Surgery, Anesthesia, & Aluminum

Insights and discussion from the cutting edge with reference to journal articles and other research papers.
CAngelS
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Surgery, Anesthesia, & Aluminum

Post by CAngelS »

It's not uncommon to see elderly patients' dementia increase following surgery (postoperative cognitive decline or dysfunction), but I have generally attributed this to trauma, along with increased frailties more common as we age and a lessened ability to "bounce back." (Also...anesthesia is just kind of freaky {& amazing!} with what it does to our systems...including, under deep anesthesia, a functional state that approximates brainstem death?!)

However, as I'm trying to understand more of the role aluminum toxicity plays in Alzheimers, I'm wondering specifically if anesthesia, other medications, blood transfusions, etc. involve any forms of aluminum or other chemicals that play a part in increased aluminum uptake resulting in post-surgical dementia?

Blood transfusions involve citrates which are known to facilitate the absorption of aluminum -- and antacids (especially if injected) may include easily absorbed aluminum (if I understand that correctly). But would either of those have an immediate impact?

Other threads on this forum touch on risks of general surgery for APOE4s and the potential benefits of IV anesthetics vs inhalation anesthetics. And it may not be significant, but it's notable to me that inhalation anesthetics may be stored in lined aluminum containers.

I'm way out of my league here, but I wondered what the scientists and researchers among us might have come across in your work? Are there any other aluminum-related issues in surgery? It's a rabbit trail that's over my head, but I'm curious.

----------

On Aluminum:
"Like the APOE-4 gene, aluminum also causes increased beta-amyloid in the brain. Aluminum also binds to oligomers of beta-amyloid to make droplets that are more neurotoxic than beta-amyloid. Aluminum accumulates in the brain with age due to increased gastrointestinal absorption of aluminum over age 70 and weakening of the blood-brain barrier in those, like my mother, with vascular disease. A meta-analysis of studies involving 1,208 participants including 613 AD patients revealed aluminum is higher than normal in brains, serum, and cerebrospinal fluid of AD patients compared with non-AD patients." - Increasing IQ, Cognition and COVID-19 Cure Rate with Essential Nutrients by Dennis N. Crouse, PhD (footnotes removed) (to read more including footnotes, see: https://prevent-alzheimers-autism-strok ... ci-and-ad/)
Oral aluminium bioavailability is increased by citrate, acidic pH, and uraemia and may be decreased by silicon-containing compounds. ...Increased oral aluminium absorption has been suggested in Alzheimer’s disease (AD) and Down’s subjects. Hman Health Risk Assessment for Aluminum, Aluminum Oxide, and Aluminum Hydroxide

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2782734/

On Related Issues:

- An article on citrates in blood transfusions:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4483798/

- A response from Laurie on the impact of citrate and aluminum absorption:
laurie wrote: Tue Jan 11, 2022 5:11 pm [RE: platelet donation & the anticoagulant used in the platelet collection process: acid citrate dextrose (ACD)]
You should be concerned. This is a mixture of citric acid and dextrose and it will facilitate the absorption of aluminum. I asked Dennis Crouse my husband who is a chemist for this answer.
(EDIT: Laurie’s husband has reconsidered the issue above & determined that citrate dextrose will not increase aluminum absorption.)

- A patent for aluminum housing of inhaled anesthetics:
the interior of the aluminum container is provided with an inert lining comprising an epoxyphenolic resin, and the inhalation anesthetic is selected from the group consisting of sevoflurane, desflurane, isoflurane, enflurane, methoxyflurane and halothane
https://patents.google.com/patent/US20110284418A1/en
- A mention by Stavia of surgery w/out gas with a good outcome utilizing propofol (yayyy!):
Stavia wrote: Thu Feb 18, 2016 4:02 am I had propofol a few months ago and have had no cognitive issues.
I asked for no gas and the anaesthetist kept me under with the propofol
- Common anesthetics:
(including propofol, ketamine, thiopental, methohexital, & etomidate, among others)
https://www.drugs.com/drug-class/genera ... terSection

- Common medications given before, during, or after surgery :
(including anticoagulants, antacids, antibiotics, sedatives, opioids, paralytic drugs, acetylcholinesterase inhibitors, etc.)
https://navinurses.com/8-most-common-su ... dications/
https://www.verywellhealth.com/drugs-us ... ry-3156830
https://www.verywellhealth.com/paralyti ... ed-3157132

- An article on surgery performed under propofol anesthesia inducing cognitive impairment and amyloid pathology in ApoE4 knock-in mouse model:
Conclusion: "Propofol anesthesia followed by surgery induced persistent changes in cognition, and pathological hippocampal changes in pre-symptomatic, but vulnerable AD mice. It would be appropriate to explore whether preclinical AD patients are more vulnerable to POCD development."

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8107235/
- Papers on cognitive disfunction and APOE4 (which Orangeblossom posted about several years ago), (FC also brought up the second article last year):
Orangeblossom wrote: Thu Jan 18, 2018 9:10 am I read this useful paper which was helpful. In particular that there is cognitive disfunction which improves. I was told it was related to cortisol and stress, mainly at the time, and the lack of sleep in the time before the op, in combination. https://www.omicsonline.org/does-genera ... p?aid=4796

and this one more specific to APOE4
http://anesthesiology.pubs.asahq.org/ar ... id=1933714

"These results provide the direct evidence for a strong association between the ApoE4 and transient postoperative cognitive dysfunction in patients undergoing inhalation anesthesia. In contrast, presence of the ApoE ε4 allele did not correlate with reduced MMSE scores in the intravenous anesthesia group"

Conclusions
"There is a strong association between ApoE4 and transient POCD in patients undergoing inhalation anesthesia. Compared with inhalation anesthesia, TIVA is more suitable for elderly patients because it has no observable effect on cognitive function of elderly patients after surgery, especially those carrying the ApoE ε4 allele."

Intersting. So it may be more about the type of anaesthetic. I had laughing gas as a child, for a minor op, but think it is mainly IV in the UK. I am unsure about the other type. these articles may be of use to read for anyone considering surgery.
- And link posted on this forum (& FB) regarding the relationship between surgery and Alzheimer's disease:
TheresaB wrote: Wed Apr 14, 2021 11:51 am In addition to this website, we (ApoE4.info) has a Facebook page where articles on current research are posted. Here are the top 10 links posted that generated the most interest during the first quarter (Jan – Mar) of this year.

...9. Posted Jan 26, 2021
Study Shows the Relationship Between Surgery and Alzheimer’s Disease
For goodness sake, if you need major surgery, have major surgery. But this may be something you'd wish to discuss with your doctor. This new study published in the Journal of Alzheimer’s Disease carried out by researchers at the Marqués de Valdecilla-IDIVAL University Hospital, in collaboration with researchers at the University of Bonn Medical Center, proposes that major surgery is a promoter or accelerator of Alzheimer’s disease (AD).
Direct Link: https://neurosciencenews.com/alzheimers ... ZFZNBnIBIM
Last edited by CAngelS on Thu Jan 27, 2022 10:41 am, edited 1 time in total.
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Re: Surgery, Anesthesia, & Aluminum

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CAngelS wrote: Wed Jan 19, 2022 5:02 pm It's not uncommon to see elderly patients' dementia increase following surgery (postoperative cognitive decline or dysfunction), but I have generally attributed this to trauma, along with increased frailties more common as we age and a lessened ability to "bounce back." (Also...anesthesia is just kind of freaky {& amazing!} with what it does to our systems...including, under deep anesthesia, a functional state that approximates brainstem death?!)
I have wondered about this also.

Have you looked into this: "Potential Risk of Aluminum Leaching with Use of Certain Fluid Warmer Devices - Letter to Health Care Providers"

I researched this a bit but not in depth. I couldn't determine how widespread the use of aluminum warming devices is. I did learn there is a manufacturer who makes aluminum free warming devices and I contacted them to thank them . https://www.fda.gov/medical-devices/let ... -providers
Apoe 3/4

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Re: Surgery, Anesthesia, & Aluminum

Post by CAngelS »

THIS. :!: I want to use undignified words here, but WOW this.

Uncoated aluminum fluid-warmers, used regularly in surgery to help patients maintain normal body temperature, LEACH TOXIC LEVELS OF ALUMINUM when used to warm electrolytes and other fluids. Warnings, recalls, etc. to follow below, but if accumulation of aluminum is as dangerous to APOE4 carriers and others as it would seem, this is substantial.

:arrow: For those of you who aren't geeked out by things like this (and are unlikely to read further:)) -- if you are planning to have surgery or another medical procedure, please discuss what type of fluid-warming device(s) may be used with your team to be sure this issue has been adequately addressed.

This seems to be a seriously significant finding -- especially related to postoperative cognitive decline or dysfunction, and I would be interested to hear other takes on it.

------------
laurie wrote: Wed Jan 19, 2022 5:45 pm Have you looked into this: "Potential Risk of Aluminum Leaching with Use of Certain Fluid Warmer Devices - Letter to Health Care Providers"

I researched this a bit but not in depth. I couldn't determine how widespread the use of aluminum warming devices is. I did learn there is a manufacturer who makes aluminum free warming devices and I contacted them to thank them . https://www.fda.gov/medical-devices/let ... -providers
For context, this involves MILLIONS of fluid warmers,
"Federal health officials have announced a series of recalls, impacting nearly 3.5 million fluid warmers used to maintain IV fluid temperatures, after determining the devices may introduce dangerous levels of aluminum ions into a patient’s bloodstream." https://www.aboutlawsuits.com/fluid-war ... ll-188579/
A related study published Feb. 19, 2019 (by researchers in Germany) found aluminum concentrations of up to 6794μg.l−1 in balanced electrolyte solution warmed in uncoated aluminum warming devices -- or MORE THAN 271 x the maximum concentration proposed by the FDA to be tolerable in parenteral nutrition. (A threshold of 25 μg.l−1 is the maximum concentration proposed by the US Food and Drug Administration to be tolerable in parenteral nutrition, which the study used as their baseline.):
[This study found that] "...balanced electrolyte solution in the uncoated device yielded aluminium concentrations of up to 6794 (3465–8002 [1868–7421]) μg.l−1"

"We conclude that using uncoated aluminium plates in fluid-warming systems can lead to a risk of administering potentially harmful concentrations of aluminium when balanced crystalloid solutions are used. ... Coating for aluminium within medical devices in direct contact with infusion fluids should be recommended." (Although such coating does not entirely mitigate aluminum exposure. - cas) And “…our results indicate that a review is necessary of the use of medical devices such as warming units that have direct contact of aluminium surfaces."

This last quote makes me wonder what other uncoated aluminum is utilized to support surgeries?? - CAS https://associationofanaesthetists-publ ... anae.14601
Further, in conjunction with its warning letter, the federal government also announced several fluid warmer Class I recalls impacting almost 3.5 MILLION devices. (Class 1 recalls are the most serious types of recalls as per the FDA, indicating that using these products may cause serious adverse health events or death.) One article highlighted several such recalls:
"The Vyaire Medical recall impacts all lots including approximately 2,899,660 enFlow Fluid Warming Systems that were distributed throughout the U.S. from January 4, 2016 to March 7, 2019.

The Smiths Medical ASD, Inc. recall impacts approximately 520,163 NORMOFLO Irrigation Fluid Warmer and Warmers Sets manufactured from January 1994 to July 2021.

The Smisson-Cartledge Biomedical, LLC recall impacts an estimated 38,786 ThermaCor 1200 Rapid Thermal Infusion System disposable sets that are part of the ThermaCor 1200 Rapid Thermal Infusion System. The devices were distributed to healthcare facilities across the nation from 2006 to present.

The Eight Medical International fluid warmer recall impacts an estimated 288 Recirculator 8.0 Disposable Lavage Kit is used with the company’s Hyperthermic Perfusion System containing product code 8100. The devices were distributed for sale from June 7, 2019 to June 7, 2021. https://www.aboutlawsuits.com/fluid-war ... ll-188579/
Vyaire Medical also conducted a recall in March 2019 (one month after the German study was released) and prior to the recall mentioned above in 2021. The number of units included in the recall at that time was even higher, involving 5,782,820 units. https://www.accessdata.fda.gov/scripts/ ... ?id=171533

It would seem at first glance that these recalls would resolve the issue, but medical recalls seem as if they are not quite that simple. The recalls are sometimes loose (not requiring companies to physically recall their products) and the devices are often distributed through third parties (as is the recall information). It is instead a limited (but encouraging) first step in a process that will hopefully further protect APOE4 patients, the elderly and very young, etc. from aluminum toxicity exposure.

Of interesting note in the article above:
"The [FDA] is instructing healthcare professionals to avoid using these fluid warmers in high-risk patient populations including those with poor renal function, neonates, infants, pregnant mothers, and the elderly because exposure to small amounts of aluminum may lead to toxicity."

It does NOT limit their use entirely. - cas

And from Smiths Medical...
https://www.drugwatcher.org/smiths-medi ... id-warmer/ (September 17, 2021)
"Instead of asking healthcare providers to return decades worth of medical devices, Smiths Medical wants distributors to alert customers to the potential risk from the use of the devices. The company is also asking distributors to give customers placards that will give them information on how to reduce the risk of aluminum exposure."

This leaves significant room for continued use in some circumstances, as do several others. - cas

I'm especially grateful for the research of T. Perl, N. Kunze-Szikszay, A. Brüauer, M. Quintel, A. L. Röhrig, K. Kerpen, and U. Telgheder & their teams at the University Medical Center in Goettingen, Germany and University Duisburg-Essen in Duisburg, Germany -- presented in their article, Aluminium Release by Coated and Uncoated Fluid-Warming Devices. THANK YOU!

Aluminum may be especially harmful for APOE4 carriers (among others), but toxic exposure is dangerous for all of us.
"If you are kind only to your friends, how are you different from anyone else?" (Matthew 5:47)
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Re: Surgery, Anesthesia, & Aluminum

Post by laurie »

Thanks for doing more reading on the warmers used in hospitals and posting links to the references.
Apoe 3/4

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Re: Surgery, Anesthesia, & Aluminum

Post by circular »

CAngelS wrote: Thu Jan 20, 2022 3:05 pmTHIS. :!: I want to use undignified words here, but WOW this.
Thanks so much! I do have surgery coming up that requires general anesthesia. I'm going to talk to the surgeon about this, but he might not even know, so I may have to plumb the depths of the hospital's surgical supplies office to learn more. The FDA warning just came out in September, so I doubt that much has been done to rid the hospital of the problem, but who knows. I'll drink almost nothing but silica water for a long time after surgery if I can't get good reassurances from them.

I couldn't find the name of the company that Laurie wrote to thank them for not using aluminum in their fluid warming products. Did you? I'd like to pass it along to the hospital if they're not already on top of this.
ApoE 3/4 > Thanks in advance for any responses made to my posts.
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Re: Surgery, Anesthesia, & Aluminum

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circular wrote: Thu Jan 20, 2022 9:02 pm
CAngelS wrote: Thu Jan 20, 2022 3:05 pmTHIS. :!: I want to use undignified words here, but WOW this.
Thanks so much! I do have surgery coming up that requires general anesthesia. I'm going to talk to the surgeon about this, but he might not even know, so I may have to plumb the depths of the hospital's surgical supplies office to learn more. The FDA warning just came out in September, so I doubt that much has been done to rid the hospital of the problem, but who knows. I'll drink almost nothing but silica water for a long time after surgery if I can't get good reassurances from them.

I couldn't find the name of the company that Laurie wrote to thank them for not using aluminum in their fluid warming products. Did you? I'd like to pass it along to the hospital if they're not already on top of this.
You’re welcome! I love the benefits of learning here together.

I’m so sorry to hear that you have surgery coming up! Still I hope this information helps make it possible to avoid any unnecessary negative impacts. I know it’s likely that you’re right about how slowly ships like this turn around, but I love your attitude!

I just did a quick search on what company Laurie might have been referencing & saw this from QinFlow, saying their units are aluminum-free: https://www.qinflow.com/

It also might be helpful to message the hospital, surgeon, anesthesiologist, surgical team (etc.) the FDA warning with the list of companies involved in recalls to ask about their response and what steps they’re taking to mitigate the risks. (Sometimes putting things in writing helps hold everyone accountable — and may even bring it to their attention.)

Some of these same companies may also provide coated aluminum warming units that could likely mitigate a great deal of the risks involved, as well.

And, as a reminder from other threads mentioned in my earlier post — as I understand it, TIVA (or injected) anesthetics have been shown to be preferable for APOE4 carriers over inhalation anesthetics.

Here’s the reference to that article again from Orangeblossom:
Orangeblossom wrote: Thu Jan 18, 2018 9:10 am http://anesthesiology.pubs.asahq.org/ar ... id=1933714

Conclusions
"There is a strong association between ApoE4 and transient POCD in patients undergoing inhalation anesthesia. Compared with inhalation anesthesia, TIVA is more suitable for elderly patients because it has no observable effect on cognitive function of elderly patients after surgery, especially those carrying the ApoE ε4 allele."
I hope you receive good responses!
Blessings — and let us know how it goes!
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Re: Surgery, Anesthesia, & Aluminum

Post by circular »

CAngelS wrote: Thu Jan 20, 2022 10:42 pm I just did a quick search on what company Laurie might have been referencing & saw this from QinFlow, saying their units are aluminum-free: https://www.qinflow.com/
Thanks for finding this, CAngelS, as well as for the other thoughts. The one you found appears to be intended more for portable use, but it's quite interesting to me with respect to another project I'm working on.

The surgery I need will require the general anesthesia. Last time I needed that I met with the anesthesiologist beforehand to discuss my concerns. I am also at higher risk of nausea after general anesthesia. I plan to request such an appointment this time around too. Last time everything went great, judging only by my own subjective experience and my husband's observational experience. I had zero cognitive disturbances and no nausea after a three hour surgery. Afterward I got the records about what the anesthesiologist had used, and I think what may have been the primary anesthetic was fentanyl. I'll be at the same hospital and ask the anesthesiologist to do whatever is necessary to keep me comfortable and "asleep" but to consult my prior, successful anesthesia record there as well (although I did "wake up groggily" as they transferred me from the transport bed to the OR table and hope that doesn't happen again!).
ApoE 3/4 > Thanks in advance for any responses made to my posts.
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Re: Surgery, Anesthesia, & Aluminum

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circular wrote: Sat Jan 22, 2022 10:56 am Thanks for finding this, CAngelS, as well as for the other thoughts. The one you found appears to be intended more for portable use, but it's quite interesting to me with respect to another project I'm working on.

The surgery I need will require the general anesthesia. Last time I needed that I met with the anesthesiologist beforehand to discuss my concerns. I am also at higher risk of nausea after general anesthesia. I plan to request such an appointment this time around too. Last time everything went great, judging only by my own subjective experience and my husband's observational experience. I had zero cognitive disturbances and no nausea after a three hour surgery. Afterward I got the records about what the anesthesiologist had used, and I think what may have been the primary anesthetic was fentanyl. I'll be at the same hospital and ask the anesthesiologist to do whatever is necessary to keep me comfortable and "asleep" but to consult my prior, successful anesthesia record there as well (although I did "wake up groggily" as they transferred me from the transport bed to the OR table and hope that doesn't happen again!).
That's interesting, Circular. I hope your share your other project when the time is right:)
And I hope your pre-op appointment and surgery go well. ("Asleep" in this case is good! ;) )

For what it's worth, the coated Fluido compact warmer used in the 2019 study on fluid-warmers leaching aluminum (https://pubmed.ncbi.nlm.nih.gov/30793280/) was found to leach far less aluminum than the uncoated enFlow version they tested. Perhaps they can use a coated warmer, if not stainless steel??
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Re: Surgery, Anesthesia, & Aluminum

Post by circular »

CAngelS wrote: Sat Jan 22, 2022 1:26 pm For what it's worth, the coated Fluido compact warmer used in the 2019 study on fluid-warmers leaching aluminum (https://pubmed.ncbi.nlm.nih.gov/30793280/) was found to leach far less aluminum than the uncoated enFlow version they tested. Perhaps they can use a coated warmer, if not stainless steel??
Thanks again. At the bottom of the FDA web page about the 'Smiths Medical Recalls NORMOFLO' there's a notice to consumers:
How Do I Report a Problem?

Health care professionals and consumers may report adverse reactions or quality problems they experienced using these devices to MedWatch: The FDA Safety Information and Adverse Event Reporting Program using an online form, regular mail, or FAX.
Of course it can be devilishly hard to trace a symptom to a source like that when there are likely other variables at play.
ApoE 3/4 > Thanks in advance for any responses made to my posts.
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Re: Surgery, Anesthesia, & Aluminum

Post by circular »

Just after my last post here, I realized I was getting a CT scan with IV iodine contrast that very afternoon. There was no time to address the fluid warmer, but I lucked out. They didn't need to use one for that.

Today I also got good news from the surgeon about fluid warmers during my surgery. He doesn't use them. He uses "Bair huggers" to keep the body warm. He says cardiothoracic surgeons and other specialties use the fluid warmers. So, depending on what surgical/medical requirements a certain specialty may have for fluid warmers, there may be cases where a surgeon typically uses them but could use "Bair huggers" instead (?).

He also had no problem with me having an appointment with the anesthesiologist before surgery "to discuss anesthesiology concerns."
ApoE 3/4 > Thanks in advance for any responses made to my posts.
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