Medical Literature

Mechanisms of neurobehavioral disturbances

What are the mechanisms of acute neurobehavioral disturbances?

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).

Unfortunately no one knows why some people suffer neurobehavioural disturbances following anaesthesia, whilst the majority, do not. To first understand a pathophysiological (abnormal) response it is instructive to understand the normal response and the mechanisms that give rise to the state of anaesthesia. Again, unfortunately, we know nothing specific about how anaesthetic agents send you to sleep.

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.

    • Broken down into the following categories:
Below outlines a list of known culprits that have been incriminated in acute post-operative psychosis in the past. They are grouped by drug function or in relation to the procedure type. The first notable medical reference was reported in the 1920’s so there has been awareness of this problem for some time. One must remember however that before the advent of anaesthesia, people’s experience of surgery was almost always associated with profound psychological trauma, with or without subsequent psychosis.

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![2]. The ethics of this relationship between an aesthetic surgeon and his patients is a real problem for some clinicians [1].

Known culprits Interim list from Pubmed:

  1. Antimalarial: mefliquone
    1. Lariam, Mephaquin or Mefliam
  2. Steroids – initiation and withdrawl o treatment
    1. Hydrocortisone
    2. Dexamethasone
  3. Phenothiazines and antihstamines in overdose (used to stop you vomiting – anti-emetics)
    1. Metaclopramide
    2. Other antihistamines
  4. Tramadol: a pain killer
  5. Antibiotics
    1. Co-amoxyclav
    2. Procaine penicillin
    3. Clarythromucin
    4. Quinilones
      1. ciprofloxacin
      2. ofloxacin
    5. Septrin
    6. Metronidazole
  6. Antivirals – herpes
  7. Anti retroviral therapy (HIV treatment)
  8. Herbal supplements
    1. Angels trumpet tea
    2. Jumson weed
    3. Salvinorin A – mexican plant
    4. Rapture
    5. St Johns Wort
    6. Sage (purple)
    7. Ginsing
  9. Anti arrythmics or anti hypertensives to control blood pressure
    1. Propranolol
  10. Congenital biochemical disorders
    1. Homocystinuria – inherited disorder of metabolism producing abnormal appearence and low IQ
    2. Porphyria
      1. Maddness of King George
  11. Dopamine D2 receptor antagonists
    1. Bromocriptine used to suppress milk production in lactating mothers
  12. Diet treatments
    1. Sibutramine – banned
    2. Phenmetrazine, a diet medication –  banned
  13. Alchohol
    1. Chronic
    2. Accute withdrawal
  14. Benzdiazepines minor tranquiliser
    1. lorazepam
  15. NSAIDs (Aspirin like drugs)
    1. indomethacin
  16. H2 receptor antagonist for treating gastric ulcers. An over the counter drug
    1. Cimetidine
  17. Bath salts
  18. Pregnancy
    1. Purpurial psychosis
    2. STOP (suction termination of pregnancy)
  19. Oral contraceptives
  20. Anaesthesia
    1. Brain damage
      1. Intra operative hypoxia
      2. Black gas anaesthesia (obsolete) 100% N2O. Suffocation by any other name
      3. Profound, sustained intraoperative hypotension with low circulating blood volume
    2. ? fentanyl – great grandson of pethidine. Not certain at all
    3. Metabolic alkalosis – blood acid too low
    4. Nitrous oxide. Standard anaesthetic agent. Incidence of problems no different between the use of N2O and no N20, unless occult B12 deficiency is revealed (pernicious anaemia) and procedure longer that 3 hours. Neuropsychiatric symptoms can precede hematologic signs and are often the presenting manifestation of B12 deficiency i.e. you cannot tell from routine pre-operative blood tests.
  21. Illicit or recreational drugs
    1. cannabis
    2. cannabinoids and derivatives
    3. cocaine
    4. methamphetamine
    5. others
  22. Thyroid disease
    1. hypothyroidism
    2. thyroidectomy – removal of thyroid gland
  23. Types of surgery
    1. thymectomy
    2. heart surgery
    3. cateract surgery
    4. hysterectomy
    5. pancreatitis
    6. neurosurgery for epilepsy
  24. Kidney failure
    1. Hyponatraemia – low serum Sodium
      1. thiazide induced “water tablet” allows excessive loss of sodium and potassioum from kidneys
      2. IADH (Innapropriate antidiuretic hormone secretion: causes water intoxication)
  25. Sepsis – bacterial endotoxins and bacteria in the blood
  26. Predisposing factors
    1. Pre-existing psychiatric history

Postsurgical psychosis: case report and review of literature

Abstract

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

Depression is associated with early postoperative outcomes following total joint arthroplasty: a nationwide database study
Abstract

The purpose of this study was to assess the incidence of the diagnosis of depression and determine the impact of this diagnosis on early postoperative outcomes following total joint arthroplasty (TJA). Multivariate analysis of the Nationwide Inpatient Sample database was used to compare the association of depression with inhospital morbidity, mortality, length of stay, and hospital charges following TJA. The rate of diagnosis of depression in the arthroplasty population was 10.0%. Patients with depression were significantly more likely to be white, female, and have Medicaid as a primary payer (all P<0.05). Depression was associated with a greater risk of post-operative psychosis (OR=1.74), anemia (OR=1.14), infection (OR=1.33), and pulmonary embolism (OR 1.20), and a lower risk of cardiac (OR=0.93) and gastrointestinal complications (OR=0.80). Depression was not associated with in-hospital mortality. Depression appears to impact early postoperative morbidity after TJA, a finding which is important for patient counseling and risk adjustment.

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

Peri-operative dexamethasone therapy and post-operative psychosis in patients undergoing major oral and maxillofacial surgery
Abstract

A broad array of behavioral symptoms, including psychosis, can transpire post-operatively following a variety of surgeries. It is difficult to diagnose the exact cause of post-operative psychosis. We report three cases, which developed psychosis post-operatively after undergoing major oral and maxillofacial surgeries. All the three patients were administered dexamethasone peri-operatively. Dexamethasone is used to prevent or reduce post-operativeedema. The exact dose of dexamethasone, which can cause psychosis, is unknown. It is important to raise awareness about this potential complication so that measures for management can be put in place in anticipation of such an event.

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

Anaesthetic neurotoxicity and neuroplasticity: an expert group report and statement based on the BJA Salzburg Seminar
Abstract

Although previously considered entirely reversible, general anaesthesia is now being viewed as a potentially significant risk to cognitive performance at both extremes of age. A large body of preclinical as well as some retrospective clinical evidence suggest that exposure to general anaesthesia could be detrimental to cognitive development in young subjects, and might also contribute to accelerated cognitive decline in the elderly. A group of experts in anaesthetic neuropharmacology and neurotoxicity convened in Salzburg, Austria for the BJA Salzburg Seminar on Anaesthetic Neurotoxicity and Neuroplasticity. This focused workshop was sponsored by the British Journal of Anaesthesia to review and critically assess currently available evidence from animal and human studies, and to consider the direction of future research. It was concluded that mounting evidence from preclinical studies reveals general anaesthetics to be powerful modulators of neuronal development and function, which could contribute to detrimental behavioural outcomes. However, definitive clinical data remain elusive. Since general anaesthesia often cannot be avoided regardless of patient age, it is important to understand the complex mechanisms and effects involved in anaesthesia-induced neurotoxicity, and to develop strategies for avoiding or limiting potential brain injury through evidence-based approaches.

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

Are anaesthetics toxic to the brain?
Abstract

It has been assumed that anaesthetics have minimal or no persistent effects after emergence from anaesthesia. However, general anaesthetics act on multiple ion channels, receptors, and cell signalling systems in the central nervous system to produce anaesthesia, so it should come as no surprise that they also have non-anaesthetic actions that range from beneficial to detrimental. Accumulating evidence is forcing the anaesthesia community to question the safety of general anaesthesia at the extremes of age. Preclinical data suggest that inhaled anaesthetics can have profound and long-lasting effects during key neurodevelopmental periods in neonatal animals by increasing neuronal cell death (apoptosis) and reducing neurogenesis. Clinical data remain conflicting on the significance of these laboratory data to the paediatric population. At the opposite extreme in age, elderly patients are recognized to be at an increased risk of postoperative cognitive dysfunction (POCD) with a well-recognized decline in cognitive function after surgery. The underlying mechanisms and the contribution of anaesthesia in particular to POCD remain unclear. Laboratory models suggest anaesthetic interactions with neurodegenerative mechanisms, such as those linked to the onset and progression of Alzheimer’s disease, but their clinical relevance remains inconclusive. Prospective randomized clinical trials are underway to address the clinical significance of these findings, but there are major challenges in designing, executing, and interpreting such trials. It is unlikely that definitive clinical studies absolving general anaesthetics of neurotoxicity will become available in the near future, requiring clinicians to use careful judgement when using these profound neurodepressants in vulnerable patients.

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/

Monitoring depth of anaesthesia in a randomized trial decreases the rate of postoperative delirium but not postoperative cognitive dysfunction
Abstract

Postoperative delirium in elderly patients is a frequent complication and associated with poor outcome. The aim of this parallel group study was to determine whether monitoring depth of anaesthesia influences the incidence of postoperative delirium.

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:
http://www.ncbi.nlm.nih.gov/pubmed/23539235

Reduced cerebral oxygen saturation during thoracic surgery predicts early postoperative cognitive dysfunction
Abstract

The objective of this prospective study is to determine cognitive dysfunction after thoracic surgery. Seventy-six patients undergoing thoracic surgery with single-lung ventilation (SLV) of an expected duration of >45 min were enrolled. Monitoring consisted of standard clinical parameters and absolute oximetry (S(ct)O(2)). The Mini-Mental State Exam (MMSE) test was used to assess cognitive function before operation and at 3 and 24 h after operation. Data were analysed using Spearman correlation test; risks for cognitive dysfunction were expressed as odds ratios. P

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

Incidence of early postoperative cognitive dysfunction and other adverse events in elderly patients undergoing elective total hip replacement (THR)
Abstract

In elderly patients cognitive dysfunction and other adverse events (AEs) can impair the outcome of surgical procedures. As THR is performed with increasing frequency in aging populations, it is important to know the impact of these problems on the postoperative result. In this prospective cohort study 60 patients older than 65 years (66.7% female, 33.3% male) who received THR were included. The cognitive function was measured preoperatively, one week and six months postoperatively by the mini-mental state test (MMSE). Shortly after surgery 4 patients (6.7%) developed postoperative cognitive dysfunction, which has recovered at six-months-follow-up. In 41 patients (68.3%) AEs were recorded. Postoperative anemia occurred as the most common AE (n=32; 53.3%). During hospital stay older patients are at an increased risk for AEs. The incidence of postoperative cognitive dysfunction was observed less often than expected. Further research is necessary to assess the effect of early interventions in case of cognitive dysfunction. With use of a simple and quickly performed test like the MMSE patients can be effectively screened for impaired cognitive function. Secure identification of those patients is mandatory to avoid complications with harmful long-term effects.
Postler A1, Neidel J, Günther KP, Kirschner S. Incidence of early postoperative cognitive dysfunction and other adverse events in elderly patients undergoing elective total hip replacement (THR). Arch Gerontol Geriatr. 2011 Nov-Dec;53(3):328-33. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21288579

Risk factors for inadequate emergence after anesthesia: emergence delirium and hypoactive emergence
Abstract
Aim

Inadequate emergence after anesthesia in the adult patient may be distinguished by the patients’ activity level into two subtypes: emergence delirium and hypoactive emergence. The aim of this study was to determine the incidence of inadequate emergence in its different forms, to identify causative factors and to examine the possible influence on postoperative length of stay in the recovery room and in the hospital.

Methods

In this prospective observational study, 1868 non-intubated adult patients who had been admitted to the recovery room were analyzed. Inadequate emergence was classified in its different forms according to the Richmond agitation and sedation scale (RASS) 10 minutes after admission to the recovery room. Emergence delirium was defined as a RASS score >or=+1, and hypoactive emergence was defined as a RASS score <or=-2.

Results

Of the 1,868 patients, 153 (8.2%) displayed symptoms of inadequate emergence: 93 patients (5.0%) screened positive for emergence delirium, and 60 patients (3.2%) showed hypoactive emergence. Significant risk factors for emergence delirium were premedication with benzodiazepines, induction of anesthesia with etomidate, younger as well as older age (age below 40 years and over 64 years), higher postoperative pain scores (NRS 6-10) and musculoskeletal surgery. Risk factors for hypoactive emergence were younger age, long duration of surgery and intraabdominal surgery. Patients with hypoactive emergence had a significantly increased length of stay in the hospital.

Conclusion

Inadequate emergence after anesthesia is a frequent complication. Preventable risk factors for emergence delirium were induction of anesthesia with etomidate, premedication with benzodiazepines and higher postoperative pain scores. Hypoactive emergence was less frequent than emergence delirium and was associated with a longer postoperative hospital stay.

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

Postoperative cognitive dysfunction of older surgical patients
Abstract

Light changes in mental function after operation occur in patients of all ages, but more frequent they are observed in older patients. The incidence of early postoperative cognitive dysfunction varies depending on surgical procedure and may be as high as 20-90% in aged patients, and occurs most often in patients undergoing cardiovascular surgery. Early postoperative cognitive dysfunction is a predictor of late postoperative cognitive dysfunction. Delirium develops in at least 50% of older surgical patients and even more frequently after cardiac surgeries (72%). Postoperative delirium, like delirium manifesting with co-existing disease, and late postoperative cognitive dysfunction are strong predictors of functional and cognitive decline in one-year period after discharge and are associated with higher morbidity and mortality, longer hospital stay, and a higher rate of institutionalization. The reasons of postoperative cognitive dysfunction and delirium are not well understood. An assessment of cognitive function should be completed as a routine in older patients, and effective prevention requires the identification of risk factors for delirium: advanced age, preexisting dementia and depression, visual and hearing impairment, Parkinson disease, emergency operation, anticholinergic drugs, and others. After operation, elderly patients must be carefully monitored for probable postoperative delirium. It is important to deepen health care professionals’ knowledge of postoperative cognitive complications in older surgical patients.

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
Abstract
Objective
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.

Summary Background Data

The incidence and risk factors of PD after major abdominal surgery in elderly patients are not well documented.

Methods

From May 2006 to May 2008, 118 patients aged 75 years or more without severe preoperative cognitive dysfunction (mini mental state examination score >10/30) and undergoing major elective abdominal surgery were included. The preoperative geriatric assessment battery consisted of 4 tests evaluating physical (instrumental activities of daily living and timed get up and go test score) and cognitive function (mini mental state examination score), and detecting the presence of an underlying depression (Short-GDS). After the operation, geriatric patients were assessed for PD by the Confusion Assessment Method. Univariate and multivariate analyses were used to determine risk factors for PD.

Results

Overall, PD occurred in 28 patients (24%). Multivariate analysis showed that an American Society of Anesthesiologists status of 3-4 (P = 0.02), impaired mobility (timed get up and go test score >20 seconds) (P = 0.009) and postoperative tramadol administration (P = 0.0009) were risk factors for PD. The mortality rate was 14% in 28 patients with PD and 3.3% in 90 patients without PD (P = 0.051). The morbidity rate was 35.5% in 28 patients with PD and 32% in 90 patients without PD (NS). The mean hospital stay was 19 +/- 11 days for patients with PD and 14 +/- 8 for patients without PD (P = 0.01). Fifteen of 24 (62.5%) surviving patients with PD and 28 of 87 (32%) surviving patients without PD were discharged to geriatric rehabilitation unit (P = 0.007).

Conclusions

PD is a frequent and severe postoperative event in elderly patients after major abdominal surgery. A perioperative geriatric assessment should be recommended to patients with an American Society of Anesthesiologists status of 3-4 and preoperative impaired mobility to facilitate the management of PD. In these patients, the postoperative administration of tramadol should be avoided.

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

Postoperative delirium in the elderly: risk factors and outcomes
Abstract
Objective

The purpose of this study was to describe the natural history, identify risk factors, and determine outcomes for the development of postoperative delirium in the elderly.

Background

Postoperative delirium is a common and deleterious complication in geriatric patients.

Methods

Subjects older than 50 years scheduled for an operation requiring a postoperative intensive care unit admission were recruited. After preoperative informed written consent, enrolled subjects had baseline cognitive and functional assessments. Postoperatively, subjects were assessed daily for delirium using the confusion assessment method-intensive care unit. Patients were also followed for outcomes.

Results

During the study period, 144 patients were enrolled before major abdominal (40%), thoracic (53%), or vascular (7%) operations. The overall incidence of delirium was 44% (64/144). The average time to onset of delirium was 2.1 +/- 0.9 days and the mean duration of delirium was 4.0 +/- 5.1 days. Several preoperative variables were associated with an increased risk of delirium including older age (P < 0.001), hypoalbuminemia (P < 0.001), impaired functional status (P < 0.001), pre-existing dementia (P < 0.001), and pre-existing comorbidities (P < 0.001). In a multivariable logistic regression model, pre-existing dementia remains the strongest risk factor for the development of postoperative delirium. Worse outcomes, including increased length of stay (P < 0.001), postdischarge institutionalization (P < 0.001), and 6 month mortality (P = 0.001), occurred in subjects who developed delirium.

Conclusions

In the current study, delirium occurred in 44% of elderly patients after a major operation. Pre-existing cognitive dysfunction was the strongest predictor of the development of postoperative delirium. Outcomes, including an increased rate of 6 month mortality, were worse in patients who developed postoperative delirium.

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

Preoperative use of statins is associated with reduced early delirium rates after cardiac surgery
Abstract
Background

Delirium is an acute deterioration of brain function characterized by fluctuating consciousness and an inability to maintain attention. Use of statins has been shown to decrease morbidity and mortality after major surgical procedures. The objective of this study was to determine an association between preoperative administration of statins and postoperative delirium in a large prospective cohort of patients undergoing cardiac surgery with cardiopulmonary bypass.

Methods

After Institutional Review Board approval, data were prospectively collected on consecutive patients undergoing cardiac surgery with cardiopulmonary bypass from April 2005 to June 2006 in an academic hospital. All patients were screened for delirium during their hospitalization using the Confusion Assessment Method in the intensive care unit. Multivariable logistic regression analysis was used to identify independent perioperative predictors of delirium after cardiac surgery. Statins were tested for a potential protective effect.

Results

Of the 1,059 patients analyzed, 122 patients (11.5%) had delirium at any time during their cardiovascular intensive care unit stay. Administration of statins had a protective effect, reducing the odds of delirium by 46%. Independent predictors of postoperative delirium included older age, preoperative depression, preoperative renal dysfunction, complex cardiac surgery, perioperative intraaortic balloon pump support, and massive blood transfusion. The model was reliable (Hosmer-Lemeshow test, P = 0.3) and discriminative (area under receiver operating characteristic curve = 0.77).

Conclusions

Preoperative administration of statins is associated with the reduced risk of postoperative delirium after cardiac surgery with cardiopulmonary bypass.

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

Postoperative psychiatric disorders in general thoracic surgery: incidence, risk factors and outcomes Abstract
Objective

Postoperative psychiatric disorders (PPDs) may complicate the post-surgical outcome. We analysed the types, incidences, risk factors and outcomes of the PPDs in non-cardiac thoracic surgery patients.

Methods

All patients (n=100) undergoing major non-cardiac thoracic surgery from January 2004 to March 2005 were investigated prospectively. The diagnosis of PPD was made based on the Diagnosis and Statistical Manual of Mental Disorders. The patients were grouped into two according to the presence (group I) or absence (group II) of PPD. Data on pre-, per- and postoperative factors, and the adverse outcomes were analysed.

Results

Eighteen patients (18%) developed PPD, including delirium in 44%, adjustment disorders in 22%, panic attack in 17%, minor depression in 11% and psychosis in 6%. The patients who developed PPD were older (58+/-17 vs 50+/-15 years, p=0.05), had a longer operation time (6+/-1 vs 5+/-2h, p=0.015) and hospital stay (13+/-9 vs 8+/-5 days, p=0.019). The morbidity and mortality rates were not significantly different between the groups (67% vs 46%; 11% vs 1%, respectively). The causative factors in the development of PPD were older age, longer operation time, abnormal serum chemistry values of sodium, potassium, calcium and glucose, hypoalbuminaemia, the presence of the postoperative respiratory distress and infection and blood transfusion (p<0.05).

Conclusion

PPDs are associated with adverse outcomes including a longer hospital stay, and increased morbidity and mortality rates. The identification, detection and elimination of these risk factors are recommended.

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

Preoperative use of statins is associated with reduced early delirium rates after cardiac surgery
Abstract
Background

Delirium is an acute deterioration of brain function characterized by fluctuating consciousness and an inability to maintain attention. Use of statins has been shown to decrease morbidity and mortality after major surgical procedures. The objective of this study was to determine an association between preoperative administration of statins and postoperative delirium in a large prospective cohort of patients undergoing cardiac surgery with cardiopulmonary bypass.

Methods

After Institutional Review Board approval, data were prospectively collected on consecutive patients undergoing cardiac surgery with cardiopulmonary bypass from April 2005 to June 2006 in an academic hospital. All patients were screened for delirium during their hospitalization using the Confusion Assessment Method in the intensive care unit. Multivariable logistic regression analysis was used to identify independent perioperative predictors of delirium after cardiac surgery. Statins were tested for a potential protective effect.

Results

Of the 1,059 patients analyzed, 122 patients (11.5%) had delirium at any time during their cardiovascular intensive care unit stay. Administration of statins had a protective effect, reducing the odds of delirium by 46%. Independent predictors of postoperative delirium included older age, preoperative depression, preoperative renal dysfunction, complex cardiac surgery, perioperative intraaortic balloon pump support, and massive blood transfusion. The model was reliable (Hosmer-Lemeshow test, P = 0.3) and discriminative (area under receiver operating characteristic curve = 0.77).

Conclusions

Preoperative administration of statins is associated with the reduced risk of postoperative delirium after cardiac surgery with cardiopulmonary bypass.

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

High risk of cognitive and functional decline after postoperative delirium. A three-year prospective study
Abstract
Background

The aim of the study was to investigate the association of postoperative delirium with the outcomes of cognitive impairment, functional disability and death.

Methods

Hip surgery patients aged 60 years or over (n = 200) underwent preoperative and daily postoperative assessment of their cognitive status during hospital stay. Outcome variables were determined at an average of 8 and 38 months after discharge from hospital.

Results

Fourty-one patients developed postoperative delirium. Delirium was a strong independent predictor of cognitive impairment and the occurrence of severe dependency in activities of daily living. The associations were more marked for the long- than for the short-term outcome. Thirty-eight months after discharge from hospital, 53.8% of the surviving patients with postoperative delirium suffered from cognitive impairment, as compared to only 4.4% of the nondelirious participants. Logistic regression analysis adjusted for age, sex, medical comorbidity and preoperative cognitive performance revealed highly significant associations between delirium and cognitive impairment (OR = 41.2; 95% CI = 4.3-396.2), subjective memory decline (OR = 6.2; 95% CI = 1.5-25.8) and incident need for long-term care (OR = 5.6; 95% CI = 1.6-19.7).

Conclusion

The present study confirms a poor prognosis after delirium in elderly patients. The findings suggest that delirium does not simply persist for a certain time but also predicts a future cognitive decline with an increased risk of dementia.

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:
http://www.ncbi.nlm.nih.gov/pubmed/18577850

Delirium in older patients in surgical intensive care units
Abstract
Purpose

To examine the frequency and course of delirium in older adults admitted to a surgical intensive care unit (SICU).

Design and Methods

Prospective, observational cohort study of 114 English-speaking participants and their surrogates, aged 65 and older, admitted to an SICU, and managed by a surgical critical care service. Chart reviews and surrogate interviews were conducted within 24 hours of SICU admission to collect information regarding evidence of dementia using the short form of the Informant Questionnaire on Cognitive Decline in the Elderly. Participants were also screened for delirium daily throughout their hospitalization with either the Confusion Assessment Method-ICU (CAM-ICU) while in the SICU or the CAM while on medical/surgical units.

Results

In this population of older adults, 18.4% had evidence of dementia on admission to the SICU. Few older adults (2.6%) were admitted to the hospital with evidence of preexisting delirium, but 28.3% developed delirium in the SICU and 22.7% during the post-SICU period. A total of 52 of 114 (45.6%) participants were delirious sometime during their hospital stay or 24 hours before hospital admission. Episodes of deep sedation and nonarousal were uncommon, occurring in only 9.7% of the sample.

Conclusions

Older adults admitted to SICUs were at high risk for developing delirium during hospitalization. Further research is needed to elucidate the risk factors for, and outcomes of, delirium in this uniquely vulnerable population.

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

Postoperative dementia: toxicity of nitrous oxide
Abstract
Introduction

Post-operative neuropsychiatric manifestations represent a frequent situation and may be due to several aetiologies. The responsibility of vitamin B12 deficiency must be evoked, especially in case of anaesthesia with a currently used substance: nitrous oxide.

Case Study

A 65 year-old man with no medical history, presented problems walking and memory loss 16 days after surgery for femoral prosthesis. Neurological examination revealed paraplegia with syndrome of combined degeneration of the spinal cord. The exploration of cognitive functions showed disorientation in time with memory disorders and disturbance of executive functioning. There was no apraxia, aphasia or agnosia. There were neither psychotic symptoms nor mood changes. MMS was at 18/30. Red blood count revealed an anaemia with macrocytosis (MGV=120 3). Vitamin B12 rate was very low (less than 30 g/l). Folate blood level was normal. Brain MRI showed moderate cerebral atrophy. Other investigations led to the diagnosis of Biermer’s disease (fundic atrophy at biopsy with presence in the serum of antibodies to intrinsic factor). The diagnosis of neurological attack related to a vitamin B12 deficiency secondary to Biermer’s disease was established, but the appearance ofdisorders in the post-operative period suggested the existence of an added factor. The recovery of informations revealed that anaesthesia was maintained by nitrous oxide during two hours and the patient exhibited pre-operative anaemia with macrocytosis. The hypothesis of decompensation of latent vitamin B12 deficiency by nitrous oxide was evoked. Replacement therapy by vitamin B12 induced real improvement of the cognitive impairment. MMS increased to 25/30.

Discussion

Cognitive impairment due to vitamin B12 deficiency is rarely dominated by isolated memorydisorders. An authentic dementia is exceptional. Our patient had a dementia diagnosed on the basis of DSM IV criteria including memory disorders, disturbance of executive functioning and significant impairment in social and occupational functioning, associated with a combined degeneration of the spinal cord, common in vitamin B12 deficiency. Furthermore, he had an unknown Biermer’s disease responsible for pre-operative deficiency which was clinically latent (there was only macrocytosis anaemia). The appearance of problems in the post-operative periodwas due to an acute decompensation of the latent deficiency induced undoubtedly by nitrous oxide used in anaesthesia. According to Christensen, nitrous oxide causes irreversible oxidation of vitamin B12 cobalt’s atom responsible for its inactivation and the appearance of clinical manifestations. Evolution under vitamin B12 replacement therapy depends on the rapidity of its founding. In our case, it led to an improvement, notably in cognitive functions.

Conclusion

Through this observation, the authors underline the necessity to search for vitamin B12 deficiency in the case of cognitive features following general anaesthesia.
El Otmani H1, El Moutawakil B, Moutaouakil F, Gam I, Rafai MA, Slassi I. Postoperative dementia: toxicity of nitrous oxide. Encephale. 2007 Jan-Feb;33(1):95-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17457299

Postoperative Cognitive Dysfunction in Middle-aged Patients
Abstract
Background:

Postoperative cognitive dysfunction (POCD) after noncardiac surgery is strongly associated with increasing age in elderly patients; middle-aged patients (aged 40–60 yr) may be expected to have a lower incidence, although subjective complaints are frequent.

Methods:

The authors compared the changes in neuropsychological test results at 1 week and 3 months in patients aged 40–60 yr, using a battery of neuropsychological tests, with those of age-matched control subjects using Z-score analysis. They assessed risk factors and associations of POCD with measures of subjective cognitive function, depression, and activities of daily living.

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

Nitrous oxide does not change the incidence of postoperative delirium or cognitive decline in elderly surgical patients
Abstract
Background

Postoperative delirium and cognitive decline are common in elderly surgical patients after non-cardiac surgery. Despite this prevalence and clinical importance, no specific aetiological factor has been identified for postoperative delirium and cognitive decline. In experimental setting in a rat model, nitrous oxide (N(2)O) produces neurotoxic effect at high concentrations and in an age-dependent manner. Whether this neurotoxic response may be observed clinically has not been previously determined. We hypothesized that in the elderly patients undergoing non-cardiac surgery, exposure to N(2)O resulted in an increased incidence of postoperative delirium than would be expected for patients not receiving N(2)O.

Methods

Patients who were >or=65 yr of age, undergoing non-cardiac surgery and requiring general anaesthesia were randomized to receive an inhalational agent and either N(2)O with oxygen or oxygen alone. A structured interview was conducted before operation and for the first two postoperative days to determine the presence of delirium using the Confusion Assessment Method.

Results

A total of 228 patients were studied with a mean (range) age of 73.9 (65-95) yr. After operation, 43.8% of patients developed delirium. By multivariate logistic regression, age [odds ratio (OR) 1.07; 95% confidence interval (CI) 1.02-1.26], dependence on performing one or more independent activities of daily living (OR 1.54; 95% CI 1.01-2.35), use of patient-controlled analgesia for postoperative pain control (OR 3.75; 95% CI 1.27-11.01) and postoperative use of benzodiazepine (OR 2.29; 95% CI 1.21-4.36) were independently associated with an increased risk for postoperative delirium. In contrast, the use of N(2)O had no association with postoperative delirium.

Conclusions

Exposure to N(2)O resulted in an equal incidence of postoperative delirium when compared with no exposure to N(2)O.

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

Acute cognitive dysfunction after hip fracture: frequency and risk factors in an optimized, multimodal, rehabilitation program
Abstract
Background

Patients undergoing hip fracture surgery often experience acute post-operative cognitive dysfunction (APOCD). The pathogenesis of APOCD is probably multifactorial, and no single intervention has been successful in its prevention. No studies have investigated the incidence of APOCD after hip fracture surgery in an optimized, multimodal, peri-operative rehabilitation regimen.

Methods

One hundred unselected hip fracture patients treated in a well-defined, optimized, multimodal, peri-operative rehabilitation regimen were included. Patients were tested upon admission and on the second, fourth and seventh post-operative days with the Mini Mental State Examination (MMSE) score.

Results

Thirty-two per cent of patients developed a significant post-operative cognitive decline, which was associated with several pre-fracture patient characteristics, including age and cognitive function, but also the number of peri-operative transfusions. The development of APOCD was also associated with impaired post-operative rehabilitation and an increased length of stay. APOCD was associated with the development of a major medical complication in 35% of all patients. In 65% of patients developing APOCD without a concomitant medical complication, the only risk factors were cognitive level and regular anti-psychotic treatment.

Conclusion

On the basis of current evidence, APOCD is prevalent amongst hip fracture patients despite multimodal intervention; future research should therefore focus on defining subgroups of hip fracture patients amenable to specific prophylactic or interventional measures against APOCD.

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:
http://www.ncbi.nlm.nih.gov/pubmed/16548854

Cognitive function after anaesthesia in the elderly
Abstract

Despite advances in perioperative care, a significant percentage of elderly patients experience transient postoperative delirium and/or long-term post-operative cognitive dysfunction (POCD). This chapter reviews the aetiology, clinical features, preventive strategies and treatment of these syndromes. Pre-operative, intra-operative, and post-operative risk factors for delirium and POCD following cardiac and non-cardiac surgery are discussed. It is most likely that the aetiology of delirium and POCD is multifactorial and may include factors such as age, decreased pre-operative cognitive function, general health status and, possibly, intra-operative events. Currently there is no single therapy that can be recommended for treating post-operative cognitive deterioration. Primary prevention of delirium and POCD is probably the most effective treatment strategy. Several large clinical trials show the effectiveness of multicomponent intervention protocols that are designed to target well-documented risk factors in order to reduce the incidence of post-operative delirium and, possibly, POCD in the elderly.

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

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

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:
http://www.ncbi.nlm.nih.gov/pubmed/12648190

Does intraoperative hyperventilation improve neurological functions of older patients after general anaesthesia?
Abstract

The purpose of the study was to investigate the effect of intraoperative hyperventilation on postoperative cognitive functions. METHODS: A total of 120 patients (60 older and 60 younger than 65 years old) were allocated randomly to group I “hyperventilation” (p(et)CO(2)=30 mmHg) or group II “normoventilation” (p(et)CO(2)=45 mmHg). Before the operation and on days 1, 3 and 6 after the operation, a battery of neuropsychological tests was performed (concentration endurance test d2, number connection test, digit symbol test). A decline of 20% in at least one test was regarded as postoperative cognitive deficit (POCD). Anaesthesia was maintained with isoflurane in nitrous oxide/oxygen supplemented with fentanyl. RESULTS: In all patients pooled, POCD was present in 26 patients (22%). In patients older than 65 years, POCD was present in 3 cases after hyperventilation and 13 cases after normoventilation ( p<0.01). In younger subjects, 5 cases of POCD were diagnosed in each ventilation group. Furthermore, POCD was more severely pronounced in older patients after normoventilation. CONCLUSION: In older patients, POCD occurred more frequently after intraoperative normoventilation. We assume that a reduced amount of noxious substances reach the brain after hyperventilation, because hyperventilation reduces the cerebral blood flow.

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

Postoperative cognitive dysfunction in middle-aged patients
Background

Postoperative cognitive dysfunction (POCD) after noncardiac surgery is strongly associated with increasing age in elderly patients; middle-aged patients (aged 40-60 yr) may be expected to have a lower incidence, although subjective complaints are frequent. METHODS: The authors compared the changes in neuropsychological test results at 1 week and 3 months in patients aged 40-60 yr, using a battery of neuropsychological tests, with those of age-matched control subjects using Z-score analysis. They assessed risk factors and associations of POCD with measures of subjective cognitive function, depression, and activities of daily living. RESULTS: At 7 days, cognitive dysfunction as defined was present in 19.2% (confidence interval [CI], 15.7-23.1) of the patients and in 4.0% (CI, 1.6-8.0) of control subjects (P < 0.001). After 3 months, the incidence was 6.2% (CI, 4.1-8.9) in patients and 4.1% (CI, 1.7-8.4) in control subjects (not significant). POCD at 7 days was associated with supplementary epidural analgesia and reported avoidance of alcohol consumption. At 3 months, 29% of patients had subjective symptoms of POCD, and this finding was associated with depression. Early POCD was associated with reports of lower activity scores at 3 months. CONCLUSIONS: Postoperative cognitive dysfunction occurs frequently but resolves by 3 months after surgery. It may be associated with decreased activity during this period. Subjective report overestimates the incidence of POCD. Patients may be helped by recognition that the problem is genuine and reassured that it is likely to be transient.

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:
http://www.ncbi.nlm.nih.gov/pubmed/12170047

Postoperative cognitive dysfunction versus complaints: a discrepancy in long-term findings
Abstract

This review describes the discrepancy in findings between postoperative cognitive performance and postoperative cognitive complaints long time after an operation under general anesthesia. Shortly (from 6 hr to 1 week) after an operation a decline in cognitive performance is reported in most studies. However, long time (from 3 weeks to 1-2 years) after an operation this is rarely found although some patients are still reporting cognitive complaints. In general this kind of research is suffering from severe methodological problems (use of insensitive tests, lack of control groups, lack of parallel tests, different definitions of cognitive decline). However, these problems cannot totally explain the discrepancy in findings in the long term. Thus, there are patients who have persistent cognitive complaints long time after an operation, that cannot be measured with cognitive tests. More psychological factors such as fixation on short-term cognitive dysfunction, mood, coping style, and personality are possible explanations for these cognitive complaints in the long term. As a consequence, these factors should be a topic in future research elucidating the persistence of these cognitive complaints long time after an operation under general anesthesia.

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

The assessment of postoperative cognitive function
Abstract

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.

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

Anesthesia and postoperative cognitive dysfunction in the elderly: a review of clinical and epidemiological observations
Abstract

Amnesic effects of anesthesia were first reported two hundred years ago, but the term postoperative cognitive dysfunction (POCD) has appeared only recently, covering a larger range of neuropsychological modifications resulting from surgical intervention. The clinical description of POCD is highly variable, ranging from concentration impairment to delirium. Significant short-term POCD is common in elderly persons, and can persist several months, varying both in time and intensity and affecting the full-range of cognitive functions (visual and auditory attention, primary and secondary memory, implicit memory, and visuospatial functioning). Incidence rates vary widely according to surgery type but also between studies for a given surgical procedure, as a result of methodological difficulties and limitations. Variability is largely attributable to the absence of a standardized POCD definition, the heterogeneity of procedures to measure cognitive deficits and the methods used for statistical analyses, but is also related to the disparity in targeted populations. The wide variation in study design and target populations precludes the application of formal meta-analysis procedures. We review the definition, epidemiology, etiology, pathophysiology and the clinical and public health implications of POCD. The effects of anesthetics are described in relation to ageing-related physiological changes. It is concluded that the complex interaction of etiological factors makes it difficult to determine at this point of time to what extent POCD may be attributed specifically to anesthetic agents.

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

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

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.

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:
http://www.ncbi.nlm.nih.gov/pubmed/10673874

Postanesthetic delirium: historical perspectives.
Abstract

Postanesthetic delirium is a type of postoperative emotional response occurring immediately after emergence from general anesthesia. Associated with excitement and confusion, the alternative terms emergence delirium or postanesthetic excitement are frequently used. Historically, the more encompassing term postoperative psychosis is used interchangeably but more frequently refers to those conditions occurring after a lucid interval of 24 to 48 hours. Either phenomenon may arise from a variety of disturbances, with drug reactions, hypoxemia, or reaction to pain being common, or it may arise from psychological causes. Reported is a case of postanesthetic delirium in a healthy young man. An historical overview of this potentially harmful condition, with specific recommendations for diagnosis and treatment, also is presented.

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

The psychiatrist in the surgical intensive care unit. I. Postoperative delirium.
Abstract

Delirium has been defined as a condition of cerebral insufficiency consisting of impairment of cognitive processes, with a characteristic slowing of the electroencephalographic pattern. Present also is a global “clouding” of consciousness, resulting from a potentially reversible impairment of ability to maintain attention. In these states there is usually a simultaneous diminution of the ability to think, perceive, and remember. Although drowsiness may be a part of this state, patients can be awake and yet delirious, with diminished consciousness of their surroundings. Postoperative delirium is seen more often in patients over 50 years of age, in those who are “vigilant” or overalert, and in those undergoing more complex surgery. Adverse influences in the postoperative period are certain drugs and the psychological stresses engendered by the ICU environment. Appropriate management obtains from attention to the impact of the strange enviornment on the patient.

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

Postoperative psychosis after heart surgery
Abstract

One hundred heart surgery patients were followed throughout their postoperative periods to assess the incidence and etiology of postcardiotomy delirium. Factors evaluated were: age, sex, history of previous psychiatric illness, history of cerebrovascular disease, cardiac diagnosis and operation, time of anesthesia, time of bypass, time spent in the intensive-care unit, and amount of sleep during the postoperative period. Six patients developed delirium, five of whom had a lucid postoperative interval; four patients had perceptual disturbances only, without loss of contact with reality; three had neurological symptoms with mild confusion; 87 kept a clear mental state. The following factors tended to be related to the occurrence of delirium and perceptual disturbances: history of preoperative psychiatric illness, advanced age, severity of preoperative and postoperative illness, and time spent in the intensive-care unit. Sleep deprivation consistently preceded onset of these symptoms with one exception. Operative factors did not seem to be of major importance. While postoperative delirium probably has multidetermined causes, the author believes that sleep deprivation superimposed on the other contributory condition is a common precipitating factor. Suggestions about the prevention and treatment of delirium are made.

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

”Perioperative

Abstract” headertype=”3″ space=”bigspace”]
Mental disorders are characterized by disturbances of thought, perception, affect and behavior, which occur as a result of brain damage. Recognizing and treating these conditions is necessary not only for psychiatrists but for all physicians. Disorder of mental function is one of the most common associated conditions in intensive care unit (ICU) patients. However, disturbances of mental function often remain unrecognized. In ICU patients, different types of mental function disorders may develop. They range from sleep disorders, severe depression, anxiety, posttraumatic stress disorder (PTSD) to cognitive disorders including delirium. The causes of mental dysfunction in ICU patients can be divided into environmental and medical. Cognitive disorders are related to mental processes such as learning ability, memory, perception and problem solving.

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

Psychiatric diseases: Need for an increased awareness among the anesthesiologists
Abstract

Psychological disorders and psychiatric diseases have been on the rise since the last three decades. An increasing number of such patients are encountered nowadays for elective or emergency surgery. A multi-array of challenges are faced while anesthetizing these patients or treating them in an intensive care unit. The problems include the deteriorated mental physiology, altered cognition and the possible drug interactions with psychotropic medications. The challenge starts from the preoperative assessment stage. Knowledge of the pharmacological profile of the various anti-psychotic drugs, their side-effects and drug interactions are of prime importance for an anesthesiologist to facilitate smooth delivery of anesthesia in such patients. It is important to formulate a clear plan to deal with any challenge in the perioperative or postoperative period. All the clinical aspects and various definitions of mental disorders in the present article have been used as per the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). We reviewed the advances in psychiatric diseases, their treatment and their implications on delivery of anesthesia.
Bajwa SJ1, Jindal R, Kaur J, Singh A. Psychiatric diseases: Need for an increased awareness among the anesthesiologists. J Anaesthesiol Clin Pharmacol. 2011 Oct; 27(4):440-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22096274

Childhood mefloquine-induced mania and psychosis: a case report
Abstract

Mefloquine, a commonly used oral antimalarial is occasionally associated with severe, neuropsychiatric adverse effects, especially in adults. Such events are extremely rare in children. The authors report on an 11-year-old, otherwise healthy girl from Eastern India, a malaria-endemic region, who developed mania and psychosis following intake of a therapeutic dose of mefloquine for Plasmodium falciparum malaria. She recovered satisfactorily with risperidone therapy. To our knowledge, there is only one documented instance of mefloquine-induced psychosis in the pediatric literature to date. Those caring for children need to realize that severe neuropsychiatric manifestations may be seen in the pediatric age group. A positive history of intake of the offending drug with careful exclusion of other etiologies usually clinches the diagnosis.

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:
http://www.ncbi.nlm.nih.gov/pubmed/19295181

Postoperative psychosis in an adolescent subsequent to oral surgical outpatient procedure
Abstract

Psychosis is a generic psychiatric term for a mental state often described as involving a “loss of contact with reality.” People experiencing psychosis may report hallucinations or delusional beliefs, and they may exhibit personality changes and disorganized thinking. This may be accompanied by unusual or bizarre behavior, as well as difficulty with social interaction and impairment in carrying out the activities of daily living. Psychiatric complications during the course of surgical treatment are well recognized and may range from acute psychotic episodes to problems of overdependency and addiction, as well as from suicidal depression to disruptive ward behavior. Although the exact cause for postoperative psychosis has not been identified, medical and substance-induced mental disorders are commonly diagnosed postoperatively in surgical patients.

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

Case of acute psychosis from herbal supplements
Abstract

A recent study estimates that 15.2 percent of American adults use nonprescription dietary supplements for weight loss. Sale of ephedrine- and ephedrine-alkaloid-containing products was prohibited by the Food and Drug Administration in February 2004 after research demonstrated an increased risk of arrhythmia, mortality and hypertension following use of products containing these sympathomimetics. Subsequently, nutritional supplement manufacturers have turned to other products to promote weight loss. The following paper reports a case study of a 28-year-old woman with no prior psychiatric history who was hospitalized secondary to an acute psychotic episode. The patient reported starting several weight-loss and nutritional sports supplements approximately one week prior to admission. The relationship between the onset of psychosis and the initiation of the dietary supplements strongly suggests a correlation exists. Heightened consumer education regarding the contents of dietary supplements, along with their potential for causing adverse effects when used alone or in combination with other medications, is warranted. Patients who choose to take dietary supplements should be encouraged to inform their health care providers about the supplements they are taking.

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

Cotrimoxazole-induced psychosis: a case report and review of literature
Abstract

We present a case of acute psychosis in a 46-year-old woman who had been treated orally with cotrimoxazole because of a severe infection of the urinary tract. She had started to develop psychotic symptoms with bizarre behavior two days before admission. Following discontinuation of antibiotic therapy, including cessation of treatment with cotrimoxazole and the induction of antipsychotic treatment, her mental state resolved to a stable premorbid level within 36 hours.

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

Antiretroviral therapy-induced psychosis: case report and brief review of the literature
Abstract
Objective:

We present a case of psychosis in an individual with known HIV infection whose symptoms developed approximately 1 month following the commencement of combination antiretroviral therapy consisting of abacavir (ABC), nevirapine and combivir. She presented with severe persecutory delusions, accompanied by mutism, posturing and catatonia. Following cessation of therapy and the introduction of a low-dose antipsychotic, her mental state resolved to a stable premorbid level, and no further disturbances of behaviour were noted. Furthermore, when re-challenged with the above combination minus ABC, there were no further episodes of psychosis. It is proposed that the aetiology of the psychosis was related to her antiretroviral therapy.

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

Metoclopramide-induced supersensitivity psychosis
Abstract
Objective:

To report 2 cases of metoclopramide-induced supersensitivity psychosis.

Case Summaries:

A 74-year-old Taiwanese man was treated with metoclopramide 5 mg 4 times daily for 6 months. A second patient, a 65-year-old Taiwanese man, was treated with metoclopramide 5 mg 4 times daily for 3 months. After discontinuation of metoclopramide, both patients developed hallucinatory experiences and delusions.

Discussion:

This is the first report of metoclopramide-induced supersensitivity psychosis. Chronic administration of a dopamine antagonist (e.g., metoclopramide) might induce dopamine receptor supersensitivity. It is hypothesized that exacerbation or occurrence of psychotic symptoms following neuroleptic withdrawal results from mesolimbic dopamine supersensitivity.

Conclusion:

The complications of long-term metoclopramide therapy should be seriously considered when the treatment regimens are being planned. Clinicians should attempt to treat patients with the lowest effective dosage of medication for the briefest therapeutic period to minimize the risks of adverse reactions.
Lu ML¹, Pan JJ, Teng HW, Su KP, Shen WW. Metoclopramide-induced supersensitivity psychosis.
Ann Pharmacother. 2002 Sep;36(9):1387-90. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12196057

Acute psychosis after anesthesia: the case for antibiomania
Abstract

We report the case of a teenager who developed a postanesthesia acute psychosis (delusions, paranoia, and hallucinations) caused by a reaction to antibiotic therapy (amoxicillin and clarithromycin), so called ‘Hoigne’s syndrome’ or ‘antibiomania.’ The differential diagnosis and a review of literature are presented. Our patient illustrates the importance of adding antibiomania as part of the differential diagnosis when altered postanesthesia behavior is observed in pediatric patients.

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

Uneventful total intravenous anaesthesia with ketamine for schizophrenic surgical patients
Abstract

Ketamine has been considered to be contraindicated for schizophrenic patients because it may induce psychological emergence reactions and psychiatric deterioration. Total intravenous anaesthesia (TIVA) with ketamine combined with droperidol and fentanyl (DFK) has been used in 14 schizophrenic patients undergoing various surgical procedures. Two patients died post-operatively of concomitant severe disease rather than from schizophrenia related pathophysiology or anaesthetic complication. One patient showed transient mild anxiety in the early post-operative period soon relieved by the patient’s routine medication. However, no patient developed exacerbations of psychosis or psychological emergence reactions during the first post-operative month. The cardiovascular state during and after DFK remained stable in all cases. It is concluded that ketamine when combined with droperidol and fentanyl is a satisfactory anaesthetic for patients with schizophrenia.

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

Fatality due to fentanyl-cocaine intoxication resulting in a fall
Abstract

This is the first report of fatal intoxication by fentanyl and cocaine outside the USA. The case involved a fall caused by toxic psychosis. The circumstantial, clinical, anatomical, histopathological and toxicological frame-work is interpreted.

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

Delusions induced by procaine penicillin: case report and review of the syndrome
Abstract

A patient manifesting an acute psychosis after receiving an injection of procaine penicillin is reported. The psychosis began immediately after drug administration and gradually abated over a forty-eight-hour period. The clinical presentation was dominated by paranoid delusions and a Capgras-like syndrome. Sixty-six previously reported cases were identified and reviewed. Patients manifested combinations of fear, auditory hallucinations, somatic hallucinations, visual hallucinations, and paranoid or religious delusions. The syndrome may occur with inadvertent intravenous injection of procaine and most likely reflects the action of procaine on limbic system structures.

Cummings JL, Barritt CF, Horan M. Delusions induced by procaine penicillin: case report and review of the syndrome. Int J Psychiatry Med. 1986-1987;16(2):163-8. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/3744684

Preoperative identification of psychiatric illness in aesthetic facial surgery patients
Abstract

The purpose of this study was to evaluate the preoperative use of a two-part standardized assessment program (Prime-MD, Biometrics Research Department, New York State Psychiatric Institute) to objectively detect psychiatric disorders in facial plastic surgery patients, and to compare its use to findings identified by the facial plastic surgeon. Seventy-five new patients requesting aesthetic facial surgery at two academic centers and two private practice locations were evaluated.

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

The psychology of aesthetic plastic surgery
Abstract

Aesthetic plastic surgery and psychology are closely linked, as the aesthetic plastic surgeon is dealing with people’s emotional, psychological, and social needs and aspirations. This article presents an overview of the relationship between the two professional disciplines. The minority of patients with psychiatric or psychological problems is described, and their treatment is considered in relation to both disciplines. We then move on to discuss the psychological and social issues that underline mainstream aesthetic surgery in the context of the psychological theory of stigma. The role of the psychologist within aesthetic surgery is discussed.

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

Short-acting anesthesia in cosmetic surgery of the breasts
Abstract

Fourteen patients subjected to short-term cosmetic operations on the mammary glands comprise the study group. Anesthesia was performed with ketamine 0.07 mg/kg/min, applied against the background of droperidol 0.1 mg/kg or diazepam 0.2 mg/kg and spontaneous ventilation with nitrous oxide and oxygen in proportion 3:1. At the end of the ketamine anesthesia 1.0 g pyracetam was applied. There was negligible decrease in the systolic arterial pressure and decreased occurrence of psychotic reactions during the early postoperative period.

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

The role of psychiatry in aesthetic surgery
Abstract

Twenty-five patients seeking aesthetic surgery were investigated and treated with the cooperation of the plastic surgeon and a psychiatrist. Three-fourths of the patients revealed psychiatric problems in their backgrounds. On the recommendation of the psychiatrist, eight cases underwent operations, in spite of psychiatric problems, and were satisfied with the treatment. Patients not operated on had been persuaded to abandon their operation after psychiatric therapy. In conclusion, the cooperation of the psychiatrist was found to be very effective in the treatment of those seeking aesthetic surgery.

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

The PreFACE: A preoperative psychosocial screen for elective facial cosmetic surgery and cosmetic dentistry patients
Abstract
Background

Currently no brief and objective screening protocol exists to assist surgeons and dentists in the identification of patients who are likely to report unsatisfactory outcomes after cosmetic surgery interventions. The aims of this study were to (1) investigate the relationship between postoperative dissatisfaction and preoperative characteristics (psychiatric disturbance, anxiety, depression, self-esteem, dysmorphic concern, and body image), and (2) empirically derive a preoperative psychosocial screening instrument to identify patients who may require preoperative assessment or counseling.

Methods

The sample composed of 84 patients (69 women and 15 men) undergoing elective cosmetic facial surgery or cosmetic dentistry. Before surgery, a self-report questionnaire was administered to the patients, which comprised questions designed to evaluate many of the psychosocial characteristics thought to be associated with unsatisfactory outcomes. Six months after surgery, a questionnaire was administered to the patients, which included items evaluating postoperative satisfaction.

Results

The findings revealed that preoperative psychiatric disturbance, anxiety, depression, low appearance evaluation, and body areas dissatisfaction are psychosocial risk factors that indicate an increased likelihood of patient dissatisfaction with surgical outcomes. The PreFACE (Preoperative FAcial Cosmetic surgery Evaluation), a brief objective preoperative screening questionnaire that can be easily and efficiently administered to elective facial cosmetic surgery and cosmetic dentistry patients, was empirically derived. It is able to identify most patients who are likely to express dissatisfaction and minimizes the selection of those who will express satisfaction. The PreFACE is recommended for validation using other cosmetic surgery populations.

Conclusions

The routine use of PreFACE is recommended for identification of patients who may benefit from preoperative counseling.

Honigman RJ¹, Jackson AC, Dowling NA. The PreFACE: A preoperative psychosocial screen for elective facial cosmetic surgery and cosmetic dentistry patients. Ann Plast Surg. 2011 Jan;66(1):16-23. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20798630

Psychological characteristics of women who undergo single and multiple cosmetic surgeries.
Abstract

Women over the age of 30 who had undergone single (N = 20) and multiple (N = 16) facial cosmetic surgery were compared with a control group (N = 49) on five personality measures. Cosmetic surgical patients were found to be more narcissistic (p = 0.05) and to have more problems with separation-individuation (p = 0.01) than the control group, but no group differences were found on measures of self-esteem and social anxiety. Cosmetic surgical patients had a more positive body image than the control group (p = 0.009). There were no differences between the single- and multiple-surgery groups. The study confirmed some, but not all, of the many prior clinical reports about personality disturbances in cosmetic surgical patients.

Dunofsky M. Psychological characteristics of women who undergo single and multiple cosmetic surgeries. Ann Plast Surg. 1997 Sep;39(3):223-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9326700

The psychiatric assessment of the patient requesting facial surgery
Abstract

Recent years have witnessed an increasing demand for cosmetic or reconstructive facial surgery. This paper addresses the pre-operative psychiatric assessment of the patient requesting facial surgery. Most patients adjust well to surgery and appreciate and accept the outcome. The psychiatrist who helps to screen difficult cases needs specific skills and must understand the body image issues involved. The psychiatrist needs to evaluate the patient’s motivations, expectations and understanding of the risks and implications of surgery. Potential problem patients are described, including the minimal defect patient, the patient with secondary gain from the deformity, the older patient, the patient in crisis, the polysurgical patient, the paranoid patient, the schizophrenic patient, and the male patient. Guidelines for evaluating the patient need to be applied flexibly. The psychiatrist must communicate with the surgeon to appreciate clearly the concerns the surgeon has about each patient.

Schweitzer I. The psychiatric assessment of the patient requesting facial surgery. Aust N Z J Psychiatry. 1989 Jun;23(2):249-54. Available from: http://www.ncbi.nlm.nih.gov/pubmed/2673200

SAFE: a practical guide to psychological factors in selecting patients for facial cosmetic surgery
Abstract

Selecting appropriate patients for facial cosmetic surgery can reduce patient management problems as well as increase the number of patients satisfied with their treatment and with the aesthetic result. In addition to medical considerations, the psychological make-up of a particular patient should play an important role in the decision to operate. Research with 55 patients undergoing aesthetic regenerative facial surgery has produced data which indicate particular personality characteristics to consider in the selection process. These four characteristics–self-evaluation of attractiveness, anxiety, fear, and expectation–are represented by the acronym SAFE; they are presented in this article along with the techniques for a surgeon to use when evaluating a patient for each characteristic. This method aids in selecting SAFE patients for surgery.

Lavell S, Lewis CM. SAFE: a practical guide to psychological factors in selecting patients for facial cosmetic surgery. Ann Plast Surg. 1984 Mar;12(3):256-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/6721387

Pulse oximetry for perioperative monitoring
Background

Monitoring with pulse oximetry might improve patient outcome by enabling an early diagnosis and consequently, correction of perioperative events that might cause postoperative complications or even death. Only a few randomized clinical trials of pulse oximetry have been performed during anaesthesia, and in the recovery room which describe perioperative hypoxaemic events, postoperative cardiopulmonary complications and cognitive dysfunction.

Objectives

The objective of this review was to assess the effect of perioperative monitoring with pulse oximetry and to clearly identify the adverse outcomes that might be prevented or improved by the use of pulse oximetry.

Search Strategy

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2003, issue 1) MEDLINE (1966 to January 2003), EMBASE (1980 to January 2003), and by checking the reference lists of trials and review articles.

Selection Criteria

All controlled trials that randomized patients to either pulse oximetry or no pulse oximetry during the perioperative period, including the operating and recovery room.

Data collection and analysis

Two reviewers independently assessed data in relation to events detectable by pulse oximetry, any serious complications that occurred during anaesthesia or in the postoperative period, intra- or postoperative mortality, and duration of recovery or intensive care stay. Formal statistical synthesis of individual trials was not performed in view of the variety of outcomes studied.

Main results

Searching identified six reports. Four studies with data from a total of 21,773 patients were considered eligible for analysis. Only two studies specifically addressed the outcomes in question, both found no evidence of an effect on the rate of postoperative complications using perioperative pulse oximetry. Two studies used hypoxaemia detectable by pulse oximetry to assess the value of perioperative monitoring, although outcomes were not given. It was found that hypoxaemia was reduced in the pulse oximetry group both in the operating theatre and in the recovery room. During observation in the recovery room, the incidence of hypoxaemia in the pulse oximetry group was 1.5-3 times less. The postoperative cognitive function using the Wechsler memory scale and continuous reaction time was independent of perioperative monitoring with pulse oximetry. The other study showed that postoperative complications occurred in 10% of the patients in the oximetry group and in 9.4% in the control group. No statistically significant differences were detected in cardiovascular, respiratory, neurologic, or infectious complications in the two groups. The duration of hospital stay was a median of five days in both groups, and an equal number of in-hospital deaths was registered in the two groups.

Reviewers conclusions

The studies confirmed that pulse oximetry can detect hypoxaemia and related events. However, we have found no evidence that pulse oximetry affects the outcome of anaesthesia. The conflicting subjective and objective results of the studies, despite an intense, methodical collection of data from a relatively large population, indicate that the value of perioperative monitoring with pulse oximetry is questionable in relation to improved reliable outcomes, effectiveness and efficiency.

Pedersen T¹, Dyrlund Pedersen B, Moller AM. Pulse oximetry for perioperative monitoring.
Cochrane Database Syst Rev. 2003;(3):CD002013. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12917918

Neuroprotection during cardiac surgery: a randomised trial of a platelet activating factor antagonist
Objective

To assess platelet activating factor (PAF) antagonists, potent neuroprotective agents in experimental cerebral dysfunction, in clinical practice. DESIGN: Double blind, minimised, placebo controlled trial of low and high dose PAF antagonist (lexipafant). SETTING: Cardiac surgery unit. PATIENTS: 150 patients undergoing coronary artery bypass graft (CABG) surgery using cardiopulmonary bypass. INTERVENTIONS: Randomisation to placebo, low dose (10 mg) or high dose (100 mg) lexipafant. MAIN OUTCOME MEASURES: Incidence of impairment on four established cognitive tests, undertaken before, five days, and three months after CABG, examined by three methods for defining impairment. RESULTS: The three groups were similar with respect to preoperative and intraoperative factors. Observed levels of cognitive impairment were less than had been predicted from previous studies. There was no difference in the groups in cognitive change scores at five days or three months. Group mean analysis showed significant time factors for all four tests but not for interactions or for the lexipafant group. A composite cognitive index, based on the aggregate of four normally distributed tests, showed a significant effect for timing of the test but not for the lexipafant group or interaction. Age, but not duration of bypass, was the most important determinant of postoperative cognitive impairment.

Conclusion

The neuroprotective PAF antagonist lexipafant did not differentially reduce the level of cognitive impairment after CABG as determined by power estimates derived from published studies. The strongest predictors of cognitive impairment were age and timing of the test after operation.

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

Quality of life and femoral neck fractures
Abstract

The worldwide increase in hip fractures is a major challenge to the health care system and society. The proper treatment of femoral neck fractures in the elderly is still controversial, and even more so from an international perspective. Optimising the treatment for improved outcomes and a reduced need for secondary surgery is mandatory for humanitarian and economical reasons. The importance of incorporating the patient’s perspective of the outcome in clinical trials has been acknowledged and there are now numerous instruments for assessing the quality of life.

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

The effect of zero-balanced ultrafiltration during cardiopulmonary bypass on S100b release and cognitive function
Abstract

Zero-balanced ultrafiltration (ZBUF) might reduce the systemic inflammatory response (SIRS) during cardiopulmonary bypass (CPB) by removing inflammatory mediators. The objective of this study was to determine the effect of ZBUF on postoperative serum S100b levels, a marker of neuronal injury. In addition, the possible effects of ZBUF on postoperative neurocognitive function were assessed. Sixty patients undergoing elective coronary bypass grafting were randomly assigned either to a control group or to a protocol group in which ZBUF was performed. Serum S100b levels were measured five minutes after intubation, at the end of bypass and eight and 20 hours after arrival at the intensive care unit (ICU). Cognitive function was assessed with neuropsychological tests on the day before the operation and the sixth day after surgery. The S100b level at 20 hours after arrival at the ICU was 0.27 g/L (SD 0.16) in the control and 0.25 g/L (SD 0.12) in the group with ZBUF. There were no statistical differences at any time between the two groups. S100b was not detectable in the ultrafiltrate, indicating that these results were not obscured by washout of S100b. Thirteen patients (52%) in the control group and 14 patients (56%) in the ZBUF group showed a cognitive deficit. In conclusion, ZBUF during CPB does not decrease the release of S100b. This result is not affected by washout. ZBUF did not reduce the incidence of early neurocognitive deficits. The role of SIRS in the development of cognitive dysfunction following CPB remains to be resolved.

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

Induced arterial hypotension for interventional thoracic aortic stent-graft placement: impact on intracranial haemodynamics and cognitive function
Abstract
Background and Objective

The study investigated the impact of induced arterial hypotension for the facilitation of endovascular stent-graft placement in patients with thoracic aortic aneurysm on cerebral blood flow velocity and neurological/neurocognitive outcome. METHODS: In 27 ASA III patients, cerebral blood flow velocity was recorded during induced arterial hypotension for endovascular stent-graft placement using transcranial Doppler sonography and the Folstein Mini Mental State Examination and the National Institute of Health Stroke Scale were performed before and after the intervention. RESULTS: Mean arterial pressure was decreased

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

Relationship between pain and opioid analgesics on the development of delirium following hip fracture
Background

Delirium and pain are common following hip fracture. Untreated pain has been shown to increase the risk of delirium in older adults undergoing elective surgery. This study was performed to examine the relationship among pain, analgesics, and other factors on delirium in hip fracture patients. METHODS: We conducted a prospective cohort study at four New York hospitals that enrolled 541 patients with hip fracture and without delirium. Delirium was identified prospectively by patient interview supplemented by medical record review. Multiple logistic regression was used to identify risk factors. RESULTS: Eighty-seven of 541 patients (16%) became delirious. Among all subjects, risk factors for delirium were cognitive impairment (relative risk, or RR, 3.6; 95% confidence interval, or CI, 1.8-7.2), abnormal blood pressure (RR 2.3, 95% CI 1.2-4.7), and heart failure (RR 2.9, 95% CI 1.6-5.3). Patients who received less than 10 mg of parenteral morphine sulfate equivalents per day were more likely to develop delirium than patients who received more analgesia (RR 5.4, 95% CI 2.4-12.3). Patients who received meperidine were at increased risk of developing delirium as compared with patients who received other opioid analgesics (RR 2.4, 95% CI 1.3-4.5). In cognitively intact patients, severe pain significantly increased the risk of delirium (RR 9.0, 95% CI 1.8-45.2). CONCLUSIONS: Using admission data, clinicians can identify patients at high risk for delirium following hip fracture. Avoiding opioids or using very low doses of opioids increased the risk of delirium. Cognitively intact patients with undertreated pain were nine times more likely to develop delirium than patients whose pain was adequately treated. Undertreated pain and inadequate analgesia appear to be risk factors for delirium in frail older adults.

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

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.

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

Cerebral blood flow and cognitive dysfunction after coronary surgery
Background

Postoperative cognitive dysfunction after cardiac surgery has been attributed both to embolic events and periods with reduced cerebral perfusion. We investigated whether cognitive dysfunction after coronary surgery is associated with changes in regional cerebral blood flow (CBF) using single photon emission computed tomography. METHODS: Before surgery and at discharge, 15 coronary surgery patients were studied. Global and regional CBF were measured using a brain-dedicated single photon emission computed tomography scanner, and neuropsychological testing with seven subtests was performed. Postoperative cognitive dysfunction was defined as a Z score above 2. Normative single photon emission computed tomography data were available from 26 healthy age-matched controls. RESULTS: Preoperative global CBF was significantly lower in patients compared with controls (53.7 versus 46.1 mL/100 g/min, p = 0.006). After surgery, global CBF significantly decreased in the patient group (46.1 versus 38.6 mL/100 g/min, p = 0.0001). No significant differences were detected in regional CBF. Cognitive dysfunction was identified in 4 of the 15 patients (26.7%, 95% CI 7.8% to 55.1%). No correlation was found between the neuropsychological Z score and global or regional CBF. CONCLUSIONS: The significant decrease in CBF after coronary surgery was uniformly distributed and was not correlated to postoperative cognitive dysfunction.

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

Internal health status belief and lower perceived functional deficit are related among anterior cruciate ligament-deficient patients
Abstract

Health locus of control has been shown to influence the recovery process after injury and surgery. This study attempted to determine relationships between patient perceptions of health locus of control and their perceived functional limitations after anterior cruciate ligament (ACL) rupture. An external health locus of control refers to the belief that one’s outcome after injury or surgery is under the control of powerful others or is determined by fate, luck, or chance. An internal health locus of control refers to the belief that one’s outcome is directly related to individual patient behaviors. TYPE OF STUDY: Quasi-experimental, posttest only design. METHODS: Over a 1-year time period, 70 consecutive patients with unilateral ACL deficiency (acute,

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

Emboli, inflammation, and CNS impairment: an overview
Abstract

Perioperative stroke occurs in 2-3% of adult cardiac surgery patients, and significant cognitive dysfunction is experienced by 40-60% of patients in the first postoperative week. Perioperative neurocognitive abnormalities are associated with a greatly increased risk of perioperative mortality, lengthy intensive care and hospital stay, and more intensive rehabilitative care. Long-term cognitive dysfunction, ranging from months to years, occurs in 25-40% of adult cardiac surgery patients, resulting in a decreased quality of life. Cerebral emboli are an important cause of perioperative neurocognitive abnormalities. Aortic cannulation, clamping, and manipulation during surgery may dislodge atheromatous materials into the cerebral circulation, leading to perioperative or postoperative stroke.

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

Vascular dementia may be the most common form of dementia in the elderly
Abstract

Cerebrovascular lesions, mainly lacunes and white matter ischemia, are common in elderly patients with dementia. Vascular dementia (VaD) is the second most common cause of dementia, after Alzheimer’s disease (AD). However, lacunar strokes have become an important factor in the clinical expression of AD. Also, population-based studies indicate that vascular risk factors increase the risk of developing AD. It is postulated here that the two main causes of VaD-stroke and ischemic heart disease (IHD)-may be responsible for the majority of cases of dementia in the elderly.

Stroke related VaD

Cerebrovascular disease (CVD) is the second leading cause of death worldwide. About 1/3 of stroke survivors [range: 25-41%] 65 years old and above develop VaD within 3 months following the ictus. In the USA alone, 125,000 new cases/year of VaD occur after ischemic stroke (about 1/3 of the 360,000 incident cases of AD). Therefore, more than 1 million elderly people are currently affected by poststroke VaD in the USA. Since current criteria identify “pure” cases of AD and VaD, it is likely that “AD plus CVD” (“mixed” dementia) could be responsible for a large number of cases currently diagnosed as probable AD. CARDIOGENIC VAD

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

Cerebral oxygen saturation assessed by near-infrared spectroscopy during coronary artery bypass grafting and early postoperative cognitive function
Background

Cerebral oxygen saturation (ScO2) can be assessed by near-infrared spectroscopy. We investigated the correlation between early postoperative cognitive performance and intraoperative ScO2 in a prospective observational setting. METHODS: Forty-seven patients undergoing elective coronary artery bypass grafting with cardiopulmonary bypass underwent preoperative and postoperative neuropsychological evaluation. Patients were classified according to the presence or absence of postoperative cognitive dysfunction.

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

Cerebral effects and blood sparing efficiency of sodium nitroprusside-induced hypotension alone and in combination with acute normovolaemic haemodilution
Abstract

The combined reduction of oxygen-carrying capacity and perfusion pressure during the combination of acute normovolaemic haemodilution (ANH) and controlled hypotension (CH) raises concerns of hypoperfusion and ischaemic injury to the brain. Forty-two patients undergoing radical prostatectomy were prospectively allocated to receive CH induced by sodium nitroprusside (mean arterial pressure (MAP) 50 mm Hg), a combination of CH+ANH (post-ANH haematocrit 29%; intraoperative MAP 50 mm Hg), or standard anaesthesia (control). Serum levels of the brain-originated proteins neuron-specific enolase (NSE) and protein S-100, blood loss, transfusion requirements, adverse effects, and postoperative recovery profile were compared among the three groups. Intraoperative blood loss in the CH group (mean (SD)) (788 (193) ml) and CH+ANH group (861 (184) ml) was significantly less than in the control group (1335 (460) ml). Significantly fewer total units of allogeneic packed red blood cells (PRBC) were transfused in the patients receiving hypotensive anaesthesia (CH, 3 units; CH+ANH, 2 units; control, 17 units). There was no difference in immediate postoperative recovery profile among the three groups as determined by the emergence from anaesthesia and time to discharge from the postanaesthesia care unit. Serum S-100 protein concentrations increased significantly in all groups from baseline to peak concentrations 2 h postoperatively (CH 0.25 (0.11) microg litre(-1); CH+ANH 0.31 (0.12) microg litre(-1); control 0.31 (0.10) microg litre(-1)). A return to baseline values was seen within 24 h postoperatively in all patients. No changes in NSE concentrations were seen. Our observations suggest that CH and CH+ANH were effective in reducing blood loss and transfusion requirements in patients undergoing radical prostatectomy. Increased serum S-100 protein concentrations imply a disturbance in astroglial cell membrane integrity and an increased endothelial permeability of the blood-brain barrier. There were no associations between serum S-100 protein or NSE and adverse cognitive effects. Further work needs to be done to determine the prognostic importance of S-100 protein and NSE as surrogate variables of postoperative cerebral complications.

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

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