PTSD following surgery -
Cognitive deterioration after ICU hospitalization and surgery
M. A. Papoulas
9th July, 2014
Setting goals for treatment“Quality of outcome in the patient’s point of view is more likely to depend on whether he or she can continue to function as before surgery.”
Post-Traumatic Stress Disorder
• Common anxiety disorder • Exposure to a terrifying event or ordeal• Physical harm• Family members can also develop PTSD • Depression, alcohol abuse, other anxiety disorders
PTSD Criteria
1. Traumatic event, life threatening, distress
2. One or more symptoms of re-experiencing the event
3. Three or more symptoms of avoidance
4. Two or more symptoms of hyperarousal
18-42% of injured patient 1-6 months post injury
2-36% one year post injury
Steel et al. Injury 2011
• Trauma is a disease• Late and long term consequences • Unavailability of proven screening and treatment
strategies• Nationwide US study of injury survivors: PTSD and
depression are independent contributors to the inability to return to work 12 months after injury
Ann Surg 2013
PTSD for surgically Hospitalized survivorsZatzick et al, Ann Surg 2013
Care Intervention
• Delivered in the inpatient ward, outpatient clinic, telephone, community rehabilitation
• Care management, pharmacotherapy, cognitive behavioral therapy (CBT)
• Motivational interview targeting alcohol abuse• Behavioral activation and pleasant activities
PTSD Symptom Severity by Treatment Group
Symptomatic and functional outcomes
Intervention Patients
• Physical function improvement (p < 0.01)• Trend level effect on alcohol consumption and
depression• More like to receive evidence based PTSD
pharmacotherapy• Equally effective in patients with TBI
• Comparative efficacy of treatments for PTSD : a meta-analysis. Van Eten. Clin Psychol Psychother ,1998
Cognitive Behavioral Therapy shows an advantage compared with pharmacotherapy
“Courage is what it takes to stand up and speak. Courage is also what it takes to sit down and listen. “
Rothbaum et al. Biol Psychiatry 2012
Cognitive deterioration after ICU hospitalization and surgery
Post-Hospital Syndrome
• Acquired, transient condition of generalized risk• Vulnerability• Critical 30-day period• 25% of Medicare patients• Deconditioning, sleep deprivation, circadian rhythm,
nutrition, immune function, delirium, oversedation.
NEJM , 2013
Postoperative Cognitive Dysfunction POCD
• Transient Cognitive impairment • Usually resolves by one year• Impairment in memory, concentration and social
integration• MRI and MRS findings • Cognitive decline acceleration, dementia
Surgery, Inflammation and Cognitive Decline
Terrando N. Mayo Clinic Proc. 2001
Systemic Infection and Delirium
• Proinflammatory cytokines and brain communication
• TNF-a persistence in brain for months
• Activated microglia : – Production of inflammatory mediators– Weaken astrocytic tight junctions– Affect neuronal function
Lancet 2010
Acute Care, Critical illness Hospitalization and Cognitive function in Older Adults
• Prospective cohort study• 1994- 2007, n = 2929, > 65 yo, without dementia • Cognitive Ability Screening Instrument (CASI)• Inclusion of participants with 2 or more study visits• Mean follow up 6.1 years
JAMA , 2010
• Noncritical and critical illness hospitalizations were each associated with greater decline in cognitive functioning scores.
• Noncritical illness hospitalizations were significantly associated with incident dementia
• N = 821 patients • MICU or SICU• Evaluation of in-hospital delirium• Global cognition and executive function assessment
3 and 12 months after discharge• Duration of delirium and use of sedative or analgesic
medications
• Duration of coma was not associated with worse global cognition and executive function scores
• No independent association between sedative or analgesic agents and long term global cognition and executive function was found
Duration of Delirium and Global Cognition Score at 12 months
Limitations
• Inability to test patients’ cognition before their emergent illness
• Unable to complete all cognitive tests
• Confounding by death or withdrawal
Alzheimer Disease
• Degenerative disease• Most common form of dementia• High Prevalence• Late onset, sporadic, multifactorial
Alzheimer’s Disease and Anesthesia
Marie P. et al. Neuroscience, 2011
Modulation of Murine Alzheimer Pathogenesis and Behavior by Surgery
• Animal Protocols (WT and x3TgAD)• Surgery and anesthetic exposure- 3 groups
1. Desflurane only
2. Desflurane and Surgery
3. Air controls
Tang et al. Ann Surg, 2013
Behavioral Testing
Learning and Memory testing
MWM Quantifies Cognition
• Escape from pool• Reference memory• Swim speed • Working memory
Motor and Coordination Assessment
Results
Mean Trials per Platform
Mean swim speed
Mean ratio of target/opp
pTau
Aβ plaques
16 w PO
Controls Desflurane Surgery
Top 10 Myths Regarding Sedation and Delirium in the ICU
1. All Mechanically Ventilated ICU Patients Require Sedatives
2. It Is Easier to Care for Deeply Sedated ICU Patients
3. Only Surgical ICU Patients Experience Pain
4. Sedatives Help to Facilitate Sleep in ICU Patients
Peitz GJ. Crit Care Med 2013
5. Delirium is a Benign and Expected Side Effect of Being in the ICU
6. Delirium Assessment and Recognition is Consistent and Uniform
7. All ICU Delirium is Similar and Can be Managed Effectively by Medications
8. Daily Interruptions of Sedative Medications are Unsafe
9. Sedative and Analgesics Do Not Accumulate with Prolonged Use
10. Deep Sedation and Amnesia Derived From Sedative Administration in ICU Result in Improved Psychological Outcomes, especially PTSD
Anesthesiol. 2011
1970s More sedation
1980s Perhaps less sedation?
1999 More control of sedation
2000 A daily wake up trial
2008 A daily wake up trial and spontaneous breathing trial
2010 No sedation
Undersedation versus oversedationTRENDS
Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation
“Wake up trial”, pause of sedation and analgesicsKress NEJM, 2000
Endpoints of daily interruption of sedative drugs in ICU
1. Decreased duration of mechanical ventilation (more than 2 days)
2. Decreased length of ICU stay (3.5 days)
3. Practical
4. Cost-effective
5. Acceptable sedation minimizing adverse effects
6. Early detection of neurologic dysfunction
What is ICU Delirium?
• Delirium is a common clinical syndrome• Inattention and acute cognitive dysfunction• Disruption of neurotransmission• Hypoactive, Hyperactive, Mixed• Think rapid onset, inattention, clouding of
consciousness, fluctuation
Why monitor for Delirium?
• 50-80% of ventilated patients develop delirium
• 20-50% of lower severity ICU patients develop delirium
• Delirium leads to increased mortality, longer hospital stay, poorer recovery, higher costs, long term neurocognitive problems.
Ely EW. JAMA, 2001
A two step approach to Assess Consciousness
Step 1
Level of Consciousness (arousal)
RASS- Sedation assessment
Step 2
Content of Consciousness (delirium)
CAM- ICU Confusion assessment
• Delirium in critically ill patients: impact on long-term health-related quality of life and cognitive functioning. van den Boogaard M, et al. Crit Care Med. 2012
• Posttraumatic stress, anxiety and depression symptoms in patients during the first year post intensive care unit discharge. Myhren H, et al. Crit Care. 2010
• Dexmedetomidine vs midazolam or propofol for sedation during prolonged mechanical ventilation: two randomized controlled trials. Jakob SM, et al. JAMA. 2012
• The association between brain volumes, delirium duration, and cognitive outcomes in intensive care unit survivors: the VISIONS cohort magnetic resonance imaging study*. Gunther ML, et al.Crit Care Med. 2012
Take-home Message
• Awareness
• Direct research at the contributing factors
• Creation of rehabilitation programs
Thank You