Impact of postanesthesia care unit delirium on self-reported cognitive function and perceived health status: a prospective observational cohort study.

PURPOSE: The objective of this study was to determine the influence of postanesthesia care unit (PACU) delirium on self-reported cognitive function and perceived health status 3 months after surgery. METHODS: This prospective observational cohort study was performed in a PACU at a high-volume prostate cancer center. We used a convenience sample of patients > 60 years undergoing elective radical prostatectomy. Patients with a history of cerebrovascular or neurodegenerative disease were excluded. Fifteen, 30, 45, and 60 following extubation, patients were screened for signs of delirium with the Confusion Assessment Method for the Intensive Care Unit. Three months after surgery self-reported cognitive function was assessed with the Cognitive Failures Questionnaire, and health status was evaluated with the 36-item Short-Form Health Survey (SF-36). RESULTS: Signs of PACU delirium were present in 32.4% (n = 72/222) of patients, and 80.2% (n = 178/222) completed the 3-month follow-up. The presence of PACU delirium signs was not significantly associated with self-reported cognitive failures (B = 0.60, 95% CI: -1.72; 2.92, p = 0.61) or SF-36 physical component scores (B = 0.19, 95% CI: 0.02; 0.36, p = 0.03) or SF-36 mental component scores (B = -0.03, 95% CI: -0.18, 0.11, p = 0.66) 3 months after radical prostatectomy. CONCLUSIONS: In a cohort of educated, highly functioning, elderly male patients who were assessed immediately after surgery and at a 3-month follow-up, we found no association between PACU delirium and self-reported cognitive failures or perceived health status, which implies that PACU delirium may be an event of limited duration and impact. TRIAL REGISTRATION: The study was registered at ClinicalTrials.gov (Identifier: NCT04168268, Date of registration: November 19, 2019).

Health-related quality of life and self-reported cognitive function in patients with delayed neurocognitive recovery after radical prostatectomy: a prospective follow-up study.

BACKGROUND: Delayed neurocognitive recovery (DNCR) is a common and serious complication after radical prostatectomy. We hypothesized that patients with DNCR in the early postoperative period would report reduced health-related quality of life (HRQoL) and more cognitive failures 12 months after surgery, compared with patients without DNCR. METHODS: We performed a 12-month follow-up on 367 patients who had been enrolled in a prospective observational trial to study the incidence of DNCR after radical prostatectomy. Patients were screened for preoperative cognitive impairment and depression. We defined DNCR as a decline in cognitive function between days 3 and 5 after surgery, compared with baseline assessments. We evaluated HRQoL and cognitive failures 12 months after surgery with the 36-item Short Form Health Survey and the Cognitive Failures Questionnaire. General linear models were used to analyze associations of DNCR with HRQoL and cognitive failures. RESULTS: Delayed neurocognitive recovery in the early postoperative period was significantly associated with self-reported cognitive failures (B for no DNCR = - 0.411 [95% CI: - 0.798;0.024], p = 0.038), but not with physical (B = 0.082 [95% CI: - 0.021;0.186], p = 0.118) or mental HRQoL (B = - 0.044 [95% CI: - 0.149;0.062], p = 0.417) 12 months after surgery. Preoperative depression screening scores were significantly associated with self-reported cognitive failures and both physical and mental HRQoL 12 months after surgery. CONCLUSIONS: Delayed neurocognitive recovery in the early period after radical prostatectomy has a long-term impact on patients' daily lives by impairing memory, attention, action, and perception. Therefore, prevention of DNCR must be a priority for physicians and researchers. Consequent preoperative screening for depressive symptoms may facilitate early psycho-oncological intervention to improve postoperative HRQoL. Trials registration DRKS00010014 , date of registration: 21.03.2016, retrospectively registered.

Comparing the effect of positioning on cerebral autoregulation during radical prostatectomy: a prospective observational study.

PURPOSE: Surgery in the prolonged extreme Trendelenburg position may lead to elevated intracranial pressure and compromise cerebral hemodynamic regulation. We hypothesized that robot-assisted radical prostatectomy with head-down tilt causes impairment of cerebral autoregulation compared with open retropubic radical prostatectomy in the supine position. METHODS: Patients scheduled for elective radical prostatectomy were included at a tertiary care prostate cancer clinic. Continuous monitoring of the cerebral autoregulation was performed using the correlation method. Based on measurements of cerebral oxygenation with near-infrared spectroscopy and invasive mean arterial blood pressure (MAP), a moving correlation coefficient was calculated to obtain the cerebral oxygenation index as an indicator of cerebral autoregulation. Cerebral autoregulation was measured continuously from induction until recovery from anesthesia. RESULTS: There was no significant difference in cerebral autoregulation between robot-assisted and open retropubic radical prostatectomy during induction (p = 0.089), intraoperatively (p = 0.162), and during recovery from anesthesia (p = 0.620). Age (B = 0.311 [95% CI 0.039; 0.583], p = 0.025) and a higher difference between baseline MAP and intraoperative MAP (B = 0.200 [95% CI 0.073; 0.327], p = 0.002) were associated with impaired cerebral autoregulation, whereas surgical technique was not (B = 3.339 [95% CI 1.275; 7.952], p = 0.155). CONCLUSION: Compared with open radical prostatectomy in the supine position, robot-assisted surgery in the extreme Trendelenburg position with capnoperitoneum did not lead to an impairment of cerebral autoregulation during the perioperative period in our study population. TRIAL REGISTRATION NUMBER: DRKS00010014, date of registration: 21.03.2016, retrospectively registered.

Comparison of intra- and postoperative analgesia and pain perception in robot-assisted vs. open radical prostatectomy.

PURPOSE: One of the advantages of minimally invasive surgery may be reduced postoperative pain and faster recovery. However, reliable comparisons of robot-assisted (RARP) vs. open radical prostatectomy (ORP) addressing perioperative pain regimen are scarce. METHODS: We identified 420 consecutive treated patients who underwent RARP (n = 254) vs. ORP (n = 166) for clinically localized prostate cancer in 2017. After 1:1 propensity score matching for age, body mass index, D'Amico risk classification and lymph node yield, intra- and postoperative pain medication doses, as well as pain perception expressed by the numeric rating scale were assessed in uni- and multivariable analyses. RESULTS: Median age was 64.9 years. Operation time was significantly shorter in ORP patients (155 vs. 175 min in RARP, p < 0.001). Overall, a median of 12.5 vs. 12 g of metamizol was administered in RARP vs. ORP patients (p = 0.2). Additionally, a median of 146.7 vs. 133.9 mg of morphine equivalent was administered in RARP vs. ORP patients (p < 0.001). The mean maximum pain perceived on day 0 was 3.2 vs. 3.6 in RARP vs. ORP patients (p = 0.1). It decreased within the following days, and again, no differences between the two groups were observed. All results were confirmed in multivariable analyses. CONCLUSIONS: When comparing RARP vs. ORP, a small increase in perioperative morphine administration at RARP may be expected. However, when assessing pain perception, no differences were observed between the two groups. Moreover, mean maximum pain perceived was very low, which may reassure patients, who are counselled for radical prostatectomy.

Impact of perioperative administration of 6 % hydroxyethyl starch 130/0.4 on serum cystatin C-derived renal function after radical prostatectomy: a single-centre retrospective study.

BACKGROUND: Hydroxyethyl starch (HES) is used for repletion of acute intravasal volume loss in surgical patients. However, in critically ill patients, HES is associated with acute kidney injury. We aimed to evaluate the effect of HES on perioperative cystatin C (cystC)-derived estimated glomerular filtration rates (eGFRcystC) in patients undergoing open and robot-assisted radical prostatectomy. METHODS: In this retrospective study we included 179 patients who underwent general anaesthesia for radical prostatectomy received HES perioperatively, and had complete cystC and fluid therapy data available. CystC and corresponding eGFRcystC at postoperative days 1, 3, and 5 were compared with preoperative baseline using Wilcox rank-sum test. RESULTS: In 179 eligible patients, 6 % HES 130/0.4 was administered in a median (25th to 75th percentile) dose of 1000 mL (1000 to 1000 mL). Baseline eGFRcystC was 109.4 mL/min (100.3 to 118.7 mL/min). eGFRcystC on postoperative days 1, 3, and 5 was 120.4 mL/min (109.4 to 134.0 mL/min), 120.4 mL/min (109.4 to 132.9 mL/min), and 117.9 mL/min (106.6 to 129.8 mL/min), respectively (p < 0.001 compared with baseline, each). No patient had an eGFRcystC-decrease of ≥25 % from baseline. CONCLUSIONS: The results indicate that the administration of a median dose of 1000 mL of 6 % HES 130/0.4 is not associated with a postoperative deterioration of renal function in patients with normal to near-normal baseline renal function undergoing radical prostatectomy.

Effect of sedative premedication with oral midazolam on postanesthesia care unit delirium in older adults: a secondary analysis following an uncontrolled before-after design.

BACKGROUND: Sedative premedication with benzodiazepines has been linked with prolonged recovery and inadequate emergence during the immediate postoperative period. We aimed to analyze the association between postanesthesia care unit (PACU) delirium and sedative premedication with oral midazolam. METHODS: We performed a secondary analysis of prospectively collected data before (midazolam cohort) and after (non-midazolam cohort) implementation of a restrictive strategy for oral premedication with midazolam. From March 2015 until July 2018, we included patients 60 years and older, who underwent elective radical prostatectomy for prostate cancer. Exclusion criteria were contraindications to premedication with midazolam, preoperative anxiety, and a history of neurological disorders. Patients, who were scheduled for postoperative admission to the intensive care unit, were excluded. Between 2015 and 2016, patients received 7.5 mg oral midazolam preoperatively (midazolam cohort). Patients included between 2017 and 2018 did not receive any sedative medication preoperatively (non-midazolam cohort). The primary endpoint was the incidence of PACU delirium. RESULTS: PACU delirium rates were 49% in the midazolam cohort (n = 214) and 33% in the non-midazolam cohort (n = 218). This difference was not statistically significant on multivariable logistic regression analysis (OR 0.847 [95% CI 0.164; 4.367]; P = 0.842). Age (OR 1.102 [95% CI 1.050; 1.156]; P < 0.001), the cumulative dose of sufentanil (OR 1.014 [95% CI 1.005; 1.024]; P = 0.005), and propofol-sufentanil for anesthesia maintenance (OR 2.805 [95% CI 1.497; 5.256]; P = 0.001) were significantly associated with PACU delirium. CONCLUSION: Midazolam for sedative premedication was not significantly associated with PACU delirium. The reduction in the incidence of PACU delirium throughout the study period may be attributable to improvements in perioperative management other than a more restrictive preoperative benzodiazepine administration.

Comparison of Cognitive Function After Robot-Assisted Prostatectomy and Open Retropubic Radical Prostatectomy: A Prospective Observational Single-Center Study.

OBJECTIVE: To assess the effects of robot-assisted radical prostatectomy in the Trendelenburg position on postoperative neurocognitive outcomes this study compared cognitive function between patients who underwent robot-assisted radical prostatectomy and those who underwent open retropubic radical prostatectomy. METHODS: Objective evaluations of pre- and postoperative cognitive function were performed upon admission and before hospital discharge, by using a neuropsychological test battery. We collected self-reported data on cognitive failures at 3 months postoperatively. Binary logistic regression analysis was used to assess the effects of surgical technique on postoperative cognitive performance. RESULTS: The pre- and postoperative neuropsychological assessments were completed by 367 patients with a median age of 64 years (range 44-76). The incidence of postoperative cognitive dysfunction was 23.9% after robot-assisted (39/165) and 22.3% after open radical prostatectomy (45/202). There was no significant difference in postoperative cognitive function during the early postoperative period (P = 0.758) and self-reported cognitive failures at 3 months (P = 0.303) between robot-assisted and open surgery. Surgical technique was not associated with early postoperative cognitive dysfunction in multivariable analysis (OR 1.012, 95%CI: 0.608-1.685, P = 0.962). CONCLUSION: Compared with open surgery in supine position postoperative neurocognitive disorders do not occur more frequently after robot-assisted radical prostatectomy in the extreme Trendelenburg position. Based on these findings potential adverse effects on cognitive function do not have to be considered in the choice of surgical approach for radical prostatectomy.

Postanesthesia care unit delirium following robot-assisted vs open retropubic radical prostatectomy: A prospective observational study.

BACKGROUND: The aim of this study was to compare the incidence of early postoperative delirium in the postanesthesia care unit (PACU) between robot-assisted radical prostatectomy (RARP) in the extreme Trendelenburg position and open retropubic radical prostatectomy (ORP) in supine position. METHODS: Patients were screened for delirium signs 15, 30, 45, and 60 minutes following extubation. RESULTS: PACU delirium was present in 39.3% of RARP (64/163) patients and 41.8% of ORP (77/184) patients. Higher age (OR 1.072, 95%CI: 1.034-1.111, P < .001), total intravenous anesthesia (OR 2.001, 95%CI: 1.243-3.221, P = .004), and anesthesia duration (OR 1.255, 95%CI: 1.067-1.476, P = .006) were associated with PACU delirium, but no association was found between surgical technique and PACU delirium. CONCLUSION: Compared with inhalational anesthesia, total intravenous anesthesia using propofol-sufentanil, higher age, and longer duration of anesthesia were associated with PACU delirium. Based on these findings, adverse effects on postoperative recovery and delirium signs do not have to be considered in the choice of surgical approach for radical prostatectomy. TRIAL REGISTRATION: https://www.drks.de/, identifier: DRKS00010014.

Histomorphologic examination of skeletal muscle preparations does not differentiate between malignant hyperthermia-susceptible and -normal patients.

BACKGROUND: It has been suggested that malignant hyperthermia (MH) can be diagnosed by specific myopathologic alterations. The purpose of this study was to investigate whether there are characteristic myopathologic changes in skeletal muscles of MH-susceptible (MHS) compared with MH-normal (MHN) patients. METHODS: Four hundred forty patients with clinical suspicion of MH were classified as MHN, MH equivocal (MHE), or MHS by the in vitro contracture test with halothane and caffeine. In addition, a small muscle sample excised from each patient was analyzed by histologic, histochemical, immunohistochemical, and computer-aided morphometric methods. RESULTS: MHN was diagnosed in 243 patients, MHE was diagnosed in 65, and MHS was diagnosed in 132. No myopathologic abnormalities were found in 53.5% of the MHN, 53.9% of the MHE, and 56.1% of the MHS patients. Thirty-five percent of all patients showed one, 9.8% showed two, and only 0.9% showed three different pathologic findings within skeletal muscle preparations. The frequency of pathologic findings did not differ between the MHN and the MHS patients; only fiber type I predominance was observed more often in MHN. MHE patients could not be assigned to a diagnostic group by detection of myopathologic alterations. In six clinically unaffected patients, a former unrecognized myopathy, such as central core disease, was diagnosed. This disease is characterized by a specific alteration (cores). CONCLUSIONS: Histologic differences between MHS and MHN statuses could not be demonstrated in this study. Histopathologic examinations can neither improve the diagnosis of MH nor contribute to a better definition of the MH status. However, histopathologic examinations might be useful to detect formerly unrecognized specific myopathies.