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Pecorella G, De Rosa F, Licchelli M, Panese G, Carugno JT, Morciano A, Tinelli A. Postoperative cognitive disorders and delirium in gynecologic surgery: Which surgery and anesthetic techniques to use to reduce the risk? Int J Gynaecol Obstet 2024; 166:954-968. [PMID: 38557928 DOI: 10.1002/ijgo.15464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 02/13/2024] [Accepted: 02/25/2024] [Indexed: 04/04/2024]
Abstract
Despite their general good health, an increasing proportion of elderly individuals require surgery due to an increase in average lifespan. However, because of their increased vulnerability, these patients need to be handled carefully to make sure that surgery does not cause more harm than good. Age-related postoperative cognitive disorders (POCD) and postoperative delirium (POD), two serious consequences that are marked by adverse neuropsychologic alterations after surgery, are particularly dangerous for the elderly. In the context of gynecologic procedures, POCD and POD are examined in this narrative review. The main question is how to limit the rates of POCD and POD in older women undergoing gynecologic procedures by maximizing the risk-benefit balance. Three crucial endpoints are considered: (1) surgical procedures to lower the rates of POCD and POD, (2) anesthetic techniques to lessen the occurrence and (3) the identification of individuals at high risk for post-surgery cognitive impairments. Risks associated with laparoscopic gynecologic procedures include the Trendelenburg posture and CO2 exposure during pneumoperitoneum, despite statistical similarities in POD and POCD frequency between laparoscopic and laparotomy techniques. Numerous risk factors are associated with surgical interventions, such as blood loss, length of operation, and position holding, all of which reduce the chance of complications when they are minimized. In order to emphasize the essential role that anesthesia and surgery play in patient care, anesthesiologists are vital in making sure that anesthesia is given as sparingly and quickly as feasible. In addition, people who are genetically predisposed to POCD may be more susceptible to the disorder. The significance of a thorough strategy combining surgical and anesthetic concerns is highlighted in this article, in order to maximize results for senior patients having gynecologic surgery.
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Affiliation(s)
- Giovanni Pecorella
- Department of Gynecology, Obstetrics and Reproduction Medicine, Saarland University, Homburg, Germany
| | - Filippo De Rosa
- Department of Anesthesia and Intensive Care, and CERICSAL (CEntro di RIcerca Clinico SALentino), "Veris delli Ponti Hospital", Scorrano, Lecce, Italy
| | - Martina Licchelli
- Department of Obstetrics and Gynecology, and CERICSAL (CEntro di RIcerca Clinico SALentino), "Veris delli Ponti Hospital", Scorrano, Lecce, Italy
| | - Gaetano Panese
- Department of Obstetrics and Gynecology, and CERICSAL (CEntro di RIcerca Clinico SALentino), "Veris delli Ponti Hospital", Scorrano, Lecce, Italy
| | - Josè Tony Carugno
- Obstetrics and Gynecology Department, Minimally Invasive Gynecology Division, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Andrea Morciano
- Panico Pelvic Floor Center, Department of Gynecology and Obstetrics, Pia Fondazione "Card. G. Panico", Tricase, Lecce, Italy
| | - Andrea Tinelli
- Department of Obstetrics and Gynecology, and CERICSAL (CEntro di RIcerca Clinico SALentino), "Veris delli Ponti Hospital", Scorrano, Lecce, Italy
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Zhang H, Zhao L, Li M, Li X, Li R, Wu D. Efficacy and safety of intranasal insulin on postoperative cognitive dysfunction in elderly patients after laparoscopic radical resection of colorectal cancer: a double-blind pilot study. Front Aging Neurosci 2024; 16:1375841. [PMID: 38915348 PMCID: PMC11194343 DOI: 10.3389/fnagi.2024.1375841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 05/30/2024] [Indexed: 06/26/2024] Open
Abstract
Objective To evaluate the efficacy and safety of intranasal insulin on postoperative cognitive dysfunction (POCD) in elderly patients after laparoscopic radical resection of colorectal cancer. Methods Older patients scheduled for laparoscopic radical resection of colorectal cancer at Beijing Luhe Hospital, Capital Medical University, between August 2023 and November 2023, were enrolled in this double-blind pilot study. Patients were randomized to the control and insulin groups at a 1:1 ratio. The primary outcome was the rate of POCD at postoperative 7 days. Results A total of 61 patients (30 in the insulin group) were analyzed. The insulin group had a significantly lower POCD rate compared with the control group at postoperative day 7 [4(13.3%) vs. 12 (38.7%), p = 0.024]. The serum levels of IL-6, TNF-α and S100β at T2-5 in the insulin group were significantly lower than those of the control group (IL-6: mean difference at T2, -4.14, p = 0.036; T3, -3.84, p = 0.039; T4, -3.37, p = 0.013; T5, -2.57, p = 0.042; TNF-α: mean difference at T2, -3.19, p = 0.002; T3, -2.35, p = 0.028; T4, -2.30, p = 0.019; T5, -1.96, p = 0.0181; S100β: mean difference at T2, -8.30, p = 0.019; T3, -23.95, p = 0.020; T4, -20.01, p = 0.023; T5, -17.67, p = 0.010). No insulin allergic reactions, nasal irritation, or hypoglycemic reactions were observed in either of the groups. Conclusion Intranasal insulin may decrease the risk of POCD and inhibit the elevated serum IL-6, TNF-α, and S100β levels in elderly patients after laparoscopic radical resection of colorectal cancer, which proves that intranasal insulin may be a promising therapeutic option for POCD. Clinical trial registration Identifier, ChiCTR2300074423.
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Affiliation(s)
- Hailong Zhang
- Department of Anesthesiology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Liqin Zhao
- Department of Anesthesiology, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Min Li
- Department of Anesthesiology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Xu Li
- Department of Anesthesiology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Ruofan Li
- Department of Gastrointestinal Surgery, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Di Wu
- Department of Anesthesiology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
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Vu EL, Brown CH, Brady KM, Hogue CW. Monitoring of cerebral blood flow autoregulation: physiologic basis, measurement, and clinical implications. Br J Anaesth 2024; 132:1260-1273. [PMID: 38471987 DOI: 10.1016/j.bja.2024.01.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 01/18/2024] [Accepted: 01/28/2024] [Indexed: 03/14/2024] Open
Abstract
Cerebral blood flow (CBF) autoregulation is the physiologic process whereby blood supply to the brain is kept constant over a range of cerebral perfusion pressures ensuring a constant supply of metabolic substrate. Clinical methods for monitoring CBF autoregulation were first developed for neurocritically ill patients and have been extended to surgical patients. These methods are based on measuring the relationship between cerebral perfusion pressure and surrogates of CBF or cerebral blood volume (CBV) at low frequencies (<0.05 Hz) of autoregulation using time or frequency domain analyses. Initially intracranial pressure monitoring or transcranial Doppler assessment of CBF velocity was utilised relative to changes in cerebral perfusion pressure or mean arterial pressure. A more clinically practical approach utilising filtered signals from near infrared spectroscopy monitors as an estimate of CBF has been validated. In contrast to the traditional teaching that 50 mm Hg is the autoregulation threshold, these investigations have found wide interindividual variability of the lower limit of autoregulation ranging from 40 to 90 mm Hg in adults and 20-55 mm Hg in children. Observational data have linked impaired CBF autoregulation metrics to adverse outcomes in patients with traumatic brain injury, ischaemic stroke, subarachnoid haemorrhage, intracerebral haemorrhage, and in surgical patients. CBF autoregulation monitoring has been described in both cardiac and noncardiac surgery. Data from a single-centre randomised study in adults found that targeting arterial pressure during cardiopulmonary bypass to above the lower limit of autoregulation led to a reduction of postoperative delirium and improved memory 1 month after surgery compared with usual care. Together, the growing body of evidence suggests that monitoring CBF autoregulation provides prognostic information on eventual patient outcomes and offers potential for therapeutic intervention. For surgical patients, personalised blood pressure management based on CBF autoregulation data holds promise as a strategy to improve patient neurocognitive outcomes.
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Affiliation(s)
- Eric L Vu
- Department of Anesthesiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; The Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Charles H Brown
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kenneth M Brady
- The Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Charles W Hogue
- The Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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Arefayne NR, Berhe YW, van Zundert AA. Incidence and Factors Related to Prolonged Postoperative Cognitive Decline (POCD) in Elderly Patients Following Surgery and Anaesthesia: A Systematic Review. J Multidiscip Healthc 2023; 16:3405-3413. [PMID: 37964799 PMCID: PMC10642348 DOI: 10.2147/jmdh.s431168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 10/24/2023] [Indexed: 11/16/2023] Open
Abstract
Aim The aim of this systematic review is to explore the current literature to provide evidence regarding the incidence and risk factors of prolonged POCD in elderly patients following cardiac and non-cardiac surgical interventions. Methods The PubMed and Google Scholar databases were searched using appropriate keywords and search engines for adequate evidence from studies meeting the inclusion criteria so as to reveal the end-point, which was the presence of prolonged POCD in elderly patients following surgery and anaesthesia. The incidence of POCD at different time intervals and the variables predicting the occurrence of POCD were analysed. Results The results of 23 articles covering 5077 patients (3694 non cardiac and 1383 cardiac surgeries) were carefully analysed. POCD occurs from the first postoperative day and lasts for potentially long periods. The incidence of POCD in this review ranged from 2.2% to 35.7%. More specifically, it ranged from 2.2% to 31.5% in non-cardiac surgeries and 11.8% to 35.7% in patients who had undergone cardiac surgeries. Some of the independent risk factors (predictors) for the development of POCD were advanced age, high concentration of neuroinflammatory mediators detectable in plasma, low SpO2, longer anaesthetic and surgical duration, and depth of anaesthesia. Conclusion This review can only provide limited evidence of prolonged POCD (more than a year) and further research that involves better study designs, larger samples, involving longer follow-up, and at different sites (multicentre) is highly advised. This in turn may help researchers and clinicians to discover the actual causes and risk factors and develop appropriate preventive and treatment protocols to tackle POCD in the ageing surgical population.
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Affiliation(s)
- Nurhusen Riskey Arefayne
- Department of Anaesthesia, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Yophtahe Woldegerima Berhe
- Department of Anaesthesia, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - André A van Zundert
- The University of Queensland & Royal Brisbane and Women’s Hospital, Department of Anaesthesia and Perioperative Medicine, Brisbane, QLD, Australia
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Mitragotri MV, Sachidananda R, Kurugodiyavar MD, Kurjogi M. Influence of spinal anaesthesia on postoperative cognitive decline in elderly population undergoing hip surgeries: A prospective observational study. Indian J Anaesth 2023; 67:736-739. [PMID: 37693031 PMCID: PMC10488567 DOI: 10.4103/ija.ija_947_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 06/20/2023] [Accepted: 06/24/2023] [Indexed: 09/12/2023] Open
Affiliation(s)
| | - Roopa Sachidananda
- Department of Anaesthesia, Karnataka Institute of Medical Sciences, Hubli, Karnataka, India
| | - Mahesh D Kurugodiyavar
- Department of Community Medicine, Karnataka Institute of Medical Sciences, Hubli, Karnataka, India
| | - Mahantesh Kurjogi
- Department of Medical Research Unit, Karnataka Institute of Medical Sciences, Hubli, Karnataka, India
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Wu W, Pu L, Hu X, Chen Q, Wang G, Wang Y. Moderate-to-high risk of obstructive sleep apnea with excessive daytime sleepiness is associated with postoperative neurocognitive disorders: a prospective one-year follow-up cohort study. Front Neurosci 2023; 17:1161279. [PMID: 37325036 PMCID: PMC10266218 DOI: 10.3389/fnins.2023.1161279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 05/08/2023] [Indexed: 06/17/2023] Open
Abstract
Background Few studies found that obstructive sleep apnea (OSA) may be related to postoperative neurocognitive disorders (PND) including postoperative delirium (POD) and cognitive decline (POCD) in the early postoperative period. However, the results are controversial and need further verification, and no research has explored the effect of OSA on the incidence of PND during the 1-year follow-up periods. Furthermore, OSA patients with excessive daytime sleepiness (EDS) as a severe phenotype have more significant neurocognitive impairments, but the relationship between OSA with EDS and PND within 1 year after surgery has not been studied. Objectives To explore the effect of moderate-to-high risk of OSA and the moderate-to-high risk of OSA with EDS on PND within 1 year after surgery. Methods In this prospective cohort study, including 227 older patients, moderate-to-high risk of OSA (using STOP-BANG), subjective EDS (using Epworth Sleepiness Scale), and objective EDS (using Actigraphy) were selected as exposures. Key outcomes included POD during hospitalization (using Confusion Assessment Method-Severity), POCD at discharge, 1-month and 1-year after surgery (using Mini-Mental State Examination and Telephone Interview for Cognitive Status-40). We applied multiple logistic regression models to estimate the effect of moderate-to-high risk of OSA and moderate-to-high risk of OSA with EDS on PND. Results In the multivariate analysis, moderate-to-high risk of OSA was not associated with POD during hospitalization and POCD at discharge, 1-month, and 1-year after surgery (p > 0.05). However, the moderate-to-high risk of OSA with subjective EDS was related to POCD at discharge compared to the moderate-to-high risk of OSA or normal group (no moderate-to-high risk of OSA and no EDS) (p < 0.05). In addition, moderate-to-high risk of OSA with objective EDS was associated with POCD at discharge, 1-month, and 1-year postoperatively compared to the moderate-to-high risk of OSA or normal group (p < 0.05). Conclusion Moderate-to-high risk of OSA with EDS, not moderate-to-high risk of OSA alone, was a clinically helpful predictor for POCD within 1-year after surgery and should be routinely assessed before surgery.
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Affiliation(s)
- Wenwen Wu
- West China School of Nursing, Sichuan University, Chengdu, Sichuan, China
- Innovation Center of Nursing Research, Nursing Key Laboratory of Sichuan Province, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Lihui Pu
- Menzies Health Institute Queensland & School of Nursing and Midwifery, Griffith University, Brisbane, QL, Australia
| | - Xiuying Hu
- Innovation Center of Nursing Research, Nursing Key Laboratory of Sichuan Province, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Qian Chen
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China School of Nursing, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Guan Wang
- Innovation Center of Nursing Research, Nursing Key Laboratory of Sichuan Province, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yanyan Wang
- Science and Technology Department, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Fillenbaum GG, Mohs R. CERAD (Consortium to Establish a Registry for Alzheimer's Disease) Neuropsychology Assessment Battery: 35 Years and Counting. J Alzheimers Dis 2023; 93:1-27. [PMID: 36938738 PMCID: PMC10175144 DOI: 10.3233/jad-230026] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
BACKGROUND In 1986, the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) was mandated to develop a brief neuropsychological assessment battery (CERAD-NAB) for AD, for uniform neuropsychological assessment, and information aggregation. Initially used across the National Institutes of Aging-funded Alzheimer's Disease Research Centers, it has become widely adopted wherever information is desired on cognitive status and change therein, particularly in older populations. OBJECTIVE Our purpose is to provide information on the multiple uses of the CERAD-NAB since its inception, and possible further developments. METHODS Since searching on "CERAD neuropsychological assessment battery" or similar terms missed important information, "CERAD" alone was entered into PubMed and SCOPUS, and CERAD-NAB use identified from the resulting studies. Use was sorted into major categories, e.g., psychometric information, norms, dementia/differential dementia diagnosis, epidemiology, intervention evaluation, genetics, etc., also translations, country of use, and alternative data gathering approaches. RESULTS CERAD-NAB is available in ∼20 languages. In addition to its initial purpose assessing AD severity, CERAD-NAB can identify mild cognitive impairment, facilitate differential dementia diagnosis, determine cognitive effects of naturally occurring and experimental interventions (e.g., air pollution, selenium in soil, exercise), has helped to clarify cognition/brain physiology-neuroanatomy, and assess cognitive status in dementia-risk conditions. Surveys of primary and tertiary care patients, and of population-based samples in multiple countries have provided information on prevalent and incident dementia, and cross-sectional and longitudinal norms for ages 35-100 years. CONCLUSION CERAD-NAB has fulfilled its original mandate, while its uses have expanded, keeping up with advances in the area of dementia.
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Affiliation(s)
- Gerda G Fillenbaum
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, NC, USA
| | - Richard Mohs
- Global Alzheimer's Platform Foundation, Washington, DC, USA
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Aceto P, Russo A, Galletta C, Schipa C, Romanò B, Luca E, Sacco E, Totaro A, Lai C, Mazza M, Federico B, Sollazzi L. Relationship between Middle Cerebral Artery Pulsatility Index and Delayed Neurocognitive Recovery in Patients undergoing Robot-Assisted Laparoscopic Prostatectomy. J Clin Med 2023; 12:jcm12031070. [PMID: 36769717 PMCID: PMC9918143 DOI: 10.3390/jcm12031070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 01/20/2023] [Accepted: 01/24/2023] [Indexed: 02/03/2023] Open
Abstract
A steep Trendelenburg (ST) position combined with pneumoperitoneum may cause alterations in cerebral blood flow with the possible occurrence of postoperative cognitive disorders. No studies have yet investigated if these alterations may be associated with the occurrence of postoperative cognitive disorders. The aim of the study was to evaluate the association between an increased middle cerebral artery pulsatility index (Pi), measured by transcranial doppler (TCD) 1 h after ST combined with pneumoperitoneum, and delayed neurocognitive recovery (dNCR) in 60 elderly patients undergoing robotic-assisted laparoscopic prostatectomy (RALP). Inclusion criteria were: ≥65 years; ASA class II-III; Mini-Mental Examination score > 23. Exclusion criteria were: neurological or psychiatric pathologies; any conditions that could interfere with test performance; severe hypertension or vascular diseases; alcohol or substance abuse; chronic pain; and an inability to understand Italian. dNCR was evaluated via neuropsychological test battery before and after surgery. Anesthesia protocol and monitoring were standardized. The middle cerebral artery Pi was measured by TCD, through the trans-temporal window and using a 2.5 MHz ultrasound probe at specific time points before and during surgery. In total, 20 patients experiencing dNCR showed a significantly higher Pi after 1 h from ST compared with patients without dNCR (1.10 (1.0-1.19 95% CI) vs. 0.87 (0.80-0.93 95% CI); p = 0.003). These results support a great vulnerability of the cerebral circulation to combined ST and pneumoperitoneum in patients who developed dNCR. TCD could be used as an intraoperative tool to prevent the occurrence of dNCR in patients undergoing RALP.
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Affiliation(s)
- Paola Aceto
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Andrea Russo
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Claudia Galletta
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Chiara Schipa
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Bruno Romanò
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Ersilia Luca
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Emilio Sacco
- Department of Urology, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Institute of Urology, Universita Cattolica del S. Cuore-Fondazione Policlinico A. Gemelli, 00168 Rome, Italy
- Correspondence:
| | - Angelo Totaro
- Department of Urology, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Institute of Urology, Universita Cattolica del S. Cuore-Fondazione Policlinico A. Gemelli, 00168 Rome, Italy
| | - Carlo Lai
- Department of Dynamic and Clinical Psychology and Health Studies, Sapienza University, 00185 Rome, Italy
| | - Marianna Mazza
- Institute of Psychiatry and Psychology, Department of Geriatrics, Neuroscience and Orthopedics, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Department of Psychiatry, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Bruno Federico
- Department of Human Sciences, Society and Health, University of Cassino and Southern Lazio, 03043 Cassino, Italy
| | - Liliana Sollazzi
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
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The Influence of Carbon Dioxide on Cerebral Autoregulation During Sevoflurane-based Anesthesia in Patients With Type 2 Diabetes. J Neurosurg Anesthesiol 2023; 35:65-73. [PMID: 34387283 DOI: 10.1097/ana.0000000000000794] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 07/06/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cerebral autoregulation (CA) continuously adjusts cerebrovascular resistance to maintain cerebral blood flow (CBF) constant despite changes in blood pressure. Also, CBF is proportional to changes in arterial carbon dioxide (CO 2 ) (cerebrovascular CO 2 reactivity). Hypercapnia elicits cerebral vasodilation that attenuates CA efficacy, while hypocapnia produces cerebral vasoconstriction that enhances CA efficacy. In this study, we quantified the influence of sevoflurane anesthesia on CO 2 reactivity and the CA-CO 2 relationship. METHODS We studied patients with type 2 diabetes mellitus (DM), prone to cerebrovascular disease, and compared them to control subjects. In 33 patients (19 DM, 14 control), end-tidal CO 2 , blood pressure, and CBF velocity were monitored awake and during sevoflurane-based anesthesia. CA, calculated with transfer function analysis assessing phase lead (degrees) between low-frequency oscillations in CBF velocity and mean arterial blood pressure, was quantified during hypocapnia, normocapnia, and hypercapnia. RESULTS In both control and DM patients, awake CO 2 reactivity was smaller (2.8%/mm Hg CO 2 ) than during sevoflurane anesthesia (3.9%/mm Hg; P <0.005). Hyperventilation increased CA efficacy more (3 deg./mm Hg CO 2 ) in controls than in DM patients (1.8 deg./mm Hg CO 2 ; P <0.001) in both awake and sevoflurane-anesthetized states. CONCLUSIONS The CA-CO 2 relationship is impaired in awake patients with type 2 DM. Sevoflurane-based anesthesia does not further impair this relationship. In patients with DM, hypocapnia induces cerebral vasoconstriction, but CA efficacy does not improve as observed in healthy subjects.
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Wang X, Chen X, Wu F, Liu Y, Yang Y, Chen W, Pan Z, Hu W, Zheng F, He H. Relationship between postoperative biomarkers of neuronal injury and postoperative cognitive dysfunction: A meta-analysis. PLoS One 2023; 18:e0284728. [PMID: 37098084 PMCID: PMC10128950 DOI: 10.1371/journal.pone.0284728] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 04/07/2023] [Indexed: 04/26/2023] Open
Abstract
Early biomarkers are needed to identify patients at risk of developing postoperative cognitive dysfunction (POCD). Our objective was to determine neuronal injury-related biomarkers with predictive values for this condition. Six biomarkers (S100β, neuron-specific enolase [NSE], amyloid beta [Aβ], tau, neurofilament light chain, and glial fibrillary acidic protein) were evaluated. According to the first postoperative sampling time, observational studies showed that S100β was significantly higher in patients with POCD than in those without POCD (standardized mean difference [SMD]: 6.92, 95% confidence interval [CI]: 4.44-9.41). The randomized controlled trial (RCT) showed that S100β (SMD: 37.31, 95% CI: 30.97-43.64) and NSE (SMD: 3.50, 95% CI: 2.71-4.28) in the POCD group were significantly higher than in the non-POCD group. The pooled data of observational studies by postoperative sampling time showed significantly higher levels of the following biomarkers in the POCD groups than in the control groups: S100β levels at 1 hour (SMD: 1.35, 95% CI: 0.07-2.64), 2 days (SMD: 27.97, 95% CI: 25.01-30.94), and 9 days (SMD: 6.41, 95% CI: 5.64-7.19); NSE levels at 1 hour (SMD: 0.92, 95% CI: 0.25-1.60), 6 hours (SMD: 0.79, 95% CI: 0.12-1.45), and 24 hours (SMD: 0.84, 95% CI: 0.38-1.29); and Aβ levels at 24 hours (SMD: 2.30, 95% CI: 1.54-3.06), 2 days (SMD: 2.30, 95% CI: 1.83-2.78), and 9 days (SMD: 2.76, 95% CI: 2.25-3.26). The pooled data of the RCT showed that the following biomarkers were significantly higher in POCD patients than in non-POCD patients: S100β levels at 2 days (SMD: 37.31, 95% CI: 30.97-43.64) and 9 days (SMD: 126.37, 95% CI: 104.97-147.76) and NSE levels at 2 days (SMD: 3.50, 95% CI: 2.71-4.28) and 9 days (SMD: 8.53, 95% CI: 7.00-10.06). High postoperative levels of S100β, NSE, and Aβ may predict POCD. The relationship between these biomarkers and POCD may be affected by sampling time.
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Affiliation(s)
- Xiaohua Wang
- Department of Anesthesiology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian Province, China
| | - Xinli Chen
- Department of Anesthesiology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian Province, China
| | - Fan Wu
- Department of Anesthesiology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian Province, China
| | - Yingchao Liu
- Department of Anesthesiology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian Province, China
| | - Yushen Yang
- Department of Anesthesiology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian Province, China
| | - Weican Chen
- Department of Anesthesiology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian Province, China
| | - Zhigang Pan
- Department of Neurosurgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian Province, China
| | - Weipeng Hu
- Department of Neurosurgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian Province, China
| | - Feng Zheng
- Department of Neurosurgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian Province, China
| | - Hefan He
- Department of Anesthesiology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian Province, China
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11
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Clinical Factors Contributing to Cognitive Function in the Acute Stage after Treatment of Intracranial Aneurysms: A Cross-Sectional Study. J Clin Med 2022; 11:jcm11175053. [PMID: 36078981 PMCID: PMC9457194 DOI: 10.3390/jcm11175053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 08/21/2022] [Accepted: 08/24/2022] [Indexed: 11/25/2022] Open
Abstract
Background: The factors affecting cognitive function after treatment of subarachnoid haemorrhage (SAH) can be categorised into aneurysmal factors, procedural factors, and complications. The aim of this study was to investigate which of these factors has greater influence on the cognitive function. Methods: We retrospectively identified 14 patients with unruptured intracranial aneurysms (UIAs) and 34 patients with SAH with mild symptoms at disease onset (Hunt and Hess grade: >3). All patients underwent neuropsychological tests within 35 days of discharge from hospitalisation for treatment. The relationship between the clinical factors and each neuropsychological test score was evaluated using multiple linear regression analysis after controlling for age and years of education. Results: Patients with UIA showed greater cognitive impairment in visual memory and the frontal/executive domains. Hypertension was associated with cognitive impairment. Patients with SAH showed greater cognitive impairment in the visuospatial, verbal memory, and frontal/executive domains. The dome-to-neck ratio, aneurysms located in the posterior circulation, microsurgical clipping, procedure time, anaesthesia duration, and complications were associated with cognitive impairment. Conclusions: Underlying diseases, procedural factors, and complications contributed to cognitive impairment after treatment of intracranial aneurysms. Since the effect of each factor on each cognitive domain was slightly different, a more in-depth study of these effects is needed.
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12
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Yu J, Park JY, Hong JH, Hwang JH, Kim YK. Effect of pneumoperitoneum and Trendelenburg position on internal carotid artery blood flow measured by ultrasound during robotic prostatectomy. Clin Physiol Funct Imaging 2022; 42:139-145. [PMID: 35018713 DOI: 10.1111/cpf.12742] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 12/20/2021] [Accepted: 01/10/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Robotic prostatectomy requires pneumoperitoneum and a steep Trendelenburg position; however, this condition may compromise cerebral blood flow. Here, we evaluated the effect of pneumoperitoneum and the steep Trendelenburg position on internal carotid artery (ICA) blood flow measured by Doppler ultrasound during robotic prostatectomy. METHODS Patients who underwent robotic prostatectomy were prospectively recruited. The ICA blood flow was measured at the following five time-points: with the patient awake and in the supine position (Ta), 10 min after anaesthetic induction in the supine position (T1), 10 (T2) and 30 (T3) min after pneumoperitoneum in the steep Trendelenburg position, and at the end of surgery in the supine position after desufflation of the pneumoperitoneum (T4). Hemodynamic and cerebrovascular variables were measured at each time-point. RESULTS A total of 28 patients were evaluated. The ICA blood flows were significantly lower at T2 and T3 than at T1 (162.3±44.7 [T2] vs. 188.0±49.6 mL/min [T1], P=0.002; 163.1±39.9 [T3] vs. 188.0±49.6 mL/min [T1], P=0.009). The ICA blood flow also differed significantly between Ta and T1 (236.8±58.3 vs. 188.0±49.6 mL/min, P<0.001). Heart rates, cardiac indexes, peak systolic velocity, and end-diastolic velocity were significantly lower at T2 and T3 than at T1. However, ICA diameter, mean blood pressure, and end-tidal carbon dioxide partial pressure did not differ significantly at all time-points. CONCLUSION Pneumoperitoneum and the steep Trendelenburg position caused decreased ICA blood flow, suggesting that they should be carefully performed during robotic prostatectomy, especially in patients at risk of postoperative cerebrovascular accident. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Jihion Yu
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jun-Young Park
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jun Hyuk Hong
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jai-Hyun Hwang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Young-Kug Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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13
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Olsen MH, Riberholt CG, Mehlsen J, Berg RM, Møller K. Reliability and validity of the mean flow index (Mx) for assessing cerebral autoregulation in humans: A systematic review of the methodology. J Cereb Blood Flow Metab 2022; 42:27-38. [PMID: 34617816 PMCID: PMC8721771 DOI: 10.1177/0271678x211052588] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Cerebral autoregulation is a complex mechanism that serves to keep cerebral blood flow relatively constant within a wide range of cerebral perfusion pressures. The mean flow index (Mx) is one of several methods to assess dynamic cerebral autoregulation, but its reliability and validity have never been assessed systematically. The purpose of the present systematic review was to evaluate the methodology, reliability and validity of Mx.Based on 128 studies, we found inconsistency in the pre-processing of the recordings and the methods for calculation of Mx. The reliability in terms of repeatability and reproducibility ranged from poor to excellent, with optimal repeatability when comparing overlapping recordings. The discriminatory ability varied depending on the patient populations; in general, those with acute brain injury exhibited a higher Mx than healthy volunteers. The prognostic ability in terms of functional outcome and mortality ranged from chance result to moderate accuracy.Since the methodology was inconsistent between studies, resulting in varying reliability and validity estimates, the results were difficult to compare. The optimal method for deriving Mx is currently unknown.
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Affiliation(s)
- Markus Harboe Olsen
- Department of Neuroanaesthesiology, 53146Rigshospitalet, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Christian Gunge Riberholt
- Department of Neuroanaesthesiology, 53146Rigshospitalet, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Department of Neurorehabilitation/Traumatic Brain Injury Unit, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jesper Mehlsen
- Surgical Pathophysiology Unit, 53146Rigshospitalet, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Ronan Mg Berg
- Department of Clinical Physiology, Nuclear Medicine & PET, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Centre for Physical Activity Research, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
| | - Kirsten Møller
- Department of Neuroanaesthesiology, 53146Rigshospitalet, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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14
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Longhitano Y, Iannuzzi F, Bonatti G, Zanza C, Messina A, Godoy D, Dabrowski W, Xiuyun L, Czosnyka M, Pelosi P, Badenes R, Robba C. Cerebral Autoregulation in Non-Brain Injured Patients: A Systematic Review. Front Neurol 2021; 12:732176. [PMID: 34899560 PMCID: PMC8660115 DOI: 10.3389/fneur.2021.732176] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 10/11/2021] [Indexed: 01/12/2023] Open
Abstract
Introduction: Cerebral autoregulation (CA) plays a fundamental role in the maintenance of adequate cerebral blood flow (CBF). CA monitoring, through direct and indirect techniques, may guide an appropriate therapeutic approach aimed at improving CBF and reducing neurological complications; so far, the role of CA has been investigated mainly in brain-injured patients. The aim of this study is to investigate the role of CA in non-brain injured patients. Methods: A systematic consultation of literature was carried out. Search terms included: “CA and sepsis,” “CA and surgery,” and “CA and non-brain injury.” Results: Our research individualized 294 studies and after screening, 22 studies were analyzed in this study. Studies were divided in three groups: CA in sepsis and septic shock, CA during surgery, and CA in the pediatric population. Studies in sepsis and intraoperative setting highlighted a relationship between the incidence of sepsis-associated delirium and impaired CA. The most investigated setting in the pediatric population is cardiac surgery, but the role and measurement of CA need to be further elucidated. Conclusion: In non-brain injured patients, impaired CA may result in cognitive dysfunction, neurological damage, worst outcome, and increased mortality. Monitoring CA might be a useful tool for the bedside optimization and individualization of the clinical management in this group of patients.
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Affiliation(s)
- Yaroslava Longhitano
- Department of Anesthesiology and Critical Care, AO St. Antonio, Biagio and Cesare Arrigo, Alessandria, Italy
| | - Francesca Iannuzzi
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Giulia Bonatti
- Anesthesia and Intensive Care, Gaslini Hospital, Genova, Italy
| | - Christian Zanza
- Foundation of "Nuovo Ospedale Alba-Bra" and Department of Emergency Medicine, Anesthesia and Critical Care Division, Michele and Pietro Ferrero Hospital, Verduno, Italy
| | - Antonio Messina
- Humanitas Clinical and Research Center - IRCCS, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Daniel Godoy
- Neurointensive Care Unit, Sanatorio Pasteur, 2 Intensive Care Unit, Hospital Carlos Malbran, Catamarca, Argentina
| | | | - Li Xiuyun
- Department of Anesthesiology & Critical Care Medicine, John Hopkins University, Baltimore, MD, United States
| | - Marek Czosnyka
- Brain Physics Laboratory, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy.,Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Rafael Badenes
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clinic Universitari de Valencia, Department of Surgery, University of Valencia, Valencia, Spain
| | - Chiara Robba
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy.,Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
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15
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Michino T, Tanabe K, Takenaka M, Akamatsu S, Uchida M, Iida M, Iida H. Edaravone attenuates sustained pial arteriolar vasoconstriction independently of the endothelial function after unclamping of an abdominal aorta in rabbits. Korean J Anesthesiol 2021; 74:531-540. [PMID: 34078039 PMCID: PMC8648506 DOI: 10.4097/kja.21155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 06/03/2021] [Indexed: 11/10/2022] Open
Abstract
Background Cerebral blood flow (CBF) has direct impacts on the neuronal function and neurocognitive disorder. Oxidative stress from abdominal aortic surgery is important in the pathophysiology of CBF impairment. We investigated whether oxidative damage from abdominal aortic surgery is associated with reduced CBF and whether vascular endothelial dysfunction modifies these associations. Methods Rabbit closed cranial window preparation was used to measure changes in the pial arteriolar diameter after unclamping following abdominal aortic cross-clamping with an intravenous free radical scavenger, edaravone (control group, n=6; edaravone 10 μg/kg/min, n=6; 100 μg/kg/min, n=6). The pial vasodilatory responses to the topical application of acetylcholine (ACh) into the cranial window were investigated before abdominal aortic cross-clamping and after unclamping with the intravenous administration of edaravone (control group, n=6; edaravone 100 μg/kg/min, n=6). Results The aortic unclamping-induced vasoconstriction was significantly attenuated under the continuous infusion of edaravone at 100 μg/kg/min. The topical application of ACh after unclamping did not produce any changes in pial arteriolar responses in comparison to before aortic cross-clamping in the control or edaravone groups. The changes in the response to topical ACh after unclamping in the saline and edaravone groups did not differ to a statistically significant extent. Conclusions Free radicals during abdominal aortic surgery might have contracted cerebral blood vessels independently of the endothelial function in rabbits. The suppression of free radicals attenuated sustained pial arteriolar vasoconstriction after aortic unclamping. Thus, the free radical scavenger might have some brain protective effect that maintains the CBF independently of the endothelial function.
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Affiliation(s)
- Tomohiro Michino
- Anesthesiology, Japanese Red Cross Takayama Hospital, Takayama-City, Gifu, Japan
| | - Kumiko Tanabe
- Department of Anesthesiology and Pain Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Motoyasu Takenaka
- Department of Anesthesiology and Pain Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | | | - Masayoshi Uchida
- Department of Anesthesiology and Pain Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Mami Iida
- Department of Internal Medicine, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Hiroki Iida
- Department of Anesthesiology and Pain Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
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16
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Intraoperative impaired cerebrovascular autoregulation and delayed neurocognitive recovery after major oncologic surgery: a secondary analysis of pooled data. J Clin Monit Comput 2021; 36:765-773. [PMID: 33860406 PMCID: PMC9162974 DOI: 10.1007/s10877-021-00706-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 04/08/2021] [Indexed: 11/22/2022]
Abstract
Cerebral blood flow is tightly regulated by cerebrovascular autoregulation (CVA), and intraoperative impairment of CVA has been linked with perioperative neurocognitive disorders. We aim to assess whether impairment of CVA during major oncologic surgery is associated with delayed neurocognitive recovery (DNCR) postoperatively. We performed a secondary analysis of prospectively collected data. Patients were included if they had undergone complete pre- and postoperative neuropsychological assessments, continuous intraoperative measurement of CVA, and major oncologic surgery for visceral, urological, or gynecological cancer. Intraoperative CVA was measured using the time-correlation method based on near-infrared-spectroscopy, and DNCR was assessed with a neuropsychological test battery. A decline in cognitive function before hospital discharge compared with a preoperative baseline assessment was defined as DNCR. One hundred ninety-five patients were included in the analysis. The median age of the study population was 65 years (IQR: 60–68); 11 patients (5.6%) were female. Forty-one patients (21.0%) fulfilled the criteria for DNCR in the early postoperative period. We found a significant association between impaired intraoperative CVA and DNCR before hospital discharge (OR = 1.042 [95% CI: 1.005; 1.080], p = 0.028). The type of surgery (radical prostatectomy vs. other major oncologic surgery; OR = 0.269 [95% CI: 0.099; 0.728], p = 0.010) and premedication with midazolam (OR = 3.360 [95% CI: 1.039; 10.870], p = 0.043) were significantly associated with the occurrence of DNCR in the early postoperative period. Intraoperative impairment of CVA is associated with postoperative neurocognitive function early after oncologic surgery. Therefore, intraoperative monitoring of CVA may be a target for neuroprotective interventions. The initial studies were retrospectively registered with primary clinical trial registries recognized by the World Health Organization (ClinicalTrials.gov Identifiers: DRKS00010014, 21.03.2016 and NCT04101006, 24.07.2019).
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17
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Cerebral autoregulation in the operating room and intensive care unit after cardiac surgery. Br J Anaesth 2021; 126:967-974. [PMID: 33741137 DOI: 10.1016/j.bja.2020.12.043] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 12/14/2020] [Accepted: 12/24/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Cerebral autoregulation monitoring is a proposed method to monitor perfusion during cardiac surgery. However, limited data exist from the ICU as prior studies have focused on intraoperative measurements. Our objective was to characterise cerebral autoregulation during surgery and early ICU care, and as a secondary analysis to explore associations with delirium. METHODS In patients undergoing cardiac surgery (n=134), cerebral oximetry values and arterial BP were monitored and recorded until the morning after surgery. A moving Pearson's correlation coefficient between mean arterial proessure (MAP) and near-infrared spectroscopy signals generated the cerebral oximetry index (COx). Three metrics were derived: (1) globally impaired autoregulation, (2) MAP time and duration outside limits of autoregulation (MAP dose), and (3) average COx. Delirium was assessed using the 3-Minute Diagnostic Interview for CAM-defined Delirium (3D-CAM) and the Confusion Assessment Method for the ICU (CAM-ICU). Autoregulation metrics were compared using χ2 and rank-sum tests, and associations with delirium were estimated using regression models, adjusted for age, bypass time, and logEuroSCORE. RESULTS The prevalence of globally impaired autoregulation was higher in the operating room vs ICU (40% vs 13%, P<0.001). The MAP dose outside limits of autoregulation was similar in the operating room and ICU (median 16.9 mm Hg×h; inter-quartile range [IQR] 10.1-38.8 vs 16.9 mm Hg×h; IQR 5.4-35.1, P=0.20). In exploratory adjusted analyses, globally impaired autoregulation in the ICU, but not the operating room, was associated with delirium. The MAP dose outside limits of autoregulation in the operating room and ICU was also associated with delirium. CONCLUSIONS Metrics of cerebral autoregulation are altered in the ICU, and may be clinically relevant with respect to delirium. Further studies are needed to investigate these findings and determine possible benefits of autoregulation-based MAP targeting in the ICU.
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18
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Risk factors of postoperative delirium in the knee and hip replacement patients: a systematic review and meta-analysis. J Orthop Surg Res 2021; 16:76. [PMID: 33482875 PMCID: PMC7821501 DOI: 10.1186/s13018-020-02127-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 11/29/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The risk factors of postoperative delirium (POD), a serious while preventable complication, developed by patients undergoing knee and replacement surgery are still under investigation. In this systematic review and meta-analysis, we identified risk factors associated with POD in knee and hip replacement. METHODS PubMed, Ovid MEDLINE, and Ovid EMBASE were used to identify original researches. The studies evaluating the risk factors of POD after knee and hip replacement were reviewed, and the qualities of the included studies were assessed with Newcastle-Ottawa Scale. Data were extracted, pooled, and a meta-analysis was completed RESULT: Twenty-two studies were finally included with a total of 11934 patients who underwent knee or hip replacement and 1841 developed POD with an incidence of 17.6% (95% confidential interval (CI) 13.2-22.0%). Eighteen significant risk factors were identified including advanced age (odds ratio (OR) 1.15 95% CI 1.08-1.22), cognitive impairment (OR 6.84, 95% CI 3.27-14.33), history of cerebrovascular events (OR 2.51, 95% CI 1.28-4.91), knee replacement (OR 1.42, 95% CI 1.00-2.02), blood loss (standardized mean difference (SMD) 0.30, 95% CI 0.15-0.44), dementia (OR 3.09, 95% CI 2.10-4.56), neurologic disorders (OR 2.26, 95% CI 1.23-4.15), psychiatric illness (OR 2.74, 95% CI 1.34-5.62), and obstructive sleep apnea (OR 4.17, 95% CI 1.72-10.09) along with several comorbidity evaluation scores and laboratory markers. CONCLUSION We identified risk factors consistently associated with the incidence of POD in knee and hip replacement. Strategies and interventions should be implemented to the patients receiving knee or hip replacement with potential risk factors identified in this meta-analysis.
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Pandin P, Estruc I, Van Hecke D, Truong HN, Marullo L, Hublet S, Van Obbergh L. Brain Aging and Anesthesia. J Cardiothorac Vasc Anesth 2020; 33 Suppl 1:S58-S66. [PMID: 31279354 DOI: 10.1053/j.jvca.2019.03.042] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Herein, the authors review the neuroanatomical and the neurophysiological aspects of the normal aging evolution based on the recent literature and briefly describe the difference between physiological and pathological brain aging, with consideration of the currently recommended anesthesia management of older patients. The population of elderly patients is growing drastically with advances in medicine that have prolonged the life span. One of the direct consequence has been a significant increase in the request for anesthesia care for older patients despite the type of surgery (cardiac vs noncardiac and mainly orthopedic). Because the brain of this category of patients undergoes a specific triple influence (immune, metabolic, and inflammatory), some particular physiological, anatomical, and structural modifications must be taken into account because they expose these patients more specifically to postoperative cognitive disturbances. To prevent type of adverse outcome, a better knowledge and understanding of these neurosciences must be promoted. The strategies developed to prevent such adverse outcomes include the determination and detection of significant at-risk patients and improvement in the titration of anesthesia to reduce exposure of anesthesia to these patients through an adapted anesthesia-induced unconsciousness that avoids, as much as possible, the risk of toxic overdose with an overly deep brain depression. To accomplish this, the unprocessed electroencephalogram (EEG) and its spectrogram may represent a significant improvement in monitoring, first by allowing for the rapid recognition of repetitive or persistent EEG suppression by the on-line reading of the raw EEG trace and second by allowing for the accurate determination of the adequate anesthetic-induced state, obtained in general in this category of patients by substantially lowered doses of anesthetic agents. This represents a new methodology for anesthesia titration that is adjusted on a more case-by-case basis and is related to the physiology of individual patients. A better understanding of aging-induced brain transformations remains the key regarding the improvement of the anesthetic management of the always growing population of elderly patients. The promotion of the unprocessed EEG may represent the best method of preventing the risk of anesthetic toxicity, including postoperative cognitive dysfunctions.
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Affiliation(s)
- Pierre Pandin
- Department of Anesthesia and Critical Care, Erasmus Academic Hospital, Université Libre de Bruxelles, Brussels, Belgium.
| | - Isabel Estruc
- Department of Anesthesia and Critical Care, Erasmus Academic Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Delphine Van Hecke
- Department of Anesthesia and Critical Care, Erasmus Academic Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Ha-Nam Truong
- Department of Anesthesia and Critical Care, Erasmus Academic Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Lucia Marullo
- Department of Anesthesia and Critical Care, Erasmus Academic Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Stephane Hublet
- Department of Anesthesia and Critical Care, Erasmus Academic Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Luc Van Obbergh
- Department of Anesthesia and Critical Care, Erasmus Academic Hospital, Université Libre de Bruxelles, Brussels, Belgium
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20
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Laser speckle contrast imaging of forehead cutaneous blood flow during carotid endarterectomy as a potential non-invasive method for surrogate monitoring of cerebral perfusion. J Clin Monit Comput 2020; 35:1263-1268. [PMID: 32926289 DOI: 10.1007/s10877-020-00590-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 09/08/2020] [Indexed: 10/23/2022]
Abstract
Monitoring cerebral perfusion is important for goal-directed anesthesia. Taking advantage of the supply of the supraorbital region and Glabella from the internal carotid artery (ICA), we evaluated changes in cutaneous blood flow using laser speckle contrast imagining (LSCI) as a potential method for indirect real-time monitoring of cerebral perfusion. Nine patients (8 men, mean age 70 years) underwent eversion carotid endarterectomy under local anesthesia. Cutaneous blood flow of the forehead was monitored using LSCI. During clamping of the common carotid artery (CCA), ipsilateral supraorbital region and Glabellas cutaneous blood flow dropped from 334 ± 135 to 221 ± 109 AU (p = 0.023) (AU: arbitrary flux units) and from 384 ± 151 to 276 ± 107 AU (p = 0.023), respectively, whilst the contralateral supraorbital region cutaneous blood flow remained unchanged. The supraorbital cutaneous blood flow did not change significantly following reperfusion of the external carotid artery (ECA) (221 ± 109 to 281 ± 154 AU; p = 0.175) and ICA (281 ± 154 to 310 ± 184 AU; p = 01). A comparable trend for Glabella followed ECA (276 ± 107 to 342 ± 170 AU; p = 0.404) and ICA (342 ± 170 to 352 ± 191 AU; p = 01) reperfusion. In patients undergoing carotid endarterectomy under local anesthesia, LSCI of the supraorbital and Glabella regions reflected clamping of the CCA but did not distinguish reperfusion of the ICA from that of the ECA.
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21
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Hasan TF, Kelley RE, Cornett EM, Urman RD, Kaye AD. Cognitive impairment assessment and interventions to optimize surgical patient outcomes. Best Pract Res Clin Anaesthesiol 2020; 34:225-253. [PMID: 32711831 DOI: 10.1016/j.bpa.2020.05.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 05/20/2020] [Indexed: 12/22/2022]
Abstract
For elderly patients undergoing elective surgical procedures, preoperative evaluation of cognition is often overlooked. Patients may experience postoperative delirium (POD) and postoperative cognitive decline (POCD), especially those with certain risk factors, including advanced age. Preoperative cognitive impairment is a leading risk factor for both POD and POCD, and studies have noted that identifying these deficiencies is critical during the preoperative period so that appropriate preventive strategies can be implemented. Comprehensive geriatric assessment is a useful approach which evaluates a patient's medical, psycho-social, and functional domains objectively. Various screening tools are available for preoperatively identifying patients with cognitive impairment. The Enhanced Recovery After Surgery (ERAS) protocols have been discussed in the context of prehabilitation as an effort to optimize a patient's physical status prior to surgery and decrease the risk of POD and POCD. Evidence-based protocols are warranted to standardize care in efforts to effectively meet the needs of these patients.
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Affiliation(s)
- Tasneem F Hasan
- Department of Neurology, Ochsner Louisiana State University Health Sciences Center, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Roger E Kelley
- Department of Neurology, Ochsner Louisiana State University Health Sciences Center, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Elyse M Cornett
- Department of Anesthesiology, Ochsner Louisiana State University Health Sciences Center, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham and Women's Hospital, 75 Francis St, Boston, Massachussetts, 02115, USA.
| | - Alan D Kaye
- Departments of Anesthesiology and Pharmacology, Toxicology, and Neurosciences, Ochsner Louisiana State University Health Sciences Center, 1501 Kings Highway, Shreveport, LA, 71103, USA.
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Zhan G, Hua D, Huang N, Wang Y, Li S, Zhou Z, Yang N, Jiang R, Zhu B, Yang L, Yu F, Xu H, Yang C, Luo A. Anesthesia and surgery induce cognitive dysfunction in elderly male mice: the role of gut microbiota. Aging (Albany NY) 2020; 11:1778-1790. [PMID: 30904902 PMCID: PMC6461176 DOI: 10.18632/aging.101871] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 03/10/2019] [Indexed: 12/14/2022]
Abstract
It is well known that the incidence of postoperative cognitive dysfunction (POCD) is high in elderly patients. The pathogenesis and therapeutic mechanisms of POCD, however, have not yet been completely elucidated. The effects of gut microbiota, particularly in terms of regulating brain function, have gradually attracted increasing attention. In this study, we investigated the potential role of gut microbiota in POCD in aged male mice and attempted to determine whether alterations in gut microbiota would be helpful in the diagnosis of POCD. POCD and non-POCD mice were classified by hierarchical cluster analysis of behavioral results. Additionally, α- and β-diversity of gut microbiota showed a differential profile between the groups. In total, 24 gut bacteria were significantly altered in POCD mice compared with those in non-POCD mice, in which 13 gut bacteria were significantly correlated with escape latency in the Morris water maze test (MWMT). Remarkably, receiver operating characteristic curves revealed that the Dehalobacteriaceae family and Dehalobacterium genus are potentially important bacteria for the diagnosis of POCD. These findings indicate that alterations in the composition of gut microbiota are probably involved in the pathogenesis of POCD in aged mice. Novel therapeutic strategies regulating specific gut bacteria may be helpful for the prevention and treatment of POCD.
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Affiliation(s)
- Gaofeng Zhan
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Dongyu Hua
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Niannian Huang
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yue Wang
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shan Li
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhiqiang Zhou
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ning Yang
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Riyue Jiang
- Department of Internal Medicine, The Third Affiliated Hospital of Soochow University, Jiangsu, China
| | - Bin Zhu
- Department of Internal Medicine, The Third Affiliated Hospital of Soochow University, Jiangsu, China
| | - Ling Yang
- Department of Internal Medicine, The Third Affiliated Hospital of Soochow University, Jiangsu, China
| | - Fan Yu
- Department of Internal Medicine, The Third Affiliated Hospital of Soochow University, Jiangsu, China
| | - Hui Xu
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chun Yang
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ailin Luo
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Cao C, Deng F, Hu Y. Dexmedetomidine alleviates postoperative cognitive dysfunction through circular RNA in aged rats. 3 Biotech 2020; 10:176. [PMID: 32226705 PMCID: PMC7093639 DOI: 10.1007/s13205-020-2163-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 03/07/2020] [Indexed: 12/16/2022] Open
Abstract
Circular RNA (circRNA) has been well studied in many diseases, whereas their role in patients with postoperative cognitive dysfunction (POCD) remains largely unclear. Here, we investigated the therapeutic effects of dexmedetomidine (Dex) on POCD and analyzed the role of circRNA as well as the pathways that may be involved. The Morris water maze test demonstrated that POCD rats have a longer incubation period than the normal group, but the latency of POCD rats was significantly lower after Dex treatment. Moreover, HE staining showed that Dex improved hippocampal pathological changes. RNA sequencing showed 164 differentially expressed circRNAs between POCD and Dex groups; 74 were upregulated and 90 were downregulated in the Dex group. A total of 20,790 target genes for differentially expressed circRNAs were observed in RNAhybrid and Miranda databases. Gene ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analyses showed that the target genes of differentially expressed circRNAs are mainly focused on positive regulation of intrinsic apoptotic signaling pathway in response to DNA damage, negative regulation of cell adhesion mediated by integrin, and response to cytokines and other function of life activities and involved in the P53 signaling pathway and nuclear factor kappa B (NF-κB) signaling pathway. Furthermore, the expression of five candidate circRNAs (circ-Shank3, circ-Cdc42bpa, circ-chrx-24658, cir-chr17-3642 and circ-Sgsm1) and target genes were consistent with the RNA sequencing results, which was verified by quantitative real-time polymerase chain reaction (qRT-PCR). These results indicate that circ-Shank3 participate in the process of Dex improved POCD through regulating the P53 and NF-κB signaling pathways and may potentially facilitate POCD treatment through the development of clinical drugs.
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Affiliation(s)
- Cao Cao
- Department of Anesthesiology, Donghu District, The Second Affiliated Hospital of Nanchang University, No. 1 Minde Road, Nanchang, 330006 Jiangxi China
| | - Fumou Deng
- Department of Anesthesiology, Donghu District, The Second Affiliated Hospital of Nanchang University, No. 1 Minde Road, Nanchang, 330006 Jiangxi China
| | - Yanhui Hu
- Department of Anesthesiology, Donghu District, The Second Affiliated Hospital of Nanchang University, No. 1 Minde Road, Nanchang, 330006 Jiangxi China
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24
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Belrose JC, Noppens RR. Anesthesiology and cognitive impairment: a narrative review of current clinical literature. BMC Anesthesiol 2019; 19:241. [PMID: 31881996 PMCID: PMC6933922 DOI: 10.1186/s12871-019-0903-7] [Citation(s) in RCA: 102] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 12/03/2019] [Indexed: 12/14/2022] Open
Abstract
Background The impact of general anesthesia on cognitive impairment is controversial and complex. A large body of evidence supports the association between exposure to surgery under general anesthesia and development of delayed neurocognitive recovery in a subset of patients. Existing literature continues to debate whether these short-term effects on cognition can be attributed to anesthetic agents themselves, or whether other variables are causative of the observed changes in cognition. Furthermore, there is conflicting data on the relationship between anesthesia exposure and the development of long-term neurocognitive disorders, or development of incident dementia in the patient population with normal preoperative cognitive function. Patients with pre-existing cognitive impairment present a unique set of anesthetic considerations, including potential medication interactions, challenges with cooperation during assessment and non-general anesthesia techniques, and the possibility that pre-existing cognitive impairment may impart a susceptibility to further cognitive dysfunction. Main body This review highlights landmark and recent studies in the field, and explores potential mechanisms involved in perioperative cognitive disorders (also known as postoperative cognitive dysfunction, POCD). Specifically, we will review clinical and preclinical evidence which implicates alterations to tau protein, inflammation, calcium dysregulation, and mitochondrial dysfunction. As our population ages and the prevalence of Alzheimer’s disease and other forms of dementia continues to increase, we require a greater understanding of potential modifiable factors that impact perioperative cognitive impairment. Conclusions Future research should aim to further characterize the associated risk factors and determine whether certain anesthetic approaches or other interventions may lower the potential risk which may be conferred by anesthesia and/or surgery in susceptible individuals.
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Affiliation(s)
- Jillian C Belrose
- Department of Anesthesia & Perioperative Medicine, Western University, London Health Sciences Center, 339 Windermere Rd, London, ON, N6A 5A5, Canada
| | - Ruediger R Noppens
- Department of Anesthesia & Perioperative Medicine, Western University, London Health Sciences Center, 339 Windermere Rd, London, ON, N6A 5A5, Canada.
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25
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Sun XY, Zheng T, Yang X, Liu L, Gao SS, Xu HB, Song YT, Tong K, Yang L, Gao Y, Wu T, Hao JR, Lu C, Ma T, Gao C. HDAC2 hyperexpression alters hippocampal neuronal transcription and microglial activity in neuroinflammation-induced cognitive dysfunction. J Neuroinflammation 2019; 16:249. [PMID: 31796106 PMCID: PMC6889553 DOI: 10.1186/s12974-019-1640-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 11/12/2019] [Indexed: 02/08/2023] Open
Abstract
Background Inflammation can induce cognitive dysfunction in patients who undergo surgery. Previous studies have demonstrated that both acute peripheral inflammation and anaesthetic insults, especially isoflurane (ISO), are risk factors for memory impairment. Few studies are currently investigating the role of ISO under acute peri-inflammatory conditions, and it is difficult to predict whether ISO can aggravate inflammation-induced cognitive deficits. HDACs, which are essential for learning, participate in the deacetylation of lysine residues and the regulation of gene transcription. However, the cell-specific mechanism of HDACs in inflammation-induced cognitive impairment remains unknown. Methods Three-month-old C57BL/6 mice were treated with single versus combined exposure to LPS injected intraperitoneally (i.p.) to simulate acute abdominal inflammation and isoflurane to investigate the role of anaesthesia and acute peripheral inflammation in cognitive impairment. Behavioural tests, Western blotting, ELISA, immunofluorescence, qRT-PCR, and ChIP assays were performed to detect memory, the expressions of inflammatory cytokines, HDAC2, BDNF, c-Fos, acetyl-H3, microglial activity, Bdnf mRNA, c-fos mRNA, and Bdnf and c-fos transcription in the hippocampus. Results LPS, but not isoflurane, induced neuroinflammation-induced memory impairment and reduced histone acetylation by upregulating histone deacetylase 2 (HDAC2) in dorsal hippocampal CaMKII+ neurons. The hyperexpression of HDAC2 in neurons was mediated by the activation of microglia. The decreased level of histone acetylation suppressed the transcription of Bdnf and c-fos and the expressions of BDNF and c-Fos, which subsequently impaired memory. The adeno-associated virus ShHdac2, which suppresses Hdac2 after injection into the dorsal hippocampus, reversed microglial activation, hippocampal glutamatergic BDNF and c-Fos expressions, and memory deficits. Conclusions Reversing HDAC2 in hippocampal CaMKII+ neurons exert a neuroprotective effect against neuroinflammation-induced memory deficits.
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Affiliation(s)
- Xiao-Yu Sun
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, 209 Tongshan Road, Xuzhou, 221004, Jiangsu, China.,Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application, Xuzhou Medical University, Xuzhou, 221004, Jiangsu, China
| | - Teng Zheng
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, 209 Tongshan Road, Xuzhou, 221004, Jiangsu, China.,Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application, Xuzhou Medical University, Xuzhou, 221004, Jiangsu, China.,Department of Anesthesiology, the First Affiliated Hospital of Soochow University, Suzhou, 215006, Jiangsu, China
| | - Xiu Yang
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, 209 Tongshan Road, Xuzhou, 221004, Jiangsu, China.,Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application, Xuzhou Medical University, Xuzhou, 221004, Jiangsu, China
| | - Le Liu
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, 209 Tongshan Road, Xuzhou, 221004, Jiangsu, China.,Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application, Xuzhou Medical University, Xuzhou, 221004, Jiangsu, China
| | - Shen-Shen Gao
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, 209 Tongshan Road, Xuzhou, 221004, Jiangsu, China.,Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application, Xuzhou Medical University, Xuzhou, 221004, Jiangsu, China
| | - Han-Bing Xu
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, 209 Tongshan Road, Xuzhou, 221004, Jiangsu, China.,Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application, Xuzhou Medical University, Xuzhou, 221004, Jiangsu, China
| | - Yu-Tong Song
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, 209 Tongshan Road, Xuzhou, 221004, Jiangsu, China.,Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application, Xuzhou Medical University, Xuzhou, 221004, Jiangsu, China
| | - Kun Tong
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, 209 Tongshan Road, Xuzhou, 221004, Jiangsu, China.,Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application, Xuzhou Medical University, Xuzhou, 221004, Jiangsu, China
| | - Li Yang
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, 209 Tongshan Road, Xuzhou, 221004, Jiangsu, China.,Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application, Xuzhou Medical University, Xuzhou, 221004, Jiangsu, China
| | - Ya Gao
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, 209 Tongshan Road, Xuzhou, 221004, Jiangsu, China.,Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application, Xuzhou Medical University, Xuzhou, 221004, Jiangsu, China
| | - Tong Wu
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, 209 Tongshan Road, Xuzhou, 221004, Jiangsu, China.,Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application, Xuzhou Medical University, Xuzhou, 221004, Jiangsu, China
| | - Jing-Ru Hao
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, 209 Tongshan Road, Xuzhou, 221004, Jiangsu, China.,Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application, Xuzhou Medical University, Xuzhou, 221004, Jiangsu, China
| | - Chen Lu
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, 209 Tongshan Road, Xuzhou, 221004, Jiangsu, China.,Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application, Xuzhou Medical University, Xuzhou, 221004, Jiangsu, China
| | - Tao Ma
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, 209 Tongshan Road, Xuzhou, 221004, Jiangsu, China.,Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application, Xuzhou Medical University, Xuzhou, 221004, Jiangsu, China
| | - Can Gao
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, 209 Tongshan Road, Xuzhou, 221004, Jiangsu, China. .,Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application, Xuzhou Medical University, Xuzhou, 221004, Jiangsu, China.
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26
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Knaak C, Vorderwülbecke G, Spies C, Piper SK, Hadzidiakos D, Borchers F, Brockhaus W, Radtke FM, Lachmann G. C-reactive protein for risk prediction of post-operative delirium and post-operative neurocognitive disorder. Acta Anaesthesiol Scand 2019; 63:1282-1289. [PMID: 31283835 DOI: 10.1111/aas.13441] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 05/12/2019] [Accepted: 06/12/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Post-operative delirium (POD) and post-operative neurocognitive disorder (NCD) are frequently seen in the elderly. Development of biomarkers for pre-operative risk prediction is of major relevance. As inflammation present before surgery might predispose to POD and post-operative NCD development, we aim to determine associations between pre-operative C-reactive protein (CRP) and the incidence of POD and post-operative NCD. METHODS In this observational study, we analyzed 314 patients enrolled in the SuDoCo trial, who had a pre-operative CRP measurement the day before surgery. Primary outcomes were POD assessed according DSM-4 from day 1 until day 7 after surgery and post-operative NCD assessed 3 months after surgery. We conducted multivariable logistic regression analysis adjusted for age, sex, randomization, body mass index, MMSE, ASA status, infection/autoimmune disease/malignoma and types of surgery to determine associations between CRP with POD and post-operative NCD, respectively. RESULTS Pre-operative CRP was independently associated with POD [OR 1.158 (95% CI 1.040, 1.291); P = .008]. Patients with CRP values ≥5 mg/dL had a 4.8-fold increased POD risk [OR 4.771 (95% CI 1.765, 12.899; P = .002)] compared to patients with lower CRP values. However, no association was seen between pre-operative CRP and post-operative NCD [OR 0.552 (95% CI 0.193, 1.581); P = .269]. CONCLUSIONS Pre-operative CRP levels were independently associated with POD but not post-operative NCD after three months. Moreover, higher pre-operative CRP levels showed higher risk for POD. This strengthens the role of inflammation in the development of POD. Assessment of CRP before surgery might allow risk stratification of POD. TRIAL REGISTRATION This study was registered with ISRCTN Register 36437985 on 02 March 2009.
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Affiliation(s)
- Cornelia Knaak
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK) Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
| | - Gerald Vorderwülbecke
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK) Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
| | - Claudia Spies
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK) Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
| | - Sophie K. Piper
- Institute of Biometry and Clinical Epidemiology Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
- Berlin Institute of Health (BIH) Berlin Germany
| | - Daniel Hadzidiakos
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK) Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
| | - Friedrich Borchers
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK) Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
| | - Wolf‐Rüdiger Brockhaus
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK) Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
| | | | - Gunnar Lachmann
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK) Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
- Berlin Institute of Health (BIH) Berlin Germany
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Li PJ, Guo YQ, Ding PY, Liu RB, Deng F, Feng XX, Yan WJ. Neuroprotective effects of a Smoothened receptor agonist against postoperative cognitive dysfunction by promoting autophagy in the dentate gyrus of aged rats. Neurol Res 2019; 41:867-874. [PMID: 31221056 DOI: 10.1080/01616412.2019.1628411] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Objectives: To investigate the effect of purmorphamine (PUR), a Shh co-receptor Smoothened (Smo) agonist, on postoperative cognitive dysfunction (POCD) rat models. Methods: Eighteen-month-old male Sprague-Dawley rats were subjected to intramedullary fixation of a tibial fracture with 7% chloral hydrate anesthesia to mimic human clinical surgery. PUR was administered via an intraperitoneal injection at a dose of 15mg/kg/day for 3 consecutive days at 6 h after surgery. The aged rats were sacrificed after performing a Morris water maze test 1, 3, and 7 days postoperatively to evaluate the expression of related proteins at the appointed time. Results: Compared to the POCD + vehicle group and sham + PUR group, the POCD + PUR group restored neurological deficit (P = 0.01). PUR administration induced upregulation of Shh expression on postoperative day 1 (P = 0.02), which continued on the third day (P = 0.008) but dropped by the 7th day (P = 0.03). Immunofluorescent analysis, similar to western blot analysis, showed a significant increase in the autophagy-marker LC3 (P = 0.006) as well as p62 degradation (P = 0.000) in the dentate gyrus of the aged rats (P = 0.000) after PUR treatment. Importantly, LC3 was mainly found in the presynaptic and postsynaptic membranes of the hippocampus. Conclusions: These results indicate a link between Shh and autophagy in the rat model of POCD, providing new insights into Shh signaling pathway-mediated mechanisms of neuroprotection and cognitive repair after POCD. It also provides a potential entry point for the development of clinical drugs.
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Affiliation(s)
- Pei-Jun Li
- Department of Anesthesiology, Gansu Province People's Hospital , LanZhou , China
| | - Ying-Qiang Guo
- Department of Anesthesiology, Gansu Province People's Hospital , LanZhou , China
| | - Pei-Yan Ding
- Department of Anesthesiology, Gansu Province People's Hospital , LanZhou , China
| | - Ruo-Bing Liu
- Department of Anesthesiology, Gansu Province People's Hospital , LanZhou , China
| | - Fei Deng
- Department of Anesthesiology, Gansu Province People's Hospital , LanZhou , China
| | - Xiao-Xue Feng
- Department of Anesthesiology, Gansu Province People's Hospital , LanZhou , China
| | - Wen-Jun Yan
- Department of Anesthesiology, Gansu Province People's Hospital , LanZhou , China.,Lanzhou University , LanZhou , China
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Ravi B, Pincus D, Choi S, Jenkinson R, Wasserstein DN, Redelmeier DA. Association of Duration of Surgery With Postoperative Delirium Among Patients Receiving Hip Fracture Repair. JAMA Netw Open 2019; 2:e190111. [PMID: 30794305 PMCID: PMC6484601 DOI: 10.1001/jamanetworkopen.2019.0111] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE Postoperative delirium in older adults receiving hip fracture surgery is associated with morbidity and increased health care costs, yet little is known of potential modifiable factors that may help limit the risks. OBJECTIVE To use population-wide individual-level data on the duration of hip fracture surgery to determine whether prolonged surgical times and type of anesthesia are associated with an increased risk of postoperative delirium. DESIGN, SETTING, AND PARTICIPANTS This retrospective population-based cohort study analyzed patients aged 65 years and older receiving hip fracture surgery between April 1, 2009, and March 30, 2017, at 80 hospitals in Ontario, Canada. Generalized estimated equations with logistic regression analysis were used to determine the relationship between procedure duration, type of anesthesia, and the occurrence of postoperative delirium. Restricted cubic splines were also generated to visualize this relationship. Data analysis was conducted from July to October 2018, revision in January 2019. EXPOSURE Surgery duration, measured as the total time in the operating room. MAIN OUTCOMES AND MEASURES A diagnosis of postoperative delirium during hospitalization. RESULTS Among 68 131 patients with surgically managed hip fracture (median [interquartile range] age, 84 [78-89] years; 72% women) identified, 7150 patients experienced postoperative delirium. In total, 26 853 patients (39.4%) received general anesthesia. Receiving general anesthesia was associated with a slightly higher rate of postoperative delirium compared with not receiving general anesthesia (2943 [11.0%] vs 4207 [10.2%]; P = .001). The risk for delirium increased with increased surgical duration-every 30-minute increase in the duration of surgery was associated with a 6% increase in the risk for delirium (adjusted odds ratio, 1.06; 95% CI, 1.03-1.08; P < .001). Prolonged surgical duration was associated with a higher incidence of postoperative delirium, and the risk was higher was in patients who had received general anesthesia (adjusted odds ratio, 1.08; 95% CI, 1.04-1.12; P < .001) than in those patients who did not receive GA (adjusted odds ratio, 1.04; 95% CI, 1.01-1.08; P = .01). CONCLUSIONS AND RELEVANCE Among older adults receiving hip fracture surgery, both an increased duration of surgery and receiving a general anesthetic were associated with an increased risk for postoperative delirium.
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Affiliation(s)
- Bheeshma Ravi
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Daniel Pincus
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Stephen Choi
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Richard Jenkinson
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - David N. Wasserstein
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Donald A. Redelmeier
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Chuan A, Short TG, Peng AZY, Wen SYB, Sun AX, Ting TH, Wan AS, Pope L, Jaeger M, Aneman A. Is cerebrovascular autoregulation associated with outcomes after major noncardiac surgery? A prospective observational pilot study. Acta Anaesthesiol Scand 2019; 63:8-17. [PMID: 30079514 DOI: 10.1111/aas.13223] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 06/15/2018] [Accepted: 07/11/2018] [Indexed: 01/13/2023]
Abstract
BACKGROUND Studies have identified multiple risk factors for development of cognitive decline after surgery. Impaired cerebrovascular autoregulation may be a contributor to postoperative cognitive decline. METHODS One hundred and forty patients admitted for major elective noncardiac surgery were recruited. Near-infrared spectroscopy was used to calculate the tissue oxygenation index of dynamic autoregulation (TOx). The primary endpoint was Day 3 cognitive recovery as assessed using the Postoperative Quality of Recovery Scale. The secondary endpoint was a combined major adverse event of death, acute myocardial infarction, cardiac arrest, stroke, pulmonary embolism, sepsis, and acute kidney injury at Day 30. RESULTS Higher optimal TOx values, signifying impaired autoregulation, were associated with worse outcomes. Patients who cognitively recovered at Day 3 (n = 47) had lower optimal TOx values (TOxopt ) than patients who did not recover (n = 22): 0.06 (0.24) vs 0.18 (0.16) (mean [SD]), P = 0.02. Patients who did not suffer a major adverse event (n = 102) had lower TOxopt than patients who did (n = 17): 0.09 (0.21) vs 0.20 (0.27), P = 0.04. When dichotomized as having impaired or intact autoregulation based on TOxopt levels, a value of TOxopt ≥0.1 correctly identified 72.7% of patients who did not cognitively recover, OR 3.3 (1.1-9.9) (Odds ratio, [95% CI]), P = 0.03. TOxopt ≥0.1 correctly identified 82.4% of patients who suffered a major adverse event, OR 4.7 (1.3-17.2), P = 0.02. CONCLUSIONS In older and higher risk patients having major noncardiac surgery, impaired cerebrovascular autoregulation was associated with failure of cognitive recovery in the early postoperative period and with 1-month mortality and morbidity.
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Affiliation(s)
- Alwin Chuan
- South Western Sydney Clinical School; University of New South Wales; Sydney New South Wales Australia
- Department of Anaesthesia; Liverpool Hospital; Sydney New South Wales Australia
| | - Timothy G. Short
- Department of Anaesthesia; Auckland City Hospital; Auckland New Zealand
| | - Alexander Z. Y. Peng
- South Western Sydney Clinical School; University of New South Wales; Sydney New South Wales Australia
| | - Shelly Y. B. Wen
- South Western Sydney Clinical School; University of New South Wales; Sydney New South Wales Australia
| | - Alice X. Sun
- South Western Sydney Clinical School; University of New South Wales; Sydney New South Wales Australia
| | - Timothy H. Ting
- South Western Sydney Clinical School; University of New South Wales; Sydney New South Wales Australia
| | - Anthony S. Wan
- South Western Sydney Clinical School; University of New South Wales; Sydney New South Wales Australia
- Department of Anaesthesia; Liverpool Hospital; Sydney New South Wales Australia
| | - Linda Pope
- Department of Anaesthesia; Liverpool Hospital; Sydney New South Wales Australia
| | - Matthias Jaeger
- South Western Sydney Clinical School; University of New South Wales; Sydney New South Wales Australia
- Department of Neurosurgery; Wollongong Hospital; Wollongong New South Wales Australia
| | - Anders Aneman
- South Western Sydney Clinical School; University of New South Wales; Sydney New South Wales Australia
- Department of Intensive Care; Liverpool Hospital; Sydney New South Wales Australia
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Abstract
We provide a synopsis of innovative research, recurring themes, and novel experimental findings pertinent to the care of neurosurgical patients and critically ill patients with neurological diseases. We cover the following broad topics: general neurosurgery, spine surgery, stroke, traumatic brain injury, monitoring, and anesthetic neurotoxicity.
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Abstract
PURPOSE OF REVIEW The extrinsic risk factors for postoperative cognitive disturbance have been a source of concern during the perioperative period, and these risk factors remain the subject of controversy. This review of recent studies focuses on the effect of these factors on postoperative cognitive disturbance during the perioperative period. RECENT FINDINGS Impairment of cerebral autoregulation may predispose patients to intraoperative cerebral malperfusion, which may subsequently induce postoperative cognitive disturbance. The neurotoxicity of several volatile anesthetics may contribute to cognitive functional decline, and the impact of intravenous anesthesia on cognitive function requires further exploration. Multimodal analgesia may not outperform traditional postoperative analgesia in preventing postoperative delirium. Furthermore, acute pain and chronic pain may exacerbate the cognitive functional decline of patients with preexisting cognitive impairment. The nuclear factor-kappa beta pathway is an important node in the neuroinflammatory network. SUMMARY Several intraoperative factors are associated with postoperative cognitive disturbance. However, if these factors are optimized in perioperative management, postoperative cognitive disturbance will improve.
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Affiliation(s)
- Huiqun Fu
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
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Liu X, Yu Y, Zhu S. Inflammatory markers in postoperative delirium (POD) and cognitive dysfunction (POCD): A meta-analysis of observational studies. PLoS One 2018; 13:e0195659. [PMID: 29641605 PMCID: PMC5895053 DOI: 10.1371/journal.pone.0195659] [Citation(s) in RCA: 121] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 03/27/2018] [Indexed: 11/19/2022] Open
Abstract
Background The aim of this study was to summarize and discuss the similarities and differences in inflammatory biomarkers in postoperative delirium (POD) and cognitive dysfunction (POCD). Methods A systematic retrieval of literature up to June 2017 in PubMed, Embase, the Cochrane Library, the China National Knowledge Infrastructure database, and the Wanfang database was conducted. Extracted data were analyzed with STATA (version 14). The standardized mean difference (SMD) and the 95% confidence interval (95% CI) of each indicator were calculated using a random effect model. We also performed tests of heterogeneity, sensitivity analysis, assessments of bias, and meta-regression in this meta-analysis. Results A total of 54 observational studies were included. By meta-analysis we found significantly increased C-reactive protein (CRP) (9 studies, SMD 0.883, 95% CI 0.130 to 1.637, P = 0.022 in POD; 10 studies, SMD -0.133, 95% CI -0.512 to 0.246, P = 0.429 in POCD) and interleukin (IL)-6 (7 studies, SMD 0.386, 95% CI 0.054 to 0.717, P = 0.022 in POD; 16 studies, SMD 0.089, 95% CI -0.133 to 0.311, P = 0.433 in POCD) concentrations in both POD and POCD patients. We also found that the SMDs of CRP and IL-6 from POCD patients were positively correlated with surgery type in the meta-regression (CRP: Coefficient = 1.555365, P = 0.001, 10 studies; IL-6: Coefficient = -0.6455521, P = 0.086, 16 studies). Conclusion Available evidence from medium-to-high quality observational studies suggests that POD and POCD are indeed correlated with the concentration of peripheral and cerebrospinal fluid (CSF) inflammatory markers. Some of these markers, such as CRP and IL-6, play roles in both POD and POCD, while others are specific to either one of them.
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Affiliation(s)
- Xuling Liu
- Zhejiang University School of Medicine, Hangzhou, Zhejiang, P.R. China
| | - Yang Yu
- Zhejiang University School of Medicine, Hangzhou, Zhejiang, P.R. China
| | - Shengmei Zhu
- Zhejiang University School of Medicine, Hangzhou, Zhejiang, P.R. China
- Department of Anesthesiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, P.R. China
- * E-mail:
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35
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Respiration-related cerebral blood flow variability increases during control-mode non-invasive ventilation in normovolemia and hypovolemia. Eur J Appl Physiol 2017; 117:2237-2249. [DOI: 10.1007/s00421-017-3711-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Accepted: 09/01/2017] [Indexed: 01/12/2023]
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36
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Sheffy N, Bentov I, Mills B, Nair BG, Rooke GA, Vavilala MS. Perioperative hypotension and discharge outcomes in non-critically injured trauma patients, a single centre retrospective cohort study. Injury 2017; 48:1956-1963. [PMID: 28733043 DOI: 10.1016/j.injury.2017.06.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 06/20/2017] [Accepted: 06/22/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND There is a lack of information on the effect of age on perioperative care and outcomes after minor trauma in the elderly. We examined the association between perioperative hypotension and discharge outcome among non-critically injured adult patients. METHODS We conducted a retrospective study of non-critically ill patients (ISS <9 or discharged within less than 24h) who received anaesthesia care for surgery and Recovery Room care at a level-1 trauma centre between 5/1/2012 and 11/30/2013. Perioperative hypotension was defined as systolic blood pressure (SBP) <90mmHg (traditional measure) for all patients, and SBP <110mmHg (strict measure) for patients ≥65years. Poor outcome was defined as death or discharge to skilled nursing facility/hospice. RESULTS 1744 patients with mean ISS 4.4 across age groups were included; 169 (10%) were ≥65years. Among patients≥65years, intraoperative hypotension occurred in >75% (131/169, traditional measure) and in >95% (162/169, strict measure); recovery room hypotension occurred in 2% (4/169) and 29% (49/169), respectively. Mean age-adjusted anaesthetic agent concentration (MAC) was similar across age groups. Opioid use decreased from 9.3 (SD 5.7) mg/h morphine equivalents in patients <55years to 6.2 (SD 4.0) mg/h in patients over 85 years. Adjusted for gender, ASA score, anaesthesia duration, morphine equivalent/hr, fluid balance, MAC and surgery type, and using traditional definition, older patients were more likely than patients <55 to experience perioperative hypotension: aRR 1.21, 95% CI 1.11-1.30 for 55-64 and aRR 1.19, 95% CI 1.07-1.32 for ages 65-74. Perioperative hypotension was associated with poor discharge outcome (aRR 1.55; 95% CI 1.04-2.31 and aRR 1.87; 95% CI 1.17-2.98, respectively). CONCLUSION Despite age related reduction in doses of volatile anaesthetic and opioids administered during anaesthesia care, and regardless of hypotension definition used, non-critically injured patients undergoing surgery experience a large perioperative hypotension burden. This burden is higher for patients 55-74 years and older and is a risk factor for poor discharge outcomes, independent of age and ASA status.
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Affiliation(s)
- Nadav Sheffy
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States; Department of Anesthesiology, Rabin Medical Center, Petah Tikva, Israel(2).
| | - Itay Bentov
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Brianna Mills
- Harborview Injury Prevention and Research Center, Seattle, WA, United States; Department of Epidemiology, University of Washington, Seattle, WA, United States; Center for Studies in Demography and Ecology, University of Washington, Seattle, WA, United States
| | - Bala G Nair
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States; Harborview Injury Prevention and Research Center, Seattle, WA, United States
| | - G Alec Rooke
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Monica S Vavilala
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States; Harborview Injury Prevention and Research Center, Seattle, WA, United States
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Mikkelsen MLG, Ambrus R, Rasmussen R, Miles JE, Poulsen HH, Moltke FB, Eriksen T. The effect of dexmedetomidine on cerebral perfusion and oxygenation in healthy piglets with normal and lowered blood pressure anaesthetized with propofol-remifentanil total intravenous anaesthesia. Acta Vet Scand 2017; 59:27. [PMID: 28468670 PMCID: PMC5415812 DOI: 10.1186/s13028-017-0293-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 04/21/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND During anaesthesia and surgery, in particular neurosurgery, preservation of cerebral perfusion and oxygenation (CPO) is essential for normal postoperative brain function. The isolated effects on CPO of either individual anaesthetic drugs or entire anaesthetic protocols are of importance in both clinical and research settings. Total intravenous anaesthesia (TIVA) with propofol and remifentanil is widely used in human neuroanaesthesia. In addition, dexmedetomidine is receiving increasing attention as an anaesthetic adjuvant in neurosurgical, intensive care, and paediatric patients. Despite the extensive use of pigs as animal models in neuroscience and the increasing use of both propofol-remifentanil and dexmedetomidine, very little is known about their combined effect on CPO in pigs with uninjured brains. This study investigates the effect of dexmedetomidine on CPO in piglets with normal and lowered blood pressure during background anaesthesia with propofol-remifentanil TIVA. Sixteen healthy female Danish pigs (crossbreeds of Danish Landrace, Yorkshire and Duroc, 25-34 kg) were used. Three animals were subsequently excluded. The animals were randomly allocated into one of two groups with either normal blood pressure (NBP, n = 6) or with induced low blood pressure (LBP, n = 7). Both groups were subjected to the same experimental protocol. Intravenous propofol induction was performed without premedication. Anaesthesia was maintained with propofol-remifentanil TIVA, and later supplemented with continuous infusion of dexmedetomidine. Assessments of cerebral perfusion obtained by laser speckle contrast imaging (LSCI) were related to cerebral oxygenation measures (PbrO2) obtained by an intracerebral Clark-type Licox probe. RESULTS Addition of dexmedetomidine resulted in a 32% reduction in median PbrO2 values for the LBP group (P = 0.03), but no significant changes in PbrO2 were observed for the NBP group. No significant changes in LSCI readings were observed in either group between any time points, despite a 28% decrease in the LBP group following dexmedetomidine administration. Caval block resulted in a significant (P = 0.02) reduction in median MAP from 68 mmHg (range 63-85) at PCB to 58 mmHg (range 53-63) in the LBP group, but no significant differences in either PbrO2 or LSCI were observed due to this intervention (P = 0.6 and P = 0.3 respectively). CONCLUSIONS Addition of dexmedetomidine to propofol-remifentanil TIVA resulted in a significant decrease in cerebral oxygenation (PbrO2) measurements in piglets with lowered blood pressure. Cerebral perfusion (LSCI) did not decrease significantly in this group. In piglets with normal blood pressure, no significant changes in cerebral perfusion or oxygenation were seen in response to addition of dexmedetomidine to the background anaesthesia.
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Affiliation(s)
- Mai Louise Grandsgaard Mikkelsen
- Department of Veterinary Clinical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, 16 Dyrlægevej, 1870 Frederiksberg C, Denmark
| | - Rikard Ambrus
- Department of Surgical Gastroenterology C, Rigshospitalet, Faculty of Health and Medical Sciences, University of Copenhagen, 9 Blegdamsvej, 2100 Copenhagen Ø, Denmark
| | - Rune Rasmussen
- Department of Neurosurgery, The Neuroscience Centre, Rigshospitalet, Faculty of Health and Medical Sciences, University of Copenhagen, 9 Blegdamsvej, 2100 Copenhagen Ø, Denmark
| | - James Edward Miles
- Department of Veterinary Clinical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, 16 Dyrlægevej, 1870 Frederiksberg C, Denmark
| | - Helle Harding Poulsen
- Department of Veterinary Clinical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, 16 Dyrlægevej, 1870 Frederiksberg C, Denmark
| | - Finn Borgbjerg Moltke
- Department of Neuroanaesthesia, Rigshospitalet, University of Copenhagen, 9 Blegdamsvej, 2100 Copenhagen Ø, Denmark
- Department of Anaesthesia, Bispebjerg and Frederiksberg Hospitals, Faculty of Health and Medical Sciences, University of Copenhagen, 23 Bispebjerg Bakke, 2400 Copenhagen NV, Denmark
| | - Thomas Eriksen
- Department of Veterinary Clinical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, 16 Dyrlægevej, 1870 Frederiksberg C, Denmark
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