Geriatric Anesthesia-related Morbidity and Mortality in China: Current Status and Trend

Perioperative neurocognitive disorder changes in elderly diabetes patients within 30 days after surgery: a retrospective cohort study

BACKGROUND

Perioperative neurocognitive disorders (PND) are a common central nervous system complication that predominantly affects the elderly. PND after surgery includes postoperative delirium (POD), delayed neurocognitive recovery up to 30 days (DNR), and postoperative neurocognitive disorder up to 12 months. Diabetes is an important independent risk factor for PND. Over the years, few studies have assessed the incidence of PND and the difference in serum biomarkers between diabetic and non-diabetic patients. We sought to examine the difference in the incidence of PND between elderly diabetic and non-diabetic patients in China and identify the risk factors of PND in elderly diabetics.

METHODS

We conducted a secondary and exploratory data analysis from our prior studies, including patients aged 65 years or older who underwent non-cardiac elective surgery with general anesthesia. We used the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and Montreal Cognitive Assessment (MoCA) to assess patient cognition.

RESULTS

A total of 236 patients were analyzed; the incidence of PND was significantly higher in diabetic than in non-diabetic patients within 30 days (59.2% vs. 36.8%) (P = 0.022). Multivariate logistic regression analysis showed that the preoperative MoCA was an independent risk factor for PND (odds ratio, 0.88 [0.8 to 0.97]; P = 0.014), and Hosmer-Lemeshow tests showed that it could predict PND in diabetic patients (P = 0.360). According to the maximum Youden index, the optimal cutoff for preoperative MoCA was 21.5 points, yielding a specificity and sensitivity of 88.0% and 55.2% for PND. The levels of glial fibrillary acidic protein (GFAP) and Tau in diabetic patients before and after surgery were significantly higher than in non-diabetic patients among cases of PND (P = 0.002 and 0.011, respectively).

CONCLUSION

The incidence of PND is higher in diabetic than in non-diabetic patients in China, and preoperative MoCA is an independent risk factor for PND in diabetics. Meanwhile, the changes in GFAP and p-Tau in diabetic patients who experienced PND were significantly higher than in non-diabetic ones.

Reoperations After Percutaneous Endoscopic Transforaminal Decompression for Treating Lumbar Spinal Stenosis: Incidence and Predictors

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

The main purpose of the present study was to report the incidence and identify predictors of reoperation in patients with lumbar spinal stenosis (LSS) treated with percutaneous endoscopic transforaminal decompression (PETD).

METHODS

This study retrospectively reviewed consecutive patients with LSS who underwent PETD at our center between January 2016 and July 2020. The incidence of reoperations was calculated. We then designed a surgical period-matched case-control study to identify predictors among demographic data, clinical baseline data, and imaging parameters.

RESULTS

This study identified 496 eligible patients. 33 (6.7%) patients underwent reoperation with a mean follow-up of 3 years, consisting 22 (4.4%) at the index level and 11 (2.2%) at the adjacent levels. There were significant differences in age and age-adjusted Charlson comorbidity index (AACCI) between the two groups, with younger age (P = .004) and lower AACCI (P = .019) in reoperation group. Age was identified as the sole independent predictor (P = .006). The duration of symptoms ≥12 months (P = .034) and the presence of heart problems (P = .012) were recognized as specific predictors among patients younger than 65 years.

CONCLUSIONS

In a mean follow-up of 3 years, the incidence of reoperation in LSS treated with PETD was 6.7%. A younger age was the independent predictor for reoperation. Younger patients with the duration of symptoms ≥12 months or without heart problems were more likely to undergo a second operation. Prospective randomized controlled trials are required to confirm these findings.

Perioperative Factors Impact on Mortality and Survival Rate of Geriatric Patients Undergoing Surgery in the COVID-19 Pandemic: A Prospective Cohort Study in Indonesia

Background: The COVID-19 pandemic continues to have an impact on geriatric patients worldwide since geriatrics itself is an age group with a high risk due to declined physiological function and many comorbidities, especially for those who undergo surgery. In this study, we determine the association between perioperative factors with 30-day mortality and a survival rate of geriatric patients undergoing surgery during COVID-19 pandemic. Methods: A prospective cohort study was conducted at 14 central hospitals in Indonesia. The recorded variables were perioperative factors, 30-day mortality, and survival rate. Analyses of associations between variables and 30-day mortality were performed using univariate/multivariable logistic regression, and survival rates were determined with Kaplan−Meier survival analysis. Results: We analyzed 1621 elderly patients. The total number of patients who survived within 30 days of observation was 4.3%. Several perioperative factors were associated with 30-day mortality (p < 0.05) is COVID-19 (OR, 4.34; 95% CI, 1.04−18.07; p = 0.04), CCI > 3 ( odds ratio [OR], 2.33; 95% confidence interval [CI], 1.03−5.26; p = 0.04), emergency surgery (OR, 3.70; 95% CI, 1.96−7.00; p ≤ 0.01), postoperative ICU care (OR, 2.70; 95% CI, 1.32−5.53; p = 0.01), and adverse events (AEs) in the ICU (OR, 3.43; 95% CI, 1.32−8.96; p = 0.01). Aligned with these findings, COVID-19, CCI > 3, and comorbidities have a log-rank p < 0.05. The six comorbidities that have log-rank p < 0.05 are moderate-to-severe renal disease (log-rank p ≤ 0.01), cerebrovascular disease (log-rank p ≤ 0.01), diabetes with chronic complications (log-rank p = 0.03), metastatic solid tumor (log-rank p = 0.02), dementia (log-rank p ≤ 0.01), and rheumatology disease (log-rank p = 0.03). Conclusions: Having at least one of these conditions, such as COVID-19, comorbidities, emergency surgery, postoperative ICU care, or an AE in the ICU were associated with increased mortality in geriatric patients undergoing surgery during the COVID-19 pandemic.

Correlation of carotid corrected flow time and respirophasic variation in blood flow peak velocity with stroke volume variation in elderly patients under general anaesthesia

BACKGROUND

Accurate assessment of volume responsiveness in elderly patients is important as it may reduce the risk of post-operative complications and enhance surgical recovery. This study evaluated the utility of two Doppler ultrasound-derived parameters, the carotid corrected flow time (FTc) and respirophasic variation in carotid artery blood flow peak velocity (ΔVpeak), to predict volume responsiveness in elderly patients under general anaesthesia.

METHODS

A total of 97 elderly patients undergoing elective abdominal surgery under general anaesthesia were enrolled in this prospective observational study. After entering the operating room, all patients underwent radial artery puncture connected with a LiDCO device to measure stroke volume variation (SVV), and fluid therapy was performed after anaesthesia induction. Patients were classified as responders if SVV ≥ 13% before fluid challenge and nonresponders if SVV < 13%. The FTc, ΔVpeak, SVV and haemodynamic data were measured by ultrasound at baseline (T0) and before (T1) and after (T2) fluid challenge. The correlations between the Doppler ultrasound-derived parameters and SVV were analysed, and the receiver operating characteristic (ROC) curves was computed to characterize both FTc and ΔVpeak as measures of volume responsiveness in elderly patients.

RESULTS

Forty-one (42.3%) patients were fluid responders. Carotid FTc before fluid challenge was negatively correlated with SVV before fluid challenge (r = -0.77; P < 0.01), and ΔVpeak was positively correlated with SVV (r = 0.72; P < 0.01). FTc and ΔVpeak predicted SVV ≥ 13% after general anaesthesia in elderly patients, with areas under the receiver operating characteristic curves (AUROCs) of 0.811 [95% confidence interval (CI), 0.721-0.900; P < 0.001] and 0.781 (95% CI, 0.686-0.875; P < 0.001), respectively. The optimal cut-off values of FTc and ΔVpeak to predict SVV ≥ 13% were 340.74 ms (sensitivity of 76.8%; specificity of 80.5%) and 11.69% (sensitivity of 78.0%; specificity of 67.9%), respectively.

CONCLUSIONS

There was a good correlation between carotid artery ultrasound parameters and SVV. FTc predicted fluid responsiveness better than ΔVpeak in elderly patients during general anaesthesia. Further study is needed before these parameters can be recommended for clinical application.

TRIAL REGISTRATION

www.chictr.org.cn (ChiCTR2000031193); registered 23 March 2020.

Comparison of Postoperative Cognitive Decline Using the Mini-Mental State Examination and Montreal Cognitive Assessment After Minor Elective Surgery in Elderly

Introduction and aim

Postoperative cognitive dysfunction (POCD) is an important complication associated with increased morbidity, mortality, and reduced quality of life. Generally, studies have focused on major surgery so there is little evidence of the incidence of cognitive dysfunction in minor surgery. We aimed to compare the Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) in terms of detecting cognitive decline in elderly patients after elective inguinal herniorrhaphy procedure with general or spinal anesthesia.

Material and methods

This observational study was conducted from June 2014 to March 2015 at Ankara Numune Education and Research Hospital. The type of anesthesia was determined according to the anesthesiologist’s preference who is blind to the study. Patients were grouped according to anesthesia received: general or spinal anesthesia. The MMSE and MoCA were evaluated presurgery and 24 hours after the operation.

Results

The postoperative (24th hour) MMSE scores of patients (26.23±2.77) were significantly lower than the preoperative scores (27.17±1.93) in only the general anesthesia group (p =0.003). The postoperative (24th hour) MoCA scores (22.87±3.88 for general and 23.13±4.08 for spinal anesthesia) were significantly lower than the preoperative scores (24.32±3.19 for general and 24.35±2.84 for spinal anesthesia) in both the general and spinal anesthesia groups (p =0.000 and 0.019, respectively). The incidence of postoperative cognitive dysfunction was 32.9% using the MoCA and 15.2% using the MMSE (p=0,018).

Conclusion

Early POCD is an important problem after elective minor surgeries, even with spinal anesthesia, in elderly patients. The MoCA is an alternative tool that can be more sensitive than the MMSE to identify cognitive decline in elderly patients undergoing minor surgeries under both general and spinal anesthesia. 

Clinical practice in the management of postoperative delirium by Chinese anesthesiologists: a cross-sectional survey designed by the European Society of Anaesthesiology

OBJECTIVE

In this survey, we assessed the current clinical management of postoperative delirium (POD) among Chinese anesthesiologists, after publishing the European POD guideline.

METHODS

We administered an electronic survey, designed according to the European POD guideline. The survey was completed using mobile devices.

RESULTS

In total, 1,514 respondents from China participated in the survey. Overall, 74.4% of participants reported that delirium is very important. More than 95% of participants stated that they routinely assessed POD. In total, 61.4% screened for POD using clinical observation and 37.6% used a delirium screening tool. Although the depth of anesthesia (a POD risk factor) was monitored, electroencephalogram monitoring was unavailable to 30.6% of respondents. Regarding treatment, only 24.1% of respondents used a standard algorithm; 58.5% used individualized treatment.

CONCLUSION

Our survey showed that there are high awareness levels among Chinese anesthesiologists regarding the importance of POD. However, routine assessment and monitoring of all patients, including perioperative anesthesia depth monitoring, and a treatment algorithm need to be implemented on a larger scale. According to the results, efforts should be made to improve the knowledge of POD among Chinese anesthesiologists.