abstracts identified by the search for eligibility and extracted data from full-text articles. Any disagreements on eligibility and inclusion were resolved by consensus. We used standard Cochrane methodological procedures. The primary outcomes were: incidence of delirium; inpatient and later mortality; and new diagnosis of dementia. We included secondary and adverse outcomes as pre-specified in the review protocol. We used risk ratios (RRs) as measures of treatment effect for dichotomous outcomes and between-group mean differences for continuous outcomes. The certainty of the evidence was assessed using GRADE. A complementary exploratory analysis was undertaker using a Bayesian component network meta-analysis fixed-effect model to evaluate the comparative effectiveness of the individual components of multicomponent interventions and describe which components were most strongly associated with reducing the incidence of delirium. MAIN RESULTS We included 22 RCTs that recruited a total of 5718 adult participants. Fourteen trials compared a multicomponent delirium prevention intervention with usual care. Two trials compared liberal and restrictive blood transfusion thresholds. The remaining six trials each investigated a different non-pharmacological intervention. Incidence of delirium was reported in all studies. Using the Cochrane risk of bias tool, we identified risks of bias in all included trials. All were at high risk of performance bias as participants and personnel were not blinded to the interventions. Nine trials were at high risk of detection bias due to lack of blinding of outcome assessors and three more were at unclear risk in this domain. Pooled data showed that multi-component non-pharmacological interventions probably reduce the incidence of delirium compared to usual care (10.5% incidence in the intervention group, compared to 18.4% in the control group, risk ratio (RR) 0.57, 95% confidence interval (CI) 0.46 to 0.71, I2 = 39%; 14 studies; 3693 participants; moderate-certainty evidence, downgraded due to risk of bias). There may be little or no effect of multicomponent interventions on inpatient mortality compared to usual care (5.2% in the intervention group, compared to 4.5% in the control group, RR 1.17, 95% CI 0.79 to 1.74, I2 = 15%; 10 studies; 2640 participants; low-certainty evidence downgraded due to inconsistency and imprecision). No studies of multicomponent interventions reported data on new diagnoses of dementia. Multicomponent interventions may result in a small reduction of around a day in the duration of a delirium episode (mean difference (MD) -0.93, 95% CI -2.01 to 0.14 days, I2 = 65%; 351 participants; low-certainty evidence downgraded due to risk of bias and imprecision). The evidence is very uncertain about the effect of multicomponent interventions on delirium severity (standardised mean difference (SMD) -0.49, 95% CI -1.13 to 0.14, I2=64%; 147 participants; very low-certainty evidence downgraded due to risk of bias and serious imprecision). Multicomponent interventions may result in a reduction in hospital length of stay compared to usual care (MD -1.30 days, 95% CI -2.56 to -0.04 days, I2=91%; 3351 participants; low-certainty evidence downgraded due to risk of bias and inconsistency), but little to no difference in new care home admission at the time of hospital discharge (RR 0.77, 95% CI 0.55 to 1.07; 536 participants; low-certainty evidence downgraded due to risk of bias and imprecision). Reporting of other adverse outcomes was limited. Our exploratory component network meta-analysis found that re-orientation (including use of familiar objects), cognitive stimulation and sleep hygiene were associated with reduced risk of incident delirium. Attention to nutrition and hydration, oxygenation, medication review, assessment of mood and bowel and bladder care were probably associated with a reduction in incident delirium but estimates included the possibility of no benefit or harm. Reducing sensory deprivation, identification of infection, mobilisation and pain control all had summary estimates that suggested potential increases in delirium incidence, but the uncertainty in the estimates was substantial. Evidence from two trials suggests that use of a liberal transfusion threshold over a restrictive transfusion threshold probably results in little to no difference in incident delirium (RR 0.92, 95% CI 0.62 to 1.36; I2 = 9%; 294 participants; moderate-certainty evidence downgraded due to risk of bias). Six other interventions were examined, but evidence for each was limited to single studies and we identified no evidence of delirium prevention. AUTHORS' CONCLUSIONS: There is moderate-certainty evidence regarding the benefit of multicomponent non-pharmacological interventions for the prevention of delirium in hospitalised adults, estimated to reduce incidence by 43% compared to usual care. We found no evidence of an effect on mortality. There is emerging evidence that these interventions may reduce hospital length of stay, with a trend towards reduced delirium duration, although the effect on delirium severity remains uncertain. Further research should focus on implementation and detailed analysis of the components of the interventions to support more effective, tailored practice recommendations.
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Affiliation(s)
- Jennifer K Burton
- Academic Geriatric Medicine, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Louise Craig
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Shun Qi Yong
- MVLS, College of Medicine and Veterinary Life Sciences, University of Glasgow, Glasgow, UK
| | - Najma Siddiqi
- Department of Health Sciences, University of York, York, UK
| | - Elizabeth A Teale
- Academic Unit of Elderly Care and Rehabilitation, University of Leeds, Bradford, UK
| | - Rebecca Woodhouse
- Department of Health Sciences, Hull York Medical School, University of York, York, UK
| | - Amanda J Barugh
- Department of Geriatric Medicine, University of Edinburgh, Edinburgh, UK
| | | | | | - Suzanne C Freeman
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Alex J Sutton
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Terry J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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14
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Long YQ, Feng XM, Shan XS, Chen QC, Xia Z, Ji FH, Liu H, Peng K. Remote Ischemic Preconditioning Reduces Acute Kidney Injury After Cardiac Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Anesth Analg 2021; 134:592-605. [PMID: 34748518 DOI: 10.1213/ane.0000000000005804] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Results from previous studies evaluating the effects of remote ischemic preconditioning (RIPC) on morbidity and mortality after cardiac surgery are inconsistent. This meta-analysis of randomized controlled trials (RCTs) aims to determine whether RIPC improves cardiac and renal outcomes in adults undergoing cardiac surgery. METHODS PubMed, EMBASE, and Cochrane Library were comprehensively searched to identify RCTs comparing RIPC with control in cardiac surgery. The coprimary outcomes were the incidence of postoperative myocardial infarction (MI) and the incidence of postoperative acute kidney injury (AKI). Meta-analyses were performed using a random-effect model. Subgroup analyses were conducted according to volatile only anesthesia versus propofol anesthesia with or without volatiles, high-risk patients versus non-high-risk patients, and Acute Kidney Injury Network (AKIN) or Kidney Disease Improving Global Outcomes (KDIGO) criteria versus other criteria for AKI diagnosis. RESULTS A total of 79 RCTs with 10,814 patients were included. While the incidence of postoperative MI did not differ between the RIPC and control groups (8.2% vs 9.7%; risk ratio [RR] = 0.87, 95% confidence interval [CI], 0.76-1.01, P = .07, I2 = 0%), RIPC significantly reduced the incidence of postoperative AKI (22% vs 24.4%; RR = 0.86, 95% CI, 0.77-0.97, P = .01, I2 = 34%). The subgroup analyses showed that RIPC was associated with a reduced incidence of MI in non-high-risk patients, and that RIPC was associated with a reduced incidence of AKI in volatile only anesthesia, in non-high-risk patients, and in the studies using AKIN or KDIGO criteria for AKI diagnosis. CONCLUSIONS This meta-analysis demonstrates that RIPC reduces the incidence of AKI after cardiac surgery. This renoprotective effect of RIPC is mainly evident during volatile only anesthesia, in non-high-risk patients, and when AKIN or KDIGO criteria used for AKI diagnosis.
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Affiliation(s)
- Yu-Qin Long
- From the Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiao-Mei Feng
- Department of Anesthesiology, University of Utah Health, Salt Lake City, Utah.,Transitional Residency Program, Intermountain Medical Center, Murray, Utah
| | - Xi-Sheng Shan
- From the Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Qing-Cai Chen
- From the Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhengyuan Xia
- Department of Anesthesiology and Pain Medicine, University of California Davis Health, Sacramento, California
| | - Fu-Hai Ji
- From the Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Hong Liu
- Department of Anesthesiology and Pain Medicine, University of California Davis Health, Sacramento, California
| | - Ke Peng
- From the Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, China
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15
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Burton JK, Craig LE, Yong SQ, Siddiqi N, Teale EA, Woodhouse R, Barugh AJ, Shepherd AM, Brunton A, Freeman SC, Sutton AJ, Quinn TJ. Non-pharmacological interventions for preventing delirium in hospitalised non-ICU patients. Cochrane Database Syst Rev 2021; 7:CD013307. [PMID: 34280303 PMCID: PMC8407051 DOI: 10.1002/14651858.cd013307.pub2] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Delirium is an acute neuropsychological disorder that is common in hospitalised patients. It can be distressing to patients and carers and it is associated with serious adverse outcomes. Treatment options for established delirium are limited and so prevention of delirium is desirable. Non-pharmacological interventions are thought to be important in delirium prevention. OBJECTIVES: To assess the effectiveness of non-pharmacological interventions designed to prevent delirium in hospitalised patients outside intensive care units (ICU). SEARCH METHODS We searched ALOIS, the specialised register of the Cochrane Dementia and Cognitive Improvement Group, with additional searches conducted in MEDLINE, Embase, PsycINFO, CINAHL, LILACS, Web of Science Core Collection, ClinicalTrials.gov and the World Health Organization Portal/ICTRP to 16 September 2020. There were no language or date restrictions applied to the electronic searches, and no methodological filters were used to restrict the search. SELECTION CRITERIA We included randomised controlled trials (RCTs) of single and multicomponent non-pharmacological interventions for preventing delirium in hospitalised adults cared for outside intensive care or high dependency settings. We only included non-pharmacological interventions which were designed and implemented to prevent delirium. DATA COLLECTION AND ANALYSIS: Two review authors independently examined titles and abstracts identified by the search for eligibility and extracted data from full-text articles. Any disagreements on eligibility and inclusion were resolved by consensus. We used standard Cochrane methodological procedures. The primary outcomes were: incidence of delirium; inpatient and later mortality; and new diagnosis of dementia. We included secondary and adverse outcomes as pre-specified in the review protocol. We used risk ratios (RRs) as measures of treatment effect for dichotomous outcomes and between-group mean differences for continuous outcomes. The certainty of the evidence was assessed using GRADE. A complementary exploratory analysis was undertaker using a Bayesian component network meta-analysis fixed-effect model to evaluate the comparative effectiveness of the individual components of multicomponent interventions and describe which components were most strongly associated with reducing the incidence of delirium. MAIN RESULTS We included 22 RCTs that recruited a total of 5718 adult participants. Fourteen trials compared a multicomponent delirium prevention intervention with usual care. Two trials compared liberal and restrictive blood transfusion thresholds. The remaining six trials each investigated a different non-pharmacological intervention. Incidence of delirium was reported in all studies. Using the Cochrane risk of bias tool, we identified risks of bias in all included trials. All were at high risk of performance bias as participants and personnel were not blinded to the interventions. Nine trials were at high risk of detection bias due to lack of blinding of outcome assessors and three more were at unclear risk in this domain. Pooled data showed that multi-component non-pharmacological interventions probably reduce the incidence of delirium compared to usual care (10.5% incidence in the intervention group, compared to 18.4% in the control group, risk ratio (RR) 0.57, 95% confidence interval (CI) 0.46 to 0.71, I2 = 39%; 14 studies; 3693 participants; moderate-certainty evidence, downgraded due to risk of bias). There may be little or no effect of multicomponent interventions on inpatient mortality compared to usual care (5.2% in the intervention group, compared to 4.5% in the control group, RR 1.17, 95% CI 0.79 to 1.74, I2 = 15%; 10 studies; 2640 participants; low-certainty evidence downgraded due to inconsistency and imprecision). No studies of multicomponent interventions reported data on new diagnoses of dementia. Multicomponent interventions may result in a small reduction of around a day in the duration of a delirium episode (mean difference (MD) -0.93, 95% CI -2.01 to 0.14 days, I2 = 65%; 351 participants; low-certainty evidence downgraded due to risk of bias and imprecision). The evidence is very uncertain about the effect of multicomponent interventions on delirium severity (standardised mean difference (SMD) -0.49, 95% CI -1.13 to 0.14, I2=64%; 147 participants; very low-certainty evidence downgraded due to risk of bias and serious imprecision). Multicomponent interventions may result in a reduction in hospital length of stay compared to usual care (MD -1.30 days, 95% CI -2.56 to -0.04 days, I2=91%; 3351 participants; low-certainty evidence downgraded due to risk of bias and inconsistency), but little to no difference in new care home admission at the time of hospital discharge (RR 0.77, 95% CI 0.55 to 1.07; 536 participants; low-certainty evidence downgraded due to risk of bias and imprecision). Reporting of other adverse outcomes was limited. Our exploratory component network meta-analysis found that re-orientation (including use of familiar objects), cognitive stimulation and sleep hygiene were associated with reduced risk of incident delirium. Attention to nutrition and hydration, oxygenation, medication review, assessment of mood and bowel and bladder care were probably associated with a reduction in incident delirium but estimates included the possibility of no benefit or harm. Reducing sensory deprivation, identification of infection, mobilisation and pain control all had summary estimates that suggested potential increases in delirium incidence, but the uncertainty in the estimates was substantial. Evidence from two trials suggests that use of a liberal transfusion threshold over a restrictive transfusion threshold probably results in little to no difference in incident delirium (RR 0.92, 95% CI 0.62 to 1.36; I2 = 9%; 294 participants; moderate-certainty evidence downgraded due to risk of bias). Six other interventions were examined, but evidence for each was limited to single studies and we identified no evidence of delirium prevention. AUTHORS' CONCLUSIONS: There is moderate-certainty evidence regarding the benefit of multicomponent non-pharmacological interventions for the prevention of delirium in hospitalised adults, estimated to reduce incidence by 43% compared to usual care. We found no evidence of an effect on mortality. There is emerging evidence that these interventions may reduce hospital length of stay, with a trend towards reduced delirium duration, although the effect on delirium severity remains uncertain. Further research should focus on implementation and detailed analysis of the components of the interventions to support more effective, tailored practice recommendations.
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Affiliation(s)
- Jennifer K Burton
- Academic Geriatric Medicine, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Louise E Craig
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Shun Qi Yong
- MVLS, College of Medicine and Veterinary Life Sciences, University of Glasgow, Glasgow, UK
| | - Najma Siddiqi
- Department of Health Sciences, University of York, York, UK
| | - Elizabeth A Teale
- Academic Unit of Elderly Care and Rehabilitation, University of Leeds, Bradford, UK
| | - Rebecca Woodhouse
- Department of Health Sciences, Hull York Medical School, University of York, York, UK
| | - Amanda J Barugh
- Department of Geriatric Medicine, University of Edinburgh, Edinburgh, UK
| | | | | | - Suzanne C Freeman
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Alex J Sutton
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Terry J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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16
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Pieri M, De Simone A, Rose S, De Domenico P, Lembo R, Denaro G, Landoni G, Monaco F. Trials Focusing on Prevention and Treatment of Delirium After Cardiac Surgery: A systematic Review of Randomized Evidence. J Cardiothorac Vasc Anesth 2020; 34:1641-1654. [DOI: 10.1053/j.jvca.2019.09.028] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 09/15/2019] [Accepted: 09/17/2019] [Indexed: 11/11/2022]
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17
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Li Y, Wang C, Bi M, Gao J, Zhang X, Tian H. Effect of dexmedetomidine on brain function and hemodynamics in patients undergoing lung cancer resection. Oncol Lett 2020; 20:1077-1082. [PMID: 32724346 PMCID: PMC7377195 DOI: 10.3892/ol.2020.11675] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 12/20/2019] [Indexed: 01/10/2023] Open
Abstract
Effect of dexmedetomidine on the brain function and hemodynamics in patients undergoing lung cancer resection were explored. Eighty-seven patients with lung cancer undergoing lung cancer resection in Weifang People's Hospital from January 2014 to June 2018 were enrolled in this study. Patients conventionally anesthetized by propofol, midazolam, sufentanil, or cisatracurium besilate (41 cases) were assigned to the control group and those anesthetized by conventional anesthetic and dexmedetomidine (46 cases) were assigned to the research group. The hemodynamic parameters, neuron-specific enolase (NSE), and astrocyte S-100p protein (S-100β) were compared between the two groups before induction (T0), 5 min after induction (T1), at the end of surgery (T2), time of extubation (T3), and 5 min after extubation (T4). The cognitive function of patients was graded by the mini-mental state examination (MMSE) after patients recovered from anesthesia. In both the control group and the research group, the levels of mean arterial pressure (MAP), heart rate (HR), and central venous pressure (CVP). were statistically higher at T2 and T3 than those at T0 (all P<0.05). The levels of MAP, HR, and CVP were statistically lower in the research group than those in the control group at T2 and T3 (P<0.05). The levels of serum NSE and S100β protein in the research group and the control group increased at T2, T3, and T4, the control group was higher than the research group at each time point, and the difference was statistically significant (P<0.05). Comparison of the MMSE score and the total case number of adverse reactions between the two groups showed no statistical difference (both P>0.05). The MMSE score was positively correlated with the serum levels of NSE and S100β in the two groups (r-values were 0.661 and 0.585, P<0.05). Dexmedetomidine can effectively protect patients' perioperative brain function with small impacts on perioperative hemodynamics, so it is worthy of clinical application.
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Affiliation(s)
- Yunfeng Li
- Department of Pharmacy, Weifang People's Hospital, Weifang, Shandong 261041, P.R. China
| | - Chunyu Wang
- Department of Anesthesiology, Qingdao Eighth People's Hospital, Qingdao, Shandong 266100, P.R. China
| | - Mingzhuang Bi
- Department of Anesthesiology, Qingdao Women and Children's Hospital, Qingdao, Shandong 266034, P.R. China
| | - Jie Gao
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266000, P.R. China
| | - Xue Zhang
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266000, P.R. China
| | - Haitao Tian
- Department of Anesthesiology, Jining No. 1 People's Hospital, Jining, Shandong 272000, P.R. China.,Jining Medical University, Jining, Shandong 272000, P.R. China
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Wang Z, Shen Z, Wang H, Zhang L, Dong R. Effect of dexmedetomidine on the cognitive function of patients undergoing gastric cancer surgery by regulating the PI3K/AKT signaling pathway. Oncol Lett 2020; 19:1151-1156. [PMID: 31966044 PMCID: PMC6955647 DOI: 10.3892/ol.2019.11224] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 10/30/2019] [Indexed: 11/05/2022] Open
Abstract
Effect of dexmedetomidine on the cognitive function of patients undergoing gastric cancer surgery by regulating the phosphoinositide 3-kinase (PI3K)/AKT signaling pathway was investigated. A total of 110 patients who were diagnosed and underwent radical gastrectomy in Ruijin Hospital North, Shanghai Jiaotong University School of Medicine from July 2016 to July 2018 were selected. In the experimental group, 60 patients were treated with dexmedetomidine infusion. In the control group, 50 patients were injected with 0.9% sodium chloride injection during the same period. The expression levels of serum inflammatory factors tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), PI3K and AKT of patients were compared between the two groups before and after surgery for 1 day. The number of adverse reactions in the two groups was compared. The correlation between mini-mental state examination (MMSE) score and the expression levels of serum IL-6, PI3K and AKT was compared. The levels of serum TNF-α, IL-6, PI3K and AKT after operation for 1 day of patients in the two groups were significantly higher than those before operation (P<0.05), and were lower in the experimental than in the control group (P<0.05). The number of postoperative cognitive dysfunction of patients in the experimental group was lower than that of patients in the control group (P<0.05). The total number of adverse reactions in the control group was higher than that of patients in the experimental group (P<0.05). The MMSE scores of the two groups were decreased at 1 day after operation and were significantly lower in the control group than in the experimental group (P<0.05). The MMSE score was negatively correlated with the expression levels of serum TNF-α, IL-6, PI3K and AKT (P<0.001). Dexmedetomidine can effectively reduce the expression levels of postoperative inflammatory factors in patients undergoing gastric cancer surgery, improve the postoperative cognitive function by regulating PI3K-Akt signaling pathway and promotes the recovery of postoperative cognitive function.
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Affiliation(s)
- Zhiyuan Wang
- Department of Anesthesiology, Ruijin Hospital North, Shanghai Jiaotong University School of Medicine, Shanghai 201801, P.R. China
| | - Zijin Shen
- Department of Anesthesiology, Ruijin Hospital North, Shanghai Jiaotong University School of Medicine, Shanghai 201801, P.R. China
| | - Haibin Wang
- Department of Anesthesiology, Ruijin Hospital North, Shanghai Jiaotong University School of Medicine, Shanghai 201801, P.R. China
| | - Lin Zhang
- Department of Anesthesiology, Ruijin Hospital North, Shanghai Jiaotong University School of Medicine, Shanghai 201801, P.R. China
| | - Rong Dong
- Department of Anesthesiology, Ruijin Hospital North, Shanghai Jiaotong University School of Medicine, Shanghai 201801, P.R. China
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Oh CS, Sa M, Park HJ, Piao L, Oh KS, Kim SH. Effects of remote ischemic preconditioning on regional cerebral oxygen saturation in patients in the beach chair position during shoulder surgery: A double-blind randomized controlled trial. J Clin Anesth 2019; 61:109661. [PMID: 31818636 DOI: 10.1016/j.jclinane.2019.109661] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 09/20/2019] [Accepted: 11/16/2019] [Indexed: 12/18/2022]
Abstract
STUDY OBJECTIVE The beach chair position for shoulder surgery induces cerebral hypoperfusion. We evaluated the effects of remote ischemic preconditioning (RIPC) prior to surgery to ameliorate cerebral desaturation in a double-blind randomized fashion. DESIGN Blinded, prospective, randomized study. SETTING Operating room & postoperative recovery room, tertiary university hospital. PATIENTS Seventy patients scheduled for shoulder surgery were recruited. After excluding 7 patients according to the exclusion criteria, 63 patients were randomized into two groups (control and RIPC). INTERVENTIONS Remote ischemic preconditioning was applied by briefly inflating a tourniquet on the thigh three times just after inducing anesthesia in the RIPC group. MEASUREMENTS The changes in regional cerebral oxygen saturation, hemodynamic values, laboratory values, and serum levels of cytokines including interleukin (IL)-1β, IL-6, IL-10 and transforming growth factor-β were measured. MAIN RESULTS The remote ischemic preconditioning group had higher regional cerebral oxygen saturation just after establishment of the beach chair position (P = 0.002) and lower cerebral desaturation (P = 0.007) during operation than the control group. Hemodynamic and laboratory values did not differ between the groups. There were no significant intergroup differences in cytokine levels. CONCLUSION Remote ischemic preconditioning before surgery ameliorates cerebral desaturation in patients in the beach chair position during shoulder surgery. Trial Registry Number: KCT0001384 (http://cris.nih.go.kr).
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Affiliation(s)
- Chung-Sik Oh
- Department of Anesthesiology and Pain Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Republic of Korea; Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Mijung Sa
- Department of Anesthesiology and Pain Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Hyun Jun Park
- Department of Infection and Immunology, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Liyun Piao
- Department of Infection and Immunology, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Kyung-Soo Oh
- Department of Orthopedic Surgery, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Seong-Hyop Kim
- Department of Anesthesiology and Pain Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Republic of Korea; Department of Infection and Immunology, Konkuk University School of Medicine, Seoul, Republic of Korea; Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Republic of Korea.
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Deferrari G, Bonanni A, Bruschi M, Alicino C, Signori A. Remote ischaemic preconditioning for renal and cardiac protection in adult patients undergoing cardiac surgery with cardiopulmonary bypass: systematic review and meta-analysis of randomized controlled trials. Nephrol Dial Transplant 2019; 33:813-824. [PMID: 28992285 DOI: 10.1093/ndt/gfx210] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 04/28/2017] [Indexed: 12/20/2022] Open
Abstract
Background The main aim of this systematic review was to assess whether remote ischaemic preconditioning (RIPC) protects kidneys and the heart in cardiac surgery with cardiopulmonary bypass (CPB) and to investigate a possible role of anaesthetic agents. Methods Randomized clinical trials (RCTs) on the effects of RIPC through limb ischaemia in adult patients undergoing cardiac surgery with CPB were searched (1965-October 2016) in PubMed, Cochrane Library and article reference lists. A random effects model on standardized mean difference (SMD) for continuous outcomes and the Peto odds ratio (OR) for dichotomous outcomes were used to meta-analyse data. Subgroup analyses to evaluate the effects of different anaesthetic regimens were pre-planned. Results Thirty-three RCTs (5999 participants) were included. In the whole group, RIPC did not significantly reduce the incidence of acute kidney injury (AKI), acute myocardial infarction, atrial fibrillation, mortality or length of intensive care unit (ICU) and hospital stays. On the contrary, RIPC significantly reduced the area under the curve for myocardial injury biomarkers (MIBs) {SMD -0.37 [95% confidence interval (CI) -0.53 to - 0.21]} and the composite endpoint incidence [OR 0.85 (95% CI 0.74-0.97)]. In the volatile anaesthetic group, RIPC significantly reduced AKI incidence [OR 0.57 (95% CI 0.41-0.79)] and marginally reduced ICU stay. Conversely, except for MIBs, RIPC had fewer non-significant effects under propofol with or without volatile anaesthetics. Conclusions RIPC did not consistently reduce morbidity and mortality in adults undergoing cardiac surgery with CPB. In the subgroup on volatile anaesthetics only, RIPC markedly and significantly reduced the incidence of AKI and composite endpoint as well as myocardial injury.
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Affiliation(s)
- Giacomo Deferrari
- Department of Cardionephrology, Istituto Clinico Di Alta Specialità (ICLAS), Rapallo (GE), Italy.,Department of Internal Medicine (Di.MI), University of Genoa, Genoa, Italy
| | - Alice Bonanni
- Department of Cardionephrology, Istituto Clinico Di Alta Specialità (ICLAS), Rapallo (GE), Italy.,Division of Nephrology, Dialysis and Transplantation and Laboratory on Pathophysiology of Uremia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Maurizio Bruschi
- Division of Nephrology, Dialysis and Transplantation and Laboratory on Pathophysiology of Uremia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Cristiano Alicino
- Department of Health Science (Di.S.Sal), University of Genoa, Genoa, Italy
| | - Alessio Signori
- Department of Health Science (Di.S.Sal), University of Genoa, Genoa, Italy
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21
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Sangeetha RP, Ramesh VJ, Kamath S, Christopher R, Bhat DI, Arvinda HR, Chakrabarti D. Effect of remote ischemic preconditioning on cerebral vasospasm and biomarkers of cerebral ischemia in aneurysmal subarachnoid hemorrhage (ERVAS): A protocol for a randomized, controlled pilot trial. Brain Circ 2019; 5:12-18. [PMID: 31001595 PMCID: PMC6458778 DOI: 10.4103/bc.bc_26_18] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 12/16/2018] [Accepted: 01/14/2019] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION: Cerebral vasospasm is a dreaded complication of aneurysmal subarachnoid hemorrhage (aSAH) predisposing to delayed cerebral ischemia. We intend to study the cerebroprotective effects of remote ischemic preconditioning (RIPC) in patients with aSAH. MATERIALS AND METHODS: This is a single-center, prospective, parallel group, randomized, pilot trial, approved by the Institutional Ethics Committee. Patients with aSAH admitted to our hospital for surgical clipping; fulfilling the trial inclusion criteria will be randomized to true RIPC (n = 12) (inflating upper extremity blood pressure cuff thrice for 5 min to 30 mmHg above systolic blood pressure) or sham RIPC (n = 12) (inflating blood pressure cuff thrice for 5 min to 30 mmHg) in 1:1 allocation ratio using a computerized random allocation sequence and block randomization. RESULTS: Our primary outcome measure is vasospasm on cerebral angiography and transcranial Doppler study, and concentration of serum S100B and neuron-specific enolase at 24 h after RIPC and on day 7 of ictus. Our secondary outcomes are safety of RIPC, cerebral oxygen saturation, and Glasgow coma score, and extended Glasgow outcome scale scores at discharge and at 1, 3, and 6 months following discharge. Outcome measures will be assessed by an observer blinded to the study intervention. CONCLUSION: If our preliminary results demonstrate a beneficial effect of RIPC, this would serve as a clinically applicable and safe preemptive method of protection against cerebral ischemia.
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Affiliation(s)
- R P Sangeetha
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - V J Ramesh
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Sriganesh Kamath
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Rita Christopher
- Department of Neurochemistry, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Dhananjaya I Bhat
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - H R Arvinda
- Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Dhritiman Chakrabarti
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
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22
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Alam A, Hana Z, Jin Z, Suen KC, Ma D. Surgery, neuroinflammation and cognitive impairment. EBioMedicine 2018; 37:547-556. [PMID: 30348620 PMCID: PMC6284418 DOI: 10.1016/j.ebiom.2018.10.021] [Citation(s) in RCA: 202] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 10/01/2018] [Accepted: 10/09/2018] [Indexed: 12/25/2022] Open
Abstract
Trauma experienced during surgery can contribute to the development of a systemic inflammatory response that can cause multi-organ dysfunction or even failure. Post-surgical neuroinflammation is a documented phenomenon that results in synaptic impairment, neuronal dysfunction and death, and impaired neurogenesis. Various pro-inflammatory cytokines, such as TNFα, maintain a state of chronic neuroinflammation, manifesting as post-operative cognitive dysfunction and post-operative delirium. Furthermore, elderly patients with post-operative cognitive dysfunction or delirium are three times more likely to experience permanent cognitive impairment or dementia. We conducted a narrative review, considering evidence extracted from various databases including Pubmed, MEDLINE and EMBASE, as well as journals and book reference lists. We found that further pre-clinical and well-powered clinical studies are required to delineate the precise pathogenesis of post-operative delirium and cognitive dysfunction. Despite the burden of post-operative neurological sequelae, clinical studies investigating therapeutic agents, such as dexmedetomidine, ibuprofen and statins, have yielded conflicting results. In addition, evidence supporting novel therapeutic avenues, such as nicotinic and HMGB-1 targeting and remote ischaemic pre-conditioning, is limited and necessitates further investigation.
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Affiliation(s)
- Azeem Alam
- Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Zac Hana
- Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Zhaosheng Jin
- Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Ka Chun Suen
- Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Daqing Ma
- Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK.
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23
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Wagner S, Quente J, Staedtler S, Koch K, Richter-Schmidinger T, Kornhuber J, Ihmsen H, Schuettler J. A high risk of sleep apnea is associated with less postoperative cognitive dysfunction after intravenous anesthesia: results of an observational pilot study. BMC Anesthesiol 2018; 18:139. [PMID: 30285632 PMCID: PMC6169037 DOI: 10.1186/s12871-018-0602-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 09/24/2018] [Indexed: 11/15/2022] Open
Abstract
Background The obstructive sleep apnea syndrome (OSAS) is characterized by temporary cerebral hypoxia which can cause cognitive dysfunction. On the other hand, hypoxia induced neurocognitive deficits are detectable after general anesthesia. The objective of this study was to evaluate the impact of a high risk of OSAS on the postoperative cognitive dysfunction after intravenous anesthesia. Methods In this single center trial between June 2012 and June 2013 43 patients aged 55 to 80 years with an estimated hospital stay of at least 3 days undergoing surgery were enrolled. Patients were screened for a high risk of OSAS using the STOP-BANG test. The cognitive function was assessed using a neuropsychological test battery, including the DemTect test for cognitive impairment and the RMBT test for memory, the day before surgery and within 36 h after extubation. Results Twenty-two of the 43 analyzed patients were identified as patients with a high risk of OSAS. Preoperatively, OSAS patients showed a significant worse performance only for the DemTect (p = 0.0043). However, when comparing pre- and postoperative test results, the OSAS patients did not show a significant loss in any test but significantly improved in RMBT test, whereas the control group showed a significant worse performance in three of eight tests. In five tests, we found a significant difference between the two groups with respect to the change from pre- to postoperative cognitive function. Conclusion Patients with a high risk of OSAS showed a less impairment of memory function and work memory performance after intravenous anesthesia. This might be explained by a beneficial effect of intrinsic hypoxic preconditioning in these patients.
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Affiliation(s)
- Soeren Wagner
- Department of Anesthesiology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany. .,Department of Anesthesiology, Katharinenhospital Klinikum Stuttgart, Kriegsbergstrasse 60, D-70174, Stuttgart, Germany.
| | - Joerg Quente
- Department of Anesthesiology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Sven Staedtler
- Department of Anesthesiology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Katharina Koch
- Department of Anesthesiology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany.,Department of Anaesthesiology, Klinikum Oldenburg AöR, University Hospital Oldenburg, Oldenburg, Germany
| | - Tanja Richter-Schmidinger
- Department of Psychiatry and Psychotherapy, University Hospital Erlangen, Friedrich-Alexander-University, Erlangen, Germany
| | - Johannes Kornhuber
- Department of Psychiatry and Psychotherapy, University Hospital Erlangen, Friedrich-Alexander-University, Erlangen, Germany
| | - Harald Ihmsen
- Department of Anesthesiology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Juergen Schuettler
- Department of Anesthesiology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
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24
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Zhao W, Zhang J, Sadowsky MG, Meng R, Ding Y, Ji X. Remote ischaemic conditioning for preventing and treating ischaemic stroke. Cochrane Database Syst Rev 2018; 7:CD012503. [PMID: 29974450 PMCID: PMC6513257 DOI: 10.1002/14651858.cd012503.pub2] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Remote ischaemic conditioning (RIC) has been developed as a neuroprotective strategy to prevent and treat ischaemic stroke. It usually involves restricting blood flow to limbs and then releasing the ischaemic blood to promote a neuroprotective effect. Preclinical studies have suggested that RIC may have beneficial effects in ischaemic stroke patients and those at risk of ischaemic stroke. However, existing evidence is insufficient to demonstrate the efficacy and safety of RIC in preventing and treating ischaemic stroke. OBJECTIVES To assess the benefits and harms of RIC for preventing ischaemic stroke and for treating people with ischaemic stroke and those at risk for ischaemic stroke. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (16 January 2018), the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 12) in the Cochrane Library (January 2018), MEDLINE Ovid (1946 to January 2018), Embase Ovid (1974 to January 2018), Web of Science Core Collection (1950 to January 2018) and three Chinese databases (January 2018). We also searched four ongoing trials registers, reference lists, and conference proceedings. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing RIC with sham RIC or medical management in people with ischaemic stroke or at risk of ischaemic stroke. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies, assessed trial quality and risk of bias, and extracted data. We used the GRADE approach to assess the quality of the evidence. MAIN RESULTS We included seven trials, involving 735 participants, in this review. We analysed the effects of RIC on preventing and treating ischaemic stroke respectively.We evaluated risk of bias and judged it to be low for generation of allocation sequence in six studies and unclear in one study; unclear for allocation concealment in four studies and low in three studies; high for incomplete outcome data (attrition bias) in five studies and low in two studies; high for blinding in three studies and low in four studies; low for selective reporting; and high for other sources of bias in six studies and low in one study.We included three trials (involving 371 participants) in the analysis of the effects of RIC on ischaemic stroke prevention. In people with symptomatic intracerebral artery stenosis, recurrent stroke was significantly reduced by RIC (risk ratio (RR) 0.32, 95% confidence interval (CI) 0.12 to 0.83; 2 trials, 182 participants, low-quality evidence). In people with carotid stenosis undergoing carotid stenting, there was no significant difference in the incidence of ischaemic stroke between participants treated with RIC and non-RIC (RR 0.22, 95% CI 0.01 to 4.03; 1 trial, 189 participants, low-quality evidence); however the stroke severity (assessed by infarct volume) was significantly lower in participants treated with RIC (mean difference (MD) -0.17 mL, 95% CI -0.23 to -0.11; 1 trial, 189 participants, low-quality evidence). Adverse events associated with RIC were significantly higher in participants treated with RIC (RR 10.91; 95% CI 2.01 to 59.28; 3 trials, 371 participants, low-quality evidence), but no severe adverse event was attributable to RIC treatment. No participants experienced death or cardiovascular events during the period of the studies; and no trial reported haemorrhagic stroke or improvement in neurological, phycological or cognitive impairment.We included four trials (involving 364 participants) in the analysis of the effects of RIC on ischaemic stroke treatment. In acute ischaemic stroke, for people receiving intravenous thrombolysis, the rate of death or dependency was significantly increased by RIC treatment compared with non-RIC treatment (RR 2.34; 95% 1.19 to 4.61; 1 trial, 285 participants, low-quality evidence). In people with acute ischaemic stroke, there was no significant difference between RIC and non-RIC for reducing stroke severity as assessed by the National Institutes of Health Stroke Scale score and the final infarct volume (standardised mean difference (SMD) -0.24 mL, 95% CI -1.02 to 0.54; 2 trials, 175 participants, very low quality evidence). There was no significant difference between RIC and non-RIC for improving the psychological impairment (SMD -0.37 points, 95% CI -1.15 to 0.41; 1 trial, 26 participants, very low quality evidence) and the cognitive impairment (SMD -0.26 points; 95% CI -0.72 to 0.21; 3 trials, 79 participants, low-quality evidence) in people with acute ischaemic stroke and cerebral small vessel disease. No trial reported ischaemic stroke, recurrent ischaemic stroke, improvement in neurological impairment, hemorrhagic stroke, cardiovascular events, and RIC associated adverse events. AUTHORS' CONCLUSIONS We found low-quality evidence that RIC may reduce the risk of recurrent stroke in participants with intracerebral artery stenosis and reduce stroke severity in participants undergoing carotid stenting, but it may increase death or dependence in participants with acute ischaemic stroke who are undergoing intravenous thrombolysis. However, there is considerable uncertainty about these conclusions because of the small number of studies and low quality of the evidence.
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Affiliation(s)
- Wenbo Zhao
- Xuanwu Hospital, Capital Medical UniversityDepartment of NeurologyBeijingChina100053
| | - Jing Zhang
- Xuanwu Hospital, Capital Medical UniversityDepartment of NeurologyBeijingChina100053
| | - Mordechai G Sadowsky
- Wayne State University School of MedicineDepartment of Neurological SurgeryDetroit, MichiganUSA
| | - Ran Meng
- Xuanwu Hospital, Capital Medical UniversityDepartment of NeurologyBeijingChina100053
| | - Yuchuan Ding
- Wayne State University School of MedicineDepartment of Neurological SurgeryDetroit, MichiganUSA
| | - Xunming Ji
- Xuanwu Hospital, Capital Medical UniversityDepartment of NeurosurgeryBeijingChina100053
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25
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Gaynor JW, Nicolson SC, Spray DM, Burnham NB, Chittams JL, Sammarco T, Walsh KW, Spray TL, Licht DJ. Remote Ischemic Preconditioning Does Not Prevent White Matter Injury in Neonates. Ann Thorac Surg 2018; 106:151-155. [PMID: 29601806 DOI: 10.1016/j.athoracsur.2018.02.060] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 02/12/2018] [Accepted: 02/20/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Remote ischemic preconditioning (RIPC) is a mechanism to protect tissues from injury during ischemia and reperfusion. We investigated the neuroprotective effects of RIPC in neonates undergoing cardiac surgery. METHODS The outcome was white matter injury (WMI), assessed by the change in volume of WMI from preoperative to postoperative brain magnetic resonance imaging (MRI). Patients were randomized to RIPC or SHAM. RIPC was induced prior to cardiopulmonary bypass by four 5-minute cycles of blood pressure cuff inflation to produce ischemia of the lower extremity. For patients randomized to SHAM, the cuff was positioned, but not inflated. RESULTS The study included 67 patients, with 33 randomized to RIPC and 34 randomized to SHAM. Preoperative and postoperative MRIs were available in 50 patients, including 26 of the 33 RIPC patients and 24 of the 34 SHAM patients. There were no differences in baseline and operative characteristics for either the overall study group or the group with evaluable MRIs. WMI was identified in 28% of the patients preoperatively and in 62% postoperatively. There was no difference in the prevalence of WMI by treatment group (p > 0.5). RIPC patients had an average change in WMI of 600 mL3, and SHAM subjects had an average WMI change of 107 mL3. There was no significant difference in the mean value of WMI change between patients who received RIPC and those who received SHAM treatments (p = 0.178). CONCLUSIONS In this randomized, blinded clinical trial, there was no evidence that use of RIPC provides neuroprotection in neonates undergoing repair of congenital heart defects with cardiopulmonary bypass.
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Affiliation(s)
- J William Gaynor
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - Susan C Nicolson
- Department of Anesthesia and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Diane M Spray
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Nancy B Burnham
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jesse L Chittams
- Biostatistics Consulting Unit, Office of Nursing Research, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Therese Sammarco
- Biostatistics Consulting Unit, Office of Nursing Research, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Kevin W Walsh
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Thomas L Spray
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Daniel J Licht
- Department of Pediatrics, Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Needham M, Webb C, Bryden D. Postoperative cognitive dysfunction and dementia: what we need to know and do. Br J Anaesth 2017; 119:i115-i125. [DOI: 10.1093/bja/aex354] [Citation(s) in RCA: 144] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Bhamidipati D, Goldhammer JE, Sperling MR, Torjman MC, McCarey MM, Whellan DJ. Cognitive Outcomes After Coronary Artery Bypass Grafting. J Cardiothorac Vasc Anesth 2017; 31:707-718. [DOI: 10.1053/j.jvca.2016.09.028] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Indexed: 12/17/2022]
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Ye Z, Su Q, Li L. The clinical effect of nicorandil on perioperative myocardial protection in patients undergoing elective PCI: A Systematic Review and Meta-Analysis. Sci Rep 2017; 7:45117. [PMID: 28322321 PMCID: PMC5359672 DOI: 10.1038/srep45117] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 02/16/2017] [Indexed: 11/19/2022] Open
Abstract
Many scholars have studied the effect of nicorandil on perioperative myocardial protection in patients undergoing elective percutaneous coronary intervention (PCI), but results are inconsistent. Therefore, we performed this meta-analysis. Finally, 16 articles, including 1616 patients, were included into this meta-analysis. Meta-analysis results showed that: (1) Nicorandil can reduce the level of CK-MB after PCI, including at 6 hours, 12 hours, 18 hours and 24 hours. (2) Nicorandil can reduce the level of TnT after PCI, including at 6 hours, 12 hours, 18 hours and 24 hours. (3) Nicorandil can reduce the incidence of adverse reactions after PCI. (4) Nicorandil cannot reduce the level of MVP after PCI, including at 12 hours and 24 hours. (5) Subgroup analysis showed that nicorandil can reduce CK-MB and TnT level at 24 hours after PCI for Chinese's population (P < 0.05), but can not reduce CK-MB and TnT level at 24 hours after PCI for non Chinese's population (P > 0.05). Our meta-analysis indicate that nicorandil can reduce myocardial injury and reduce the incidence of adverse reaction caused by PCI for Chinese's population, but is not obvious for non Chinese's population. However, this conclusion still needs to be confirmed in the future.
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Affiliation(s)
- Ziliang Ye
- Department of cardiology, The First Affiliated Hospital of Guangxi Medical University, Guangxi Cardiovascular institue, Nanning, Guangxi, 530021, China
| | - Qiang Su
- Department of cardiology, The First Affiliated Hospital of Guangxi Medical University, Guangxi Cardiovascular institue, Nanning, Guangxi, 530021, China
| | - Lang Li
- Department of cardiology, The First Affiliated Hospital of Guangxi Medical University, Guangxi Cardiovascular institue, Nanning, Guangxi, 530021, China
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Abstract
Remote ischemic preconditioning (RIPC) is an intriguing process whereby transient regional ischemia and reperfusion episodes to remote tissues including skeletal, renal, mesenteric provide protection to the heart against sustained ischemia-reperfusion-induced injury. Clinically, this technique has been used in patients undergoing various surgical interventions including coronary artery bypass graft surgery, abdominal aortic aneurysm repair, percutaneous coronary intervention, and heart valve surgery. The endogenous opioid system is extensively expressed in the brain to modulate pain sensation. Besides the role of opioids in relieving pain, numerous researchers have found their critical involvement in evoking cardioprotective effects. Endogenous opioids including endorphins, enkephalins, and dynorphins are released during RIPC and are critically involved in mediating RIPC-induced cardioprotective effects. It has been suggested that during RIPC, the endogenous opioids may be released into the systemic circulation and may travel via bloodstream that act on the myocardial opioid receptors to induce cardioprotection. The present review describes the potential role of opioids in mediating RIPC-induced cardioprotection.
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Affiliation(s)
- Puneet Kaur Randhawa
- 1 Department of Pharmaceutical Sciences and Drug Research, Punjabi University, Patiala, Patiala, Punjab, India
| | - Amteshwar Singh Jaggi
- 1 Department of Pharmaceutical Sciences and Drug Research, Punjabi University, Patiala, Patiala, Punjab, India
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Randhawa PK, Jaggi AS. Unraveling the role of adenosine in remote ischemic preconditioning-induced cardioprotection. Life Sci 2016; 155:140-6. [PMID: 27157518 DOI: 10.1016/j.lfs.2016.05.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 05/03/2016] [Accepted: 05/04/2016] [Indexed: 12/25/2022]
Abstract
Remote ischemic preconditioning (RIPC) induced by alternate cycles of preconditioning ischemia and reperfusion protects the heart against sustained ischemia-reperfusion-induced injury. This technique has been translated to clinical levels in patients undergoing various surgical interventions including coronary artery bypass graft surgery, abdominal aortic aneurysm repair, percutaneous coronary intervention and heart valve surgery. Adenosine is a master regulator of energy metabolism and reduces myocardial ischemia-reperfusion-induced injury. Furthermore, adenosine is a critical trigger as well as a mediator in RIPC-induced cardioprotection and scientists have demonstrated the role of adenosine by showing an increase in its levels in the systemic circulation during RIPC delivery. Furthermore, the blockade of cardioprotective effects of RIPC in the presence of specific adenosine receptor blockers and transgenic animals with targeted ablation of A1 receptors has also demonstrated its critical role in RIPC. The studies have shown that adenosine may elicit cardioprotection via activation of neurogenic pathway. The present review describes the possible role and mechanism of adenosine in mediating RIPC-induced cardioprotection.
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Affiliation(s)
- Puneet Kaur Randhawa
- Department of Pharmaceutical Sciences and Drug Research, Punjabi University Patiala, 147002, India
| | - Amteshwar Singh Jaggi
- Department of Pharmaceutical Sciences and Drug Research, Punjabi University Patiala, 147002, India.
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Siddiqi N, Harrison JK, Clegg A, Teale EA, Young J, Taylor J, Simpkins SA. Interventions for preventing delirium in hospitalised non-ICU patients. Cochrane Database Syst Rev 2016; 3:CD005563. [PMID: 26967259 PMCID: PMC10431752 DOI: 10.1002/14651858.cd005563.pub3] [Citation(s) in RCA: 172] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Delirium is a common mental disorder, which is distressing and has serious adverse outcomes in hospitalised patients. Prevention of delirium is desirable from the perspective of patients and carers, and healthcare providers. It is currently unclear, however, whether interventions for preventing delirium are effective. OBJECTIVES To assess the effectiveness of interventions for preventing delirium in hospitalised non-Intensive Care Unit (ICU) patients. SEARCH METHODS We searched ALOIS - the Cochrane Dementia and Cognitive Improvement Group's Specialized Register on 4 December 2015 for all randomised studies on preventing delirium. We also searched MEDLINE (Ovid SP), EMBASE (Ovid SP), PsycINFO (Ovid SP), Central (The Cochrane Library), CINAHL (EBSCOhost), LILACS (BIREME), Web of Science core collection (ISI Web of Science), ClinicalTrials.gov and the WHO meta register of trials, ICTRP. SELECTION CRITERIA We included randomised controlled trials (RCTs) of single and multi- component non-pharmacological and pharmacological interventions for preventing delirium in hospitalised non-ICU patients. DATA COLLECTION AND ANALYSIS Two review authors examined titles and abstracts of citations identified by the search for eligibility and extracted data independently, with any disagreements settled by consensus. The primary outcome was incidence of delirium; secondary outcomes included duration and severity of delirium, institutional care at discharge, quality of life and healthcare costs. We used risk ratios (RRs) as measures of treatment effect for dichotomous outcomes; and between group mean differences and standard deviations for continuous outcomes. MAIN RESULTS We included 39 trials that recruited 16,082 participants, assessing 22 different interventions or comparisons. Fourteen trials were placebo-controlled, 15 evaluated a delirium prevention intervention against usual care, and 10 compared two different interventions. Thirty-two studies were conducted in patients undergoing surgery, the majority in orthopaedic settings. Seven studies were conducted in general medical or geriatric medicine settings.We found multi-component interventions reduced the incidence of delirium compared to usual care (RR 0.69, 95% CI 0.59 to 0.81; seven studies; 1950 participants; moderate-quality evidence). Effect sizes were similar in medical (RR 0.63, 95% CI 0.43 to 0.92; four studies; 1365 participants) and surgical settings (RR 0.71, 95% CI 0.59 to 0.85; three studies; 585 participants). In the subgroup of patients with pre-existing dementia, the effect of multi-component interventions remains uncertain (RR 0.90, 95% CI 0.59 to 1.36; one study, 50 participants; low-quality evidence).There is no clear evidence that cholinesterase inhibitors are effective in preventing delirium compared to placebo (RR 0.68, 95% CI, 0.17 to 2.62; two studies, 113 participants; very low-quality evidence).Three trials provide no clear evidence of an effect of antipsychotic medications as a group on the incidence of delirium (RR 0.73, 95% CI, 0.33 to 1.59; 916 participants; very low-quality evidence). In a pre-planned subgroup analysis there was no evidence for effectiveness of a typical antipsychotic (haloperidol) (RR 1.05, 95% CI 0.69 to 1.60; two studies; 516 participants, low-quality evidence). However, delirium incidence was lower (RR 0.36, 95% CI 0.24 to 0.52; one study; 400 participants, moderate-quality evidence) for patients treated with an atypical antipsychotic (olanzapine) compared to placebo (moderate-quality evidence).There is no clear evidence that melatonin or melatonin agonists reduce delirium incidence compared to placebo (RR 0.41, 95% CI 0.09 to 1.89; three studies, 529 participants; low-quality evidence).There is moderate-quality evidence that Bispectral Index (BIS)-guided anaesthesia reduces the incidence of delirium compared to BIS-blinded anaesthesia or clinical judgement (RR 0.71, 95% CI 0.60 to 0.85; two studies; 2057 participants).It is not possible to generate robust evidence statements for a range of additional pharmacological and anaesthetic interventions due to small numbers of trials, of variable methodological quality. AUTHORS' CONCLUSIONS There is strong evidence supporting multi-component interventions to prevent delirium in hospitalised patients. There is no clear evidence that cholinesterase inhibitors, antipsychotic medication or melatonin reduce the incidence of delirium. Using the Bispectral Index to monitor and control depth of anaesthesia reduces the incidence of postoperative delirium. The role of drugs and other anaesthetic techniques to prevent delirium remains uncertain.
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Affiliation(s)
- Najma Siddiqi
- University of YorkDepartment of Health SciencesHeslingtonYorkNorth YorkshireUKY010 5DD
| | - Jennifer K Harrison
- University of EdinburghCentre for Cognitive Ageing and Cognitive Epidemiology and the Alzheimer Scotland Dementia Research CentreDepartment of Geriatric Medicine, The Royal Infirmary of Edinburgh, Room S164251 Little France CrescentEdinburghUKEH16 4SB
| | - Andrew Clegg
- University of LeedsAcademic Unit of Elderly Care and RehabilitationBradford Institute for Health ResearchBradfordUKBD9 6RJ
| | - Elizabeth A Teale
- University of LeedsAcademic Unit of Elderly Care and RehabilitationBradford Institute for Health ResearchBradfordUKBD9 6RJ
| | - John Young
- Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust/University of LeedsAcademic Unit of Elderly Care and RehabilitationBradfordUK
| | - James Taylor
- Bradford Teaching Hospitals NHS Foundation TrustDepartment of AnaesthesiaBradfordUKBD9 6RJ
| | - Samantha A Simpkins
- Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust/University of LeedsAcademic Unit of Elderly Care and RehabilitationBradfordUK
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Hudetz JA, Pagel PS. Letter in Reply. J Cardiothorac Vasc Anesth 2015; 29:e74. [PMID: 26303863 DOI: 10.1053/j.jvca.2015.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Indexed: 11/11/2022]
Affiliation(s)
- Judith A Hudetz
- Anesthesia Service, Clement J. Zablocki Veterans Affairs Medical Center Milwaukee, WI
| | - Paul S Pagel
- Anesthesia Service, Clement J. Zablocki Veterans Affairs Medical Center Milwaukee, WI
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Zhang XY, Zhang YB, Liu B. Assessing Effect of Remote Ischemic Preconditioning on Postoperative Cognitive Function After Cardiac Surgery Using Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2015; 29:e73-4. [PMID: 26300217 DOI: 10.1053/j.jvca.2015.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2015] [Indexed: 02/05/2023]
Affiliation(s)
- Xi-Yang Zhang
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
| | - Ya-Bing Zhang
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
| | - Bin Liu
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
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Berger M, Nadler JW, Browndyke J, Terrando N, Ponnusamy V, Cohen HJ, Whitson HE, Mathew JP. Postoperative Cognitive Dysfunction: Minding the Gaps in Our Knowledge of a Common Postoperative Complication in the Elderly. Anesthesiol Clin 2015; 33:517-50. [PMID: 26315636 DOI: 10.1016/j.anclin.2015.05.008] [Citation(s) in RCA: 170] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Postoperative cognitive dysfunction (POCD) is a common complication associated with significant morbidity and mortality in elderly patients. There is much interest in and controversy about POCD, reflected partly in the increasing number of articles published on POCD recently. Recent work suggests surgery may also be associated with cognitive improvement in some patients, termed postoperative cognitive improvement (POCI). As the number of surgeries performed worldwide approaches 250 million per year, optimizing postoperative cognitive function and preventing/treating POCD are major public health issues. In this article, we review the literature on POCD and POCI, and discuss current research challenges in this area.
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Affiliation(s)
- Miles Berger
- Department of Anesthesiology, Duke University Medical Center, Duke South, Orange Zone, Room 4317, Durham, NC 27710, USA.
| | - Jacob W Nadler
- Department of Anesthesiology, Duke University Medical Center, Duke South, Orange Zone, Room 4317, Durham, NC 27710, USA
| | - Jeffrey Browndyke
- Department of Anesthesiology, Duke University Medical Center, Duke South, Orange Zone, Room 4317, Durham, NC 27710, USA
| | - Niccolo Terrando
- Department of Anesthesiology, Duke University Medical Center, Duke South, Orange Zone, Room 4317, Durham, NC 27710, USA
| | - Vikram Ponnusamy
- Department of Anesthesiology, Duke University Medical Center, Duke South, Orange Zone, Room 4317, Durham, NC 27710, USA
| | - Harvey Jay Cohen
- Department of Anesthesiology, Duke University Medical Center, Duke South, Orange Zone, Room 4317, Durham, NC 27710, USA
| | - Heather E Whitson
- Department of Anesthesiology, Duke University Medical Center, Duke South, Orange Zone, Room 4317, Durham, NC 27710, USA
| | - Joseph P Mathew
- Department of Anesthesiology, Duke University Medical Center, Duke South, Orange Zone, Room 4317, Durham, NC 27710, USA
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Zhan HT, Purcell ST, Bush RL. Preoperative optimization of the vascular surgery patient. Vasc Health Risk Manag 2015; 11:379-85. [PMID: 26170688 PMCID: PMC4492637 DOI: 10.2147/vhrm.s83492] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
It is well known that patients who suffer from peripheral (noncardiac) vascular disease often have coexisting atherosclerotic diseases of the heart. This may leave the patients susceptible to major adverse cardiac events, including death, myocardial infarction, unstable angina, and pulmonary edema, during the perioperative time period, in addition to the many other complications they may sustain as they undergo vascular surgery procedures, regardless of whether the procedure is performed as an open or endovascular modality. As these patients are at particularly high risk, up to 16% in published studies, for postoperative cardiac complications, many proposals and algorithms for perioperative optimization have been suggested and studied in the literature. Moreover, in patients with recent coronary stents, the risk of non-cardiac surgery on adverse cardiac events is incremental in the first 6 months following stent implantation. Just as postoperative management of patients is vital to the outcome of a patient, preoperative assessment and optimization may reduce, and possibly completely alleviate, the risks of major postoperative complications, as well as assist in the decision-making process regarding the appropriate surgical and anesthetic management. This review article addresses several tools and therapies that treating physicians may employ to medically optimize a patient before they undergo noncardiac vascular surgery.
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Affiliation(s)
- Henry T Zhan
- Texas A&M Health Science Center College of Medicine, Bryan, TX, USA
| | - Seth T Purcell
- Texas A&M Health Science Center College of Medicine, Bryan, TX, USA ; Baylor Scott and White, Temple, TX, USA
| | - Ruth L Bush
- Texas A&M Health Science Center College of Medicine, Bryan, TX, USA
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Thushara Vijayakumar N, Sangwan A, Sharma B, Majid A, Rajanikant GK. Cerebral Ischemic Preconditioning: the Road So Far…. Mol Neurobiol 2015; 53:2579-93. [PMID: 26081149 DOI: 10.1007/s12035-015-9278-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 06/02/2015] [Indexed: 12/25/2022]
Abstract
Cerebral preconditioning constitutes the brain's adaptation to lethal ischemia when first exposed to mild doses of a subtoxic stressor. The phenomenon of preconditioning has been largely studied in the heart, and data from in vivo and in vitro models from past 2-3 decades have provided sufficient evidence that similar machinery exists in the brain as well. Since preconditioning results in a transient protective phenotype labeled as ischemic tolerance, it can open many doors in the medical warfare against stroke, a debilitating cerebrovascular disorder that kills or cripples thousands of people worldwide every year. Preconditioning can be induced by a variety of stimuli from hypoxia to pharmacological anesthetics, and each, in turn, induces tolerance by activating a multitude of proteins, enzymes, receptors, transcription factors, and other biomolecules eventually leading to genomic reprogramming. The intracellular signaling pathways and molecular cascades behind preconditioning are extensively being investigated, and several first-rate papers have come out in the last few years centered on the topic of cerebral ischemic tolerance. However, translating the experimental knowledge into the clinical scaffold still evades practicality and faces several challenges. Of the various preconditioning strategies, remote ischemic preconditioning and pharmacological preconditioning appears to be more clinically relevant for the management of ischemic stroke. In this review, we discuss current developments in the field of cerebral preconditioning and then examine the potential of various preconditioning agents to confer neuroprotection in the brain.
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Affiliation(s)
- N Thushara Vijayakumar
- School of Biotechnology, DBT-Centre for Bioinformatics, National Institute of Technology Calicut, Calicut, 673601, India
| | - Amit Sangwan
- School of Biotechnology, DBT-Centre for Bioinformatics, National Institute of Technology Calicut, Calicut, 673601, India
| | - Bhargy Sharma
- School of Biotechnology, DBT-Centre for Bioinformatics, National Institute of Technology Calicut, Calicut, 673601, India
| | - Arshad Majid
- Institute for Translational Neuroscience (SITraN), University of Sheffield, Sheffield, UK
| | - G K Rajanikant
- School of Biotechnology, DBT-Centre for Bioinformatics, National Institute of Technology Calicut, Calicut, 673601, India.
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