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Introduction: Among older adults undergoing surgery, postoperative delirium is the most common complication. Cognitive impairment and dementia are major risk factors for postoperative delirium, yet they are frequently under‐recognized. It is well established that applying delirium preventive interventions to at‐risk individuals can reduce the likelihood of delirium by up to 40%. The aim of this study was to evaluate how often delirium preventive interventions are missing in patients at risk for delirium due to baseline cognitive impairment. Methods: We conducted a retrospective study using data from the observational study Perioperative Anesthesia Neurocognitive Disorder Assessment‐Geriatric (PANDA‐G) and clinical data from the University of California San Francisco delirium prevention bundle. Patients age 65+ received preoperative multidomain cognitive assessment as part of a research protocol prior to undergoing inpatient spine surgery at a single major academic institution. Results of the cognitive testing were not available to clinical teams. Using electronic medical records, we evaluated if patients who were cognitively impaired at baseline received delirium prevention orders, sleep orders, and avoidance of AGS Beers Criteria® potentially inappropriate medications. Results: Of the 245 patients included in the study, 42% were women. The mean [SD] age was 72 [5.2] years. Preoperative cognitive impairment was identified in 40% of participants (N = 98), and of these, 34% had postoperative delirium. Of patients with preoperative cognitive impairment, 45% did not receive delirium preventive orders, 43% received PIMs, and 49% were missing sleep orders. At least one of the three delirium preventive interventions was missing in 70% of the patients. Discussion: Undiagnosed preoperative cognitive impairment among older adults undergoing spine surgery is common. When cognitive test results were not available to clinicians, patients with baseline cognitive impairment frequently did not receive evidence‐based delirium preventive interventions. These findings highlight an opportunity to improve perioperative brain health care via preoperative cognitive assessment and clinical communication. [ABSTRACT FROM AUTHOR]

Background: One year after elective hip or knee total joint arthroplasty (TJA), >30% of older adults meet criteria for postoperative neurocognitive disorder. However, this is not contextualized with long‐term cognitive outcomes in comparable surgical and nonsurgical controls. We analyzed population‐based data to compare long‐term cognitive outcomes in older adults after TJA, other surgeries, and with and without arthritis pain. Methods: This was a retrospective observational analysis of United States older adults in the Health and Retirement Study (HRS) who underwent elective TJA, or elective surgery without expected functional benefits (e.g., cholecystectomy; inguinal herniorrhaphy), between 1998 and 2018 at aged 65 or older. TJA recipients were also age‐ and sex‐matched to nonsurgical controls who reported moderate–severe arthritic pain or denied pain, so that comparison groups included surgical and nonsurgical (pain‐suffering and pain‐free) controls. We modeled biennially‐assessed memory performance, a measure of direct and proxy cognitive assessments, before and after surgery, normalized to the rate of memory decline ("cognitive aging") in controls to express effect size estimates as excess, or fewer, months of memory decline. We used linear mixed effects models adjusted for preoperative health and demographic factors, including frailty, flexibly capturing time before/after surgery (knots at −4, 0, 8 years; discontinuity at surgery). Results: There were 1947 TJA recipients (average age 74; 63% women; 1358 knee, 589 hip) and 1631 surgical controls (average age 76; 38% women). Memory decline 3 years after TJA was similar to surgical controls (5.2 [95% confidence interval, CI −1.2 to 11.5] months less memory decline in the TJA group, p = 0.11) and nonsurgical controls. At 5 years, TJA recipients experienced 5.0 [95% CI −0.9 to 10.9] months less memory decline than arthritic pain nonsurgical controls. Conclusion: There is no systematic accelerated memory decline at 3 years after TJA compared with surgical or nonsurgical controls. See related editorial by Tammy Hshieh and article by Reich et al. in this issue. [ABSTRACT FROM AUTHOR]

Background: Postoperative delirium is a common postsurgical complication in older patients and is associated with high morbidity and mortality. The objective of this study was to determine whether a digital cognitive assessment and patient characteristics could identify those at‐risk. Methods: Patients 65 years and older undergoing spine surgeries ≥3 h were evaluated as part of a single‐center prospective observational cohort study at an academic medical center, from January 1, 2019, to December 31, 2020. Of 220 eligible patients, 161 were enrolled and 152 completed the study. The primary outcome of postoperative delirium was measured by the Confusion Assessment Method for the Intensive Care Unit or the Nursing Delirium Screening Scale, administered by trained nursing staff independent from the study protocol. Baseline cognitive impairment was identified using the tablet‐based TabCAT Brain Health Assessment. Results: Of the 152 patients included in this study, 46% were women. The mean [SD] age was 72 [5.4] years. Baseline cognitive impairment was identified in 38% of participants, and 26% had postoperative delirium. In multivariable analysis, impaired Brain Health Assessment Cognitive Score (OR 2.45; 95% CI, 1.05–5.67; p = 0.037), depression (OR 4.54; 95% CI, 1.73–11.89; p = 0.002), and higher surgical complexity Tier 4 (OR 5.88; 95% CI, 1.55–22.26; p = 0.009) were associated with postoperative delirium. The multivariate model was 72% accurate for predicting postoperative delirium, compared to 45% for the electronic medical record‐based risk stratification model currently in use. Conclusion: In this prospective cohort study of spine surgery patients, age, cognitive impairment, depression, and surgical complexity identified patients at high risk for postoperative delirium. Integration of scalable digital assessments into preoperative workflows could identify high‐risk patients, automate decision support for timely interventions that can improve patient outcomes and lower hospital costs, and provide a baseline cognitive assessment to monitor for postoperative cognitive change. [ABSTRACT FROM AUTHOR]

Summary: Introduction: Understanding the duration of pediatric general anesthesia exposure in contemporary practice is important for identifying groups at risk for long general anesthesia exposures and designing trials examining associations between general anesthesia exposure and neurodevelopmental outcomes. Methods: We performed a retrospective cohort analysis to estimate pediatric general anesthesia exposure duration during 2010‐2015 using the National Anesthesia Clinical Outcomes Registry. Results: A total of 1 548 021 pediatric general anesthetics were included. Median general anesthesia duration was 57 minutes (IQR: 28‐86) with 90th percentile 145 minutes. Children aged <1 year had the longest median exposure duration (79 minutes, IQR: 39‐119) with 90th percentile 210 minutes, and 13.7% of this very young cohort was exposed for >3 hours. High ASA physical status and care at a university hospital were associated with longer exposure times. Conclusion: While the vast majority (94%) of children undergoing general anesthesia are exposed for <3 hours, certain groups may be at increased risk for longer exposures. These findings may help guide the design of future trials aimed at understanding neurodevelopmental impact of prolonged exposure in these high‐risk groups. [ABSTRACT FROM AUTHOR]

Abstract: Background: During kidney transplantation, intraoperative fluid management can affect post‐transplant graft function. It is unclear whether or not central venous pressure (CVP) monitoring is required to guide fluid therapy during kidney transplantation. Methods: We compared post‐transplant graft function in recipients of living donor kidney transplants between August 2006 and March 2009 based on the use or absence of intraoperative CVP monitoring. Graft function, assessed using the creatinine reduction ratio on postoperative day 2 (CCR2), was evaluated by multivariable linear regression analysis and in a propensity‐matched cohort. Results: Two hundred and ninety patients were included in the analysis. Central venous pressure was monitored in 84 patients (29%). There was no difference in post‐transplant graft function, as measured by CCR2, between patients with and without CVP monitoring in both unadjusted and multivariable‐adjusted analyses. There were also no statistically significant differences in CCR2, delayed graft function, or 3‐month renal function between those monitored with CVP and those without, in the propensity‐matched cohort. Conclusions: In this single‐center analysis, immediate post‐transplant renal function was not associated with the use of intraoperative CVP monitoring. [ABSTRACT FROM AUTHOR]

Autografting is the gold standard in the repair of peripheral nerve injuries that are not amenable to end-to-end coaptation. However, because autografts result in donor-site defects and are a limited resource, an effective substitute would be valuable. In a rat model, we compared isografts with Integra NeuraGen® (NG) nerve guides, which are a commercially available type I collagen conduit, with processed rat allografts comparable to AxoGen's Avance® human decellularized allograft product. In a 14-mm sciatic nerve gap model, isograft was superior to processed allograft, which was in turn superior to NG conduit at 6 weeks postoperatively ( P < 0.05 for number of myelinated fibers both at midgraft and distal to the graft). At 12 weeks, these differences were no longer apparent. In a 28-mm graft model, isografts again performed better than processed allografts at both 6 and 22 weeks; regeneration through the NG conduit was often insufficient for analysis in this long graft model. Functional tests confirmed the superiority of isografts, although processed allografts permitted successful reinnervation of distal targets not seen in the NG conduit groups. Processed allografts were inherently non-immunogenic and maintained some internal laminin structure. We conclude that, particularly in a long gap model, nerve graft alternatives fail to confer the regenerative advantages of an isograft. However, AxoGen processed allografts are superior to a currently available conduit-style nerve guide, the Integra NeuraGen®. They provide an alternative for reconstruction of short nerve gaps where a conduit might otherwise be used. Muscle Nerve, 2008 [ABSTRACT FROM AUTHOR]