The Effects of Ketamine on Cognitive Function in Elderly Patients Undergoing Ophthalmic Surgery

Effect of Esketamine on Postoperative Delirium in Patients Undergoing Cardiac Valve Replacement with Cardiopulmonary Bypass: A Randomized Controlled Trial

BACKGROUND

The aim of this study was to investigate the effects of esketamine on the risk of postoperative delirium (POD) in adults undergoing on-pump cardiac valve surgery.

METHODS

In this randomized, triple-blind, controlled trial, 116 adult patients with an American Society of Anesthesiologists (ASA) grade Ⅱ or Ⅲ and a New York Heart Association (NYHA) grade Ⅱ or Ⅲ who underwent cardiac valve surgery with cardiopulmonary bypass were included. Esketamine (0.25 mg/kg) or normal saline was administered intravenously before anesthesia induction. The primary outcome was POD, defined as a positive delirium assessment according to the 3-minute confusion assessment method (CAM) or the confusion assessment method for the intensive care unit (CAM-ICU) on a twice-daily basis for 7 days after surgery. Delirium duration and the delirium subtype were also recorded. The cognitive status of patients was measured according to the Mini-Mental State Examination at baseline, discharge, 30 days postoperatively and 3 months postoperatively.

RESULTS

A total of 112 patients (mean age, 52 years; 53.6% female) were enrolled; 56 were assigned to receive esketamine, and 56 were assigned to receive placebo. POD occurred in 13 (23.2%) patients in the esketamine group and in 25 (44.6%) patients in the placebo group (relative risk [RR], 0.52, 95% confidence interval [CI], 0.28-0.91; P = .018). Thirteen patients (23.2%) in the esketamine group and 24 (42.9%) patients in the placebo group had multiple episodes of delirium (RR, 0.54, 95% CI, 0.28-0.92), and 13 (23.2%) vs 22 (39.3%) patients exhibited the hyperactive subtype.

CONCLUSIONS

A single dose of esketamine (0.25 mg/kg) injected intravenously before anesthesia induction reduced the incidence of delirium in relatively young patients with ASA grade Ⅱ or Ⅲ who underwent on-pump cardiac surgery.

Effects of esketamine on postoperative negative emotions and early cognitive disorders in patients undergoing non-cardiac thoracic surgery: A randomized controlled trial

STUDY OBJECTIVE

To investigate whether a single dosage of esketamine injection in the anesthesia period could improve postoperative negative emotions and early cognitive function in patients undergoing non-cardiac thoracic surgery.

DESIGN

A prospective single center double blinded randomized placebo-controlled trial.

SETTING

Perioperative period; operating room, post anesthesia care unit and hospital ward.

PATIENTS

129 adult patients that underwent elective non-cardiac thoracic surgery under general anesthesia.

INTERVENTIONS

During the operation, pharmacologic prevention of postoperative negative emotion and early cognitive disorder with 0.2 mg/kg (Low esketamine group) and 0.5 mg/kg esketamine (High esketamine group) vs. placebo.

MEASUREMENTS

Emotion and early cognitive performance were assessed on the day before surgery (POD-1), postoperative day 1 (POD1) and day 3 (POD3) using HADS-A, HADS-D, Pain Visual Analogue Scale (VAS), Confusion Assessment Method (CAM), Mini-Mental State Examination (MMSE), and serum biomarkers (S100β, BDNF, IL-6, acetylcholine, and norepinephrine).

MAIN RESULTS

The high esketamine group showed significantly lower HADS-A and HADS-D scores than control group on POD1 and POD3. No significant differences were observed between the low esketamine group and the control group. The esketamine-treated groups showed lower pain VAS scores than the control group at 2 h and on the first day after operation. There were no significant differences among the three groups in CAM and MMSE scores. However, the high esketamine group had lower S100β and IL-6 levels, and higher BDNF levels postoperatively, while serum acetylcholine and norepinephrine were not significantly different.

CONCLUSIONS

A single intraoperative injection of 0.5 mg/kg esketamine can alleviate postoperative anxiety, depression, and pain to some extent. Although cognitive function behavioral evaluation did not show obvious benefits, it can also reduce the production of pro-inflammatory and brain injury-related factors while promoting the generation of brain-derived neurotrophic factor. Registration Trial registry: http://www.chictr.org.cn/; Identifier: ChiCTR2100047067.

Effect of Ketamine on Postoperative Neurocognitive Disorders: A Systematic Review and Meta-Analysis

BACKGROUND

Neurocognitive alterations in the perioperative period might be caused by a wide variety of factors including pain, blood loss, hypotension, hypoxia, micro- and macroemboli, cardiopulmonary bypass (CPB), reperfusion damage, and surgery itself, and all are risk factors for developing postoperative delirium (POD) and postoperative cognitive dysfunction (POCD). The objective of this study was to evaluate the effect of ketamine on neurocognitive dysfunction after anesthesia.

METHODS

We conducted a meta-analysis of randomized controlled trials (RCTs) comparing ketamine use (experimental group) with placebo (controls).

RESULTS

The model favors the control group over the experimental group in terms of frequency of hallucinations (the risk ratio with 95% CI is 1.54 [1.09, 2.19], p-value = 0.02), the number of patients readmitted within 30 days (RR with 95% CI is 0.25 [0.09, 0.70]), and the number of adverse events (overall RR with 95% CI is 1.31 [1.06, 1.62]). In terms of morphine consumption, the model favors the experimental group.

CONCLUSION

There was no statistically significant difference in incidences of postoperative delirium, vasopressor requirement, and fentanyl consumption between the ketamine and control groups. However, hallucinations were more frequently reported in the ketamine group.

Preventing postoperative cognitive dysfunction using anesthetic drugs in elderly patients undergoing noncardiac surgery: a systematic review and meta-analysis

Postoperative cognitive dysfunction (POCD) is a common neurological system disorder in surgical patients. The choice of anesthetic can potentially reduce POCD. The authors performed this network meta-analysis to compare different anesthetic drugs in reducing the incidence of POCD for elderly people undergoing noncardiac surgery. We searched MEDLINE, EMBASE, the Cochrane Library, and the Web of Science for randomized controlled trials comparing the different anesthetic drugs for noncardiac surgery in elderly from inception until July, 2022. The protocol was registered on the PROSPERO database (CRD#42020183014). A total of 34 trials involving 4314 patients undergoing noncardiac surgery in elderly were included. The incidence of POCD for each anesthetic drug was placebo (27.7%), dexmedetomidine (12.9%), ketamine (15.2%), propofol (16.8%), fentanyl (23.9%), midazolam (11.3%), sufentanil (6.3%), sevoflurane (24.0%), and desflurane (28.3%). Pairwise and network meta-analysis showed dexmedetomidine was significantly reducing the incidence of POCD when compared with placebo. Network meta-analysis also suggested dexmedetomidine was significantly reducing the incidence of POCD when compared with sevoflurane. Sufentanil and dexmedetomidine ranked the first and second in reducing the incidence of POCD with the surface under the cumulative ranking curve value of 87.4 and 81.5%. Sufentanil and dexmedetomidine had the greatest possibility to reduce the incidence of POCD for elderly people undergoing noncardiac surgery.

Tau protein plays a role in the mechanism of cognitive disorders induced by anesthetic drugs

Cognitive disorders are mental health disorders that can affect cognitive ability. Surgery and anesthesia have been proposed to increase the incidence of cognitive dysfunction, including declines in memory, learning, attention and executive function. Tau protein is a microtubule-associated protein located in the axons of neurons and is important for microtubule assembly and stability; its biological function is mainly regulated by phosphorylation. Phosphorylated tau protein has been associated with cognitive dysfunction mediated by disrupting the stability of the microtubule structure. There is an increasing consensus that anesthetic drugs can cause cognitive impairment. Herein, we reviewed the latest literature and compared the relationship between tau protein and cognitive impairment caused by different anesthetics. Our results substantiated that tau protein phosphorylation is essential in cognitive dysfunction caused by anesthetic drugs, and the possible mechanism can be summarized as "anesthetic drugs-kinase/phosphatase-p-Tau-cognitive impairment".

Ketamine Sedation for Noninvasive Ventilation in Distressed Elderly Patients with Acute Decompensated Heart Failure: Is it Safe?

How to cite this article: Karim HMR, Esquinas AM. Ketamine Sedation for Noninvasive Ventilation in Distressed Elderly Patients with Acute Decompensated Heart Failure: Is it Safe? Indian J Crit Care Med 2022;26(10):1161.

[Forms of anesthesia in ophthalmology]

The range of anesthesiological procedures in ophthalmology has not changed significantly over the last decades, with local anesthesia clearly coming to the fore. The development of minimally invasive surgical techniques requires significantly less analgesia and economic constraints to shorten operating times. The increasing proportion of outpatient ophthalmic surgery requires a short analgesia of the surgical area with as few complications as possible. Nevertheless, the selection of the procedures, which are described here in detail, must be made individually for each patient. General anesthesia continues to have its place, especially in cases of reduced compliance and difficult surgical conditions. The close cooperation between anesthetists and ophthalmic surgeons, e.g. for analgosedation in the outpatient area, can create a very pleasant surgical experience for the patient. An important goal should always be sufficient anxiolysis, analgesia and, in special operations, sufficient akinesia.

Intravenous vs Oral Acetaminophen as a Component of Multimodal Analgesia After Total Hip Arthroplasty: A Randomized, Blinded Trial

BACKGROUND

Multimodal analgesia including acetaminophen is increasingly popular for analgesia after total hip arthroplasty (THA). Intravenous (IV) administration of acetaminophen has pharmacokinetic benefits, but unclear clinical advantages. The authors hypothesized that IV acetaminophen would reduce pain with activity, opioid usage, or opioid-related side effects, compared to oral acetaminophen.

METHODS

In this double-blinded, randomized, controlled trial, 154 THA patients received either IV or oral acetaminophen as part of a comprehensive opioid-sparing multimodal analgesia strategy. Primary outcomes were pain with physical therapy on postoperative day (POD) 1, opioid side effects (POD 1), and cumulative opioid use.

RESULTS

There was no difference in opioid side effects, pain scores, or opioid use between the groups.

CONCLUSION

Patients in both groups had low pain scores, minimal opioid side effects, and limited opioid usage (corresponding to 6 doses of tramadol 100 mg over 3 days). This highlights multimodal analgesia as an effective method of pain control for THA.

Geriatric Pharmacology: An Update

An aging worldwide population demands that anesthesiologists consider geriatrics a unique subset of patients requiring customization of practice. This article reviews the current literature investigating physiologic changes of the elderly that affect pharmacokinetics and pharmacodynamics. Changes in drug absorption, distribution, metabolism, and excretion are discussed as well as the ultimate effects of medications. Implications for practice regarding specific anesthetic and analgesic drugs are addressed. Despite the immense body of research that contributes to understanding of geriatric pharmacology, elderly patients often are excluded from rigorous research trials, and further scientific investigation to inform best practices for this group of patients is needed.

Intraoperative ketamine administration to prevent delirium or postoperative cognitive dysfunction: A systematic review and meta-analysis

BACKGROUND

Postoperative cognitive complications are associated with substantial morbidity and mortality. Ketamine has been suggested to have neuroprotective effects in various settings. This systematic review evaluates the effects of intraoperative ketamine administration on postoperative delirium and postoperative cognitive dysfunction (POCD).

METHODS

Medline, Embase and Central were searched to 4 March 2018 without date or language restrictions. We considered randomised controlled trials (RCTs) comparing intraoperative ketamine administration versus no intervention in adults undergoing surgery under general anaesthesia. Primary outcomes were postoperative delirium and POCD. Non-cognitive adverse events, mortality and length of stay were considered as secondary outcomes. Data were independently extracted. The quality of the evidence (GRADE approach) was assessed following recommendations from the Cochrane collaboration. Risk ratios were calculated for binary outcomes, mean differences for continuous outcomes. We planned to explore the effects of age, specific anaesthesia regimen, depth of anaesthesia and intraoperative haemodynamic events through subgroup analyses.

RESULTS

Six RCTs were included. The incidence of postoperative delirium did not differ between groups (4 trials, 557 patients, RR 0.83, 95% CI [0.25, 2.80]), but patients receiving ketamine seemed at lower risk of POCD (3 trials, 163 patients, RR 0.34, 95% CI [0.15, 0.73]). However, both analyses presented limitations. Therefore, the quality of the evidence (GRADE) was deemed low (postoperative delirium) and very low (POCD).

CONCLUSION

The effect of ketamine on postoperative delirium remains unclear but its administration may offer some protection towards POCD. Large, well-designed randomised trials are urgently needed to further clarify the efficacy of ketamine on neurocognitive outcomes.

Treatment of Behavior Disturbances with Ketamine in a Patient Diagnosed with Major Neurocognitive Disorder

A 77-year-old woman who had been previously diagnosed with a major neurocognitive disorder became highly agitated and aggressive in a long-term care facility. She did not respond to intramuscular (IM) haloperidol plus lorazepam and had to be transported to the local emergency department (ED). In the ambulance, she remained highly agitated and was given 200 mg IM ketamine. Within minutes of receiving this, she de-escalated dramatically with no apparent adverse effects and remained stable for several days. Although ketamine has been used recently in pre-hospital settings and EDs to reduce agitated behavior, there has been little if any investigation of its potential for reducing behavior disturbances in patients who suffer from major neurocognitive disorders. Ketamine could potentially be a promising treatment option for this population, but more research is needed.

Factors Influencing Quality of Pain Management in a Physician Staffed Helicopter Emergency Medical Service

BACKGROUND

Pain is frequently encountered in the prehospital setting and needs to be treated quickly and sufficiently. However, incidences of insufficient analgesia after prehospital treatment by emergency medical services are reported to be as high as 43%. The purpose of this analysis was to identify modifiable factors in a specific emergency patient cohort that influence the pain suffered by patients when admitted to the hospital.

METHODS

For that purpose, this retrospective observational study included all patients with significant pain treated by a Swiss physician-staffed helicopter emergency service between April and October 2011 with the following characteristics to limit selection bias: Age > 15 years, numerical rating scale (NRS) for pain documented at the scene and at hospital admission, NRS > 3 at the scene, initial Glasgow coma scale > 12, and National Advisory Committee for Aeronautics score < VI. Univariate and multivariable logistic regression analyses were performed to evaluate patient and mission characteristics of helicopter emergency service associated with insufficient pain management.

RESULTS

A total of 778 patients were included in the analysis. Insufficient pain management (NRS > 3 at hospital admission) was identified in 298 patients (38%). Factors associated with insufficient pain management were higher National Advisory Committee for Aeronautics scores, high NRS at the scene, nontrauma patients, no analgesic administration, and treatment by a female physician. In 16% (128 patients), despite ongoing pain, no analgesics were administered. Factors associated with this untreated persisting pain were short time at the scene (below 10 minutes), secondary missions of helicopter emergency service, moderate pain at the scene, and nontrauma patients. Sufficient management of severe pain is significantly better if ketamine is combined with an opioid (65%), compared to a ketamine or opioid monotherapy (46%, P = .007).

CONCLUSIONS

In the studied specific Swiss cohort, nontrauma patients, patients on secondary missions, patients treated only for a short time at the scene before transport, patients who receive no analgesic, and treatment by a female physician may be risk factors for insufficient pain management. Patients suffering pain at the scene (NRS > 3) should receive an analgesic whenever possible. Patients with severe pain at the scene (NRS ≥ 8) may benefit from the combination of ketamine with an opioid. The finding about sex differences concerning analgesic administration is intriguing and possibly worthy of further study.

Pharmacologic Considerations of Anesthetic Agents in Geriatric Patients

Aging is a natural process of declining organ function and reserve. Census data show that the geriatric population is expected to grow to nearly 30%. More than half of geriatric patients have 1 or more surgical procedures in their lifetimes. Moreover, this is the population at greatest risk of morbidity and mortality with any given complication. There is remarkable variability in health across the age spectrum, from fit to frail and compromised. This variability requires a unique approach to anesthetic delivery and drug dosing on an individual basis to avoid complications such as postoperative cognitive dysfunction and delirium.