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1.
Bryson GL Wyand A Wozny D Rees L Taljaard M Nathan H 《Journal canadien d'anesthésie》2011,58(3):267-274
Background
The Clock Drawing Test (CDT) is a screening tool for dementia that tests a variety of cognitive domains. The CDT takes a maximum of two minutes to complete and might be helpful in identifying postoperative cognitive disorders at the bedside. The objective of this study was to evaluate the accuracy of the CDT in a population at high risk for postoperative cognitive disordersMethods
In this prospective observational cohort study, patients were recruited who were ≥ 60 yr of age and scheduled for elective open repair of the abdominal aorta. Delirium was assessed using the Confusion Assessment Method (CAM) on postoperative days (POD) 2 and 4 and at discharge. Cognitive function was assessed with neuropsychometric tests before surgery and at discharge. Postoperative cognitive dysfunction (POCD) was determined using the Reliable Change Index. Clock Drawing Tests were administered at all time points. Agreement between the CDT and test for delirium or POCD was assessed with Cohen’s Kappa statistic.Results
Delirium was noted in 30 of 83 patients (36%; 95% confidence interval [CI] 26 to 46%) during their hospital stay, while POCD was noted in 48 of 78 patients (60%; 95% CI 51 to 72%) at discharge. Agreement between the CDT and CAM was poor at three intervals (Kappa 0.06 to 0.29), as was POCD at discharge (Kappa 0.46). Sensitivity of the CDT was <0.71 for both delirium and POCD at all intervals. False positives and negatives were common.Conclusion
Agreement between CDT and tests for delirium and POCD was poor; sensitivity was inadequate for a screening test. (ClinicalTrials.gov number, NCT00911677). 相似文献2.
Fernando José Abelha Vera Fernandes Miguela Botelho Patricia Santos Alice Santos J. C. Machado Henrique Barros 《Journal of anesthesia》2012,26(3):412-421
Background
A relationship between patients with a genetic predisposition to and those who develop postoperative delirium has not been yet determined. The aim of this study was to determine whether there is an association between apolipoprotein E epsilon 4 allele (APOE4) and delirium after major surgery.Methods
Of 230 intensive care patients admitted to the post anesthesia care unit (PACU) over a period of 3?months, 173 were enrolled in the study. Patients?? demographics and intra- and postoperative data were collected. Patients were followed for the development of delirium using the Intensive Care Delirium Screening Checklist, and DNA was obtained at PACU admission to determine apolipoprotein E genotype.Results
Fifteen percent of patients developed delirium after surgery. Twenty-four patients had one copy of APOE4. The presence of APOE4 was not associated with an increased risk of early postoperative delirium (4% vs. 17%; P?=?0.088). The presence of APOE4 was not associated with differences in any studied variables. Multivariate analysis identified age [odds ratio (OR) 9.3, 95% confidence interval (CI) 2.0?C43.0, P?=?0.004 for age ??65?years), congestive heart disease (OR 6.2, 95% CI 2.0?C19.3, P?=?0.002), and emergency surgery (OR 59.7, 95% CI 6.7?C530.5, P?<?0.001) as independent predictors for development of delirium. The Simplified Acute Physiology Score II (SAPS II) and The Acute Physiology and Chronic Health Evaluation II (APACHE II) were significantly higher in patients with delirium (P?<?0.001 and 0.008, respectively). Hospital mortality rates of these patients was higher and they had a longer median PACU stay.Conclusions
Apolipoprotein e4 carrier status was not associated with an increased risk for early postoperative delirium. Age, congestive heart failure, and emergency surgery were independent risk factors for the development of delirium after major surgery. 相似文献3.
Finn M. Radtke Martin Franck Sabine Schust Lina Boehme Andreas Pascher Hermann J. Bail Matthes Seeling Alawi Luetz Klaus-D. Wernecke Andreas Heinz Claudia D. Spies 《World journal of surgery》2010,34(3):487-494
Background
Postoperative delirium is associated with adverse outcome. The aim of this study was to find a valid and easy-to-use tool to screen for postoperative delirium on the surgical ward.Methods
Data were collected from 88 patients who underwent elective surgery. Delirium screening was performed daily until the sixth postoperative day using the Confusion Assessment Method (CAM), the Nursing Delirium Screening Scale (Nu-DESC), and the Delirium Detection Score (DDS), and the DSM-IV criteria as the gold standard.Results
Seventeen of 88 patients (19%) developed delirium on at least one of the postoperative days according to the gold standard. The DDS scored positive for 40 (45%) patients, the CAM for 15 (17%), and the Nu-DESC for 28 (32%) patients. Sensitivity and specificity were 0.71 and 0.87 for the DDS, 0.75 and 1.00 for the CAM, and 0.98 and 0.92 for the Nu-DESC. The interrater reliability was 0.83 for the Nu-DESC, 0.77 for the DDS, and 1.00 for the CAM.Conclusions
All scores showed high specificity but differed in their sensitivity. The Nu-DESC proved to be the most sensitive test for screening for a postoperative delirium on the surgical ward followed by the CAM and DDS when compared to the gold standard. 相似文献4.
Purpose
Postoperative delirium often remains undiagnosed and therefore untreated. The purpose of this continuing professional development module is to identify patients at high risk of developing delirium following non-cardiac surgery and to provide tools to aid in the diagnosis of delirium at the bedside. Optimal prevention and treatment strategies are recommended.Principal findings
Delirium is characterized by an acute onset and a fluctuating course, inattention, disorganized thinking and an altered level of consciousness, and occurs in up to 40% of patients in the perioperative period. The pathophysiology of delirium is multifactorial, but it is believed to be related to inflammation, altered neurotransmission, and stress in the patient who has had surgery. Acetylcholine and dopamine appear to play a significant role. There is an increased risk of a poor outcome in patients who develop delirium, including a longer hospital stay and death. Surgical and patient factors play a significant role in predicting who will subsequently develop delirium. Prevention is much more effective than treatment in the management of delirium. The most effective prevention strategies include proactive geriatric assessment and care of the patient on a geriatrics surgical ward as well as prophylactic low-dose antipsychotic agents. From an anesthetic perspective, evidence in some surgical populations would support the use of regional techniques and minimal sedation. If delirium develops, treatment with low-dose oral antipsychotics appears to be most effective.Conclusions
Delirium is a serious condition that must be recognized early and treated promptly to minimize deleterious outcomes. In order to institute prevention strategies and treat the condition effectively when it occurs, the anesthesiologist must be vigilant in identifying patients at risk and in screening for this condition. 相似文献5.
Endovascular versus open approach to aortic aneurysm repair surgery: rates of postoperative delirium
Konrad Salata BHSc Rita Katznelson MD W. Scott Beattie MD PhD Jo Carroll RN Thomas F. Lindsay MD George Djaiani MD 《Journal canadien d'anesthésie》2012,59(6):556-561
Purpose
Our objective was to compare open and endovascular aortic aneurysm repair with respect to postoperative delirium.Methods
After Institutional Ethics Review Board approval, we conducted a retrospective review of all patients who underwent abdominal and thoraco-abdominal aortic aneurysm repair surgery at Toronto General Hospital during June 2006 to December 2007. Patients were classed into either the OPEN or the endovascular (EVAR) group based on the type of surgery and were assessed for the presence of delirium after surgery. The NEECHAM Confusion Scale and the validated chart review instrument were used for diagnosis of delirium. Patients with dementia and/or abnormal levels of consciousness preoperatively were excluded.Results
There were 256 patients included in the study, 149 (58%) in the OPEN group and 107 (42%) in the EVAR group. Patients in the EVAR group were considerably older, 74 (10) yr vs 68 (9) yr, and they had shorter duration of surgery, 150 [119, 180] min vs 200 [165, 260] min, respectively, P?<?0.0001. Postoperative delirium was present in 43 (29%) patients in the OPEN group and 14 (13%) patients in the EVAR group (95% confidence interval [CI], 22 to 36 vs 95% CI, 7 to 19, respectively; P?=?0.003). Hospital length of stay was 8.3 [6.6, 13.4] days in the OPEN group and 4.5 [3.1, 6.4] days in the EVAR group, P?<?0.0001.Conclusions
Perioperative management of patients undergoing endovascular aortic aneurysm repair was associated with lower rates of delirium after surgery than that of patients undergoing open aortic aneurysm repair. 相似文献6.
Rita Katznelson MD George Djaiani MD Nicholas Mitsakakis MSc Thomas F. Lindsay MDCM Gordon Tait PhD Zeev Friedman MD Marcin Wasowicz MD W. Scott Beattie MD PhD 《Journal canadien d'anesthésie》2009,56(11):793-801
Purpose
To determine if there is an association between perioperative administration of beta-blockers and postoperative delirium in patients undergoing vascular surgery.Methods
After Institutional Review Board approval, data were retrospectively collected on patients who underwent vascular surgery in an academic hospital during the period January 2006 to January 2007. Patients with preoperative altered level of consciousness, carotid endarterectomy, or discharge within 24 h of surgery were excluded from the study. Identification of delirium was based on evaluation of the level of consciousness with the NEECHAM Confusion Scale and/or a chart-based instrument for delirium. Multivariable logistic regression analysis was used to identify independent perioperative predictors of postoperative delirium. Beta-blockers were tested for a potential effect.Results
The incidence of postoperative delirium was 128/582 (22%). Independent predictors included age (OR 1.04, 95% CI [1.02–1.07]), history of cerebrovascular accident/transient ischemic attack (OR 2.64, 95% CI [1.57–4.55]), and depression (OR 3.56, 95% CI [1.53–8.28]). Open aortic reconstruction was associated with an OR of 5.34, 95% CI (2.54–11.2) and amputation with an OR of 4.66, 95% CI (1.96–11.09). Preoperative beta-blocker administration increased the odds of postoperative delirium 2.06 times (95% CI [1.18–3.6]). Statin administration reduced the odds of delirium by 44% (95% CI [0.37–0.88]). The model was reliable (Hosmer–Lemeshow test, P = 0.72) and discriminative (area under the receiver operating characteristic [ROC] curve = 0.729).Conclusions
Preoperative administration of beta-blockers is associated with an increased risk of postoperative delirium after vascular surgery. Conversely, preoperative statin administration is associated with a lower risk of postoperative delirium. A randomized prospective controlled trial is required to validate these findings. 相似文献7.
Intraoperative ketamine administration to prevent delirium or postoperative cognitive dysfunction: A systematic review and meta‐analysis
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F. Hovaguimian C. Tschopp B. Beck‐Schimmer M. Puhan 《Acta anaesthesiologica Scandinavica》2018,62(9):1182-1193
Background
Postoperative cognitive complications are associated with substantial morbidity and mortality. Ketamine has been suggested to have neuroprotective effects in various settings. This systematic review evaluates the effects of intraoperative ketamine administration on postoperative delirium and postoperative cognitive dysfunction (POCD).Methods
Medline, Embase and Central were searched to 4 March 2018 without date or language restrictions. We considered randomised controlled trials (RCTs) comparing intraoperative ketamine administration versus no intervention in adults undergoing surgery under general anaesthesia. Primary outcomes were postoperative delirium and POCD. Non‐cognitive adverse events, mortality and length of stay were considered as secondary outcomes. Data were independently extracted. The quality of the evidence (GRADE approach) was assessed following recommendations from the Cochrane collaboration. Risk ratios were calculated for binary outcomes, mean differences for continuous outcomes. We planned to explore the effects of age, specific anaesthesia regimen, depth of anaesthesia and intraoperative haemodynamic events through subgroup analyses.Results
Six RCTs were included. The incidence of postoperative delirium did not differ between groups (4 trials, 557 patients, RR 0.83, 95% CI [0.25, 2.80]), but patients receiving ketamine seemed at lower risk of POCD (3 trials, 163 patients, RR 0.34, 95% CI [0.15, 0.73]). However, both analyses presented limitations. Therefore, the quality of the evidence (GRADE) was deemed low (postoperative delirium) and very low (POCD).Conclusion
The effect of ketamine on postoperative delirium remains unclear but its administration may offer some protection towards POCD. Large, well‐designed randomised trials are urgently needed to further clarify the efficacy of ketamine on neurocognitive outcomes.8.
Shinji Fukata Yasuji Kawabata Ken Fujisiro Yuichi Katagawa Kojiro Kuroiwa Hirotoshi Akiyama Yasuhito Terabe Masahiko Ando Takashi Kawamura Hideyuki Hattori 《Surgery today》2014,44(12):2305-2313
Purpose
Postoperative delirium is the most common postoperative complication in the elderly. The purpose of this study was to evaluate the safety and effectiveness of the preventive administration of low-dose haloperidol on the development of postoperative delirium after abdominal or orthopedic surgery in elderly patients.Subjects
A total of 119 patients aged 75 years or older who underwent elective surgery for digestive or orthopedic disease were included in this study.Methods
Patients were divided into those who did (intervention group, n = 59) and did not (control group, n = 60) receive 2.5 mg of haloperidol at 18:00 daily for 3 days after surgery; a randomized, open-label prospective study was performed on these groups. The primary endpoint was the incidence of postoperative delirium during the first 7 days after the operation.Results
The incidence of postoperative delirium in all patients was 37.8 %. No side effects involving haloperidol were noted; however, the incidences of postoperative delirium were 42.4 and 33.3 % in the intervention and control groups, respectively, which were not significantly different (p = 0.309). No significant effect of the treatment was observed on the severity or persistence of postoperative delirium.Conclusions
The preventive administration of low-dose haloperidol did not induce any adverse events, but also did not significantly decrease the incidence or severity of postoperative delirium or shorten its persistence. 相似文献9.
Jason B. O’Neal Frederic T. BillingsIV Xulei Liu Matthew S. Shotwell Yafen Liang Ashish S. Shah Jesse M. Ehrenfeld Jonathan P. Wanderer Andrew D. Shaw 《Journal canadien d'anesthésie》2017,64(11):1129-1137
Purpose
Cardiopulmonary bypass (CPB) induces a significant inflammatory response that may increase the risk for delirium. We hypothesized that exposure to CPB during coronary artery bypass grafting (CABG) surgery would correlate with an increased risk of delirium.Methods
We reviewed clinical data from two databases at our medical centre - the Cardiac Surgery Perioperative Outcomes Database and the Society of Thoracic Surgeons Database. Patients undergoing elective CABG surgery (on-pump and off-pump) from November 1, 2009 to September 30, 2015 were included in the study. Delirium was defined as any postoperative positive Confusion Assessment Method for the Intensive Care Unit exam during the intensive care unit stay. We performed logistic regression to isolate the association between CPB exposure and delirium adjusted for predetermined risk factors and potential confounders.Results
During the study period, 2,280 patients underwent elective CABG surgery, with 384 patients (16.9%) exposed to CPB. Delirium was diagnosed in 451 patients (19.8%). Exposure to CPB showed a significant independent association with delirium. Patients exposed to CPB for 142 min (90th percentile of CPB duration) vs those exposed for 54 min (10th percentile) had an adjusted relative risk (RR) of delirium of 2.18 (95% confidence interval [CI], 1.39 to 3.07; P = 0.002) vs a RR of 1.51 (95% CI, 0.92 to 2.29; P = 0.10), respectively.Conclusions
The use and duration of cardiopulmonary bypass were associated with an increased risk of delirium in patients undergoing CABG surgery.Trial registration
www.clinicaltrials.gov, NCT02548975. Registered 4 September 2015.10.
Mari Takeuchi MD Hiroya Takeuchi MD Daisuke Fujisawa MD Kaya Miyajima MD Kimio Yoshimura MD Saori Hashiguchi MD Soji Ozawa MD Nobutoshi Ando MD Joichiro Shirahase MD Yuko Kitagawa MD Masaru Mimura MD 《Annals of surgical oncology》2012,19(12):3963-3970
Background
Postoperative delirium is a common complication after major surgery and is characterized by acute confusion with fluctuating consciousness. The aim of this study was to investigate the incidence and risk factors of postoperative delirium in patients with esophageal cancer.Methods
We conducted a retrospective cohort analysis of 306 consecutive patients who had undergone an esophagectomy at Keio University Hospital from January 1998 to December 2009. All data were assessed by psychiatrists, and delirium was diagnosed according to criteria of the Diagnostic and Statistical Manual Disorder, fourth edition. Univariate and multivariate analyses were performed.Results
Postoperative delirium developed in 153 (50.0?%) of 306 patients. One hundred fourteen (37.3?%) of the 306 patients required psychoactive medication for symptoms associated with delirium. Univariate analyses showed that older age, male gender, additional flunitrazepam for sedation in intensive care unit (ICU) after surgery, longer periods of time under mechanical ventilation after surgery, longer ICU stays, occurrence of postoperative complications, and longer hospital stays were significantly associated with postoperative delirium. Multivariate analysis revealed that development of delirium was linked to older age, additional flunitrazepam in ICU, and occurrence of postoperative complication.Conclusions
The development of postoperative delirium in patients with esophageal cancer is a problem that cannot be ignored. Our results suggest that the risk of developing delirium is associated with older age, use of flunitrazepam in ICU, and postoperative complications. 相似文献11.
George Djaiani MD Rita Katznelson MD Ludwik Fedorko MD PhD Vivek Rao MD PhD Robin Green PhD Jo Carroll RN Jacek Karski MD 《Journal canadien d'anesthésie》2012,59(5):449-455
Purpose
Recently, we showed that processing of shed blood with a continuous-flow cell saver during cardiopulmonary bypass resulted in a clinically significant reduction in postoperative cognitive decline (POCD) six weeks after coronary artery bypass graft (CABG) surgery. The current study examined if the early benefit of reduced POCD was sustained in the same patient population at one-year follow-up.Methods
One hundred seventy patients (cell saver group, n?=?84; controls, n?=?86) underwent neuropsychological testing at baseline and one year after surgery. The raw scores for each test were converted to Z-scores, and a combined Z-score of ten main variables was then calculated for each study group.Results
Postoperative cognitive decline was present in 16 of 84 (19%) patients in the cell saver group (95% confidence interval [CI], 10.8 to 27.2) vs 15 of 86 (17.4%) patients in the control group (95% CI, 9.6 to 25.2) (P?=?0.786). Six of the 15 patients in the control group with POCD at six weeks had the impairment at one year and five did not; four were lost to follow-up. Three of the six cell saver patients with POCD at six weeks still had impairment at one year, two did not, and one was not tested. Thirteen (15.4%) and nine (10.5%) patients in the cell saver and control groups, respectively, developed new POCD which was not evident at the six-week follow-up.Conclusions
The short-term preservation of cognitive function in elderly patients using the cell saver management strategy did not translate into a long-term benefit one year after CABG surgery. The presence of progressing cerebrovascular disease may be responsible for the long-term cognitive decline. (ClinicalTrials.gov number, NCT00193999). 相似文献12.
Mu-Huo Ji Hong-Mei Yuan Guang-Fen Zhang Xiao-Min Li Lin Dong Wei-Yan Li Zhi-Qiang Zhou Jian-Jun Yang 《Journal of anesthesia》2013,27(2):236-242
Purpose
We hypothesized that different patterns of biomarkers of brain injury and inflammation exist in aged patients with postoperative cognitive dysfunction (POCD) after total hip-replacement with spinal anesthesia.Methods
Eighty-three patients older than 65 years undergoing elective total hip-replacement surgery were enrolled in this prospective observational study. The CSF levels of Tau, phosphorylated-tau (pTau), amyloidβ1–42 (Aβ1–42), Tau/Aβ1–42, pTau/Aβ1–42, BDNF, IL-6, and IL-1β were measured preoperatively. Perioperative plasma levels of IL-1β, IL-6, brain-derived neurotrophic factor (BDNF), C-reactive protein (CRP), and malonaldehyde (MDA) as well as neurocognitive tests were determined preoperatively and seven days postoperatively.Results
Sixty-one patients completed both the CSF and blood samples collection and the neurocognitive tests. POCD occurred in 24.6 % of patients at seven days after surgery. Patients with POCD had significantly higher IL-1β, Tau/Aβ1–42, pTau/Aβ1–42, and a lower level of Aβ1–42 in CSF when compared with the Non-POCD group (P < 0.05). Furthermore, POCD patients displayed significantly higher plasma levels of MDA when compared with Non-POCD patients at seven days after surgery (P < 0.05). There was no difference in preoperative CSF levels of Tau, IL-6, and pTau as well as plasma levels of IL-1β, IL-6, BDNF and CRP between POCD and Non-POCD groups (P > 0.05).Conclusion
The POCD patients were associated with higher postoperative plasma levels of MDA, and higher IL-1β and lower Aβ1–42 levels in preoperative CSF that might predispose the development of POCD in aged patients following total hip-replacement surgery with spinal anesthesia. 相似文献13.
Background
Delirium is defined by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR) as a potentially reversible disturbance of consciousness and a change of cognition caused by a medical condition, drug intoxication, or medication side effect. Delirium affects up to 80?% of intensive care unit (ICU) patients and is associated with increased morbidity and mortality. One risk factor for development of delirium in ventilated intensive care unit patients is sedation. The German S3 guidelines on “Analgesie, Sedierung und Delirmanagement in der Intensivmedizin” (analgesia, sedation and delirium management in intensive care medicine) of the DGAI (German Society for Anesthesiology and Intensive Care Medicine) and the DIVI (German Interdisciplinary Association for Intensive Care and Emergency Medicine) recommend midazolam and propofol for sedation, although both drugs are associated with a high incidence of delirium.Aim
Within the framework of this study the question arose whether the barbiturate methohexital could be associated with a lower incidence of delirium in comparison to midazolam or propofol in analgosedated and ventilated ICU patients.Material and methods
This was a prospective nonrandomized observational cohort study in a mixed medical surgical intensive care unit. Patients ventilated within 72 h after admittance were consecutively allocated to either propofol/remifentanil versus methohexital/remifentanil (expected ventilation duration ≤?7 days) or midazolam/fentanyl versus methohexital/fentanyl (expected ventilation duration >?7 days) by the attending senior consultant anesthetist at the time of admission and/or intubation. Primary endpoint was delirium at any time during the ICU stay. Delirium was checked every 8 h by ICU nurses using the intensive care delirium screening checklist (ICDSC), with delirium defined as ICDSC ≥?4 points. Before evaluation of the ICDSC the Richmond agitation sedation scale (RASS) score and the visual analogue scale for pain (VAS target ≤?4) were measured. To assure reliable evaluation of the ICDSC, the RASS score of the patient at the time of evaluation had to be ≥???2. Assuming an incidence of delirium in the midazolam group of 70?% and in the methohexital group of 35?%, 16 patients were needed each in the midazolam/fentanyl and the methohexital/fentanyl cohorts (p?=?0.05, β =?0.1). Assuming an incidence of delirium in the propofol group of 50?% and in the methohexital group again of 35?%, 94 patients were needed in the propofol/remifentanil and methohexital/remifentanil groups, respectively (p?=?0.05, β =?0.1).Results
A total of 222 patients were evaluated, 34 in the methohexital vs. midazolam group and 188 in the methohexital vs. propofol group. Out of 16 patients sedated with midazolam, 15 developed delirium (94?%) in contrast to only 5 out of 18 patients sedated with methohexital (28?%). Thus compared to midazolam the sedation with methohexital reduced the incidence of delirium by 66?% (p?<?0.001) corresponding to a number needed to treat (NNT) of 1.5. Out of 94 patients in the propofol/remifentanil group, 64 developed delirium (68?%) in contrast to only 23 out of 94 in the methohexital/remifentanil group (24?%). Thus compared to propofol the sedation with methohexital reduced the incidence of delirium by 44?% (p?<?0.001), corresponding to an NNT of 2.5.Conclusion
Sedation with methohexital compared to midazolam or propofol reduced the incidence of delirium by more than 50?% in ventilated ICU patients. 相似文献14.
Purpose
To review the mechanisms of sedative-hypnotic action with respect to the risk of delirium imparted by drugs that act on γ-amino-butyric-acid type A receptors or α2 adrenoceptors.Source
MEDLINE was searched for relevant articles.Principal findings
Development of the acute confusional state of delirium is associated with longer intensive care unit (ICU) and hospital lengths of stay, significantly higher risk of functional decline, and increased mortality. Disruption of sleep is a modifiable risk factor that may contribute to delirium and cognitive dysfunction in ICU patients. Among the functions of sleep are repair of defective processes and restoration of the brain to a state in which it is ready to acquire new knowledge. It is logical that disruption of these processes may produce acute confusion. Delirium develops through a complex interaction between the patient’s baseline vulnerability (patient’s predisposing risk factors before hospitalization) and precipitating factors or insults (modifiable events that occur during hospitalization). The latter factors include both sleep disruption and sedation. We present a hypothesis that these two factors are causally linked through effects on memory. Our hypothesis explains why patients randomized to receive an α2 adrenoceptor agonist are less likely to develop delirium (and the attendant cognitive dysfunction) than those randomized to receive benzodiazepines.Conclusion
Herein we present our hypothesis that alternate mechanisms of hypnotic action may differentiate the deleriogenic properties of the two classes of sedatives. Future studies should focus on whether a causal relationship can be established between sedative administration, sleep disruption, and delirium. 相似文献15.
Ming-hua Chen Yan Liao Peng-fei Rong Rong Hu Guo-xin Lin Wen Ouyang 《Journal of anesthesia》2013,27(4):487-492
Purpose
Postoperative cognitive dysfunction (POCD) is a formidable public health issue, which would not only affect the quality of life among elderly patients but also lead to pulmonary infection and increased mortality. While, there is a lack of an effective indicator in predicting POCD. As one pivotal part of the limbic system in brain, hippocampus is associated with cognitive function. Hippocampal atrophy could indicate the degree of changes in cognitive function.Methods
Forty-one ASA II or III patients (23 male, 18 female) aged ≥65 years undergoing open gastrointestinal tract surgery were enrolled in this study. MRI was performed to measure the volume of hippocampal formation before surgery and the results were standardized according to individual intracranial volume. All patients underwent a battery of neuropsychological tests including sensitive tests on the Wechsler adult memory scale and Wechsler adult intelligence scale, trail making test and the grooved pegboard test. We used the Z score to identify POCD as recommended by ISPOCD. All patients were then divided into POCD group and non-POCD group according to the results of the neuropsychological tests. The results of the tests were correlated with the volume of hippocampal formation measured by MRI. The value of MRI measurement of hippocampal volume in predicting POCD was analyzed. Multivariate linear correlation analyses of compositive Z score using potential contributing factors such as age, duration of anesthesia, education and hippocampal volume was carried out.Results
Thirty-six patients completed the whole battery of neuropsychological tests after surgery. Thirteen of the 36 patients were found to have POCD (36 %) on the postoperative 4th day. The hippocampal volume was significantly smaller in POCD group (4.75 ± 0.23) than in non-POCD group (5.06 ± 0.31). Hippocampal volume had great influence on Z score, and had negative correlation with Z score.Conclusion
The MRI measurement of hippocampal volume is suggested to be valuable as a predictor of POCD in the elderly. 相似文献16.
Pinheiro-Júnior S Pinhel MA Nakazone MA Pinheiro A Amorim GF Florim GM Mazeti CM Gregório ML Moschetta MG Brito GB Brienze SL Nonino CB Brandão AC Souza DR 《Obesity surgery》2012,22(4):623-633
Background
The manifestation of cholelithiasis after bariatric surgery may depend on genetic factors related to lipid metabolism, including apolipoprotein E (APOE) and cholesteryl ester transfer protein (CETP) gene polymorphisms.Methods
We investigated the association between APOE HhaI and CETP TaqIB polymorphisms [PCR-RFLP] and occurrence of cholelithiasis over up to 8?months of follow-up after gastroplasty to Roux-en-Y gastric bypass in 220 patients distributed in Group 1 (G1) 114 with cholelithiasis postoperatively and Group 2 (G2) 106 without cholelithiasis, including biochemical and anthropometric profiles analyses.Results
In our series, the allelic and genotypic distributions of CETP TaqIB and APOE HhaI polymorphisms were similar in both groups (P?>?0.05). The subgroup analysis evidenced that 54% of the patients from G1, APOE*4 allele carriers compared with APOE*3/3 carriers, presented altered low-density lipoprotein cholesterol (LDL cholesterol) serum levels (P?=?0.022) before bariatric surgery. The B1 allele for CETP was associated to more quickly elevation of HDL cholesterol levels just in individuals without cholelitiasis (P?0.0001). The multivariate logistic regression analysis demonstrates correlation between APOE*4 allele, higher total cholesterol (TC) serum levels and prediposition to cholelitiasis in preoperative period. However, the presence of postoperative cholelithiasis was not associated with altered lipid profile.Conclusions
The CETP TaqIB and APOE HhaI polymorphisms do not seem to have association with gallstones in the late postoperative bariatric surgery, considering that these genetic variants do not differ subgroups of patients who are eligible to routine prophylactic cholecystectomy, at least in Brazilian population. 相似文献17.
Klugkist M Sedemund-Adib B Schmidtke C Schmucker P Sievers HH Hüppe M 《Der Anaesthesist》2008,57(5):464-474
Objective
Since 2001 the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), a method for the diagnosis of delirium, has been available for the Anglo American area which can also be applied to mechanically ventilated patients. This study was conducted to answer the following questions: 1. Can a German version of the CAM-ICU be applied to patients after cardiac surgery? 2. What is the prevalence rate of postoperative delirium after cardiac surgery diagnosed by the CAM-ICU? 3. Do patients with and without the diagnosis delirium differ in the clinical variables usually associated with this disorder in cardiac surgery?Methods
A total of 194 patients undergoing cardiac surgery served as the analysis sample (85.5% of the total group). The CAM-ICU was carried out every day for 5 days after the operation. Sociodemographic and clinical variables were collected to examine the validity of CAM-ICU. Postoperative complaints were assessed by the Anaesthesiological Questionnaire for Patients (ANP).Results
Postoperatively, the CAM-ICU could be applied to almost all patients without any problems. The prevalence rate of delirium was 28.4% and 85.5% of the delirium diagnosed was a hypoactive subtype when diagnosed for the first time. Patients with delirium diagnosed by CAM-ICU were older (p<0.001), had a lower educational level (p<0.05), longer anaesthesia time and operation time (p<0.05), a longer postoperative ICU stay (p<0.001), were mechanically ventilated for a longer time postoperatively (p<0.001), more often reintubated (p<0.01) and had higher leucocytes postoperatively (p<0.10). More patients with delirium had the lowest postoperatively measured oxygen saturation below 95% (p<0.01).Conclusion
The CAM-ICU is an economic method for the assessment of delirium which can easily be learned. It can be applied to patients after cardiac surgery without any problems. 相似文献18.
Takeshi Uzuka Toshiro Ito Takayuki Hagiwara Yohsuke Yanase Tetsuya Koyanagi Yoshihiko Kurimoto Nobuyoshi Kawaharada Tetsuya Higami 《General thoracic and cardiovascular surgery》2013,61(2):84-88
Objective
Early thrombosed aortic dissection is a form of aortic dissection and includes the condition called aortic intramural hematoma. It was generally considered as surgical emergency. However, the optimal treatment strategy for acute type A intramural hematoma is becoming controversial after recent studies indicated more benign clinical course for this disease. We evaluated our strategy that integrated medical therapy, serial imaging, and timed surgery.Methods
We reviewed 34 consecutive patients who were admitted to our hospital for early thrombosed Stanford type A acute aortic dissection from 2006 to 2011. Medical therapy or timed surgery was offered on the basis of radiological findings. Emergency or urgent surgery was not considered for a hemodynamically stable patient unless the ascending aortic diameter was ≧50 mm or the thickness of the thrombosed false lumen was ≧10 mm. Follow-up computed tomography was performed to detect a potential progression to aortic dissection.Results
During the average follow-up period of 24.3 months, there was no aortic dissection-related mortality. And aortic dissection-related event was not recorded in patients who had surgical repair; however, in patients who did not have surgery, 3 (8.8 %) surgical conversions were recorded due to aortic dissection progression during the follow-up period. Twenty-one patients (61.8 %) ultimately had surgical repair, and 13 patients (38.2 %) had complete medical therapy. The overall survival rate at 3 years was 86.5 %.Conclusions
Our strategy for the treatment of early thrombosed Stanford type A acute aortic dissection is reasonable, and the mid-term results were acceptable. 相似文献19.
de Luis DA Aller R Conde R Izaola O Pacheco D Sagrado MG Primo D 《Journal of gastrointestinal surgery》2012,16(6):1194-1198
Background
The high variation in responses to bariatric surgery might be partially explained by genetic effects. Recently, common polymorphisms of the fat mass and obesity-associated gene (FTO) have been linked to obesity in some populations. Only two studies have investigated the effect of FTO variants on weight loss of morbid obese patients undergoing bariatric surgery with contradictory results.Objective
We decided to investigate the role of the rs9939609 FTO gene polymorphism on outcomes after a biliopancreatic diversion surgery (BPD) in morbidly obese patients.Design
A sample of 119 morbidly obese patients' body mass index (BMI)?>?40?kg/m2 were operated. Weight, fat mass, blood pressure, basal glucose, triacylglycerols, total cholesterol, low density lipoprotein cholesterol and high density lipoprotein cholesterol were measured at basal visit and at each visit (basal, 3, 9 and 12?months). The frequency of metabolic comorbidities was recorded at each visit.Results
Thirty-seven patients (31.1%) had genotype TT (wild type group), 58 (48.7%) patients had genotype TA and 24 patients (20.2%) had genotype AA. In the wild and mutant type groups, BMI, weight, waist circumference, systolic blood pressure and diastolic blood pressure decreased in a significant way. In the wild type groups, glucose, total cholesterol, low density lipoprotein (LDL) cholesterol and triacylglycerol concentrations decreased at 3, 9 and 12?months after surgery. In the mutant type groups, glucose, total cholesterol and triacylglycerol concentrations decreased at 3, 9 and 12?months after surgery. LDL cholesterol decreased at 9 and 12?months after surgery. Initial weight percent loss at 3?months of follow-up was higher in the wild type group (26.1% vs. 18.6%: p?0.05). The initial weight percent loss at 9 or 12?months was similar in both genotypes.Conclusion
Our study showed a higher initial weight loss at 3?months after the TT variant of FTO gene (rs9939609). However, the weight loss at 9 and 12?months of BPD was similar in both genotypes with a significant improvement in biochemical parameters and cardiovascular comorbidities. 相似文献20.