The Stress Response to Surgery and Postoperative Delirium

Cerejeira, Joaquim; Batista, Pedro; Nogueira, V.; Vaz‐Serra, Adriano; Mukaetova‐Ladinska, Elizabeta B.

doi:10.1177/0891988713495449

Cited by 105 publications

(45 citation statements)

References 66 publications

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“…Cortisol levels have been found to be elevated in plasma and cerebrospinal fluid of patients with delirium in a diversity of medical and surgical conditions in line with the hypothesis of an ‘aberrant stress response' of delirium [44,45,46]. However, it remains unclear if cortisol elevation is the result of a primary dysfunction of the HPA axis or represents a secondary change to a more intense inflammatory reaction.…”

Section: Clinical Correlates Of Acute Neuroinflammationmentioning

confidence: 83%

The Immunology of Delirium

Cerejeira

Lagarto

Mukaetova‐Ladinska

2014

Neuroimmunomodulation

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Delirium is an acute neuropsychiatric syndrome characterized by acute-onset global cognitive deficits, perceptual and behavioural disturbances affecting mainly elderly subjects with underlying medical or surgical conditions. The pathophysiology of delirium is complex and inflammation is a relevant precipitant factor of this syndrome, although it remains unclear how acute systemic inflammation induces the clinical picture of delirium. The central nervous system is able to detect peripheral infection or tissue destruction through circulating immune mediators and neural ascending signs. Activated microglia is responsible for an acute neuroinflammatory reaction underlying the symptoms of sickness. In healthy conditions descending pathways from the paraventricular nucleus, locus coeruleus and dorsal motor nucleus organize a centralized response to influence the immune response at the periphery and restore homeostasis. In the context of ageing and chronic neurodegeneration, adaptive changes to acute insults are characterized by exaggerated production of pro-inflammatory cytokines by primed microglia coupled with dysfunction of brain-to-immune pathways. In animal models, these changes underlie a more severe manifestation of sickness behaviour with working memory deficits suggesting that inattention, a core feature of delirium, can be a clinical correlate of an increased neuroinflammatory reaction. In patients with delirium, higher levels of pro-inflammatory cytokines and cortisol were identified in plasma and cerebrospinal fluid. However, to date it has not been clarified how peripheral inflammatory or endocrine biomarkers can reflect the likelihood or severity of delirium symptoms. In the future, a better understanding of the interaction between the brain and peripheral organs and the exact mechanism by which systemic inflammation can lead to delirium, will allow the development of new therapeutic agents.

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Section: Clinical Correlates Of Acute Neuroinflammationmentioning

confidence: 83%

The Immunology of Delirium

Cerejeira

Lagarto

Mukaetova‐Ladinska

2014

Neuroimmunomodulation

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“…[29–31] It is important to note that while these have been found to be significantly elevated in patients with delirium, they are not specific for delirium. [32, 33]…”

Section: Pathophysiologymentioning

confidence: 99%

Postoperative Delirium in the Geriatric Patient

Schenning

Deiner

2015

Anesthesiology Clinics

113

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SYNOPSIS Postoperative delirium, a common complication in older surgical patients, is independently associated with increased morbidity and mortality. Patients over the age of 65 years receive greater than 1/3 of the over 40 million anesthetics delivered yearly in the United States. This number is expected to increase with the aging of the population. Thus, it is increasingly important that perioperative clinicians who care for geriatric patients have an understanding of the complex syndrome of postoperative delirium.

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“…While there is data to suggest that hyperresponsiveness of the HPA axis is associated with PD in elderly surgical patients, there has been no direct comparison of anesthetic agents and their ability to reduce the stress response and PD (15). …”

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confidence: 99%

Do Stress Markers and Anesthetic Technique Predict Delirium in the Elderly?

Deiner¹,

Lin²,

Bodansky³

et al. 2014

Dement Geriatr Cogn Disord

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Background: Postoperative delirium (PD) is a prevalent complication of elderly surgical patients, which predisposes to worsened cognitive recovery and dementia. Risk of PD has been associated with increasing magnitude of the hypothalamic-pituitary-adrenal stress response (serum cortisol, epinephrine and norepinephrine) to surgery. Anesthetics suppress this response; however, some (total intravenous anesthesia, TIVA) more than others (anesthetic gases). Prior comparisons of anesthetics have been equivocal but have not included stress markers. We hypothesized that TIVA would decrease serum stress markers and the incidence of PD. Methods: We performed a prospective cohort study of 76 elderly major surgical patients. Patients received TIVA or sevoflurane gas, and blood was drawn for serum markers pre-, intra-, and postoperatively. PD was assessed with the Confusion Assessment Method. We compared stress markers and PD between patients who received TIVA versus sevoflurane, and then modeled PD including stress and anesthetic. Results: The group that received TIVA during surgery demonstrated lower levels of all stress markers compared to the gas group, but no difference in PD. However, across groups, the postoperative norepinephrine level was much higher in patients who developed PD. Other markers and other times had no effect. Conclusion: The development of PD depends more on postoperative stress than intraoperative stress or anesthetic.

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The Stress Response to Surgery and Postoperative Delirium

Abstract: Hypothalamic-pituitary-adrenal axis hyperresponsiveness and a less frequent suppression of the GH/IGF-1 axis in response to acute stress are possibly involved in delirium pathophysiology.

Cited by 105 publications

References 66 publications

The Immunology of Delirium

The Immunology of Delirium

Postoperative Delirium in the Geriatric Patient

Do Stress Markers and Anesthetic Technique Predict Delirium in the Elderly?

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