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PubMed2006

Regional anaesthesia versus general anaesthesia, morbidity and mortality.

The regional versus general anaesthesia debate is an age-old debate that has brought about few clear answers. Most concur that multiple factors including the patient, the surgery, the method of regional and general anaesthesia, and the quality of perioperative care, all influence surgical outcome. In this age of evidence-based medicine, the heterogenous data available need to be reconciled with the advances in perioperative care and the significant decline in complications associated with the surgical process as a whole. This review considers general issues such as the type of available evidence, and its limitations, particularly with regard to the relatively broad question of neuraxial versus general anaesthesia. It then assesses current evidence on regional versus general anaesthesia for specific scenarios such as hip fracture surgery, carotid endarterectomy, Caesarean section, ambulatory orthopaedic surgery, and postoperative cognitive dysfunction in elderly patients after non-cardiac surgery.

Anesthesia, Conduction↗

PubMed2005

Perioperative management of special populations: the geriatric patient.

Americans over age 65 represent the fastest growing segment of the United States population. As a result, the demographic landscape of America is changing. Knowledge of aged physiology is necessary to construct a risk-benefit analysis tailored for each patient to improve perioperative outcomes and lower the morbidity and mortality rates among the elderly. Benefit estimates should account for a patient's life expectancy and quality of life before and after surgery. With aging, baseline functions of almost every organ system undergo progressive decline resulting in a decreased physiologic reserve and ability to compensate for stress. Pain control, postoperative cognitive dysfunction, end-of-life issues, and realistic expectations after surgery are paramount issues throughout the perioperative period.

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PubMed2004

Controversial significance of early S100B levels after cardiac surgery.

BACKGROUND: The brain-derived protein S100B has been shown to be a useful marker of brain injury of different etiologies. Cognitive dysfunction after cardiac surgery using cardiopulmonary bypass has been reported to occur in up to 70% of patients. In this study we tried to evaluate S100B as a marker for cognitive dysfunction after coronary bypass surgery with cardiopulmonary bypass in a model where the inflow of S100B from shed mediastinal blood was corrected for. METHODS: 56 patients scheduled for coronary artery bypass grafting underwent prospective neuropsychological testing. The test scores were standardized and an impairment index was constructed. S100B was sampled at the end of surgery, hourly for the first 6 hours, and then 8, 10, 15, 24 and 48 hours after surgery. None of the patients received autotransfusion. RESULTS: In simple linear analysis, no significant relation was found between S100B levels and neuropsychological outcome. In a backwards stepwise regression analysis the three variables, S100B levels at the end of cardiopulmonary bypass, S100B levels 1 hour later and the age of the patients were found to explain part of the neuropsychological deterioration (r = 0.49, p < 0.005). CONCLUSIONS: In this study we found that S100B levels 1 hour after surgery seem to be the most informative. Our attempt to control the increased levels of S100B caused by contamination from the surgical field did not yield different results. We conclude that the clinical value of S100B as a predictive measurement of postoperative cognitive dysfunction after cardiac surgery is limited.

Age Factors↗

PubMed1993

A prospective randomised study of local versus general anaesthesia for cataract surgery.

One hundred and sixty-nine patients (aged 65-98 years) were randomised to receive either local or general anaesthesia for cataract surgery. Cognitive function was assessed using a battery of psychometric tests performed pre-operatively, and at 24 h, 2 weeks and 3 months postoperatively. Oxygen saturation, blood pressure and heart rate were monitored and the results recorded throughout the anaesthetic and immediate recovery period. In the general anaesthetic group, 19% of patients experienced at least one episode of oxygen desaturation during the procedure compared with none in the local anaesthetic group. Pulse rate and blood pressure were stable in the local anaesthetic group compared with the general anaesthetic group where marked fluctuations were noted; 61% of patients in the general anaesthetic group experienced falls in systolic blood pressure greater than 30% of the pre-induction value. No evidence of long-term postoperative cognitive dysfunction was detected and there was no significant difference between the performances of the two groups.

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PubMed2003

Failure of intraoperative jugular bulb S-100B and neuron-specific enolase sampling to predict cognitive injury after carotid endarterectomy.

OBJECTIVE: Cognitive decline occurs in 25% of patients after carotid endarterectomy (CEA). Elevated serum concentrations of S-100B and neuron-specific enolase (NSE) occur after stroke, and serum S-100B levels at 24 hours are associated with clinical outcome after both stroke and CEA. We hypothesized that we could detect acute elevations in serum levels of these markers obtained intraoperatively from the jugular bulb (JB) and that these elevations would predict cognitive dysfunction postoperatively as measured by neuropsychometric test performance. METHODS: Forty-three patients scheduled for elective CEA were assessed with a battery of neuropsychometric tests before and 1 day after surgery. Before the carotid artery was clamped, a 6-French Fogarty catheter was inserted into the facial vein and threaded 6 cm rostrally into the JB. Serum samples were withdrawn from this catheter and simultaneously from a radial arterial catheter (A-line) at three time points: before clamping, 15 minutes into clamping, and after unclamping the carotid artery. Concentrations between groups were compared by analysis of variance and paired t tests. RESULTS: Total deficit scores were significantly worse in 13 (30%) of the 43 patients 1 day after surgery. There was a trend toward elevations in JB concentrations of S-100B relative to A-line levels 15 minutes after cross-clamping (11% elevation, P = 0.079, paired t test). In addition, 15 minutes after clamping of the carotid artery, levels of S-100B from the JB were significantly elevated compared with levels at baseline (P = 0.040, one-way analysis of variance). No significant changes were found between any time point in levels of S-100B from the A-line blood or of NSE from either the JB or the A-line. Subtle cognitive decline after CEA was not correlated with intraoperative levels of S-100B or NSE, but there was a weak, statistically nonsignificant, association between a rise in 15-minute S-100B levels and cognitive injury that was not seen with JB samples. CONCLUSION: Although intraoperative levels of S-100B and NSE from the JB failed to predict cognitive injury, carotid cross-clamping, independent of injury, seems to be associated with early elevations in S-100B.

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PubMed2001

Medical utility of apoe allele determination in assessing the need for antioxidant therapy.

The APOE varepsilon4 allele is associated with a variety of conditions such as Alzheimer's disease, coronary artery disease, stroke and postoperative cognitive dysfunction. The common pathophysiological feature that appears to explain these positive clinical associations with APOE varepsilon4 allele may relate to the decreased endogenous anti-oxidant capability of an individual. A significant body of existing clinical data supports the assumption that diseases associated with the varepsilon4 allele can be alleviated by antioxidant therapies, such as vitamin E. Therefore, we hypothesize that determination of an individual's APOE allele status has medical utility as an efficient method to identify patient subgroups susceptible to oxidative damage. We suggest that prospective studies are needed to determine if individuals at high risk for diseases characterized by oxidative damage and/or who have an APOE varepsilon4 allele might benefit significantly from available antioxidant intervention at a relatively early and asymptomatic age.

Alleles↗

PubMed2005

[Pharmacological peculiarities and problems with older patients].

Because of demographic developments, the fraction of the German population over 65 years of age in the year 2025 will have risen to 20% and will continue to rise so that in 2030 this number will have doubled compared to today's numbers. This has a huge impact on the requirements for anaesthesiologic procedures. In addition to the frequent multi-morbidity in this age group, physiologic changes also occur in the elderly which have to be taken into consideration during the entire perioperative management of these patients. Renal, cardiovascular and hepatic function are impaired in many elderly patients. A major concern in addition to cardiovascular and operative complications is the postoperative cognitive dysfunction (POCD), not only because of its implications for the patient but also because of economical consequences. Regional anaesthesia has some benefits when compared to general anaesthesia as it leads to a reduction in thromboembolic and respiratory complications.

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PubMed2004

Jugular venous oxygen saturation during mild hypothermic versus normothermic cardiopulmonary bypass in elderly patients.

PURPOSE: Age is known to be a major risk factor for adverse postoperative cognitive dysfunction after cardiac surgery. We conducted this study to determine if jugular venous oxygen saturation (SjvO(2)) differed during mild hypothermic (32 degrees C) and normothermic cardiopulmonary bypass (CPB) in elderly patients. METHODS: Sixty patients aged over 70 years who underwent elective coronary artery bypass grafting were randomly divided into two groups. Group 1 ( n = 30) underwent normothermic CPB (>35 degrees C) and group 2 ( n = 30) underwent mild hypothermic CPB (32 degrees C). For the continuous monitoring of SjvO(2), a fiberoptic oximetry oxygen saturation catheter was inserted into the right jugular bulb after the induction of anesthesia. Hemodynamic parameters, and arterial and jugular venous blood gases were measured at seven time points. RESULTS: The SjvO(2) in the normothermic group was lower at the onset of CPB and 20 min after the onset, than from the time of induction of anesthesia until the start of surgery (period 1), the respective SjvO(2) values being 50.3% +/- 1.0%, 50.1% +/- 1.6%, and 59.5% +/- 1.9% ( P < 0.05). However, in the mild hypothermic group there were no changes in the SjvO(2) value throughout the study. The cerebral desaturation time (when the SjvO(2) value was <50%) and the ratio of the cerebral desaturation time to the total CPB time in the normothermic group differed significantly from those in the hypothermic group, being 19 +/- 11 min and 17% +/- 10%, and 9 +/- 3 min and 8% +/- 4%, respectively ( P < 0.05). CONCLUSIONS: The SjvO(2) value was better during mild hypothermic CPB than during normothermic CPB in elderly patients.

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PubMed2006

A retrospective study of changes in cerebral oxygenation using a cerebral oximeter in older patients undergoing prolonged major abdominal surgery.

BACKGROUND AND OBJECTIVE: The objective was to carry out a retrospective study of changes in regional cerebral oxygen saturation (rSO2) using the Somanetics Invos Cerebral Oximeter (SICO) in older patients undergoing prolonged major abdominal surgery. Since evidence is accumulating that detection and correction of falls in rSO2 may be associated with a reduced incidence of postoperative cognitive dysfunction, the study assessed the incidence and possible predisposing factors for significant falls in rSO2 and strategies for correction. METHODS: Data from 46 consecutive patients aged 55 yr or above undergoing major abdominal surgery were collected and studied. A SICO electrode was placed over the right forehead prior to commencement of anaesthesia and values of rSO2 were recorded automatically on a floppy disk at 20 s intervals throughout the procedure and until transfer of the patient to the postanaesthesia care unit. Anaesthesia and physiological data were routinely collected by the author on an anaesthetic record computer and transferred to an Excel spreadsheet for analysis. RESULTS: Average duration of the surgery exceeded 7 h. Average blood loss was 1363 mL (interquartile range 500-2000). In 11 of the 46 patients the rSO2 drop exceeded 20%, and in six, there was a significant temporal association of rSO2 drop with ongoing major haemorrhage. In 23 of the 46 patients, a maximum drop in rSO2 occurred, which was about 15% or more. Fall in rSO2 in the 46 patients significantly correlated with blood loss (P < 0.05) and percentage fall in haemoglobin (Hb) (P = 0.01) but not with lowest Hb. Despite maintenance of conventional haemodynamic parameters such as systolic blood pressure (BP) in most patients, the fall in rSO2 seemed only reversible by blood transfusion. In five of the six patients who experienced the greatest decline in rSO2 during haemorrhage, there was no correlation between fall in rSO2 and systolic BP. CONCLUSIONS: This retrospective study confirms that a significant reduction in rSO2 is a common accompaniment to prolonged major abdominal surgery in elderly patients, especially if associated with blood loss, and is correctable by blood transfusion. In most cases, these changes would have gone unnoticed with conventional monitoring.

Abdomen↗

PubMed2006

Alzheimer's disease and anaesthesia: implications for the central cholinergic system.

Alzheimer's disease (AD) is associated with a loss of cholinergic neurons resulting in profound memory disturbances and irreversible impairment of cognitive function. The central cholinergic system is involved in the action of general anaesthetic agents. Anaesthetic modulation of cholinergic transmission has profound effects on brain function via a cascade of synaptic and postsynaptic events by binding both nicotinic and muscarinic receptors. During general anaesthesia, decrease in acetylcholine release and depression of cholinergic transmission facilitates the desirable effects of general anaesthetics, such as loss of consciousness, pain, voluntary movements and memory. From this point of view, patients with AD, characterized by a compromised neuronal transmission, represent particular cases in which the choice of anaesthesia drugs may have a negative effect on the postoperative outcome. A future challenge may be the identification of brain targets of general anaesthetics which do not expose patients to postoperative cognitive dysfunction, nor interfere with prognosis of brain degenerative disease.

Alzheimer Disease↗

PubMed2006

The common inhalation anesthetic isoflurane induces apoptosis and increases amyloid beta protein levels.

BACKGROUND: The common inhalation anesthetic isoflurane has previously been reported to enhance the aggregation and cytotoxicity of the Alzheimer disease-associated amyloid beta protein (Abeta), the principal peptide component of cerebral beta-amyloid deposits. METHODS: H4 human neuroglioma cells stably transfected to express human full-length wild-type amyloid precursor protein (APP) were exposed to 2% isoflurane for 6 h. The cells and conditioned media were harvested at the end of the treatment. Caspase-3 activation, processing of APP, cell viability, and Abeta levels were measured with quantitative Western blotting, cell viability kit, and enzyme-linked immunosorbent assay sandwich. The control condition consisted of 5% CO2 plus 21% O2 and balanced nitrogen, which did not affect caspase-3 activation, cell viability, APP processing, or Abeta generation. RESULTS: Two percent isoflurane caused apoptosis, altered processing of APP, and increased production of Abeta in H4 human neuroglioma cell lines. Isoflurane-induced apoptosis was independent of changes in Abeta and APP holoprotein levels. However, isoflurane-induced apoptosis was potentiated by increased levels of APP C-terminal fragments. CONCLUSION: A clinically relevant concentration of isoflurane induces apoptosis, alters APP processing, and increases Abeta production in a human neuroglioma cell line. Because altered processing of APP leading to accumulation of Abeta is a key event in the pathogenesis of Alzheimer disease, these findings may have implications for use of this anesthetic agent in individuals with excessive levels of cerebral Abeta and elderly patients at increased risk for postoperative cognitive dysfunction.

Amyloid beta-Peptides↗

PubMed2002

The elderly outpatient: current anesthetic implications.

PURPOSE OF REVIEW: The present overview describes recent contributions to the literature with regard to choice of anesthetic techniques, approaches to anesthetic management of elderly outpatients undergoing arthroscopy and other procedures, reconsideration of the problem of postoperative delirium in the elderly patient, and a general summary of perioperative management and assessment of anesthetic risk in older adults. RECENT FINDINGS: Major advances in monitoring technology, pharmacology, and comprehensive preoperative assessment have reduced the probability of major adverse outcomes for geriatric surgical patients to low levels. Therefore, it has become difficult to demonstrate clear-cut superiority for any specific anesthetic agent or approach. Nevertheless, the need for prompt and complete recovery of consciousness and rapid discharge after surgery presents additional challenges for the anesthesiologist who is caring for elderly outpatients with regard to prompt recovery of cognitive function and suppression of nausea and vomiting. SUMMARY: The efficiency and speed with which outpatient surgery and anesthetic recovery can be conducted in older adults continue to improve. Monitors of depth of anesthesia, ultra-short-acting agents, and combined techniques have minimized minor complications such as nausea and vomiting, and have improved the speed with which these patients recover from anesthesia. A small proportion of elderly surgical outpatients remain at risk for residual postoperative cognitive dysfunction.

Journal Article↗

PubMed1995

Jugular bulb saturation and mixed venous saturation during cardiopulmonary bypass.

Systemic venous oxygen saturation is clinically used as an indicator of a satisfactory oxygen supply demand balance on cardiopulmonary bypass (CBP). Cerebral desaturation has been associated with postoperative cognitive dysfunction and has an incidence of 17% to 23% on bypass. We tested the hypothesis that systemic venous saturation did not correlate with jugular bulb venous saturation. Blood was drawn from the radial artery, jugular bulb catheter, and venous return line for determination of pH, oxygen tension and saturation, and carbon dioxide tension at four times during bypass: warm 1 (following initiation of CPB); cold 1 (stable hypothermia); cold 2 (hypothermia prior to rewarm); and warm 2 (nasopharyngeal temperature 36 degrees C to 37 degrees C). Correlations of jugular bulb and systemic venous saturation at cold 1 were r = 0.29, r2 = 0.08, and p = 0.0005, and at warm 2 were r = 0.22, r2 = 0.05, and p = 0.007. We conclude that systemic saturation is a poor indicator of cerebral saturation. The poor association of jugular and systemic pump venous saturations underscores our inability to evaluate adequacy of cerebral perfusion. Jugular saturation is lower than pump venous return blood, especially at times of lower oxygen delivery, thus either continuous invasive or noninvasive evaluation of cerebral oxygenation is required to evaluate the adequacy of cerebral perfusion.

Aged↗

PubMed2006

Neurologic complications in noncardiac surgery.

In this article, the incidence of nervous system injuries associated with noncardiac surgery is reviewed briefly. In general, these can be divided into injuries that are clinically apparent (eg, stroke or peripheral nerve damage), which may generally be detectable on clinical examination, and more subtle forms of brain injury (eg, personality changes and postoperative cognitive dysfunction), injuries that are primarily detected by neuropsychological testing.

Anesthesia↗

PubMed2003

Dynamic characteristics of cerebral lipid microemboli: videomicroscopy studies in rats.

UNLABELLED: Cerebral lipid microemboli (LME) may cause postoperative cognitive dysfunction after orthopedic and cardiovascular surgery. In 13 anesthetized rats, we created a cranial window to study LME using orthogonal polarization spectral imaging videomicroscopy. All rats received 0.2 mL of human marrow fat, obtained from surgical waste during arthroplasty, injected into the superior vena cava. Five rats died within seconds of this injection, despite resuscitation efforts. Seven minutes later, we injected an additional 0.1 mL in 6 of the 8 surviving rats. We observed the videomicroscopy for 1 h in all 8 rats. Arterial blood pressure (BP) was continuously measured. No LME were observed in the first 7 min (n = 8); however, within seconds of the additional 0.1 mL injection, mean BP decreased from 79 +/- 31 mm Hg to 28 +/- 12 mm Hg (n = 6; P < 0.02). Epinephrine and crystalloid infusion increased BP to 161 +/- 9 mm Hg and 20-100 LME were seen within 5 min. LME changed shape and fragmentation, erosion, and streaming patterns were noted, with transient arteriolar occlusion (10-220 s). Increasing BP resulted in reperfusion of occluded arterioles. No venous LME were noted. Postmortem, brain and lung LME were found with no patent foramen ovale. This model may be useful in studying cerebral LME. IMPLICATIONS: Marrow lipid may pass through the lung during orthopedic surgery, creating cerebral lipid microemboli (LME). We created a cranial window in rats to study LME flowing through pial-cortical vessels. Cerebral LME appeared after resuscitation from hypotension and vessel occlusion was transient. This model may be useful in studying cerebral LME.

Animals↗

PubMed2005

Plasma concentrations of nitric oxide products and cognitive dysfunction following coronary artery bypass surgery.

BACKGROUND AND OBJECTIVE: Prospective longitudinal studies now indicate that cognitive dysfunction following coronary artery bypass surgery (CABG) is both common and persistent. This dysfunction is due in part to the inflammatory response and cerebral ischaemia-reperfusion, with nitric oxide (NO) as an important mediator of both. We hypothesized that a clinically significant association exists between plasma concentrations of nitrate/nitrite (NO3-/NO2-) and cognitive dysfunction after CABG. METHODS: Cognitive assessment was performed on 36 adult patients the day before CABG, on the fourth postoperative day and 3 months postoperatively. Patient spouses (n = 10) were also studied. RESULTS: A new cognitive deficit was present in 22/36 (62%) 4 days postoperatively and in 16/35 (49%) of patients, 3 months postoperatively. Patients who had cognitive dysfunction 3 months postoperatively were more likely to have cognitive dysfunction and increased plasma NO3-/NO2- concentrations compared to the non-deficit group preoperatively (22.6 (9.2) vs. 27.6 (8.4)) (P = 0.002). Plasma NOx (NO3- plus NO2-) concentrations were greater in patients with cognitive dysfunction 3 months postoperatively, 2 h (24.2 (6.3) vs. 19.1 (5.2)) (P = 0.002), and 12 h postoperatively (24.8 (7.6) vs. 18.8 (5.6)) (P = 0.001). There was, however, a time course similarity in NOx elevations for both deficit and non-deficit groups. CONCLUSIONS: Perioperative plasma NOx concentrations do not serve as an effective biomarker of cognitive deficit after CABG.

Adult↗

PubMed2002

Postoperative hyperthermia is associated with cognitive dysfunction after coronary artery bypass graft surgery.

BACKGROUND AND PURPOSE: Temperature is a well-known modulator of experimental cerebral injury. We hypothesized that hyperthermia would be associated with a worsened cognitive outcome after coronary artery bypass graft surgery (CABG). METHODS: Three hundred consenting patients undergoing cardiopulmonary bypass for CABG had hourly postoperative temperatures recorded. The degree of postoperative hyperthermia was determined by using the maximum temperature within the first 24 hours as well as by calculating the area under the curve for temperatures >37 degrees C. Patients underwent a battery of cognitive testing both before surgery and 6 weeks after surgery. By use of factor analysis, 4 cognitive domains (scores) were identified, and the mean of the 4 scores was used to calculate the cognitive index (CI). Cognitive change was calculated as the 6-week CI minus the baseline CI. Multivariable linear regression (controlling for age, baseline cognitive function, and temperature during cardiopulmonary bypass) was used to compare postoperative hyperthermia with the postoperative cognitive change. RESULTS: The maximum temperature within the first 24 hours after CABG ranged from 37.2 degrees C to 39.3 degrees C. There was no relationship between area under the curve for temperatures >37 degrees C and cognitive dysfunction (P=0.45). However, the maximum postoperative temperature was associated with a greater amount of cognitive dysfunction at 6 weeks (P=0.05). CONCLUSIONS: This is the first report relating postoperative hyperthermia to cognitive dysfunction after cardiac surgery. Whether the hyperthermia caused the worsened outcome or whether processes that resulted in the worsened cognitive outcome also produced hyperthermia requires further investigation. In addition, interventions to avoid postoperative hyperthermia may be warranted to improve cerebral outcome after cardiac surgery.

Area Under Curve↗

PubMed2001

[Postoperative cognitive disorders in the elderly].

TWO DISTINCT CATEGORIES: Postoperative cognitive disorders include delirium and long-term cognitive dysfunction. DELERIUM: Delirium is an acute state occurring early during the postoperative period. It may be considered as an acute cerebral insufficiency which may be consecutive both to the negative effects of aging and chronic illness on cognitive function, and to the cerebral impact of operative stress. In addition, precipitating postoperative medical factors may facilitate cerebral failure. Only a few studies have been devoted to prevention programs aimed at reducing the risk of postoperative delirium. Nevertheless, we can hypothesize that a preoperative gerontology assessment would be effective in determining risk factors of delirium in old patients and thus enable proposing individual postoperative management. LONG-TERM COGNITIVE DYSFUNCTION: The definition of this clinical picture is less precise than delirium. Long-term cognitive dysfunction corresponds to a loss of cognitive performance in the weeks and months after anesthesia. The IPOCD1 study conducted in a large cohort of elderly patients has shown that postoperative cognitive dysfunction was present in 25.8% of patients 1 week after surgery and in 9.9% 3 months after surgery. One to two years after surgery, cognitive dysfunction was observed in 10.4% of patients compared with 10.6% in a control population of non-operated patients. We would suggest that in many cases, postoperative cognitive dysfunction may result from preoperative dementia unmasked by surgery.

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