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Liu Z, Li R, Wang S, Zhou Y, Yin L, Qu Y, Peng C. Postoperative delirium after hysteroscopy in young woman: A case report. Medicine (Baltimore) 2019; 98:e17663. [PMID: 31689778 PMCID: PMC6946505 DOI: 10.1097/md.0000000000017663] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 08/24/2019] [Accepted: 09/26/2019] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Postoperative delirium is extremely rare in young women and in minimally invasive endoscopic surgeries in gynecology and obstetrics. It greatly affects both physicians and patients. This report presents a special case of postoperative delirium after hysteroscopy in a young woman and a literature review of the associated etiology, diagnosis, and treatment. PATIENT CONCERNS A 39-year-old woman was admitted to the gynecology ward following irregular vaginal bleeding for 3 months and an intrauterine space-occupying lesion for 1 week. Hysteroscopy, endometrial polypectomy, and fractional curettage procedures were successfully performed; however, the patient became unresponsive after surgery. DIAGNOSIS Postoperative delirium. INTERVENTIONS Sedatives and vasoactive medicines, such as dexmedetomidine, midazolam, and dopamine were administered for maintenance treatment. OUTCOMES The patients gradually regained consciousness. LESSONS Physicians should attach importance and improvise effective clinical management strategies for postoperative delirium based on clinical specialty characteristics and related guidelines.
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Affiliation(s)
- Zhen Liu
- Department of Obstetrics and Gynecology
| | - Ran Li
- Department of Anesthesiology, Peking University First Hospital, Beijing, China
| | | | | | - Ling Yin
- Department of Obstetrics and Gynecology
| | - Yuan Qu
- Department of Anesthesiology, Peking University First Hospital, Beijing, China
| | - Chao Peng
- Department of Obstetrics and Gynecology
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Three blind mice: a tail of discordant trials. Br J Anaesth 2019; 124:121-125. [PMID: 31676036 DOI: 10.1016/j.bja.2019.09.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 09/25/2019] [Accepted: 09/25/2019] [Indexed: 12/19/2022] Open
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153
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Curto RA, Edwards CC, Lin C, Brown CH. Lengthy complex lumbar fusion surgery in high-risk elderly patient under spinal anesthesia: A case report. Int J Surg Case Rep 2019; 65:131-134. [PMID: 31704664 PMCID: PMC6920206 DOI: 10.1016/j.ijscr.2019.10.053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 10/21/2019] [Indexed: 11/18/2022] Open
Abstract
The longest reported lumbar surgery in an elderly patient under spinal anesthesia. Spinal Anesthesia is a feasible option for lengthy geriatric lumbar surgery. SA affords effective anesthesia with possibly lower physiological stress to some older patients. Spinal Anesthesia may have elongated efficacy in the elderly population.
Introduction Spinal Anesthesia (SA) continues to be an emerging technique for lumbar fusion surgery in the elderly population. SA is an appealing option in the high-risk geriatric population for several reasons, including the potential for reduced systematic stress, reduced blood loss, and reduced post-operative delirium. The safe limits of spine surgery under SA remain undetermined. Presentation of case The following case-study describes an elderly high-risk patient (ASA III) with severe spinal stenosis and degenerative scoliosis who presented with lower back and right leg pain and underwent a 3-level lumbar fusion surgery with spinal anesthesia. The procedure lasted 3 h and 44 min with sufficient anesthesia maintained throughout. The patient experienced minor post-operative complications, but had an excellent clinical outcome at 3-month follow-up. Discussion Further research should be conducted to define the temporal limits of SA in elderly patients and the etiology of post-operative complications following lumbar fusion surgery under spinal anesthesia in the geriatric population. Conclusion The case reported, herein, demonstrates the feasibility of SA in elderly patients undergoing lengthy complex lumbar surgeries who have been designated “high-risk” patients (ASA > II) and provides support for future investigation into surgical and anesthesia treatment options for geriatric high-risk patients presenting with complex lumbar spine pathologies.
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Affiliation(s)
- Ryan A Curto
- The Maryland Spine Center, Mercy Medical Center, 301 St. Paul Pl, Baltimore, MD 21202, United States.
| | - Charles C Edwards
- The Maryland Spine Center, Mercy Medical Center, 301 St. Paul Pl, Baltimore, MD 21202, United States
| | - Charles Lin
- Department of Anesthesiology, Mercy Medical Center, 301 St. Paul Pl, Baltimore, MD 21202, United States
| | - Charles H Brown
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Sheikh Zayed Tower, 1800 Orleans St., Baltimore, MD 21287, United States
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Brown CH, Jones EL, Lin C, Esmaili M, Gorashi Y, Skelton RA, Kaganov D, Colantuoni EA, Yanek LR, Neufeld KJ, Kamath V, Sieber FE, Dean CL, Edwards CC, Hogue CW. Shaping anesthetic techniques to reduce post-operative delirium (SHARP) study: a protocol for a prospective pragmatic randomized controlled trial to evaluate spinal anesthesia with targeted sedation compared with general anesthesia in older adults undergoing lumbar spine fusion surgery. BMC Anesthesiol 2019; 19:192. [PMID: 31656179 PMCID: PMC6815448 DOI: 10.1186/s12871-019-0867-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 10/07/2019] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Postoperative delirium is common in older adults, especially in those patients undergoing spine surgery, in whom it is estimated to occur in > 30% of patients. Although previously thought to be transient, it is now recognized that delirium is associated with both short- and long-term complications. Optimizing the depth of anesthesia may represent a modifiable strategy for delirium prevention. However, previous studies have generally not focused on reducing the depth of anesthesia beyond levels consistent with general anesthesia. Additionally, the results of prior studies have been conflicting. The primary aim of this study is to determine whether reduced depth of anesthesia using spinal anesthesia reduces the incidence of delirium after lumbar fusion surgery compared with general anesthesia. METHODS This single-center randomized controlled trial is enrolling 218 older adults undergoing lumbar fusion surgery. Patients are randomized to reduced depth of anesthesia in the context of spinal anesthesia with targeted sedation using processed electroencephalogram monitoring versus general anesthesia without processed electroencephalogram monitoring. All patients are evaluated for delirium using the Confusion Assessment Method for 3 days after surgery or until discharge and undergo assessments of cognition, function, health-related quality of life, and pain at 3- and 12-months after surgery. The primary outcome is any occurrence of delirium. The main secondary outcome is change in the Mini-Mental Status Examination (or telephone equivalent) at 3-months after surgery. DISCUSSION Delirium is an important complication after surgery in older adults. The results of this study will examine whether reduced depth of anesthesia using spinal anesthesia with targeted depth of sedation represents a modifiable intervention to reduce the incidence of delirium and other long-term outcomes. The results of this study will be presented at national meetings and published in peer-reviewed journals with the goal of improving perioperative outcomes for older adults. TRIAL REGISTRATION Clinicaltrials.gov , NCT03133845. This study was submitted to Clinicaltrials.gov on October 23, 2015; however, it was not formally registered until April 28, 2017 due to formatting requirements from the registry, so the formal registration is retrospective.
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Affiliation(s)
- Charles H. Brown
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Zayed 6208, 1800 Orleans St, Baltimore, MD 21287 USA
| | - Emily L. Jones
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Zayed 6208, 1800 Orleans St, Baltimore, MD 21287 USA
| | - Charles Lin
- Mercy Anesthesiology Associates, 300 St. Paul Place, Baltimore, MD 21202 USA
| | - Melody Esmaili
- Mercy Anesthesiology Associates, 300 St. Paul Place, Baltimore, MD 21202 USA
| | - Yara Gorashi
- Tufts University School of Medicine, 145 Harrison Ave, Boston, MA 02111 USA
| | - Richard A. Skelton
- University of Miami Miller School of Medicine, 1600 NW 10th avenue, Miami, FL 33136 USA
| | - Daniel Kaganov
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Zayed 6208, 1800 Orleans St, Baltimore, MD 21287 USA
| | - Elizabeth A. Colantuoni
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, Baltimore, MD 21287 USA
| | - Lisa R. Yanek
- Department of Medicine, Johns Hopkins University School of Medicine, 1830 Building; 8024, 600 N. Wolfe St, Baltimore, MD 21287 USA
| | - Karin J. Neufeld
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, A4 Center Suite 457, 4940 Eastern Avenue, Baltimore, MD 21224 USA
| | - Vidyulata Kamath
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, A4 Center Suite 457, 4940 Eastern Avenue, Baltimore, MD 21224 USA
| | - Frederick E. Sieber
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Zayed 6208, 1800 Orleans St, Baltimore, MD 21287 USA
| | - Clayton L. Dean
- The Maryland Spine Center at Mercy, 301 St. Paul Place, Baltimore, MD 21202 USA
| | - Charles C. Edwards
- The Maryland Spine Center at Mercy, 301 St. Paul Place, Baltimore, MD 21202 USA
| | - Charles W. Hogue
- Department of Anesthesiology, Northwestern Feinberg School of Medicine, NMH/Feinberg Room 5-704, 251 E Huron, Northwestern Feinberg School of Medicine, Chicago, IL 60611 USA
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155
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Gutierrez R, Egaña JI, Saez I, Reyes F, Briceño C, Venegas M, Lavado I, Penna A. Intraoperative Low Alpha Power in the Electroencephalogram Is Associated With Postoperative Subsyndromal Delirium. Front Syst Neurosci 2019; 13:56. [PMID: 31680886 PMCID: PMC6813625 DOI: 10.3389/fnsys.2019.00056] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 10/03/2019] [Indexed: 12/15/2022] Open
Abstract
Background Postoperative delirium (PD) and subsyndromal delirium (PSSD) are frequent complications in older patients associated with poor long-term outcome. It has been suggested that certain electroencephalogram features may be capable of identifying patients at risk during surgery. Thus, the goal of this study was to characterize intraoperative electroencephalographic markers to identify patients prone to develop PD or PSSD. Methods We conducted an exploratory observational study in older patients scheduled for elective major abdominal surgery. Intraoperative 16 channels electroencephalogram was recorded, and PD/PSSD were diagnosed after surgery with the confusion assessment method (CAM). The total power spectra and relative power of alpha band were calculated. Results PD was diagnosed in 2 patients (6.7%), and 11 patients (36.7%) developed PSSD. All of them (13 patients, PD/PSSD group) were compared with patients without any alterations in CAM (17 patients, control group). There were no detectable power spectrum differences before anesthesia between both groups of patients. However, PD/PSSD group in comparison with control group had a lower intraoperative absolute alpha power during anesthesia (4.4 ± 3.8 dB vs. 9.6 ± 3.2 dB, p = 0.0004) and a lower relative alpha power (0.09 ± 0.06 vs. 0.21 ± 0.08, p < 0.0001). These differences were independent of the anesthetic dose. Finally, relative alpha power had a good ability to identify patients with CAM alterations in the ROC analysis (area under the curve 0.90 (CI 0.78-1), p < 0.001). Discussion In conclusion, a low intraoperative alpha power is a novel electroencephalogram marker to identify patients who will develop alterations in CAM - i.e., with PD or PSSD - after surgery.
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Affiliation(s)
- Rodrigo Gutierrez
- Departamento de Anestesiología y Medicina Perioperatoria, Hospital Clínico, Universidad de Chile, Santiago, Chile.,Centro de Investigación Clínica Avanzada (CICA), Facultad de Medicina, Hospital Clínico, Universidad de Chile, Santiago, Chile
| | - Jose I Egaña
- Departamento de Anestesiología y Medicina Perioperatoria, Hospital Clínico, Universidad de Chile, Santiago, Chile
| | - Iván Saez
- Centro de Investigación Clínica Avanzada (CICA), Facultad de Medicina, Hospital Clínico, Universidad de Chile, Santiago, Chile
| | - Fernando Reyes
- Departamento de Anestesiología y Medicina Perioperatoria, Hospital Clínico, Universidad de Chile, Santiago, Chile
| | - Constanza Briceño
- Departamento de Terapia Ocupacional y Ciencia de la Ocupación, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Mariana Venegas
- Escuela de Medicina, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Isidora Lavado
- Escuela de Medicina, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Antonello Penna
- Departamento de Anestesiología y Medicina Perioperatoria, Hospital Clínico, Universidad de Chile, Santiago, Chile.,Centro de Investigación Clínica Avanzada (CICA), Facultad de Medicina, Hospital Clínico, Universidad de Chile, Santiago, Chile
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156
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Romagnoli S, Franchi F, Ricci Z. Processed EEG monitoring for anesthesia and intensive care practice. Minerva Anestesiol 2019; 85:1219-1230. [PMID: 31630505 DOI: 10.23736/s0375-9393.19.13478-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Individual response to sedatives and hypnotics is characterized by high variability and the identification of a personalized dose during anesthesia in the operating room and during sedation in the intensive care unit may have beneficial effects. Although the brain is the main target of general intravenous and inhaled anesthetic agents, electroencephalography (EEG) is not routinely utilized to explore cerebral response to sedation and anesthesia probably because EEG trace reading is complex and requires encephalographers' skills. Automated processing algorithms (processed EEG, pEEG) of raw EEG traces provide easy-to-use indices that can be utilized to optimize anesthetic management. A large number of high-quality studies and the recommendations of international scientific societies have confirmed the deleterious consequences of inadequate or excessively deep anesthesia (and sedation) level. In this context, anesthesia in the operating rooms and moderate/deep sedation in intensive care units driven by pEEG monitors could become a standard practice in the near future. The aim of the present review was to provide an overview of current knowledge and debate on available technologies for pEEG monitoring and their role in clinical practice for anesthesia and sedation.
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Affiliation(s)
- Stefano Romagnoli
- Section of Anesthesiology and Intensive Care, Department of Health Science, University of Florence, Florence, Italy - .,Department of Anesthesiology and Intensive Care, Careggi University Hospital, Florence, Italy -
| | - Federico Franchi
- Department of Medicine, Surgery and Neuroscience, Anesthesiology and Intensive Care, University Hospital of Siena, Siena, Italy
| | - Zaccaria Ricci
- Unit of Pediatric Cardiac Intensive Care, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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157
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Wildes TS, Avidan MS. Critical appraisal of ENGAGES: cognitive dissonance and anesthesia research. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:599. [PMID: 31807580 DOI: 10.21037/atm.2019.09.48] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- Troy S Wildes
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
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158
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Lewis SR, Pritchard MW, Fawcett LJ, Punjasawadwong Y. Bispectral index for improving intraoperative awareness and early postoperative recovery in adults. Cochrane Database Syst Rev 2019; 9:CD003843. [PMID: 31557307 PMCID: PMC6763215 DOI: 10.1002/14651858.cd003843.pub4] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The use of clinical signs, or end-tidal anaesthetic gas (ETAG), may not be reliable in measuring the hypnotic component of anaesthesia and may lead to either overdosage or underdosage resulting in adverse effects because of too deep or too light anaesthesia. Intraoperative awareness, whilst uncommon, may lead to serious psychological disturbance, and alternative methods to monitor the depth of anaesthesia may reduce the incidence of serious events. Bispectral index (BIS) is a numerical scale based on electrical activity in the brain. Using a BIS monitor to guide the dose of anaesthetic may have advantages over clinical signs or ETAG. This is an update of a review last published in 2014. OBJECTIVES To assess the effectiveness of BIS to reduce the risk of intraoperative awareness and early recovery times from general anaesthesia in adults undergoing surgery. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, and Web of Science on 26 March 2019. We searched clinical trial registers and grey literature, and handsearched reference lists of included studies and related reviews. SELECTION CRITERIA We included randomized controlled trials (RCTs) and quasi-RCTs in which BIS was used to guide anaesthesia compared with standard practice which was either clinical signs or end-tidal anaesthetic gas (ETAG) to guide the anaesthetic dose. We included adult participants undergoing any type of surgery under general anaesthesia regardless of whether included participants had a high risk of intraoperative awareness. We included only studies in which investigators aimed to evaluate the effectiveness of BIS for its role in monitoring intraoperative depth of anaesthesia or potential improvements in early recovery times from anaesthesia. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion, extracted data, and assessed risk of bias. We assessed the certainty of evidence with GRADE. MAIN RESULTS We included 52 studies with 41,331 participants; two studies were quasi-randomized and the remaining studies were RCTs. All studies included participants undergoing surgery under general anaesthesia. Three studies recruited only participants who were at high risk of intraoperative awareness, whilst two studies specifically recruited an unselected participant group. We analysed the data according to two comparison groups: BIS versus clinical signs; and BIS versus ETAG. Forty-eight studies used clinical signs as a comparison method, which included titration of anaesthesia according to criteria such as blood pressure or heart rate and, six studies used ETAG to guide anaesthesia. Whilst BIS target values differed between studies, all were within a range of values between 40 to 60.BIS versus clinical signsWe found low-certainty evidence that BIS-guided anaesthesia may reduce the risk of intraoperative awareness in a surgical population that were unselected or at high risk of awareness (Peto odds ratio (OR) 0.36, 95% CI 0.21 to 0.60; I2 = 61%; 27 studies; 9765 participants). However, events were rare with only five of 27 studies with reported incidences; we found that incidences of intraoperative awareness when BIS was used were three per 1000 (95% CI 2 to 6 per 1000) compared to nine per 1000 when anaesthesia was guided by clinical signs. Of the five studies with event data, one included participants at high risk of awareness and one included unselected participants, four used a structured questionnaire for assessment, and two used an adjudication process to identify confirmed or definite awareness.Early recovery times were also improved when BIS was used. We found low-certainty evidence that BIS may reduce the time to eye opening by mean difference (MD) 1.78 minutes (95% CI -2.53 to -1.03 minutes; 22 studies; 1494 participants), the time to orientation by MD 3.18 minutes (95% CI -4.03 to -2.33 minutes; 6 studies; 273 participants), and the time to discharge from the postanaesthesia care unit (PACU) by MD 6.86 minutes (95% CI -11.72 to -2 minutes; 13 studies; 930 participants).BIS versus ETAGAgain, events of intraoperative awareness were extremely rare, and we found no evidence of a difference in incidences of intraoperative awareness according to whether anaesthesia was guided by BIS or by ETAG in a surgical population at unselected or at high risk of awareness (Peto OR 1.13, 95% CI 0.56 to 2.26; I2 = 37%; 5 studies; 26,572 participants; low-certainty evidence). Incidences of intraoperative awareness were one per 1000 in both groups. Only three of five studies reported events, two included participants at high risk of awareness and one included unselected participants, all used a structured questionnaire for assessment and an adjudication process to identify confirmed or definite awareness.One large study (9376 participants) reported a reduced time to discharge from the PACU by a median of three minutes less, and we judged the certainty of this evidence to be low. No studies measured or reported the time to eye opening and the time to orientation.Certainty of the evidenceWe used GRADE to downgrade the evidence for all outcomes to low certainty. The incidence of intraoperative awareness is so infrequent such that, despite the inclusion of some large multi-centre studies in analyses, we believed that the effect estimates were imprecise. In addition, analyses included studies that we judged to have limitations owing to some assessments of high or unclear bias and in all studies, it was not possible to blind anaesthetists to the different methods of monitoring depth of anaesthesia.Studies often did not report a clear definition of intraoperative awareness. Time points of measurement differed, and methods used to identify intraoperative awareness also differed and we expected that some assessment tools were more comprehensive than others. AUTHORS' CONCLUSIONS Intraoperative awareness is infrequent and, despite identifying a large number of eligible studies, evidence for the effectiveness of using BIS to guide anaesthetic depth is imprecise. We found that BIS-guided anaesthesia compared to clinical signs may reduce the risk of intraoperative awareness and improve early recovery times in people undergoing surgery under general anaesthesia but we found no evidence of a difference between BIS-guided anaesthesia and ETAG-guided anaesthesia. We found six studies awaiting classification and two ongoing studies; inclusion of these studies in future updates may increase the certainty of the evidence.
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Affiliation(s)
- Sharon R Lewis
- Lancaster Patient Safety Research Unit, Royal Lancaster Infirmary, Pointer Court 1, Ashton Road, Lancaster, UK, LA1 4RP
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159
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Chen YC, Sun WZ. Postoperative cognitive dysfunction in premenopausal versus postmenopausal women. Climacteric 2019; 23:165-172. [DOI: 10.1080/13697137.2019.1653840] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Y.-C. Chen
- Department of Anesthesiology, Far Eastern Memorial Hospital, New Taipei City, Taiwan
- Graduate Institute of Brain and Mind Sciences, College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Anesthesiology, En Chun Kong Hospital, New Taipei City, Taiwan
| | - W.-Z. Sun
- Graduate Institute of Brain and Mind Sciences, College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
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160
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161
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Liveris A, Stein DM. Delirium in the Elderly Surgical Patient. CURRENT GERIATRICS REPORTS 2019. [DOI: 10.1007/s13670-019-00288-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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162
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Daiello LA, Racine AM, Gou RY, Marcantonio ER, Xie Z, Kunze LJ, Vlassakov KV, Inouye SK, Jones RN. Postoperative Delirium and Postoperative Cognitive Dysfunction: Overlap and Divergence. Anesthesiology 2019; 131:477-491. [PMID: 31166241 PMCID: PMC6692220 DOI: 10.1097/aln.0000000000002729] [Citation(s) in RCA: 167] [Impact Index Per Article: 33.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Postoperative delirium and postoperative cognitive dysfunction share risk factors and may co-occur, but their relationship is not well established. The primary goals of this study were to describe the prevalence of postoperative cognitive dysfunction and to investigate its association with in-hospital delirium. The authors hypothesized that delirium would be a significant risk factor for postoperative cognitive dysfunction during follow-up. METHODS This study used data from an observational study of cognitive outcomes after major noncardiac surgery, the Successful Aging after Elective Surgery study. Postoperative delirium was evaluated each hospital day with confusion assessment method-based interviews supplemented by chart reviews. Postoperative cognitive dysfunction was determined using methods adapted from the International Study of Postoperative Cognitive Dysfunction. Associations between delirium and postoperative cognitive dysfunction were examined at 1, 2, and 6 months. RESULTS One hundred thirty-four of 560 participants (24%) developed delirium during hospitalization. Slightly fewer than half (47%, 256 of 548) met the International Study of Postoperative Cognitive Dysfunction-defined threshold for postoperative cognitive dysfunction at 1 month, but this proportion decreased at 2 months (23%, 123 of 536) and 6 months (16%, 85 of 528). At each follow-up, the level of agreement between delirium and postoperative cognitive dysfunction was poor (kappa less than .08) and correlations were small (r less than .16). The relative risk of postoperative cognitive dysfunction was significantly elevated for patients with a history of postoperative delirium at 1 month (relative risk = 1.34; 95% CI, 1.07-1.67), but not 2 months (relative risk = 1.08; 95% CI, 0.72-1.64), or 6 months (relative risk = 1.21; 95% CI, 0.71-2.09). CONCLUSIONS Delirium significantly increased the risk of postoperative cognitive dysfunction in the first postoperative month; this relationship did not hold in longer-term follow-up. At each evaluation, postoperative cognitive dysfunction was more common among patients without delirium. Postoperative delirium and postoperative cognitive dysfunction may be distinct manifestations of perioperative neurocognitive deficits.
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Affiliation(s)
- Lori A. Daiello
- Alzheimer’s Disease and Memory Disorders Center, Rhode Island Hospital, Providence, RI
- Department of Neurology, Brown University Warren Alpert Medical School, Providence RI
| | - Annie M. Racine
- Institute for Aging Research, Hebrew SeniorLife, Boston, MA
- Harvard Medical School, Boston, MA
| | - Ray Yun Gou
- Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | - Edward R. Marcantonio
- Harvard Medical School, Boston, MA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Zhongcong Xie
- Harvard Medical School, Boston, MA
- Department of Anesthesia, Massachusetts General Hospital, Boston, MA
| | - Lisa J Kunze
- Harvard Medical School, Boston, MA
- Department of Anesthesia and Critical Care, Beth Israel Deaconess Medical Center, Boston, MA
| | - Kamen V. Vlassakov
- Harvard Medical School, Boston, MA
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Sharon K. Inouye
- Institute for Aging Research, Hebrew SeniorLife, Boston, MA
- Harvard Medical School, Boston, MA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Richard N. Jones
- Department of Psychiatry and Human Behavior, Brown University Warren Alpert Medical School, Providence RI
- Department of Neurology, Brown University Warren Alpert Medical School, Providence RI
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163
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Koch S, Radtke F, Spies C. A call for a more rigorous screening of postoperative delirium. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:S192. [PMID: 31656771 DOI: 10.21037/atm.2019.07.32] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Susanne Koch
- Department of Anesthesiology and Intensive Care Medicine, Campus Virchow-Klinikum and Campus Charité Mitte, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
| | - Finn Radtke
- Anaestesiafdelingen, Naestved Sygehus, Naestved, Denmark
| | - Claudia Spies
- Department of Anesthesiology and Intensive Care Medicine, Campus Virchow-Klinikum and Campus Charité Mitte, Charité-Universitätsmedizin Berlin, Berlin, Germany
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164
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Drexler B. Sinnvolle Ergänzung oder technische Spielerei? Anaesthesist 2019; 68:581-582. [DOI: 10.1007/s00101-019-0619-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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165
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Dexmedetomidine Prevents Cognitive Decline by Enhancing Resolution of High Mobility Group Box 1 Protein-induced Inflammation through a Vagomimetic Action in Mice. Anesthesiology 2019; 128:921-931. [PMID: 29252509 DOI: 10.1097/aln.0000000000002038] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Inflammation initiated by damage-associated molecular patterns has been implicated for the cognitive decline associated with surgical trauma and serious illness. We determined whether resolution of inflammation mediates dexmedetomidine-induced reduction of damage-associated molecular pattern-induced cognitive decline. METHODS Cognitive decline (assessed by trace fear conditioning) was induced with high molecular group box 1 protein, a damage-associated molecular pattern, in mice that also received blockers of neural (vagal) and humoral inflammation-resolving pathways. Systemic and neuroinflammation was assessed by proinflammatory cytokines. RESULTS Damage-associated molecular pattern-induced cognitive decline and inflammation (mean ± SD) was reversed by dexmedetomidine (trace fear conditioning: 58.77 ± 8.69% vs. 41.45 ± 7.64%, P < 0.0001; plasma interleukin [IL]-1β: 7.0 ± 2.2 pg/ml vs. 49.8 ± 6.0 pg/ml, P < 0.0001; plasma IL-6: 3.2 ± 1.6 pg/ml vs. 19.5 ± 1.7 pg/ml, P < 0.0001; hippocampal IL-1β: 4.1 ± 3.0 pg/mg vs. 41.6 ± 8.0 pg/mg, P < 0.0001; hippocampal IL-6: 3.4 ± 1.3 pg/mg vs. 16.2 ± 2.7 pg/mg, P < 0.0001). Reversal by dexmedetomidine was prevented by blockade of vagomimetic imidazoline and α7 nicotinic acetylcholine receptors but not by α2 adrenoceptor blockade. Netrin-1, the orchestrator of inflammation-resolution, was upregulated (fold-change) by dexmedetomidine (lung: 1.5 ± 0.1 vs. 0.7 ± 0.1, P < 0.0001; spleen: 1.5 ± 0.2 vs. 0.6 ± 0.2, P < 0.0001), resulting in upregulation of proresolving (lipoxin-A4: 1.7 ± 0.2 vs. 0.9 ± 0.2, P < 0.0001) and downregulation of proinflammatory (leukotriene-B4: 1.0 ± 0.2 vs. 3.0 ± 0.3, P < 0.0001) humoral mediators that was prevented by α7 nicotinic acetylcholine receptor blockade. CONCLUSIONS Dexmedetomidine resolves inflammation through vagomimetic (neural) and humoral pathways, thereby preventing damage-associated molecular pattern-mediated cognitive decline.
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Koch S, Stegherr AM, Rupp L, Kruppa J, Prager C, Kramer S, Fahlenkamp A, Spies C. Emergence delirium in children is not related to intraoperative burst suppression - prospective, observational electrography study. BMC Anesthesiol 2019; 19:146. [PMID: 31395011 PMCID: PMC6688308 DOI: 10.1186/s12871-019-0819-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 07/31/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Emergence-delirium is the most frequent brain dysfunction in children recovering from general anaesthesia, though the pathophysiological background remains unclear. The presented study analysed an association between emergence delirium and intraoperative Burst Suppression activity in the electroencephalogram, a period of very deep hypnosis during general anaesthesia. METHODS In this prospective, observational cohort study at the Charité - university hospital in Berlin / Germany children aged 0.5 to 8 years, undergoing planned surgery, were included between September 2015 and February 2017. Intraoperative bi-frontal electroencephalograms were recorded. Occurrence and duration of Burst Suppression periods were visually analysed. Emergence delirium was assessed using the Pediatric Assessment of Emergence Delirium Score. RESULTS From 97 children being analysed within this study, 40 children developed emergence delirium, and 57 children did not. Overall 52% of the children displayed intraoperative Burst Suppression periods; however, occurrence and duration of Burst Suppression (Emergence delirium group 55% / 261 + 462 s vs. Non-emergence delirium group 49% / 318 + 531 s) did not differ significantly between both groups. CONCLUSIONS Our data reveal no correlation between the occurrence and duration of intraoperative Burst Suppression activity and the incidence of emergence delirium. Burst Suppression occurrence is frequent; however, it does not seem to have an unfavourable impact on cerebral function at emergence from general anaesthesia in children. TRAIL REGISTRATION NCT02481999, June 25, 2015.
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Affiliation(s)
- Susanne Koch
- Department of Anaesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum and Campus Charité Mitte, Augustenburger Platz 1, 13353, Berlin, Germany. .,Berlin Institute of Health (BIH), Anna-Louisa-Karsch 2, 10178, Berlin, Germany.
| | - Anna-Maria Stegherr
- Department of Anaesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum and Campus Charité Mitte, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Leopold Rupp
- Department of Anaesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum and Campus Charité Mitte, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Jochen Kruppa
- Charité-Universitätsmedizin BerlinInstitute of Biometry and Clinical Epidemiology, Campus Charité Mitte, Charitéplatz 1, 10117, Berlin, Germany.,Berlin Institute of Health (BIH), Anna-Louisa-Karsch 2, 10178, Berlin, Germany
| | - Christine Prager
- Department of Paediatria and Neurology, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum and Campus Charité Mitte, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Sylvia Kramer
- Department of Anaesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum and Campus Charité Mitte, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Astrid Fahlenkamp
- Department of Anaesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum and Campus Charité Mitte, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Claudia Spies
- Department of Anaesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum and Campus Charité Mitte, Augustenburger Platz 1, 13353, Berlin, Germany
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167
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Hirota K. Preoperative management and postoperative delirium. J Anesth 2019; 34:1-4. [DOI: 10.1007/s00540-019-02660-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 06/29/2019] [Indexed: 02/08/2023]
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168
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Tojo A, Uchimoto K, Inagawa G, Goto T. Desflurane impairs hippocampal learning on day 1 of exposure: a prospective laboratory study in rats. BMC Anesthesiol 2019; 19:119. [PMID: 31272380 PMCID: PMC6610887 DOI: 10.1186/s12871-019-0793-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 06/27/2019] [Indexed: 12/05/2022] Open
Abstract
Background Quick and complete recovery of cognitive function after general anesthesia is desirable, particularly for working-age patients. Desflurane is less likely to have long-term effects than older-generation inhalational anesthetics, however, its short-term effects have not been fully investigated. Our objective was to elucidate the short-term effects of desflurane exposure on learning and memory in young adult rats. Methods Seven-week old male Sprague–Dawley rats were exposed to air (control), or desflurane at 0.7 or 1.2 minimum alveolar concentration (MAC) for 2 h (day 0). The inhibitory avoidance (IA) test was performed on day 1 to delineate the effects on contextual learning. Separate groups of control and 1.2 MAC desflurane animals underwent the IA test on days 3 and 7 to examine the time-dependent changes. Because the IA test is known to be dependent on the long-term potentiation (LTP) of the hippocampus and the trafficking of the GluR1 subunit of the α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor into the synapses, the effects of 1.2 MAC desflurane on these phenomena were evaluated on day 1. Results Desflurane at 1.2 MAC, but not 0.7 MAC, significantly decreased the IA latencies on day 1 compared with the control (one-way ANOVA, F [2,48] = 5.974, P = 0.005, post hoc Tukey’s, mean difference [95% confidence interval], control vs. 1.2 MAC, 168 [49.9 to 287], P = 0.004; control vs. 0.7 MAC, 67.5 [− 51.2 to 186], P = 0.362). The latencies were not affected on days 3 and 7 (day 3, control vs. desflurane, P = 0.861; day 7, control vs. desflurane, P > 0.999). Consistently, hippocampal LTP on day 1 was significantly suppressed in the desflurane group compared with the control group (P = 0.006). Moreover, immunoblotting analysis of synaptic GluR1 expression revealed that desflurane exposure significantly suppressed GluR1 delivery to the synapses after IA training. Conclusion Exposure to a relatively high concentration of desflurane caused reversible learning and memory impairment in young adult rats associated with suppression of GluR1 delivery to the synapses in the hippocampus.
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Affiliation(s)
- Ayako Tojo
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Graduate School of Medicine, 3-9, Fukuura, Kanazawa-ku, Yokohama, Japan.
| | - Kazuhiro Uchimoto
- Department of Intensive Care, Yokohama City University Medical Centre, 4-57, Urafune-cho, Minami-ku, Yokohama, Japan
| | - Gaku Inagawa
- Department of Anesthesiology, Yokohama Municipal Citizen's Hospital, 56, Okazawa-cho, Hodogaya-ku, Yokohama, Japan
| | - Takahisa Goto
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Graduate School of Medicine, 3-9, Fukuura, Kanazawa-ku, Yokohama, Japan
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169
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Ni K, Cooter M, Gupta DK, Thomas J, Hopkins TJ, Miller TE, James ML, Kertai MD, Berger M. Paradox of age: older patients receive higher age-adjusted minimum alveolar concentration fractions of volatile anaesthetics yet display higher bispectral index values. Br J Anaesth 2019; 123:288-297. [PMID: 31279479 DOI: 10.1016/j.bja.2019.05.040] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 04/26/2019] [Accepted: 05/06/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Minimum alveolar concentration (MAC) and MAC-awake decrease with age. We hypothesised that, in clinical practice, (i) end-tidal MAC fraction in older patients would decline by less than the predicted age-dependent MAC decrease (i.e. older patients would receive relatively excessive anaesthetic concentrations), and (ii) bispectral index (BIS) values would therefore be lower in older patients. METHODS We examined the relationship between end-tidal MAC fraction, BIS values, and age in 4699 patients > 30 yr in age at a single centre using unadjusted local regression (locally estimated scatterplot smoothing), Spearman's correlation, stratification, and robust univariable and multivariable linear regression. RESULTS The end-tidal MAC fraction in older patients declined by 3.01% per decade (95% confidence interval [CI]: 2.56-3.45; P<0.001), less than the 6.47% MAC decrease per decade that we found in a meta-regression analysis of published studies of age-dependent changes in MAC (P<0.001), and less than the age-dependent decrease in MAC-awake. The BIS values correlated positively with age (ρ=0.15; 95% CI: 0.12-0.17; P<0.001), and inversely with the age-adjusted end-tidal MAC (aaMAC) fraction (ρ= -0.13; 95% CI: -0.16, -0.11; P<0.001). CONCLUSIONS The age-dependent decline in end-tidal MAC fraction delivered in clinical practice at our institution was less than the age-dependent percentage decrease in MAC and MAC-awake determined from published studies. Despite receiving higher aaMAC fractions, older patients paradoxically showed higher BIS values. This most likely suggests that the BIS algorithm is inaccurate in older adults.
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Affiliation(s)
- Katherine Ni
- Mount Sinai School of Medicine, New York, NY, USA
| | - Mary Cooter
- Anesthesiology Department, Duke University Medical Center, Durham, NC, USA
| | - Dhanesh K Gupta
- Anesthesiology Department, Duke University Medical Center, Durham, NC, USA
| | - Jake Thomas
- Anesthesiology Department, Duke University Medical Center, Durham, NC, USA; Trinity College of Arts and Sciences, Duke University, Durham, NC, USA
| | - Thomas J Hopkins
- Anesthesiology Department, Duke University Medical Center, Durham, NC, USA
| | - Timothy E Miller
- Anesthesiology Department, Duke University Medical Center, Durham, NC, USA
| | - Michael L James
- Trinity College of Arts and Sciences, Duke University, Durham, NC, USA; Neurology Department, Duke University Medical Center, Durham, NC, USA
| | - Miklos D Kertai
- Division of Cardiothoracic Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Miles Berger
- Anesthesiology Department, Duke University Medical Center, Durham, NC, USA.
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Perioperative Risk Factors for Postoperative Delirium in Patients Undergoing Esophagectomy. Ann Thorac Surg 2019; 108:190-195. [DOI: 10.1016/j.athoracsur.2019.01.040] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 01/15/2019] [Accepted: 01/17/2019] [Indexed: 12/12/2022]
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171
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Iqbal F, Thompson AJ, Riaz S, Pehar M, Rice T, Syed NI. Anesthetics: from modes of action to unconsciousness and neurotoxicity. J Neurophysiol 2019; 122:760-787. [PMID: 31242059 DOI: 10.1152/jn.00210.2019] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Modern anesthetic compounds and advanced monitoring tools have revolutionized the field of medicine, allowing for complex surgical procedures to occur safely and effectively. Faster induction times and quicker recovery periods of current anesthetic agents have also helped reduce health care costs significantly. Moreover, extensive research has allowed for a better understanding of anesthetic modes of action, thus facilitating the development of more effective and safer compounds. Notwithstanding the realization that anesthetics are a prerequisite to all surgical procedures, evidence is emerging to support the notion that exposure of the developing brain to certain anesthetics may impact future brain development and function. Whereas the data in support of this postulate from human studies is equivocal, the vast majority of animal research strongly suggests that anesthetics are indeed cytotoxic at multiple brain structure and function levels. In this review, we first highlight various modes of anesthetic action and then debate the evidence of harm from both basic science and clinical studies perspectives. We present evidence from animal and human studies vis-à-vis the possible detrimental effects of anesthetic agents on both the young developing and the elderly aging brain while discussing potential ways to mitigate these effects. We hope that this review will, on the one hand, invoke debate vis-à-vis the evidence of anesthetic harm in young children and the elderly, and on the other hand, incentivize the search for better and less toxic anesthetic compounds.
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Affiliation(s)
- Fahad Iqbal
- Vi Riddell Pain Program, Alberta Children's Hospital Research Institute, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Andrew J Thompson
- Vi Riddell Pain Program, Alberta Children's Hospital Research Institute, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Neuroscience, Faculty of Science, University of Calgary, Calgary, Alberta, Canada
| | - Saba Riaz
- Vi Riddell Pain Program, Alberta Children's Hospital Research Institute, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Marcus Pehar
- Vi Riddell Pain Program, Alberta Children's Hospital Research Institute, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Tiffany Rice
- Department of Anesthesiology, Perioperative and Pain Medicine, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Naweed I Syed
- Vi Riddell Pain Program, Alberta Children's Hospital Research Institute, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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172
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Janssen TL, Alberts AR, Hooft L, Mattace-Raso F, Mosk CA, van der Laan L. Prevention of postoperative delirium in elderly patients planned for elective surgery: systematic review and meta-analysis. Clin Interv Aging 2019; 14:1095-1117. [PMID: 31354253 PMCID: PMC6590846 DOI: 10.2147/cia.s201323] [Citation(s) in RCA: 106] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Accepted: 03/06/2019] [Indexed: 01/09/2023] Open
Abstract
Introduction: Vulnerable or “frail” patients are susceptible to the development of delirium when exposed to triggers such as surgical procedures. Once delirium occurs, interventions have little effect on severity or duration, emphasizing the importance of primary prevention. This review provides an overview of interventions to prevent postoperative delirium in elderly patients undergoing elective surgery. Methods: A literature search was conducted in March 2018. Randomized controlled trials (RCTs) and before-and-after studies on interventions with potential effects on postoperative delirium in elderly surgical patients were included. Acute admission, planned ICU admission, and cardiac patients were excluded. Full texts were reviewed, and quality was assessed by two independent reviewers. Primary outcome was the incidence of delirium. Secondary outcomes were severity and duration of delirium. Pooled risk ratios (RRs) were calculated for incidences of delirium where similar intervention techniques were used. Results: Thirty-one RCTs and four before-and-after studies were included for analysis. In 19 studies, intervention decreased the incidences of postoperative delirium. Severity was reduced in three out of nine studies which reported severity of delirium. Duration was reduced in three out of six studies. Pooled analysis showed a significant reduction in delirium incidence for dexmedetomidine treatment, and bispectral index (BIS)-guided anaesthesia. Based on sensitivity analyses, by leaving out studies with a high risk of bias, multicomponent interventions and antipsychotics can also significantly reduce the incidence of delirium. Conclusion: Multicomponent interventions, the use of antipsychotics, BIS-guidance, and dexmedetomidine treatment can successfully reduce the incidence of postoperative delirium in elderly patients undergoing elective, non-cardiac surgery. However, present studies are heterogeneous, and high-quality studies are scarce. Future studies should add these preventive methods to already existing multimodal and multidisciplinary interventions to tackle as many precipitating factors as possible, starting in the pre-admission period.
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Affiliation(s)
- T L Janssen
- Department of Surgery, Amphia Hospital Breda, Breda, The Netherlands
| | - A R Alberts
- Department of Surgery, Amphia Hospital Breda, Breda, The Netherlands
| | - L Hooft
- Cochrane Netherlands, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Fus Mattace-Raso
- Department of Geriatrics, Erasmus MC University Hospital Rotterdam, Rotterdam, The Netherlands
| | - C A Mosk
- Department of Surgery, Amphia Hospital Breda, Breda, The Netherlands
| | - L van der Laan
- Department of Surgery, Amphia Hospital Breda, Breda, The Netherlands
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173
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Rengel KF, Pandharipande PP, Hughes CG. Special Considerations for the Aging Brain and Perioperative Neurocognitive Dysfunction. Anesthesiol Clin 2019; 37:521-536. [PMID: 31337482 DOI: 10.1016/j.anclin.2019.04.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Postoperative delirium and postoperative cognitive dysfunction (POCD) occur commonly in older adults after surgery and are frequently underrecognized. Delirium has been associated with worse outcomes, and both delirium and cognitive dysfunction increase the risk of long-term cognitive decline. Although the pathophysiology of delirium and POCD have not been clearly defined, risk factors for both include increasing age, lower levels of education, and baseline cognitive impairment. In addition, developing delirium increases the risk of POCD. This article examines interventions that may reduce the risk of developing delirium and POCD and improve long-term recovery and outcomes in the vulnerable older population.
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Affiliation(s)
- Kimberly F Rengel
- Department of Anesthesiology, Division of Anesthesiology Critical Care Medicine, Vanderbilt University School of Medicine, 1211 21st Avenue South, 422 MAB, Nashville, TN 37212, USA.
| | - Pratik P Pandharipande
- Department of Anesthesiology, Division of Anesthesiology Critical Care Medicine, Vanderbilt University School of Medicine, 1211 21st Avenue South, 422 MAB, Nashville, TN 37212, USA
| | - Christopher G Hughes
- Department of Anesthesiology, Division of Anesthesiology Critical Care Medicine, Vanderbilt University School of Medicine, 1211 21st Avenue South, 422 MAB, Nashville, TN 37212, USA
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174
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Shortal BP, Hickman LB, Mak-McCully RA, Wang W, Brennan C, Ung H, Litt B, Tarnal V, Janke E, Picton P, Blain-Moraes S, Maybrier HR, Muench MR, Lin N, Avidan MS, Mashour GA, McKinstry-Wu AR, Kelz MB, Palanca BJ, Proekt A. Duration of EEG suppression does not predict recovery time or degree of cognitive impairment after general anaesthesia in human volunteers. Br J Anaesth 2019; 123:206-218. [PMID: 31202561 DOI: 10.1016/j.bja.2019.03.046] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 02/14/2019] [Accepted: 03/08/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Burst suppression occurs in the EEG during coma and under general anaesthesia. It has been assumed that burst suppression represents a deeper state of anaesthesia from which it is more difficult to recover. This has not been directly demonstrated, however. Here, we test this hypothesis directly by assessing relationships between EEG suppression in human volunteers and recovery of consciousness. METHODS We recorded the EEG of 27 healthy humans (nine women/18 men) anaesthetised with isoflurane 1.3 minimum alveolar concentration (MAC) for 3 h. Periods of EEG suppression and non-suppression were separated using principal component analysis of the spectrogram. After emergence, participants completed the digit symbol substitution test and the psychomotor vigilance test. RESULTS Volunteers demonstrated marked variability in multiple features of the suppressed EEG. In order to test the hypothesis that, for an individual subject, inclusion of features of suppression would improve accuracy of a model built to predict time of emergence, two types of models were constructed: one with a suppression-related feature included and one without. Contrary to our hypothesis, Akaike information criterion demonstrated that the addition of a suppression-related feature did not improve the ability of the model to predict time to emergence. Furthermore, the amounts of EEG suppression and decrements in cognitive task performance relative to pre-anaesthesia baseline were not significantly correlated. CONCLUSIONS These findings suggest that, in contrast to current assumptions, EEG suppression in and of itself is not an important determinant of recovery time or the degree of cognitive impairment upon emergence from anaesthesia in healthy adults.
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Affiliation(s)
- B P Shortal
- Neuroscience Graduate Group, University of Pennsylvania, Philadelphia, PA, USA
| | - L B Hickman
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO, USA
| | - R A Mak-McCully
- Center for Sleep and Circadian Neurobiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - W Wang
- Department of Mathematics, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - C Brennan
- Neuroscience Graduate Group, University of Pennsylvania, Philadelphia, PA, USA
| | - H Ung
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA
| | - B Litt
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA; Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - V Tarnal
- Center for Consciousness Science, Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - E Janke
- Center for Consciousness Science, Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - P Picton
- Center for Consciousness Science, Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - S Blain-Moraes
- School of Physical and Occupational Therapy, McGill University, Montreal, QC, Canada
| | - H R Maybrier
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO, USA
| | - M R Muench
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO, USA
| | - N Lin
- Department of Mathematics, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - M S Avidan
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO, USA
| | - G A Mashour
- Center for Consciousness Science, Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - A R McKinstry-Wu
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - M B Kelz
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - B J Palanca
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO, USA
| | - A Proekt
- School of Physical and Occupational Therapy, McGill University, Montreal, QC, Canada; Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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- Department of Anesthesiology and Critical Care, University of Pennsylvania, USA; Department of Anesthesiology, Washington University, St. Louis, MO, USA; Center for Consciousness Science, Department of Anesthesiology, Ann Arbor, MI, USA
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175
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Ahmad M, Patel JN, Vipparthy SC, Divecha C, Barzallo PX, Kim M, Schrader SC, Barzallo M, Mungee S. Conscious Sedation Versus General Anesthesia in Transcatheter Aortic Valve Replacement: A Cost and Outcome Analysis. Cureus 2019; 11:e4812. [PMID: 31281765 PMCID: PMC6599466 DOI: 10.7759/cureus.4812] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Transcatheter aortic valve replacement (TAVR) has emerged as an alternative treatment for aortic stenosis in patients who are at moderate to high risk for surgical aortic valve replacement. The use of conscious sedation (CS) as compared with general anesthesia (GA) has shown better clinical outcomes for TAVR patients. Whether CS has any cost-benefit is still unknown. We analyze our local TAVR registry with a focus on the cost comparison between CS and GA for the TAVR population. Methods It is a retrospective chart review of 434 patients who received TAVR at our local center from December 2012 to April 2018. Patients who had their procedure aborted and those requiring a cardiopulmonary bypass or surgical conversion (16 patients) were excluded. The final sample size was 418. Patients were divided into two groups based on whether they received CS or GA. Primary outcomes were intensive care unit (ICU) hours, length of stay in hospital, readmission, or death at 30 days. The secondary outcome was the cost of TAVR admission. The cost was divided into direct and indirect costs. The student's T-test and chi-square tests were used for continuous and categorical variables, respectively. Adjusted logistic regression and multivariate analyses were run for primary and secondary outcomes. Results Of the 418 patients (age: 80.9±8.5, male: 52%) CS was given to 194 patients (46.4%) while GA was given in 224 patients(53.6%). The GA group had comparatively older age (81.8 vs. 80.0; p=0.03) and a higher average Society of Thoracic Surgery (STS) score (8.4 vs 5.7; p<0.001). Patients who received CS had a significantly shorter ICU stay (31.5 vs. 41.6 hours, p<0.001) and total days in the hospital (2.9 vs. 3.8 days, p=0.01). Readmission and mortality at 30 days were not different between the groups. There was no statistical difference in cost between the two groups ($72,809 vs. $71,497: p=0.656). Conclusion Using CS compared with GA improves morbidity for TAVR patients, in the form of ICU stay and the total length of stay in hospital. We did not find a significant difference in the cost of TAVR admission between CS and GA.
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Affiliation(s)
- Mansoor Ahmad
- Internal Medicine, University of Illinois College of Medicine at Peoria, Peoria, USA
| | - Jay N Patel
- Cardiology, University of Illinois College of Medicine at Peoria, Peoria, USA
| | - Sharath C Vipparthy
- Cardiology, University of Illinois College of Medicine at Peoria, Peoria, USA
| | - Chirag Divecha
- Cardiology, University of Illinois College of Medicine at Peoria, Peoria, USA
| | - Pablo X Barzallo
- Cardiology, University of Illinois College of Medicine at Peoria, Peoria, USA
| | - Minchul Kim
- Internal Medicine, University of Illinois College of Medicine at Peoria, Peoria, USA
| | - Steven C Schrader
- Anesthesiology, University of Illinois College of Medicine at Peoria, Peoria, USA
| | - Marco Barzallo
- Cardiology, University of Illinois College of Medicine at Peoria, Peoria, USA
| | - Sudhir Mungee
- Cardiology, University of Illinois College of Medicine at Peoria, Peoria, USA
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176
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Electroencephalography-guided anaesthetic administration does not impact postoperative delirium among older adults undergoing major surgery: an independent discussion of the ENGAGES trial. Br J Anaesth 2019; 123:112-117. [PMID: 31079835 DOI: 10.1016/j.bja.2019.03.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 03/08/2019] [Indexed: 12/20/2022] Open
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177
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Glumac S, Kardum G, Karanovic N. Postoperative Cognitive Decline After Cardiac Surgery: A Narrative Review of Current Knowledge in 2019. Med Sci Monit 2019; 25:3262-3270. [PMID: 31048667 PMCID: PMC6511113 DOI: 10.12659/msm.914435] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
The growing number of publications concerning postoperative cognitive decline (POCD) after cardiac surgery is indicative of the health-related and economic-related importance of this intriguing issue. Significantly, the reported POCD incidence over the years has remained steady due to various unresolved challenges regarding the examination of this multidisciplinary topic. In particular, a universally accepted POCD definition has not been established, and the pathogenesis is still vaguely understood. However, numerous recent studies have focused on the role of the inflammatory response to a surgical procedure in POCD occurrence. Therefore, this traditional narrative review summarizes and evaluates the latest findings, with special attention paid to the difficulties of defining POCD as well as the involvement of inflammation in POCD development. We searched the MEDLINE, Scopus, PsycINFO and CENTRAL databases for the best evidence, which was classified according to the Oxford Centre for Evidence-based Medicine. To our knowledge, this is the first narrative review that identified class-1 evidence (systematic review of randomized trials), although most evidence is still at class-2 or below. Furthermore, we revealed that defining POCD is a very controversial matter and that the inflammatory response plays an important role in the mutually overlapping processes included in POCD development. Thus, developing the definition of POCD represents an absolute priority in POCD investigations, and the inflammatory response to cardiac surgery merits further research.
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Affiliation(s)
- Sandro Glumac
- Department of Anesthesiology and Intensive Care, University Hospital of Split, Split, Croatia
| | - Goran Kardum
- Department of Psychology, Faculty of Humanities and Social Sciences, University of Split, Split, Croatia
| | - Nenad Karanovic
- Department of Anesthesiology and Intensive Care, University Hospital of Split, Split, Croatia.,Department of Anesthesiology and Intensive Medicine, School of Medicine, University of Split, Split, Croatia
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178
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Abstract
Postoperative delirium is a common and harrowing complication in older surgical patients. Those with cognitive impairment or dementia are at especially high risk for developing postoperative delirium; ominously, it is hypothesized that delirium can accelerate cognitive decline and the onset of dementia, or worsen the severity of dementia. Awareness of delirium has grown in recent years as various medical societies have launched initiatives to prevent postoperative delirium and alleviate its impact. Unfortunately, delirium pathophysiology is not well understood and this likely contributes to the current state of low-quality evidence that informs perioperative guidelines. Along these lines, recent prevention trials involving ketamine and dexmedetomidine have demonstrated inconsistent findings. Non-pharmacologic multicomponent initiatives, such as the Hospital Elder Life Program, have consistently reduced delirium incidence and burden across various hospital settings. However, a substantial portion of delirium occurrences are still not prevented, and effective prevention and management strategies are needed to complement such multicomponent non-pharmacologic therapies. In this narrative review, we examine the current understanding of delirium neurobiology and summarize the present state of prevention and management efforts.
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Affiliation(s)
- Phillip Vlisides
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan, USA.,Center for Consciousness Science, University of Michigan Medical School,, Ann Arbor, MI, USA
| | - Michael Avidan
- Department of Anesthesiology, Washington University School of Medicine, Saint Louis, Missouri, USA
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179
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Abstract
PURPOSE OF REVIEW To summarize recent recommendations on intraoperative electroencephalogram (EEG) neuromonitoring in the elderly aimed at the prevention of postoperative delirium and long-term neurocognitive decline. We discuss recent perioperative EEG investigations relating to aging and cognitive dysfunction, and their implications on intraoperative EEG neuromonitoring in elderly patients. RECENT FINDINGS The incidence of postoperative delirium in elderly can be reduced by monitoring depth of anesthesia, using an index number (0-100) derived from processed frontal EEG readings. The recently published European Society of Anaesthesiology guideline on postoperative delirium in elderly now recommends guiding general anesthesia with such indices (Level A). However, intraoperative EEG signatures are heavily influenced by age, cognitive function, and choice of anesthetic agents. Detailed spectral EEG analysis and research on EEG-based functional connectivity provide new insights into the pathophysiology of neuronal excitability, which is seen in elderly patients with postoperative delirium. SUMMARY Anesthesiologists should become acquainted with intraoperative EEG signatures and their relation to age, anesthetic agents, and the risk of postoperative cognitive complications. A working knowledge would allow an optimized and individualized provision of general anesthesia for the elderly.
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180
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Kaiser HA, Hight D. The meaning and impact of interpreting the EEG when using EEG derived ‘depth of anesthesia’ indices. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2019. [DOI: 10.1016/j.tacc.2019.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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181
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Honorato-Cia C, Martinez-Simon A. The anesthesiologist and the EEG: Current uses and future trends in the operating room. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2019. [DOI: 10.1016/j.tacc.2018.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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182
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Quan C, Chen J, Luo Y, Zhou L, He X, Liao Y, Chou J, Guo Q, Chen AF, Wen O. BIS-guided deep anesthesia decreases short-term postoperative cognitive dysfunction and peripheral inflammation in elderly patients undergoing abdominal surgery. Brain Behav 2019; 9:e01238. [PMID: 30815998 PMCID: PMC6456817 DOI: 10.1002/brb3.1238] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 01/18/2019] [Accepted: 01/19/2019] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES Postoperative cognitive dysfunction (POCD) is a common clinical complication, with an underlying pathophysiology linked to heightened levels of neuroinflammation. However, it requires clarification as to whether the depth of anesthesia modulates postoperative cognitive dysfunction. This study investigated the association between depth of anesthesia and POCD in elderly patients undergoing abdominal surgery. METHODS A total of 120 patients aged 60 years or older who were planned for abdominal surgery under total intravenous anesthesia were included in this study. The depth of anesthesia was guided by monitoring Bispectral Index (BIS) data. All study participants completed a battery of nine neuropsychological tests before surgery and at 7 days and 3 months after surgery. POCD was calculated by using the reliable change index. Plasma concentration of C-reactive protein (CRP), interleukin (IL)-1β, IL-10, S-100β, and norepinephrine (NE) were measured. RESULTS The incidence of POCD at 7 days after surgery in the deep anesthesia group was 19.2% (10/52), which was significantly lower (p = 0.032) than the light anesthesia group 39.6% (21/53). The depth of anesthesia had no effect on POCD at 3 months after surgery (10.3% vs 14.6%, respectively, p = 0.558). Similarly, plasma levels of CRP and IL-1β in deep anesthesia group were lower than that in light anesthesia group at 7 days after surgery (p < 0.05), but not at 3 months after surgery (p > 0.05). There were no significant differences in the plasma concentration of IL-10, S-100β, and NE between the groups (p > 0.05). CONCLUSIONS Deep anesthesia under total intravenous anesthesia could decrease the occurrence of short-term POCD and inhibit postoperative peripheral inflammation in elderly patients undergoing abdominal surgery, compared with light anesthesia.
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Affiliation(s)
- Chengxuan Quan
- Department of Anesthesiathe Third Xiangya Hospital of Central South UniversityChangshaChina
| | - Jia Chen
- Department of Anesthesiathe Third Xiangya Hospital of Central South UniversityChangshaChina
| | - Yuting Luo
- Department of Anesthesiathe Third Xiangya Hospital of Central South UniversityChangshaChina
| | - Lei Zhou
- Department of Anesthesiathe Third Xiangya Hospital of Central South UniversityChangshaChina
| | - Xi He
- Department of Anesthesiathe Third Xiangya Hospital of Central South UniversityChangshaChina
| | - Yan Liao
- Department of Anesthesiathe Third Xiangya Hospital of Central South UniversityChangshaChina
| | - Jing Chou
- Department of Anesthesiathe Third Xiangya Hospital of Central South UniversityChangshaChina
| | - Qulian Guo
- Department of AnesthesiaXiangya Hospital of Central South UniversityChangshaChina
| | - Alex F. Chen
- Department of Cardiologythe Third Xiangya Hospital of Central South UniversityChangshaChina
- Department of SurgeryUniversity of Pittsburgh School of Medicine and Veterans Affairs Pittsburgh Healthcare SystemPittsburghPennsylvania
| | - Ouyang Wen
- Department of Anesthesiathe Third Xiangya Hospital of Central South UniversityChangshaChina
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183
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Chaiwat O, Chanidnuan M, Pancharoen W, Vijitmala K, Danpornprasert P, Toadithep P, Thanakiattiwibun C. Postoperative delirium in critically ill surgical patients: incidence, risk factors, and predictive scores. BMC Anesthesiol 2019; 19:39. [PMID: 30894129 PMCID: PMC6425578 DOI: 10.1186/s12871-019-0694-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Accepted: 02/11/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND A common postoperative complication found among patients who are critically ill is delirium, which has a high mortality rate. A predictive model is needed to identify high-risk patients in order to apply strategies which will prevent and/or reduce adverse outcomes. OBJECTIVES To identify the incidence of, and the risk factors for, postoperative delirium (POD) in surgical intensive care unit (SICU) patients, and to determine predictive scores for the development of POD. METHODS This study enrolled adults aged over 18 years who had undergone an operation within the preceding week and who had been admitted to a SICU for a period that was expected to be longer than 24 h. The CAM - ICU score was used to determine the occurrence of delirium. RESULTS Of the 250 patients enrolled, delirium was found in 61 (24.4%). The independent risk factors for delirium that were identified by a multivariate analysis comprised age, diabetes mellitus, severity of disease (SOFA score), perioperative use of benzodiazepine, and mechanical ventilation. A predictive score (age + (5 × SOFA) + (15 × Benzodiazepine use) + (20 × DM) + (20 × mechanical ventilation) + (20 × modified IQCODE > 3.42)) was created. The area under the receiver operating characteristic (ROC) curve (AUC) was 0.84 (95% CI: 0.786 to 0.897). The cut point of 125 demonstrated a sensitivity of 72.13% and a specificity of 80.95%, and the hospital mortality rate was significantly greater among the delirious than the non-delirious patients (25% vs. 6%, p < 0.01). CONCLUSIONS POD was experienced postoperatively by a quarter of the surgical patients who were critically ill. A risk score utilizing 6 variables was able to predict which patients would develop POD. The identification of high-risk patients following SICU admission can provide a basis for intervention strategies to improve outcomes. TRIAL REGISTRATION Thai Clinical Trials Registry TCTR20181204006 . Date registered on December 4, 2018. Retrospectively registered.
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Affiliation(s)
- Onuma Chaiwat
- Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand. .,Integrated Perioperative Geriatric Excellent Research Center, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
| | - Mellada Chanidnuan
- Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand
| | - Worapat Pancharoen
- Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand
| | - Kittiya Vijitmala
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Praniti Danpornprasert
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Puriwat Toadithep
- Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand
| | - Chayanan Thanakiattiwibun
- Integrated Perioperative Geriatric Excellent Research Center, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
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184
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Wu L, Zhao H, Weng H, Ma D. Lasting effects of general anesthetics on the brain in the young and elderly: "mixed picture" of neurotoxicity, neuroprotection and cognitive impairment. J Anesth 2019; 33:321-335. [PMID: 30859366 PMCID: PMC6443620 DOI: 10.1007/s00540-019-02623-7] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 02/04/2019] [Indexed: 12/22/2022]
Abstract
General anesthetics are commonly used in major surgery. To achieve the depth of anesthesia for surgery, patients are being subjected to a variety of general anesthetics, alone or in combination. It has been long held an illusory concept that the general anesthesia is entirely reversible and that the central nervous system is returned to its pristine state once the anesthetic agent is eliminated from the active site. However, studies indicate that perturbation of the normal functioning of these targets may result in long-lasting desirable or undesirable effects. This review focuses on the impact of general anesthetic exposure to the brain and summarizes the molecular and cellular mechanisms by which general anesthetics may induce long-lasting undesirable effects when exposed at the developing stage of the brain. The vulnerability of aging brain to general anesthetics, specifically in the context of cognitive disorders and Alzheimer’s disease pathogeneses are also discussed. Moreover, we will review emerging evidence regarding the neuroprotective property of xenon and anesthetic adjuvant dexmedetomidine in the immature and mature brains. In conclusion, “mixed picture” effects of general anesthetics should be well acknowledged and should be implemented into daily clinical practice for better patient outcome.
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Affiliation(s)
- Lingzhi Wu
- Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea and Westminster Hospital, London, UK
| | - Hailin Zhao
- Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea and Westminster Hospital, London, UK
| | - Hao Weng
- Department of Anesthesiology, Shanghai Fengxian District Central Hospital, Shanghai Jiao Tong University Affiliated Sixth People's Hospital South Campus, Fengxian District, Shanghai, China
| | - Daqing Ma
- Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea and Westminster Hospital, London, UK.
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185
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Jovin DG, Katlaps KG, Ellis BK, Dharmaraj B. Neuroprotection against stroke and encephalopathy after cardiac surgery. Interv Med Appl Sci 2019; 11:27-37. [PMID: 32148901 PMCID: PMC7044570 DOI: 10.1556/1646.11.2019.01] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Cerebral ischemia in the perioperative period is a major risk factor for stroke, encephalopathy, and cognitive decline after cardiothoracic surgery. After coronary artery bypass grafting, both stroke and encephalopathy can result in poor patient outcomes and increased mortality. Neuroprotection aims to lessen the severity and occurrence of further injury mediated by stroke and encephalopathy and to aid the recovery of conditions already present. Several pharmacological and non-pharmacological methods of neuroprotection have been investigated in experimental studies and in animal models, and, although some have shown effectiveness in protection of the central nervous system, for most, clinical research is lacking or did not show the expected results. This review summarizes the value and need for neuroprotection in the context of cardiothoracic surgery and examines the use and effectiveness of several agents and methods with an emphasis on clinical trials and clinically relevant neuroprotectants.
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Affiliation(s)
- Daniel G Jovin
- Cardiothoracic Research, Department of Surgery, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, VA, USA
| | - Karl G Katlaps
- Cardiothoracic Research, Department of Surgery, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, VA, USA
| | - Ben K Ellis
- Cardiothoracic Research, Department of Surgery, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, VA, USA
| | - Benita Dharmaraj
- Cardiothoracic Research, Department of Surgery, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, VA, USA
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186
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Brown CH, Hasan RK, Brady MB. Is Less Really More? Conscious Sedation or General Anesthesia for Transcatheter Aortic Valve Replacement. Circulation 2019; 136:2141-2143. [PMID: 29180493 DOI: 10.1161/circulationaha.117.031281] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Charles H Brown
- Department of Anesthesiology and Critical Care Medicine (C.H.B., M.B.B.)
| | - Rani K Hasan
- Department of Internal Medicine, Division of Cardiology (R.K.H.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Mary Beth Brady
- Department of Anesthesiology and Critical Care Medicine (C.H.B., M.B.B.)
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187
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Vlisides PE, Ioannidis JPA, Avidan MS. Hypnotic depth and postoperative death: a Bayesian perspective and an Independent Discussion of a clinical trial. Br J Anaesth 2019; 122:421-427. [PMID: 30857598 DOI: 10.1016/j.bja.2019.01.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Accepted: 01/17/2019] [Indexed: 01/13/2023] Open
Affiliation(s)
- Phillip E Vlisides
- University of Michigan Medical School, Department of Anesthesiology, Ann Arbor, MI, USA
| | - John P A Ioannidis
- Stanford University, Meta-Research Innovation Center, Palo Alto, CA, USA
| | - Michael S Avidan
- Washington University in Saint Louis School of Medicine, Department of Anesthesiology, St. Louis, MO, USA.
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188
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Gaskell A, Pullon R, Hight D, Termaat J, Mans G, Voss L, Kreuzer M, Schmid S, Kratzer S, Rodriguez A, Schneider G, Garcia P, Sleigh J. Modulation of frontal EEG alpha oscillations during maintenance and emergence phases of general anaesthesia to improve early neurocognitive recovery in older patients: protocol for a randomised controlled trial. Trials 2019; 20:146. [PMID: 30795794 PMCID: PMC6387545 DOI: 10.1186/s13063-019-3178-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 01/03/2019] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Postoperative delirium may manifest in the immediate post-anaesthesia care period. Such episodes appear to be predictive of further episodes of inpatient delirium and associated adverse outcomes. Frontal electroencephalogram (EEG) findings of suppression patterns and low proprietary index values have been associated with postoperative delirium and poor outcomes. However, the efficacy of titrating anaesthesia to proprietary index targets for preventing delirium remains contentious. We aim to assess the efficacy of two strategies which we hypothesise could prevent post-anaesthesia care unit (PACU) delirium by maximising the alpha oscillation observed in frontal EEG channels during the maintenance and emergence phases of anaesthesia. METHODS This is a 2 × 2 factorial, double-blind, stratified, randomised control trial of 600 patients. Eligible patients are those aged 60 years or over who are undergoing non-cardiac, non-intracranial, volatile-based anaesthesia of expected duration of more than 2 h. Patients will be stratified by pre-operative cognitive status, surgery type and site. For the maintenance phase of anaesthesia, patients will be randomised (1:1) to an alpha power-maximisation anaesthesia titration strategy versus standard care avoiding suppression patterns in the EEG. For the emergence phase of anaesthesia, patients will be randomised (1:1) to early cessation of volatile anaesthesia and emergence from an intravenous infusion of propofol versus standard emergence from volatile anaesthesia only. The primary study outcomes are the power of the frontal alpha oscillation during the maintenance and emergence phases of anaesthesia. Our main clinical outcome of interest is PACU delirium. DISCUSSION This is a largely exploratory study; the extent to which EEG signatures can be modified by titration of pharmacological agents is not known. The underlying concept is maximisation of anaesthetic efficacy by individualised drug titration to a clearly defined EEG feature. The interventions are already clinically used strategies in anaesthetic practice, but have not been formally evaluated. The addition of propofol during the emergence phase of volatile-based general anaesthesia is known to reduce emergence delirium in children; however, the efficacy of this strategy in older patients is not known. TRIAL REGISTRATION Australian and New Zealand Clinical Trial Registry, ID: 12617001354370 . Registered on 27/09/2017.
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Affiliation(s)
- Amy Gaskell
- Department of Anaesthesiology, Waikato Clinical Campus, University of Auckland, Hamilton, New Zealand
- Department of Anaesthesia and Pain Medicine, Waikato District Health Board, Hamilton, New Zealand
| | - Rebecca Pullon
- Department of Anaesthesiology, Waikato Clinical Campus, University of Auckland, Hamilton, New Zealand
| | - Darren Hight
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jonathan Termaat
- Department of Anaesthesia and Pain Medicine, Waikato District Health Board, Hamilton, New Zealand
| | - Gay Mans
- Department of Anaesthesia and Pain Medicine, Waikato District Health Board, Hamilton, New Zealand
| | - Logan Voss
- Department of Anaesthesiology, Waikato Clinical Campus, University of Auckland, Hamilton, New Zealand
- Department of Anaesthesia and Pain Medicine, Waikato District Health Board, Hamilton, New Zealand
| | - Matthias Kreuzer
- Department for Anesthesiology and Critical Care, Technische Universität München, Munich, Germany
| | - Sebastian Schmid
- Department for Anesthesiology and Critical Care, Technische Universität München, Munich, Germany
| | - Stephan Kratzer
- Department for Anesthesiology and Critical Care, Technische Universität München, Munich, Germany
| | - Amy Rodriguez
- Center for Visual and Neurocognitive Rehabilitation, Atlanta VA Medical Center, Atlanta, GA USA
- Department of Neurology, Emory University School of Medicine, Atlanta, GA USA
| | - Gerhard Schneider
- Department for Anesthesiology and Critical Care, Technische Universität München, Munich, Germany
| | - Paul Garcia
- Department of Bioinformatics, Emory University School of Medicine, Atlanta, GA USA
- Department of Anesthesiology, Columbia University, New York, USA
- Neuroanaesthesia Division, Columbia University Medical Center, New York, USA
- New York Presbyterian Hospital, Irving, New York, USA
| | - Jamie Sleigh
- Department of Anaesthesiology, Waikato Clinical Campus, University of Auckland, Hamilton, New Zealand
- Department of Anaesthesia and Pain Medicine, Waikato District Health Board, Hamilton, New Zealand
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189
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Nassif EF, Arsène-Henry A, Kirova YM. Brain metastases and treatment: multiplying cognitive toxicities. Expert Rev Anticancer Ther 2019; 19:327-341. [PMID: 30755047 DOI: 10.1080/14737140.2019.1582336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Thirty per cent of cancer patients develop brain metastases, with multiple combination or sequential treatment modalities available, to treat systemic or central nervous system (CNS) disease. Most patients experience toxicities as a result of these treatments, of which cognitive impairment is one of the adverse events most commonly reported, causing major impairment of the patient's quality of life. Areas covered: This article reviews the role of cancer treatments in cognitive decline of patients with brain metastases: surgery, radiotherapy, chemotherapy, targeted therapies, immunotherapies and hormone therapy. Pathological and molecular mechanisms, as well as future directions for limiting cognitive toxicities are also presented. Other causes of cognitive impairment in this population are discussed in order to refine the benefit-risk balance of each treatment modality. Expert opinion: Cumulative cognitive toxicity should be taken into account, and tailored to the patient's cognitive risk in the light of the expected survival benefit. Standardization of cognitive assessment in this context is needed in order to better appreciate each treatment's responsibility in cognitive impairment, keeping in mind disease itself impacts cognition in this context.
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Affiliation(s)
- Elise F Nassif
- a Department of Radiotherapy , Institut Curie , Paris , France
| | | | - Youlia M Kirova
- a Department of Radiotherapy , Institut Curie , Paris , France
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190
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Wildes TS, Mickle AM, Ben Abdallah A, Maybrier HR, Oberhaus J, Budelier TP, Kronzer A, McKinnon SL, Park D, Torres BA, Graetz TJ, Emmert DA, Palanca BJ, Goswami S, Jordan K, Lin N, Fritz BA, Stevens TW, Jacobsohn E, Schmitt EM, Inouye SK, Stark S, Lenze EJ, Avidan MS. Effect of Electroencephalography-Guided Anesthetic Administration on Postoperative Delirium Among Older Adults Undergoing Major Surgery: The ENGAGES Randomized Clinical Trial. JAMA 2019; 321:473-483. [PMID: 30721296 PMCID: PMC6439616 DOI: 10.1001/jama.2018.22005] [Citation(s) in RCA: 252] [Impact Index Per Article: 50.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
IMPORTANCE Intraoperative electroencephalogram (EEG) waveform suppression, often suggesting excessive general anesthesia, has been associated with postoperative delirium. OBJECTIVE To assess whether EEG-guided anesthetic administration decreases the incidence of postoperative delirium. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial of 1232 adults aged 60 years and older undergoing major surgery and receiving general anesthesia at Barnes-Jewish Hospital in St Louis. Recruitment was from January 2015 to May 2018, with follow-up until July 2018. INTERVENTIONS Patients were randomized 1:1 (stratified by cardiac vs noncardiac surgery and positive vs negative recent fall history) to receive EEG-guided anesthetic administration (n = 614) or usual anesthetic care (n = 618). MAIN OUTCOMES AND MEASURES The primary outcome was incident delirium during postoperative days 1 through 5. Intraoperative measures included anesthetic concentration, EEG suppression, and hypotension. Adverse events included undesirable intraoperative movement, intraoperative awareness with recall, postoperative nausea and vomiting, medical complications, and death. RESULTS Of the 1232 randomized patients (median age, 69 years [range, 60 to 95]; 563 women [45.7%]), 1213 (98.5%) were assessed for the primary outcome. Delirium during postoperative days 1 to 5 occurred in 157 of 604 patients (26.0%) in the guided group and 140 of 609 patients (23.0%) in the usual care group (difference, 3.0% [95% CI, -2.0% to 8.0%]; P = .22). Median end-tidal volatile anesthetic concentration was significantly lower in the guided group than the usual care group (0.69 vs 0.80 minimum alveolar concentration; difference, -0.11 [95% CI, -0.13 to -0.10), and median cumulative time with EEG suppression was significantly less (7 vs 13 minutes; difference, -6.0 [95% CI, -9.9 to -2.1]). There was no significant difference between groups in the median cumulative time with mean arterial pressure below 60 mm Hg (7 vs 7 minutes; difference, 0.0 [95% CI, -1.7 to 1.7]). Undesirable movement occurred in 137 patients (22.3%) in the guided and 95 (15.4%) in the usual care group. No patients reported intraoperative awareness. Postoperative nausea and vomiting was reported in 48 patients (7.8%) in the guided and 55 patients (8.9%) in the usual care group. Serious adverse events were reported in 124 patients (20.2%) in the guided and 130 (21.0%) in the usual care group. Within 30 days of surgery, 4 patients (0.65%) in the guided group and 19 (3.07%) in the usual care group died. CONCLUSIONS AND RELEVANCE Among older adults undergoing major surgery, EEG-guided anesthetic administration, compared with usual care, did not decrease the incidence of postoperative delirium. This finding does not support the use of EEG-guided anesthetic administration for this indication. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02241655.
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Affiliation(s)
- Troy S. Wildes
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Angela M. Mickle
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Arbi Ben Abdallah
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Hannah R. Maybrier
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Jordan Oberhaus
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Thaddeus P. Budelier
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Alex Kronzer
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Sherry L. McKinnon
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Daniel Park
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Brian A. Torres
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Thomas J. Graetz
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Daniel A. Emmert
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Ben J. Palanca
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Shreya Goswami
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Katherine Jordan
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Nan Lin
- Department of Mathematics, Washington University School of Medicine, St Louis, Missouri
| | - Bradley A. Fritz
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Tracey W. Stevens
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Eric Jacobsohn
- Department of Anesthesiology, University of Manitoba, Winnipeg, Canada
| | - Eva M. Schmitt
- Department of Medicine, Beth Israel-Deaconess Medical Center, Hebrew Senior Life, Harvard Medical School, Boston, Massachusetts
| | - Sharon K. Inouye
- Department of Medicine, Beth Israel-Deaconess Medical Center, Hebrew Senior Life, Harvard Medical School, Boston, Massachusetts
| | - Susan Stark
- Department of Occupational Therapy, Washington University School of Medicine, St Louis, Missouri
| | - Eric J. Lenze
- Department of Psychiatry, Washington University School of Medicine, St Louis, Missouri
| | - Michael S. Avidan
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
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191
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Sun W, Qiu ZT. Pre-operative methylprednisolone and postoperative delirium after hip fracture surgery. Anaesthesia 2019; 74:260. [PMID: 30656657 DOI: 10.1111/anae.14557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- W Sun
- The First Affiliated Hospital of Shantou University Medical College, Shantou, China
| | - Z T Qiu
- The First Affiliated Hospital of Shantou University Medical College, Shantou, China
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192
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Langer T, Santini A, Zadek F, Chiodi M, Pugni P, Cordolcini V, Bonanomi B, Rosini F, Marcucci M, Valenza F, Marenghi C, Inglese S, Pesenti A, Gattinoni L. Intraoperative hypotension is not associated with postoperative cognitive dysfunction in elderly patients undergoing general anesthesia for surgery: results of a randomized controlled pilot trial. J Clin Anesth 2019; 52:111-118. [DOI: 10.1016/j.jclinane.2018.09.021] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 09/11/2018] [Accepted: 09/11/2018] [Indexed: 01/14/2023]
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193
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Lachmann G, Feinkohl I, Borchers F, Ottens TH, Nathoe HM, Sauer AM, Dieleman JM, Radtke FM, van Dijk D, Spies C, Pischon T. Diabetes, but Not Hypertension and Obesity, Is Associated with Postoperative Cognitive Dysfunction. Dement Geriatr Cogn Disord 2019; 46:193-206. [PMID: 30326480 DOI: 10.1159/000492962] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 08/16/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Older people undergoing surgery are at risk of developing postoperative cognitive dysfunction (POCD), but little is known of risk factors predisposing patients to POCD. Our objective was to estimate the risk of POCD associated with exposure to preoperative diabetes, hypertension, and obesity. METHODS Original data from 3 randomised controlled trials (OCTOPUS, DECS, SuDoCo) were obtained for secondary analysis on diabetes, hypertension, baseline blood pressure, obesity (BMI ≥30 kg/m2), and BMI as risk factors for POCD in multiple logistic regression models. Risk estimates were pooled across the 3 studies. RESULTS Analyses totalled 1,034 patients. POCD occurred in 5.2% of patients in DECS, in 9.4% in SuDoCo, and in 32.1% of patients in OCTOPUS. After adjustment for age, sex, surgery type, randomisation, obesity, and hypertension, diabetes was associated with a 1.84-fold increased risk of POCD (OR 1.84; 95% CI 1.14, 2.97; p = 0.01). Obesity, BMI, hypertension, and baseline blood pressure were each not associated with POCD in fully adjusted models (all p > 0.05). CONCLUSION Diabetes, but not obesity or hypertension, is associated with increased POCD risk. Consideration of diabetes status may be helpful for risk assessment of surgical patients.
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Affiliation(s)
- 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
| | - Insa Feinkohl
- Molecular Epidemiology Research Group, Max-Delbrueck-Center for Molecular Medicine in the Helmholtz Association (MDC), 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
| | - Thomas H Ottens
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Hendrik M Nathoe
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Anne-Mette Sauer
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jan M Dieleman
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Finn M Radtke
- Anaestesiafdelingen, Næstved Sygehus, Næstved, Denmark
| | - Diederik van Dijk
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
| | - 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
| | - Tobias Pischon
- Molecular Epidemiology Research Group, Max-Delbrueck-Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany.,Charité - Universitätsmedizin Berlin, Berlin, Germany.,MDC/BIH Biobank, Max-Delbrueck-Center for Molecular Medicine in the Helmholtz Association (MDC), and Berlin Institute of Health (BIH), Berlin, Germany
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194
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Clemmesen C. Pre-operative methylprednisolone and postoperative delirium after hip fracture surgery - a reply. Anaesthesia 2019; 74:261. [PMID: 30656655 DOI: 10.1111/anae.14575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- C Clemmesen
- Copenhagen University Hospital, Hvidovre, Denmark
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195
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Predicting postoperative delirium and postoperative cognitive decline with combined intraoperative electroencephalogram monitoring and cerebral near-infrared spectroscopy in patients undergoing cardiac interventions. J Clin Monit Comput 2019; 33:999-1009. [DOI: 10.1007/s10877-019-00253-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Accepted: 01/03/2019] [Indexed: 10/27/2022]
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196
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Processed Electroencephalogram Monitoring and Postoperative Delirium: A Systematic Review and Meta-analysis. Anesthesiology 2019; 129:417-427. [PMID: 29912008 DOI: 10.1097/aln.0000000000002323] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
WHAT WE ALREADY KNOW ABOUT THIS TOPIC WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Postoperative delirium complicates approximately 15 to 20% of major operations in patients at least 65 yr old and is associated with adverse outcomes and increased resource utilization. Furthermore, patients with postoperative delirium might also be at risk of developing long-term postoperative cognitive dysfunction. One potentially modifiable variable is use of intraoperative processed electroencephalogram to guide anesthesia. This systematic review and meta-analysis examines the relationship between processed electroencephalogram monitoring and postoperative delirium and cognitive dysfunction. METHODS A systematic search for randomized controlled trials was conducted using Ovid MEDLINE, PubMed, EMBASE, Cochrane Library, and Google search using the keywords processed electroencephalogram, Bispectral Index, postoperative delirium, postoperative cognitive dysfunction. Screening and data extraction were conducted by two independent reviewers, and risk of bias was assessed. Postoperative delirium combined-effect estimates calculated with a fixed-effects model were expressed as odds ratios with 95% CIs. RESULTS Thirteen of 369 search results met inclusion criteria. Postoperative cognitive dysfunction data were excluded in meta-analysis because of heterogeneity of outcome measurements; results were discussed descriptively. Five studies were included in the quantitative postoperative delirium analysis, with data pooled from 2,654 patients. The risk of bias was low in three studies and unclear for the other two. The use of processed electroencephalogram-guided anesthesia was associated with a 38% reduction in odds for developing postoperative delirium (odds ratio = 0.62; P < 0.001; 95% CI, 0.51 to 0.76). CONCLUSIONS Processed electroencephalogram-guided anesthesia was associated with a decrease in postoperative delirium. The mechanism explaining this association, however, is yet to be determined. The data are insufficient to assess the relationship between processed electroencephalogram monitoring and postoperative cognitive dysfunction.
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197
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Kinjo S, Lim E, Magsaysay MV, Sands LP, Leung JM. Volatile anaesthetics and postoperative delirium in older surgical patients-A secondary analysis of prospective cohort studies. Acta Anaesthesiol Scand 2019; 63:18-26. [PMID: 30051465 DOI: 10.1111/aas.13227] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 07/06/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Volatile Anaesthetics (VAs) may be associated with postoperative delirium (POD). However, to date, the effects of VAs on POD are not completely understood. The objective of this study was to investigate the incidence of POD in different VA groups. METHODS A secondary analysis was conducted using a database created from prospective cohort studies in patients who underwent elective major noncardiac surgery. Patients who received general anaesthesia with desflurane, isoflurane, or sevoflurane were included in the study. POD occurring on either of the first two postoperative days was measured using the Confusion Assessment Method. RESULTS Five hundred and thirty-two patients were included in this study, with a mean age of 73.5 ± 6.0 years (range, 65-96 years). The overall incidence of POD on either postoperative day 1 or 2 was 41%. A higher incidence of POD was noted in the desflurane group compared with the isoflurane group (Odds Ratio = 3.35, 95% CI = 1.54-7.28). The incidence of POD between the sevoflurane and isoflurane or desflurane group was not statistically significant. CONCLUSION Each VA may have different effects on postoperative cognition. Further studies using a prospective randomized approach will be necessary to discern whether anaesthetic type or management affects the occurrence of postoperative delirium.
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Affiliation(s)
- Sakura Kinjo
- Department of Anesthesia and Perioperative Care; University of California, San Francisco; San Francisco California
| | - Eunjung Lim
- Biostatistics Core Facility; Department of Complementary & Integrative Medicine; John A Burns School of Medicine; University of Hawaii; Honolulu Hawaii
| | - Maria Victoria Magsaysay
- Department of Anesthesia and Perioperative Care; University of California, San Francisco; San Francisco California
| | - Laura P. Sands
- Human Development Center for Gerontology; Virginia Polytechnic Institute and State University; Blacksburg Indiana
| | - Jacqueline M. Leung
- Department of Anesthesia and Perioperative Care; University of California, San Francisco; San Francisco California
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198
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Koch S, Feinkohl I, Chakravarty S, Windmann V, Lichtner G, Pischon T, Brown EN, Spies C. Cognitive Impairment Is Associated with Absolute Intraoperative Frontal α-Band Power but Not with Baseline α-Band Power: A Pilot Study. Dement Geriatr Cogn Disord 2019; 48:83-92. [PMID: 31578031 PMCID: PMC7367434 DOI: 10.1159/000502950] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 08/26/2019] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Cognitive abilities decline with aging, leading to a higher risk for the development of postoperative delirium or postoperative neurocognitive disorders after general anesthesia. Since frontal α-band power is known to be highly correlated with cognitive function in general, we hypothesized that preoperative cognitive impairment is associated with lower baseline and intraoperative frontal α-band power in older adults. METHODS Patients aged ≥65 years undergoing elective surgery were included in this prospective observational study. Cognitive function was assessed on the day before surgery using six age-sensitive cognitive tests. Scores on those tests were entered into a principal component analysis to calculate a composite "g score" of global cognitive ability. Patient groups were dichotomized into a lower cognitive group (LC) reaching the lower 1/3 of "g scores" and a normal cognitive group (NC) consisting of the upper 2/3 of "g scores." Continuous pre- and intraoperative frontal electroencephalograms (EEGs) were recorded. EEG spectra were analyzed at baseline, before start of anesthesia medication, and during a stable intraoperative period. Significant differences in band power between the NC and LC groups were computed by using a frequency domain (δ 0.5-3 Hz, θ 4-7 Hz, α 8-12 Hz, β 13-30 Hz)-based bootstrapping algorithm. RESULTS Of 38 included patients (mean age 72 years), 24 patients were in the NC group, and 14 patients had lower cognitive abilities (LC). Intraoperative α-band power was significantly reduced in the LC group compared to the NC group (NC -1.6 [-4.48/1.17] dB vs. LC -6.0 [-9.02/-2.64] dB), and intraoperative α-band power was positively correlated with "g score" (Spearman correlation: r = 0.381; p = 0.018). Baseline EEG power did not show any associations with "g." CONCLUSIONS Preoperative cognitive impairment in older adults is associated with intraoperative absolute frontal α-band power, but not baseline α-band power.
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Affiliation(s)
- Susanne Koch
- Department of Anaesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany, .,Berlin Institute of Health (BIH), Berlin, Germany,
| | - Insa Feinkohl
- Molecular Epidemiology Research Group, Max-Delbrueck Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
| | | | - Victoria Windmann
- Department of Anaesthesiology and Intensive Care Medicine, Charité – Universitätsmedizin Berlin, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany
| | - Gregor Lichtner
- Department of Anaesthesiology and Intensive Care Medicine, Charité – Universitätsmedizin Berlin, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany
| | - Tobias Pischon
- Berlin Institute of Health (BIH), Berlin, Germany;,Molecular Epidemiology Research Group, Max-Delbrueck Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany;,MDC/BIH Biobank, Max-Delbrueck Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
| | - Emery N. Brown
- Picower Institute for Learning and Memory, MIT, Cambridge, MA, USA;,Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA;,Institute for Medical Engineering and Science, MIT, Cambridge, MA, USA;,Institute for Data, Systems and Society, MIT, Cambridge, MA, USA;,Harvard-MIT Health Sciences and Technology Program, Massachusetts Institute of Technology, Cambridge, MA, USA;,Department of Brain and Cognitive Sciences, MIT, Cambridge, MA, USA
| | - Claudia Spies
- Department of Anaesthesiology and Intensive Care Medicine, Charité – Universitätsmedizin Berlin, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany
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199
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Sargin M, Uluer MS, Şimşek B. The effect of bispectral index monitoring on cognitive performance following sedation for outpatient colonoscopy: a randomized controlled trial. SAO PAULO MED J 2019; 137:305-311. [PMID: 31508796 PMCID: PMC9744010 DOI: 10.1590/1516-3180.2018.0383210519] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 05/21/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Bispectral index (BIS) monitoring can positively affect cognitive performance through decreasing the use of sedative agents. We aimed to evaluate the effect of BIS monitoring on early cognitive performance among patients undergoing sedation for colonoscopy. DESIGN AND SETTING Randomized, controlled trial in a university hospital. METHODS 100 patients were randomized into two groups. In the monitored group (n = 50), the depth of anesthesia was monitored using the BIS, and BIS scores were maintained between 60 and 80. In the usual care group (n = 50), BIS monitoring was not performed. To determine the patients' baseline cognitive performance levels, the mini-mental state examination (MMSE), Trieger dot test (TDT) and clock drawing test (CDT) were used. The patients' post-procedure cognitive performance levels were determined when they were classified as ready for discharge. RESULTS The total volume (mg) of propofol used [median (range) IQR] in the sedation procedure was lower in the monitored group [100 (50-200) 100-140] than in the usual care group [150 (75-200) 100-200] (P < 0.001). The discharge scores [mean (SD)] using MMSE and CDT were higher in the monitored group [26 (3) and 3 (1), respectively] than in the usual care group [23 (3) and 2 (1), respectively] (P = 0.002 and P = 0.002, respectively). The discharge scores using TDT [mean (SD)] were lower in the monitored group [11 (7)] than in the usual care group [15 (11)] (P = 0.033). CONCLUSION BIS monitoring among sedated patients was associated with lower propofol use and smaller decline in cognitive performance. CLINICAL TRIAL REGISTRATION This trial was registered in the Australian New Zealand Clinical Trial Registry (ACTRN12617000134325).
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Affiliation(s)
- Mehmet Sargin
- MD, Assistant Professor, Anesthesiology and Reanimation Department, Selçuk Üniversitesi Tıp Fakültesi, Konya, Turkey.
| | - Mehmet Selçuk Uluer
- MD. Physician, Anesthesiology and Reanimation Department, Health Sciences University, Konya Eğitim ve Araştırma Hastanesi, Konya, Turkey.
| | - Barış Şimşek
- MD. Physician, Anesthesiology and Reanimation Department, Health Sciences University, Konya Eğitim ve Araştırma Hastanesi, Konya, Turkey.
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200
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Chamorro-Jambrina C, Chamorro-Falero C. No apague el cerebro. Med Intensiva 2019; 43:1-2. [DOI: 10.1016/j.medin.2018.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 07/18/2018] [Accepted: 07/18/2018] [Indexed: 11/29/2022]
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