Postoperative cognitive dysfunction in elderly patients undergoing hip arthroplasty

The impact of remimazolam sedation during neuraxial anesthesia on perioperative cognitive function in elderly patients: a multicenter randomized controlled study

Background

Remimazolam, a novel ultra-short-acting benzodiazepine, is a potential sedative for non-general anesthesia surgery in the elderly. This study aimed to investigate the appropriate sedative dosage of remimazolam and its effects on perioperative cognitive function in elderly patients undergoing non-general anesthesia surgery.

Methods

This multicenter, placebo-controlled trial enrolled 330 elderly patients undergoing non-general anesthesia procedures at eight centers in China from July 2021 to February 2022, with 238 ultimately completing the study. The primary endpoints were the dose of successful sedation with remimazolam and the changes in perioperative cognitive function. Adverse events were recorded to assess drug safety.

Results

The induction dose of remimazolam for sedation in spinal anesthesia in elderly patients was 5.38 mg (95% confidence interval [CI], 5.20-5.56), maintained at a rate of 0.223 mg·kg-1·h-1 (95% CI, 0.201-0.237) with no serious adverse effects. Compared with the standard saline group, there was no statistical difference in the MMSE scores on Day 2 morning (P = 0.886), Day 2 afternoon (P = 0.864), and Day 7 (P = 0.613), and no statistical difference in the MoCA scores on Day 2 morning (P = 0.687), Day 2 afternoon (P = 0.827), and Day 7 (P = 0.483) in remimazolam group.

Conclusion

Remimazolam besylate is an effective sedative for elderly patients undergoing neuraxial anesthesia. It was successfully induced at a dose of 5.38 mg and maintained at 0.223 mg·kg-1·h-1, demonstrating a good safety profile without affecting short-term postoperative cognitive function.

Clinical Trial Registration

http://www.chictr.org.cn (ChiCTR2100048744).

Development and validation of a postoperative delirium risk prediction model for non-cardiac surgery in elderly patients

Background

Postoperative delirium (POD) is one of the common central nervous system complications in elderly patients after non-cardiac surgery. Therefore, it is necessary to develop and validate a preoperative model for POD risk prediction.

Methods

This study selected 663 elderly patients undergoing non-cardiac elective surgery under general anesthesia for tracheal intubation in general surgery, from September 1st, 2020 to June 1st, 2022. Simple random sampling method was used according to 7: 3. The occurrence of POD within 1 to 7 days after the operation (or before discharge) was followed up by the confusion assessment method (CAM). This study innovatively included the pittsburgh sleep quality index (PSQI) and the numerical pain score (NRS) for clinical work, to explore the relationship between sleep quality and postoperative pain and POD. Univariate and Multivariable Logistic regression analysis was used to analyze stepwise regression to screen independent risk factors for POD. The creation of prediction models involved the integration of outcomes through the implementation of logistic regression analysis. In addition, internal validation is employed to ensure the reproducibility of the model.

Results

A total of 663 elderly patients were enrolled in this study, and 131 (19.76%) patients developed POD. The incidence of POD in each department was not statistically significant. The predictors in the POD column line graph included age, Mini Mental State Examination (MMSE) score, history of diabetes, years of education, sleep quality index, ASA classification, duration of anesthesia and NRS score. The formula Z= 8.293 + 0.102 × age - 1.214 × MMSE + 1.285 × diabetesHistory - 0.304 × yearsOfEducation + 0.602 × PSQI + 1.893 × ASA + 0.027 × anesthesiaTime + 1.297 × NRS. Conducive to the validation group to evaluate the prediction model, the validation group AUC is 0.939 (95% CI 0.894-0.969), the sensitivity is 94.44%, and the specificity is 85.09%. The calibration curves show a good fit between the clinically predicted situation and the actual situation.

Conclusion

The clinical prediction model constructed based on these independent risk factors has a good predictive performance, which can provide reference for the early screening and prevention of POD in clinical work.

Trial registration

ChiCTR2000033639 Retrospectively registered (date of registration: 06/07/2020).

Low preoperative estimated glomerular filtration rate level is a risk factor for postoperative cognitive dysfunction in elderly undergoing elective total hip replacement: a prospective observational study

BACKGROUND

Postoperative cognitive dysfunction (POCD) is a postoperative complication of the central nervous system, especially in elderly patients. Growing evidence shows a close relationship between the kidney and cognition. This study aimed to evaluate the relationship between the subsequent risk of POCD and indicators related to the kidney.

METHODS

A total of 93 eligible patients (≥65 years old) undergoing elective total hip replacement were enrolled. Before and 1 day after surgery, blood samples were collected from enrolled patients. Mini-Mental State Examination and Montreal Cognitive Assessment were conducted 1 day before surgery and 1 week after surgery or at discharge. The receiver operating characteristic curve was used to examine the predictive value of the estimated glomerular filtration rate (eGFR) for POCD. Univariate and multiple logistic regression models were used to analyze the risk factors of POCD.

RESULTS

Thirty patients (32.26%) were assessed for POCD 1 week after surgery. The preoperative eGFR level in the POCD group was significantly lower than in the non-POCD group (P < 0.001). The area under the curve of eGFR was 0.739 (95% CI, 0.630-0.848; P < 0.001). The multivariable logistic regression analysis results showed that preoperative eGFR was independently associated with POCD (odds ratio = 0.965, 95% CI = 0.935-0.996, P = 0.028) after adjustment for mixed factors.

CONCLUSION

Low eGFR is associated with an increased risk of POCD in patients undergoing elective total hip replacement surgery. Low eGFR is an effective predictor of incident POCD.

Effects of pericapsular nerve group block on early postoperative cognitive function in older people undergoing hip arthroplasty: a randomized controlled clinical trial

BACKGROUND

Pericapsular nerve group (PENG) block has emerged as a reliable analgesia technique for hip arthroplasty (HA). However, the effects of PENG block on perioperative neurocognitive disorder (PND) after HA has not yet been assessed. The present study aimed to investigate the effects of PENG block on early postoperative cognitive function in older people undergoing hip arthroplasty.

METHODS

Sixty older patients undergoing HA under spinal anesthesia were randomly assigned to group P (n = 30) receiving PENG block with ropivacaine and patient-controlled intravenous analgesia (PCIA) pump with sufentanil after surgery or group C (n = 30) only receiving PCIA pump with sufentanil after surgery. The primary outcome was the Mini-Mental State Examination (MMSE) score at 7 days postoperatively. Secondary outcomes consisted of the incidence of PND 7 days postoperatively, the static VAS pain scores at 6, 12, 24, and 48 h postoperatively; cumulative sufentanil consumption and the requirement of rescue analgesia during the 0-24 h period after surgery; quality of recovery-15 (QoR-15) scale scores at 24 h postoperatively; and the plasma levels of high mobility group box protein 1 (HMGB1) preoperatively and 1 day after surgery, and adverse events.

RESULTS

After surgery, the PENG block group had higher MMSE score than the control group at 7 days postoperatively (27.0 ± 1.8 vs. 26.1 ± 1.7, P = 0.048), with a mean difference of 0.9 (95%CI, 0.1-0.9). The incidence of PND at 7 days postoperatively was 6.7% in group P, lower than that of 30% in group C (P = 0.044). In group P, the static VAS scores at 6, 12, and 24 h postoperatively were significantly lower than those in group C (all P < 0.05). Compared with group C, the cumulative sufentanil consumption and the number of patients required rescue analgesia during the 0-24 h period after surgery were significantly lower in group P (all P < 0.05). The scores of QoR-15 scale were higher in group P at 24 h postoperatively than those in group C (P < 0.05). Patients in group P showed lower plasma levels of HMGB1 than group C at 1 day after surgery (P < 0.05), and the rate of complications didn't differ between both groups.

CONCLUSIONS

Older people undergoing HA receiving a PENG block for perioperative analgesia experience improved early postoperative cognitive function, reduced postoperative pain, higher quality of recovery, and less postoperative inflammatory response.

TRIAL REGISTRATION

Chictr.org.cn identifier ChiCTR2200061055 (Date of registry: 15/06/2022, prospectively registered).

The Effects of Vitamin D on Movement and Cognitive Function in Senile Mice After Sevoflurane Anaesthesia

BACKGROUND

Vitamin D (VD) is a neuroactive steroid involved in many brain functions, such as neurotrophic, neuroimmune control and neurotransmission, which affects the growth and function of the brain. The purpose of this study is to explore the effect of VD on motor and cognitive function of aged mice after sevoflurane anesthesia.

METHOD

We established sevoflurane anesthesia model and VD(-) and VD(+) mice model. The VD concentration of mice in each group was determined by enzyme-linked immunosorbent assay (ELISA). An open-field test was used to evaluate the mice's capacity for movement and exploration. A Y-maze test was used to gauge the mice's short-term memory. The primary purpose of the water-maze experiment was to examine mice's long-term spatial memory.

RESULTS

The ELISA results showed that the model was successfully constructed. In the open-field test, VD increased the exercise distance of mice (P < .05). In the Y-maze experiment, VD improved short-term memory impairment in mice (P < .05). In the water-maze test, VD increased the activity time and platform crossing number of mice in the target quadrant. (P < .05).

CONCLUSION

Sevoflurane anesthesia caused cognitive dysfunction in aged mice, including reduced learning ability, memory loss, lower motor and exploratory abilities and depression, and VD deficiency aggravated these impairments. By supplementing with VD, learning ability and long-term memory were enhanced, motor and exploratory abilities were improved, and depression levels were reduced. Anxiety was also improved.

Current perspectives on postoperative cognitive dysfunction in geriatric patients: insights from clinical practice

Postoperative cognitive dysfunction (POCD) is a common and serious postoperative complication in elderly patients, affecting cognitive function and quality of life. Its pathophysiology is complex, involving age-related cognitive decline, surgical and anesthetic factors, systemic and neuroinflammation, as well as genetic and environmental contributors. Comprehensive preoperative assessment and optimization, the selection of appropriate anesthetic agents, minimally invasive surgical techniques, and early postoperative rehabilitation and cognitive training are effective strategies to reduce the incidence of POCD. Recent research suggests that anti-inflammatory drugs and neuroprotective agents may be promising in preventing POCD. Additionally, non-pharmacological interventions, including cognitive and physical training, have shown positive effects. Future research directions should include large-scale clinical trials and mechanistic studies to further understand and manage POCD, along with integrating new findings into clinical practice. Continuous education and training for healthcare professionals are essential to ensure the effective application of the latest research findings in patient care. Through multidisciplinary collaboration and ongoing improvements, these efforts can significantly enhance the cognitive function and quality of life of elderly surgical patients.

Gut microbiota-derived metabolite trimethylamine N-oxide aggravates cognitive dysfunction induced by femoral fracture operation in mice

An increasing number of elderly individuals are experiencing postoperative cognitive dysfunction (POCD) problems after undergoing hip replacement surgery, with gut microbiota metabolites playing a role in its pathogenesis. Among these, the specific effects of trimethylamine N-oxide (TMAO) on POCD are still unclear. This study aimed to explore the role of TMAO on cognitive dysfunction and underlying mechanisms in mice. The POCD model was created through femoral fracture surgery in elderly mice, followed by cognitive function assessments using the Morris Water Maze and Novel Object Recognition tests. The gut microbiota depletion and fecal microbiota transplantation were performed to examine the relationship between TMAO levels and cognitive outcomes. The effects of TMAO treatment on cognitive dysfunction, microglial activation, and inflammatory cytokine levels in the brain were also evaluated, with additional assessment of the role of microglial ablation in reducing TMAO-induced cognitive impairment. Elevated TMAO levels were found to be associated with cognitive decline in mice following femoral fracture surgery, with gut microbiota depletion mitigating both TMAO elevation and cognitive dysfunction. In contrast, fecal microbiota transplantation from postoperative mice resulted in accelerated cognitive dysfunction and TMAO accumulation in germ-free mice. Furthermore, TMAO treatment worsened cognitive deficits, neuroinflammation, and promoted microglial activation, which were reversed through the ablation of microglia. TMAO exacerbates cognitive dysfunction and neuroinflammation in POCD mice, with microglial activation playing a crucial role in this process. Our findings may provide new therapeutic strategies for managing TMAO-related POCD and improving the quality of life for elderly patients.

The Association of Cerebral Oxygen Desaturation with Postoperative Cognitive Dysfunction in Older Patients: A Review

Postoperative cognitive dysfunction (POCD) is a neurological complication associated with surgery and anesthesia that is commonly observed in older patients, and it can significantly affect patient prognosis and survival. Therefore, predicting and preventing POCD is important. Regional cerebral oxygen saturation (rSO2) reflects cerebral perfusion and oxygenation, and decreased intraoperative cerebral oxygen saturation has been reported to increase the risk of POCD. In this review, we elucidated the important relationship between the decline in rSO2 and risk of POCD in older patients. We also emphasized the importance of monitoring rSO2 during surgery to predict and prevent adverse perioperative cognitive outcomes. The findings reveal that incorporating intraoperative rSO2 monitoring into clinical practice has potential benefits, such as protecting cognitive function, reducing perioperative adverse outcomes, and ultimately improving the overall quality of life of older adults.

Correlation between heart rate variability and perioperative neurocognitive disorders in patients undergoing non-cardiac surgery: A retrospective cohort study

OBJECTIVE

With the improvement of medical level, the number of elderly patients is increasing, and the postoperative outcome of the patients cannot be ignored. However, there have been no studies on the relationship between preoperative heart rate variability (HRV) and Perioperative Neurocognitive Disorders (PND). The purpose of this study was to explore the correlation between (HRV) and (PND), postoperative intensive care unit (ICU), and hospital stay in patients undergoing non-cardiac surgery.

METHOD

This retrospective analysis included 687 inpatients who underwent 24-hour dynamic electrocardiogram examination in our six departments from January 2021 to January 2022. Patients were divided into two groups based on heart rate variability (HRV): high and low. Possible risk factors of perioperative outcomes were screened using univariate analysis, and risk factors were included in multivariate logistic regression to screen for independent risk factors. The subgroup analysis was carried out to evaluate the robustness of the results. The nomogram of PND multi-factor logistic prediction model was constructed. The receiver operating characteristic (ROC) curve was drawn, and the calibration curve was drawn by bootstrap resampling 1000 times for internal verification to evaluate the prediction ability of nomogram.

RESULT

A total of 687 eligible patients were included. The incidence of low HRV was 36.7% and the incidence of PND was 7.6%. The incidence of PND in the low HRV group was higher than that in the high HRV group (11.8% vs 5.2%), the postoperative ICU transfer rate was higher (15.9% than 9.3%P = 0.009), and the hospital stay was longer [15 (11, 19) vs (13), 0.015]. The multivariable logistic regression analysis showed that after adjusting for other factors, decreased low HRV was identified as an independent risk factor for the occurrence of PND (Adjusted Odds Ratio = 2.095; 95% Confidence Interval: 1.160-3.784; P = 0.014) and postoperative ICU admission (Adjusted Odds Ratio = 1.925; 95% Confidence Interval: 1.128-3.286; P = 0.016). This study drew a nomogram column chart for a multivariate logistic regression model, incorporating age and HRV. The calibration curve shows that the predicted value of the model for the occurrence of cardio-cerebrovascular events is in good agreement with the actual observed value, with C-index of 0.696 (95% CI: 0.626 ~ 0.766). Subgroup analysis showed that low HRV was an independent risk factor for PND in patients with gastrointestinal surgery and ASA Ⅲ, aged ≥ 65 years.

CONCLUSION

In patients undergoing non-cardiac surgery, the low HRV was an independent risk factor for PND and postoperative transfer to the ICU, and the hospitalization time of patients with low HRV was prolonged. Through establishing a risk prediction model for the occurrence of PND, high-risk patients can be identified during the perioperative period for early intervention.

Postoperative cognitive dysfunction-current research progress

Postoperative cognitive dysfunction (POCD) commonly occurs after surgery, particularly in elderly individuals. It is characterized by a notable decline in cognitive performance, encompassing memory, attention, coordination, orientation, verbal fluency, and executive function. This reduction in cognitive abilities contributes to extended hospital stays and heightened mortality. The prevalence of POCD can reach 40% within 1 week following cardiovascular surgery and remains as high as 17% 3 months post-surgery. Furthermore, POCD exacerbates the long-term risk of Alzheimer's disease (AD). As a result, numerous studies have been conducted to investigate the molecular mechanisms underlying POCD and potential preventive strategies. This article provides a review of the research progress on POCD.

Effectiveness of dexmedetomidine on postoperative cognitive dysfunction in elderly patients with fracture: A systematic review

BACKGROUND

Previous studies have explored the effectiveness of dexmedetomidine on postoperative cognitive dysfunction (POCD) in elderly patients with fracture. However, no systematic review has addressed this issue. Thus, this systematic review investigated the effectiveness of dexmedetomidine on POCD in elderly patients with fracture.

METHODS

In this study, we searched electronic databases of PubMed, EMBASE, Cochrane Library, China National Knowledge Infrastructure, Wang Fang and China Science and Technology Journal Database from their initiation to July 1, 2022. We considered randomized controlled trials of dexmedetomidine on POCD in elderly patients with fracture in this study. Primary outcome was measured by mini-mental state examination. Secondary outcomes were measured by total occurrence rate of postoperative cognitive dysfunction, occurrence rate of delirium, visual analogue scale and occurrence rate of adverse events.

RESULTS

A total of 10 studies involving 969 elderly patients with fracture are included in this study. Meta-analysis results showed that there were significant differences on mini-mental state examination at 1-day post-surgery [mean difference (MD) = 2.17; random 95% confidence interval (CI), 1.06, 3.28; P < .001; I²=98%], 3-day post-surgery (MD = 2.70; random 95% CI, 1.51, 3.89; P < .001; I²=98%), and 7-day post-surgery (MD = 1.21; random 95% CI, 0.50, 1.93; P < .001; I²=86%), total occurrence rate of postoperative cognitive dysfunction (odds ratio [OR] = 0.26; fixed 95% CI, 0.11, 0.60; P = .002; I²= 0%), occurrence rate of delirium (OR = 0.29; fixed 95% CI, 0.11, 0.78; P = .01; I²= 0%), visual analogue scale (MD = -1.23; random 95% CI, -1.74, -0.72; P < .001; I²=95%), and occurrence rate of adverse events (OR = 0.32; fixed 95% CI, 0.20, 0.50; P < .001; I²= 0%) between the 2 groups.

CONCLUSION

The results of this study showed that dexmedetomidine could effectively manage POCD in elderly patients with fracture. However, the overall quality of included trials is not too high. Thus, the present findings should be cautiously referred.

Correlation between neutrophil/lymphocyte ratio, platelet/lymphocyte ratio and postoperative cognitive dysfunction in elderly patients with esophageal cancer

The present study intends to investigate the correlation between neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR) and postoperative cognitive dysfunction (POCD) in elderly patients with esophageal cancer. Elderly patients >65 years old with esophageal cancer in our department from October 2017 to June 2021 were included in the study. The cognitive function of the patients was assessed by the mini-mental state examination (MMSE) Scale at 1day, 3 days, and 7days after surgery. POCD was considered when the scores were <27 points, and the remaining patients were included in the control group. A total of 104 elderly patients with esophageal cancer were included in this study, and 24 patients developed POCD, with an incidence of 23.1%. The expression of NLR and PLR in both 2 groups was increased on the 1st postoperative day compared with that before surgery. There was no significant difference in the expression of NLR and PLR between the 2 groups before operation, but the expression of both in the POCD group was significantly higher than that in the control group after operation (P < .05). Logistic regression analysis showed that smoking, postoperative NLR and postoperative PLR were independent risk factors for POCD. Spearman test showed that NLR was negatively correlated with MMSE scores at postoperative 1 day and 3 days (P < .05), while PLR was negatively correlated with MMSE scores at postoperative 1 day, 3 days and 7 days (P < .05). The Area Under receiver operating characteristic curve (AUC) of postoperative NLR for predicting POCD in elderly patients with esophageal cancer was 0.656, and the AUC of postoperative PLR was 0.722. After combination of NLR and PLR, the AUC increased to 0.803 with the sensitivity of 66.7% and specificity of 82.5%. The expression level of postoperative NLR and PLR in elderly patients with esophageal cancer combined with POCD is significantly increased, which is associated with postoperative cognitive impairment. Moreover, the combination of NLR and PLR has a good predictive ability for POCD, which could be used as a potential biomarker for early diagnosis of POCD.

Demographic changes and surgery caseloads for hip arthroplasty over the last 50 years: a retrospective study

AIMS OF THE STUDY

Data on the demographic changes over time for hip arthroplasty are rare in Switzerland. The aim of the study was to evaluate the influence of these changes on the distribution of age, gender, operated hip side, place of residence and caseload per surgeon over the last 50 years of hip arthroplasty at the Kantonsspital St. Gallen.

METHODS

For this retrospective explorative study, data were collected from the operating theatre journals of hip replacements performed at Kantonsspital St. Gallen from 1969 to 2019. Every fifth year was included, which resulted in 5-year sampling rate over the observation period. The journals were handwritten until 1999 and digital from 2004 to 2019. The following data were obtained: age, sex, type of hip arthroplasty, side of operated hip, place of residence and name of main surgeon. Apart from overall descriptive statistics, we applied the Mann-Whitney U-test to test for differences in age and the binomial test for categorical variables. A linear regression model was applied to investigate the relationship between patients' ages and historical data of life expectancy of the Swiss population.

RESULTS

We included 2,963 patients, of whom 1,318 were men (median age = 67 yr., p25 = 59 yr., p75 = 74 yr.) and 1,608 women (median age = 72 yr., p25 = 63 yr., p75 = 79 yr.). Overall, women were significantly older than men, irrespective of whether they received primary total hip arthroplasty (median age = 70 yr. vs 66 yr., p25 = 61 yr. vs 58 yr., p75 = 77 yr. vs 73 yr., p <0.001), hemiarthroplasty (median age = 84 yr. vs 78.5 yr., p25 = 78 yr. vs 71 yr., p75 = 89 yr. vs 85 yr., p <0.001) or total revision arthroplasty (median age = 71 yr. vs 70 yr., p25 = 64.25 yr. vs 63 yr., p75 = 78 yr. vs 75 yr., p = 0.036). A trend toward rising median age is evident looking at the whole period observed from 1969 to 2019. Except for women in the total revision arthroplasty group (r = 0.226), a high correlation between increasing median age of patients undergoing hip replacement and life expectancy was found (r ≥0.663). Significantly more primary total hip prostheses (p = 0.003) and hip hemiprostheses (p <0.001) were implanted in women than in men between 1969 and 2019. Overall, no significant difference in side distribution was seen in the primary total hip arthroplasty (p = 0.061), total revision arthroplasty (p = 1.000) and hemiarthroplasty (p = 0.365) group. In contrast to earlier years, most patients in recent years are operated on by high-volume surgeons (>50 operations per surgeon per year).

CONCLUSIONS

Demographic changes of patients undergoing total hip replacement reflect the overall demographic changes in the Swiss population. Over the last 50 years the indication for prosthetic hip replacements has not been extended to younger ages. The caseload in hip arthroplasty has changed over the last 50 years towards high-volume surgeons.

Effects of thoracic paravertebral block combined with s-ketamine on postoperative pain and cognitive function after thoracoscopic surgery

Objectives

To assess the effects of thoracic paravertebral block and s-ketamine on postoperative pain and perioperative neurocognitive disorder (PND) in video-assisted thoracoscopic surgery.

Methods

Patients (n = 120) aged 45-65 undergoing video-assisted thoracoscopic surgery were allocated randomly into the following three groups: patients in the C group received general anaesthesia; patients in the thoracic paravertebral block group, i.e. the TP group, received general anaesthesia and ultrasound-guided paravertebral block; and patients in the s-ketamine combined with ultrasound-guided thoracic paravertebral nerve block group, i.e. the TS group, received combined anaesthesia, which was administered as follows: general anaesthesia + ultrasound-guided paravertebral block + perioperative s-ketamine (a bolus of 0.3 mg/kg, followed by an infusion of 0.2 mg/kg/h until 30 min before the end of the surgical procedure).

Results

Cognitive function was measured using the Mini-Mental State Examination 1 day preoperatively, 1 day postoperatively, and 3 months postoperatively. Z-score was used to determine the incidence of PND. Postoperative pain was assessed using the visual analogue scale at 0.5 and 24 h postoperatively. The use of opioid drugs, intraoperative vital signs, and other secondary outcomes were also recorded. The final analysis included a total of 110 patients. The intraoperative heart rate and mean arterial pressure in the TS and TP groups were lower than that for group C (P＜0.05). After surgery, patients in the TS group exhibited significantly lower pain scores at 0.5 h and 24 h (P＜0.001 and P = 0.004,respectively) as well as significantly lower rates of postoperative nausea, vomiting, and pulmonary complications (P＜0.05). The incidence of PND in the TP and TS groups was lower than those who received general anaesthesia. However, there was no significant difference in the incidence of PND between the TP and TS groups (P＞0.05).

Conclusions

Ultrasound-guided paravertebral nerve block combined with s-ketamine decreased acute postoperative pain and improved the quality of recovery. However, perioperative s-ketamine did not improve cognitive function in patients under general anaesthesia with thoracic paravertebral block.

Fascia iliaca compartment block can reduce the incidence of early post-operative cognitive impairment in elderly patients with high-risk hip replacement

Objective

In this study, we aimed to observe the effects of ultrasound-guided fascia iliaca compartment block (FICB) combined with hypobaric spinal anesthesia on post-operative pain and cognitive function in elderly patients with high-risk hip replacement.

Methods

A total of 84 elderly patients-aged 65-85 years, with American Society of Anesthesiologists physical status III-IV, and scheduled for hip arthroplasty between September 2021 and May 2022-were selected. One or more organs with moderate to severe impairment were included in all patients. The patients were randomly divided into a hypobaric spinal anesthesia group (group C, control group) and an ultrasound-guided FICB combined with hypobaric spinal anesthesia group (group E, experimental group). Group C was given 3.5 mL of 0.32% ropivacaine hypobaric spinal anesthesia, and group E received ultrasound-guided FICB combined with 3.5 mL of 0.32% ropivacaine hypobaric spinal anesthesia. The patients were compared using the visual analog scale (VAS) for pain, Harris hip function score, and simple Mini-Mental State Examination (MMSE) scale. Blood β-amyloid (Aβ) and neuronal microtubule-associated protein (tau) levels were measured. We compared intraoperative conditions and post-operative complications between the two groups to assess the effects of FICB combined with hypobaric spinal anesthesia on post-operative pain and cognitive function in elderly patients with high-risk hip replacement.

Results

At 1 and 3 days after the operation, patients in group C had significantly higher VAS and lower MMES scores than those in group E. The differences were statistically significant at 1 (P < 0.01) and 3 (P < 0.05) days after the operation. At 1 day after operation, the Harris score of patients in group C was significantly lower than that of patients in group E (P < 0.05). The Aβ and tau levels of patients in group C were significantly higher than those of patients in group E at 1 day after the operation (P < 0.01). The Aβ levels of patients in group C were significantly higher than those of patients in group E at 3 days after the operation (P < 0.05). The intraoperative conditions and post-operative complication rates did not differ significantly between the two groups. At 1 day before and 5 days after the operation, there was no difference in any of the indicators.

Conclusion

By lowering pain and managing Aβ and tau protein concentrations, FICB can successfully lower the incidence of early post-operative cognitive impairment in elderly patients with high-risk hip replacement.

Clinical trial registration

www.chictr.org.cn, identifier: ChiCTR2100051162.

Heterogeneous nuclear ribonucleoprotein A2/B1 as a novel biomarker in elderly patients for the prediction of postoperative neurocognitive dysfunction: A prospective nested case-control study

Background and objective

Postoperative neurocognitive dysfunction (PND) occurs in up to 54% of older patients, giving rise to the heavy psychological and economic burdens to patients and society. To date, the development of PND biomarkers remains a challenge. Heterogeneous nuclear ribonucleoprotein A2/B1 (hnRNPA2/B1) is an RNA-binding protein whose prion-like structure is prone to mutation and hence leads to neurodegenerative diseases, but its expression changes in PND remains unclear. Here, we detect the preoperative hnRNPA2/B1 level in patients with PND, and to explore its value in the prediction and diagnosis of PND.

Methods

The study included 161 elderly patients undergoing lumbar decompression and fusion in Nankai University Affinity the Third Central Hospital from September 2021 to July 2022. Neuropsychological and psychometric evaluations were performed before surgery, 1 week and 3 months after surgery to diagnose the occurrence of PND, then the peripheral blood was collected from patients before induction of anesthesia. The concentration in plasma of hnRNPA2/B1 and amyloid-β 42 were determined by enzyme-linked immunosorbent assay. The median fluorescence intensity and mRNA levels of hnRNPA2/B1 in peripheral blood mononuclear cells was detected by indirect intracellular staining flow cytometry and quantitative real-time PCR, respectively.

Results

The preoperative hnRNPA2/B1 level in patients with PND was higher both in short-time and long-time follow-up. We found significantly higher concentrations of hnRNPA2/B1 in PND at 7 days after surgery (median, 72.26 pg/mL vs. 54.95 pg/mL, p = 0.022) compared with patients without PND, and so as 3 months after surgery (median, 102.93 pg/mL vs. 56.38 pg/mL, p = 0.012). The area under the curve (AUC) was predicted to be 0.686 at 7 days after surgery and 0.735 at 3 months. In addition, when combining several clinical information, the diagnostic efficiency of hnRNPA2/B1 for PND could further increase (AUC, 0.707 at 7 days, 0.808 at 3 months).

Conclusion

Based on the findings reported here, hnRNPA2/B1 may serve as a new and powerful predictive biomarker to identify elderly patients with PND.

Ultrasound Radiomics-Guided Iliac Fascia Block on Postoperative Cognitive Dysfunction in Elderly Patients Undergoing Hip Surgery

Objective. Elderly patients with hip surgery are prone to postoperative cognitive dysfunction (POCD), leading to health management difficulties. This study is aimed at investigating the effect of ultrasound radiomics-guided iliac fascia block on POCD. Methods. A total of 67 cases of patients who had undergone hip joint surgery were divided into a training set ( $n=47$ ) and a validation set (radiomics-guided group, $n=20$ ). The patients were intervened with ultrasound radiomics-guided iliac fascia block, and the maximum relevance minimum redundancy sifts out the image omics features obtained from 2D ultrasound images of patients. Another 20 patients undergone general anesthesia served as control. The incidence of POCD, the total amount of fentanyl, the visual analogue score (VAS) at different time points, and the levels of CRP and NSE in plasma were compared between the two groups. Results. The AUC on the training and validation sets were higher than 0.940. The incidence of POCD in the radiomics-guided and general anesthesia group was 5% and 30%, respectively ( $P=0.037$ ). Compared with the general anesthesia group, the dosage of fentanyl in the radiomics-guided was lower, the VAS score at 6 h, 1 d, and 2 d after operation was smaller, and the levels of CRP and NSE were lower (all $P<0.05$ ). Conclusions. For elderly patients with hip surgery, the ultrasound radiomics-guided iliac fascia block can reduce the incidence of POCD and improve the effect of nerve block.

Inflammatory markers in postoperative cognitive dysfunction for patients undergoing total hip arthroplasty: a meta-analysis

BACKGROUND

Postoperative cognitive dysfunction (POCD) is a poorly understood disorder, very common even after total hip arthroplasty (THA). It is widely considered that inflammation response play a role in the pathogenesis of POCD.

AIMS

The aim of the present study was to investigate whether inflammation cytokine concentrations could serve as biomarkers for POCD in patients undergoing THA.

METHODS

A systematic search of databases was conducted to retrieve publications measuring circulating inflammatory markers of patients with and without POCD after THA. Inflammatory markers identified in more than two studies were pooled. The standardized mean difference (SMD) and the 95% confidence interval (95% CI) were calculated for each outcome. Fail-safe N statistics was calculated to estimate possible publication bias.

RESULTS

The pooled incidence rate of POCD after THA by combining 11 cohort studies was 31%. A total of five inflammatory markers, CRP, S-100B, IL-1β, IL-6 and TNF-α, were assessed. Significantly higher pre-operative CRP (P = 0.012) and S-100B (P < 0.0001) as well as post-operative CPR (P = 0.005) and IL-6 (P < 0.0001) at 6 h were found in POCD compared with non-POCD patients undergoing THA. Fail-safe N statistics revealed that these results are robust.

DISCUSSION

The current evidence suggests that some of the inflammatory markers, including CRP, S-100B, and IL-6, were correlated with the occurrence of POCD after THA.

CONCLUSION

Monitor of inflammatory markers might help early diagnosis of POCD after THA and development of preventive strategies.

Electroacupuncture for the Prevention of Postoperative Cognitive Dysfunction Among Older Adults Undergoing Hip and Knee Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background: Postoperative cognitive dysfunction (POCD) is a common surgical complication in elderly patients undergoing hip and knee replacement. Electroacupuncture (EA) may have a protective effect on postoperative cognitive function, but relevant evidence remains uncertain. Objective: To systematically evaluate the evidence of EA for the prevention of POCD after total joint arthroplasty. Methods: PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), China National Knowledge Infrastructure (CNKI), Wanfang Data, VIP, and Chinese Biomedical Literature Database (CBM) databases were searched until May 1, 2021. Randomized controlled trials (RCTs) in which patients undergoing hip and knee replacement pretreated with EA for preventing POCD were included. The risk of bias was assessed by the Cochrane Collaboration tool. Meta-analysis was performed using Review Manager version 5.4. Results: A total of 11 RCTs with 949 patients were identified. Meta-analysis showed that compared with controls, EA pretreatment significantly reduced the incidence of POCD at 1, 3, and 7 days and 3 and 6 months after the operation. EA was also superior in improving the Mini-Mental State Examination (MMSE) scores on the third postoperative day, but not on the first postoperative day. Neuron-specific enolase (NSE) and interleukin-1β (IL-1β) in the EA group were significantly lower than that in the control group. There was no difference in S100β between the EA group and the control group. Compared to the control group, tumor necrosis factor-α (TNF-α) levels were not significantly lower in the EA group at postoperative hour 0, while significantly decreased at postoperative hours 24 and 48. Conclusion: Our results suggest that EA pretreatment is an effective adjunctive therapy for reducing the incidence of POCD for patients receiving total joint replacement surgery. Its effect was embodied in improving the MMSE scores and NSE, IL-1β, and TNF-α levels, whereas it had no significant effect on S100β levels. Meanwhile, the benefits of EA for improving POCD need further strengthening and support from more large-scale, high-quality, and good-homogeneity RCTs. Systematic Review Registration: https://osf.io/xb3e8.

The Association between Postoperative Cognitive Dysfunction and Cerebral Oximetry during Geriatric Orthopedic Surgery: A Randomized Controlled Study

Background

Postoperative cognitive dysfunction (POCD) refers to disorders affecting orientation, attention, perception, consciousness, and judgment that develop after geriatric orthopedic surgery. Cerebral blood oxygen saturation detection is a way to diagnose cerebral oxygen supply during operation. At present, more and more applications are used for early diagnosis of postoperative cognitive function. Therefore, the present study is to analyze the relationship between postoperative cognitive dysfunction and cerebral blood oxygen saturation in elderly orthopedic patients.

Methods

This study enrolled 90 elderly patients undergoing orthopedic surgery in our hospital. According to the postoperative cognitive dysfunction, they were divided into POCD group (N = 45) and no-POCD (N = 45) group. The cognitive and psychological function and cerebral blood oxygen saturation were analyzed before and 3 months after the operation. Finally, the indicators of cognitive psychological function and the indicators of cerebral blood oxygen saturation are correlated and analyzed.

Results

Compared with the normal group, patients with cognitive dysfunction at 3 months after surgery time below preoperative rScO2, time below a 10% decrease from preoperative rScO2, CDL preoperative, minimum rScO2 value, and maximum rScO2 value have significant changes. The results of the correlation analysis found that there is also a significant correlation between the postoperative cognitive and psychological function of the patient and the cerebral blood oxygen saturation at 3 weeks after the operation.

Conclusion

In elderly orthopedic patients, there is a significant relationship between cerebral blood oxygen saturation detection and cognitive function 3 months after surgery.

Protective role of dexmedetomidine against sevoflurane-induced postoperative cognitive dysfunction via the microRNA-129/TLR4 axis

The involvement of Dexmedetomidine (Dex) has been indicated in postoperative cognitive dysfunction (POCD), while the mechanism is not well characterized. This study estimated the mechanism of Dex in POCD. Rats were anesthetized with sevoflurane (SEV) to evoke POCD and then subjected to Morris water maze test to detect the cognitive and behavioral function. Then, the damage of hippocampus and cortex, and apoptosis and activity of neurons were examined. Microarray analysis was performed to screen out the differentially expressed microRNAs (miRs) in rats after Dex treatment. The cognitive and behavioral functions and neuronal activity of rats were detected after miR-129 antagomir injection. The target of miR-129 was predicted. The levels of TLR4 and NF-κB p65 in hippocampus and cortex were measured. Dex treatment alleviated SEV-induced behavior and cognitive impairments in rats, promoted neuronal activity and hindered neuronal apoptosis. After treatment with Dex, miR-129 expression was elevated in brain tissues, and the neuroprotection of Dex on POCD rats was partially annulled after injection of miR-129 antagomir. Furthermore, miR-129 targeted TLR4 and prevented the phosphorylation of NF-κB p65. In summary, Dex ameliorated SEV-induced POCD by elevating miR-129 and inhibiting TLR4 and NF-κB p65 phosphorylation. This study may shed new lights on POCD treatment.

TNF-α - mediated peripheral and central inflammation are associated with increased incidence of PND in acute postoperative pain

Background

Acute postoperative pain plays an important role in the perioperative neurocognitive disorders (PND). The pathogenesis of PND is still unknown, but it is generally believed that peripheral and central nervous system inflammation play an important role, and acute postoperative pain is also thought to aggravate postoperative inflammatory response. The aim of the present study is to explore the effect of acute postoperative pain on peripheral and central nervous system inflammation and related cognitive impairment behaviour in elderly rats after surgery.

Methods

Rats were assigned into four groups: control, surgery for internal fixation for tibial fracture, surgery with analgesia using intraperitoneal morphine, and morphine without surgery. Pain was assessed by the Subjective Pain Scale. The spatial memory of rats was assessed by the Morris water maze (delayed matching task) from the second day to the seventh day after surgery (POD2-POD7). In part of the rats, the pro-inflammatory cytokines TNF-α in plasma, the medial prefrontal cortex (mPFC), and the hippocampus were determined by ELISA on the POD2. The activation of microglia and the expression of c-Fos in the hippocampal CA1 regions and mPFC were detected by the immunohistochemical method on the POD2.

Results

Acute postoperative pain and spatial memory impairment occurred after operation, and postoperative analgesia could significantly improve the both parameters. Additionally, on the POD2, the levels of TNF-α in plasma, hippocampus and mPFC were significantly increased, while the activation of microglia cells and the expression c-Fos in the hippocampal CA1 regions and mPFC were significantly increased. And postoperative analgesia with morphine significantly inhibited the above reactions.

Conclusion

Our data suggest that acute postoperative pain increases the incidence of perioperative neurocognitive disorders. Peripheral and central nervous system inflammation may be involved in this cognitive impairment. And reducing the intensity of acute postoperative pain may be one of the main preventive strategies for PND.

Elderly hip fracture patients: surgical timing and factors to consider

PURPOSE OF REVIEW

Hip fractures of the elderly population are a common trauma and numbers are increasing due to ageing societies. Although this is an ordinary low energy impact injury and surgical repair techniques show good results, the perioperative course is characterized by an unparalleled disproportionate perioperative morbidity and mortality.

RECENT FINDINGS

Most studies focus on outcome-related data. Little is known on how to prevent and treat adverse sequelae, ranging from mild physical challenges to neurobiological disorders and death.

SUMMARY

Although the contribution of the anaesthetic technique per se seems to be small, the role of the anaesthesiologist as a perioperative physician is undisputed. From focusing on comorbidities and initiating preoperative optimization to intraoperative and postoperative care, there is a huge area to be covered by our faculty to ensure a reasonable outcome defined as quality of postoperative life rather than merely in terms of a successful surgical repair. Protocol-driven perioperative approaches should be employed focusing on pre, intraoperative and postoperative optimization of the patient to facilitate early repair of the fracture that may then translate into better outcomes and hence alleviate the individual patient's burden as well as the socioeconomic load for society.

Patients with hip fracture and total hip arthroplasty surgery differ in anthropometric, but not cardiovascular screening abnormalities

Background

With the rising number of hip surgeries, simple and cost-effective tools for surgery risk assessment are warranted. The analysis of heart rate variability (HRV) may not only provide critical insights into the general frailty of patients with hip surgery, but also allow for better differentiation of health profiles in different hip surgery groups. Using HRV analysis, the present study compared cardiovascular as well as anthropometric parameters between patients with hip surgery, the hip fracture surgery group (HFS) and the total hip arthroplasty group (THA), and a control group.

Methods

71 participants (56.3% women), aged 60–85 years, took part, divided into three groups—patients after hip surgery (21 HFS and 30 THA patients) and a control group (20 participants). Electrocardiogram was recorded at baseline and after the application of a physical stressor (grip strength). A 3 (group) × 2 (time) repeated measures ANOVA, and a chi square test were carried out to test for group differences.

Results

Higher weight (p = .002), body mass index (p = .001), and systolic blood pressure (p = .034) were found in THA patients compared to HFS patients. Lower calf circumference (p = .009) and diastolic blood pressure (p = .048) were observed for the HFS group compared to the control group. For cardiovascular parameters, significant differences emerged between the HFS group and the control group in HR (p = .005), SDNN (p = .034) and SD2 (p = .012). No significant differences in cardiovascular parameters were observed between the two hip surgery groups: neither at baseline nor during stressor recovery.

Conclusions

While HRV seems to differentiate well between HFS patients and controls, more research with larger samples is needed to scrutinize similaritites and differences in cardiovascular profiles between HFS and THA patients.

Outpatient dental care for people with disabilities under general anaesthesia in Switzerland

BACKGROUND

Life expectancy of people with permanent disabilities has increased. The dental care of these vulnerable patients is one of the greatest challenges for the dentist and the dental team due to limited or non-existent cooperation and the associated lack of health competence. In order to be able to provide safe and acceptable, quality dental treatment without psychological and physical stress for these patients, it is therefore necessary to resort to sedation or general anaesthesia (GA) under medical supervision. The aim of the analysis is to highlight the need for dental treatment performed under GA for people with disabilities and the associated indications and treatment patterns.

METHODS

Ten-year retrospective analysis of outpatient dental care under GA for people with disabilities.

RESULTS

Of all adult patients (n = 221) who attended the GA pre-assessment, 69.7% (n = 154) received dental treatment under GA based on the clinical findings or in cases of suspected pain. Most patients received one GA. A total of 205 dental treatment sessions were performed under GA mostly for conservative (n = 442, 52%) and surgical (n = 389, 45.8%) procedures. Endodontic treatment (n = 19, 2.2%) was rare. The failure rate related to all teeth in need of treatment (n = 850) was 5.1% (n = 43), in most cases due to secondary caries (n = 40; 93.0%). Patients were enrolled in an annual recall for dental examination and prophylaxis without GA. Non-compliant patients for whom oral hygiene was impossible received a periodic GA.

CONCLUSION

There is a high need of people with disabilities for dental treatment under GA. Main indications for treatment under GA are dental complaints, pain or suspected pain. Dental care can be successful if, for the benefit of patients with special needs, all carers cooperate closely. Caregivers have to be trained in nutrition control as well as in oral hygiene. These factors in conjunction help to prevent dental emergencies.