老年人后中枢神经系统并发症ppt课件

1、 Department of Anesthesiology and ICU, Renji Hospital Affiliated Shanghai Jiao Tong University 杭燕南Yannan HangWith increase of the number of elderly surgical patients( 65yr 26.3 % of 12379 surgical patients in Renji Hospital, 2019), more postoperative CNS complications (cerebral infarction, hemorrhag

2、e, and mental disorder) have been reported. Postoperative CNS complications will arise incidence of the other system complications, delay the recovery time, increase mortality ratio, stay longer time in hospital and increase medical cost. Sometime, it is the early signs of other postoperative compli

3、cations like infection or cardiovascular diseases.Stroke: Cerebral hemorrhage, cerebral infarction High morbidity in elderly (51-65yr) More patients with preoperative cerebral infarction High risk with postoperative cerebral infarction 9 time mortality with cerebral infarction and hemorrhage Always

4、combined with hypertension, coronary heart diseases or DM Pay more attention before , during and after operation, take some pre-treatmentl1.Pre-existed cerebrocardial diseasesl2.Thrombus or gas embolus caused by operation, anesthesia or drugsl3.fluctuation of perioperative blood pressure, hypertensi

5、onl4.long time hypotensionl5.keep in bed, less moving or hyper-coagulationlF, 80yr, alimentary perforation, acute penetrative peritonitis, toxic shock. Cerebral infarction 1yr before. lRadical resection of right colon carcinoma under general anesthesia.lGreat changes of perioperative blood pressure,

6、 BP:70/50mmHg，long duration of hypotensionlCarried to SICU, supply enough solution and maintain the balance of electrolyte and pHlStable life signs, but faint consciousness with opening eyes after calling, bad movement of left bodylLarge area cerebral infarction diagnosed by CT 3days laterlSomnolenc

7、e 6hr after end of operation, mis-diagnosed as later resuscitationlLarge area cerebral infarction was found with CT scanlExtubation the next day in SICUlF,65yr,BP 150/95mmHg, cholecystectomy and drainage of common bile duct under general anesthesialM, 5yr, fracture of femoral necklReplacement of fem

8、oral head under spinal-epidural anestheisalBP 150/90mmHg(preoperation);BPmin 80/60mmHg, treated with ephedrine; BP 105/70mmHg(end of operation)lPCIA after operationlStop PCIA when find patients with bad reaction at operation night, BP 106/80mmHglCerebral infarction by CT, BP 105/80mmHglCardiac infar

9、ction, shock and respiratory failure at 3dlDie at 5dlLater resuscitation in elderly after operation should be paid more attention. Physical and radial exam should be taken if the patients with nerve system signs like hemiplegia or movinglKeep stable blood pressure since hypertension will cause hemor

10、rhage and hypotension will cause infarctionlcerebral infarction was found more after endarterectomylHyper-coagulation station in elderly which cause the embolus formation that results in cerebral infarctionlPay more attention to the aged, cerebral diseases, hypertension for reduce the morbidity of c

11、erebral infarction：lAvoid fluctuation of BPlVessels dilation drugs like Fu Fang Dan Shen, Nimodipine, etc.lIf necessary, use aspirin, low dose heparin postoperative acute confusional state postoperative delirium postoperative cognitive dysfunction postoperative acute brain failure postoperative orga

12、nic brain syndrome postoperative toxic psychosisA syndrome of reversal fluctuated acute mental disorder which happens several days after operation. It concludes consciousness, cognition, direction, feeling, mental action, etc.II. Postoperative mental state changesl10 times in the elderly with cardio

13、vascular surgeryl0.02-0.07% in patients without neurosurgery or cardiovascular surgery l4.8% in 1980s，1.5-3.0% in 1990sSurgical types Morbidity（）（）Aortic aneurysm 46Open heart surgery 777Hepatic or lung transplantation 50Great orthopedics surgery 1341Upper abdominal surgery 717Morbidity of postopera

14、tive mental disorderSurgery type Cases Mental morbidity disorderGeneral surgery 221 34 General surgery 221 34 15.3815.38Orthopedics 17 Orthopedics 17 2 11.762 11.76Urinary surgery 14 1 Urinary surgery 14 1 7.147.14Lung surgery 58 Lung surgery 58 8 13.798 13.79Open heart surgery 70 23 Open heart surg

15、ery 70 23 32.8632.86Total 380 Total 380 68 17.8968 17.89SICU(2019,11-2019,3) 380 elderly postoperative patients not including neurosurgery, hepatocirrhosis, aged dementia in Renji Hospital Related factorsX2PAge0.24560.6202Gender0.83150.3618General surgery0.57950.4465Orthopedics surgery0.22260.6371Ur

16、inary surgery0.39680.5288Lung surgery0.07830.7796CABG 17.4254 0.0001With hypertention4.9644 0.0259With Diabetes mellitus6.7109 0.0096Perioperitive hypotention or hypoxemia 35.3916 0.0001Postoperative glycemia0.21540.6426Related factors analysisType Case Mental disorder morbidity(%) Coronary bypass 2

17、01 29 14.3*Valve replacement 104 4 3.85Total 305 33 10.82*Compared to VR group P0.05Multi-centers study by Renji Hospital and other three hospitals in PudongHospitalCasePOCDmorbidity Renji32721.9% Pudong Peoples38923.7% 7th Peoples401435.0% Gongli251040.0%Total1354029.6%5 patients with postoperative

18、 delirium (7%) Morbidity of POCDRelated factors NumberPOCDmorbidityGender Male672131.3%Female681927.9%Age656940820.0%7074361027.8%75592237.3%Related factors No POCDmorbidity Surgerytype Abdominal surgery712338.0%Orthopedics surgery28725.0%Urinary surgery14321.4%Genecology surgery9333.3%Others13430.8

19、%Duration of perioperative hypotension10min11763.6% 10min231147.8%No1012221.8%Anesthesia Spinal36719.4%General842833.3%Epidural+General15533.3%Related factors NoPOCD morbidity Anesthesia duration 2h701724.3%2h4h431432.6%4h22940.9%Perioperative hemorrhage 500ml962324.0%500ml391743.6%EducationIllitera

20、te411331.7%Elementary 471429.8%Junior 27933.3%Senior or high level20420.0% LOGISTIC AnalysisRisksSCOREPRisksSCOREPGender0.1340.715Hypertension1.2700.260ASA0.6520.132Education1.0440.307Body weight0.3650.55Abesthesia types1.7911.181Age4.1440.042*Anesthesia duration3.1570.076Smoking0.4030.526Operation

21、types1.0150.314Drinking0.2650.407Perioperative hemorrhage3.2800.070DM0.0560.813Perioperative hypotension duration4.3610.037 *Probability equation：P=e2.431A+0.094B+5.819/(1+ e2.431A+0.094B+5.819)P=POCD morbidity,A=Perioperative hypotension duration, B=age Morbidity of POCD(8 countries, 13 medical cen

22、ters, 1218 cases)Pediatric open heart surgery 2545Middle aged with non-cardiac surgery 19Elderly non-cardiac surgery(within one week postoperative) 25.8%B. Etiology 1.high aged 2-10 folds in elderly patients(65yr) compared to youth Seymour found the patients aged over 75 yr with 3 folds compared to

23、the patients within 65-75 yr 2.Hypertension and DM High risk of POCD in elderly patients with preoperative DM or hypertension. which usually companied with cerebrocardial disease The metabolic disorder caused by DM ,operation, hypotension, trauma and stress may induce brain damage3.Cerebrocardial di

24、seases More morbidity of POCD in elderly patients with preoperative cardiac infarction and stroke.It may be related to the damage of cerebral vessels auto-regulation.Carotid stenosis is always combined with other cerebrocardial diseases which results in POCD when hypotension. 4.Abuse of Alcohol or d

25、rugs Long time bibulosity or drug abuse like benzodiazepines or anticholinergics，which increase the aged POCD5.Operation and anesthesia CABG is with high morbidity of POCD which may related to the bypass duration, low temperature, metabolism-blood matching, recovery time, gas embolusLarge orthopedic

26、s surgery is with high risk of POMD which caused by fat embolus.Anesthetics may affect CNS like anticholinergics, ketamine, etomidate, NO, halothaneIts the management not anesthesia type that influence the POCD6. Perioperative physical changes During operation：hypoxemia,hypotension, large blood loss

27、, transfusion, over ventilation, low PaCO2, CABG, et Postoperation：hypoxemia,hypotension, infection, electrolyte disorder, low or high pH, malnutrition7. Mental factors and environmentover nervous or anxiety arouse POCDBad environment cause insomnia even trepidation, Wilson reported that the morbidi

28、ty of POCD is -6 folds in ICU than in common wards8. GenesApoE participate the fat metabolism, cholesterin balance and growth and rehabilitation of nerve system, it even related to the plasticity of hippocampi and action of acetylcholine transfer enzymes. Its reported that ApoE is related to the POM

29、D after CABGMutation of cholecystokinin (CCK) gene may related to the POMDC. Mechanism and PathologyPOCD may related to disturbance of the CNS, endocrine system and immunity systemMany factors combined degeneration in elderly patients result in POCD Changes of CNS in aged peopleMorphologyBrain weigh

30、tNeuron number Complex of dendirtesSynapse number astrocytemicrogliocyte PhysiologyBrain blood flow 1020%，but it matches the brain oxygen metablosmVessels auto-regulation may exist and reaction to CO2 or hypoxemia is normalBiochemistryNeurotransmitters like DA、5HT、Ach、GABA changeCognitionReaction ti

31、me prolongCognition procedure prolongadapt abilityShort memory 2.Brain damageNeuron-specific enolase (NSEand S-100 protein may relate to glia damageIts reported that the NSE and S-100 increased after CPB3. Abnormity of central nerve transmitters 5-HT and NE: study, sleeping, awake.The drop of its le

32、vel may related to the POMDGlutamicGluand GABA: Main exciting and inhibiting transmitters in brain Ach : notice, memory, sleeping.Anticholinergics may decrease it4.Abnormity of hypothalamus-pituitary-adrenal cortex axis and immunityStress and trauma will cause the activation of hypothalamus-pituitar

33、y-adrenal cortex axis which increase the glucocorticoid level and release of inflammatory cells like IL-1,IL-2,IL-6, and -TNF. Neurotransmitters like Ach, 5-HT and NE will be influenced then.D. Clinical signsPOCD most occurs within 4d, especially in night.Major signs are abnormity of consciousness,

34、cognition and mental action. Patients are always suffered with bad judging, less logistic and 70% with illusion or hallucinationClinical differentiation:Mania type Excitement of sympathetic nerve, alert to stimulus and more movementDepression type Poor reaction to stimulus and timid activityMixed ty

35、pe fluctuated between the above two types E. diagnosis 1. Clinical signs and mental assessment tables Patients with mania type are easy recognized, but it is hard to distinguish the another type. The objective assessment methods will be helpful then. Most used as following: Confusion Assessment Meth

36、od，CAM Intensive Care Delirium Screening Checklist2. CT and EEG1 CT is important for distinguishing the hemorrhage, infarction or other organs disorder2 EEG is helpful to diagnose the POMDRhythm of brain waves becomes lower, especially the wave, it related to the damage level.Since such changes are

37、also seen in the high aged or dementia people, the EEG should be read dynamically.3. laboratory Carbamide, glucose, electrolytes, hepatic function, artery gas analysis, cell account, germiculture, EKG, chest X-ray, etc. should be taken for excluding other diseasesF. Prevention 1. Enough preoperative

38、 preparation, including psychology comfort 2. Chose right operation types and anesthetics 3. Maintain suitable anesthesia depth, keep the circulation stable and supply enough oxygen 4. Careful postoperative monitoring, effective analgesia, prevent respiratory failure, avoid disturbance of pH and ele

39、ctrolytes, give vitamin, treatment of infection G.Treatment1.General oxygen inhaling, keep the stable circulation, treat the disturbance of pH and electrolytes, supply vitamin and amino acids2.drugs Droperidol, benzodiazepines, propofol, chlorpromazine, etc.3. psychology comfort by relatives and com

40、munication will be good for the depressed patientslIII. Influence of anesthesia on memory functionlMidazolam：activity of GABAA receptors, arouse antegrade amnesia ,large dose with retrograde amnesia lKetamine：interdiction to NMDA receptors, inhibit neuron nicotine receptors. It damage the memory aft

41、er abdominal injection in ratslPropofol：Reduce the number of GABA neurons, it is disbennifit growth of nerve system, damage the memory function in rats, low dose with antegrade amnesia , and high dose with retrograde amnesia Halothane：antegrade amnesia ，reinforce the memory of parry trainingEnflurane：reinforce the study of rats in 8 walls labyrinth *Nerve action affected for 5hr after halothane or enflurane inhaled for 3.5