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Raksamani K, Tangvipattanapong M, Charoenpithakwong N, Silarat S, Pantisawat N, Sanphasitvong V, Raykateeraroj N. Postoperative stroke in acute type A aortic dissection: incidence, outcomes, and perioperative risk factors. BMC Surg 2024; 24:214. [PMID: 39048964 PMCID: PMC11267853 DOI: 10.1186/s12893-024-02499-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Accepted: 07/09/2024] [Indexed: 07/27/2024] Open
Abstract
BACKGROUND Despite advances in surgical techniques, the incidence of stroke following acute type A aortic dissection (ATAAD) repair remains markedly high, with substantial immediate and long-term adverse outcomes such as elevated mortality, extended hospital stays, and persistent neurological impairments. The complexity of managing ATAAD extends beyond the operation itself, highlighting a crucial gap in research concerning modifiable preoperative patient conditions and perioperative anesthetic management strategies. OBJECTIVES This investigation aimed to elucidate the incidence, consequences, and perioperative determinants of stroke following surgical intervention for acute type A aortic dissection (ATAAD). METHODS In a multicenter retrospective analysis, 516 ATAAD surgery patients were evaluated. The data included demographic information, clinical profiles, surgical modalities, and outcomes. The primary endpoint was postoperative stroke incidence, with hospital mortality and other complications serving as secondary endpoints. RESULTS Postoperative stroke occurred in 13.6% of patients (70 out of 516) and was associated with significant extension of the ICU (median 10 vs. 5 days, P < 0.001) and hospital stay (median 18 vs. 12 days, P < 0.001). The following key independent stroke risk factors were identified: modified Frailty Index (mFI) ≥ 4 (odds ratio [OR]: 4.18, 95% confidence interval [CI]: 1.24-14.1, P = 0.021), common carotid artery malperfusion (OR: 3.76, 95% CI: 1.23-11.44, P = 0.02), pre-cardiopulmonary bypass (CPB) hypotension (mean arterial pressure ≤ 50 mmHg; OR: 2.17, 95% CI: 1.06-4.44, P = 0.035), ≥ 20% intraoperative decrease in cerebral regional oxygen saturation (rSO2) (OR: 1.93, 95% CI: 1.02-3.64, P = 0.042), and post-CPB vasoactive-inotropic score (VIS) ≥ 10 (OR: 2.24, 95% CI: 1.21-4.14, P = 0.01). CONCLUSIONS Postoperative stroke significantly increases ICU and hospital durations in ATAAD surgery patients. These findings highlight the critical need to identify and mitigate major risks, such as high mFI, common carotid artery malperfusion, pre-CPB hypotension, significant cerebral rSO2 reductions, and elevated post-CPB VIS, to improve outcomes and reduce stroke prevalence. TRIAL REGISTRATION Thai Clinical Trials Registry (TCTR20230615002). Date registered on June 15, 2023. Retrospectively registered.
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Affiliation(s)
- Kasana Raksamani
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok Noi, Bangkok, 10700, Thailand
| | - Manisa Tangvipattanapong
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok Noi, Bangkok, 10700, Thailand
| | - Napat Charoenpithakwong
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok Noi, Bangkok, 10700, Thailand
| | - Suparit Silarat
- Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | | | - Vutthipong Sanphasitvong
- Division of Cardio-Thoracic Vascular Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Nattaya Raykateeraroj
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok Noi, Bangkok, 10700, Thailand.
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Lo HZ, Wee CF, Low CE, Teo YH, Teo YN, Yun CY, Syn NL, Tan BYQ, Chai P, Yeo LLL, Yeo TC, Chong YF, Poh KK, Kong WKF, Wong RCC, Chan MY, Sia CH. Contemporary Incidence of Cognitive Impairment or Dementia in Patients Undergoing Coronary Artery Bypass Grafting: A Systematic Review and Meta-Analysis. Dement Geriatr Cogn Disord 2024:1-15. [PMID: 39047685 DOI: 10.1159/000540450] [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: 03/25/2024] [Accepted: 07/08/2024] [Indexed: 07/27/2024] Open
Abstract
INTRODUCTION Despite the high prevalence of cognitive impairment or dementia post-coronary artery bypass grafting (CABG), the incidence of cognitive impairment or dementia post-CABG in contemporary practice is currently unclear. Therefore, this paper aims to investigate the incidence and associated risk factors of cognitive impairment or dementia in patients' post-CABG. METHODS A systematic search across three databases (PubMed, SCOPUS, and Embase) was conducted for studies published in or after 2013 that reported cognitive impairment or dementia post-CABG. Subgroup analyses and meta-regression by risk factors were performed to determine their influence on the results. RESULTS This analysis included 23 studies with a total of 2,620 patients. The incidence of cognitive impairment or dementia less than 1 month, 2 to 6 months, and more than 12 months post-CABG was 35.96% (95% confidence interval [CI]: 28.22-44.51, I2 = 87%), 21.33% (95% CI: 13.44-32.15, I2 = 88%), and 39.13% (95% CI: 21.72-58.84, I2 = 84%), respectively. Meta-regression revealed that studies with more than 80% of the cohort diagnosed with hypertension were significantly associated with incidence of cognitive impairment or dementia less than 1 month post-CABG. CONCLUSION This meta-analysis demonstrates a high incidence of cognitive impairment or dementia in patients' post-CABG in contemporary practice, particularly less than 1 month post-CABG and more than 12 months post-CABG. We found that hypertension was a significant risk factor in the short-term (less than 1 month) follow-up period for cognitive impairment or dementia post-CABG. Future research should be done to assess strategies to reduce cognitive impairment post-CABG.
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Affiliation(s)
- Hui Zhen Lo
- School of Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia,
| | - Caitlin Fern Wee
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Chen Ee Low
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yao Hao Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yao Neng Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Choi Ying Yun
- Department of Cardiology, National University Heart Centre Singapore, Singapore, Singapore
| | - Nicholas L Syn
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Benjamin Y Q Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Ping Chai
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, Singapore, Singapore
| | - Leonard L L Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Tiong-Cheng Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, Singapore, Singapore
| | - Yao Feng Chong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Kian-Keong Poh
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, Singapore, Singapore
| | - William K F Kong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, Singapore, Singapore
| | - Raymond C C Wong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, Singapore, Singapore
| | - Mark Y Chan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, Singapore, Singapore
| | - Ching-Hui Sia
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, Singapore, Singapore
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Bhuiyan P, Sun Z, Chen Y, Qian Y. Peripheral surgery triggers mast cells activation: Focusing on neuroinflammation. Behav Brain Res 2023; 452:114593. [PMID: 37499912 DOI: 10.1016/j.bbr.2023.114593] [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: 03/14/2023] [Revised: 06/12/2023] [Accepted: 07/20/2023] [Indexed: 07/29/2023]
Abstract
Peripheral surgery can lead to a systemic aseptic inflammatory response comprising several mediators aiming at restoring tissue homeostasis. It induces inflammatory mechanisms through neuroimmune interaction between the periphery and to brain which also plays a critical role in causing cognitive impairments. Accumulating scientific evidence revealed that acute neuroinflammation of the brain triggered by peripheral surgery that causes peripheral inflammation leads to transmitting signals into the brain through immune cells. Mast cells (MCs) play an important role in the acute neuroinflammation induced by peripheral surgical trauma. After peripheral surgery, brain-resident MCs can be rapidly activated followed by releasing histamine, tryptase, and other inflammatory mediators. These mediators then interact with other immune cells in the peripheral and amplify the signal into the brain by disrupting BBB and activating principle innate immune cells of brain including microglia, astrocytes, and vascular endothelial cells, which release abundant inflammatory mediators and in turn accelerate the activation of brain MCs, amplify the cascade effect of neuroinflammatory response. Surgical stress may induce HPA axis activation by releasing corticotropin-releasing hormone (CRH) subsequently influence the activation of brain MCs, thus resulting in impaired synaptic plasticity. Herein, we discuss the better understating of MCs mediated neuroinflammation mechanisms after peripheral surgery and potential therapeutic targets for controlling inflammatory cascades.
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Affiliation(s)
- Piplu Bhuiyan
- Department of Anesthesiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, Jiangsu, People's Republic of China
| | - Zhaochu Sun
- Department of Anesthesiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, Jiangsu, People's Republic of China
| | - Yinan Chen
- Department of Anesthesiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, Jiangsu, People's Republic of China.
| | - Yanning Qian
- Department of Anesthesiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, Jiangsu, People's Republic of China.
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Wadaskar DR, Isal VG, Jain RA, Basantwani SJ. Utility of cerebral oximetry in balloon mitral valvotomy and its correlation with post-procedure neurological complications: A pragmatic prospective observational study. Indian J Anaesth 2023; 67:432-438. [PMID: 37333692 PMCID: PMC10269980 DOI: 10.4103/ija.ija_986_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 02/02/2023] [Accepted: 03/01/2023] [Indexed: 06/20/2023] Open
Abstract
Background and Aims Neurological complications (NCs) are significantly associated with reduced regional cerebral saturation (rSO2) in patients undergoing cardiac surgeries, as assessed with cerebral oximetry (COx). However, limited evidence is available in patients undergoing balloon mitral valvotomy (BMV). Thus, we evaluated the utility of COx in patients undergoing BMV, the incidence of BMV-related NCs and the association of >20% reduction in rSO2 with NCs. Methods This pragmatic, prospective, observational study was performed after ethical approval, over November 2018 to August 2020, in the cardiology catherization laboratory of a tertiary care hospital. The study involved 100 adult patients undergoing BMV for symptomatic mitral stenosis. The patients were evaluated at initial presentation, pre-BMV, post-BMV and 3 months after the BMV. Results The incidence of NCs was 7%, including transient ischaemic attack (n = 3), slurred speech (n = 2) and hemiparesis (n = 2). A significantly greater proportion of patients with NCs had a > 20% decrease in the rSO2 (P value = 0.020). At >20% cut-off, the COx had a sensitivity and specificity of 57.1% and 80%, respectively, in the prediction of NCs. Female sex (P value = 0.039), history of cerebrovascular episodes (P value < 0.001) and number of balloon attempts (P value < 0.001) were significantly associated with NCs. Patients with and without NCs had a significantly greater post-BMV mean % change in rSO2 than pre-BMV (both right and left sides), but the magnitude of mean % change was greater in those with NCs. Conclusions COx alone has low sensitivity and specificity in the prediction of NCs and cannot reliably predict the development of post-BMV NCs.
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Affiliation(s)
- Dhawal R. Wadaskar
- Department of Anaesthesiology, Jawaharlal Nehru Medical College (JNMC), DMIMS, Sawangi Meghe, Wardha, Maharashtra, India
| | - Vidya G. Isal
- Department of Anaesthesiology, Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai, Maharashtra, India
| | - Ruchi A. Jain
- Department of Anaesthesiology, Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai, Maharashtra, India
| | - Shakuntala J. Basantwani
- Department of Anaesthesiology, Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai, Maharashtra, India
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5
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Moore CC, Yu S, Aljure O. A comprehensive review of cerebral oximetry in cardiac surgery. J Card Surg 2022; 37:5418-5433. [PMID: 36423259 DOI: 10.1111/jocs.17232] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 09/03/2022] [Accepted: 11/09/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Patients who undergo cardiac surgery are at increased risk of stroke, postoperative cognitive decline, and delirium. These neurocognitive complications have led to increased costs, intensive care unit stays, morbidity, and mortality. As a result, there is a significant push to mitigate any neurological complications in cardiac surgery patients. Near-infrared spectroscopy to measure regional cerebral oxygen saturations has gained consideration due to its noninvasive and user-friendly nature. Cerebral oximetry desaturations during cardiac surgery have been linked to an array of adverse clinical outcomes. However, the most effective intraoperative interventions to protect this vulnerable patient population have yet to be ascertained. AIM OF STUDY To provide a comprehensive summary of the intraoperative management for cerebral oximetry desaturations during cardiac surgery. The review highlights clinical outcomes from cerebral oximetry use to quantify the importance of identifying cerebral desaturations during cardiac surgery. The review then interrogates possible interventions for cerebral oximetry desaturations in an effort to determine which interventions are most efficacious and to enlighten possible areas for further research. METHODS A narrative review of randomized controlled trials, observational studies, and systematic reviews with metanalyses was performed through August 2021. RESULTS There is significant heterogeneity among patient populations for which cerebral oximetry monitoring has been studied in cardiac surgery. Further, the definition of a clinically significant cerebral desaturation and the assessment of neurocognitive outcomes varied substantially across studies. As a result, metanalysis is challenging and few conclusions can be drawn. Cerebral oximetry use during cardiac surgery has not been associated with improvements in neurocognitive outcomes, morbidity, or mortality to date. The evidence to support a particular intervention for an acute desaturation is equivocal. CONCLUSIONS Future research is needed to quantify a clinically significant cerebral desaturation and to determine which interventions for an acute desaturation effectively improve clinical outcomes.
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Affiliation(s)
- Christina C Moore
- Jackson Memorial Hospital/University of Miami Miller School of Medicine, Miami, Florida, USA
| | | | - Oscar Aljure
- Jackson Memorial Hospital/University of Miami Miller School of Medicine, Miami, Florida, USA
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Onur T, Karaca Ü, Ata F, Sayan HE, Onur A, Yilmaz C, Balkaya AN, Eriş C. Intraoperative hyperoxygenation may negatively affect postoperative cognitive functions in coronary artery bypass graft operations: A randomized controlled study. J Card Surg 2022; 37:2552-2563. [PMID: 35678327 DOI: 10.1111/jocs.16661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 03/09/2022] [Accepted: 05/09/2022] [Indexed: 01/06/2023]
Abstract
OBJECTIVE In this study, it was aimed to compare various parameters during surgery and postoperative cognitive functions in patients undergoing coronary artery bypass graft (CABG) surgery using different levels of perioperative oxygen. METHODS One hundred patients scheduled for elective CABG surgery were included in the study. The patients were divided into two groups according to arterial oxygen levels during surgery. In the normoxia group (NG) (n = 50), partial arterial oxygen pressure (PaO2 ) was between ≥100 and <180 mmHg with at least 40% fraction of inspired oxygen (FiO2 ) mechanical ventilation (MV), and in the hyperoxia group (HG) (n = 50), PaO2 was ≥180 mmHg with 100% FiO2 MV. Hemodynamic parameters, peripheral oxygen saturation (SpO2 ), regional cerebral oxygen saturation (rSO2 ) measured from bilateral sensors, and blood gas values were recorded at the planned measurement times. Postoperative features (mortality and infection rates, length of stay in the hospital, and intensive care unit) and complications of the patients have been recorded (low cardiac output syndrome, renal failure, delirium). Mini-Mental State Examination (MMSE) test was applied to the patients before and at the 12th, 24th hours; on the first, third, sixth months after surgery. RESULTS Extubation time was found to be shorter in NG (p < .05). Between the groups, rSO2 and mean arterial pressure were found to be significantly lower in HG at the time of T4 measurement (p = .042, p = .038, respectively). MMSE values of the groups at the first, third, and sixth months were found to be significantly higher in NG (p = .017, p = .014, p = .002, respectively). CONCLUSION Hyperoxemia application during CABG may be associated with worse postoperative late-term cognitive functions.
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Affiliation(s)
- Tuğba Onur
- Departmant of Anesthesiology and Reanimation, University of Health Sciences Bursa Yüksek İhtisas Training and Research Hospital, Bursa, Turkey
| | - Ümran Karaca
- Departmant of Anesthesiology and Reanimation, University of Health Sciences Bursa Yüksek İhtisas Training and Research Hospital, Bursa, Turkey
| | - Filiz Ata
- Departmant of Anesthesiology and Reanimation, University of Health Sciences Bursa Yüksek İhtisas Training and Research Hospital, Bursa, Turkey
| | - Halil E Sayan
- Departmant of Anesthesiology and Reanimation, University of Health Sciences Bursa Yüksek İhtisas Training and Research Hospital, Bursa, Turkey
| | - Anıl Onur
- Departmant of Anesthesiology and Reanimation, University of Health Sciences Bursa Yüksek İhtisas Training and Research Hospital, Bursa, Turkey
| | - Canan Yilmaz
- Departmant of Anesthesiology and Reanimation, University of Health Sciences Bursa Yüksek İhtisas Training and Research Hospital, Bursa, Turkey
| | - Ayşe N Balkaya
- Departmant of Anesthesiology and Reanimation, University of Health Sciences Bursa Yüksek İhtisas Training and Research Hospital, Bursa, Turkey
| | - Cüneyt Eriş
- Departmant of Cardiovascular Surgery, University of Health Sciences Bursa Yüksek İhtisas Training and Research Hospital, Bursa, Turkey
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Ding Y, Yu J, Cui F, Li J. Comparison of Intravenous and Inhalational Anesthetic on Postoperative Cognitive Outcomes in Elderly Patients Undergoing Cancer Surgery: Systematic Review and Meta-analysis. J Perianesth Nurs 2022; 37:683-690. [PMID: 35618615 DOI: 10.1016/j.jopan.2021.11.017] [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: 09/15/2021] [Revised: 11/26/2021] [Accepted: 11/28/2021] [Indexed: 11/20/2022]
Abstract
PURPOSE Previous studies have documented consistent findings on the long-term cognitive effects such as postoperative cognitive dysfunction (POCD), delirium and delayed recovery among elderly undergoing cancer surgery. This review was conducted to compare the effect of intravenous and inhalational anesthetic on the postoperative cognitive outcomes among elderly patients undergoing cancer surgery. DESIGN Systematic review and meta-analysis METHODS: We searched Medline, EMBASE, PubMed Central, ScienceDirect, Google Scholar, and Cochrane library from inception until May 2021. We carried out a meta-analysis with a random-effects model and reported pooled risk ratio (RR) or standardized mean difference (SMD) with 95% confidence interval (CI) depending on the type of outcome. FINDINGS In total, we analyzed 10 studies including 2,333 participants. Half of the studies had high risk of bias. For the cognitive score, the pooled SMD was -0.87 [95% CI: -3.97 to 2.24] indicating no statistically significant difference between inhalational and intravenous anesthetic. For POCD, the pooled RR was 1.24 (95% CI: 0.83-1.84); for postoperative delirium, the pooled RR was 2.26 (95% CI: 0.79-6.44); for delayed neurocognitive recovery, the pooled RR was 1.49 (95% CI: 1.09-2.03). CONCLUSION Inhalational anesthetics did not show a significant difference in postoperative cognitive outcomes, except delayed neurocognitive recovery, compared to intravenous anesthetic following cancer surgery.
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Affiliation(s)
- Yongbo Ding
- Department of Anesthesiology, Yantai Yuhuangding Hospital, Yantai, Shandong, China
| | - Jianhong Yu
- Department of Anesthesiology, Yantai Yuhuangding Hospital, Yantai, Shandong, China
| | - Fenghe Cui
- Department of Anesthesiology, Yantai Yuhuangding Hospital, Yantai, Shandong, China.
| | - Jie Li
- Department of Anesthesiology, Yantai Yuhuangding Hospital, Yantai, Shandong, China
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Yang J, Dong HQ, Liu YH, Ji MH, Zhang X, Dai HY, Sun ZC, Liu L, Zhou J, Sha HH, Qian YN, Li QG, Yao H, Li NN. Laparotomy-Induced Peripheral Inflammation Activates NR2B Receptors on the Brain Mast Cells and Results in Neuroinflammation in a Vagus Nerve-Dependent Manner. Front Cell Neurosci 2022; 16:771156. [PMID: 35221919 PMCID: PMC8866729 DOI: 10.3389/fncel.2022.771156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 01/13/2022] [Indexed: 11/13/2022] Open
Abstract
Background: The pathophysiological mechanisms underlying postoperative cognitive dysfunction (POCD) remain unclear over the years. Neuroinflammation caused by surgery has been recognized as an important element in the development of POCD. Many studies also suggest that the vagus nerve plays an important role in transmitting peripheral injury signals to the central nervous system (CNS) and the resultant neuroinflammation. Previously, we have demonstrated that brain mast cells (BMCs), as the “first responders”, play a vital role in neuroinflammation and POCD. However, how the vagus nerve communicates with BMCs in POCD has not yet been clarified. Methods: In the current study, we highlighted the role of the vagus nerve as a conduction highway in surgery-induced neuroinflammation for the first time. In our model, we tested if mice underwent unilateral cervical vagotomy (VGX) had less neuroinflammation compared to the shams after laparotomy (LP) at an early stage. To further investigate the roles of mast cells and glutamate in the process, we employed KitW-sh mice and primary bone marrow-derived MCs to verify the glutamate-NR2B axis on MCs once again. Results: Our results demonstrated that there were higher levels of glutamate and BMCs activation as early as 4 h after LP. Meanwhile, vagotomy could partially block the increases and reduce neuroinflammation caused by peripheral inflammation during the acute phase. Excitingly, inhibition of NR2B receptor and knockout of mast cells can attenuateneuroinflammation induced by glutamate. Conclusion: Taken together, our findings indicate that the vagus is a high-speed pathway in the transmission of peripheral inflammation to the CNS. Activation of BMCs triggered a neuroinflammatory cascade. Inhibition of NR2B receptor on BMCs can reduce glutamate-induced BMCs activation, neuroinflammation, and memory impairment, suggesting a novel treatment strategy for POCD.
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Affiliation(s)
- Jing Yang
- Department of Anesthesiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.,Department of Anesthesiology, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hong-Quan Dong
- Department of Anesthesiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yan-Hu Liu
- Cardiovascular Center, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Mu-Huo Ji
- Department of Anesthesiology, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xun Zhang
- Cardiovascular Center, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hong-Yu Dai
- Department of Anesthesiology, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China.,Cardiovascular Center, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zhao-Chu Sun
- Department of Anesthesiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Lu Liu
- Department of Anesthesiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jian Zhou
- Cardiovascular Center, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Huan-Huan Sha
- Department of Anesthesiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yan-Ning Qian
- Department of Anesthesiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Qing-Guo Li
- Cardiovascular Center, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hao Yao
- Department of Anesthesiology, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China.,Cardiovascular Center, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Na-Na Li
- Department of Anesthesiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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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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Ellermann SF, L Scheeren TW, Jongman RM, Nordhoff K, Schnabel CL, Molema G, Theilmeier G, Meurs MV. Plasma from patients undergoing coronary artery bypass graft surgery does not activate endothelial cells under shear stress in vitro. Int J Crit Illn Inj Sci 2021; 11:142-150. [PMID: 34760660 PMCID: PMC8547679 DOI: 10.4103/ijciis.ijciis_197_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 03/26/2021] [Accepted: 03/31/2021] [Indexed: 11/11/2022] Open
Abstract
Background: Cardiac surgery with cardiopulmonary bypass (CPB) is commonly associated with acute kidney injury, and microvascular endothelial inflammation is a potential underlying mechanism. We hypothesized that pro-inflammatory components of plasma from patients who underwent coronary artery bypass graft surgery with CPB induce endothelial adhesion molecule expression when incorporating altered shear stress in the in vitro model. Methods: The clinical characteristics and markers of systemic inflammation and kidney injury were analyzed pre and postoperatively in 29 patients undergoing coronary artery bypass grafting with CPB. The effects of tumor necrosis factor (TNF)-α and patient plasma on the expression of endothelial inflammation and adhesion markers were analyzed in vitro. Results: Plasma TNF-α was elevated 6 h postoperation (median: 7.3 pg/ml (range: 2.5–94.8 pg/ml)). Neutrophil gelatinase-associated lipocalin in plasma peaked 6 h (99.8 ng/ml (52.6–359.1 ng/ml)) and in urine 24 h postoperation (1.6 ng/mg (0.2–6.4 ng/mg)). Urinary kidney injury molecule-1 concentration peaked 24 h postoperation (0.5 ng/mg (0.2–1.2 ng/mg). In vitro, the expression of E-selectin was induced by 20 pg/ml TNF-α. In addition, the expression of interleukin-8, intercellular adhesion molecule-1, and vascular cell adhesion molecule-1 was induced by 100 pg/ml TNF-α. Compared to healthy control plasma exposure, postoperative plasma did not increase the expression of markers of endothelial inflammation and adhesion under shear stress in vitro. Conclusion: Patients undergoing CPB surgery showed mild systemic inflammation and kidney injury. However, the plasma components did not stimulate endothelial inflammation and adhesion molecule expression in vitro.
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Affiliation(s)
- Sophie F Ellermann
- Department of Pathology and Medical Biology, Oldenburg, Germany.,Department of Critical Care, Oldenburg, Germany.,Department of Anaesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Perioperative Inflammation and Infection, Department of Human Medicine, Faculty of Medicine and Health Sciences, Carl von Ossietzky University, Oldenburg, Germany
| | - Thomas W L Scheeren
- Department of Anaesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Rianne M Jongman
- Department of Pathology and Medical Biology, Oldenburg, Germany.,Department of Anaesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Katja Nordhoff
- Department of Food Safety, Lower Saxony State Office for Consumer Protection and Food Safety, Oldenburg, Germany
| | - Christiane L Schnabel
- Perioperative Inflammation and Infection, Department of Human Medicine, Faculty of Medicine and Health Sciences, Carl von Ossietzky University, Oldenburg, Germany.,Institute of Immunology, College of Veterinary Medicine, Leipzig University, Leipzig, Germany
| | - Grietje Molema
- Department of Pathology and Medical Biology, Oldenburg, Germany
| | - Gregor Theilmeier
- Perioperative Inflammation and Infection, Department of Human Medicine, Faculty of Medicine and Health Sciences, Carl von Ossietzky University, Oldenburg, Germany
| | - Matijs Van Meurs
- Department of Pathology and Medical Biology, Oldenburg, Germany.,Department of Critical Care, Oldenburg, Germany
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11
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Prolonged postoperative cerebral oxygen desaturation after cardiac surgery: A prospective observational study. Eur J Anaesthesiol 2021; 38:966-974. [PMID: 33186311 DOI: 10.1097/eja.0000000000001391] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Near-infrared spectroscopy (NIRS) is used routinely to monitor cerebral tissue oxygen saturation (SctO2) during cardiopulmonary bypass (CPB) but is rarely employed outside the operating room. Previous studies indicate that patients are at risk of postoperative cerebral oxygen desaturation after cardiac surgery. OBJECTIVES We aimed to assess perioperative and postoperative changes in NIRS-derived SctO2 in cardiac surgery patients. DESIGN Prospective observational study. SETTING The study was conducted in a tertiary referral university hospital in Australia from December 2017 to December 2018. PATIENTS We studied 34 adult patients (70.6% men) undergoing cardiac surgery requiring CPB and a reference group of 36 patients undergoing non-cardiac surgical procedures under general anaesthesia. MAIN OUTCOME MEASURES We measured SctO2 at baseline, during and after surgery, and then once daily until hospital discharge, for a maximum of 7 days. We used multivariate linear mixed-effects modelling to adjust for all relevant imbalances between the two groups. RESULTS In the cardiac surgery group, SctO2 was 63.7% [95% confidence interval (CI), 62.0 to 65.5] at baseline and 61.0% (95% CI, 59.1 to 62.9, P = 0.01) on arrival in the ICU. From day 2 to day 7 after cardiac surgery, SctO2 progressively declined. At hospital discharge, SctO2 was significantly lower than baseline, at 53.5% (95% CI, 51.8 to 55.2, P < 0.001). In the reference group, postoperative SctO2 was not significantly different from baseline. On multivariable analysis, cardiac surgery, peripheral vascular disease and time since the operation were associated with greater cerebral desaturation, whereas higher haemoglobin concentrations were associated with slightly better cerebral oxygenation. CONCLUSION After cardiac surgery on CPB, but not after non-cardiac surgery, most patients experience prolonged cerebral desaturation. Such postoperative desaturation remained unresolved 7 days after surgery. The underlying mechanisms and time to resolution of such cerebral desaturations require further investigation.
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12
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Lappalainen L, Rajamaki B, Tolppanen AM, Hartikainen S. Coronary artery revascularizations and cognitive decline - A systematic review. Curr Probl Cardiol 2021; 47:100960. [PMID: 34363848 DOI: 10.1016/j.cpcardiol.2021.100960] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 07/30/2021] [Indexed: 12/19/2022]
Abstract
Coronary artery disease (CAD) is a risk factor for cognitive decline. The aim of this study was to systematically review recent literature on whether coronary artery revascularizations are associated to cognitive decline and dementia. Pubmed, Scopus, and CINAHL (EBSCO) were searched systematically from January 2009 till September 2020. Studies were conducted on persons with CAD undergoing coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) procedure compared to other coronary artery disease treatments, and the outcome was cognitive decline or dementia. Altogether four of the 680 reviewed articles met inclusion criteria. Results were inconsistent, and the outcome measurements heterogeneous between studies. Our findings indicate an evidence gap in the current understanding of long-term outcomes following coronary artery revascularization. However, evidence of long-term effects on cognition would complement our understanding of their benefits. There is a need for more studies on long-term cognitive outcomes after coronary artery revascularizations.
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Affiliation(s)
- Laura Lappalainen
- School of Pharmacy, University of Eastern Finland, P.O. Box 1627, FI-70211, Kuopio, Finland.
| | - Blair Rajamaki
- Kuopio Research Centre of Geriatric Care, University of Eastern Finland, P.O. Box 1627, FI-70211 Kuopio, Finland; School of Pharmacy, University of Eastern Finland, P.O. Box 1627, FI-70211, Kuopio, Finland
| | - Anna-Maija Tolppanen
- Kuopio Research Centre of Geriatric Care, University of Eastern Finland, P.O. Box 1627, FI-70211 Kuopio, Finland; School of Pharmacy, University of Eastern Finland, P.O. Box 1627, FI-70211, Kuopio, Finland
| | - Sirpa Hartikainen
- Kuopio Research Centre of Geriatric Care, University of Eastern Finland, P.O. Box 1627, FI-70211 Kuopio, Finland; School of Pharmacy, University of Eastern Finland, P.O. Box 1627, FI-70211, Kuopio, Finland
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13
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Miniksar ÖH, Çiçekçioğlu F, Kılıç M, Honca M, Miniksar DY, Gocmen AY, Kaçmaz O, Öz H. Decreased brain-derived neurotrophic factor levels may predict early perioperative neurocognitive disorder in patients undergoing coronary artery bypass surgery: A prospective observational pilot study. J Clin Anesth 2021; 71:110235. [PMID: 33774438 DOI: 10.1016/j.jclinane.2021.110235] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 02/11/2021] [Accepted: 02/12/2021] [Indexed: 02/07/2023]
Abstract
STUDY OBJECTIVE To determine the prognostic value of the change in intraoperative BDNF (Brain-derived neurotrophic factor) levels during cardiac surgery with cardiopulmonary bypass (CPB) on early perioperative neurocognitive disorder (PND). DESIGN Prospective observational pilot study. SETTING The study was performed in the Medical Faculty Hospital, from January 2020 to August 2020. PATIENTS 45 adult patients undergoing elective coronary artery bypass surgery (CABG) with CPB. INTERVENTIONS None. MEASUREMENTS Cognitive function was evaluated 1 day before and 4 days after the surgery. Serum BDNF levels were measured at four time points (T1: after induction; T2: with aortic cross-clamp; T3: without aortic cross-clamp; T4: 4 days after surgery) by enzyme-linked immunosorbent assay. MAIN RESULTS The incidence of PND was 37.8% four days after surgery. Serum BDNF (T2 and T4) levels were significantly lower in PND group compared to non- PND group (p = 0.003 and p = 0.016, respectively). Moreover, lactate, rSO2 (regional cerebral oxygen saturation), aortic cross-clamp time, CPB duration, and the amount of blood transfusion differed between the groups. Logistic regression analysis identified serum BDNF-T2, age, cross-clamp time, and rSO2-T2 as independent risk factors for PND. Based on the ROC analysis, the area under curve (AUC) of BDNF-T2 concentration for prediction of PND was 0.759 with sensitivity of 71.4% and specificity of 64.7% (p < 0.01). CONCLUSION Intraoperative BDNF serum levels may be a useful biomarker in predicting PND in patients undergoing CABG surgery. More comprehensive studies is needed in order to confirm the effect of decreasing intraoperative BDNF serum levels on the development of PND. TRIAL REGISTRATION NUMBER NCT04250935 www.clinicaltrials.gov.
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Affiliation(s)
- Ökkeş Hakan Miniksar
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Yozgat Bozok University, Yozgat, Turkey.
| | - Ferit Çiçekçioğlu
- Department of Cardiovascular Surgery, Faculty of Medicine, Yozgat Bozok University, Yozgat, Turkey
| | - Mahmut Kılıç
- Department of Public Health, Faculty of Medicine, Yozgat Bozok University, Yozgat, Turkey
| | - Mehtap Honca
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Yozgat Bozok University, Yozgat, Turkey
| | - Dilşad Yıldız Miniksar
- Department of Child and Adolescent Psychiatry, Faculty of Medicine, Yozgat Bozok University, Yozgat, Turkey
| | - Ayse Yesim Gocmen
- Department of Biochemistry, Faculty of Medicine, Yozgat Bozok University, Yozgat, Turkey
| | - Osman Kaçmaz
- Department of Anesthesiology and Reanimation, Malatya Training and Research Hospital, Turgut Ozal University, Malatya, Turkey
| | - Hakan Öz
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Yozgat Bozok University, Yozgat, Turkey
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14
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Milne B, Gilbey T, Gautel L, Kunst G. Neuromonitoring and Neurocognitive Outcomes in Cardiac Surgery: A Narrative Review. J Cardiothorac Vasc Anesth 2021; 36:2098-2113. [PMID: 34420812 DOI: 10.1053/j.jvca.2021.07.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 06/28/2021] [Accepted: 07/15/2021] [Indexed: 12/30/2022]
Abstract
Neurocognitive dysfunction after cardiac surgery can present with diverse clinical phenotypes, which include postoperative delirium, postoperative cognitive dysfunction, and stroke, and it presents a significant healthcare burden for both patients and providers. Neurologic monitoring during cardiac surgery includes several modalities assessing cerebral perfusion and oxygenation (near-infrared spectroscopy, transcranial Doppler and jugular venous bulb saturation monitoring) and those that measure cerebral function (processed and unprocessed electroencephalogram), reflecting an absence of a single, definitive neuromonitor. This narrative review briefly describes the technologic basis of these neuromonitoring modalities, before exploring their use in clinical practice, both as tools to predict neurocognitive dysfunction, and with a bundle of interventions designed to optimize cerebral oxygen supply, with the aim of reducing postoperative delirium and cognitive dysfunction following cardiac surgery.
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Affiliation(s)
- Benjamin Milne
- Department of Anaesthetics and Pain Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Thomas Gilbey
- Department of Anaesthetics and Pain Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Livia Gautel
- Department of Anaesthetics and Pain Medicine, King's College Hospital NHS Foundation Trust, London, UK; School of Biological Sciences in Edinburgh, University of Edinburgh, Edinburgh, UK; School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Excellence, London, UK
| | - Gudrun Kunst
- Department of Anaesthetics and Pain Medicine, King's College Hospital NHS Foundation Trust, London, UK; School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Excellence, London, UK.
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15
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Semrau JS, Motamed M, Ross-White A, Boyd JG. Cerebral oximetry and preventing neurological complication post-cardiac surgery: a systematic review. Eur J Cardiothorac Surg 2021; 59:1144-1154. [PMID: 33517375 DOI: 10.1093/ejcts/ezaa485] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 12/02/2020] [Accepted: 12/09/2020] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES This systematic review aims to provide an up-to-date summary of the current literature examining the relationship between intraoperative regional cerebral oxygen saturation and neurological complications after cardiac surgery. METHODS Observational and interventional studies investigating the link between regional cerebral oxygen saturation and postoperative delirium, cognitive dysfunction and stroke were included. After database searching and study screening, study characteristics and major findings were extracted. RESULTS Twenty-seven studies were identified. Of the observational studies (n = 17), 8 reported that regional cerebral oxygen desaturations were significantly associated with neurological complications after cardiac surgery. Of the interventional studies (n = 10), 3 provided evidence for monitoring cerebral oximetry during cardiac surgery as a means of reducing incidence of postoperative cognitive dysfunction or stroke. There was significant heterogeneity in the tools and rigor used to diagnose neurological complications. CONCLUSIONS Studies to date show an inconsistent relationship between regional cerebral oxygen saturation and neurological outcomes after cardiac surgery, and lack of clear benefit of targeting cerebral oximetry to minimize neurological complications. Standardized assessments, definitions of impairment and desaturation thresholds will help determine the benefits of cerebral oximetry monitoring during cardiac surgery.
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Affiliation(s)
- Joanna S Semrau
- Centre for Neuroscience Studies, Queen's University, Kingston, ON, Canada
| | - Mehras Motamed
- School of Medicine, Faculty of Health Sciences, Queen's University, Kingston, ON, Canada
| | | | - J Gordon Boyd
- Centre for Neuroscience Studies, Queen's University, Kingston, ON, Canada.,Kingston Health Sciences Centre, Kingston, ON, Canada.,Department of Critical Care, Faculty of Health Sciences, Queen's University, Kingston, ON, Canada
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16
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Blokzijl F, Keus F, Houterman S, Dieperink W, van der Horst ICC, Reneman MF, Absalom AR, Mariani MA. Does postoperative cognitive decline after coronary bypass affect quality of life? Open Heart 2021; 8:openhrt-2020-001569. [PMID: 33888591 PMCID: PMC8070880 DOI: 10.1136/openhrt-2020-001569] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 02/12/2021] [Accepted: 04/06/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE This study aimed to explore the influence of coronary artery bypass grafting (CABG) on both postoperative cognitive dysfunction and quality of life (QoL) and the association between the two patient-related outcomes. METHODS In a prospective, observational cohort study, patients with elective, isolated CABG were included. Cognitive function was assessed using the Cogstate computerised cognitive test battery preoperatively, 3 days and 6 months after surgery. QoL was measured preoperatively and at 6 months using the RAND-36 questionnaire including the Physical Component Score (PCS) and the Mental Component Score (MCS). Regression analysis, with adjustment for confounders, was used to evaluate the association between postoperative cognitive dysfunction and QoL. RESULTS A total of 142 patients were included in the study. Evidence of persistent cognitive dysfunction was observed in 33% of patients after 6 months. At 6 months, the PCS had improved in 59% and decreased in 21% of patients, and the MCS increased in 49% and decreased in 29%. Postoperative cognitive changes were not associated with QoL scores. CONCLUSIONS Postoperative cognitive dysfunction and decreased QoL are common 6 months after surgery, although cognitive function and QoL were found to have improved in many patients at 6 months of follow-up. Impaired cognitive function is not associated with impaired QoL at 6 months. TRIAL REGISTRATION NUMBER NCT03774342.
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Affiliation(s)
- Fredrike Blokzijl
- Department of Cardiothoracic Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - Frederik Keus
- Department of Critical Care, University Medical Centre Groningen, Groningen, The Netherlands
| | - Saskia Houterman
- Department of Education and Research, Catharina Hospital, Eindhoven, The Netherlands
| | - Willem Dieperink
- Department of Critical Care, University Medical Centre Groningen, Groningen, The Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Michiel F Reneman
- Department of Rehabilitation Medicine, University Medical Centre Groningen, Groningen, The Netherlands
| | - Anthony R Absalom
- Department of Anesthesiology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Massimo A Mariani
- Department of Cardiothoracic Surgery, University Medical Centre Groningen, Groningen, The Netherlands
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17
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de Keijzer IN, Poterman M, Absalom AR, Vos JJ, Mariani MA, Scheeren TWL. Comparison of renal region, cerebral and peripheral oxygenation for predicting postoperative renal impairment after CABG. J Clin Monit Comput 2021; 36:735-743. [PMID: 33876337 PMCID: PMC9162967 DOI: 10.1007/s10877-021-00701-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 03/31/2021] [Indexed: 11/25/2022]
Abstract
Patients undergoing coronary artery bypass grafting (CABG) are at risk of developing postoperative renal impairment, amongst others caused by renal ischemia and hypoxia. Intra-operative monitoring of renal region tissue oxygenation (SrtO2) might be a useful tool to detect renal hypoxia and predict postoperative renal impairment. Therefore, the aim of this study was to assess the ability of intra-operative SrtO2 to predict postoperative renal impairment, defined as an increase of serum creatinine concentrations of > 10% from individual baseline, and compare this with the predictive abilities of peripheral and cerebral tissue oxygenation (SptO2 and SctO2, respectively) and renal specific tissue deoxygenation. Forty-one patients undergoing elective CABG were included. Near-infrared spectroscopy (NIRS) was used to measure renal region, peripheral (thenar muscle) and cerebral tissue oxygenation during surgery. Renal region specific tissue deoxygenation was defined as a proportionally larger decrease in SrtO2 than SptO2. ROC analyses were used to compare predictive abilities. We did not observe an association between tissue oxygenation measured in the renal region and cerebral oxygenation and postoperative renal impairment in this small retrospective study. In contrast, SptO2 decrease > 10% from baseline was a reasonable predictor with an AUROC of 0.767 (95%CI 0.619 to 0.14; p = 0.010). Tissue oxygenation of the renal region, although non-invasively and continuously available, cannot be used in adults to predict postoperative renal impairment after CABG. Instead, peripheral tissue deoxygenation was able to predict postoperative renal impairment, suggesting that SptO2 provides a better indication of ‘general’ tissue oxygenation status. Registered at ClinicalTrials.gov: NCT01347827, first submitted April 27, 2011.
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Affiliation(s)
- Ilonka N de Keijzer
- Department of Anaesthesiology, University Medical Centre Groningen, Hanzeplein 1, Groningen, 9713 GZ, The Netherlands.
| | - Marieke Poterman
- Department of Anaesthesiology, University Medical Centre Groningen, Hanzeplein 1, Groningen, 9713 GZ, The Netherlands
| | - Anthony R Absalom
- Department of Anaesthesiology, University Medical Centre Groningen, Hanzeplein 1, Groningen, 9713 GZ, The Netherlands
| | - Jaap Jan Vos
- Department of Anaesthesiology, University Medical Centre Groningen, Hanzeplein 1, Groningen, 9713 GZ, The Netherlands
| | - Massimo A Mariani
- Department of Cardiothoracic Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - Thomas W L Scheeren
- Department of Anaesthesiology, University Medical Centre Groningen, Hanzeplein 1, Groningen, 9713 GZ, The Netherlands
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18
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Tasbihgou SR, Dijkstra S, Atmosoerodjo SD, Tigchelaar I, Huet R, Mariani MA, Absalom AR. A prospective pilot study assessing levels of preoperative physical activity and postoperative neurocognitive disorder among patients undergoing elective coronary artery bypass graft surgery. PLoS One 2020; 15:e0240128. [PMID: 33048965 PMCID: PMC7553306 DOI: 10.1371/journal.pone.0240128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 09/20/2020] [Indexed: 11/17/2022] Open
Abstract
Physical inactivity and a sedentary lifestyle are associated with a chronic low-level inflammatory state which has been implicated in the pathogenesis of cardiovascular disease. There is growing interest in exercise programs as part of surgical ‘prehabilitation’. We therefore studied preoperative physical activity levels of patients undergoing elective Coronary Artery Bypass Graft (CABG) surgery, and performed an exploratory analysis of the influence of physical activity on postoperative outcome. The Short Questionnaire to Assess Health (SQUASH) was used to assess physical activity among 100 patients, of mean (SD) age 65.4 (7.6) years. Additionally, handgrip strength was measured, and the get-up-and-go test was conducted. Anxiety, depression, and quality of life were assessed, and a computerised cognitive test battery was used to assess cognitive performance preoperatively, and three months after surgery. Preoperatively, 76% of patients met the recommended national guidelines for physical activity. The incidence of pre-existing medical conditions, and other pre-operative patient features were similar in active and inactive patients. Preoperative physical activity was significantly inversely related to the logistic EuroSCORE. The level of physical activity was also significantly inversely related with preoperative C-reactive protein (CRP) and peak postoperative CRP, but physical activity did not appear to be associated with any adverse postoperative outcomes or extended length of hospital stay. The incidence of postoperative neurocognitive disorder (PNCD) at 3 months postoperatively was 26%. Cognitive performance was not related with physical activity levels. In summary, this was the first study to assess activity levels of cardiac surgical patients with the SQUASH questionnaire. The majority of patients were physically active. Although physical activity was associated with lower levels of inflammation in this pilot study, it was not associated with an improved clinical or cognitive postoperative outcome.
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Affiliation(s)
- Setayesh R Tasbihgou
- Department of Anesthesiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Sandra Dijkstra
- Department of Cardiothoracic Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Sawal D Atmosoerodjo
- Department of Anesthesiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Iris Tigchelaar
- Laboratory for Experimental Ophthalmology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Rolf Huet
- Department of Anesthesiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Massimo A Mariani
- Department of Cardiothoracic Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Anthony R Absalom
- Department of Anesthesiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
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19
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Blokzijl F, Houterman S, van Straten BHM, Daeter E, Brandon Bravo Bruinsma GJ, Dieperink W, Reneman MF, Keus F, van der Horst ICC, Mariani MA. Quality of life after coronary bypass: a multicentre study of routinely collected health data in the Netherlands†. Eur J Cardiothorac Surg 2020; 56:526-533. [PMID: 30879073 PMCID: PMC6735900 DOI: 10.1093/ejcts/ezz051] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 01/11/2019] [Accepted: 01/31/2019] [Indexed: 12/25/2022] Open
Affiliation(s)
- Fredrike Blokzijl
- Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | | | - Bart H M van Straten
- Department of Cardiothoracic Surgery, Catharina Hospital Eindhoven, Eindhoven, Netherlands
| | - Edgar Daeter
- Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, Netherlands
| | | | - Willem Dieperink
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Michiel F Reneman
- Department of Rehabilitation Medicine, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Frederik Keus
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Iwan C C van der Horst
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Massimo A Mariani
- Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
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20
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Mauldon H, Dieberg G, Smart N, King N. Effect of Age on Clinical Outcomes Following On-/Off-Pump Coronary Artery Bypass: Meta-Analysis and Meta-Regression. Braz J Cardiovasc Surg 2020; 35:797-814. [PMID: 33118746 PMCID: PMC7598957 DOI: 10.21470/1678-9741-2018-0388] [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] [Indexed: 11/04/2022] Open
Abstract
Objective There is currently much debate about which patients would benefit more after on- or off-pump coronary artery bypass grafting (CABG). The aim of this meta-analysis and meta-regression is to investigate the effect of age on short-term clinical outcomes after these approaches. Methods To identify potential studies, systematic searches were carried out in the Excerpta Medica dataBASE (EMBASE), PubMed, Web of Science, and the Cochrane Central Register of Controlled Trials (CENTRAL). The search strategy included the key concepts of “cardiopulmonary bypass” AND “coronary artery bypass grafting” AND “off pump” OR “on pump”. This was followed by a meta-analysis and meta-regression investigating the effect of age on the incidences of stroke, myocardial infarction (MI), and mortality. Results Thirty-seven studies including 15,324 participants were analysed. Overall, there was a significant odds reduction for patients receiving off-pump CABG suffering a stroke (odds ratio [OR] 0.770, 95% confidence intervals [CI] 0.594, 0.998, P=0.048); however, when patients were subdivided according to different age bands, this difference disappeared. There were also no significant differences in the odds of mortality (OR 0.876, 95% CI 0.703, 1.093, P=0.241) or MI (OR 0.937, 95% CI 0.795, 1.105, P=0.439). Meta-regression analysis revealed no significant relationship between age and stroke (P=0.652), age and mortality (P=548), and age and MI (P=0.464). Conclusion Patients undergoing CABG are becoming older and may suffer from multiple comorbidities increasing their risk profile. However, with respect to short-term clinical outcomes, the patient’s age does not help in determining whether off- or on-pump is superior.
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Affiliation(s)
- Hayley Mauldon
- University of Plymouth Ringgold Standard Institution Plymouth United Kingdom of Great Britain and Northern Ireland University of Plymouth, Ringgold Standard Institution, Plymouth, United Kingdom of Great Britain and Northern Ireland
| | - Gudrun Dieberg
- University of New England Ringgold Standard Institution Armidale Australia University of New England, Ringgold Standard Institution, Armidale, Australia
| | - Neil Smart
- University of New England Ringgold Standard Institution Armidale Australia University of New England, Ringgold Standard Institution, Armidale, Australia
| | - Nicola King
- University of Plymouth Ringgold Standard Institution Plymouth United Kingdom of Great Britain and Northern Ireland University of Plymouth, Ringgold Standard Institution, Plymouth, United Kingdom of Great Britain and Northern Ireland
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Thiele RH, Shaw AD, Bartels K, Brown CH, Grocott H, Heringlake M, Gan TJ, Miller TE, McEvoy MD. American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on the Role of Neuromonitoring in Perioperative Outcomes: Cerebral Near-Infrared Spectroscopy. Anesth Analg 2020; 131:1444-1455. [DOI: 10.1213/ane.0000000000005081] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
Better ways to manage preoperative, intraoperative and postoperative care of surgical patients is the bailiwick of anesthesiologists. Although we care for patients of all ages, protecting the cognitive capacity of elderly patients more frequently requires procedures and practices that go beyond routine care for nonelderly adults. This narrative review will consider current understanding of the reasons that elderly patients need enhanced care, and recommendations for that care based on established and recent empirical research. In that latter regard, unless and until we are able to classify anesthetic neurotoxicity as a rare complication, the first-do-no-harm approach should: (1) add anesthesia to surgical intervention on the physiological cost side of the cost/benefit ratio when making decisions about whether and when to proceed with surgery; (2) minimize anesthetic depth and periods of electroencephalographic suppression; (3) limit the duration of continuous anesthesia whenever possible; (4) consider the possibility that regional anesthesia with deep sedation may be as neurotoxic as general anesthesia; and (5) when feasible, use regional anesthesia with light or no sedation.
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Tasbihgou SR, Absalom AR. Postoperative neurocognitive disorders. Korean J Anesthesiol 2020; 74:15-22. [PMID: 32623846 PMCID: PMC7862941 DOI: 10.4097/kja.20294] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 07/01/2020] [Indexed: 12/16/2022] Open
Abstract
A decline in cognitive function is a frequent complication of major surgery. Postoperative cognitive impairments have generally been divided into short- (postoperative delirium) and long-term disturbances (postoperative cognitive dysfunction [POCD]). Long-term impairments are often subtle and overlooked. They need to be objectively assessed using neuropsychological tests to be diagnosed. Although POCD has been the subject of considerable research over the past decades, it remains uncertain why some patients do not return to preoperative levels of cognitive function. Surgery and anesthesia have both been implicated to play a role in POCD development, and certain patient-related factors, such as advanced age and low preoperative baseline cognitive function, have consistently been found to predict postoperative cognitive decline. This article will present an overview of POCD and its etiology and provide advice on possible strategies on its prevention.
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Affiliation(s)
- Setayesh Reza Tasbihgou
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Anthony Ray Absalom
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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24
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Eertmans W, De Deyne C, Genbrugge C, Marcus B, Bouneb S, Beran M, Fret T, Gutermann H, Boer W, Vander Laenen M, Heylen R, Mesotten D, Vanelderen P, Jans F. Association between postoperative delirium and postoperative cerebral oxygen desaturation in older patients after cardiac surgery. Br J Anaesth 2020; 124:146-153. [DOI: 10.1016/j.bja.2019.09.042] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 09/21/2019] [Accepted: 09/30/2019] [Indexed: 01/14/2023] Open
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26
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Scheeren TWL, Kuizenga MH, Maurer H, Struys MMRF, Heringlake M. Electroencephalography and Brain Oxygenation Monitoring in the Perioperative Period. Anesth Analg 2019; 128:265-277. [PMID: 29369096 DOI: 10.1213/ane.0000000000002812] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Maintaining brain function and integrity is a pivotal part of anesthesiological practice. The present overview aims to describe the current role of the 2 most frequently used monitoring methods for evaluation brain function in the perioperative period, ie, electroencephalography (EEG) and brain oxygenation monitoring. Available evidence suggests that EEG-derived parameters give additional information about depth of anesthesia for optimizing anesthetic titration. The effects on reduction of drug consumption or recovery time are heterogeneous, but most studies show a reduction of recovery times if anesthesia is titrated along processed EEG. It has been hypothesized that future EEG-derived indices will allow a better understanding of the neurophysiological principles of anesthetic-induced alteration of consciousness instead of the probabilistic approach most often used nowadays.Brain oxygenation can be either measured directly in brain parenchyma via a surgical burr hole, estimated from the venous outflow of the brain via a catheter in the jugular bulb, or assessed noninvasively by near-infrared spectroscopy. The latter method has increasingly been accepted clinically due to its ease of use and increasing evidence that near-infrared spectroscopy-derived cerebral oxygen saturation levels are associated with neurological and/or general perioperative complications and increased mortality. Furthermore, a goal-directed strategy aiming to avoid cerebral desaturations might help to reduce these complications. Recent evidence points out that this technology may additionally be used to assess autoregulation of cerebral blood flow and thereby help to titrate arterial blood pressure to the individual needs and for bedside diagnosis of disturbed autoregulation.
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Affiliation(s)
- Thomas W L Scheeren
- From the Department of Anaesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Merel H Kuizenga
- From the Department of Anaesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Holger Maurer
- Department of Anesthesiology and Intensive Care Medicine, University of Lübeck, Lübeck, Germany
| | - Michel M R F Struys
- From the Department of Anaesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Matthias Heringlake
- Department of Anesthesiology and Intensive Care Medicine, University of Lübeck, Lübeck, Germany
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27
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Charlesworth M, Klein AA, White SM. A bibliometric analysis of the conversion and reporting of pilot studies published in six anaesthesia journals. Anaesthesia 2019; 75:247-253. [DOI: 10.1111/anae.14817] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2019] [Indexed: 12/17/2022]
Affiliation(s)
- M. Charlesworth
- Department of Cardiothoracic Anaesthesia Critical Care and ECMO Wythenshawe Hospital ManchesterUK
| | - A. A. Klein
- Department of Cardiothoracic Anaesthesia and Intensive Care Royal Papworth Hospital CambridgeUK
| | - S. M. White
- Department of Anaesthesia Royal Sussex County Hospital Brighton UK
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28
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Ajtahed SS, Rezapour T, Etemadi S, Moradi H, Habibi Asgarabad M, Ekhtiari H. Efficacy of Neurocognitive Rehabilitation After Coronary Artery Bypass Graft Surgery in Improving Quality of Life: An Interventional Trial. Front Psychol 2019; 10:1759. [PMID: 31440180 PMCID: PMC6694840 DOI: 10.3389/fpsyg.2019.01759] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 07/15/2019] [Indexed: 12/22/2022] Open
Abstract
Introduction Cognitive deficits are frequent after coronary artery bypass graft (CABG) surgery and consequently could lead to a decrease in quality of life. This is the first study that has been conducted with the aim of examining the efficacy of a computerized cognitive rehabilitation therapy (CCRT) in improving quality of life in patients after CABG surgery. Methods In this study, an interventional trial with pre-, post-, and follow-up assessments in active (CCRT), active control and control groups was conducted. Seventy-five patients after CABG surgery were selected and assigned to the groups (n = 25 for each group). CCRT consists of four modules of attention, working memory, response inhibition and processing speed training with graded schedule in 20-min sessions three times per week within 8 weeks. Cognitive functions (attention and working memory) were assessed by the tests of continuous performance, Flanker, useful field of view and digit span at three time points: pre- and post-intervention (T0 and T1) and 6-month follow-up (T2). Quality of life was assessed by the SF-36 questionnaire at the same time points. The CCRT group received the cognitive rehabilitation for 2 months, active control group received a sham version of CCRT in an equal time duration and control group did not receive any cognitive intervention. Results Repeated measures analysis of variance (ANOVA) revealed a time by group interaction on cognitive functions, with CCRT producing a significant improvement at T1 (p < 0.01) and these improvements were maintained at T2. Moreover, in CCRT and active control groups, quality of life (QoL) improved at T1 and these improvements remained stable throughout follow-up (T2). However, improvement of QoL in CCRT group was greater than improvement of QoL in the other two groups at T1. Pearson’s correlation analysis shows a positive correlation between QoL improvement and sustained attention and working memory enhancement (p < 0.05). Conclusion Cognitive rehabilitation can lead to a significant improvement in the cognitive functions that have been trained in patients receiving CABG. Interestingly enough, cognitive rehabilitation can also improve quality of life in patients after CABG surgery and this improvement is maintained for at least 6 months.
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Affiliation(s)
| | - Tara Rezapour
- Department of Psychology, University of Tehran, Tehran, Iran
| | | | - Hadi Moradi
- School of Electrical and Computer Engineering, University of Tehran, Tehran, Iran
| | - Mojtaba Habibi Asgarabad
- Department of Health Psychology, School of Behavioral Sciences and Mental Health, Iran University of Medical Sciences, Tehran, Iran
| | - Hamed Ekhtiari
- Iranian National Center for Addiction Studies, Tehran University of Medical Sciences, Tehran, Iran.,Translational Neuroscience Program, Institute for Cognitive Science Studies, Tehran, Iran.,Research Center for Molecular and Cellular Imaging, Tehran University of Medical Sciences, Tehran, Iran
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29
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Holmgaard F, Vedel AG, Rasmussen LS, Paulson OB, Nilsson JC, Ravn HB. The association between postoperative cognitive dysfunction and cerebral oximetry during cardiac surgery: a secondary analysis of a randomised trial. Br J Anaesth 2019; 123:196-205. [PMID: 31104758 DOI: 10.1016/j.bja.2019.03.045] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 03/11/2019] [Accepted: 03/15/2019] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Postoperative cognitive dysfunction (POCD) occurs commonly after cardiac surgery. Near-infrared spectroscopy (NIRS) has been used to monitor regional cerebral oxygen saturation (rScO2) in order to minimise the occurrence of POCD by applying dedicated interventions when rScO2 decreases. However, the association between rScO2 intraoperatively and POCD has not been clarified. METHODS This is a secondary analysis of a randomised trial with physician-blinded NIRS monitoring and cognitive testing at discharge from hospital and at 3 months after surgery. The association between intraoperative rScO2 values and POCD at discharge from hospital and at 3 months after surgery was investigated. The prespecified candidate predictive variable of interest was cumulative time during surgery with rScO2 ≥10% below its preoperative value. RESULTS One hundred and fifty-three patients had complete NIRS data and neurocognitive assessments at discharge, and 44 of these patients (29%) had POCD. At 3 months, 148 patients had complete data, and 12 (8%) of these patients had POCD. The median time with rScO2 >10% below preoperative values did not differ for patients with and without POCD at discharge (difference=0.0 min; Hodges-Lehmann 95% confidence interval, -3.11-1.47, P=0.88). Other rScO2 time thresholds that were assessed were also not significantly different between those with and without POCD at discharge. This applied both to absolute rScO2 values and relative changes from preoperative values. Similar results were found in relation to POCD at 3 months. CONCLUSIONS No significant association was found between intraoperative rScO2 values and POCD. These findings bring into question the rationale for attempting to avoid decreases in rScO2 if the goal is to prevent POCD. CLINICAL TRIAL REGISTRATION NCT02185885.
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Affiliation(s)
- Frederik Holmgaard
- Department of Cardiothoracic Anesthesia, Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Anne G Vedel
- Department of Cardiothoracic Anesthesia, Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; Department of Anesthesia, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Lars S Rasmussen
- Department of Anesthesia, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Olaf B Paulson
- Neurobiological Research Unit, The Neuro Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jens C Nilsson
- Department of Cardiothoracic Anesthesia, Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Hanne B Ravn
- Department of Cardiothoracic Anesthesia, Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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30
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Yuan SM, Lin H. Postoperative Cognitive Dysfunction after Coronary Artery Bypass Grafting. Braz J Cardiovasc Surg 2019; 34:76-84. [PMID: 30810678 PMCID: PMC6385821 DOI: 10.21470/1678-9741-2018-0165] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 09/21/2018] [Indexed: 12/18/2022] Open
Abstract
Postoperative cognitive dysfunction is a common complication following cardiac
surgery. The incidence of cognitive dysfunction is more pronounced in patients
receiving a cardiac operation than in those undergoing a non-cardiac operation.
Clinical observations demonstrated that pulsatile flow was superior to
nonpulsatile flow, and membrane oxygenator was superior to bubble oxygenator in
terms of postoperative cognitive status. Nevertheless, cognitive assessments in
patients receiving an on-pump and off-pump coronary artery bypass surgery have
yielded inconsistent results. The exact mechanisms of postoperative cognitive
dysfunction following coronary artery bypass grafting remain uncertain. The dual
effects, neuroprotective and neurotoxic, of anesthetics should be thoroughly
investigated. The diagnosis should be based on a comprehensive cognitive
evaluation with neuropsychiatric tests, cerebral biomarker inspections, and
electroencephalographic examination. The management strategies for cognitive
dysfunction can be preventive or therapeutic. The preventive strategies of
modifying surgical facilities and techniques can be effective for preventing the
development of postoperative cognitive dysfunction. Investigational therapies
may offer novel strategies of treatments. Anesthetic preconditioning might be
helpful for the improvement of this dysfunction.
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Affiliation(s)
- Shi-Min Yuan
- Department of Cardiothoracic Surgery, The First Hospital of Putian, Teaching Hospital, Fujian Medical University, Putian, Fujian Province, People's Republic of China
| | - Hong Lin
- Department of Cardiology, The First Hospital of Putian, Teaching Hospital, Fujian Medical University, Putian, Fujian Province, People's Republic of China
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31
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Oldham MA, Vachon J, Yuh D, Lee HB. Cognitive Outcomes After Heart Valve Surgery: A Systematic Review and Meta-Analysis. J Am Geriatr Soc 2018; 66:2327-2334. [PMID: 30307031 DOI: 10.1111/jgs.15601] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To summarize evidence on cognitive outcomes after heart valve surgery; secondary aim, to examine whether aortic and mitral valve surgery are associated with different cognitive outcomes. DESIGN Preferred Reporting Items for Systematic Reviews and Meta-Analyses systematic review and meta-analysis. SETTING Cardiac surgery. PARTICIPANTS Individuals undergoing heart valve surgery. MEASUREMENTS We searched MEDLINE, EMBASE, and PsycINFO for peer-reviewed reports of individuals undergoing heart valve surgery who underwent pre- and postoperative cognitive assessment. Our initial search returned 1,475 articles, of which 12 were included. Postoperative cognitive results were divided into those from 1 week to 1 month (early outcomes, npooled = 450) and from 2 to 6 months (intermediate outcomes; npooled = 722). No studies with longer-term outcomes were identified. RESULTS Subjects had moderate early cognitive decline from baseline (Becker mean gain effect size (ES)=-0.39 ± 0.27) that improved slightly by 2 to 6 months (ES=-0.25 ± 0.38). Individuals undergoing aortic valve surgery-who were older on average than those undergoing mitral valve surgery (68 vs 57)-had greater early cognitive decline than those undergoing mitral valve surgery (ES=-0.68 vs -0.12), but both cohorts had similar decline 2 to 6 months postoperatively (ES=-0.27 vs -0.20). CONCLUSIONS Heart valve surgery is associated with cognitive decline over the 6 months after surgery, but outcomes beyond 6 months are unclear. These findings highlight the cognitive vulnerability of this population, especially older adults with aortic stenosis. © 2018 American Geriatrics Society and Wiley Periodicals, Inc. J Am Geriatr Soc 66:2327-2334, 2018.
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Affiliation(s)
- Mark A Oldham
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York
| | - Jacqueline Vachon
- Oncology Department, Ingram School of Nursing, McGill University, Montréal, Quebec, Canada
| | - David Yuh
- Department of Surgery, Stamford Hospital, Stamford, Connecticut
| | - Hochang B Lee
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York
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Berger M, Terrando N, Smith SK, Browndyke JN, Newman MF, Mathew JP. Neurocognitive Function after Cardiac Surgery: From Phenotypes to Mechanisms. Anesthesiology 2018; 129:829-851. [PMID: 29621031 PMCID: PMC6148379 DOI: 10.1097/aln.0000000000002194] [Citation(s) in RCA: 146] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
For half a century, it has been known that some patients experience neurocognitive dysfunction after cardiac surgery; however, defining its incidence, course, and causes remains challenging and controversial. Various terms have been used to describe neurocognitive dysfunction at different times after cardiac surgery, ranging from "postoperative delirium" to "postoperative cognitive dysfunction or decline." Delirium is a clinical diagnosis included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Postoperative cognitive dysfunction is not included in the DSM-5 and has been heterogeneously defined, though a recent international nomenclature effort has proposed standardized definitions for it. Here, the authors discuss pathophysiologic mechanisms that may underlie these complications, review the literature on methods to prevent them, and discuss novel approaches to understand their etiology that may lead to novel treatment strategies. Future studies should measure both delirium and postoperative cognitive dysfunction to help clarify the relationship between these important postoperative complications.
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Affiliation(s)
- Miles Berger
- Assistant Professor, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Niccolò Terrando
- Assistant Professor, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - S. Kendall Smith
- Critical Care Fellow, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Jeffrey N. Browndyke
- Assistant Professor, Division of Geriatric Behavioral Health, Department of Psychiatry & Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - Mark F. Newman
- Merel H. Harmel Professor of Anesthesiology, and President of the Private Diagnostic Clinic, Duke University Medical Center, Durham, NC
| | - Joseph P. Mathew
- Jerry Reves, MD Professor and Chair, Department of Anesthesiology, Duke University Medical Center, Durham, NC
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Semrau JS, Scott SH, Hamilton AG, Petsikas D, Payne DM, Bisleri G, Saha T, Boyd JG. The relationship between cerebral oxygen saturation and quantitative metrics of neurological function after coronary bypass surgery: a feasibility study. THE JOURNAL OF CARDIOVASCULAR SURGERY 2018; 59:716-728. [PMID: 29616521 DOI: 10.23736/s0021-9509.18.10280-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND It is well-known that patients undergoing coronary artery bypass grafting (CABG) surgery may experience neurological dysfunction following their operation. However, the nature of this dysfunction has not been properly quantified. Furthermore, the relationship between postoperative impairment and cerebral oxygen saturation during surgery has remained unclear. This study aims to define the feasibility of using robotic technology to quantify post-CABG neurocognitive function, and to correlate these objective metrics with intraoperative cerebral oxygenation. METHODS Neurological function was tested using robotic technology and a standardized questionnaire before and 3 months after surgery. In addition, frontal lobe cerebral oxygenation was recorded using the FORESIGHT near-infrared spectrometer for the duration of the operation. Pre- and postoperative neurological assessment was performed for 24 participants. Of those 24, 20 participants had cerebral oxygenation recorded during their surgery. RESULTS The cerebral oximeter captured 97.2% of the data. Majority of patients experienced no significant decline in overall neurocognitive function. Abnormal postoperative scores were most frequent in a sensorimotor task that involved additional cognitive load. In this reverse visually guided reaching task, postoperative scores significantly correlated with mean and minimum intraoperative cerebral oxygenation values, with lower values being associated with worse performance. CONCLUSIONS It is feasible to use robotic technology as a quantitative and objective neurocognitive assessment method for patients undergoing CABG. The relationship between quantitative metrics of neurocognitive function and intraoperative cerebral oxygenation warrants further investigation.
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Affiliation(s)
- Joanna S Semrau
- Center for Neuroscience Studies, Queen's University, Kingston, Canada
| | - Stephen H Scott
- Center for Neuroscience Studies, Queen's University, Kingston, Canada.,Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Canada
| | - Andrew G Hamilton
- Kingston General Hospital, Kingston, Canada.,Department of Surgery, Queen's University, Kingston, Canada
| | - Dimitri Petsikas
- Kingston General Hospital, Kingston, Canada.,Department of Surgery, Queen's University, Kingston, Canada
| | - Darrin M Payne
- Kingston General Hospital, Kingston, Canada.,Department of Surgery, Queen's University, Kingston, Canada
| | - Gianluigi Bisleri
- Kingston General Hospital, Kingston, Canada.,Department of Surgery, Queen's University, Kingston, Canada
| | - Tarit Saha
- Kingston General Hospital, Kingston, Canada.,Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Canada
| | - John G Boyd
- Center for Neuroscience Studies, Queen's University, Kingston, Canada - .,Kingston General Hospital, Kingston, Canada.,Department of Critical Care (Neurology), Queen's University, Kingston, Canada
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Nontshe M, Khan S, Mandebvu T, Merrifield B, Rodseth RN. Sample-size determination and adherence in randomised controlled trials published in anaesthetic journals. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2018. [DOI: 10.1080/22201181.2018.1439602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- M Nontshe
- Metropolitan Department of Anaesthetics, Critical Care and Pain Management, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - S Khan
- Metropolitan Department of Anaesthetics, Critical Care and Pain Management, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - T Mandebvu
- Metropolitan Department of Anaesthetics, Critical Care and Pain Management, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - B Merrifield
- Metropolitan Department of Anaesthetics, Critical Care and Pain Management, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - RN Rodseth
- Metropolitan Department of Anaesthetics, Critical Care and Pain Management, University of KwaZulu-Natal, Pietermaritzburg, South Africa
- Outcomes Research Consortium, Cleveland Clinic, Cleveland, OH, USA
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Şahan C, Sungur Z, Çamcı E, Sivrikoz N, Sayin Ö, Gurvit H, Şentürk M. Effects of cerebral oxygen changes during coronary bypass surgery on postoperative cognitive dysfunction in elderly patients: a pilot study. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2018. [PMID: 29287674 PMCID: PMC9391798 DOI: 10.1016/j.bjane.2017.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and objectives Postoperative cognitive dysfunction is common after cardiac surgery. Adequate cerebral perfusion is essential and near infrared spectroscopy (NIRS) can measure cerebral oxygenation. Aim of this study is to compare incidence of early and late postoperative cognitive dysfunction in elderly patients treated with conventional or near infrared spectroscopy monitoring. Methods Patients undergoing coronary surgery above 60 years, were included and randomized to 2 groups; control and NIRS groups. Peroperative management was NIRS guided in GN; and with conventional approach in control group. Test battery was performed before surgery, at first week and 3rd month postoperatively. The battery comprised clock drawing, memory, word list generation, digit spam and visuospatial skills subtests. Postoperative cognitive dysfunction was defined as drop of 1 SD (standard deviation) from baseline on two or more tests. Mann-Whitney U test was used for comparison of quantitative measurements; Chi-square exact test to compare quantitative data. Results Twenty-one patients in control group and 19 in NIRS group completed study. Demographic and operative data were similar. At first week postoperative cognitive dysfunction were present in 9 (45%) and 7 (41%) of patients in control group and NIRS group respectively. At third month 10 patients (50%) were assessed as postoperative cognitive dysfunction; incidence was 4 (24%) in NIRS group (p:0.055). Early and late postoperative cognitive dysfunction group had significantly longer ICU stay (1.74 + 0.56 vs. 2.94 + 0.95; p < 0.001; 1.91 + 0.7 vs. 2.79 + 1.05; p < 0.01) and longer hospital stay (9.19 + 2.8 vs. 11.88 + 1.7; p < 0.01; 9.48 + 2.6 vs. 11.36 + 2.4; p < 0.05). Conclusion In this pilot study conventional monitoring and near infrared spectroscopy resulted in similar rates of early postoperative cognitive dysfunction. Late cognitive dysfunction tended to ameliorate with near infrared spectroscopy. Early and late cognitive declines were associated with prolonged ICU and hospital stays.
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Intraoperative cerebral oximetry-based management for optimizing perioperative outcomes: a meta-analysis of randomized controlled trials. Can J Anaesth 2018; 65:529-542. [DOI: 10.1007/s12630-018-1065-7] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 12/10/2017] [Accepted: 12/10/2017] [Indexed: 12/13/2022] Open
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[Effects of cerebral oxygen changes during coronary bypass surgery on postoperative cognitive dysfunction in elderly patients: a pilot study]. Rev Bras Anestesiol 2017; 68:142-148. [PMID: 29287674 DOI: 10.1016/j.bjan.2017.10.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 10/05/2017] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Postoperative cognitive dysfunction is common after cardiac surgery. Adequate cerebral perfusion is essential and near infrared spectroscopy (NIRS) can measure cerebral oxygenation. Aim of this study is to compare incidence of early and late postoperative cognitive dysfunction in elderly patients treated with conventional or near infrared spectroscopy monitoring. METHODS Patients undergoing coronary surgery above 60 years, were included and randomized to 2 groups; control and NIRS groups. Peroperative management was NIRS guided in GN; and with conventional approach in control group. Test battery was performed before surgery, at first week and 3 rd month postoperatively. The battery comprised clock drawing, memory, word list generation, digit spam and visuospatial skills subtests. Postoperative cognitive dysfunction was defined as drop of 1 SD (standard deviation) from baseline on two or more tests. Mann-Whitney U test was used for comparison of quantitative measurements; Chi-square exact test to compare quantitative data. RESULTS Twenty-one patients in control group and 19 in NIRS group completed study. Demographic and operative data were similar. At first week postoperative cognitive dysfunction were present in 9 (45%) and 7 (41%) of patients in control group and NIRS group respectively. At third month 10 patients (50%) were assessed as postoperative cognitive dysfunction; incidence was 4 (24%) in NIRS group (p:0.055). Early and late postoperative cognitive dysfunction group had significantly longer ICU stay (1.74+0.56 vs. 2.94+0.95; p<0.001; 1.91+0.7 vs. 2.79+1.05; p<0.01) and longer hospital stay (9.19+2.8 vs. 11.88+1.7; p<0.01; 9.48+2.6 vs. 11.36+2.4; p<0.05). CONCLUSION In this pilot study conventional monitoring and near infrared spectroscopy resulted in similar rates of early postoperative cognitive dysfunction. Late cognitive dysfunction tended to ameliorate with near infrared spectroscopy. Early and late cognitive declines were associated with prolonged ICU and hospital stays.
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Serraino GF, Murphy GJ. Effects of cerebral near-infrared spectroscopy on the outcome of patients undergoing cardiac surgery: a systematic review of randomised trials. BMJ Open 2017; 7:e016613. [PMID: 28882917 PMCID: PMC5595187 DOI: 10.1136/bmjopen-2017-016613] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES Goal-directed optimisation of cerebral oxygenation using near-infrared spectroscopy (NIRS) during cardiopulmonary bypass is widely used. We tested the hypotheses that the use of NIRS cerebral oximetry results in reductions in cerebral injury (neurocognitive function, serum biomarkers), injury to other organs including the heart and brain, transfusion rates, mortality and resource use. DESIGN Systematic review and meta-analysis. SETTING Tertiary cardiac surgery centres in North America, Europe and Asia. PARTICIPANTS A search of Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, Medline, Embase, and the Cumulative Index to Nursing and Allied Health Literature Plus from inception to November 2016 identified 10 randomised trials, enrolling a total of 1466 patients, all in adult cardiac surgery. INTERVENTIONS NIRS-based algorithms designed to optimise cerebral oxygenation versus standard care (non-NIRS-based) protocols in cardiac surgery patients during cardiopulmonary bypass. OUTCOME MEASURES Mortality, organ injury affecting the brain, heart and kidneys, red cell transfusion and resource use. RESULTS Two of the 10 trials identified in the literature search were considered at low risk of bias. Random-effects meta-analysis demonstrated similar mortality (risk ratio (RR) 0.76, 95% CI 0.30 to 1.96), major morbidity including stroke (RR 1. 08, 95% CI 0.40 to 2.91), red cell transfusion and resource use in NIRS-treated patients and controls, with little or no heterogeneity. Grades of Recommendation, Assessment, Development and Evaluation of the quality of the evidence was low or very low for all of the outcomes assessed. CONCLUSIONS The results of this systematic review did not support the hypotheses that cerebral NIRS-based algorithms have clinical benefits in cardiac surgery. TRIAL REGISTRATION NUMBER PROSPERO CRD42015027696.
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Affiliation(s)
- Giuseppe Filiberto Serraino
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, UK
| | - Gavin J Murphy
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, UK
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Murphy GJ, Mumford AD, Rogers CA, Wordsworth S, Stokes EA, Verheyden V, Kumar T, Harris J, Clayton G, Ellis L, Plummer Z, Dott W, Serraino F, Wozniak M, Morris T, Nath M, Sterne JA, Angelini GD, Reeves BC. Diagnostic and therapeutic medical devices for safer blood management in cardiac surgery: systematic reviews, observational studies and randomised controlled trials. PROGRAMME GRANTS FOR APPLIED RESEARCH 2017. [DOI: 10.3310/pgfar05170] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BackgroundAnaemia, coagulopathic bleeding and transfusion are strongly associated with organ failure, sepsis and death following cardiac surgery.ObjectiveTo evaluate the clinical effectiveness and cost-effectiveness of medical devices used as diagnostic and therapeutic tools for the management of anaemia and bleeding in cardiac surgery.Methods and resultsWorkstream 1 – in the COagulation and Platelet laboratory Testing in Cardiac surgery (COPTIC) study we demonstrated that risk assessment using baseline clinical factors predicted bleeding with a high degree of accuracy. The results from point-of-care (POC) platelet aggregometry or viscoelastometry tests or an expanded range of laboratory reference tests for coagulopathy did not improve predictive accuracy beyond that achieved with the clinical risk score alone. The routine use of POC tests was not cost-effective. A systematic review concluded that POC-based algorithms are not clinically effective. We developed two new clinical risk prediction scores for transfusion and bleeding that are available as e-calculators. Workstream 2 – in the PAtient-SPecific Oxygen monitoring to Reduce blood Transfusion during heart surgery (PASPORT) trial and a systematic review we demonstrated that personalised near-infrared spectroscopy-based algorithms for the optimisation of tissue oxygenation, or as indicators for red cell transfusion, were neither clinically effective nor cost-effective. Workstream 3 – in the REDWASH trial we failed to demonstrate a reduction in inflammation or organ injury in recipients of mechanically washed red cells compared with standard (unwashed) red cells.LimitationsExisting studies evaluating the predictive accuracy or effectiveness of POC tests of coagulopathy or near-infrared spectroscopy were at high risk of bias. Interventions that alter red cell transfusion exposure, a common surrogate outcome in most trials, were not found to be clinically effective.ConclusionsA systematic assessment of devices in clinical use as blood management adjuncts in cardiac surgery did not demonstrate clinical effectiveness or cost-effectiveness. The contribution of anaemia and coagulopathy to adverse clinical outcomes following cardiac surgery remains poorly understood. Further research to define the pathogenesis of these conditions may lead to more accurate diagnoses, more effective treatments and potentially improved clinical outcomes.Study registrationCurrent Controlled Trials ISRCTN20778544 (COPTIC study) and PROSPERO CRD42016033831 (systematic review) (workstream 1); Current Controlled Trials ISRCTN23557269 (PASPORT trial) and PROSPERO CRD4201502769 (systematic review) (workstream 2); and Current Controlled Trials ISRCTN27076315 (REDWASH trial) (workstream 3).FundingThis project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 5, No. 17. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Gavin J Murphy
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Andrew D Mumford
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, UK
| | - Chris A Rogers
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Elizabeth A Stokes
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Veerle Verheyden
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Tracy Kumar
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Jessica Harris
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Gemma Clayton
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Lucy Ellis
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Zoe Plummer
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - William Dott
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Filiberto Serraino
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Marcin Wozniak
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Tom Morris
- Leicester Clinical Trials Unit, University of Leicester, Leicester, UK
| | - Mintu Nath
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Jonathan A Sterne
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Gianni D Angelini
- Bristol Heart Institute, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Barnaby C Reeves
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
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Chan MJ, Chung T, Glassford NJ, Bellomo R. Near-Infrared Spectroscopy in Adult Cardiac Surgery Patients: A Systematic Review and Meta-Analysis. J Cardiothorac Vasc Anesth 2017; 31:1155-1165. [DOI: 10.1053/j.jvca.2017.02.187] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Indexed: 11/11/2022]
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Kok WF, Koerts J, Tucha O, Scheeren TWL, Absalom AR. Neuronal damage biomarkers in the identification of patients at risk of long-term postoperative cognitive dysfunction after cardiac surgery. Anaesthesia 2016; 72:359-369. [DOI: 10.1111/anae.13712] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2016] [Indexed: 11/29/2022]
Affiliation(s)
- W. F. Kok
- Department of Clinical Pharmacy and Pharmacology; University Medical Centre Groningen; University of Groningen; Groningen The Netherlands
| | - J. Koerts
- Department of Clinical and Developmental Neuropsychology; University Medical Centre Groningen; University of Groningen; Groningen The Netherlands
| | - O. Tucha
- Department of Clinical and Developmental Neuropsychology; University Medical Centre Groningen; University of Groningen; Groningen The Netherlands
| | - T. W. L. Scheeren
- Department of Anesthesiology; University Medical Centre Groningen; University of Groningen; Groningen The Netherlands
| | - A. R. Absalom
- Department of Anesthesiology; University Medical Centre Groningen; University of Groningen; Groningen The Netherlands
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Rasmussen LA, Ryhammer PK, Greisen J, Bhavsar RR, Lorentzen AG, Jakobsen CJ. Ultrashort acting remifentanil is not superior to long-acting sufentanil in preserving cognitive function—a randomized study. J Clin Anesth 2016; 33:127-34. [DOI: 10.1016/j.jclinane.2016.03.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Revised: 01/30/2016] [Accepted: 03/08/2016] [Indexed: 10/21/2022]
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Hovens IB, van Leeuwen BL, Mariani MA, Kraneveld AD, Schoemaker RG. Postoperative cognitive dysfunction and neuroinflammation; Cardiac surgery and abdominal surgery are not the same. Brain Behav Immun 2016; 54:178-193. [PMID: 26867718 DOI: 10.1016/j.bbi.2016.02.003] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 01/25/2016] [Accepted: 02/07/2016] [Indexed: 12/21/2022] Open
Abstract
Postoperative cognitive dysfunction (POCD) is a debilitating surgical complication, with cardiac surgery patients at particular risk. To gain insight in the mechanisms underlying the higher incidence of POCD after cardiac versus non-cardiac surgery, systemic and central inflammatory changes, alterations in intraneuronal pathways, and cognitive performance were studied after cardiac and abdominal surgery in rats. Male Wistar rats were subjected to ischemia reperfusion of the upper mesenteric artery (abdominal surgery) or the left coronary artery (cardiac surgery). Control rats remained naïve, received anesthesia only, or received thoracic sham surgery. Rats were subjected to affective and cognitive behavioral tests in postoperative week 2. Plasma concentrations of inflammatory factors, and markers for neuroinflammation (NGAL and microglial activity) and the BDNF pathway (BDNF, p38MAPK and DCX) were determined. Spatial memory was impaired after both abdominal and cardiac surgery, but only cardiac surgery impaired spatial learning and object recognition. While all surgical procedures elicited a pronounced acute systemic inflammatory response, NGAL and TNFα levels were particularly increased after abdominal surgery. Conversely, NGAL in plasma and the paraventricular nucleus of the hypothalamus and microglial activity in hippocampus and prefrontal cortex on postoperative day 14 were increased after cardiac, but not abdominal surgery. Both surgery types induced hippocampal alterations in BDNF signaling. These results suggest that POCD after cardiac surgery, compared to non-cardiac surgery, affects different cognitive domains and hence may be more extended rather than more severe. Moreover, while abdominal surgery effects seem limited to hippocampal brain regions, cardiac surgery seems associated with more wide spread alterations in the brain.
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Affiliation(s)
- Iris B Hovens
- Department of Molecular Neurobiology, University of Groningen, Nijenborgh 7, 9747 AG Groningen, The Netherlands; Department of Surgery and Surgical Oncology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands.
| | - Barbara L van Leeuwen
- Department of Surgery and Surgical Oncology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Massimo A Mariani
- Department of Cardio-Thoracic Surgery, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Aletta D Kraneveld
- Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Universiteitsweg 99, 3584 CG Utrecht, The Netherlands
| | - Regien G Schoemaker
- Department of Molecular Neurobiology, University of Groningen, Nijenborgh 7, 9747 AG Groningen, The Netherlands; Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
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Kowalewski M, Pawliszak W, Malvindi PG, Bokszanski MP, Perlinski D, Raffa GM, Kowalkowska ME, Zaborowska K, Navarese EP, Kolodziejczak M, Kowalewski J, Tarelli G, Taggart DP, Anisimowicz L. Off-pump coronary artery bypass grafting improves short-term outcomes in high-risk patients compared with on-pump coronary artery bypass grafting: Meta-analysis. J Thorac Cardiovasc Surg 2015; 151:60-77.e1-58. [PMID: 26433633 DOI: 10.1016/j.jtcvs.2015.08.042] [Citation(s) in RCA: 131] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 07/27/2015] [Accepted: 08/12/2015] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To assess the benefits and risks of off-pump coronary artery bypass (OPCAB) versus coronary artery bypass grafting (CABG) through a meta-analysis of randomized controlled trials (RCTs), and to investigate the relationship between outcomes and patient risk profile. METHODS PubMed, Embase, the Cumulative Index of Nursing and Allied Health Literature, Scopus, Web of Science, Cochrane Library, and major conference proceedings databases were searched for RCTs comparing OPCAB and CABG and reporting short-term (≤ 30 days) outcomes. Endpoints assessed were all-cause mortality, myocardial infarction (MI), and cerebral stroke. RESULTS The meta-analysis included 100 studies, with a total of 19,192 subjects. There was no difference between the 2 techniques with respect to all-cause mortality and MI (odds ratio [OR], 0.88; 95% confidence interval [CI], 0.71-1.09; P = .25; I(2) = 0% and OR, 0.90; 95% CI, 0.77-1.05; P = .19; I(2) = 0%, respectively). OPCAB was associated with a significant 28% reduction in the odds of cerebral stroke (OR, 0.72; 95% CI, 0.56-0.92; P = .009; I(2) = 0%). A significant relationship between patient risk profile and benefits from OPCAB was found in terms of all-cause mortality (P < .01), MI (P < .01), and cerebral stroke (P < .01). CONCLUSIONS OPCAB is associated with a significant reduction in the odds of cerebral stroke compared with conventional CABG. In addition, benefits of OPCAB in terms of death, MI, and cerebral stroke are significantly related to patient risk profile, suggesting that OPCAB should be strongly considered in high-risk patients.
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Affiliation(s)
- Mariusz Kowalewski
- Department of Cardiac Surgery, Dr Antoni Jurasz Memorial University Hospital, Bydgoszcz, Poland; Faculty of Health Sciences, Nicolaus Copernicus University, Collegium Medicum, Bydgoszcz, Poland; Systematic Investigation and Research on Interventions and Outcomes (SIRIO) MEDICINE Research Network, Düsseldorf, Germany.
| | - Wojciech Pawliszak
- Department of Cardiac Surgery, Dr Antoni Jurasz Memorial University Hospital, Bydgoszcz, Poland
| | - Pietro Giorgio Malvindi
- University Hospital Southampton NHS Foundation Trust, Wessex Cardiothoracic Centre, Southampton, United Kingdom
| | - Marek Pawel Bokszanski
- Department of Cardiac Surgery, Dr Antoni Jurasz Memorial University Hospital, Bydgoszcz, Poland
| | - Damian Perlinski
- Department of Cardiac Surgery, Dr Antoni Jurasz Memorial University Hospital, Bydgoszcz, Poland
| | - Giuseppe Maria Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS - ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Magdalena Ewa Kowalkowska
- Systematic Investigation and Research on Interventions and Outcomes (SIRIO) MEDICINE Research Network, Düsseldorf, Germany; Department and Clinic of Obstetrics, Gynecology, and Oncological Gynecology, Collegium Medicum, Bydgoszcz, Poland
| | - Katarzyna Zaborowska
- Department of Cardiac Surgery, Dr Antoni Jurasz Memorial University Hospital, Bydgoszcz, Poland
| | - Eliano Pio Navarese
- Systematic Investigation and Research on Interventions and Outcomes (SIRIO) MEDICINE Research Network, Düsseldorf, Germany; Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Michalina Kolodziejczak
- Systematic Investigation and Research on Interventions and Outcomes (SIRIO) MEDICINE Research Network, Düsseldorf, Germany; Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Toruń, Poland
| | - Janusz Kowalewski
- Lung Cancer and Thoracic Surgery Department, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Toruń, Poland
| | - Giuseppe Tarelli
- Department of Cardiac Surgery, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - David Paul Taggart
- Department of Cardiac Surgery, John Radcliffe Hospital, Oxford, United Kingdom
| | - Lech Anisimowicz
- Department of Cardiac Surgery, Dr Antoni Jurasz Memorial University Hospital, Bydgoszcz, Poland
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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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Hillebrand J, Zheng Z, Ploss A, Herrmann E, Moritz A, Martens S. Axillary artery cannulation provides balanced cerebral oxygenation. Heart Vessels 2015; 31:1077-83. [PMID: 26113457 DOI: 10.1007/s00380-015-0704-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 06/12/2015] [Indexed: 10/23/2022]
Abstract
Deterioration of cerebral performance remains a major problem after cardiac surgery. Axillary artery cannulation can improve clinical outcome, but some experimental series show a malperfusion of the right hemisphere. The aim of our clinical study was to analyze the intraoperative investigation of cerebral oxygenation in two different arterial cannulation sites by use of near-infrared spectroscopic oximetry (NIRO). We compared retrospectively the cerebral saturation of 20 patients with aortic cannulation (group AoC) and 20 patients with right axillary artery cannulation (group AxC) during either valve, coronary artery bypass graft (CABG), combined procedures, or aortic surgery. Patients were monitored with bihemispheric NIRO (NIRO-200, Hamamatsu, Herrsching, Germany). The oxygenation data were calculated as tissue oxygenation index (TOI). And the cardiopulmonary bypass time was considered with special regard to potentially dangerous phases for cerebral desaturation like the starting of the extracorporeal circulation (ECC), cross-clamping, rewarming phase, aortic declamping, and stopping of ECC. Patients were then postoperatively evaluated by a standardized neurological examination. During the entire CPB time and the specific phases potentially at risk for cerebral desaturation, no statistically significant drop of cerebral oxygenation (>20 % for >60 s) was detected after aortic and right axillary artery cannulation, respectively. Furthermore, no significant difference in TOI was found comparing the left and right hemisphere in each group. Postoperatively 2 transient confusional syndromes (CS) were observed after aortic and 3 CS after axillary artery cannulation. Right axillary artery cannulation provides balanced cerebral oxygenation in both hemispheres during extracorporeal circulation and its specific phases potentially at risk for cerebral malperfusion. It might therefore reduce the risk of neurological injury by reduction of solid embolization and maintenance of balanced cerebral oxygenation.
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Affiliation(s)
- Julia Hillebrand
- Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University Hospital of the Westfaelische Wilhelms-University Muenster, Albert-Schweitzer-Campus 1, D-48159, Muenster, Germany.
| | - Zhi Zheng
- Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe-University Hospital, Frankfurt am Main, Germany
| | - Anja Ploss
- Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe-University Hospital, Frankfurt am Main, Germany
| | - Eva Herrmann
- Institute of Biostatistics and Mathematical Modeling, Johann Wolfgang Goethe-University Hospital, Frankfurt am Main, Germany
| | - Anton Moritz
- Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe-University Hospital, Frankfurt am Main, Germany
| | - Sven Martens
- Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University Hospital of the Westfaelische Wilhelms-University Muenster, Albert-Schweitzer-Campus 1, D-48159, Muenster, Germany
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