1、With increase of the number of elderly surgical patients(65yr 26.3%of 12379 surgical patients in Renji Hospital,2019),more postoperative CNS complications(cerebral infarction,hemorrhage,and mental disorder)have been reported.Postoperative CNS complications will arise incidence of the other system co
2、mplications,delay the recovery time,increase mortality ratio,stay longer time in hospital and increase medical cost.Sometime,it is the early signs of other postoperative complications like infection or cardiovascular diseases.Stroke:Cerebral hemorrhage,cerebral infarction High morbidity in elderly(5
3、1-65yr)More patients with preoperative cerebral infarction High risk with postoperative cerebral infarction 9 time mortality with cerebral infarction and hemorrhage Always combined with hypertension,coronary heart diseases or DM Pay more attention before,during and after operation,take some pre-trea
4、tmentl1.Pre-existed cerebrocardial diseasesl2.Thrombus or gas embolus caused by operation,anesthesia or drugsl3.fluctuation of perioperative blood pressure,hypertensionl4.long time hypotensionl5.keep in bed,less moving or hyper-coagulationlF,80yr,alimentary perforation,acute penetrative peritonitis,
5、toxic shock.Cerebral infarction 1yr before.lRadical resection of right colon carcinoma under general anesthesia.lGreat changes of perioperative blood pressure,BP:70/50mmHg，long duration of hypotensionlCarried to SICU,supply enough solution and maintain the balance of electrolyte and pHlStable life s
6、igns,but faint consciousness with opening eyes after calling,bad movement of left bodylLarge area cerebral infarction diagnosed by CT 3days laterlSomnolence 6hr after end of operation,mis-diagnosed as later resuscitationlLarge area cerebral infarction was found with CT scanlExtubation the next day i
7、n SICUlF,65yr,BP 150/95mmHg,cholecystectomy and drainage of common bile duct under general anesthesialM,5yr,fracture of femoral necklReplacement of femoral head under spinal-epidural anestheisalBP 150/90mmHg(preoperation);BPmin 80/60mmHg,treated with ephedrine;BP 105/70mmHg(end of operation)lPCIA af
8、ter operationlStop PCIA when find patients with bad reaction at operation night,BP 106/80mmHglCerebral infarction by CT,BP 105/80mmHglCardiac infarction,shock and respiratory failure at 3dlDie at 5dlLater resuscitation in elderly after operation should be paid more attention.Physical and radial exam
9、 should be taken if the patients with nerve system signs like hemiplegia or movinglKeep stable blood pressure since hypertension will cause hemorrhage and hypotension will cause infarctionlcerebral infarction was found more after endarterectomylHyper-coagulation station in elderly which cause the em
10、bolus formation that results in cerebral infarctionlPay more attention to the aged,cerebral diseases,hypertension for reduce the morbidity of cerebral infarction：Avoid fluctuation of BPAvoid fluctuation of BPVessels dilation drugs like Fu Fang Dan Vessels dilation drugs like Fu Fang Dan Shen,Nimodip
11、ine,etc.Shen,Nimodipine,etc.If necessary,use aspirin,low dose If necessary,use aspirin,low dose heparinheparin postoperative acute confusional state postoperative delirium postoperative cognitive dysfunction postoperative acute brain failure postoperative organic brain syndrome postoperative toxic p
12、sychosisA syndrome of reversal fluctuated acute mental disorder which happens several days after operation.It concludes consciousness,cognition,direction,feeling,mental action,etc.II.Postoperative mental state changesl10 times in the elderly with cardiovascular surgeryl0.02-0.07%in patients without
13、neurosurgery or cardiovascular surgery l4.8%in 1980s，1.5-3.0%in 1990sSurgical types Morbidity（）（）Aortic aneurysm 46Open heart surgery 777Hepatic or lung transplantation 50Great orthopedics surgery 1341Upper abdominal surgery 717Morbidity of postoperative mental disorderSurgery type Cases Mental morb
14、idity（）（）disorderGeneral surgeryGeneral surgery 221 34 15.38OrthopedicsOrthopedics 17 2 11.76Urinary surgeryUrinary surgery 14 1 7.14Lung surgeryLung surgery 58 8 13.79Open heart surgery 70 23 32.86Total 380 68 17.89SICU(2019,11-2019,3)380 elderly postoperative patients not including neurosurgery,he
15、patocirrhosis,aged dementia in Renji Hospital Related factorsX2PAge0.24560.6202Gender0.83150.3618General surgery0.57950.4465Orthopedics surgery0.22260.6371Urinary surgery0.39680.5288Lung surgery0.07830.7796CABG 17.4254 0.0001With hypertention4.9644 0.0259With Diabetes mellitus6.7109 0.0096Perioperit
16、ive hypotention or hypoxemia 35.3916 0.0001Postoperative glycemia0.21540.6426Related factors analysisType Case Mental disorder morbidity(%)Coronary bypass 201 29 14.3*Valve replacement 104 4 3.85Total 305 33 10.82*Compared to VR group P0.05Multi-centers study by Renji Hospital and other three hospit
17、als in PudongHospitalCasePOCDmorbidity Renji32721.9%Pudong Peoples38923.7%7th Peoples401435.0%Gongli251040.0%Total1354029.6%5 patients with postoperative delirium(7%)Morbidity of POCDRelated factors NumberPOCDmorbidityGender Male672131.3%Female681927.9%Age656940820.0%7074361027.8%75592237.3%Related
18、factors No POCDmorbidity Surgerytype Abdominal surgery712338.0%Orthopedics surgery28725.0%Urinary surgery14321.4%Genecology surgery9333.3%Others13430.8%Duration of perioperative hypotension10min11763.6%10min231147.8%No1012221.8%Anesthesia Spinal36719.4%General842833.3%Epidural+General15533.3%Related
19、 factors NoPOCD morbidity Anesthesia duration 2h701724.3%2h4h431432.6%4h22940.9%Perioperative hemorrhage 500ml962324.0%500ml391743.6%EducationIlliterate411331.7%Elementary 471429.8%Junior 27933.3%Senior or high level20420.0%LOGISTIC AnalysisRisksSCOREPRisksSCOREPGender0.1340.715Hypertension1.2700.26
20、0ASA0.6520.132Education1.0440.307Body weight0.3650.55Abesthesia types1.7911.181Age4.1440.042*Anesthesia duration3.1570.076Smoking0.4030.526Operation types1.0150.314Drinking0.2650.407Perioperative hemorrhage3.2800.070DM0.0560.813Perioperative hypotension duration4.3610.037*Probability equation：P=e2.4
21、31A+0.094B+5.819/(1+e2.431A+0.094B+5.819)P=POCD morbidity,A=Perioperative hypotension duration,B=age Morbidity of POCD(8 countries,13 medical centers,1218 cases)Pediatric open heart surgery 2545Middle aged with non-cardiac surgery 19Elderly non-cardiac surgery(within one week postoperative)25.8%B.Et
22、iology 1.high aged 2-10 folds in elderly patients(65yr)compared to youth Seymour found the patients aged over 75 yr with 3 folds compared to the patients within 65-75 yr 2.Hypertension and DM High risk of POCD in elderly patients with preoperative DM or hypertension.which usually companied with cere
23、brocardial disease The metabolic disorder caused by DM,operation,hypotension,trauma and stress may induce brain damage3.Cerebrocardial diseases More morbidity of POCD in elderly patients with preoperative cardiac infarction and stroke.It may be related to the damage of cerebral vessels auto-regulati
24、on.Carotid stenosis is always combined with other cerebrocardial diseases which results in POCD when hypotension.4.Abuse of Alcohol or drugs Long time bibulosity or drug abuse like benzodiazepines or anticholinergics，which increase the aged POCD5.Operation and anesthesia CABG is with high morbidity
25、of POCD which may related to the bypass duration,low temperature,metabolism-blood matching,recovery time,gas embolusLarge orthopedics surgery is with high risk of POMD which caused by fat embolus.Anesthetics may affect CNS like anticholinergics,ketamine,etomidate,NO,halothaneIts the management not a
26、nesthesia type that influence the POCD6.Perioperative physical changes During operation：hypoxemia,hypotension,large blood loss,transfusion,over ventilation,low PaCO2,CABG,et Postoperation：hypoxemia,hypotension,infection,electrolyte disorder,low or high pH,malnutrition7.Mental factors and environment
27、over nervous or anxiety arouse POCDBad environment cause insomnia even trepidation,Wilson reported that the morbidity of POCD is-6 folds in ICU than in common wards8.GenesApoE participate the fat metabolism,cholesterin balance and growth and rehabilitation of nerve system,it even related to the plas
28、ticity of hippocampi and action of acetylcholine transfer enzymes.Its reported that ApoE is related to the POMD after CABGMutation of cholecystokinin(CCK)gene may related to the POMDC.Mechanism and PathologyPOCD may related to disturbance of the CNS,endocrine system and immunity systemMany factors c
29、ombined degeneration in elderly patients result in POCD Changes of CNS in aged peopleMorphologyBrain weightNeuron number Complex of dendirtesSynapse number astrocytemicrogliocyte PhysiologyBrain blood flow 1020%，but it matches the brain oxygen metablosmVessels auto-regulation may exist and reaction
30、to CO2 or hypoxemia is normalBiochemistryNeurotransmitters like DA、5HT、Ach、GABA changeCognitionReaction time prolongCognition procedure prolongadapt abilityShort memory 2.Brain damageNeuron-specific enolase(NSE）and S-100 protein may relate to glia damageIts reported that the NSE and S-100 increased
31、after CPB3.Abnormity of central nerve transmitters 5-HT and NE:study,sleeping,awake.The drop of its level may related to the POMDGlutamic（Glu）and GABA:Main exciting and inhibiting transmitters in brain Ach:notice,memory,sleeping.Anticholinergics may decrease it4.Abnormity of hypothalamus-pituitary-a
32、drenal cortex axis and immunityStress and trauma will cause the activation of hypothalamus-pituitary-adrenal cortex axis which increase the glucocorticoid level and release of inflammatory cells like IL-1,IL-2,IL-6,and-TNF.Neurotransmitters like Ach,5-HT and NE will be influenced then.D.Clinical sig
33、nsPOCD most occurs within 4d,especially in night.Major signs are abnormity of consciousness,cognition and mental action.Patients are always suffered with bad judging,less logistic and 70%with illusion or hallucinationClinical differentiation:Mania type Excitement of sympathetic nerve,alert to stimul
34、us and more movementDepression type Poor reaction to stimulus and timid activityMixed type fluctuated between the above two types E.diagnosis 1.Clinical signs and mental assessment tables Patients with mania type are easy recognized,but it is hard to distinguish the another type.The objective assess
35、ment methods will be helpful then.Most used as following:Confusion Assessment Method，（，（CAM）Intensive Care Delirium Screening Checklist2.CT and EEG（1）CT is important for distinguishing the hemorrhage,infarction or other organs disorder（2）EEG is helpful to diagnose the POMDRhythm of brain waves becom
36、es lower,especially the wave,it related to the damage level.Since such changes are also seen in the high aged or dementia people,the EEG should be read dynamically.3.laboratory Carbamide,glucose,electrolytes,hepatic function,artery gas analysis,cell account,germiculture,EKG,chest X-ray,etc.should be
37、 taken for excluding other diseasesF.Prevention 1.Enough preoperative preparation,including psychology comfort 2.Chose right operation types and anesthetics 3.Maintain suitable anesthesia depth,keep the circulation stable and supply enough oxygen 4.Careful postoperative monitoring,effective analgesi
38、a,prevent respiratory failure,avoid disturbance of pH and electrolytes,give vitamin,treatment of infection G.Treatment1.General oxygen inhaling,keep the stable circulation,treat the disturbance of pH and electrolytes,supply vitamin and amino acids2.drugs Droperidol,benzodiazepines,propofol,chlorprom
39、azine,etc.3.psychologypsychology comfort by relatives and communication will be good for the depressed patientslIII.Influence of anesthesia on memory functionMidazolam：activity of GABAA receptors,arouse antegrade amnesia,large dose with retrograde amnesia Ketamine：interdiction to NMDA receptors,inhi
40、bit neuron nicotine receptors.It damage the memory after abdominal injection in ratsPropofol：Reduce the number of GABA neurons,it is disbennifit growth of nerve system,damage the memory function in rats,low dose with antegrade amnesia,and high dose with retrograde amnesia Halothane：antegrade amnesia
41、，reinforce the memory of parry trainingEnflurane：reinforce the study of rats in 8 walls labyrinth *Nerve action affected for 5hr after halothane or enflurane inhaled for 3.5min *Nature fast waves and slow waves could be interrupted 24 hr after short duration of inhalationIsoflurane：reinforce the GAB
42、AA receptors，cause apoptosis of nerve cells when used alone or with midazolam and N2O in rats and affect the study memory and cognition,sometime with antegrade amnesia l POMD could happen in different aged patients,some of which become the chronic diseases.It influence patients resuscitation and dai
43、ly life.The exact causes are still unknown,but the anesthetics have their own effects.lMost studies about POMD are still based on animal labs.The further study of mechanism of general anesthesia could enhance the understanding of POMD.Anesthetics like Ach,NE,Dopamine,etc.affect the release of neuro-
44、trasmitters and damage potential memory.But the effects of anesthetics on study memory are uncertain.ASA NEWSLETTER (May 2019)The elderly patients are with high morbidity of POMD that affects the prognosis greatly and be always ignored by doctors.We should pay attentions to its risk factors and clin
45、ical signs as more and more elderly patients were undergone operations now.Improvement the anesthesia level,effectively respiratory and circulation management,treatment of POMD will benefit to the recovery of elderly patients,reduce the postoperative complications,decrease the medical cost,enhance the life qualitySICU,Renji Hospital
