Anesthesia & POCD

are we the culprit?

 Ratna F. Soenarto
Dept. of Anesthesiology & Intensive Care
Faculty of Medicine, Universitas Indonesia - Cipto Mangunkusumo Hospital
Jakarta

Jakarta Perioperative Meeting

July, 6, 2019
 CONCENT
RATION

VISUO
SPATIAL
ATTENTIO
N MEMORY

LANGUAGE
EXECUTIVE

COGNITIVE FUNCTION
= mental processes required for everyday living.

Dafydd Gwilym Lloyd DG, Ma D, Vizcaychipi MP. Cognitive decline after anaesthesia and critical care. Continuing
Education in Anaesthesia Critical Care & Pain. 2012;12(3):105–9
 MILD COGNITIVE
DYFUNCTION

DEMENTIA
A syndr in disturbance of
intellectual ability

Johansson M. Cognitive impairment and its consequences in everyday. [dissertation]. Sweden: Linköping University; 2015
• Normal/demented person
• Decline in cognitive measurement, or
• Subject’s self report
• Daily activity is normal/unsignificantly
dusturbed

10-20% in >65 y.o

MILD COGNITIVE
DYFUNCTION within 5 yr

AGEing
DEMENTIA
A syndr in disturbance of
intellectual ability

Johansson M. Cognitive impairment and its consequences in everyday. [dissertation]. Sweden: Linköping University; 2015
PostOperativeCognitiveDysfunction
 COGNITIVE DYSFUNCTION

POSTOPERATIVE COGNITIVE DECLINE

COGNITIVE IMPAIRMENT

A syndrome, defined by :
• a drop in cognitive performance
• on a set of neuropsychological tests
• from before to after surgery
Berger M, Nadler J, Browndyke J, Posunnamy V, Cohen HJ, Whitson HE, et al. Postoperative cognitive
dysfunction: Minding the gaps in our knowledge of a common postoperative complication in the elderly.
Anesthesiol Clin. 2015; 33(3):517-50
 POCD is a decline in cognitive function immediately after surgery.1

• Commonly general anesthesia

• Geriatric patients
• Usually reversible
• Could be irreversible in elderly2
• Quality of life ↓, dependency ↑
• Morbidity ↑

1. Khalil S, Roussel J, Schubert A, Emory L. Postoperative Cognitive Dysfunction: An Updated Review. J

Neurol Neurophysiol 2015;6(2):1-8

2. Tomaszewski D. Biomarkers of brain damage and postoperative cognitive disorders in orthopedic

patients: an update. Biomed Research International. 2015: article ID 402959.s.1-16.
 3 CLINICAL CONDITIONS OF COGNITIVE CHANGE3

3. Dafydd Gwilym Lloyd DG, Ma D, Vizcaychipi MP. Cognitive decline after anaesthesia and critical care. Continuing
Education in Anaesthesia Critical Care & Pain. 2012;12(3):105–9
 Volatile anesthetics increase amyloid-β peptide
concentration.

Amyloid-β peptide

• related to learning & memory deficiency, neurodegeneration

• cont infusion (rats) impaired learning & memory
• higher concentration in old rats than younger rats

2. Tomaszewski D. Biomarkers of brain damage and postoperative cognitive disorders in orthopedic

patients: an update. Biomed Research International. 2015: article ID 402959.s.1-16.
 Intravenous anesthetics increase phosphorilation of
Tau protein.

Tau protein

• A protein that stabilizes the axonal microtubules

• Found in brain & spinal cord.
• Phosphorilation associated with neuronal death.
• Increased concentration found in POCD
• Correlation between increased Tau protein & the size of brain
infarction
Clinical events might be
related to anesthesia
• hypotension
• hypoxia
• hypovolemia
 REDUCING O2 DELIVERY
to the BRAIN

Q x {(Hb x 1.34 x SaO2) + (0.003 x PaO2)}

 What about
O2 extraction?
HYPERVENTILATI
ON
 TEMP
MONITORING
 ✓
Is ANESTHESIA the cause?
 regional
anesthesia

general
anesthesia

monitored
anesthesia care
Evered et al.:

• CABG (on pump, gen. anesthesia) : 16% POCD

• Coronary angiography (sedation only) : 21% POCD
• Total hip arthroplasty (spinal & gen. anesthesia) : 16% POCD

Silbert et al :

ESWL under GA vs ESWL under spinal

POCD after spinal : almost 3x after GA

1. Khalil S, Roussel J, Schubert A, Emory L. Postoperative Cognitive Dysfunction: An Updated Review. J

Neurol Neurophysiol 2015;6(2):1-8
Except age, no factor is proven to cause POCD
Surgery could be the strong trigger
Psychological-neurological factors may play a role
 100%

80%

60%
RISK
OF
POCD 40%

20%
75 80
65 70
0% 55 60
45 50
40

AGE

Soenarto RF, Mansjoer A, Amir N, Aprianti M, Perdana A. Cardiopulmonary Bypass Alone Does Not Cause Postoperative
Cognitive Dysfunction Following Open Heart Surgery. Anesth Pain Med. 2018; 8(6):e83610.
Many events can lead to cerebral ischaemia.
Real time monitoring?
Can it help us to “DO SOMETHING” to
manage cerebral oxygenation?
 rSO2
Regional (cerebral) O2 saturation can represent
cerebral oxygenation

Near InfraRed
Spectroscopy
 NEAR INFRA-RED SPECTROSCOPY

• rSO2 represents true brain

perfusion
• absolute value is NOT
reliable
• TREND
• how low?
• for how long?
EQUANOX™
FORE SIGHT™
INVOS™
 Probability to experience POCD based on total
desaturation time

RF Soenarto, J Hidayat, Eureka O. Hubungan disfungsi kognitif Ppascabedah jantung terbuka dengan nilai NEAR-INFRARED SPECTROSCOPY serta kandungan oksigen
dan ekstraksi oksigen intrabedah . [Tesis]. Jakarta: Universitas Indonesia; 2019
It is clear that elderly patients are at high risk to experience POCD,
no matter what anesthesia technique/drug is used.

Care should be taken for high risk patients

• avoid hypotension
• avoid hypothermia
• treat hypovolemia
• treat anemia
• treat pain
• avoid hyperventilation
 Non medical activities could probably
prevent POCD

• Physiological daily (& nightly) life

• Social contacts
• Short preop. fasting period
• Frequent visits by relatives after surgery
• Early discharge from hospital

* Wang et al. Postoperative Cognitive Dysfunction: Current Developments in Mechanism and Prevention.
Med Sci Monit. 2014; 20: 1908–12.
 Lifestyle based cognitive protection is possible and might
have a positive impact on geriatric surgical outcomes. A pre-
emptive, non-pharmacologic approach to POCD
prevention—and better perioperative brain health—is an
exciting prospect for geriatric surgical patients. Exercise is
medicine that does not require a prescription.

Culley DJ, Crosby G. Prehabilitation for Prevention of Postoperative Cognitive Dysfunction? Anesthesiology. 2015;123(1):7-9
• Exact mechanism of POCD is still unclear
• The only risk proven : age
• Anesthesia causes POCD is debateable
• Anything happens intraoperatively can cause
POCD
• Many things are proposed to prevent POCD