Presse Med
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The brain is both the orchestrator as well as the target of the innate immune system's response to the aseptic trauma of surgery. When trauma-induced inflammation is not appropriately regulated persistent neuro-inflammation interferes with the synaptic plasticity that underlies the learning and memory aspects of cognition. The complications that ensue, include postoperative delirium (POD) and postoperative cognitive dysfunction (POCD) at two poles of a constellation that is now termed perioperative neurocognitive disorders. ⋯ With so many "moving parts" the innate immune system is vulnerable in clinical settings that include advanced age and lifestyle-induced diseases such as "unhealthy" obesity and the inevitable insulin resistance. Under these conditions, inflammation may become exaggerated and long-lived. Consideration is provided how to identify the high-risk surgical patient and both pharmacological (including biological compounds) and non-pharmacological strategies to customize care.
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Delirium in the perioperative period is a wide-reaching problem that directly affects important clinical outcomes. It is essential that anesthesiologists understand how to define and diagnose delirium, identify patients at high risk for developing delirium, recognize precipitating factors to appropriately adjust care plans, and manage patients who develop delirium in the acute postoperative period. Importantly, delirium remains underdiagnosed in the perioperative setting, but many screening and assessment tools are readily available to aid non-psychiatric trained personnel in identifying delirium. Finally, understanding and implementing strategies to prevent patients from developing delirium is of utmost importance, as evidence-based pharmacological treatments for delirium are minimal and have significant limitations.