Intraoperative Oxidative Stress Associated With Postoperative Delirium

[BLADEMDA]

Perhaps, we need to re-think the high Fio2 concept for our surgical patients at risk of post op delirium.

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[Consigliere]

Perhaps, we need to re-think the high Fio2 concept for our surgical patients at risk of post op delirium.

Will do

 

[BLADEMDA]

Honolulu—Intraoperative oxidative stress is associated with postoperative delirium in ICU patients after cardiac surgery, a study has found.

Researchers from Vanderbilt University Medical Center, in Nashville, Tenn., came to this conclusion after they found plasma concentrations of F2-isoprostanes and isofurans, markers of oxidative damage, are associated with delirium. They measured plasma concentrations of F2-isoprostanes and isofurans throughout the surgical period in 385 patients undergoing cardiac surgery.

The researchers noted that 106 patients (27.5%) developed delirium. In an analysis that accounted for other possible contributors to delirium, a 10-pg/mL increase in F2-isoprostanes during surgery was associated with a 15% increase in the odds for developing delirium after surgery (P=0.02), whereas a 10-pg/mL increase in isofurans was associated with a 6% increase (P=0.04).

“We found that plasma markers of oxidative damage increase during cardiac surgery, and that increased concentrations of these markers are associated with increased postoperative delirium,” said Marcos Lopez, MD, MS, assistant professor and B.H. Robbins Scholar in the Division of Anesthesiology Critical Care Medicine at Vanderbilt, who presented the findings at the 2017 annual meeting of the Society for Critical Care Management (abstract 26).

“Delirium is a common problem after cardiac surgery, and is associated with long-term cognitive decline and increased mortality,” Dr. Lopez said.

Dr. Lopez said in vitro studies suggest that some gas anesthetics, local anesthetics and propofol may reduce oxidative damage. “It is possible that sedatives and anesthetics may have differing effects or no effect on oxidative damage,” he said. “Oxidative damage increases with surgery. This could be related to surgical procedure, use of cardiopulmonary bypass, ischemia and reperfusion of tissues, or even excess oxygen administration.”

 

[BLADEMDA]

IMHO, patients at risk of POCD and Delirium may do better with less "stress" perioperatively. At this time, there are no studies showing any difference between anesthetic techniques for reducing POCD or delirium.

That said, perhaps the use of low dose Precedex combined with lose dose Ketafol utilizing a regional anesthetic would be the best technique for those with known mild cognitive impairment preoperatively.

 

[BLADEMDA]

Effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial.

Effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlle... - PubMed - NCBI

 

[BLADEMDA]

General anesthetic and the risk of dementia in elderly patients: current insights

Good review article on POCD

 

[BLADEMDA]

Ketamine attenuates hypocapnia-induced neuronal damage in the caudoputamen in a rat model of chronic cerebral hypoperfusion

Ketamine attenuates hypocapnia-induced neuronal damage in the caudoputamen in a rat model of chronic cerebral hypoperfusion

 

[BLADEMDA]

Recent research suggests that, in addition to preventing acute postoperative pain, a subanaesthetic dose of intraoperative ketamine could decrease the incidence of postoperative delirium as well as other neurological and psychiatric outcomes.

 

[MaximusD]

Try to titrate to 40% fio2 after induction lately.

 

[BLADEMDA]

Try to titrate to 40% fio2 after induction lately.

I'd be happy if PROVIDERS stopped using 80-100% FIO2 on all their patients especially those at risk of POCD or Delirium.

 

[Robotic Wis-Hipple]

First, who is doing every case with 80-100% FiO2? This makes zero sense to me.

Second, looking at plasma markers of oxidative stress in cardiac surgery with its periods of malperfusion, nonpulsatile flow, and reperfusion and making a loose connection to generalize that increased FiO2 may increase delirium is a little silly to me. Cardiac surgery quite literally is the case with the most potential confounders present.

 

[pgg]

Clearly we need a large, multicenter, prospective, blinded, 3-arm RCT comparing POCD in patients who undergo surgery with an FiO2 of 100%, 50%, and 0%.

 

[fakin' the funk]

Put those ISOFURANS right on my CAUDOPUTAMEN, amirite fellas??!!

 

[MaximusD]

Clearly we need a large, multicenter, prospective, blinded, 3-arm RCT comparing POCD in patients who undergo surgery with an FiO2 of 100%, 50%, and 0%.

I see what you did there.

 

[IlDestriero]

I think the "too much oxygen is bad" data came out in the 80's. If your extenders are using 80-100% O2 routinely, they're about 30 years behind in their CME.


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Il Destriero

 

[BLADEMDA]

I think the "too much oxygen is bad" data came out in the 80's. If your extenders are using 80-100% O2 routinely, they're about 30 years behind in their CME.


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Il Destriero

No. They believed the small "N" studies which show high Fio2 Is good for the patient.

Effect of intraoperative high inspired oxygen fraction on surgical site infection, postoperative nausea and vomiting, and pulmonary function: syste... - PubMed - NCBI

Effect of intra-operative high inspired oxygen fraction on surgical site infection: a meta-analysis of randomized controlled trials. - PubMed - NCBI

 

[BLADEMDA]

• Format: Abstract

Send to



Crit Care. 2016 Aug 16;20(1):239. doi: 10.1186/s13054-016-1427-x.
Does hyperoxia enhance susceptibility to secondary pulmonary infection in the ICU?
Nußbaum B1,2, Radermacher P3, Asfar P4,5, Hartmann C1,2.
Author information

Abstract
Hyperoxia is common practice in the acute management of circulatory shock, and observational studies report that it is present in more than 50 % of mechanically ventilated patients during the first 24 h after intensive care unit (ICU) admission. On the other hand, "oxygen toxicity" due to the increased formation of reactive oxygen species limits its use due to serious deleterious side effects. However, formation of reactive oxygen species to boost bacterial killing is one of the body's anti-microbial auto-defense mechanisms and, hence, O2 has been referred to as an antibiotic. Consequently, hyperoxia during the peri-operative period has been advocated for surgical patients in order to reduce surgical site infection. However, there is ample evidence that long-term exposure to hyperoxia impaired bacterial phagocytosis and thereby aggravated both bacterial burden and dissemination. Moreover, a recent retrospective study identified the number of days with hyperoxia, defined as a PaO2 > 120 mmHg only, as an independent risk factor of ventilator-associated pneumonia in patients needing mechanical ventilation for more than 48 h. Since so far the optimal oxygenation target is unknown for ICU patients, "conservative" O2 therapy represents the treatment of choice to avoid exposure to both hypoxemia and excess hyperoxemia.

 

[pgg]

Maybe they should be using IV vitamin C to offset the oxidative damage caused by the high FiO2 they use.

 

[BLADEMDA]

Can Respir J. 2017;2017:2834956. doi: 10.1155/2017/2834956. Epub 2017 Jan 26.
Harmful Effects of Hyperoxia in Postcardiac Arrest, Sepsis, Traumatic Brain Injury, or Stroke: The Importance of Individualized Oxygen Therapy in Critically Ill Patients.
Vincent JL1, Taccone FS1, He X2.
Author information

Abstract
The beneficial effects of oxygen are widely known, but the potentially harmful effects of high oxygenation concentrations in blood and tissues have been less widely discussed. Providing supplementary oxygen can increase oxygen delivery in hypoxaemic patients, thus supporting cell function and metabolism and limiting organ dysfunction, but, in patients who are not hypoxaemic, supplemental oxygen will increase oxygen concentrations into nonphysiological hyperoxaemic ranges and may be associated with harmful effects. Here, we discuss the potentially harmful effects of hyperoxaemia in various groups of critically ill patients, including postcardiac arrest, traumatic brain injury or stroke, and sepsis. In all these groups, there is evidence that hyperoxia can be harmful and that oxygen prescription should be individualized according to repeated assessment of ongoing oxygen requirements.

 

[BLADEMDA]

Maybe they should be using IV vitamin C to offset the oxidative damage caused by the high FiO2 they use.

Or just turn the FIO2 down.

 

[pgg]

Or just turn the FIO2 down.

That works too.

 

[deleted162650]

At my last gig there was no pipeline air. You either ran some nitrous or 100% O2 on everyone (just had to make sure air e-cylinder was full for trachs and airway laser cases).