Nicolai Goettel

Postoperative Delirium in Cardiac Surgery: An Unavoidable Menace?

From the *Department for Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine, and Pain Therapy, University Hospital Basel, Basel, Switzerland; and †Department of Anesthesia and Intensive Medicine, Cantonal Hospital Baden, Baden, Switzerland. Address reprint requests to Alexa Hollinger, MD, Anesthesiology, University Hospital Basel, Spitalstrasse 21, CH-4031, Basel, Switzerland E-mail: alexa.hollinger@usb.ch

Day surgery craniotomy for unruptured cerebral aneurysms: a single center experience.

Background: Ambulatory day surgery is an evolving specialty in line with demands of modern medicine, health care services, and economics, but its role in neurovascular surgery remains controversial. The purpose of this study was to describe our experience of patients undergoing elective clipping of intact cerebral aneurysms as day surgery. Methods: This retrospective and prospective observational study was carried out as a cohort review of patients who underwent outpatient clipping of an intact intracranial aneurysm at the Toronto Western Hospital, University Health Network, between May 2009 and November 2012. Patients were categorized as success (discharged on the same day) or failure (requiring unplanned postoperative hospital admission) of day surgery. Data included the preoperative assessment of the patient, anesthetic management, postoperative care, and the incidence of perioperative complications. Outcomes were duration of hospital stay, and any problems preventing same-day discharge. Results: During the study period 25 patients aged 54±9 years underwent outpatient aneurysm repair. Seventeen patients (68%) successfully completed day surgery, and 8 patients (32%) were admitted to the hospital after surgery due to perioperative complications. Duration of hospital stay in the failure group ranged from 2 to 18 days. Conclusions: Our data demonstrates that surgical clipping of unruptured cerebral aneurysms may be performed in an outpatient setting. Careful selection of day surgery candidates and postoperative assessment for complications is needed. Further research is needed to identify potential risk factors and to target patient subgroups for successful ambulatory surgery.

Associations Between Impaired Cerebral Blood Flow Autoregulation, Cerebral Oxygenation, and Biomarkers of Brain Injury and Postoperative Cognitive Dysfunction in Elderly Patients After Major Noncardiac Surgery

BACKGROUND: Increasing evidence links postoperative cognitive dysfunction (POCD) to surgery and anesthesia. POCD is recognized as an important neuropsychological adverse outcome in surgical patients, particularly the elderly. This prospective cohort study aimed to investigate whether POCD is associated with impaired intraoperative cerebral autoregulation and oxygenation, and increased levels of biomarkers of brain injury. METHODS: Study subjects were patients ≥65 years of age scheduled for major noncardiac surgery. Cognitive function was assessed before and 1 week after surgery. POCD was diagnosed if a decline of >1 standard deviation of z-scores was present in ≥2 variables of the test battery. The incidence of POCD 1 week after surgery was modeled as a multivariable function of the index of autoregulation (MxA) and tissue oxygenation index (TOI), adjusting for baseline neuropsychological assessment battery (Consortium to Establish a Registry for Alzheimer’s Disease-Neuropsychological Assessment Battery [CERAD-NAB]) total score and the maximum C-reactive protein (CRP) concentration. The biomarkers of brain injury neuron-specific enolase and S100&bgr; protein, age, and level of education were included in secondary multivariable logistic regression analyses. RESULTS: Of the 82 patients who completed the study, 38 (46%) presented with POCD 1 week after surgery. In the multivariable regression analysis, higher intraoperative MxA (odds ratio [OR; 95% confidence interval (CI)], 1.39 [1.01–1.90] for an increase of 0.1 units, P = .08 after Bonferroni adjustment), signifying less effective autoregulation, was not associated with higher odds of POCD. The univariable logistic regression model for MxA yielded an association with POCD (OR [95% CI], 1.44 [1.06–1.95], P = .020). Tissue oxygenation index (1.12 [0.41–3.01] for an increase of 10%, P = 1.0 after Bonferroni adjustment) and baseline CERAD-NAB total score (0.80 [0.45–1.42] for an increase of 10 points, P = .45) did not affect the odds of POCD. POCD was associated with elevated CRP on postoperative day 2 (median [interquartile range]; 175 [81–294] vs 112 [62–142] mg/L, P = .033); however, the maximum CRP value (OR [95% CI], 1.35 [0.97–1.87] for a 2-fold increase, P = .07) had no distinct effect on POCD. CONCLUSIONS: Impairment of intraoperative cerebral blood flow autoregulation is not predictive of early POCD in elderly patients, although secondary analyses indicate that an association probably exists.

GERMAN NORMATIVE DATA FOR THE MONTREAL COGNITIVE ASSESSMENT

90 years (M1⁄462.4, SD1⁄421.4). Participants had an average education level of 14.9 (SD1⁄41.4) years. Measures included: (1) gender characteristicsBem’s Sex Role Inventory, (2) trait empathyInterpersonal Reactivity Index, measuring cognitive and emotional empathy, (3) state empathymeasuring emotional empathy in response to an empathy induction, and (4) prosocial behaviormonetary donation to a person in need in response to an empathy induction. Results:Self-reported femininity was positively correlated with trait cognitive empathy in older adults (r 1⁄4 .3, p < .05). Furthermore, older adults’ state emotional empathy in response to an empathy induction was positively correlated with androgynous (r1⁄4 .3, p< .01) and feminine (r1⁄4 .3, p< .01) characteristics. Older women gave greater monetary donations than older men in response to an empathy-inducing situation (p < .01). Conclusions:The results suggest that gender-related characteristics, in particular femininity and androgyny, may play an important or adaptive role in the maintenance of empathy and prosocial behavior in older adulthood. Furthermore, older adults’ behavior may reflect their motivation to prioritize experiences that bring them emotional meaning, as purported by the socioemotional selectivity theory (Carstensen et al., 1999). Future studies characterizing empathy and gender characteristics across the lifespan will lead to valuable insights about mechanisms for prosocial behavior in aging that is relevant to such fields as caregiving and volunteerism. References: Bailey, P. E., Henry, J. D., & Hippel, W. V. (2008). Empathy and social functioning in late adulthood. Aging & Mental Health, 12(4), 499-503. Beadle, J. N., Sheehan, A. H., Dahlben, B., & Gutchess, A. H. (2015). Aging, empathy, and prosociality. The Journals of Gerontology: Series B, 70(2), 213-222. Gale-Ross, R., Baird, A., & Towson, S. (2009). Gender role, life satisfaction, and wellness: Androgyny in a southwestern ontario sample. Canadian Journal on Aging /La Revue Canadienne Du Vieillissement, 28(2), 135-146. Carstensen, L., M. Isaacowitz, D., & Charles, S. (1999). Taking time seriously: A theory of socioemotional selectivity. The American Psychologist, 54, 81. Sze, J. A., Gyurak, A., Goodkind, M. S. & Levenson, R. W. (2012). Greater emotional empathy and prosocial behavior in late life. Emotion (Washington, D.C.), 12(5), 1129-1140.

Transiente und permanente kognitive Defizite nach chirurgischen Operationen

Zusammenfassung. Eine von Arzten oft unterschatze Befurchtung von alteren Patienten ist das Auftreten von vorubergehenden, oder sogar bleibenden, kognitiven Einbussen als Folge einer Operation. Als...

Postoperative visual loss following cerebral arteriovenous malformation surgery: a case report

We report the case of a 46 year-old woman presenting with unilateral postoperative visual loss after right frontal craniotomy for resection of an arteriovenous malformation in the supine position. The intraoperative course was uneventful with maintenance of hemodynamic stability. Blood loss was 300 ml; postoperative hemoglobin was 12.4 g/dl. In the recovery room, the patient reported loss of vision in her right eye. Ophthalmologic examination revealed decreased visual acuity, color vision, and visual field. Assessment of the retina was normal, but the patient showed a relative afferent pupillary defect consistent with the clinical diagnosis of ischemic optic neuropathy. Postoperative computer tomogram showed normal perfusion of ophthalmic artery and vein, no hemorrhage or signs of cerebral ischemia or edema. The patient recovered most of her vision 3 months after surgery. Anesthesiologists should be aware that this condition may follow uncomplicated intracranial surgeries in the supine position, and should obtain prompt ophthalmologic consultation when a patient develops postoperative visual loss.

Feasibility and safety of outpatient neurosurgery: an observational outcome study of cerebral aneurysm surgery as ambulatory day surgery

A need for postoperative hospital admission has generally been assumed in the treatment of patients with cerebral aneurysms. Ambulatory day surgery (DS) is an evolving specialty in line with demands of modern medicine, healthcare services and economics, but its role in neurovascular surgery remains controversial. To our knowledge, this is the first description of aneurysm surgery and its anesthetic management on DS basis. Previous work has shown that outpatient neurosurgery in feasible and well accepted [1-4]. When dealing with neurosurgical outpatients, a close collaboration of the anesthetic and surgical teams into the postoperative period remains crucial to identify and treat complications, which may eventually lead to unplanned hospital admission. These interventions demand a high neurosurgical and specific anesthesiologic expertise, which may often only be found in dedicated centers with a high patient turn-over. From the anesthetic point of view, the important areas of consideration for DS include the choice of anesthetic techniques and agents allowing DS, assuring maximum standards of anesthetic safety, and quality of care, as well as the management of PONV, and postoperative analgesia [5, 6]. As a retrospective review of a unique single-center experience, and representing a small cohort size (n=24), we acknowledge the limitations of our study. The study was not powered to reveal specific risk factors for DS failure. Applicability of outpatient neurosurgery may differ between various health care systems. Although it appears safe and effective in our institution, infrastructural and medico-legal concerns may limit the adoption of the outpatient strategy in other neurosurgical programs worldwide.