The sensitivity and specificity of statistical rules for diagnosing delayed neurocognitive recovery with Montreal cognitive assessment in elderly surgical patients: A cohort study

Preoperative biomarkers associated with delayed neurocognitive recovery

To identify baseline biomarkers of delayed neurocognitive recovery (dNCR) using monitors commonly used in anesthesia. In this sub-study of observational prospective cohorts, we evaluated adult patients submitted to general anesthesia in a tertiary academic center in the United States. Electroencephalographic (EEG) features and cerebral oximetry were assessed in the perioperative period. The primary outcome was dNCR, defined as a decrease of 2 scores in the global Montreal Cognitive Assessment (MoCA) between the baseline and postoperative period. Forty-six adults (median [IQR] age, 65 [15]; 57% females; 65% American Society of Anesthesiologists (ASA) 3 were analyzed. Thirty-one patients developed dNCR (67%). Baseline higher EEG power in the lower alpha band (AUC = 0.73 (95% CI 0.48-0.93)) and lower alpha peak frequency (AUC = 0.83 (95% CI 0.48-1)), as well as lower cerebral oximetry (68 [5] vs 72 [3], p = 0.011) were associated with dNCR. Higher EEG power in the lower alpha band, lower alpha peak frequency, and lower cerebral oximetry values can be surrogates of baseline brain vulnerability.

Comparison of Propofol-Based Total Intravenous Anesthesia versus Volatile Anesthesia with Sevoflurane for Postoperative Delirium in Adult Coronary Artery Bypass Grafting Surgery: A Prospective Randomized Single-Blinded Study

OBJECTIVES

To compare the incidence of delirium and early (at 1 week) postoperative cognitive dysfunction (POCD) between propofol-based total intravenous anesthesia (TIVA) and volatile anesthesia with sevoflurane in adult patients undergoing elective coronary artery bypass graft surgery (CABG) with cardiopulmonary bypass (CPB).

DESIGN

This was a prospective randomized single-blinded study.

SETTING

The study was conducted at a single institution, the Sree Chitra Tirunal Institute for Medical Sciences and Technology, a tertiary care institution and university-level teaching hospital.

PARTICIPANTS

Seventy-two patients undergoing elective CABG under CPB participated in this study.

INTERVENTIONS

This study was conducted on 72 adult patients (>18 years) undergoing elective CABG under CPB who were randomized to receive propofol or sevoflurane. Anesthetic depth was monitored to maintain the bispectral index between 40 and 60. Delirium was assessed using the Confusion Assessment Method for the Intensive Care Unit. Early POCD was diagnosed when there was a reduction of >2 points in the Montreal Cognitive Assessment score compared to baseline. Cerebral oximetry changes using near-infrared spectroscopy (NIRS), atheroma grades, and intraoperative variables were compared between the 2 groups.

MEASUREMENTS & MAIN RESULTS

Seventy-two patients were randomized to receive propofol (n = 36) or sevoflurane (n = 36). The mean patient age was 59.4 ± 8.6 years. The baseline and intraoperative variables, including atheroma grades, NIRS values, hemoglobin, glycemic control, and oxygenation, were comparable in the 2 groups. Fifteen patients (21.7%) patients developed delirium, and 31 patients (44.9%) had early POCD. The incidence of delirium was higher with sevoflurane (n = 12; 34.2%) compared to propofol (n = 3; 8.8%) (odds ratio [OR], 1.72; 95% confidence interval [CI], 1.13-2.62; p = 0.027)*. POCD was higher with sevoflurane (n = 20; 57.1%) compared to propofol (n = 11; 32.3%) (OR, 1.63; 95% CI, 1.01-2.62; p = 0.038)*. In patients aged >65 years, delirium was higher with sevoflurane (7/11; 63.6%) compared to propofol (1/7; 14.2%) (p = 0.03)*.

CONCLUSIONS

Propofol-based TIVA was associated with a lower incidence of delirium and POCD compared to sevoflurane in this cohort of patients undergoing CABG under CPB. Large-scale, multicenter randomized trials with longer follow-up are needed to substantiate the clinical relevance of this observation.

The Combination of Presurgical Cortical Gray Matter Volumetry and Cerebral Perfusion Improves the Efficacy of Predicting Postoperative Cognitive Impairment of Elderly Patients

BACKGROUND

Postoperative cognitive dysfunction (POCD) is a common complication of the central nervous system in elderly surgical patients. Structural MRI and arterial spin labelling (ASL) techniques found that the grey matter volume and cerebral perfusion in some specific brain areas are associated with the occurrence of POCD, but the results are inconsistent, and the predictive accuracy is low. We hypothesised that the combination of cortical grey matter volumetry and cerebral blood flow yield higher accuracy than either of the methods in discriminating the elderly individuals who are susceptible to POCD after abdominal surgery.

MATERIALS AND METHODS

Participants underwent neuropsychological testing before and after surgery. Postoperative cognitive dysfunction (POCD) was defined as a decrease in cognitive score of at least 20%. ASL-MRI and T1-weighted imaging were performed before surgery. We compared differences in cerebral blood flow (CBF) and cortical grey matter characteristics between POCD and non-POCD patients and generated receiver operating characteristic curves.

RESULTS

Out of 51 patients, 9 (17%) were diagnosed with POCD. CBF in the inferior frontal gyrus was lower in the POCD group compared to the non-POCD group (p < 0.001), and the volume of cortical grey matter in the anterior cingulate gyrus was higher in the POCD group (p < 0.001). The highest AUC value was 0.973.

CONCLUSIONS

The combination of cortical grey matter volumetry and cerebral perfusion based on ASL-MRI has improved efficacy in the early warning of POCD to elderly abdominal surgical patients.

Predicative factors and development of a nomogram for postoperative delayed neurocognitive recovery in elderly patients with gastric cancer

BACKGROUND

Delayed neurocognitive recovery (DNR) is a common complication after radical gastrectomy and closely associated with poor outcomes. This study aimed to investigate predictors and develop a nomogram prediction model for DNR.

METHODS

Elderly gastric cancer (GC) patients (≥ 65 years) undergoing elective laparoscopic radical gastrectomy between 2018 and 2022 were prospectively included in this study. DNR was diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V, 2013). Independent risk factors for DNR were screened by the multivariate logistic regression analysis. Based on these factors, the nomogram model was established and validated by R.

RESULTS

A total of 312 elderly GC patients were enrolled in the training set, with an incidence of DNR within postoperative 1 month of 23.4% (73/312). Multivariate logistic regression analysis indicated that age (OR: 1.207, 95%CI: 1.113-1.309, P < 0.001), nutritional risk screening 2002 (NRS2002) score (OR: 1.716, 95%CI: 1.211-2.433, P = 0.002), neutrophil-to-lymphocyte ratio (NLR) (OR: 1.976, 95%CI: 1.099-3.552, P = 0.023), albumin-to-fibrinogen ratio (AFR) (OR: 0.774, 95%CI: 0.620-0.966, P = 0.024), and prognostic nutritional index (PNI) (OR: 0.768, 95%CI: 0.706-0.835, P < 0.001) were five independent factors for DNR in elderly GC patients. The constructed nomogram model based on these five factors has a good predictive value for DNR with an area under the curve (AUC) of 0.863.

CONCLUSIONS

In conclusions, the established nomogram model based on age, NRS-2002, NLR, AFR, and PNI has a well predictive value for postoperative DNR in elderly GC patients.

Effects of biophilic virtual reality on cognitive function of patients undergoing laparoscopic surgery: study protocol for a sham randomised controlled trial

INTRODUCTION

Virtual reality (VR) is already being used for cognitive or emotional rehabilitation. However, its role in postoperative cognitive dysfunction (POCD) has not been fully recognised. Due to the lack of an effective postoperative follow-up system, the incidence of POCD in China is not clear, and although many drugs have been proposed to improve POCD in the animal study, their clinical applications are limited, while VR provides an innovative method to provide non-pharmacological management.

METHODS AND DESIGN

This is a single-centre, randomised, double-blind, sham-controlled clinical trial. In this study, 600 patients over 55 years old undergoing laparoscopic surgery will be recruited. Participants will be randomly assigned to receive biophilic VR or sham VR (1:1 ratio), all patients have 20 min of exposure per day during the hospital stay. The primary outcome is the impact of VR on the incidence of POCD. Secondary outcomes include perioperative anxiety and instrumental activities of daily living. Changes in the performance of the neurocognitive batteries are measured by a local resident doctor. Serum samples will be collected on the day before surgery and 7 days after surgery.

ETHICS AND DISSEMINATION

This trial has ethical approval from the Medical Ethics Committee of the Affiliated Hospital of Medical School of Ningbo University (KY20210302). The study is sponsored by Ningbo University and Ningbo Science and Technology Bureau.

CONTACT

Dr. Mao Haijiao, Chair of the hospital medical Ethics committee (ndfylunli@126.com). Trial results will be submitted for publication in peer-reviewed journals, patient recruitment began in April 2021. Written informed consent is obtained for all participants. All information acquired will be disseminated via national or international conferences and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ChiCTR2000040919.