Cognitive Training to Reduce Memory Disturbance Associated With Postoperative Cognitive Impairment After Elective Noncardiac Surgery: An Experimental Study.

PURPOSE: Assess the efficiency of a cognitive training program using an artificial intelligence application to optimize cognitive reserve and reduce memory disturbance in patients aged 55 to 75 after Class II-III elective noncardiac surgery. DESIGN: Experimental with random assignment. METHODS: The study was conducted on 80 patients undergoing surgery at the Teknon Medical Center Hospital in Barcelona, from April 2018 to June 2021. Both groups were evaluated with cognitive tests before surgery and 7 and 30 days after surgery. The experimental group was subjected to cognitive training for 10 days before surgery to improve their cognitive reserve. FINDINGS: Significant differences were found between the study groups 30 days after surgery in the three screening tests (Mini-Cog, T@M, and MFE). The intervention group presented with fewer cognitive and memory alterations. Age and pre-existing comorbidities were not correlated with an impact on memory impairment or cognitive function. CONCLUSIONS: A cognitive training program based on artificial intelligence, prescribed and monitored by anesthesia nurses has a positive impact on increasing cognitive reserve and reducing memory disturbance in patients aged 55 to 75 undergoing Class II to III elective, noncardiac surgery. This intervention may serve as a prehabilitation strategy in patients with a risk of cognitive dysfunction evaluated by anesthesia nurses for the purpose of preserving their cognitive function and optimizing their recovery.

Perioperative opioid-minimization approach as a useful protocol in the management of patients with Ehlers-Danlos syndrome-hypermobility type, craniocervical instability and severe chronic pain who are to undergo occipito-cervical fixation.

Patients suffering from connective tissue disorders like Ehlers-Danlos syndrome hypermobility type/joint hypermobility syndrome (EDS-HT/JHS) may be affected by craniocervical instability (CCI). These patients experience myalgic encephalomyelitis, chronic fatigue, depression, extreme occipital-cervical pain, and severe widespread pain that is difficult to relieve with opioids. This complex and painful condition can be explained by the development of chronic neuroinflammation, opioid-induced hyperalgesia, and central sensitization. Given the challenges in treating such severe physical pain, we evaluated all the analgesic methods previously used in the perioperative setting, and updated information was presented. It covers important physiopathological aspects for the perioperative care of patients with EDS-HT/JHS and CCI undergoing occipital-cervical/thoracic fixation/fusion. Moreover, a change of paradigm from the current opioid-based management of anesthesia/analgesia in these patients to the perioperative opioid minimization strategies used by the authors was analyzed and proposed as follow-up considerations from our previous case series. These strategies are based on total-intravenous opioid-free anesthesia, multimodal analgesia, and a postoperative combination of anti-hyperalgesic coadjuvants (lidocaine, ketamine, and dexmedetomidine) with an opioid-sparing effect.

Opioid-free anesthesia for patients with joint hypermobility syndrome undergoing craneo-cervical fixation: a case-series study focused on anti-hyperalgesic approach.

BACKGROUND: Patients with Ehlers-Danlos Syndrome/Hypermobility Type (EDS-HT/JHS) and Craneo-Cervical Instability frequently suffer from severe widespread pain which is difficult to control. Chronic neuroinflammation, opioid-induced hyperalgesia, and central sensitization may explain this painful condition. The aim of this study was to determine if opioid-free anesthesia plus the postoperative administration of lidocaine, ketamine and dexmedetomidine can reduce postoperative pain and the need of methadone rescues in comparison with opioid-based management in these patients undergoing Craneo-Cervical Fixation (CCF). The secondary aim was to assess the needs of opioids at hospital-discharge, incidence of gastrointestinal complications and the requirement of anxiolytic. METHODS: A retrospective, consecutive case series study was designed. 42 patients with EDS-HT/JHS undergoing CCF were enrolled in two groups: an OFA-plus Group that received opioid-free anesthesia with propofol, lidocaine, ketamine and dexmedetomidine, and OP Group, opioid-based anesthesia-analgesia. The main variables: Preoperative Visual Analogue Score (VAS), postoperative VAS on the 1st, 2nd, 4th and 6th days, sufentanil or morphine requirements, need for methadone rescue, and VAS at hospital-discharge. Data was presented by mean ± SD, percentage, median or interquartile range. Chi-squared or Fisher's test. 95% C.I and P values < 0.05. RESULTS: Nineteen patients in OFA-plus, and 23 patients in OP group. VAS was lower in OFA-plus on the postoperative days evaluated (p < 0.001).VAS at hospital-discharge was lower in OFA-plus: 4.96 (4.54-5.37) vs. OP 6.39 (6.07-6.71) (p < 0.001). Methadone requirement was lower in the OFA-plus (p < 0.001). 78% of patients in OFA-plus didn't need methadone rescue. 95% in OP group needed methadone rescues at high doses(> 15 mg/day). No differences regarding equivalent doses of sufentanil or morphine consumption on the 2nd, 4th, and 6th postoperative days were found. OFA-plus decreased ileus, nausea and vomiting (p < 0.001). 60.9% in OFA-plus group decreased opioid requirements at hospital-discharge compared with preoperative values. A 77% reduction of anxiolytics requirements was shown. CONCLUSION: OFA-plus management for patients undergoing CCF with EDS-HT/JHS shows significant reduction in postoperative pain and at hospital-discharge compared with opioid-based anesthesia. OFA-plus management decreases the total doses of methadone rescues, reduces anxiolytic requirements and gastrointestinal side-effects, except for constipation. OFA-plus management is a feasible option to improve postoperative pain control, reducing the opioids' use and their postoperative side-effects in patients undergoing CCF with EDS-HT/JHS.

Disfunción cognitiva postoperatoria / Postoperative cognitive dysfunction: a concept analy

IntroduccIón. La disfunción cognitiva postoperatoria (DCPO) es una complicación frecuente, generalmente subestimada y que comporta un impacto negativo en la calidad de vida de los pacientes y sus familias. La heterogeneidad de los estudios clínicos publicados hasta la fecha actual explica la falta de una definición clara y estandarizada del constructo. Objetivo. Examinar críticamente el concepto de DCPO con el fin de desarrollar una concepción precisa y diferenciada de este fenómeno. Método. Análisis de concepto fundamentado en la técnica descrita por Wilson a partir de la revisión de la literatura publicada para examinar las características que definen el concepto y sus atributos. resultados. La DCPO es una complicación derivada del acto quirúrgico y anestésico; su etiología es desconocida, aunque la hipótesis fisiopatológica más aceptada es la de la neuroinflamación. Los factores de riesgo evidenciados son la edad avanzada y un nivel educacional bajo. Es un trastorno transitorio y reversible en la mayoría de los casos; de no ser así, puede desencadenar demencia. La enfermera tiene un papel fundamental en la identificación y en la detección precoz de los signos y síntomas asociados. conclusIones. El análisis resultante de este trabajo ayuda a dilucidar el concepto y permite diferenciarlo de otros afines. Se pone de manifiesto la relevancia clínica del trastorno y permite apuntar nuevas estrategias de intervención para mejorar la seguridad de los pacientes y la práctica clínica

Background. Postoperative Cognitive Dysfunction (POCD) is a frequent complication, generally underestimated and has a very negative impact on patients and their family's quality of life. At present there is no clear concept nor standardized definition POCD, possibly to the heterogeneity of the published scientific literature. Objective. To review with criticism the POCD’s concept by analyzing the current state of scientific literature in order to develop an accurate conception of this phenomenon. Method. To review the published literature and apply concept analysis based on Wilson's method to examine the characteristics that define the concept and its attributes. Results. The POCD is a complication derived from the surgical and anesthetic act, its etiology is unknown, although the most accepted physiopathological hypothesis is neuroinflammation. The most evidenced risk factors are advanced age and a low educational level. In most cases, it is a transient and reversible disorder, otherwise it can trigger dementia. Nurses play a fundamental role in the identification and early detection of associated signs and symptoms. Conclusions. The analysis resulting from this work might help to clarify the concept of POCD and allowing to establish its differences from other similar entities. It highlights the clinical relevance of the disorder and allows us to point out new intervention strategies to improve patient safety and clinical practice