Preoperative Cognitive Impairment and Postoperative Delirium in Elderly Surgical Patients: A Retrospective Large Cohort Study (The CIPOD Study).

OBJECTIVE: To test the hypothesis that in surgical patients ≥70 years, preoperative cognitive impairment is independently associated with postoperative delirium. BACKGROUND: Postoperative delirium is common among elderly surgical patients and is associated with longer hospitalization and significant morbidity. Some evidence suggest that baseline cognitive impairment is an important risk factor. Routine screening for both preoperative cognitive impairment and postoperative delirium is recommended for older surgical patients. As of 2019, we implemented such routine perioperative screening in all elective surgical patients ≥70 years. METHODS: Retrospective single-center analysis of prospectively collected data between January and December 2020. All elective noncardiac surgical patients ≥70 years without pre-existing dementia were included. Postoperative delirium, defined as 4A's test score ≥4, was evaluated in the postanesthesia care unit and during the initial 2 postoperative days. Patients' electronic records were also reviewed for delirium symptoms and other adverse outcomes. RESULTS: Of 1518 eligible patients, 1338 (88%) were screened preoperatively [mean (SD) age 77 (6) years], of whom 21% (n=279) had cognitive impairment (Mini-Cog score ≤2). Postoperative delirium occurred in 15% (199/1338). Patients with cognitive impairment had more postoperative delirium [30% vs. 11%, adjusted odds ratio (95% confidence interval) 3.3 (2.3-4.7)]. They also had a higher incidence of a composite of postoperative complications [20% vs. 12%, adjusted odds ratio: 1.8 (1.2-2.5)], and median 1-day longer hospital stay [median (interquartile range): 6 (3,12) vs. 5 (3,9) days]. CONCLUSIONS: One-fifth of elective surgical patients ≥70 years present to surgery with preoperative cognitive impairment. These patients are at increased risk of postoperative delirium and major adverse outcomes.

Intraoperative Neurophysiology for Optimization of Percutaneous Spinothalamic Cordotomy for Intractable Cancer Pain.

BACKGROUND: Percutaneous ablation of the cervical spinothalamic tract (STT) remains a therapeutic remedy for intractable cancer pain. However, it is accompanied by the risk of collateral damage to essential spinal cord circuitry, including the corticospinal tract (CST). Recent studies describe threshold-based mapping of the CST with the objective of motor bundle preservation during intramedullary spinal cord and supratentorial surgery. OBJECTIVE: To assess the possibility that application of spinal cord mapping using intraoperative neuromonitoring in percutaneous cordotomy procedures may aid in minimizing iatrogenic motor tract injury. METHODS: We retrospectively reviewed the files of 11 patients who underwent percutaneous cervical cordotomy for intractable oncological pain. We performed quantitative electromyogram (EMG) recordings to stimulation of the ablation needle prior to the STT-ablative stage. We compared evoked motor and sensory electrical thresholds, and the electrical span between them as a reliable method to confirm safe electrode location inside the STT. RESULTS: Quantified EMG data were collected in 11 patients suffering from intractable cancer pain. The threshold range for evoking motor activity was 0.3 to 1.2 V. Stimulation artifacts were detected from trapezius muscles even at the lowest stimulation intensity, while thenar muscles were found to be maximally sensitive and specific. The minimal stimulation intensity difference between the motor and the sensory threshold, set as "Δ-threshold," was 0.26 V, with no new motor deficit at 3 days or 1 month postoperatively. CONCLUSION: Selective STT ablation is an effective procedure for treating intractable pain. It can be aided by quantitative evoked EMG recordings, with tailored parameters and thresholds.

Neurosurgical ablative procedures for intractable cancer pain.

OBJECTIVECancer patients suffering from severe refractory pain may benefit from targeted ablative neurosurgical procedures aimed to disconnect pain pathways in the spinal cord or the brain. These patients often present with a plethora of medical problems requiring careful consideration before surgical interventions. The authors present their experience at an interdisciplinary clinic aimed to facilitate appropriate patient selection for neurosurgical procedures, and the outcome of these interventions.METHODSThis study was a retrospective review of all patients who underwent neurosurgical interventions for cancer pain in the authors' hospital between March 2015 and April 2018. All patients had advanced metastatic cancer with limited life expectancy and suffered from intractable oncological pain.RESULTSSixty patients underwent surgery during the study period. Forty-three patients with localized pain underwent disconnection of the spinal pain pathways: 34 percutaneous-cervical and 5 open-thoracic cordotomies, 2 stereotactic mesencephalotomies, and 2 midline myelotomies. Thirty-nine of 42 patients (93%) who completed these procedures had excellent immediate postoperative pain relief. At 1 month the improvement was maintained in 30/36 patients (83%) available for follow-up. There was 1 case of hemiparesis.Twenty patients with diffuse pain underwent stereotactic cingulotomy. Nineteen of these patients reported substantial pain relief immediately after the operation. At 1 month good pain relief was maintained in 13/17 patients (76%) available for follow-up, and good pain relief was also found at 3 months in 7/11 patients (64%). There was no major morbidity or mortality.CONCLUSIONSWith careful patient selection and tailoring of the appropriate procedure to the patient's pain syndrome, the authors' experience indicates that neurosurgical procedures are safe and effective in alleviating suffering in patients with intractable cancer pain.

Severe acidosis does not predict fatal outcomes in intensive care unit patients: a retrospective analysis.

PURPOSE: Severe acidosis is a potentially life-threatening acid-base imbalance. The outcome of patients with severe acidosis has only been anecdotally described. We therefore assessed the discharge rate of such patients from the intensive care unit (ICU) and survival time after the event. METHODS: A retrospective evaluation of medical records of patients admitted to the ICU of Tel Aviv Medical Center between 2005 and 2010, in whom arterial blood pH less than 6.8 was documented during their ICU stay, was performed. RESULTS: Twenty-eight patients were suitable for study entry. Septic shock was the most common underlying medical condition (33%). Nine (32.1%) patients were either discharged alive or survived for at least 30 days in the ICU after their arterial blood pH measurement was less than 6.8. More than a quarter of the patients with life-threatening acidosis (n = 8; 28.6%) were discharged home and returned to their prehospitalization daily activity. Mean follow-up period for these patients was 132 ± 111 weeks. Multivariate analysis identified hyperkalemia, Acute Physiology and Chronic Health Evaluation II score, and Glasgow Coma Scale as determinants for ICU death after severe acidosis. CONCLUSIONS: A significant number of patients can outlast severe acidosis and return to their prehospitalization status. Larger studies are needed to define the patient population most likely to benefit from aggressive resuscitation efforts during severe acidosis.

Postoperative discomfort (other than pain) - a neglected feature of postanesthesia patient care.

OBJECTIVE: Patients may experience various kinds of discomfort other than pain during the immediate period following surgery and anesthesia. These complaints may not be dealt with, especially when they are shadowed by the more pressing need to alleviate pain. The issue of discomfort in the setting of an adult post anesthesia care unit (PACU) has not been adequately addressed. We assessed the extent of unreported distressing or unpleasant events among patients who had undergone general surgery or orthopedic procedures under standard general anesthesia and their recall 24 h afterwards. METHODS: As customary, the PACU staff recorded vital signs, and assessed pain level; if pain score was 90% recalled 24 h after surgery having had postoperative discomfort. PACU staff needs to inquire for and attempt reducing such events.