Postoperative Cognitive Decline Research Articles

Deep brain stimulation of the subthalamic nucleus in Parkinson's disease: Relationship between the electrode trajectory and cognitive decline

IntroductionIt remains to be clarified whether penetration of the caudate nucleus increases the risk of cognitive decline in patients with Parkinson's disease (PD) undergoing deep brain stimulation (DBS) of the subthalamic nucleus (STN). MethodsA retrospective analysis of pre/postoperative neuropsychological changes was performed with 46 consecutive patients with PD who underwent DBS of the STN. In particular, to evaluate the possible relationship between cognitive changes and DBS lead trajectories, repeated-measures ANCOVAs were conducted to analyze the effects of group (23 patients with vs 23 patients without penetration of the caudate nucleus) and time (T0 vs T1) for each neuropsychological test. ResultsA statistically significant main effect of time was observed in the Trail Making Test - Part B (TMT-B), as well as in both the phonemic and semantic (F [1, 44] = 35.59, p < 0.001, PrtEta2 = 0.447) verbal fluency tasks, and the results suggested postoperative cognitive decline. However, no significant interaction effects of time and group were observed. The results indicated that the extent of the decline was comparable between the caudate and non-caudate penetration groups, and no relationship was found between cognitive changes and caudate penetration. ConclusionAlthough postoperative cognitive decline was observed in some attentional-executive functions, which were assessed by the verbal fluency and TMT-B tasks, the trajectory passing through the caudate appeared not to increase the risk of cognitive decline in patients with PD undergoing DBS of the STN.

Prevention of Early Postoperative Decline (PEaPoD): protocol for a randomized, controlled feasibility trial

BackgroundDelirium is associated with a significantly increased risk of postoperative morbidity and mortality. Furthermore, delirium has been associated with an increased risk of prolonged cognitive deficits and accelerated long-term cognitive decline. To date, experimental interventions for delirium have mainly focused on alternative pharmacologic and behavioral strategies in the postoperative period. Few studies have examined whether proactive strategies started before surgery can prevent delirium or reduce its sequelae. Neurocognitive training programs such as Lumosity have been shown to be effective in increasing cognitive performance in both elderly healthy volunteers and patients suffering from a myriad of acute and chronic medical conditions. When initiated in the preoperative period, such training programs may serve as interesting and novel patient-led interventions for the prevention of delirium and postoperative cognitive decline (POCD). We hypothesize that perioperative neurocognitive training is feasible in the older cardiac surgical population and are testing this hypothesis using a randomized controlled design.MethodsThe Prevention of Early Postoperative Decline (PEaPoD) study is a randomized, controlled trial with a target enrollment of 45 elderly cardiac surgical patients. Subjects will be randomized in a 1:1 ratio to undergo either at least 10 days of preoperative neurocognitive training, continued for 4 weeks postoperatively, or usual care control. The primary outcome, feasibility, will be assessed by study recruitment and adherence to protocol. Secondary outcomes will include potential differences in the incidence of postoperative in-hospital delirium and POCD up to 6 months, as determined by the Confusion Assessment Method and the Montreal Cognitive Assessment.DiscussionPEaPoD will be the first trial investigating the use of perioperative cognitive training to potentially reduce delirium and POCD in the cardiac surgical population. Information gleaned from this feasibility study will prove valuable in designing future efficacy studies aimed at determining whether this low-risk, patient-led intervention can reduce serious postoperative morbidity.Trial registrationClinicalTrials.gov, NCT02908464. Registered on 21 September 2016.

Surveying the Literature

Surveying the Literature

PREOPERATIVE FRAILTY PREDICTS POSTOPERATIVE LONG-TERM COGNITIVE DECLINE INDEPENDENT OF DELIRIUM

AbstractFrailty is present in almost half of all older surgical patients. Although frailty has been associated with cognitive decline, this has not been examined in the context of surgery. It is also not known if this relationship is independent of delirium, an established risk factor for postoperative cognitive decline. We probed these questions in the Successful Aging after Elective Surgery cohort of 560 dementia-free older adults (≥70 years old) undergoing elective surgery. Frailty and delirium were measured, respectively, by the Fried Frailty Index and the Confusion Assessment Method supplemented by medical chart review. Postoperative cognitive trajectory was measured as the slope of the General Cognitive Performance (GCP) score, a composite derived from results of a neuropsychological battery administered 2–36 months post-surgery. 64 (12%) of patients were robust, 280 (56%) were pre-frail, and 160 (32%) were frail. Delirium occurred in 134 patients (24%) overall. Compared to the rate of GCP decline among robust patients, decline was steeper by -0.47 points/year (95% CI -0.83, -0.14, p=.005) among pre-frail patients and by -0.48 points/year (95% CI -0.88, -0.07, p=.02) among frail patients. This effect was independent of age, sex, and education. Notably, the known influence of delirium on cognitive decline did not account for the association between frailty and cognitive decline. These results suggest pre-frailty, frailty and delirium are independently associated with accelerated postoperative cognitive decline, with effects of similar magnitude to each other and to mild cognitive impairment. Preoperative frailty screening could identify patients at higher risk of cognitive decline after surgery.

Cerebral embolization during endovascular infrarenal, juxtarenal, and suprarenal aortic aneurysm repair, high-risk maneuvers, and associated neurologic outcomes

BackgroundRisk factors for postoperative cognitive decline after noncardiac surgery are multifactorial and poorly understood. Evidence suggests that perioperative microembolic damage to the brain on movement of wires and catheters during endovascular aortic procedures may play an important role. Endovascular aortic aneurysm repair requires invasive manipulation of wires and cannulas within the aorta, but research into cerebral emboli during aortic aneurysm repair and cognitive or neurologic injury is scarce and limited to thoracic aneurysms. This study prospectively studied embolic phenomena detected in the middle cerebral artery during infrarenal, juxtarenal, and thoracic endovascular aortic repair (TEVAR) and investigated links to delirium, stroke, and postoperative cognitive decline. MethodsThere were 60 patients who received continuous left-sided perioperative transcranial Doppler monitoring during endovascular aortic aneurysm repair (bifurcated graft for infrarenal aneurysm, n = 18; endovascular aneurysm sealing graft, n = 16; endovascular aneurysm sealing and renal “chimney” stent, n = 17; and thoracic aneurysm, n = 3). The procedure was time stamped for events such as stiff wire insertion and graft deployment. A battery of cognitive tests designed to test several cognitive domains were performed preoperatively and at 90 days postoperatively. ResultsTEVAR and chimney grafts demonstrated significantly greater numbers of total procedural emboli compared with standard bifurcated grafts (mean emboli, 36.2 and 13.39, respectively; bifurcated graft, 5.81; P < .05). The highest risk maneuvers were guidewire and pigtail catheter insertion. This was the case for all procedures including infrarenal aneurysm repair. A higher perioperative embolic load was associated with medium-term cognitive decline in list recall but not with incidence of delirium or stroke. Risk of cognitive decline did not relate to procedure type. Antiplatelet use failed to demonstrate a protective effect. ConclusionsPatients are at risk of cerebral emboli during several types of endovascular aortic surgery, although TEVAR remains the highest risk procedure. As yet, there are no validated protective measures available to prevent cerebral emboli and their associated risks of clinical and subclinical neurologic injury.

Neurocognitive Function after Cardiac Surgery: From Phenotypes to Mechanisms.

For half a century, it has been known that some patients experience neurocognitive dysfunction after cardiac surgery; however, defining its incidence, course, and causes remains challenging and controversial. Various terms have been used to describe neurocognitive dysfunction at different times after cardiac surgery, ranging from "postoperative delirium" to "postoperative cognitive dysfunction or decline." Delirium is a clinical diagnosis included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Postoperative cognitive dysfunction is not included in the DSM-5 and has been heterogeneously defined, though a recent international nomenclature effort has proposed standardized definitions for it. Here, the authors discuss pathophysiologic mechanisms that may underlie these complications, review the literature on methods to prevent them, and discuss novel approaches to understand their etiology that may lead to novel treatment strategies. Future studies should measure both delirium and postoperative cognitive dysfunction to help clarify the relationship between these important postoperative complications.

Longitudinal Changes in Regional Cerebral Perfusion and Cognition After Cardiac Operation

Cardiac operation has been associated with increased risk of postoperative cognitive decline, as well as dementia risk in the general population. Few studies, however, have examined the impact of coronary revascularization or valve replacement or repair operation on longitudinal cerebral perfusion changes or their association with cognitive function. We examined longitudinal changes in cerebral perfusion among 54 individuals with cardiac disease; 27 undergoing cardiac operation and 27 matched control patients. Arterial spin labeling magnetic resonance perfusion imaging was used to quantify cerebral blood flow within the anterior communicating artery, middle cerebral artery (MCA), and posterior communicating artery vascular territories before operation and postoperatively at 6 weeks and 1 year. Cognitive performance was examined during the same intervals by using a battery of tests that tapped memory, executive, information processing and upper extremity motor functions. Repeated measures, mixed models were used to examine for perfusion changes and theassociation between perfusion changes and cognition. Significant postoperative increases in perfusion were observed at 6 weeks within the MCA vascular territory after cardiac operation (p= 0.035 for interaction). Perfusion changes were most notable in distal territories of the MCA and posterior communicating artery at 6 weeks, with no additional changes at 1 year. Postoperative increases in MCA perfusion at 6 weeks were associated with improved psychomotor speed (β= 0.35, p= 0.016), whereas no important differences were found between the groups in vascular territory perfusion and cognition at 1 year. Cardiac operation is associated with important short-term increases in MCA perfusion with associated improvements in psychomotor speed.

Cognitive Decline after Delirium in Patients Undergoing Cardiac Surgery.

Cardiac surgery is associated with cognitive decline and postoperative delirium. The relationship between postoperative delirium and cognitive decline after cardiac surgery is unclear The development of postoperative delirium is associated with a greater degree of cognitive decline 1 month after cardiac surgery. The development of postoperative delirium is not a predictor of cognitive decline 1 yr after cardiac surgery. Delirium is common after cardiac surgery and has been associated with morbidity, mortality, and cognitive decline. However, there are conflicting reports on the magnitude, trajectory, and domains of cognitive change that might be affected. The authors hypothesized that patients with delirium would experience greater cognitive decline at 1 month and 1 yr after cardiac surgery compared to those without delirium. Patients who underwent coronary artery bypass and/or valve surgery with cardiopulmonary bypass were eligible for this cohort study. Delirium was assessed with the Confusion Assessment Method. A neuropsychologic battery was administered before surgery, at 1 month, and at 1 yr later. Linear regression was used to examine the association between delirium and change in composite cognitive Z score from baseline to 1 month (primary outcome). Secondary outcomes were domain-specific changes at 1 month and composite and domain-specific changes at 1 yr. The incidence of delirium in 142 patients was 53.5%. Patients with delirium had greater decline in composite cognitive Z score at 1 month (greater decline by -0.29; 95% CI, -0.54 to -0.05; P = 0.020) and in the domains of visuoconstruction and processing speed. From baseline to 1 yr, there was no difference between delirious and nondelirious patients with respect to change in composite cognitive Z score, although greater decline in processing speed persisted among the delirious patients. Patients who developed delirium had greater decline in a composite measure of cognition and in visuoconstruction and processing speed domains at 1 month. The differences in cognitive change by delirium were not significant at 1 yr, with the exception of processing speed.

Cognitive function in patients with coronary artery disease: A literature review.

ObjectiveCognitive function impairment is a well-documented complication of cerebrovascular disease (CBVD). Less is known about what factors affect the deterioration of cognitive function in patients with coronary artery disease (CAD). The aim of this review is to explore recent studies investigating factors associated with cognitive function in patients with CAD.MethodsStudies published from 2010 to 2016 were identified through a systematic search of MEDLINE/PubMed and were included if they addressed factors affecting cognitive function in the CAD population.ResultsOf the 227 publications identified, 32 were selected for the review. Five factors tentatively affecting cognitive function in patients with CAD were identified: coronary artery bypass grafting (CABG) surgery, apolipoprotein E4 (APOE4) genotype, left ventricular ejection fraction (LVEF), medication use, and various hormones and biomarkers.ConclusionNew techniques in CABG surgery have proven to alleviate postoperative cognitive decline. Researchers are still debating the effects of APOE4 genotype, LVEF, and the use of cardiovascular medications on cognitive function. Thyroid hormones and biomarkers are associated with cognitive function, but the exact nature of the association is debatable. Longitudinal studies should clarify those associations. In addition, cross-sectional studies addressing other causes of cognitive decline in patients with CAD are warranted.

Analysis of the perioperative change in cognitive function of patients with risk factors for cognitive impairment in cardiovascular surgery.

The purpose of the present study is to assess the perioperative changes in the cognitive function of patients after cardiovascular surgery (CVS) and to find out risk factors for early postoperative cognitive decline. From December 2013 to March 2017, 291 patients underwent elective or urgent CVS with cardiopulmonary bypass in our institution. One hundred and fifteen patients, who agreed to an evaluation of their cognitive function, were included in this study. The cognitive function was evaluated by the HDS-R and MMSE at three time points: before surgery, in the early postoperative period and at discharge. The patients' characteristics, perioperative data, HDS-R and MMSE scores were obtained by reviewing their medical records retrospectively. The patients were stratified into three age groups. In all of the age groups, the early postoperative cognitive functional scores were severely decreased in comparison to the preoperative values. However, by the time of discharge, the function had improved to the same level as before surgery in each of the groups. In addition, the similar tendency was observed in patients with preoperative cognitive dysfunction. Moreover, multiple regression analysis demonstrated that preoperative cognitive function and age were significant risk factors for early cognitive impairment. Although preoperative cognitive decline and patients' age were the risk factors for early postoperative cognitive impairment after CVS, a significant recovery can be expected even in elderly patients or patients with low preoperative cognitive function by the time of discharge.

Cardiac Surgery is Associated with Neuronal Damage

Background: Post-operative cognitive (POCD) decline is common in cardiac surgery and may be caused by neuronal damage. Plasma concentrations of the neuronal proteins tau and neurofilament light (NFL) are established biomarkers for acute neuronal injury. Our objective was to investigate if cardiac surgery is associated with neuronal injury reflected by changes in these plasma biomarkers. Methods: We performed a single centre case-control study of 25 patients undergoing cardiac surgery and 26 patients undergoing otolaryngeal surgery. The cohorts were sampled at several time-points before, during and after surgery and plasma concentrations of tau, NFL, and betaamyloid (Aβ40 and Aβ42) were measured. Findings: s Tau levels increased greatly by 1700% during cardiac surgery compared to baseline and normalized seven days post-surgery. NFL levels rose sharply seven days post-surgery (1100%). No changes were observed in patients undergoing otolaryngeal surgery. Furthermore, cardiac surgery patients on extracorporeal circulation (on-pump) had higher levels of tau (up to 2200%) and NFL (up to 430%) compared to cardiac surgery patients off-pump. However, the levels of tau and NFL were still significantly elevated in the cardiac surgery patients off-pump compared to the patients undergoing otolaryngeal surgery. Only minor fluctuations were observed for Aβ40 and Aβ42. Interpretation: Cardiac surgery, but not otolaryngeal surgery, is associated with massive release of neuronal-specific proteins indicating neuronal injury, which is aggravated by extracorporeal circulation. Thus, neuronal damage may contribute to the increased frequency of POCD in cardiac surgery. Analyses of NFL and tau may help to improve surgical procedures to minimize neuronal damage and possibly POCD. Funding Statement: This study was funded by grants no. N/ST/ZB/14/001/1128, 143-28594L, 133-28785L, N/ST/ZB/16/001/1128 from Medical University of Bialystok Clinical Hospital, Poland, the Swedish Research Council, Swedish State Support for Clinical Research, Alzheimer’s Association, the Knut and Alice Wallenberg Foundation, the Torsten Soderberg Foundation, the Alzheimer Foundation (Sweden), the European Research Council (grant number 681712), the Innovative Medicines Initiative Joint Undertaking under EMIF grant agreement n° 115372, resources of which are composed of financial contribution from the European Union's Seventh Framework Programme (FP7/2007-2013) and EFPIA companies. Declaration of Interests: PL received consultation and/or lecture honoraria from IBL International, Fujirebio Europe, AJ Roboscreen, and Roche. KB has served as a consultant or at advisory boards for Alzheon, BioArctic, Biogen, Eli Lilly, Fujirebio Europe, IBL International, Merck, Novartis, Pfizer and Roche Diagnostics. HZ has served on scientific advisory boards for Eli Lilly, Roche 17 Diagnostics, Wave, Samumed and CogRx, and has received travel support from Teva. None of the other authors declares competing interests. Ethics Approval Statement: The study was approved by the Ethical Committee, Medical University of Bialystok Clinical Hospital, Poland. All patients gave written informed consent.

Does laparoscopic colorectal surgery result in short and long term post-operative cognitive decline (POCD)? (Preprint)

Does laparoscopic colorectal surgery result in short and long term post-operative cognitive decline (POCD)? (Preprint)

Perioperative Cardiovascular Evaluation of Patients Oxygen Balance and Tissue Metabolic Score (TMS)

During the perioperative period of cardiovascular surgeries an imbalance between oxygen supply and demand may lead to postoperative cognitive decline that may affect about 20% of the operated patients.

Dexmedetomidine and intravenous acetaminophen for the prevention of postoperative delirium following cardiac surgery (DEXACET trial): protocol for a prospective randomized controlled trial

BackgroundPostoperative delirium is common in elderly cardiac surgery patients. It is multifactorial and is influenced by the patient’s baseline status and the nature of the medical and surgical interventions that the patient receives. Some of these factors are potentially modifiable, including postoperative sedation and analgesia protocols. This study has been designed to evaluate the effectiveness of postoperative intravenous acetaminophen in conjunction with either dexmedetomidine or propofol in decreasing the incidence of delirium.MethodsThis is a prospective, randomized, placebo-controlled, double-blinded, factorial trial that includes patients who are at least 60 years old and who are undergoing cardiac surgeries involving cardiopulmonary bypass, including coronary artery bypass graft (CABG) and combined CABG/valve surgeries. Patients are randomly assigned to receive one of four postoperative analgesic-sedation regimens: (1) acetaminophen and dexmedetomidine, (2) acetaminophen and propofol, (3) dexmedetomidine and placebo, or (4) propofol and placebo. The primary outcome, incidence of delirium, will be assessed with the Confusion Assessment Method (CAM or CAM-ICU). The secondary outcome, postoperative cognitive decline, will be assessed with the Montreal Cognitive Assessment. Additional secondary outcomes, including duration of delirium, postoperative analgesic requirement, length of stay, and incidence of adverse events, will also be reported. Data will be analyzed in 120 randomly assigned patients who received at least one dose of the study medication(s) on a modified intention-to-treat basis.DiscussionThis study has been approved by the institutional review board at Beth Israel Deaconess Medical Center, and the trial is currently recruiting. This study will systematically examine the implications of modification in postoperative sedative/analgesic protocols after cardiac surgery, specifically for short- and long-term cognitive outcomes. Any positive outcomes from this study could direct simple yet effective practice changes aimed to reduce morbidity.Trial registrationClinicalTrials.gov Identifier: NCT02546765, registered January 13, 2015.

Individual cognitive change after DBS-surgery in Parkinson's disease patients using Reliable Change Index Methodology.

SummaryLong-term therapy of Parkinson’s disease (PD) with levodopa (L-DOPA) is associated with a high risk of developing motor fluctuations and dyskinesia. Deep brain stimulation (DBS) in PD patients of the subthalamic nucleus can improve these motor complications. Although the positive effect on motor symptoms has been proven, postoperative cognitive decline has been documented. To tackle the impact of PD-DBS on cognition, 18 DBS patients were compared to 25 best medically treated Parkinson’s patients, 24 Mild Cognitive Impairment (MCI) patients and 12 healthy controls using the Neuropsychological Test Battery Vienna-long (NTBV-long) for cognitive outcome 12 months after first examination. Reliable change index methodology was used. Overall, there was cognitive change in individual patients, but the change was very heterogeneous with gains and losses. Further research is needed to identify the mechanisms that lead to improvement or deterioration of cognitive functions in individual cases.

The Beneficial Effects of Cognitive Training With Simple Calculation and Reading Aloud (SCRA) in the Elderly Postoperative Population: A Pilot Randomized Controlled Trial.

Background: There has been little research conducted regarding cognitive treatments for the elderly postsurgical population. Patients aged ≥60 years have an increased risk of postoperative cognitive decline, a condition in which cognitive functions are negatively affected. This cognitive decline can lead to a decline in quality of life. In order to maintain a high quality of life, the elderly postsurgical population may benefit from treatment to maintain and/or improve their cognitive functions. This pilot study investigates the effect of simple calculation and reading aloud (SCRA) cognitive training in elderly Japanese postsurgical patients.Methods: Elderly patients undergoing non-cardiovascular thoracic surgery under general anesthesia were recruited (n = 12). Subjects were randomly divided into two groups—one that receives 12 weeks of SCRA intervention, and a waitlisted control group. Before and after the intervention, we measured cognitive function [Mini-Mental Status Exam-Japanese (MMSE-J), Frontal Assessment Battery (FAB), computerized Cogstate Brief Battery (CBB)] and emotional state [General Health Questionnaire-12 (GHQ-12), Geriatric Depression Scale (GDS), Quality of Life Scale-5 (QOL-5)].Results: Group difference analyses using ANCOVA with permutation test showed that the intervention SCRA group had a significant improvement in FAB motor programming sub-score, GDS, and QOL-5 compared to the control group. Within-group analyses using Wilcoxon signed-rank test to compare baseline and follow-up showed that the SCRA intervention group total FAB scores, FAB motor programming sub-scores, and QOL-5 scores were significantly improved.Discussion: This pilot study showed that there are important implications for the beneficial effects of SCRA intervention on cognitive function and emotional state in the postoperative elderly population; however, further investigations are necessary to reach any conclusions.Trial registration: This study was registered with the University Hospital Medical Information Network (UMIN) Clinical Trial Registry (UMIN000019832).

Dexmedetomidine promotes the recovery of neurogenesis in aged mouse with postoperative cognitive dysfunction

Recently, growing evidence has demonstrated Dexmedetomidine (Dex) a promising intervene preventing postoperative cognitive decline (POCD) following surgery, which is associated with neuroinflammation leading to neuronal apoptosis and deregulated neurogenesis. Previous studies suggested the anti-inflammation and anti-neuroapoptosis action of Dex. Therefore we hypothesize the promoting neurogenesis of Dex linked to stimulating BDNF and subsequent p-MPAK production in a rat model of POCD. In the present study, the POCD animal model was established by performing an exploratory laparotomy under isoflurane anaesthesia in old rats, utilizing which Dex response is confirmed by behavioural tests. Inflammatory biomarkers as IL-1β and TNF-α, mature neuron percentage measured by doublecortin staining (DCX), promoting factors as brain derived growth factor (BDNF), phosphorylated cAMP response element binding protein (CREB) and proteins of kinase A (PKA), MAPK production as p-P38-MAPK protein express were measured. Herein, we showed that surgery reduced DCX-positive neurons and expression of BDNF representing neurogenesis profoundly. As expected, Dex rescued the associated cognitive impairment and inflammatory changes, as well as up-regulated expression of BDNF, PKA, p-CREB/CREB and following p-P38-MAPK regulation. Our results confirmed the protective Dex response and indicated the proneurogenesis role of it as well, suggesting the mechanism of beneficial effects of Dex to prevent POCD.

Fish Oil Supplementation Does Not Affect Cognitive Outcomes in Cardiac Surgery Patients in the Omega-3 Fatty Acids for Prevention of Post-Operative Atrial Fibrillation (OPERA) Trial

Cognitive decline has been reported following cardiac surgery, leading to great interest in interventions to minimize its occurrence. Long-chain n-3 (ω-3) polyunsaturated fatty acids (PUFAs) have been associated with less cognitive decline in observational studies, yet no trials have tested the effects of n-3 PUFAs on cognitive decline after surgery. We sought to determine whether perioperative n-3 PUFA supplementation reduces postoperative cognitive decline in patients postcardiac surgery. The study comprised a randomized, double-blind, placebo-controlled, multicenter, clinical trial conducted on cardiac surgery recipients at 9 tertiary care medical centers across the United States. Patients were randomly assigned to receive fish oil (1-g capsules containing ≥840 mg n-3 PUFAs as ethyl esters) or placebo, with preoperative loading of 8-10 g over 2-5 d followed postoperatively by 2 g/d until hospital discharge or postoperative day 10, whichever came first. Global cognition was assessed using in-person testing over 30 d with the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) (primary outcome), Mini-Mental State Exam (secondary outcome), and Trails A and B (secondary outcome) tests. All end points were prespecified. Statistical methods were employed, including descriptive statistics, logistic regression, and various sensitivity analyses. A total of 320 US patients were enrolled in the Omega-3 Fatty Acids for Prevention of Post-Operative Atrial Fibrillation (OPERA) Cognitive Trial (OCT), a substudy of OPERA. The median age was 62 y (IQR 53, 70 y). No differences in global cognition were observed between placebo and fish oil groups at day 30 (P = 0.32) for the primary outcome, a composite neuropsychological RBANS score. The population demonstrated resolution of initial 4-d cognitive decline back to baseline function by 30 d on the RBANS. Perioperative supplementation with n-3 PUFAs in cardiac surgical patients did not influence cognition ≤30 d after discharge. Modern anesthetic, surgical, and postoperative care may be mitigating previously observed long-term declines in cognitive function following cardiac surgery. This trial was registered at clinicaltrials.gov as NCT00970489.

A Prospective Cohort Evaluation of the Cortisol Response to Cardiac Surgery with Occurrence of Early Postoperative Cognitive Decline.

BackgroundA recent study reported that patients with higher cortisol levels on the 1st postoperative morning after cardiac surgery exhibited an increased risk of early postoperative cognitive decline (POCD). Therefore, we conducted the current study to gain further insight into the stress response to a surgical procedure as a potential risk factor for early POCD after cardiac surgery.Material/MethodsThis prospective cohort study enrolled 125 patients undergoing elective cardiac surgery with or without cardiopulmonary bypass (CPB). Patient serum cortisol levels were determined 1 day before surgery (at 08: 00) and on the 1st (at 08: 00, 16: 00 and 24: 00), 3rd (at 08: 00), and 5th (at 08: 00) postoperative days. A battery of 9 neuropsychological tests were used to assess the participants 2 days before the surgical procedure and on the 6th postoperative day. POCD was defined as a decrease in performance of 1 SD or greater between the postoperative and preoperative z scores on at least 1 neuropsychological test. A mixed-design ANOVA was used to determine the correlations of the perioperative cortisol levels with the occurrence of POCD and with the surgical technique performed.ResultsMixed-design ANOVA showed no statistically significant differences in the cortisol levels between non-POCD and POCD patients (F=0.52, P=0.690) or between patients with and without CPB (F=2.02, P=0.103) at the 6 perioperative time points.ConclusionsThe occurrence of early POCD and the use of CPB were not associated with significantly higher cortisol levels in the repeated measurement design.

An Adverse Event Analysis: Inadvertent Exsanguination Following Left Ventricular Assist Device Implantation in a Child

Neurologic deficit subsequent to cardiac surgery remains a cause of postoperative morbidity and mortality. Although myriad risk factors for postoperative cognitive decline have been identified, their individual influence remains undefined. Although less emphasis is now placed on the heart lung machine as the major source of postoperative cognitive decline, the conduct of cardiopulmonary bypass and, in particular, the management of the bypass circuit remain key to patient safety. We present a case of inadvertent intraoperative exsanguination of a patient following open heart surgery for implantation of a left ventricular assist device. The patient suffered significant neurologic damage. However, the nature of the patient's cerebral injury indicated thromboembolism as the likely cause, rather than hypoxic-ischemic injury caused by hypoperfusion. Subsequent investigation of the incident identified several possible sources and potential causes of embolization to the brain that could not rule out the exsanguination event as a contributing factor.