Clinical Orthopaedics and Related Research®

, Volume 472, Issue 5, pp 1453–1466 | Cite as

The Influence of Anesthesia and Pain Management on Cognitive Dysfunction After Joint Arthroplasty: A Systematic Review

  • Michael G. Zywiel
  • Atul Prabhu
  • Anthony V. Perruccio
  • Rajiv Gandhi
Symposium: Perioperative Pain Management in Orthopaedic Surgery

Abstract

Background

Despite the overall success of total joint arthroplasty, patients undergoing this procedure remain susceptible to cognitive decline and/or delirium, collectively termed postoperative cognitive dysfunction. However, no consensus exists as to whether general or regional anesthesia results in a lower likelihood that a patient may experience this complication, and controversy surrounds the role of pain management strategies to minimize the incidence of postoperative cognitive dysfunction.

Questions/purposes

We systematically reviewed the English-language literature to assess the influence of the following anesthetic and/or pain management strategies on the risk for postoperative cognitive dysfunction in patients undergoing elective joint arthroplasty: (1) general versus regional anesthesia, (2) different parenteral, neuraxial, or inhaled agents within a given type of anesthetic (general or regional), (3) multimodal anesthetic techniques, and (4) different postoperative pain management regimens.

Methods

A systematic search was performed of the MEDLINE® and EMBASE™ databases to identify all studies that assessed the influence of anesthetic and/or pain management strategies on the risk for postoperative cognitive dysfunction after elective joint arthroplasty. Twenty-eight studies were included in the final review, of which 21 (75%) were randomized controlled (Level I) trials, two (7%) were prospective comparative (Level II) studies, two (7%) used a case-control (Level III) design, and three (11%) used retrospective comparative (Level III) methodology.

Results

The evidence published to date suggests that general anesthesia may be associated with increased risk of early postoperative cognitive dysfunction in the early postoperative period as compared to regional anesthesia, although this effect was not seen beyond 7 days. Optimization of depth of general anesthesia with comprehensive intraoperative cerebral monitoring may be beneficial, although evidence is equivocal. Multimodal anesthesia protocols have not been definitively demonstrated to reduce the incidence of postoperative cognitive dysfunction. Nonopioid postoperative pain management techniques, limiting narcotics to oral formulations and avoiding morphine, appear to reduce the risk of postoperative cognitive dysfunction.

Conclusions

Both anesthetic and pain management strategies appear to influence the risk of early cognitive dysfunction after elective joint arthroplasty, although only one study identified differences that persisted beyond 1 week after surgery. Investigators should strive to use accepted, validated tools for the assessment of postoperative cognitive dysfunction and to carefully report details of the anesthetic and analgesic techniques used in future studies.

References

  1. 1.
    American Psychiatric Association. Diagnostic and Statistical Manual of Mental Health Disorders: DSM-5. Washington, DC: American Psychatric Publishing; 2013.Google Scholar
  2. 2.
    Ancelin ML, de Roquefeuil G, Ledesert B, Bonnel F, Cheminal JC, Ritchie K. Exposure to anaesthetic agents, cognitive functioning and depressive symptomatology in the elderly. Br J Psychiatry. 2001;178:360–366.PubMedCrossRefGoogle Scholar
  3. 3.
    Anwer HM, Swelem SE, el-Sheshai A, Moustafa AA. Postoperative cognitive dysfunction in adult and elderly patients—general anesthesia vs subarachnoid or epidural analgesia. Middle East J Anesthesiol. 2006;18:1123–1138.PubMedGoogle Scholar
  4. 4.
    Ballard C, Jones E, Gauge N, Aarsland D, Nilsen OB, Saxby BK, Lowery D, Corbett A, Wesnes K, Katsaiti E, Arden J, Amoako D, Prophet N, Purushothaman B, Green D. Optimised anaesthesia to reduce post operative cognitive decline (POCD) in older patients undergoing elective surgery, a randomised controlled trial. PLoS One. 2012;7:e37410.PubMedCentralPubMedCrossRefGoogle Scholar
  5. 5.
    Castellsague J, Riera-Guardia N, Calingaert B, Varas-Lorenzo C, Fourrier-Reglat A, Nicotra F, Sturkenboom M, Perez-Gutthann S. Individual NSAIDs and upper gastrointestinal complications: a systematic review and meta-analysis of observational studies (the SOS project). Drug Saf. 2012;35:1127–1146.PubMedCentralPubMedCrossRefGoogle Scholar
  6. 6.
    Chaput AJ, Bryson GL. Postoperative delirium: risk factors and management: continuing professional development. Can J Anaesth. 2012;59:304–320.PubMedCrossRefGoogle Scholar
  7. 7.
    Colwell CW Jr, Morris BA. Patient-controlled analgesia compared with intramuscular injection of analgesics for the management of pain after an orthopaedic procedure. J Bone Joint Surg Am. 1995;77:726–733.PubMedGoogle Scholar
  8. 8.
    Contin AM, Perez-Jara J, Alonso-Contin A, Enguix A, Ramos F. Postoperative delirium after elective orthopedic surgery. Int J Geriatr Psychiatry. 2005;20:595–597.PubMedCrossRefGoogle Scholar
  9. 9.
    Dasgupta M, Dumbrell AC. Preoperative risk assessment for delirium after noncardiac surgery: a systematic review. J Am Geriatr Soc. 2006;54:1578–1589.PubMedCrossRefGoogle Scholar
  10. 10.
    Deiner S, Silverstein JH. Postoperative delirium and cognitive dysfunction. Br J Anaesth. 2009;103(suppl 1):i41–i46.PubMedCentralPubMedCrossRefGoogle Scholar
  11. 11.
    Deo H, West G, Butcher C, Lewis P. The prevalence of cognitive dysfunction after conventional and computer-assisted total knee replacement. Knee. 2011;18:117–120.PubMedCrossRefGoogle Scholar
  12. 12.
    Fernandez-Galinski D, Pulido C, Real J, Rodriguez A, Puig MM. Comparison of two protocols using low doses of bupivacaine for spinal anaesthesia during joint replacement in elderly patients. Pain Clinic. 2005;17:15–24.CrossRefGoogle Scholar
  13. 13.
    Garcia Rodriguez LA, Jick H. Risk of upper gastrointestinal bleeding and perforation associated with individual non-steroidal anti-inflammatory drugs. Lancet. 1994;343:769–772.Google Scholar
  14. 14.
    Ghoneim MM, Hinrichs JV, O’Hara MW, Mehta MP, Pathak D, Kumar V, Clark CR. Comparison of psychologic and cognitive functions after general or regional anesthesia. Anesthesiology. 1988;69:507–515.PubMedCrossRefGoogle Scholar
  15. 15.
    Goyal N, McKenzie J, Sharkey PF, Parvizi J, Hozack WJ, Austin MS. The 2012 Chitranjan Ranawat Award. Intraarticular analgesia after TKA reduces pain: a randomized, double-blinded, placebo-controlled, prospective study. Clin Orthop Relat Res. 2013;471:64–75.PubMedCentralPubMedCrossRefGoogle Scholar
  16. 16.
    Hartrick CT, Bourne MH, Gargiulo K, Damaraju CV, Vallow S, Hewitt DJ. Fentanyl iontophoretic transdermal system for acute-pain management after orthopedic surgery: a comparative study with morphine intravenous patient-controlled analgesia. Reg Anesth Pain Med. 2006;31:546–554.PubMedGoogle Scholar
  17. 17.
    Hebl JR, Kopp SL, Ali MH, Horlocker TT, Dilger JA, Lennon RL, Williams BA, Hanssen AD, Pagnano MW. A comprehensive anesthesia protocol that emphasizes peripheral nerve blockade for total knee and total hip arthroplasty. J Bone Joint Surg Am. 2005;87(suppl 2):63–70.PubMedCrossRefGoogle Scholar
  18. 18.
    Herrick IA, Ganapathy S, Komar W, Kirkby J, Moote CA, Dobkowski W, Eliasziw M. Postoperative cognitive impairment in the elderly: choice of patient-controlled analgesia opioid. Anaesthesia. 1996;51:356–360.PubMedCrossRefGoogle Scholar
  19. 19.
    Ilahi OA, Davidson JP, Tullos HS. Continuous epidural analgesia using fentanyl and bupivacaine after total knee arthroplasty. Clin Orthop Relat Res. 1994;299:44–52.PubMedGoogle Scholar
  20. 20.
    Inan N, Cakan T, Ozen M, Aydin N, Gurel D, Baltaci B. The effect of opioid administration by different routes on the psychological functions of elderly patients. Agri. 2007;19:32–38.PubMedGoogle Scholar
  21. 21.
    Inouye SK. Delirium in older persons. N Engl J Med. 2006;354:1157–1165.PubMedCrossRefGoogle Scholar
  22. 22.
    Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med. 1990;113:941–948.PubMedCrossRefGoogle Scholar
  23. 23.
    Johnson RL, Kopp SL, Hebl JR, Erwin PJ, Mantilla CB. Falls and major orthopaedic surgery with peripheral nerve blockade: a systematic review and meta-analysis. Br J Anaesth. 2013;110:518–528.PubMedCrossRefPubMedCentralGoogle Scholar
  24. 24.
    Jones MJ, Piggott SE, Vaughan RS, Bayer AJ, Newcombe RG, Twining TC, Pathy J, Rosen M. Cognitive and functional competence after anaesthesia in patients aged over 60: controlled trial of general and regional anaesthesia for elective hip or knee replacement. BMJ. 1990;300:1683–1687.PubMedCentralPubMedCrossRefGoogle Scholar
  25. 25.
    Kandasami M, Kinninmonth AW, Sarungi M, Baines J, Scott NB. Femoral nerve block for total knee replacement—a word of caution. Knee. 2009;16:98–100.PubMedCrossRefGoogle Scholar
  26. 26.
    Kudoh A, Takase H, Takazawa T. A comparison of anesthetic quality in propofol-spinal anesthesia and propofol-fentanyl anesthesia for total knee arthroplasty in elderly patients. J Clin Anesth. 2004;16:405–410.PubMedCrossRefGoogle Scholar
  27. 27.
    Langford RM, Joshi GP, Gan TJ, Mattera MS, Chen WH, Revicki DA, Chen C, Zlateva G. Reduction in opioid-related adverse events and improvement in function with parecoxib followed by valdecoxib treatment after non-cardiac surgery: a randomized, double-blind, placebo-controlled, parallel-group trial. Clin Drug Investig. 2009;29:577–590.PubMedCrossRefGoogle Scholar
  28. 28.
    Leskinen J, Eskelinen A, Huhtala H, Paavolainen P, Remes V. The incidence of knee arthroplasty for primary osteoarthritis grows rapidly among baby boomers: a population-based study in Finland. Arthritis Rheum. 2012;64:423–428.PubMedCrossRefGoogle Scholar
  29. 29.
    Leung JM, Sands LP, Vaurio LE, Wang Y. Nitrous oxide does not change the incidence of postoperative delirium or cognitive decline in elderly surgical patients. Br J Anaesth. 2006;96:754–760.PubMedCrossRefGoogle Scholar
  30. 30.
    Lie SA, Pratt N, Ryan P, Engesaeter LB, Havelin LI, Furnes O, Graves S. Duration of the increase in early postoperative mortality after elective hip and knee replacement. J Bone Joint Surg Am. 2010;92:58–63.PubMedCrossRefGoogle Scholar
  31. 31.
    Losina E, Thornhill TS, Rome BN, Wright J, Katz JN. The dramatic increase in total knee replacement utilization rates in the United States cannot be fully explained by growth in population size and the obesity epidemic. J Bone Joint Surg Am. 2012;94:201–207.PubMedCentralPubMedCrossRefGoogle Scholar
  32. 32.
    Macfarlane AJ, Prasad GA, Chan VW, Brull R. Does regional anaesthesia improve outcome after total hip arthroplasty? A systematic review. Br J Anaesth. 2009;103:335–345.PubMedCrossRefGoogle Scholar
  33. 33.
    Marcantonio ER, Juarez G, Goldman L, Mangione CM, Ludwig LE, Lind L, Katz N, Cook EF, Orav EJ, Lee TH. The relationship of postoperative delirium with psychoactive medications. JAMA. 1994;272:1518–1522.PubMedCrossRefGoogle Scholar
  34. 34.
    Marino J, Russo J, Kenny M, Herenstein R, Livote E, Chelly JE. Continuous lumbar plexus block for postoperative pain control after total hip arthroplasty: a randomized controlled trial. J Bone Joint Surg Am. 2009;91:29–37.PubMedCrossRefGoogle Scholar
  35. 35.
    Nielson WR, Gelb AW, Casey JE, Penny FJ, Merchant RN, Manninen PH. Long-term cognitive and social sequelae of general versus regional anesthesia during arthroplasty in the elderly. Anesthesiology. 1990;73:1103–1109.PubMedCrossRefGoogle Scholar
  36. 36.
    Peters CL, Shirley B, Erickson J. The effect of a new multimodal perioperative anesthetic regimen on postoperative pain, side effects, rehabilitation, and length of hospital stay after total joint arthroplasty. J Arthroplasty. 2006;21:132–138.PubMedCrossRefGoogle Scholar
  37. 37.
    Postler A, Neidel J, Gunther KP, Kirschner S. Incidence of early postoperative cognitive dysfunction and other adverse events in elderly patients undergoing elective total hip replacement (THR). Arch Gerontol Geriatr. 2011;53:328–333.PubMedCrossRefGoogle Scholar
  38. 38.
    Rasmussen LS, Johnson T, Kuipers HM, Kristensen D, Siersma VD, Vila P, Jolles J, Papaioannou A, Abildstrom H, Silverstein JH, Bonal JA, Raeder J, Nielsen IK, Korttila K, Munoz L, Dodds C, Hanning CD, Moller JT. Does anaesthesia cause postoperative cognitive dysfunction? A randomised study of regional versus general anaesthesia in 438 elderly patients. Acta Anaesthesiol Scand. 2003;47:260–266.PubMedCrossRefGoogle Scholar
  39. 39.
    Rasmussen LS, Schmehl W, Jakobsson J. Comparison of xenon with propofol for supplementary general anaesthesia for knee replacement: a randomized study. Br J Anaesth. 2006;97:154–159.PubMedCrossRefGoogle Scholar
  40. 40.
    Ravi B, Croxford R, Reichmann WM, Losina E, Katz JN, Hawker GA. The changing demographics of total joint arthroplasty recipients in the United States and Ontario from 2001 to 2007. Best Pract Res Clin Rheumatol. 2012;26:637–647.PubMedCrossRefGoogle Scholar
  41. 41.
    Rodriguez RA, Tellier A, Grabowski J, Fazekas A, Turek M, Miller D, Wherrett C, Villeneuve PJ, Giachino A. Cognitive dysfunction after total knee arthroplasty: effects of intraoperative cerebral embolization and postoperative complications. J Arthroplasty. 2005;20:763–771.PubMedCrossRefGoogle Scholar
  42. 42.
    Rudolph JL, Marcantonio ER. Review articles: postoperative delirium: acute change with long-term implications. Anesth Analg. 2011;112:1202–1211.PubMedCentralPubMedCrossRefGoogle Scholar
  43. 43.
    Skytta ET, Jarkko L, Antti E, Huhtala H, Ville R. Increasing incidence of hip arthroplasty for primary osteoarthritis in 30- to 59-year-old patients. Acta Orthop. 2011;82:1–5.PubMedCentralPubMedCrossRefGoogle Scholar
  44. 44.
    Steinmetz J, Funder KS, Dahl BT, Rasmussen LS. Depth of anaesthesia and post-operative cognitive dysfunction. Acta Anaesthesiol Scand. 2010;54:162–168.PubMedCrossRefGoogle Scholar
  45. 45.
    Williams-Russo P, Sharrock NE, Mattis S, Szatrowski TP, Charlson ME. Cognitive effects after epidural vs general anesthesia in older adults: a randomized trial. JAMA. 1995;274:44–50.PubMedCrossRefGoogle Scholar
  46. 46.
    Williams-Russo P, Urquhart BL, Sharrock NE, Charlson ME. Post-operative delirium: predictors and prognosis in elderly orthopedic patients. J Am Geriatr Soc. 1992;40:759–767.PubMedGoogle Scholar
  47. 47.
    Wong J, Song D, Blanshard H, Grady D, Chung F. Titration of isoflurane using BIS index improves early recovery of elderly patients undergoing orthopedic surgeries. Can J Anaesth. 2002;49:13–18.PubMedCrossRefGoogle Scholar
  48. 48.
    YaDeau JT, Cahill JB, Zawadsky MW, Sharrock NE, Bottner F, Morelli CM, Kahn RL, Sculco TP. The effects of femoral nerve blockade in conjunction with epidural analgesia after total knee arthroplasty. Anesth Analg. 2005;101:891–895.PubMedCrossRefGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2013

Authors and Affiliations

  • Michael G. Zywiel
    • 1
  • Atul Prabhu
    • 2
  • Anthony V. Perruccio
    • 1
    • 3
  • Rajiv Gandhi
    • 1
  1. 1.Division of Orthopaedic Surgery, Toronto Western HospitalUniversity of TorontoTorontoCanada
  2. 2.Department of Anesthesia, Toronto Western HospitalUniversity of TorontoTorontoCanada
  3. 3.Institute of Health Policy, Management & EvaluationUniversity of TorontoTorontoCanada

Personalised recommendations