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DETERMINING THE DEGREE AND STRUCTURE OF COGNITIVE CHANGES AFTER OPERATIONS WITH GENERAL ANESTHESIA AND THEIR CORRECTION
Dubivska S.,
Doctor of Medical Sciences, Associate Professor, Professor of the Department of Emergency Medicine, Anesthesiology and intensive care Kharkov National Medical University Hryhorov Yu.,
Doctor of Medical Sciences, Professor, Professor, Department of Surgery No. 1, Kharkov National Medical University
Viedienieva R.
Doctor neuropathologist, head of the aviation medicine laboratory Ivan Kozhedub Kharkov National Air Force University
Abstract
With increasing life expectancy and increasing the number of elderly people, the number of surgical interventions in patients older than 60 years is growing. Surgery performed under general anesthesia is a serious risk factor for postoperative cognitive dysfunction. The purpose of this study is to determine the degree and structure of the impact of general anesthesia on the state of cognitive function of patients of different ages with the subsequent development of methods for its correction in patients with acute surgical pathology.
The results of changes in the degree and structure of cognitive function in patients with a surgical profile after surgery under general anesthesia obtained during the study allowed forming a method of correction of these disorders. It includes the appointment of neuroprotective drugs according to the appropriate scheme. Patients 30 minutes before surgery, again 12 hours after surgery and daily for 5 days intravenously, citicoline is administered. The treatment improves the state of cognitive function and restores the preoperative level in the shortest time. This is especially important in the elderly and senile.
Keywords: anesthetic, surgery, anesthesia, cognitive function, neuroprotection.
With increasing life expectancy and increasing the number of elderly people, the number of surgical interventions in patients older than 60 years is growing. Surgery performed under general anesthesia is a serious risk factor for postoperative cognitive dysfunction [13].
Methods of prevention and treatment of postoperative cognitive dysfunction continue to be developed, and it happens in three directions: protection of the brain during exposure to factors (cerebroprotection), restoration of brain function in the early period after exposure to a harmful factor (cerebroresuscitation) and long-term recovery of brain function. ].
Correction of cognitive functions in the post-anesthesia period is the final link in the general therapy of postoperative cognitive dysfunction after measures for its prevention in the pre- and intraoperative period. To prevent and treat CNS damage, it is not enough to affect neurons alone, because the protection of brain tissue re-
quires the protection of all cells, including glia and vascular endothelium. In the early postoperative period, changes in the cognitive sphere of varying severity are detected in approximately 30% of surgeries performed under general anesthesia, which are observed in 10% of patients within three months [4-16].
Under general anesthesia in all age groups are characteristic changes, among which should be noted changes in brain perfusion, intracranial pressure and other brain functions, neurotoxic effects with impaired synaptogenesis, induction of neurodegeneration, and stimulation of neuronal apoptosis. As a result, these changes can lead to the subsequent emergence of various disorders of higher brain activity. The nature of postoperative changes in the cognitive sphere depends on the type of anesthesia, somatic and neurological status, as well as the age of the patient. Postoperative cognitive dysfunction is manifested mainly by disorders of
memory, thinking, speed and logic, difficulty concentrating, reactivity. These changes reduce mental performance, mood, adaptogenic traits [10, 11].
The purpose of this study is to determine the degree and structure of the impact of general anesthesia on the state of cognitive function of patients of different ages with the subsequent development of methods for its correction in patients with acute surgical pathology.
The study was conducted in surgical departments of various profiles on the basis of the Kharkov City Clinical Hospital of Ambulance and Emergency Care. prof. OI Meshchaninova. All patients received standard intravenous premedication. Surgery was performed under general multicomponent anesthesia with artificial lung ventilation using propofol and fentanyl.
All patients enrolled in the study signed an informed general consent form to consent to participate in the study. The research is a fragment of the research work of the Department of Emergency Medicine, An-esthesiology and Intensive Care of the Kharkov National Medical University of the Ministry of Health of Ukraine.
To achieve this goal, we conducted a study of the cognitive sphere in young, middle, elderly and senile patients with acute surgical pathology before surgery and for 1, 7, 30 days after surgery compared to the pre-operative period.
Research methods.
Cognitive research: MMSE scale, clock drawing test, "10 words" test, battery of tests for frontal dysfunction, Schulte method. Patients were acquainted with the data about their disease, the amount of planned surgery, possible complications. All patients underwent a full set of preoperative examination according to the clinical protocol.
The exclusion criteria were:
- Repeated surgery (twice patients were not included in the study);
- Diseases of the central nervous system (including infectious, degenerative, metabolic, oncological, etc., as well as traumatic brain injury, epilepsy, psychosis);
- Taking tranquilizers, antidepressants, drugs;
- Drug, drug and alcohol dependence;
- Development of excitation of the central nervous system in the postoperative period.
Results.
Changes in cognitive function in the preoperative period. In young and middle-aged patients in the pre-operative period, according to MMSE, the rate is below normal by 9.0%, elderly patients by 23.3%. The indication on the clock drawing test in young and middle-aged patients remained within the norm, in elderly patients below the norm by 10.0%. According to the FAB scale, in young and middle-aged patients the indicators are lower by 5.5%, in the elderly - by 16.6% of the norm. According to the method of AR Luria data of young and middle-aged patients were below normal by 15.0%, elderly - by 40.0%. A study using the Schulte method indicates that young and middle-aged patients were within normal limits, and elderly patients - 16.6% below normal.
During the study, we obtained data indicating a decrease in the postoperative period of cognitive function
in patients with urgent surgical pathology under general anesthesia, in all age groups, which may persist for a long time. Taking into account the literature data on the pathogenetic effect of general anesthesia on the state of the cognitive sphere, the results of our study, a scheme for the use of citicolic in a set of therapeutic measures was formulated. Taking into account the data of the obtained research and literature data, we developed a method and obtained a Patent for a utility model № 89336 "Method of correction of postoperative cognitive dysfunctions" (2014) [17].
In the course of the study using the appropriate schemes for the correction of cognitive changes, we obtained the following results.
On the 1st day in the postoperative period in the study of the cognitive sphere on the MMSE scale in young and middle-aged patients, the indicators were reduced by 6.5% compared with the preoperative period and normalized on the 7th day of the study. In elderly patients on the 1st day after surgery, MMSE values decreased by another 16.7%, which was observed on the seventh day, and almost recovered to the operative level on the 30th day.
Clock drawing test scores in young and middle-aged patients on day 1 of the study were reduced by 10.0% and normalized on day 7 after surgery. In elderly patients, the clock drawing test data decreased by another 20.0% on the 1st day after surgery and on the 7th day the decrease was within 10.0%, with subsequent normalization by 30 days.
According to the FAB scale, in young and middle-aged patients the decrease was another 5.6% from the previous ones, and recovered to the operative level on the 7th day and became within the norm on the 30th day. And in elderly patients the decrease on the FAB scale by 1 day was greater than the previous by 9.8%, which was further observed on the 7th day of the study and almost recovered to the preoperative level by 30 days, but were below the standard norm by 22.2%.
According to the method of A.R. Luria patients at all stages of the study required from 6 to 9 repetitions, there were from 2 to 5 errors depending on age. In young and middle-aged patients, this figure decreased by 24.6% and returned to pre-operative level on day 7. In the elderly, the reductions were significant and partially resumed on day 30 of the study.
Patients at different stages of the study showed an increase in the number of errors and a change in the average value of the degree of ability to work according to the results of Schulte tables. In young patients, the indicators were restored after 7 days, in elderly patients after 30 days differed from preoperative values by 11.2%.
Conclusions.
The results of changes in the degree and structure of cognitive function in patients with a surgical profile after surgery under general anesthesia obtained during the study allowed forming a method of correction of these disorders. It includes the appointment of neuro-protective drugs according to the appropriate scheme. Patients 30 minutes before surgery, again 12 hours after surgery and daily for 5 days intravenously, citicoline is
administered. The treatment improves the state of cognitive function and restores the preoperative level in the shortest time. This is especially important in the elderly and senile.
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