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.
Anaesthetic and sedative drugs transiently disrupt normal neural activity to facilitate healthcare procedures in children, but they can also cause long-term brain injury in experimental animal ...models. The US Food and Drug Administration (FDA) has recently advised that repeated or lengthy exposures to anaesthetic and sedative drugs prior to 3 yr of age have the potential to harm the development of children's brains and added warnings to these drug labels. Paediatric anaesthesia toxicity could represent a significant public health issue, and concern about this potential injury in children has become an important issue for families, paediatric clinicians and healthcare regulators. Since late 2015, important new data from five major clinical studies have been published. This narrative review aims to provide a brief overview of the preclinical and clinical literature, including a comprehensive review of these recent additions to the human literature. We integrate these new data with prior studies to provide further insights into how these clinical findings can be applied to children.
Pulmonary aspiration of gastric contents during the perioperative period in infants and children may be associated with postoperative mortality or pulmonary morbidity. There has not been a recent ...determination of the frequency of this event and its outcomes in infants and children.
The authors prospectively identified all cases of pulmonary aspiration of gastric contents during the perioperative courses of 56,138 consecutive patients younger than 18 yr of age who underwent 63,180 general anesthetics for procedures performed in all surgical specialties from July 1985 through June 1997 at the Mayo Clinic.
Pulmonary aspiration occurred in 24 patients (1: 2,632 anesthetics; 0.04%). Children undergoing emergency procedures had a greater frequency of pulmonary aspiration compared to those undergoing elective procedures (1:373 vs. 1:4,544, P < 0.001). Fifteen of the 24 children who aspirated gastric contents did not develop respiratory symptoms within 2 h of aspiration, and none of these 15 developed pulmonary sequelae. Five of these nine children who aspirated and in whom respiratory symptoms developed within 2 h subsequently had pulmonary complications treated with respiratory support (P < 0.003). Three children were treated with mechanical ventilation for more than 48 h, but no child died of sequelae of pulmonary aspiration.
In this study population, the frequency of perioperative pulmonary aspiration in children was quite low. Serious respiratory morbidity was rare, and there were no associated deaths. Infants and children with clinically apparent pulmonary aspiration in whom symptoms did not develop within 2 h did not have respiratory sequelae.
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.
While acute lung injury (ALI) is among the most serious postoperative pulmonary complications, its incidence, risk factors and outcome have not been prospectively studied.
To determine the incidence ...and survival of ALI associated postoperative respiratory failure and its association with intraoperative ventilator settings, specifically tidal volume.
Prospective, nested, case control study.
Single tertiary referral centre.
4420 consecutive patients without ALI undergoing high risk elective surgeries for postoperative pulmonary complications.
Incidence of ALI, survival and 2:1 matched case control comparison of intraoperative exposures.
238 (5.4%) patients developed postoperative respiratory failure. Causes included ALI in 83 (35%), hydrostatic pulmonary oedema in 74 (31%), shock in 27 (11.3%), pneumonia in nine (4%), carbon dioxide retention in eight (3.4%) and miscellaneous in 37 (15%). Compared with match controls (n = 166), ALI cases had lower 60 day and 1 year survival (99% vs 73% and 92% vs 56%; p<0.001). Cases were more likely to have a history of smoking, chronic obstructive pulmonary disease and diabetes, and to be exposed to longer duration of surgery, intraoperative hypotension and larger amount of fluid and transfusions. After adjustment for non-ventilator parameters, mean first hour peak airway pressure (OR 1.07; 95% CI 1.02 to 1.15 cm H(2)O) but not tidal volume (OR 1.03; 95% CI 0.84 to 1.26 ml/kg), positive end expiratory pressure (OR 0.89; 95% CI 0.77 to 1.04 cm H(2)O) or fraction of inspired oxygen (OR 1.0; 95% CI 0.98 to 1.03) were associated with ALI.
ALI is the most common cause of postoperative respiratory failure and is associated with markedly lower postoperative survival. Intraoperative tidal volume was not associated with an increased risk for early postoperative ALI.
‘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.
Background
The International Federation of Gynecology and Obstetrics (FIGO) systems for nomenclature of symptoms of normal and abnormal uterine bleeding (AUB) in the reproductive years (FIGO AUB ...System 1) and for classification of causes of AUB (FIGO AUB System 2; PALM‐COEIN) were first published together in 2011. The purpose was to harmonize the definitions of normal and abnormal bleeding symptoms and to classify and subclassify underlying potential causes of AUB in the reproductive years to facilitate research, education, and clinical care. The systems were designed to be flexible and to be periodically reviewed and modified as appropriate.
Objectives
To review, clarify, and, where appropriate, revise the previously published systems.
Methodology and outcome
To a large extent, the process has been an iterative one involving the FIGO Menstrual Disorders Committee, as well as a number of invited contributions from epidemiologists, gynecologists, and other experts in the field from around the world between 2012 and 2017. Face‐to‐face meetings have been held in Rome, Vancouver, and Singapore, and have been augmented by a number of teleconferences and other communications designed to evaluate various aspects of the systems. Where substantial change was considered, anonymous voting, in some instances using a modified RAND Delphi technique, was utilized.
Revisions are presented for the two FIGO systems describing structured normal uterine bleeding and abnormal uterine bleeding symptoms, and the PALM‐COEIN classification of potential causes.
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.
Background The aim of this exploratory study was to establish whether we could improve skeletal health with a physiological regimen of SSR in young women with premature ovarian failure (POF).
...Patients and Methods In an open‐label randomized controlled crossover trial, 34 women with POF were randomized to 4‐week cycles of pSSR (transdermal oestradiol, 100 μg daily for week 1, 150 μg for weeks 2–4; vaginal progesterone, 200 mg twice daily for weeks 3–4) or standard hormone replacement treatment (sHRT) (oral ethinyloestradiol 30 μg and 1·5 mg norethisterone daily for weeks 1–3, week 4 ‘pill‐free’) for 12 months. Bone mineral density (BMD) was measured by DEXA at study entry and after each 12‐month treatment period. Blood samples for hormones and markers of bone formation (bone alkaline phosphatase, BALP and type I collagen N‐terminal propeptide, PINP) and bone resorption (CrossLaps) were collected pre‐/postwashout and after 3, 6 and 12 months of each treatment.
Results Eighteen women, mean 27 (range 19–39) years, completed the study. Both regimens caused similar suppression of LH and FSH. Mean baseline lumbar spine BMD z‐score was −0·89 (95% CI −1·27 to −0·51) and increased by +0·17 (CI +0·07 to +0·27) in response to pSSR (P = 0·003), compared with +0·07 (CI −0·03 to +0·18) during standard HRT (P = 0·2). During pSSR, the increment in lumbar spine BMD z‐score was related positively to oestradiol (r = +0·49, P = 0·04) and inversely to FSH (r = −0·65, P = 0·004). Bone formation markers, BALP and P1NP increased in the pSSR arm (anovaP < 0·001) but decreased in the sHRT arm (P < 0·01). Both treatments suppressed the bone resorption marker, CrossLaps (P < 0·001).
Conclusion We conclude that pSSR over 12 months has a beneficial affect on bone mass acquisition on the lumbar spine in women with POF, mediated by increased bone formation and decreased bone resorption.
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