May Journal Club FY19

[Kristen Horsman]

This month's journal club is presented by Dahlia Rouchon. She chose an excellent article that discusses cognitive impairment in older adults undergoing surgery with anesthesia.

Here is a link to the article.

The questions to answer are:

1. Have you had family members express concern with post operative cognitive decline?
2. How often do you use IA in elderly population for ambulatory cases?
3. What benefit have you seen with propofol TIVA in elderly population?

[Jennifer Hannon]

1. I've had family members express concern with memory loss in the preop questions. Also, Moms in my group ask me about cognitive development and anesthesia safety in their babies. Most start with an anecdote they've heard and then relate that to their loved one. I try to report the statistics, and report what the experts like AAP and NIH have recommended.

2. I ambulatory cases, Propofol is very nice. I usually use that when I can for all populations. Sevo is the ambulatory inhalation agent I would choose.

3. Propofol is short-acting. While fat increases in the elderly, it's not that significant after age 40, and so redistribution of a lipid-based drug is managed with timely anesthesia, and establishing a good steady-state infusion. It's the slower circulation to address too, but a little goes a long way in the elderly, and so I see a benefit as not needing as much Propofol for elderly patients and still achieving good anesthesia and timely wakeups.

[Jackie Howell]

1. In my experience I have not had families express concern about this in the preoperative setting. I have found myself informing family members on what to expect in the elderly patient in the days to come after a general anesthetic.
2. I would estimate I use IA 75% of the time for ambulatory cases.
3. I've experienced that elderly patients recover more quickly with a primary TIVA anesthetic. Regardless of IA or propofol TIVA, I always try to implement BIS monitoring so I can minimize the anesthetic exposure to the patient.

[kel]

I have not had family members express concern with post op cognitive decline but I tend to talk about this subject during my consent conversation with my very old clients
I also use Propofol + BIS as the primary anesthetic for most ambulatory cases on my elderly clients
There have been a significant number of times that clinically the elderly client seemed to be very alert and awake shortly after a TIVA

[klinden]

I haven't had family ask, but I have had pts ask.
2. I don't routinely use IA for elderly pts.
3. I haven't found any difference between using Des and using propofol TIVA.

[Ben Waldbaum]

1. Have you had family members express concern with post operative cognitive decline?
Rarely

2. How often do you use IA in elderly population for ambulatory cases?
There is no data to support better cognitive outcomes with TIVA. I would only use TIVA if there is an indication for it besides the concern of post operative cognitive decline

3. What benefit have you seen with propofol TIVA in elderly population?
The study says explicitly the minor effect may be from surgery, from the disease process, or anesthesia. And it definitely does not pin point an anesthestic agent. It does, however, say one should not change their practice based on this study. The data is not high level evidence.

[kty67]

1. My father-in-law had open heart surgery at age 79 and from that moment his cognitive status declined significantly. All family members are now scared to have anesthesia and call me with their concerns. I thought it was more due to a procedure.
2. I use Propofol infusion a lot in ambulatory surgery and endo. But for much older population, I think it drops their BP much more than IA, so I like Sevo for older patients.
3. I like to use Propofol in general for any age population, patients wake up much smoother and happier.

[Sarah Rollison]

1. Have you had family members express concern with post operative cognitive decline?

- I have had a few patient family members who have expressed concern for this, but usually this was only with patients who had previously experienced postoperative cognitive dysfunction. Many times they request that we use short acting agents to prevent any issues after surgery, however I am quick to ensure them that there is a possibility that all agents, and potentially the anesthetic/surgical exposure can be the cause for dysfunction afterward. In certain instances, regional anesthesia was opted for instead.

2. How often do you use IA in elderly population for ambulatory cases?

- I frequently use propofol infusion for ambulatory elderly patients, however I use it in conjunction with an anesthetic gas. Although I like the idea of using less gas, I have also seen a severe hemodynamic compromise with propofol infusion in these patients. I do also like to use a BIS in these cases especially if available, as sometimes hemodynamic monitoring may not accurately reflect depth of anesthesia (i.e. beta blockade).

3. What benefit have you seen with propofol TIVA in elderly population?

- I find that in the elderly population it is easier to get an amnestic/anesthetic effect with less drug, and because of this, the termination of action is brisk with propofol I like that it allows them a faster wake up and a smoother emergence from anesthesia.

[angie brooks]

1. Have you had family members express concern with post operative cognitive decline?
There have been times that I have had families question the probability of cognitive issues post op. We have the discussion about possibilities and duration depending on length of surgery/anesthetic etc. This is usually the case when there is already an issue with their declining cognitive state.
2. How often do you use IA in elderly population for ambulatory cases?
I use IA in most cases that call for a GA.
3. What benefit have you seen with propofol TIVA in elderly population?
I was involved in study involving elderly patients with hip fractures that were given either spinal/propofol or GETA with inhalational. There was a slight improvement in the population that received spinal/propofol.

[Jocelyn Datud]

1. Rarely do I get patients who ask about post-operative cognitive disorder. Most of the time, the patients or family members who inquire about it are those that experienced it before.
2. I use inhalation agent most of the time together with BIS. I remind my self that for this type of population, less is more.
3. In ortho cases, it is amazing to see how spinal and propofol works great with the geriatric population.

[C. Velarde]

1. I have come across some family members that are concerned about post op cognitive function. I discussed with them what is baseline for the patient and tell them little if any change will occur. I do let them know that pain meds can also affect their mental status as well as sun down factors in a unit or lack of sleep depending on the constant vital signs /blood work necessary while in the hospital. I let the family and patient know what the potential possibilities are so the do not blame an anesthetic alone for post op confusion/ irritability.
2. I do use a IA when giving GA. BIS is a good monitoring system to give less anesthetic.
3. Propofol and regional blocks seems to work well in the elderly population. Sometimes a minimal dose of propofol goes a long way as well as some fentanyl.

[Kim Hall]

1. I have only been asked a few times about post op cognitive function. I agree that those who do ask have baseline cognitive decline or previously experienced such as in the ICU setting.
2. I often use IA in the elderly population for ambulatory cases.
3. I agree that the propofol TIVA allows for faster recovery time.

[Robin Boynton]

1. I have not had any family members express any concern about cognitive decline after anesthesia, but I have had a few patients ask about it.

2. More and more I have been using Tiva in all ambulatory patients...especially those who present with dementia.

3. In the elderly population I have seen a smoother emergence and often times faster than with IA.

[Chuck Eder]

My uncle had shoulder surgery a few years ago. He had regional plus GA for the procedure (not sure if he had volatile or TIVA) He complained of some short term memory loss for approximately 6-9 months post op.
I typically use IA in most patients unless not indicated. It seems there is not a lot of evidence to make you use one technique as opposed to another per the article.

TIVA can sometimes provide for a smoother wake up , especially with those cases that last 1-3 hours. Usually don't need as much of a dose for the elderly population.