Tadas Lenkutis

Background: Postoperative cognitive dysfunction (POCD) commonly affects elderly patients, but the impact of BIS-guided sedation during elective orthopedic surgery under spinal anesthesia remains unclear. The aim was to compare BIS-controlled versus standard clinically guided sedation on POCD in elderly patients undergoing elective knee arthroplasty. Methods: This was a prospective, patient- and outcome assessor-blinded, randomized controlled clinical study. Participants were randomized into two groups: BIS-targeted sedation (BIS group > 70) and standard clinical sedation (non-BIS group). All patients received the same anesthetic and analgesic. The primary outcome was the change in cognitive function over time. Cognitive function was assessed four times using the Addenbrooke’s Cognitive Examination–Revised (ACE-R) questionnaire. Higher scores indicate better cognitive performance. The emotional status was evaluated two times using the Hospital Anxiety and Depression Scale (HADS) . Results: Ninety-two patients (46 per group) were included in the final analysis. No statistically significant differences in total ACE-R score were found between the two groups at any time point ( p > 0.05). Within the BIS group, total ACE-R scores were significantly higher on postoperative day (POD) 90 than preoperatively (PO) (87 (65–96) vs. 92 (70–98), p = 0.007). In the non-BIS group, total ACE-R scores increased significantly at several time points: from PO to 30 POD (87 (48–96) vs. 90.5 (40–98), p = 0.007), from PO to 90 POD (87 (48–96) vs. (91 (40–99), p < 0.001), and from 2 to 30 POD (88 (45–98) vs. 90.5 (40–98), p = 0.005). Significant decline in the number of patients experiencing probable anxiety at 30 POD compared with PO in both groups (BIS 28.3% to 2.2%, p = 0.004; non-BIS 32.6% to 8.7%, p = 0.015). Conclusions: This study did not demonstrate superiority of BIS-controlled sedation compared to clinically guided sedation with regard to cognitive outcomes. Further studies are needed. Trial registration: ClinicalTrials.gov (NCT06241859, January 28, 2024)

Background and objectives: Cardiac surgery with cardiopulmonary bypass (CPB) is associated with endothelial glycocalyx injury and perioperative endothelial dysfunction. Syndecan-1 is commonly used as a biomarker of glycocalyx shedding, but data on its perioperative changes and their relationship with operative and patient-related factors remain limited. The aim of this study was to evaluate perioperative Syndecan-1 dynamics during coronary artery bypass grafting (CABG) with CPB and to assess associations with ischemia–reperfusion exposure and patient characteristics. Materials and methods: This prospective observational study included 147 patients undergoing elective CABG with CPB. Syndecan-1 concentrations were measured at five time points: before induction of anaesthesia, immediately after aortic cross-clamp application, immediately after aortic declamping, on arrival at the ICU and 24 h after surgery. Perioperative changes were analysed using non-parametric tests, Spearman’s rank correlation analysis and mixed-effects modelling. The study was registered at ClinicalTrials.gov (NCT03491163; registered on 29 March 2018). Results: Syndecan-1 concentrations changed significantly over time (p < 0.001), increasing from a baseline median of 49.74 ng/mL to a peak of 147.78 ng/mL at ICU admission, followed by a partial decline to 65.26 ng/mL at 24 h. Aortic cross-clamp duration was weakly but significantly associated with Syndecan-1 concentration at ICU admission (r_s = 0.243, p = 0.003) and with perioperative increases from baseline to ICU admission (ΔS4-1: r_s = 0.196, p = 0.017) and from aortic clamping to ICU admission (ΔS4-2: r_s = 0.207, p = 0.012). No significant associations were observed between CPB duration and Syndecan-1 concentrations in univariable analyses. In the mixed-effects model, a significant non-linear temporal pattern of Syndecan-1 concentrations was observed (both linear and quadratic time terms, p < 0.001). Male sex (β = 0.247, p = 0.009) and aortic cross-clamp duration (β = 0.016, p = 0.005) were independently associated with higher Syndecan-1 concentrations, whereas smoking status, age, BMI, diabetes status, EuroSCORE II, and CPB duration were not independently associated. Conclusions: Syndecan-1 concentrations increase significantly during cardiac surgery with cardiopulmonary bypass, peaking at ICU admission and partially declining within 24 h. Aortic cross-clamping duration, but not total CPB duration, showed weak associations with glycocalyx shedding. Male sex was independently associated with higher Syndecan-1 concentrations. These findings support ischemia–reperfusion injury as an important contributor to endothelial glycocalyx shedding during cardiac surgery.

Background: Giant descending thoracic aortic aneurysm (GDTAA) is a rare vascular disease characterized by an aortic diameter exceeding 10 cm. GDTAA carries a significant risk of rupture and mortality and requires timely diagnosis and intervention. Despite the clinical severity of the disease, the literature on GDTAA remains sparse, particularly in cases with extreme aneurysmal dilatation.Case Presentation: We present the case of a 68-year-old man with a GDTAA of 14.08 × 10.04 cm, one of the largest ever reported. The patient initially presented with recurrent syncope, chronic cough and fatigue. Imaging studies, including Computed Tomography (CT) angiography, revealed a massive aneurysmal dilatation in the distal post-arch segment of the descending aorta with compression of the trachea and bronchi. The patient underwent a successful open surgical repair with a Dacron graft and simultaneous Coronary Artery Bypass Grafting (CABG). Postoperative complications included respiratory acidosis, emphysema and transient haemodynamic instability, which were effectively treated. The patient was discharged in a stable condition on the tenth postoperative day.Conclusion: This case highlights the importance of early recognition and surgical intervention in GDTAA in order to prevent catastrophic consequences. Comprehensive preoperative evaluation, careful surgical planning and attentive postoperative care are essential for optimal recovery. Our results emphasise the importance of modern imaging techniques for accurate anatomical assessment and risk stratification in patients with extreme aneurysm growth. Further research is needed to establish standardised protocols for the treatment of GDTAA.

Background and Objectives: Cardiac surgery is associated with various durations of cerebral autoregulation (CA) impairment and can significantly impact cognitive function. Cognitive functions such as memory, psychomotor speed, and attention are significantly impacted after cardiac surgery, necessitating prioritization of these areas in cognitive function tests. There is a lack of research connecting cerebral autoregulation impairment to specific cognitive function domains after cardiac surgery. This study aimed to determine if impaired cerebral autoregulation is associated with postoperative memory impairment and to test the hypothesis that the duration of this impairment affects the development of postoperative memory issues. Materials and Methods: A prospective study was conducted in 2021–2023. After approval of the Ethics Committee and with patient’s written consent, 83 adult patients undergoing elective on-pump coronary artery bypass graft (CABG) surgery were enrolled. All patients were assessed for cognitive function 1 day before surgery using the Mini-Mental state examination (MMSE-2) test as a screening tool and the Hopkins Verbal Learning Test-Revised (HVLT-R) to assess memory specifically. To diagnose possible memory impairment (IM), all patients underwent a repeat assessment of cognitive function on the 7th–10th postoperative day. Cerebral autoregulation monitoring using transcranial Doppler was performed. Cerebral autoregulation status index (Mx) was recorded using Intensive Care Brain Monitoring System software, 9.1.5.23 (Cambridge, UK). Results: According to our research, the incidence of postoperative memory impairment is 30.1%. Temporary cerebral autoregulation impairment occurs in all patients undergoing elective in-pump CABG surgery. The duration of the single longest CA impairment event in seconds (LCAI) and the LCAI dose were higher in patients with postoperative memory impairment, p = 0.006 and p < 0.007, respectively. Conclusions: Cerebral autoregulation impairment is important in developing memory loss after cardiac surgery. The duration and dose of the LCAI event are predictive of postoperative memory impairment.

Background: Patients may experience a variety of neurological complications after heart surgery. The most common complication observed in clinical practice is delayed neurocognitive recovery (dNCR). The role of the anesthesiologist is very important, as the risk of dNCR may be reduced, depending on the anesthesia tactic chosen. Although the possibility that neuropsychological complications are less common in patients undergoing combined anesthesia (general + epidural) than in patients undergoing general anesthesia is not yet confirmed, the results are being discussed. The aim of this study was to determine impact of combined anesthesia (general + epidural) on cognitive functions of patients after cardiac surgery. Methods: The prospective, case-controlled study included 80 patients undergoing cardiac surgery from 2015 to 2017 at the Department of Cardiothoracic and Vascular Surgery in the Hospital of Lithuanian University of Health Sciences Kauno Klinikos. After approval from the local bioethics center, informed consent was obtained from all study participants. Inclusion criteria were age 51 to 80 years, elective cardiac surgery, left ventricular ejection fraction > 35%, anamnesis of not using agents affecting the central nervous system, absence of neuropathology, and sufficient renal function. Exclusion criteria were patients suffering from diseases causing cognitive function or using agents affecting the central nervous system, emergency or re-surgery, carotid artery atherosclerosis with artery diameter 50 or more percent reduction, and a patient’s disagreement. MMSE test and 6-CIT test were used for a cognitive function assessment, Trail making test and WAIS Digital Symbol Substitution test were used for psychomotor function assessment. All tests were used a day before surgery and seven days after surgery. According to the planned anesthesia, patients were assigned into two groups: 1 – combined general + epidural anesthesia and 2 – general anesthesia. Standardized protocol of anesthesia was followed for all patients. Preoperative patients and surgery factors, preoperative and postoperative neuropsychological test results were recorded. Results: Eighty patients were enrolled in the study. Both groups did not differ in demographic, perioperative values, and baseline (preoperative) test results. Postoperative (7th day) WAIS (P = .042) and 6-item cognitive impairment (P = .016) test results were statistically different when comparing the GA and CA groups. Comparing preoperative and postoperative test results, there was a significant decline in the WAIS test score in the GA group (P = .013).