Vijaya N.R.Gottumukkala,M.B., B.S., M.D.(Anes), F.R.C.A.

座長

稲田 英一　先生

順天堂大学医学部麻酔科学・ペインクリニック講座　主任教授大学院医学研究科麻酔科学・疼痛制御学　教授

演者 ※同時通訳付き

共催公益社団法人 日本麻酔科学会コヴィディエンジャパン株式会社

Professor, Department of Anesthesiologyand Perioperative Medicine,Division of Anesthesiology and Critical Care,The University of Texas MD AndersonCancer Center, Houston, TX

2019年5月30日（木）12：00～ 13：00

第17会場神戸国際会議場 3F国際会議室

日本麻酔科学会第66回学術集会共催セミナー【L1-17】

学術集会の事前参加登録者に限り、共催セミナーの事前予約が可能です学術集会Websiteよりご予約くださいhttp://www.congre.co.jp/jsa66/registration.html

Beyond Enhanced Recovery After Surgery : Improving Brain Health

Vijaya N.R. Gottumukkala, M.B., B.S., M.D.(Anes), F.R.C.A.

Professor, Department of Anesthesiology and Perioperative Medicine,Division of Anesthesiology and Critical Care,The University of Texas MD Anderson Cancer Center,Houston, TX

Beyond Enhanced Recovery After Surgery:Improving Brain Health

Enhanced Recovery Programs （ERP） are widely utilized in surgical and perioperative practices around the world to minimize symptom burden, enhance functional recovery, minimize complications and reduce length of stay after surgery. However, to improve long term perioperative outcomes and to evolve ERP as the paradigm of value based care in perioperative practice our specialty has to focus on minimizing preventable complications and to focus on key topics in high risk patients. Postoperative delirium （POD） in the elderly is common and is associated with significant mortality and morbidity, including cognitive decline.

Delirium is a clinical condition characterized by disturbances in consciousness, orientation, memory, thought, perception, and behavior. It is acute in onset and follows a fluctuating course. It occurs in hyperactive, hypoactive, or mixed forms in up to 50% of elderly hospital inpatients. Patients with pre-existing dementia and other neurocognitive deficits are at a higher risk for POD. POD is independently associated with significant increases in functional disability, length of hospital stay, rates of admission to long-term care institutions, rates of death, and healthcare costs.1 Postoperative delirium is the most common post-operative complication in older adults and represents a medical emergency that requires immediate assessment and treatment.2 In one study the five year mortality following delirium was 7.35 fold greater than patient with similar covariates, who did not have delirium.3 Between 2000 and 2050, the proportion of the world's population over 60 years will double from about 11% to 22%. The absolute number of people aged 60 years and over is expected to increase from 605 million to 2 billion over the same period.4,5 Approximately 53% of all surgical procedures are performed on patients over the age of 65. It is estimated that approximately half of the population over the age of 65 will require surgery once in their lives6. These numbers are sobering and one can estimate the tremendous cost and burden that will be placed on a healthcare system that remains far from adequate in meeting such a demand.

Although many factors may contribute to post-operative delirium, in the high risk patient- particularly the elderly and those with diminished cerebral or cognitive reserve （the vulnerable brain）, inadequate intraoperative cerebral blood flow （CBF） due to hypotension, and deep levels of anesthesia are some of the potentially modifiable factors that can

contribute to delirium.7 Circumstantial evidence for this hypothesis is that significant reduction of regional and whole CBF are found in critically ill delirious patients. Moreover, improvement in rCBF values are seen after recovery from delirium.8 Furthermore, cerebral hypoperfusion is also found in geriatric patients with dementia.9 Intraoperative sedation levels are also possible modifiable risk factor for postoperative delirium. Monitoring depth of anesthesia （DOA） has been proposed to rationalize the use of anesthetic drugs, and several studies suggest it may be useful to decrease postoperative delirium.10

In conclusion, closely monitoring intraoperative depth of anesthesia and cerebral perfusion in high risk patients undergoing major surgery, and evaluating them postoperatively for delirium could help us better understand the pathophysiology to design intervention strategies to minimize the risk for postoperative delirium.

1. Cole MG. Delirium in Elderly Patients. The American Journal of Geriatric Psychiatry. 2004; 12(1):7-21.2. Cascella M, Muzio MR, Bimonte S, Cuomo A, Jakobsson JG. Postoperative delirium and postoperative cognitive dysfunction: updates in pathophysiology,

potential translational approaches to clinical practice and further research perspectives. Minerva anestesiologica. 2017.3. Moskowitz EE, Overbey DM, Jones TS, et al. Post-operative delirium is associated with increased 5year mortality. The American Journal of Surgery. 2017;214(6):1036-1038.4. WHO. Ageing and life-course. 2014.5. Cole MG. Delirium in Elderly Patients. The American Journal of Geriatric Psychiatry.12(1):7-21.6. Yang R, Wolfson M, Lewis MC. Unique Aspects of the Elderly Surgical Population: An Anesthesiologist’s Perspective. Geriatric Orthopaedic Surgery &

Rehabilitation. 2011;2(2):56-64.7. Burkhart CS, Rossi A, Dell-Kuster S, et al. Effect of age on intraoperative cerebrovascular autoregulation and near-infrared spectroscopy-derived cerebral

oxygenation. Br J Anaesth. 2011;107(5):742-748.8. Yokota H, Ogawa S, Kurokawa A, Yamamoto Y. Regional cerebral blood flow in delirium patients. Psychiatry and Clinical Neurosciences. 2003;57(3):337-339.9. Caplan GA, Lan Z, Newton L, Kvelde T, McVeigh C, Hill MA. Transcranial Doppler to Measure Cerebral Blood Flow in Delirium Superimposed on Dementia. A Cohort Study. Journal of the American Medical Directors Association. 2014;15(5):355-360.10. Lima MF, Mondadori LA, Chibana AY, Gilio DB, Giroud Joaquim EH, Michard F. Outcome impact of hemodynamic and depth of anesthesia monitoring during

major cancer surgery: a before–after study. Journal of clinical monitoring and computing. 2018.