The Geriatric Surgical Patient:
anesthetic technique, stress
response, and postoperative
cognition
Stacie Deiner M.D. Assistant Professor of
Anesthesiology, Geriatrics and Palliative Care, and
Neurosurgery
The Icahn School of Medicine at Mount Sinai NY, NY
GEMSSTAR Project
• Arose from my experience with the Dexlirium Project
• Found a low incidence of delirium in our population
• But many patients received Total IntraVenous Anesthesia
(TIVA) NOT gas
• TIVA responsible for our findings?
• If so, what would be the mechanism?
TIVA
• Suppresses the stress response
• Increased stress response with worse cognitive
outcomes in stressed geriatric rats (Chapman TR et al J Neurosci
2010)
• Caveats
– Delirium and Postoperative Cognitive Dysfunction
(POCD) are not the same
– People are not animals
– Older patients are not the general population
Human Alzheimer and Inflammation
Biomarkers after Anesthesia and
Surgery.
Tang, Junxia; Baranov, Dimitry; Hammond, Mary; Shaw, Leslie;
Eckenhoff, Maryellen; Eckenhoff, Roderic
Anesthesiology 2011.
© 2011 American Society of Anesthesiologists, Inc. Published by American Society of Anesthesiologists, Inc.
2
Liu et al
• propofol v. sevoflurane v. epidural v. control
• 2 years after anesthesia, AD cases same
between the groups.
• progressive MCI was greater in the
sevoflurane group than in the control group.
Liu, Y et al Am J Med Sci 2013
Specific Aims
1. Compare the stress response by measuring
serum norepinephrine (NE) and cortisol in GS
vs. TIVA groups Hypothesis: TIVA will be
associated with a lesser stress response
2. Determine the incidence of delirium and POCD
in patients who receive GS vs. TIVA Hypothesis:
TIVA will be associated with a lower incidence of
delirium.
Study design
• Study design: Prospective cohort study (not randomized)
• Subjects: >68 years old for major elective noncardiac
surgery. Identified by the computerized scheduling
system at Mount Sinai Hospital
• Outcomes: Delirium, POCD, postoperative complications
• Measured at screen, 3 and 6 months.
• Predictors:
• Primary: anesthetics technique (GS vs. TIVA),
• Secondary: serum norepinephrine, cortisol
GEMSSTAR: Gas vs. TIVA
Similarities: gender, diabetes, CVA, CAD, Renal
disease
Differences:
Age 76.3 vs. 73.5 p=.021
ASA status: Gas group III> TIVA p=.021
Much higher peak norepinephrine (341 vs. 136
vs. pg/ml) p<.001 and cortisol (31.8 vs. 4.8
mcg/dl) p <.001
Delirium
• Delirium in the recovery room
– 3.3% of Gas group
– 8.1% of TIVA group
– p=.622
• Postoperative Delirium (days 1-3)
– 22.2% of Gas group
– 15% of TIVA group
– p= .556
Modeling causes of Delirium
• All variables with univariate association <.2
– Baseline MMSE
– Recovery room delirium
– Diabetes
– ASA
– gender
– peak norepinephrine levels
– surgical duration
– Plus variables with clinical relevance: e.g.age
Model to Predict Delirium Including Diabetes,
Serum Peak Norepinephrine, and
Surgical Duration
The Plan
• Completed recruitment goal:76 patients
• Complete cognitive assessment at 3 and 6
months
• Analysis of blood samples for ApoE genotype
Include Apo E genotype in the model
• Examine immediate stress response and long
term cognition
Next research questions
• The role of DM in delirium
– Blood brain barrier dysfunction
– Interaction with stress response
– Microvascular disease
• The relationship between short term cognitive
disturbance and long term cognitive outcomes
Thank you
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American Geriatrics Society
NIA GEMSSTAR program
Mt. Sinai Alzheimer’s Disease Research Center
Columbia University Mailman School of Public
Health MS/POR Scholars Program
• Mentor: Dr. Mary Sano
• Dr. Jeffrey Silverstein
• Mt. Sinai Research Coordinators Team
GEMSSTAR Program
• Grants for Early Medical/Surgical Subspecialists’
Transition to Aging Research (R03) Grants for Early
Medical/Surgical Subspecialists’ Transition to Aging
Research (R03)
– Supported by NIA
– Matched by American Geriatrics Society and Foundations for
Anesthesia Education and Research
• Training award
• Pilot study
• Education
– Columbia Mailman School of Public Health Department of
Biostatistics
– Master’s in Patient Oriented Research