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CASE REPORT
Year : 2019  |  Volume : 22  |  Issue : 6  |  Page : 877-880

Postoperative cognitive dysfunction developed in donor nephrectomy- Case report


1 Department of Anesthesiology, Health Sciences University, Gazi Yaşargil Training and Research Hospital, Diyarbakır, Turkey
2 Anesthesiology, Health Sciences University, Ümraniye Training and Research Hospital, Istanbul, Turkey
3 Department of Anesthesiology, Health Sciences University, Gazi Yaşargil Training and Research Hospital, Diyarbakır; Anesthesiology, Health Sciences University, Ümraniye Training and Research Hospital, Istanbul, Turkey

Date of Acceptance20-Sep-2018
Date of Web Publication12-Jun-2019

Correspondence Address:
Dr. E T Kilic
Anesthesiology, Health Sciences University, Ümraniye Training and Research Hospital, Istanbul
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_483_18

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   Abstract 


With the effects of anesthetic drugs on all organs and systems, it is known it affects the central nervous system functions at different grades and durations beyond acute unconsciousness. This causes cognitive functions of upper brain activities to be affected at varying degrees after anesthesia. After exposure to anesthetic agents, psychomotor and cognitive functions are deteriorated for 10--12 h, with sensitive tests it was showed that this deterioration lasted for 1--2 days. It has also been reported that this process can last till 3 months. Rapid recovery and mental readiness of patients, applied general anesthesia, are important objects for anesthesiologists. Postoperative cognitive functions are assessed in order to investigate mental changes caused by anesthesia and surgery or determine the level of recovery by determining the effects of anesthetics. In this case report, postoperative cognitive dysfunction (POCD) after donor nephrectomy was aimed.

Keywords: Central nervous system, cognitive functions, mental changes, postoperative


How to cite this article:
Akelma H, Kilic E T, Salik F, Bicak E A, Kaya S. Postoperative cognitive dysfunction developed in donor nephrectomy- Case report. Niger J Clin Pract 2019;22:877-80

How to cite this URL:
Akelma H, Kilic E T, Salik F, Bicak E A, Kaya S. Postoperative cognitive dysfunction developed in donor nephrectomy- Case report. Niger J Clin Pract [serial online] 2019 [cited 2019 Jun 24];22:877-80. Available from: http://www.njcponline.com/text.asp?2019/22/6/877/260036




   Case Presentation Top


In a preoperative evaluation of a 49-year-old female patient, donor candidate for renal transplantation did not have any systemic disease and had normal biochemical, hormonal, and cognitive functions.

The patient who was taken to the operating room was monitored for noninvasive arterial pressure, spo2, heat, ECG (Mindray Beneviev T5). Initial Tension Arterial: 170/90 mmHg Sp02: 98% Apex Heart Beat: 95/min. were recorded. Anesthesia induction was performed with 2 mg midazolam, 2.5 mg/kg propofol, and 1.5 mcg/kg fentanyl. Following induction, 0.6 mg/kg rocuronium was administered intravenously (i.v) to patient and she was intubated. Anesthesia was maintained with a mixture of sevoflurane 2 MAC, 50% O2, and 50% air. The patient received 110 ml/h isotonic solution. Hemodynamic and respiratory parameters were recorded continuously. Surgery lasted about 200 min. When the surgical operation terminated, the patient was administered 2 mg neostigmine and 1 mg atropine i.v for reversal purpose. When adequate spontaneous respiration and muscle strength was reached, the patient was extubated and taken to postoperative care unit. Patient was monitored approximately for 30 min, transferred to the transplantation unit when the Aldrete review score (ADS) was 10 [Figure 1].
Figure 1: The first day scores of MMDT

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No intraoperative complications were encountered (hypotension, hypertension, or desaturation). Hourly laboratory values were within normal limits. The patient received i.v 10 mg metoclopramide and 50 mg ranitidine to prevent postoperative nausea and vomiting. Tramadol (100 mg) and 1 g of paracetamol i.v were applied in order to maintain postoperative analgesia.

At the first postoperative hour, regression was observed in cognitive functions compared with preoperative period. The patient had place and time orientation disorder, retrograde amnesia developed (did not know anything about transplantation, for example, did not have information on why the kidney was taken). Urgent consultation was made by anesthesia department. The result of mini mental state examination (MMSE) performed during the visit was found as 15/30 [Figure 2]. All cognitive functions of the patient returned to preoperative level on day 2 postoperative examination. The result of the MMSE was found to be 27/30 [Figure 3]. In routine postoperative examinations, all values were within normal limits. In the psychiatric consultation, patient evaluated as no cooperation, orientation, retrograde amnesia, and MMSE were found as 30/30. The patient was discharged when no pathology was detected in later follow-ups.
Figure 2: The second day scores of MMDT

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Figure 3: Aldrete recovery score

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   Discussion Top


POCD is a condition that occurs after the central nervous system is affected by varying amounts of time, from memory lapse to concentration and to delirium. The mechanism of POCD is not fully known. It is thought that the contributing factors are multifactorial. Development of POCD after major surgery is not uncommon. Cognitive dysfunction is not the same as delirium, encephalopathy, or change in consciousness; it can be defined as the loss of memory and intellectual abilities of the patient after the short-term effect of the surgeon. Patient's personal characteristics that increase the risk of POCD are cardiovascular risk factors such as cerebrovascular disease, undetected cognitive impairment, dementia, hypertension, diabetes, or peripheral artery disease.[1],[2],[3] We did not find any pathologic findings other than mild mix type respiratory dysfunction. No pathological findings were detected in the hourly blood gases examined in preoperative and intraoperative periods of our patient.

Surgical risk factors are surgical technique (duration of cardiopulmonary bypass and aortic cross clamping), manipulation of diseased aorta, hypotension, and hypothermia. Atherothromboembolic events are the possible etiological mechanisms of hypoxia secondary to hypoperfusion in flow area.[3] In addition, hypotension because of the venous return of the heart may occur after compression of the vena-cava due to nephrectomy position.

In our case in the preoperative period appropriate fluid replacement was administered in order to avoid the hemodynamic changes due to the inoperative nephrectomy position do not occur. No hypothermia or hyperthermia occurred in the heat follow-up in our patient and there was no finding of thromboembolism in patient in the postoperative period.

Among the factors that play role in postoperative cognitive functions are the anesthetic drugs. Propofol, which is frequently used in anesthesia induction and total intravenous anesthesia, is a hypnotic agent, which is preferred with its rapid clearance and early recovery properties. Gökpınar, et al.[4] found an increase in cognitive function scores at the postoperative 15th and 60th min in their study which they conducted on studies with propofol and N2O anesthesia applied. İzdeş et al.[5] determined 100% recovery time as 30 min according to postanesthetic performance test and orientation score after single dose propofol.

The most frequently used volatile anesthetics, desflurane, and sevoflurane have been accused by changing central nervous system activity and affecting postoperative cognitive function. Sevoflurane and desflurane are the preferred inhalation agents due to the short recovery time compared with long acting isoflurane. Chen et al. found that desflurane and sevoflurane were similar in terms of recovery of postoperative cognitive functions.[6]

In studies of Scholz et al.[7] that they compared sevoflurane with isoflurane anesthesia, in the sevoflurane and isoflurane groups, they found the time of awakening and orientation as different. Lüleci et al.[8] reported that when they evaluated and compared cognitive functions after sevoflurane and isoflurane applications, there was no difference between groups till 90th and the 120th min, significantly higher in sevoflurane group. Sevoflurane was used as a volatile anesthetic in our patient. In light of literature, we think that the first factor we should discuss in the development of POCD in our patients is sevoflurane.

Unusual anxiety, depression, euphoria, or delirium may be seen in patients in the postoperative period. Preoperative emotional characteristics of patients are the most important factor affecting postoperative emotional state.[9] Especially the stress of being organ donor, fear of surgery and death are the reasons that increase anxiety in transplantation patients. We often encounter fear of death and advanced stress in the hospital we work in. Our patient also had this situation. For this reason, we think that we can discuss this factor secondly regarding POCD status in our patient.

The majority of patients after major surgery use postoperative analgesics. When the type of analgesic is examined, opiate analgesics are used by anesthesiologist in patients.

Sevim Çelik et al.[10] stated that even though opiate use is not statistically significant in elderly patients, they caused cognitive function changes. In preoperative and postoperative 1 and 3 days, averages of MMSE scores were found to be lower in patients who use opiate than patients who use other analgesic types.[10]

However, in some studies, it was reported that postoperative opiates did not cause a statistically significant change in cognitive functions of elderly patients.[11] We believe that this factor is the third most effective factor to discuss in the present situation, despite the fact that 120 mcg of fentanyl and 100 mg of tradamol are used in our present case and the case is not elder. Despite the dose that we apply is low, opiate analgesics affect patients differently due to the genetic differences of analgesics. We think that it might mentally affect our patient. When the patient was transferred from postoperative intensive care unit, there was no sedation or mental problem. However, we think there may be a possibility of re-release later.

Radtke in another study divided the patients' activity level into two subtypes, emergence delirium and hypoactive emergence in order to determine the real incidence in the recovery room. In conclusion, inadequate emergence was found as a frequent complication. In our case presentation, we defined our patient's activity level as a POCD. Our patient did not show any signs of delirium or emergence.[12]

Cotoia in another controlled randomized study evaluated general anesthesia with bispectral index (BIS) guidance. They performed MMSE before general anesthesia and 15 min after tracheal extubation. One of our limitations is BIS control. Volatile BIS-guided anesthesia can be used in future for comparison.[13]

Antiemetics such as bronchodilators, steroids, and metoclopramide which are frequently used in lung cancer patients can cause anxiety. Drugs causing encephalopathy and delirium can also cause anxiety simultaneously.[14] The patient received i.v 10 mg metoclopramide and 50 mg ranitidine to prevent postoperative nausea and vomiting in our case. We believe this factor is the 4th most effective factor we can discuss.

MMSE is easy and widely used in measuring cognitive functions. MMSE can be measured both early and late period. Öztin et al.[15] state that recurrent postoperative MMSE measurements may be used to assess the agent used in maintenance of anesthesia. We evaluated the cognitive functions of our case by MMSE.

The neuropsychological tests used in our country are affected by cultural and language differences. For this reason, validity and reliability tests should be performed for the community that it will be used for. Gender, literacy, and age are other factors that influence neuropsychological test results. We used the MMSE test that was assessed for reliability and validity in the presence of a psychiatrist chairside of the patient.

We think that we may discuss the fear of a patient in preoperative period about death of himself/herself or recipient child, his/her emotional state stress and excessive anxiety state, volatile anesthetics used in general anesthesia applied, or opiates significantly affect cognitive functions postoperatively. According to these results, it is important to evaluate the cognitive function of the donor and recipient who will have transplantation surgery during acceptance to anesthesia by MMSE. To diagnose the emotional state, it is necessary to identify those who are under risk. It is important to provide preoperative care and postoperative care plan to prevent complications related to cognitive dysfunction.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Mashour GA, Forman SA, Campagna JA. Mechanisms of general anesthesia: From molecules to mind. Best Pract Res Clin Anaesthesiol 2005;19:349-64.  Back to cited text no. 1
    
2.
Heinke W, Koelsch S. The effects of anesthetics on brain activity and cognitive function. Curr Opin Anaesthesiol 2005;18:625-31.  Back to cited text no. 2
    
3.
Mollar JT, Cluitmans P, Ramussen LS, Houx P, Rasmussen H, Canet J, et al. Long-term postoperative cognitive dysfunction in the elderly ISPOCD1 study. ISPOCD investigators. International study of post-operative cognitive dysfunction. LANCET 1998;351:857-61.  Back to cited text no. 3
    
4.
Gökpınar AB, Öztekin S, Fırat V, Hamamcıoǧlu G, Tutan A. Propofol-N2O anestezisinin üst kortikal beyin fonksiyonları üzerine etkileri. Türk Anest Rean Cem Mecmuası 1993;21:274-6.  Back to cited text no. 4
    
5.
İzdeş S, Karabay T, Bozkırlı F, Önder M, Çelebi H. Propofol Sonrası Psikomotor İyileşme. Türk Anest Rean Cem Mecmuası 1995;23:246-351.  Back to cited text no. 5
    
6.
Chen X, Zhao M, White PF, Li S, Tang J, Wender RH, et al. The recovery of cognitive function after general anesthesia in elderly patients: A comparison of desflurane and sevoflurane. Anesth Analg 2001;93:1489-94.  Back to cited text no. 6
    
7.
Scholz J, Bischoff P, Szafarczyk W, Heetel S, Schulte J. Comparison of sevoflurane and isoflurane in ambulatory surgery. Results of a multicenter study. Anaesthesist 1996;45(Suppl 1):63-70.  Back to cited text no. 7
    
8.
Lüleci N, Erinçler T, Gül R, Kafesçiler K, Tutan A. Sevofluran ve izofluran uygulamalarından sonra anesteziden çıkış ve kognitif fonksiyonların geri dönüşü. Karadeniz Tıp Dergisi 1997;10:1-2.  Back to cited text no. 8
    
9.
Kouchoukos NT, Blackstone EH, Doty DB, Hanley FL, Karp RB, editors. Postoperative care. In: Kirklin/Barratt-Boyes Cardiac Surgery. 3rd ed. Philadelphia: Churchill Livingstone; 2003: p. 221-5.  Back to cited text no. 9
    
10.
Çelik S, Kavacık D, Nair A, Şeker N, Demirel L. Evaluation of cognitive dysfunction in elderly patients undergoing surgery. Bakırköy Med Journal 2015;11:66-73.  Back to cited text no. 10
    
11.
Krenk L, Kehlet H, Bæk Hansen T, Solgaard S, Soballe K, Rasmussen LS. Cognitive dysfunction after fast-track hip and knee replacement. Anesth Analg 2014;118:1034-40.  Back to cited text no. 11
    
12.
Radtke FM, Franck M, Hagemann L, Seeling M, Wernecke KD, Spies CD. Risk factors for inadequate emergence after anesthesia: Emergence delirium and hypoactive emergence. Minerva Anesthesiol 2010;76:394-403.  Back to cited text no. 12
    
13.
Cotoia A, Mirabella L, Beck R, Matrella P, Assenzo V, Cinnella G, et al. Effects of closed-loop intravenous anesthesia guided by bispectral index in adult patients on emergence delirium: A randomized controlled study. Minerva Anestesiol 2018;84:437-46.  Back to cited text no. 13
    
14.
Elbi H. Kanser ve psikiyatrik sorunlar. Ege Psikiyatri Sürekli Yayınları 1997;2:173-87.  Back to cited text no. 14
    
15.
Öztin CÖ, Topal A, Duman A. Remifentanil Sevofluran Azotprotoksit anestezisinde Propofol ve Tiyopentol'un Orta ve ileri yaştaki kadınlarda Derlenmeye ve erken kognitif fonksiyonlara etkisi. Türk Anest Rean Der Dergisi 2002;30:209-17.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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