We examined the risk for postoperative delirium (POD) in patients with mild cognitive impairment (MCI) or dementia, and the association between POD and subsequent development of MCI or dementia in ...cognitively normal elderly patients.
Patients ≥65 yr of age enrolled in the Mayo Clinic Study of Aging who were exposed to any type of anaesthesia from 2004 to 2014 were included. Cognitive status was evaluated before and after surgery by neuropsychological testing and clinical assessment, and was defined as normal or MCI/dementia. Postoperative delirium was detected with the Confusion Assessment Method for the intensive care unit. Logistic regression analyses were performed.
Among 2014 surgical patients, 74 (3.7%) developed POD. Before surgery, 1667 participants were cognitively normal, and 347 met MCI/dementia criteria. The frequency of POD was higher in patients with pre-existing MCI/dementia compared with no MCI/dementia {8.7 vs 2.6%; odds ratio (OR) 2.53, 95% confidence interval (CI) 1.52–4.21; P<0.001}. Postoperative delirium was associated with lower education OR, 3.40 (95% CI, 1.60–7.40); P=0.002 for those with <12 vs ≥16 yr of schooling. Of the 1667 patients cognitively normal at their most recent assessment, 1152 returned for postoperative evaluation, and 109 (9.5%) met MCI/dementia criteria. The frequency of MCI/dementia at the first postoperative evaluation was higher in patients who experienced POD compared with those who did not 33.3 vs 9.0%; adjusted OR, 3.00 (95% CI, 1.12–8.05); P=0.029.
Mild cognitive impairment or dementia is a risk for POD. Elderly patients who have not been diagnosed with MCI or dementia but experience POD are more likely to be diagnosed subsequently with MCI or dementia.
Single preoperative gabapentinoid (gabapentin and pregabalin) administration has been associated with respiratory depression during Phase I anaesthesia recovery. In this study, we assess for ...associations between chronic (home) use and perioperative administration (preoperative and postoperative) of gabapentinoids, and risk for severe over-sedation or respiratory depression as inferred from the use of naloxone.
From 2011 to 2016, we identified patients undergoing general anaesthesia discharged to standard postoperative wards and administered naloxone within 48 h of surgery in a single centre. These patients were 2:1 matched on age, sex, and type of procedure. Patient and perioperative characteristics were abstracted and compared to assess for risk for naloxone administration.
We identified 128 patients that received naloxone after operation odds ratio 1.2; 95% confidence interval (CI) 1.0, 1.4 per 1000 general anaesthetics. Patients on chronic or postoperative gabapentinoid therapy were at significantly higher risk for receiving naloxone after operation. Multivariable analysis detected significant interactions between chronic and postoperative use of gabapentinoids, where continuation of chronic gabapentinoid medications into the postoperative period was associated with an increased rate of naloxone administration (6.30, 95% CI 2.4, 16.7; P=0.001). Obstructive sleep apnoea (P=0.005) and preoperative disability (P=0.003) were also associated with an increased risk for postoperative naloxone administration. Patients who received naloxone had longer hospital stays and higher rates of postoperative delirium.
Continuation of chronic gabapentinoid medications into the postoperative period is associated with the increased use of naloxone to reverse over-sedation or respiratory depression. Such patients requiring this therapy warrant high levels of postoperative monitoring.
Systemic opioids are immunosuppressive, which could promote tumour recurrence. We, therefore, test the hypothesis that supplementing general anaesthesia with neuraxial analgesia improves long-term ...oncological outcomes in patients having radical prostatectomy for adenocarcinoma.
Patients who had general anaesthesia with neuraxial analgesia (n=1642) were matched 1:1 based on age, surgical year, pathological stage, Gleason scores, and presence of lymph node disease with those who had general anaesthesia only. Medical records were reviewed. Outcomes of interest were systemic cancer progression, recurrence, prostate cancer mortality, and all-cause mortality. Data were analysed using stratified proportional hazards regression, the Kaplan–Meier method, and log-rank tests. The median follow-up was 9 yr.
After adjusting for comorbidities, positive surgical margins, and adjuvant hormonal and radiation therapies within 90 postoperative days, general anaesthesia only was associated with increased risk for systemic progression hazard ratio (HR)=2.81, 95% confidence interval (CI) 1.31–6.05; P=0.008 and higher overall mortality (HR=1.32, 95% CI 1.00–1.74; P=0.047). Although not statistically significant, similar findings were observed for the outcome of prostate cancer deaths (adjusted HR=2.2, 95% CI 0.88–5.60; P=0.091).
This large retrospective analysis suggests a possible beneficial effect of regional anaesthetic techniques on oncological outcomes after prostate surgery for cancer; however, these findings need to be confirmed (or refuted) in randomized trials.
Recent studies show that intraoperative mechanical ventilation using low tidal volumes (VT) can prevent postoperative pulmonary complications (PPCs). The aim of this individual patient data ...meta-analysis is to evaluate the individual associations between VT size and positive end-expiratory pressure (PEEP) level and occurrence of PPC.
Randomized controlled trials comparing protective ventilation (low VT with or without high levels of PEEP) and conventional ventilation (high VT with low PEEP) in patients undergoing general surgery. The primary outcome was development of PPC. Predefined prognostic factors were tested using multivariate logistic regression.
Fifteen randomized controlled trials were included (2,127 patients). There were 97 cases of PPC in 1,118 patients (8.7%) assigned to protective ventilation and 148 cases in 1,009 patients (14.7%) assigned to conventional ventilation (adjusted relative risk, 0.64; 95% CI, 0.46 to 0.88; P < 0.01). There were 85 cases of PPC in 957 patients (8.9%) assigned to ventilation with low VT and high PEEP levels and 63 cases in 525 patients (12%) assigned to ventilation with low VT and low PEEP levels (adjusted relative risk, 0.93; 95% CI, 0.64 to 1.37; P = 0.72). A dose-response relationship was found between the appearance of PPC and VT size (R2 = 0.39) but not between the appearance of PPC and PEEP level (R2 = 0.08).
These data support the beneficial effects of ventilation with use of low VT in patients undergoing surgery. Further trials are necessary to define the role of intraoperative higher PEEP to prevent PPC during nonopen abdominal surgery.
The link between exposure to general anaesthesia and surgery (exposure) and cognitive decline in older adults is debated. We hypothesised that it is associated with cognitive decline.
We analysed the ...longitudinal cognitive function trajectory in a cohort of older adults. Models assessed the rate of change in cognition over time, and its association with exposure to anaesthesia and surgery. Analyses assessed whether exposure in the 20 yr before enrolment is associated with cognitive decline when compared with those unexposed, and whether post-enrolment exposure is associated with a change in cognition in those unexposed before enrolment.
We included 1819 subjects with median (25th and 75th percentiles) follow-up of 5.1 (2.7–7.6) yr and 4 (3–6) cognitive assessments. Exposure in the previous 20 yr was associated with a greater negative slope compared with not exposed (slope: –0.077 vs –0.059; difference: –0.018; 95% confidence interval: –0.032, –0.003; P=0.015). Post-enrolment exposure in those previously unexposed was associated with a change in slope after exposure (slope: –0.100 vs –0.059 for post-exposure vs pre-exposure, respectively; difference: –0.041; 95% confidence interval: –0.074, –0.008; P=0.016). Cognitive impairment could be attributed to declines in memory and attention/executive cognitive domains.
In older adults, exposure to general anaesthesia and surgery was associated with a subtle decline in cognitive z-scores. For an individual with no prior exposure and with exposure after enrolment, the decline in cognitive function over a 5 yr period after the exposure would be 0.2 standard deviations more than the expected decline as a result of ageing. This small cognitive decline could be meaningful for individuals with already low baseline cognition.
‘Open lung’ ventilation is commonly used in patients with acute lung injury and has been shown to improve intraoperative oxygenation in obese patients undergoing laparoscopic surgery. The feasibility ...of an ‘open lung’ ventilatory strategy in elderly patients under general anaesthesia has not previously been assessed.
‘Open lung’ ventilation (recruitment manoeuvres, tidal volume 6 ml kg−1 predicted body weight, and 12 cm H2O PEEP) (RM group) was compared with conventional ventilation (no recruitment manoeuvres, tidal volume 10 ml kg−1 predicted body weight, and zero end-expiratory pressure) in elderly patients (>65 yr) undergoing major open abdominal surgery with regard to oxygenation, respiratory system mechanics, and haemodynamic stability. We also monitored the serum levels of the interleukins (IL)-6 and IL-8 before and after surgery to determine whether the systemic inflammatory response to surgery depends on the ventilatory strategy used.
Twenty patients were included in each group. The RM group tolerated open lung ventilation without significant haemodynamic instability. Intraoperative Pao2 improved in the RM group (P<0.01) and deteriorated in controls (P=0.01), but postoperative Pao2 was similar in both groups. The RM group had improved breathing mechanics as evidenced by increased dynamic compliance (36%) and decreased airway resistance (21%). Both IL-6 and IL-8 significantly increased after surgery, but the magnitude of increase did not differ between the groups.
A lung recruitment strategy in elderly patients is well tolerated and improves intraoperative oxygenation and lung mechanics during laparotomy.
The objective of this study was to determine the relationship between perioperative complications and the severity of obstructive sleep apnoea (OSA) in patients undergoing bariatric surgery who had ...undergone preoperative polysomnography (PSG).
The records of 797 patients, age >18 yr, who underwent bariatric operations (442 open and 355 laparoscopic procedures) at Mayo Clinic and were assessed before operation by PSG, were reviewed retrospectively. OSA was quantified using the apnoea–hypopnoea index (AHI) as none (≤4), mild (5–15), moderate (16–30), and severe (≥31). Pulmonary, surgical, and ‘other’ complications within the first 30 postoperative days were analysed according to OSA severity. Logistic regression was used to assess the multivariable association of OSA, age, sex, BMI, and surgical approach with postoperative complications.
Most patients with OSA (93%) received perioperative positive airway pressure therapy, and all patients were closely monitored after operation with pulse oximetry on either regular nursing floors or in intensive or intermediate care units. At least one postoperative complication occurred in 259 patients (33%). In a multivariable model, the overall complication rate was increased with open procedures compared with laparoscopic. In addition, increased BMI and age were associated with increased likelihood of pulmonary and other complications. Complication rates were not associated with OSA severity.
In obese patients evaluated before operation by PSG before bariatric surgery and managed accordingly, the severity of OSA, as assessed by the AHI, was not associated with the rate of perioperative complications. These results cannot determine whether unrecognized and untreated OSA increases risk.
Lung injury is a serious complication of surgery. We did a systematic review and meta-analysis to assess whether incidence, morbidity, and in-hospital mortality associated with postoperative lung ...injury are affected by type of surgery and whether outcomes are dependent on type of ventilation.
We searched MEDLINE, CINAHL, Web of Science, and Cochrane Central Register of Controlled Trials for observational studies and randomised controlled trials published up to April, 2014, comparing lung-protective mechanical ventilation with conventional mechanical ventilation during abdominal or thoracic surgery in adults. Individual patients' data were assessed. Attributable mortality was calculated by subtracting the in-hospital mortality of patients without postoperative lung injury from that of patients with postoperative lung injury.
We identified 12 investigations involving 3365 patients. The total incidence of postoperative lung injury was similar for abdominal and thoracic surgery (3·4% vs 4·3%, p=0·198). Patients who developed postoperative lung injury were older, had higher American Society of Anesthesiology scores and prevalence of sepsis or pneumonia, more frequently had received blood transfusions during surgery, and received ventilation with higher tidal volumes, lower positive end-expiratory pressure levels, or both, than patients who did not. Patients with postoperative lung injury spent longer in intensive care (8·0 SD 12·4 vs 1·1 3·7 days, p<0·0001) and hospital (20·9 18·1 vs 14·7 14·3 days, p<0·0001) and had higher in-hospital mortality (20·3% vs 1·4% p<0·0001) than those without injury. Overall attributable mortality for postoperative lung injury was 19% (95% CI 18-19), and differed significantly between abdominal and thoracic surgery patients (12·2%, 95% CI 12·0-12·6 vs 26·5%, 26·2-27·0, p=0·0008). The risk of in-hospital mortality was independent of ventilation strategy (adjusted HR 0·71, 95% CI 0·41-1·22).
Postoperative lung injury is associated with increases in in-hospital mortality and durations of stay in intensive care and hospital. Attributable mortality due to postoperative lung injury is higher after thoracic surgery than after abdominal surgery. Lung-protective mechanical ventilation strategies reduce incidence of postoperative lung injury but does not improve mortality.
None.
Background
Surgery for catecholamine‐producing tumours can be complicated by intraoperative and postoperative haemodynamic instability. Several perioperative management strategies have emerged but ...none has been evaluated in randomized trials. To assess this issue, contemporary perioperative management and outcome data from 21 centres were collected.
Methods
Twenty‐one centres contributed outcome data from patients who had surgery for phaeochromocytoma and paraganglioma between 2000 and 2017. The data included the number of patients with and without α‐receptor blockade, surgical and anaesthetic techniques, complications and perioperative mortality.
Results
Across all centres, data were reported on 1860 patients with phaeochromocytoma or paraganglioma, of whom 343 underwent surgery without α‐receptor blockade. The majority of operations (78·9 per cent) were performed using minimally invasive techniques, including 16·1 per cent adrenal cortex‐sparing procedures. The cardiovascular complication rate was 5·0 per cent overall: 5·9 per cent (90 of 1517) in patients with preoperative α‐receptor blockade and 0·9 per cent (3 of 343) among patients without α‐receptor blockade. The mortality rate was 0·5 per cent overall (9 of 1860): 0·5 per cent (8 of 517) in pretreated and 0·3 per cent (1 of 343) in non‐pretreated patients.
Conclusion
There is substantial variability in the perioperative management of catecholamine‐producing tumours, yet the overall complication rate is low. Further studies are needed to better define the optimal management approach, and reappraisal of international perioperative guidelines appears desirable.
Antecedentes
La cirugía de los tumores productores de catecolaminas puede complicarse por la inestabilidad hemodinámica intraoperatoria y postoperatoria. Se han propuesto distintas estrategias de manejo perioperatorio, pero ninguna ha sido evaluada en ensayos aleatorizados. Para evaluar este tema, se han recogido los datos de los resultados y del manejo perioperatorio contemporáneo de 21 centros.
Métodos
Veintiún centros aportaron datos de los resultados de los pacientes operados por feocromocitoma y paraganglioma entre 2000‐2017. Los datos incluyeron el número de pacientes con y sin bloqueo del receptor α, las técnicas quirúrgicas y anestésicas, las complicaciones y la mortalidad perioperatoria.
Resultados
Los centros en su conjunto aportaron datos de 1.860 pacientes con feocromocitoma y paraganglioma, de los cuales 343 pacientes fueron intervenidos sin bloqueo del receptor α. La gran mayoría (79%) de las cirugías se realizaron utilizando técnicas mínimamente invasivas, incluido un 17% de procedimientos con preservación de la corteza suprarrenal. La tasa de complicaciones cardiovasculares fue de 5,0% en total; 5,9% (90/1517) en pacientes con bloqueo preoperatorio de los receptores α y 0,9% (3/343) en pacientes no pretratados. La mortalidad global fue del 0,5% (9/1860); 0,5% (8/1517) en pacientes pretratados y 0,3% (1/343) en pacientes no tratados previamente.
Conclusión
Existe una variabilidad sustancial en el manejo perioperatorio de los tumores productores de catecolaminas, aunque la tasa global de complicaciones es baja. Este estudio brinda la oportunidad para efectuar comparaciones sistemáticas entre estrategias de prácticas terapéuticas variables. Se necesitan más estudios para definir mejor el enfoque de manejo óptimo y parece conveniente volver a evaluar las guías internacionales perioperatorias.
Morbidity and mortality rates are difficult to determine in rare diseases like phaeochromocytoma. To date there has been no randomized study of the perioperative management of these patients. Therefore, an international and interdisciplinary effort was made to provide a broad overview of the current management of phaeochromocytoma.
Adverse effects frequent with preoperative blocking
Background
Postoperative nausea and vomiting (PONV) is a common and unpleasant complication of general anesthesia. There are well-known risk factors that predispose a patient to develop PONV. While ...studies exist that explore PONV incidence in gravid and non-gravid women separately, limited studies exist to compare the two cohorts to identify if pregnancy is associated with increased risk for PONV or differences in PONV prophylaxis and treatment.
Methods
This is a retrospective case–control cohort study, with 1:2 matching based on age, year of surgery, and surgical procedure. Electronic medical records were abstracted for demographic information, predisposing risk factors, prophylactic antiemetics, PONV documentation, rescue antiemetics, PACU stay, and length of hospitalization. Analyses of risk factors for PONV were performed using logistic and multinomial logistic regression analyses.
Results
237 gravid women who underwent non-obstetric procedures with general anesthesia were identified and matched with 474 non-gravid women. PONV complicated the course of 51 (21.5%) gravid and 72 (15.2%) non-gravid women. The number of prophylactic antiemetics was fewer among gravid (median 2 1, 2) than non-gravid (3 2, 3) women (P < 0.001). No association was found between gravid status and risk for PONV (adjusted odds ratio 1.35 95%CI 0.84, 2.17, P = 0.222). Gravid women had longer hospital lengths of stay (P < 0.001), despite having shorter surgical duration (P = 0.015).
Conclusions
The risk for PONV is similar between gravid and similarly aged women. However, anesthesiologists administer fewer prophylactic antiemetics to gravid women during non-obstetric surgery.
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