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Luo T, Deng Z, Ren Q, Mu F, Zhang Y, Wang H. Effects of esketamine on postoperative negative emotions and early cognitive disorders in patients undergoing non-cardiac thoracic surgery: A randomized controlled trial. J Clin Anesth 2024; 95:111447. [PMID: 38522144 DOI: 10.1016/j.jclinane.2024.111447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 12/10/2023] [Accepted: 03/10/2024] [Indexed: 03/26/2024]
Abstract
STUDY OBJECTIVE To investigate whether a single dosage of esketamine injection in the anesthesia period could improve postoperative negative emotions and early cognitive function in patients undergoing non-cardiac thoracic surgery. DESIGN A prospective single center double blinded randomized placebo-controlled trial. SETTING Perioperative period; operating room, post anesthesia care unit and hospital ward. PATIENTS 129 adult patients that underwent elective non-cardiac thoracic surgery under general anesthesia. INTERVENTIONS During the operation, pharmacologic prevention of postoperative negative emotion and early cognitive disorder with 0.2 mg/kg (Low esketamine group) and 0.5 mg/kg esketamine (High esketamine group) vs. placebo. MEASUREMENTS Emotion and early cognitive performance were assessed on the day before surgery (POD-1), postoperative day 1 (POD1) and day 3 (POD3) using HADS-A, HADS-D, Pain Visual Analogue Scale (VAS), Confusion Assessment Method (CAM), Mini-Mental State Examination (MMSE), and serum biomarkers (S100β, BDNF, IL-6, acetylcholine, and norepinephrine). MAIN RESULTS The high esketamine group showed significantly lower HADS-A and HADS-D scores than control group on POD1 and POD3. No significant differences were observed between the low esketamine group and the control group. The esketamine-treated groups showed lower pain VAS scores than the control group at 2 h and on the first day after operation. There were no significant differences among the three groups in CAM and MMSE scores. However, the high esketamine group had lower S100β and IL-6 levels, and higher BDNF levels postoperatively, while serum acetylcholine and norepinephrine were not significantly different. CONCLUSIONS A single intraoperative injection of 0.5 mg/kg esketamine can alleviate postoperative anxiety, depression, and pain to some extent. Although cognitive function behavioral evaluation did not show obvious benefits, it can also reduce the production of pro-inflammatory and brain injury-related factors while promoting the generation of brain-derived neurotrophic factor. Registration Trial registry: http://www.chictr.org.cn/; Identifier: ChiCTR2100047067.
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Affiliation(s)
- Tianyuan Luo
- Department of Anesthesiology, Affiliated Hospital of Zunyi Medical University, Zunyi 563100, China; Guizhou Key Laboratory of Anesthesia and Organ Protection, Zunyi 563100, China
| | - Zhimin Deng
- Department of Anesthesiology, Affiliated Hospital of Zunyi Medical University, Zunyi 563100, China
| | - Qiyang Ren
- Department of Anesthesiology, Affiliated Hospital of Zunyi Medical University, Zunyi 563100, China
| | - Fangfang Mu
- Department of Anesthesiology, Affiliated Hospital of Zunyi Medical University, Zunyi 563100, China
| | - You Zhang
- Department of Anesthesiology, Affiliated Hospital of Zunyi Medical University, Zunyi 563100, China
| | - Haiying Wang
- Department of Anesthesiology, Affiliated Hospital of Zunyi Medical University, Zunyi 563100, China; Guizhou Key Laboratory of Anesthesia and Organ Protection, Zunyi 563100, China.
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Ozdemi̇r C, Isik B, Koca G, Inan MA. Effects of mid‑gestational sevoflurane and magnesium sulfate on maternal oxidative stress, inflammation and fetal brain histopathology. Exp Ther Med 2024; 28:286. [PMID: 38827470 PMCID: PMC11140313 DOI: 10.3892/etm.2024.12574] [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: 07/04/2023] [Accepted: 03/08/2024] [Indexed: 06/04/2024] Open
Abstract
Models of inflammation, oxidative stress, hyperoxia and hypoxia have demonstrated that magnesium sulfate (MgSO4), a commonly used drug in obstetrics, has neuroprotective potential. In the present study, the effects of MgSO4 treatment on inflammation, oxidative stress and fetal brain histopathology were evaluated in an experimental rat model following sevoflurane (Sv) exposure during the mid-gestational period. Rats were randomly divided into groups: C (control; no injections or anesthesia), Sv (exposure to 2.5% Sv for 2 h), MgSO4 (administered 270 mg/kg MgSO4 intraperitoneally) and Sv + MgSO4 (Sv administered 30 min after MgSO4 injection). Inflammatory and oxidative stress markers were measured in the serum and neurotoxicity was investigated histopathologically in fetal brain tissue. Short-term mid-gestational exposure to a 1.1 minimum alveolar concentration of Sv did not significantly increase the levels of any of the measured biochemical markers, except for TNF-α. Histopathological evaluations demonstrated no findings suggestive of pathological apoptosis, neuroinflammation or oxidative stress-induced cell damage. MgSO4 injection prior to anesthesia caused no significant differences in biochemical or histopathological marker levels compared to the C and Sv groups. The present study indicated that short-term exposure to Sv could potentially be considered a harmless external stimulus to the fetal brain.
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Affiliation(s)
- Cagri Ozdemi̇r
- Department of Anesthesiology and Reanimation, Mamak State Hospital, 06270 Ankara, Turkey
| | - Berrin Isik
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Gazi University, 06560 Ankara, Turkey
| | - Gulce Koca
- Department of Medical Biochemistry, Faculty of Medicine, Gazi University, 06560 Ankara, Turkey
| | - Mehmet Arda Inan
- Department of Medical Pathology, Faculty of Medicine, Gazi University, 06560 Ankara, Turkey
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Nešković N, Budrovac D, Kristek G, Kovačić B, Škiljić S. Postoperative cognitive dysfunction: Review of pathophysiology, diagnostics and preventive strategies. J Perioper Pract 2024:17504589241229909. [PMID: 38619150 DOI: 10.1177/17504589241229909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
Postoperative cognitive impairment is a common disorder after major surgery. Advances in medicine and treatment have resulted in an increasingly ageing population undergoing major surgical procedures. Since age is the most important risk factor for postoperative cognitive decline, it is not surprising that impairment of cognitive functions after surgery was recorded in almost a third of elderly patients. Postoperative cognitive dysfunction is part of the spectrum of postoperative cognitive impairment and researchers often confuse it with postoperative delirium and delayed neurocognitive recovery. This is the cause of great differences in the results of research that is focused on the incidence and possible prevention of postoperative cognitive dysfunction. In this review, we focused on current recommendations for a uniform nomenclature of postoperative cognitive impairment and diagnosis of postoperative cognitive dysfunction, the presumed pathophysiology of postoperative cognitive dysfunction and recommendations for its treatment and possible prevention strategies.
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Affiliation(s)
- Nenad Nešković
- Department of Anaesthesiology, Resuscitation and Intensive Care, Osijek University Hospital, Osijek, Croatia
- Medical Faculty Osijek, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
| | - Dino Budrovac
- Department of Anaesthesiology, Resuscitation and Intensive Care, Osijek University Hospital, Osijek, Croatia
- Medical Faculty Osijek, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
| | - Gordana Kristek
- Department of Anaesthesiology, Resuscitation and Intensive Care, Osijek University Hospital, Osijek, Croatia
- Medical Faculty Osijek, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
| | - Borna Kovačić
- Department of Anaesthesiology, Resuscitation and Intensive Care, Osijek University Hospital, Osijek, Croatia
- Department of General Surgery, Osijek University Hospital, Osijek, Croatia
| | - Sonja Škiljić
- Department of Anaesthesiology, Resuscitation and Intensive Care, Osijek University Hospital, Osijek, Croatia
- Medical Faculty Osijek, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
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Xiong X, Shao Y, Chen D, Chen B, Lan X, Shi J. Effect of Esketamine on Postoperative Delirium in Patients Undergoing Cardiac Valve Replacement with Cardiopulmonary Bypass: A Randomized Controlled Trial. Anesth Analg 2024:00000539-990000000-00781. [PMID: 38446699 DOI: 10.1213/ane.0000000000006925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
BACKGROUND The aim of this study was to investigate the effects of esketamine on the risk of postoperative delirium (POD) in adults undergoing on-pump cardiac valve surgery. METHODS In this randomized, triple-blind, controlled trial, 116 adult patients with an American Society of Anesthesiologists (ASA) grade Ⅱ or Ⅲ and a New York Heart Association (NYHA) grade Ⅱ or Ⅲ who underwent cardiac valve surgery with cardiopulmonary bypass were included. Esketamine (0.25 mg/kg) or normal saline was administered intravenously before anesthesia induction. The primary outcome was POD, defined as a positive delirium assessment according to the 3-minute confusion assessment method (CAM) or the confusion assessment method for the intensive care unit (CAM-ICU) on a twice-daily basis for 7 days after surgery. Delirium duration and the delirium subtype were also recorded. The cognitive status of patients was measured according to the Mini-Mental State Examination at baseline, discharge, 30 days postoperatively and 3 months postoperatively. RESULTS A total of 112 patients (mean age, 52 years; 53.6% female) were enrolled; 56 were assigned to receive esketamine, and 56 were assigned to receive placebo. POD occurred in 13 (23.2%) patients in the esketamine group and in 25 (44.6%) patients in the placebo group (relative risk [RR], 0.52, 95% confidence interval [CI], 0.28-0.91; P = .018). Thirteen patients (23.2%) in the esketamine group and 24 (42.9%) patients in the placebo group had multiple episodes of delirium (RR, 0.54, 95% CI, 0.28-0.92), and 13 (23.2%) vs 22 (39.3%) patients exhibited the hyperactive subtype. CONCLUSIONS A single dose of esketamine (0.25 mg/kg) injected intravenously before anesthesia induction reduced the incidence of delirium in relatively young patients with ASA grade Ⅱ or Ⅲ who underwent on-pump cardiac surgery.
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Affiliation(s)
- Xinglong Xiong
- From the Department of Anesthesiology, The Affiliated Hospital of Guizhou Medical University, Guiyang, P. R. China
| | - Yi Shao
- From the Department of Anesthesiology, The Affiliated Hospital of Guizhou Medical University, Guiyang, P. R. China
| | - Dongxu Chen
- Department of Anesthesiology, West China Second Hospital, Sichuan University, Chengdu, P. R. China
| | - Bo Chen
- From the Department of Anesthesiology, The Affiliated Hospital of Guizhou Medical University, Guiyang, P. R. China
| | - Xin Lan
- From the Department of Anesthesiology, The Affiliated Hospital of Guizhou Medical University, Guiyang, P. R. China
| | - Jing Shi
- From the Department of Anesthesiology, The Affiliated Hospital of Guizhou Medical University, Guiyang, P. R. China
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Zhang A, Zhou Y, Zheng X, Zhou W, Gu Y, Jiang Z, Yao Y, Wei W. Effects of S-ketamine added to patient-controlled analgesia on early postoperative pain and recovery in patients undergoing thoracoscopic lung surgery: A randomized double-blinded controlled trial. J Clin Anesth 2024; 92:111299. [PMID: 37939610 DOI: 10.1016/j.jclinane.2023.111299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 09/22/2023] [Accepted: 10/13/2023] [Indexed: 11/10/2023]
Abstract
STUDY OBJECTIVE To investigate whether the addition of S-ketamine to patient-controlled hydromorphone analgesia decreases postoperative moderate-to-severe pain and improves the quality of recovery (QoR) in patients undergoing thoracoscopic lung surgery. DESIGN Single-center prospective randomized double-blinded controlled trial. SETTING Tertiary university hospital. PATIENTS 242 patients undergoing thoracoscopic lung surgery. INTERVENTIONS Patients were randomized to receive intravenous patient-controlled analgesia (IV-PCA) with hydromorphone alone or hydromorphone combined with S-ketamine (0.5 mg/kg/48 h, 1 mg/kg/48 h, or 2 mg/kg/48 h). MEASUREMENTS Primary outcome was proportion of patients with moderate-to-severe pain. (numerical rating scale [NRS] pain scores ≥4 when coughing) within 2 days after surgery. Postoperative QoR scores and other prespecified outcomes were also recorded. MAIN RESULTS Of 242 enrolled patients, 220 were included in the final analysis. The results demonstrated that the incidence of postoperative moderate-to-severe pain was significantly different between the hydromorphone group and combined S-ketamine group (absolute difference, 27.9%; 95% confidence interval [CI], 11.7% to 42.1%; P < 0.001). Patients who received S-ketamine had lower NRS pain scores at rest and when coughing on postoperative day 1 (POD1; median difference 1 and 1, P < 0.001) and postoperative day 2 (POD2; median difference 1 and 1, P < 0.001). The QoR-15 scores were higher in the combined S-ketamine group on POD1 (mean difference 6, P < 0.001) and POD2 (mean difference 6, P < 0.001) than in the hydromorphone group. A higher dose of S-ketamine was associated with deeper sedation. No differences were detected in the other safety outcomes. CONCLUSIONS Addition of S-ketamine to IV-PCA hydromorphone significantly reduced the incidence of postoperative moderate-to-severe pain and improved the QoR in patients undergoing thoracoscopic lung surgery. TRIAL REGISTRATION Chinese Clinical Trail Register (identifier: ChiCTR2200058890).
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Affiliation(s)
- Anyu Zhang
- Department of Anesthesiology, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou 510095, Guangdong, China
| | - Yongxin Zhou
- Department of Anesthesiology, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou 510095, Guangdong, China
| | - Xi Zheng
- Department of Anesthesiology, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou 510095, Guangdong, China
| | - Weichao Zhou
- Department of Anesthesiology, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou 510095, Guangdong, China
| | - Yu Gu
- Department of Anesthesiology, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou 510095, Guangdong, China
| | - Zeyong Jiang
- Department of Thoracic Surgery, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou 510095, Guangdong, China
| | - Yonghua Yao
- Department of Anesthesiology, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou 510095, Guangdong, China
| | - Wei Wei
- Department of Anesthesiology, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou 510095, Guangdong, China.
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Zhou N, Chen C, Liu Y, Yu Z, Chen Y. Efficacy of intraoperative subanesthetic dose of ketamine/esketamine in preventing postoperative cognitive dysfunction: a systematic review and meta-analysis. Ther Adv Psychopharmacol 2023; 13:20451253231200261. [PMID: 37915364 PMCID: PMC10617260 DOI: 10.1177/20451253231200261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 08/21/2023] [Indexed: 11/03/2023] Open
Abstract
Background Postoperative cognitive dysfunction (POCD) is a common complication after anesthesia surgery, especially in older people, that can persist weeks or months after surgery as a short-term impairment of cognitive abilities, or even for a prolonged duration over years, potentially progressing into permanent cognitive dysfunction. However, the pathogenesis of POCD is not fully understood, and therefore an optimal solution for preventing POCD has yet to be established. Some studies have shown that intraoperative ketamine/esketamine reduces the incidence of POCD, but this remains controversial. Objectives We evaluated the effect of intraoperative subanesthetic doses of ketamine/esketamine versus no intervention in adults undergoing general anesthesia surgery on the incidence of POCD. Data Sources We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and searched the PubMed, Embase, Ovid, Cochrane, Scopus, and Web of Science databases for the MeSH terms 'ketamine', 'esketamine', and 'Postoperative Cognitive Complications' from database inception to 25 June 2023. Results We found no statistically significant difference in the incidence of POCD within 7 days for intraoperative subanesthetic dose of ketamine/esketamine compared with the control group [relative risk (RR) = 0.57, 95% confidence interval (CI): 0.32, 1.01], and the results from the subgroup analysis based on age (>60 years) also revealed that the difference was not statistically significant (RR = 0.49, 95% CI: 0.23, 1.04). Conclusion Compared with controls, intraoperative subanesthetic dose of ketamine/esketamine has no advantage in preventing POCD in patients, or in elderly patients. This study provides reference data for POCD research and clinical drug intervention strategies. Registration Prospective Register of Systematic Reviews (PROSPERO; registration number CRD42023401159).
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Affiliation(s)
- Na Zhou
- School of Nursing, Southwest Medical University, Luzhou, Sichuan Province, People’s Republic of China
- Department of Cardiology, The First Affiliated Hospital, Chengdu Medical College, Chengdu, Sichuan Province, People’s Republic of China
| | - Chengchuan Chen
- Department of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, People’s Republic of China
| | - Yubei Liu
- School of Nursing, Southwest Medical University, Luzhou, Sichuan Province, People’s Republic of China
| | - Zhaolan Yu
- Department of Nephrology, The Affiliated Hospital of Southwest Medical University, No. 25 Taiping Street, Luzhou, Sichuan Province 646000, People’s Republic of China
| | - Yanhua Chen
- Department of Nursing, The Affiliated Hospital of Southwest Medical University, No. 25 Taiping Street, Luzhou, Sichuan Province 646000, People’s Republic of China
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Viderman D, Aubakirova M, Nabidollayeva F, Yegembayeva N, Bilotta F, Badenes R, Abdildin Y. Effect of Ketamine on Postoperative Neurocognitive Disorders: A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:4314. [PMID: 37445346 DOI: 10.3390/jcm12134314] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/16/2023] [Accepted: 06/21/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND Neurocognitive alterations in the perioperative period might be caused by a wide variety of factors including pain, blood loss, hypotension, hypoxia, micro- and macroemboli, cardiopulmonary bypass (CPB), reperfusion damage, and surgery itself, and all are risk factors for developing postoperative delirium (POD) and postoperative cognitive dysfunction (POCD). The objective of this study was to evaluate the effect of ketamine on neurocognitive dysfunction after anesthesia. METHODS We conducted a meta-analysis of randomized controlled trials (RCTs) comparing ketamine use (experimental group) with placebo (controls). RESULTS The model favors the control group over the experimental group in terms of frequency of hallucinations (the risk ratio with 95% CI is 1.54 [1.09, 2.19], p-value = 0.02), the number of patients readmitted within 30 days (RR with 95% CI is 0.25 [0.09, 0.70]), and the number of adverse events (overall RR with 95% CI is 1.31 [1.06, 1.62]). In terms of morphine consumption, the model favors the experimental group. CONCLUSION There was no statistically significant difference in incidences of postoperative delirium, vasopressor requirement, and fentanyl consumption between the ketamine and control groups. However, hallucinations were more frequently reported in the ketamine group.
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Affiliation(s)
- Dmitriy Viderman
- Department of Biomedical Sciences, Nazarbayev University School of Medicine (NUSOM), Kerei and Zhanibek Khandar Str. 5/1, Astana 010000, Kazakhstan
- Department of Anesthesiology and Intensive Care, National Research Oncology Center, Astana 010000, Kazakhstan
| | - Mina Aubakirova
- Department of Biomedical Sciences, Nazarbayev University School of Medicine (NUSOM), Kerei and Zhanibek Khandar Str. 5/1, Astana 010000, Kazakhstan
| | - Fatima Nabidollayeva
- School of Engineering and Digital Sciences, Nazarbayev University, Astana 010000, Kazakhstan
| | - Nurgul Yegembayeva
- Department of Biomedical Sciences, Nazarbayev University School of Medicine (NUSOM), Kerei and Zhanibek Khandar Str. 5/1, Astana 010000, Kazakhstan
| | - Federico Bilotta
- Department of Anesthesia and Intensive Care, University La Sapienza, 00185 Rome, Italy
| | - Rafael Badenes
- Department of Anaesthesiology and Intensive Care, Hospital Clìnico Universitario de Valencia, University of Valencia, 46003 Valencia, Spain
| | - Yerkin Abdildin
- School of Engineering and Digital Sciences, Nazarbayev University, Astana 010000, Kazakhstan
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Liu T, Zhang X, Li A, Liu T, Yang X, Zhang H, Lei Y, Yang Q, Dong H. Effects of intra-operative administration of subanesthetic s-ketamine on emergence from sevoflurane anesthesia: a randomized double-blind placebo-controlled study. BMC Anesthesiol 2023; 23:221. [PMID: 37353750 PMCID: PMC10288804 DOI: 10.1186/s12871-023-02170-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 06/09/2023] [Indexed: 06/25/2023] Open
Abstract
BACKGROUND Ketamine is administered in the perioperative period for its benefits in analgesia, anti-agitation and anti-depression when administered at a small dose. However, it is not clear whether the intra-operative administration of ketamine would affect emergence under sevoflurane anesthesia. To investigate this effect, we designed this trial. METHODS In this randomized, double-blind, placebo-controlled study, we enrolled 44 female patients aged 18-60 who were scheduled to elective laparoscopic gynecological surgeries. All patients were randomly assigned to saline or s-ketamine group. In s-ketamine group, patients received 0.125 mg/kg s-ketamine 30 min after the start of surgery. In saline group, patients were administered the same volume of saline. Sevoflurane and remifentanil were used to maintain general anesthesia. The primary outcome was emergence time. We also assessed postoperative agitation, cognitive function, and delirium. In addition, we collected and analyzed prefrontal electroencephalogram (EEG) during and after general anesthesia. RESULTS There were no significant differences in emergence time between s-ketamine group and saline group (10.80 ± 3.77 min vs. 10.00 ± 2.78 min, P = 0.457). Neither postoperative agitation (4 [3, 4] vs. 4 [3, 4], P = 0.835) nor cognitive function (25.84 ± 2.69 vs. 25.55 ± 2.19, P = 0.412) differed between groups. No postoperative delirium was observed in either group. Subanesthetic s-ketamine resulted in active EEG with decreased power of slow (-0.35 ± 1.13 dB vs. -1.63 ± 1.03 dB, P = 0.003), delta (-0.22 ± 1.11 dB vs. -1.32 ± 1.09 dB, P = 0.011) and alpha (-0.31 ± 0.71 dB vs. -1.71 ± 1.34 dB, P = 0.0003) waves and increased power of beta-gamma bands (-0.30 ± 0.89 dB vs. 4.20 ± 2.08 dB, P < 0.0001) during sevoflurane anesthesia, as well as an increased alpha peak frequency (-0.16 ± 0.48 Hz vs. 0.31 ± 0.73 Hz, P = 0.026). EEG patterns did not differ during the recovery period after emergence between groups. CONCLUSION Ketamine administered during sevoflurane anesthesia had no apparent influence on emergence time in young and middle-aged female patients undergoing laparoscopic surgery. Subanesthetic s-ketamine induced an active prefrontal EEG pattern during sevoflurane anesthesia but did not raise neurological side effects after surgery. TRIAL REGISTRATION Chinese Clinical Trial Registry, ChiCTR2100046479 (date: 16/05/2021).
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Affiliation(s)
- Tiantian Liu
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, 127 Changle West Road, Xi'an, 710032, China
| | - Xinxin Zhang
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, 127 Changle West Road, Xi'an, 710032, China
| | - Ao Li
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, 127 Changle West Road, Xi'an, 710032, China
| | - Tingting Liu
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, 127 Changle West Road, Xi'an, 710032, China
| | - Xue Yang
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, 127 Changle West Road, Xi'an, 710032, China
| | - Huanhuan Zhang
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, 127 Changle West Road, Xi'an, 710032, China
| | - Yanling Lei
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, 127 Changle West Road, Xi'an, 710032, China
| | - Qianzi Yang
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, 127 Changle West Road, Xi'an, 710032, China.
- Department of Anesthesiology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China.
| | - Hailong Dong
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, 127 Changle West Road, Xi'an, 710032, China.
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Zhang T, Deng D, Huang S, Fu D, Wang T, Xu F, Ma L, Ding Y, Wang K, Wang Y, Zhao W, Chen X. A retrospect and outlook on the neuroprotective effects of anesthetics in the era of endovascular therapy. Front Neurosci 2023; 17:1140275. [PMID: 37056305 PMCID: PMC10086253 DOI: 10.3389/fnins.2023.1140275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 03/13/2023] [Indexed: 03/30/2023] Open
Abstract
Studies on the neuroprotective effects of anesthetics were carried out more than half a century ago. Subsequently, many cell and animal experiments attempted to verify the findings. However, in clinical trials, the neuroprotective effects of anesthetics were not observed. These contradictory results suggest a mismatch between basic research and clinical trials. The Stroke Therapy Academic Industry Roundtable X (STAIR) proposed that the emergence of endovascular thrombectomy (EVT) would provide a proper platform to verify the neuroprotective effects of anesthetics because the haemodynamics of patients undergoing EVT is very close to the ischaemia–reperfusion model in basic research. With the widespread use of EVT, it is necessary for us to re-examine the neuroprotective effects of anesthetics to guide the use of anesthetics during EVT because the choice of anesthesia is still based on team experience without definite guidelines. In this paper, we describe the research status of anesthesia in EVT and summarize the neuroprotective mechanisms of some anesthetics. Then, we focus on the contradictory results between clinical trials and basic research and discuss the causes. Finally, we provide an outlook on the neuroprotective effects of anesthetics in the era of endovascular therapy.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Xiangdong Chen
- *Correspondence: Xiangdong Chen, ; orcid.org/0000-0003-3347-2947
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Zhang LM, Wu ZY, Liu JZ, Li Y, Lv JM, Wang LY, Shan YD, Song RX, Miao HT, Zhang W, Zhang DX. Subanesthetic dose of S-ketamine improved cognitive dysfunction via the inhibition of hippocampal astrocytosis in a mouse model of post-stroke chronic stress. J Psychiatr Res 2023; 158:1-14. [PMID: 36542981 DOI: 10.1016/j.jpsychires.2022.12.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 10/21/2022] [Accepted: 12/10/2022] [Indexed: 12/23/2022]
Abstract
Post-stroke chronic stress (PSCS) is generally associated with the poorer recovery and more pronounced cognitive dysfunction. Recent evidence has implied that S-ketamine can reduce suicidal ideation in treatment-resistant depression. In this current study, we aimed to investigate whether the administration of S-ketamine ameliorated cognitive deficits under PSCS conditions, which was established by a model combining middle cerebral artery occlusion (MCAO) and chronic restraint stress. Our data suggested that mice exposed to PSCS exhibited depression-like behavior and cognitive impairment, which coincided with astrocytosis as indicated by increased GFAP-positive cells and impairment of long-time potentiation (LTP) in the hippocampal CA1. Subanesthetic doses (10 mg/kg) of S-ketamine have significantly mitigated depression-like behaviors, cognitive deficits and LTP impairment, reduced astrocytosis, excessive GABA, and inflammatory factors, including NLRP3 and IL-18 in astrocytes in the CA1. Besides, neuroprotective effects induced by S-ketamine administration were found in vitro but could be partially reversed by an agonist of the NLRP3 nigericin. Our current data also suggests that the subanesthetic doses of S-ketamine improved cognitive dysfunction via the inhibition of hippocampal astrocytosis in a mouse model of PSCS.
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Affiliation(s)
- Li-Min Zhang
- Department of Anesthesiology, Hebei Province Cangzhou Hospital of Integrated Traditional and Western Medicine, Cangzhou, China; Hebei Key Laboratory of Integrated Traditional and Western Medicine in Osteoarthrosis Research (Preparing), Hebei Province Cangzhou Hospital of Integrated Traditional and Western Medicine, Cangzhou, China.
| | - Zhi-You Wu
- Graduated School, Hebei Medical University, Shijiazhuang, China.
| | - Ji-Zhen Liu
- Department of Anesthesiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
| | - Yan Li
- Department of Anesthesiology, Cangzhou Central Hospital, Cangzhou, China.
| | - Jin-Meng Lv
- Hebei Key Laboratory of Integrated Traditional and Western Medicine in Osteoarthrosis Research (Preparing), Hebei Province Cangzhou Hospital of Integrated Traditional and Western Medicine, Cangzhou, China; Anesthesia and Trauma Research Unit, Department of Anesthesiology, Hebei Province Cangzhou Hospital of Integrated Traditional and Western Medicine, Cangzhou, China.
| | - Lu-Ying Wang
- Hebei Key Laboratory of Integrated Traditional and Western Medicine in Osteoarthrosis Research (Preparing), Hebei Province Cangzhou Hospital of Integrated Traditional and Western Medicine, Cangzhou, China; Anesthesia and Trauma Research Unit, Department of Anesthesiology, Hebei Province Cangzhou Hospital of Integrated Traditional and Western Medicine, Cangzhou, China.
| | - Yu-Dong Shan
- Hebei Key Laboratory of Integrated Traditional and Western Medicine in Osteoarthrosis Research (Preparing), Hebei Province Cangzhou Hospital of Integrated Traditional and Western Medicine, Cangzhou, China; Anesthesia and Trauma Research Unit, Department of Anesthesiology, Hebei Province Cangzhou Hospital of Integrated Traditional and Western Medicine, Cangzhou, China.
| | - Rong-Xin Song
- Graduated School, Hebei Medical University, Shijiazhuang, China.
| | - Hui-Tao Miao
- Graduated School, Hebei Medical University, Shijiazhuang, China.
| | - Wei Zhang
- Department of Anesthesiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
| | - Dong-Xue Zhang
- Department of Gerontology, Cangzhou Central Hospital, Cangzhou, China.
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11
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Zhang M, Yin Y. Dual roles of anesthetics in postoperative cognitive dysfunction: Regulation of microglial activation through inflammatory signaling pathways. Front Immunol 2023; 14:1102312. [PMID: 36776829 PMCID: PMC9911670 DOI: 10.3389/fimmu.2023.1102312] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 01/17/2023] [Indexed: 01/28/2023] Open
Abstract
Postoperative cognitive dysfunction (POCD) is a prevalent clinical entity following surgery and is characterized by declined neurocognitive function. Neuroinflammation mediated by microglia is the essential mechanism of POCD. Anesthetics are thought to be a major contributor to the development of POCD, as they promote microglial activation and induce neuroinflammation. However, this claim remains controversial. Anesthetics can exert both anti- and pro-inflammatory effects by modulating microglial activation, suggesting that anesthetics may play dual roles in the pathogenesis of POCD. Here, we review the mechanisms by which the commonly used anesthetics regulate microglial activation via inflammatory signaling pathways, showing both anti- and pro-inflammatory properties of anesthetics, and indicating how perioperative administration of anesthetics might either relieve or worsen POCD development. The potential for anesthetics to enhance cognitive performance based on their anti-inflammatory properties is further discussed, emphasizing that the beneficial effects of anesthetics vary depending on dose, exposure time, and patients' characteristics. To minimize the incidence of POCD, we recommend considering these factors to select appropriate anesthetics.
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Affiliation(s)
- Mengxue Zhang
- Department of Anesthesiology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin, China.,Tianjin's Clinical Research Center for Cancer, Tianjin, China.,Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
| | - Yiqing Yin
- Department of Anesthesiology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin, China.,Tianjin's Clinical Research Center for Cancer, Tianjin, China.,Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
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12
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Han C, Ji H, Guo Y, Fei Y, Wang C, Yuan Y, Ruan Z, Ma T. Effect of Subanesthetic Dose of Esketamine on Perioperative Neurocognitive Disorders in Elderly Undergoing Gastrointestinal Surgery: A Randomized Controlled Trial. Drug Des Devel Ther 2023; 17:863-873. [PMID: 36974331 PMCID: PMC10039635 DOI: 10.2147/dddt.s401161] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 03/09/2023] [Indexed: 03/29/2023] Open
Abstract
Background Perioperative neurocognitive disorders (PND), including delayed neurocognitive recovery (dNCR) and postoperative cognitive dysfunction (POCD), are common postoperative complications in elderly patients and adversely affect their prognosis. The study was designed to explore the effects of esketamine on postoperative cognitive function in elderly patients who underwent gastrointestinal surgery under general anesthesia and its potential mechanism. Methods Eighty-four patients aged 65 and above undergoing gastrointestinal surgery were randomly divided into 2 groups: the esketamine group (group S) and the control group (group C). Group S received intravenous sub-anesthetic doses of esketamine (0.15 mg/kg) 5 minutes before the initiation of surgery, while group C received the same volume of saline. A battery of neuropsychological tests was used to assess cognitive function before surgery, 7 days, and 3 months after surgery. The primary outcome was the incidence of dNCR at 7 days postoperatively and POCD at 3 months postoperatively in both groups. The secondary outcome measures included changes in the levels of serum interleukin-6 (IL-6) and calcium-binding protein β (S100β) before and 1 day after surgery. Results The incidence of dNCR in group S was lower than that of group C (18.15% vs 38.24% P=0.033). Contrarily, there was no difference in both groups regarding POCD 3 months postoperatively (6.06% vs 14.37% P=0.247). Plasma IL-6 and S100β levels were significantly elevated in both groups on postoperative day 1 (p<0.05), but esketamine pretreatment reduced these levels to some extent compared with group C (p<0.05). Conclusion Sub-anesthetic doses of esketamine might reduce the incidence of dNCR and improve early postoperative cognitive function in elderly patients undergoing gastrointestinal surgery, which might be related to the anti-neuroinflammation effects of esketamine.
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Affiliation(s)
- Chao Han
- Department of Anesthesiology, The Affiliated Yixing Hospital of Jiangsu University, Yixing, Jiangsu, 214200, People’s Republic of China
- Yixing Clinical College, Medical College of Yangzhou University, Yixing, Jiangsu, 214200, People’s Republic of China
- Correspondence: Chao Han, Department of Anesthesiology, The Affiliated Yixing Hospital of Jiangsu University, Yixing, Jiangsu, 214200, People’s Republic of China, Tel +86 13961568178, Fax +86 051087921010, Email
| | - Haiyan Ji
- Department of Anesthesiology, The Affiliated Yixing Hospital of Jiangsu University, Yixing, Jiangsu, 214200, People’s Republic of China
| | - Yaxin Guo
- Department of Anesthesiology, The Affiliated Yixing Hospital of Jiangsu University, Yixing, Jiangsu, 214200, People’s Republic of China
| | - Yuanhui Fei
- Department of Anesthesiology, The Affiliated Yixing Hospital of Jiangsu University, Yixing, Jiangsu, 214200, People’s Republic of China
| | - Chunhui Wang
- Department of Anesthesiology, The Affiliated Yixing Hospital of Jiangsu University, Yixing, Jiangsu, 214200, People’s Republic of China
| | - Yanbo Yuan
- Department of Anesthesiology, The Affiliated Yixing Hospital of Jiangsu University, Yixing, Jiangsu, 214200, People’s Republic of China
| | - Zhihui Ruan
- Department of Anesthesiology, The Affiliated Yixing Hospital of Jiangsu University, Yixing, Jiangsu, 214200, People’s Republic of China
| | - Tieliang Ma
- Department of Anesthesiology, The Affiliated Yixing Hospital of Jiangsu University, Yixing, Jiangsu, 214200, People’s Republic of China
- Yixing Clinical College, Medical College of Yangzhou University, Yixing, Jiangsu, 214200, People’s Republic of China
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13
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Akhlagh S, Jouybar R, Zohoori K, Khademi S, Mani A, reza Akhlagh S, Asadpour E. The effect of melatonin on cognitive functions following coronary artery bypass grafting: A triple-blind randomized-controlled trial. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2023; 28:14. [PMID: 37064795 PMCID: PMC10098135 DOI: 10.4103/jrms.jrms_118_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 08/23/2022] [Accepted: 09/26/2022] [Indexed: 03/18/2023]
Abstract
Background Cognitive dysfunction presents one of the chief causes of postoperative morbidity. Melatonin as a neurohormone can improve neurocognitive functioning and sleep disorders. We evaluated the effect of melatonin on the postoperative cognitive function of patients undergoing coronary artery bypass grafting (CABG). Materials and Methods A triple-blind randomized-controlled trial was conducted on 66 CABG candidates in Namazee Hospital (Shiraz, Iran). Patients were assigned equally into two groups receiving melatonin 10 mg or a placebo daily for 4 weeks before surgery and 2 days after surgery in the intensive care unit. The Mini-Mental State Examination (MMSE), Tower of London (ToL), and Wechsler Adults Intelligence Scale-Revised (WAIS-R) cognitive function tests were performed in both groups 4 weeks before surgery (time point 1), 2 days after surgery (time point 2), and 6 weeks after initial administration of melatonin (time point 3). Results The mean change score (time point 3-time point 1) differed significantly between the two groups in the MMSE (P ≤ 0.001), ToL total score (P = 0.001), and WAIS-R general IQ (P ≤ 0.001), picture completion (P ≤ 0.001), vocabulary (P = 0.024), and digit span (P = 0.01). On the other hand, no significant differences were detected in the WAIS-R block design, ToL total time delay, ToL total lab, and ToL total result scores. Conclusion The MMSE and WAIS-R tests revealed that melatonin might have prophylactic effects against postoperative cognitive disturbance in patients undergoing elective CABG.
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14
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Chen Z, Wang S, Meng Z, Ye Y, Shan G, Wang X, Zhao X, Jin Y. Tau protein plays a role in the mechanism of cognitive disorders induced by anesthetic drugs. Front Neurosci 2023; 17:1145318. [PMID: 36937655 PMCID: PMC10015606 DOI: 10.3389/fnins.2023.1145318] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 02/13/2023] [Indexed: 03/08/2023] Open
Abstract
Cognitive disorders are mental health disorders that can affect cognitive ability. Surgery and anesthesia have been proposed to increase the incidence of cognitive dysfunction, including declines in memory, learning, attention and executive function. Tau protein is a microtubule-associated protein located in the axons of neurons and is important for microtubule assembly and stability; its biological function is mainly regulated by phosphorylation. Phosphorylated tau protein has been associated with cognitive dysfunction mediated by disrupting the stability of the microtubule structure. There is an increasing consensus that anesthetic drugs can cause cognitive impairment. Herein, we reviewed the latest literature and compared the relationship between tau protein and cognitive impairment caused by different anesthetics. Our results substantiated that tau protein phosphorylation is essential in cognitive dysfunction caused by anesthetic drugs, and the possible mechanism can be summarized as "anesthetic drugs-kinase/phosphatase-p-Tau-cognitive impairment".
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15
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Guran E, Hu J, Wefel JS, Chung C, Cata JP. Perioperative considerations in patients with chemotherapy-induced cognitive impairment: a narrative review. Br J Anaesth 2022; 129:909-922. [PMID: 36270848 DOI: 10.1016/j.bja.2022.08.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 08/01/2022] [Accepted: 08/23/2022] [Indexed: 11/02/2022] Open
Abstract
Patients with cancer may suffer from a decline in their cognitive function after various cancer therapies, including surgery, radiation, and chemotherapy, and in some cases, this decline in cognitive function persists even years after completion of treatment. Chemobrain or chemotherapy-induced cognitive impairment, a well-established clinical syndrome, has become an increasing concern as the number of successfully treated cancer patients has increased significantly. Chemotherapy-induced cognitive impairment can originate from direct neurotoxicity, neuroinflammation, and oxidative stress, resulting in alterations in grey matter volume, white matter integrity, and brain connectivity. Surgery has been associated with exacerbating the inflammatory response associated with chemotherapy and predisposes patients to develop postoperative cognitive dysfunction. As the proportion of patients living longer after these therapies increases, the magnitude of impact and growing concern of post-treatment cognitive dysfunction in these patients has also come to the fore. We review the clinical presentation, potential mechanisms, predisposing factors, diagnostic methods, neuropsychological testing, and imaging findings of chemotherapy-induced cognitive impairment and its intersection with postoperative cognitive dysfunction.
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Affiliation(s)
- Ekin Guran
- Department of Anaesthesiology and Reanimation, University of Health Sciences, Ankara Oncology Training and Research Hospital, Ankara, Turkey; Anaesthesiology and Surgical Oncology Research Group, Houston, TX, USA
| | - Jian Hu
- Department of Cancer Biology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey S Wefel
- Department of Neuro-Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Caroline Chung
- Department of Neuro-Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Juan P Cata
- Anaesthesiology and Surgical Oncology Research Group, Houston, TX, USA; Department of Anaesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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16
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Chavda V, Patel S. Voglibose and saxagliptin ameliorate the post-surgical stress and cognitive dysfunction in chronic anaesthesia exposed diabetic MCAo induced ischemic rats. IBRO Neurosci Rep 2022; 13:426-435. [PMID: 36386599 PMCID: PMC9650028 DOI: 10.1016/j.ibneur.2022.10.009] [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: 10/16/2021] [Accepted: 10/23/2022] [Indexed: 11/11/2022] Open
Abstract
Background Chronic surgical anaesthesia and uncontrolled hyperglycemia are bidirectional risk factors for the development of psychiatric, cerebrovascular, and cardiovascular diseases. Objective The current study was designed to elucidate the neuroprotective effects of anti-diabetic agents in pre and post-surgical anaesthesia exposure on diabetic ischemic rats. Methods The diabetes type-2 was induced and rats having more than 250 gm/dl blood glucose levels were considered for study. Administration of anaesthetic agents (ketamine 100 mg/kg IP, xylazine 10 mg/kg IP) were done pre and post MCAo surgery for 7 days. The treatment with anti-diabetic agents (voglibose, saxagliptin, repaglinide, dapagliflozin) was carried out after 7 days of Post MCAo surgery for one week. After treatment, assessment of neurobehavioral function was carried out using Morris Water Maze. After that, brains were excised and bloods were collected from all groups subjected for assessment of neuromodulator levels, oxidative stress parameters, serum biochemical biomarkers. Results The treatment with voglibose and saxagliptin not only improved neuromodulator levels statistically significant (p < 0.001) and cognitive profile but also significantly improved (p < 0.01) overall stroke serum biomarkers (Serum Glucose, GGT, CRP, CK-MB, LDH). Conclusion The results of the present study, suggested that chronic exposure of anaesthesia worsens the cognition and increases risk of stroke biomarkers in diabetic conditions. We can conclude that voglibose, saxagliptin, and dapagliflozin can significantly improve the postoperative mortality, morbidity, and cognitive dysfunction caused by post-surgical stress and chronic anaesthesia-induced cognitive dysfunction.
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Affiliation(s)
| | - Snehal Patel
- Correspondence to: Department of Pharmacology, Institute of Pharmacy, Nirma University, Ahmedabad, Gujarat, India.
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17
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Réhabilitation améliorée après chirurgie cardiaque adulte sous CEC ou à cœur battant 2021. ANESTHÉSIE & RÉANIMATION 2022. [DOI: 10.1016/j.anrea.2022.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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18
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Ornowska M, Wormsbecker A, Andolfatto G, Leung T, Khan I, Medvedev G. The use of ketamine as a neuroprotective agent following cardiac arrest: A scoping review of current literature. CNS Neurosci Ther 2022; 29:104-110. [PMID: 36184822 PMCID: PMC9804040 DOI: 10.1111/cns.13983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 09/12/2022] [Accepted: 09/13/2022] [Indexed: 02/06/2023] Open
Abstract
AIMS The objective of this article is to summarize the state of the literature surrounding the use of ketamine as a neuroprotective agent following cardiac arrest. METHODS Five electronic databases were used to search for studies related to the use of ketamine for neuroprotection following cardiac arrest. This search was performed once in May 2020, and an updated search was conducted in May 2021 and March 2022. RESULTS All searches combined retrieved 181 results; no clinical trials were identified. As such, the authors were limited to writing a scoping review of the literature rather than a systematic review. CONCLUSIONS The current state of the literature describes the mechanism of action of ketamine as a neuroprotective agent through its action as an NMDA antagonist. There is evidence of its efficacy as a neuroprotective agent in preclinical models of cardiac arrest. Current published clinical work supports the use of ketamine ameliorating neurologic outcomes in other conditions such as epilepsy, traumatic brain injury, and depression. The current state of the literature is reflective of the notion that the use of ketamine following cardiac arrest may result in improved neurologic outcomes. Future research directions should focus on the use of ketamine as a possible clinical intervention following cardiac arrest.
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Affiliation(s)
- Marlena Ornowska
- Department of Biomedical PhysiologySimon Fraser UniversityBurnabyBritish ColumbiaCanada
| | - Andrew Wormsbecker
- Royal Columbian Hospital, Fraser Health AuthorityNew WestminsterBritish ColumbiaCanada,Division of Critical Care, Department of MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Gary Andolfatto
- Department of Emergency Medicine, Department of MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Tim S. Leung
- Royal Columbian Hospital, Fraser Health AuthorityNew WestminsterBritish ColumbiaCanada,Faculty of Pharmaceutical SciencesUniversity of British ColumbiaVancouverBritish ColumbiaCanada,Lower Mainland Pharmacy ServicesVancouverBritish ColumbiaCanada
| | - Idan Khan
- Royal Columbian Hospital, Fraser Health AuthorityNew WestminsterBritish ColumbiaCanada,Department of Emergency Medicine, Department of MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - George Medvedev
- Royal Columbian Hospital, Fraser Health AuthorityNew WestminsterBritish ColumbiaCanada,Division of Neurology, Department of MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
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19
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Sunjoyo A, Nugroho A. Neuroprotective Agents: A Simple Overview. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.10329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Neuroprotective agents are medications that can alter the course of metabolic events and have neuroprotective function. Neuroprotective agents are needed in patients undergoing a surgical procedure and clinical conditions that correspond with the central nervous system (CNS); also, in intensive care, the neuroprotective agents are often used to prevent complications and patient deterioration. Over the years, there is still no clear understanding of the potential for neuroprotection and the interactions between various drugs that serve a crucial role in anesthetic care and critical illness. This literature review will discuss further the mechanism of neuronal damage and various neuroprotective agents.
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20
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Tiberio PJ, Prendergast NT, Girard TD. Pharmacologic Management of Delirium in the Intensive Care Unit. Clin Chest Med 2022; 43:411-424. [PMID: 36116811 DOI: 10.1016/j.ccm.2022.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Delirium, often underdiagnosed in the intensive care unit, is a common complication of critical illness that contributes to significant morbidity and mortality. Clinicians should be aware of common risk factors and triggers and should work to mitigate these as much as possible to reduce the occurrence of delirium. This review first provides an overview of the epidemiology, pathophysiology, evaluation, and consequences of delirium in critically ill patients. Presented next is the current evidence for the pharmacologic management of delirium, focusing on prevention and treatment of delirium in the intensive care unit. It concludes by outlining some emerging treatments of delirium.
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Affiliation(s)
- Perry J Tiberio
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, NW 628 UPMC Montefiore, 3459 Fifth Avenue, Pittsburgh, PA 15213, USA
| | - Niall T Prendergast
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, NW 628 UPMC Montefiore, 3459 Fifth Avenue, Pittsburgh, PA 15213, USA
| | - Timothy D Girard
- Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh, 3520 Fifth Avenue, 101 Keystone Building, Pittsburgh, PA, 15213, USA.
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21
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Ketamine administration ameliorates anesthesia and surgery‑induced cognitive dysfunction via activation of TRPV4 channel opening. Exp Ther Med 2022; 24:478. [PMID: 35761804 PMCID: PMC9214599 DOI: 10.3892/etm.2022.11405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 05/16/2022] [Indexed: 11/05/2022] Open
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22
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Erdman HB, Kornilov E, Kahana E, Zarchi O, Reiner J, Socher A, Strauss I, Firman S, Israel Z, Bergman H, Tamir I. Asleep DBS under ketamine sedation: Proof of concept. Neurobiol Dis 2022; 170:105747. [PMID: 35550159 DOI: 10.1016/j.nbd.2022.105747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 04/28/2022] [Accepted: 05/05/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Deep brain stimulation (DBS) is commonly and safely performed for selective Parkinson's disease patients. Many centers perform DBS lead positioning exclusively under local anesthesia, to optimize brain microelectrode recordings (MER) and testing of stimulation-related therapeutic and side effects. These measures enable physiological identification of the DBS borders and subdomains based on electrophysiological properties like firing rates and patterns, intra-operative evaluation of therapeutic window, and improvement of lead placement accuracy. Nevertheless, due to the challenges of awake surgery, some centers use sedation or general anesthesia, despite the distortion of discharge properties and interference with clinical testing, resulting in potential impact on surgical outcomes. Thus, there is a need for a novel anesthesia regimen that enables sedation without compromising intra-operative monitoring. OBJECTIVE This open-label study investigates the use of low-dose ketamine for conscious sedation during microelectrode recordings and lead positioning in subthalamic nucleus (STN) DBS for Parkinson's disease patients. METHODS Three anesthetic regimens were retrospectively compared in 38 surgeries (74 MER trajectories, 5962 recording sites) across three DBS centers: 1) Interleaved propofol-ketamine (PK), 2) Interleaved propofol-awake (PA), and 3) Fully awake (AA). RESULTS All anesthesia regimens achieved satisfactory MER. Detection of STN borders and subdomains by expert electrophysiologist was similar between the groups. Electrophysiological signature of the STN under ketamine was not inferior to either control group. All patients completed stimulation testing. CONCLUSIONS This study supports a low-dose ketamine anesthesia regimen for DBS which allows microelectrode recordings and stimulation testing that are not inferior to those conducted under awake and propofol-awake regimens and may optimize patient experience. A prospective double-blind study that would also compare patients' satisfaction level and clinical outcome should be performed to confirm these findings.
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Affiliation(s)
- Halen Baker Erdman
- Department of Medical Neurobiology, Hebrew University, Jerusalem, Israel.
| | - Evgeniya Kornilov
- Department of Anesthesiology, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel; Department of Neurobiology, Weizmann Institute of Science, Rehovot, Israel
| | - Eilat Kahana
- Department of Anesthesiology, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
| | - Omer Zarchi
- Intraoperative Neurophysiology Unit, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
| | - Johnathan Reiner
- Department of Neurology, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
| | - Achinoam Socher
- Department of Neurology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ido Strauss
- Department of Neurosurgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Shimon Firman
- Department of Anesthesiology, Critical Care Medicine, and Pain Management, Hadassah Medical Center, Hebrew University, Jerusalem, Israel
| | - Zvi Israel
- Department of Neurosurgery, Hadassah Medical Center, Hebrew University, Jerusalem, Israel
| | - Hagai Bergman
- Department of Medical Neurobiology, Hebrew University, Jerusalem, Israel; Department of Neurosurgery, Hadassah Medical Center, Hebrew University, Jerusalem, Israel; The Edmond and Lily Safra Center for Brain Sciences, Hebrew University, Jerusalem, Israel
| | - Idit Tamir
- Department of Neurosurgery, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel.
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23
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The Effects of Dexmedetomidine on Perioperative Neurocognitive Outcomes After Cardiac Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Ann Surg 2022; 275:864-871. [PMID: 35543164 DOI: 10.1097/sla.0000000000005196] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The purpose of this systematic review and meta-analysis is to examine the effect of DEX on delayed dNCR (cognitive dysfunction ≥ 1 week postoperative) after cardiac surgery. BACKGROUND DEX has salutary effects on cognitive outcomes following cardiac surgery, however, studies are limited by inconsistent assessment tools, timing, and definitions of dysfunction. It is imperative to identify accurate point estimates of effect of DEX on clinically relevant changes in cognitive function. METHODS Randomized trials of adults undergoing cardiac surgery comparing perioperative DEX to placebo or alternate sedation and assessing cognitive function ≥ 1 week postoperative were included. Data was abstracted by three reviewers independently and in parallel according to PRISMA guidelines. The primary outcome is dNCR. To classify as dNCR, cognitive function must decrease by at least the minimal clinically important difference or accepted alternate measure (eg, Reliable Change Index ≥1.96). Bias was assessed with the Cochrane Collaboration tool. Data was pooled using a random effects model. RESULTS Nine trials (942 participants) were included in qualitative analysis, of which seven were included in the meta-analysis of dNCR. DEX reduced the incidence of dNCR (OR 0.39, 95% CI 0.25-0.61, P < 0.0001) compared to placebo/no DEX. There was no difference in the incidence of delirium (OR 0.69, 95% CI 0.35-1.34, P = 0.27) or incidence of hemodynamic instability (OR 1.14, 95% CI 0.59-2.18, P = 0.70) associated with perioperative DEX. CONCLUSIONS DEX reduced the incidence of dNCR 1 week after cardiac surgery. Although this meta-analysis demonstrates short term cognitive outcomes are improved after cardiac surgery with perioperative DEX, future trials examining long term cognitive outcomes, using robust cognitive assessments, and new perioperative neurocognitive disorders nomenclature with objective diagnostic criteria are necessary.
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Jin X, Li P, Michalski D, Li S, Zhang Y, Jolkkonen J, Cui L, Didwischus N, Xuan W, Boltze J. Perioperative stroke: A perspective on challenges and opportunities for experimental treatment and diagnostic strategies. CNS Neurosci Ther 2022; 28:497-509. [PMID: 35224865 PMCID: PMC8928912 DOI: 10.1111/cns.13816] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 01/31/2022] [Accepted: 02/04/2022] [Indexed: 02/06/2023] Open
Abstract
Perioperative stroke is an ischemic or hemorrhagic cerebral event during or up to 30 days after surgery. It is a feared condition due to a relatively high incidence, difficulties in timely detection, and unfavorable outcome compared to spontaneously occurring stroke. Recent preclinical data suggest that specific pathophysiological mechanisms such as aggravated neuroinflammation contribute to the detrimental impact of perioperative stroke. Conventional treatment options are limited in the perioperative setting due to difficult diagnosis and medications affecting coagulation in may cases. On the contrary, the chance to anticipate cerebrovascular events at the time of surgery may pave the way for prevention strategies. This review provides an overview on perioperative stroke incidence, related problems, and underlying pathophysiological mechanisms. Based on this analysis, we assess experimental stroke treatments including neuroprotective approaches, cell therapies, and conditioning medicine strategies regarding their potential use in perioperative stroke. Interestingly, the specific aspects of perioperative stroke might enable a more effective application of experimental treatment strategies such as classical neuroprotection whereas others including cell therapies may be of limited use. We also discuss experimental diagnostic options for perioperative stroke augmenting classical clinical and imaging stroke diagnosis. While some experimental stroke treatments may have specific advantages in perioperative stroke, the paucity of established guidelines or multicenter clinical research initiatives currently limits their thorough investigation.
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Affiliation(s)
- Xia Jin
- Department of Anesthesiology, Renji Hospital, School of Medicine Shanghai Jiaotong University, Shanghai, China
| | - Peiying Li
- Department of Anesthesiology, Renji Hospital, School of Medicine Shanghai Jiaotong University, Shanghai, China
| | | | - Shen Li
- Department of Neurology and Psychiatry, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Yueman Zhang
- Department of Anesthesiology, Renji Hospital, School of Medicine Shanghai Jiaotong University, Shanghai, China
| | - Jukka Jolkkonen
- Department of Neurology and A. I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, Kuopio, Finland
| | - Lili Cui
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Nadine Didwischus
- School of Life Sciences, University of Warwick, Coventry, UK.,Department of Radiology, University of Pittsburgh, Pittsburgh, USA.,McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, USA
| | - Wei Xuan
- Department of Anesthesiology, Renji Hospital, School of Medicine Shanghai Jiaotong University, Shanghai, China
| | - Johannes Boltze
- School of Life Sciences, University of Warwick, Coventry, UK
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Singh A, Broad J, Brenna CTA, Kaustov L, Choi S. The Effects of Dexmedetomidine on Perioperative Neurocognitive Outcomes After Noncardiac Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. ANNALS OF SURGERY OPEN 2022; 3:e130. [PMID: 37600088 PMCID: PMC10431438 DOI: 10.1097/as9.0000000000000130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 01/06/2022] [Indexed: 11/25/2022] Open
Abstract
Objective The purpose of this review is to examine the effect of dexmedetomidine on delayed neurocognitive recovery (dNCR; cognitive dysfunction ≥1 week postoperative) after major noncardiac surgery. Background Dexmedetomidine (DEX) effectively reduces delirium in the intensive care unit and reportedly attenuates cognitive decline following major noncardiac surgery. Ascertaining the true effect on postoperative cognition is difficult because studies are limited by suboptimal selection of cognitive assessment tools, timing of testing, and criteria for defining significant cognitive decline. Methods Prospective randomized trials comparing perioperative DEX to placebo for major noncardiac surgery assessing cognitive function ≥1 week postoperative were included. Pediatric, nonhuman, and non-English trials, and those where executive function was not assessed were excluded. Data were abstracted by 3 reviewers independently and in parallel according to PRISMA guidelines. The a priori binary primary outcome is dNCR defined as cognitive function declining by the minimal clinically important difference or accepted alternate measure (eg, Reliable Change Index ≥1.96). Bias was assessed with the Cochrane Collaboration tool. Data were pooled using a random effects model. Results Among 287 citations identified, 26 (9%) met criteria for full-text retrieval. Eleven randomized trials (1233 participants) were included for qualitative analysis, and 7 trials (616 participants) were included for meta-analysis of dNCR. Dexmedetomidine did not reduce the incidence of dNCR significantly (OR 0.57, 95% CI 0.30-1.10, P = 0.09) compared with placebo. There was no difference in the incidence of delirium (OR 0.94, 95% CI 0.55-1.63, P = 0.83) and a higher incidence of hemodynamic instability (OR 2.11, 95% CI 1.22-3.65, P = 0.008). Conclusions Dexmedetomidine does not reduce dNCR 1 week after major noncardiac surgery. This meta-analysis does not yet support the use of perioperative DEX to improve short term cognitive outcomes at this time; trials underway may yet change this conclusion while larger trials are needed to refine the point estimate of effect and examine long-term cognitive outcomes.
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Affiliation(s)
- Amara Singh
- From the Department of Anesthesia, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Perioperative Brain Health Centre, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Jeremy Broad
- From the Department of Anesthesia, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Connor T. A. Brenna
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Perioperative Brain Health Centre, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Lilia Kaustov
- From the Department of Anesthesia, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
- Perioperative Brain Health Centre, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Stephen Choi
- From the Department of Anesthesia, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Perioperative Brain Health Centre, Sunnybrook Research Institute, Toronto, ON, Canada
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Wilson SH, Wilson PR, Bridges KH, Bell LH, Clark CA. Nonopioid Analgesics for the Perioperative Geriatric Patient: A Narrative Review. Anesth Analg 2022; 135:290-306. [PMID: 35202007 DOI: 10.1213/ane.0000000000005944] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Management of acute perioperative pain in the geriatric patient can be challenging as the physiologic and pharmacokinetic changes associated with aging may predispose older patients to opioid-related side effects. Furthermore, elderly adults are more susceptible to postoperative delirium and postoperative cognitive dysfunction, which may be exacerbated by both poorly controlled postoperative pain and commonly used pain medications. This narrative review summarizes the literature published in the past 10 years for several nonopioid analgesics commonly prescribed to the geriatric patient in the perioperative period. Nonopioid analgesics are broken down as follows: medications prescribed throughout the perioperative period (acetaminophen and nonsteroidal anti-inflammatory drugs), medications limited to the acute perioperative setting (N-methyl-D-aspartate receptor antagonists, dexmedetomidine, dexamethasone, and local anesthetics), and medications to be used with caution in the geriatric patient population (gabapentinoids and muscle relaxants). Our search identified 1757 citations, but only 33 specifically focused on geriatric analgesia. Of these, only 21 were randomized clinical trials' and 1 was a systematic review. While guidance in tailoring pain regimens that focus on the use of nonopioid medications in the geriatric patient is lacking, we summarize the current literature and highlight that some nonopioid medications may extend benefits to the geriatric patient beyond analgesia.
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Affiliation(s)
- Sylvia H Wilson
- From the Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, South Carolina
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Giuliano K, Etchill E, Velez AK, Wilson MA, Blue ME, Troncoso JC, Baumgartner WA, Lawton JS. Ketamine Mitigates Neurobehavioral Deficits in a Canine Model of Hypothermic Circulatory Arrest. Semin Thorac Cardiovasc Surg 2022; 35:251-258. [PMID: 34995752 PMCID: PMC9253200 DOI: 10.1053/j.semtcvs.2021.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 12/02/2021] [Indexed: 12/13/2022]
Abstract
Hypothermic circulatory arrest is a protective technique used when complete cessation of circulation is required during cardiac surgery. Prior efforts to decrease neurologic injury with the NMDA receptor antagonist MK801 were limited by unacceptable side effects. We hypothesized that ketamine would provide neuroprotection without dose-limiting side effects. Canines were peripherally cannulated for cardiopulmonary bypass, cooled to 18°C, and underwent 90 minutes of circulatory arrest. Ketamine-treated canines (n = 5; total dose 2.85 mg/kg) were compared to untreated controls (n = 10). A validated neurobehavioral deficit score was obtained at 24, 48, and 72 hours (0 = no deficits/normal exam; higher score represents increasing deficits). Biomarkers of neuronal injury in the cerebrospinal fluid were examined at baseline and at 8, 24, 48, and 72 hours. Brain histopathologic injury was scored at 72 hours (higher score indicates more necrosis and apoptosis). Ketamine-treated canines had significantly improved, lower neurobehavioral deficit scores compared to controls (overall P = 0.003; 24 hours: median 72 vs 112, P = 0.030; 48 hours: 47 vs 90, P = 0.021; 72 hours: 30 vs 89, P = 0.069). Although the histopathologic injury scores of ketamine-treated canines (median 12) were lower than controls (16), there was no statistical difference (P = 0.10). Levels of phosphorylated neurofilament-H and neuron specific enolase, markers of neuronal injury, were significantly lower in ketamine-treated animals (P = 0.010 and = 0.039, respectively). Ketamine significantly reduced neurologic deficits and biomarkers of injury in canines after hypothermic circulatory arrest. Ketamine represents a safe and approved medication that may be useful as a pharmacologic neuroprotectant during cardiac surgery with circulatory arrest.
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Affiliation(s)
- Katherine Giuliano
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins, Baltimore, MD, USA
| | - Eric Etchill
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins, Baltimore, MD, USA
| | - Ana K Velez
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins, Baltimore, MD, USA
| | - Mary Ann Wilson
- Hugo W. Moser Research at Kennedy Krieger, Baltimore, Maryland, USA
| | - Mary E Blue
- Hugo W. Moser Research at Kennedy Krieger, Baltimore, Maryland, USA
| | | | - William A Baumgartner
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins, Baltimore, MD, USA
| | - Jennifer S Lawton
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins, Baltimore, MD, USA.
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Chen M, Han Y, Que B, Zhou R, Gan J, Dong X. Prophylactic Effects of Sub-anesthesia Ketamine on Cognitive Decline, Neuroinflammation, and Oxidative Stress in Elderly Mice. Am J Alzheimers Dis Other Demen 2022; 37:15333175221141531. [PMID: 36474365 PMCID: PMC10581114 DOI: 10.1177/15333175221141531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Cognitive dysfunction is a very common postoperative complication. The study aimed at investigating the effects of ketamine on the cognition of elderly mice after anesthesia and surgery (AS). We reported that AS impaired the cognition of elderly mice, while ketamine helped to maintain the cognitive function. Ketamine decreased the levels of TNF-α, IL-6, IL-1β and the expression of p-TAU, S100B in hippocampal induced by AS. In addition, AS triggered severe oxidative stress in hippocampal, while ketamine inhibited it. Oxidative stress induced autophagy of hippocampal neurons via inhibiting PI3K/AKT/mTOR pathway. Ketamine could activate PI3K pathway and inhibit autophagy in hippocampal, thus maintain the loss of hippocampal neurons. The study suggested that ketamine inhibited the neuroinflammation and oxidative stress, reduced the autophagy of hippocampal neurons via PI3K/AKT/mTOR pathway. It may provide novel methods for the protection of cognitive function in elderly during perioperative period.
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Affiliation(s)
- Minmin Chen
- Department of Anesthesiology, Hangzhou Women’s Hospital, Hangzhou, China
| | - Yinqiu Han
- Department of Anesthesiology, Hangzhou Women’s Hospital, Hangzhou, China
| | - Bin Que
- Department of Anesthesiology, Hangzhou Hospital of Traditional Chinese Medicine, Hangzhou, China
| | - Rong Zhou
- Department of Anesthesiology, Hangzhou Hospital of Traditional Chinese Medicine, Hangzhou, China
| | - Jianhui Gan
- Department of Anesthesiology, Tangshan People’s Hospital, North China University of Science and Technology, Tangshan, China
| | - Xiaoyun Dong
- Department of Anesthesiology, Hangzhou Women’s Hospital, Hangzhou, China
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Newman MF, Berger M, Mathew JP. Postoperative Cognitive Dysfunction and Delirium. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00042-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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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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Contemporary Neuroprotection Strategies during Cardiac Surgery: State of the Art Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182312747. [PMID: 34886474 PMCID: PMC8657178 DOI: 10.3390/ijerph182312747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 11/22/2021] [Accepted: 11/30/2021] [Indexed: 12/30/2022]
Abstract
Open-heart surgery is the leading cause of neuronal injury in the perioperative state, with some patients complicating with cerebrovascular accidents and delirium. Neurological fallout places an immense burden on the psychological well-being of the person affected, their family, and the healthcare system. Several randomised control trials (RCTs) have attempted to identify therapeutic and interventional strategies that reduce the morbidity and mortality rate in patients that experience perioperative neurological complications. However, there is still no consensus on the best strategy that yields improved patient outcomes, such that standardised neuroprotection protocols do not exist in a significant number of anaesthesia departments. This review aims to discuss contemporary evidence for preventing and managing risk factors for neuronal injury, mechanisms of injury, and neuroprotection interventions that lead to improved patient outcomes. Furthermore, a summary of existing RCTs and large observational studies are examined to determine which strategies are supported by science and which lack definitive evidence. We have established that the overall evidence for pharmacological neuroprotection is weak. Most neuroprotective strategies are based on animal studies, which cannot be fully extrapolated to the human population, and there is still no consensus on the optimal neuroprotective strategies for patients undergoing cardiac surgery. Large multicenter studies using universal standardised neurological fallout definitions are still required to evaluate the beneficial effects of the existing neuroprotective techniques.
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O’Gara BP, Gao L, Marcantonio ER, Subramaniam B. Sleep, Pain, and Cognition: Modifiable Targets for Optimal Perioperative Brain Health. Anesthesiology 2021; 135:1132-1152. [PMID: 34731233 PMCID: PMC8578455 DOI: 10.1097/aln.0000000000004046] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The prevention of perioperative neurocognitive disorders is a priority for patients, families, clinicians, and researchers. Given the multiple risk factors present throughout the perioperative period, a multicomponent preventative approach may be most effective. The objectives of this narrative review are to highlight the importance of sleep, pain, and cognition on the risk of perioperative neurocognitive disorders and to discuss the evidence behind interventions targeting these modifiable risk factors. Sleep disruption is associated with postoperative delirium, but the benefit of sleep-related interventions is uncertain. Pain is a risk factor for postoperative delirium, but its impact on other postoperative neurocognitive disorders is unknown. Multimodal analgesia and opioid avoidance are emerging as best practices, but data supporting their efficacy to prevent delirium are limited. Poor preoperative cognitive function is a strong predictor of postoperative neurocognitive disorder, and work is ongoing to determine whether it can be modified to prevent perioperative neurocognitive disorders.
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Affiliation(s)
- Brian P O’Gara
- Beth Israel Deaconess Medical Center. Department of Anesthesiology, Critical Care and Pain Medicine. Harvard Medical School. Boston, MA, USA
| | - Lei Gao
- Massachusetts General Hospital. Department of Anesthesia. Harvard Medical School. Boston, MA, USA
| | - Edward R Marcantonio
- Beth Israel Deaconess Medical Center. Department of Medicine. Harvard Medical School. Boston, MA, USA
| | - Balachundhar Subramaniam
- Beth Israel Deaconess Medical Center. Department of Anesthesiology, Critical Care and Pain Medicine. Harvard Medical School. Boston, MA, USA
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Abstract
Delirium, an acute disturbance in mental status due to another medical condition, is common and morbid in the intensive care unit. Despite its clear association with multiple common risk factors and important outcomes, including mortality and long-term cognitive impairment, both the ultimate causes of and ideal treatments for delirium remain unclear. Studies suggest that neuroinflammation, hypoxia, alterations in energy metabolism, and imbalances in multiple neurotransmitter pathways contribute to delirium, but commonly used treatments (e.g., antipsychotic medications) target only one or a few of these potential mechanisms and are not supported by evidence of efficacy. At this time, the optimal treatment for delirium during critical illness remains avoidance of risk factors, though ongoing trials may expand on the promise shown by agents such as melatonin and dexmedetomidine. Expected final online publication date for the Annual Review of Medicine, Volume 73 is January 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
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Affiliation(s)
- Niall T Prendergast
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania 15213, USA
| | - Perry J Tiberio
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania 15213, USA
| | - Timothy D Girard
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania 15213, USA;
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Wang CM, Chen WC, Zhang Y, Lin S, He HF. Update on the Mechanism and Treatment of Sevoflurane-Induced Postoperative Cognitive Dysfunction. Front Aging Neurosci 2021; 13:702231. [PMID: 34305576 PMCID: PMC8296910 DOI: 10.3389/fnagi.2021.702231] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 06/08/2021] [Indexed: 12/14/2022] Open
Abstract
Sevoflurane is one of the most widely used anesthetics for the induction and maintenance of general anesthesia in surgical patients. Sevoflurane treatment may increase the incidence of postoperative cognitive dysfunction (POCD), and patients with POCD exhibit lower cognitive abilities than before the operation. POCD affects the lives of patients and places an additional burden on patients and their families. Understanding the mechanism of sevoflurane-induced POCD may improve prevention and treatment of POCD. In this paper, we review the diagnosis of POCD, introduce animal models of POCD in clinical research, analyze the possible mechanisms of sevoflurane-induced POCD, and summarize advances in treatment for this condition.
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Affiliation(s)
- Cong-Mei Wang
- Department of Anesthesiology, The Second Affiliated Hospital, Fujian Medical University, Quanzhou, China
| | - Wei-Can Chen
- Department of Anesthesiology, The Second Affiliated Hospital, Fujian Medical University, Quanzhou, China
| | - Yan Zhang
- Department of Anesthesiology, The Second Affiliated Hospital, Fujian Medical University, Quanzhou, China
| | - Shu Lin
- Department of Anesthesiology, The Second Affiliated Hospital, Fujian Medical University, Quanzhou, China.,Diabetes and Metabolism Division, Garvan Institute of Medical Research, Darlinghurst, Sydney, NSW, Australia.,Centre of Neurological and Metabolic Research, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - He-Fan He
- Department of Anesthesiology, The Second Affiliated Hospital, Fujian Medical University, Quanzhou, China
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Zhou JY, Hamilton P, Macres S, Peña M, Tang S. Update on Ketamine. Adv Anesth 2021; 38:97-113. [PMID: 34106842 DOI: 10.1016/j.aan.2020.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Jon Y Zhou
- UC Davis Department of Anesthesiology and Pain Medicine, UC Davis Medical Center, 4150 V Street, Suite 1200 PSSB, Sacramento, CA 95817, USA.
| | - Perry Hamilton
- UC Davis Department of Anesthesiology and Pain Medicine, UC Davis Medical Center, 4150 V Street, Suite 1200 PSSB, Sacramento, CA 95817, USA. https://twitter.com/pvham1011
| | - Stephen Macres
- UC Davis Department of Anesthesiology and Pain Medicine, UC Davis Medical Center, 4150 V Street, Suite 1200 PSSB, Sacramento, CA 95817, USA
| | - Matthew Peña
- UC Davis Department of Anesthesiology and Pain Medicine, UC Davis Medical Center, 4150 V Street, Suite 1200 PSSB, Sacramento, CA 95817, USA
| | - Schirin Tang
- UC Davis Department of Anesthesiology and Pain Medicine, UC Davis Medical Center, 4150 V Street, Suite 1200 PSSB, Sacramento, CA 95817, USA. https://twitter.com/SchirinMD
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Burfeind KG, Tirado Navales AA, Togioka BM, Schenning K. Prevention of postoperative delirium through the avoidance of potentially inappropriate medications in a geriatric surgical patient. BMJ Case Rep 2021; 14:14/4/e240403. [PMID: 33875501 PMCID: PMC8057549 DOI: 10.1136/bcr-2020-240403] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
We demonstrate the utility of risk stratification for postoperative delirium in geriatric patients and show that postoperative delirium can be prevented in high-risk patients when potentially inappropriate medications (PIMs) (medications that are best avoided in older adults) are avoided. In this case, a 65-year-old woman underwent two debridement procedures with similar presurgical risk for postoperative delirium. There was no risk stratification or preoperative cognitive assessment in the first procedure, she received PIMs and developed postoperative delirium. In the second procedure, PIMs were intentionally avoided and postoperative delirium did not occur. This case supports recent recommendations from the European Society of Anaesthesiology, the American Society of Anesthesiologists and the American Geriatrics Society that providers assess a patient's cognitive function and delirium risk profile preoperatively to appropriately guide perioperative management.
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Affiliation(s)
- Kevin G Burfeind
- Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, Oregon, USA.,Medical Scientist Training Program, Oregon Health & Science University, Portland, Oregon, USA
| | - Andrés A Tirado Navales
- Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Brandon Michael Togioka
- Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Katie Schenning
- Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, Oregon, USA
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Zheng BH, Liu XM, Zhao P, Li P. A review on neurodevelopmental abnormalities in congenital heart disease: focus on minimizing the deleterious effects on patients. ALL LIFE 2021. [DOI: 10.1080/26895293.2021.1899992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
- Bai-hong Zheng
- Department of Pediatrics, the Second Hospital of Jilin University, Changchun, Jilin, People’s Republic of China
| | - Xiu-min Liu
- Department of Clinical Laboratory, the Second Hospital of Jilin University, Changchun, People’s Republic of China
| | - Peng Zhao
- Department of Anesthesiology, the Second Hospital of Jilin University, Changchun, People’s Republic of China
| | - Ping Li
- Department of Developmental Pediatrics, the Second Hospital of Jilin University, Changchun, Jilin, People’s Republic of China
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Intranasal Insulin Administration to Prevent Delayed Neurocognitive Recovery and Postoperative Neurocognitive Disorder: A Narrative Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18052681. [PMID: 33799976 PMCID: PMC7967645 DOI: 10.3390/ijerph18052681] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 02/26/2021] [Accepted: 03/02/2021] [Indexed: 11/29/2022]
Abstract
Delayed neurocognitive recovery and postoperative neurocognitive disorders are major complications of surgery, hospitalization, and anesthesia that are receiving increasing attention. Their incidence is reported to be 10–80% after cardiac surgery and 10–26% after non-cardiac surgery. Some of the risk factors include advanced age, level of education, history of diabetes mellitus, malnutrition, perioperative hyperglycemia, depth of anesthesia, blood pressure fluctuation during surgery, chronic respiratory diseases, etc. Scientific evidence suggests a causal association between anesthesia and delayed neurocognitive recovery or postoperative neurocognitive disorders, and various pathophysiological mechanisms have been proposed: mitochondrial dysfunction, neuroinflammation, increase in tau protein phosphorylation, accumulation of amyloid-β protein, etc. Insulin receptors in the central nervous system have a non-metabolic role and act through a neuromodulator-like action, while an interaction between anesthetics and central nervous system insulin receptors might contribute to anesthesia-induced delayed neurocognitive recovery or postoperative neurocognitive disorders. Acute or chronic intranasal insulin administration, which has no influence on the blood glucose concentration, appears to improve working memory, verbal fluency, attention, recognition of objects, etc., in animal models, cognitively healthy humans, and memory-impaired patients by restoring the insulin receptor signaling pathway, attenuating anesthesia-induced tau protein hyperphosphorylation, etc. The aim of this review is to report preclinical and clinical evidence of the implication of intranasal insulin for preventing changes in the brain molecular pattern and/or neurobehavioral impairment, which influence anesthesia-induced delayed neurocognitive recovery or postoperative neurocognitive disorders.
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Glumac S, Kardum G, Karanović N. IS IT TIME TO REDEFINE COGNITIVE DYSFUNCTION AFTER CARDIAC SURGERY? THE IMPORTANCE OF METHODOLOGICAL CONSISTENCY. Acta Clin Croat 2021; 60:127-130. [PMID: 34588732 PMCID: PMC8305368 DOI: 10.20471/acc.2021.60.01.18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 02/04/2020] [Indexed: 12/03/2022] Open
Abstract
High incidence and significance of repercussions on patient health and healthcare system make postoperative cognitive dysfunction (POCD) a major problem following cardiac surgery. POCD frequency drops over time since surgery and its occurrence are related to different aspects of cognitive deterioration that markedly impair the patient quality of life. Therefore, a substantial number of papers have focused on this complex postoperative complication, however, with limited achievement in clarifying it. The underlying mechanisms of POCD development and contributing factors are still unclear. A significant issue in POCD research is the lack of uniformity in defining cognitive impairment among investigators, including unique terminology of cognitive changes, a battery of appropriate neuropsychological tests, timing of assessment, and statistical approach. Thus, the aim of this review is to address the difficulties in establishing POCD definition, with inclusion of specific recommendations based on recent publications.
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Affiliation(s)
| | - Goran Kardum
- 1Department of Anesthesiology and Intensive Care, Split University Hospital Centre, Split, Croatia; 2Department of Psychology, Faculty of Humanities and Social Sciences, University of Split, Split, Croatia; 3Department of Anesthesiology and Intensive Medicine, School of Medicine, University of Split, Split, Croatia
| | - Nenad Karanović
- 1Department of Anesthesiology and Intensive Care, Split University Hospital Centre, Split, Croatia; 2Department of Psychology, Faculty of Humanities and Social Sciences, University of Split, Split, Croatia; 3Department of Anesthesiology and Intensive Medicine, School of Medicine, University of Split, Split, Croatia
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Mart MF, Williams Roberson S, Salas B, Pandharipande PP, Ely EW. Prevention and Management of Delirium in the Intensive Care Unit. Semin Respir Crit Care Med 2021; 42:112-126. [PMID: 32746469 PMCID: PMC7855536 DOI: 10.1055/s-0040-1710572] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Delirium is a debilitating form of brain dysfunction frequently encountered in the intensive care unit (ICU). It is associated with increased morbidity and mortality, longer lengths of stay, higher hospital costs, and cognitive impairment that persists long after hospital discharge. Predisposing factors include smoking, hypertension, cardiac disease, sepsis, and premorbid dementia. Precipitating factors include respiratory failure and shock, metabolic disturbances, prolonged mechanical ventilation, pain, immobility, and sedatives and adverse environmental conditions impairing vision, hearing, and sleep. Historically, antipsychotic medications were the mainstay of delirium treatment in the critically ill. Based on more recent literature, the current Society of Critical Care Medicine (SCCM) guidelines suggest against routine use of antipsychotics for delirium in critically ill adults. Other pharmacologic interventions (e.g., dexmedetomidine) are under investigation and their impact is not yet clear. Nonpharmacologic interventions thus remain the cornerstone of delirium management. This approach is summarized in the ABCDEF bundle (Assess, prevent, and manage pain; Both SAT and SBT; Choice of analgesia and sedation; Delirium: assess, prevent, and manage; Early mobility and exercise; Family engagement and empowerment). The implementation of this bundle reduces the odds of developing delirium and the chances of needing mechanical ventilation, yet there are challenges to its implementation. There is an urgent need for ongoing studies to more effectively mitigate risk factors and to better understand the pathobiology underlying ICU delirium so as to identify additional potential treatments. Further refinements of therapeutic options, from drugs to rehabilitation, are current areas ripe for study to improve the short- and long-term outcomes of critically ill patients with delirium.
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Affiliation(s)
- Matthew F. Mart
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, Tennessee
| | - Shawniqua Williams Roberson
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, Tennessee
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Bioengineering, Vanderbilt University, Nashville, Tennessee
| | - Barbara Salas
- The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Pratik P. Pandharipande
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, Tennessee
- Division of Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - E. Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, Tennessee
- Vanderbilt Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- VA Tennessee Valley Healthcare System Geriatric Research Education and Clinical Center (GRECC), Nashville, Tennessee
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Giuliano K, Etchill E, Zhou X, Lui C, Suarez-Pierre A, Sharma R, Wilson MA, Blue ME, Troncoso JC, Kannan S, Johnston MV, Sharma A, Kannan RM, Baumgartner WA, Lawton J. NMDA Receptor Antagonism for Neuroprotection in a Canine Model of Hypothermic Circulatory Arrest. J Surg Res 2020; 260:177-189. [PMID: 33348169 DOI: 10.1016/j.jss.2020.11.075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 11/10/2020] [Accepted: 11/15/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Hypothermic circulatory arrest (HCA) is associated with neurologic morbidity, in part mediated by activation of the N-methyl-D-aspartate glutamate receptor causing excitotoxicity and neuronal apoptosis. Using a canine model, we hypothesized that the N-methyl-D-aspartate receptor antagonist MK801 would provide neuroprotection and that MK801 conjugation to dendrimer nanoparticles would improve efficacy. MATERIALS AND METHODS Male hound dogs were placed on cardiopulmonary bypass, cooled to 18°C, and underwent 90 min of HCA. Dendrimer conjugates (d-MK801) were prepared by covalently linking dendrimer surface OH groups to MK801. Six experimental groups received either saline (control), medium- (0.15 mg/kg) or high-dose (1.56 mg/kg) MK801, or low- (0.05 mg/kg), medium-, or high-dose d-MK801. At 24, 48, and 72 h after HCA, animals were scored by a standardized neurobehavioral paradigm (higher scores indicate increasing deficits). Cerebrospinal fluid was obtained at baseline, eight, 24, 48, and 72 h after HCA. At 72 h, brains were examined for histopathologic injury in a blinded manner (higher scores indicate more injury). RESULTS Neurobehavioral deficit scores were reduced by low-dose d-MK801 on postoperative day two (P < 0.05) and by medium-dose d-MK801 on postoperative day 3 (P = 0.05) compared with saline controls, but free drug had no effect. In contrast, high-dose free MK801 significantly improved histopathology scores compared with saline (P < 0.05) and altered biomarkers of injury in cerebrospinal fluid, with a significant reduction in phosphorylated neurofilament-H for high-dose MK801 versus saline (P < 0.05). CONCLUSIONS Treatment with MK-801 demonstrated significant improvement in neurobehavioral and histopathology scores after HCA, although not consistently across doses and conjugates.
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Affiliation(s)
- Katherine Giuliano
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Eric Etchill
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Xun Zhou
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Cecillia Lui
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alejandro Suarez-Pierre
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rishi Sharma
- Center for Nanomedicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mary Ann Wilson
- Hugo W. Moser Research Institute at Kennedy Krieger, Baltimore, Maryland
| | - Mary E Blue
- Hugo W. Moser Research Institute at Kennedy Krieger, Baltimore, Maryland
| | - Juan C Troncoso
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sujatha Kannan
- Center for Nanomedicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael V Johnston
- Hugo W. Moser Research Institute at Kennedy Krieger, Baltimore, Maryland
| | - Anjali Sharma
- Center for Nanomedicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Willian A Baumgartner
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jennifer Lawton
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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Van Dyk K, Siddarth P, Rossetti M, Ercoli LM, Milillo MM, Lavretsky H. Memantine can protect against inflammation-based cognitive decline in geriatric depression. Brain Behav Immun Health 2020; 9:100167. [PMID: 34589902 PMCID: PMC8474499 DOI: 10.1016/j.bbih.2020.100167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 10/22/2020] [Accepted: 10/23/2020] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Geriatric depression is frequently accompanied by cognitive complaints and inflammation that increase risk for treatment-resistant depression and dementia. Memantine, a neuroprotective drug, can improve depression, inflammation, and help prevent cognitive decline. In our six-month clinical trial, escitalopram/memantine (ESC/MEM) improved mood and cognition compared to escitalopram/placebo treatment (ESC/PBO; NCT01902004). In this report, we examined the impact of baseline inflammation on mood and cognitive outcomes. MATERIALS AND METHODS We measured a panel of inflammatory cytokine markers using Human 38-plex magnetic cytokine/chemokine kits (EMD Millipore, HCYTMAG-60K-PX38) in 90 older adults 60 years and older with major depression enrolled in a 6-month double-blind placebo-controlled trial of escitalopram + memantine (ESC/MEM) in depressed older adults with subjective memory complaints. Four cytokine factors were derived and linear models were estimated to examine the predictive ability of cytokine levels on treatment induced change in depression and cognition. RESULTS Of the 90 randomized participants, 62 completed the 6-month follow up assessment. Both groups improved significantly on depression severity (HAM-D score), but not on cognitive outcomes at six months. Cytokine factor scores were not significantly different between ESC/MEM (n = 45) and ESC/PBO (n = 45) at baseline. Pro-inflammatory biomarkers at baseline predicted a decline in executive functioning in the ESC/PBO group but not in the ESC/MEM group, interaction F(1,52) = 4.63, p = .04. DISCUSSION In this exploratory analysis, the addition of memantine to escitalopram provided a protective effect on executive functioning in older depressed adults. Future studies are needed to replicate the association of cytokine markers to antidepressant and neuroprotective treatment-related change in cognition in geriatric depression.
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Affiliation(s)
- Kathleen Van Dyk
- Semel Institute for Neuroscience and Human Behavior, UCLA, Los Angeles, CA, USA
| | - Prabha Siddarth
- Semel Institute for Neuroscience and Human Behavior, UCLA, Los Angeles, CA, USA
| | - Maura Rossetti
- UCLA Immunogenetics Center, Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Linda M. Ercoli
- Semel Institute for Neuroscience and Human Behavior, UCLA, Los Angeles, CA, USA
| | - Michaela M. Milillo
- Semel Institute for Neuroscience and Human Behavior, UCLA, Los Angeles, CA, USA
| | - Helen Lavretsky
- Semel Institute for Neuroscience and Human Behavior, UCLA, Los Angeles, CA, USA
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Li M, Yang Y, Ma Y, Wang Q. Pharmacological Agents That Prevent Postoperative Cognitive Dysfunction in Patients With General Anesthesia: A Network Meta-analysis. Am J Ther 2020; 28:e420-e433. [PMID: 34228651 DOI: 10.1097/mjt.0000000000001271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Postoperative cognitive dysfunction (POCD) is associated with prolonged hospital stays, increased mortality, and negative socioeconomic consequences. Dexmedetomidine, ketamine, dexamethasone, and lidocaine have previously been reported to be effective for preventing POCD. STUDY QUESTION In this network meta-analysis, we apply direct and indirect comparisons to rank these pharmacological agents in terms of their effect on POCD, through which we seek to provide evidence for future clinical medication. DATA SOURCES A comprehensive literature search of PubMed, EMBASE, the Cochrane Library, and Web of Science was conducted to identify randomized controlled trials that examined the effects of dexmedetomidine, ketamine, dexamethasone, or lidocaine on POCD induced by general anesthesia. STUDY DESIGN For eligible studies, 2 reviewers independently extracted data and assessed the respective risk of bias. Bayesian network meta-analysis was conducted using R-3.4.1 software. A total of 30 articles were included in this meta-analysis. RESULTS Direct comparison showed that dexmedetomidine [odds ratio (OR) = 0.42, 95% confidence interval (CI): 0.32-0.55] may decrease the incidence of POCD for noncardiac surgery; dexmedetomidine (OR = 0.08, 95% CI: 0.01-0.63) and ketamine (OR = 0.09, 95% CI: 0.02-0.32) were found to decrease POCD for cardiac surgery. The R-software ranking result for prevention of POCD was dexmedetomidine, lidocaine, ketamine, placebo, and dexamethasone, respectively, in noncardiac surgery, and dexmedetomidine, ketamine, lidocaine, placebo, and dexamethasone in cardiac surgery. CONCLUSION Dexmedetomidine exhibited obvious superiority to other agents for noncardiac surgery; dexmedetomidine and ketamine exhibited a significantly better performance than other agents for cardiac surgery. Dexamethasone did not show better efficacy than the placebo. However, more rigorously designed studies comprising larger sample sizes are needed to confirm our findings.
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Affiliation(s)
- Mingguo Li
- Institute of Urology, Chinese Medicine Hospital of Linyi, Linyi City, China
| | - Yuanyuan Yang
- Department of Anesthesiology, Women and Children's Health Care Hospital of Linyi, Linyi City, China
| | - Yanfang Ma
- The Evidence Based Medicine Center, Lanzhou University, Lanzhou City, China; and
| | - Qi Wang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
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Zhao S, Chen F, Wang D, Han W, Zhang Y, Yin Q. NLRP3 inflammasomes are involved in the progression of postoperative cognitive dysfunction: from mechanism to treatment. Neurosurg Rev 2020; 44:1815-1831. [PMID: 32918635 DOI: 10.1007/s10143-020-01387-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 08/25/2020] [Accepted: 09/03/2020] [Indexed: 12/15/2022]
Abstract
Postoperative cognitive dysfunction (POCD) involves patient memory and learning decline after surgery. POCD not only presents challenges for postoperative nursing and recovery but may also cause permanent brain damage for patients, including children and the aged, with vulnerable central nervous systems. Its occurrence is mainly influenced by surgical trauma, anesthetics, and the health condition of the patient. There is a lack of imaging and experimental diagnosis; therefore, patients can only be diagnosed by clinical observation, which may underestimate the morbidity, resulting in decreased treatment efficacy. Except for symptomatic support therapy, there is a relative lack of effective drugs specific for the treatment of POCD, because the precise mechanism of POCD remains to be determined. One current hypothesis is that postoperative inflammation promotes the progression of POCD. Accumulating research has indicated that overactivation of NOD-, LRR- and pyrin domain-containing protein 3 (NLRP3) inflammasomes contribute to the POCD progression, suggesting that targeting NLRP3 inflammasomes may be an effective therapy to treat POCD. In this review, we summarize recent studies and systematically describe the pathogenesis, treatment progression, and potential treatment options of targeting NLRP3 inflammasomes in POCD patients.
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Affiliation(s)
- Shuai Zhao
- Department of Anesthesiology, First Hospital of Jilin University, 71 Xinmin Avenue, Changchun, 130021, China
| | - Fan Chen
- Department of Neurosurgery, University of Medicine Greifswald, Greifswald, Germany
| | - Dunwei Wang
- Department of Anesthesiology, First Hospital of Jilin University, 71 Xinmin Avenue, Changchun, 130021, China
| | - Wei Han
- Department of Anesthesiology, First Hospital of Jilin University, 71 Xinmin Avenue, Changchun, 130021, China
| | - Yuan Zhang
- Department of Anesthesiology, First Hospital of Jilin University, 71 Xinmin Avenue, Changchun, 130021, China.
| | - Qiliang Yin
- Department of Oncology, First Hospital of Jilin University, Changchun, China.
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Tian L, Luan H, Zhu P, Zhang Z, Bao H. A randomized controlled trial for measuring effects on cognitive functions of adding ketamine to propofol during sedation for colonoscopy. Medicine (Baltimore) 2020; 99:e21859. [PMID: 32899015 PMCID: PMC7478513 DOI: 10.1097/md.0000000000021859] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The purpose of this study was to evaluate the effects of adding ketamine to propofol on cognitive functions in patients undergoing sedation for colonoscopy. METHODS In this randomized, double-blinded, and controlled study, 200 patients were randomly allocated to ketamine/propofol admixture group (Group KP, n = 100), and propofol group (Group P, n = 100). Patients in Group KP received 0.25 mg/kg of ketamine and 0.5 mg/kg of propofol. Patients in Group P received 0.5 mg/kg propofol. Cognitive functions were measured using CogState battery before and after the colonoscopy procedure. Ninety five patients in Group KP and 92 patients in Group P had completed the CogStates tests and were included in the data analysis. RESULTS Compared with before procedure baseline, the performance on detection and identification tasks were significantly impaired after the procedure in both Group KP (P = .004, P = .001) and Group P patients (P = .005, P < .001). However, one-card learning accuracy and One-back memory was only impaired in Group KP patients (P = .006, P = .040) after the endoscopy but left intact in Group P patients. Group KP patients showed more severe impairment in one-card learning accuracy compared with Group P patients (P = .044). Group KP patients have better 5 minutes MAP (P = .005) and were also less likely to suffer from complications such as respiratory depression (P = .023) and hypotension (P = .015). OAA/S scores, BIS, MAP, complications, recovery times, and endoscopist and patient satisfaction were similar between the 2 groups. CONCLUSION Although adding ketamine to propofol for sedation in colonoscopy provided fewer complications such as respiratory depression and hypotension, it also causes more impairment in cognitive functions.
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Affiliation(s)
- Liang Tian
- Department of Anesthesiology, Lianyungang Clinical College of Nanjing Medical University, The First People's Hospital of Lianyungang, Lianyungang
| | - Hengfei Luan
- Department of Anesthesiology, Lianyungang Clinical College of Nanjing Medical University, The First People's Hospital of Lianyungang, Lianyungang
| | - Pin Zhu
- Department of Anesthesiology, Lianyungang Clinical College of Nanjing Medical University, The First People's Hospital of Lianyungang, Lianyungang
| | - Zhiyuan Zhang
- Department of Pathology, Basic Medical Sciences of Nanjing Medical University
| | - Hongguang Bao
- Department of Anesthesiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
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Deng F, Cai L, Zhou B, Zhou Z, Xu G. Whole transcriptome sequencing reveals dexmedetomidine-improves postoperative cognitive dysfunction in rats via modulating lncRNA. 3 Biotech 2020; 10:202. [PMID: 32309111 PMCID: PMC7154046 DOI: 10.1007/s13205-020-02190-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 04/01/2020] [Indexed: 10/24/2022] Open
Abstract
The aim of this study was to explore the underlying mechanism and function of dexmedetomidine (Dex)-regulated long non-coding RNAs (lncRNAs) in improving postoperative cognitive dysfunction (POCD) in rats. The established POCD model, Dex treatment model in rats, Morris water maze testing, and HE staining assays were used to evaluate the efficacy of Dex in POCD treatment in rats. Hippocampus samples of rats from the POCD group and the Dex group were used for lncRNA sequencing. The expression of five differentially expressed lncRNAs (DElncRNAs) was verified by quantitative reverse transcription PCR (qRT-PCR). Competing endogenous RNAs (ceRNA) network was constructed using Cytoscape. The concentration of inflammatory cytokines were measured by ELISA. Microglia proliferation and apoptosis were assessed using CCK-8 assay and flow cytometry, respectively. In the Dex group, the escape latency was shorter, neuron cell injury levels were alleviated, and the expression levels of TNF-α and IL-1β were significantly down-regulated compared with the POCD group. A total of 60 DE lncRNAs were identified, including 16 up- and 44 down-regulated lncRNAs in the Dex group. KEGG pathway analysis revealed that DElncRNAs were significantly enriched in cytokine-cytokine receptor interactions, the p53 signaling pathway, and the NF-kappa B signaling pathway. The qRT-PCR results and ceRNA network suggested that the lncRNA LOC102546895 may play a key role in POCD. LOC102546895 inhibited proliferation while promoting apoptosis in microglial cells and promoted the mRNA and protein expression of the target gene Npas4. Our findings showed that Dex alleviated POCD in rats and regulated lncRNAs expression profile in the hippocampus tissues of rats with POCD. In conclusion, our study outcome proposes that Dex-regulated lncRNA LOC102546895 may play a role in rats with POCD through targeting Npas4.
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Affiliation(s)
- Fumou Deng
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, No.1 Minde Road, Donghu District, Nanchang, Jiangxi China
| | - Lily Cai
- Department of Clinical Laboratory, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi China
| | - Bin Zhou
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, No.1 Minde Road, Donghu District, Nanchang, Jiangxi China
| | - Zhidong Zhou
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, No.1 Minde Road, Donghu District, Nanchang, Jiangxi China
| | - GuoHai Xu
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, No.1 Minde Road, Donghu District, Nanchang, Jiangxi China
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Ortoleva J. Consider Adjunctive Ketamine in Mechanically Ventilated Coronavirus Disease-2019 Patients. J Cardiothorac Vasc Anesth 2020; 34:2580. [PMID: 32563630 PMCID: PMC7187876 DOI: 10.1053/j.jvca.2020.04.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 04/14/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Jamel Ortoleva
- Department of Anesthesiology and Perioperative Medicine Tufts Medical Center Boston, MA.
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Manasco AT, Stephens RJ, Yaeger LH, Roberts BW, Fuller BM. Ketamine sedation in mechanically ventilated patients: A systematic review and meta-analysis. J Crit Care 2020; 56:80-88. [DOI: 10.1016/j.jcrc.2019.12.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 12/04/2019] [Accepted: 12/06/2019] [Indexed: 11/16/2022]
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Kapoor MC. Neurological dysfunction after cardiac surgery and cardiac intensive care admission: A narrative review part 2: Cognitive dysfunction after critical illness; potential contributors in surgery and intensive care; pathogenesis; and therapies to prevent/treat perioperative neurological dysfunction. Ann Card Anaesth 2020; 23:391-400. [PMID: 33109793 PMCID: PMC7879886 DOI: 10.4103/aca.aca_139_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Severe cognitive decline and cognitive dysfunction has been attributed to patient's stay in the cardiovascular intensive care unit. Prolonged mechanical ventilation, long duration of stay, sedation protocols, and sleep deprivation contribute to patients developing neurocognitive disorder after intensive care admission and it is associated with poor clinical outcomes. Trauma of surgery, stress of critical care, and administration of anaesthesia evoke a systemic inflammatory response and trigger neuroinflammation and oxidative stress. Anaesthetic agents modulate the function of the GABA receptors. The persistence of these effects in the postoperative period promotes development of cognitive dysfunction. A number of drugs are under investigation to restrict or prevent this cognitive decline.
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Affiliation(s)
- Mukul C Kapoor
- Department of Anaesthesia, Max Smart Super Specialty Hospital, Saket, Delhi, India
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50
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Powelson EB, Reed MJ, Bentov I. Perioperative Management of Delirium in Geriatric Patients. CURRENT ANESTHESIOLOGY REPORTS 2019. [DOI: 10.1007/s40140-019-00353-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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