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Van Cleve WC, Nair BG, Rooke GA. Associations Between Age and Dosing of Volatile Anesthetics in 2 Academic Hospitals. Anesth Analg 2015; 121:645-651. [PMID: 26097989 DOI: 10.1213/ane.0000000000000819] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The inverse relationship between age and dose requirement for potent volatile anesthetics is well established, but the question of whether anesthetic providers consider this relationship in practice remains unanswered. We sought to determine whether there is an association between patient age and the mean dose of volatile anesthetic delivered during maintenance of anesthesia. METHODS This was a retrospective cross-sectional study of patients receiving a single potent volatile anesthetic at 2 academic hospitals using data recorded in an anesthesia information management system. Multivariate linear models were constructed at each hospital to examine the relationship between age and mean minimum alveolar concentration (MAC) fraction delivered during the maintenance of anesthesia. RESULTS A total of 7878 cases at the 2 hospitals were included for analysis. For patients aged <65 years, we observed decreasing doses of volatile anesthetics as age increased. Per decade, mean delivered MAC fraction decreased by an estimated 1.8% (95% confidence interval, 1.5-2.2, P < 0.0001), smaller than the 6.7% decrease suggested by previous studies of human anesthetic requirements. At age >65 years, the magnitude of the inverse association between age and MAC fraction was higher (3.8% decrease per decade; 95% confidence interval, 2.9-4.7). CONCLUSIONS Increasing age is associated with decreased absolute doses of potent volatile anesthetics, an association that seems to strengthen as patients enter the geriatric age range. The observed decreases in absolute anesthetic dose were less than those predicted by previous research and therefore represent an overall increase in "age-adjusted dose" as patients grow older.
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Affiliation(s)
- William C Van Cleve
- From the Department of Anesthesiology and Pain Medicine, University of Washington, Washington, D.C
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302
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Soehle M, Dittmann A, Ellerkmann RK, Baumgarten G, Putensen C, Guenther U. Intraoperative burst suppression is associated with postoperative delirium following cardiac surgery: a prospective, observational study. BMC Anesthesiol 2015; 15:61. [PMID: 25928189 PMCID: PMC4419445 DOI: 10.1186/s12871-015-0051-7] [Citation(s) in RCA: 144] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Accepted: 04/22/2015] [Indexed: 11/10/2022] Open
Abstract
Background Postoperative delirium (POD) occurs frequently after cardiac surgery and is associated with increased morbidity and mortality. We analysed whether perioperative bilateral BIS monitoring may detect abnormalities before the onset of POD in cardiac surgery patients. Methods In a prospective observational study, 81 patients undergoing cardiac surgery were included. Bilateral Bispectral Index (BIS)-monitoring was applied during the pre-, intra- and postoperative period, and BIS, EEG Asymmetry (ASYM), and Burst Suppression Ratio (BSR) were recorded. POD was diagnosed according to the Confusion Assessment Method for the Intensive Care Unit, and patients were divided into a delirium and non-delirium group. Results POD was detected in 26 patients (32%). A trend towards a lower ASYM was observed in the delirium group as compared to the non-delirium group on the preoperative day (ASYM = 48.2 ± 3.6% versus 50.0 ± 4.7%, mean ± sd, p = 0.087) as well as before induction of anaesthesia, with oral midazolam anxiolysis (median ASYM = 49.5%, IQR [47.4;51.5] versus 50.6%, IQR [49.1;54.2], p = 0.081). Delirious patients remained significantly (p = 0.018) longer in a burst suppression state intraoperatively (107 minutes, IQR [47;170] versus 44 minutes, IQR [11;120]) than non-delirious patients. Receiver operating analysis revealed burst suppression duration (area under the curve = 0.73, p = 0.001) and BSR (AUC = 0.68, p = 0.009) as predictors of POD. Conclusions Intraoperative assessment of BSR may identify patients at risk of POD and should be investigated in further studies. So far it remains unknown whether there is a causal relationship or rather an association between intraoperative burst suppression and the development of POD. Trial registration clinicaltrials.gov NCT01048775
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Affiliation(s)
- Martin Soehle
- Department of Anaesthesiology and Intensive Care Medicine, University of Bonn, Bonn, Germany.
| | | | - Richard K Ellerkmann
- Department of Anaesthesiology and Intensive Care Medicine, University of Bonn, Bonn, Germany.
| | - Georg Baumgarten
- Department of Anaesthesiology and Intensive Care Medicine, University of Bonn, Bonn, Germany.
| | - Christian Putensen
- Department of Anaesthesiology and Intensive Care Medicine, University of Bonn, Bonn, Germany.
| | - Ulf Guenther
- Department of Anaesthesiology and Intensive Care Medicine, University of Bonn, Bonn, Germany.
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303
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Trafidło T, Gaszyński T, Gaszyński W, Nowakowska-Domagała K. Intraoperative monitoring of cerebral NIRS oximetry leads to better postoperative cognitive performance: A pilot study. Int J Surg 2015; 16:23-30. [DOI: 10.1016/j.ijsu.2015.02.009] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2014] [Revised: 02/04/2015] [Accepted: 02/12/2015] [Indexed: 11/29/2022]
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305
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Evered LA, Silbert B, Scott DA. The impact of the peri-operative period on cognition in older individuals. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2015. [DOI: 10.1002/jppr.1069] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Lisbeth A. Evered
- Department of Anaesthesia, Centre for Anaesthesia and Cognitive Function; St. Vincent's Hospital Melbourne; Fitzroy Australia
- Melbourne Medical School; University of Melbourne; Melbourne Australia
| | - Brendan Silbert
- Department of Anaesthesia, Centre for Anaesthesia and Cognitive Function; St. Vincent's Hospital Melbourne; Fitzroy Australia
- Melbourne Medical School; University of Melbourne; Melbourne Australia
| | - David A. Scott
- Department of Anaesthesia, Centre for Anaesthesia and Cognitive Function; St. Vincent's Hospital Melbourne; Fitzroy Australia
- Melbourne Medical School; University of Melbourne; Melbourne Australia
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306
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Postoperative delirium is an independent risk factor for posttraumatic stress disorder in the elderly patient. Eur J Anaesthesiol 2015; 32:147-51. [DOI: 10.1097/eja.0000000000000107] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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307
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Luk TTH, Jia B, Pang EYT, Lau VNM, Lam CKM, Chu MHM, Han R, Chan MTV. Depth of Anesthesia and Postoperative Delirium. CURRENT ANESTHESIOLOGY REPORTS 2015. [DOI: 10.1007/s40140-014-0088-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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308
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Schenning KJ, Deiner SG. Postoperative Delirium: A Review of Risk Factors and Tools of Prediction. CURRENT ANESTHESIOLOGY REPORTS 2015. [DOI: 10.1007/s40140-014-0086-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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309
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Green D, Ballard C, Kunst G. Depth of anaesthesia optimisation and postoperative cognitive dysfunction. Br J Anaesth 2015; 114:343-4. [DOI: 10.1093/bja/aeu471] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
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310
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Nadelson M, Sanders R, Avidan M. Neurotoxicity of general anaesthesia is hypothetical. Br J Anaesth 2015; 114:344-5. [DOI: 10.1093/bja/aeu476] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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311
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Inouye SK, Robinson T, Blaum C, Busby-Whitehead J, Boustani M, Chalian A, Deiner S, Fick D, Hutchison L, Johanning J, Katlic M, Kempton J, Kennedy M, Kimchi E, Ko C, Leung J, Mattison M, Mohanty S, Nana A, Needham D, Neufeld K, Richter H. Postoperative Delirium in Older Adults: Best Practice Statement from the American Geriatrics Society. J Am Coll Surg 2015; 220:136-48.e1. [DOI: 10.1016/j.jamcollsurg.2014.10.019] [Citation(s) in RCA: 291] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 10/24/2014] [Indexed: 12/17/2022]
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312
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Clancy O, Edginton T, Casarin A, Vizcaychipi MP. The psychological and neurocognitive consequences of critical illness. A pragmatic review of current evidence. J Intensive Care Soc 2015; 16:226-233. [PMID: 28979415 DOI: 10.1177/1751143715569637] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Mortality rates alone are no longer a sufficient guide to quality of care. Due to medical advances, patients are surviving for longer following critical illness and major surgery; therefore, functional outcomes and long-term quality of life are of increasing consequence. Post-operative cognitive dysfunction has been acknowledged as a complication following anaesthesia for many years, and interest in persistent cognitive dysfunction following a critical illness is growing. Psychological and neurocognitive sequelae following discharge from intensive care are acknowledged to occur with sufficient significance to have recently coined the term 'the post-intensive care syndrome'. Rehabilitation following critical illness has been highlighted as an important goal in recently published national UK guidelines, including the need to focus on both physical and non-physical recovery. Neuropsychological and cognitive consequences following anaesthesia and critical illness are significant. The exact pathophysiological mechanisms linking delirium, cognitive dysfunction and neuropsychological symptoms following critical illness are not fully elucidated but have been studied elsewhere and are outside the scope of this article. There is limited evidence as yet for specific peri-operative preventative strategies, but early management and rehabilitation strategies following intensive care discharge are now emerging. This article aims to summarise the issues and appraise current options for management, including both neuroprotective and neurorehabilitative strategies in intensive care.
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Affiliation(s)
- Olivia Clancy
- Department of Anaesthesia, Chelsea and Westminster Hospital, London, UK.,Imperial College Faculty of Medicine, London, UK
| | - Trudi Edginton
- Department of Psychology, The University of Westminster, London, UK
| | - Annalisa Casarin
- Department of Anaesthesia, Chelsea and Westminster Hospital, London, UK.,Department of Anaesthesia, Watford General Hospital, London, UK
| | - Marcela P Vizcaychipi
- Department of Anaesthesia, Chelsea and Westminster Hospital, London, UK.,Imperial College Faculty of Medicine, London, UK
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313
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Cerebral oximetry: Three questions to ask. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2015. [DOI: 10.1016/j.rcae.2014.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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314
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315
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Card E, Pandharipande P, Tomes C, Lee C, Wood J, Nelson D, Graves A, Shintani A, Ely EW, Hughes C. Emergence from general anaesthesia and evolution of delirium signs in the post-anaesthesia care unit. Br J Anaesth 2014; 115:411-7. [PMID: 25540068 DOI: 10.1093/bja/aeu442] [Citation(s) in RCA: 106] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2014] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Emergence from anaesthesia is often accompanied by signs of delirium, including fluctuating mental status and inattention. The evolution of these signs of delirium requires investigation since delirium in the post-anaesthesia care unit (PACU) may be associated with worse outcomes. METHODS Adult patients emerging from anaesthesia were assessed for agitated emergence in the operating room using the Richmond Agitation-Sedation Scale (RASS). The Confusion Assessment Method for the Intensive Care Unit was then used to evaluate delirium signs at PACU admission and during PACU stay at 30 min, 1 h, and discharge. Signs consistent with delirium were classified as hyperactive vs hypoactive based upon a positive CAM-ICU assessment and the concomitant RASS score. Multivariable logistic regression was utilized to assess potential risk factors for delirium during PACU stay including age, American Society of Anesthesiologists classification, and opioid and benzodiazepine exposure. RESULTS Among 400 patients enrolled, 19% had agitated emergence. Delirium signs were present at PACU admission, 30 min, 1 h, and PACU discharge in 124 (31%), 59 (15%), 32 (8%), and 15 (4%) patients, respectively. In patients with delirium signs, hypoactive signs were present in 56% at PACU admission and in 92% during PACU stay. Perioperative opioids were associated with delirium signs during PACU stay (P=0.02). CONCLUSIONS A significant proportion of patients develop delirium signs in the immediate postoperative period, primarily manifesting with a hypoactive subtype. These signs often persist to PACU discharge, suggesting the need for structured delirium monitoring in the PACU to identify patients potentially at risk for worse outcomes in the postoperative period.
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Affiliation(s)
- E Card
- Department of Anesthesiology, Perioperative Clinical Research Institute
| | - P Pandharipande
- Department of Anesthesiology, Perioperative Clinical Research Institute, Department of Anesthesiology, Division of Critical Care Department of Perioperative Services, Department of Urologic Surgery Department of Biostatistics and Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center and the VA Tennessee Valley Health Care System Geriatric Research Education Clinical Center (GRECC), Nashville, TN, USA
| | - C Tomes
- Department of Perioperative Services
| | - C Lee
- Department of Perioperative Services
| | - J Wood
- Department of Perioperative Services
| | - D Nelson
- Department of Anesthesiology, Perioperative Clinical Research Institute
| | | | | | - E W Ely
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center and the VA Tennessee Valley Health Care System Geriatric Research Education Clinical Center (GRECC), Nashville, TN, USA
| | - C Hughes
- Department of Anesthesiology, Division of Critical Care
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316
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317
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Strøm C, Rasmussen L. Challenges in anaesthesia for elderly. ACTA ACUST UNITED AC 2014; 35C:23-29. [DOI: 10.1016/j.sdj.2014.11.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Accepted: 11/17/2014] [Indexed: 01/13/2023]
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318
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319
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Silbert B, Evered L, Scott D. Incidence of postoperative cognitive dysfunction after general or spinal anaesthesia for extracorporeal shock wave lithotripsy. Br J Anaesth 2014; 113:784-91. [DOI: 10.1093/bja/aeu163] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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320
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Berger M, Burke J, Eckenhoff R, Mathew J. Alzheimer's disease, anesthesia, and surgery: a clinically focused review. J Cardiothorac Vasc Anesth 2014; 28:1609-23. [PMID: 25267693 DOI: 10.1053/j.jvca.2014.04.014] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Indexed: 02/08/2023]
Affiliation(s)
| | - James Burke
- Neurology, Duke University Medical Center, Durham, NC
| | - Roderick Eckenhoff
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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321
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322
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Hussain M, Berger M, Eckenhoff RG, Seitz DP. General anesthetic and the risk of dementia in elderly patients: current insights. Clin Interv Aging 2014; 9:1619-28. [PMID: 25284995 PMCID: PMC4181446 DOI: 10.2147/cia.s49680] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
In this review, we aim to provide clinical insights into the relationship between surgery, general anesthesia (GA), and dementia, particularly Alzheimer’s disease (AD). The pathogenesis of AD is complex, involving specific disease-linked proteins (amyloid-beta [Aβ] and tau), inflammation, and neurotransmitter dysregulation. Many points in this complex pathogenesis can potentially be influenced by both surgery and anesthetics. It has been demonstrated in some in vitro, animal, and human studies that some anesthetics are associated with increased aggregation and oligomerization of Aβ peptide and enhanced accumulation and hyperphosphorylation of tau protein. Two neurocognitive syndromes that have been studied in relation to surgery and anesthesia are postoperative delirium and postoperative cognitive dysfunction, both of which occur more commonly in older adults after surgery and anesthesia. Neither the route of anesthesia nor the type of anesthetic appears to be significantly associated with the development of postoperative delirium or postoperative cognitive dysfunction. A meta-analysis of case-control studies found no association between prior exposure to surgery utilizing GA and incident AD (pooled odds ratio =1.05, P=0.43). The few cohort studies on this topic have shown varying associations between surgery, GA, and AD, with one showing an increased risk, and another demonstrating a decreased risk. A recent randomized trial has shown that patients who received sevoflurane during spinal surgery were more likely to have progression of preexisting mild cognitive impairment compared to controls and to patients who received propofol or epidural anesthesia. Given the inconsistent evidence on the association between surgery, anesthetic type, and AD, well-designed and adequately powered studies with longer follow-up periods are required to establish a clear causal association between surgery, GA, and AD.
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Affiliation(s)
- Maria Hussain
- Division of Geriatric Psychiatry, Department of Psychiatry, Queen's University, Durham, NC, USA
| | - Miles Berger
- Anesthesiology Department, Duke University Medical Center, Durham, NC, USA
| | - Roderic G Eckenhoff
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Dallas P Seitz
- Division of Geriatric Psychiatry, Department of Psychiatry, Queen's University, Durham, NC, USA
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323
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Mashour GA, Woodrum DT, Avidan MS. Neurological complications of surgery and anaesthesia. Br J Anaesth 2014; 114:194-203. [PMID: 25204699 DOI: 10.1093/bja/aeu296] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Injury to the central and peripheral nervous systems is often permanent. As such, adverse neurological outcomes of surgery and anaesthesia can be devastating for patients and their families. In this article, we review the incidence, risk factors, outcomes, prevention, and treatment of a number of important neurological complications in the perioperative period.
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Affiliation(s)
- G A Mashour
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - D T Woodrum
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - M S Avidan
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
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324
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Punjasawadwong Y, Chau-in W, Laopaiboon M, Punjasawadwong S. Processed electroencephalogram indices for amelioration of postoperative delirium and cognitive dysfunction following non-cardiac and non-neurosurgical procedures. Hippokratia 2014. [DOI: 10.1002/14651858.cd011283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Yodying Punjasawadwong
- Chiang Mai University; Department of Anesthesiology, Faculty of Medicine; Chiang Mai Thailand 50200
| | - Waraporn Chau-in
- Faculty of Medicine, Khon Kaen University; Department of Anesthesiology; 19-32 Chuabchuen Road Khon Kaen Thailand
| | - Malinee Laopaiboon
- Khon Kaen University; Department of Biostatistics and Demography, Faculty of Public Health; Khon Kaen Thailand 40002
| | - Sirivimol Punjasawadwong
- Faculty of Medicine, Chiang Mai University; Department of Anesthesiology; Chiang Mai Thailand 50200
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325
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Jildenstål PK, Rawal N, Hallén JL, Berggren L, Jakobsson JG. Perioperative management in order to minimise postoperative delirium and postoperative cognitive dysfunction: Results from a Swedish web-based survey. Ann Med Surg (Lond) 2014; 3:100-7. [PMID: 25568795 PMCID: PMC4284452 DOI: 10.1016/j.amsu.2014.07.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Revised: 07/14/2014] [Accepted: 07/17/2014] [Indexed: 11/01/2022] Open
Abstract
UNLABELLED Cognitive side-effects such as emergence agitation (EA), postoperative delirium (POD) and postoperative cognitive dysfunction (POCD) are not infrequently complicating the postoperative care especially in elderly and fragile patients. The aim of the present survey was to gain insight regarding concern and interest in prevention and treatment strategies for postoperative delirium and dysfunction, and the use of EEG-based depth-of-anaesthesia monitoring possibly reducing the risk for cognitive side effects among anaesthesia personnel. METHODS A web-based validated questionnaire was sent to all Swedish anaesthesiologists and nurse anaesthetists during summer 2013. The questionnaire consisted of 3 sections, subjective preferences, routines and practices related to the perioperative handling of EA, POD, POCD. RESULTS The response rate was 52%. Cardiovascular/pulmonary risks where assessed as importance by 98, 97% of responders while 69% considered the risk of neurocognitive side-effects important. When asked explicitly around cognitive side-effects 89%, 37% and 44% assessed awareness, POC and POD respectively of importance. EEG-based depth-of-anaesthesia monitors were used in 50% of hospitals. The responders were not convinced about the benefits of such monitors even in at-risk patients. Structured protocols for the management of postoperative cognitive side-effects were available only in few hospitals. CONCLUSION Swedish anaesthesia personnel are concerned about the risk of postoperative cognitive side-effects but are more concerned about cardiovascular/pulmonary risks, pain, PONV and the rare event of awareness. Most respondents were not convinced about the use of depth-of-anaesthesia monitors. There is a need to improve knowledge around risk factors, prevention and management of postoperative cognitive side effects.
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Affiliation(s)
- Pether K Jildenstål
- Department of Anaesthesiology and Intensive Care, University Hospital, Örebro, Sweden
| | - Narinder Rawal
- Department of Anaesthesiology and Intensive Care, University Hospital, Örebro, Sweden
| | - Jan L Hallén
- Department of Anaesthesiology and Intensive Care, University Hospital, Örebro, Sweden
| | - Lars Berggren
- Department of Anaesthesiology and Intensive Care, University Hospital, Örebro, Sweden ; CAMTÖ, Centre for Assessment of Medical Technology in Örebro, Sweden
| | - Jan G Jakobsson
- Institution for Clinical Science, Karolinska Institutet, Danderyds Hospital, 182 88 Stockholm, Sweden
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326
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Short TG, Leslie K, Campbell D, Chan MTV, Corcoran T, O'Loughlin E, Frampton C, Myles P. A pilot study for a prospective, randomized, double-blind trial of the influence of anesthetic depth on long-term outcome. Anesth Analg 2014; 118:981-6. [PMID: 24781568 DOI: 10.1213/ane.0000000000000209] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Deep general anesthesia has been associated with increased mortality in 5 observational studies. The association may be causal or an epiphenomenon due to increased anesthetic sensitivity in high-risk patients. We conducted a pilot study to assess the feasibility of performing a definitive randomized controlled trial. The aims of the study were to determine whether anesthetic depth targeting in a high-risk group was feasible and to document anesthetic doses and arterial blood pressures associated with "deep" and "light" general anesthesia. METHODS ASA physical status III and IV patients, aged ≥60 years, having surgery lasting ≥2 hours, with expected hospital stay ≥2 days, and receiving general anesthesia were randomly allocated to a Bispectral Index (BIS) or spectral entropy (SE) target of 35 ("low" group) or 50 ("high" group). The primary end point was mean BIS or SE. Secondary end points were postanesthesia care unit length of stay and pain scores, quality of recovery score, hospital length of stay, postoperative complications, and death. A composite end point of postoperative complications (pneumonia, myocardial infarction, stroke, pulmonary embolism, heart failure, and death) was determined at 1 year. RESULTS One hundred twenty-five patients were recruited. The mean of the median BIS/SE values for each patient during the maintenance phase of anesthesia in the low and high groups was significantly different: 39 vs 48 (mean difference 8 [95% confidence interval {CI95}, 6 to 10], P < 0.001). There was also a significant difference in mean volatile anesthetic administration (minimum alveolar concentration): 0.98 vs 0.64 (mean difference -0.35 [CI95, -0.44 to -0.26], P < 0.001) and target propofol concentrations: 4.0 vs 3.1 μg/mL (mean difference -0.8 [CI95, -1.2 to -0.3], P = 0.004). Intraoperative mean arterial blood pressures were similar (85 vs 87 mm Hg; mean difference 2 [CI95, -2 to 6], P = 0.86), and there were no differences in short-term recovery characteristics or hospital length of stay. There was a significant difference in the incidence of wound infection at 30 days (13% vs 3%; risk difference -10% [CI95, -21 to -0.1], P = 0.04). At 1 year, the composite rates of complications in the low and high groups were 28% and 17% (risk difference -11 [CI95, -25 to 4], P = 0.15) and mortality rates were 12% and 9%, respectively (risk difference -2 [CI95, -14 to 9], P = 0.70). CONCLUSIONS This pilot study demonstrated that depth of anesthesia targeting with BIS or SE was achievable in a high-risk population with adequate separation of processed electroencephalogram monitor targets. The expected incidence of postoperative complications and mortality occurred. We conclude that a large, multicenter, randomized controlled trial is feasible.
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Affiliation(s)
- Timothy G Short
- From the *Department of Anaesthesia, Auckland City Hospital, Auckland, New Zealand; †Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Victoria, Australia; ‡Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China; §Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Perth; ‖School of Medicine and Pharmacology, University of Western Australia; ¶Department of Anaesthesia, Fremantle Hospital, Fremantle, Western Australia, Australia; #Department of Statistics, University of Canterbury, Christchurch, New Zealand; **Department of Anaesthesia and Perioperative Medicine, Alfred Hospital, Melbourne; and ††Anaesthesia and Perioperative Medicine, Monash University, Melbourne, Victoria, Australia
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Escallier KE, Nadelson MR, Zhou D, Avidan MS. Monitoring the brain: processed electroencephalogram and peri‐operative outcomes. Anaesthesia 2014; 69:899-910. [DOI: 10.1111/anae.12711] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2014] [Indexed: 11/29/2022]
Affiliation(s)
- K. E. Escallier
- Washington University School of Medicine Saint Louis Missouri USA
| | - M. R. Nadelson
- Washington University School of Medicine Saint Louis Missouri USA
| | - D. Zhou
- Washington University School of Medicine Saint Louis Missouri USA
| | - M. S. Avidan
- Washington University School of Medicine Saint Louis Missouri USA
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Berger M, Nadler J, Mathew JP. Preventing delirium after cardiothoracic surgery: provocative but preliminary evidence for bispectral index monitoring. Anesth Analg 2014; 118:706-7. [PMID: 24651223 DOI: 10.1213/ane.0000000000000130] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Miles Berger
- From the Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
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329
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Whitlock EL, Torres BA, Lin N, Helsten DL, Nadelson MR, Mashour GA, Avidan MS. Postoperative delirium in a substudy of cardiothoracic surgical patients in the BAG-RECALL clinical trial. Anesth Analg 2014; 118:809-17. [PMID: 24413548 DOI: 10.1213/ane.0000000000000028] [Citation(s) in RCA: 135] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Postoperative delirium in the intensive care unit (ICU) is a frequent complication after cardiac or thoracic surgery and is associated with increased morbidity and mortality. METHODS In this single-center substudy of the BAG-RECALL trial (NCT00682825), we screened patients after cardiac or thoracic surgery in the ICU twice daily for delirium using the Confusion Assessment Method for the ICU. The primary outcome was the incidence of delirium in patients who had been randomized to intraoperative Bispectral Index (BIS)-guided and end-tidal anesthetic concentration-guided depth of anesthesia protocols. As a secondary analysis, a Bayesian stochastic search variable selection strategy was used to rank a field of candidate risk factors for delirium, followed by binary logistic regression. RESULTS Of 310 patients assessed, 28 of 149 (18.8%) in the BIS group and 45 of 161 (28.0%) in the end-tidal anesthetic concentration group developed postoperative delirium in the ICU (odds ratio 0.60, 95% confidence interval, 0.35-1.02, P= 0.058). Low average volatile anesthetic dose, intraoperative transfusion, ASA physical status, and European System for Cardiac Operative Risk Evaluation were identified as independent predictors of delirium. CONCLUSIONS A larger randomized study should determine whether brain monitoring with BIS or an alternative method decreases delirium after cardiac or thoracic surgery. The association between low anesthetic concentration and delirium is a surprising finding and could reflect that patients with poor health are both more sensitive to the effects of volatile anesthetic drugs and are also more likely to develop postoperative delirium. Investigation of candidate methods to prevent delirium should be prioritized in view of the established association between postoperative delirium and adverse patient outcomes.
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Affiliation(s)
- Elizabeth L Whitlock
- From the *Department of Anesthesiology, Washington University School of Medicine; †Department of Mathematics, Washington University in Saint Louis, Saint Louis, Missouri; and ‡Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan
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330
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Cognitive dysfunction following desflurane versus sevoflurane general anesthesia in elderly patients: a randomized controlled trial. Med Gas Res 2014; 4:6. [PMID: 24666542 PMCID: PMC3976084 DOI: 10.1186/2045-9912-4-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2013] [Accepted: 02/24/2014] [Indexed: 11/10/2022] Open
Abstract
As life expectancy increases, more patients ≥65 years undergo general anesthesia. Anesthetic agents may contribute to postoperative cognitive dysfunction, and incidence may differ with anesthetic agents or intraoperative anesthesia depth. Responses to anesthetic adjuvants vary among elderly patients. Processed electroencephalography guidance of anesthetic may better ensure equivalent cerebral suppression. This study investigates postoperative cognitive dysfunction differences in elderly patients given desflurane or sevoflurane using processed electroencephalography guidance. IRB approved, randomized trial enrolled consenting patients ≥65 years scheduled for elective surgery requiring general anesthesia ≥120 minute duration. After written informed consent, patients were randomly assigned to sevoflurane or desflurane. No perioperative benzodiazepines were administered. Cognitive impairment was measured by an investigator blinded to group assignment using mini-Mental Status Examination (MMSE) at baseline; 1, 6, and 24 hours after the end of anesthesia. Mean arterial pressure was maintained within 20% of baseline. Anesthetic dose was adjusted to maintain moderate general anesthesia per processed electroencephalograpy (Patient State Index 25 to 50). The primary outcome measure was intergroup difference in MMSE change 1 hour after anesthesia (median; 95% confidence interval). 110 patients consented; 26 were not included for analysis (no general anesthesia; withdrew consent; baseline MMSE abnormality; inability to perform postoperative MMSE; data capture failure); 47 sevoflurane and 37 desflurane were analyzed. There were no significant differences in patient characteristics; intraoperative mean blood pressure (desflurane 86.4; 81.3 to 89.6 versus sevoflurane 82.5; 80.2 to 86.1 mmHg; p = 0.42) or Patient State Index (desflurane 41.9; 39.0 to 44.0 versus sevoflurane 41.0; 37.5 to 44.0; p = 0.60) despite a lower MAC fraction in desflurane (0.82; 0.77 to 0.86) versus sevoflurane (0.96; 0.91 to 1.03; p < 0.001). MMSE decreased 1 hour after anesthesia (p < 0.001). The decrease at one hour was larger in sevoflurane (−2.5; −3.3 to −1.8) than desflurane (−1.3; −2.2 to −0.5; p = 0.03). MMSE returned to baseline by 6 hours after anesthesia.
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331
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Theuerkauf N, Guenther U. Delir auf der Intensivstation. Med Klin Intensivmed Notfmed 2014; 109:129-36. [DOI: 10.1007/s00063-014-0354-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Revised: 02/10/2014] [Accepted: 02/10/2014] [Indexed: 11/24/2022]
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332
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Pysyk CL. Factors for perioperative delirium. Br J Anaesth 2014; 112:577-8. [PMID: 24535510 DOI: 10.1093/bja/aeu022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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333
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Jildenstål PK, Hallén JL, Rawal N, Berggren L, Jakobsson JG. AAI-guided anaesthesia is associated with lower incidence of 24-h MMSE < 25 and may impact the IL-6 response. Int J Surg 2014; 12:290-5. [PMID: 24509399 DOI: 10.1016/j.ijsu.2014.02.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Revised: 01/21/2014] [Accepted: 02/06/2014] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Trauma stress and neuro-inflammation caused by surgery/anaesthesia releases cytokines. This study analysed impact of Auditory Evoked Potential Index (AAI) depth-of-anaesthesia titration on the early plasma IL-6 release after eye surgery under general anaesthesia. METHOD This is a subgroup analysis of a prospective randomized study on the effect of auditory evoked potential guided anaesthesia for eye surgery. Plasma IL-6 levels taken before, 5 and 24 h after end of surgery from 450 patients undergoing elective ophthalmic surgery under desflurane anaesthesia were analysed. Minimal mental state examination (MMSE) was also tested at 24-h. RESULTS IL- 6 increased significantly at both 5 and further at 24 h after surgery (3.2, 4.5 and 5.1 base-line, 5 and 24-h respectively), the IL-6 increase showed different patterns between the 2 groups; IL-6 was significantly increased in the control group of patients between preoperative baseline and 24 h after surgery (p = 0.008) also between 5 h and 24 h, (p = 0.006) after surgery while the AAI-group had only minor non-significant changes. The 18 patients that showed a 24-h MMSE score less than 25 had a significant higher 24-h IL-6 compared to the 390 patients with a MMSE score > 24 (p = 0.002). CONCLUSION The IL-6 increase after surgery was less pronounced in patients where anaesthesia was titrated by AAI compared to anaesthesia adjusted on clinical signs only. IL-6 were also found to be higher in patients with a MMSE < 25 at 24-h. Further studies are warranted evaluating the role of depth of anaesthesia monitoring on the risk for early cognitive impairment and neuro-inflammation. TRIAL REGISTRATION Clinicaltrials.gov identifier: NA/study were conducted between January 2005-April 2008.
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Affiliation(s)
- Pether K Jildenstål
- Department of Anaesthesiology and Intensive Care, University Hospital, Örebro, Sweden
| | - Jan L Hallén
- Department of Anaesthesiology and Intensive Care, University Hospital, Örebro, Sweden
| | - Narinder Rawal
- Department of Anaesthesiology and Intensive Care, University Hospital, Örebro, Sweden
| | - Lars Berggren
- Department of Anaesthesiology and Intensive Care, University Hospital, Örebro, Sweden; CAMTÖ, Centre for Assessment of Medical Technology in Örebro, Sweden
| | - Jan G Jakobsson
- Department of Anaesthesiology and Intensive Care, Institution for Clinical Science at The Karolinska Institutet, Danderyds University Hospital, 182 88 Stockholm, Stockholm, Sweden.
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334
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Affiliation(s)
- Jeffrey H. Silverstein
- Departments of Anesthesiology, Surgery and Geriatrics & Adult Development. Icahn School of Medicine at Mount Sinai
- Department of Anesthesiology, Box 1010, Icahn School of Medicine, 1 Gustave L. Levy Place, New York, New York 10029-6574 telephone 212-241-7749, fax 212-836-3906
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335
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Hemmings H, Jevtovic-Todorovic V. Special issue on anaesthetic neurotoxicity and neuroplasticity. Br J Anaesth 2013; 110 Suppl 1:i1-2. [DOI: 10.1093/bja/aet195] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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