Jeffrey H. Silverstein

Long-term postoperative cognitive dysfunction in the elderly: ISPOCD1 study

BACKGROUND Long-term postoperative cognitive dysfunction may occur in the elderly. Age may be a risk factor and hypoxaemia and arterial hypotension causative factors. We investigated these hypotheses in an international multicentre study. METHODS 1218 patients aged at least 60 years completed neuropsychological tests before and 1 week and 3 months after major non-cardiac surgery. We measured oxygen saturation by continuous pulse oximetry before surgery and throughout the day of and the first 3 nights after surgery. We recorded blood pressure every 3 min by oscillometry during the operation and every 15-30 min for the rest of that day and night. We identified postoperative cognitive dysfunction with neuropsychological tests compared with controls recruited from the UK (n=176) and the same countries as study centres (n=145). FINDINGS Postoperative cognitive dysfunction was present in 266 (25.8% [95% CI 23.1-28.5]) of patients 1 week after surgery and in 94 (9.9% [8.1-12.0]) 3 months after surgery, compared with 3.4% and 2.8%, respectively, of UK controls (p<0.0001 and p=0.0037, respectively). Increasing age and duration of anaesthesia, little education, a second operation, postoperative infections, and respiratory complications were risk factors for early postoperative cognitive dysfunction, but only age was a risk factor for late postoperative cognitive dysfunction. Hypoxaemia and hypotension were not significant risk factors at any time. INTERPRETATION Our findings have implications for studies of the causes of cognitive decline and, in clinical practice, for the information given to patients before surgery.

Does anaesthesia cause postoperative cognitive dysfunction? A randomised study of regional versus general anaesthesia in 438 elderly patients

Background:  Postoperative cognitive dysfunction (POCD) is a common complication after cardiac and major non‐cardiac surgery with general anaesthesia in the elderly. We hypothesized that the incidence of POCD would be less with regional anaesthesia rather than general.

Postoperative delirium and cognitive dysfunction.

Postoperative delirium and cognitive dysfunction (POCD) are topics of special importance in the geriatric surgical population. They are separate entities, whose relationship has yet to be fully elucidated. Although not limited to geriatric patients, the incidence and impact of both are more profound in geriatric patients. Delirium has been shown to be associated with longer and more costly hospital course and higher likelihood of death within 6 months or postoperative institutionalization. POCD has been associated with increased mortality, risk of leaving the labour market prematurely, and dependency on social transfer payments. Here, we review their definitions and aetiology, and discuss treatment and prevention in elderly patients undergoing major non-cardiac surgery. Good basic care demands identification of at-risk patients, awareness of common perioperative aggravating factors, simple prevention interventions, recognition of the disease states, and basic treatments for patients with severe hyperactive manifestations.

Beneficial effects from β-adrenergic blockade in elderly patients undergoing noncardiac surgery

BackgroundPerioperative β-blockade has been shown to improve long-term cardiac outcome in noncardiac surgical patients. A possible mechanism for the reduced risk of perioperative myocardial infarction is the attenuation of the excitotoxic effects of catecholamine surges by β-blockade. It was hypothe

Cognitive dysfunction after minor surgery in the elderly

Background:  Major surgery is frequently associated with postoperative cognitive dysfunction (POCD) in elderly patients. Type of surgery and hospitalization may be important prognostic factors. The aims of the study were to find the incidence and risk factors for POCD in elderly patients undergoing minor surgery.

The effectiveness of adjunctive hypnosis with surgical patients: a meta-analysis.

Hypnosis is a nonpharmacologic means for managing adverse surgical side effects. Typically, reviews of the hypnosis literature have been narrative in nature, focused on specific outcome domains (e.g., patients’ self-reported pain), and rarely address the impact of different modes of the hypnosis administration. Therefore, it is important to take a quantitative approach to assessing the beneficial impact of adjunctive hypnosis for surgical patients, as well as to examine whether the beneficial impact of hypnosis goes beyond patients’ pain and method of the administration. We conducted meta-analyses of published controlled studies (n = 20) that used hypnosis with surgical patients to determine: 1) overall, whether hypnosis has a significant beneficial impact, 2) whether there are outcomes for which hypnosis is relatively more effective, and 3) whether the method of hypnotic induction (live versus audiotape) affects hypnosis efficacy. Our results revealed a significant effect size (D = 1.20), indicating that surgical patients in hypnosis treatment groups had better outcomes than 89% of patients in control groups. No significant differences were found between clinical outcome categories or between methods of the induction of hypnosis. These results support the position that hypnosis is an effective adjunctive procedure for a wide variety of surgical patients.

Fasting regulates hypothalamic neuropeptide Y, agouti-related peptide, and proopiomelanocortin in diabetic mice independent of changes in leptin or insulin.

Fasting increases hypothalamic neuropeptide Y (NPY) and agouti-related peptide (AGRP) messenger RNA (mRNA) and reduces hypothalamic POMC mRNA, and is also characterized by a reduction in plasma leptin, insulin, and glucose, each of which has been implicated in the regulation of hypothalamic gene expression. To further evaluate the roles of leptin, insulin, and glucose in mediating effects of fasting, we examined hypothalamic gene expression in nondiabetic and streptozotocin (STZ)-induced diabetic mice both under ad lib fed and 48-h fasted conditions. In both diabetic and nondiabetic mice, fasting stimulated hypothalamic NPY and AGRP mRNA and inhibited hypothalamic POMC mRNA and adipose leptin mRNA. However, in diabetic mice fasting had no effect on plasma leptin and insulin while decreasing plasma glucose, whereas in nondiabetic mice fasting decreased plasma leptin, insulin, and glucose. Furthermore, in nondiabetic fasted mice, NPY and AGRP mRNA were higher, and POMC mRNA and plasma glucose were lower, th...

Higher Hb level is associated with better early functional recovery after hip fracture repair

BACKGROUND: The benefits and indications for blood transfusion are controversial. One possible reason to transfuse is to improve functional recovery after major surgery. However, the data linking improved function with higher Hb concentration are limited.

Postoperative urinary retention.

Postoperative urinary retention (PUR) is a common complication of surgery and anesthesia. The risk of retention is especially high after anorectal surgery, hernia repair, and orthopedic surgery and increases with advancing age. Certain anesthetic and analgesic modalities, particularly spinal anesthesia with long-acting local anesthetics and epidural analgesia, promote the development of urinary retention. Portable ultrasound provides rapid and accurate assessment of bladder volume and aids in the diagnosis and management of PUR. Catheterization is recommended when bladder volume exceeds 600 mL to prevent the negative sequelae of prolonged bladder overdistention.

Addiction and Substance Abuse in Anesthesiology

Despite substantial advances in our understanding of addiction and the technology and therapeutic approaches used to fight this disease, addiction still remains a major issue in the anesthesia workplace, and outcomes have not appreciably changed. Although alcoholism and other forms of impairment, such as addiction to other substances and mental illness, impact anesthesiologists at rates similar to those in other professions, as recently as 2005, the drug of choice for anesthesiologists entering treatment was still an opioid. There exists a considerable association between chemical dependence and other psychopathology, and successful treatment for addiction is less likely when comorbid psychopathology is not treated. Individuals under evaluation or treatment for substance abuse should have an evaluation with subsequent management of comorbid psychiatric conditions. Participation in self-help groups is still considered a vital component in the therapy of the impaired physician, along with regular monitoring if the anesthesiologist wishes to attempt reentry into clinical practice.