Wooding Denise J, Field Thalia S, Schwarz Stephan K W, MacDonell Su-Yin, Farmer Jaycee, Rajan Shobana, Flexman Alana M
Faculty of Medicine.
Department of Medicine, Vancouver Stroke Program and Division of Neurology.
J Neurosurg Anesthesiol. 2023 Jan 1;35(1):10-18. doi: 10.1097/ANA.0000000000000861. Epub 2022 Jul 14.
Perioperative complications such as stroke, delirium, and neurocognitive dysfunction are common and responsible for increased morbidity and mortality. Our objective was to characterize and synthesize the contemporary guidelines on perioperative brain health for noncardiac, non-neurologic surgery in a scoping review. We performed a structured search for articles providing recommendations on brain health published between 2016 and 2021 and included the following complications: perioperative stroke and perioperative neurocognitive disorders, the latter of which encompasses postoperative delirium and a spectrum of postoperative cognitive dysfunction. We categorized recommendations by subtopic (stroke, postoperative delirium, postoperative cognitive dysfunction), type (disclosure/ethics/policies, prevention, risk stratification, screening/diagnosis, and management), and pharmacological versus nonpharmacological strategies. We noted country of origin, specialty of the authors, evidence grade (if available), and concordance/discordance between recommendations. Eight publications provided 129 recommendations, originating from the United States (n=5), Europe (n=1), United Kingdom (n=1), and China (n=1). Three publications (37%) applied grading of evidence as follows: Grading of Recommendations, Assessment, Development, and Evaluations (GRADE): A, 30%; B, 36%; C, 30%; D, 4%. We identified 42 instances of concordant recommendations (≥2 publications) on 15 themes, including risk factor identification, risk disclosure, baseline neurocognitive testing, nonpharmacological perioperative neurocognitive disorder prevention, intraoperative monitoring to prevent perioperative neurocognitive disorders, avoidance of benzodiazepines, delaying elective surgery after stroke, and emergency imaging and rapid restoration of cerebral perfusion after perioperative stroke. We identified 19 instances of discordant recommendations on 7 themes, including the use of regional anesthesia and monitoring for perioperative stroke prevention, pharmacological perioperative neurocognitive disorder management, and postoperative stroke screening. We synthesized recommendations for clinical practice and highlighted areas where high-quality evidence is required to inform best practices in perioperative brain health.
中风、谵妄和神经认知功能障碍等围手术期并发症很常见，是发病率和死亡率增加的原因。我们的目标是在一项范围综述中，对非心脏、非神经外科手术围手术期脑健康的当代指南进行特征描述和综合分析。我们对2016年至2021年期间发表的关于脑健康建议的文章进行了结构化搜索，纳入以下并发症：围手术期中风和围手术期神经认知障碍，后者包括术后谵妄和一系列术后认知功能障碍。我们按子主题（中风、术后谵妄、术后认知功能障碍）、类型（披露/伦理/政策、预防、风险分层、筛查/诊断和管理）以及药物与非药物策略对建议进行分类。我们记录了文献的原产国、作者的专业、证据等级（如可用）以及建议之间的一致性/不一致性。八项出版物提供了129条建议，分别来自美国（n = 5）、欧洲（n = 1）、英国（n = 1）和中国（n = 1）。三项出版物（37%）采用了如下证据分级：推荐分级、评估、制定和评价（GRADE）：A，30%；B，36%；C，30%；D，4%。我们在15个主题上确定了42例一致的建议（≥2项出版物），包括危险因素识别、风险披露、基线神经认知测试、围手术期神经认知障碍的非药物预防、预防围手术期神经认知障碍的术中监测、避免使用苯二氮䓬类药物、中风后推迟择期手术以及围手术期中风后的紧急成像和脑灌注快速恢复。我们在7个主题上确定了19例不一致的建议，包括区域麻醉的使用和围手术期中风预防的监测、围手术期神经认知障碍的药物管理以及术后中风筛查。我们综合了临床实践建议，并强调了需要高质量证据以指导围手术期脑健康最佳实践的领域。
