Impact of anesthesia on neurocognitive outcome /

delirium

José A. Aguirre, MD, MSc jose.aguirre@balgrist.ch

Division of Anesthesiology, Balgrist University Hospital, Zurich Forchstrasse 340, CH-8008 Zürich

www.balgrist.ch

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Disclosure

Agenda •  Postoperative delirium: What? Why? •  Postoperative cognitive dysfunction: What?

Why? •  Incidence? Risk factors? •  Impact of anesthesia? •  Prophylaxis? Therapy? •  Recommendations & Conclusions

Delirium

•  Acute decline in attention, executive functions and cognition. –  hyperactive and hypoactive (more frequent) forms –  first or second postoperative day –  symptoms worsen at night

•  Seen in 37% of surgical patient, higher incidence > 70y and in the orthopedic (30 -69%) population

Reade MC et al, NEJM 2014; 370:444-54 McDaniel et al. Curr Opin Crit Care 2012; 18:372-6

Postoperative cognitive dysfunction

•  Postoperative decline of cognitive functions –  7-25% one week after surgery –  9.9-12.7% 3 months after surgery –  after hip surgery 18-50%

•  Risk factors: Age, ASA classification, education level, length of stay in hospital, type and length of surgery, alcohol abuse and postoperative complications

•  Delirium associated to early POCD (< 7 d), especially long-duration delirium (>3d)

Silbert B et al. Best Pract & Res Clin Anaesth 2011; 25:379-93 Jin F et al. BJA 2001; 87:608-24 Fong HK et al. A&A 2006; 102:1255-66 POCD: postoperative cognitive dysfunction

Haseneder R et al. Anaesthesist 2012; 61:437-43

NEJM 2014; 370:444-54

NEJM 2014; 370:444-54

Best Pract Res Clin Anaesthesiol 2011; 25:379-93

Impact of postoperative cognitive dysfunction on costs

•  In hypertensive patients there seems to be a correlation between minimum intraoperative MAP and decline in cognitive function 1d and 1m after surgery.

•  POCD at 3m but not at 1w was associated with increased mortality.

•  Risk to leave labor market prematurely due to disability or voluntary was higher in patients with 1w POCD. More social transfer payments for 1w POCD patients were observed.

Yocum GT et al. Anesthesiology 2009; 110:254-61 Steinmetz J et al. Anesthesiology 2009; 110:548-55

MAP: mean arterial pressure d : day; w: week; m: month

Impact of postoperative cognitive dysfunction on costs

•  More than 50% of cardiac surgery patients show POCD in the 5-years follow up.

•  Each year POCD –  complicates hospital stays for more than 2.3 million

older people –  involves more than 17.5 millions inpatient days –  accounts for more than $4 billion of Medicare

expenditures in the USA –  causes additional costs after discharge due to

institutionalization, rehabilitation and home care

Newman MF et al. Stroke 2001; 32:2874-81 Inouye SK et al. NEJM 1999; 340:669-76

Regional or general anesthesia???

Perhaps you might want to update your Facebook status

to “unconscious” before we start?

Bingham AE et al. RAMP 2012; 37:583-94 Ilfeld BM; A&A 2011; 113:904-25 Le-Wendling L et al. Curr Opin Anaesthesiol 2008; 21:602-09

Impact of the anesthesia technique

How to deal with literature?

Loadsman JA. Current Opin Anesthesiol 2012; 25:730-735

RAorGA?

•  TopthreereasonsforRAfromtheanesthesiologist‘spointofview:

– cardiovascularstability

–  respiratorystabilitywithpreserva>onofprotec>veairwayreflexes

–  rapidpostopera>verecovery

Hoehener D et al. BJA 2008; 100:8-16 Asehnoune K et al. Ann Fr Anesth Reanim 2000; 19:577-81

RA: regional anesthesia GA: general anesthesia

•  TopthreereasonsforRAfromthepa>ent‘spointofview:

– staying„awake“

– earlyfamilycontact

– earlyfoodintake

Hoehener D et al. BJA 2008; 100:8-16 De Andres J et al. REDAR 1993; 20:498-505

RA: regional anesthesia GA: general anesthesia

RAorGA?

Whyseda>onduringRA?

•  DrawbacksofRAfromthepa>ent‘spointofview:

– painatpuncturesite

–  fearofneedles

–  recalloftheprocedure

Hoehener D et al. BJA 2008; 100:8-16 Gajraj NM et al. Anaesthesia 1995; 50:740-41 LonsdaleM et al. Anaesthesia 1991; 46:410-2 Macario A et al. A&A 1999; 89:652-8 Wildsmith JA. Anaesthesia 1990; 45:984-85 RA: regional anesthesia

Swiss Propofol Cow

Sieber FE et al. Mayo Clin Proc 2010; 85:18-26

Pos

tope

rativ

e de

liriu

m (%

)

Coburn M et al. Anaesthesist 2010; 59:177-85

a)   Moller J Lancet 1998; 351:857-61 b)  Monk TG Anesthesiol 2008; 108:18-30 c)   Abildstorm H Ac AnSca 2000; 44:1246-51 d)  Johnson T Anesthesiol 2002; 96:1351-57 e)   Monk TG Anesthesiol 2008; 108:18-30 f)   Monk TG Anesthesiol 2008; 108:18-30

Non-Cardiac Surgery: a, c, d: - ortho / visceral / thoracic - minimum 4d in hospital b, e, f: -  minimum 2h surgery -  minimum 2d in hospital

Post OP time point

Author / Year / Nr of patients Surgery Difference incidence POCD

7d Riis et al. 1983 / n 20 Hip ns

7d Bigler et al. 1985 / n 40 Hip ns

7d Hughes et al. 1988 / n 30 Hip ns

7d Ghoneim et al. 1988 / n 105 Mixed ns 7d Williams-Russo et al. 1995 / n 264 Knee ns

7d Rasmussen et al. 2003 / n 438 Mixed p = 0.04

90d Ghoneim et al. 1988 / n 105 Mixed ns

90d Nielson et al. 1990 / n 98 Knee ns

90d Haan et al. 1991 / n 53 Urology ns

90d Rasmussen et al. 2003 / n 438 Mixed ns

Coburn M et al. Anaesthesist 2010; 59:177-85

Severe methodological problems: Study was interrupted due to: - randomization problems - in the given time not enough patients included

Advantage or RA over GA only seen in a subanalysis after exclusion of patients who did not get the planned anesthesia

POCD incidence at week 1: heart surgery (43%) vs. hip surgery (17%)

At 3 months incidence of POCD independent from type of surgery and anesthesia regimen

A&A 2011; 112:1179-85

POCD incidence at week 1: heart surgery (43%) vs. hip surgery (17%)

At 3 months incidence of POCD independent from type of surgery and anesthesia regimen

A&A 2011; 112:1179-85

The noncardiac surgery patients underwent elective first-time THJR surgery. Anesthesia comprised temazepam premedication, spinal anesthesia with midazolam sedation up to 5 mg, and then a light general anesthetic using propofol and/or a volatile anesthetic with the aim of maintaining a bispectral index <60 (BIS Monitor; Aspect Medical Systems, Norwood, MA). After surgery, analgesia was provided by morphine patient-controlled analgesia for 48 hours, then oxycodone.

Anaesthesia 2014; 69:259-69

Which peri-operative interventions during non-cardiac surgery have been independently associated with a reduction in delirium within the first seven postoperative days?

Anaesthesia 2014; 69:259-69

Anaesthesia 2014; 69:259-69

Anaesthesia 2014; 69:259-69 Austin J. Anaesthesia 2014; 69:511-26

Main findings •  Peri-operative geriatric consultation and lighter

anesthesia are associated with decreased incidence of postoperative delirium

•  Prophylactic haldoperidol and general opposed to regional anesthesia show a possible protection

Anaesthesia 2014; 69:259-69 Austin J. Anaesthesia 2014; 69:511-26

BUT •  Study quality

–  Jadad score peri-operative geriatric consultation studies ≤ 3 –  Jadad score ligth vs. deep anesthesia studies > 3

•  Study bias –  peri-operative geriatric consultation studies: no publication bias –  ligth vs. deep anesthesia studies: possible publication bias

•  Study power –  power inadequate for ALL interventions included with

exception of the peri-operative geriatric consultation

Mason SE et al. Journal of Alzheimer’s Disease 2010; 22:S67-79

Forest plot of 9 studies comparing GA and non-GA in the development of POCD

POCD: postoperative cognitive dysfunction GA: general anesthesia

Mason SE et al. Journal of Alzheimer’s Disease 2010; 22:S67-79

Forest plot of 5 studies comparing GA and RA in the development of POD

POD: postoperative delirium GA: general anesthesia RA: regional anesthesia

Mason SE et al. Journal of Alzheimer’s Disease 2010; 22:S67-79

Forest plot of 2 studies comparing GA and RA in the development of POCD

POCD: postoperative cognitive dysfunction GA: general anesthesia RA: regional anesthesia

•  Before you change your well-working concepts due to literature, read all the papers yourself!

•  There is no difference between GA and RA for the outcomes delirium / POCD

•  There is no clear difference between the drug chosen for GA (iv or inhalative)

Conclusions

GA: general anesthesia RA: regional anesthesia

Silbert B et al. Best Pract Res Clin Anesthesiol 2011; 25:379-93 Everded L et al. A&A 2011; 112: ahead of print Jankowski Ch et al. A&A 2011; 112:1186-93 Rasmussen LS. Best Pract Res Clin Anaesthesiol 2006; 20:315–30 Rasmussen LS et al. Acta Anaesthesiol Scand 2003; 47:260–6 Royse CF et al. Anaesthesia 2011; 66:455.64 Schoen J et al. BJA 2011; 106:840-50

•  Haldoperidol and probably α2-agonists could show prophylactic effects on delirium and POCD

•  Treat hyperactive delirium according to your pharmacological standard

•  Avoid risk factors for delirium and POCD in the ICU / PACU

•  Organize a follow up in the case of delirium / POCD

Conclusions

ICU: intensive care unit PACU: post anesthesia care unit

However, better studies are needed…

The maintenance of hemostasis before, during and after surgery is of pivotal importance.

Bedford PD Lancet 1955; 269:259-63

Monitoring? - BIS? - NIRS?

Prevention? - α2 Agonists? - Haldoperidol - Light sedation?

Treatment protocols? - Controlled hypotension? - Target directed protocols? - Geriatric consultation?