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Oblique coronal reconstruction with soft tissue window. Perforation on the right lateral aspect of the cervical trachea (yellow arrow) with associated pneumomediastinum (red arrow); (B) Transverse CT image with lung reconstruction. Soft tissue emphysema (green arrow); (C) In vivo tracheal perforation (*) revealing endotracheal tube.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "B. Estero Serrano de la Cruz, M. Ruano Santiago, E. Herrera Martín, P. Ramos Curado" "autores" => array:4 [ 0 => array:2 [ "nombre" => "B." "apellidos" => "Estero Serrano de la Cruz" ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Ruano Santiago" ] 2 => array:2 [ "nombre" => "E." "apellidos" => "Herrera Martín" ] 3 => array:2 [ "nombre" => "P." 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Valverde, C. Aldecoa, N. Fábregas, J.L. Fernández-Candil" "autores" => array:7 [ 0 => array:4 [ "nombre" => "E.M." "apellidos" => "Aldana" "email" => array:1 [ 0 => "evamaria.aldana@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "N." "apellidos" => "Pérez de Arriba" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "J.L." "apellidos" => "Valverde" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "C." "apellidos" => "Aldecoa" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 4 => array:3 [ "nombre" => "N." "apellidos" => "Fábregas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 5 => array:3 [ "nombre" => "J.L." "apellidos" => "Fernández-Candil" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] ] ] 6 => array:2 [ "colaborador" => "on behalf of the Neuroscience Section Working Group" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">♦</span>" "identificador" => "fn0005" ] ] ] ] "afiliaciones" => array:5 [ 0 => array:3 [ "entidad" => "Anestesiología y Reanimación, Hospital Vithas Xanit Internacional, Benalmádena, Málaga, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Anestesiología y Reanimación, Hospital Universitario Central de Asturias, Oviedo, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Anestesiología y Reanimación, Hospital Universitario Rio Hortega, Valladolid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Anestesiología y Reanimación, Hospital Clínic, Universidad de Barcelona, Barcelona, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Anestesiología y Reanimación, Hospital del Mar, Barcelona, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Encuesta nacional sobre disfunción cognitiva perioperatoria" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 978 "Ancho" => 2500 "Tamanyo" => 126149 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Assessment of cognitive dysfunction in the preoperative visit.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Most respondents perform this assessment “sometimes” and 37% never do so, giving a combined total of approximately 70%.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The preservation of brain health and cognitive recovery is a concern for healthcare professionals, patients, and their families, given the prevalence of perioperative cognitive dysfunction (PCD).<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> PCD includes postoperative delirium (POD), delayed neurocognitive recovery (DNCR), and both mild and severe postoperative neurocognitive disorder (PNCD) (or dementia),<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> depending on the time of presentation (5–7 days for POD, 30 days for DNCR, and up to 12 months for PNCD).<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–4</span></a> POD is considered a medical emergency. It is one of the most frequent postoperative complications in patients aged over 65 (40%–50%)<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> and is the most common manifestation of brain dysfunction in critically ill patients. Delayed neurocognitive recovery after anaesthesia and surgery can be considered a consequence of prolonged postoperative acute encephalopathy, and occurs in 50%–75% of patients undergoing mechanical ventilation in the Critical Care Unit (CCU).<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The incidence varies depending on the type of surgery: 33% in patients undergoing urgent abdominal surgery, 50% in those undergoing hip fracture repair, and 14%–51% in patients undergoing cardiopulmonary bypass surgery. POD has a potential mortality rate of 25% but can be prevented in up to 40% of cases, so it is of the utmost importance to develop guidelines that put forward strategies to prevent this complication.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">DNCR and PNCD can only be diagnosed on the basis of a pre- and postoperative cognitive evaluation. They occur in 20%–26% of patients, and are also associated with increased mortality.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> The incidence varies in the literature, partly due to implementation of the 2013 PADIS guidelines for POD, updated in 2018, particularly in CCU patients.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Clinical practice guidelines and consensus documents for the prevention and treatment of POD have been published by several scientific associations, including the American Geriatrics Society,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> the Perioperative Brain Health Expert Panel,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> the 2017 European Society of Anaesthesiology and Critical Care (ESAIC) Guidelines,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> updated in 2023,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> among others that we will mention later. There are no guidelines for DNCR and PNCD.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> PCD is a major issue, and diagnosis and treatment of this disorder must be one of the primary objectives of quality healthcare. In this context, the Neurosciences Task Force of the Spanish Society of Anaesthesiology, Resuscitation and Pain Therapy (SEDAR) decided to perform a national survey to determine the opinions and clinical practices of Spanish anaesthesiologists in respect of PCD.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">The survey questionnaire were drawn up on the basis of guidelines, surveys and methodological recommendations, mainly the ESAIC 2017 Guidelines, which were updated in 2023,<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> the Perioperative Brain Health Expert Panel,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> and the recommendations for conducting surveys publish by Story et al.,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> among others. The survey was created using Google Forms®, and consisted of 22 questions divided into 4 sections: 1 on demographic data, and 3 on the respondent’s opinions and practices regarding the pre-, intra-, and postoperative management of PCD. The questions were all close-ended, and many were multiple-choice. The questionnaire was amended after being reviewed by the members of the Neuroscience division.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The study was approved by decision No. 311/19 of the Research Ethics Committee of the Principality of Asturias in December 2019.</p><p id="par0030" class="elsevierStylePara elsevierViewall">An invitation to take part in the survey was sent to all anaesthesiologists on the SEDAR database in an email that included a brief introduction to the survey, a link to the questionnaire and instructions for completing it, and the contact information of the authors. Participation was voluntary, anonymous, and no incentives were provided.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The survey was open from 27 February to 27 July 2021.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The descriptive analysis consisted of the frequency of distribution of the responses and was generated automatically by the survey tool (Google Survey®). The survey questionnaire is attached.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0045" class="elsevierStylePara elsevierViewall">Of 3,205 anaesthesiologists contacted, 544 responded, which represents a response rate of 17%.</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Demographics</span><p id="par0050" class="elsevierStylePara elsevierViewall">The vast majority were specialists and a small percentage were still in training.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Almost half of the respondents worked in hospitals with 501 to 1,000 beds, and almost a third in hospitals with 200–500 beds.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Most worked in the operating room, followed by Intensive Care/Resuscitation units (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Preoperative period</span><p id="par0065" class="elsevierStylePara elsevierViewall">The majority of respondents indicated that they never or only occasionally perform a preoperative cognitive impairment assessment (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). In the preoperative visit, 68% only informed patients and/or family members about the possibility of developing PCD if the patient presented risk factors (RF); 22.6% never did so.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Intraoperative period</span><p id="par0070" class="elsevierStylePara elsevierViewall">Most (79.6%) hospitals do not have protocols for the intraoperative management of patients at risk of PCD.</p><p id="par0075" class="elsevierStylePara elsevierViewall">When planning surgery, the RFs most frequently considered were: risk of respiratory events (79.4%), risk of postoperative pain (76.5%), and risk of cardiac events (75.2%). The risk of PCD and the patient’s preference for a particular technique were also taken into account in 23% of cases.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The anaesthesia technique in terms PCD was regional anaesthesia (RA) without sedation (51.7%) and RA with sedation but without benzodiazepines (BDZ) (37.3%).</p><p id="par0085" class="elsevierStylePara elsevierViewall">The drugs that respondents associated with a higher risk of PCD were: BDZ 88.8%, anticholinergics 57.9%, opioids 55.7%, ketamine 53.7% and halogenated anaesthetics 34.7% (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Nearly all (83.5%) respondents routinely monitored depth of anaesthesia (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>), and 71.7% believe that monitoring depth of anaesthesia can prevent the appearance of PCD.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Postoperative period</span><p id="par0095" class="elsevierStylePara elsevierViewall">Only 39% of respondents considered that the most common type of PCD is hyperactive, followed by hypoactive (25.4%) and mixed (15.8%). Almost 20% did not know the most common type of PCD.</p><p id="par0100" class="elsevierStylePara elsevierViewall">Around half (48%) acknowledged that PCD was rarely or only occasionally assessed using a tool or test in their postoperative units; 29.4% do not perform any assessment, and 7.7% only perform a clinical assessment.</p><p id="par0105" class="elsevierStylePara elsevierViewall">The Richmond Agitation-Sedation Scale (RASS) was used to assess PCD 47.6% of cases, followed by the Confusion Assessment Method (CAM/CAM-ICU) in 35%; 35.2% could not name the tool used (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">For 62.5% of those surveyed, the combination of a pharmacological and non-pharmacological approach would be the first treatment option for both hypoactive and hyperactive DPO.</p><p id="par0115" class="elsevierStylePara elsevierViewall">Just over a third (34.9%) of respondents always noted the diagnosis of PCD in the patient’s medical history and informed the patient and/or family, while another third (33.5%) only did so occasionally.</p><p id="par0120" class="elsevierStylePara elsevierViewall">Following a suspicion of PCD, 50.6% of respondents did not follow-up or refer the patient to a specialist (neurologist, neuropsychologist, geriatrician, psychiatrist, etc.); only 16.9% did so.</p><p id="par0125" class="elsevierStylePara elsevierViewall">Nearly all (92.6%) participants agree with the statement: “Delirium and postoperative cognitive impairment are underdiagnosed” (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>).</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discussion</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Preoperative period</span><p id="par0130" class="elsevierStylePara elsevierViewall">Age, dementia, and preoperative cognitive impairment are independent RFs for PCD. For this reason, clinical guides recommend performing a cognitive assessment in patients over 65 years of age who are scheduled for surgery. The Mini-mental State Examination (MMSE) is a validated preoperative screening tool. This scale is widely used in clinical research, but less so in clinical practice due to copyright issues. Other tests, such as the Montreal Cognitive Assessment (MOCA), the Mini-Cog test, and Addenbrooke's Cognitive Examination, are free to use<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and are recommended in the clinical practice guidelines of the American Geriatrics Society, ASA, ESAIC, and the Perioperative Neurotoxicity Working Group.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,7,10,11</span></a> Patients likely to meet the criteria for “frailty” should be screened using the Fried scale, given the strong association between frailty and PCD.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Like Spanish clinicians, those in other countries do not routinely assess cognitive function before surgery, One of the barriers to implementing widespread effective screening could be the lack of an ideal pre-anaesthesia tool, which could be defined as a validated, brief, self-reported, automated scale that is available in several languages, and adapted to different cultures and educational levels.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,11</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">It stands to reason that warning patients, their family and/or caregivers of the risk of developing PCD will enable them to make informed decision. This risk must be included in the informed consent.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,13</span></a> Our results suggest that, in Spain as well as in other countries, this practice has not yet become widespread.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Intraoperative period</span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Anaesthesia technique</span><p id="par0145" class="elsevierStylePara elsevierViewall">Our survey shows that the use of protocols for the intraoperative management of patients at risk of developing PCD is minimal. This is consistent with surveys performed in other countries such as the UK, Australia,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Sweden,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Portugal,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> which show that the choice of anaesthesia technique is more often based on the risk of cardiac events, respiratory events and postoperative pain than the risk of nausea and vomiting, postoperative cognitive alterations, or the patient's wishes.</p><p id="par0150" class="elsevierStylePara elsevierViewall">Almost 90% of respondents consider RA (without sedation or with sedation without BZDs) to be the most PCD-protective anaesthesia technique. This is also consistent with other surveys, in which 95% of anaesthesiologists preferred RA (spinal, epidural or combined) in patients with RFs for CPD scheduled for hip fracture repair.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,15</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Despite this, there is still no general consensus on the ideal anaesthesia technique. In a retrospective study of 41,766 orthopaedic surgery patients, the incidence of POD was lower in patients receiving RA compared to general anaesthesia (GA).<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> However, the RAGA<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> and REGAIN<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> randomized studies found no significant differences in the incidence of POD between RA and GA in hip fracture arthroplasty. In their meta-analysis, Fanelli et al. found no significant differences in the incidence of POD at 7 days in patients receiving GA vs. RA.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> In the ISPOCD 2 study, no differences were found between RA and GA in terms of cognitive dysfunction at 3 months in 438 elderly patients undergoing major non-cardiac surgery.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">Postoperative regional nerve blocks could prevent POD and improve pain management; however, RA alone, with no intraoperative block, compared to GA does not reduce POD, suggesting that other factors may influence this type of delirium.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> Regional blocks appear to have a preventive effect in patients with no history of cognitive deficit, but do not prevent POD in those with prior cognitive dysfunction.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">This issue needs to be explored further in studies comparing total intravenous anaesthesia, halogenated anaesthesia, and opioid-free anaesthesia.</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Drugs associated with the appearance of PCD</span><p id="par0170" class="elsevierStylePara elsevierViewall">In elderly patients, it is important to avoid drugs that induce PCD, particular POD, such as BDZs, anticholinergics, diphenhydramine, hydroxyzine, H2 antagonists, sedative-hypnotics, meperidine, corticosteroids, scopolamine, relaxants and non-Cox non-steroidal anti-inflammatory drugs. Combining several different drugs should also be avoided.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,21</span></a> However, BDZs continue to be widely used perioperatively, and midazolam continues to be one of the most used sedatives in the CCU, although the percentages vary in different studies.</p><p id="par0175" class="elsevierStylePara elsevierViewall">Current guidelines advise against opioids,<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4,9</span></a> although inadequate analgesia appears to be a significantly greater risk factor for DPO than the use of high-dose opioids. There is little evidence on the relationship between pain, pain control techniques, and DNCR and PNCD.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">Some studies have investigated the potential role of ketamine in preventing POD. Avidan et al. compared 2 doses of ketamine (0.5<span class="elsevierStyleHsp" style=""></span>mg/kg vs. 1<span class="elsevierStyleHsp" style=""></span>mg/kg) administered after anaesthesia induction, and found no difference in the incidence of POD, peak pain scores or opioid consumption, although the number of postoperative hallucinations and nightmares increased with escalating doses of ketamine.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">Regarding halogenated anaesthetics, a recent prospective cohort study was unable to confirm that sevoflurane affected the severity or incidence of POD in a dose-dependent manner.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> Given the low level of evidence and weak recommendations, further studies are needed to investigate the potential protective effect of haloperidol, hypnotic drugs, melatonin, ketamine, RA/GA, and biomarkers.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Depth of anaesthesia monitoring</span><p id="par0190" class="elsevierStylePara elsevierViewall">Our survey shows that depth of anaesthesia monitors are widely available and routinely used in Spain. The same is not true in other countries.</p><p id="par0195" class="elsevierStylePara elsevierViewall">The survey performed by Bilotta et al. showed that 97% of respondents had access to a monitor, but only 21% used it in most surgeries.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">In Portugal, anaesthesia monitors are available in 96.6% of operating rooms, and half of all respondents nearly always use them.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> In Spain, 80% of respondents believe that monitoring depth of anaesthesia can prevent the appearance of PCD. No surveys have hitherto investigated this issue.</p><p id="par0205" class="elsevierStylePara elsevierViewall">A recent systematic review and meta-analysis evaluating whether the use of processed electroencephalogram (EEG) monitoring reduced the incidence of PCD found that the most widely recommended EEG index in the literature, the bispectral index (BIS), reduced the risk of POD (RR 0.78) and neurocognitive disorder (RR 0.69). Despite this, the authors found insufficient evidence to recommend the use of the BIS monitor to specifically reduce the risk of PCD, but recommended using it to guide anaesthesia management and detect the appearance of unintentional suppression rates.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> Retrospective studies have found an association between the appearance of suppression rates and POD,<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27,28</span></a> and several good quality clinical practice guidelines support the use of processed EEG monitors to guide depth of anaesthesia in elderly patients as a means of reducing PCD,<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,27</span></a> although none of these findings has a high level of evidence and strong recommendation.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">Consideration should be given to whether BIS readings provide a valid measure of anaesthesia depth when they are not compared with raw EEG and spectral density matrix. Recent studies have shown that these indices should not be used without expert visual analysis of the EEG band.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">In the ESAIC guidelines, the use of multiparameter, intraoperative EEG monitoring, focussing on burst suppression activity and including the density spectral array, helps guide depth of anaesthesia and decreases the risk of POD, but has a low quality of evidence and weak recommendation.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> This is the subject of much discussion, because the studies included in meta-analyses need to group the population based on more homogeneous criteria in order to avoid bias.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> Anaesthesiologists must be trained to not only observe the numerical index provided by processed EEG monitors, but also understand and interpret the raw EEG data and spectral density matrix. In elderly patients with cortical degeneration and low EEG power, deep anaesthesia frequently causes burst suppression activity in unprocessed EEG monitors, and this has been identified as a risk factor for POD and NPCD in particular, and PCD in general. Burst suppression can be detected in raw EEG data if they are shown on the monitor. Furthermore, low intraoperative alpha band power could be related with an increased risk of POD.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Postoperative period</span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Type of delirium</span><p id="par0220" class="elsevierStylePara elsevierViewall">Respondents to our survey rated hyperactive POD as the most common form of delirium; however, hypoactive delirium is known to be the most prevalent motor subtype in critically ill patients, although mixed delirium lasts longer and is associated with prolonged hospital stay and greater mortality.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25,29</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">Despite this, other surveys have shown that hyperactive delirium is still considered the most frequent type, with psychomotor agitation being an essential diagnostic factor.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a></p></span></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Routine assessment of delirium and screening tools</span><p id="par0230" class="elsevierStylePara elsevierViewall">Due to the low sensitivity and high specificity of clinical assessment, guidelines and consensus documents recommend screening for DPO daily using validated tests for the first 5 postoperative days in the general population, and every 8<span class="elsevierStyleHsp" style=""></span>h in CCU patients.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> Hypoactive delirium may be missed if a screening instrument is not used.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a></p><p id="par0235" class="elsevierStylePara elsevierViewall">Despite this, almost half of our respondents reported that they only sometimes or rarely performed a delirium assessment using a test, and a third never did so. It is striking to note that almost half used the RASS scale to diagnose delirium, even though it is designed to assess sedation,<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> not delirium. The American Geriatrics Society recommends the CAM, the Delirium Symptom Interview (DSI), and the Nursing Delirium Screening Scale (NuDesc) as generally validated instruments.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,10</span></a> CCU patients have needs that are appropriate to their condition, and validated tests such as the CAM-ICU and the ICDSC are recommended in these cases,<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,10</span></a> and are also supported by NICE guidelines.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> European guidelines also show that the AT4, CAM, CAM_ICU, along with other scales are used in post-anaesthesia care units (PACU).<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> These tools, plus the ICDSC, are summarized by Wilson et al. in their comprehensive review.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a></p><p id="par0240" class="elsevierStylePara elsevierViewall">Our results are similar to those of other surveys.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,15</span></a> For example, 83.5% of members of the American Society of Anesthesiologists rarely or hardly ever perform postoperative screening using a test.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Underdiagnosis of delirium</span><p id="par0245" class="elsevierStylePara elsevierViewall">Most respondents to our questionnaire work in the operating room, and over 90% believe that PCD is underdiagnosed. This may be due to the low availability of continuing professional development and education programmes for health personnel. In other surveys, perception of POD increased by up to 50% if the questionnaire included a definition of delirium. Despite this, clinicians appear to be aware of the importance of these entities.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Treatment</span><p id="par0250" class="elsevierStylePara elsevierViewall">More than two-thirds of respondents to our questionnaire would use both a pharmacological and non-pharmacological approach as first-line treatment for POD.</p><p id="par0255" class="elsevierStylePara elsevierViewall">In Belleli et al., 73.9% of respondents used a non-pharmacological approach to hypoactive POD, while both pharmacological and non-pharmacological strategies were most frequently used to treat hyperactive POD.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a></p><p id="par0260" class="elsevierStylePara elsevierViewall">There is strong evidence that non-pharmacological preventive measures are effective and are associated with minimal side effects, and all authors and guidelines agree that these should be used as first line treatment for POD.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> POD can be prevented by identifying RFs and predisposing and precipitating factors, such as those included in Pawel et al.,<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> and by implementing non-pharmacological intervention measures such as those included in the ABCDEF package,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> the National Institute for Health and Care Excellence (NICE) guidelines,<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> the tools designed by the Hospital Elder Life initiative Program (HELP<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> and the recommendations and degrees of evidence of the ESAIC Guidelines.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0265" class="elsevierStylePara elsevierViewall">Further studies are needed to determine whether implementing these measures after the onset of delirium can alter its course, severity and morbidity, particularly in cardiac surgery, where Pawel et al. were unable to show that non-pharmacological interventions had any effect on the onset of delirium, although they have positive impact on delirium in patients undergoing orthopaedic procedures and scheduled surgery.<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">35,36</span></a></p><p id="par0270" class="elsevierStylePara elsevierViewall">There is no evidence that typical or atypical antipsychotics or other drugs, such as clonidine, melatonin, have a clear effect on the incidence of POD. There is a high level of evidence and a strong recommendation to use perioperative dexmedetomidine to prevent POD, although the benefits should be weighed up against the side effects of this drug. This approach has sparked considerable interest, since it can be used both intra- and postoperatively, and can also be used in cardiac surgery (weak recommendation).<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0275" class="elsevierStylePara elsevierViewall">A non-pharmacological strategy should be the first line of treatment for POD, and antipsychotics or BDZs should be avoided in patients with no signs of agitation and/or likelihood of harming themselves or others. In patients exhibiting severe agitation, typical or atypical antipsychotics should only be used if behavioural interventions have not been effective. BDZs are specifically indicated in the case of BDZ or alcohol withdrawal syndrome.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,31,37</span></a></p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Noting POD in the medical history, informing the patient and their family, and long-term follow-up</span><p id="par0280" class="elsevierStylePara elsevierViewall">In Spain, unlike other countries, diagnosis of POD is rarely noted in the patient’s medical history and the patient and their family are rarely informed.</p><p id="par0285" class="elsevierStylePara elsevierViewall">Spain, however, is on a par with other countries in the lack of long-term follow-up and referral to other specialists.</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Limitations</span><p id="par0290" class="elsevierStylePara elsevierViewall">Although our response rate may appear low, it is similar<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15,38</span></a> to that of surveys recently performed in other countries. Another limitation is that the results may be biased, as anaesthesiologists with an interest in POD are more likely to complete the questionnaire. Most respondent anaesthesiologists habitually work in the operating room. The profile of the typical respondent - fully qualified anaesthesiologist working in a large hospital – may have influenced their responses, so this factor must be taken into consideration when interpreting our results. Another potential bias is the failure to evaluate adherence to guidelines, although mention is made of the use of protocols. Furthermore, our study does not compare the responses to the questionnaire with objective observation of real clinical practice, and focuses more on POD than DNCR and PNCD due to the proliferation of scientific evidence on the former.</p></span></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Conclusions</span><p id="par0295" class="elsevierStylePara elsevierViewall">Our survey shows that the tendency among responding anaesthesiologists to underestimate the impact of PCD can increase postoperative morbidity and mortality. This finding can lay the foundation for improvements in the care and clinical outcomes of elderly patients undergoing surgery and anaesthesia. Steps should be taken to raise awareness among anaesthesiologist of this underdiagnosed problem, such as developing guidelines and protocols, and promoting training and continuing professional development programs at the national and regional level. Giving anaesthesiologists prominence in multidisciplinary perioperative care teams will help implement these recommendations.</p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Conflict of interest</span><p id="par0300" class="elsevierStylePara elsevierViewall">The authors have no potential conflicts of interest related to the contents of this article.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres2209028" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1853116" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2209029" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1853115" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and methods" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Results" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Demographics" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Preoperative period" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Intraoperative period" ] 3 => array:2 [ "identificador" => "sec0035" "titulo" => "Postoperative period" ] ] ] 7 => array:3 [ "identificador" => "sec0040" "titulo" => "Discussion" "secciones" => array:10 [ 0 => array:2 [ "identificador" => "sec0045" "titulo" => "Preoperative period" ] 1 => array:3 [ "identificador" => "sec0050" "titulo" => "Intraoperative period" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0055" "titulo" => "Anaesthesia technique" ] ] ] 2 => array:2 [ "identificador" => "sec0060" "titulo" => "Drugs associated with the appearance of PCD" ] 3 => array:2 [ "identificador" => "sec0065" "titulo" => "Depth of anaesthesia monitoring" ] 4 => array:3 [ "identificador" => "sec0070" "titulo" => "Postoperative period" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0075" "titulo" => "Type of delirium" ] ] ] 5 => array:2 [ "identificador" => "sec0080" "titulo" => "Routine assessment of delirium and screening tools" ] 6 => array:2 [ "identificador" => "sec0085" "titulo" => "Underdiagnosis of delirium" ] 7 => array:2 [ "identificador" => "sec0090" "titulo" => "Treatment" ] 8 => array:2 [ "identificador" => "sec0095" "titulo" => "Noting POD in the medical history, informing the patient and their family, and long-term follow-up" ] 9 => array:2 [ "identificador" => "sec0100" "titulo" => "Limitations" ] ] ] 8 => array:2 [ "identificador" => "sec0105" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0110" "titulo" => "Conflict of interest" ] 10 => array:2 [ "identificador" => "xack761502" "titulo" => "Acknowledgements" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2023-05-23" "fechaAceptado" => "2024-02-15" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1853116" "palabras" => array:6 [ 0 => "Perioperative cognitive dysfunction" 1 => "Survey" 2 => "Postoperative delirium" 3 => "Anesthetic depth monitoring" 4 => "Risk factors" 5 => "Screening" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1853115" "palabras" => array:6 [ 0 => "Disfunción cognitiva perioperatoria" 1 => "Encuesta" 2 => "Delirium postoperatorio" 3 => "Monitorización de la profundidad anestésica" 4 => "Factores de riesgo" 5 => "Screening" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Perioperative cognitive dysfunction (PCD) is a very prevalent clinical syndrome due to the progressive aging of the surgical population.The aim of our study is to evaluate the clinical practice of Spanish anesthesiologists surveyed regarding this entity.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Prospective online survey conducted by the Neurosciences Section and distributed by SEDAR.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">544 responses were obtained, with a participation rate of 17%. 54.4% of respondents never make a preoperative assessment of cognitive impairment, only 7.5% always do it. 79.6% lack an intraoperative management protocol for the patient at risk of PCD. In the anesthetic planning, only 23.3% of the patients was kept in mind. Eighty-nine percent considered regional anesthesia with or without sedation preferable to general anesthesia for the prevention of PCD. 88.8% considered benzodiazepines to present a high risk of PCD. 71.7% considered that anesthetic depth monitoring could prevent postoperative cognitive deficit. Routine evaluation of postoperative delirium is low, only 14%. More than 80% recognize that PCD is underdiagnosed.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Among Spanish anesthesiologists surveyed, PCD is still a little known and underappreciated entity. It is necessary to raise awareness of the need to detect risk factors for PCD, as well as postoperative assessment and diagnosis. Therefore, the development of guidelines and protocols and the implementation of continuing education programs in which anesthesiologists should be key members of multidisciplinary teams in charge of perioperative care are suggested.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">La disfunción cognitiva perioperatoria (DCP) es un síndrome clínico muy prevalente debido al progresivo envejecimiento de la población quirúrgica. El objetivo de nuestro estudio es evaluar la práctica clínica de los anestesiólogos españoles encuestados respecto a esta entidad.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y métodos</span><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Encuesta online prospectiva realizada por la Sección de Neurociencias y distribuida por la SEDAR.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Se obtuvieron 544 respuestas, con una participación del 17%. El 54,4% de los encuestados no hace nunca una valoración preoperatoria del deterioro cognitivo, sólo el 7,5% la realiza siempre. El 79,6% carece de protocolo de manejo intraoperatorio del paciente en riesgo de DCP. En la planificación anestésica, el DCP solo era tenido en cuenta por un 23,3%. El 89% considera la anestesia regional con o sin sedación preferible a la anestesia general para prevenir el DCP. Un 88,8% opina que las benzodiacepinas presentan un alto riesgo de DCP. Un 71,7% considera que la monitorización de la profundidad anestésica podría prevenir el déficit cognitivo postoperatorio. La evaluación rutinaria del delirium postoperatorio es baja, solo un 14%. Más del 80% reconoce que el DCP está infradiagnosticado.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Entre los anestesiólogos españoles encuestados, la DCP es aún una entidad poco conocida y valorada. Es necesario concienciar sobre la necesidad de detectar los factores de riesgo de DCP y la evaluación postoperatoria. Por ello se sugiere el desarrollo de guías y protocolos, la implementación de programas de formación continuada en los que los anestesiólogos deberían ser miembros clave de equipos multidisciplinares encargados de la atención perioperatoria.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:3 [ "etiqueta" => "♦" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">The members of the Neuroscience Section Working Group are mentioned in <a class="elsevierStyleCrossRef" href="#sec0115">Annex A</a>.</p>" "identificador" => "fn0005" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:3 [ "apendice" => "<p id="par0310" class="elsevierStylePara elsevierViewall">Aldana E.M. (Anestesiología y Reanimación, Hospital Vithas Xanit Internacional, Benalmádena, Málaga, España), Aldecoa C. (Anestesiología y Reanimación, Hospital Universitario Rio Hortega, Valladolid, España), Belda I. (Anestesiología y Reanimación, Hospital Clínic, Universidad de Barcelona, Barcelona, España), Benito H. (Anestesiología y Reanimación, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España), Cassinello C. (Anestesiología y Reanimación, Hospital Universitario Infanta Sofía, Madrid, España), Fábregas N. (Anestesiología y Reanimación, Hospital Clínic, Universidad de Barcelona, Barcelona, España), Gracia I. (Anestesiología y Reanimación, Hospital Clínic, Universidad de Barcelona, Barcelona, España), Fernández-Candil J.L. (Anestesiología y Reanimación, Parc de Salut Mar, Barcelona, España), Pérez N. (Anestesiología y Reanimación, Hospital Universitario Central de Asturias, Oviedo, España), Valencia L. (Anestesiología y Reanimación, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, España) y Valverde J.L. (Anestesiología y Reanimación, Hospital Vithas Xanit Internacional, Benalmádena, Málaga, España).</p>" "titulo" => "Annex A. Working Group Section Neurosciences" "identificador" => "sec0115" ] ] ] ] "multimedia" => array:6 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 978 "Ancho" => 2500 "Tamanyo" => 126149 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Assessment of cognitive dysfunction in the preoperative visit.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Most respondents perform this assessment “sometimes” and 37% never do so, giving a combined total of approximately 70%.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1006 "Ancho" => 2500 "Tamanyo" => 134726 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Drugs associated with development of PCD.</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Respondents believe that benzodiazepines (88.8%) and anticholinergics (58%) have the greatest effect on the development of PCD.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 892 "Ancho" => 2508 "Tamanyo" => 108333 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Use of anaesthesia depth monitors.</p> <p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">This is among the questions with the greatest consensus: 83.5% of respondents routinely use anaesthesia depth monitors.</p>" ] ] 3 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 986 "Ancho" => 2508 "Tamanyo" => 151705 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">POD tests.</p> <p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Some (35%) respondents do not know which tests to use, although 47% use the Richmond scale and 35% use the CAM in patients presenting delirium (usually only in the event of hyperactive delirium).</p>" ] ] 4 => array:8 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 883 "Ancho" => 2508 "Tamanyo" => 122641 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Agreement with the statement “PCD is under-diagnosed”.</p> <p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">More than 80% of respondents consider POD and PCD to be under-diagnosed.</p>" ] ] 5 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0030" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Current position \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>93.4% were specialists \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>6.6% were residents. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Clinical experience in anaesthesiology, including residency time \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Less than or equal to 4 years: 7.2% (39) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>From 4 to 10 years: 21% (114) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>From 11 to 20 years: 30.1% (164) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Twenty years or more: 41.7% (227) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Habitual place of work \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Pre-anaesthesia 2.5% (13) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Operating room: 79.8% (434) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Postoperative care (PACU) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Critical care (Resuscitation/ICU): 12.5% (68) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Pain clinic 5% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Other \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Number of beds in your hospital \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Less than 200: 14% (76) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Between 200 and 500: 28.1% (153) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Between 501 and 1000: 45% (245) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>More than 1000: 12.9% (70) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Under 35 years: 19.3% (105) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Between 35 and 50 years: 44.5% (242) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Between 51 and 65 years: 34.9% (190) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Over 65 years: 1.3% (7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sex \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Men 37.5% (204) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Women 62.5% (340) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3604220.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Demographic data. Percentage of respondents.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:38 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "State of the clinical science of perioperative brain health: report from the American Society of Anesthesiologists Brain Health Initiative Summit 2018" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "E. Mahanna-Gabrielli" 1 => "K.J. Schenning" 2 => "L.I. Eriksson" 3 => "J.N. Browndyke" 4 => "C.B. Wright" 5 => "D.J. Culley" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.bja.2019.07.004" "Revista" => array:7 [ "tituloSerie" => "Br J Anaesth." 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