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Background The impact of general anesthesia on cognitive impairment is controversial and complex. A large body of evidence supports the association between exposure to surgery under general anesthesia and development of delayed neurocognitive recovery in a subset of patients. Existing literature continues to debate whether these short-term effects on cognition can be attributed to anesthetic agents themselves, or whether other variables are causative of the observed changes in cognition. Furthermore, there is conflicting data on the relationship between anesthesia exposure and the development of long-term neurocognitive disorders, or development of incident dementia in the patient population with normal preoperative cognitive function. Patients with pre-existing cognitive impairment present a unique set of anesthetic considerations, including potential medication interactions, challenges with cooperation during assessment and non-general anesthesia techniques, and the possibility that pre-existing cognitive impairment may impart a susceptibility to further cognitive dysfunction. Main body This review highlights landmark and recent studies in the field, and explores potential mechanisms involved in perioperative cognitive disorders (also known as postoperative cognitive dysfunction, POCD). Specifically, we will review clinical and preclinical evidence which implicates alterations to tau protein, inflammation, calcium dysregulation, and mitochondrial dysfunction. As our population ages and the prevalence of Alzheimer’s disease and other forms of dementia continues to increase, we require a greater understanding of potential modifiable factors that impact perioperative cognitive impairment. Conclusions Future research should aim to further characterize the associated risk factors and determine whether certain anesthetic approaches or other interventions may lower the potential risk which may be conferred by anesthesia and/or surgery in susceptible individuals.

Background Anxiety during the preoperative period is the most common problem with a number of postoperative complications such as an increase in postoperative pain, delay of healing and prolong the hospital stay. Further, patients with a high level of preoperative anxiety require higher doses of anesthetic agents and recover poorly. Despite its serious health complications, its magnitude and associated factors have been poorly explored in Ethiopia particularly in the selected study areas. Objective To assess preoperative anxiety and associated factors among adult surgical patients in Debre Markos and Felege Hiwot Referral Hospitals, Northwest Ethiopia. Method An institution based cross-sectional study was conducted on 353 patients scheduled for surgery using a systematic random sampling technique. The data were collected using the state version of the state-trait anxiety inventory scale. All collected data were entered into Epi-Data version 3.1 and analysis was done by using SPSS version 20 software. Binary logistic regression was performed to assess the effect of independent variables on the dependent variable. A p -value <  0.05 was considered as statistically significant. Results Overall, 61% (95%CI (55.5–65.7)) patients had significant high level of preoperative anxiety. The most common reported factor responsible for preoperative anxiety was fear of complications 187(52.4%). There was a statistically significant high level of pre-operative anxiety among female patients [AOR 2.19 (95%CI (1.29–3.71))] and patients who lack preoperative information [AOR 2.03(95%CI (1.22–3.39))]. Conclusion The prevalence of preoperative anxiety was high. The level of preoperative anxiety significantly associated with sex, preoperative information provision, and previous surgical experience. Preoperative psychosocial assessment should be incorporated into a routine nursing practice and every patient should be provided with preoperative information before surgery.

Background Frailty is a frequent and underdiagnosed functional syndrome involving reduced physiological reserves and an increased vulnerability against stressors, with severe individual and socioeconomic consequences. A routine frailty assessment was implemented at our preoperative anaesthesia clinic to identify patients at risk. Objective This study examines the relationship between frailty status and the incidence of in-hospital postoperative complications in elderly surgical patients across several surgical disciplines. Design Retrospective observational analysis. Setting Single center, major tertiary care university hospital. Data collection took place between June 2016 and March 2017. Patients Patients 65 years old or older were evaluated for frailty using Fried’s 5-point frailty assessment prior to elective non-cardiac surgery. Patients were classified into non-frail (0 criteria, reference group), pre-frail (1–2 positive criteria) and frail (3–5 positive criteria) groups. Main outcome measures The incidence of postoperative complications was assessed until discharge from the hospital, using the roster from the National VA Surgical Quality Improvement Program. Propensity score matching and logistic regression analysis were performed. Results From 1186 elderly patients, 46.9% were classified as pre-frail ( n  = 556), and 11.4% as frail ( n  = 135). The rate of complications were significantly higher in the pre-frail (34.7%) and frail groups (47.4%), as compared to the non-frail group (27.5%). Similarly, length of stay (non-frail: 5.0 [3.0;7.0], pre-frail: 7.0 [3.0;9.0], frail 8.0 [4.5;12.0]; p  < 0.001) and discharges to care facilities (non-frail:1.6%, pre-frail: 7.4%, frail: 17.8%); p < 0.001) were significantly associated with frailty status. After propensity score matching and logistic regression analysis, the risk for developing postoperative complications was approximately two-fold for pre-frail (OR 1.78; 95% CI 1.04–3.05) and frail (OR 2.08; 95% CI 1.21–3.60) patients. Conclusions The preoperative frailty assessment of elderly patients identified pre-frail and frail subgroups to have the highest rate of postoperative complications, regardless of age, surgical discipline, and surgical risk. Significantly increased length of hospitalisation and discharges to care facilities were also observed. Implementation of routine frailty assessments appear to be an effective tool in identifying patients with increased risk. Now future studies are needed to investigate whether patients benefit from optimization of patient counselling, process planning, and risk reduction protocols based on the application of risk stratification.

Background Postoperative delirium (POD) occurs frequently after cardiac surgery and is associated with increased morbidity and mortality. We analysed whether perioperative bilateral BIS monitoring may detect abnormalities before the onset of POD in cardiac surgery patients. Methods In a prospective observational study, 81 patients undergoing cardiac surgery were included. Bilateral Bispectral Index (BIS)-monitoring was applied during the pre-, intra- and postoperative period, and BIS, EEG Asymmetry (ASYM), and Burst Suppression Ratio (BSR) were recorded. POD was diagnosed according to the Confusion Assessment Method for the Intensive Care Unit, and patients were divided into a delirium and non-delirium group. Results POD was detected in 26 patients (32%). A trend towards a lower ASYM was observed in the delirium group as compared to the non-delirium group on the preoperative day (ASYM = 48.2 ± 3.6% versus 50.0 ± 4.7%, mean ± sd, p = 0.087) as well as before induction of anaesthesia, with oral midazolam anxiolysis (median ASYM = 49.5%, IQR [47.4;51.5] versus 50.6%, IQR [49.1;54.2], p = 0.081). Delirious patients remained significantly (p = 0.018) longer in a burst suppression state intraoperatively (107 minutes, IQR [47;170] versus 44 minutes, IQR [11;120]) than non-delirious patients. Receiver operating analysis revealed burst suppression duration (area under the curve = 0.73, p = 0.001) and BSR (AUC = 0.68, p = 0.009) as predictors of POD. Conclusions Intraoperative assessment of BSR may identify patients at risk of POD and should be investigated in further studies. So far it remains unknown whether there is a causal relationship or rather an association between intraoperative burst suppression and the development of POD. Trial registration clinicaltrials.gov NCT01048775

Background It is unclear if anaesthesia maintenance with propofol is advantageous or beneficial over inhalational agents. This study is intended to compare the effects of propofol vs. inhalational agents in maintaining general anaesthesia on patient-relevant outcomes and patient satisfaction. Methods Studies were identified by electronic database searches in PubMed™, EMBASE™ and the Cochrane™ library between 01/01/1985 and 01/08/2016. Randomized controlled trials (RCTs) of peer-reviewed journals were studied. Of 6688 studies identified, 229 RCTs were included with a total of 20,991 patients. Quality control, assessment of risk of bias, meta-bias, meta-regression and certainty in evidence were performed according to Cochrane. Common estimates were derived from fixed or random-effects models depending on the presence of heterogeneity. Post-operative nausea and vomiting (PONV) was the primary outcome. Post-operative pain, emergence agitation, time to recovery, hospital length of stay, post-anaesthetic shivering and haemodynamic instability were considered key secondary outcomes. Results The risk for PONV was lower with propofol than with inhalational agents (relative risk (RR) 0.61 [0.53, 0.69], p  < 0.00001). Additionally, pain score after extubation and time in the post-operative anaesthesia care unit (PACU) were reduced with propofol (mean difference (MD) − 0.51 [− 0.81, − 0.20], p  = 0.001; MD − 2.91 min [− 5.47, − 0.35], p  = 0.03). In turn, time to respiratory recovery and tracheal extubation were longer with propofol than with inhalational agents (MD 0.82 min [0.20, 1.45], p  = 0.01; MD 0.70 min [0.03, 1.38], p  = 0.04, respectively). Notably, patient satisfaction, as reported by the number of satisfied patients and scores, was higher with propofol (RR 1.06 [1.01, 1.10], p  = 0.02; MD 0.13 [0.00, 0.26], p  = 0.05). Secondary analyses supported the primary results. Conclusions Based on the present meta-analysis there are several advantages of anaesthesia maintenance with propofol over inhalational agents. While these benefits result in an increased patient satisfaction, the clinical and economic relevance of these findings still need to be addressed in adequately powered prospective clinical trials.

Background The efficacy of tranexamic acid (TXA) to reduce perioperative blood loss and allogeneic blood transfusion in cardiac surgeries has been proved in previous studies, but its adverse effects especially seizure has always been a problem of concern. This meta-analysis aims to provide information on the optimal dosage and delivery method which is effective with the least adverse outcomes. Methods We searched Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE for all relevant articles published before 2018/12/31. Inclusion criteria were adult patients undergoing elective heart surgeries, and only randomized control trials comparing TXA with placebo were considered. Two authors independently assessed trial quality and extracted relevant data. Results We included 49 studies with 10,591 patients into analysis. TXA significantly reduced transfusion rate (RR 0.71, 95% CI 0.65 to 0.78, P<0.00001). The overall transfusion rate was 35%(1573/4477) for patients using TXA and 49%(2190/4408) for patients in the control group. Peri-operative blood loss (MD − 246.98 ml, 95% CI − 287.89 to − 206.06 ml, P<0.00001) and re-operation rate (RR 0.62, 95% CI 0.49 to 0.79, P<0.0001) were also reduced significantly. TXA usage did not increase risk of mortality, myocardial infarction, stroke, pulmonary embolism and renal dysfunction, but was associated with a significantly increase in seizure attack (RR 3.21, 95% CI 1.04 to 9.90, P  = 0.04).The overall rate of seizure attack was 0.62%(21/3378) for patients using TXA and 0.15%(5/3406) for patients in the control group. In subgroup analysis, TXA was effective for both on-pump and off-pump surgeries. Topical application didn’t reduce the need for transfusion requirement, while intravenous delivery no matter as bolus injection alone or bolus plus continuous infusion were effective. Intravenous high-dose TXA didn’t further decrease transfusion rate compared with low-dose regimen, and increased the risk of seizure by 4.83 times. No patients in the low-dose group had seizure attack. Conclusions TXA was effective in reducing transfusion requirement in all kinds of cardiac surgeries. Low-dose intravenous infusion was the most preferable delivery method which was as effective as high-dose regimen in reducing transfusion rate without increasing the risk of seizure.

Background Hip fracture is a trauma of the elderly. The worldwide number of patients in need of surgery after hip fracture will increase in the coming years. The 30-day mortality ranges between 4 and 14%. Patients’ outcome may be improved by anaesthesia technique (general vs. neuraxial anaesthesia). There is a dearth of evidence from randomised studies regarding to the optimal anaesthesia technique. However, several large non-randomised studies addressing this question have been published from the onset of 2010. Methods To compare the 30-day mortality rate, in-hospital mortality rate and length of hospital stay after neuraxial (epidural/spinal) or general anaesthesia in hip fracture patients (≥ 18 years old) we prepared a systematic review and meta-analysis. A systematic search for appropriate retrospective observational and prospective randomised studies in Embase and PubMed databases was performed in the time-period from 01.01.2010 to 21.11.2016. Additionally a forward searching in google scholar, a level one reference list searching and a formal searching of trial registries was performed. Results Twenty retrospective observational and three prospective randomised controlled studies were included. There was no difference in the 30-day mortality [OR 0.99; 95% CI (0.94 to 1.04), p  = 0.60] between the general and the neuraxial anaesthesia group. The in-hospital mortality [OR 0.85; 95% CI (0.76 to 0.95), p  = 0.004] and the length of hospital stay were significantly shorter in the neuraxial anaesthesia group [MD -0.26; 95% CI (−0.36 to −0.17); p  < 0.00001]. Conclusion Neuraxial anaesthesia is associated with a reduced in-hospital mortality and length of hospitalisation. However, type of anaesthesia did not influence the 30-day mortality. In future there is a need for large randomised studies to examine the association between the type of anaesthesia, post-operative complications and mortality.

Background Surgery-induced neuroinflammation plays an important role in postoperative cognitive dysfunction (POCD). Gut microbiota is a key regulator of neurological inflammation. Nurturing with prebiotics is an effective microbiota manipulation that can regulate host immunity and cognition. The aim of the present study was to test whether administration of the prebiotic Bimuno® (galactooligosaccharide (B-GOS) mixture) could ameliorate POCD and attenuate surgery-induced neuroinflammation through the microbiota-brain-axis. Methods Adult rats undergoing abdominal surgery under isoflurane anesthesia were fed with water or prebiotic B-GOS supplementation (15 g/L) for 3 weeks. Novel objective recognition task was employed for testing cognitive changes on postoperative day three. Expression of microglial marker Iba-1 in the hippocampus was assessed by immunohistochemical staining. Expression levels of phenotypic gene markers of activated microglia (M1: iNOS, CD68, CD32; M2: Ym1, CD206, and SOCS3) in hippocampus were determined by quantitative polymerase chain reaction (qPCR). Inflammatory cytokines in the hippocampus were assessed using enzyme-linked immunosorbent assay (ELISA). Feces were collected for microbial community analysis. Results Rats exhibited an impairment in novel objective recognition 3 days after surgery compared with control rats ( P  < .01). In the hippocampus, expressions of Iba-1 and M1 markers of surgical rats were significantly upregulated. Similarly, expressions of SOCS3 and CD206 in the hippocampus were upregulated. Additionally, increasing levels of IL-6 and IL-4 were evident in the hippocampus. Administration of B-GOS significantly alleviated cognitive decline induced by surgery ( P  < .01). B-GOS-fed rats showed a significantly downregulated activation of microglia and expressions of M1-related genes and SOCS3 and IL-6. While there was no significant difference in expressions of CD206 and Ym1 and IL-4 between the surgical and B-GOS groups. Analysis of gut microbiome found that administration of B-GOS induced a significant change beta diversity of the gut microbiome and proliferation of Bifidobacterium and other potentially anti-inflammatory microbes. Conclusions Administration of B-GOS has a beneficial effect on regulating neuroinflammatory and cognitive impairment in a rat model of abdominal surgery and was associated with the manipulation of gut microbiota.

Randomized controlled trials (RCTs) are considered the gold standard for clinical research, thus having a high impact on clinical guidelines and our daily patients’ care. However, various treatment strategies which we consider “evidence based” have never been subject to a prospective RCT, as we would rate it unethical to withheld an established treatment to individuals in an placebo controlled trial. In a recent BMC Anesthesiology publication, Trentino et al. analyzed the usefulness of observational studies in assessing benefit and risk of different transfusion strategies. The authors nicely reviewed and summarized similarities and differences, advantages and limitations, between different study types frequently used in transfusion medicine. In this interesting article, the authors conclude, that ‘when comparing the results of observational studies with RCTs assessing transfusion outcomes, it is important that one consider not only the study method, but also the key elements of the study design’. Thus, in this commentary we now discuss the pro’s and con’s of different study types, even irrespective of transfusion medicine.

Background Perioperative neurocognitive disorders (PND) is a common postoperative complication including postoperative delirium (POD), postoperative cognitive decline (POCD) or delayed neurocognitive recovery. It is still controversial whether the use of intraoperative cerebral function monitoring can decrease the incidence of PND. The purpose of this study was to evaluate the effects of different cerebral function monitoring (electroencephalography (EEG) and regional cerebral oxygen saturation (rSO 2 ) monitoring) on PND based on the data from randomized controlled trials (RCTs). Methods The electronic databases of Ovid MEDLINE, PubMed, EMBASE, Cochrane Library database were systematically searched using the indicated keywords from their inception to April 2020. The odds ratio (OR) or mean difference (MD) with 95% confidence interval (CI) were employed to analyze the data. Heterogeneity across analyzed studies was assessed with chi-square test and I 2 test. Results Twenty two RCTs with 6356 patients were included in the final analysis. Data from 12 studies including 4976 patients were analyzed to assess the association between the EEG-guided anesthesia and PND. The results showed that EEG-guided anesthesia could reduce the incidence of POD in patients undergoing non-cardiac surgery (OR: 0.73; 95% CI: 0.57–0.95; P  = 0.02), but had no effect on patients undergoing cardiac surgery (OR: 0.44; 95% CI: 0.05–3.54; P  = 0.44). The use of intraoperative EEG monitoring reduced the incidence of POCD up to 3 months after the surgery (OR: 0.69; 95% CI: 0.49–0.96; P  = 0.03), but the incidence of early POCD remained unaffected (OR: 0.61; 95% CI: 0.35–1.07; P  = 0.09). The remaining 10 studies compared the effect of rSO 2 monitoring to routine care in a total of 1380 participants on the incidence of PND. The results indicated that intraoperative monitoring of rSO 2 could reduce the incidence of POCD (OR 0.53, 95% CI 0.39–0.73; P  < 0.0001), whereas no significant difference was found regarding the incidence of POD (OR: 0.74; 95% CI: 0.48–1.14; P  = 0.17). Conclusions The findings in the present study indicated that intraoperative use of EEG or/and rSO 2 monitor could decrease the risk of PND. Trial registration PROSPREO registration number: CRD42019130512 .