Post-operative cognitive dysfunction (POCD)

[aghast1]

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Since it appears many on this list do not believe that level of consciousness (LOC) monitoring is a worthwhile endeavor, I would like to elicit comment on POCD.

It is like the Tooth Fairy, the Ether Bunny & Santa Claus?

Cute story but doesn't really exist?

If it does exist & LOC monitoring is worthless, what measures do you think would decrease the occurrence?

Finally rain in SoCal,

aghast1

 

[Gern Blansten]

Why don't you just tell us the answer?

 

[Planktonmd]

Since it appears many on this list do not believe that level of consciousness (LOC) monitoring is a worthwhile endeavor, I would like to elicit comment on POCD.

It is like the Tooth Fairy, the Ether Bunny & Santa Claus?

Cute story but doesn't really exist?

If it does exist & LOC monitoring is worthless, what measures do you think would decrease the occurrence?

Finally rain in SoCal,

aghast1

Post operative cognitive dysfunction is a phenomenon that we still don't fully understand because there are many things that we don't understand on how anesthesia affects the brain,
Monitoring the level of consciousness is not currently possible because there is no such monitor available and because you can not monitor things that you can not define.

 

[Planktonmd]

Why don't you just tell us the answer?

🙂
Trust me, he will.

 

[Intubate]

the Ether Bunny. i love that.

 

[aghast1]

the Ether Bunny. i love that.

Who's there?

Ether

Ether who?

Ether Bunny

Knock, knock

Who's there?

Notha

Notha who?

A notha Ether Bunny

Knock, knock

Who's there?

Stella

Stella who?

Stella notha Ether Bunny

Knock, knock

Who's there?

Orange

Orange who?

Orange ya glad is not a notha Ether Bunny?

aghast1

 

[aghast1]

Post operative cognitive dysfunction is a phenomenon that we still don't fully understand because there are many things that we don't understand on how anesthesia affects the brain,
Monitoring the level of consciousness is not currently possible because there is no such monitor available and because you can not monitor things that you can not define.

"...there are many things that we don't understand on how anesthesia affects the brain,"

How about just about everything about how anesthesia affects the brain?😴

Anytime there is more than one theory about the mechanism of anesthesia, it simply means 'we don't know.'

Does that mean we do not produce the anesthetic state on a daily basis? Obviously not. Although, some of us produce better outcomes reproducibly.🙂

The ASA attempted to define levels of sedation/anesthesia but left almost as much to speculation as it defined.

Still something is better than nothing.

I added BIS levels to minimal, moderate, deep sedation and anesthesia to facilitate communication between colleagues, not as a means of obtaining billing.

Sedation implies that local anesthesia plays some role in the case mgmt. IN MIA, adequate local analgesia is critical to success.

GA implies that local analgesia is superfluous.

IMHO, anesthesia is the combination of hypnosis (includes amnesia) and analgesia (includes a degree of relaxation).

With adequate local analgesia, my surgeons have never required more relaxation than provided by MIA to imbricate the rectus sheaths of abdominoplasty patients (2-300 now).

General anesthesia must include general (or systemic) analgesia.

"Monitoring the level of consciousness is not currently possible because there is no such monitor available..."

Anyone who could make such a statement in the face of >3,000 published scientific papers on BIS is clearly wedded to their antediluvian belief system and will not be shaken from it.

As I have said before, beliefs are not rational and therefore are not subject to rational discussion.

You can go your own way😱, I'll go mine😀.

aghast1

 

[aghast1]

Post operative cognitive dysfunction is a phenomenon that we still don't fully understand because there are many things that we don't understand on how anesthesia affects the brain,
Monitoring the level of consciousness is not currently possible because there is no such monitor available and because you can not monitor things that you can not define.

"...there are many things that we don't understand on how anesthesia affects the brain,"

How about just about everything about how anesthesia affects the brain?😴

Anytime there is more than one theory about the mechanism of anesthesia, it simply means 'we don't know.'

Does that mean we do not produce the anesthetic state on a daily basis? Obviously not. Although, some of us produce better outcomes reproducibly.🙂

The ASA attempted to define levels of sedation/anesthesia but left almost as much to speculation as it defined.

Still something is better than nothing.

I added BIS levels to minimal, moderate, deep sedation and anesthesia to facilitate communication between colleagues, not as a means of obtaining billing.

Sedation implies that local anesthesia plays some role in the case mgmt. IN MIA, adequate local analgesia is critical to success.

GA implies that local analgesia is superfluous.

IMHO, anesthesia is the combination of hypnosis (includes amnesia) and analgesia (includes a degree of relaxation).

With adequate local analgesia, my surgeons have never required more relaxation than provided by MIA to imbricate the rectus sheaths of abdominoplasty patients (2-300 now).

General anesthesia must include general (or systemic) analgesia.

"Monitoring the level of consciousness is not currently possible because there is no such monitor available..."

Anyone who could make such a statement in the face of >3,000 published scientific papers on BIS is clearly wedded to their antediluvian belief system and will not be shaken from it.

As I have said before, beliefs are not rational and therefore are not subject to rational discussion.

My outcomes correlate to the rational published papers demonstrating improved propofol titration with BIS.

You can go your own way😱, I'll go mine😀.

aghast1

 

[Planktonmd]

As I have said before, beliefs are not rational and therefore are not subject to rational discussion.

You can go your own way😱, I'll go mine😀.

aghast1

No, beliefs could be rational when they are the results of evidence based science.
On the other hand, delusions, and particularly grandiose delusions, are definitely not rational and are deep rooted in an imaginary world.

 

[Planktonmd]

Anyone who could make such a statement in the face of >3,000 published scientific papers on BIS aghast1

Why don't you tell us the definition of "level of consciousness" ?

 

[aghast1]

No, beliefs could be rational when they are the results of evidence based science.
On the other hand, delusions, and particularly grandiose delusions, are definitely not rational and are deep rooted in an imaginary world.

I could be delusional but since many around the globe who followed my paradigm reproduce my stellar outcomes, I think not.😍

aghast1

 

[aghast1]

Why don't you tell us the definition of "level of consciousness" ?

This post will not satisfy the philosophers or 'scientists.'

It is my working 'definition.'

Are you 'awake' or 'asleep?'

If you are awake, you respond to painful stimuli unless there is adequate local analgesia (i.e. the dentist office, pure local).

If you are asleep, do you respond to painful stimuli or not?

If you respond, you not receiving general (or adequate general) anesthesia. (or are you an ASA VI) an organ donor?😱)

Now we are back to tail clamping rats - is it an intact spinal cord generating mvmt. or the higher cortical centers? Is there a difference? Hmmmm.

If you do not respond to painful stimuli, do you fail to respond for lack of input (adequate local anesthesia)?

Are you dissociated with increased laryngeal or 'life preserving' reflexes?

or are you with general anesthesia (asleep with systemic analgesia) with depressed laryngeal reflexes and increased risk of aspiration.

If you elect to employ a level of consciousness monitor (like a BIS or PSA) AND you elect to use agents that primarily affect the cortex (propofol, sevo, or des), you can generate numbers that correlate with level of consciousness. Clearly better than OAA/S scores as well as easier to other to reproduce your paradigm.

If, on the other hand, you administer agents that do not primarily act on the cortex (benzodiazepines or opioids), then level of consciousnss monitors will not serve you well.

Yours for better & reproducible outcomes,

aghast1

 

[Planktonmd]

This post will not satisfy the philosophers or 'scientists.'

It is my working 'definition.'

Are you 'awake' or 'asleep?'

If you are awake, you respond to painful stimuli unless there is adequate local analgesia (i.e. the dentist office, pure local).

If you are asleep, do you respond to painful stimuli or not?

If you respond, you not receiving general (or adequate general) anesthesia. (or are you an ASA VI) an organ donor?😱)

Now we are back to tail clamping rats - is it an intact spinal cord generating mvmt. or the higher cortical centers? Is there a difference? Hmmmm.

If you do not respond to painful stimuli, do you fail to respond for lack of input (adequate local anesthesia)?

Are you dissociated with increased laryngeal or 'life preserving' reflexes?

or are you with general anesthesia (asleep with systemic analgesia) with depressed laryngeal reflexes and increased risk of aspiration.

If you elect to employ a level of consciousness monitor (like a BIS or PSA) AND you elect to use agents that primarily affect the cortex (propofol, sevo, or des), you can generate numbers that correlate with level of consciousness. Clearly better than OAA/S scores as well as easier to other to reproduce your paradigm.

If, on the other hand, you administer agents that do not primarily act on the cortex (benzodiazepines or opioids), then level of consciousnss monitors will not serve you well.

Yours for better & reproducible outcomes,

aghast1

😕
So obviously the bottom line is: You really don't know what the "level of consciousness" exactly is, but you are confident that you can measure it with a monitor.
One more thing you keep missing: Ketmaine is a "Systemic analgesic" among other things, so the moment you add ketamine to your concucsion you are adding a systemic analgesic and it is a GA by your own definition.

 

[Planktonmd]

I could be delusional but since many around the globe who followed my paradigm reproduce my stellar outcomes, I think not.😍

aghast1

Wrong again,
Being followed by others does not prove that you are not delusional, actually history is full of examples of delusional people who became healers and prophets.

 

[aghast1]

😕
So obviously the bottom line is: You really don't know what the "level of consciousness" exactly is, but you are confident that you can measure it with a monitor.
One more thing you keep missing: Ketmaine is a "Systemic analgesic" among other things, so the moment you add ketamine to your concucsion you are adding a systemic analgesic and it is a GA by your own definition.

"You really don't know what the "level of consciousness" exactly is"

So you do?

My (BIS aided) outcomes are congruent with my operational definition of level of consciousness.

Got outcomes?🙂

"Ketamine is a "Systemic analgesic" "

Aside from the fact that ketamine is a dissociative agent, it may only appear to be a systemic analgesia when given continuously as in TIVA.

In case you haven't been following, I give a single 50 mg dose of ketamine which has an effective time frame of 10-20 minutes of my typical 2.5 hr case.

Once the 10-20 min elapses, pts will respond if the local analgesia is inadequate or the surgeon stimulates an area without local.

Lastly, ketamine intensifies laryngeal or 'life preserving' reflexes. Occasional laryngospasm is the 'evidence' of this statement. Happens in about 1% of cases.

Systemic analgesia in the form of opioids or stinky cases have entirely the opposite effect on the laryngeal reflexes which is why we always ask about the po intake.

FWIW, the pharyngeal reflexes responsible for the cessation of swallowing with propofol are not the same as the laryngeal reflexes.

Later dude,

aghast1

 

[aghast1]

Wrong again,
Being followed by others does not prove that you are not delusional, actually history is full of examples of delusional people who became healers and prophets.

What part of 'reproducible outcomes' do not not understand?😱

People would not employ my paradigm if it wasn't reproducing my published outcomes, a problem too small for you to be bothered.

History is also full of fools who insisted on keeping their heads in the sands to resist the tide of needed change; i.e. better outcomes.

Just wait. Pay for performance will be coming to your institution soon.

Since the only way to get someone's attention is to 'kick' them in their wallet, I suspect better outcomes may soon become of interest to you.

Have a nice day🙂

aghast1

 

[Planktonmd]

What part of 'reproducible outcomes' do not not understand?😱

People would not employ my paradigm if it wasn't reproducing my published outcomes, a problem too small for you to be bothered.

History is also full of fools who insisted on keeping their heads in the sands to resist the tide of needed change; i.e. better outcomes.

Just wait. Pay for performance will be coming to your institution soon.

Since the only way to get someone's attention is to 'kick' them in their wallet, I suspect better outcomes may soon become of interest to you.

Have a nice day🙂

aghast1

I think that grandiose delusions can be treated sometimes.

 

[numbmd]

POCD is interesting, What studies do you have that shows BIS monitoring affects POCD? I'll have to look when I get back to work, but there was a study where they took elderly patients, made them NPO, brought them in for surgery, put them on the OR table, gave them NO meds, took them off the table, brought them to the recovery room, and followed them.

Guess what? Some of them had cognitive dysfunction.

Maybe their BIS was too high.

PS. Anesthesiology had a great review article on mechanisms of anesthesia. A few months back. A little tough to get through, but worthwhile.

 

[aghast1]

POCD is interesting, What studies do you have that shows BIS monitoring affects POCD? I'll have to look when I get back to work, but there was a study where they took elderly patients, made them NPO, brought them in for surgery, put them on the OR table, gave them NO meds, took them off the table, brought them to the recovery room, and followed them.

Guess what? Some of them had cognitive dysfunction.

Maybe their BIS was too high.

PS. Anesthesiology had a great review article on mechanisms of anesthesia. A few months back. A little tough to get through, but worthwhile.

It is intuitively obvious that if you give more anesthesia (i.e. BIS <45) than is necessary to the elderly and pts. s/p CVA, that POCD might be an issue. Prospective studies are in the works.

Much like it was intuitively obvious if you knew how asleep the patient was, it was less likely for them to be awake when you thought they were asleep. Subsequent prospective study confirmed this.

"Maybe their BIS was too high."

You forgot the 🙄

Your example proves nothing without the administration of drugs.

IMHO, it is preferable to measure the the target organ of our meds.👍

aghast1

 

[dhb]

there are actually studies that show better outcome in the "low" bis group...

 

[aghast1]

there are actually studies that show better outcome in the "low" bis group...

Let me get this correctly

If research supported by Aspect is positive, then we deny it

If contrary research is published then we extol it.

My outcomes are congruent with my practice.

aghast1

 

[dhb]

hardly an extoliation, i don't give a $hit if it's high or low since i don't use it

 

[aghast1]

hardly an extoliation, i don't give a $hit if it's high or low since i don't use it

good for you

will make no difference in my life but may make in your pts. lives

keep using the discredited vital signs trends

aghast1

 

[numbmd]

Actually, my example proves nothing because I have no article quoted. However, once I produce the source, it proves that some cognitive dysfunction is merely the result of a disruption of someone's schedule, not the result of any drug or combination that leads to deep anesthesia.

 

[aghast1]

Actually, my example proves nothing because I have no article quoted. However, once I produce the source, it proves that some cognitive dysfunction is merely the result of a disruption of someone's schedule, not the result of any drug or combination that leads to deep anesthesia.

"...some cognitive dysfunction is merely the result of a disruption of someone's schedule, not the result of any drug or combination that leads to deep anesthesia."😕

Dude, as anesthesiologists and crnas,we give drugs (in addition to disrupting schedules), most commonly too much for fear of giving too little.👎

aghast1