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Torbati S, Daneshmehr A, Pouraliakbar H, Asgharian M, Ahmadi Tafti SH, Shum-Tim D, Heidari A. Personalized evaluation of the passive myocardium in ischemic cardiomyopathy via computational modeling using Bayesian optimization. Biomech Model Mechanobiol 2024; 23:1591-1606. [PMID: 38954283 DOI: 10.1007/s10237-024-01856-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 04/28/2024] [Indexed: 07/04/2024]
Abstract
Biomechanics-based patient-specific modeling is a promising approach that has proved invaluable for its clinical potential to assess the adversities caused by ischemic heart disease (IHD). In the present study, we propose a framework to find the passive material properties of the myocardium and the unloaded shape of cardiac ventricles simultaneously in patients diagnosed with ischemic cardiomyopathy (ICM). This was achieved by minimizing the difference between the simulated and the target end-diastolic pressure-volume relationships (EDPVRs) using black-box Bayesian optimization, based on the finite element analysis (FEA). End-diastolic (ED) biventricular geometry and the location of the ischemia were determined from cardiac magnetic resonance (CMR) imaging. We employed our pipeline to model the cardiac ventricles of three patients aged between 57 and 66 years, with and without the inclusion of valves. An excellent agreement between the simulated and the target EDPVRs has been reached. Our results revealed that the incorporation of valvular springs typically leads to lower hyperelastic parameters for both healthy and ischemic myocardium, as well as a higher fiber Green strain in the viable regions compared to models without valvular stiffness. Furthermore, the addition of valve-related effects did not result in significant changes in myofiber stress after optimization. We concluded that more accurate results could be obtained when cardiac valves were considered in modeling ventricles. The present novel and practical methodology paves the way for developing digital twins of ischemic cardiac ventricles, providing a non-invasive assessment for designing optimal personalized therapies in precision medicine.
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Affiliation(s)
- Saeed Torbati
- Research Center for Advanced Technologies in Cardiovascular Medicine, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
- School of Mechanical Engineering, College of Engineering, University of Tehran, Tehran, Iran
| | - Alireza Daneshmehr
- School of Mechanical Engineering, College of Engineering, University of Tehran, Tehran, Iran
| | - Hamidreza Pouraliakbar
- Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Masoud Asgharian
- Department of Mathematics and Statistics, McGill University, Montreal, QC, Canada
| | - Seyed Hossein Ahmadi Tafti
- Research Center for Advanced Technologies in Cardiovascular Medicine, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran.
- Department of Surgery, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran.
| | - Dominique Shum-Tim
- Division of Cardiac Surgery, Department of Surgery, McGill University, Montreal, QC, Canada
| | - Alireza Heidari
- Department of Mathematics and Statistics, McGill University, Montreal, QC, Canada.
- Department of Mechanical Engineering, McGill University, Montreal, QC, Canada.
- Department of Biomedical Engineering, McGill University, Montreal, QC, Canada.
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Atkins KJ, Silbert B, Scott DA, Evered LA. Prevalence of neurocognitive disorders 5 years after elective orthopaedic surgery. Anaesthesia 2024; 79:1053-1061. [PMID: 38985478 DOI: 10.1111/anae.16365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2024] [Indexed: 07/11/2024]
Abstract
BACKGROUND Peri-operative neurocognitive disorders are one of the most common complications affecting older adults after anaesthesia and surgery. It is not clear how exposure to surgery and anaesthesia contributes to the prevalence of long-term neurocognitive disorders. This study aimed to report the prevalence of neurocognitive disorders, and explore pre-operative factors associated with neurocognitive disorders 5 years after elective orthopaedic surgery. METHODS A prospective, 5-year longitudinal, cohort study was performed recruiting patients (aged ≥ 60 y) undergoing elective orthopaedic surgery and a contemporaneous non-surgical control group. Neurocognitive disorder was evaluated and classified at baseline and 5-year review incorporating: self- and informant-reported cognition; functional participation; and performance on neuropsychological tests. RESULTS Recruitment at 5-year follow-up included 195 patients and 21 control participants. In the patient cohort the prevalence of neurocognitive disorder was 38.1% (n = 75), with 61 (30.1%) meeting the criteria for mild neurocognitive disorder and 14 (7.1%) for major neurocognitive disorder. At 5-year follow-up, 121 (61.4%) patients were classified with a neurocognitive disorder, with 88 (44.7%) characterised with mild neurocognitive disorder and 33 (16.8%) with major neurocognitive disorder. Age (odds ratio (95%CI) 1.07 (1.02-1.13); p = 0.01) and baseline cognitive impairment (odds ratio (95%CI) 2.1 (1.06-4.15); p = 0.03) were significant predictors of neurocognitive disorder 5 years after surgery. CONCLUSION More than half of older adult patients had some form of neurocognitive disorder 5 years after elective orthopaedic surgery. Surgery and anaesthesia may be associated with the trajectory of cognitive decline in at-risk older adults, including those with pre-operative cognitive impairment. Cognitive screening should be factored into pre-operative assessments of older adults to inform subsequent care.
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Affiliation(s)
- Kelly J Atkins
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
| | - Brendan Silbert
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
- Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
| | - David A Scott
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
- Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
| | - Lis A Evered
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
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Zhou W, Zhu B, Weng Y, Chen C, Ni J, Shen W, Lan W, Wang J. The Combination of Presurgical Cortical Gray Matter Volumetry and Cerebral Perfusion Improves the Efficacy of Predicting Postoperative Cognitive Impairment of Elderly Patients. Tomography 2024; 10:1379-1396. [PMID: 39330750 PMCID: PMC11435822 DOI: 10.3390/tomography10090104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2024] [Revised: 08/23/2024] [Accepted: 08/28/2024] [Indexed: 09/28/2024] Open
Abstract
BACKGROUND Postoperative cognitive dysfunction (POCD) is a common complication of the central nervous system in elderly surgical patients. Structural MRI and arterial spin labelling (ASL) techniques found that the grey matter volume and cerebral perfusion in some specific brain areas are associated with the occurrence of POCD, but the results are inconsistent, and the predictive accuracy is low. We hypothesised that the combination of cortical grey matter volumetry and cerebral blood flow yield higher accuracy than either of the methods in discriminating the elderly individuals who are susceptible to POCD after abdominal surgery. MATERIALS AND METHODS Participants underwent neuropsychological testing before and after surgery. Postoperative cognitive dysfunction (POCD) was defined as a decrease in cognitive score of at least 20%. ASL-MRI and T1-weighted imaging were performed before surgery. We compared differences in cerebral blood flow (CBF) and cortical grey matter characteristics between POCD and non-POCD patients and generated receiver operating characteristic curves. RESULTS Out of 51 patients, 9 (17%) were diagnosed with POCD. CBF in the inferior frontal gyrus was lower in the POCD group compared to the non-POCD group (p < 0.001), and the volume of cortical grey matter in the anterior cingulate gyrus was higher in the POCD group (p < 0.001). The highest AUC value was 0.973. CONCLUSIONS The combination of cortical grey matter volumetry and cerebral perfusion based on ASL-MRI has improved efficacy in the early warning of POCD to elderly abdominal surgical patients.
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Affiliation(s)
- Weijian Zhou
- Department of Radiology, The First Affiliated Hospital of Ningbo University, Ningbo 315010, China
- Health Science Centre, Ningbo University, Ningbo 315211, China
| | - Binbin Zhu
- Department of Anaesthesiology, The First Affiliated Hospital of Ningbo University, Ningbo 315010, China
- Health Science Centre, Ningbo University, Ningbo 315211, China
| | - Yifei Weng
- Department of Radiology, The First Affiliated Hospital of Xiamen University, 55 Zhenhai Road, Siming District, Xiamen 361026, China
| | - Chunqu Chen
- Health Science Centre, Ningbo University, Ningbo 315211, China
| | - Jiajing Ni
- Department of Radiology, The First Affiliated Hospital of Ningbo University, Ningbo 315010, China
- Health Science Centre, Ningbo University, Ningbo 315211, China
| | - Wenqi Shen
- Department of Radiology, The First Affiliated Hospital of Ningbo University, Ningbo 315010, China
- Health Science Centre, Ningbo University, Ningbo 315211, China
| | - Wenting Lan
- Department of Radiology, The First Affiliated Hospital of Ningbo University, Ningbo 315010, China
| | - Jianhua Wang
- Department of Radiology, The First Affiliated Hospital of Ningbo University, Ningbo 315010, China
- Department of Radiology, The First Affiliated Hospital of Xiamen University, 55 Zhenhai Road, Siming District, Xiamen 361026, China
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Peri-Operative Risk Factors Associated with Post-Operative Cognitive Dysfunction (POCD): An Umbrella Review of Meta-Analyses of Observational Studies. J Clin Med 2023; 12:jcm12041610. [PMID: 36836145 PMCID: PMC9965885 DOI: 10.3390/jcm12041610] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 02/12/2023] [Accepted: 02/14/2023] [Indexed: 02/19/2023] Open
Abstract
This umbrella review aimed to systematically identify the peri-operative risk factors associated with post-operative cognitive dysfunction (POCD) using meta-analyses of observational studies. To date, no review has synthesised nor assessed the strength of the available evidence examining risk factors for POCD. Database searches from journal inception to December 2022 consisted of systematic reviews with meta-analyses that included observational studies examining pre-, intra- and post-operative risk factors for POCD. A total of 330 papers were initially screened. Eleven meta-analyses were included in this umbrella review, which consisted of 73 risk factors in a total population of 67,622 participants. Most pertained to pre-operative risk factors (74%) that were predominantly examined using prospective designs and in cardiac-related surgeries (71%). Overall, 31 of the 73 factors (42%) were associated with a higher risk of POCD. However, there was no convincing (class I) or highly suggestive (class II) evidence for associations between risk factors and POCD, and suggestive evidence (class III) was limited to two risk factors (pre-operative age and pre-operative diabetes). Given that the overall strength of the evidence is limited, further large-scale studies that examine risk factors across various surgery types are recommended.
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Tang AB, Diaz‐Ramirez LG, Smith AK, Lee SJ, Whitlock EL. Preoperative Factors Predict Memory Decline After Coronary Artery Bypass Grafting or Percutaneous Coronary Intervention in an Epidemiological Cohort of Older Adults. J Am Heart Assoc 2023; 12:e027849. [PMID: 36583424 PMCID: PMC9973564 DOI: 10.1161/jaha.122.027849] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 12/05/2022] [Indexed: 12/31/2022]
Abstract
Background Durable memory decline may occur in older adults after surgical (coronary artery bypass grafting [CABG]) or nonsurgical (percutaneous coronary intervention) coronary revascularization. However, it is unknown whether individual memory risk can be predicted. We reanalyzed an epidemiological cohort of older adults to predict memory decline at ≈1 year after revascularization. Methods and Results We studied Health and Retirement Study participants who underwent CABG or percutaneous coronary intervention at age ≥65 years between 1998 and 2015 and participated in ≥1 biennial postprocedure assessment. Using a memory score based on direct and proxy cognitive tests, we identified participants whose actual postprocedure memory score was 1-2 ("mild") or >2 ("major") SDs below expected postprocedure performance. We modeled probability of memory decline using logistic regression on preoperatively known factors and evaluated model discrimination and calibration. A total of 1390 participants (551 CABG, 839 percutaneous coronary intervention) underwent CABG/percutaneous coronary intervention at 75±6 years old; 40% were women. The cohort was 83% non-Hispanic White, 8.4% non-Hispanic Black, 6.4% Hispanic ethnicity, and 1.7% from other groups masked by the HRS (Health and Retirement Study) to preserve participant confidentiality. At a median of 1.1 (interquartile range, 0.6-1.6) years after procedure, 267 (19%) had mild memory decline and 88 (6.3%) had major memory decline. Factors predicting memory decline included older age, frailty, and off-pump CABG; obesity was protective. The optimism-corrected area under the receiver operator characteristic curve was 0.73 (95% CI, 0.71-0.77). A cutoff of 50% probability of memory decline identified 14% of the cohort as high risk, and was 94% specific and 30% sensitive for late memory decline. Conclusions Preoperative factors can be used to predict late memory decline after coronary revascularization in an epidemiological cohort with high specificity.
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Affiliation(s)
| | | | - Alexander K. Smith
- Division of Geriatrics, Department of MedicineUCSF School of MedicineSan FranciscoCA
| | - Sei J. Lee
- Division of Geriatrics, Department of MedicineUCSF School of MedicineSan FranciscoCA
| | - Elizabeth L. Whitlock
- Department of Anesthesia & Perioperative CareUCSF School of MedicineSan FranciscoCAUnited States
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Safavynia SA, Goldstein PA, Evered LA. Mitigation of perioperative neurocognitive disorders: A holistic approach. Front Aging Neurosci 2022; 14:949148. [PMID: 35966792 PMCID: PMC9363758 DOI: 10.3389/fnagi.2022.949148] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 07/11/2022] [Indexed: 11/30/2022] Open
Abstract
William Morton introduced the world to ether anesthesia for use during surgery in the Bullfinch Building of the Massachusetts General Hospital on October 16, 1846. For nearly two centuries, the prevailing wisdom had been that the effects of general anesthetics were rapidly and fully reversible, with no apparent long-term adverse sequelae. Despite occasional concerns of a possible association between surgery and anesthesia with dementia since 1887 (Savage, 1887), our initial belief was robustly punctured following the publication in 1998 of the International Study of Post-Operative Cognitive Dysfunction [ISPOCD 1] study by Moller et al. (1998) in The Lancet, in which they demonstrated in a prospective fashion that there were in fact persistent adverse effects on neurocognitive function up to 3 months following surgery and that these effects were common. Since the publication of that landmark study, significant strides have been made in redefining the terminology describing cognitive dysfunction, identifying those patients most at risk, and establishing the underlying etiology of the condition, particularly with respect to the relative contributions of anesthesia and surgery. In 2018, the International Nomenclature Consensus Working Group proposed new nomenclature to standardize identification of and classify perioperative cognitive changes under the umbrella of perioperative neurocognitive disorders (PND) (Evered et al., 2018a). Since then, the new nomenclature has tried to describe post-surgical cognitive derangements within a unifying framework and has brought to light the need to standardize methodology in clinical studies and motivate such studies with hypotheses of PND pathogenesis. In this narrative review, we highlight the relevant literature regarding recent key developments in PND identification and management throughout the perioperative period. We provide an overview of the new nomenclature and its implications for interpreting risk factors identified by clinical association studies. We then describe current hypotheses for PND development, using data from clinical association studies and neurophysiologic data where appropriate. Finally, we offer broad clinical guidelines for mitigating PND in the perioperative period, highlighting the role of Brain Enhanced Recovery After Surgery (Brain-ERAS) protocols.
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Affiliation(s)
- Seyed A. Safavynia
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, United States
| | - Peter A. Goldstein
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, United States
- Department of Medicine, Weill Cornell Medicine, New York, NY, United States
- Feil Family Brain & Mind Research Institute, Weill Cornell Medicine, New York, NY, United States
| | - Lisbeth A. Evered
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, United States
- Feil Family Brain & Mind Research Institute, Weill Cornell Medicine, New York, NY, United States
- Department of Anaesthesia and Acute Pain Medicine, St. Vincent’s Hospital, Melbourne, VIC, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia
- *Correspondence: Lisbeth A. Evered,
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Linassi F, De Laurenzis A, Maran E, Gadaldi A, Spano' L, Gerosa G, Pittarello D, Zanatta P, Carron M. Influence of Previous General Anesthesia on Cognitive Impairment: An Observational Study Among 151 Patients. Front Hum Neurosci 2022; 16:810046. [PMID: 35652004 PMCID: PMC9148968 DOI: 10.3389/fnhum.2022.810046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 04/14/2022] [Indexed: 11/26/2022] Open
Abstract
Introduction Preoperative neurocognitive disorder (preO-NCD) is a common condition affecting 14–51. 7% of the elderly population. General anesthesia has already been associated with the one-year post-operative neurocognitive disorder (PostO-NCD), specifically, a deficit in executive function, measured by the Trail Making Test B (TMT-B), but its long-term effects on cognitive function have not been investigated. We aimed to detect preO-NCD prevalence in patients scheduled for cardiac surgery and further investigate the possible role of previous general anesthesia (pGA) in general preoperative cognitive status [measured via the Montreal Cognitive Assessment (MoCA)] and/or in executive functioning (measured via TMT-B). Methods In this observational, prospective study, 151 adult patients scheduled for elective cardiac surgery underwent MoCA and TMT-B. Data on age, education, pGA, comorbidities, and laboratory results were collected. Results We discovered a general cognitive function impairment of 79.5% and an executive function impairment of 22%. Aging is associated with an increased likelihood (OR 2.99, p = 0.047) and education with a decreased likelihood (OR 0.35, p = 0.0045) of general cognitive impairment, but only education was significantly associated with a decreased likelihood (OR 0.22, p = 0.021) of executive function impairment. While pGA did not significantly affect preO-NCD, a noteworthy interaction between aging and pGA was found, resulting in a synergistic effect, increasing the likelihood of executive function impairment (OR 9.740, p = 0.0174). Conclusion We found a high prevalence of preO-NCD in patients scheduled for cardiac surgery. General cognitive function impairment is highly associated with advancing age (not pGA). However, older patients with at least one pGA appeared to be at an increased risk of preO-NCD, especially executive function impairment, suggesting that TMT-B should be associated with MoCA in the preoperative cognitive evaluation in this population.
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Affiliation(s)
- Federico Linassi
- Department of Pharmaceutical and Pharmacological Sciences, University of Padova, Padova, Italy
- *Correspondence: Federico Linassi
| | - Alessandro De Laurenzis
- Department of Medicine, Anaesthesiology and Intensive Care, University of Padova, Padova, Italy
| | - Eleonora Maran
- Department of Medicine, Anaesthesiology and Intensive Care, University of Padova, Padova, Italy
| | - Alessandra Gadaldi
- Department of Medicine, Anaesthesiology and Intensive Care, University of Padova, Padova, Italy
| | - Leonardo Spano'
- Department of Medicine, Anaesthesiology and Intensive Care, University of Padova, Padova, Italy
| | - Gino Gerosa
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Demetrio Pittarello
- Department of Medicine, Anaesthesiology and Intensive Care, University of Padova, Padova, Italy
| | - Paolo Zanatta
- Department of Anesthesia and Intensive Care, Integrated University Hospital of Verona, Verona, Italy
| | - Michele Carron
- Department of Medicine, Anaesthesiology and Intensive Care, University of Padova, Padova, Italy
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Acute peri‐operative neurocognitive disorders: a narrative review. Anaesthesia 2022; 77 Suppl 1:34-42. [DOI: 10.1111/anae.15613] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2021] [Indexed: 12/18/2022]
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9
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O'Bryan LJ, Atkins KJ, Lipszyc A, Scott DA, Silbert BS, Evered LA. Inflammatory Biomarker Levels After Propofol or Sevoflurane Anesthesia: A Meta-analysis. Anesth Analg 2022; 134:69-81. [PMID: 34908547 DOI: 10.1213/ane.0000000000005671] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND The perioperative inflammatory response may be implicated in adverse outcomes including neurocognitive dysfunction and cancer recurrence after oncological surgery. The immunomodulatory role of anesthetic agents has been demonstrated in vitro; however, its clinical relevance is unclear. The purpose of this meta-analysis was to compare propofol and sevoflurane with respect to biomarkers of perioperative inflammation. The secondary aim was to correlate markers of inflammation with clinical measures of perioperative cognition. METHODS Databases were searched for randomized controlled trials examining perioperative inflammation after general anesthesia using propofol compared to sevoflurane. Inflammatory biomarkers investigated were interleukin (IL)-6, IL-10, tissue necrosis factor alpha (TNF-α), and C-reactive protein (CRP). The secondary outcome was incidence of perioperative neurocognitive disorders. Meta-analysis with metaregression was performed to determine the difference between propofol and sevoflurane. RESULTS Twenty-three studies were included with 1611 participants. Studies varied by surgery type, duration, and participant age. There was an increase in the mean inflammatory biomarker levels following surgery, with meta-analysis revealing no difference in effect between propofol and sevoflurane. Heterogeneity between studies was high, with surgery type, duration, and patient age contributing to the variance across studies. Only 5 studies examined postoperative cognitive outcomes; thus, a meta-analysis could not be performed. Nonetheless, of these 5 studies, 4 reported a reduced incidence of cognitive decline associated with propofol use. CONCLUSIONS Surgery induces an inflammatory response; however, the inflammatory response did not differ as a function of anesthetic technique. This absence of an effect suggests that patient and surgical variables may have a far more significant impact on the postoperative inflammatory responses than anesthetic technique. The majority of studies assessing perioperative cognition in older patients reported a benefit associated with the use of propofol; however, larger trials using homogenous outcomes are needed to demonstrate such an effect.
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Affiliation(s)
- Liam J O'Bryan
- From the Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Kelly J Atkins
- From the Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital, Melbourne, Victoria, Australia.,Centre for Integrated Critical Care, Melbourne Medical School, University of Melbourne, Parville, Victoria, Australia
| | - Adam Lipszyc
- From the Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - David A Scott
- From the Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital, Melbourne, Victoria, Australia.,Centre for Integrated Critical Care, Melbourne Medical School, University of Melbourne, Parville, Victoria, Australia
| | - Brendan S Silbert
- From the Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital, Melbourne, Victoria, Australia.,Centre for Integrated Critical Care, Melbourne Medical School, University of Melbourne, Parville, Victoria, Australia
| | - Lis A Evered
- From the Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital, Melbourne, Victoria, Australia.,Centre for Integrated Critical Care, Melbourne Medical School, University of Melbourne, Parville, Victoria, Australia.,Department of Anesthesiology, Weill Cornell Medicine, New York, New York
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10
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Chua NJ, Dimopoulos G, Scott DA, Silbert BS, Evered LA. Impaired cognitive performance on MoCA testing at discharge in elderly patients following day endoscopy and its relationship to preoperative mild cognitive impairment. Anaesth Intensive Care 2021; 49:357-365. [PMID: 34378411 DOI: 10.1177/0310057x21997459] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In patients admitted to hospital, preoperative mild cognitive impairment predicts postoperative complications. The effect of mild cognitive impairment on discharge readiness among the day stay surgery population is unknown. Our aims were to determine the incidence of impaired cognitive performance at discharge after day stay endoscopy and whether pre-existing mild cognitive impairment was associated with its development. A single-centre cohort study of elective day stay endoscopy patients was undertaken. Over a three-month period, data were collected from 69 patients aged 65 years and over. Patients were cognitively assessed on admission and discharge using the Montreal cognitive assessment tool and the three-minute diagnostic confusion assessment method. At baseline, patients who scored 1.5 or more standard deviations below age-adjusted levels on the Montreal cognitive assessment tool in conjunction with a subjective memory complaint were classified as having mild cognitive impairment. At discharge, patients were classified as having impaired cognitive performance if there was a reduction in the Montreal cognitive assessment tool score by at least two points. We also assessed delirium and subsyndromal delirium at discharge using the three-minute diagnostic confusion assessment method. We identified mild cognitive impairment in 23 patients (33.3%) on admission, and impaired performance on the Montreal cognitive assessment tool test at discharge in 35 (50.7%) patients. There was no association between mild cognitive impairment on admission and impaired cognitive performance at discharge (50.0% versus 51.1%, P = 0.94). This study demonstrates that evidence of impaired cognitive performance on the Montreal cognitive assessment tool testing is present after day stay endoscopy in over 50% of elderly patients, but this is not associated with preoperative cognitive status.
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Affiliation(s)
- Nathan J Chua
- Melbourne Medical School, University of Melbourne, Melbourne, Australia.,Department of Acute Pain and Anaesthesia, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Georgia Dimopoulos
- Melbourne Medical School, University of Melbourne, Melbourne, Australia.,Department of Acute Pain and Anaesthesia, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - David A Scott
- Melbourne Medical School, University of Melbourne, Melbourne, Australia.,Department of Acute Pain and Anaesthesia, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Brendan S Silbert
- Melbourne Medical School, University of Melbourne, Melbourne, Australia.,Department of Acute Pain and Anaesthesia, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Lisbeth A Evered
- Melbourne Medical School, University of Melbourne, Melbourne, Australia.,Department of Acute Pain and Anaesthesia, St Vincent's Hospital Melbourne, Melbourne, Australia.,Department of Anesthesiology, Weill Cornell Medicine, New York, USA
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11
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Choi S, Jerath A, Jones P, Avramescu S, Djaiani G, Syed S, Saha T, Kaustov L, Kiss A, D'Aragon F, Hedlin P, Rajamohan R, Couture EJ, Singh A, Mapplebeck JC, Wong S, Orser BA. Cognitive Outcomes after DEXmedetomidine sedation in cardiac surgery: CODEX randomised controlled trial protocol. BMJ Open 2021; 11:e046851. [PMID: 33849856 PMCID: PMC8051371 DOI: 10.1136/bmjopen-2020-046851] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Older patients undergoing cardiac surgery carry the highest risk for developing major postoperative neurocognitive disorder (postoperative NCD or P-NCD) with up to 25% incidence 3 months after surgery. P-NCD is associated with significant morbidity, mortality, loss of independence, premature retirement and increased healthcare costs. This multicentre randomised trial is investigating the efficacy of postoperative dexmedetomidine sedation in reducing the incidence of major P-NCD after cardiac surgery compared with standard protocols. CODEX will be the largest interventional trial with major P-NCD as the primary outcome. METHODS AND ANALYSIS CODEX is recruiting patients ≥60 years old, undergoing elective cardiac surgery and without pre-existing major cognitive dysfunction or dementia. Eligible participants are randomised to receive postoperative dexmedetomidine or standard institutional sedation protocols in the intensive care unit. Baseline preoperative cognitive function is assessed with the computer-based Cogstate Brief Battery. The primary outcome, major P-NCD, 3 months after surgery is defined as a decrease in cognitive function ≥1.96 SD below age-matched, non-operative controls. Secondary outcomes include delirium, major P-NCD at 6/12 months, depressive symptoms, mild P-NCD and quality of surgical recovery at 3/6/12 months. The specific diagnostic criteria used in this protocol are consistent with the recommendations for clinical assessment and management of NCD from the Nomenclature Consensus Working Group on perioperative cognitive changes. Intention-to-treat analysis will compare major P-NCD at 3 months between study groups. ETHICS AND DISSEMINATION CODEX was approved by Sunnybrook Health Sciences Centre Research Ethics Board (REB) (Project ID 1743). This will be the first multicentre, randomised controlled trial to assess the efficacy of a pharmacological intervention to reduce the incidence of major P-NCD after cardiac surgery in patients ≥60 years old. Dissemination of the study results will include briefings of key findings and interpretation, conference presentations and peer-reviewed publications. TRIAL REGISTRATION NUMBER NCT04289142.
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Affiliation(s)
- Stephen Choi
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Angela Jerath
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Philip Jones
- Department of Anesthsia and Perioperative Medicine, University of Western Ontario, London, Ontario, Canada
| | - Sinziana Avramescu
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia, Humber River Hospital, Toronto, Ontario, Canada
| | - George Djaiani
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Summer Syed
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Tarit Saha
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ontario, Canada
| | - Lilia Kaustov
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Alex Kiss
- Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Frédérick D'Aragon
- Départment d'anesthésiologie, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Peter Hedlin
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Raja Rajamohan
- Department of Anesthesiology, Pharmacology & Therapeutics, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Etienne J Couture
- Department of Anesthesiology and Cardiac Surgical Intensive Care Division, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Amara Singh
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Josiane Cs Mapplebeck
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Sophia Wong
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Beverley Anne Orser
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
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Zhu M, Qi Y, He H, Zhang S, Mei Y. Effect of quadratus lumborum block on postoperative cognitive function in elderly patients undergoing laparoscopic radical gastrectomy: a randomized controlled trial. BMC Geriatr 2021; 21:238. [PMID: 33836651 PMCID: PMC8033654 DOI: 10.1186/s12877-021-02179-w] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 03/25/2021] [Indexed: 11/30/2022] Open
Abstract
Background Quadratus lumborum block (QLB) is a novel and effective postoperative analgesia method for abdominal surgeries. However, whether QLB can affect early postoperative cognitive function by inhibiting surgical traumatic stress and the inflammatory response remains unclear. This study aimed to explore the effect of QLB on postoperative cognitive function in elderly patients undergoing laparoscopic radical gastrectomy. Methods Sixty-four elderly patients who underwent laparoscopic radical gastrectomy were randomly divided into the QLB group (Q group, n = 32) and control group (C group, n = 32). The Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) were used to measure cognitive function 1 day before and 7 days after surgery. Postoperative cognitive dysfunction (POCD) was defined as a decline of ≥ 1 SD in both tests. The visual analog scale (VAS) scores 6 h (T1), 24 h (T2), and 48 h (T3) after surgery were measured. The serum levels of high mobility group box protein 1 (HMGB1), interleukin-6 (IL-6), and tumor necrosis factor-α (TNF-α) were evaluated 1 day before surgery (baseline), and 1 day (day 1) and 3 days after surgery (day 3). The intraoperative remifentanil dosage, sufentanil consumption 24 h after surgery, recovery time from anesthesia, and adverse effects were also compared. Results POCD was present in two patients in the QLB group and eight patients in the C group 7 days after surgery (6.7 % vs. 27.6 %, P = 0.032). The MMSE and MoCA scores were similar in both groups preoperatively, and the two scores were higher in the QLB group than in the C group 7 days after surgery (P < 0.05). The VAS scores were significantly lower in the Q group at all times after surgery (P < 0.05). Compared with the C group, the levels of HMGB1, TNF-α, and IL-6 were significantly decreased 1 and 3 days after surgery in the QLB group (P < 0.05). The remifentanil consumption intraoperatively and sufentanil 24 h postoperatively were significantly lower in the QLB group (P < 0.05). The recovery time from anesthesia was shorter in the QLB group (P < 0.05). No severe adverse effects occurred in either group. Conclusions QLB could improve postoperative cognitive function in elderly patients undergoing laparoscopic radical gastrectomy. This may be related to the suppression of the inflammatory response after surgery. Trial registration Chictr.org.cn identifier ChiCTR1900027574 (Date of registry: 19/11/2019, prospectively registered).
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Affiliation(s)
- Manhua Zhu
- Department of Anesthesiology, Ningbo Medical Center Lihuili Hospital, Ningbo University, No.1111 Jiangnan Road, Zhejiang, 315040, Ningbo, China.
| | - Yong Qi
- Department of Anesthesiology, Ningbo Medical Center Lihuili Hospital, Ningbo University, No.1111 Jiangnan Road, Zhejiang, 315040, Ningbo, China
| | - Huijuan He
- Department of Anesthesiology, Ningbo Medical Center Lihuili Hospital, Ningbo University, No.1111 Jiangnan Road, Zhejiang, 315040, Ningbo, China
| | - Song Zhang
- Department of Anesthesiology, Ningbo Medical Center Lihuili Hospital, Ningbo University, No.1111 Jiangnan Road, Zhejiang, 315040, Ningbo, China
| | - Yuliu Mei
- Department of Anesthesiology,Ningbo Beilun People's Hospital, No1288 Lushan East Road, Zhejiang, 315800, Ningbo, China
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Evered LA, Goldstein PA. Reducing Perioperative Neurocognitive Disorders (PND) Through Depth of Anesthesia Monitoring: A Critical Review. Int J Gen Med 2021; 14:153-162. [PMID: 33469352 PMCID: PMC7813450 DOI: 10.2147/ijgm.s242230] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 01/05/2021] [Indexed: 11/24/2022] Open
Abstract
General anesthesia has been administered for over 150 years, and in that time, has become progressively safer. Improvements in outcomes have been driven by multiple advances, including the use of non-invasive monitors to assess cardiovascular and respiratory status. More recent advances have included the development and use of monitors to measure neurologic status by means of “processed” electroencephalography (pEEG), wherein the frontal EEG signal is analyzed by proprietary algorithms to produce a dimensionless number (scaled from 0 to 100), wherein low values are associated with deepening levels of sedation that progresses to loss of consciousness. Such monitors have been shown to enable anesthetic titration so as to expedite emergence and early recovery, and their use is advocated for the prevention of intraoperative awareness in the setting of administration of total intravenous anesthesia and neuromuscular blockade. Whether their use can minimize, or prevent, longer term adverse events is a matter of debate. In this narrative review of the most recent literature, we provide an assessment on the use of pEEG monitors in the prevention of a notable, and important, postoperative adverse outcome – delirium – in elderly patients. As we will discuss, the existing data do not support its routine use for the prevention of postoperative delirium in this, or any other, patient population.
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Affiliation(s)
- Lisbeth A Evered
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA.,Department of Anaesthesia and Acute Pain Medicine, St. Vincent's Hospital, Melbourne, VIC, Australia.,Department of Medicine, University of Melbourne, Melbourne, VIC, Australia.,Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
| | - Peter A Goldstein
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA.,Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA.,Department of Medicine, Weill Cornell Medicine, New York, NY, USA
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14
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Velazquez EJ. Percutaneous Coronary Intervention or Coronary Artery Bypass Grafting to Treat Ischemic Cardiomyopathy? JAMA Cardiol 2020; 5:641-642. [PMID: 32267462 DOI: 10.1001/jamacardio.2020.0597] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Eric J. Velazquez
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
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15
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Green AR. How Can We Optimize Care and Outcomes for Patients with Mild Cognitive Impairment and Acute Myocardial Infarction? J Gen Intern Med 2020; 35:5-7. [PMID: 31659666 PMCID: PMC6957667 DOI: 10.1007/s11606-019-05484-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Ariel R Green
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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16
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State of the clinical science of perioperative brain health: report from the American Society of Anesthesiologists Brain Health Initiative Summit 2018. Br J Anaesth 2019; 123:464-478. [PMID: 31439308 DOI: 10.1016/j.bja.2019.07.004] [Citation(s) in RCA: 127] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 06/25/2019] [Accepted: 07/02/2019] [Indexed: 12/20/2022] Open
Abstract
Cognitive recovery after anaesthesia and surgery is a concern for older adults, their families, and caregivers. Reports of patients who were 'never the same' prompted a scientific inquiry into the nature of what patients have experienced. In June 2018, the ASA Brain Health Initiative held a summit to discuss the state of the science on perioperative cognition, and to create an implementation plan for patients and providers leveraging the current evidence. This group included representatives from the AARP (formerly the American Association of Retired Persons), American College of Surgeons, American Heart Association, and Alzheimer's Association Perioperative Cognition and Delirium Professional Interest Area. This paper summarises the state of the relevant clinical science, including risk factors, identification and diagnosis, prognosis, disparities, outcomes, and treatment of perioperative neurocognitive disorders. Finally, we discuss gaps in current knowledge with suggestions for future directions and opportunities for clinical and translational projects.
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Langer T, Santini A, Zadek F, Chiodi M, Pugni P, Cordolcini V, Bonanomi B, Rosini F, Marcucci M, Valenza F, Marenghi C, Inglese S, Pesenti A, Gattinoni L. Intraoperative hypotension is not associated with postoperative cognitive dysfunction in elderly patients undergoing general anesthesia for surgery: results of a randomized controlled pilot trial. J Clin Anesth 2019; 52:111-118. [DOI: 10.1016/j.jclinane.2018.09.021] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 09/11/2018] [Accepted: 09/11/2018] [Indexed: 01/14/2023]
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18
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Cigarroa JG, Bailey SR. Does Cardiac Catheterization Accelerate Decline in Cognitive Function or Serve as an Inflection Point for Evaluation? J Am Heart Assoc 2018. [PMID: 29525781 PMCID: PMC5907577 DOI: 10.1161/jaha.118.008751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Joaquin G Cigarroa
- Janey Briscoe Center for Cardiovascular Research, Janey and Dolph Briscoe Division of Cardiology, UT Health Long School of Medicine, San Antonio, TX
| | - Steven R Bailey
- Janey Briscoe Center for Cardiovascular Research, Janey and Dolph Briscoe Division of Cardiology, UT Health Long School of Medicine, San Antonio, TX
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