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Varpaei HA, Robbins LB, Ling J, Lehto RH, Bender CM. Anaesthesia-related cognitive dysfunction following cardiothoracic surgery in late middle-age and younger adults: A scoping review. Nurs Crit Care 2024; 29:457-465. [PMID: 37985012 DOI: 10.1111/nicc.13001] [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: 07/28/2023] [Revised: 10/16/2023] [Accepted: 10/18/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND The incidence of postoperative cognitive dysfunction (POCD) is notably high after cardiac surgery, ranging from 25% to 30%, and is associated with a lower quality of life, increased patient dependency, and heightened mortality. Anaesthesia during cardiothoracic surgery significantly contributes to the risk of POCD in older adults by adversely affecting the brain, including reductions in blood flow and oxygen levels. AIM This review aimed to evaluate factors associated with anaesthesia-related postoperative cognitive dysfunction (POCD) among adults younger than 65 years who underwent cardiothoracic surgeries. STUDY DESIGN A systematic keyword search, following the scoping review framework, was performed in the PubMed and CINAHL databases. Original English-language studies that included adults younger than 65 years and addressed cognitive function after surgery along with anaesthesia management were included. Retrospective studies, animal research and in vitro and in vivo studies were excluded. RESULTS Twenty-three articles were included (65.2% interventional studies). All studies lacked theoretical or conceptual frameworks. Ketamine's neuroprotective potential is questionable, and intravenous lidocaine may be considered a possible early agent for preventing POCD, but long-term effectiveness is uncertain. Compared to inhalational anaesthesia, total intravenous anaesthesia (TIVA) may be related to a decreased incidence of POCD. Variation in POCD assessment impacted the lack of homogeneity in obtained data. Moreover, the shorter-term timing of POCD evaluation such as in early days after surgery could be greatly influenced by medication and delirium. CONCLUSION Although strategies such as TIVA, the use of neuroprotective anaesthetics and comprehensive preoperative assessments are suggested to prevent POCD, this multifactorial phenomenon cannot be explicitly attributed solely to anaesthetics or anaesthesia-related techniques. Use of standardized, reliable and valid tools for POCD assessment is encouraged for cross-study comparison. RELEVANCE TO CLINICAL PRACTICE Nurses and certified nurse anaesthetists must be aware of risk factors for postoperative delirium and POCD so they can assess patients before and after surgery. Patients and caregivers need to be educated about cognitive changes after surgery and advised to report them to their health care provider if they occur.
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Affiliation(s)
| | - Lorraine B Robbins
- College of Nursing, Michigan State University, East Lansing, Michigan, USA
| | - Jiying Ling
- College of Nursing, Michigan State University, East Lansing, Michigan, USA
| | - Rebecca H Lehto
- College of Nursing, Michigan State University, East Lansing, Michigan, USA
| | - Catherine M Bender
- Nursing and Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Zhao Q, Wan H, Pan H, Xu Y. Postoperative cognitive dysfunction-current research progress. Front Behav Neurosci 2024; 18:1328790. [PMID: 38357422 PMCID: PMC10865506 DOI: 10.3389/fnbeh.2024.1328790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 01/15/2024] [Indexed: 02/16/2024] Open
Abstract
Postoperative cognitive dysfunction (POCD) commonly occurs after surgery, particularly in elderly individuals. It is characterized by a notable decline in cognitive performance, encompassing memory, attention, coordination, orientation, verbal fluency, and executive function. This reduction in cognitive abilities contributes to extended hospital stays and heightened mortality. The prevalence of POCD can reach 40% within 1 week following cardiovascular surgery and remains as high as 17% 3 months post-surgery. Furthermore, POCD exacerbates the long-term risk of Alzheimer's disease (AD). As a result, numerous studies have been conducted to investigate the molecular mechanisms underlying POCD and potential preventive strategies. This article provides a review of the research progress on POCD.
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Affiliation(s)
| | | | - Hui Pan
- Department of Anesthesiology, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Yiquan Xu
- Department of Anesthesiology, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
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Ghia S, Savadjian A, Shin D, Diluozzo G, Weiner MM, Bhatt HV. Hypothermic Circulatory Arrest in Adult Aortic Arch Surgery: A Review of Hypothermic Circulatory Arrest and its Anesthetic Implications. J Cardiothorac Vasc Anesth 2023; 37:2634-2645. [PMID: 37723023 DOI: 10.1053/j.jvca.2023.08.139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 08/11/2023] [Accepted: 08/20/2023] [Indexed: 09/20/2023]
Abstract
Diseases affecting the aortic arch often require surgical intervention. Hypothermic circulatory arrest (HCA) enables a safe approach during open aortic arch surgeries. Additionally, HCA provides neuroprotection by reducing cerebral metabolism and oxygen requirements. However, HCA comes with significant risks (eg, neurologic dysfunction, stroke, and coagulopathy), and the cardiac anesthesiologist must completely understand the surgical techniques, possible complications, and management strategies.
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Affiliation(s)
- Samit Ghia
- Department of Anesthesiology, Critical Care and Perioperative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Andre Savadjian
- Department of Anesthesiology and Critical Care, Duke University School of Medicine, Durham, NC
| | - DaWi Shin
- Department of Anesthesiology, Critical Care and Perioperative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Gabriele Diluozzo
- Department of Cardiovascular Surgery, Yale School of Medicine, Bridgeport, CT
| | - Menachem M Weiner
- Department of Anesthesiology, Critical Care and Perioperative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Himani V Bhatt
- Department of Anesthesiology, Critical Care and Perioperative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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Geng C, Hu B, Jiang J, Zhang Y, Tang W, Pan M, Sun L, Chen P, Wang H. The effect of intravenous lidocaine on postoperative cognitive dysfunction: a systematic review and meta-analysis. BMC Anesthesiol 2023; 23:299. [PMID: 37670239 PMCID: PMC10478315 DOI: 10.1186/s12871-023-02202-0] [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: 02/16/2023] [Accepted: 07/07/2023] [Indexed: 09/07/2023] Open
Abstract
BACKGROUND Postoperative cognitive dysfunction (POCD) has been reported as a significant complication in elderly patients. Various methods have been proposed for reducing the incidence and severity of POCD. Intravenous lidocaine administration has been reported in the literature to reduce POCD, but the effect of lidocaine remains controversial. METHODS We screened Medline, Embase, Cochrane Library, and China National Knowledge Infrastructure (up to April 2022) databases following a search strategy for intravenous lidocaine on POCD. We also screened related bibliographies on lidocaine for POCD. Ten articles comprising 1517 patients were selected and analyzed. We divided the postoperative follow-up period as follows: short term (<30 days), medium term (30-90 days), and long term (>90 days). OUTCOMES We found that lidocaine could attenuate the overall incidence of POCD, especially in the short term. There were no differences between lidocaine and placebo on the overall severity of POCD. CONCLUSION Lidocaine administered intravenously could attenuate the overall incidence of POCD and its severity in the short term.
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Affiliation(s)
- Chuan Geng
- Department of Anesthesiology, Fengxian People's Hospital, Fengxian County, Xuzhou City, 221700, Jiangsu Province, China
| | - Baoji Hu
- Department of Anesthesiology, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Shanghai, 201399, China
| | - Jihong Jiang
- Department of Anesthesiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, China
| | - Yunhe Zhang
- Department of Centre ICU, Shanghai East Hospital, School of medicine, Tongji University, Shanghai, 200085, China
| | - Weiqing Tang
- Department of Anesthesiology, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Shanghai, 201399, China
| | - Mengzhi Pan
- Department of Anesthesiology, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Shanghai, 201399, China
| | - Leilei Sun
- Department of Anesthesiology, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Shanghai, 201399, China
| | - Peifen Chen
- Department of Respiratory Diseases, The Third People's Hospital of Shenzhen, the Second Affiliated Hospital of Southern University of Science and Technology, Shenzhen, 518112, Guangdong, China.
| | - Hengyue Wang
- Faculty of Anesthesiology, Changhai Hospital, Naval Medical University, Shanghai, 200433, China.
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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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Qeva E, Sollazzo C, Bilotta F. Insulin signaling in the central nervous system, a possible pathophysiological mechanism of anesthesia-induced delayed neurocognitive recovery/postoperative neurocognitive disorder: a narrative review. Expert Rev Neurother 2022; 22:839-847. [PMID: 36332201 DOI: 10.1080/14737175.2022.2144234] [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: 11/06/2022]
Abstract
INTRODUCTION Impairment in neurocognitive functions ranges between delayed neurocognitive recovery (DNR) and postoperative neurocognitive disorders (pNCD). Incidence varies from 11% after noncardiac surgery to 60% after cardiac surgery. AREAS COVERED Insulin receptors (IRs) signaling pathway in the central nervous system (CNS) could be a possible pathophysiological mechanism of anesthesia-induced DNR/pNCD and perioperative intranasal insulin administration could be a preventive approach. This hypothesis is supported by the following evidence: effects of IRs-CNS signaling pathway on neuromodulation; higher incidence of DNR/pNCD in patients with insulin resistance; neurotoxicity of IRs signaling pathways after anesthetic exposure; improvement of neurocognitive impairment after insulin exposure. This narrative review was conducted after a literature search of PubMed, EMBASE and SCOPUS online medical data performed in May 2022. EXPERT OPINION Perioperative intranasal insulin is shown to be protective and future studies should address: the role of insulin as a neuromodulator; its integration into neuroprotection approaches; patient populations that might benefit from this approach; a well-defined protocol of intranasal insulin administration in a perioperative background and other disciplines; and possible collateral effects.
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Affiliation(s)
- Ega Qeva
- Department of Anesthesia and Intensive Care Medicine, "Sapienza" University of Rome, 'Policlinico Umberto I' Hospital, 00161 Rome, Italy.,Department of Anesthesia, Intensive Care and Emergency, University of Turin, 'Città Della Salute e Della Scienza' Hospital, 10126 Turin, Italy
| | - Camilla Sollazzo
- Department of Anesthesia and Intensive Care Medicine, "Sapienza" University of Rome, 'Policlinico Umberto I' Hospital, 00161 Rome, Italy
| | - Federico Bilotta
- Department of Anesthesia and Intensive Care Medicine, "Sapienza" University of Rome, 'Policlinico Umberto I' Hospital, 00161 Rome, Italy
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Hung KC, Ho CN, Liu WC, Yew M, Chang YJ, Lin YT, Hung IY, Chen JY, Huang PW, Sun CK. Prophylactic effect of intravenous lidocaine against cognitive deficit after cardiac surgery: A PRISMA-compliant meta-analysis and trial sequential analysis. Medicine (Baltimore) 2022; 101:e30476. [PMID: 36107567 PMCID: PMC9439840 DOI: 10.1097/md.0000000000030476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND This study aimed at providing an updated evidence of the association between intraoperative lidocaine and risk of postcardiac surgery cognitive deficit. METHODS Randomized clinical trials (RCTs) investigating effects of intravenous lidocaine against cognitive deficit in adults undergoing cardiac surgeries were retrieved from the EMBASE, MEDLINE, Google scholar, and Cochrane controlled trials register databases from inception till May 2021. Risk of cognitive deficit was the primary endpoint, while secondary endpoints were length of stay (LOS) in intensive care unit/hospital. Impact of individual studies and cumulative evidence reliability were evaluated with sensitivity analyses and trial sequential analysis, respectively. RESULTS Six RCTs involving 963 patients published from 1999 to 2019 were included. In early postoperative period (i.e., 2 weeks), the use of intravenous lidocaine (overall incidence = 14.8%) was associated with a lower risk of cognitive deficit compared to that with placebo (overall incidence = 33.1%) (relative risk = 0.49, 95% confidence interval: 0.32-0.75). However, sensitivity analysis and trial sequential analysis signified insufficient evidence to arrive at a firm conclusion. In the late postoperative period (i.e., 6-10 weeks), perioperative intravenous lidocaine (overall incidence = 37.9%) did not reduce the risk of cognitive deficit (relative risk = 0.99, 95% confidence interval: 0.84) compared to the placebo (overall incidence = 38.6%). Intravenous lidocaine was associated with a shortened LOS in intensive care unit/hospital with weak evidence. CONCLUSION Our results indicated a prophylactic effect of intravenous lidocaine against cognitive deficit only at the early postoperative period despite insufficient evidence. Further large-scale studies are warranted to assess its use for the prevention of cognitive deficit and enhancement of recovery (e.g., LOS).
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Affiliation(s)
- Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical Center, Tainan city, Taiwan
| | - Chun-Ning Ho
- Department of Anesthesiology, Chi Mei Medical Center, Tainan city, Taiwan
| | - Wei-Cheng Liu
- Department of Anesthesiology, Chi Mei Medical Center, Tainan city, Taiwan
| | - Ming Yew
- Department of Anesthesiology, Chi Mei Medical Center, Tainan city, Taiwan
| | - Ying-Jen Chang
- Department of Anesthesiology, Chi Mei Medical Center, Tainan city, Taiwan
| | - Yao-Tsung Lin
- Department of Anesthesiology, Chi Mei Medical Center, Tainan city, Taiwan
| | - I-Yin Hung
- Department of Anesthesiology, Chi Mei Medical Center, Tainan city, Taiwan
| | - Jen-Yin Chen
- Department of Anesthesiology, Chi Mei Medical Center, Tainan city, Taiwan
| | - Ping-Wen Huang
- Department of Emergency Medicine, Show Chwan Memorial Hospital, Changhua city, Taiwan
| | - Cheuk-Kwan Sun
- Department of Emergency Medicine, E-Da Hospital, Kaohsiung city, Taiwan
- College of Medicine, I-Shou University, Kaohsiung city, Taiwan
- *Correspondence: Cheuk-Kwan Sun, Department of Emergency Medicine, E-Da Hospital, Kaohsiung, Taiwan, No.1, Yida Road, Jiaosu Village, Yanchao District, Kaohsiung City 82445, Taiwan (e-mail: )
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8
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Parasternal After Cardiac Surgery (PACS): a prospective, randomised, double-blinded, placebo-controlled trial study protocol for evaluating a continuous bilateral parasternal block with lidocaine after open cardiac surgery through sternotomy. Trials 2022; 23:516. [PMID: 35725494 PMCID: PMC9208208 DOI: 10.1186/s13063-022-06469-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 06/09/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Multimodal analgesia that provides optimal pain treatment with minimal side effects is important for optimal recovery after open cardiac surgery. Regional anaesthesia can be used to block noxious nerve signals. Because sternotomy causes considerable pain that lasts several days, a continuous nerve block is advantageous. Previous studies on continuous sternal wound infusion or parasternal blocks with long-acting local anaesthetics have shown mixed results. This study aims to determine whether a continuous bilateral parasternal block with lidocaine, which is a short-acting local anaesthetic that has a favourable safety/toxicity profile, results in effective analgesia. We hypothesise that a 72-hour continuous parasternal block with 0.5% lidocaine at a rate of 7 ml/hour on each side provides effective analgesia and reduces opioid requirement. We will evaluate whether recovery is enhanced. METHODS In a prospective, randomised, double-blinded manner, 45 patients will receive a continuous parasternal block with either 0.5% lidocaine or saline. The primary endpoint is cumulated intravenous morphine by patient-controlled analgesia at 72 hours. Secondary end-points include the following: (1) the cumulated numerical rating scale (NRS) score recorded three times daily at 72 hours; (2) the cumulated NRS score after two deep breaths three times daily at 72 hours; (3) the NRS score at rest and after two deep breaths at 2, 4, 8 and 12 weeks after surgery; (4) oxycodone requirement at 2, 4, 8 and 12 weeks after surgery; (5) Quality of Recovery-15 score preoperatively compared with that at 24, 48 and 72 hours, and at 2, 4, 8 and 12 weeks after surgery; (6) preoperative peak expiratory flow compared with postoperative daily values for 3 days; and (7) serum concentrations of interleukin-6 and lidocaine at 1, 24, 48 and 72 hours postoperatively compared with preoperative values. DISCUSSION Adequate analgesia is important for quality of care and vital to a rapid recovery after cardiac surgery. This study aims to determine whether a continuous parasternal block with a short-acting local anaesthetic improves analgesia and recovery after open cardiac procedures. TRIAL REGISTRATION The study was registered in the European Clinical Trials Database on 27/9/2019 (registration number: 2018-004672-35).
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Buren MA, Theologis A, Zuraek A, Behrends M, Clark AJ, Leung JM. Lidocaine Infusion for the Management of Postoperative Pain and Delirium (LIMPP): protocol for a randomised control trial. BMJ Open 2022; 12:e059416. [PMID: 35667730 PMCID: PMC9171272 DOI: 10.1136/bmjopen-2021-059416] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 11/22/2021] [Accepted: 04/06/2022] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Postoperative delirium is a frequent adverse event following elective non-cardiac surgery. The occurrence of delirium increases the risk of functional impairment, placement to facilities other than home after discharge, cognitive impairment at discharge, as well as in-hospital and possibly long-term mortality. Unfortunately, there is a dearth of effective strategies to minimise the risk from modifiable risk factors, including postoperative pain control and the analgesic regimen. Use of potent opioids, currently the backbone of postoperative pain control, alters cognition and has been associated with an increased risk of postoperative delirium. Literature supports the intraoperative use of lidocaine infusions to decrease postoperative opioid requirements, however, whether the use of postoperative lidocaine infusions is associated with lower opioid requirements and subsequently a reduction in postoperative delirium has not been investigated. METHODS AND ANALYSIS The Lidocaine Infusion for the Management of Postoperative Pain and Delirium trial is a randomised, double-blinded study of a postoperative 48-hour infusion of lidocaine at 1.33 mg/kg/hour versus placebo in older patients undergoing major reconstructive spinal surgery at the University of California, San Francisco. Our primary outcome is incident delirium measured daily by the Confusion Assessment Method in the first three postoperative days. Secondary outcomes include delirium severity, changes in cognition, pain scores, opioid use, incidence of opioid related side effects and functional benefits including time to discharge and improved recovery from surgery. Lidocaine safety will be assessed with daily screening questionnaires and lidocaine plasma levels. ETHICS AND DISSEMINATION This study protocol has been approved by the ethics board at the University of California, San Francisco. The results of this study will be published in a peer-review journal and presented at national conferences as poster or oral presentations. Participants wishing to know the results of this study will be contacted directly on data publication. TRIAL REGISTRATION NUMBER NCT05010148.
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Affiliation(s)
- Marc Alan Buren
- Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Alekos Theologis
- Orthopedic Surgery, University of California San Francisco, San Francisco, California, USA
| | - Ariadne Zuraek
- Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Matthias Behrends
- Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Aaron J Clark
- Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Jacqueline M Leung
- Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
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10
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Zhu Y, Wang F, Yang L, Zhu T. Intravenous Lidocaine Infusion Reduce Post-operative Pain and Length of Hospital in Elderly Patients Undergoing Surgery: Meta-analysis of Randomized Controlled Trials. Surg Innov 2022; 29:632-645. [PMID: 35285312 DOI: 10.1177/15533506211045283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Objective. It is debated wheter intravenous (IV) lidocaine improves post-operative pain and has other potential benefits in elderly patients. This systematic review and meta-analysis aimed to estimate the effect of perioperative continuous IV lidocaine in elderly patients undergoing surgery. Method. PubMed/Medline, Web of Science, Embase, and CENTRAL databases (through OVID SP) were searched independently until October 10, 2020 by two authors. We included all randomized controlled trials that compared the effect of continuous IV lidocaine and any placebo or no treatment in elderly patients after surgery. Primary outcomes were length of hospital stay and post-operative pain score. Results. Eighteen studies (988 patients) were included. Meta-analysis suggested that IV lidocaine reduced the post-operative pain scores 2 hours (standardized mean difference [SMD]: −1.58, 95% confidence interval [CI]: −2.03 to −1.13), 4 hours (SMD:−1.20, 95% CI: −2.02 to −.39), 8 hours (SMD:−.82, 95% CI: −1.51 to −.13), 12 hours (SMD:−.66, 95% CI: −1.28 to −.04), and 24 hours (SMD:−.42, 95% CI: −.72 to −.12) post-operatively. Moreover, those patients given IV lidocaine had a shorter length of hospital stay (MD: −.24, 95% CI: −.71 to −.23) and required fewer opioid drugs (SMD: −.31, 95% CI: −.31 to −.01). Conclusion. The evidence suggested that IV lidocaine significantly reduced post-operative pain intensity and opioid consumption and shortened the length of hospital stay in elderly patients. IV lidocaine decreased the incidence of post-operative nausea while it could not reduce the incidence of post-operative vomiting and accelerate the recovery of gastrointestinal function.
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Affiliation(s)
- Yihao Zhu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
- Department of Anesthesiology, The Affiliated Hospital, School of Medicine, UESTC, Chengdu Women's & Children's Central Hospital, Chengdu, China
| | - Fei Wang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
- Department of Anesthesiology, Sichuan Academy of Medical Science and Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Lei Yang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Tao Zhu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
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Berger M, Browndyke JN, Cooter Wright M, Nobuhara C, Reese M, Acker L, Bullock WM, Colin BJ, Devinney MJ, Moretti EW, Moul JW, Ohlendorf B, Laskowitz DT, Waligorska T, Shaw LM, Whitson HE, Cohen HJ, Mathew JP. Postoperative changes in cognition and cerebrospinal fluid neurodegenerative disease biomarkers. Ann Clin Transl Neurol 2022; 9:155-170. [PMID: 35104057 PMCID: PMC8862419 DOI: 10.1002/acn3.51499] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 12/21/2021] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE Numerous investigators have theorized that postoperative changes in Alzheimer's disease neuropathology may underlie postoperative neurocognitive disorders. Thus, we determined the relationship between postoperative changes in cognition and cerebrospinal (CSF) tau, p-tau-181p, or Aβ levels after non-cardiac, non-neurologic surgery in older adults. METHODS Participants underwent cognitive testing before and 6 weeks after surgery, and lumbar punctures before, 24 h after, and 6 weeks after surgery. Cognitive scores were combined via factor analysis into an overall cognitive index. In total, 110 patients returned for 6-week postoperative testing and were included in the analysis. RESULTS There was no significant change from before to 24 h or 6 weeks following surgery in CSF tau (median [median absolute deviation] change before to 24 h: 0.00 [4.36] pg/mL, p = 0.853; change before to 6 weeks: -1.21 [3.98] pg/mL, p = 0.827). There were also no significant changes in CSF p-tau-181p or Aβ over this period. There was no change in cognitive index (mean [95% CI] 0.040 [-0.018, 0.098], p = 0.175) from before to 6 weeks after surgery, although there were postoperative declines in verbal memory (-0.346 [-0.523, -0.170], p = 0.003) and improvements in executive function (0.394, [0.310, 0.479], p < 0.001). There were no significant correlations between preoperative to 6-week postoperative changes in cognition and CSF tau, p-tau-181p, or Aβ42 changes over this interval (p > 0.05 for each). INTERPRETATION Neurocognitive changes after non-cardiac, non-neurologic surgery in the majority of cognitively healthy, community-dwelling older adults are unlikely to be related to postoperative changes in AD neuropathology (as assessed by CSF Aβ, tau or p-tau-181p levels or the p-tau-181p/Aβ or tau/Aβ ratios). TRIAL REGISTRATION clinicaltrials.gov (NCT01993836).
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Affiliation(s)
- Miles Berger
- Department of AnesthesiologyDuke University Medical CenterDurhamNorth CarolinaUSA
- Center for the Study of Aging and Human DevelopmentDuke University Medical CenterDurhamNorth CarolinaUSA
- Center for Cognitive NeuroscienceDuke UniversityDurhamNorth CarolinaUSA
| | - Jeffrey N. Browndyke
- Center for the Study of Aging and Human DevelopmentDuke University Medical CenterDurhamNorth CarolinaUSA
- Center for Cognitive NeuroscienceDuke UniversityDurhamNorth CarolinaUSA
- Division of Geriatric Behavioral Health, Department of Psychiatry and Behavioral MedicineDuke University Medical CenterDurhamNorth CarolinaUSA
- Duke Brain Imaging and Analysis CenterDurhamNorth CarolinaUSA
| | - Mary Cooter Wright
- Department of AnesthesiologyDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Chloe Nobuhara
- Duke University School of MedicineDurhamNorth CarolinaUSA
| | - Melody Reese
- Department of AnesthesiologyDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Leah Acker
- Department of AnesthesiologyDuke University Medical CenterDurhamNorth CarolinaUSA
| | - W. Michael Bullock
- Department of AnesthesiologyDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Brian J. Colin
- Department of AnesthesiologyDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Michael J. Devinney
- Department of AnesthesiologyDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Eugene W. Moretti
- Department of AnesthesiologyDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Judd W. Moul
- Urology Division, Department of SurgeryDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Brian Ohlendorf
- Department of AnesthesiologyDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Daniel T. Laskowitz
- Department of AnesthesiologyDuke University Medical CenterDurhamNorth CarolinaUSA
- Department of NeurologyDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Teresa Waligorska
- Department of Pathology and Lab Medicine, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Leslie M. Shaw
- Department of Pathology and Lab Medicine, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Heather E. Whitson
- Center for the Study of Aging and Human DevelopmentDuke University Medical CenterDurhamNorth CarolinaUSA
- Department of MedicineDuke University Medical CenterDurhamNorth CarolinaUSA
- Geriatrics Research Education and Clinical Center (GRECC)Durham VA Medical CenterDurhamNCUSA
| | - Harvey J. Cohen
- Center for the Study of Aging and Human DevelopmentDuke University Medical CenterDurhamNorth CarolinaUSA
- Department of MedicineDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Joseph P. Mathew
- Department of AnesthesiologyDuke University Medical CenterDurhamNorth CarolinaUSA
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12
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Augoustides JG. Protecting the Central Nervous System During Cardiac Surgery. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00022-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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13
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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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14
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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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15
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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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16
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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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17
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Sun Y, Huang X. Effect of lidocaine on the incidence of postoperative neurocognitive disorder at different time points after cardiac surgery. Asian J Surg 2021; 45:1715-1716. [PMID: 34836759 DOI: 10.1016/j.asjsur.2021.11.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 11/19/2021] [Indexed: 11/02/2022] Open
Affiliation(s)
- Yuan Sun
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Xiao Huang
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China.
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18
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Ghadimi K, Cappiello J, Cooter-Wright M, Haney JC, Reynolds JM, Bottiger BA, Klapper JA, Levy JH, Hartwig MG. Inhaled Pulmonary Vasodilator Therapy in Adult Lung Transplant: A Randomized Clinical Trial. JAMA Surg 2021; 157:e215856. [PMID: 34787647 DOI: 10.1001/jamasurg.2021.5856] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Inhaled nitric oxide (iNO) is commonly administered for selectively inhaled pulmonary vasodilation and prevention of oxidative injury after lung transplant (LT). Inhaled epoprostenol (iEPO) has been introduced worldwide as a cost-saving alternative to iNO without high-grade evidence for this indication. Objective To investigate whether the use of iEPO will lead to similar rates of severe/grade 3 primary graft dysfunction (PGD-3) after adult LT when compared with use of iNO. Design, Setting, and Participants This health system-funded, randomized, blinded (to participants, clinicians, data managers, and the statistician), parallel-designed, equivalence clinical trial included 201 adult patients who underwent single or bilateral LT between May 30, 2017, and March 21, 2020. Patients were grouped into 5 strata according to key prognostic clinical features and randomized per stratum to receive either iNO or iEPO at the time of LT via 1:1 treatment allocation. Interventions Treatment with iNO or iEPO initiated in the operating room before lung allograft reperfusion and administered continously until cessation criteria met in the intensive care unit (ICU). Main Outcomes and Measures The primary outcome was PGD-3 development at 24, 48, or 72 hours after LT. The primary analysis was for equivalence using a two one-sided test (TOST) procedure (90% CI) with a margin of 19% for between-group PGD-3 risk difference. Secondary outcomes included duration of mechanical ventilation, hospital and ICU lengths of stay, incidence and severity of acute kidney injury, postoperative tracheostomy placement, and in-hospital, 30-day, and 90-day mortality rates. An intention-to-treat analysis was performed for the primary and secondary outcomes, supplemented by per-protocol analysis for the primary outcome. Results A total of 201 randomized patients met eligibility criteria at the time of LT (129 men [64.2%]). In the intention-to-treat population, 103 patients received iEPO and 98 received iNO. The primary outcome occurred in 46 of 103 patients (44.7%) in the iEPO group and 39 of 98 (39.8%) in the iNO group, leading to a risk difference of 4.9% (TOST 90% CI, -6.4% to 16.2%; P = .02 for equivalence). There were no significant between-group differences for secondary outcomes. Conclusions and Relevance Among patients undergoing LT, use of iEPO was associated with similar risks for PGD-3 development and other postoperative outcomes compared with the use of iNO. Trial Registration ClinicalTrials.gov identifier: NCT03081052.
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Affiliation(s)
- Kamrouz Ghadimi
- Department of Anesthesiology & Critical Care, Duke University School of Medicine, Durham, North Carolina
| | - Jhaymie Cappiello
- Department of Respiratory Care Services, Duke University Medical Center, Durham, North Carolina
| | - Mary Cooter-Wright
- Department of Anesthesiology & Critical Care, Duke University School of Medicine, Durham, North Carolina
| | - John C Haney
- Department of Surgery, Thoracic Transplant Surgery, Duke University School of Medicine, Durham, North Carolina
| | - John M Reynolds
- Department of Medicine, Transplant Pulmonology, Duke University School of Medicine, Durham, North Carolina
| | - Brandi A Bottiger
- Department of Anesthesiology & Critical Care, Duke University School of Medicine, Durham, North Carolina
| | - Jacob A Klapper
- Department of Surgery, Thoracic Transplant Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Jerrold H Levy
- Department of Anesthesiology & Critical Care, Duke University School of Medicine, Durham, North Carolina
| | - Matthew G Hartwig
- Department of Surgery, Thoracic Transplant Surgery, Duke University School of Medicine, Durham, North Carolina
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Schuler BR, Lupi KE, Szumita PM, Kovacevic MP. Evaluating the Safety of Continuous Infusion Lidocaine for Postoperative Pain. Clin J Pain 2021; 37:657-663. [PMID: 34265786 DOI: 10.1097/ajp.0000000000000960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 06/17/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES The aim was to evaluate the safety of intravenous lidocaine for postoperative pain and the impact on opioid requirements and pain scores. MATERIALS AND METHODS This was a single-center, retrospective, single-arm analysis of adult patients who received intravenous lidocaine for postoperative pain from January 2016 to December 2019. Patients were excluded if they received lidocaine for any indication other than pain or if lidocaine was only given intraoperatively. The primary outcome of this analysis was to determine the incidence of adverse effects (AEs) and the reason for discontinuation of lidocaine. Secondary outcomes included median daily pain scores (visual analog scale and Critical-Care Pain Observation Tool) and opioid consumption (daily morphine milligram equivalents) 24 hours before infusion and during day 1. RESULTS A total of 452 patients were evaluated of which 298 (65.9%) patients met inclusion criteria. Of the 154 patients excluded, 153 did not receive lidocaine postoperatively. The median duration of infusion was 34 [20:48] hours with a median initial and maintenance rate of 1 mg/kg/h dosed on ideal body weight. In our analysis, 174 (58.4%) patients had a documented AE during infusion and 38 (12.8%) had lidocaine discontinued because of an AE. The most common AE was nausea in 62 (20.8%) patients and the most common reason for discontinuation was confusion in 8 (2.7%) patients. Daily morphine milligram equivalents (P<0.001) and visual analog scale (P<0.001) significantly decreased when comparing 24 hours before infusion and day 1. CONCLUSION Although a majority of patients receiving lidocaine for postoperative pain experienced an AE, this did not result in discontinuation in most patients.
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Affiliation(s)
- Brian R Schuler
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA
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20
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Nazarnia S, Subramaniam K. Nonopioid Analgesics in Postoperative Pain Management After Cardiac Surgery. Semin Cardiothorac Vasc Anesth 2021; 25:280-288. [PMID: 33899581 DOI: 10.1177/1089253221998552] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Opioid analgesia is still considered the standard of practice for cardiac surgery. In recent years, combinations of several nonnarcotic analgesics and regional analgesia have shown promise in restricting opioid use during and after cardiac surgery. Ketamine infusion, dexmedetomidine infusion, acetaminophen, ketorolac, and gabapentin are useful adjuvants in cardiac anesthesia practice and have opioid-sparing properties. The beneficial effects of nonnarcotic multimodal analgesia on intraoperative stress response, recovery profile, postoperative pain, and persistent opioid use after cardiac surgery are yet to be established, and further randomized clinical trials are required.
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Affiliation(s)
- Soheyla Nazarnia
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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21
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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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22
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Roth S, Torregroza C, Feige K, Preckel B, Hollmann MW, Weber NC, Huhn R. Pharmacological Conditioning of the Heart: An Update on Experimental Developments and Clinical Implications. Int J Mol Sci 2021; 22:ijms22052519. [PMID: 33802308 PMCID: PMC7959135 DOI: 10.3390/ijms22052519] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 02/26/2021] [Accepted: 02/26/2021] [Indexed: 12/13/2022] Open
Abstract
The aim of pharmacological conditioning is to protect the heart against myocardial ischemia-reperfusion (I/R) injury and its consequences. There is extensive literature that reports a multitude of different cardioprotective signaling molecules and mechanisms in diverse experimental protocols. Several pharmacological agents have been evaluated in terms of myocardial I/R injury. While results from experimental studies are immensely encouraging, translation into the clinical setting remains unsatisfactory. This narrative review wants to focus on two aspects: (1) give a comprehensive update on new developments of pharmacological conditioning in the experimental setting concentrating on recent literature of the last two years and (2) briefly summarize clinical evidence of these cardioprotective substances in the perioperative setting highlighting their clinical implications. By directly opposing each pharmacological agent regarding its recent experimental knowledge and most important available clinical data, a clear overview is given demonstrating the remaining gap between basic research and clinical practice. Finally, future perspectives are given on how we might overcome the limited translatability in the field of pharmacological conditioning.
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Affiliation(s)
- Sebastian Roth
- Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, Moorenstr. 5, 40225 Duesseldorf, Germany; (S.R.); (K.F.); (R.H.)
| | - Carolin Torregroza
- Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, Moorenstr. 5, 40225 Duesseldorf, Germany; (S.R.); (K.F.); (R.H.)
- Department of Anesthesiology, Amsterdam University Medical Center (AUMC), Location AMC, Meibergdreef 9, 1100 DD Amsterdam, The Netherlands; (B.P.); (M.W.H.); (N.C.W.)
- Correspondence:
| | - Katharina Feige
- Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, Moorenstr. 5, 40225 Duesseldorf, Germany; (S.R.); (K.F.); (R.H.)
| | - Benedikt Preckel
- Department of Anesthesiology, Amsterdam University Medical Center (AUMC), Location AMC, Meibergdreef 9, 1100 DD Amsterdam, The Netherlands; (B.P.); (M.W.H.); (N.C.W.)
| | - Markus W. Hollmann
- Department of Anesthesiology, Amsterdam University Medical Center (AUMC), Location AMC, Meibergdreef 9, 1100 DD Amsterdam, The Netherlands; (B.P.); (M.W.H.); (N.C.W.)
| | - Nina C. Weber
- Department of Anesthesiology, Amsterdam University Medical Center (AUMC), Location AMC, Meibergdreef 9, 1100 DD Amsterdam, The Netherlands; (B.P.); (M.W.H.); (N.C.W.)
| | - Ragnar Huhn
- Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, Moorenstr. 5, 40225 Duesseldorf, Germany; (S.R.); (K.F.); (R.H.)
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Hogue CW, Brown CH, Hori D, Ono M, Nomura Y, Balmert LC, Srdanovic N, Grafman J, Brady K. Personalized Blood Pressure Management During Cardiac Surgery With Cerebral Autoregulation Monitoring: A Randomized Trial. Semin Thorac Cardiovasc Surg 2021; 33:429-438. [DOI: 10.1053/j.semtcvs.2020.09.032] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 09/08/2020] [Indexed: 01/12/2023]
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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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Tasbihgou SR, Absalom AR. Postoperative neurocognitive disorders. Korean J Anesthesiol 2020; 74:15-22. [PMID: 32623846 PMCID: PMC7862941 DOI: 10.4097/kja.20294] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 07/01/2020] [Indexed: 12/16/2022] Open
Abstract
A decline in cognitive function is a frequent complication of major surgery. Postoperative cognitive impairments have generally been divided into short- (postoperative delirium) and long-term disturbances (postoperative cognitive dysfunction [POCD]). Long-term impairments are often subtle and overlooked. They need to be objectively assessed using neuropsychological tests to be diagnosed. Although POCD has been the subject of considerable research over the past decades, it remains uncertain why some patients do not return to preoperative levels of cognitive function. Surgery and anesthesia have both been implicated to play a role in POCD development, and certain patient-related factors, such as advanced age and low preoperative baseline cognitive function, have consistently been found to predict postoperative cognitive decline. This article will present an overview of POCD and its etiology and provide advice on possible strategies on its prevention.
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Affiliation(s)
- Setayesh Reza Tasbihgou
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Anthony Ray Absalom
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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26
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Xiao QX, Liu Q, Deng R, Gao ZW, Zhang Y. Postoperative cognitive dysfunction in elderly patients undergoing hip arthroplasty. Psychogeriatrics 2020; 20:501-509. [PMID: 31976614 DOI: 10.1111/psyg.12516] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 05/01/2019] [Accepted: 01/04/2020] [Indexed: 12/13/2022]
Abstract
Even after successful hip arthroplasty, elderly patients who have undergone this procedure remain subject to cognitive decline and may collectively develop postoperative cognitive dysfunction (POCD). However, no consensus exists as to the risk factors resulting in a higher likelihood that a patient may present with this complication, and the aetiology of POCD is not well understood. We conducted a systematic review of papers concerning the influence of POCD-related risk factors in patients undergoing hip arthroplasty but limited the literature search to papers in English. A systematic and electronic search for manuscripts in the PubMed database was performed in order to identify all studies in which the risk factors for POCD were investigated. Articles were also obtained from the authors' files. Keywords for the search were postoperative cognitive dysfunction/change/impairment/decline/deficit, elderly/older/aged patients, and hip arthroplasty/replacement surgery. The evidence published to date suggests that POCD is a multifactorial disease, which includes an individual patient's characteristics, surgery, type of anaesthesia, and pain levels. All of these factors can increase the risk of POCD incidence. There are a number of factors that appear to influence the risk of early cognitive dysfunction after hip arthroplasty. Nevertheless, the specific mechanism and explicit risk factors associated with this cognitive dysfunction are not completely understood. Hip arthroplasty has made it possible for older patients to find relief from pain and improve their function, whereas it also increases the risk for suffering POCD that may affect these patients' quality of life and increase their mortality. Therefore, it is worthwhile investigating the mechanism of POCD in future studies in order to prevent and treat this condition.
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Affiliation(s)
- Qiu-Xia Xiao
- Department of Anesthesiology, Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University, Luzhou, China
| | - Qing Liu
- Department of Anesthesiology, Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University, Luzhou, China
| | - Rui Deng
- Department of Anesthesiology, Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University, Luzhou, China
| | - Zhi-Wei Gao
- Department of Anesthesiology, Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University, Luzhou, China
| | - Ying Zhang
- Department of Anesthesiology, Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University, Luzhou, China
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Klinger RY, Cooter M, Bisanar T, Terrando N, Berger M, Podgoreanu MV, Stafford-Smith M, Newman MF, Mathew JP. Intravenous Lidocaine Does Not Improve Neurologic Outcomes after Cardiac Surgery: A Randomized Controlled Trial. Anesthesiology 2020; 130:958-970. [PMID: 30870159 DOI: 10.1097/aln.0000000000002668] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Cognitive decline after cardiac surgery occurs frequently and persists in a significant proportion of patients. Preclinical studies and human trials suggest that intravenous lidocaine may confer protection in the setting of neurologic injury. It was hypothesized that lidocaine administration would reduce cognitive decline after cardiac surgery compared to placebo. METHODS After institutional review board approval, 478 patients undergoing cardiac surgery were enrolled into this multicenter, prospective, randomized, double-blinded, placebo-controlled, parallel group trial. Subjects were randomized to lidocaine 1 mg/kg bolus after the induction of anesthesia followed by a continuous infusion (48 μg · kg · min for the first hour, 24 μg · kg · min for the second hour, and 10 μg · kg · min for the next 46 h) or saline with identical volume and rate changes to preserve blinding. Cognitive function was assessed preoperatively and at 6 weeks and 1 yr postoperatively using a standard neurocognitive test battery. The primary outcome was change in cognitive function between baseline and 6 weeks postoperatively, adjusting for age, years of education, baseline cognition, race, and procedure type. RESULTS Among the 420 allocated subjects who returned for 6-week follow-up (lidocaine: N = 211; placebo: N = 209), there was no difference in the continuous cognitive score change (adjusted mean difference [95% CI], 0.02 (-0.05, 0.08); P = 0.626). Cognitive deficit (greater than 1 SD decline in at least one cognitive domain) at 6 weeks occurred in 41% (87 of 211) in the lidocaine group versus 40% (83 of 209) in the placebo group (adjusted odds ratio [95% CI], 0.94 [0.63, 1.41]; P = 0.766). There were no differences in any quality of life outcomes between treatment groups. At the 1-yr follow-up, there continued to be no difference in cognitive score change, cognitive deficit, or quality of life. CONCLUSIONS Intravenous lidocaine administered during and after cardiac surgery did not reduce postoperative cognitive decline at 6 weeks.
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Affiliation(s)
- Rebecca Y Klinger
- From the Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina (R.Y.K., M.C., T.B., N.T., M.B., M.V.P., M.S.-S., J.P.M.) the Department of Anesthesiology, University of Kentucky School of Medicine, Lexington, Kentucky (M.F.N.)
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Evered L, Silbert B, Knopman DS, Scott DA, DeKosky ST, Rasmussen LS, Oh ES, Crosby G, Berger M, Eckenhoff RG. Recommendations for the Nomenclature of Cognitive Change Associated with Anaesthesia and Surgery-20181. J Alzheimers Dis 2019; 66:1-10. [PMID: 30347621 DOI: 10.3233/jad-189004] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Cognitive change affecting patients after anaesthesia and surgery has been recognised for more than 100 yr. Research into cognitive change after anaesthesia and surgery accelerated in the 1980s when multiple studies utilised detailed neuropsychological testing for assessment of cognitive change after cardiac surgery. This body of work consistently documented decline in cognitive function in elderly patients after anaesthesia and surgery, and cognitive changes have been identified up to 7.5 yr afterwards. Importantly, other studies have identified that the incidence of cognitive change is similar after non-cardiac surgery. Other than the inclusion of non-surgical control groups to calculate postoperative cognitive dysfunction, research into these cognitive changes in the perioperative period has been undertaken in isolation from cognitive studies in the general population. The aim of this work is to develop similar terminology to that used in cognitive classifications of the general population for use in investigations of cognitive changes after anaesthesia and surgery. A multispecialty working group followed a modified Delphi procedure with no prespecified number of rounds comprised of three face-to-face meetings followed by online editing of draft versions.Two major classification guidelines [Diagnostic and Statistical Manual for Mental Disorders, fifth edition (DSM-5) and National Institute for Aging and the Alzheimer Association (NIA-AA)] are used outside of anaesthesia and surgery, and may be useful for inclusion of biomarkers in research. For clinical purposes, it is recommended to use the DSM-5 nomenclature. The working group recommends that 'perioperative neurocognitive disorders' be used as an overarching term for cognitive impairment identified in the preoperative or postoperative period. This includes cognitive decline diagnosed before operation (described as neurocognitive disorder); any form of acute event (postoperative delirium) and cognitive decline diagnosed up to 30 days after the procedure (delayed neurocognitive recovery) and up to 12 months (postoperative neurocognitive disorder).
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Affiliation(s)
- L Evered
- St Vincent's Hospital, Melbourne, Fitzroy, VIC, Australia.,University of Melbourne, Fitzroy, VIC, Australia
| | - B Silbert
- St Vincent's Hospital, Melbourne, Fitzroy, VIC, Australia.,University of Melbourne, Fitzroy, VIC, Australia
| | - D S Knopman
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - D A Scott
- St Vincent's Hospital, Melbourne, Fitzroy, VIC, Australia.,University of Melbourne, Fitzroy, VIC, Australia
| | - S T DeKosky
- Department of Neurology, McKnight Brain Institute, University of Florida, Gainesville, FL, USA
| | - L S Rasmussen
- Department of Anaesthesia, Center of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - E S Oh
- Division of Geriatric Medicine and Gerontology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - G Crosby
- Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | - M Berger
- Neurologic Outcomes Research Group, Anesthesiology Department, Duke University Medical Center, Durham, NC, USA
| | - R G Eckenhoff
- Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
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Recommendations for the Nomenclature of Cognitive Change Associated with Anaesthesia and Surgery-2018. Anesthesiology 2019; 129:872-879. [PMID: 30325806 DOI: 10.1097/aln.0000000000002334] [Citation(s) in RCA: 290] [Impact Index Per Article: 58.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Cognitive change affecting patients after anaesthesia and surgery has been recognised for more than 100 yr. Research into cognitive change after anaesthesia and surgery accelerated in the 1980s when multiple studies utilised detailed neuropsychological testing for assessment of cognitive change after cardiac surgery. This body of work consistently documented decline in cognitive function in elderly patients after anaesthesia and surgery, and cognitive changes have been identified up to 7.5 yr afterwards. Importantly, other studies have identified that the incidence of cognitive change is similar after non-cardiac surgery. Other than the inclusion of non-surgical control groups to calculate postoperative cognitive dysfunction, research into these cognitive changes in the perioperative period has been undertaken in isolation from cognitive studies in the general population. The aim of this work is to develop similar terminology to that used in cognitive classifications of the general population for use in investigations of cognitive changes after anaesthesia and surgery. A multispecialty working group followed a modified Delphi procedure with no prespecified number of rounds comprised of three face-to-face meetings followed by online editing of draft versions.Two major classification guidelines (Diagnostic and Statistical Manual for Mental Disorders, fifth edition [DSM-5] and National Institute for Aging and the Alzheimer Association [NIA-AA]) are used outside of anaesthesia and surgery, and may be useful for inclusion of biomarkers in research. For clinical purposes, it is recommended to use the DSM-5 nomenclature. The working group recommends that 'perioperative neurocognitive disorders' be used as an overarching term for cognitive impairment identified in the preoperative or postoperative period. This includes cognitive decline diagnosed before operation (described as neurocognitive disorder); any form of acute event (postoperative delirium) and cognitive decline diagnosed up to 30 days after the procedure (delayed neurocognitive recovery) and up to 12 months (postoperative neurocognitive disorder).
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30
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Evered L, Silbert B, Knopman DS, Scott DA, DeKosky ST, Rasmussen LS, Oh ES, Crosby G, Berger M, Eckenhoff RG. Recommendations for the Nomenclature of Cognitive Change Associated With Anaesthesia and Surgery-2018. Anesth Analg 2019; 127:1189-1195. [PMID: 30325748 DOI: 10.1213/ane.0000000000003634] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Cognitive change affecting patients after anaesthesia and surgery has been recognised for more than 100 yr. Research into cognitive change after anaesthesia and surgery accelerated in the 1980s when multiple studies utilised detailed neuropsychological testing for assessment of cognitive change after cardiac surgery. This body of work consistently documented decline in cognitive function in elderly patients after anaesthesia and surgery, and cognitive changes have been identified up to 7.5 yr afterwards. Importantly, other studies have identified that the incidence of cognitive change is similar after non-cardiac surgery. Other than the inclusion of non-surgical control groups to calculate postoperative cognitive dysfunction, research into these cognitive changes in the perioperative period has been undertaken in isolation from cognitive studies in the general population. The aim of this work is to develop similar terminology to that used in cognitive classifications of the general population for use in investigations of cognitive changes after anaesthesia and surgery. A multispecialty working group followed a modified Delphi procedure with no prespecified number of rounds comprised of three face-to-face meetings followed by online editing of draft versions.Two major classification guidelines [Diagnostic and Statistical Manual for Mental Disorders, fifth edition (DSM-5) and National Institute for Aging and the Alzheimer Association (NIA-AA)] are used outside of anaesthesia and surgery, and may be useful for inclusion of biomarkers in research. For clinical purposes, it is recommended to use the DSM-5 nomenclature. The working group recommends that 'perioperative neurocognitive disorders' be used as an overarching term for cognitive impairment identified in the preoperative or postoperative period. This includes cognitive decline diagnosed before operation (described as neurocognitive disorder); any form of acute event (postoperative delirium) and cognitive decline diagnosed up to 30 days after the procedure (delayed neurocognitive recovery) and up to 12 months (postoperative neurocognitive disorder).
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Affiliation(s)
- L Evered
- St Vincent's Hospital, Melbourne, Fitzroy, Victoria, Australia.,University of Melbourne, Fitzroy, Victoria, Australia
| | - B Silbert
- St Vincent's Hospital, Melbourne, Fitzroy, Victoria, Australia.,University of Melbourne, Fitzroy, Victoria, Australia
| | - D S Knopman
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - D A Scott
- St Vincent's Hospital, Melbourne, Fitzroy, Victoria, Australia.,University of Melbourne, Fitzroy, Victoria, Australia
| | - S T DeKosky
- Department of Neurology, McKnight Brain Institute, University of Florida, Gainesville, FL, USA
| | - L S Rasmussen
- Department of Anaesthesia, Center of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - E S Oh
- Division of Geriatric Medicine and Gerontology, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - G Crosby
- Harvard Medical School, Brigham & Women's Hospital, Boston, MA, USA
| | - M Berger
- Neurologic Outcomes Research Group, Anesthesiology Department, Duke University Medical Center, Durham, NC, USA
| | - R G Eckenhoff
- Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
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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: 116] [Impact Index Per Article: 23.2] [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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32
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Jovin DG, Katlaps KG, Ellis BK, Dharmaraj B. Neuroprotection against stroke and encephalopathy after cardiac surgery. Interv Med Appl Sci 2019; 11:27-37. [PMID: 32148901 PMCID: PMC7044570 DOI: 10.1556/1646.11.2019.01] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Cerebral ischemia in the perioperative period is a major risk factor for stroke, encephalopathy, and cognitive decline after cardiothoracic surgery. After coronary artery bypass grafting, both stroke and encephalopathy can result in poor patient outcomes and increased mortality. Neuroprotection aims to lessen the severity and occurrence of further injury mediated by stroke and encephalopathy and to aid the recovery of conditions already present. Several pharmacological and non-pharmacological methods of neuroprotection have been investigated in experimental studies and in animal models, and, although some have shown effectiveness in protection of the central nervous system, for most, clinical research is lacking or did not show the expected results. This review summarizes the value and need for neuroprotection in the context of cardiothoracic surgery and examines the use and effectiveness of several agents and methods with an emphasis on clinical trials and clinically relevant neuroprotectants.
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Affiliation(s)
- Daniel G Jovin
- Cardiothoracic Research, Department of Surgery, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, VA, USA
| | - Karl G Katlaps
- Cardiothoracic Research, Department of Surgery, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, VA, USA
| | - Ben K Ellis
- Cardiothoracic Research, Department of Surgery, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, VA, USA
| | - Benita Dharmaraj
- Cardiothoracic Research, Department of Surgery, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, VA, USA
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Postoperative cognitive dysfunction in noncardiac surgery: A review. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2019. [DOI: 10.1016/j.tacc.2018.08.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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34
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Slupe AM, Kirsch JR. Effects of anesthesia on cerebral blood flow, metabolism, and neuroprotection. J Cereb Blood Flow Metab 2018; 38:2192-2208. [PMID: 30009645 PMCID: PMC6282215 DOI: 10.1177/0271678x18789273] [Citation(s) in RCA: 163] [Impact Index Per Article: 27.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 06/11/2018] [Accepted: 06/25/2018] [Indexed: 12/12/2022]
Abstract
Administration of anesthetic agents fundamentally shifts the responsibility for maintenance of homeostasis from the patient and their intrinsic physiological regulatory mechanisms to the anesthesiologist. Continuous delivery of oxygen and nutrients to the brain is necessary to prevent irreversible injury and arises from a complex series of regulatory mechanisms that ensure uninterrupted cerebral blood flow. Our understanding of these regulatory mechanisms and the effects of anesthetics on them has been driven by the tireless work of pioneers in the field. It is of paramount importance that the anesthesiologist shares this understanding. Herein, we will review the physiological determinants of cerebral blood flow and how delivery of anesthesia impacts these processes.
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Affiliation(s)
- Andrew M Slupe
- Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Jeffrey R Kirsch
- Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University, Portland, OR, USA
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35
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Evered L, Silbert B, Knopman DS, Scott DA, DeKosky ST, Rasmussen LS, Oh ES, Crosby G, Berger M, Eckenhoff RG, Ames D, Chan H, Deiner S, Dijk D, Eriksson L, Galasko D, Hogan K, Inouye S, Lyketsos C, cantonio E, Maruff P, Maze M, Orser B, Ottens T, Price C, Sachdev P, Schenning K, Seiber F, Silverstein J, Steinmetz J, Terrando N, Trzapacz P, Whittington R, Xie Z. Recommendations for the nomenclature of cognitive change associated with anaesthesia and surgery-2018. Acta Anaesthesiol Scand 2018; 62:1473-1480. [PMID: 30325016 DOI: 10.1111/aas.13250] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Cognitive change affecting patients after anaesthesia and surgery has been recognised for more than 100 yr. Research into cognitive change after anaesthesia and surgery accelerated in the 1980s when multiple studies utilised detailed neuropsychological testing for assessment of cognitive change after cardiac surgery. This body of work consistently documented decline in cognitive function in elderly patients after anaesthesia and surgery, and cognitive changes have been identified up to 7.5 yr afterwards. Importantly, other studies have identified that the incidence of cognitive change is similar after non-cardiac surgery. Other than the inclusion of non-surgical control groups to calculate postoperative cognitive dysfunction, research into these cognitive changes in the perioperative period has been undertaken in isolation from cognitive studies in the general population. The aim of this work is to develop similar terminology to that used in cognitive classifications of the general population for use in investigations of cognitive changes after anaesthesia and surgery. A multispecialty working group followed a modified Delphi procedure with no prespecified number of rounds comprised of three face-to-face meetings followed by online editing of draft versions. Two major classification guidelines [Diagnostic and Statistical Manual for Mental Disorders, fifth edition (DSM-5) and National Institute for Aging and the Alzheimer Association (NIA-AA)] are used outside of anaesthesia and surgery, and may be useful for inclusion of biomarkers in research. For clinical purposes, it is recommended to use the DSM-5 nomenclature. The working group recommends that 'perioperative neurocognitive disorders' be used as an overarching term for cognitive impairment identified in the preoperative or postoperative period. This includes cognitive decline diagnosed before operation (described as neurocognitive disorder); any form of acute event (postoperative delirium) and cognitive decline diagnosed up to 30 days after the procedure (delayed neurocognitive recovery) and up to 12 months (postoperative neurocognitive disorder).
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Affiliation(s)
- Lis Evered
- St Vincent's Hospital Melbourne, Fitzroy Victoria Australia
- University of Melbourne Fitzroy Victoria Australia
| | - Brendan Silbert
- St Vincent's Hospital Melbourne, Fitzroy Victoria Australia
- University of Melbourne Fitzroy Victoria Australia
| | | | - David A. Scott
- St Vincent's Hospital Melbourne, Fitzroy Victoria Australia
- University of Melbourne Fitzroy Victoria Australia
| | - Steven T. DeKosky
- Department of Neurology McKnight Brain Institute University of Florida Gainesville FL USA
| | - Lars S. Rasmussen
- Department of Anaesthesia Center of Head and Orthopaedics, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Esther S. Oh
- Division of Geriatric Medicine and Gerontology the Johns Hopkins University School of Medicine Baltimore MD USA
| | - Greg Crosby
- Harvard Medical School Brigham & Women's Hospital Boston MA USA
| | - Miles Berger
- Neurologic Outcomes Research Group Anesthesiology Department Duke University Medical Center Durham NC USA
| | - R. G. Eckenhoff
- Department of Anesthesiology and Critical Care University of Pennsylvania School of Medicine Philadelphia PA USA
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Recommendations for the nomenclature of cognitive change associated with anaesthesia and surgery—2018. Can J Anaesth 2018; 65:1248-1257. [DOI: 10.1007/s12630-018-1216-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Revised: 09/12/2017] [Accepted: 10/02/2017] [Indexed: 10/28/2022] Open
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Ntalouka MP, Arnaoutoglou E, Tzimas P. Postoperative cognitive disorders: an update. Hippokratia 2018; 22:147-154. [PMID: 31695301 PMCID: PMC6825421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Cognitive dysfunction is a common complication after surgery. It is a major cause for increased, sometimes long-term, morbidity and mortality. METHODS In this narrative review we performed a literature search regarding postoperative cognitive decline regarding risk factors, the type of surgical intervention, potential neuroprotective effects of anesthetic drugs, and associated quality of life and healthcare costs. RESULTS Several risk factors are implicated in postoperative cognitive impairment. Cardiac surgery and specific orthopedic interventions are associated with a higher incidence of postoperative cognitive disorders. Results regarding the neuroprotective effects of anesthetics agents are still controversial but promising. Postoperative cognitive alterations are a major public healthcare issue as they impair the everyday quality of life, and expand the yearlong expenses. CONCLUSIONS Postoperative cognitive disorders are devastating, potentially life-threatening complications. High-suspicion, especially in high-risk patients and operations, and adoption of available neuroprotective strategies may prove lifesaving. HIPPOKRATIA 2018, 22(4): 147-154.
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Affiliation(s)
- M P Ntalouka
- Department of Anesthesiology and Postoperative Intensive Care, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
- Department of Anesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - E Arnaoutoglou
- Department of Anesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - P Tzimas
- Department of Anesthesiology and Postoperative Intensive Care, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
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Berger M, Terrando N, Smith SK, Browndyke JN, Newman MF, Mathew JP. Neurocognitive Function after Cardiac Surgery: From Phenotypes to Mechanisms. Anesthesiology 2018; 129:829-851. [PMID: 29621031 PMCID: PMC6148379 DOI: 10.1097/aln.0000000000002194] [Citation(s) in RCA: 146] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
For half a century, it has been known that some patients experience neurocognitive dysfunction after cardiac surgery; however, defining its incidence, course, and causes remains challenging and controversial. Various terms have been used to describe neurocognitive dysfunction at different times after cardiac surgery, ranging from "postoperative delirium" to "postoperative cognitive dysfunction or decline." Delirium is a clinical diagnosis included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Postoperative cognitive dysfunction is not included in the DSM-5 and has been heterogeneously defined, though a recent international nomenclature effort has proposed standardized definitions for it. Here, the authors discuss pathophysiologic mechanisms that may underlie these complications, review the literature on methods to prevent them, and discuss novel approaches to understand their etiology that may lead to novel treatment strategies. Future studies should measure both delirium and postoperative cognitive dysfunction to help clarify the relationship between these important postoperative complications.
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Affiliation(s)
- Miles Berger
- Assistant Professor, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Niccolò Terrando
- Assistant Professor, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - S. Kendall Smith
- Critical Care Fellow, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Jeffrey N. Browndyke
- Assistant Professor, Division of Geriatric Behavioral Health, Department of Psychiatry & Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - Mark F. Newman
- Merel H. Harmel Professor of Anesthesiology, and President of the Private Diagnostic Clinic, Duke University Medical Center, Durham, NC
| | - Joseph P. Mathew
- Jerry Reves, MD Professor and Chair, Department of Anesthesiology, Duke University Medical Center, Durham, NC
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Beaussier M, Delbos A, Maurice-Szamburski A, Ecoffey C, Mercadal L. Perioperative Use of Intravenous Lidocaine. Drugs 2018; 78:1229-1246. [DOI: 10.1007/s40265-018-0955-x] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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41
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Evered L, Silbert B, Knopman DS, Scott DA, DeKosky ST, Rasmussen LS, Oh ES, Crosby G, Berger M, Eckenhoff RG. Recommendations for the nomenclature of cognitive change associated with anaesthesia and surgery-2018. Br J Anaesth 2018; 121:1005-1012. [PMID: 30336844 DOI: 10.1016/j.bja.2017.11.087] [Citation(s) in RCA: 396] [Impact Index Per Article: 66.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Revised: 09/12/2017] [Accepted: 10/02/2017] [Indexed: 12/11/2022] Open
Abstract
Cognitive change affecting patients after anaesthesia and surgery has been recognised for more than 100 yr. Research into cognitive change after anaesthesia and surgery accelerated in the 1980s when multiple studies utilised detailed neuropsychological testing for assessment of cognitive change after cardiac surgery. This body of work consistently documented decline in cognitive function in elderly patients after anaesthesia and surgery, and cognitive changes have been identified up to 7.5 yr afterwards. Importantly, other studies have identified that the incidence of cognitive change is similar after non-cardiac surgery. Other than the inclusion of non-surgical control groups to calculate postoperative cognitive dysfunction, research into these cognitive changes in the perioperative period has been undertaken in isolation from cognitive studies in the general population. The aim of this work is to develop similar terminology to that used in cognitive classifications of the general population for use in investigations of cognitive changes after anaesthesia and surgery. A multispecialty working group followed a modified Delphi procedure with no prespecified number of rounds comprised of three face-to-face meetings followed by online editing of draft versions. Two major classification guidelines [Diagnostic and Statistical Manual for Mental Disorders, fifth edition (DSM-5) and National Institute for Aging and the Alzheimer Association (NIA-AA)] are used outside of anaesthesia and surgery, and may be useful for inclusion of biomarkers in research. For clinical purposes, it is recommended to use the DSM-5 nomenclature. The working group recommends that 'perioperative neurocognitive disorders' be used as an overarching term for cognitive impairment identified in the preoperative or postoperative period. This includes cognitive decline diagnosed before operation (described as neurocognitive disorder); any form of acute event (postoperative delirium) and cognitive decline diagnosed up to 30 days after the procedure (delayed neurocognitive recovery) and up to 12 months (postoperative neurocognitive disorder).
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Affiliation(s)
- L Evered
- St Vincent's Hospital, Melbourne, Fitzroy, Victoria, Australia; University of Melbourne, Fitzroy, Victoria, Australia.
| | - B Silbert
- St Vincent's Hospital, Melbourne, Fitzroy, Victoria, Australia; University of Melbourne, Fitzroy, Victoria, Australia
| | - D S Knopman
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - D A Scott
- St Vincent's Hospital, Melbourne, Fitzroy, Victoria, Australia; University of Melbourne, Fitzroy, Victoria, Australia
| | - S T DeKosky
- Department of Neurology, McKnight Brain Institute, University of Florida, Gainesville, FL, USA
| | - L S Rasmussen
- Department of Anaesthesia, Center of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - E S Oh
- Division of Geriatric Medicine and Gerontology, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - G Crosby
- Harvard Medical School, Brigham & Women's Hospital, Boston, MA, USA
| | - M Berger
- Neurologic Outcomes Research Group, Anesthesiology Department, Duke University Medical Center, Durham, NC, USA
| | - R G Eckenhoff
- Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
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Weibel S, Jelting Y, Pace NL, Helf A, Eberhart LHJ, Hahnenkamp K, Hollmann MW, Poepping DM, Schnabel A, Kranke P. Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery in adults. Cochrane Database Syst Rev 2018; 6:CD009642. [PMID: 29864216 PMCID: PMC6513586 DOI: 10.1002/14651858.cd009642.pub3] [Citation(s) in RCA: 129] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The management of postoperative pain and recovery is still unsatisfactory in a number of cases in clinical practice. Opioids used for postoperative analgesia are frequently associated with adverse effects, including nausea and constipation, preventing smooth postoperative recovery. Not all patients are suitable for, and benefit from, epidural analgesia that is used to improve postoperative recovery. The non-opioid, lidocaine, was investigated in several studies for its use in multimodal management strategies to reduce postoperative pain and enhance recovery. This review was published in 2015 and updated in January 2017. OBJECTIVES To assess the effects (benefits and risks) of perioperative intravenous (IV) lidocaine infusion compared to placebo/no treatment or compared to epidural analgesia on postoperative pain and recovery in adults undergoing various surgical procedures. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, and reference lists of articles in January 2017. We searched one trial registry contacted researchers in the field, and handsearched journals and congress proceedings. We updated this search in February 2018, but have not yet incorporated these results into the review. SELECTION CRITERIA We included randomized controlled trials comparing the effect of continuous perioperative IV lidocaine infusion either with placebo, or no treatment, or with thoracic epidural analgesia (TEA) in adults undergoing elective or urgent surgery under general anaesthesia. The IV lidocaine infusion must have been started intraoperatively, prior to incision, and continued at least until the end of surgery. DATA COLLECTION AND ANALYSIS We used Cochrane's standard methodological procedures. Our primary outcomes were: pain score at rest; gastrointestinal recovery and adverse events. Secondary outcomes included: postoperative nausea and postoperative opioid consumption. We used GRADE to assess the quality of evidence for each outcome. MAIN RESULTS We included 23 new trials in the update. In total, the review included 68 trials (4525 randomized participants). Two trials compared IV lidocaine with TEA. In all remaining trials, placebo or no treatment was used as a comparator. Trials involved participants undergoing open abdominal (22), laparoscopic abdominal (20), or various other surgical procedures (26). The application scheme of systemic lidocaine strongly varies between the studies related to both dose (1 mg/kg/h to 5 mg/kg/h) and termination of the infusion (from the end of surgery until several days after).The risk of bias was low with respect to selection bias (random sequence generation), performance bias, attrition bias, and detection bias in more than 50% of the included studies. For allocation concealment and selective reporting, the quality assessment yielded low risk of bias for only approximately 20% of the included studies.IV Lidocaine compared to placebo or no treatment We are uncertain whether IV lidocaine improves postoperative pain compared to placebo or no treatment at early time points (1 to 4 hours) (standardized mean difference (SMD) -0.50, 95% confidence interval (CI) -0.72 to -0.28; 29 studies, 1656 participants; very low-quality evidence) after surgery. Due to variation in the standard deviation (SD) in the studies, this would equate to an average pain reduction of between 0.37 cm and 2.48 cm on a 0 to 10 cm visual analogue scale . Assuming approximately 1 cm on a 0 to 10 cm pain scale is clinically meaningful, we ruled out a clinically relevant reduction in pain with lidocaine at intermediate (24 hours) (SMD -0.14, 95% CI -0.25 to -0.04; 33 studies, 1847 participants; moderate-quality evidence), and at late time points (48 hours) (SMD -0.11, 95% CI -0.25 to 0.04; 24 studies, 1404 participants; moderate-quality evidence). Due to variation in the SD in the studies, this would equate to an average pain reduction of between 0.10 cm to 0.48 cm at 24 hours and 0.08 cm to 0.42 cm at 48 hours. In contrast to the original review in 2015, we did not find any significant subgroup differences for different surgical procedures.We are uncertain whether lidocaine reduces the risk of ileus (risk ratio (RR) 0.37, 95% CI 0.15 to 0.87; 4 studies, 273 participants), time to first defaecation/bowel movement (mean difference (MD) -7.92 hours, 95% CI -12.71 to -3.13; 12 studies, 684 participants), risk of postoperative nausea (overall, i.e. 0 up to 72 hours) (RR 0.78, 95% CI 0.67 to 0.91; 35 studies, 1903 participants), and opioid consumption (overall) (MD -4.52 mg morphine equivalents , 95% CI -6.25 to -2.79; 40 studies, 2201 participants); quality of evidence was very low for all these outcomes.The effect of IV lidocaine on adverse effects compared to placebo treatment is uncertain, as only a small number of studies systematically analysed the occurrence of adverse effects (very low-quality evidence).IV Lidocaine compared to TEAThe effects of IV lidocaine compared with TEA are unclear (pain at 24 hours (MD 1.51, 95% CI -0.29 to 3.32; 2 studies, 102 participants), pain at 48 hours (MD 0.98, 95% CI -1.19 to 3.16; 2 studies, 102 participants), time to first bowel movement (MD -1.66, 95% CI -10.88 to 7.56; 2 studies, 102 participants); all very low-quality evidence). The risk for ileus and for postoperative nausea (overall) is also unclear, as only one small trial assessed these outcomes (very low-quality evidence). No trial assessed the outcomes, 'pain at early time points' and 'opioid consumption (overall)'. The effect of IV lidocaine on adverse effects compared to TEA is uncertain (very low-quality evidence). AUTHORS' CONCLUSIONS We are uncertain whether IV perioperative lidocaine, when compared to placebo or no treatment, has a beneficial impact on pain scores in the early postoperative phase, and on gastrointestinal recovery, postoperative nausea, and opioid consumption. The quality of evidence was limited due to inconsistency, imprecision, and study quality. Lidocaine probably has no clinically relevant effect on pain scores later than 24 hours. Few studies have systematically assessed the incidence of adverse effects. There is a lack of evidence about the effects of IV lidocaine compared with epidural anaesthesia in terms of the optimal dose and timing (including the duration) of the administration. We identified three ongoing studies, and 18 studies are awaiting classification; the results of the review may change when these studies are published and included in the review.
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Affiliation(s)
- Stephanie Weibel
- University of WürzburgDepartment of Anaesthesia and Critical CareOberduerrbacher Str. 6WürzburgGermany
| | - Yvonne Jelting
- University of WürzburgDepartment of Anaesthesia and Critical CareOberduerrbacher Str. 6WürzburgGermany
| | - Nathan L Pace
- University of UtahDepartment of Anesthesiology3C444 SOM30 North 1900 EastSalt Lake CityUTUSA84132‐2304
| | - Antonia Helf
- University of WürzburgDepartment of Anaesthesia and Critical CareOberduerrbacher Str. 6WürzburgGermany
| | - Leopold HJ Eberhart
- Philipps‐University MarburgDepartment of Anaesthesiology & Intensive Care MedicineBaldingerstrasse 1MarburgGermany35043
| | - Klaus Hahnenkamp
- University HospitalDepartment of AnesthesiologyGreifswaldGermany17475
| | - Markus W Hollmann
- Academic Medical Center (AMC) University of AmsterdamDepartment of AnaesthesiologyMeibergdreef 9AmsterdamNetherlands1105 DD
| | - Daniel M Poepping
- University Hospital MünsterDepartment of Anesthesiology and Intensive CareAlbert Schweitzer Str. 33MünsterGermany48149
| | - Alexander Schnabel
- University of WürzburgDepartment of Anaesthesia and Critical CareOberduerrbacher Str. 6WürzburgGermany
| | - Peter Kranke
- University of WürzburgDepartment of Anaesthesia and Critical CareOberduerrbacher Str. 6WürzburgGermany
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Habibi MR, Habibi V, Habibi A, Soleimani A. Lidocaine dose-response effect on postoperative cognitive deficit: meta-analysis and meta-regression. Expert Rev Clin Pharmacol 2018; 11:361-371. [PMID: 29310468 DOI: 10.1080/17512433.2018.1425614] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION The true influence of the perioperative intravenous lidocaine on the development of postoperative cognitive deficit (POCD) in coronary artery bypass grafting (CABG) remains controversial. The principal aim is to undertake a meta-regression to determine whether moderator variables mediate the relationship between lidocaine and POCD. Areas covered: We searched the Web of Science, PubMed database, Scopus and the Cochrane Library database (up to June 2017) and systematically reviewed a list of retrieved articles. Our final review includes only randomized controlled trials (RCTs) that compared infusion of lidocaine and placebo during cardiopulmonary bypass (CPB). Mantel-Haenszel risk ratio (MH RR) and corresponding 95% confidence interval (CI) was used to report the overall effect and meta-regression analysis. A total of 688 patients in five RCTs were included. POCD occurred in 34% of all cases. Perioperative lidocaine reduces POCD (MH RR 0.702 (95% CI: 0.541-0.909). Younger age, male gender, longer CPB and higher concentration of lidocaine significantly mediate the relationship between lidocaine and POCD in favour of the neuroprotective effect of lidocaine. Expert commentary: The neuroprotective effect of lidocaine on POCD is consistent in spite of longer CPB time. A higher concentration of lidocaine strengthened the neuroprotective effect of lidocaine.
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Affiliation(s)
- Mohammad Reza Habibi
- a Department of Anesthesiology, Faculty of Medicine , Mazandaran University of Medical Sciences , Sari , Iran
| | - Valiollah Habibi
- b Department of Cardiac Surgery, Faculty of Medicine , Mazandaran University of Medical Sciences , Sari , Iran
| | - Ali Habibi
- c Medical Student, Faculty of Medicine , Mazandaran University of Medical Sciences , Sari , Iran
| | - Aria Soleimani
- a Department of Anesthesiology, Faculty of Medicine , Mazandaran University of Medical Sciences , Sari , Iran
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González MM, Altermatt F. Is intravenous lidocaine effective for decreasing pain and speeding up recovery after surgery? Medwave 2017; 17:e7121. [PMID: 29286359 DOI: 10.5867/medwave.2017.09.7121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 12/26/2017] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Lidocaine is widely used in anesthesia due to its multiple properties, including its role as analgesic. However, it is not entirely clear which are the real benefits of its use in the perioperative setting. METHODS To answer this question we used Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach. RESULTS AND CONCLUSIONS We identified 15 systematic reviews including 53 studies overall, all of them randomized controlled trials. We concluded the use of intravenous perioperative lidocaine probably results in a clinically irrelevant difference in pain and length of hospital stay, but it probably prevents postoperative nausea and vomiting.
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Affiliation(s)
- María Magdalena González
- Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; Proyecto Epistemonikos, Santiago, Chile
| | - Fernando Altermatt
- Proyecto Epistemonikos, Santiago, Chile; Departamento de Anestesiología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile. . Address: Centro Evidencia Uc, Pontificia Universidad Católica de Chile, Centro de Innovación UC Anacleto Angelini, Avda. Vicuña Mackenna 4860, Macul, Santiago, Chile
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Klamt JG, Vicente WVDA, Garcia LV, Carmona F, Abrão J, Menardi AC, Manso PH. Neuroprotective Anesthesia Regimen and Intensive Management for Pediatric Cardiac Surgery with Cardiopulmonary Bypass: a Review and Initial Experience. Braz J Cardiovasc Surg 2017; 32:523-529. [PMID: 29267616 PMCID: PMC5731303 DOI: 10.21470/1678-9741-2016-0064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Accepted: 06/11/2017] [Indexed: 12/15/2022] Open
Abstract
This article describes our proposal for routine anesthesia, intraoperative
medical management, cerebral and physiological monitoring during pediatric
cardiac surgery with cardiopulmonary bypass that intend to provide appropriate
anesthesia (analgesia, hypnosis), neuroprotection, adequate cerebral and
systemic oxygen supply, and preventing against drugs neurotoxicity. A concise
retrospective data is presented.
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Affiliation(s)
- Jyrson Guilherme Klamt
- Hospital das Clinicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
| | - Walter Villela de Andrade Vicente
- Hospital das Clinicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
| | - Luis Vicente Garcia
- Hospital das Clinicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
| | - Fabio Carmona
- Hospital das Clinicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
| | - João Abrão
- Hospital das Clinicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
| | - Antônio Carlos Menardi
- Hospital das Clinicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
| | - Paulo Henrique Manso
- Hospital das Clinicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
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Skvarc DR, Berk M, Byrne LK, Dean OM, Dodd S, Lewis M, Marriott A, Moore EM, Morris G, Page RS, Gray L. Post-Operative Cognitive Dysfunction: An exploration of the inflammatory hypothesis and novel therapies. Neurosci Biobehav Rev 2017; 84:116-133. [PMID: 29180259 DOI: 10.1016/j.neubiorev.2017.11.011] [Citation(s) in RCA: 196] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 10/16/2017] [Accepted: 11/20/2017] [Indexed: 12/11/2022]
Abstract
Post-Operative Cognitive Dysfunction (POCD) is a highly prevalent condition with significant clinical, social and financial impacts for patients and their communities. The underlying pathophysiology is becoming increasingly understood, with the role of neuroinflammation and oxidative stress secondary to surgery and anaesthesia strongly implicated. This review aims to describe the putative mechanisms by which surgery-induced inflammation produces cognitive sequelae, with a focus on identifying potential novel therapies based upon their ability to modify these pathways.
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Affiliation(s)
- David R Skvarc
- School of Psychology, Deakin University, Melbourne, Australia; Deakin University, Innovations in Mental and Physical Health and Clinical Treatment (IMPACT) Strategic Research Centre, Barwon Health, Geelong, Australia.
| | - Michael Berk
- Deakin University, Innovations in Mental and Physical Health and Clinical Treatment (IMPACT) Strategic Research Centre, Barwon Health, Geelong, Australia; Deakin University, School of Medicine, Geelong, Australia; Orygen, The National Centre of Excellence in Youth Mental Health, The Department of Psychiatry and the Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Parkville, Australia.
| | - Linda K Byrne
- School of Psychology, Deakin University, Melbourne, Australia.
| | - Olivia M Dean
- Deakin University, Innovations in Mental and Physical Health and Clinical Treatment (IMPACT) Strategic Research Centre, Barwon Health, Geelong, Australia; Deakin University, School of Medicine, Geelong, Australia; Orygen, The National Centre of Excellence in Youth Mental Health, The Department of Psychiatry and the Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Parkville, Australia
| | - Seetal Dodd
- Deakin University, Innovations in Mental and Physical Health and Clinical Treatment (IMPACT) Strategic Research Centre, Barwon Health, Geelong, Australia; Deakin University, School of Medicine, Geelong, Australia
| | - Matthew Lewis
- School of Psychology, Deakin University, Melbourne, Australia; Aged Psychiatry Service, Caulfield Hospital, Alfred Health, Caulfield, Australia
| | - Andrew Marriott
- Department of Anaesthesia, Perioperative Medicine & Pain Management, Barwon Health, Geelong, Australia; Deakin University, Innovations in Mental and Physical Health and Clinical Treatment (IMPACT) Strategic Research Centre, Barwon Health, Geelong, Australia; Deakin University, School of Medicine, Geelong, Australia; Orygen, The National Centre of Excellence in Youth Mental Health, The Department of Psychiatry and the Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Parkville, Australia
| | - Eileen M Moore
- Department of Anaesthesia, Perioperative Medicine & Pain Management, Barwon Health, Geelong, Australia; Deakin University, Innovations in Mental and Physical Health and Clinical Treatment (IMPACT) Strategic Research Centre, Barwon Health, Geelong, Australia
| | | | - Richard S Page
- Deakin University, School of Medicine, Geelong, Australia; Department of Orthopaedics, Barwon Health, Geelong, Australia
| | - Laura Gray
- Deakin University, School of Medicine, Geelong, Australia.
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Kang F, Tang C, Han M, Chai X, Huang X, Li J. Effects of Dexmedetomidine-Isoflurane versus Isoflurane Anesthesia on Brain Injury After Cardiac Valve Replacement Surgery. J Cardiothorac Vasc Anesth 2017; 32:1581-1586. [PMID: 29277297 DOI: 10.1053/j.jvca.2017.11.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To compare dexmedetomidine combined with isoflurane versus isoflurane anesthesia on brain injury after cardiac surgery. DESIGN A prospective, randomized, single-blind study. SETTING University hospital. PARTICIPANTS Adult patients undergoing elective valve replacement surgery. INTERVENTIONS Ninety-seven patients scheduled for valve replacement surgery were randomly divided into 2 groups: dexmedetomidine and isoflurane (Dex-Iso, n = 50) and isoflurane alone (Iso, n = 47). Dexemedetomidine was infused at 0.6 μg/kg as a bolus, followed with 0.2 μg/kg/h until the end of surgery. MEASUREMENTS AND MAIN RESULTS Jugular blood samples were drawn for analysis of matrix metalloproteinase-9 (MMP-9) and glial fibrillary acidic protein (GFAP) levels on time points of: T1 (before induction); T2 (5 minutes after cardiopulmonary bypass [CPB] onset); T3 (after CPB off); T4 (the first day after operation); T5 (the second day after operation). Plasma lactate levels in arterial and jugular venous blood also were quantified. The difference between arterial and jugular bulb venous blood lactate levels (AVDL) was calculated. An antisaccadic eye movement (ASEM) test was carried out on the day before the operation and the seventh day postoperatively. In both groups, serum MMP-9 and GFAP concentrations increased after CPB, with the peak values occurring after CPB. At time point T5, MMP-9 and GFAP levels were close to those at T1. MMP-9 concentrations in the Dex-Iso group were lower than the Iso group at T3 and T4. GFAP concentrations in the Dex-Iso group were lower at T3 but were higher than the Iso group at T2. No significant differences were found in AVDL between the 2 groups perioperatively except at T2. The ASEM scores decreased significantly postoperatively. There was no significant difference in the ASEM scores between the 2 treatment groups before and after the operation. CONCLUSIONS The use of dexmedetomidine decreased the biochemical markers of brain injury but did not improve the neuropsychological test result after cardiac surgery.
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Affiliation(s)
- Fang Kang
- Department of Anesthesiology, Anhui Provincial Hospital Affiliated to Anhui Medical University, Anhui Province, China
| | - ChaoLiang Tang
- Department of Anesthesiology, Anhui Provincial Hospital Affiliated to Anhui Medical University, Anhui Province, China
| | - MingMing Han
- Department of Anesthesiology, Anhui Provincial Hospital Affiliated to Anhui Medical University, Anhui Province, China
| | - XiaoQing Chai
- Department of Anesthesiology, Anhui Provincial Hospital Affiliated to Anhui Medical University, Anhui Province, China
| | - Xiang Huang
- Department of Anesthesiology, Anhui Provincial Hospital Affiliated to Anhui Medical University, Anhui Province, China
| | - Juan Li
- Department of Anesthesiology, Anhui Provincial Hospital Affiliated to Anhui Medical University, Anhui Province, China.
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Bhamidipati D, Goldhammer JE, Sperling MR, Torjman MC, McCarey MM, Whellan DJ. Cognitive Outcomes After Coronary Artery Bypass Grafting. J Cardiothorac Vasc Anesth 2017; 31:707-718. [DOI: 10.1053/j.jvca.2016.09.028] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Indexed: 12/17/2022]
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Abstract
Perioperative lidocaine infusion improves analgesia and recovery after some surgical procedures, possibly through systemic antiinflammatory effects. This commentary provides the clinician with evidence for rational use of perioperative lidocaine infusion in procedures where it is of demonstrated benefit.
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