Jan Stygall

This article describes a systematic review on the research into postoperative cognitive dysfunction (POCD) in noncardiac surgery to ascertain the status of the evidence and to examine the methodologies used in studies. The review demonstrated that in the early weeks after major noncardiac surgery, a significant proportion of people show POCD, with the elderly being more at risk. Minimal evidence was found that patients continue to show POCD up to 6 months and beyond. Studies on regional versus general anesthesia have not found differences in POCD. Many studies were found to be underpowered, and a number of other methodologic difficulties were identified. These include the different types of surgery in studies and variations in the number and range of neuropsychological tests used. A particular issue is the variety of definitions used to classify individuals as having POCD.

BACKGROUND: Good postoperative recovery is increasingly recognized as an important outcome after surgery. The authors created a new Post-operative Quality Recovery Scale (PQRS) that tracks multiple domains of recovery from immediate to long-term time periods in patients of varying ages, languages, and cultures. METHODS: The parameters of importance to both clinicians and patients were identified. After an initial pilot study of 133 patients, the PQRS was refined. It consists of six domains (physiologic, nociceptive, emotive, activities of daily living, cognitive, and overall patient perspective). An observational study of 701 patients was performed with the refined PQRS to assess its capacity to evaluate and track recovery and to discriminate between patients. It was conducted in eight countries and in five languages, involving patients more than or equal to 6 yr undergoing elective surgery with general anesthesia. Recovery was assessed before surgery and at multiple time periods postoperatively. Recovery was defined as return to baseline values or better. RESULTS: Seven hundred one patients completed the PQRS. Mean completion time was 4.8 (SD 2.8) min. Recovery scores improved with time. Physiologic recovery was complete in 34% of subjects by 40 min. By the third postoperative day, complete recovery was obtained in 11% of cases (all domains): 48.7% nociceptive, 81.8% emotive, 68.8% activities of daily living, and only 33.5% cognitive. Overall, 95.8% of the patients reported that they were "satisfied or totally satisfied" with their anesthetic care. CONCLUSION: The scores on the PQRS demonstrated an improvement over time, consistent with an expected recovery after surgery and anesthesia, and an ability to discriminate between individuals. Many patients had incomplete recovery by the third postoperative day.

BACKGROUND AND PURPOSE: Percutaneous transluminal angioplasty (PTA) is currently being assessed for the treatment of carotid stenosis. In comparison with carotid endarterectomy (CEA), there is evidence of an increased risk of cerebral microembolism during the procedure. We have sought evidence of any neuropsychological sequelae of carotid PTA and compared it with CEA to demonstrate the relative safety of the 2 treatment options. METHODS: The neuropsychological outcomes after CEA and PTA were compared in 2 matched groups of patients with severe symptomatic carotid stenosis, 96% of whom had been randomized in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS), at a single center. Transcranial Doppler insonation of the middle cerebral artery was used to measure cerebral reactivity in response to carbon dioxide inhalation before treatment and then to detect microembolization of the ipsilateral cerebral hemisphere and measure changes in blood flow velocity during the procedures. The performance on a neuropsychological test battery administered before, 6 weeks after, and 6 months after the procedure was compared in 20 patients undergoing PTA and 26 having CEA. RESULTS: At 6 weeks, 5 patients in each group showed a similar decline in neuropsychological performance; global measures showed no significant difference between the 2 procedures, despite a significantly higher incidence of microemboli during PTA. Both groups showed a marked reduction in anxiety after treatment. CONCLUSIONS: The findings provide some reassurance that PTA is not associated with greater cerebral complications than CEA, despite the higher embolic load recorded by transcranial Doppler ultrasonography during angioplasty.