is postoperative cognitive dysfunction preventable in ...€¦ · decline function of brain and...
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Is Postoperative
cognitive dysfunction preventable in elderly ?
Roman Záhorec
2.dpt. Anesthesiology and Intensive Medicine,
Medical School , St. Elizabeths Cancer Institute
Comenius University , Bratislava
Decline function of brain and other organs with advanced age Brown E 2013, Rivera R, Anesthesiology 2009, vol.110,
Decreased neurotransmitter
synthesis
Mitochondrial ff. Decline
Loss of dendritic connections
Loss of cerebral mass
Decreased dynamics of
spines, microglia ff.
Seniors need less anesthetics
and easy enter burst suppression
Long-term survival after anesthesia in seniors . Robinson , Ann Surg 2009, 250(3): 449-458.
6-month mortality :
POD and POCD
Severe anemia,
hypoalbuminemia
Functional disability
and immobility - ADL,
Comorbidities severity
POCD definition and clinical dg.
Long lasting deficites of neuropsychological functions
Memory short-term,
Concentration, attention decline
Instrumental activity decreased
Mood and temperament changes
Battery of neuropsychological tests, writing, painting. (MMSE, CAM, PQRS,RASS)
Steinmetz J et al, Anesthesiology 2009
Predisposing and precipitating factors
Anxiety, fear, stress,
Sleep deprivation,
Depth of anesthesia,
Benzodiazepins,
Hypotension, Hypoxia
Surgical stress, SIRS
Infection, Inflammation
AGE, Dementia,
Stroke/TIA, Frailty
Immobility, Physical
Restrain, Co-morbidity
Hypertension,
Malnutrition
Enviroment ICU/ward
•PAIN
•ANXIETY •Hypothermia
• Hypothalamus • ANS
• Catecholamines
•Cortisol •Glucagon •GH , AVP,
Adrenomedulin
• IL-1,2,6 •TNF-a • Acute
Phase • SIRS
systemic
inflammatory
Reaction
1.
3.
POD § POCD
SIRS
STRESS
Pathophysiology and mechansims of POCD Cibelli AoN 2010, Degos V., Anesthesiology 2013
ANAESTHESIA
Anesthetics -neuromediators, brain injury
due to hypotension/hypoperfusion, neuroinflammation
SURGICAL
STRESS and
SURGICAL SIRS
PT.
PREDISPOSITION
AGE, FRAILTY,
Inflammation subclin.
Dementia, Stroke/TIA
ICU enviroment, noise,
Alarms, Light,sleep depriv.
Iatrogenic behaviour
POCD lasting more than
3 months
Depths of anesthesia
BIS < 40 more than 1 h.
Hypotension sAP< 90
more than 30 minutes
Increased mortality Social support
Impaired QoL
Labor activity,
Leaving work
RISK of POCD . Long-term consequences of POCD
Steinmetz J et al. , Anesthesiology 2009
Increased
mortality
in 1 year
Social
dependency
Impaired
Quality of Life
Decline
instrumental
activities
Mood §
temperament
Changes
Risk of leaving
work ability
Saczynski J., NEJM 2012, 347 POD § POCD is a dynamic
and complex neuropsycholog. process
Royse CF , PQRS , Anesthesiology 2010, 113(4): 892-905
Royse CF , PQRS , Anesthesiology 2010, 113(4): 892-905
Risk and Precipitating factors of POCD
in perioperative period
Infection / chronic
Inflammation Prevention of
Infections, Modulat.
Deep
anesthesia
BIS < 40
Avoid BIS < 40,
meas. depth.Anesth
Hypoxia,
ischemia Avoid hypoxemia,
Normotension dAP
Dehydratation
Hypotension Crystalloids ,
Normotension
Hypoglycaemia
Hypoalbuminemi Glucose/glycemi
Nutriton/antioxid
.
Avoid benzodiazepins Benzodiazepins
Drugs and supplements for POCD § POD prevention ?
Dexmedetomidin - Vegos 2013, Riker 2009, Rukonen 2009,
Pandharipande PP JAMA 2007.
Antipsychotic drugs – haloperidol, risperidon, Kaneko
1999, Kalisvaart 2005, Prakanattane 2007
Ketamin low dose 0,5 mg/kg g.a. induction Hudetz 2009
Melatonin , in premedication Torok , 2014
Vitamin D supplemention - Morandi ,2013
Multicomponent intervention - Lunstrom 2007, Zhang 2013
Light sedation during spinal anesthesia BIS80 Sieber
2010
Is POCD preventable ?
Preventable
Multicomponent
strategy
In elderly
Considering role of
INFLAMMATION
AVOID MAJOR
SURGERY
BEHAVIOURAL
SOCIAL SUPPORT,
EXERCISE,
ACTIVITY
Prevention strategies of POCD Modulation inflammation § Avoid major surgery
Avoid /treat infection
Modulation of inflamm. Neuroinflammation
Anaesthesia managm. Moderate anaesthesia BIS 40-50, SaO2 95%
Prevent hypotension, hypoxemia
Miniinvasive surgery
Invasive radiology
Surgery under locoregional anaesthesia
Modulate surgical SIRS and surgical stress
Communicate before surgery and anaesth.
Hospital Elder Life Program
•Increased physical
and psych. Activity
•Exercise
•Nutrition and drink
•Psychologic supp.
•Family, friends, relat
communication
THANK YOU for ATTENTION ...