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Pecorella G, De Rosa F, Licchelli M, Panese G, Carugno JT, Morciano A, Tinelli A. Postoperative cognitive disorders and delirium in gynecologic surgery: Which surgery and anesthetic techniques to use to reduce the risk? Int J Gynaecol Obstet 2024. [PMID: 38557928 DOI: 10.1002/ijgo.15464] [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: 04/17/2023] [Revised: 02/13/2024] [Accepted: 02/25/2024] [Indexed: 04/04/2024]
Abstract
Despite their general good health, an increasing proportion of elderly individuals require surgery due to an increase in average lifespan. However, because of their increased vulnerability, these patients need to be handled carefully to make sure that surgery does not cause more harm than good. Age-related postoperative cognitive disorders (POCD) and postoperative delirium (POD), two serious consequences that are marked by adverse neuropsychologic alterations after surgery, are particularly dangerous for the elderly. In the context of gynecologic procedures, POCD and POD are examined in this narrative review. The main question is how to limit the rates of POCD and POD in older women undergoing gynecologic procedures by maximizing the risk-benefit balance. Three crucial endpoints are considered: (1) surgical procedures to lower the rates of POCD and POD, (2) anesthetic techniques to lessen the occurrence and (3) the identification of individuals at high risk for post-surgery cognitive impairments. Risks associated with laparoscopic gynecologic procedures include the Trendelenburg posture and CO2 exposure during pneumoperitoneum, despite statistical similarities in POD and POCD frequency between laparoscopic and laparotomy techniques. Numerous risk factors are associated with surgical interventions, such as blood loss, length of operation, and position holding, all of which reduce the chance of complications when they are minimized. In order to emphasize the essential role that anesthesia and surgery play in patient care, anesthesiologists are vital in making sure that anesthesia is given as sparingly and quickly as feasible. In addition, people who are genetically predisposed to POCD may be more susceptible to the disorder. The significance of a thorough strategy combining surgical and anesthetic concerns is highlighted in this article, in order to maximize results for senior patients having gynecologic surgery.
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Affiliation(s)
- Giovanni Pecorella
- Department of Gynecology, Obstetrics and Reproduction Medicine, Saarland University, Homburg, Germany
| | - Filippo De Rosa
- Department of Anesthesia and Intensive Care, and CERICSAL (CEntro di RIcerca Clinico SALentino), "Veris delli Ponti Hospital", Scorrano, Lecce, Italy
| | - Martina Licchelli
- Department of Obstetrics and Gynecology, and CERICSAL (CEntro di RIcerca Clinico SALentino), "Veris delli Ponti Hospital", Scorrano, Lecce, Italy
| | - Gaetano Panese
- Department of Obstetrics and Gynecology, and CERICSAL (CEntro di RIcerca Clinico SALentino), "Veris delli Ponti Hospital", Scorrano, Lecce, Italy
| | - Josè Tony Carugno
- Obstetrics and Gynecology Department, Minimally Invasive Gynecology Division, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Andrea Morciano
- Panico Pelvic Floor Center, Department of Gynecology and Obstetrics, Pia Fondazione "Card. G. Panico", Tricase, Lecce, Italy
| | - Andrea Tinelli
- Department of Obstetrics and Gynecology, and CERICSAL (CEntro di RIcerca Clinico SALentino), "Veris delli Ponti Hospital", Scorrano, Lecce, Italy
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Megari K, Kosmidis MH. Protecting the Brain While Healing Hearts: The Protective Role of Cognitive Reserve in Cardiac Surgery. Am J Geriatr Psychiatry 2024; 32:195-204. [PMID: 37926673 DOI: 10.1016/j.jagp.2023.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 09/23/2023] [Accepted: 10/04/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVE One of the most significant complications following coronary artery bypass grafting (CABG) is postoperative cognitive decline (POCD). CABG patients frequently experience considerable postoperative cognitive dysfunction (POCD), including decline in attention, orientation, memory, judgment, and social functioning. DESIGN These negative effects may potentially be resolved by a protective factor, cognitive reserve (CR) that has been considered to function as a buffer against the consequences of neuropathology. SETTING We explored the frequency of POCD and CR in coronary artery disease patients undergoing CABG. We hypothesized that high levels of CR would protect against POCD after cardiac surgery. PARTICIPANTS We assessed 101 patients before surgery, and 4 months after cardiopulmonary bypass surgery with the use of extracorporeal circulation. MEASUREMENTS Measures of cognitive functions, CR, anxiety, and depression were included in the assessment. RESULTS Each patient was placed in the high (n = 50) or low CR (n = 51) group, based on median split. Chi-square tests effect showed that patients with low CR were more likely to a great extend to demonstrate postsurgical cognitive decline in attention, memory, visuospatial perception and executive functions than patients with high CR upon postsurgery neuropsychological assessment. CONCLUSIONS Our results suggest that CR can forecast neuropsychological outcomes of cardiac surgery, recognizing the patients with low CR and help them to participate to interventions programs that could slow cognitive aging or reduce the risk of dementia and enhance their overall postsurgical functional outcome.
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Affiliation(s)
- Kalliopi Megari
- Lab of Cognitive Neuroscience, School of Psychology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Mary H Kosmidis
- Lab of Cognitive Neuroscience, School of Psychology, Aristotle University of Thessaloniki, Thessaloniki, Greece.
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Rengel KF, Boncyk CS, DiNizo D, Hughes CG. Perioperative Neurocognitive Disorders in Adults Requiring Cardiac Surgery: Screening, Prevention, and Management. Semin Cardiothorac Vasc Anesth 2023; 27:25-41. [PMID: 36137773 DOI: 10.1177/10892532221127812] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Neurocognitive changes are the most common complication after cardiac surgery, ranging from acute postoperative delirium to prolonged postoperative neurocognitive disorder. Changes in cognition are distressing to patients and families and associated with worse outcomes overall. This review outlines definitions and diagnostic criteria, risk factors for, and mechanisms of Perioperative Neurocognitive Disorders and offers strategies for preoperative screening and perioperative prevention and management of neurocognitive complications.
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Affiliation(s)
- Kimberly F Rengel
- Division of Anesthesia Critical Care Medicine, Department of Anesthesiology, 12328Vanderbilt University Medical Center, Nashville, TN, USA.,Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christina S Boncyk
- Division of Anesthesia Critical Care Medicine, Department of Anesthesiology, 12328Vanderbilt University Medical Center, Nashville, TN, USA.,Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Daniella DiNizo
- Scope Anesthesia of North Carolina, Charlotte, NC, USA.,Pulmonary and Critical Care Consultants, Carolinas Medical Center, 2351Atrium Health, Charlotte, NC, USA
| | - Christopher G Hughes
- Division of Anesthesia Critical Care Medicine, Department of Anesthesiology, 12328Vanderbilt University Medical Center, Nashville, TN, USA.,Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, 12328Vanderbilt University Medical Center, Nashville, TN, USA.,Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
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Pang Y, Li Y, Zhang Y, Wang H, Lang J, Han L, Liu H, Xiong X, Gu L, Wu X. Effects of inflammation and oxidative stress on postoperative delirium in cardiac surgery. Front Cardiovasc Med 2022; 9:1049600. [PMID: 36505383 PMCID: PMC9731159 DOI: 10.3389/fcvm.2022.1049600] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 11/07/2022] [Indexed: 11/23/2022] Open
Abstract
The past decade has witnessed unprecedented medical progress, which has translated into cardiac surgery being increasingly common and safe. However, complications such as postoperative delirium remain a major concern. Although the pathophysiological changes of delirium after cardiac surgery remain poorly understood, it is widely thought that inflammation and oxidative stress may be potential triggers of delirium. The development of delirium following cardiac surgery is associated with perioperative risk factors. Multiple interventions are being explored to prevent and treat delirium. Therefore, research on the potential role of biomarkers in delirium as well as identification of perioperative risk factors and pharmacological interventions are necessary to mitigate the development of delirium.
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Affiliation(s)
- Yi Pang
- Bengbu Medical College, Bengbu, Anhui, China
| | - Yuntao Li
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yonggang Zhang
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Hongfa Wang
- Center for Rehabilitation Medicine, Department of Anesthesiology, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Junhui Lang
- Center for Rehabilitation Medicine, Department of Anesthesiology, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Liang Han
- Center for Rehabilitation Medicine, Department of Anesthesiology, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - He Liu
- Department of Anesthesiology, The Affiliated Huzhou Hospital, Zhejiang University School of Medicine, Huzhou Central Hospital, Huzhou, China
| | - Xiaoxing Xiong
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Lijuan Gu
- Central Laboratory, Renmin Hospital of Wuhan University, Wuhan, China
| | - Xiaomin Wu
- Center for Rehabilitation Medicine, Department of Anesthesiology, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China,*Correspondence: Xiaomin Wu,
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Han J, Huang H, Lei Z, Pan R, Chen X, Chen Y, Lu T. Association Between the Early Serum Lipid Metabolism Profile and Delayed Neurocognitive Recovery After Cardiopulmonary Bypass in Cardiac Surgical Patients: a Pilot Study. J Cardiovasc Transl Res 2022:10.1007/s12265-022-10332-y. [PMID: 36271179 DOI: 10.1007/s12265-022-10332-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 10/10/2022] [Indexed: 11/26/2022]
Abstract
Cardiac surgery with extracorporeal circulation is considered to be one of the surgical types with the highest incidence of delayed neurocognitive recovery (DNR), but the mechanism is unclear. Metabolomics technology can be used to understand the early postoperative metabolic profile and find the relationship between serum metabolites and disease. We performed untargeted analyses of postoperative serum metabolites in all surgical groups, as well as serum metabolites in healthy nonsurgical adults, by using liquid chromatography‒mass spectrometry (LC‒MS). DNR after cardiopulmonary bypass surgery occurred in 35% of surgical patients. Sixty-nine metabolites were found to be associated with DNR. Lipids and lipid-like molecules occupy a total of 55 positions. Lipid metabolism occupies an important position in the serum metabolic profile of DNR patients in the early postoperative period. Phosphatidylinositol (PI), sphingomyelin (SM), and phosphatidylglycerol (PG) appear at the highest frequency. Correlation analysis and receiver operator characteristic curve analysis confirmed PI and SM as potential biomarkers for an increased risk of DNR.
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Affiliation(s)
- Jingjing Han
- Department of Anesthesiology, First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Gulou District, Nanjing City, Jiangsu Province, 210029, China
| | - He Huang
- Department of Anesthesiology, First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Gulou District, Nanjing City, Jiangsu Province, 210029, China
| | - Zheng Lei
- Department of Anesthesiology, First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Gulou District, Nanjing City, Jiangsu Province, 210029, China
| | - Rui Pan
- Department of Anesthesiology, First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Gulou District, Nanjing City, Jiangsu Province, 210029, China
| | - Xiaodong Chen
- Department of Anesthesiology, First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Gulou District, Nanjing City, Jiangsu Province, 210029, China
| | - Yu Chen
- Department of Anesthesiology, First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Gulou District, Nanjing City, Jiangsu Province, 210029, China.
| | - Ting Lu
- Department of Anesthesiology, First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Gulou District, Nanjing City, Jiangsu Province, 210029, China.
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Huang H, Han J, Li Y, Yang Y, Shen J, Fu Q, Chen Y. Early Serum Metabolism Profile of Post-operative Delirium in Elderly Patients Following Cardiac Surgery With Cardiopulmonary Bypass. Front Aging Neurosci 2022; 14:857902. [PMID: 35754961 PMCID: PMC9226449 DOI: 10.3389/fnagi.2022.857902] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 05/23/2022] [Indexed: 11/13/2022] Open
Abstract
Background Cardiac surgery with cardiopulmonary bypass (CPB) is considered to be one of the surgical types with the highest incidence of post-operative delirium (POD). POD has been associated with a prolonged intensive care and hospital stay, long-term neurocognitive deterioration, and increased mortality. However, the specific pathogenesis of POD is still unclear. Untargeted metabolomics techniques can be used to understand the changes of serum metabolites in early POD to discover the relationship between serum metabolites and disease. Materials and Methods The present study recruited 58 elderly patients undergoing cardiac surgery with CPB. Serum was collected within the first 24 h after surgery. The Confusion Assessment Method (CAM) and ICU-CAM assessments were used to identify patients who experienced POD. All patients with normal post-operative cognitive assessment were included in the non-POD groups. Moreover, we collected serum from 20 healthy adult volunteers. We performed untargeted analyses of post-operative serum metabolites in all surgical groups, as well as serum metabolites in healthy non-surgical adults by using liquid chromatography mass spectrometry (LC/MS) and analyzed metabolic profiles and related metabolites. Results The probability of POD after cardiac surgery were 31%. There were statistically significant differences in post-operative mechanical ventilation time, ICU stay time and post-operative hospital stay between POD and non-POD group (P < 0.05). And ICU stay time was an independent risk factor for POD. The analysis revealed that a total of 51 differentially expressed metabolites (DEMs) were identified by comparing the POD and non-POD group, mostly lipids and lipid-like molecules. Three phosphatidylinositol (PI) were down-regulated in POD group, i.e., PI [18:0/18:2 (9Z, 12Z)], PI [20:4 (8Z, 11Z, 14Z, 17Z)/18:0], and PI [18:1 (9Z)/20:3 (8Z, 11Z, 14Z)]. The receiver operating characteristic (ROC) curve analysis showed that three kinds of PI metabolites had the highest area under the curve (AUC), which were 0.789, 0.781, and 0.715, respectively. Correlation analysis showed that the expression of three PIs was negatively correlated with the incidence of POD. Conclusion Our findings suggest that lipid metabolism plays an important role in the serum metabolic profile of elderly patients with POD in the early post-operative period. Low serum lipid metabolic PI was associated with incidence of POD in elderly following cardiac bypass surgery, which may provide new insights into the pathogenesis of POD.
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Affiliation(s)
- He Huang
- Department of Anesthesiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jingjing Han
- Department of Anesthesiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yan Li
- Department of Anesthesiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yonglin Yang
- Division of Infectious Diseases, Taizhou Clinical Medical School of Nanjing Medical University (Taizhou People's Hospital), Taizhou, China
| | - Jian Shen
- Department of Anesthesiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Qiang Fu
- Nanjing Red Cross Blood Center, Nanjing, China
| | - Yu Chen
- Department of Anesthesiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Relander K, Hietanen M, Rämö J, Vento A, Tikkala I, Roine RO, Lindsberg PJ, Soinne L. Differential Cognitive Functioning and Benefit From Surgery in Patients Undergoing Coronary Artery Bypass Grafting and Carotid Endarterectomy. Front Neurol 2022; 13:824486. [PMID: 35350398 PMCID: PMC8957972 DOI: 10.3389/fneur.2022.824486] [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: 11/29/2021] [Accepted: 01/24/2022] [Indexed: 11/13/2022] Open
Abstract
Background Stenosing atherosclerosis in both coronary and carotid arteries can adversely affect cognition. Also their surgical treatments, coronary artery bypass grafting (CABG) and carotid endarterectomy (CEA), are associated with cognitive changes, but the mechanisms of cognitive decline or improvement may not be the same. This study was designed to compare the cognitive profile and outcome in patients undergoing surgical treatment for coronary or carotid disease. Methods A total of 100 CABG patients and 44 CEA patients were recruited in two previously reported studies. They were subjected to a comprehensive neuropsychological examination prior to surgery and in the acute (3-8 days) and stable (3 months) phase after operation. A group of 17 matched healthy controls were assessed with similar intervals. We used linear mixed models to compare cognitive trajectories within six functional domains between the CABG, CEA and control groups. Postoperative cognitive dysfunction (POCD) and improvement (POCI) were determined with the reliable change index method in comparison with healthy controls. Results Before surgery, the CEA patients performed worse than CABG patients or healthy controls in the domains of executive functioning and processing speed. The CABG patients exhibited postoperative cognitive dysfunction more often than the CEA patients in most cognitive domains in the acute phase but had regained their performance in the stable phase. The CEA patients showed more marked postoperative improvement in executive functioning than the CABG group in the acute phase, but the difference did not reach significance in the stable phase. Conclusion Our findings suggest that anterior cerebral dysfunction in CEA patients impairs preoperative cognition more severely than global brain dysfunction in CABG patients. However, CEA may have more beneficial effects on cognition than CABG, specifically in executive functions mainly operated by the prefrontal lobes. In addition, the results underline that POCD is a heterogeneous condition and dependent on type of revascularization surgery.
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Affiliation(s)
- Kristiina Relander
- Division of Neuropsychology, Neurocenter, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Marja Hietanen
- Division of Neuropsychology, Neurocenter, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Juhani Rämö
- Division of Cardiac Surgery, Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Antti Vento
- Division of Cardiac Surgery, Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Irene Tikkala
- Division of Neuropsychology, Neurocenter, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Risto O Roine
- University of Turku and Turku University Hospital, Turku, Finland
| | - Perttu J Lindsberg
- Department of Neurology, Neurocenter, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - Lauri Soinne
- Department of Neurology, Neurocenter, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
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Muedra V, Rodilla V, Llansola M, Agustí A, Pla C, Canto A, Hernández-Rabaza V. Potential Neuroprotective Role of Sugammadex: A Clinical Study on Cognitive Function Assessment in an Enhanced Recovery After Cardiac Surgery Approach and an Experimental Study. Front Cell Neurosci 2022; 16:789796. [PMID: 35264931 PMCID: PMC8900639 DOI: 10.3389/fncel.2022.789796] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 01/07/2022] [Indexed: 12/11/2022] Open
Abstract
Background Postoperative cognitive dysfunction affects the quality of recovery, particularly affecting the elderly, and poses a burden on the health system. We hypothesize that the use of sugammadex (SG) could optimize the quality of postoperative cognitive function and overall recovery through a neuroprotective effect. Methods A pilot observational study on patients undergoing cardiac surgery with enhanced recovery after cardiac surgery (ERACS) approach, was designed to compare SG-treated (n = 14) vs. neostigmine (NG)-treated (n = 7) patients. The Postoperative Quality Recovery Scale (PQRS) was used at different times to evaluate cognitive function and overall recovery of the patients. An online survey among anesthesiologists on SG use was also performed. Additionally, an animal model study was designed to explore the effects of SG on the hippocampus. Results Sugammadex (SG) was associated with favorable postoperative recovery in cognitive domains particularly 30 days after surgery in patients undergoing aortic valve replacement by cardiopulmonary bypass and the ERACS approach; however, it failed to demonstrate a short-term decrease in length of intensive care unit (ICU) and hospital stay. The survey information indicated a positive appreciation of SG recovery properties. SG reverts postoperative memory deficit and induces the expression of anti-inflammatory microglial markers. Conclusion The results show a postoperative cognitive improvement by SG treatment in patients undergoing aortic valve replacement procedure by the ERACS approach. Additionally, experimental data from an animal model of mild surgery confirm the cognitive effect of SG and suggest a potential effect over glia cells as an underlying mechanism.
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Affiliation(s)
- Vicente Muedra
- Department of Medicine and Surgery, Faculty of Health Sciences, Institute of Biomedical Sciences, CEU Cardenal Herrera University, CEU Universities, Valencia, Spain
- Department of Anesthesiology, Intensive Care Unit and Pain Therapy, University La Ribera Hospital, Valencia, Spain
- *Correspondence: Vicente Muedra,
| | - Vicent Rodilla
- Department of Pharmacy, Faculty of Health Sciences, Institute of Biomedical Sciences, Cardenal Herrera CEU University, CEU Universities, Valencia, Spain
| | - Marta Llansola
- Neurobiology Laboratory, Centro de Investigación Príncipe Felipe (CIPF), Valencia, Spain
| | - Ana Agustí
- Nutrition and Health Research Unit, Department of Microbial Ecology, Institute of Agrochemistry and Food Technology, Spanish Council for Scientific Research (IATA-CSIC), Valencia, Spain
| | - Clara Pla
- Department of Anesthesiology, Intensive Care Unit and Pain Therapy, University La Ribera Hospital, Valencia, Spain
| | - Antolín Canto
- Department of Biomedical Sciences, Faculty of Health Sciences, Institute of Biomedical Sciences, Cardenal Herrera CEU University, CEU Universities, Valencia, Spain
| | - Vicente Hernández-Rabaza
- Department of Biomedical Sciences, Faculty of Health Sciences, Institute of Biomedical Sciences, Cardenal Herrera CEU University, CEU Universities, Valencia, Spain
- Vicente Hernández-Rabaza,
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Syrova I, Kovalenko A, Trubnikova O, Maleva O, Chernobai A, Lozhkin I, Barbarash O. Cerebrovascular complications in patients with moderate and small stenosis of the carotid arteries in the hospital period of coronary artery bypass grafting using cardiopulmonary bypass. Zh Nevrol Psikhiatr Im S S Korsakova 2022; 122:73-79. [DOI: 10.17116/jnevro202212208173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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10
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Targeted temperature management in cardiac surgery: a systematic review and meta-analysis on postoperative cognitive outcomes. Br J Anaesth 2021; 128:11-25. [PMID: 34862000 DOI: 10.1016/j.bja.2021.09.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 09/20/2021] [Accepted: 09/27/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Postoperative cognitive decline occurs commonly after cardiac surgery. The available literature is inconclusive on the role of intraoperative causal or protective factors. METHODS We systematically reviewed studies evaluating delayed neurocognitive recovery (DNR), postoperative neurocognitive disorder (NCD), stroke, and the mortality rates among patients undergoing hypothermic or normothermic cardiopulmonary bypass (CPB). We further performed a subgroup analysis for age, surgery type (coronary artery bypass grafting [CABG], valve surgery, or combined), and the mean arterial blood pressure (MAP) during CPB, and conducted a proportion meta-analysis after calculation of single proportions and confidence intervals (CIs). RESULTS We included a total of 58 studies with 9609 patients in our analysis. Among these, 1906 of 4010 patients (47.5%) had DNR, and 2071 of 7160 (28.9%) had postoperative NCD. Ninety of 4625 patients (2.0%) had a stroke, and 174 of 7589 (2.3%) died. There was no statistically significant relationship between the considered variables and DNR, NCD, stroke, and mortality. In the subgroup analysis comparing hypothermic with normothermic CPB, we found higher NCD rates after combined surgery; for normothermic CPB cases only, the rates of DNR and NCD were lower after combined surgery compared with CABG surgery. A MAP >70 mm Hg compared with MAP=50-70 mm Hg during CPB was associated with a lower rate of DNR. CONCLUSIONS Temperature, MAP during cardiopulmonary bypass age, and surgery type were not associated with neurocognitive disorders, stroke, and mortality in cardiac surgery. Normothermic cardiopulmonary bypass, particularly when performed with MAP >70 mm Hg, may reduce the risk of postoperative neurocognitive decline after cardiac surgery. PROSPERO REGISTRATION NUMBER CRD42019140844.
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Bochmann K, Meineri M, Ender JK, von Aspern K, Flo Forner A, Janai AR, Zakhary WZA. Interventions Triggered During Routine Use of NIRS Cerebral Oxygenation Monitoring in Cardiac Surgical Patients. J Cardiothorac Vasc Anesth 2021; 36:2022-2030. [PMID: 34736862 DOI: 10.1053/j.jvca.2021.09.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 09/15/2021] [Accepted: 09/27/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The purpose of this study was to determine the incidence and types of interventions triggered during a drop of baseline near-infraredspectroscopy (NIRS) values in consecutive cardiac surgical patients. DESIGN A single-center, retrospective observational study. SETTING A university-affiliated tertiary care center. PARTICIPANTS Three thousand three hundred two consecutive cardiac surgical patients from October 2016 to August 2017 Interventions: None. MEASUREMENTS AND MAIN RESULTS Of the 1,972 patients who met the inclusion criteria, 576 (29.2%) patients showed NIRS deviation of -20% from baseline. Interventions performed during the drop of baseline NIRS values were documented in 285 (14.4%) patients, with a total of 391 interventions. Three hundred fifteen (80%) interventions were triggered by a deviation in NIRS and concomitant changes in standard monitoring parameters. Seventy-six (20%) interventions were triggered by NIRS deviation alone, with no concomitant pathologic deviation in standard monitoring. A total of 279 (71%) interventions were performed on patients who had no recommendation for NIRS monitoring by current national guidelines. Out of these, 30 (7.7%) interventions (1.3% of all patients) were performed based on NIRS monitoring alone. The higher risk deviation group had longer intensive care unit and hospital lengths of stays (one and 15 days) and postoperative delirium when compared with the no-deviation group (zero and 13 days) Conclusions: The authors' data suggested that most interventions triggered during the drop of baseline values during routine use of NIRS would have also been triggered by the concomitant changes in standard monitoring parameters. Routine use of NIRS for all cardiac surgical patients still is debatable and needs to be evaluated in a large prospective trial.
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Affiliation(s)
- Kati Bochmann
- Department of Anesthesiology and Intensive Care Medicine, Heart Center Leipzig, Leipzig, Germany; Resident physician, Internal medicine, Klinikum Chemnitz, Chemnitz, Germany
| | - Massimiliano Meineri
- Department of Anesthesiology and Intensive Care Medicine, Heart Center Leipzig, Leipzig, Germany
| | - Joerg K Ender
- Department of Anesthesiology and Intensive Care Medicine, Heart Center Leipzig, Leipzig, Germany
| | | | - Anna Flo Forner
- Department of Anesthesiology and Intensive Care Medicine, Heart Center Leipzig, Leipzig, Germany
| | - Aniruddha R Janai
- Department of Anesthesiology and Intensive Care Medicine, Heart Center Leipzig, Leipzig, Germany
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12
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Robinson A, Pituskin E, Norris CM. Patient-Reported Cognitive Outcomes Following Cardiac Surgery: A Descriptive Review. J Patient Exp 2021; 8:2374373521989250. [PMID: 34179365 PMCID: PMC8205391 DOI: 10.1177/2374373521989250] [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] [Indexed: 11/17/2022] Open
Abstract
A descriptive review was conducted to evaluate the evidence of cognitive patient-reported outcome measures (PROMs) following cardiac surgery. The search of electronic databases resulted in 400 unique manuscripts. Nine studies met the criteria to be part of the final review. Results of the review suggest that there are few validated PROMs that assess cognitive function in the cardiac surgical population. Furthermore, PROMs have not been used to assess overall cognitive function following cardiac surgery within the past decade. However, one domain of cognitive function—memory—was described, with up to half of patients reporting a decline postoperatively. Perceived changes in cognitive function may impact health-related quality of life and a patient’s overall view of the success of their surgery. Early identification of cognitive changes measured with PROMs may encourage earlier intervention and improve patient-centered care. In clinical practice, nurses may be in the best position to administer PROMs preoperatively and postoperatively.
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Affiliation(s)
- Amanda Robinson
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Edith Pituskin
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Colleen M Norris
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
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13
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Shaban A, Leira EC. Neurologic complications of heart surgery. HANDBOOK OF CLINICAL NEUROLOGY 2021; 177:65-75. [PMID: 33632458 DOI: 10.1016/b978-0-12-819814-8.00007-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Cardiac surgeries are commonly associated with neurologic complications. The type and complexity of the surgery, as well as patients' comorbidities, determine the risk for these complications. Awareness and swift recognition of these complications may have significant implications on management and prognosis. Recent trials resulted in an expansion of the time window to treat patients with acute ischemic stroke with intravenous thrombolysis and/or mechanical thrombectomy using advanced neuroimaging for screening. The expanded time window increases the reperfusion treatment options for patients that suffer a periprocedural ischemic stroke. Moreover, there is now limited data available to help guide management of intracerebral hemorrhage in patients undergoing treatment with anticoagulation for highly thrombogenic conditions, such as left ventricular assist devices and mechanical valves. In addition to cerebrovascular complications patients undergoing heart surgery are at increased risk for seizures, contrast toxicity, cognitive changes, psychological complications, and peripheral nerve injuries. We review the neurological complications associated with the most common cardiac surgeries and discuss clinical presentation, diagnosis and management strategies.
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Affiliation(s)
- Amir Shaban
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa City, IA, United States.
| | - Enrique C Leira
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa City, IA, United States; Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA, United States
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14
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Greaves D, Psaltis PJ, Davis DHJ, Ross TJ, Ghezzi ES, Lampit A, Smith AE, Keage HAD. Risk Factors for Delirium and Cognitive Decline Following Coronary Artery Bypass Grafting Surgery: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2020; 9:e017275. [PMID: 33164631 PMCID: PMC7763731 DOI: 10.1161/jaha.120.017275] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background Coronary artery bypass grafting (CABG) is known to improve heart function and quality of life, while rates of surgery‐related mortality are low. However, delirium and cognitive decline are common complications. We sought to identify preoperative, intraoperative, and postoperative risk or protective factors associated with delirium and cognitive decline (across time) in patients undergoing CABG. Methods and Results We conducted a systematic search of Medline, PsycINFO, EMBASE, and Cochrane (March 26, 2019) for peer‐reviewed, English publications reporting post‐CABG delirium or cognitive decline data, for at least one risk factor. Random‐effects meta‐analyses estimated pooled odds ratio for categorical data and mean difference or standardized mean difference for continuous data. Ninety‐seven studies, comprising data from 60 479 patients who underwent CABG, were included. Moderate to large and statistically significant risk factors for delirium were as follows: (1) preoperative cognitive impairment, depression, stroke history, and higher European System for Cardiac Operative Risk Evaluation (EuroSCORE) score, (2) intraoperative increase in intubation time, and (3) postoperative presence of arrythmia and increased days in the intensive care unit; higher preoperative cognitive performance was protective for delirium. Moderate to large and statistically significant risk factors for acute cognitive decline were as follows: (1) preoperative depression and older age, (2) intraoperative increase in intubation time, and (3) postoperative presence of delirium and increased days in the intensive care unit. Presence of depression preoperatively was a moderate risk factor for midterm (1–6 months) post‐CABG cognitive decline. Conclusions This meta‐analysis identified several key risk factors for delirium and cognitive decline following CABG, most of which are nonmodifiable. Future research should target preoperative risk factors, such as depression or cognitive impairment, which are potentially modifiable. Registration URL: https://www.crd.york.ac.uk/prospero/; Unique identifier: CRD42020149276.
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Affiliation(s)
- Danielle Greaves
- Cognitive Ageing and Impairment Neurosciences Laboratory, Justice and Society Academic Unit University of South Australia Adelaide Australia
| | - Peter J Psaltis
- Vascular Research Centre Lifelong Health Theme South Australian Health and Medical Research Institute Adelaide Australia.,Adelaide Medical School University of Adelaide Adelaide Australia.,Department of Cardiology Royal Adelaide Hospital Central Adelaide Local Health Network Adelaide Australia
| | - Daniel H J Davis
- Medical Reasearch Council Unit for Lifelong Health and Ageing Unit at UCL London United Kingdom
| | - Tyler J Ross
- Cognitive Ageing and Impairment Neurosciences Laboratory, Justice and Society Academic Unit University of South Australia Adelaide Australia
| | - Erica S Ghezzi
- Cognitive Ageing and Impairment Neurosciences Laboratory, Justice and Society Academic Unit University of South Australia Adelaide Australia
| | - Amit Lampit
- Academic Unit for Psychiatry of Old Age Department of Psychiatry University of Melbourne Melbourne Australia.,Department of Neurology Charité-Universitätsmedizin Berlin Berlin Germany
| | - Ashleigh E Smith
- Cognitive Ageing and Impairment Neurosciences Laboratory, Justice and Society Academic Unit University of South Australia Adelaide Australia.,Alliance for Research in Exercise, Nutrition and Activity Allied Health and Human Performance Academic Unit University of South Australia Adelaide Australia
| | - Hannah A D Keage
- Cognitive Ageing and Impairment Neurosciences Laboratory, Justice and Society Academic Unit University of South Australia Adelaide Australia
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15
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Current Evidence Regarding Biomarkers Used to Aid Postoperative Delirium Diagnosis in the Field of Cardiac Surgery-Review. ACTA ACUST UNITED AC 2020; 56:medicina56100493. [PMID: 32987655 PMCID: PMC7598630 DOI: 10.3390/medicina56100493] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 09/17/2020] [Accepted: 09/22/2020] [Indexed: 12/16/2022]
Abstract
Postoperative cognitive disorders after cardiac surgery may manifest as postoperative delirium (POD) or later as postoperative cognitive dysfunction (POCD). The incidence of POD after cardiac surgery ranges from 16% to 73%. In contrast to POD, POCD is usually diagnosed after the discharge from hospital, with an incidence of 30 to 70% of cases, very often noticed only by close relative or friends, decreasing after six (20–30%) and twelve (15–25%) months after surgery. Perioperative cognitive disorders are associated with adverse short- and long-term effects, including increased morbidity and mortality. Due to the complexity of delirium pathomechanisms and the difficulties in the diagnosis, researchers have not yet found a clear answer to the question of which patient will be at a higher risk of developing delirium. The risk for POD and POCD in older patients with numerous comorbidities like hypertension, diabetes, and previous ischemic stroke is relatively high, and the predisposing cognitive profile for both conditions is important. The aim of this narrative review was to identify and describe biomarkers used in the diagnosis of delirium after cardiac surgery by presenting a search through studies regarding this subject, which have been published during the last ten years. The authors discussed brain-derived biomarkers, inflammation-related biomarkers, neurotransmitter-based biomarkers, and others. Work based on inflammation-related biomarkers, which are characterized by the low cost of implementation and the effectiveness of delirium diagnosis, seems to be the closest to the goal of discovering an inexpensive and effective marker. Currently, the use of a panel of tests, and not a single biomarker, brings us closer to the discovery of a test, or rather a set of tests ideal for the diagnosis of delirium after cardiac surgery.
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16
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Relander K, Hietanen M, Rantanen K, Rämö J, Vento A, Saastamoinen KP, Roine RO, Soinne L. Postoperative cognitive change after cardiac surgery predicts long-term cognitive outcome. Brain Behav 2020; 10:e01750. [PMID: 32681544 PMCID: PMC7507551 DOI: 10.1002/brb3.1750] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 06/17/2020] [Accepted: 06/19/2020] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Postoperative cognitive dysfunction (POCD) is a common consequence of coronary artery bypass grafting. However, domain-specific associations between postoperative changes and long-term performance are poorly known. The aim of this study was to investigate whether domain-specific cognitive changes after cardiac surgery predict long-term cognitive outcome. MATERIALS AND METHODS We assessed 100 patients (86 men, mean age 60) before coronary artery bypass grafting, with re-examinations after one week, three months, and a mean of 6.7 years. The extensive neuropsychological test battery was organized into seven functional cognitive domains. Cognitive decline and improvement were defined with the reliable change index derived from 17 matching healthy controls. Analyses were adjusted for baseline cognitive performance, age, gender, education and cardiovascular risks factors. RESULTS On group level, one week after surgery 71% patients showed cognitive decline and 9% improvement in any functional domain, as compared to preoperative results. Three months postsurgery, decline was observed in 47% and improvement in 25% of patients. Executive functioning was the most sensitive domain to both decline and improvement. Postoperative dysfunction predicted long-term cognitive deterioration six years after operation, particularly in the domain of executive functioning. CONCLUSIONS POCD after coronary artery bypass grafting is an essential risk factor for long-term deterioration and an indication for neuropsychological follow-up. Assessment of change in executive functioning after coronary artery bypass grafting may help to identify patients at risk for unfavorable long-term outcome.
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Affiliation(s)
- Kristiina Relander
- Clinical Neurosciences, Neuropsychology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Marja Hietanen
- Clinical Neurosciences, Neuropsychology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Kirsi Rantanen
- Clinical Neurosciences, Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Juhani Rämö
- Department of Cardiac Surgery, Heart and Lung Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Antti Vento
- Department of Cardiac Surgery, Heart and Lung Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Kari-Pekka Saastamoinen
- Clinical Neurosciences, Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Risto O Roine
- University of Turku and Turku University Hospital, Turku, Finland
| | - Lauri Soinne
- Clinical Neurosciences, Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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17
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Greaves D, Psaltis PJ, Lampit A, Davis DHJ, Smith AE, Bourke A, Worthington MG, Valenzuela MJ, Keage HAD. Computerised cognitive training to improve cognition including delirium following coronary artery bypass grafting surgery: protocol for a blinded randomised controlled trial. BMJ Open 2020; 10:e034551. [PMID: 32029497 PMCID: PMC7045123 DOI: 10.1136/bmjopen-2019-034551] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Coronary artery bypass grafting (CABG) surgery is known to improve vascular function and cardiac-related mortality rates; however, it is associated with high rates of postoperative cognitive decline and delirium. Previous attempts to prevent post-CABG cognitive decline using pharmacological and surgical approaches have been largely unsuccessful. Cognitive prehabilitation and rehabilitation are a viable yet untested option for CABG patients. We aim to investigate the effects of preoperative cognitive training on delirium incidence, and preoperative and postoperative cognitive training on cognitive decline at 4 months post-CABG. METHODS AND ANALYSIS This study is a randomised, single-blinded, controlled trial investigating the use of computerised cognitive training (CCT) both pre-CABG and post-CABG (intervention group) compared with usual care (control group) in older adults undergoing CABG in Adelaide, South Australia. Those in the intervention group will complete 1-2 weeks of CCT preoperatively (45-60 min sessions, 3.5 sessions/week) and 12 weeks of CCT postoperatively (commencing 1 month following surgery, 45-60 min sessions, 3 sessions/week). All participants will undergo cognitive testing preoperatively, over their hospital stay including delirium, and postoperatively for up to 1 year. The primary delirium outcome variable will be delirium incidence (presence vs absence); the primary cognitive decline variable will be at 4 months (significant decline vs no significant decline/improvement from baseline). Logistic regression modelling will be used, with age and gender as covariates. Secondary outcomes include cognitive decline from baseline to discharge, and at 6 months and 1 year post-CABG. ETHICS AND DISSEMINATION Ethics approval was obtained from the Central Adelaide Local Health Network Human Research Ethics Committee (South Australia, Australia) and the University of South Australia Human Ethics Committee, with original approval obtained on 13 December 2017. It is anticipated that approximately two to four publications and multiple conference presentations (national and international) will result from this research. TRIAL REGISTRATION NUMBER This clinical trial is registered with the Australian New Zealand Clinical Trials Registry and relates to the pre-results stage. Registration number: ACTRN12618000799257.
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Affiliation(s)
- Danielle Greaves
- Cognitive Ageing and Impairment Neurosciences Laboratory (CAIN), School of Psychology, Social Work and Social Policy, University of South Australia Division of Education, Arts and Social Sciences, Adelaide, South Australia, Australia
| | - Peter J Psaltis
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Vascular Research Centre, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- Department of Cardiology, Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Amit Lampit
- Academic Unit for Psychiatry of Old Age, Department of Psychiatry, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Daniel H J Davis
- MRC Unit for Lifelong Health and Ageing, University College London, London, UK
| | - Ashleigh E Smith
- Alliance for Research in Exercise, Nutrition and Activity (ARENA), University of South Australia Division of Health Sciences, Adelaide, South Australia, Australia
| | - Alice Bourke
- Department of Geriatric and Rehabilitation Medicine, Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Michael G Worthington
- Department of Cardiothoracic Surgery, Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Michael J Valenzuela
- Brain and Mind Centre and Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Hannah A D Keage
- Cognitive Ageing and Impairment Neurosciences Laboratory (CAIN), School of Psychology, Social Work and Social Policy, University of South Australia Division of Education, Arts and Social Sciences, Adelaide, South Australia, Australia
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19
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Vedel AG, Holmgaard F, Siersma V, Langkilde A, Paulson OB, Ravn HB, Nilsson JC, Rasmussen LS. Domain-specific cognitive dysfunction after cardiac surgery. A secondary analysis of a randomized trial. Acta Anaesthesiol Scand 2019; 63:730-738. [PMID: 30891734 DOI: 10.1111/aas.13343] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 02/11/2019] [Accepted: 02/17/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Brain injury and cognitive dysfunction are serious complications after cardiac surgery. In the perfusion pressure cerebral infarcts (PPCI) trial, we allocated cardiac surgery patients to a mean arterial pressure of either 70-80 mm Hg (high-target) or 40-50 mm Hg (low-target) during cardiopulmonary bypass. In this secondary analysis, we aimed to assess potential differences in domain-specific patterns of cognitive deterioration between allocation groups and to investigate any associations of postoperative cognitive dysfunction (POCD) with diffusion-weighted magnetic resonance imaging (DWI)-detected brain lesions. METHODS Of the 197 patients randomized in the PPCI trial, 89 in the low-target group and 80 in the high-target group had complete DWI datasets, and 92 and 80 patients had complete data for an evaluation of cognitive function at discharge respectively. Cognitive function was assessed prior to surgery, at discharge and at 3 months. DWI was obtained at baseline and on postoperative days 3 to 6. RESULTS We found no statistically significant differences between the two groups when comparing the proportion of patients with a domain-specific deterioration over the pre-defined critical level in seven individual test variables at discharge. Significant deterioration was most common in tests thought to assess cognitive flexibility and interference susceptibility and least common in the memory test. POCD at discharge was more frequent in patients with DWI-positive brain lesions (OR adjusted for age and group allocation: 2.24 [95% CI 1.48-3.00], P = 0.036). CONCLUSIONS Domain-specific patterns of POCD were comparable between groups. A significant association was seen between DWI-positive brain lesions and POCD.
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Affiliation(s)
- Anne G. Vedel
- Department of Cardiothoracic Anaesthesiology Heart Centre, Rigshospitalet, University of Copenhagen Copenhagen Denmark
- Department of Anaesthesia Centre of Head and Orthopedics, Rigshospitalet, University of Copenhagen Copenhagen Denmark
| | - Frederik Holmgaard
- Department of Cardiothoracic Anaesthesiology Heart Centre, Rigshospitalet, University of Copenhagen Copenhagen Denmark
| | - Volkert Siersma
- The Research Unit for General Practice and Section of General Practice, Department of Public Health University of Copenhagen Copenhagen Denmark
| | - Annika Langkilde
- Department of Radiology Diagnostic Centre, Rigshospitalet, University of Copenhagen Copenhagen, Copenhagen Denmark
| | - Olaf B. Paulson
- Neurobiology Research Unit Neuroscience Centre, Rigshospitalet, University of Copenhagen Copenhagen Denmark
| | - Hanne B. Ravn
- Department of Cardiothoracic Anaesthesiology Heart Centre, Rigshospitalet, University of Copenhagen Copenhagen Denmark
| | - Jens Chr. Nilsson
- Department of Cardiothoracic Anaesthesiology Heart Centre, Rigshospitalet, University of Copenhagen Copenhagen Denmark
| | - Lars S. Rasmussen
- Department of Anaesthesia Centre of Head and Orthopedics, Rigshospitalet, University of Copenhagen Copenhagen Denmark
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20
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Glumac S, Kardum G, Karanovic N. Postoperative Cognitive Decline After Cardiac Surgery: A Narrative Review of Current Knowledge in 2019. Med Sci Monit 2019; 25:3262-3270. [PMID: 31048667 PMCID: PMC6511113 DOI: 10.12659/msm.914435] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
The growing number of publications concerning postoperative cognitive decline (POCD) after cardiac surgery is indicative of the health-related and economic-related importance of this intriguing issue. Significantly, the reported POCD incidence over the years has remained steady due to various unresolved challenges regarding the examination of this multidisciplinary topic. In particular, a universally accepted POCD definition has not been established, and the pathogenesis is still vaguely understood. However, numerous recent studies have focused on the role of the inflammatory response to a surgical procedure in POCD occurrence. Therefore, this traditional narrative review summarizes and evaluates the latest findings, with special attention paid to the difficulties of defining POCD as well as the involvement of inflammation in POCD development. We searched the MEDLINE, Scopus, PsycINFO and CENTRAL databases for the best evidence, which was classified according to the Oxford Centre for Evidence-based Medicine. To our knowledge, this is the first narrative review that identified class-1 evidence (systematic review of randomized trials), although most evidence is still at class-2 or below. Furthermore, we revealed that defining POCD is a very controversial matter and that the inflammatory response plays an important role in the mutually overlapping processes included in POCD development. Thus, developing the definition of POCD represents an absolute priority in POCD investigations, and the inflammatory response to cardiac surgery merits further research.
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Affiliation(s)
- Sandro Glumac
- Department of Anesthesiology and Intensive Care, University Hospital of Split, Split, Croatia
| | - Goran Kardum
- Department of Psychology, Faculty of Humanities and Social Sciences, University of Split, Split, Croatia
| | - Nenad Karanovic
- Department of Anesthesiology and Intensive Care, University Hospital of Split, Split, Croatia.,Department of Anesthesiology and Intensive Medicine, School of Medicine, University of Split, Split, Croatia
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