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J T Moller

Publications and source records attributed to J T Moller.

At least 19 recordsLinked to original sources
PubMed2005

Is peri-operative cortisol secretion related to post-operative cognitive dysfunction?

BACKGROUND: The pattern of cortisol secretion is influenced by surgery. As cortisol can adversely affect neuronal function, this may be an important factor in the development of post-operative cognitive dysfunction (POCD). We hypothesized that the incidence of POCD would be related to changes in cortisol level. METHODS: We studied 187 patients aged over 60 years undergoing major non-cardiac surgery with general or regional anaesthesia. Saliva cortisol levels were measured pre-operatively and at 1 day, 7 days and 3 months post-operatively in the morning (08.00 h) and in the afternoon (16.00 h) using salivettes. Cognitive function was assessed pre-operatively, on day 7 and at 3 months using four neuropsychological tests. POCD was defined as a combined Z score of greater than 1.96. RESULTS: After surgery, salivary cortisol concentrations increased significantly. POCD was detected in 18.8% of subjects at 1 week and in 15.2% after 3 months. The pre-operative ratios between the morning and afternoon cortisol concentrations (am/pm ratios) were 2.8 and 2.7 in patients with POCD at 1 week vs. those without POCD at 1 week, respectively. The am/pm ratios decreased significantly post-operatively to 1.9 and 1.6 at 1 week, respectively (P = 0.02 for both). In an analysis considering all am/pm ratios, it was found that the persistent flattening in am/pm ratio was significantly related to POCD at 1 week. CONCLUSION: The pattern of diurnal variation in cortisol level was significantly related to POCD. Thus, circadian rhythm disturbance or metabolic endocrine stress could be an important mechanism in the development of cognitive dysfunction after major surgery.

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PubMed2003

Does anaesthesia cause postoperative cognitive dysfunction? A randomised study of regional versus general anaesthesia in 438 elderly patients.

BACKGROUND: Postoperative cognitive dysfunction (POCD) is a common complication after cardiac and major non-cardiac surgery with general anaesthesia in the elderly. We hypothesized that the incidence of POCD would be less with regional anaesthesia rather than general. METHODS: We included patients aged over 60 years undergoing major non-cardiac surgery. After giving written informed consent, patients were randomly allocated to general or regional anaesthesia. Cognitive function was assessed using four neuropsychological tests undertaken preoperatively and at 7 days and 3 months postoperatively. POCD was defined as a combined Z score >1.96 or a Z score >1.96 in two or more test parameters. RESULTS: At 7 days, POCD was found in 37/188 patients (19.7%, [14.3-26.1%]) after general anaesthesia and in 22/176 (12.5%, [8.0-18.3%]) after regional anaesthesia, P = 0.06. After 3 months, POCD was present in 25/175 patients (14.3%, [9.5-20.4%]) after general anaesthesia vs. 23/165 (13.9%, [9.0-20.2%]) after regional anaesthesia, P = 0.93. The incidence of POCD after 1 week was significantly greater after general anaesthesia when we excluded patients who did not receive the allocated anaesthetic: 33/156 (21.2%[15.0-28.4%]) vs. 20/158 (12.7%[7.9-18.9%]) (P = 0.04). Mortality was significantly greater after general anaesthesia (4/217 vs. 0/211 (P < 0.05)). CONCLUSION: No significant difference was found in the incidence of cognitive dysfunction 3 months after either general or regional anaesthesia in elderly patients. Thus, there seems to be no causative relationship between general anaesthesia and long-term POCD. Regional anaesthesia may decrease mortality and the incidence of POCD early after surgery.

Activities of Daily Living↗
PubMed2003

Cognitive dysfunction after minor surgery in the elderly.

BACKGROUND: Major surgery is frequently associated with postoperative cognitive dysfunction (POCD) in elderly patients. Type of surgery and hospitalization may be important prognostic factors. The aims of the study were to find the incidence and risk factors for POCD in elderly patients undergoing minor surgery. METHODS: We enrolled 372 patients aged greater than 60 years scheduled for minor surgery under general anesthesia. According to local practice, patients were allocated to either in- (199) or out-patient (173) care. Cognitive function was assessed using neuropsychological testing preoperatively and 7 days and 3 months postoperatively. Postoperative cognitive dysfunction was defined using Z-score analysis. RESULTS: At 7 days, the incidence (confidence interval) of POCD in patients undergoing minor surgery was 6.8% (4.3-10.1). At 3 months the incidence of POCD was 6.6% (4.1-10.0). Logistic regression analysis identified the following significant risk factors: age greater than 70 years (odds ratio [OR]: 3.8 [1.7-8.7], P = 0.01) and in- vs. out-patient surgery (OR: 2.8 [1.2-6.3], P = 0.04). CONCLUSIONS: Our finding of less cognitive dysfunction in the first postoperative week in elderly patients undergoing minor surgery on an out-patient basis supports a strategy of avoiding hospitalization of older patients when possible.

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PubMed2002

Biochemical markers for brain damage after cardiac surgery -- time profile and correlation with cognitive dysfunction.

BACKGROUND: Cerebral dysfunction is common after cardiac surgery and may be reflected in increasing blood concentrations of neuron specific enolase (NSE) and S-100 beta protein. The aim of the study was to determine the optimal timing of blood sampling. METHODS: We studied 15 patients undergoing coronary artery bypass grafting. Serum concentrations of NSE and S-100 beta protein were measured before surgery and after 12, 18, 24, 30, and 36 h. Neuropsychological testing was performed before surgery, at discharge from hospital and after 3 months. RESULTS: Serum concentrations of both NSE and S-100 beta protein increased significantly. At the first postoperative test, seven patients had cognitive dysfunction and a significant correlation was found between the composite z-score and the increase in the NSE level after 36 h (R = 0.76, P=0.001). The median increase in NSE after 36 h was 4.1 microg/l in patients having cognitive dysfunction and 0.9 microg/l in the remaining patients (P<0.05). No significant correlation was found between cognitive dysfunction and the increase in S-100 beta protein. After 3 months, no statistically significant correlation was found between either NSE or S-100 beta protein and cognitive dysfunction. CONCLUSION: NSE seems to be a useful blood marker for early cognitive dysfunction after coronary artery bypass grafting, optimal timing of blood sampling being at approximately 36 h postoperatively.

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PubMed2001

The assessment of postoperative cognitive function.

Postoperative cognitive function (POCD) has been subject to extensive research. In the literature, large differences are apparent in methodology such as the test batteries, the interval between sessions, the endpoints to be analysed, statistical methods, and how neuropsychological deficits are defined. Traditionally, intelligence tests or tests developed for clinical neuropsychology have been used. The tests for detecting POCD should be based on well-described sensitivity and suitability in relation to surgical patients. In tests using scores, floor/ceiling effects may compromise the evaluation if the tests are either too easy or to difficult. Uncontrolled testing facilities and change of test personnel may affect the test performance. Practice effects are pronounced in neuropsychological tests but have generally been ignored. The use of a suitable normative population is essential to allow correction for practice effects and variability between sessions. Missing follow-up may severely compromise valid conclusions since subjects unable or unwilling to be examined are particularly prone to suffer from POCD. In the statistical analysis of the test results, the evaluation should be based on differences between pre- and postoperative performance. Parametric statistical tests are not relevant unless the appropriate Gaussian distributions are present, perhaps after transformation of data. The definition of cognitive dysfunction should be restrictive and the criteria should be fulfilled in only a small proportion of volunteers. In the literature, these requirements often have not been fulfilled. This precludes a reasonable estimation of the incidence of POCD and the conclusions of comparative studies should be interpreted with great caution. In this review article, we present a number of recommendations for the design and execution of studies within this area. In addition, the critical reader may use these recommendations in the evaluation of the literature.

Affect↗
PubMed2000

Central nervous system dysfunction after anesthesia in the geriatric patient.

Cerebral infarction, bleeding, long-lasting hypofusion, and profound hypoxia are well-known factors behind central nervous system dysfunction after anesthesia. Other explanations may be the metabolic-endocrine stress response and psychologic factors related to changes in the environment. The clinical presentations can be obvious as in cerebral death or stroke but delirium also may be readily recognized. A more subtle and long-lasting deterioration in cognitive function is called postoperative cognitive dysfunction. This condition can only be detected with the use of neuropsychologic testing and recently, postoperative cognitive dysfunction has been detected as the most common cerebral complication after noncardiac surgery in elderly patients.

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PubMed2000

Subtle brain damage cannot be detected by measuring neuron-specific enolase and S-100beta protein after carotid endarterectomy.

OBJECTIVE: To assess whether subtle brain damage after carotid endarterectomy could be detected using serum levels of neuron-specific enolase (NSE) or S-100beta protein. DESIGN: Prospective noninterventional study. SETTING: University hospital. PARTICIPANTS: Twenty-two patients undergoing carotid endarterectomy and 16 patients undergoing repair of abdominal aortic aneurysm. INTERVENTIONS: Serum levels of NSE and S-100beta protein were measured in all patients before surgery and postoperatively at 12, 24, 36, and 48 hours. In patients undergoing carotid endarterectomy, neuropsychologic testing was performed before surgery and postoperatively at discharge from the hospital and after 3 months using a neuropsychologic test battery. MEASUREMENTS AND MAIN RESULTS: Compared with abdominal aortic surgery patients, the preoperative serum concentration of NSE was significantly higher in carotid artery surgery patients. Postoperatively, the NSE serum level decreased significantly after uncomplicated carotid artery surgery, and the level was then similar to that in the aortic surgery patients. Before operation, the S-100beta protein levels were similar in the two groups, but a significant increase was seen in aortic surgery patients postoperatively. Neuropsychologic testing after uncomplicated carotid artery surgery revealed cognitive dysfunction in 2 of 20 (10%) of the patients after 5 days and 3 of 16 (19%) of the patients after 3 months. There was no correlation between the change in cognitive function and the changes in blood levels of either NSE or S-100 protein. CONCLUSIONS: Subtle brain damage after carotid artery surgery could not be detected by measuring blood levels of NSE and S-100beta protein. The NSE level was significantly higher before carotid artery surgery and decreased postoperatively to the level observed in aortic surgery.

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PubMed2000

Cognitive dysfunction 1-2 years after non-cardiac surgery in the elderly. ISPOCD group. International Study of Post-Operative Cognitive Dysfunction.

BACKGROUND: Postoperative cognitive dysfunction (POCD) is a well-recognised complication of cardiac surgery, but evidence of POCD after general surgery has been lacking. We recently showed that POCD was present in 9.9% of elderly patients 3 months after major non-cardiac surgery. The aim of the present study was to investigate whether POCD persists for 1-2 years after operation. METHODS: A total of 336 elderly patients (median age 69 years, range 60-86) was studied after major surgery under general anesthesia. Psychometric testing was performed before surgery and at a median of 7, 98 and 532 days postoperatively using a neuropsychological test battery with 7 subtests. A control group of 47 non-hospitalised volunteers of similar age were tested with the test battery at the same intervals. RESULTS: 1-2 years after surgery, 35 out of 336 patients (10.4%, CI: 7.2-13.7%) had cognitive dysfunction. Three patients had POCD at all three postoperative test sessions (0.9%). From our definition of POCD, there is only a 1:64000 likelihood that a single subject would have POCD at all three test points by chance. Logistic regression analysis identified age, early POCD, and infection within the first three postoperative months as significant risk factors for long-term cognitive dysfunction. Five of 47 normal controls fulfilled the criteria for cognitive dysfunction 1-2 years after initial testing (10.6%, CI: 1.8-19.4%), i.e. a similar incidence of age-related cognitive impairment as among patients. CONCLUSION: POCD is a reversible condition in the majority of cases but may persist in approximately 1% of patients.

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PubMed2000

Do blood concentrations of neurone specific enolase and S-100 beta protein reflect cognitive dysfunction after abdominal surgery?ISPOCD Group.

Neurone specific enolase (NSE) and S-100 beta protein have been used as markers of brain damage. We hypothesized that blood concentrations of NSE and S-100 beta protein reflect cognitive dysfunction after abdominal surgery. We studied 65 elderly patients in whom neuropsychological testing was performed before abdominal surgery, at discharge from hospital and after 3 months. Serum concentrations of NSE and S-100 beta protein were measured before surgery and after 24, 48 and 72 h. Serum concentrations of S-100 beta protein increased significantly while NSE concentrations decreased significantly. The increase in S-100 beta protein concentration after 48 h was significantly greater in patients with delirium. No correlation was found between cognitive dysfunction and S-100 beta protein or NSE concentration. We conclude that blood concentrations of S-100 beta protein increase after abdominal surgery and may be related to postoperative delirium.

Abdomen↗
PubMed1999

Does preoperative night pulse oximetry provide a reliable baseline?

BACKGROUND: Postoperative hypoxaemia may be detected by pulse oximetry monitoring of the arterial haemoglobin saturation (SpO2). The SpO2-values obtained on the preoperative night are presumed to represent baseline values for the patients. The aim of this study was to evaluate the possible difference between nocturnal SpO2-values in the patient's home and in the hospital before operation. METHODS: We included 20 patients, 60 years or older, who underwent continuous monitoring of SpO2 on one night in the patient's home and on the night following hospitalisation before surgery. The alarms were turned off and the values were not accessible to the hospital staff. The SpO2 value was stored every 10 s. We described the general oxygen saturation level using the median of all valid values and we calculated the number of valid SpO2-values at 3 levels: above 90%, between 86 and 90%, and below 86%. RESULTS: The number of valid SpO2-values at home and in the hospital were 2186 and 2330, respectively; the median value was 96% on both occasions. Only 0.36% of the values were below 91% on the two occasions and there were no statistically significant differences between the number of SpO2-values at any of the considered levels. CONCLUSION: Arterial oxygen saturation values measured on the preoperative night in the hospital seem reliable as baseline values for elderly patients.

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PubMed1999

Do blood levels of neuron-specific enolase and S-100 protein reflect cognitive dysfunction after coronary artery bypass?

BACKGROUND: Neuron-specific enolase (NSE) and S-100 protein have been used as markers for major brain damage. Cognitive dysfunction after cardiac surgery represents subtle brain damage that is detected by neuropsychological testing. We hypothesised that blood levels of NSE and S-100 protein would increase after coronary artery bypass surgery and that the change in blood level would correlate with the change in cognitive function. METHODS: We included 35 elderly patients undergoing coronary artery bypass surgery. Neuropsychological testing was performed before surgery and postoperatively at discharge from hospital and after 3 months using a neuropsychological test battery. Serum levels of NSE and S-100 protein were measured before surgery and postoperatively after 24 h and 48 h. RESULTS: Serum level of both NSE and S-100 protein increased significantly 24 and 48 h after coronary artery bypass. Only the increase in NSE after 24 h was found to correlate with the degree of cognitive dysfunction at discharge from hospital. The increase in S-100 protein after 24 h correlated significantly with the duration of cardiopulmonary bypass. CONCLUSION: NSE seems to be a useful blood marker for early cognitive dysfunction after coronary artery bypass surgery.

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PubMed1999

Benzodiazepines and postoperative cognitive dysfunction in the elderly. ISPOCD Group. International Study of Postoperative Cognitive Dysfunction.

Postoperative cognitive dysfunction (POCD) has been attributed to long-acting sedatives. We hypothesized that diazepam and its active metabolites could be detected in blood after surgery and correlated with POCD, 1 week after surgery in elderly patients. We studied 35 patients, 60 yr or older, undergoing abdominal surgery with general anaesthesia, including diazepam. Neuropsychological tests were performed before surgery and at discharge, where blood concentrations (free fraction) of benzodiazepines were also measured. POCD was found in 17 patients (48.6%). Diazepam or desmethyldiazepam was detected in 34 patients; median postoperative blood concentrations were 0.06 and 0.10 mumol kg-1, respectively. In a multiple regression analysis considering age, duration of anaesthesia and blood concentrations of diazepam and desmethyldiazepam, only age was found to correlate with the composite z-score (F test, P < 0.01). The postoperative cognitive dysfunction we found in elderly patients after operation could not be explained by benzodiazepine concentrations detected in blood.

Abdomen↗
PubMed1998

Long-term postoperative cognitive dysfunction in the elderly ISPOCD1 study. ISPOCD investigators. International Study of Post-Operative Cognitive Dysfunction.

BACKGROUND: Long-term postoperative cognitive dysfunction may occur in the elderly. Age may be a risk factor and hypoxaemia and arterial hypotension causative factors. We investigated these hypotheses in an international multicentre study. METHODS: 1218 patients aged at least 60 years completed neuropsychological tests before and 1 week and 3 months after major non-cardiac surgery. We measured oxygen saturation by continuous pulse oximetry before surgery and throughout the day of and the first 3 nights after surgery. We recorded blood pressure every 3 min by oscillometry during the operation and every 15-30 min for the rest of that day and night. We identified postoperative cognitive dysfunction with neuropsychological tests compared with controls recruited from the UK (n=176) and the same countries as study centres (n=145). FINDINGS: Postoperative cognitive dysfunction was present in 266 (25.8% [95% CI 23.1-28.5]) of patients 1 week after surgery and in 94 (9.9% [8.1-12.0]) 3 months after surgery, compared with 3.4% and 2.8%, respectively, of UK controls (p<0.0001 and p=0.0037, respectively). Increasing age and duration of anaesthesia, little education, a second operation, postoperative infections, and respiratory complications were risk factors for early postoperative cognitive dysfunction, but only age was a risk factor for late postoperative cognitive dysfunction. Hypoxaemia and hypotension were not significant risk factors at any time. INTERPRETATION: Our findings have implications for studies of the causes of cognitive decline and, in clinical practice, for the information given to patients before surgery.

Abdomen↗
PubMed1993

Hypoxaemia after osteosynthesis of hip fractures.

Hypoxaemia may cause postoperative confusion after operations for hip fractures in elderly patients. Twenty-two consecutive patients, with a median age of 73 years, had fractures fixed with a sliding hip screw within 48 hours of admission. The incidence of hypoxaemia was investigated postoperatively using a pulse oximeter. We have demonstrated that this complication occurs frequently on the first day and severe hypoxaemia can be prevented by supplementary oxygen therapy. Our results support the hypothesis that postoperative confusion can be caused by hypoxaemia.

Aged↗
PubMed1993

Evaluation of three transportable multigas anesthetic monitors: the Bruel & Kjaer Anesthetic Gas Monitor 1304, the Datex Capnomac Ultima, and the Nellcor N-2500.

We compared the performance of three newly developed anesthetic agent (AA) monitors: the Bruel & Kjaer Anesthetic Agent Monitor 1304 (BK 1304), the Datex Capnomac Ultima (ULTIMA), and the Nellcor N-2500 (N-2500). The following were investigated: the linearity and accuracy in measuring AAs, oxygen, carbon dioxide, and nitrous oxide; the linearity and accuracy during warm-up time; the effect of increasing respiratory rate on the accuracy; the consequences of a difference between monitored and delivered AA and of delivering a mixture of AAs; and, finally, the effect of water vapor and alcohol. For all three monitors we found that the accuracy in determining the respiratory and anesthetic gases was sufficient for clinical use (the N-2500 does not measure oxygen). Because of the calibration mixture supplied with the device, however, the ULTIMA recorded values that were 10 to 12% (relative) less than the AA that was present. The BK 1304 had greater accuracy at higher respiratory rates than did the other two monitors, probably favoring its use in pediatric anesthesia. The N-2500 will detect which agent (isoflurane, enflurane, or halothane) is being used, alone or in a mixture. With the two other monitors the user must define which agent is given. In some situations a difference between this and the one actually delivered can theoretically lead to an overdose of AA, with the ULTIMA up to a 14.9 minimal alveolar concentration (MAC) overdose. No interference from alcohol or water vapor in the expired air was found.(ABSTRACT TRUNCATED AT 250 WORDS)

Anesthesia, Inhalation↗
PubMed1993

Perioperative monitoring with pulse oximetry and late postoperative cognitive dysfunction.

In a randomized, blinded clinical study, we have used objective and subjective measures to determine if perioperative monitoring with pulse oximetry--by virtue of its potential to lessen hypoxaemia--would decrease late postoperative cognitive dysfunction. We investigated 736 adult patients undergoing elective procedures (other than cardiac, neurosurgical or for cancer) under regional or general anaesthesia, allocated randomly to undergo (group I) or not to undergo (group II) pulse oximetry monitoring in the operating theatre and recovery room. Cognitive function was evaluated using the Wechsler memory scale (WMS) and continuous reaction time (RT) test the day before surgery, and on the 7th day after operation or at discharge if that occurred before postoperative day 7. A questionnaire sent 6 weeks after surgery elicited patients' subjective perceptions regarding cognitive abilities. There were no significant differences between the two groups in either the total WMS score, the score for each WMS subtests or RT test. The questionnaire revealed that 7% in group I and 11% in group II believed cognitive abilities had decreased (ns). For the 40 patients whose WMS scores were 10 points less after than before operation, a follow-up study was undertaken 3 months after surgery. At that time, the median WMS score had returned to the preoperative value. We conclude that, for these 736 patients, subjective and objective measures did not indicate less postoperative cognitive impairment after perioperative monitoring with pulse oximetry.

Adolescent↗
PubMed1993

Randomized evaluation of pulse oximetry in 20,802 patients: I. Design, demography, pulse oximetry failure rate, and overall complication rate.

BACKGROUND: Although pulse oximetry is currently in widespread use, there are few data documenting improvement in patient outcome as a result of the use of oximetry. The authors describe the study design, patient demographic findings, data validation, pulse oximetry failure rate, and overall postoperative complication rates in the first large prospective randomized multicenter clinical trial on perioperative pulse oximetry monitoring. METHODS: In five Danish hospitals, by random assignment, monitoring did or did not include pulse oximetry for patients 18 yr of age and older, whether scheduled for elective or emergency operations, or for regional or general anesthesia, except during cardiac and neurosurgical procedures. Operational definitions were established for perioperative events and postoperative complications. The data were collected preoperatively, during anesthesia, in the postanesthesia care unit, and until the day of discharge from the hospital or the seventh postoperative day. RESULTS: Of 20,802 patients, 10,312 were assigned to the oximetry group and 10,490, to the control group. In general, the demographic data, patient factors, and anesthetic agents used were distributed evenly. A slight intergroup difference was found in the distribution of age, duration of surgery, some types of surgery, and some types of anesthesia. The total failure rate of the oximetry was 2.5%, but it increased to 7.2% in patients with American Society of Anesthesiologists physical status 4 (P < 0.00001). In 14.9% of the patients, one or more events occurred in the operating room and 13.5% in the postanesthesia care unit. The overall postoperative complication rate was 9.7%. The total rates of cardiovascular and respiratory complications were 2.78% and 3.50%, respectively. Within the first seven postoperative days, 0.47% of the patients died. Anesthesia was not thought to have been solely responsible for any death, but in 7 patients (1 per 3,365), it was a possible contributory factor. CONCLUSIONS: Despite the finding of a few significant inter-group differences, the randomization was well balanced with a high validity of data. The overall postoperative complication rate was similar to that in other recent morbidity and mortality studies.

Adult↗