Early postoperative cognitive dysfunction after upper limb surgery

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Abstract
Background. Early postoperative cognitive decline may interfere with mobilisation of a patient, and rehabilitation recommendations after orthopaedic surgery on the upper limb. The aim of the study was to assess early postoperative cognitive dynamics, pain, sleep quality, stress response, neuron-specific enolase (NSE) and haemodynamics. Materials and methods. A prospective clinical analysis included 45 adult patients who underwent elective orthopaedic surgery on the upper limb under combined anaesthesia with propofol, fentanyl and a regional component. Cognitive function was assessed before surgery and on postoperative days 1, 3 and 7 using Montreal Cognitive Assessment (MoCA), Mini-Mental State Examination, Frontal Assessment Battery, Trail Making Test, Part B (TMT-B) and Symbol Digit Modalities Test (SDMT). Additionally, the following parameters were analysed: pain intensity, sleep quality — by the Richards-Campbell Sleep Questionnaire (RCSQ), glucose, cortisol, NSE and haemodynamic variables. Friedman test, Wilcoxon test with Holm correction, Kendall’s W and Spearman’s ρ were used. Results. On postoperative day 1, all cognitive tests showed unidirectional deterioration. The greatest changes were observed in SDMT and TMT-B: SDMT decreased by 7.38 points, and TMT-B completion time increased by 19.53 s compared with the preoperative level (p < 0.001). The largest effect sizes were found for SDMT (Kendall’s W = 0.797) and TMT-B (W = 0.625). Clinically significant deterioration for SDMT on day 1 was recorded in 77.8 % of patients and in 48.9 % for TMT-B. On day 3, cognitive performance partially recovered; by day 7, MoCA and TMT-B no longer differed statistically from baseline. Sleep quality showed the greatest decrease on day 1, with RCSQ reduced by 18.49 mm (p < 0.001). Worsening of RCSQ was associated with deterioration in TMT-B (ρ = 0.551; Holm-adjusted p = 0.0016). Intraoperative cortisol increase was also associated with TMT-B deterioration (ρ = 0.440; Holm-adjusted p = 0.043). Haemodynamics remained stable, rescue morphine requirement was low (4.4 %), and no persistent association between NSE dynamics and cognitive tests was found. Conclusions. Combined anaesthesia for orthopaedic surgery on the upper limb was accompanied by early transient cognitive decline. SDMT and TMT-B were the most sensitive tests. Cortisol increase and reduced sleep quality were associated with deterioration in TMT-B.

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