Best Practices for Postoperative Brain Health

Berger, Miles; Schenning, Katie J.; Brown, Charles H.; Deiner, Stacie; Whittington, Robert A.; Eckenhoff, Roderic G.; Angst, Martin S.; Avramescu, Sinziana; Bekker, Alex; Brzeziński, Marek; Crosby, Greg; Culley, Deborah J.; Eckenhoff, Maryellen F.; Eriksson, Lars; Evered, Lis; Ibinson, Jim; Kline, Richard; Kofke, Andy; Ma, Daqing; Mathew, Joseph P.; Maze, Mervyn; Orser, Beverley A.; Price, Catherine C.; Scott, David A.; Silbert, Brendan; Su, Diansan; Terrando, Niccolò; Wang, Dian-Shi; Wei, Huafeng; Xie, Zhoncong; Zuo, Zhiyi

doi:10.1213/ane.0000000000003841

Cited by 213 publications

(143 citation statements)

References 79 publications

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“…Furthermore, the mean age of the study population was 63.9 and 66.9 in the GA and spinal groups, respectively, and patients with pre-existing cognitive dysfunction were excluded from the study, which limits generalizability of the findings to individuals of advanced age and individuals with dementia. Indeed, the practice guidelines for perioperative brain health published in 2018 concluded that, based on current available data, there is insufficient evidence to recommend the use of regional anesthesia instead of general anesthesia [23].…”

Section: Main Bodymentioning

confidence: 99%

“…Although there is a need for further research and additional data to guide perioperative management of elderly individuals, recommendations have been developed based on current evidence [23]. The fifth international perioperative neurotoxicity working groups included over 30 experts who developed recommendations specific to postoperative brain health in individuals > 65 years of age.…”

Section: Main Bodymentioning

confidence: 99%

“…(4) Postoperative follow-up: additional research is required to determine feasibility, efficacy, and cost-effectiveness of postoperative follow-up to assess cognitive outcomes [23].…”

Section: Main Bodymentioning

confidence: 99%

“…The potential for confusion and limited cooperation may make approaches such as neuraxial anesthesia, peripheral nerve blocks, or sedation more challenging. In terms of pharmacologic management, it is commonly accepted that short-acting medications should be used, and medications which may increase risk of postoperative confusion should be avoided [23, 54, 55]. Available evidence does not support the hypothesis that these patients are more sensitive to anesthetic agents; however, the sample size employed in these studies and use of the BIS monitor as a surrogate of anesthetic depth make it challenging to draw any definitive conclusion [27, 56].…”

Section: Main Bodymentioning

confidence: 99%

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Anesthesiology and cognitive impairment: a narrative review of current clinical literature

2019

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Background: The impact of general anesthesia on cognitive impairment is controversial and complex. A large body of evidence supports the association between exposure to surgery under general anesthesia and development of delayed neurocognitive recovery in a subset of patients. Existing literature continues to debate whether these short-term effects on cognition can be attributed to anesthetic agents themselves, or whether other variables are causative of the observed changes in cognition. Furthermore, there is conflicting data on the relationship between anesthesia exposure and the development of long-term neurocognitive disorders, or development of incident dementia in the patient population with normal preoperative cognitive function. Patients with pre-existing cognitive impairment present a unique set of anesthetic considerations, including potential medication interactions, challenges with cooperation during assessment and non-general anesthesia techniques, and the possibility that pre-existing cognitive impairment may impart a susceptibility to further cognitive dysfunction. Main body: This review highlights landmark and recent studies in the field, and explores potential mechanisms involved in perioperative cognitive disorders (also known as postoperative cognitive dysfunction, POCD). Specifically, we will review clinical and preclinical evidence which implicates alterations to tau protein, inflammation, calcium dysregulation, and mitochondrial dysfunction. As our population ages and the prevalence of Alzheimer's disease and other forms of dementia continues to increase, we require a greater understanding of potential modifiable factors that impact perioperative cognitive impairment. Conclusions: Future research should aim to further characterize the associated risk factors and determine whether certain anesthetic approaches or other interventions may lower the potential risk which may be conferred by anesthesia and/or surgery in susceptible individuals.

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Section: Main Bodymentioning

confidence: 99%

Section: Main Bodymentioning

confidence: 99%

“…(4) Postoperative follow-up: additional research is required to determine feasibility, efficacy, and cost-effectiveness of postoperative follow-up to assess cognitive outcomes [23].…”

Section: Main Bodymentioning

confidence: 99%

Section: Main Bodymentioning

confidence: 99%

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Anesthesiology and cognitive impairment: a narrative review of current clinical literature

2019

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“…1,2 Of note, postoperative cognitive dysfunction (POCD) is a significant complication after surgery that impairs learning, memory, and other cognitive functions. 3,4 POCD occurs days to weeks after surgery and could become a persistent disorder, being associated with an increased mortality within the first 3 months post-surgery. 5 Hence, strategies to better prevent and control the development of POCD are urgently needed.…”

Section: Introductionmentioning

confidence: 99%

miR-124/VAMP3 is a novel therapeutic target for mitigation of surgical trauma-induced microglial activation

Chen

Sun

Chen

et al. 2019

Sig Transduct Target Ther

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Activation of microglia and the subsequently elevated inflammatory cytokine release in the brain during surgery predispose individuals to cognitive dysfunction, also known as postoperative cognitive dysfunction (POCD). miR-124 is one of the most abundant microRNAs in the brain that regulates microglial function. Elucidating the role of miR-124 in microglial activation in the context of surgery may therefore promote understanding of as well as therapeutic development for post-surgical disorders involving microglial activation. The downstream targets of miR-124 were investigated using bioinformatic screening and dual-luciferase reporter assay validation, and vesicle-associated membrane protein 3 (VAMP3) was identified as a potential target. The kinetics of miR-124/VAMP3 expression was first examined in vitro in microglial cells (primary microglia and BV2 microglial cells) following lipopolysaccharide (LPS) stimulation. LPS induced a time-dependent decrease of miR-124 and upregulated the expression of VAMP3. Manipulating miR-124/VAMP3 expression by using miR-124 mimics or VAMP3-specific siRNA in LPS-stimulated BV2 microglial cells inhibited BV2 microglial activation-associated inflammatory cytokine release. To further examine the role of miR-124/VAMP3 in a surgical setting, we employed a rat surgical trauma model. Significant microglial activation and altered miR-124/VAMP3 expression were observed following surgical trauma. We also altered miR-124/VAMP3 expression in the rat surgical trauma model by administration of exogenous miR-124 and by using electroacupuncture, which is a clinically applicable treatment that modulates microglial function and minimizes postoperative disorders. We determined that electroacupuncture treatment specifically increases the expression of miR-124 in the hypothalamus and hippocampus. Increased miR-124 expression with a concomitant decrease in VAMP3 expression resulted in decreased inflammatory cytokine release related to microglial activation post-surgery. Our study indicates that miR-124/VAMP3 is involved in surgery-induced microglial activation and that targeting miR-124/VAMP3 could be a potential therapeutic strategy for postoperative disorders involving microglial activation.

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Economic Burden of Postoperative Neurocognitive Disorders Among US Medicare Patients

et al. 2020

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IMPORTANCE Postoperative neurocognitive disorders (PNDs) after surgical procedures are common and may be associated with increased health care expenditures. OBJECTIVE To quantify the economic burden associated with a PND diagnosis in 1 year following surgical treatment among older patients in the United States. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used claims data from the Bundled Payments for Care Improvement Advanced Model from 4285 hospitals that submitted Medicare Fee-for-service (FFS) claims between January 2013 and December 2016. All Medicare patients aged 65 years or older who underwent an inpatient hospital admission associated with a surgical procedure, did not experience a PND before index admission, and were not undergoing dialysis or concurrently enrolled in Medicaid were included. Data were analyzed from October 2019 and May 2020. EXPOSURES PND, defined as an International Classification of Diseases, Ninth or Tenth Revision, diagnosis of delirium, mild cognitive impairment, or dementia within 1 year of discharge from the index surgical admission. MAIN OUTCOMES AND MEASURES The primary outcome was total inflation-adjusted Medicare postacute care payments within 1 year after the index surgical procedure. RESULTS A total of 2 380 473 patients (mean [SD] age, 75.36 (7.31) years; 1 336 736 [56.1%] women) who underwent surgical procedures were included, of whom 44 974 patients (1.9%) were diagnosed with a PND. Among all patients, most were White (2 142 157 patients [90.0%]), presenting for orthopedic surgery (1 523 782 patients [64.0%]) in urban medical centers (2 179 893 patients [91.6%]) that were private nonprofits (1 798 749 patients [75.6%]). Patients with a PND, compared with those without a PND, experienced a significantly longer hospital length of stay (mean [SD], 5.91 [6.01] days vs 4.29 [4.18] days; P < .001), were less likely to be discharged home (9947 patients [22.1%] vs 914 925 patients [39.2%]; P < .001), and had a higher incidence of mortality at 1 year after treatment (4580 patients [10.2%] vs 103 767 patients [4.4%]; P < .

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Best Practices for Postoperative Brain Health

Cited by 213 publications

References 79 publications

Anesthesiology and cognitive impairment: a narrative review of current clinical literature

Anesthesiology and cognitive impairment: a narrative review of current clinical literature

miR-124/VAMP3 is a novel therapeutic target for mitigation of surgical trauma-induced microglial activation

Economic Burden of Postoperative Neurocognitive Disorders Among US Medicare Patients

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