Perioperative Evaluation of Brain Health.

As the global population is aging and surgical needs rise, the occurrence of perioperative neurocognitive disorders (PND) is becoming a significant concern. PND refers to cognitive changes that occur before or after surgery, including neurocognitive disorders, postoperative delirium, and delayed neurocognitive recovery. To address this issue, a brain health assessment initiative within a multidisciplinary team is an emerging concept. Assessing cognitive function, comorbidities, severity of neurocognitive disorders, medications, nutritional status, sleep quality, and other factors can help mitigate the risk of PND and improve patient outcomes.

Presence of Preoperative Neurodegeneration Biofluid Markers in Patients with Postoperative Delirium.

BACKGROUND: The pathophysiology of delirium is incompletely understood, including what molecular pathways are involved in brain vulnerability to delirium. This study examined whether preoperative plasma neurodegeneration markers were elevated in patients who subsequently developed postoperative delirium through a retrospective case-control study. METHODS: Inclusion criteria were patients of 65 yr of age or older, undergoing elective noncardiac surgery with a hospital stay of 2 days or more. Concentrations of preoperative plasma P-Tau181, neurofilament light chain, amyloid ß1-42 (Aß42), and glial fibrillary acidic protein were measured with a digital immunoassay platform. The primary outcome was postoperative delirium measured by the Confusion Assessment Method. The study included propensity score matching by age and sex with nearest neighbor, such that each patient in the delirium group was matched by age and sex with a patient in the no-delirium group. RESULTS: The initial cohort consists of 189 patients with no delirium and 102 patients who developed postoperative delirium. Of 291 patients aged 72.5 ± 5.8 yr, 50.5% were women, and 102 (35%) developed postoperative delirium. The final cohort in the analysis consisted of a no-delirium group (n = 102) and a delirium group (n = 102) matched by age and sex using the propensity score method. Of the four biomarkers assayed, the median value for neurofilament light chain was 32.05 pg/ml for the delirium group versus 23.7 pg/ml in the no-delirium group. The distribution of biomarker values significantly differed between the delirium and no-delirium groups (P = 0.02 by the Kolmogorov-Smirnov test) with the largest cumulative probability difference appearing at the biomarker value of 32.05 pg/ml. CONCLUSIONS: These results suggest that patients who subsequently developed delirium are more likely to be experiencing clinically silent neurodegenerative changes before surgery, reflected by changes in plasma neurofilament light chain biomarker concentrations, which may identify individuals with a preoperative vulnerability to subsequent cognitive decline.

Agreement Between the Mini-Cog in the Preoperative Clinic and on the Day of Surgery and Association With Postanesthesia Care Unit Delirium: A Cohort Study of Cognitive Screening in Older Adults.

BACKGROUND: Cognitive impairment is common in older surgical patients and is associated with postoperative delirium. However, cognitive function is inconsistently assessed preoperatively, leading to missed opportunities to recognize vulnerable patients. We designed a prospective cohort study to assess the agreement of the Mini-Cog screening tool administered in the preoperative clinic (clinic-day test) or immediately before surgery (surgery-day test) and to determine whether a positive screening for cognitive dysfunction in the surgery-day test is associated with postoperative delirium in the postanesthesia care unit (PACU). METHODS: This was a cohort study of patients aged 65-89 years, scheduled for elective, inpatient surgery under general anesthesia between June 20, 2018 and August 3, 2018. Mini-Cog test scores were obtained during a clinic-day test and surgery-day test. The Short Confusion Assessment Method was performed in the PACU. Agreement between Mini-Cog clinic-day and surgery-day test scores was estimated using an ordinally weighted kappa statistic, κ. Multivariable logistic regression was used to determine whether there was an association between a positive screen for cognitive impairment and PACU delirium. Odds ratio analysis was performed to determine whether the Mini-Cog score was associated with PACU delirium. RESULTS: Of 128 patients meeting eligibility criteria, 80 patients were enrolled. Ten had cognitive impairment based on the Mini-Cog clinic-day test score, while 70 did not. Age, sex, race, education level, subjective memory impairment, and American Society of Anesthesiologists (ASA) physical status were equivalent in the 2 groups. The mean number of days between the clinic-day score and the surgery-day score was 8.4 days (standard deviation [SD] = 6.9). Mini-Cog clinic-day and surgery-day scores had high agreement (κ = 0.78; 95% confidence interval [CI], 0.69-0.87; P < .001), and both scores were highly predictive of PACU delirium. Patients with Mini-Cog surgery-day scores compatible with cognitive impairment (Mini-Cog scores ≤2) had an estimated 12.8 times higher odds of PACU delirium compared to patients with normal cognitive function or Mini-Cog scores >2 (odds ratio [OR] = 12.8; 95% CI, 2.6-63.8, P = .002). Similarly, patients with Mini-Cog clinic-day test scores compatible with cognitive impairment had an estimated 29 times higher odds of PACU delirium compared to patients with normal cognitive function (OR = 29.0; 95% CI, 2.6-63.8, P < .001). CONCLUSIONS: These data support the approach of using the Mini-Cog on the day of surgery to screen for cognitive impairment in older patients. Importantly, Mini-Cog surgery-day test scores compatible with cognitive impairment (≤2) were strongly associated with PACU delirium.

Adult Emergence Agitation: A Veteran-Focused Narrative Review.

Emergence agitation (EA) is a self-limited state of psychomotor excitement during awakening from general anesthesia. EA is confined to the emergence period as consciousness is restored, which sharply distinguishes it from other postoperative delirium states. Sporadic episodes of EA may become violent with the potential for harm to both patients and caregivers, but the long-term consequences of such events are not fully understood. Current literature on EA in adults is limited to small-scale studies with inconsistent nomenclature, variable time periods that define emergence, a host of different surgical populations, and conflicting diagnostic criteria. Therefore, true incidence rates and risk factors are unknown. In adult noncardiac surgery, the incidence of EA is approximately 19%. Limited data suggest that young adults undergoing otolaryngology operations with volatile anesthetic maintenance may be at the highest risk for EA. Currently suggested EA mechanisms are theoretical but might reflect underblunted sympathetic activation in response to various internal (eg, flashbacks or anxiety) or external (eg, surgical pain) stimuli as consciousness returns. Supplemental dexmedetomidine and ketamine may be utilized for EA prevention. Compared to the civilian population, military veterans may be more vulnerable to EA due to high rates of posttraumatic stress disorder (PTSD) manifesting as violent flashbacks; however, confirmatory data are limited. Nonetheless, expert military medical providers suggest that use of patient-centered rapport tactics, PTSD trigger identification and avoidance, and grounding measures may alleviate hyperactive emergence phenomena. Future research is needed to better characterize EA in veterans and validate prophylactic measures to optimize care for these patients. This narrative review provides readers with an important framework to distinguish EA from delirium. Furthermore, we summarize current knowledge of EA risk factors, mechanisms, and adult management strategies and specifically revisit them in the context of veteran perioperative health. The anesthesiology care team is ideally positioned to further explore EA and develop effective prevention and treatment protocols.

Association of Plasma Neurofilament Light with Postoperative Delirium.

OBJECTIVE: To examine the association of the plasma neuroaxonal injury markers neurofilament light (NfL), total tau, glial fibrillary acid protein, and ubiquitin carboxyl-terminal hydrolase L1 with delirium, delirium severity, and cognitive performance. METHODS: Delirium case-no delirium control (n = 108) pairs were matched by age, sex, surgery type, cognition, and vascular comorbidities. Biomarkers were measured in plasma collected preoperatively (PREOP), and 2 days (POD2) and 30 days postoperatively (PO1MO) using Simoa technology (Quanterix, Lexington, MA). The Confusion Assessment Method (CAM) and CAM-S (Severity) were used to measure delirium and delirium severity, respectively. Cognitive function was measured with General Cognitive Performance (GCP) scores. RESULTS: Delirium cases had higher NfL on POD2 and PO1MO (median matched pair difference = 16.2pg/ml and 13.6pg/ml, respectively; p < 0.05). Patients with PREOP and POD2 NfL in the highest quartile (Q4) had increased risk for incident delirium (adjusted odds ratio [OR] = 3.7 [95% confidence interval (CI) = 1.1-12.6] and 4.6 [95% CI = 1.2-18.2], respectively) and experienced more severe delirium, with sum CAM-S scores 7.8 points (95% CI = 1.6-14.0) and 9.3 points higher (95% CI = 3.2-15.5). At PO1MO, delirium cases had continued high NfL (adjusted OR = 9.7, 95% CI = 2.3-41.4), and those with Q4 NfL values showed a -2.3 point decline in GCP score (-2.3 points, 95% CI = -4.7 to -0.9). INTERPRETATION: Patients with the highest PREOP or POD2 NfL levels were more likely to develop delirium. Elevated NfL at PO1MO was associated with delirium and greater cognitive decline. These findings suggest NfL may be useful as a predictive biomarker for delirium risk and long-term cognitive decline, and once confirmed would provide pathophysiological evidence for neuroaxonal injury following delirium. ANN NEUROL 2020;88:984-994.

Relationship between emotional states before cardiac valve surgeries with postoperative complications.

OBJECTIVE: To investigate associations between preoperative anxiety and depression symptoms and postoperative complications and the sociodemographic and clinical characteristics of patients undergoing valve repair surgery. METHOD: Observational, exploratory and prospective study. The consecutive non-probabilistic sample consisted of patients undergoing their first valve repair surgery. Data were collected from September 2013 to September 2015, in a university hospital in the interior of São Paulo, Brazil. Symptoms were assessed using the Hospital Anxiety and Depression Scale and analyzed using Mann-Whitney and Spearman correlation; alpha was established at 5%. RESULTS: Among the 70 participants, depressive symptoms were more frequent among women (p=0.042) and among patients experiencing postoperative agitation (p=0.039) Conclusion: In this study, depressive symptoms were associated with being a woman and postoperative agitation; the same was not true in regard to anxiety symptoms.

Delirium in the intensive care setting dependent on the Richmond Agitation and Sedation Scale (RASS): Inattention and visuo-spatial impairment as potential screening domains.

OBJECTIVE: In the intensive care setting, delirium is a common occurrence; however, the impact of the level of alertness has never been evaluated. Therefore, this study aimed to assess the delirium characteristics in the drowsy, as well as the alert and calm patient. METHOD: In this prospective cohort study, 225 intensive care patients with Richmond Agitation and Sedation Scale (RASS) scores of -1 - drowsy and 0 - alert and calm were evaluated with the Delirium Rating Scale-Revised-1998 (DRS-R-98) and the Diagnostic and Statistical Manual 4th edition text revision (DSM-IV-TR)-determined diagnosis of delirium. RESULTS: In total, 85 drowsy and 140 alert and calm patients were included. Crucial items for the correct identification of delirium were sleep-wake cycle disturbances, language abnormalities, thought process alterations, psychomotor retardation, disorientation, inattention, short- and long-term memory, as well as visuo-spatial impairment, and the temporal onset. Conversely, perceptual disturbances, delusions, affective lability, psychomotor agitation, or fluctuations were items, which identified delirium less correctly. Further, the severities of inattentiveness and visuo-spatial impairment were indicative of delirium in both alert- or calmness and drowsiness. SIGNIFICANCE OF RESULTS: The impairment in the cognitive domain, psychomotor retardation, and sleep-wake cycle disturbances correctly identified delirium irrespective of the level alertness. Further, inattentiveness and - to a lesser degree - visuo-spatial impairment could represent a specific marker for delirium in the intensive care setting meriting further evaluation.

Role of perceived stress in postoperative delirium: an investigation among elderly patients.

Objectives: This study examined levels of perceived stress (PS), postoperative delirium (POD) and associated factors among Thai elderly patients undergoing elective noncardiac surgery.Background and aims: Preoperative PS and change after operation have not been widely studied. Moreover, psychological factors associated with PS and POD has been poorly investigated.Materials and Methods: In total, 429 elderly patients were recruited at a university hospital. The preoperative evaluation included sociodemographic data, health behaviors at risk, Perceived Stress Scale (PSS-10), Neuroticism Inventory (NI), Mental State Examination T10 (MSET10), Montreal Cognitive Assessment (MoCA) and Geriatric Depression Scale (GDS-15). Three-day postoperative evaluation included PSS-10 and Confusion Assessment Method Algorithm (CAM) or CAM-ICU for Delirium. Multiple regression and logistic regression analysis were performed to determine potential predictors.Results: Females were 58.97%, and the mean age was 69.93 ± 6.87 years. Mean pre- and postoperative PS were 12.77 ± 5.41 and 13.39 ± 5.26, respectively (P < 0.05). Multiple regression revealed that neuroticism, depression, and BMI predicted PS significantly. None of the independent variables was found to predict postoperative PS except for preoperative PS (p <.001). POD at the recovery room was predicted by preoperative PS (odds ratio = 1.181, 95% CI = 1.019-1.369), whereas overall POD was predicted by MoCA (odds ratio = .864, 95% CI = .771 -.968).Conclusion: Preoperative PS was significant in that it was associated with postoperative PS and POD. A careful assessment of preoperative PS as well as providing brief interventions for patients with high levels of this condition may reduce the risk of POD.

Randomized controlled trial of acupuncture to prevent emergence delirium in children undergoing myringotomy tube placement.

BACKGROUND: Myringotomy tube placement is a pediatric procedure frequently performed under inhalational anesthesia without intravenous line placement. Emergence delirium is common following sevoflurane anesthesia, and can lead to patient harm and escalation of nursing care. Our goal was to determine if intraoperative acupuncture, compared to standard of care, reduces emergence delirium in children undergoing myringotomy tube placement. METHODS: Single center, randomized, controlled trial at a university hospital, including children ages 1-6 years with ASA physical status 1-3 scheduled for myringotomy tube placement. Participants were stratified based on midazolam premedication and randomized to intraoperative acupuncture (AC, N.=49) or standard anesthesia care (SC, N.=50). Acupuncture needles were placed in bilateral Heart 7 (HT7) and ear Shen Men points after anesthesia induction. A blinded observer in the PACU assessed emergence delirium using the Pediatric Anesthesia Emergence Delirium (PAED) scale. Endpoints were highest PAED score in the recovery room and post-discharge agitation and sleep quality. RESULTS: Patient baseline characteristics were similar between treatment groups. With midazolam premedication, the highest PAED score was 11.6 in patients receiving AC and 12.0 for SC. Without midazolam premedication, the highest PAED was 11.8 in patients receiving AC and 10.7 for SC. The overall PAED score difference between AC and SC groups was 0.33 (95% CI -1.5, 2.2, P=0.723). CONCLUSIONS: Intraoperative acupuncture at HT7 and ear Shen Men did not reduce PAED scores after myringotomy tube placement. Based on these data, it is therefore unlikely that a larger study of the same design would demonstrate a significant effect of intraoperative acupuncture on emergence delirium after brief sevoflurane anesthesia. However, other acupuncture points or techniques could be considered.

Intraoperative Oxidative Damage and Delirium after Cardiac Surgery.

BACKGROUND: Mechanisms of postoperative delirium remain poorly understood, limiting development of effective treatments. We tested the hypothesis that intraoperative oxidative damage is associated with delirium and neuronal injury and that disruption of the blood-brain barrier modifies these associations. METHODS: In a prespecified cohort study of 400 cardiac surgery patients enrolled in a clinical trial of atorvastatin to reduce kidney injury and delirium, we measured plasma concentrations of F2-isoprostanes and isofurans using gas chromatography-mass spectrometry to quantify oxidative damage, ubiquitin carboxyl-terminal hydrolase isozyme L1 to quantify neuronal injury, and S100 calcium-binding protein B using enzyme-linked immunosorbent assays to quantify blood-brain barrier disruption before, during, and after surgery. We performed the Confusion Assessment Method for the Intensive Care Unit twice daily to diagnose delirium. We measured the independent associations between intraoperative F2-isoprostanes and isofurans and delirium (primary outcome) and postoperative ubiquitin carboxyl-terminal hydrolase isozyme L1 (secondary outcome), and we assessed if S100 calcium-binding protein B modified these associations. RESULTS: Delirium occurred in 109 of 400 (27.3%) patients for a median (10th, 90th percentile) of 1.0 (0.5, 3.0) days. In the total cohort, plasma ubiquitin carboxyl-terminal hydrolase isozyme L1 concentration was 6.3 ng/ml (2.7, 14.9) at baseline and 12.4 ng/ml (7.9, 31.2) on postoperative day 1. F2-isoprostanes and isofurans increased throughout surgery, and the log-transformed sum of intraoperative F2-isoprostanes and isofurans was independently associated with increased odds of postoperative delirium (odds ratio, 3.70 [95% CI, 1.41 to 9.70]; P = 0.008) and with increased postoperative ubiquitin carboxyl-terminal hydrolase isozyme L1 (ratio of geometric means, 1.42 [1.11 to 1.81]; P = 0.005). The association between increased intraoperative F2-isoprostanes and isofurans and increased postoperative ubiquitin carboxyl-terminal hydrolase isozyme L1 was amplified in patients with elevated S100 calcium-binding protein B (P = 0.049). CONCLUSIONS: Intraoperative oxidative damage was associated with increased postoperative delirium and neuronal injury, and the association between oxidative damage and neuronal injury was stronger among patients with increased blood-brain barrier disruption.

Relationship between emotional states before cardiac valve surgeries with postoperative complications / Relaciones entre el estado emocional antes de la cirugía cardíaca valvar con complicaciones en el post-operatorio / Relações entre o estado emocional antes da cirurgia cardíaca valvar com complicações no pós-operatório

ABSTRACT Objective: To investigate associations between preoperative anxiety and depression symptoms and postoperative complications and the sociodemographic and clinical characteristics of patients undergoing valve repair surgery. Method: Observational, exploratory and prospective study. The consecutive non-probabilistic sample consisted of patients undergoing their first valve repair surgery. Data were collected from September 2013 to September 2015, in a university hospital in the interior of São Paulo, Brazil. Symptoms were assessed using the Hospital Anxiety and Depression Scale and analyzed using Mann-Whitney and Spearman correlation; alpha was established at 5%. Results: Among the 70 participants, depressive symptoms were more frequent among women (p=0.042) and among patients experiencing postoperative agitation (p=0.039) Conclusion: In this study, depressive symptoms were associated with being a woman and postoperative agitation; the same was not true in regard to anxiety symptoms.

RESUMEN Objetivo: Investigar la asociación de los síntomas de ansiedad y depresión preoperatorios con complicaciones en postoperatorio y con características sociodemográficas y clínicas de pacientes sometidos a la corrección quirúrgica de valvopatías. Método: Estudio observacional, exploratorio y prospectivo. Muestra consecutiva y no probabilística fue constituida por pacientes sometidos a la primera cirugía de corrección de valvopatías. Los datos fueron recolectados de septiembre/2013 a septiembre/2015, en un hospital universitario del interior del São Paulo. Los síntomas fueron evaluados por el Hospital Anxiety and Depression Scale. Los datos fueron analizados por las pruebas de Mann-Whitney y Correlación de Spearman, alpha=5%. Resultados: Entre los 70 pacientes, fue encontrado mayor presencia de síntomas depresivos entre las mujeres (p=0,042) y en el grupo con agitación (p=0,039) en el postoperatorio. Conclusión: En el grupo estudiado, los síntomas depresivos se asociaron al sexo femenino y la agitación en el postoperatorio, lo que no ocurrió con los síntomas de ansiedad.

RESUMO Objetivo: Investigar a associação dos sintomas de ansiedade e depressão pré-operatórios com complicações no pós-operatório e com características sociodemográficas e clínicas de pacientes submetidos à correção cirúrgica de valvopatias. Método: Estudo observacional, exploratório e prospectivo. Uma amostra consecutiva e não probabilística foi constituída por pacientes submetidos à primeira cirurgia de correção de valvopatias. Os dados foram coletados de setembro/2013 a setembro/2015, em um hospital universitário do interior paulista. Os sintomas foram avaliados pela Hospital Anxiety and Depression Scale. Os dados foram analisados pelos testes de Mann-Whitney e Correlação de Spearman, alpha de 5%. Resultados: Entre os 70 pacientes, encontrou-se maior presença de sintomas depressivos entre as mulheres (p=0,042) e no grupo com agitação (p=0,039) no pós-operatório. Conclusão: No grupo estudado, sintomas depressivos foram associados ao sexo feminino e a agitação no pós-operatório, o que não ocorreu com os sintomas de ansiedade.

Special Considerations for the Aging Brain and Perioperative Neurocognitive Dysfunction.

Postoperative delirium and postoperative cognitive dysfunction (POCD) occur commonly in older adults after surgery and are frequently underrecognized. Delirium has been associated with worse outcomes, and both delirium and cognitive dysfunction increase the risk of long-term cognitive decline. Although the pathophysiology of delirium and POCD have not been clearly defined, risk factors for both include increasing age, lower levels of education, and baseline cognitive impairment. In addition, developing delirium increases the risk of POCD. This article examines interventions that may reduce the risk of developing delirium and POCD and improve long-term recovery and outcomes in the vulnerable older population.

The effect of midazolam administration for the prevention of emergence agitation in pediatric patients with extreme fear and non-cooperation undergoing dental treatment under sevoflurane anesthesia, a double-blind, randomized study.

Background: Sevoflurane is generally the preferred anesthetic agent for general anesthesia in pediatric patients, due to its rapid induction and recovery characteristics. However, it has been recognized that a major complication is emergence agitation when awakening from general anesthesia. The aim of this study was to evaluate the occurrence rate of emergence agitation in the operating room and postoperative recovery area following intraoperative administration of midazolam to pediatric patients under general anesthesia. Patients and methods: One hundred and twenty pediatric patients undergoing dental treatment under sevoflurane anesthesia were enrolled in this study. The patients were divided into three groups (n=40 each in the 0.1 mg/kg midazolam, 0.05 mg/kg midazolam, and control with saline groups). Midazolam or saline was injected intravenously approximately 30 minutes before the end of the dental treatment. We used the Richmond Agitation and Sedation Scale (RASS) to assess the level of sedation and drowsiness at emergence phase in the operating room. We also used the Pediatric Anesthesia Emergence Delirium Scale (PAED) to assess the level of agitation and delirium at the full recovery phase from anesthesia in the recovery area. Results: At the emergence phase, the incidence of emergence agitation in the 0.1 mg/kg midazolam group was significantly lower than in the other groups (p=0.0010). At the recovery phase, there was no significant difference among the three groups. The odds ratio between PAED score and RASS score was 4.0 using logistic regression analysis. The odds ratio between PAED score and Disability was 2.5. Conclusion: Administration of a single dose of 0.1 mg/kg midazolam dose significantly decreases the incidence of severe emergence agitation at the emergence after sevoflurane anesthesia, but not at the recovery phase. Furthermore, the evaluation of sedative and agitation condition using RASS score at emergence from anesthesia is useful to predict occurrence of agitation in the recovery phase.

Effects of an abnormal mini-mental state examination score on postoperative outcomes in geriatric surgical patients: a meta-analysis.

BACKGROUND: Perioperative cognitive impairment (CI) following surgeries is prevalent in geriatric surgical population aged 60 and older. This meta-analysis was designed to investigate whether the Mini-Mental State Examination (MMSE) has prognostic value on adverse outcomes in aged surgical patients. METHODS: PubMed, Cochrane, Embase and Medline through the Ovid were searched. Meta-analyses were carried out for CI versus non-cognitive impairment (NCI). Quality of evidence was assessed by the GRADE approach. RESULTS: One randomized controlled trial, two retrospective cohort trials, and 18 prospective cohort trials were included in the meta-analysis. Perioperative diagnosis of CI by the MMSE had higher rates of patients suffering from postoperative delirium (POD) [odd ratio (OR) 5.02, 95% confidence interval (CI) 3.27, 7.71, P < 0.00001], in-hospital mortality (OR 7.51, 95% CI 2.17, 26.02, P = 0.001), mortality within 1 year (OR 2.53, 95% CI 1.95,3.29, P < 0.00001). Postoperative CI patients had no extended length of stay in orthopedic [standardized mean difference (SMD) -0.10, 95% CI -0.20, 0.17, P = 0.91)] nor rehabilitation wards ((SMD, 0.04; 95% CI, - 0.23 to 0.31; P = 0.78). CONCLUSION: Older patients with perioperative CI were more likely to suffer from POD and mortality. The MMSE showed certain value on risk stratification and prognosis evaluation in geriatric surgical population. TRIAL REGISTRATION: PROSPERO CRD42018108739 .

Screening for delirium after surgery: validation of the 4 A's test (4AT) in the post-anaesthesia care unit.

Postoperative delirium is common and has multiple adverse consequences. Guidelines recommend routine screening for postoperative delirium beginning in the post-anaesthesia care unit. The 4 A's test (4AT) is a widely used assessment tool for delirium but there are no studies evaluating its use in the post-anaesthesia care unit. We evaluated the performance of the 4AT in the post-anaesthesia care unit in a tertiary German medical centre. Adults who were able to provide informed consent, were not scheduled for postoperative intensive care, and who did not have dementia or severe neuropsychiatric disorders underwent screening by trained research staff with the Nurse Delirium Screening Scale and a new German translation of the 4AT in a random order at the point of discharge from the post-anaesthesia care unit. Reference standard assessment of delirium was psychiatric evaluation by experienced clinicians. Five hundred and forty-three patients (mean age (SD) 52 (18) years) were analysed; 22 (4.1%) patients developed delirium. The sensitivity and specificity of the 4AT were 95.5% (95%CI 77.2-99.9) and 99.2% (95%CI 98.1-99.8), respectively. The area under the receiver operator characteristic curve was 0.998 (95%CI 0.995-1.000). The Nursing Delirium Screening Scale had a sensitivity of 27.3% (95%CI 10.7-50.2) and specificity of 99.4% (95%CI 98.3-99.9), with an area under the curve of 0.761 (95%CI 0.629-0.894). These findings suggest that the 4AT is an effective and robust instrument for delirium detection in the post-anaesthesia care unit.

Preoperative Depression and Plasma Cortisol Levels as Predictors of Delirium after Cardiac Surgery.

BACKGROUND: Delirium is common in old patients who undergo cardiac surgery, and it is associated with adverse outcomes. The genesis of delirium is thought to be multi-factorial, but it is still not well understood. Symptoms of depression and elevated cortisol level have been described in some previous studies as factors associated with delirium, suggesting a shared pathophysiology. AIMS: The objective of the present study was to determine whether preoperative depression symptoms and increased cortisol level represent risk factors for delirium after cardiac surgery. METHODS: We performed a prospective cohort study in 183 patients aged >50 years undergoing elective cardiac surgery. The Geriatric Depression Scale (GDS) was used to assess patients for depressive symptoms before surgery. Preoperative plasma cortisol levels were available in 145 participants. Delirium was diagnosed using the Confusion Assessment Method for Intensive Care Unit (CAM-ICU) during the first 7 days after surgery. Spearman correlation was used for correlations between GDS, Mini-Mental State Examination (MMSE), Charlson comorbidity index, and age. Binary logistic regression was used to determine whether GDS and cortisol levels predict postoperative delirium. RESULTS: Delirium occurred in 60 patients out of 183 (32.8%) included and lasted 2.3 days (SD 1.36). GDS was correlated with age (p = 0.001) and comorbidity index (p = 0.003) and inversely correlated with MMSE score (p < 0.001). Higher preoperative GDS scores were associated with incidence of delirium in the postoperative period (p = 0.002). The association was significant after controlling for age, MMSE score, history of stroke, and Charlson comorbidity index (p = 0.045). Preoperative cortisol level was not associated with the development of postoperative delirium. CONCLUSION: Our results suggest that a higher preoperative depression score is associated with an increased risk of postoperative delirium. On the other hand, preoperative plasma cortisol level does not seem to be a predictor of delirium after surgery. Further studies are needed to determine the potential of preoperative depression treatment to prevent postoperative delirium.

A prospective, observational study of cerebrovascular autoregulation and its association with delirium following cardiac surgery.

This aim of this prospective observational cohort study was to evaluate any association between postoperatively impaired cerebrovascular autoregulation and the onset of delirium following cardiac surgery. Previous studies have shown that impaired intra-operative cerebrovascular autoregulation during cardiopulmonary bypass is associated with delirium. However, postoperative changes in cerebrovascular autoregulation and its association with delirium have not been investigated. One-hundred and eight consecutive adult cardiac surgical patients without baseline cognitive dysfunction or aphasia were included in the study. Cerebrovascular autoregulation was assessed by the Pearson correlation between near-infrared spectroscopy-derived cerebral tissue oxygen saturation and mean arterial pressure to derive the tissue oximetry index. Cerebrovascular autoregulation was monitored for a minimum of 90 min on postoperative day 0 and postoperative day 1. Delirium was assessed throughout intensive care unit admission using the confusion assessment method for the intensive care unit. We observed delirium in 24 of the 108 patients studied. The mean (SD) tissue oximetry index was higher in delirious patients on postoperative day 0 compared with non-delirious patients; 0.270 (0.199) vs. 0.180 (0.142), p = 0.044, but not on postoperative day 1; 0.130 (0.160) vs. 0.150 (0.130), p = 0.543. All patients showed improvement in tissue oximetry index on postoperative day 1 compared with postoperative day 0. Logistic regression analysis demonstrated tissue oximetry index on postoperative day 0 to be independently associated with delirium; odds ratio 1.05 (95%CI 1.01-1.10), p = 0.043. In conclusion, we found an association between impaired cerebrovascular autoregulation, measured by near-infrared spectroscopy, and delirium in the early postoperative period.

The effect of an immersive virtual reality tour of the operating theater on emergence delirium in children undergoing general anesthesia: A randomized controlled trial.

BACKGROUND AND AIMS: An immersive virtual reality tour of the operating theater could reduce preoperative anxiety. This study was designed to determine whether a preoperative immersive virtual reality tour demonstrates a reduction in emergence delirium through reducing the preoperative anxiety in children undergoing general anesthesia. METHODS: Eighty-six children were randomly allocated into either the control or virtual reality group. The control group received conventional education regarding the perioperative process. The virtual reality group watched a 4-minute virtual reality video showing the operating theater and explaining the perioperative process. Incidence and severity of emergence delirium were the main outcomes. Secondary outcomes included preoperative anxiety using modified Yale Preoperative Anxiety Scale and postoperative behavioral disturbance. RESULTS: Eighty children completed the final analysis (control group = 39, virtual reality group = 41). The incidence (risk ratio [95% CI]: 1.1 [0.5-2.8], P = 0.773) and severity of emergence delirium (mean difference [95% CI]: -0.2 [-2.7 to 2.2], P = 0.791) were similar in the two groups. After the intervention, children in the virtual reality group had a significantly lower modified Yale Preoperative Anxiety score than those in the control group (mean difference [95% CI]: 9.2 [0.3-18.2], P = 0.022). No difference was observed regarding postoperative behavioral disturbance between the two groups at postoperative 1 day (mean difference [95% CI]: -0.1 [-0.3 to 0.1], P = 0.671) and 14 day (mean difference [95% CI]: -0.0 [-0.1 to 0.0], P = 0.329). CONCLUSION: Preoperative immersive virtual reality tour of the operating theater did not reduce the incidence and severity of emergence delirium, although it was effective in alleviating preoperative anxiety in children.

Recommendations for the nomenclature of cognitive change associated with anaesthesia and surgery-2018.

Cognitive change affecting patients after anaesthesia and surgery has been recognised for more than 100 yr. Research into cognitive change after anaesthesia and surgery accelerated in the 1980s when multiple studies utilised detailed neuropsychological testing for assessment of cognitive change after cardiac surgery. This body of work consistently documented decline in cognitive function in elderly patients after anaesthesia and surgery, and cognitive changes have been identified up to 7.5 yr afterwards. Importantly, other studies have identified that the incidence of cognitive change is similar after non-cardiac surgery. Other than the inclusion of non-surgical control groups to calculate postoperative cognitive dysfunction, research into these cognitive changes in the perioperative period has been undertaken in isolation from cognitive studies in the general population. The aim of this work is to develop similar terminology to that used in cognitive classifications of the general population for use in investigations of cognitive changes after anaesthesia and surgery. A multispecialty working group followed a modified Delphi procedure with no prespecified number of rounds comprised of three face-to-face meetings followed by online editing of draft versions. Two major classification guidelines [Diagnostic and Statistical Manual for Mental Disorders, fifth edition (DSM-5) and National Institute for Aging and the Alzheimer Association (NIA-AA)] are used outside of anaesthesia and surgery, and may be useful for inclusion of biomarkers in research. For clinical purposes, it is recommended to use the DSM-5 nomenclature. The working group recommends that 'perioperative neurocognitive disorders' be used as an overarching term for cognitive impairment identified in the preoperative or postoperative period. This includes cognitive decline diagnosed before operation (described as neurocognitive disorder); any form of acute event (postoperative delirium) and cognitive decline diagnosed up to 30 days after the procedure (delayed neurocognitive recovery) and up to 12 months (postoperative neurocognitive disorder).