Early Inhalational anaesthetic agents were a unique group of drugs that come primarily from a broad group of ether-based solvents. Mixing sulphuric acid with alcohol made the original ether anaesthetic, whilst a combination of acetone and household bleach is used to make chloroform (no longer used due to toxicity). Current anaesthetic agents derive from manipulations of these simple molecules but are selected for properties such as their ease of evaporation at room temperature, their lack of flammability and their inability to damage organs either directly or via any metabolized breakdown products produced by the liver (non-toxicity).
The probable mechanism of action of anaesthetic agents is an effect on protein structures, located on cell membranes that act as gates, permitting or inhibiting the passage of ions (e.g. sodium, potassium, calcium and magnesium) through nerve cell membranes. The passage of ions through cell membranes is necessary for the normal electrical conduction function of nerve cells. Inhibiting electrical conduction prevents nerves from communicating with each other and thus in the absence of communication information can neither enter the consciousness nor physical responses be initiated. Bizarrely the narcotic effect of anaesthetic agents may be reversed by the application of increased barometric pressure.
In addition to anaesthesia (lack of sense), patients require powerful but short acting painkillers (analgesia), usually narcotics such as fentanyl , remifentanil, alfentanil or long acting opiates such as morphine or dihydromorphine. Finally, in order to help the surgeon see the operation site, patient’s movements are prevented by the use of muscle relaxants.
These latter drugs were originally derived from climbing plants found in the Amazon basin. They are known and used locally as arrow poisons. , Modern relaxants are usually based on a steroid or similar large molecule compound with the active muscle relaxant component “bolted on”.
The effects of anaesthetic agents are not confined to the central nervous system and these agents may influence other systems including the immune system. For example sedatives, injectable anesthetics, opioids, and local anesthetics have immunomodulatory effects that may have positive or negative consequences on disease processes such as endotoxemia, generalized sepsis, tumor growth and metastasis, and ischemia-reperfusion injury.
Some of these unexpected actions may be responsible for changes in certain individuals that may give rise to postoperative neurobehavioural disturbances.
Some patients presenting for elective aesthetic procedures may suffer from some minor form of abnormal functional dysmorphism. Body dysmorphic disorder (BDD, also known as body dysmorphia, dysmorphic syndrome; originally dysmorphophobia) is a chronic mental illness, a somatoform disorder, wherein the afflicted individual is concerned with body image, manifested as excessive concern about and preoccupation with a perceived defect of their physical appearance. We probably all have these concerns to a greater or lesser extent and it may be more prevalent amongst different socio-economic groups than others.
Having a concern about appearance, justified or not, and allowing yourself to take significant risks to deal with these concerns does distinguish some individuals from others. Those who subject themselves to surgery to correct an objective abnormality (painful, worn out knee) may be considered as a separate group to those who take a similar risk for a subjective abnormality. There is some evidence to support this in the references that follow. Plastic surgeons are more sensitive to this issue when the patient is a man as men come back and shoot you if they are not satisfied!. The ethics of this relationship between an aesthetic surgeon and his patients is a real problem for some clinicians .
Known culprits Interim list from Pubmed:
A wide range of behavioral symptoms may occur following surgery, including depression, hallucinations, true psychosis, mania, and impulsivity. Psychoses, including those that occur postoperatively, are among the most frequent indications for hospitalization in the United States and are associated with a substantially increased rate of morbidity. The exact cause of postoperative psychosis has not been identified. A 59-year-old woman who developed acute psychosis after cholecystectomy is described here. The patient was brought to Mount Vernon Hospital in New York because she exhibited acute disruptive behavior following endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy performed on 2 consecutive days. The patient was psychotic and was unable to be managed; she was disorganized, confused, and perplexed. Findings of computed tomography of the head, electroencephalography, and chemical and hematologic tests were normal. The patient was treated with lorazepam 1 mg every 6 h, olanzapine 5 mg at bedtime, and clonazepam 1 mg at bedtime. She experienced a mixture of auditory and visual hallucinations with a paranoid perspective and was then treated with haloperidol 5 mg, diphenhydramine chloride 25 mg, and divalproex sodium 500 mg. After 1 wk, the patient was described as acutely psychotic; antipsychotic medication dosages were readjusted and the patient’s condition stabilized. The association between surgical procedures and psychosis is thoroughly reviewed here. Awareness, ability to diagnose, and an understanding of the cause of psychotic symptoms that emerge following surgery must be established if physicians are to provide better care and more effective treatment.
Abdullah MS¹, Al-Waili NS, Baban NK, Butler GJ, Sultan L. Postsurgical psychosis: case report and review of literature. Adv Ther. 2006 Mar-Apr;23(2):325-31. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16751164
Browne JA, Sandberg BF, D’Apuzzo MR, Novicoff WM. Depression is associated with early postoperative outcomes following total joint arthroplasty: a nationwide database study. J Arthroplasty. 2014 Mar;29(3):481-3. doi: 10.1016/j.arth.2013.08.025. Epub 2013 Oct 3. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24090662
Koteswara CM, Patnaik P. Peri-operative dexamethasone therapy and post-operative psychosis in patients undergoing major oral and maxillofacial surgery. J Anaesthesiol Clin Pharmacol 2014 [cited 2014 Jul 30];30;94-6. Available from: http://www.joacp.org/article.asp?issn=0970-9185;year=2014;volume=30;issue=1;spage=94;epage=96;aulast=Koteswara
Jevtovic-Todorovic V1, Absalom AR, Blomgren K, Brambrink A, Crosby G, Culley DJ et al. Anaesthetic neurotoxicity and neuroplasticity: an expert group report and statement based on the BJA Salzburg Seminar. Br. J. Anaesth. (2013) 111 (2): 143-151. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23722106
A. E. Hudson1 and H. C. Hemmings Jr. Are anaesthetics toxic to the brain? Br J Anaesth. Jul 2011; 107(1): 30-37. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3159425/
Radtke FM1, Franck M, Lendner J, Krüger S, Wernecke KD, Spies CD. Monitoring depth of anaesthesia in a randomized trial decreases the rate of postoperative delirium but not postoperative cognitive dysfunction. Br. J. Anaesth. (2013) 110 (suppl 1): i98-i105. Available from:
L. Tang, R. Kazan, R. Taddei, C. Zaouter, S. Cyr, and T. M. Hemmerling. Reduced cerebral oxygen saturation during thoracic surgery predicts early postoperative cognitive dysfunction. Br. J. Anaesth. (2012) 108 (4): 623-629. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22311364
Radtke FM1, Franck M, Hagemann L, Seeling M, Wernecke KD, Spies CD. Risk factors for inadequate emergence after anesthesia: emergence delirium and hypoactive emergence. Minerva Anestesiol. 2010 Jun;76(6):394-403. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20473252
Damuleviciene G1, Lesauskaite V, Macijauskiene J. Postoperative cognitive dysfunction of older surgical patients. Medicina (Kaunas).2010; 46(3):169-75. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20516755
Impaired mobility, ASA status and administration of tramadol are risk factors for postoperative delirium in patients aged 75 years or more after major abdominal surgery
The aim of this prospective study was to determine incidence, duration, and risk factors for postoperative delirium (PD) in elderly patients undergoing major abdominal surgery.
Brouquet A1, Cudennec T, Benoist S, Moulias S, Beauchet A, Penna C, et al. Impaired mobility, ASA status and administration of tramadol are risk factors for postoperative delirium in patients aged 75 years or more after major abdominal surgery. Ann Surg. 2010 Apr;251(4):759-65. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20224380
Robinson TN1, Raeburn CD, Tran ZV, Angles EM, Brenner LA, Moss M. Postoperative delirium in the elderly: risk factors and outcomes. Ann Surg. 2009 Jan; 249(1):173-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19106695
Katznelson R¹, Djaiani GN, Borger MA, Friedman Z, Abbey SE, Fedorko L et al. Preoperative use of statins is associated with reduced early delirium rates after cardiac surgery.
Anesthesiology. 2009 Jan;110(1):67-73. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19104172
Copyright 2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.
Ozyurtkan MO1, Yildizeli B, Kuşçu K, Bekiroğlu N, Bostanci K, Batirel HF, et al. Postoperative psychiatric disorders in general thoracic surgery: incidence, risk factors and outcomes. Eur J Cardiothorac Surg. 2010 May;37(5):1152-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20117012
Katznelson R¹, Djaiani GN, Borger MA, Friedman Z, Abbey SE, Fedorko L, Karski J, et al. Preoperative use of statins is associated with reduced early delirium rates after cardiac surgery. Anesthesiology. 2009 Jan;110(1):67-73. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19104172
Bickel H¹, Gradinger R, Kochs E, Förstl H. High risk of cognitive and functional decline after postoperative delirium. A three-year prospective study. Dement Geriatr Cogn Disord. 2008;26(1):26-31. Available from:
Balas MC¹, Deutschman CS, Sullivan-Marx EM, Strumpf NE, Alston RP, Richmond TS. Delirium in older patients in surgical intensive care units. J Nurs Scholarsh. 2007;39(2):147-54. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17535315
Johnson, Tim F.R.C.A.; Monk, Terri M.D.; Rasmussen, Lars S. M.D.; Abildstrom, Hanne M.D.§.; Houx, Peter Ph.D.; Korttila, Kari M.D.; et al. Postoperative Cognitive Dysfunction in Middle-aged Patients. Anesthesiology: June 2002 – Volume 96 – Issue 6 – pp 1351-1357. Available from: http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1944002
Leung JM¹, Sands LP, Vaurio LE, Wang Y. Nitrous oxide does not change the incidence of postoperative delirium or cognitive decline in elderly surgical patients. Br J Anaesth. 2006 Jun;96(6):754-60. Epub 2006 May 2. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16670110
Bitsch MS¹, Foss NB, Kristensen BB, Kehlet H. Acute cognitive dysfunction after hip fracture: frequency and risk factors in an optimized, multimodal, rehabilitation program. Acta Anaesthesiol Scand. 2006 Apr; 50(4):428-36. Available from:
Bekker AY, Weeks EJ. Cognitive function after anaesthesia in the elderly. Best Pract Res Clin Anaesthesiol. 2003 Jun;17(2):259-72. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12817919
Rasmussen LS¹, Johnson T, Kuipers HM, Kristensen D, Siersma VD, Vila P, et al. Does anaesthesia cause postoperative cognitive dysfunction? A randomised study of regional versus general anaesthesia in 438 elderly patients. Acta Anaesthesiol Scand. 2003 Mar;47(3):260-6. Available from:
Linstedt U¹, Meyer O, Berkau A, Kropp P, Zenz M, Maier C. Does intraoperative hyperventilation improve neurological functions of older patients after general anaesthesia? Anaesthesist. 2002 Jun; 51(6):457-62. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12391531
Johnson T, Monk T, Rasmussen LS, Abildstrom H, Houx P, Korttila K, et al. Postoperative cognitive dysfunction in middle-aged patients. Anesthesiology. 2002 Jun;96(6):1351-7. Available from:
Dijkstra JB¹, Jolles J. Postoperative cognitive dysfunction versus complaints: a discrepancy in long-term findings. Neuropsychol Rev. 2002 Mar;12(1):1-14. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12090716
Rasmussen LS¹, Larsen K, Houx P, Skovgaard LT, Hanning CD, Moller JT. The assessment of postoperative cognitive function. Acta Anaesthesiol Scand. 2001 Mar;45(3):275-89. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11207462
Ancelin ML¹, De Roquefeuil G, Ritchie K. Anesthesia and postoperative cognitive dysfunction in the elderly: a review of clinical and epidemiological observations. Rev Epidemiol Sante Publique. 2000 Oct;48(5):459-72. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11084526
Rasmussen LS¹, Steentoft A, Rasmussen H, Kristensen PA, Moller JT. Benzodiazepines and postoperative cognitive dysfunction in the elderly. ISPOCD Group. International Study of Postoperative Cognitive Dysfunction. Br J Anaesth. 1999 Oct;83(4):585-9. Available from:
Olympio MA. Postanesthetic delirium: historical perspectives. J Clin Anesth. 1991 Jan-Feb;3(1):60-3. Available from: http://www.ncbi.nlm.nih.gov/pubmed/2007046
Nadelson T. The psychiatrist in the surgical intensive care unit. I. Postoperative delirium. Arch Surg. 1976 Feb; 111(2):113-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/1252115
Sveinsson IS. Postoperative psychosis after heart surgery. J Thorac Cardiovasc Surg. 1975 Oct;70(4):717-26. Available from: http://www.ncbi.nlm.nih.gov/pubmed/1177486
Cognitive disorders are usually not prominent in the early postoperative period and in many cases are discovered after hospital discharge because of difficulties in performing everyday activities at home or at work. The etiology of postoperative cognitive impairment is unclear. Older age, previous presence of cognitive dysfunction, severity of disease, and polypharmacy with more than four drugs are some of the risk factors identified. Delirium is a multifactorial disorder. It is an acute confusional state characterized by alteration of consciousness with reduced ability to focus, sustain, or shift attention. It is considered as the most common form of mental distress in ICU patients.
Nearly 30% of all hospitalized patients pass through delirium phase during their hospital stay. Delirium can last for several days to several weeks. Almost always it ends with complete withdrawal of psychopathological symptoms. Sometimes it can evolve into a chronic brain syndrome (dementia). The causes are often multifactorial and require a number of measures to ease the symptoms. Delirious patient is at risk of complications of immobility and confusion, leading to a high prevalence of irreversible functional decline. An interdisciplinary approach to delirium should also include family or other caregivers. In the diagnosis of delirium, several tests are used to complement clinical assessment.
Among the most commonly used are the Confusion Assessment Method (CAM-ICU) and Clinical Dementia Rating (CDR) test. Depression is a common disorder among patients treated at ICU and occurs due to the impact of the disease on the body and the quality of life, independence, employment and other aspects of life. Depression can interfere with the speed of recovery, affects the postoperative quality of life, and in a certain number of patients may lead to suicidal thoughts and intentions. Phobias and generalized anxiety are the most common anxiety disorders. Generalized anxiety disorder is characterized by strong, excessive anxiety and worry about everyday life events. PTSD is delayed and/or protracted response to a stressful event or situation, extremely threatening or catastrophic nature, which is outside the common experience of people and would hit or traumatize almost all people. Treatment of delirium and other disorders is causal.
The causes of psychosis are often multifactorial and require a number of measures to ease symptoms. The primary objective of prevention is appropriate therapy and correction of potential imbalances possibly underlying disturbances, stabilization of vital functions as well as early return to daily activities. Doctors and other medical staff must be aware of the importance and consequences of behavioural and emotional disorders in critically ill patients. Additional research is needed to discover the ways to prevent and/ or reduce the frequency and severity of the consequences and treatment of cognitive and emotional disorders.
Tonković D1, Adam VN, Kovacević M, Bogović TZ, Drvar Z, Baronica R, 2012 Perioperative disorders of mental functions. Acta Med Croatica. 2012 Mar;66(1):73-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23088091
Thapa R¹, Biswas B. Childhood mefloquine-induced mania and psychosis: a case report. J Child Neurol. 2009 Aug;24(8):1008-9. doi: 10.1177/0883073809332700. Epub 2009 Mar 18. Available from:
Bansal V¹, Kumar S, Mowar A, Sharma S, Gupta S. Postoperative psychosis in an adolescent subsequent to oral surgical outpatient procedure. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009 Apr; 107(4):458-61. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19327637
Peterson E¹, Stoebner A, Weatherill J, Kutscher E. Case of acute psychosis from herbal supplements. S D Med. 2008 May; 61(5):173-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18630028
Weis S, Karagülle D, Kornhuber J, Bayerlein K. Cotrimoxazole-induced psychosis: a case report and review of literature. Pharmacopsychiatry. 2006 Nov;39(6):236-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17124650
Foster R¹, Olajide D, Everall IP. Antiretroviral therapy-induced psychosis: case report and brief review of the literature. HIV Med. 2003 Apr;4(2):139-44. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12702135
Przybylo HJ¹, Przybylo JH, Todd Davis A, Coté CJ. Acute psychosis after anesthesia: the case for antibiomania. Paediatr Anaesth. 2005 Aug;15(8):703-5. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16029408
Ishihara H¹, Kudo H, Murakawa T, Kudo A, Takahashi S, Matsuki A. Uneventful total intravenous anaesthesia with ketamine for schizophrenic surgical patients. Eur J Anaesthesiol. 1997 Jan;14(1):47-51. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9049558
Ferrara SD¹, Snenghi R, Tedeschi L. Fatality due to fentanyl-cocaine intoxication resulting in a fall. Int J Legal Med. 1994;106(5):271-3. Available from: http://www.ncbi.nlm.nih.gov/pubmed/8068573
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Thomas JR, Sclafani AP, Hamilton M, McDonough E. Preoperative identification of psychiatric illness in aesthetic facial surgery patients. Aesthetic Plast Surg. 2001 Jan-Feb;25(1):64-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11322401
Bradbury E. The psychology of aesthetic plastic surgery. Aesthetic Plast Surg. 1994 Summer;18(3):301-5. Available from: http://www.ncbi.nlm.nih.gov/pubmed/7976766
Ivanova-Stoilova Ts, Tepavicharova P. Short-acting anesthesia in cosmetic surgery of the breasts. Khirurgiia (Sofiia). 1989;42(4):50-3. Available from: http://www.ncbi.nlm.nih.gov/pubmed/2585984
Ohjimi H¹, Shioya N, Ishigooka J. The role of psychiatry in aesthetic surgery. Aesthetic Plast Surg. 1988 Aug;12(3):187-90. Available from: http://www.ncbi.nlm.nih.gov/pubmed/3189037
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Pedersen T¹, Dyrlund Pedersen B, Moller AM. Pulse oximetry for perioperative monitoring.
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Taggart DP¹, Browne SM, Wade DT, Halligan PW. Neuroprotection during cardiac surgery: a randomised trial of a platelet activating factor antagonist. Heart. 2003 Aug;89(8):897-900. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12860868
We evaluated two quality of life instruments, the EQ-5D and the SF-36, in patients with femoral neck fractures and also measured the quality of life two years after different interventions. The EQ-5D was validated in two prospective studies and it appeared to be an appropriate quality of life instrument in elderly patients with femoral neck fractures. There was a good correlation between the quality of life (EQ-5Dindexscores) and other outcome measures such as pain, mobility and independence in activities of daily living (ADL). The results also showed high responsiveness, i.e., ability to capture clinically important changes, for both the EQ-5D and the SF-36. The questionnaire response rate for both instruments was high. The rated prefracture EQ-5Dindexscores showed good correspondence with the scores of an age-matched Swedish reference population.
The quality of life in patients with femoral neck fractures treated with internal fixation (IF) decreased, particularly in patients with fracture healing complications. The fracture healing complications rate at two years in patients with displaced femoral neck fractures treated with IF was 36% compared with 7% in patients with undisplaced fractures. The quality of life of patients with uneventfully healed fractures at two year was lower in patients with primary displaced fractures than in patients with primary undisplaced fractures. In a prospective randomised trial, patients with displaced femoral neck fractures were randomised to IF or total hip replacement (THR). IF resulted in more complications than THR, 36% versus 4%, and necessitated more reoperations, 42% versus 4%. Hip function and quality of life (EQ-5D) were generally better in the THR group.
In summary, THR yielded a better outcome than IF for an elderly, relatively healthy, lucid patient with a displaced femoral neck fracture. In a study of elderly women with femoral neck fractures, nearly half of the patients displayed signs of protein-energy malnutrition. Underweight was associated with muscle fatigue, cognitive dysfunction and a low quality of life (Nottingham Health Profile). In a prospective randomised trial, protein-rich liquid supplementation in combination with an anabolic steroid given for 6 months to lean elderly women after a femoral neck fracture was shown to positively affect lean body mass, ADL and quality of life (EQ-5D). Fracture healing complications had a negative impact on body weight, lean body mass and quality of life.
Tidermark J. Quality of life and femoral neck fractures. Acta Orthop Scand Suppl. 2003 Apr;74(309):1-42. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12811943
de Baar M¹, Diephuis JC, Moons KG, Holtkamp J, Hijman R, Kalkman CJ. The effect of zero-balanced ultrafiltration during cardiopulmonary bypass on S100b release and cognitive function. Perfusion. 2003 Mar;18(1):9-14. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12705644
von Knobelsdorff G¹, Hoppner RM, Tonner PH, Paris A, Nienaber CA, Scholz J, et al.
Induced arterial hypotension for interventional thoracic aortic stent-graft placement: impact on intracranial haemodynamics and cognitive function. Eur J Anaesthesiol. 2003 Feb;20(2):134-40
Available from: http://www.ncbi.nlm.nih.gov/pubmed/12622498
Morrison RS¹, Magaziner J, Gilbert M, Koval KJ, McLaughlin MA, Orosz G et al.
Relationship between pain and opioid analgesics on the development of delirium following hip fracture. J Gerontol A Biol Sci Med Sci. 2003 Jan;58(1):76-81. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12560416
Rasmussen LS¹, Christiansen M, Eliasen K, Sander-Jensen K, Moller JT. Biochemical markers for brain damage after cardiac surgery – time profile and correlation with cognitive dysfunction. Acta Anaesthesiol Scand. 2002 May;46(5):547-51. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12027849
Abildstrom H, Hogh P, Sperling B, Moller JT, Yndgaard S, Rasmussen LS. Cerebral blood flow and cognitive dysfunction after coronary surgery. Ann Thorac Surg. 2002 Apr;73(4):1174-8; discussion 1178-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11996259
Nyland J¹, Johnson DL, Caborn DN, Brindle T. Internal health status belief and lower perceived functional deficit are related among anterior cruciate ligament-deficient patients. Arthroscopy. 2002 May-Jun;18(5):515-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11987063
Nevertheless, acute and chronic neurocognitive dysfunction frequently occurs in non-cardiac surgery patients as well, suggesting that some element of surgery and/or anesthesia itself causes or contributes to this phenomenon. One possible cause may be central nervous system (CNS) responses to peripheral tissue injury or inflammation. The CNS is sensitive to systemic pro-inflammatory mediators such as endotoxin and the cytokines interleukin-6 and interleukin- 8, which are activated by surgical trauma. This article discusses the behavior and effects of these inflammatory agents and their intensification in combination with postoperative hyperthermia. The potential beneficial role of pharmacological agents such as heparin, lidocaine, and aprotinin is also examined.
Hindman BJ. Emboli, inflammation, and CNS impairment: an overview. Heart Surg Forum. 2002;5(3):249-53. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12538140
By 2020, IHD leading to congestive heart failure (CHF) will become the leading cause of disability worldwide. Vascular cognitive impairment occurs in 26% of patients discharged from hospitals after treatment for CHF. Cognitive dysfunction correlates with left ventricular dysfunction and systolic blood pressure below 130 mm Hg. CHF is a leading cause of hospital admissions in Western nations (4.5 million cases in the USA alone) and is a growing problem in developing countries. Furthermore, over 800,000 patients/year undergo coronary artery bypass graft (CABG) surgery worldwide, including 300,000 patients in the USA. Measurable cognitive dysfunction occurs post-CABG in 80-90% of patients at hospital discharge. Long-term (5 years) incidence of cognitive defects is 42%. Finally, an international study found short-term postoperative cognitive dysfunction in 26% of patients (>60 years) after abdominal or orthopedic surgery; most of them may be instances of VaD. In conclusion, VaD may be the most underdiagnosed and undertreated form of dementia in the elderly.
Roman GC. Vascular dementia may be the most common form of dementia in the elderly.
J Neurol Sci. 2002 Nov 15;203-204:7-10. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12417349
Cognitive dysfunction was defined as an individual test score decrease of more than one standard deviation in two or more of the five tests. During operation ScO2 was continuously measured using an INVOS 4100 device. Cerebral oxygen saturation values were analyzed with reference to two cutoff points, which should reflect low cerebral oxygenation: an ScO2 less than 40% and a drop of more than 25% from individual baseline values. The duration and extent of ScO2 values below these two cutoff points was compared between the patients with and without cognitive dysfunction. RESULTS: Sixteen patients (34%) showed postoperative cognitive dysfunction.
Cerebral oxygen saturation values less than 40% occurred in 17 patients for a mean (+/- standard error of the mean) of 17.2 +/- 6.5 minutes, whereas a decrease of more than 25% from baseline values occurred in 37 patients for 52.7 +/- 7.8 minutes. The duration and extent below the two cutoff ScO2 values was similar in patients with and without cognitive dysfunction. CONCLUSIONS: Intraoperative regional ScO2 as assessed by near-infrared spectroscopy with the INVOS 4100 device is not predictive for postoperative cognitive performance in patients undergoing coronary artery bypass grafting with cardiopulmonary bypass.
Reents W¹, Muellges W, Franke D, Babin-Ebell J, Elert O. Cerebral oxygen saturation assessed by near-infrared spectroscopy during coronary artery bypass grafting and early postoperative cognitive function. Ann Thorac Surg. 2002 Jul;74(1):109-14. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12118739
Suttner SW¹, Piper SN, Lang K, Huttner I, Kumle B, Boldt J. Cerebral effects and blood sparing efficiency of sodium nitroprusside-induced hypotension alone and in combination with acute normovolaemic haemodilution. Br J Anaesth. 2001 Nov;87(5):699-705. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11878519