Perioperative Medicine

About

Vital statistics projections are that by early this current century, the elderly population will increase sharply due to aging of the baby boomers. By 2030, estimates are that one out of five Americans will be 65 years of age or older, while one out of four elderly individuals will be ≥ 85 years of age. The elderly population will have an increased likelihood of requiring surgery. Statistics show that approximately 12% of adults will require surgery each year as compared with 21% of the elderly who will require some form of anesthesia and surgery.

With the continued aging of the population and more older patients needing surgery, improvement of the perioperative care delivery and outcome of the older subjects is critically important, Our group focuses on outcomes research in older surgical patients, with the overall goal to identify methods to improve perioperative care delivery and outcomes of older surgical patients.

Research

The Perioperative Medicine Research Group headed by Dr. Leung focuses on outcomes research involving older surgical patients. Compared to their younger counterparts, older patients tend to have more severe illnesses and poorer clinical outcome after surgery. Of the adverse outcomes, postoperative delirium and cognitive decline are particularly common among the elderly. In our previous work, we found that the occurrence of postoperative delirium has significant implications for health care resource utilization. In a cohort study conducted since 2001, we found patients with postoperative delirium were three times more likely to be discharged to either a skilled nursing facility, another hospital, or nursing home than those without delirium. Furthermore, the duration of in-hospital stay was significantly longer in those with postoperative delirium compared to those without. Therefore, an effective strategy in reducing or preventing postoperative delirium will likely lead to a shorter hospital stay and reduce resource utilization. Despite the prevalence and clinical importance of postoperative delirium and cognitive decline, no specific causative factor has yet been identified for these two conditions, and no preventive therapy is currently available. As a result, our current research focuses on identification of the causes for postoperative delirium and cognitive decline, in order to develop effective strategies to decrease the incidence and severity of these adverse neurological outcomes in older patients undergoing major surgery. Examples of active studies:
1. Cohort study in patients aged ≥ 65 years undergoing major noncardiac surgery to identify the role of predisposing patient risk factors, precipitating events and the interaction of these on the occurrence of postoperative delirium.

2. Clinical trial to determine if intensive pain management using a non-narcotic adjuvant will decrease the incidence of on postoperative delirium and cognitive dysfunction. This study is funded by the NIH http://projectreporter.nih.gov/project_info_details.cfm?aid=7727936, and registered under clinicaltrials.gov (NCT00221338).

3. The relationship between sleep disruption and ICU delirium.

People

Principal investigator: Jacqueline M. Leung, MD, MPH
Professor of Anesthesia & Perioperative Care
University of California, San Francisco

Sakura Kinjo, MD
Associate Clinical Professor of Anesthesia & Perioperative Care
University of California, San Francisco

Joel Kramer, Psy.D.
Professor of Neuropsychology in Neurology
University of California, San Francisco
http://memory.ucsf.edu 

Laura P. Sands, PhD
Professor, School of Nursing, Purdue University
http://www.nursing.purdue.edu/facstaff/?uid=lsands

Jan Hirsch, MD
Assistant Professor of Anesthesia

 

 

Publications
Outcomes Research in the Older Surgical Patients

Outcomes Research in the Older Surgical Patients

Does using a femoral nerve block for total knee replacement decrease postoperative delirium?
Kinjo S, Lim E, Sands LP, Bozic KJ, Leung JM.
Anesthesiology. 2012 Mar 10;12:4. No abstract available.
PMID: 22405052 [PubMed - in process]

Prediction of postoperative pain using path analysis in older patients.
Kinjo S, Sands LP, Lim E, Paul S, Leung JM.
Anesthesiology. 2012 Feb;26(1):1-8. Epub 2011 Oct 20. No abstract available.
PMID: 22012171 [PubMed - in process]

Perioperative cognitive decline in the aging population.
Terrando N, Brzezinski M, Degos V, Eriksson LI, Kramer JH, Leung JM, Miller BL, Seeley WW, Vacas S, Weiner MW, Yaffe K, Young WL, Xie Z, Maze M.
Mayo Clin Proc. 2011 Sep;86(9):885-93. No abstract available.
PMID: 21878601 [PubMed - indexed for MEDLINE]

Factors associated with recovery from early postoperative delirium.
DeCrane SK, Sands L, Ashland M, Lim E, Tsai TL, Paul S, Leung JM.
J Perianesth Nurs. 2011 Aug;26(4):231-41. No abstract available.
PMID: 21803271 [PubMed - indexed for MEDLINE]

Brief report: preoperative frailty in older surgical patients is associated with early postoperative delirium.
Leung JM, Tsai TL, Sands LP.
Anesth Analg. 2011 May;112(5):1199-201. Epub 2011 Mar 3. No abstract available.
PMID: 21372278 [PubMed - in process]

An Update on Postoperative Cognitive Dysfunction.
Tsai TL, Sands LP, Leung JM.
Adv Anesth. 2010;28(1):269-284. No abstract available.
PMID: 21151735 [PubMed]

Postoperative delirium: are there modifiable risk factors?
Leung JM.
Eur J Anaesthesiol. 2010 May;27(5):403-5. No abstract available.
PMID: 20386385 [PubMed - indexed for MEDLINE]

Long-term cognitive decline: is there a link to surgery and anesthesia?
Leung JM, Sands LP.
Anesthesiology. 2009 Nov;111(5):964-70.
PMID: 19786857 [PubMed - indexed for MEDLINE]

Does postoperative delirium limit the use of patient-controlled analgesia in older surgical patients?
Leung JM, Sands LP, Paul S, Joseph T, Kinjo S, Tsai T.
Anesthesiology. 2009 Sep;111(3):625-31.
PMID: 19672166 [PubMed - indexed for MEDLINE]

Apolipoprotein E e4 allele increases the risk of early postoperative delirium in older patients undergoing noncardiac surgery.
Leung JM, Sands LP, Wang Y, Poon A, Kwok PY, Kane JP, Pullinger CR.
Anesthesiology. 2007 Sep;107(3):406-11.
PMID: 17721242 [PubMed - indexed for MEDLINE]

The effects of postoperative pain and its management on postoperative cognitive dysfunction.
Wang Y, Sands LP, Vaurio L, Mullen EA, Leung JM.
Am J Geriatr Psychiatry. 2007 Jan;15(1):50-9.
PMID: 17194815 [PubMed - indexed for MEDLINE]

Pilot clinical trial of gabapentin to decrease postoperative delirium in older patients.
Leung JM, Sands LP, Rico M, Petersen KL, Rowbotham MC, Dahl JB, Ames C, Chou D, Weinstein P.
Neurology. 2006 Oct 10;67(7):1251-3. Epub 2006 Aug 16.
PMID: 16914695 [PubMed - indexed for MEDLINE]

Nitrous oxide does not change the incidence of postoperative delirium or cognitive decline in elderly surgical patients.
Leung JM, Sands LP, Vaurio LE, Wang Y.
Br J Anaesth. 2006 Jun;96(6):754-60. Epub 2006 May 2.
PMID: 16670110 [PubMed - indexed for MEDLINE]

Postoperative delirium: the importance of pain and pain management.
Vaurio LE, Sands LP, Wang Y, Mullen EA, Leung JM.
Anesth Analg. 2006 Apr;102(4):1267-73.
PMID: 16551935 [PubMed - indexed for MEDLINE]
The role of postoperative analgesia in delirium and cognitive decline in elderly patients: a systematic review.
Fong HK, Sands LP, Leung JM.
Anesth Analg. 2006 Apr;102(4):1255-66. Review.
PMID: 16551934 [PubMed - indexed for MEDLINE]
Are preoperative depressive symptoms associated with postoperative delirium in geriatric surgical patients?
Leung JM, Sands LP, Mullen EA, Wang Y, Vaurio L.
J Gerontol A Biol Sci Med Sci. 2005 Dec;60(12):1563-8.
PMID: 16424289 [PubMed - indexed for MEDLINE]
Prognostic significance of postoperative in-hospital complications in elderly patients. II. Long-term quality of life.
Manku K, Leung JM.
Anesth Analg. 2003 Feb;96(2):590-4, table of contents.
PMID: 12538217 [PubMed - indexed for MEDLINE]
Prognostic significance of postoperative in-hospital complications in elderly patients. I. Long-term survival.
Manku K, Bacchetti P, Leung JM.
Anesth Analg. 2003 Feb;96(2):583-9, table of contents.
PMID: 12538216 [PubMed - indexed for MEDLINE]
Sample size calculations in clinical research.
Bacchetti P, Leung JM.
Anesthesiology. 2002 Oct;97(4):1028-9; author reply 1029-32. No abstract available.
PMID: 12357184 [PubMed - indexed for MEDLINE]
Preoperative electrocardiogram abnormalities do not predict postoperative cardiac complications in geriatric surgical patients.
Liu LL, Dzankic S, Leung JM.
J Am Geriatr Soc. 2002 Jul;50(7):1186-91.
PMID: 12133011 [PubMed - indexed for MEDLINE]
Relative importance of preoperative health status versus intraoperative factors in predicting postoperative adverse outcomes in geriatric surgical patients.
Leung JM, Dzankic S.
J Am Geriatr Soc. 2001 Aug;49(8):1080-5.
PMID: 11555070 [PubMed - indexed for MEDLINE]

Predicting adverse postoperative outcomes in patients aged 80 years or older.
Liu LL, Leung JM.
J Am Geriatr Soc. 2000 Apr;48(4):405-12.
PMID: 10798467 [PubMed - indexed for MEDLINE]

The prevalence and predictive value of abnormal preoperative laboratory tests in elderly surgical patients.
Dzankic S, Pastor D, Gonzalez C, Leung JM.
Anesth Analg. 2001 Aug;93(2):301-8, 2nd contents page.
PMID: 11473849 [PubMed - indexed for MEDLINE]
Cardiovascular Research

Histologic assessment of right atrial appendage myocardium in patients with atrial fibrillation after coronary artery bypass graft surgery. 
Nakai T, Chandy J, Nakai K, Bellows WH, Flachsbart K, Lee RJ, Leung JM.
Cardiology. 2007;108(2):90-6. Epub 2006 Sep 28.
PMID: 17008797 [PubMed - indexed for MEDLINE]

Impairment of left atrial function predicts post-operative atrial fibrillation after coronary artery bypass graft surgery.
Leung JM, Bellows WH, Schiller NB.
Eur Heart J. 2004 Oct;25(20):1836-44.
PMID: 15474699 [PubMed - indexed for MEDLINE]

Does intraoperative evaluation of left ventricular contractile reserve predict myocardial viability? A clinical study using dobutamine stress echocardiography in patients undergoing coronary artery bypass graft surgery.
Leung JM, Bellows WH, Pastor D.
Anesth Analg. 2004 Sep;99(3):647-54, table of contents.
PMID: 15333387 [PubMed - indexed for MEDLINE]

Increases in P-wave dispersion predict postoperative atrial fibrillation after coronary artery bypass graft surgery.
Chandy J, Nakai T, Lee RJ, Bellows WH, Dzankic S, Leung JM.
Anesth Analg. 2004 Feb;98(2):303-10, table of contents.
PMID: 14742359 [PubMed - indexed for MEDLINE]

The prevalence of preoperative diastolic filling abnormalities in geriatric surgical patients.
Phillip B, Pastor D, Bellows W, Leung JM.
Anesth Analg. 2003 Nov;97(5):1214-21.
PMID: 14570626 [PubMed - indexed for MEDLINE]

Comparison of left atrial dimensions by transesophageal and transthoracic echocardiography.
Block M, Hourigan L, Bellows WH, Reeves J 3rd, Romson JL, Tran M, Pastor D, Schiller NB, Leung JM.
J Am Soc Echocardiogr. 2002 Feb;15(2):143-9.
PMID: 11836489 [PubMed - indexed for MEDLINE]

The relative importance of left atrial function versus dimension in predicting atrial fibrillation after coronary artery bypass graft surgery.
Nakai T, Lee RJ, Schiller NB, Bellows WH, Dzankic S, Reeves J 3rd, Romson J, Ferguson S, Leung JM.
Am Heart J. 2002 Jan;143(1):181-6.
PMID: 11773931 [PubMed - indexed for MEDLINE]

Electrocardiographic ST-segment changes during acute, severe isovolemic hemodilution in humans.
Leung JM, Weiskopf RB, Feiner J, Hopf HW, Kelley S, Viele M, Lieberman J, Watson J, Noorani M, Pastor D, Yeap H, Ho R, Toy P.
Anesthesiology. 2000 Oct;93(4):1004-10.
PMID: 11020755 [PubMed - indexed for MEDLINE]

Effects of dobutamine on hemodynamics and left ventricular performance after cardiopulmonary bypass in cardiac surgical patients.
Romson JL, Leung JM, Bellows WH, Bronstein M, Keith F, Moores W, Flachsbart K, Richter R, Pastor D, Fisher DM.
Anesthesiology. 1999 Nov;91(5):1318-28. Erratum in: Anesthesiology 2000 Jan;92(1):296.
PMID: 10551583 [PubMed - indexed for MEDLINE]

Diabetes and not lack of treatment with atenolol predicts decreased survival after noncardiac surgery.
Leung JM.
Anesthesiology. 1999 Apr;90(4):1226-7. No abstract available.
PMID: 10201703 [PubMed - indexed for MEDLINE]

Beta blockade in non-cardiac surgical patients.
Leung JM.
Anesthesiology. 1998 Sep;89(3):795-7. No abstract available.
PMID: 9743425 [PubMed - indexed for MEDLINE]

Dissociation between haemodynamics and sympathetic activation during anaesthetic induction with desfluranes.
Leung JM, Pastor DA.
Can J Anaesth. 1998 Jun;45(6):533-40.
PMID: 9669006 [PubMed - indexed for MEDLINE]

Automated electrocardiograph ST segment trending monitors: accuracy in detecting myocardial ischemia.
Leung JM, Voskanian A, Bellows WH, Pastor D.
Anesth Analg. 1998 Jul;87(1):4-10.
PMID: 9661536 [PubMed - indexed for MEDLINE]

Human cardiovascular and metabolic response to acute, severe isovolemic anemia.
Weiskopf RB, Viele MK, Feiner J, Kelley S, Lieberman J, Noorani M, Leung JM, Fisher DM, Murray WR, Toy P, Moore MA.
JAMA. 1998 Jan 21;279(3):217-21. Erratum in: JAMA 1998 Oct 28;280(16):1404.
PMID: 9438742 [PubMed - indexed for MEDLINE]

Transesophageal echocardiography in myocardial revascularization: II. Influence on intraoperative decision making.
Bergquist BD, Bellows WH, Leung JM.
Anesth Analg. 1996 Jun;82(6):1139-45.
PMID: 8638781 [PubMed - indexed for MEDLINE]

Transesophageal echocardiography in myocardial revascularization: I. Accuracy of intraoperative real-time interpretation.
Bergquist BD, Leung JM, Bellows WH.
Anesth Analg. 1996 Jun;82(6):1132-8.
PMID: 8638780 [PubMed - indexed for MEDLINE]

Role of epidural anesthesia and analgesia on postoperative patient outcome.
Leung JM.
Anesthesiology. 1995 Nov;83(5):1132. No abstract available.
PMID: 7486171 [PubMed - indexed for MEDLINE]

Left ventricular end-systolic cavity obliteration as an estimate of intraoperative hypovolemia.
Leung JM, Levine EH.
Anesthesiology. 1994 Nov;81(5):1102-9.
PMID: 7978468 [PubMed - indexed for MEDLINE]

Relationship of the proinflammatory cytokines to myocardial ischemia and dysfunction after uncomplicated coronary revascularization.
Hennein HA, Ebba H, Rodriguez JL, Merrick SH, Keith FM, Bronstein MH, Leung JM, Mangano DT, Greenfield LJ, Rankin JS.
J Thorac Cardiovasc Surg. 1994 Oct;108(4):626-35.
PMID: 7934095 [PubMed - indexed for MEDLINE]

An initial multicenter, randomized controlled trial on the safety and efficacy of acadesine in patients undergoing coronary artery bypass graft surgery. SPI Research Group.
Leung JM, Stanley T 3rd, Mathew J, Curling P, Barash P, Salmenpera M, Reves JG, Hollenberg M, Mangano DT.
Anesth Analg. 1994 Mar;78(3):420-34.
PMID: 7818622 [PubMed - indexed for MEDLINE]

Clinical evidence of myocardial stunning in patients undergoing CABG surgery.
Leung JM.
J Card Surg. 1993 Mar;8(2 Suppl):220-3. Review.
PMID: 8461506 [PubMed - indexed for MEDLINE]

Perioperative monitoring of myocardial ischemia.
Bergquist BD, Leung JM.
Int Anesthesiol Clin. 1993 Summer;31(3):23-44. Review. No abstract available.
PMID: 8375909 [PubMed - indexed for MEDLINE]

Perioperative myocardial ischemia.
Leung JM.
West J Med. 1992 Nov;157(5):565-6. No abstract available.
PMID: 1441503 [PubMed - indexed for MEDLINE]

Effects of steal-prone anatomy on intraoperative myocardial ischemia. The SPI Research Group.
Leung JM, Hollenberg M, O'Kelly BF, Kao A, Mangano DT.
J Am Coll Cardiol. 1992 Nov 1;20(5):1205-12.
PMID: 1401623 [PubMed - indexed for MEDLINE]

Monitoring for myocardial ischemia during noncardiac surgery. A technology assessment of transesophageal echocardiography and 12-lead electrocardiography. The Study of Perioperative Ischemia Research Group.
Eisenberg MJ, London MJ, Leung JM, Browner WS, Hollenberg M, Tubau JF, Tateo IM, Schiller NB, Mangano DT.
JAMA. 1992 Jul 8;268(2):210-6.
PMID: 1608139 [PubMed - indexed for MEDLINE]

The risk of myocardial ischemia in patients receiving desflurane versus sufentanil anesthesia for coronary artery bypass graft surgery. The S.P.I. Research Group.
Helman JD, Leung JM, Bellows WH, Pineda N, Roach GW, Reeves JD 3rd, Howse J, McEnany MT, Mangano DT.
Anesthesiology. 1992 Jul;77(1):47-62.
PMID: 1535185 [PubMed - indexed for MEDLINE]

Nifedipine reduces the incidence of myocardial infarction and transient ischemia in patients undergoing coronary bypass grafting.
Leung JM, Browner WS.
Circulation. 1992 Jun;85(6):2334-5. No abstract available.
PMID: 1591854 [PubMed - indexed for MEDLINE]

Postoperative myocardial ischemia. Therapeutic trials using intensive analgesia following surgery. The Study of Perioperative Ischemia (SPI) Research Group.
Mangano DT, Siliciano D, Hollenberg M, Leung JM, Browner WS, Goehner P, Merrick S, Verrier E.
Anesthesiology. 1992 Mar;76(3):342-53.
PMID: 1531742 [PubMed - indexed for MEDLINE]

The role of hemodynamics in perioperative myocardial ischemia.
Leung JM.
Int Anesthesiol Clin. 1992 Winter;30(1):63-79. Review. No abstract available.
PMID: 1577543 [PubMed - indexed for MEDLINE]

Ventricular dysrhythmias in patients undergoing coronary artery bypass graft surgery: incidence, characteristics, and prognostic importance.
Study of Perioperative Ischemia (SPI) Research Group.

Smith RC, Leung JM, Keith FM, Merrick S, Mangano DT.
Am Heart J. 1992 Jan;123(1):73-81.
PMID: 1370363 [PubMed - indexed for MEDLINE]

Isoflurane anesthesia and myocardial ischemia: comparative risk versus sufentanil anesthesia in patients undergoing coronary artery bypass graft surgery. The SPI (Study of Perioperative Ischemia) Research Group.
Leung JM, Goehner P, O'Kelly BF, Hollenberg M, Pineda N, Cason BA, Mangano DT.
Anesthesiology. 1991 May;74(5):838-47.
PMID: 1826989 [PubMed - indexed for MEDLINE]

Postoperative myocardial ischemia in patients undergoing coronary artery bypass graft surgery. S.P.I. Research Group.
Smith RC, Leung JM, Mangano DT.
Anesthesiology. 1991 Mar;74(3):464-73.
PMID: 2001026 [PubMed - indexed for MEDLINE]

Relationship of regional wall motion abnormalities to hemodynamic indices of myocardial oxygen supply and demand in patients undergoing CABG surgery.
Leung JM, O'Kelly BF, Mangano DT.
Anesthesiology. 1990 Nov;73(5):802-14.
PMID: 2240670 [PubMed - indexed for MEDLINE]

Prognostic importance of postbypass regional wall-motion abnormalities in patients undergoing coronary artery bypass graft surgery. SPI Research Group.
Leung JM, O'Kelly B, Browner WS, Tubau J, Hollenberg M, Mangano DT.
Anesthesiology. 1989 Jul;71(1):16-25.
PMID: 2787609 [PubMed - indexed for MEDLINE]

Transesophageal echocardiographic assessment of left ventricular function.
Leung JM, Schiller NB, Mangano DT.
Int J Card Imaging. 1989;5(1):63-70. Review. No abstract available.
PMID: 2693536 [PubMed - indexed for MEDLINE]

 

 

Other Research

The prevalence and predictors of the use of alternative medicine in presurgical patients in five California hospitals.
Leung JM, Dzankic S, Manku K, Yuan S.
Anesth Analg. 2001 Oct;93(4):1062-8.
PMID: 11574384 [PubMed - indexed for MEDLINE]

Safety and efficacy of intravenous Carbicarb in patients undergoing surgery: comparison with sodium bicarbonate in the treatment of mild metabolic acidosis. SPI Research Group. Study of Perioperative Ischemia.
Leung JM, Landow L, Franks M, Soja-Strzepa D, Heard SO, Arieff AI, Mangano DT.
Crit Care Med. 1994 Oct;22(10):1540-9. Erratum in: Crit Care Med 1995 Feb;23(2):420.
PMID: 7924363 [PubMed - indexed for MEDLINE]

Safety of low-dose intraoperative bicarbonate therapy: a prospective, double-blind, randomized study. The Study of Perioperative Ischemia (SPI) Research Group.
Mark NH, Leung JM, Arieff AI, Mangano DT.
Crit Care Med. 1993 May;21(5):659-65.
PMID: 8386997 [PubMed - indexed for MEDLINE]

Jobs

We currently have five staff research associates, and can take on 1-2 students (pre-med or medical) from time to time. We also have non-paid positions for individuals who would like to learn about research and serve as volunteer researchers. We sometimes will take on postdoctoral fellows who have self-funding.

Interested individuals should send their CV to Jacqueline.Leung@ucsf.edu

Contact Us

Email: leungj@anesthesia.ucsf.edu
Phone: 415-476-0711
Fax: 415-476-9516

Mailing Address:
Box 0648
Department of Anesthesia & Perioperative Care
University of California, San Francisco
521 Parnassus Avenue, San Francisco, CA 94143-0730

Locations:
Research Office: U-368P
Dr. Leung’s office: C-450