Materials and Methods
This prospective and observational study was initiated after obtaining
the approval for the study from Izmir Bozyaka Training and Research
Hospital Ethics Committee on 27/03/2013 with decision number 17/7. The
study evaluated Mini Mental Test (MMT) scores of patients who received
total hip replacement surgery in Izmir Bozyaka Training and Research
Hospital from November 2013 to September 2014. In the assessment, Mini
Mental Test (MMT) was used for literate and Modified Mini Mental Test
(MMMT) was used for illiterate patients (7). Test scores were obtained
on the initial admission day (MMT1), 24 hours prior to surgery (MMT2)
and 24 hours after the surgery (MMT3). A drop of 4 points or more
between each test was defined as significant cognitive dysfunction
development. Patients who did not have any change or a change less than
4 points between MMT1 and MMT3 were grouped as “no cognitive
dysfunction” (Group 1) and patients with a difference more than 4
points between MMT1 and MMT3 were grouped as “cognitive dysfunction”
(Group 2). All analyses were performed using those 2 patient groups.
Patients who were planned to undergo total hip replacement surgery
without cement over 18 years of age and within ASA Group 1, 2 and 3
according to ASA physical status score were included in the study.
Patients younger than 18, who did not speak Turkish, precense the
history of cancer diagnosis, previous steroid treatment, serebro
vascular disease history in last 6 months, central nervous system
diseases (current meningitis, encephalitis, tumors, major degenerative
diseases), dementia, Alzheimer’s and Parkinson’s Disease,
neuropsychiatric diseases or received antidepressant, antipsychotic or
anticonvulsive treatment in the last 6 months, uncooperative patients,
substance abuse, severe organ failure (end-stage liver failure,
dialysis-dependent kidney failure), requiring ICU following surgery,
patients where regional anesthesia was contraindicated (Idiopathic
intracranial hypertension (IIH), clotting disorders, infection on
operational site) and pregnant patients were excluded from the study.
No premedication was performed on patients during preoperative period.
Hydration during preoperative period was performed by IV 0.9% NaCl
aqueous solution with a fasting period of 6-10 hours prior to surgery.
In our study, combined spinal-epidural anesthesia was used for
anesthesia for all the patients. Surgical intervention was allowed on
the patients with sensory block on T8 dermatome levels. Patients also
received gradually 0.5 mg IV bolus midazolam until to be Ramsey Sedation
Scale 3.
During anesthesia, decreasing systolic blood pressure more than 20%
compared to preoperative period was defined as hypotension. 5 mg IV
Ephedrine was administered to the patients when their mean arterial
blood pressure levels decreased 50 mmHg or below despite fluid
replacement. Bradycardia was defined as pulses below 40 bpm and was
treated with 0.5 mg IV atropine.
Postoperative pain management was planned according to Visual Analogue
Scale (VAS). In patients with VAS score 3 and above, 10 ml isobaric
bupivacaine 0.125% was administered through epidural catheter. No
additional medication (opiates or NSAIDs) were used for analgesia.
Demographics, education levels, employment status, operation
indications, ASA scores, comorbid diseases and tobacco use of all
patients were questioned and recorded. Scores of MMT or MMMT of patients
on their initial admission, 24 hours prior to surgery and 24 hours after
surgery and its parameters were all recorded and classified.
The period from hospitalization to the surgery date was calculated and
recorded. Patients’ hemoglobin, hematocrit, serum electrolyte levels on
initial admission, preoperative and postoperative periods, anesthesia
duration, surgery duration, administered midazolam, atropine and
ephedrine doses, crystalloid, colloid, blood and blood products used
during surgery and total blood loss volume were all recorded.