วันเสาร์ที่ 25 เมษายน พ.ศ. 2569

Perioperative Neurocognitive Disorders (PND)

Perioperative Neurocognitive Disorders (PND)

🎯 Definition (สำคัญมาก)

PND = cognitive / behavioral / affective change ช่วง perioperative
ประกอบด้วย:

1.       Preexisting cognitive impairment

2.       Postoperative delirium

3.       Delayed neurocognitive recovery (≤30 วัน)

4.       Neurocognitive disorder (postoperative) (≤12 เดือน)

📊 Epidemiology

  • Delirium:
    • สูงใน elderly (>65 yr): 4–55%
  • Delayed recovery: 17–43%
  • Persistent NCD: ~12% ใน major surgery

⚠️ Clinical types

1. Postoperative delirium

  • hallmark:
    • ↓ attention + altered consciousness
  • subtype:
    • hyperactive (agitation)
    • hypoactive (พบบ่อยกว่า)

👉 Hypoactive = underdiagnosed

2. Delayed neurocognitive recovery

  • ≤30 วัน
  • ส่วนใหญ่ recover

3. NCD (postoperative)

  • 30 วัน ถึง 12 เดือน
  • mild → brain fog
  • major → dementia-like

🧬 Pathophysiology

  • Systemic inflammation → neuroinflammation
  • brain vulnerability (aging / dementia) → amplified response

🔴 Risk factors (High yield)

Patient-related

  • Age >65 (strongest)
  • Preexisting cognitive impairment
  • Frailty
  • Alcohol
  • Polypharmacy
  • DM, vascular disease, stroke
  • Sleep disturbance

Surgery-related

  • Major surgery (cardiac, ortho, abdominal)
  • Long duration
  • complexity

Others

  • Institutional factors (care quality)

🟢 PREOPERATIVE

1. Cognitive screening (สำคัญ)

  • Mini-Cog / MMSE
  • CAM (Confusion Assessment Method) baseline
  • สอบถาม family

👉 ใช้เป็น baseline + risk stratification

2. Risk stratification

  • Identify high-risk → implement prevention bundle

3. Counseling

  • แจ้งผู้ป่วย + ญาติ:
    • risk delirium / cognitive decline
    • prognosis

4. Cognitive prehabilitation

  • evidence ยังไม่ชัด

🟡 INTRAOPERATIVE

1. Avoid excessive anesthetic depth

  • ใช้:
    • ETAC (end-tidal anesthetic concentration) (MAC (minimum alveolar concentration)-adjusted)
    • EEG / BIS monitoring

👉 avoid:

  • burst suppression
  • deep anesthesia

2. Avoid hypotension

  • Target:
    • MAP ≥65 mmHg
    • within ±20% baseline

👉 MAP <55 mmHg → ↑ delirium risk

3. Avoid cerebral desaturation

  • rSO₂ (regional cerebral oxygen saturation) monitoring (selected cases)

4. Sedation strategy

  • Avoid oversedation (especially regional anesthesia)

5. Drug-related risks

🚫 High risk drugs

  • Benzodiazepines
  • Gabapentinoids
  • Anticholinergics
  • Meperidine
  • Diphenhydramine

⚠️ Opioids

  • both:
    • overdose → delirium
    • undertreated pain → delirium

👉 ต้อง balance

🟢 Potentially protective

  • NSAIDs / COX-2 inhibitors
  • Acetaminophen
  • Dexmedetomidine (evidence supportive)

6. Anesthetic technique

  • GA vs regional → no clear superiority
  • TIVA vs inhalation → similar delirium risk

🔵 POSTOPERATIVE

1. Prevention bundle (สำคัญที่สุด)

  • Reorientation
  • Early mobilization
  • Sleep hygiene
  • Hydration
  • Avoid restraints
  • Use glasses/hearing aids
  • Pain control (opioid-sparing)

2. Screening

  • CAM / CAM-ICU / 3D-CAM

3. Management

Delirium

  • treat reversible causes:
    • drug
    • infection
    • metabolic
  • severe agitation:
    • haloperidol low dose

Cognitive decline

  • ไม่มี specific treatment
  • refer:
    • geriatrics / neurology

🔥 Prognosis (ต้องจำ)

  • Delirium → ↑ mortality + LOS
  • ↑ risk dementia
  • ~40% ไม่กลับ baseline

🧠 Clinical pearls

  • 🧓 Age + baseline cognition = strongest predictors
  • 💤 Sleep disturbance → major trigger
  • 💊 Benzodiazepine = avoid in elderly
  • 🩸 Hypotension + cerebral hypoxia = preventable causes
  • 🧠 Hypoactive delirium = miss easily → ต้อง screen
  • 🔁 Delirium = often reversible → treat cause

🧭 Take-home message

PND = “brain complication of surgery”
→ prevention สำคัญกว่า treatment

เน้น:

  • identify high-risk
  • optimize intraop physiology
  • multidisciplinary postoperative care

 

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