The Effects of Propofol and Sevoflurane on Postoperative Delirium in Older Patients: A Randomized Clinical Trial Study

The effect of two different modes of anaesthesia maintenance on postoperative delirium in elderly patient with low preoperative mini-cog score

BACKGROUND

Postoperative delirium is a common distressing symptom experienced following laparoscopic cholecystectomy. The study aimed to investigate the influence of a low preoperative Mini-Cog testing score and 2 different anesthesia methods: total intravenous anaesthesia (TIVA) versus sevoflurane, on postoperative delirium in elderly patients undergoing laparoscopic cholecystectomy.

METHODS

A total of 84 patients over 60 years old who underwent laparoscopic cholecystectomy between March 1and - October 1 2023 were included in the study. Patients with a Mini-Cog score of 0-2 were considered to have low and possibly impaired neurocognitive function. We invastigated the effects of preoperative Mini-Cog score and the two anesthesia methods used on the incidence of postoperative delirium.

RESULTS

The proportion of patients with low Mini-Cog score in the preoperative period was 17.9%. Sevoflurane and TIVA was used in 41 and 43 patients respectively. The incidence of postoperative delirium in patients with low preoperative Mini-Cog scores was 66.7% at postoperative 0 h and 33.3% at the 1st hours. Postoperative delirium was found to be statistically higher in patients with low Mini-cog scores than in those with negatively-screened for Mini-cog scores (p: 0.01-0.035). In patients using sevoflurane, the incidence of postoperative delirium was 26.8% and 24.4% at the 0 and 1st hours, respectively. This was found to be statistically higher than in patients receiving TIVA (p: 0.036 - 0.010).

CONCLUSION

Low Mini-Cog score was an indicator of a higher risk of early postoperative delirium. Sevoflurane is more likely to cause postoperative delirium than TIVA.

TRIAL REGISTRATION

The study was registered on ClinicalTrials.gov (Identifier: NCT06597812) .

Characteristics associated with effectiveness in postoperative delirium research: a systematic review of randomised controlled trials with meta-regression and meta-analysis

BACKGROUND

Postoperative delirium remains prevalent despite extensive research through randomised trials aimed at reducing its incidence. Understanding trial characteristics associated with interventions' effectiveness facilitates data interpretation.

METHODS

Trial characteristics were extracted from eligible trials identified through two systematic literature searches. Multivariable meta-regression was used to investigate trial characteristics associated with effectiveness estimated using odds ratios. Meta-analysis was used to investigate pooled effectiveness.

RESULTS

We identified 201 eligible trials. Compared with China, trials from the USA/Canada (ratio of odds ratio, 1.89; 95% confidence interval, 1.45-2.45) and Europe/Australia/New Zealand (1.67; 1.29-2.18) had an 89% and 67% higher odds ratio, respectively, suggesting reduced effectiveness. The effectiveness was enhanced when the incidence of postoperative delirium increased (0.85; 0.79-0.92, per 10% increase). Trials with concerns related to deviations from intended interventions reported increased effectiveness compared with those at low risk (0.69; 0.53-0.90). Compared with usual care, certain interventions appeared to have reduced the incidence of postoperative delirium in low-risk trials with low-to-moderate certainty of evidence. However, these findings should be considered inconclusive because of challenges in grouping heterogeneous interventions, the limited number of eligible trials, the prevalence of small-scale studies, and potential publication bias.

CONCLUSIONS

The effectiveness of postoperative delirium trials varied based on the region of trial origin, the incidence of delirium, and the risk of bias. The limitations caution against drawing definitive conclusions from different bodies of evidence. These findings highlight the imperative need to improve the quality of research on a global scale.

SYSTEMATIC REVIEW PROTOCOL

PROSPERO (CRD42023413984).

Effect of different anesthetic modalities on postoperative delirium in elderly hip fractures: A meta-analysis

BACKGROUND

Previous findings on the effect of general versus spinal anesthesia on postoperative delirium in elderly people with hip fractures are somewhat controversial. This article included the latest randomized controlled study for meta-analysis to evaluate the effect of general anesthesia (GA) and spinal anesthesia (SA) on delirium after hip fracture surgery in the elderly, so as to guide the clinical.

METHODS

Cochrane Library, PubMed, Web Of Science, and Embase were searched from inception up to January 16, 2024. Randomized controlled trial (RCT) was included to evaluate the postoperative results of GA and SA in elderly patients (≥50 years old) undergoing hip fracture surgery. Two researchers independently screened for inclusion in the study and extracted data. Heterogeneity was assessed by the I²and Chi-square tests, and P < .1 or I² ≥ 50% indicated marked heterogeneity among studies. The Mantel-Haenszel method was used to estimate the combined relative risk ratio (RR) and the corresponding 95% confidence interval (CI) for the binary variables.

RESULTS

Nine randomized controlled trials were included. There was no significant difference (RR = 0.93, 95% CI = 0.774-1.111, P > .05) in the incidence of postoperative delirium between the GA group and the SA group. In intraoperative blood transfusion (RR = 1.0, 95% CI = 0.77-1.28, Z = 0.04, P = .971), pulmonary embolism (RR = 0.795, 95% CI = 0.332-1.904, Z = 0.59, P = .606), pneumonia (RR = 1.47, 95% CI = 0.75-2.87, P = .675), myocardial infarction (RR = 0.97, 95% CI = 0.24-3.86, Z = 0.05, P = .961), heart failure (RR = 0.80, 95% CI = 0.26-2.42, Z = 0.40, P = .961), urinary retention (RR = 1.42, 95% CI = 0.77-2.61, Z = 1.11, P = .267) were similar between the 2 anesthetic techniques.

CONCLUSION

There is no significant difference in the effect of GA and SA on postoperative delirium in elderly patients with hip fracture, and their effects on postoperative complications are similar.

Relationship Between Coronary Artery Revascularization and Postoperative Delirium: Progress and Perspectives

Brain dysfunction resulting from damage to the heart-brain link leads to a decline in cognitive function. This, in turn, gives rise to the clinical symptom of perioperative delirium in patients undergoing coronary artery revascularization. Those affected are provided symptomatic treatment, but many do not recover fully. Thus, medium- and long-term mortality and adverse event rates remain relatively high in patients with perioperative delirium. Despite the relatively high incidence of perioperative delirium in patients undergoing coronary artery revascularization, it has not been systematically investigated. Inflammation, vascular damage, neuronal damage, and embolism are all involved in the injury process. Here, we discuss the incidence rate, pathological mechanisms, and prognosis of delirium after coronary artery revascularization. We also discuss in detail the risk factors for delirium after coronary artery revascularization, such as anxiety, depression, mode of operation, and drug use. We hope that prevention, early diagnosis, assessment, and potential treatment can be achieved by cardiologists to improve patient prognosis.

Association Between Anesthetics and Postoperative Delirium in Elderly Patients Undergoing Spine Surgery: Propofol Versus Sevoflurane

STUDY DESIGNS

Retrospective Observational StudyObjectives: To compare the incidence of POD after propofol- and sevoflurane-based anesthesia in elderly patients undergoing spine surgery.

METHODS

In this study, the medical records of elderly patients ≥ 65 years of age who underwent spine surgery under total intravenous anesthesia with propofol or inhalational anesthesia with sevoflurane were reviewed. The primary outcome was the incidence of POD after propofol- and sevoflurane-based anesthesia. Secondary outcomes included postoperative 30-day complications, length of postoperative hospital stay, associations of patient characteristics, and surgery- and anesthesia-related data with the development of POD, and associations of anesthetics with clinical outcomes such as postoperative 30-day complications, and length of postoperative hospital stay.

RESULTS

Of the 281 patients, POD occurred in 29 patients (10.3%). POD occurred more frequently in the sevoflurane group than in the propofol group (15.7% vs. 5.0%, respectively; P=.003). The multivariable logistic regression analysis showed that sevoflurane-based anesthesia was associated with an increased risk of POD compared with propofol-based anesthesia (odds ratio [OR], 4.120; 95% confidence interval [CI], 1.549-10.954; P = .005), whereas anesthetics were not associated with postoperative 30-day complications and the length of postoperative hospital stay. Older age (OR, 1.242 CI, 1.130-1.366; P < .001) and higher mean pain score at postoperative day 1 (OR, 1.338 CI, 1.056-1.696; P = .016) were also associated with an increased risk of POD.

CONCLUSIONS

Propofol-based anesthesia was associated with a lower incidence of POD than sevoflurane-based anesthesia in elderly patients after spine surgery.

Update of the European Society of Anaesthesiology and Intensive Care Medicine evidence-based and consensus-based guideline on postoperative delirium in adult patients

Postoperative delirium (POD) remains a common, dangerous and resource-consuming adverse event but is often preventable. The whole peri-operative team can play a key role in its management. This update to the 2017 ESAIC Guideline on the prevention of POD is evidence-based and consensus-based and considers the literature between 01 April 2015, and 28 February 2022. The search terms of the broad literature search were identical to those used in the first version of the guideline published in 2017. POD was defined in accordance with the DSM-5 criteria. POD had to be measured with a validated POD screening tool, at least once per day for at least 3 days starting in the recovery room or postanaesthesia care unit on the day of surgery or, at latest, on postoperative day 1. Recent literature confirmed the pathogenic role of surgery-induced inflammation, and this concept reinforces the positive role of multicomponent strategies aimed to reduce the surgical stress response. Although some putative precipitating risk factors are not modifiable (length of surgery, surgical site), others (such as depth of anaesthesia, appropriate analgesia and haemodynamic stability) are under the control of the anaesthesiologists. Multicomponent preoperative, intra-operative and postoperative preventive measures showed potential to reduce the incidence and duration of POD, confirming the pivotal role of a comprehensive and team-based approach to improve patients' clinical and functional status.

Impact of propofol and sevoflurane anesthesia on cognition and emotion in gastric cancer patients undergoing radical resection

BACKGROUND

Propofol and sevoflurane are commonly used anesthetic agents for maintenance anesthesia during radical resection of gastric cancer. However, there is a debate concerning their differential effects on cognitive function, anxiety, and depression in patients undergoing this procedure.

AIM

To compare the effects of propofol and sevoflurane anesthesia on postoperative cognitive function, anxiety, depression, and organ function in patients undergoing radical resection of gastric cancer.

METHODS

A total of 80 patients were involved in this research. The subjects were divided into two groups: Propofol group and sevoflurane group. The evaluation scale for cognitive function was the Loewenstein occupational therapy cognitive assessment (LOTCA), and anxiety and depression were assessed with the aid of the self-rating anxiety scale (SAS) and self-rating depression scale (SDS). Hemodynamic indicators, oxidative stress levels, and pulmonary function were also measured.

RESULTS

The LOTCA score at 1 d after surgery was significantly lower in the propofol group than in the sevoflurane group. Additionally, the SAS and SDS scores of the sevoflurane group were significantly lower than those of the propofol group. The sevoflurane group showed greater stability in heart rate as well as the mean arterial pressure compared to the propofol group. Moreover, the sevoflurane group displayed better pulmonary function and less lung injury than the propofol group.

CONCLUSION

Both propofol and sevoflurane could be utilized as maintenance anesthesia during radical resection of gastric cancer. Propofol anesthesia has a minimal effect on patients' pulmonary function, consequently enhancing their postoperative recovery. Sevoflurane anesthesia causes less impairment on patients' cognitive function and mitigates negative emotions, leading to an improved postoperative mental state. Therefore, the selection of anesthetic agents should be based on the individual patient's specific circumstances.

The effect of intravenous and inhalation anesthesia in general on the cognition of elderly patients undergoing non-cardiac surgery: a systematic review and meta-analysis

Background

Postoperative cognitive dysfunction (POCD) is a postoperative complication that often occurs in the elderly. This systematic review and meta-analysis aimed to compare intravenous anesthetics (propofol) with inhalation anesthetics (sevoflurane) regarding the occurrence of POCD in the elderly who underwent non-cardiac surgery.

Methods

The investigators searched for published articles from the PubMed, Embase, Web of Science, Scopus, Cochrane, and Clinicalkey databases. Clinical studies comparing the incidence of POCD in elderly patients undergoing intravenous or inhalation anesthesia in general were selected. Primary outcomes included the occurrence of POCD at 1, 3, and 7 days. The secondary outcomes were the patient's plasma S-100β protein levels (pg*mL-1) and delayed neurocognitive recovery incidence 5-7 days after surgery.

Results

Fifteen studies including 3,817 patients were enrolled in the systematic review. Ten studies involving 1,829 patients were enrolled in the meta-analysis. The results demonstrate that there was no difference between the intravenous and inhalation groups in the incidence of POCD within 1-7 days (95% CI 0.73-1.26, p = 0.77) and the occurrence of delayed neurocognitive recovery 5-7 days after surgery (95% CI -353.15 to -295.44, p = 0.28). Plasma S-100β protein levels in the intravenous anesthesia group were lower than those in the inhalation group (95% CI 0.48-1.24, p < 0.001).

Conclusion

For elderly patients undergoing non-cardiac surgery, inhalation anesthesia was comparable to intravenous anesthesia in terms of the occurrence of short-term POCD. Inhalation anesthesia may cause greater damage to the nervous system, with delayed recovery of cognitive function after 5-7 days showing no difference.

Systematic review

identifier (CRD42021251317).

Delirium in older patients given propofol or sevoflurane anaesthesia for major cancer surgery: a multicentre randomised trial

BACKGROUND

Delirium is a common and disturbing postoperative complication that might be ameliorated by propofol-based anaesthesia. We therefore tested the primary hypothesis that there is less delirium after propofol-based than after sevoflurane-based anaesthesia within 7 days of major cancer surgery.

METHODS

This multicentre randomised trial was conducted in 14 tertiary care hospitals in China. Patients aged 65-90 yr undergoing major cancer surgery were randomised to either propofol-based anaesthesia or to sevoflurane-based anaesthesia. The primary endpoint was the incidence of delirium within 7 postoperative days.

RESULTS

A total of 1228 subjects were enrolled and randomised, with 1195 subjects included in the modified intention-to-treat analysis (mean age 71 yr; 422 [35%] women); one subject died before delirium assessment. Delirium occurred in 8.4% (50/597) of subjects given propofol-based anaesthesia vs 12.4% (74/597) of subjects given sevoflurane-based anaesthesia (relative risk 0.68 [95% confidence interval {CI}: 0.48-0.95]; P=0.023; adjusted relative risk 0.59 [95% CI: 0.39-0.90]; P=0.014). Delirium reduction mainly occurred on the first day after surgery, with a prevalence of 5.4% (32/597) with propofol anaesthesia vs 10.7% (64/597) with sevoflurane anaesthesia (relative risk 0.50 [95% CI: 0.33-0.75]; P=0.001). Secondary endpoints, including ICU admission, postoperative duration of hospitalisation, major complications within 30 days, cognitive function at 30 days and 3 yr, and safety outcomes, did not differ significantly between groups.

CONCLUSIONS

Delirium was a third less common after propofol than sevoflurane anaesthesia in older patients having major cancer surgery. Clinicians might therefore reasonably select propofol-based anaesthesia in patients at high risk of postoperative delirium.

CLINICAL TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR-IPR-15006209) and ClinicalTrials.gov (NCT02662257).

Preoperative Plasma Tau-PT217 and Tau-PT181 Are Associated With Postoperative Delirium

OBJECTIVE

This study aims to identify blood biomarkers of postoperative delirium.

BACKGROUND

Phosphorylated tau at threonine 217 (Tau-PT217) and 181 (Tau-PT181) are new Alzheimer disease biomarkers. Postoperative delirium is associated with Alzheimer disease. We assessed associations between Tau-PT217 or Tau-PT181 and postoperative delirium.

METHODS

Of 491 patients (65 years old or older) who had a knee replacement, hip replacement, or laminectomy, 139 participants were eligible and included in the analysis. Presence and severity of postoperative delirium were assessed in the patients. Preoperative plasma concentrations of Tau-PT217 and Tau-PT181 were determined by a newly established Nanoneedle technology.

RESULTS

Of 139 participants (73±6 years old, 55% female), 18 (13%) developed postoperative delirium. Participants who developed postoperative delirium had higher preoperative plasma concentrations of Tau-PT217 and Tau-PT181 than participants who did not. Preoperative plasma concentrations of Tau-PT217 or Tau-PT181 were independently associated with postoperative delirium after adjusting for age, education, and preoperative Mini-Mental State score [odds ratio (OR) per unit change in the biomarker: 2.05, 95% confidence interval (CI):1.61-2.62, P <0.001 for Tau-PT217; and OR: 4.12; 95% CI: 2.55--6.67, P <0.001 for Tau-PT181]. The areas under the receiver operating curve for predicting delirium were 0.969 (Tau-PT217) and 0.885 (Tau-PT181). The preoperative plasma concentrations of Tau-PT217 or Tau-PT181 were also associated with delirium severity [beta coefficient (β) per unit change in the biomarker: 0.14; 95% CI: 0.09-0.19, P <0.001 for Tau-PT217; and β: 0.41; 95% CI: 0.12-0.70, P =0.006 for Tau-PT181).

CONCLUSIONS

Preoperative plasma concentrations of Tau-PT217 and Tau-PT181 were associated with postoperative delirium, with Tau-PT217 being a stronger indicator of postoperative delirium than Tau-PT181.

Comparison of the effects of remimazolam tosylate and propofol on postoperative delirium among older adults undergoing major non-cardiac surgery: protocol for a randomised controlled trial

INTRODUCTION

Postoperative delirium (POD) is a common cognitive disturbance in elderly individuals that is characterised by acute and fluctuating impairments in attention and awareness. Remimazolam tosylate is a novel, ultrashort-acting benzodiazepine, and there is limited evidence of its correlation with the incidence of early POD. The aim of this study is to evaluate the incidence of POD after anaesthesia induction and maintenance with remimazolam tosylate or propofol in elderly patients undergoing major non-cardiac surgery.

METHODS AND ANALYSIS

This is a single-centre, randomised controlled trial. 636 elderly patients undergoing major non-cardiac surgery will be enrolled and randomised at a 1:1 ratio to receive total intravenous anaesthesia with either remimazolam tosylate or propofol. The primary outcome is the incidence of POD within 5 days after surgery. Delirium will be assessed twice daily by the 3 min Diagnostic Interview for the Confusion Assessment Method or the Confusion Assessment Method for the intensive care unit (ICU) for ICU patients. Secondary outcomes are the onset and duration of delirium, cognitive function at discharge and within 1-year postoperatively, postoperative analgesia within 5 days, chronic pain at 3 months, quality of recovery and postoperative inflammatory biomarker levels.

ETHICS AND DISSEMINATION

The study was approved by the institutional ethics committee of the National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (approval No. 22/520-3722). Written informed consent will be obtained from each patient before enrolment. The results of this trial will be presented at scientific conferences and in peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

ChiCTR2300067368.

The association between gut microbiota and postoperative delirium in patients

Postoperative delirium is a common postoperative complication in older patients, and its pathogenesis and biomarkers remain largely undetermined. The gut microbiota has been shown to regulate brain function, and therefore, it is vital to explore the association between gut microbiota and postoperative delirium. Of 220 patients (65 years old or older) who had a knee replacement, hip replacement, or laminectomy under general or spinal anesthesia, 86 participants were included in the data analysis. The incidence (primary outcome) and severity of postoperative delirium were assessed for two days. Fecal swabs were collected from participants immediately after surgery. The 16S rRNA gene sequencing was used to assess gut microbiota. Principal component analyses along with a literature review were used to identify plausible gut microbiota, and three gut bacteria were further studied for their associations with postoperative delirium. Of the 86 participants [age 71.0 (69.0-76.0, 25-75% percentile of quartile), 53% female], 10 (12%) developed postoperative delirium. Postoperative gut bacteria Parabacteroides distasonis was associated with postoperative delirium after adjusting for age and sex (Odds Ratio [OR] 2.13, 95% Confidence Interval (CI): 1.09-4.17, P = 0.026). The association between delirium and both Prevotella (OR: 0.59, 95% CI: 0.33-1.04, P = 0.067) and Collinsella (OR: 0.57, 95% CI: 0.27-1.24, P = 0.158) did not meet statistical significance. These findings suggest that there may be an association between postoperative gut microbiota, specifically Parabacteroides distasonis, and postoperative delirium. However, further research is needed to confirm these findings and better understand the gut-brain axis's role in postoperative outcomes.

The association between gut microbiota and postoperative delirium in patients

Postoperative delirium is one of the most common postoperative complications in older patients. Its pathogenesis and biomarkers, however, remain largely undetermined. Majority of human microbiota is gut microbiota and gut microbiota has been shown to regulate brain function. Therefore, this study aimed to determine the association between gut microbiota and postoperative delirium in patients. Of 220 patients (65 years old or older) who had a knee replacement, hip replacement, or laminectomy under general or spinal anesthesia, 86 participants were included in the data analysis. The incidence (primary outcome) and severity of postoperative delirium was assessed for two days. Fecal swabs were collected from participants immediately after surgery. The 16S rRNA gene sequencing was used to assess gut microbiota. Using principal component analyses along with a literature review to identify biologically plausible mechanisms, and three bacterials were studied for their associations with postoperative delirium. Of the 86 participants [age 71.0 (69.0-76.0, 25%-75% percentile of quartile), 53% female], ten (12%) developed postoperative delirium. Postoperative gut bacteria Parabacteroides distasonis (Odds Ratio [OR] 2.13, 95% Confidence Interval (CI): 1.09-4.17, P = 0.026) was associated with postoperative delirium after adjusting for age and sex. The association between delirium and both Prevotella (OR: 0.59, 95% CI: 0.33-1.04, P = 0.067) and Collinsella (OR: 0.57, 95% CI: 0.27-1.24, P = 0.158) did not meet statistical significance. These findings suggest that postoperative gut microbiota (e.g., Parabacteroides distasonis ) may serve as biomarkers in the pathogenesis of postoperative delirium, pending confirmative studies.

Effect of Remimazolam on Postoperative Delirium in Older Adult Patients Undergoing Orthopedic Surgery: A Prospective Randomized Controlled Clinical Trial

Background

Postoperative delirium is common in older adult patients and associated with a poor prognosis. The use of benzodiazepine was identified as an independent risk factor for delirium, but there is no randomized controlled trial regarding the relationship between remimazolam, a new ultra-short acting benzodiazepine, and postoperative delirium. We designed a randomized controlled trial to evaluate if remimazolam increases the incidence of postoperative delirium compared with propofol in older adult patients undergoing orthopedic surgery with general anesthesia.

Patients and Methods

We enrolled 320 patients aged more than 60 with American Society of Anesthesiologists physical status I-III who underwent orthopedic surgery. Patients were randomized to two groups to receive intraoperative remimazolam or propofol, respectively. Our primary outcome was the incidence of delirium within 3 days after surgery. Secondary outcome was emergence quality including the incidence of emergence agitation, extubation time, and length of post-anesthesia care unit (PACU) stay. Adverse events were also recorded.

Results

The incidence of postoperative delirium was 15.6% in the remimazolam group and 12.4% in the propofol group (Risk ratio, 1.26; 95% CI, 0.72 to 2.21; Risk difference, 3.2%; 95% CI, -4.7% to 11.2%; P = 0.42). No significant differences were observed for time of delirium onset, duration of delirium, and delirium subtype between the two groups. Patients in remimazolam group had a lower incidence of hypotension after induction and consumed less vasoactive drugs intraoperatively, but had a longer postoperative extubation time and PACU stay.

Conclusion

General anesthesia with remimazolam was not associated with an increased incidence of postoperative delirium compared with propofol in older adult patients undergoing orthopedic surgery.

Research progress on perioperative blood-brain barrier damage and its potential mechanism

The blood-brain barrier (BBB) is an important barrier separating the central nervous system from the periphery. The composition includes endothelial cells, pericytes, astrocytes, synapses and tight junction proteins. During the perioperative period, anesthesia and surgical operations are also a kind of stress to the body, which may be accompanied by blood-brain barrier damage and brain metabolism dysfunction. Perioperative blood-brain barrier destruction is closely associated with cognitive impairment and may increase the risk of postoperative mortality, which is not conducive to enhanced recovery after surgery. However, the potential pathophysiological process and specific mechanism of blood-brain barrier damage during the perioperative period have not been fully elucidated. Changes in blood-brain barrier permeability, inflammation and neuroinflammation, oxidative stress, ferroptosis, and intestinal dysbiosis may be involved in blood-brain barrier damage. We aim to review the research progress of perioperative blood-brain barrier damage and its potential adverse effects and potential molecular mechanisms, and provide ideas for the study of homeostasis maintenance of brain function and precision anesthesia.

Postoperative delirium in geriatric patients with hip fractures

Postoperative delirium (POD) is a frequent complication in geriatric patients with hip fractures, which is linked to poorer functional recovery, longer hospital stays, and higher short-and long-term mortality. Patients with increased age, preoperative cognitive impairment, comorbidities, perioperative polypharmacy, and delayed surgery are more prone to develop POD after hip fracture surgery. In this narrative review, we outlined the latest findings on postoperative delirium in geriatric patients with hip fractures, focusing on its pathophysiology, diagnosis, prevention, and treatment. Perioperative risk prediction, avoidance of certain medications, and orthogeriatric comprehensive care are all examples of effective interventions. Choices of anesthesia technique may not be associated with a significant difference in the incidence of postoperative delirium in geriatric patients with hip fractures. There are few pharmaceutical measures available for POD treatment. Dexmedetomidine and multimodal analgesia may be effective for managing postoperative delirium, and adverse complications should be considered when using antipsychotics. In conclusion, perioperative risk intervention based on orthogeriatric comprehensive care is the most effective strategy for preventing postoperative delirium in geriatric patients with hip fractures.

Sevoflurane-induced POCD-associated exosomes delivered miR-584-5p regulates the growth of human microglia HMC3 cells through targeting BDNF

BACKGROUND

Inhalation of sevoflurane can cause neuronal apoptosis, and cognitive disorders, inducing to the occurrence and progression of post operative cognitive dysfunction (POCD). This study aimed to explore the roles of sevoflurane-induced POCD-associated exosomes on HMC3 cells and its related mechanisms.

METHODS

Exosomes were isolated from the plasma of sevoflurane-induced POCD or non-POCD patients, and were then sent for small RNA sequencing. Real-time quantitative PCR (RT-qPCR) was used to verify the sequencing results, and miR-584-5p was chosen for subsequent study. HMC3 cells were respectively transfected with POCD-derived exosomes and miR-584-5p mimics, and cell viability and apoptosis were measured. Dual-luciferase reporter gene assay was applied to confirm the target of miR-584-5p.

RESULTS

After sequencing, 301 differentially expressed miRNAs were identified, including 184 up-regulated miRNAs and 117 down-regulated miRNAs, and were significantly enriched in 3577 GO terms and 121 KEGG pathways. Due to the high level of miR-584-5p in sevoflurane-treated POCD-derived exosomes, HMC3 cells with miR-584-5p enrichment were successfully established. Compared with the control group, POCD-derived exosomes and miR-584-5p significantly inhibited viability and promoted apoptosis of HMC3 cells (P < 0.05). The IL-1β and TNF-α levels were significantly increased after POCD-derived exosomes and miR-584-5p mimics treatment compared to the control group (P < 0.05). Besides, POCD-derived exosomes and miR-584-5p mimics significantly down-regulated the expression levels of BDNF and p-TrkB, and up-regulated Caspase 3 and IL-1β. Finally, BDNF was confirmed to be the target of miR-584-5p.

CONCLUSIONS

Sevoflurane-induced POCD-associated exosomes delivered miR-584-5p may regulate the growth of HMC3 cells via targeting BDNF.

The effects of anesthesia methods and anesthetics on postoperative delirium in the elderly patients: A systematic review and network meta-analysis

Study objective

Postoperative delirium (POD) is one of the serious postoperative complications in elderly patients, which is always related to long-term mortality. Anesthesia is often considered a risk factor for POD. This systematic review and network meta-analysis (NMA) aimed to assess the impact of different anesthesia methods and anesthetics on POD.

Measurements

We searched for studies published in PubMed, Embase, Web of Science, Scopus, and Cochrane Library (CENTRAL) from inception to 18 March 2022. RevMan 5.3 and CINeMA 2.0.0 were used to assess the risk of bias and confidence. Data analysis using STATA 17.0 and R 4.1.2. STATA 17.0 was used to calculate the surface under the cumulative ranking curve (SUCRA) and provide network plots with CINeMA 2.0.0. NMA was performed with R 4.1.2 software gemtc packages in RStudio.

Main results

This NMA included 19 RCTs with 5,406 patients. In the pairwise meta-analysis results, only regional anesthesia (RA) with general anesthesia (GA) vs. GA (Log OR: –1.08; 95% CI: –1.54, –0.63) were statistically different in POD incidence. In the NMA results, there was no statistical difference between anesthesia methods, and psoas compartment block (PCB) with bupivacaine was superior to the desflurane, propofol, sevoflurane, and spinal anesthesia with bupivacaine of POD occurrence.

Conclusion

Our study indicated that RA and GA had no significant effect on POD, and there was no difference between anesthesia methods. Pairwise meta-analysis showed that, except for RA with GA vs. GA, the rest of the results were not statistically different. Besides, PCB with bupivacaine may benefit to reduce POD incidence.

Systematic review registration

https://www.crd.york.ac.uk/prospero/dis play_record.php?ID=CRD42022319499, identifier PROSPERO 2022 CRD42022319499.

Impact of propofol versus sevoflurane on the incidence of postoperative delirium in elderly patients after spine surgery: study protocol of a randomized controlled trial

Background

Postoperative delirium in elderly patients is a common and costly complication after surgery. Propofol and sevoflurane are commonly used anesthetics during general anesthesia, and the sedative and anti-inflammatory mechanisms of the two medications are different. The aim of this trial is to compare the impact of propofol with sevoflurane on the incidence of postoperative delirium in elderly patients after spine surgery.

Methods

A single-center randomized controlled trial will be performed at First Affiliated Hospital of Shandong First Medical University, China. A total of 298 participants will be enrolled in the study and randomized to propofol infusion or sevoflurane inhalation groups. The primary outcome is the incidence of delirium within 7 days after surgery. Secondary outcomes include the day of postoperative delirium onset, duration (time from first to last delirium-positive day), and total delirium-positive days among patients who developed delirium; tracheal intubation time in PACU; the length of stay in PACU; the rate of postoperative shivering; the rate of postoperative nausea and vomiting; the rate of emergence agitation; pain severity; QoR40 at the first day after surgery; the length of stay in hospital after surgery; and the incidence of non-delirium complications within 30 days after surgery.

Discussion

The primary objective of this study is to compare the impact of propofol and sevoflurane on the incidence of postoperative delirium for elderly patients undergoing spine surgery. The results may help inform strategies to the optimal selection of maintenance drugs for general anesthesia in elderly patients undergoing spine surgery.

Trial registration

ClinicalTrials.govNCT05158998. Registered on 14 December 2021

On the horns of a dilemma: choosing total intravenous anaesthesia or volatile anaesthesia

There are two established techniques of delivering general anaesthesia: propofol-based total intravenous anaesthesia (TIVA) and volatile agent-based inhaled anaesthesia. Both techniques are offered as standard of care and have an established safety track record lasting more than 30 years. However, it is not currently known whether the choice of anaesthetic technique results in a fundamentally different patient experience or affects early, intermediate-term, and longer-term postoperative outcomes. This editorial comments on a recently published study that suggests that inhaled volatile anaesthesia might be associated with fewer postoperative surgical complications than propofol-based TIVA for patients undergoing colorectal cancer surgery. We consider the strengths and limitations of the study, place these findings in the context of the broader evidence, and discuss how the current controversies regarding anaesthetic technique can be resolved, thereby helping to bring precision medicine into the modern practice of perioperative care.

The Effect of Propofol versus Sevoflurane on Postoperative Delirium in Parkinson's Disease Patients Undergoing Deep Brain Stimulation Surgery: An Observational Study

BACKGROUND

The selection of the maintenance of general anesthesia may affect the development of postoperative delirium (POD), notably for Parkinson's disease (PD) patients, due to their lower cognitive reserve. The present study was designed to compare the potential impact of propofol vs. sevoflurane based general anesthesia maintenance methods on the development of POD in PD patients following deep brain stimulation (DBS) surgery.

METHODS

A total of 125 PD patients who were scheduled to undergo DBS surgery were randomly divided into the propofol (n = 63) and the sevoflurane groups (n = 62). The patients in the two groups randomly received propofol- or sevoflurane-based general anesthesia. The Confusion Assessment Method (CAM) was employed by an investigator who was blinded to the anesthesia regimen and was administered twice per day from postoperative day 1 until discharge.

RESULTS

The incidence of POD was 22.22% (14/63) with propofol anesthesia and 20.97% (13/62) with sevoflurane anesthesia (p = 0.865). In addition, no difference was noted in the duration and severity of delirium between the propofol and sevoflurane groups.

CONCLUSIONS

In the present study, propofol- and sevoflurane-based general anesthesia exhibited comparable results with regard to the POD incidence in PD patients undergoing deep brain stimulation surgery.

Analysis of Influencing Factors of Serum Stress Index and Prognosis of HICH Patients by Different Anesthesia Methods Combined with Small Bone Window Microsurgery

In order to investigate the effects of sevoflurane on the serum stress index level and prognosis of patients with hypertensive cerebral hemorrhage (HICH) during small bone window microsurgery, a total of 102 HICH patients are selected for analysis. MAP values in both groups decreased significantly at T1 and T2 (P < 0.05), and the changes in MAP and HR indexes in the sevoflurane combined group were more stable than those in the control group. The time of postoperative awakening in the sevoflurane combined group decreases significantly than the control group (P < 0.001). The levels of T-AOC and GSH-Px in both groups increase significantly after operation, and those in the sevoflurane combined group increase significantly than the control group (P < 0.001). The levels of MDA and 8-OHDG in the sevoflurane combined group decrease significantly than the control group after operation (P < 0.05). Spearman correlation coefficient analysis shows that the levels of T-AOC and GSH-Px are negatively correlated with the prognosis of HICH patients, while MDA and 8-OHDG are positively correlated with the prognosis of HICH patients (P < 0.001). Sevoflurane interventional anesthesia has a high anesthetic effect in small bone window microsurgery, which has positive effects on controlling blood pressure of HICH patients, shortening postoperative recovery time and improving patients' stress response and neurological function. This paper conducts an in-depth analysis of the prognosis of HICH patients, indicating that the prognosis of HICH patients is closely related to their serum stress indicators T-AOC, GSH-Px, MDA, and 8-OHDG, providing a new direction for follow-up clinical diagnosis and treatment of HICH patients and accurate prognosis assessment.

Necrostatin-1 Against Sevoflurane-Induced Cognitive Dysfunction Involves Activation of BDNF/TrkB Pathway and Inhibition of Necroptosis in Aged Rats

Postoperative cognitive dysfunction (POCD) induced by anesthesia or surgery has become a common complication in the aged population. Sevoflurane, a clinical inhalation anesthetic, could stimulate calcium overload and necroptosis to POCD. In addition, necroptosis inhibitor necrostatin-1 (Nec-1) alleviated cognitive impairment caused by multiple causes, including postoperative cognitive impairment. However, whether Nec-1 exerts a neuroprotective effect on POCD via calcium and necroptosis remains unclear. We anesthetized Sprague-Dawley rats with sevoflurane to construct the POCD model and to explore the mechanism underlying neuroprotective effects of Nec-1 in POCD. Rats were treated with Nec-1 (6.25 mg/kg) 1 h prior to anesthesia. Open field test and Morris water maze were employed to detect the cognitive function. In this study, rats exposed to sevoflurane displayed cognitive dysfunction without changes in spontaneous activity; however, the sevoflurane-induced POCD could be relieved by Nec-1 pretreatment. Nec-1 decreased sevoflurane-induced calcium overload and calpain activity in the hippocampus. In addition, Nec-1 alleviated the expression of p-RIPK1, RIPK1, p-RIPK3, RIPK3, p-MLKL and MLKL. Furthermore, Nec-1 remarkably increased BDNF and p-TrkB/TrkB expression in the hippocampus of aged rats. Ultimately, our research manifests evidence that Nec-1 may play a neuroprotective role against sevoflurane-induced cognitive impairment via the increase of BDNF/TrkB and suppression of necroptosis-related pathway.

Inflammatory Biomarker Levels After Propofol or Sevoflurane Anesthesia: A Meta-analysis

BACKGROUND

The perioperative inflammatory response may be implicated in adverse outcomes including neurocognitive dysfunction and cancer recurrence after oncological surgery. The immunomodulatory role of anesthetic agents has been demonstrated in vitro; however, its clinical relevance is unclear. The purpose of this meta-analysis was to compare propofol and sevoflurane with respect to biomarkers of perioperative inflammation. The secondary aim was to correlate markers of inflammation with clinical measures of perioperative cognition.

METHODS

Databases were searched for randomized controlled trials examining perioperative inflammation after general anesthesia using propofol compared to sevoflurane. Inflammatory biomarkers investigated were interleukin (IL)-6, IL-10, tissue necrosis factor alpha (TNF-α), and C-reactive protein (CRP). The secondary outcome was incidence of perioperative neurocognitive disorders. Meta-analysis with metaregression was performed to determine the difference between propofol and sevoflurane.

RESULTS

Twenty-three studies were included with 1611 participants. Studies varied by surgery type, duration, and participant age. There was an increase in the mean inflammatory biomarker levels following surgery, with meta-analysis revealing no difference in effect between propofol and sevoflurane. Heterogeneity between studies was high, with surgery type, duration, and patient age contributing to the variance across studies. Only 5 studies examined postoperative cognitive outcomes; thus, a meta-analysis could not be performed. Nonetheless, of these 5 studies, 4 reported a reduced incidence of cognitive decline associated with propofol use.

CONCLUSIONS

Surgery induces an inflammatory response; however, the inflammatory response did not differ as a function of anesthetic technique. This absence of an effect suggests that patient and surgical variables may have a far more significant impact on the postoperative inflammatory responses than anesthetic technique. The majority of studies assessing perioperative cognition in older patients reported a benefit associated with the use of propofol; however, larger trials using homogenous outcomes are needed to demonstrate such an effect.

Develop a Clinical Prediction Model for Postoperative Cognitive Dysfunction after Major Noncardiac Surgery in Elderly Patients: A Protocol for a Prospective Observational Study

Perioperative neurocognitive disorders (PNDs) refer to cognitive decline identified in the preoperative or postoperative period. It has been reported that the incidence of postoperative neurocognitive impairment after noncardiac surgery in patients older than 65 at 1 week was 25.8∼41.4%, and at 3 months 9.9∼12.7%. PNDs will last months or even develop to permanent dementia, leading to prolonged hospital stays, reduced quality of life, and increased mortality within 1 year. Despite the high incidence and poor prognosis of PNDs in the aged population, no effective clinical prediction model has been established to predict postoperative cognitive decline preoperatively. To develop a clinical prediction model for postoperative neurocognitive dysfunction, a prospective observational study (Clinical trial registration number: ChiCTR2000036304) will be performed in the Shanghai General Hospital during January 2021 to October 2022. A sample size of 675 patients aged >65 years old, male or female, and scheduled for elective major noncardiac surgery will be recruited. A battery of neuropsychological tests will be used to test the cognitive function of patients at 1 week, 1 month, and 3 months postoperatively. We will evaluate the associations of PNDs with a bunch of candidate predictors including general characteristics of patients, blood biomarkers, indices associated with anesthesia and surgery, retinal nerve-fiber layer thickness, and frailty index to develop the clinical prediction model by using multiple logistic regression analysis and least absolute shrinkage and the selection operator (LASSO) method. The k-fold cross-validation method will be utilized to validate the clinical prediction model. In conclusion, this study was aimed to develop a clinical prediction model for postoperative cognitive dysfunction of old patients. It is anticipated that the knowledge gained from this study will facilitate clinical decision-making for anesthetists and surgeons managing the aged patients undergoing noncardiac surgery.