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Werner P, Winter M, Mahr S, Stelzmueller ME, Zimpfer D, Ehrlich M. Cerebral Protection Strategies in Aortic Arch Surgery-Past Developments, Current Evidence, and Future Innovation. Bioengineering (Basel) 2024; 11:775. [PMID: 39199732 PMCID: PMC11351742 DOI: 10.3390/bioengineering11080775] [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: 05/22/2024] [Revised: 07/18/2024] [Accepted: 07/26/2024] [Indexed: 09/01/2024] Open
Abstract
Surgery of the aortic arch remains a complex procedure, with neurological events such as stroke remaining its most dreaded complications. Changes in surgical technique and the continuous innovation in neuroprotective strategies have led to a significant decrease in cerebral and spinal events. Different modes of cerebral perfusion, varying grades of hypothermia, and a number of pharmacological strategies all aim to reduce hypoxic and ischemic cerebral injury, yet there is no evidence indicating the clear superiority of one method over another. While surgical results continue to improve, novel hybrid and interventional techniques are just entering the stage and the question of optimal neuroprotection remains up to date. Within this perspective statement, we want to shed light on the current evidence and controversies of cerebral protection in aortic arch surgery, as well as what is on the horizon in this fast-evolving field. We further present our institutional approach as a large tertiary aortic reference center.
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Affiliation(s)
- Paul Werner
- Correspondence: (P.W.); (M.W.); Tel.: +431-40400-69890 (P.W.)
| | - Martin Winter
- Correspondence: (P.W.); (M.W.); Tel.: +431-40400-69890 (P.W.)
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Abdel Rady MM, Osman AM, Abo Elfadl GM, Ahmed HM, Sayed S, Abdallah AO, Ali WN. Effects of intravenous single-bolus lidocaine infusion versus intravenous single-bolus magnesium sulfate infusion on postoperative pain, emotional status, and quality of life in patients undergoing spine fusion surgery: a randomized study. Minerva Anestesiol 2024; 90:397-408. [PMID: 38771164 DOI: 10.23736/s0375-9393.24.17868-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
BACKGROUND We assessed the efficiency of intravenous adjuvants in decreasing opioid intake and pain scores after spine fusion surgery. METHODS This study included 120 patients aged 18-60 listed for spine fusion surgery under general anesthesia. Patients were randomly assigned to four groups: Group (Lidocaine): received IV lidocaine 4 mg/kg in 50 mL volume over 30 min. Group (Magnesium): received IV magnesium sulfate 30mg/kg in 50 mL volume over 30 min. Group (combined Lidocaine and Magnesium): received IV lidocaine 4 mg/kg in 50 mL volume over 30 min.+IV magnesium sulfate 30mg/kg in 50 mL volume over 30 min. Group (Control): received IV saline 50 mL. The time to the first request analgesia, the postoperative pain score, total analgesic use, patient satisfaction, anxiety, depression, mental state, quality of life, and side effects were measured. RESULTS The combined group had more extended time for the first analgesic request and fewer rescue analgesia doses than the other groups. NRS scores at rest or movement were statistically significantly lower in the lidocaine group and the combined group compared to the control group (P1, P3<0.05) at almost all times. This combination reduces anxiety and depression and improves overall health up to three months after a single infusion. The combined group had higher patient satisfaction. CONCLUSIONS A synergistic effect of a combination of lidocaine and magnesium sulfate on perioperative pain was found. It reduces analgesic consumption, depression, and anxiety and improves overall health up to three months after a single infusion dose.
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Affiliation(s)
- Marwa M Abdel Rady
- Faculty of Medicine, New Valley University, Kharga, Egypt -
- Department of Anesthesia and Intensive Care, Assiut University Hospital, Assiut, Egypt -
| | - Ayman M Osman
- Department of Anesthesia and Intensive Care, Assiut University Hospital, Assiut, Egypt
| | - Ghada M Abo Elfadl
- Department of Anesthesia and Intensive Care, Assiut University Hospital, Assiut, Egypt
| | - Haitham M Ahmed
- Department of Anesthesia and Intensive Care, Assiut University Hospital, Assiut, Egypt
| | - Sherif Sayed
- Department of Anesthesia and Intensive Care, Assiut University Hospital, Assiut, Egypt
| | - Ahmed O Abdallah
- Department of Anesthesia and Intensive Care, Assiut University Hospital, Assiut, Egypt
| | - Wesam N Ali
- Department of Anesthesia and Intensive Care, Assiut University Hospital, Assiut, Egypt
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Hughes GC, Chen EP, Browndyke JN, Szeto WY, DiMaio JM, Brinkman WT, Gaca JG, Blumenthal JA, Karhausen JA, Bisanar T, James ML, Yanez D, Li YJ, Mathew JP. Cognitive Effects of Body Temperature During Hypothermic Circulatory Arrest Trial (GOT ICE): A Randomized Clinical Trial Comparing Outcomes After Aortic Arch Surgery. Circulation 2024; 149:658-668. [PMID: 38084590 PMCID: PMC10922813 DOI: 10.1161/circulationaha.123.067022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 11/10/2023] [Indexed: 02/28/2024]
Abstract
BACKGROUND Deep hypothermia has been the standard for hypothermic circulatory arrest (HCA) during aortic arch surgery. However, centers worldwide have shifted toward lesser hypothermia with antegrade cerebral perfusion. This has been supported by retrospective data, but there has yet to be a multicenter, prospective randomized study comparing deep versus moderate hypothermia during HCA. METHODS This was a randomized single-blind trial (GOT ICE [Cognitive Effects of Body Temperature During Hypothermic Circulatory Arrest]) of patients undergoing arch surgery with HCA plus antegrade cerebral perfusion at 4 US referral aortic centers (August 2016-December 2021). Patients were randomized to 1 of 3 hypothermia groups: DP, deep (≤20.0 °C); LM, low-moderate (20.1-24.0 °C); and HM, high-moderate (24.1-28.0 °C). The primary outcome was composite global cognitive change score between baseline and 4 weeks postoperatively. Analysis followed the intention-to-treat principle to evaluate if: (1) LM noninferior to DP on global cognitive change score; (2) DP superior to HM. The secondary outcomes were domain-specific cognitive change scores, neuroimaging findings, quality of life, and adverse events. RESULTS A total of 308 patients consented; 282 met inclusion and were randomized. A total of 273 completed surgery, and 251 completed the 4-week follow-up (DP, 85 [34%]; LM, 80 [34%]; HM, 86 [34%]). Mean global cognitive change score from baseline to 4 weeks in the LM group was noninferior to the DP group; likewise, no significant difference was observed between DP and HM. Noninferiority of LM versus DP, and lack of difference between DP and HM, remained for domain-specific cognitive change scores, except structured verbal memory, with noninferiority of LM versus DP not established and structured verbal memory better preserved in DP versus HM (P = 0.036). There were no significant differences in structural or functional magnetic resonance imaging brain imaging between groups postoperatively. Regardless of temperature, patients who underwent HCA demonstrated significant reductions in cerebral gray matter volume, cortical thickness, and regional brain functional connectivity. Thirty-day in-hospital mortality, major morbidity, and quality of life were not different between groups. CONCLUSIONS This randomized multicenter study evaluating arch surgery HCA temperature strategies found low-moderate hypothermia noninferior to traditional deep hypothermia on global cognitive change 4 weeks after surgery, although in secondary analysis, structured verbal memory was better preserved in the deep group. The verbal memory differences in the low- and high-moderate groups and structural and functional connectivity reductions from baseline merit further investigation and suggest opportunities to further optimize brain perfusion during HCA. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT02834065.
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Affiliation(s)
- G Chad Hughes
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery (G.C.H., E.P.C., J.G.G.), Duke University Medical Center, Durham, NC
| | - Edward P Chen
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery (G.C.H., E.P.C., J.G.G.), Duke University Medical Center, Durham, NC
| | - Jeffrey N Browndyke
- Department of Psychiatry & Behavioral Sciences, Division of Behavioral Medicine & Neurosciences (J.N.B., J.A.B.), Duke University Medical Center, Durham, NC
| | - Wilson Y Szeto
- Department of Surgery, Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia (W.Y.S.)
| | - J Michael DiMaio
- The Heart Hospital, Baylor Scott and White, Plano, TX (J.M.D., W.T.B.)
| | | | - Jeffrey G Gaca
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery (G.C.H., E.P.C., J.G.G.), Duke University Medical Center, Durham, NC
| | - James A Blumenthal
- Department of Psychiatry & Behavioral Sciences, Division of Behavioral Medicine & Neurosciences (J.N.B., J.A.B.), Duke University Medical Center, Durham, NC
| | - Jorn A Karhausen
- Department of Anesthesiology (J.A.K., T.B., M.L.J., J.P.M.), Duke University School of Medicine, Durham, NC
| | - Tiffany Bisanar
- Department of Anesthesiology (J.A.K., T.B., M.L.J., J.P.M.), Duke University School of Medicine, Durham, NC
| | - Michael L James
- Department of Anesthesiology (J.A.K., T.B., M.L.J., J.P.M.), Duke University School of Medicine, Durham, NC
- Department of Neurology (M.L.J.), Duke University School of Medicine, Durham, NC
| | - David Yanez
- Department of Biostatistics and Bioinformatics (D.Y., Y.-J.L.), Duke University School of Medicine, Durham, NC
| | - Yi-Ju Li
- Department of Biostatistics and Bioinformatics (D.Y., Y.-J.L.), Duke University School of Medicine, Durham, NC
| | - Joseph P Mathew
- Department of Anesthesiology (J.A.K., T.B., M.L.J., J.P.M.), Duke University School of Medicine, Durham, NC
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Reese M, Christensen S, Anolick H, Roberts KC, Wong MK, Wright MC, Acker L, Browndyke JN, Woldorff MG, Berger M. EEG pre-burst suppression: characterization and inverse association with preoperative cognitive function in older adults. Front Aging Neurosci 2023; 15:1229081. [PMID: 37711992 PMCID: PMC10499509 DOI: 10.3389/fnagi.2023.1229081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 08/01/2023] [Indexed: 09/16/2023] Open
Abstract
The most common complication in older surgical patients is postoperative delirium (POD). POD is associated with preoperative cognitive impairment and longer durations of intraoperative burst suppression (BSup) - electroencephalography (EEG) with repeated periods of suppression (very low-voltage brain activity). However, BSup has modest sensitivity for predicting POD. We hypothesized that a brain state of lowered EEG power immediately precedes BSup, which we have termed "pre-burst suppression" (preBSup). Further, we hypothesized that even patients without BSup experience these preBSup transient reductions in EEG power, and that preBSup (like BSup) would be associated with preoperative cognitive function and delirium risk. Data included 83 32-channel intraoperative EEG recordings of the first hour of surgery from 2 prospective cohort studies of patients ≥age 60 scheduled for ≥2-h non-cardiac, non-neurologic surgery under general anesthesia (maintained with a potent inhaled anesthetic or a propofol infusion). Among patients with BSup, we defined preBSup as the difference in 3-35 Hz power (dB) during the 1-s preceding BSup relative to the average 3-35 Hz power of their intraoperative EEG recording. We then recorded the percentage of time that each patient spent in preBSup, including those without BSup. Next, we characterized the association between percentage of time in preBSup and (1) percentage of time in BSup, (2) preoperative cognitive function, and (3) POD incidence. The percentage of time in preBSup and BSup were correlated (Spearman's ρ [95% CI]: 0.52 [0.34, 0.66], p < 0.001). The percentage of time in BSup, preBSup, or their combination were each inversely associated with preoperative cognitive function (β [95% CI]: -0.10 [-0.19, -0.01], p = 0.024; -0.04 [-0.06, -0.01], p = 0.009; -0.04 [-0.06, -0.01], p = 0.003, respectively). Consistent with prior literature, BSup was significantly associated with POD (odds ratio [95% CI]: 1.34 [1.01, 1.78], p = 0.043), though this association did not hold for preBSup (odds ratio [95% CI]: 1.04 [0.95, 1.14], p = 0.421). While all patients had ≥1 preBSup instance, only 20.5% of patients had ≥1 BSup instance. These exploratory findings suggest that future studies are warranted to further study the extent to which preBSup, even in the absence of BSup, can identify patients with impaired preoperative cognition and/or POD risk.
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Affiliation(s)
- Melody Reese
- Department of Anesthesiology, School of Medicine, Duke University, Durham, NC, United States
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, NC, United States
| | | | - Harel Anolick
- Pratt School of Engineering, Duke University, Durham, NC, United States
| | - Kenneth C. Roberts
- Center for Cognitive Neuroscience, Duke University, Durham, NC, United States
| | - Megan K. Wong
- School of Medicine, Duke University, Durham, NC, United States
| | - Mary Cooter Wright
- Department of Anesthesiology, School of Medicine, Duke University, Durham, NC, United States
| | - Leah Acker
- Department of Anesthesiology, School of Medicine, Duke University, Durham, NC, United States
| | | | - Marty G. Woldorff
- Center for Cognitive Neuroscience, Duke University, Durham, NC, United States
- Department of Psychiatry, Duke University, Durham, NC, United States
- Department of Psychology and Neuroscience, Duke University, Durham, NC, United States
| | - Miles Berger
- Department of Anesthesiology, School of Medicine, Duke University, Durham, NC, United States
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, NC, United States
- Center for Cognitive Neuroscience, Duke University, Durham, NC, United States
- Alzheimer’s Disease Research Center, Duke University, Durham, NC, United States
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Bowden T, Hurt CS, Sanders J, Aitken LM. Effectiveness of cognitive interventions for adult surgical patients after general anaesthesia to improve cognitive functioning: A systematic review. J Clin Nurs 2023; 32:3117-3129. [PMID: 35733323 PMCID: PMC10946716 DOI: 10.1111/jocn.16423] [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: 01/28/2022] [Revised: 05/23/2022] [Accepted: 05/30/2022] [Indexed: 11/29/2022]
Abstract
AIMS AND OBJECTIVES To examine the effectiveness of cognitive interventions after general anaesthesia to improve cognitive functioning. BACKGROUND The number of surgical procedures performed worldwide is large and growing. Postoperative cognitive dysfunction is a common complication associated with poor postoperative outcomes. A variety of cognitive interventions have been developed to maintain or improve cognitive function in one or more cognitive domains. Cognitive interventions have shown to be effective in healthy older populations, those with mild cognitive impairment, and those with heart failure. The impact of cognitive interventions in surgical patients after general anaesthesia is a relatively new focus of research and is therefore less well established. METHODS Seven bibliographic databases were searched in relation to 'surgery' and 'cognitive interventions'; no date or language limits were imposed. Studies including adult patients who were scheduled for, or who had undergone surgery under general anaesthesia, had a baseline cognitive assessment using a validated measurement, and had engaged with any cognition-based intervention were included. Full-text review for inclusion, quality assessment and data extraction were undertaken independently by two authors. This study is reported in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. RESULTS A total of 550 papers were identified for possible inclusion, of which nine met the inclusion criteria and were included in the review. The majority were randomised controlled trials (RCTs) (n = 6 [66.7%]). Four studies used computerised cognitive interventions, while five used traditional cognitive interventions. Most of the studies used multi-domain cognitive training focusing on two or more domains (n = 7 [77.8%]) while two studies used single-domain cognitive training. Memory (n = 7 [77.8%]) and attention (n = 5 [55.6%]) were the cognitive domains most often targeted during the intervention. CONCLUSIONS The use of cognitive interventions demonstrated some efficacy in improving cognitive function after general anaesthesia, particularly those targeting memory. RELEVANCE FOR CLINICAL PRACTICE The findings of this review suggest that cognitive interventions show promise at improving cognitive performance in patients with POCD and could be usefully implemented in clinical practice to improve patient outcomes.
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Affiliation(s)
- Tracey Bowden
- School of Health SciencesCity, University of LondonLondonUK
| | | | - Julie Sanders
- St Bartholomew's HospitalBarts Health NHS TrustLondonUK
- The William Harvey Research InstituteQueen Mary University LondonLondonUK
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Ma XF, Lv SJ, Wei SQ, Mao BR, Zhao XX, Jiang XQ, Zeng F, Du XK. Influences of dexmedetomidine on stress responses and postoperative cognitive and coagulation functions in patients undergoing radical gastrectomy under general anesthesia. World J Gastrointest Surg 2023; 15:1169-1177. [PMID: 37405107 PMCID: PMC10315113 DOI: 10.4240/wjgs.v15.i6.1169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 03/22/2023] [Accepted: 04/19/2023] [Indexed: 06/15/2023] Open
Abstract
BACKGROUND Radical gastrectomy (RG) is commonly used in the treatment of patients with gastric cancer (GC), but this procedure may lead to stress responses, postoperative cognitive dysfunction, and blood coagulation abnormalities in patients.
AIM To investigate the influences of dexmedetomidine (DEX) on stress responses and postoperative cognitive and coagulation functions in patients undergoing RG under general anesthesia (GA).
METHODS One hundred and two patients undergoing RG for GC under GA from February 2020 to February 2022 were retrospectively reviewed. Of these, 50 patients had received conventional anesthesia intervention [control group (CG)] and 52 patients had received DEX in addition to routine anesthesia intervention [observation group (OG)]. Inflammatory factor (IFs; tumor necrosis factor-α, TNF-α; interleukin-6, IL-6), stress responses (cortisol, Cor; adrenocorticotropic hormone, ACTH), cognitive function (CF; Mini-Mental State Examination, MMSE), neurological function (neuron-specific enolase, NSE; S100 calcium-binding protein B, S100B), and coagulation function (prothrombin time, PT; thromboxane B2, TXB2; fibrinogen, FIB) were compared between the two groups before surgery (T0), as well as at 6 h (T1) and 24 h (T2) after surgery.
RESULTS Compared with T0, TNF-α, IL-6, Cor, ACTH, NSE, S100B, PT, TXB2, and FIB showed a significant increase in both groups at T1 and T2, but with even lower levels in OG vs CG. Both groups showed a significant reduction in the MMSE score at T1 and T2 compared with T0, but the MMSE score was notably higher in OG compared with CG.
CONCLUSION In addition to a potent inhibitory effect on postoperative IFs and stress responses in GC patients undergoing RG under GA, DEX may also alleviate the coagulation dysfunction and improve the postoperative CF of these patients.
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Affiliation(s)
- Xiang-Fei Ma
- Department of Anesthesiology, The Second Affiliated Hospital of Guangxi Medical University, Nanning 530007, Guangxi Zhuang Autonomous Region, China
| | - Shi-Jia Lv
- Department of Anesthesiology, The Second Affiliated Hospital of Guangxi Medical University, Nanning 530007, Guangxi Zhuang Autonomous Region, China
| | - Shen-Qiao Wei
- Department of Anesthesiology, The Second Affiliated Hospital of Guangxi Medical University, Nanning 530007, Guangxi Zhuang Autonomous Region, China
| | - Bing-Rong Mao
- Department of Anesthesiology, The Second Affiliated Hospital of Guangxi Medical University, Nanning 530007, Guangxi Zhuang Autonomous Region, China
| | - Xiu-Xia Zhao
- Department of Anesthesiology, The Second Affiliated Hospital of Guangxi Medical University, Nanning 530007, Guangxi Zhuang Autonomous Region, China
| | - Xiao-Qing Jiang
- Department of Anesthesiology, The Second Affiliated Hospital of Guangxi Medical University, Nanning 530007, Guangxi Zhuang Autonomous Region, China
| | - Fei Zeng
- Department of Anesthesiology, The Second Affiliated Hospital of Guangxi Medical University, Nanning 530007, Guangxi Zhuang Autonomous Region, China
| | - Xue-Ke Du
- Department of Anesthesiology, The Second Affiliated Hospital of Guangxi Medical University, Nanning 530007, Guangxi Zhuang Autonomous Region, China
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Perioperative Neurofilament Light Plasma Concentrations and Cognition before and after Cardiac Surgery: A Prospective Nested Cohort Study. Anesthesiology 2022; 137:303-314. [PMID: 35984933 DOI: 10.1097/aln.0000000000004327] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Neurofilament light is a marker of neuronal injury and can be measured in blood. Postoperative increases in neurofilament light have been associated with delirium after noncardiac surgery. However, few studies have examined the association of neurofilament light changes with postdischarge cognition in cardiac surgery patients, who are at highest risk for neuronal injury and cognitive decline. The authors hypothesized that increased neurofilament light (both baseline and change) would be associated with worse neuropsychological status up to 1 yr after cardiac surgery. METHODS This observational study was nested in a trial of cardiac surgery patients, in which blood pressure during bypass was targeted using cerebral autoregulation monitoring. Plasma concentrations of neurofilament light were measured at baseline and postoperative day 1. Neuropsychological testing was performed at baseline, 1 month after surgery, and 1 yr after surgery. Primary outcomes were baseline and change from baseline in a composite z-score of all cognitive tests. RESULTS Among 167 patients, cognitive outcomes were available in 80% (134 of 167) and 61% (102 of 167) at 1 month and 1 yr after surgery, respectively. The median baseline concentration of neurofilament light was 18.2 pg/ml (interquartile range, 13.4 to 28.1), and on postoperative day 1 was 28.5 pg/ml (interquartile range, 19.3 to 45.0). Higher baseline log neurofilament light was associated with worse baseline cognitive z-score (adjusted slope, -0.60; 95% CI, -0.90 to -0.30; P < 0.001), no change in z-score from baseline to 1 month (0.11; 95% CI, -0.19 to 0.41; P = 0.475), and improvement in z-score from baseline to 1 yr (0.56; 95% CI, 0.31 to 0.81; P < 0.001). Whereas some patients had an improvement in cognition at 1 yr and others a decline, an increase in neurofilament light from baseline to postoperative day 1 was associated with a greater decline in cognition at 1 yr. CONCLUSIONS Higher baseline neurofilament light concentration was associated with worse baseline cognition but improvement in cognition at 1 yr. A postoperative increase in neurofilament light was associated with a greater cognitive decline at 1 yr. EDITOR’S PERSPECTIVE
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Jitsinthunun T, Raksakietisak M, Pantubtim C, Mahatnirunkul P. Effects of Magnesium Sulfate on Intraoperative Blood Loss and Anesthetic Requirement in Meningioma Patients Undergoing Craniotomy with Tumor Removal: A Prospective Randomized Study. JOURNAL OF NEUROANAESTHESIOLOGY AND CRITICAL CARE 2022. [DOI: 10.1055/s-0042-1750692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
Abstract
Background Meningioma brain tumor is associated with significant blood loss. Magnesium (Mg), a calcium blocker, can facilitate blood pressure control during surgery. This study aimed to evaluate effects of magnesium on blood loss, anesthetic requirement, and its neuroprotective effect in meningioma patients undergoing craniotomy.
Methods Eighty patients aged between 18 and 70, American Society of Anesthesiologists physical status I and II, diagnosed with meningioma and scheduled for craniotomy tumor removal were randomized into two groups. Group M (Mg) received intravenous magnesium sulfate 40 mg/kg over 30 minutes initiated at skin incision and followed by continuous infusion of 10 mg/kg/h until dura closure. Group N (NSS) received 0.9% NaCl as placebo. Anesthesiologists in charge, surgeons, and patients were all blinded. The assessed outcomes were perioperative blood loss, anesthetic requirement, and pre- and postoperative neurocognitive functions assessed by Montreal Cognitive Assessment (MoCA).
Results Thirty-eight patients in each group were analyzed. In group M, the intraoperative blood losses were 500 (70, 2300) mL, and 510 (100, 1600) mL in group N (p = 0.315). Patients who received blood within 24 hours were 39.5% in group M and 47.4% in group N (p = 0.644). No differences were observed in anesthetic requirement, intraoperative mean arterial pressure, hypotensive episodes, and vasopressor usages. There were no significant differences in postoperative MoCA score. Magnesium levels did not exceed acceptable levels.
Conclusions Magnesium administration in meningioma patients had no significant effects on blood loss, anesthetic requirement, and postoperative cognitive function.
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Affiliation(s)
- Thanawut Jitsinthunun
- Department of Anaesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Manee Raksakietisak
- Department of Anaesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chanitda Pantubtim
- Department of Anaesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Porntip Mahatnirunkul
- Department of Anaesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
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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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10
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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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11
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Oyeyemi DM, Cooter M, Chung S, Whitson HE, Browndyke JN, Devinney MJ, Smith PJ, Garrigues GE, Moretti E, Moul JW, Cohen HJ, Mathew JP, Berger M. Relationship Between Depression/Anxiety and Cognitive Function Before and 6 Weeks After Major Non-Cardiac Surgery in Older Adults. J Geriatr Psychiatry Neurol 2022; 35:145-154. [PMID: 33380241 PMCID: PMC8243391 DOI: 10.1177/0891988720978791] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To determine the relationship between affective measures and cognition before and after non-cardiac surgery in older adults. METHODS Observational prospective cohort study in 103 surgical patients age ≥ 60 years old. All participants underwent cognitive testing, Center for Epidemiologic Studies-Depression, and State Anxiety Inventory screening before and 6 weeks after surgery. Cognitive test scores were combined by factor analysis into 4 cognitive domains, whose mean was defined as the continuous cognitive index (CCI). Postoperative global cognitive change was defined by CCI change from before to after surgery, with negative CCI change indicating worsened postoperative global cognition and vice versa. RESULTS Lower global cognition before surgery was associated with greater baseline depression severity (Spearman's r = -0.30, p = 0.002) and baseline anxiety severity (Spearman's r = -0.25, p = 0.010), and these associations were similar following surgery (r = -0.36, p < 0.001; r = -0.26, p = 0.008, respectively). Neither baseline depression or anxiety severity, nor postoperative changes in depression or anxiety severity, were associated with pre- to postoperative global cognitive change. CONCLUSIONS Greater depression and anxiety severity were each associated with poorer cognitive performance both before and after surgery in older adults. Yet, neither baseline depression or anxiety symptoms, nor postoperative change in these symptoms, were associated with postoperative cognitive change.
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Affiliation(s)
- Deborah M Oyeyemi
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Mary Cooter
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Stacey Chung
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Heather E Whitson
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, NC, USA
| | - Jeffrey N Browndyke
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
- Center for Cognitive Neuroscience, Duke Institute for Brain Sciences, Duke University, Durham, NC, USA
| | - Michael J Devinney
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Patrick J Smith
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Grant E Garrigues
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA
| | - Eugene Moretti
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Judd W Moul
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Harvey Jay Cohen
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, NC, USA
| | - Joseph P Mathew
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Miles Berger
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, NC, USA
- Center for Cognitive Neuroscience, Duke Institute for Brain Sciences, Duke University, Durham, NC, USA
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12
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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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13
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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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14
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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: 44] [Impact Index Per Article: 14.7] [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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15
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VanDusen KW, Li YJ, Cai V, Hall A, Hiles S, Thompson JW, Moseley MA, Cooter M, Acker L, Levy JH, Ghadimi K, Quiñones QJ, Devinney MJ, Chung S, Terrando N, Moretti EW, Browndyke JN, Mathew JP, Berger M. Cerebrospinal Fluid Proteome Changes in Older Non-Cardiac Surgical Patients with Postoperative Cognitive Dysfunction. J Alzheimers Dis 2021; 80:1281-1297. [PMID: 33682719 PMCID: PMC8052629 DOI: 10.3233/jad-201544] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Postoperative cognitive dysfunction (POCD), a syndrome of cognitive deficits occurring 1–12 months after surgery primarily in older patients, is associated with poor postoperative outcomes. POCD is hypothesized to result from neuroinflammation; however, the pathways involved remain unclear. Unbiased proteomic analyses have been used to identify neuroinflammatory pathways in multiple neurologic diseases and syndromes but have not yet been applied to POCD. Objective: To utilize unbiased mass spectrometry-based proteomics to identify potential neuroinflammatory pathways underlying POCD. Methods: Unbiased LC-MS/MS proteomics was performed on immunodepleted cerebrospinal fluid (CSF) samples obtained before, 24 hours after, and 6 weeks after major non-cardiac surgery in older adults who did (n = 8) or did not develop POCD (n = 6). Linear mixed models were used to select peptides and proteins with intensity differences for pathway analysis. Results: Mass spectrometry quantified 8,258 peptides from 1,222 proteins in > 50%of patient samples at all three time points. Twelve peptides from 11 proteins showed differences in expression over time between patients with versus without POCD (q < 0.05), including proteins previously implicated in neurodegenerative disease pathophysiology. Additionally, 283 peptides from 182 proteins were identified with trend-level differences (q < 0.25) in expression over time between these groups. Among these, pathway analysis revealed that 50 were from 17 proteins mapping to complement and coagulation pathways (q = 2.44*10–13). Conclusion: These data demonstrate the feasibility of performing unbiased mass spectrometry on perioperative CSF samples to identify pathways associated with POCD. Additionally, they provide hypothesis-generating evidence for CSF complement and coagulation pathway changes in patients with POCD.
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Affiliation(s)
- Keith W VanDusen
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Yi-Ju Li
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA.,Duke Molecular Physiology Institute, Duke University, Durham, NC, USA
| | - Victor Cai
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Ashley Hall
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Sarah Hiles
- Duke Center for Genomic and Computational Biology, Duke University, Durham, NC, USA
| | - J Will Thompson
- Duke Center for Genomic and Computational Biology, Duke University, Durham, NC, USA
| | - M Arthur Moseley
- Duke Center for Genomic and Computational Biology, Duke University, Durham, NC, USA
| | - Mary Cooter
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Leah Acker
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Jerrold H Levy
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Kamrouz Ghadimi
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Quintin J Quiñones
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Michael J Devinney
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Stacey Chung
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Niccolò Terrando
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Eugene W Moretti
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Jeffrey N Browndyke
- Department of Psychiatry & Behavioral Sciences, Division of Geriatric Behavioral Health, Duke University Medical Center, Durham, NC, USA.,Duke Institute for Brain Sciences, Duke University, Durham, NC, USA.,Center for Cognitive Neuroscience, Duke University Medical Center, Durham, NC, USA
| | - Joseph P Mathew
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Miles Berger
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA.,Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA.,Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA.,Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
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16
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Lappalainen L, Rajamaki B, Tolppanen AM, Hartikainen S. Coronary artery revascularizations and cognitive decline - A systematic review. Curr Probl Cardiol 2021; 47:100960. [PMID: 34363848 DOI: 10.1016/j.cpcardiol.2021.100960] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 07/30/2021] [Indexed: 12/19/2022]
Abstract
Coronary artery disease (CAD) is a risk factor for cognitive decline. The aim of this study was to systematically review recent literature on whether coronary artery revascularizations are associated to cognitive decline and dementia. Pubmed, Scopus, and CINAHL (EBSCO) were searched systematically from January 2009 till September 2020. Studies were conducted on persons with CAD undergoing coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) procedure compared to other coronary artery disease treatments, and the outcome was cognitive decline or dementia. Altogether four of the 680 reviewed articles met inclusion criteria. Results were inconsistent, and the outcome measurements heterogeneous between studies. Our findings indicate an evidence gap in the current understanding of long-term outcomes following coronary artery revascularization. However, evidence of long-term effects on cognition would complement our understanding of their benefits. There is a need for more studies on long-term cognitive outcomes after coronary artery revascularizations.
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Affiliation(s)
- Laura Lappalainen
- School of Pharmacy, University of Eastern Finland, P.O. Box 1627, FI-70211, Kuopio, Finland.
| | - Blair Rajamaki
- Kuopio Research Centre of Geriatric Care, University of Eastern Finland, P.O. Box 1627, FI-70211 Kuopio, Finland; School of Pharmacy, University of Eastern Finland, P.O. Box 1627, FI-70211, Kuopio, Finland
| | - Anna-Maija Tolppanen
- Kuopio Research Centre of Geriatric Care, University of Eastern Finland, P.O. Box 1627, FI-70211 Kuopio, Finland; School of Pharmacy, University of Eastern Finland, P.O. Box 1627, FI-70211, Kuopio, Finland
| | - Sirpa Hartikainen
- Kuopio Research Centre of Geriatric Care, University of Eastern Finland, P.O. Box 1627, FI-70211 Kuopio, Finland; School of Pharmacy, University of Eastern Finland, P.O. Box 1627, FI-70211, Kuopio, Finland
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17
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Risk factors and predictive value of perioperative neurocognitive disorders in elderly patients with gastrointestinal tumors. BMC Anesthesiol 2021; 21:193. [PMID: 34281529 PMCID: PMC8287702 DOI: 10.1186/s12871-021-01405-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 06/17/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND This study aims to investigate the risk factors of perioperative neurocognitive disorders (PNDs) mainly including postoperative cognitive dysfunction (POCD) in elderly patients with gastrointestinal tumors, and evaluate its predictive value. METHODS A total of 222 eligible elderly patients (≥65 years) scheduled for elective gastroenterectomy under general anesthesia were enrolled. The cognitive function assessment was carried out 1 day before surgery and 7 days after surgery. Receiver operating characteristic curve analysis was performed to evaluate the predictive value of risk factors for early POCD. The risk factors for POCD were analyzed using univariate and multivariate logistic regression model. RESULTS Of all the 222 enrolled patients, 91 (41.0%) developed early POCD and 40 (18.0%) were identified as major POCD within 7 days after the surgery. Visual analogue score (VAS, 1st day, resting) ≥4 (OR = 7.618[3.231-17.962], P < 0.001) and alcohol exposure (OR = 2.398[1.174-4.900], P = 0.016) were independent risk factors for early POCD. VAS score (1st, resting) ≥4 (OR = 13.823[4.779-39.981], P < 0.001), preoperative white blood cell (WBC) levels ≥10 × 10*9/L (OR = 5.548[1.128-26.221], P = 0.035), blood loss ≥500 ml (OR = 3.317[1.094-10.059], P = 0.034), history of hypertension (OR = 3.046[1.267-7.322], P = 0.013), and neutrophil-lymphocyte ratio (NLR) ≥2 (OR = 3.261[1.020-10.419], P = 0.046) were independent risk factors for major POCD. Receiver operating characteristic curve analysis indicated that VAS score (1st day, resting) was a significant predictor for major POCD with a cut-off value of 2.68 and an area under the curve of 0.860 (95% confidence interval: 0.801-0.920, P < 0.001). CONCLUSIONS The risk factors for early POCD after gastroenterectomy included high VAS score (1st day, resting) and alcohol exposure. High VAS score, preoperative WBC levels ≥10 × 10*9/L, blood loss ≥500 ml, NLR ≥2, and history of hypertension were independent risk factors for major POCD. Among them, VAS score was one of the important predictors.
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18
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Lomivorotov VV, Moroz G, Abubakirov M, Osinsky R, Landoni G. Volatile and Intravenous Anesthetics for Brain Protection in Cardiac Surgery: Does the Choice of Anesthesia Matter? J Cardiothorac Vasc Anesth 2021; 36:567-576. [PMID: 33766470 DOI: 10.1053/j.jvca.2021.02.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 02/16/2021] [Accepted: 02/17/2021] [Indexed: 11/11/2022]
Abstract
Postoperative neurologic complications have a significant effect on morbidity, mortality, and long-term disability in patients undergoing cardiac surgery. The etiology of brain injury in patients undergoing cardiac surgery is multifactorial and remains unclear. There are several perioperative causative factors for neurologic complications, including microembolization, hypoperfusion, and systemic inflammatory response syndrome. Despite technologic advances and the development of new anesthetic drugs, there remains a high rate of postoperative neurologic complications. Moreover, despite the strong evidence that volatile anesthesia exerts cardioprotective effects in patients undergoing cardiac surgery, the neuroprotective effects of volatile agents remain unclear. Several studies have reported an association of using volatile anesthetics with improvement of biochemical markers of brain injury and postoperative neurocognitive function. However, there is a need for additional studies to define the optimal anesthetic drug for protecting the brain in patients undergoing cardiac surgery.
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Affiliation(s)
- Vladimir V Lomivorotov
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk, Russia; Department of Anesthesiology and Intensive Care, Novosibirsk State University, Novosibirsk, Russia.
| | - Gleb Moroz
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Marat Abubakirov
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Roman Osinsky
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Giovanni Landoni
- Anesthesia and Intensive Care Department, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
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19
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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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20
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VanDusen KW, Eleswarpu S, Moretti EW, Devinney MJ, Crabtree DM, Laskowitz DT, Woldorff MG, Roberts KC, Whittle J, Browndyke JN, Cooter M, Rockhold FW, Anakwenze O, Bolognesi MP, Easley ME, Ferrandino MN, Jiranek WA, Berger M, Adams SB, Amundsen CL, Avasarala P, Barber MD, Berchuck A, Blazer DG, Brassard R, Brigman BE, Christensen SK, Cox MW, Davidson BA, DeOrio JK, Erdmann D, Erickson MM, Funk BL, Gadsden J, Gage MJ, Gingrich JR, Greenup RA, Ha C, Habib A, Hachem RA, Hall AE, Hartwig MG, Havrilesky LJ, Heflin MT, Holland C, Hollenbeck ST, Hopkins TJ, Inman BA, Jang DW, Kahmke RR, Karikari I, Kawasaki A, Klapper JA, Klifto CS, Klinger R, Knechtle SJ, Lagoo-Deenadayalan SA, Lee WT, Levinson H, Lewis BD, Lidsky ME, Lipkin ME, Mantyh CR, McDonald SR, Migaly J, Miller TE, Mithani SK, Mosca PJ, Moul JW, Novick TL, Olson SA, Pappas TN, Park JJ, Peterson AC, Phillips BT, Polascik TJ, Potash P, Preminger GM, Previs RA, Robertson CN, Scales CD, Shah KN, Scheri RP, Siddiqui NY, Smani S, Southerland KW, Stang MT, Syed A, Szydlowska A, Thacker JK, Terrando N, Toulgoat-DuBois Y, Visco AG, Weidner AC, Yanamadala M, Zani S. The MARBLE Study Protocol: Modulating ApoE Signaling to Reduce Brain Inflammation, DeLirium, and PostopErative Cognitive Dysfunction. J Alzheimers Dis 2020; 75:1319-1328. [PMID: 32417770 PMCID: PMC7923142 DOI: 10.3233/jad-191185] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Perioperative neurocognitive disorders (PND) are common complications in older adults associated with increased 1-year mortality and long-term cognitive decline. One risk factor for worsened long-term postoperative cognitive trajectory is the Alzheimer's disease (AD) genetic risk factor APOE4. APOE4 is thought to elevate AD risk partly by increasing neuroinflammation, which is also a theorized mechanism for PND. Yet, it is unclear whether modulating apoE4 protein signaling in older surgical patients would reduce PND risk or severity. OBJECTIVE MARBLE is a randomized, blinded, placebo-controlled phase II sequential dose escalation trial designed to evaluate perioperative administration of an apoE mimetic peptide drug, CN-105, in older adults (age≥60 years). The primary aim is evaluating the safety of CN-105 administration, as measured by adverse event rates in CN-105 versus placebo-treated patients. Secondary aims include assessing perioperative CN-105 administration feasibility and its efficacy for reducing postoperative neuroinflammation and PND severity. METHODS 201 patients undergoing non-cardiac, non-neurological surgery will be randomized to control or CN-105 treatment groups and receive placebo or drug before and every six hours after surgery, for up to three days after surgery. Chart reviews, pre- and postoperative cognitive testing, delirium screening, and blood and CSF analyses will be performed to examine effects of CN-105 on perioperative adverse event rates, cognition, and neuroinflammation. Trial results will be disseminated by presentations at conferences and peer-reviewed publications. CONCLUSION MARBLE is a transdisciplinary study designed to measure CN-105 safety and efficacy for preventing PND in older adults and to provide insight into the pathogenesis of these geriatric syndromes.
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Affiliation(s)
- Keith W. VanDusen
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Sarada Eleswarpu
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Eugene W. Moretti
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | | | - Donna M. Crabtree
- Duke Office of Clinical Research, Duke University, Durham, North Carolina
| | | | - Marty G. Woldorff
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
- Department of Psychology and Neuroscience, Duke University, Durham, North Carolina
| | - Kenneth C. Roberts
- Center for Cognitive Neuroscience, Duke University Medical Center, Durham, North Carolina
| | - John Whittle
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Jeffrey N. Browndyke
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
| | - Mary Cooter
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | | | - Oke Anakwenze
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | | | - Mark E. Easley
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | | | - William A. Jiranek
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - Miles Berger
- Department of Anesthesiology, Duke University, Durham, North Carolina
- Center for Cognitive Neuroscience, Duke University Medical Center, Durham, North Carolina
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, North Carolina
| | | | - Samuel B. Adams
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - Cindy L. Amundsen
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina
| | - Pallavi Avasarala
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Matthew D. Barber
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina
| | - Andrew Berchuck
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina
| | | | - Rachele Brassard
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Brian E. Brigman
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | | | - Mitchel W. Cox
- Department of Surgery, Duke University, Durham, North Carolina
| | - Brittany A. Davidson
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina
| | - James K. DeOrio
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - Detlev Erdmann
- Department of Surgery, Duke University, Durham, North Carolina
| | | | - Bonita L. Funk
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Jeffrey Gadsden
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Mark J. Gage
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | | | | | - Christine Ha
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Ashraf Habib
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Ralph Abi Hachem
- Department of Surgery, Duke University, Durham, North Carolina
- Department of Neurosurgery, Duke University, Durham, North Carolina
| | - Ashley E. Hall
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | | | - Laura J. Havrilesky
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina
| | - Mitchell T. Heflin
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, North Carolina
- Department of Medicine, Duke University, Durham, North Carolina
| | - Courtney Holland
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | | | - Thomas J. Hopkins
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Brant A. Inman
- Department of Surgery, Duke University, Durham, North Carolina
| | - David W. Jang
- Department of Surgery, Duke University, Durham, North Carolina
- Department of Neurosurgery, Duke University, Durham, North Carolina
| | | | - Isaac Karikari
- Department of Neurosurgery, Duke University, Durham, North Carolina
| | - Amie Kawasaki
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina
| | | | | | - Rebecca Klinger
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | | | | | - Walter T. Lee
- Department of Surgery, Duke University, Durham, North Carolina
| | - Howard Levinson
- Department of Surgery, Duke University, Durham, North Carolina
- Department of Dermatology, Duke University, Durham, North Carolina
- Department of Pathology, Duke University, Durham, North Carolina
| | - Brian D. Lewis
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | | | | | | | - Shelley R. McDonald
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, North Carolina
- Department of Medicine, Duke University, Durham, North Carolina
| | - John Migaly
- Department of Surgery, Duke University, Durham, North Carolina
| | - Timothy E. Miller
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | | | - Paul J. Mosca
- Department of Surgery, Duke University, Durham, North Carolina
| | - Judd W. Moul
- Department of Surgery, Duke University, Durham, North Carolina
| | | | - Steven A. Olson
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | | | - John J. Park
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | | | | | | | - Peter Potash
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | | | - Rebecca A. Previs
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina
| | | | - Charles D. Scales
- Department of Surgery, Duke University, Durham, North Carolina
- Department of Population Health Sciences, Duke University, Durham, North Carolina
| | - Kevin N. Shah
- Department of Surgery, Duke University, Durham, North Carolina
| | | | - Nazema Y. Siddiqui
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina
| | - Shayan Smani
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | | | | | - Ayesha Syed
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Alicja Szydlowska
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | | | - Niccolò Terrando
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | | | - Anthony G. Visco
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina
| | - Alison C. Weidner
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina
| | - Mamata Yanamadala
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, North Carolina
- Department of Medicine, Duke University, Durham, North Carolina
| | - Sabino Zani
- Department of Surgery, Duke University, Durham, North Carolina
- Department of Mechanical Engineering and Materials Science, Duke University, Durham, North Carolina
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21
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State of the clinical science of perioperative brain health: report from the American Society of Anesthesiologists Brain Health Initiative Summit 2018. Br J Anaesth 2019; 123:464-478. [PMID: 31439308 DOI: 10.1016/j.bja.2019.07.004] [Citation(s) in RCA: 127] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 06/25/2019] [Accepted: 07/02/2019] [Indexed: 12/20/2022] Open
Abstract
Cognitive recovery after anaesthesia and surgery is a concern for older adults, their families, and caregivers. Reports of patients who were 'never the same' prompted a scientific inquiry into the nature of what patients have experienced. In June 2018, the ASA Brain Health Initiative held a summit to discuss the state of the science on perioperative cognition, and to create an implementation plan for patients and providers leveraging the current evidence. This group included representatives from the AARP (formerly the American Association of Retired Persons), American College of Surgeons, American Heart Association, and Alzheimer's Association Perioperative Cognition and Delirium Professional Interest Area. This paper summarises the state of the relevant clinical science, including risk factors, identification and diagnosis, prognosis, disparities, outcomes, and treatment of perioperative neurocognitive disorders. Finally, we discuss gaps in current knowledge with suggestions for future directions and opportunities for clinical and translational projects.
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22
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Sharma A, Arora L, Subramani S, Simmons J, Mohananey D, Ramakrishna H. Analysis of the 2018 American Heart Association Focused Update on Advanced Cardiovascular Life Support Use of Antiarrhythmic Drugs During and Immediately After Cardiac Arrest. J Cardiothorac Vasc Anesth 2019; 34:537-544. [PMID: 31097339 DOI: 10.1053/j.jvca.2019.03.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 03/31/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Archit Sharma
- Divisions of Cardiothoracic Anesthesiology Solid Organ Transplant and Critical Care, Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Lovkesh Arora
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Sudhakar Subramani
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Jonathan Simmons
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Divyanshu Mohananey
- Division of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Harish Ramakrishna
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, AZ.
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23
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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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24
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Berger M, Oyeyemi D, Olurinde MO, Whitson HE, Weinhold KJ, Woldorff MG, Lipsitz LA, Moretti E, Giattino CM, Roberts KC, Zhou J, Bunning T, Ferrandino M, Scheri RP, Cooter M, Chan C, Cabeza R, Browndyke JN, Murdoch DM, Devinney MJ, Shaw LM, Cohen HJ, Mathew JP. The INTUIT Study: Investigating Neuroinflammation Underlying Postoperative Cognitive Dysfunction. J Am Geriatr Soc 2019; 67:794-798. [PMID: 30674067 DOI: 10.1111/jgs.15770] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 12/20/2018] [Accepted: 12/20/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND/OBJECTIVES Every year, up to 40% of the more than 16 million older Americans who undergo anesthesia/surgery develop postoperative cognitive dysfunction (POCD) or delirium. Each of these distinct syndromes is associated with decreased quality of life, increased mortality, and a possible increased risk of Alzheimer's disease. One pathologic process hypothesized to underlie both delirium and POCD is neuroinflammation. The INTUIT study described here will determine the extent to which postoperative increases in cerebrospinal fluid (CSF) monocyte chemoattractant protein 1 (MCP-1) levels and monocyte numbers are associated with delirium and/or POCD and their underlying brain connectivity changes. DESIGN Observational prospective cohort. SETTING Duke University Medical Center, Duke Regional Hospital, and Duke Raleigh Hospital. PARTICIPANTS Patients 60 years of age or older (N = 200) undergoing noncardiac/nonneurologic surgery. MEASUREMENTS Participants will undergo cognitive testing before, 6 weeks, and 1 year after surgery. Delirium screening will be performed on postoperative days 1 to 5. Blood and CSF samples are obtained before surgery, and 24 hours, 6 weeks, and 1 year after surgery. CSF MCP-1 levels are measured by enzyme-linked immunosorbent assay, and CSF monocytes are assessed by flow cytometry. Half the patients will also undergo pre- and postoperative functional magnetic resonance imaging scans. 32-channel intraoperative electroencephalogram (EEG) recordings will be performed to identify intraoperative EEG correlates of neuroinflammation and/or postoperative cognitive resilience. Eighty patients will also undergo home sleep apnea testing to determine the relationships between sleep apnea severity, neuroinflammation, and impaired postoperative cognition. Additional assessments will help evaluate relationships between delirium, POCD, and other geriatric syndromes. CONCLUSION INTUIT will use a transdisciplinary approach to study the role of neuroinflammation in postoperative delirium and cognitive dysfunction and their associated functional brain connectivity changes, and it may identify novel targets for treating and/or preventing delirium and POCD and their sequelae. J Am Geriatr Soc 67:794-798, 2019.
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Affiliation(s)
- Miles Berger
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina.,Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, North Carolina.,Center for Cognitive Neuroscience, Duke University Medical Center, Durham, North Carolina
| | - Deborah Oyeyemi
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina.,Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Mobolaji O Olurinde
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Heather E Whitson
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, North Carolina.,Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Kent J Weinhold
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Marty G Woldorff
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina.,Department of Psychology and Neuroscience, Duke University, Durham, North Carolina
| | - Lewis A Lipsitz
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Eugene Moretti
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Charles M Giattino
- Center for Cognitive Neuroscience, Duke University Medical Center, Durham, North Carolina.,Department of Psychology and Neuroscience, Duke University, Durham, North Carolina
| | - Kenneth C Roberts
- Center for Cognitive Neuroscience, Duke University Medical Center, Durham, North Carolina
| | - Junhong Zhou
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Thomas Bunning
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Michael Ferrandino
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Randall P Scheri
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Mary Cooter
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Cliburn Chan
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Roberto Cabeza
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina.,Department of Psychology and Neuroscience, Duke University, Durham, North Carolina
| | - Jeffrey N Browndyke
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
| | - David M Murdoch
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Michael J Devinney
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Leslie M Shaw
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Harvey Jay Cohen
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, North Carolina.,Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Joseph P Mathew
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
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25
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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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26
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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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27
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Manetta F, Mullan CW, Catalano MA. Neuroprotective Strategies in Repair and Replacement of the Aortic Arch. Int J Angiol 2018; 27:98-109. [PMID: 29896042 PMCID: PMC5995688 DOI: 10.1055/s-0038-1649512] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Aortic arch surgery is a technical challenge, and cerebral protection during distal anastomosis is a continued topic of controversy and discussion. The physiologic effects of hypothermic arrest and adjunctive cerebral perfusion have yet to be fully defined, and the optimal strategies are still undetermined. This review highlights the historical context, physiological rationale, and clinical efficacy of various neuroprotective strategies during arch operations.
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Affiliation(s)
- Frank Manetta
- Department of Cardiovascular and Thoracic Surgery, Barbara and Donald Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Clancy W. Mullan
- Department of Cardiovascular and Thoracic Surgery, Barbara and Donald Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Michael A. Catalano
- Department of Cardiovascular and Thoracic Surgery, Barbara and Donald Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
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28
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Browndyke JN, Berger M, Smith PJ, Harshbarger TB, Monge ZA, Panchal V, Bisanar TL, Glower DD, Alexander JH, Cabeza R, Welsh‐Bohmer K, Newman MF, Mathew JP. Task-related changes in degree centrality and local coherence of the posterior cingulate cortex after major cardiac surgery in older adults. Hum Brain Mapp 2018; 39:985-1003. [PMID: 29164774 PMCID: PMC5764802 DOI: 10.1002/hbm.23898] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 10/24/2017] [Accepted: 11/13/2017] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES Older adults often display postoperative cognitive decline (POCD) after surgery, yet it is unclear to what extent functional connectivity (FC) alterations may underlie these deficits. We examined for postoperative voxel-wise FC changes in response to increased working memory load demands in cardiac surgery patients and nonsurgical controls. EXPERIMENTAL DESIGN Older cardiac surgery patients (n = 25) completed a verbal N-back working memory task during MRI scanning and cognitive testing before and 6 weeks after surgery; nonsurgical controls with cardiac disease (n = 26) underwent these assessments at identical time intervals. We measured postoperative changes in degree centrality, the number of edges attached to a brain node, and local coherence, the temporal homogeneity of regional functional correlations, using voxel-wise graph theory-based FC metrics. Group × time differences were evaluated in these FC metrics associated with increased N-back working memory load (2-back > 1-back), using a two-stage partitioned variance, mixed ANCOVA. PRINCIPAL OBSERVATIONS Cardiac surgery patients demonstrated postoperative working memory load-related degree centrality increases in the left dorsal posterior cingulate cortex (dPCC; p < .001, cluster p-FWE < .05). The dPCC also showed a postoperative increase in working memory load-associated local coherence (p < .001, cluster p-FWE < .05). dPCC degree centrality and local coherence increases were inversely associated with global cognitive change in surgery patients (p < .01), but not in controls. CONCLUSIONS Cardiac surgery patients showed postoperative increases in working memory load-associated degree centrality and local coherence of the dPCC that were inversely associated with postoperative global cognitive outcomes and independent of perioperative cerebrovascular damage.
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Affiliation(s)
- Jeffrey N. Browndyke
- Geriatric Behavioral Health Division, Department of Psychiatry & Behavioral SciencesDuke University Health SystemDurhamNorth Carolina
- Duke Institute for Brain Sciences, Duke UniversityDurhamNorth Carolina
- Duke Brain Imaging and Analysis Center, Duke UniversityDurhamNorth Carolina
| | - Miles Berger
- Division of Neuroanesthesiology, Department of AnesthesiologyDuke University Medical CenterDurhamNorth Carolina
| | - Patrick J. Smith
- Behavioral Medicine Division, Department of Psychiatry & Behavioral SciencesDuke University Medical CenterDurhamNorth Carolina
| | - Todd B. Harshbarger
- Duke Brain Imaging and Analysis Center, Duke UniversityDurhamNorth Carolina
- Department of RadiologyDuke University Medical CenterDurhamNorth Carolina
| | - Zachary A. Monge
- Center for Cognitive Neuroscience, Duke UniversityDurhamNorth Carolina
| | - Viral Panchal
- Department of AnesthesiologyDuke University Medical CenterDurhamNorth Carolina
| | - Tiffany L. Bisanar
- Department of AnesthesiologyDuke University Medical CenterDurhamNorth Carolina
| | - Donald D. Glower
- Cardiovascular & Thoracic Division, Department of SurgeryDuke University Medical CenterDurhamNorth Carolina
| | - John H. Alexander
- Duke Clinical Research Institute, Duke University Medical CenterDurhamNorth Carolina
| | - Roberto Cabeza
- Duke Institute for Brain Sciences, Duke UniversityDurhamNorth Carolina
- Duke Brain Imaging and Analysis Center, Duke UniversityDurhamNorth Carolina
- Center for Cognitive Neuroscience, Duke UniversityDurhamNorth Carolina
| | - Kathleen Welsh‐Bohmer
- Geriatric Behavioral Health Division, Department of Psychiatry & Behavioral SciencesDuke University Health SystemDurhamNorth Carolina
- Department of NeurologyDuke University Medical CenterDurhamNorth Carolina
| | - Mark F. Newman
- Department of AnesthesiologyDuke University Medical CenterDurhamNorth Carolina
| | - Joseph P. Mathew
- Department of AnesthesiologyDuke University Medical CenterDurhamNorth Carolina
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29
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30
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Hupp S, Ribes S, Seele J, Bischoff C, Förtsch C, Maier E, Benz R, Mitchell TJ, Nau R, Iliev AI. Magnesium therapy improves outcome in Streptococcus pneumoniae meningitis by altering pneumolysin pore formation. Br J Pharmacol 2017; 174:4295-4307. [PMID: 28888095 DOI: 10.1111/bph.14027] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 08/26/2017] [Accepted: 08/29/2017] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND AND PURPOSE Streptococcus pneumoniae is the most common cause of bacterial meningitis in adults and is characterized by high lethality and substantial cognitive disabilities in survivors. Here, we have studied the capacity of an established therapeutic agent, magnesium, to improve survival in pneumococcal meningitis by modulating the neurological effects of the major pneumococcal pathogenic factor, pneumolysin. EXPERIMENTAL APPROACH We used mixed primary glial and acute brain slice cultures, pneumolysin injection in infant rats, a mouse meningitis model and complementary approaches such as Western blot, a black lipid bilayer conductance assay and live imaging of primary glial cells. KEY RESULTS Treatment with therapeutic concentrations of magnesium chloride (500 mg·kg-1 in animals and 2 mM in cultures) prevented pneumolysin-induced brain swelling and tissue remodelling both in brain slices and in animal models. In contrast to other divalent ions, which diminish the membrane binding of pneumolysin in non-therapeutic concentrations, magnesium delayed toxin-driven pore formation without affecting its membrane binding or the conductance profile of its pores. Finally, magnesium prolonged the survival and improved clinical condition of mice with pneumococcal meningitis, in the absence of antibiotic treatment. CONCLUSIONS AND IMPLICATIONS Magnesium is a well-established and safe therapeutic agent that has demonstrated capacity for attenuating pneumolysin-triggered pathogenic effects on the brain. The improved animal survival and clinical condition in the meningitis model identifies magnesium as a promising candidate for adjunctive treatment of pneumococcal meningitis, together with antibiotic therapy.
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Affiliation(s)
- Sabrina Hupp
- Institute of Anatomy, University of Bern, Bern, Switzerland.,DFG Membrane/Cytoskeleton Interaction Group, Institute of Pharmacology and Toxicology & Rudolf Virchow Center for Experimental Medicine, University of Würzburg, Würzburg, Germany
| | - Sandra Ribes
- Department of Neuropathology, University Medical Center Göttingen, Göttingen, Germany.,Department of Geriatrics, Evangelisches Krankenhaus Göttingen-Weende, Göttingen, Germany
| | - Jana Seele
- Department of Neuropathology, University Medical Center Göttingen, Göttingen, Germany.,Department of Geriatrics, Evangelisches Krankenhaus Göttingen-Weende, Göttingen, Germany
| | - Carolin Bischoff
- DFG Membrane/Cytoskeleton Interaction Group, Institute of Pharmacology and Toxicology & Rudolf Virchow Center for Experimental Medicine, University of Würzburg, Würzburg, Germany
| | - Christina Förtsch
- DFG Membrane/Cytoskeleton Interaction Group, Institute of Pharmacology and Toxicology & Rudolf Virchow Center for Experimental Medicine, University of Würzburg, Würzburg, Germany
| | - Elke Maier
- Rudolf Virchow Center for Experimental Medicine, University of Würzburg, Würzburg, Germany
| | - Roland Benz
- Rudolf Virchow Center for Experimental Medicine, University of Würzburg, Würzburg, Germany
| | - Timothy J Mitchell
- Institute of Microbiology and Infection, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Roland Nau
- Department of Neuropathology, University Medical Center Göttingen, Göttingen, Germany.,Department of Geriatrics, Evangelisches Krankenhaus Göttingen-Weende, Göttingen, Germany
| | - Asparouh I Iliev
- Institute of Anatomy, University of Bern, Bern, Switzerland.,DFG Membrane/Cytoskeleton Interaction Group, Institute of Pharmacology and Toxicology & Rudolf Virchow Center for Experimental Medicine, University of Würzburg, Würzburg, Germany
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31
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Giattino CM, Gardner JE, Sbahi FM, Roberts KC, Cooter M, Moretti E, Browndyke JN, Mathew JP, Woldorff MG, Berger M. Intraoperative Frontal Alpha-Band Power Correlates with Preoperative Neurocognitive Function in Older Adults. Front Syst Neurosci 2017; 11:24. [PMID: 28533746 PMCID: PMC5420579 DOI: 10.3389/fnsys.2017.00024] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 04/05/2017] [Indexed: 12/19/2022] Open
Abstract
Each year over 16 million older Americans undergo general anesthesia for surgery, and up to 40% develop postoperative delirium and/or cognitive dysfunction (POCD). Delirium and POCD are each associated with decreased quality of life, early retirement, increased 1-year mortality, and long-term cognitive decline. Multiple investigators have thus suggested that anesthesia and surgery place severe stress on the aging brain, and that patients with less ability to withstand this stress will be at increased risk for developing postoperative delirium and POCD. Delirium and POCD risk are increased in patients with lower preoperative cognitive function, yet preoperative cognitive function is not routinely assessed, and no intraoperative physiological predictors have been found that correlate with lower preoperative cognitive function. Since general anesthesia causes alpha-band (8–12 Hz) electroencephalogram (EEG) power to decrease occipitally and increase frontally (known as “anteriorization”), and anesthetic-induced frontal alpha power is reduced in older adults, we hypothesized that lower intraoperative frontal alpha power might correlate with lower preoperative cognitive function. Here, we provide evidence that such a correlation exists, suggesting that lower intraoperative frontal alpha power could be used as a physiological marker to identify older adults with lower preoperative cognitive function. Lower intraoperative frontal alpha power could thus be used to target these at-risk patients for possible therapeutic interventions to help prevent postoperative delirium and POCD, or for increased postoperative monitoring and follow-up. More generally, these results suggest that understanding interindividual differences in how the brain responds to anesthetic drugs can be used as a probe of neurocognitive function (and dysfunction), and might be a useful measure of neurocognitive function in older adults.
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Affiliation(s)
- Charles M Giattino
- Center for Cognitive Neuroscience, Duke UniversityDurham, NC, USA.,Department of Psychology and Neuroscience, Duke UniversityDurham, NC, USA
| | - Jacob E Gardner
- Center for Cognitive Neuroscience, Duke UniversityDurham, NC, USA
| | - Faris M Sbahi
- Center for Cognitive Neuroscience, Duke UniversityDurham, NC, USA.,Department of Anesthesiology, Duke University Medical CenterDurham, NC, USA
| | | | - Mary Cooter
- Department of Anesthesiology, Duke University Medical CenterDurham, NC, USA
| | - Eugene Moretti
- Department of Anesthesiology, Duke University Medical CenterDurham, NC, USA
| | - Jeffrey N Browndyke
- Department of Psychiatry and Behavioral Sciences, Duke University Medical CenterDurham, NC, USA
| | - Joseph P Mathew
- Department of Anesthesiology, Duke University Medical CenterDurham, NC, USA
| | - Marty G Woldorff
- Center for Cognitive Neuroscience, Duke UniversityDurham, NC, USA.,Department of Psychology and Neuroscience, Duke UniversityDurham, NC, USA.,Department of Psychiatry and Behavioral Sciences, Duke University Medical CenterDurham, NC, USA.,Department of Neurobiology, Duke University Medical CenterDurham, NC, USA
| | - Miles Berger
- Department of Anesthesiology, Duke University Medical CenterDurham, NC, USA
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Fernández Suárez FE, Fernández Del Valle D, González Alvarez A, Pérez-Lozano B. Intraoperative care for aortic surgery using circulatory arrest. J Thorac Dis 2017; 9:S508-S520. [PMID: 28616347 PMCID: PMC5462730 DOI: 10.21037/jtd.2017.04.67] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 04/06/2017] [Indexed: 11/06/2022]
Abstract
The total circulatory arrest (CA) is necessary to achieve optimal surgical conditions in certain aortic pathologies, especially in those affecting the ascending aorta and aortic arch. During this procedure it is necessary to protect all the organs of ischemia, especially those of the central nervous system and for this purpose several strategies have been developed. The first and most important protective method is systemic hypothermia. The degree of hypothermia and the route of application have been evolving and currently tend to use moderate hypothermia (MH) (20.1-28 °C) associated with unilateral or bilateral selective cerebral perfusion methods. In this way the neurological results are better, the interval of security is greater and the times of extracorporeal circulation are smaller. Even so, it is necessary to take into account that there is the possibility of ischemia in the lower part of the body, especially of the abdominal viscera and the spinal cord, therefore the time of circulatory stop should be limited and not to exceed 80 minutes. Evidence of possible neurological drug protection is very weak and only mannitol, magnesium, and statins can produce some benefit. Inhalational anesthetics and some intravenous seem to have advantages, but more studies would be needed to test their long-term benefit. Other important parameters to be monitored during these procedures are blood glucose, anemia and coagulation disorders and acid-base balance. The recommended monitoring is common in complex cardiovascular procedures and it is of special importance the neurological monitoring that can be performed with several techniques, although currently the most used are Bispectral Index (BIS) and Near-Infrared Spectroscopy (NIRS). It is also essential to monitor the temperature routinely at the nasopharyngeal and bladder level and it is important to control coagulation with rotational thromboelastometry (ROTEM).
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Affiliation(s)
| | | | - Adrián González Alvarez
- Department of Anesthesiology, Central University Hospital of Asturias, Oviedo, Asturias, Spain
| | - Blanca Pérez-Lozano
- Department of Anesthesiology, Central University Hospital of Asturias, Oviedo, Asturias, Spain
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Feinkohl I, Winterer G, D. Spies C, Pischon T. Cognitive Reserve and the Risk of Postoperative Cognitive Dysfunction. DEUTSCHES ARZTEBLATT INTERNATIONAL 2017; 114:110-117. [PMID: 28302254 PMCID: PMC5359463 DOI: 10.3238/arztebl.2017.0110] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 05/25/2016] [Accepted: 10/22/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND Post-operative cognitive dysfunction (POCD) occurs in 10 to 54% of older patients during the first few weeks after surgery, but little is known about risk factors predisposing to POCD. METHODS Systematic literature review and meta-analysis of cognitive reserve indicators and POCD risk. RESULTS Fifteen studies on 5104 patients were included. Follow-up periods spanned 1 day to 6 months. Educational level was the most commonly assessed cognitive reserve indicator, and a longer time spent in education was associated with a reduced risk of POCD (relative risk [RR] per year increment 0.90; 95% confidence interval: [0.87; 0.94]), i.e. each year increase in education was associated with a 10% reduced risk. Similar findings were made for some analyses on education as a categorical predictor (high school versus further/higher education, RR 1.71, [1.30; 2.25]; lower than high school versus further/higher education, RR 1.69, [1.17; 2.44]) though risk was equivalent for patients with high school education and those with lower than high school education (RR 1.02; [0.78; 1.32]). CONCLUSION Patients with a relatively higher level of education are at reduced risk of POCD. Risk stratification of surgical patients according to educational level may prove useful.
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Affiliation(s)
- Insa Feinkohl
- Molecular Epidemiology Research Group, Max Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin-Buch
| | | | | | - Tobias Pischon
- Charité – Universitätsmedizin Berlin
- MDC/BIH Biobank, Max Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin-Buch and Berlin Institute of Health (BIH), Berlin
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Wong A, Erdman M, Hammond DA, Holt T, Holzhausen JM, Horng M, Huang LL, Jarvis J, Kram B, Kram S, Lesch C, Mercer J, Rech MA, Rivosecchi R, Stump B, Teevan C, Day S. Major publications in the critical care pharmacotherapy literature in 2015. Am J Health Syst Pharm 2017; 74:295-311. [PMID: 28122702 DOI: 10.2146/ajhp160144] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
PURPOSE Recently published practice guidelines and research reports on pharmacotherapy in critical care patient populations are summarized. SUMMARY The Critical Care Pharmacotherapy Literature Update (CCPLU) Group is composed of over 50 experienced critical care pharmacists who evaluate 31 peer-reviewed journals monthly to identify literature pertaining to pharmacotherapy in critical care populations. Articles are chosen for summarization in a monthly CCPLU Group publication on the basis of applicability and relevance to clinical practice and strength of study design. From January to December 2015, a total of 121 articles were summarized; of these, 3 articles presenting clinical practice guidelines and 12 articles presenting original research findings were objectively selected for inclusion in this review based on their potential to change or reinforce current evidence-based practice. The reviewed guidelines address the management of intracranial hemorrhage (ICH), adult advanced cardiac life support (ACLS) and post-cardiac arrest care, and the management of supraventricular tachycardia (SVT). The reviewed research reports address topics such as nutrition in critically ill adults, administration of β-lactams for severe sepsis, anticoagulant selection in the context of continuous renal replacement therapy, early goal-directed therapy in septic shock, magnesium use for neuroprotection in acute stroke, and progesterone use in patients with traumatic brain injury. CONCLUSION Important recent additions to the critical care pharmacy literature include updated joint clinical practice guidelines on the management of spontaneous ICH, ACLS, and SVT.
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Affiliation(s)
- Adrian Wong
- Brigham and Women's Hospital/MCPHS University, Boston, MA
| | - Michael Erdman
- University of Florida Health-Jacksonville, Jacksonville, FL
| | | | - Tara Holt
- IU Health Methodist, Indianapolis, IN
| | | | | | | | | | | | - Shawn Kram
- Medical and Cardiothoracic ICU, Duke University Medical Center, Durham, NC
| | - Christine Lesch
- NeuroICU, NewYork-Presbyterian Hospital, Columbia University Medical Center, New York, NY
| | | | | | | | | | | | - Sarah Day
- Doctors Hospital OhioHealth, Columbus, OH
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Pearce A, Lockwood C, van den Heuvel C, Pearce J. The use of therapeutic magnesium for neuroprotection during global cerebral ischemia associated with cardiac arrest and cardiac surgery in adults: a systematic review. JBI DATABASE OF SYSTEMATIC REVIEWS AND IMPLEMENTATION REPORTS 2017; 15:86-118. [PMID: 28085730 DOI: 10.11124/jbisrir-2016-003236] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND Global cerebral ischemia occurs due to reduced blood supply to the brain. This is commonly caused by a cessation of myocardial activity associated with cardiac arrest and cardiac surgery. Survival is not the only important outcome because neurological dysfunction impacts on quality of life, reducing independent living. Magnesium has been identified as a potential neuroprotective agent; however, its role in this context is not yet clear. OBJECTIVES The objective of this review was to present the best currently available evidence related to the neuroprotective effects of magnesium during a period of global cerebral ischemia in adults with cardiac arrest or cardiac surgery. INCLUSION CRITERIA TYPES OF PARTICIPANTS The current review considered adults aged over 18 years who were at risk of global cerebral ischemia associated with cardiac arrest or cardiac surgery. Studies of patients with existing neurological deficits or under the age of 18 years were excluded from the review. TYPES OF INTERVENTION(S)/PHENOMENA OF INTEREST The intervention of interest was magnesium administered in doses of at least of 2 g compared to placebo to adult patients within 24 hours of cardiac arrest or cardiac surgery. TYPES OF STUDIES The current review considered experimental designs including randomized controlled trials, non-randomized controlled trials and quasi-experimental designs. OUTCOMES The outcome of interest were neurological recovery post-cardiac arrest or cardiac surgery, as measured by objective scales, such as but not limited to, cerebral performance category, brain stem reflexes, Glasgow Coma Score and independent living or dependent living status. To enable assessment of the available data, neuroprotection was examined by breaking down neurological outcomes into three domains - functional neurological outcomes, neurophysiological outcomes and neuropsychological outcomes. SEARCH STRATEGY The search strategy aimed to find both published and unpublished studies between January 1980 and August 2014, utilizing the Joanna Briggs Institute (JBI) three-step search strategy. Databases searched included PubMed, Embase, CINAHL, Cochrane Central Register of Controlled Trials, Australian Clinical Trials Register, Australian and New Zealand Clinical Trials Register, Clinical Trials, European Clinical Trials Register and ISRCTN Registry. METHODOLOGICAL QUALITY The studies included in this review were of moderate-to-good-quality randomized controlled trials. Studies included measured neurological outcome using functional neurological assessment, neuropsychiatric assessment or neurophysiological assessment. DATA EXTRACTION Data were extracted using standardized templates provided by the JBI Meta-analysis of Statistics Assessment and Review Instrument software. DATA SYNTHESIS Quantitative data were, where possible, pooled in statistical meta-analysis using Review Manager 5.3 (The Nordic Cochrane Centre, Cochrane; Copenhagen, Denmark). Where statistical pooling was not possible, the findings were presented in narrative form, including tables and figures, to aid in data presentation, where appropriate. RESULTS Seven studies with a total of 1164 participants were included in this review. Neurological outcome was categorized into three domains: functional neurological, neurophysiological and neuropsychological outcomes. Meta-analysis of three studies assessing the neuroprotective properties of magnesium administration post cardiac arrest found improved functional neurological outcome (odds ratio 0.44; 95% confidence interval 0.24-0.81). CONCLUSION Magnesium may improve functional neurological outcome in patients who suffer global cerebral ischemia associated with cardiac surgery and cardiac arrest. Magnesium does not decrease neuropsychological decline.Further testing of neurological outcomes in the domains of functional outcomes, neurophysiological markers and neuropsychological tests are required to further understanding of the neuroprotective effects of magnesium. Suitable dosing regimens should be investigated prior to introduction into clinical practice. Further research is required to investigate the optimal magnesium dose.
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Affiliation(s)
- Anna Pearce
- 1Joanna Briggs Institute, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia 2School of Medical Sciences, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia 3School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Canberra, Australia
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Cognitive Outcomes of Cardiovascular Surgical Procedures in the Old: An Important but Neglected Area. Heart Lung Circ 2016; 25:1148-1153. [PMID: 27726955 DOI: 10.1016/j.hlc.2016.09.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 09/09/2016] [Indexed: 01/08/2023]
Abstract
Older individuals can now undergo invasive cardiovascular procedures without serious concern about mortality, and the numbers and proportions of the over 65s and 85s doing so in Australia has been increasing over the last 20 years. There is overwhelming evidence linking cardiovascular conditions to late-life (65 years and over) cognitive impairment and dementia including Alzheimer's Disease, primarily due to impaired cerebrovascularisation and cascading neuropathological processes. Somewhat paradoxically, these cardiovascular interventions, carried out with the primary aim of revascularisation, are not usually associated with short- or long-term improvements in cognitive function in older adults. We discuss factors associated with cognitive outcomes post-cardiovascular surgeries in patients over 65 years of age. There are many opportunities for future research: we know almost nothing about cognitive outcomes following invasive cardiac procedures in the oldest old (85 years and over) nor how to predict the cognitive/delirium outcome using pre-surgical data, and lastly, intervention opportunities exist both pre and postoperatively that have not been tested. As our population ages with increased cardiovascular burden and rates of cardiovascular interventions and surgeries, it is critical that we understand the cognitive consequences of these procedures, who is at greatest risk, and ways to optimise cognition.
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Berger M, Nadler JW, Browndyke J, Terrando N, Ponnusamy V, Cohen HJ, Whitson HE, Mathew JP. Postoperative Cognitive Dysfunction: Minding the Gaps in Our Knowledge of a Common Postoperative Complication in the Elderly. Anesthesiol Clin 2015; 33:517-50. [PMID: 26315636 DOI: 10.1016/j.anclin.2015.05.008] [Citation(s) in RCA: 170] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Postoperative cognitive dysfunction (POCD) is a common complication associated with significant morbidity and mortality in elderly patients. There is much interest in and controversy about POCD, reflected partly in the increasing number of articles published on POCD recently. Recent work suggests surgery may also be associated with cognitive improvement in some patients, termed postoperative cognitive improvement (POCI). As the number of surgeries performed worldwide approaches 250 million per year, optimizing postoperative cognitive function and preventing/treating POCD are major public health issues. In this article, we review the literature on POCD and POCI, and discuss current research challenges in this area.
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Affiliation(s)
- Miles Berger
- Department of Anesthesiology, Duke University Medical Center, Duke South, Orange Zone, Room 4317, Durham, NC 27710, USA.
| | - Jacob W Nadler
- Department of Anesthesiology, Duke University Medical Center, Duke South, Orange Zone, Room 4317, Durham, NC 27710, USA
| | - Jeffrey Browndyke
- Department of Anesthesiology, Duke University Medical Center, Duke South, Orange Zone, Room 4317, Durham, NC 27710, USA
| | - Niccolo Terrando
- Department of Anesthesiology, Duke University Medical Center, Duke South, Orange Zone, Room 4317, Durham, NC 27710, USA
| | - Vikram Ponnusamy
- Department of Anesthesiology, Duke University Medical Center, Duke South, Orange Zone, Room 4317, Durham, NC 27710, USA
| | - Harvey Jay Cohen
- Department of Anesthesiology, Duke University Medical Center, Duke South, Orange Zone, Room 4317, Durham, NC 27710, USA
| | - Heather E Whitson
- Department of Anesthesiology, Duke University Medical Center, Duke South, Orange Zone, Room 4317, Durham, NC 27710, USA
| | - Joseph P Mathew
- Department of Anesthesiology, Duke University Medical Center, Duke South, Orange Zone, Room 4317, Durham, NC 27710, USA
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Sun YY, Li Y, Wali B, Li Y, Lee J, Heinmiller A, Abe K, Stein DG, Mao H, Sayeed I, Kuan CY. Prophylactic Edaravone Prevents Transient Hypoxic-Ischemic Brain Injury: Implications for Perioperative Neuroprotection. Stroke 2015; 46:1947-55. [PMID: 26060244 DOI: 10.1161/strokeaha.115.009162] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 05/11/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND PURPOSE Hypoperfusion-induced thrombosis is an important mechanism for postsurgery stroke and cognitive decline, but there are no perioperative neuroprotectants to date. This study investigated whether prophylactic application of Edaravone, a free radical scavenger already used in treating ischemic stroke in Japan, can prevent infarct and cognitive deficits in a murine model of transient cerebral hypoxia-ischemia. METHODS Adult male C57BL/6 mice were subjected to transient hypoxic-ischemic (tHI) insult that consists of 30-minute occlusion of the unilateral common carotid artery and exposure to 7.5% oxygen. Edaravone or saline was prophylactically applied to compare their effects on cortical oxygen saturation, blood flow, coagulation, oxidative stress, metabolites, and learning-memory using methods that include photoacoustic imaging, laser speckle contrast imaging, solid-state NMR, and Morris water maze. The effects on infarct size by Edaravone application at different time points after tHI were also compared. RESULTS Prophylactic administration of Edaravone (4.5 mg/kg×2, IP, 1 hour before and 1 hour after tHI) improved vascular reperfusion, oxygen saturation, and the maintenance of brain metabolites, reducing oxidative stress, thrombosis, white-matter injury, and learning impairment after tHI insult. Delayed Edaravone treatment after 3 h post-tHI became unable to reduce infarct size. CONCLUSIONS Acute application of Edaravone may be a useful strategy to prevent postsurgery stroke and cognitive impairment, especially in patients with severe carotid stenosis.
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Affiliation(s)
- Yu-Yo Sun
- From the Department of Pediatrics and Center for Neurodegenerative Diseases, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA (Y.-Y.S., Y.L., J.L., C.-Y.K.); Department of Emergency Medicine, Brain Research Laboratory, Emory University School of Medicine, Atlanta, GA (B.W., D.G.S., I.S.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA (Y.L., H.M.); VisualSonics Inc. Toronto, ON, Canada (A.H.); and Department of Neurology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan (K.A.)
| | - Yikun Li
- From the Department of Pediatrics and Center for Neurodegenerative Diseases, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA (Y.-Y.S., Y.L., J.L., C.-Y.K.); Department of Emergency Medicine, Brain Research Laboratory, Emory University School of Medicine, Atlanta, GA (B.W., D.G.S., I.S.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA (Y.L., H.M.); VisualSonics Inc. Toronto, ON, Canada (A.H.); and Department of Neurology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan (K.A.)
| | - Bushra Wali
- From the Department of Pediatrics and Center for Neurodegenerative Diseases, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA (Y.-Y.S., Y.L., J.L., C.-Y.K.); Department of Emergency Medicine, Brain Research Laboratory, Emory University School of Medicine, Atlanta, GA (B.W., D.G.S., I.S.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA (Y.L., H.M.); VisualSonics Inc. Toronto, ON, Canada (A.H.); and Department of Neurology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan (K.A.)
| | - Yuancheng Li
- From the Department of Pediatrics and Center for Neurodegenerative Diseases, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA (Y.-Y.S., Y.L., J.L., C.-Y.K.); Department of Emergency Medicine, Brain Research Laboratory, Emory University School of Medicine, Atlanta, GA (B.W., D.G.S., I.S.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA (Y.L., H.M.); VisualSonics Inc. Toronto, ON, Canada (A.H.); and Department of Neurology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan (K.A.)
| | - Jolly Lee
- From the Department of Pediatrics and Center for Neurodegenerative Diseases, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA (Y.-Y.S., Y.L., J.L., C.-Y.K.); Department of Emergency Medicine, Brain Research Laboratory, Emory University School of Medicine, Atlanta, GA (B.W., D.G.S., I.S.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA (Y.L., H.M.); VisualSonics Inc. Toronto, ON, Canada (A.H.); and Department of Neurology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan (K.A.)
| | - Andrew Heinmiller
- From the Department of Pediatrics and Center for Neurodegenerative Diseases, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA (Y.-Y.S., Y.L., J.L., C.-Y.K.); Department of Emergency Medicine, Brain Research Laboratory, Emory University School of Medicine, Atlanta, GA (B.W., D.G.S., I.S.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA (Y.L., H.M.); VisualSonics Inc. Toronto, ON, Canada (A.H.); and Department of Neurology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan (K.A.)
| | - Koji Abe
- From the Department of Pediatrics and Center for Neurodegenerative Diseases, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA (Y.-Y.S., Y.L., J.L., C.-Y.K.); Department of Emergency Medicine, Brain Research Laboratory, Emory University School of Medicine, Atlanta, GA (B.W., D.G.S., I.S.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA (Y.L., H.M.); VisualSonics Inc. Toronto, ON, Canada (A.H.); and Department of Neurology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan (K.A.)
| | - Donald G Stein
- From the Department of Pediatrics and Center for Neurodegenerative Diseases, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA (Y.-Y.S., Y.L., J.L., C.-Y.K.); Department of Emergency Medicine, Brain Research Laboratory, Emory University School of Medicine, Atlanta, GA (B.W., D.G.S., I.S.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA (Y.L., H.M.); VisualSonics Inc. Toronto, ON, Canada (A.H.); and Department of Neurology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan (K.A.)
| | - Hui Mao
- From the Department of Pediatrics and Center for Neurodegenerative Diseases, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA (Y.-Y.S., Y.L., J.L., C.-Y.K.); Department of Emergency Medicine, Brain Research Laboratory, Emory University School of Medicine, Atlanta, GA (B.W., D.G.S., I.S.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA (Y.L., H.M.); VisualSonics Inc. Toronto, ON, Canada (A.H.); and Department of Neurology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan (K.A.)
| | - Iqbal Sayeed
- From the Department of Pediatrics and Center for Neurodegenerative Diseases, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA (Y.-Y.S., Y.L., J.L., C.-Y.K.); Department of Emergency Medicine, Brain Research Laboratory, Emory University School of Medicine, Atlanta, GA (B.W., D.G.S., I.S.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA (Y.L., H.M.); VisualSonics Inc. Toronto, ON, Canada (A.H.); and Department of Neurology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan (K.A.)
| | - Chia-Yi Kuan
- From the Department of Pediatrics and Center for Neurodegenerative Diseases, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA (Y.-Y.S., Y.L., J.L., C.-Y.K.); Department of Emergency Medicine, Brain Research Laboratory, Emory University School of Medicine, Atlanta, GA (B.W., D.G.S., I.S.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA (Y.L., H.M.); VisualSonics Inc. Toronto, ON, Canada (A.H.); and Department of Neurology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan (K.A.).
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Weiner MM, Wicker J, Fischer GW, Adams DH, Bronster D, Evans AS, Murkin JM, Grocott HP. CASE 5–2015. J Cardiothorac Vasc Anesth 2015; 29:791-6. [DOI: 10.1053/j.jvca.2014.10.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Indexed: 01/19/2023]
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Graber LC, Quillinan N, Marrotte EJ, McDonagh DL, Bartels K. Neurocognitive outcomes after extracorporeal membrane oxygenation. Best Pract Res Clin Anaesthesiol 2015; 29:125-35. [DOI: 10.1016/j.bpa.2015.03.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 03/03/2015] [Accepted: 03/20/2015] [Indexed: 01/05/2023]
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Pearce A, Lockwood C, Van Den Heuvel C. The use of therapeutic magnesium for neuroprotection during global cerebral ischemia associated with cardiac arrest and cardiac bypass surgery in adults: a systematic review protocol. ACTA ACUST UNITED AC 2015. [DOI: 10.11124/01938924-201513040-00002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Bartels K, Li YJ, Li YW, White WD, Laskowitz DT, Kertai MD, Stafford-Smith M, Podgoreanu MV, Newman MF, Mathew JP. Apolipoprotein epsilon 4 genotype is associated with less improvement in cognitive function five years after cardiac surgery: a retrospective cohort study. Can J Anaesth 2015; 62:618-26. [PMID: 25744138 DOI: 10.1007/s12630-015-0337-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 02/04/2015] [Indexed: 10/23/2022] Open
Abstract
PURPOSE Cognitive performance after cardiac surgery can be impaired, and genetic risk factors have previously been suggested. When compared with other isoforms of the gene, the apolipoprotein epsilon 4 (APOE4) allele is associated with worse outcomes in many neurologic disorders. We hypothesized that the APOE4 allele is associated with less favourable cognitive function five years after surgery. METHODS Caucasian patients enrolled in previously reported prospective cognitive trials in both cardiac and non-cardiac surgery participated in this retrospective cohort study. Neuropsychological function was assessed at baseline and five years postoperatively. The relationship between change in cognitive index score and APOE was evaluated using multivariable linear regression. An additive genetic model toward the epsilon 4 allele was applied with adjustment for baseline cognition, years of education, age, presence of diabetes in both cohorts, and presence of coronary artery disease in the non-cardiac surgery cohort. RESULTS A total of 357 patients were included in this study. In the cardiac surgery group (n = 233), baseline cognitive index (P < 0.001), years of education (P = 0.04), age at time of surgery (P < 0.001), and the APOE4 allele (P = 0.009), were associated with a five-year change in cognitive index. Patients carrying the APOE4 allele showed less improvement in cognitive index scores five years after cardiac surgery compared with patients without the APOE4 allele. In the non-cardiac surgery (n = 124) group, no association was found between APOE4 allele status and change in cognitive index. CONCLUSION We report an association between APOE4 and neurocognitive function five years following cardiac surgery. Preoperative identification of patients with the APOE4 genotype may improve stratification of cardiac surgery patients at risk for a less favourable cognitive trajectory.
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Affiliation(s)
- Karsten Bartels
- Department of Anesthesiology, Duke University Medical Center, DUMC, Box 3094 Mail # 41, 2301 Erwin Road, 5688 HAFS, Durham, NC, 27710, USA
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McDonagh DL, Berger M, Mathew JP, Graffagnino C, Milano CA, Newman MF. Neurological complications of cardiac surgery. Lancet Neurol 2014; 13:490-502. [PMID: 24703207 PMCID: PMC5928518 DOI: 10.1016/s1474-4422(14)70004-3] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
As increasing numbers of elderly people undergo cardiac surgery, neurologists are frequently called upon to assess patients with neurological complications from the procedure. Some complications mandate acute intervention, whereas others need longer term observation and management. A large amount of published literature exists about these complications and guidance on best practice is constantly changing. Similarly, despite technological advances in surgical intervention and modifications in surgical technique to make cardiac procedures safer, these advances often create new avenues for neurological injury. Accordingly, rapid and precise neurological assessment and therapeutic intervention rests on a solid understanding of the evidence base and procedural variables.
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Affiliation(s)
- David L McDonagh
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA; Department of Neurology, Duke University Medical Center, Durham, NC, USA.
| | - Miles Berger
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Joseph P Mathew
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | | | - Carmelo A Milano
- Department of Surgery (Division of Cardiovascular and Thoracic Surgery), Duke University Medical Center, Durham, NC, USA
| | - Mark F Newman
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
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Mathew JP, Laskowitz DT, Newman MF. Response to letter regarding article, "Intraoperative magnesium administration does not improve neurocognitive function after cardiac surgery". Stroke 2014; 45:e45. [PMID: 24448987 DOI: 10.1161/strokeaha.113.004025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Joseph P Mathew
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
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Derakhshan I. Letter by Derakhshan regarding article, "Intraoperative magnesium administration does not improve neurocognitive function following cardiac surgery". Stroke 2014; 45:e44. [PMID: 24448993 DOI: 10.1161/strokeaha.113.004005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Iraj Derakhshan
- Formerly at Department of Neurology, Cincinnati and Case Western Reserve University, Cleveland, OH
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Hilberath JN, Muehlschlegel JD. Noteworthy articles in 2013 for cardiothoracic anesthesiologists. Semin Cardiothorac Vasc Anesth 2013; 18:6-11. [PMID: 24345780 DOI: 10.1177/1089253213516805] [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: 11/15/2022]
Abstract
In 2013, the field of cardiothoracic anesthesiology has continued to grow at the same astounding rate as in previous years. It has become increasingly difficult for practicing anesthesiologists to stay current on impactful publications related to our exciting subspecialty. The scientific output has expanded to such a great extent that following the literature in specialty journals barely scrapes the surface of available knowledge. With the recent emphasis on teamwork spanning multiple medical specialties in the care for complex patients, the door has opened for our research to be presented in nontraditional, nonanesthesiology venues. In this review, we have selected a small sample of noteworthy contributions to the field of cardiothoracic and vascular anesthesiology published in 2013 with potential impact on our clinical practice.
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Affiliation(s)
- Jan N Hilberath
- 1Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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