EBM/ Journal Reading

The InThe InThe InThe Inflflflfluence of Anesthesia and Pain uence of Anesthesia and Pain uence of Anesthesia and Pain uence of Anesthesia and Pain Management on Cognitive Dysfunction After Management on Cognitive Dysfunction After Management on Cognitive Dysfunction After Management on Cognitive Dysfunction After Joint ArthroplastyJoint ArthroplastyJoint ArthroplastyJoint Arthroplasty

A Systematic Review

Michael G. Zywiel MD, Atul PrabhuPhD, Rajiv Gandhi MSc, MDClinical Orthopaedics and Related Research (2014) 472:1453Clinical Orthopaedics and Related Research (2014) 472:14531466

報告人: R2

主持人: VS

2015.06.19 07AM

uence of Anesthesia and Pain uence of Anesthesia and Pain uence of Anesthesia and Pain uence of Anesthesia and Pain Management on Cognitive Dysfunction After Management on Cognitive Dysfunction After Management on Cognitive Dysfunction After Management on Cognitive Dysfunction After

Prabhu MD, Anthony V. Perruccio

and Related Research (2014) 472:1453-and Related Research (2014) 472:1453-

R2 倪銘陽

VS 戴元基 教授

2015.06.19 07AM

Introduction

• Postoperative cognitive decline and/or deliriumranging from 7% to 75%

• Definition, patient population, and assessment

→Delayed mobilization and discharge from

Long-term cognitive dysfunctionLong-term cognitive dysfunction

Potentially increased rates of return to hospital and mortality

• Etiology-multifactorial-Major surgery, impairment

• Optimal choice of anesthetic and pain management strategies to minimize the incidence of postoperative cognitive dysfunction

cognitive decline and/or delirium, with reported rates

, patient population, and assessment tools

mobilization and discharge from hospital

increased rates of return to hospital and mortality

surgery, Older age, and Preexisting cognitive

choice of anesthetic and pain management strategies to minimize the incidence of postoperative cognitive dysfunction

Introduction

• Postoperative cognitive decline and/or deliriumranging from 7% to 75%

• Definition, patient population, and assessment

→Delayed mobilization and discharge from

Long-term cognitive dysfunctionLong-term cognitive dysfunction

Potentially increased rates of return to hospital and mortality

• Etiology-multifactorial-Major surgery, impairment

• Optimal choice of anesthetic and pain management strategies to minimize the incidence of postoperative cognitive dysfunction

cognitive decline and/or delirium, with reported rates

, patient population, and assessment tools

mobilization and discharge from hospital

increased rates of return to hospital and mortality

surgery, Older age, and Preexisting cognitive

choice of anesthetic and pain management strategies to minimize the incidence of postoperative cognitive dysfunction

Introduction

• Systematically reviewed the English language influence of anesthetic and/ or pain management strategies on the risk for postoperative cognitive dysfunction in patients undergoing elective joint arthroplasty

• (1) General as compared to regional

• (2) Different parenteral, neuraxial, or inhaled agents within a given type of

anesthetic (general or regional)

• (3) Multimodal anesthetic techniques

• (4) Different postoperative pain management

English language literature to assess the anesthetic and/ or pain management strategies on the

risk for postoperative cognitive dysfunction in patients undergoing

as compared to regional anesthesia

, or inhaled agents within a given type of

techniques

postoperative pain management regimens

Search Criteria and StrategyEligibility Criteria

• Different types of anesthesia (eg, general,

• Postoperative cognitive dysfunction

• Any acute change in neurocognitive status after surgery, including postoperative cognitive decline, delirium, or postoperative cognitive decline, delirium, or

• (1) Only patients who underwent elective major joint arthroplasty (specifically, hip, knee, shoulder, elbow, or ankle)

• (2) Patients who underwent any of a number of different surgical procedures including elective orthopaedichospitalization were deemed eligible for inclusion

Search Criteria and StrategyCriteria

, general, neuraxial, regional)

cognitive dysfunction

acute change in neurocognitive status after surgery, including postoperative cognitive decline, delirium, or confusionpostoperative cognitive decline, delirium, or confusion

elective major joint arthroplasty (specifically, hip, knee, shoulder, elbow, or ankle)

who underwent any of a number of different surgical orthopaedic surgery requiring

hospitalization were deemed eligible for inclusion

Eligibility Criteria

• Comparative studies –two different pain management strategies, irrespective of study design

• Exclusion

• Case series assessing the incidence of postoperative cognitive dysfunction with a single pain management strategywith a single pain management strategy

• No English full-text versions

Eligibility Criteria

two different pain management strategies,

incidence of postoperative cognitive dysfunction strategystrategy

Information Sources and Search• Source:

• Ovid MEDLINE and EMBASE databases to identify all studies published up 2013

• Anesthetic and/or pain management sdysfunction

• Citation titles and abstracts: • Citation titles and abstracts: • (Delirium or cognitive or cognition or confusion or confused

• (Pain management or anesthesia or anaesthesiaspinal or epidural or multimodal or pain control)

• (Arthroplasty or joint replacement or elective non-cardiac or non cardiac)

• Second search of the same databases• MeSH headings: ‘‘(pain management or anesthesia

(delirium or postoperative complications).’’

Information Sources and Search

databases to identify all studies published up to March

nt strategies on postoperative cognitive

(Delirium or cognitive or cognition or confusion or confused)

anaesthesia or anesthetic or anaesthetic or pain control)

(Arthroplasty or joint replacement or elective joint or orthopaedic or orthopedic or

Second search of the same databasespain management or anesthesia) and orthopedic procedures and

(delirium or postoperative complications).’’

Study Selection

Data Collection

• (1) Study details, including study design

• (2) Study population details• Number of patients and their mean age (range

• Any reported inclusion/exclusion criteria

• (3) Details of pain management strategies• (3) Details of pain management strategies• Type of anesthesia

• Analgesic and/or anesthetic medications

• (4) Details of assessment of postoperative cognitive • Assessment tools

• Time point and frequency of assessment(s

• Reported incidence of postoperative cognitive dysfunction

study design and level of evidence

mean age (range)

inclusion/exclusion criteria, and the surgical procedures performed

strategiesstrategies

and/or anesthetic medications given including route and dosing

assessment of postoperative cognitive dysfunction

of assessment(s)

incidence of postoperative cognitive dysfunction

Study Designs and Populations

• 21 of 28 (75%) used a prospective randomized design effects of pain management strategiesdysfunction

• 9 of 21 (43%) explicitly reported blinding of patients, clinicians, • 9 of 21 (43%) explicitly reported blinding of patients, clinicians, and/or assessors to the participants’ treatment

• 9 of 21 (43%) reported performing an a delirium for the outcome of postoperative cognitive dysfunction

Populations

prospective randomized design to compare the effects of pain management strategies on postoperative cognitive

blinding of patients, clinicians, blinding of patients, clinicians, and/or assessors to the participants’ treatment arm allocation

reported performing an a priori power calculation outcome of postoperative cognitive dysfunction

Definitions and assessment tools for postoperative cognitive dysfunction

• 11 studies assessed postoperative cognitive dysfunction using multiple validated neuropsychologic

• 11 studies assessed either cognitive dysfunction or confusion *without specifying diagnostic criteria*

5 studies assessed postoperative cognitive dysfunction • 5 studies assessed postoperative cognitive dysfunction • Confusion Assessment Method-which

screening

• Diagnostic and Statistical Manual of Mental Disorders

• 4 studies assessed postoperative cognitive dysfunction by an observed change in scores on the Mini Mental Status Examination

• 2 assessed for change on the Wechsler Adult Intelligence Scale

and assessment tools for postoperative cognitive dysfunction

assessed postoperative cognitive dysfunction using neuropsychologic and/or cognitive tests

assessed either cognitive dysfunction or confusion criteria*

assessed postoperative cognitive dysfunction assessed postoperative cognitive dysfunction which has been validated for delirium

and Statistical Manual of Mental Disorders criteria for delirium

cognitive dysfunction by an the Mini Mental Status Examination

Wechsler Adult Intelligence Scale

ResultsThe Use of General Versus Regional AnesthesiaThe Use of General Versus Regional Anesthesia

The Use of Different Anesthetic and/or Analgesic Techniques Within a Given Type of Anesthesia • Optimization of depth of general anesthesia with comprehensive

intraoperative cerebral monitoring

• Maintenance of anesthesia using EEG monitoring with faster time to orientation in the recovery room with faster time to orientation in the recovery room in daily psychometric test results up to Postoperative Day 3

The Use of Different Anesthetic and/or Analgesic Techniques Within a Given Type

depth of general anesthesia with comprehensive intraoperative cerebral monitoring may be beneficial

EEG monitoring was associated faster time to orientation in the recovery room but no difference faster time to orientation in the recovery room but no difference

test results up to Postoperative Day 3

Multimodal Anesthetic

Diagnostic criteria for confusion were not specified

The study was not specifically powered to detect a difference in postoperative

cognitive dysfunction.

Anesthetic Techniques

specified

study was not specifically powered to detect a difference in postoperative

Postoperative Pain Management Strategies• In general, the findings suggest that pain management strategies that minimize the use

of narcotics postoperatively have a beneficial effect on early postoperative cognitive dysfunction

Postoperative Pain Management

In general, the findings suggest that pain management strategies that minimize the use of narcotics postoperatively have a beneficial effect on early postoperative cognitive

Discussion

• General anesthesia may be associated with cognitive dysfunction, with no effect seen beyond 7 days.

• Optimization of depth of sedation through the use of monitoring may also be beneficial, although

• Multimodal anesthesia protocols themselves • Multimodal anesthesia protocols themselves reduce the incidence of postoperative cognitive

• Strategies that minimized the use of narcotic medications postoperatively did appear to be helpful

may be associated with early postoperative , with no effect seen beyond 7 days.

of depth of sedation through the use of adjunct , although evidence is limited

themselves were not found to themselves were not found to reduce the incidence of postoperative cognitive dysfunction

minimized the use of narcotic medications postoperatively did appear to be helpful

Limitations of the present study

• Failed to identify one or more studies that assessed the risk of postoperative cognitive dysfunctionand/or pain management techniques

• A number of the included studies did not • A number of the included studies did not used for the diagnosis of confusion and/or cognitive

• Supports the overall trend toward the use of elective joint arthroplasty surgery, which has found favor in part due to benefits in terms of improved postoperative pain control and decreased nausea and vomiting

of the present study

to identify one or more studies that assessed the incidence or risk of postoperative cognitive dysfunction associated with anesthetic

techniques

number of the included studies did not specify what criteria were number of the included studies did not specify what criteria were for the diagnosis of confusion and/or cognitive dysfunction

Supports the overall trend toward the use of regional techniques for , which has found favor in part due

to benefits in terms of improved postoperative pain control and

• Little has been reported on the effects of protocols on the risk of postoperative cognitive dysfunction per se,

• several studies comparing different postoperative pain management strategies showed benefit for individual components typically included in multimodal protocolsmultimodal protocols

• This includes avoiding narcotic use through the shotorcontinuousperipheralnerveblocksand

• Surgeons and anesthesiologists should preferentially select morphine agents and transition to oral narcotics as soon as possible to minimize the risk of postoperative cognitive dysfunction

has been reported on the effects of multimodal anesthetic on the risk of postoperative cognitive dysfunction per se,

studies comparing different postoperative pain management benefit for individual components typically included in

This includes avoiding narcotic use through the useofsingle-shotorcontinuousperipheralnerveblocksand/ or NSAIDs

Surgeons and anesthesiologists should preferentially select non and transition to oral narcotics as soon as possible

to minimize the risk of postoperative cognitive dysfunction

• Continuous-infusion peripheral nerve catheters • Pros: May be beneficial in terms of reducing the risk of postoperative

cognitive dysfunction (potentially because of requirements)

• Cons: • Cons: • Several authors have noted an increased incidence of complications, including

weakness and falls, with the use of this

• Importance of early mobilization- continwith caution

• Both IV and oral NSAIDs may be of • The risks of major gastrointestinal com

may not be trivial in certain patient populations

peripheral nerve catheters reducing the risk of postoperative

(potentially because of decreased narcotic

authors have noted an increased incidence of complications, including muscle weakness and falls, with the use of this technique

ntinuous peripheral nerve blockades should be used

IV and oral NSAIDs may be of benefit complications, including fatal hemorrhage

may not be trivial in certain patient populations

In summary

• Both anesthetic and pain management strategies do appear to influence the risk of cognitive dysfunction after elective joint arthroplasty

• The optimal strategy includes the use of regional anesthesia• The optimal strategy includes the use of regional anesthesiacombined with multimodal techniques that minimize the need for postoperative narcotics in general, and especially non oral narcotics or morphine in any

• Authors strongly encourage other investigators to adopt the use of widely accepted, validated tools for cognitive dysfunction

anesthetic and pain management strategies do appear to the risk of cognitive dysfunction after elective joint

use of regional anesthesia, use of regional anesthesia, multimodal techniques that minimize the need for

in general, and especially avoiding the use of narcotics or morphine in any form

strongly encourage other investigators to adopt the use of for the assessment of postoperative

• Thank you for your attention!

• detailed reporting of the potential ranalgesic techniques will facilitate future metaadequately control for the wide range of potential

• affecting the risk of postoperative cognitive dysfunction and help • affecting the risk of postoperative cognitive dysfunction and help better define optimal anesthetic andelective joint arthroplasty.

tial risk factors and the anesthetic and analgesic techniques will facilitate future meta-analyses that can adequately control for the wide range of potential factors

affecting the risk of postoperative cognitive dysfunction and help affecting the risk of postoperative cognitive dysfunction and help and pain management strategies for