Šprung, Juraj

IMPORTANCE Hospitalizations are associated with cognitive decline in older adults. OBJECTIVE To determine the association between hospitalization characteristics and the trajectory of cognitive function in older adults. DESIGN Population‐based longitudinal study of cognitive aging. SETTING Olmsted Medical Center and Mayo Clinic, the only centers in Olmsted County, Minnesota, with hospitalization capacity. PARTICIPANTS Individuals without dementia at baseline, with consecutive cognitive assessments from 2004 through 2017, and at least one visit after the age of 60. MEASUREMENTS The primary outcome was longitudinal changes in global cognitive z ‐score. Secondary outcomes were changes in four cognitive domains: memory, attention/executive function, language, and visuospatial skills. Hospitalization characteristics analyzed included elective versus nonelective, medical versus surgical, critical care versus no critical care admission, and long versus short duration admissions. RESULTS Of 4,587 participants, 1,622 had 1 and more hospital admission. Before hospitalization, the average slope of the global z ‐score was −0.031 units/year. After hospitalization, the rate of annual global z ‐score accelerated by −0.051 (95% CI = −0.057, −0.045) units, P < .001, resulting in an estimated annual slope after the first hospitalization of −0.082. The accelerated decline was found in all four cognitive domains (memory, visuospatial, language, and executive, all P < .001). The acceleration of the decline in global z ‐score following hospitalization was greater for medical compared to surgical hospitalizations (slope change following hospitalization = −0.064 vs −0.034 for medical vs surgical, P < .001), and nonelective compared to elective admissions (slope change following hospitalization = −0.075 vs −0.037 for nonelective vs elective, P < .001). The acceleration of cognitive decline was not different for hospitalization with intensive care unit admission versus not. CONCLUSIONS Hospitalization of older adults is associated with accelerated decline of global and domain‐specific cognitive domains, with the rate of decline dependent upon type of admission. The clinical impact of this accelerated decline will depend on the individual's baseline cognitive reserve and expected longevity.

BACKGROUND: Two prior population-based (children born in Olmsted County, MN), retrospective cohort studies both found that multiple exposures to anesthesia before age 3 were associated with a significant increase in the frequency of attention-deficit hyperactivity disorder (ADHD) and learning disabilities (LD) later in life. The primary purpose of this secondary analysis of these data was to test the hypothesis that a single exposure to anesthesia before age 3 was associated with an increased risk of ADHD. We also examined the association of single exposures with LD and the need for individualized educational plans as secondary outcomes. METHODS: This analysis includes 5339 children who were unexposed to general anesthesia before age 3 (4876 born from 1976 to 1982 and 463 born from 1996 to 2000), and 1054 children who had a single exposure to anesthesia before age 3 (481 born from 1976 to 1982 and 573 born from 1996 to 2000). The primary outcome of interest was ADHD. Secondary outcomes included LD (reading, mathematics, and written language) and the need for individualized educational programs (speech/language and emotion/behavior). To compare the incidence of each outcome between those who were unexposed and singly exposed to anesthesia before the age of 3 years, an inverse probability of treatment weighted proportional hazards model was used. RESULTS: For children not exposed to anesthesia, the estimated cumulative frequency (95% confidence interval [CI]) of ADHD at age 18 was 7.3% (95% CI, 6.5–8.1) and 13.0% (95% CI, 10.1–16.8) for the 1976–1982 and 1996–2000 cohorts, respectively. For children exposed to a single anesthetic before age 3, the cumulative frequency of ADHD was 8.1% (95% CI, 5.3–12.4) and 17.6% (95% CI, 14.0–21.9) for the 1976–1982 and 1996–2000 cohorts, respectively. In weighted analyses, single exposures were not significantly associated with an increased frequency of ADHD (hazard ratio [HR], 1.21; 95% CI, 0.91–1.60; P = .184). Single exposures were also not associated with an increased frequency of any LD (HR, 0.98; 95% CI, 0.78–1.23), or the need for individualized education plans. CONCLUSIONS: This analysis did not find evidence that single exposures to procedures requiring general anesthesia, before age 3, are associated with an increased risk of developing ADHD, LD, or the need for individualized educational plans in later life.

Purpose To assess if the choice of acetaminophen formulation (intravenous vs oral) when administered preoperatively for ambulatory cystoscopy procedures is associated with differences in anesthetic outcomes. Methods Medical records of adult patients undergoing ambulatory cystoscopy procedures at an outpatient procedural center from July 1, 2014, through November 30, 2017, were abstracted. The association between anesthetic outcomes (severe pain, rescue opioids, postoperative nausea, and vomiting) and acetaminophen formulation was assessed. Propensity-adjusted analyses were performed using inverse probability of treatment weighting to account for potential confounders. Results During the study time frame, there were 611 intravenous and 2955 oral acetaminophen administrations for cystoscopy procedures. Postoperative bladder spasms were a major contributor to severe pain and complicated 1036 cases, with similar rates between intravenous (N = 183, 29.9%) and oral (N = 853, 28.9%) formulations, P = .625. After adjusting for bladder spasms, intravenous acetaminophen was associated with longer anesthesia recovery (estimate 5.2 [95% CI 0.5-9.9] minutes, P = .030), use of rescue opioids (odds ratio 1.33 [1.07-1.66], P = .012), and postoperative nausea and vomiting (1.40 [1.02-1.93], P = .037), but not severe pain (1.07 [0.81-1.40], P = .640). Conclusion Preoperative intravenous acetaminophen compared to oral acetaminophen for ambulatory cystoscopy procedures was not associated with better anesthetic outcomes. Bladder spasms were a major contributor to postoperative pain.

ObjectivesDelayed anesthesia recovery following endoscopic sinus surgery (ESS) can be an indicator of immediate complications and negatively impact healthcare efficiency. This study aims to examine clinical factors with a focus on improving clinical practice.MethodsMedical records of patients undergoing ESS under general anesthesia from 2014 to 2018 were reviewed. Based on the interquartile range of anesthesia recovery for the cohort, patients in the upper quartile were categorized as “prolonged” and the lowest three quartiles as “goal” recovery. Patient and surgical characteristics were investigated.ResultsAnalyzing 416 patients who underwent ESS, the median anesthesia recovery time was 48 [35–66] minutes. Prolonged recovery was associated with higher body mass index (odds ratio 1.50 [95% confidence interval 1.03–2.18] per 10 kg/m2, P = .03) and surgical duration (1.37 [1.10–1.72] per hour, P < .01). Inversely, goal recovery was associated with preoperative acetaminophen (0.61 [0.38–0.98], P = .04) and intraoperative remifentanil (0.55 [0.32–0.93], P = .03). Patients with prolonged recovery had higher rates of severe pain (33 (31.7%) vs. 25 (8.0%), P < .01), respiratory depression (7 [6.7] vs. 2 [0.6], P < .01), oversedation (39 [37.5] vs. 39 [12.5], P < .01), and the need for rescue opioids (52 [50] vs. 71 [22.8], P < .01). In addition to reduced postanesthesia recovery time, patients who were administered preemptive acetaminophen had lower rates of severe pain (OR 0.55 [0.31–0.98], P = .04) and nausea and vomiting (0.39 [0.17–0.87], P = .02).ConclusionOur findings substantiate the use of acetaminophen and remifentanil in ESS, facilitating anesthesia recovery. Broadly consideration of preemptive acetaminophen could further increase postoperative comfort in ESS.Level of Evidence4 – Retrospective. Laryngoscope, 131:E815–E820, 2021

Postoperative delirium (POD) is common among surgical patients admitted to the intensive care unit (ICU) and is associated with increased resource utilization, morbidity, and death. Our primary aim was to compare rates of POD using administrative International Classification of Diseases, Ninth Revision, records and automated interrogation of electronic health records from Confusion Assessment Method for the ICU (CAM-ICU) screening. The secondary aim was to assess POD risk associated with patient and perioperative characteristics. Electronic health records of surgical patients admitted to the ICU during 2011 through 2014 were abstracted for POD assessment by CAM-ICU and by administrative codes, Charlson comorbidity index, surgical characteristics, and Acute Physiology, Age, Chronic Health Evaluation III scores. Of 6338 patients, CAM-ICU identified 606 (9.6%) and administrative records identified 55 (0.9%) POD cases, with agreement on 50 cases. In multivariable logistic regression based on POD identified with CAM-ICU, preexisting dementia had the strongest association with POD (odds ratio [95% confidence interval], 6.47 [3.68–11.37]; P < 0.001). Other associations found were older age, congestive heart failure, chronic pulmonary disease, increased surgical duration, emergency cases, blood transfusions, postoperative ventilation, and higher Acute Physiology, Age, Chronic Health Evaluation III scores (all P ≤ 0.01). POD cases had lengthier ICU and hospital stays and a higher mortality rate (all P < 0.001). CAM-ICU scores identified higher rates of POD than a search for POD based on administrative codes. Preoperative presence of dementia and major comorbidities were associated with POD. Delirium in surgical patients is associated with worse outcomes.

The Charlson Comorbidity Index (CCI) has not been assessed for elderly (95 years of age or older) surgical patients. We examined the association between the CCI and life-threatening complications and 30-day mortality rate. Medical records of patients 95 years old or older from 2004 through 2008 were reviewed for major postoperative morbidity or death. Logistic regression analyses of age, sex, the CCI, American College of Cardiology/American Heart Association Surgical Risk Stratification, and surgical urgency were performed to identify associations with poor surgical outcome. One hundred eighty-seven patients were identified (mean [standard deviation] age, 96.6 [1.9] years; median [interquartile range] CCI, 4 [2 to 6]). Ninety patients (48.1%) underwent moderate-risk and 20 (10.7%) underwent high-risk surgical procedures. Twenty patients (10.7%) died within 30 postoperative days and 20 others had major morbidity. Only moderate-risk ( P = 0.045) and high-risk surgical procedures ( P = 0.001) were associated with poor outcome. Patients of advanced age have high rates of morbidity and death after surgical procedures. These events are associated with surgical risk stratification and are independent of patient comorbidities. Risks, benefits, and alternatives must be considered carefully and discussed with patients and their families before deciding to proceed with high-risk surgery.

Abstract Background Surgery for catecholamine-producing tumours can be complicated by intraoperative and postoperative haemodynamic instability. Several perioperative management strategies have emerged but none has been evaluated in randomized trials. To assess this issue, contemporary perioperative management and outcome data from 21 centres were collected. Methods Twenty-one centres contributed outcome data from patients who had surgery for phaeochromocytoma and paraganglioma between 2000 and 2017. The data included the number of patients with and without α-receptor blockade, surgical and anaesthetic techniques, complications and perioperative mortality. Results Across all centres, data were reported on 1860 patients with phaeochromocytoma or paraganglioma, of whom 343 underwent surgery without α-receptor blockade. The majority of operations (78·9 per cent) were performed using minimally invasive techniques, including 16·1 per cent adrenal cortex-sparing procedures. The cardiovascular complication rate was 5·0 per cent overall: 5·9 per cent (90 of 1517) in patients with preoperative α-receptor blockade and 0·9 per cent (3 of 343) among patients without α-receptor blockade. The mortality rate was 0·5 per cent overall (9 of 1860): 0·5 per cent (8 of 517) in pretreated and 0·3 per cent (1 of 343) in non-pretreated patients. Conclusion There is substantial variability in the perioperative management of catecholamine-producing tumours, yet the overall complication rate is low. Further studies are needed to better define the optimal management approach, and reappraisal of international perioperative guidelines appears desirable.

BACKGROUND: We evaluated the hypothesis that the rate of postoperative decline in global cognition is greater in older adults exposed to general anesthesia with nitrous oxide (N 2 O) compared to general anesthesia without N 2 O. METHODS: Longitudinal measures of cognitive function were analyzed in nondemented adults, 70–91 years of age, enrolled in the Mayo Clinic Study of Aging. Linear mixed-effects models with time-varying covariates assessed the relationship between exposure to surgery with general anesthesia (surgery/GA) with or without N 2 O and the rate of long-term cognitive changes. Global cognition and domain-specific cognitive outcomes were defined using z scores, which measure how far an observation is, in standard deviations, from the unimpaired population mean. RESULTS: The analysis included 1819 participants: 280 exposed to GA without N 2 O following enrollment and before censoring during follow-up (median [interquartile range {IQR}] follow-up of 5.4 [3.9–7.9] years); 256 exposed to GA with N 2 O (follow-up 5.6 [4.0–7.9] years); and 1283 not exposed to surgery/GA (follow-up 4.1 [2.5–6.4] years). The slope of the global cognitive z score was significantly more negative following exposure to surgery/GA after enrollment (change in slope of −0.062 [95% confidence interval {CI}, −0.085 to −0.039] for GA without N 2 O, and −0.058 [95% CI, −0.080 to −0.035] for GA with N 2 O, both P < .001). The change in slope following exposure to surgery/GA did not differ between those exposed to anesthesia without versus with N 2 O (estimated difference −0.004 [95% CI, −0.035 to 0.026], P = .783). CONCLUSIONS: Exposure to surgery/GA is associated with a small, but statistically significant decline in cognitive z scores. Cognitive decline did not differ between anesthetics with and without N 2 O. This finding provides evidence that the use of N 2 O in older adults does not need to be avoided because of concerns related to decline in cognition.