The impact of cognitive reserve on delayed neurocognitive recovery after major non-cardiac surgery: an exploratory substudy.

Introduction: Delayed neurocognitive recovery is a common and severe complication after surgery and anesthesia with an adverse impact on daily living, morbidity, and mortality. High cognitive reserve may mitigate the development of delayed neurocognitive recovery, however, supporting data is lacking. We aimed to assess the association between cognitive reserve and delayed neurocognitive recovery in the early postoperative period. Methods: This is a substudy of two prospective observational studies. Adult patients undergoing elective major non-cardiac surgery, who were fluent in German, were eligible for study participation. Patients with any pre-existing central nervous system disorders were excluded. Cognitive reserve was assessed using the Cognitive Reserve Index questionnaire. Delayed neurocognitive recovery was defined as a decline in cognitive function compared with baseline assessments and was evaluated with a battery of neuropsychological tests on the day of hospital admission and between day three post procedure and before hospital discharge. Results: A total of 67 patients with a median age of 67 [IQR: (63-73)] years were included in our analysis. We found delayed neurocognitive recovery in 22.4% of patients. There was a significant association between Cognitive Reserve Index questionnaire total score and the occurrence of delayed neurocognitive recovery in the early postoperative period [OR = 0.938, (95% CI, 0.891; 0.988), p = 0.015]. Conclusion: Higher cognitive reserve in elderly patients undergoing major non-cardiac surgery decreases the risk for subsequent delayed neurocognitive recovery in the early postoperative period.

Effect of sedative premedication with oral midazolam on postanesthesia care unit delirium in older adults: a secondary analysis following an uncontrolled before-after design.

BACKGROUND: Sedative premedication with benzodiazepines has been linked with prolonged recovery and inadequate emergence during the immediate postoperative period. We aimed to analyze the association between postanesthesia care unit (PACU) delirium and sedative premedication with oral midazolam. METHODS: We performed a secondary analysis of prospectively collected data before (midazolam cohort) and after (non-midazolam cohort) implementation of a restrictive strategy for oral premedication with midazolam. From March 2015 until July 2018, we included patients 60 years and older, who underwent elective radical prostatectomy for prostate cancer. Exclusion criteria were contraindications to premedication with midazolam, preoperative anxiety, and a history of neurological disorders. Patients, who were scheduled for postoperative admission to the intensive care unit, were excluded. Between 2015 and 2016, patients received 7.5 mg oral midazolam preoperatively (midazolam cohort). Patients included between 2017 and 2018 did not receive any sedative medication preoperatively (non-midazolam cohort). The primary endpoint was the incidence of PACU delirium. RESULTS: PACU delirium rates were 49% in the midazolam cohort (n = 214) and 33% in the non-midazolam cohort (n = 218). This difference was not statistically significant on multivariable logistic regression analysis (OR 0.847 [95% CI 0.164; 4.367]; P = 0.842). Age (OR 1.102 [95% CI 1.050; 1.156]; P < 0.001), the cumulative dose of sufentanil (OR 1.014 [95% CI 1.005; 1.024]; P = 0.005), and propofol-sufentanil for anesthesia maintenance (OR 2.805 [95% CI 1.497; 5.256]; P = 0.001) were significantly associated with PACU delirium. CONCLUSION: Midazolam for sedative premedication was not significantly associated with PACU delirium. The reduction in the incidence of PACU delirium throughout the study period may be attributable to improvements in perioperative management other than a more restrictive preoperative benzodiazepine administration.

[Targeted temperature management after cardiac arrest : What is new?] / Gezieltes Temperaturmanagement nach Reanimation : Was gibt es Neues?

The current guidelines of the European Resuscitation Council recommend targeted temperature management to improve functional neurological outcome in comatose survivors after cardiac arrest. With the pathophysiological background of hypothermia-induced neuroprotection for prevention of hypoxic-ischemic encephalopathy, targeted temperature management is a key measure and represents a central aspect in postresuscitation care.In the 2021 guidelines the application of targeted temperature management in postresuscitation care has been recommended for all rhythms and irrespective of the location of cardiac arrest. Targeted temperature management is advocated for adult patients who remain unresponsive following return of spontaneous circulation (ROSC) after either out-of-hospital cardiac arrest or in-hospital cardiac arrest. The body temperature should be maintained at a constant value between 32 °C and 36 °C for at least 24 h. To avoid rebound hyperthermia, fever following targeted temperature management, defined as a temperature above 37.7 °C, should be prevented and treated for at least 72 h after ROSC in persistently comatose patients. The routine use of prehospital cooling by rapid infusion of large volumes of cold i.v. fluid immediately after ROSC is not recommended.Based on a systematic review of the current literature, this article summarizes the results of randomized trials and new findings on targeted temperature management in comatose adult patients after cardiac arrest. The review has a particular focus on the most recent evidence regarding the optimum range of target temperatures. Furthermore, recent data on preclinical management, different patient populations, the duration of targeted temperature management, cooling methods and rebound hyperthermia are discussed.The impact of targeted temperature management on neurological outcome after cardiac arrest has been a matter of controversy. Despite contradictory results and heterogeneity of study designs, the current evidence supports the relevance and the necessity of strict temperature control in postresuscitation care for neuroprotection and improvement in functional neurological outcomes.

Impact of postanesthesia care unit delirium on self-reported cognitive function and perceived health status: a prospective observational cohort study.

PURPOSE: The objective of this study was to determine the influence of postanesthesia care unit (PACU) delirium on self-reported cognitive function and perceived health status 3 months after surgery. METHODS: This prospective observational cohort study was performed in a PACU at a high-volume prostate cancer center. We used a convenience sample of patients > 60 years undergoing elective radical prostatectomy. Patients with a history of cerebrovascular or neurodegenerative disease were excluded. Fifteen, 30, 45, and 60 following extubation, patients were screened for signs of delirium with the Confusion Assessment Method for the Intensive Care Unit. Three months after surgery self-reported cognitive function was assessed with the Cognitive Failures Questionnaire, and health status was evaluated with the 36-item Short-Form Health Survey (SF-36). RESULTS: Signs of PACU delirium were present in 32.4% (n = 72/222) of patients, and 80.2% (n = 178/222) completed the 3-month follow-up. The presence of PACU delirium signs was not significantly associated with self-reported cognitive failures (B = 0.60, 95% CI: -1.72; 2.92, p = 0.61) or SF-36 physical component scores (B = 0.19, 95% CI: 0.02; 0.36, p = 0.03) or SF-36 mental component scores (B = -0.03, 95% CI: -0.18, 0.11, p = 0.66) 3 months after radical prostatectomy. CONCLUSIONS: In a cohort of educated, highly functioning, elderly male patients who were assessed immediately after surgery and at a 3-month follow-up, we found no association between PACU delirium and self-reported cognitive failures or perceived health status, which implies that PACU delirium may be an event of limited duration and impact. TRIAL REGISTRATION: The study was registered at ClinicalTrials.gov (Identifier: NCT04168268, Date of registration: November 19, 2019).