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Bouchez S, Gruenbaum BF, Van Vaerenbergh G, De Somer F. The evolving role of the modern perfusionist: Insights from processed electro-encephalography. Perfusion 2024:2676591241284864. [PMID: 39263861 DOI: 10.1177/02676591241284864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2024]
Abstract
Introduction: Since its origin in the 1920s, electroencephalography (EEG) has become a viable option for anesthesia and perfusion teams to monitor anesthetic delivery, optimizing drug dosage and enhancing patient safety. Patients undergoing cardiopulmonary bypass (CPB) are at particular high risk for excessive or inadequate anesthetic doses. During CPB, traditional physiological indicators such as heart rate and blood pressure can be significantly altered. These abnormalities are compounded by rapid changes in anesthetic concentration from hemodilution, circuit absorption, and altered pharmacokinetics. Method: This narrative highlights the use of processed EEG with spectral analysis for anesthetic management during CPB. Conclusion: We emphasize that neuromonitoring using processed EEG during CPB can assess adequacy of anesthesia delivery and monitor for pathologic conditions that can compromise brain function such as inadequate cerebral blood flow, emboli, and seizures. This information is highly valuable for the clinical team including the perfusionist, who regularly diagnose and manage these pathological conditions.
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Affiliation(s)
- Stefaan Bouchez
- Department of Anesthesia, Intensive Care and Emergency Medicine, OLV Aalst, Aalst, Belgium
| | - Benjamin F Gruenbaum
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA
| | | | - Filip De Somer
- Department of Cardiac Surgery, Ghent University Hospital, Ghent, Belgium
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Schwerin S, Schneider G, Kreuzer M, Kratzer S. Impact of Age on the Occurrence of Processed Electroencephalographic Burst Suppression. Anesth Analg 2024:00000539-990000000-00915. [PMID: 39178156 DOI: 10.1213/ane.0000000000007143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2024]
Abstract
BACKGROUND Patient age is assumed to be an important risk factor for the occurrence of burst suppression, yet this has still to be confirmed by large datasets. METHODS In this single-center retrospective analysis at a university hospital, the electronic patient records of 38,628 patients (≥18 years) receiving general anesthesia between January 2016 and December 2018 were analyzed. Risk factors for burst suppression were evaluated using univariate and multivariable analysis. We measured the incidence of burst suppression as indicated by the burst suppression ratio (BSR) of the Entropy Module, the maximum and mean BSR values, relative burst suppression duration, mean volatile anesthetic concentrations, and mean age-adjusted minimum alveolar concentrations (aaMAC) at burst suppression, and cases of potentially misclassified burst suppression episodes. Analyses were done separately for the total anesthesia period, as well as for the Induction and Maintenance phase. The association with age was evaluated using linear and polynomial fits and by calculating correlation coefficients. RESULTS Of the 54,266 patients analyzed, 38,628 were included, and 19,079 patients exhibited episodes with BSR >0. Patients with BSR >0 were significantly older, and age had the highest predictive power for BSR >0 (area under the receiving operating characteristic [AUROC] = 0.646 [0.638-0.654]) compared to other patient or procedural factors. The probability of BSR >0 increased linearly with patient age (ρ = 0.96-0.99) between 1.9% and 9.8% per year. While maximal and mean BSR showed a nonlinear relationship with age, relative burst suppression duration also increased linearly during maintenance (ρ = 0.83). Further, episodes potentially indicating burst suppression that were not detected by the Entropy BSR algorithm also became more frequent with age. Volatile anesthetic concentrations sufficient to induce BSR >0 were negatively correlated with age (sevoflurane: ρ = -0.71), but remained close to an aaMAC of 1.0. CONCLUSIONS The probability of burst suppression during general anesthesia increases linearly with age in adult patients, while lower anesthetic concentrations induce burst suppression with increasing patient age. Simultaneously, algorithm-based burst suppression detection appears to perform worse in older patients. These findings highlight the necessity to further enhance EEG application and surveillance strategies in anesthesia.
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Affiliation(s)
- Stefan Schwerin
- From the Department of Anesthesiology and Intensive Care Medicine, Technical University of Munich School of Medicine and Health, Munich, Germany
| | - Gerhard Schneider
- From the Department of Anesthesiology and Intensive Care Medicine, Technical University of Munich School of Medicine and Health, Munich, Germany
| | - Matthias Kreuzer
- From the Department of Anesthesiology and Intensive Care Medicine, Technical University of Munich School of Medicine and Health, Munich, Germany
| | - Stephan Kratzer
- Department of Anesthesia and Intensive Care Medicine, Hessing Foundation, Augsburg, Germany
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Kinateder T, Kratzer S, Husemann C, Hautmann H, García PS, Schneider G, Kreuzer M. Electroencephalogram-Based Anesthesia Indices Differently React to Modulations of Alpha-Oscillatory Activity. Anesth Analg 2024:00000539-990000000-00892. [PMID: 39093724 DOI: 10.1213/ane.0000000000007042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
BACKGROUND The electroencephalographic (EEG) provides the anesthesiologist with information regarding the level of anesthesia. Processed EEG indices are available that reflect the level of anesthesia as a single number. Strong oscillatory EEG activity in the alpha-band may be associated with an adequate level of anesthesia and a lower incidence of cognitive sequelae. So far, we do not know how the processed indices would react to changes in the alpha-band activity. Hence, we modulated the alpha-oscillatory activity of intraoperative EEG to assess possible index changes. METHODS We performed our analyses based on data from 2 studies. Intraoperative EEG was extracted, and we isolated the alpha-band activity by band-pass filtering (8-12 Hz). We added or subtracted this activity to the original EEG in different steps with different amplifications of the alpha signal. We then replayed these signals to the bispectral index (BIS), the Entropy Module (state entropy [SE]), the CONOX (qCON), and the SEDLine (patient state index [PSI]); and evaluated the alpha-band modulation's impact on the respective index. RESULTS The indices behaved differently to the modulation. In general, indices decreased with stronger alpha-band activity, but the rate of change was different with SE showing the strongest change (9% per step) and PSI and BIS (<5% per step) showing the weakest change. A simple regression analysis revealed a decrease of 0.02 to 0.09 index points with increasing alpha amplification. CONCLUSIONS While the alpha-band in the intraoperative EEG seems to carry information regarding the quality of anesthesia, changes in the alpha-band activity do neither strongly nor uniformly influence processed EEG indices. Hence, to assess alpha-oscillatory activity's strength, the user needs to focus on the raw EEG or its spectral representation also displayed on the monitoring systems.
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Affiliation(s)
- Thomas Kinateder
- From the Department of Anesthesiology and Intensive Care, School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - Stephan Kratzer
- Department of Anesthesia, Critical Care and Pain Medicine, Hessing Foundation, Augsburg, Germany
| | - Cornelius Husemann
- From the Department of Anesthesiology and Intensive Care, School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - Hubert Hautmann
- Department of Internal Medicine and Pneumology, Klinik Ottobeuren, Ottobeuren, Germany
| | - Paul S García
- Department of Anesthesiology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Gerhard Schneider
- From the Department of Anesthesiology and Intensive Care, School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - Matthias Kreuzer
- From the Department of Anesthesiology and Intensive Care, School of Medicine and Health, Technical University of Munich, Munich, Germany
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Thomsen KK, Sessler DI, Krause L, Hoppe P, Opitz B, Kessler T, Chindris V, Bergholz A, Flick M, Kouz K, Zöllner C, Schulte-Uentrop L, Saugel B. Processed electroencephalography-guided general anesthesia and norepinephrine requirements: A randomized trial in patients having vascular surgery. J Clin Anesth 2024; 95:111459. [PMID: 38599161 DOI: 10.1016/j.jclinane.2024.111459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 03/19/2024] [Accepted: 03/26/2024] [Indexed: 04/12/2024]
Abstract
STUDY OBJECTIVE Processed electroencephalography (pEEG) may help clinicians optimize depth of general anesthesia. Avoiding excessive depth of anesthesia may reduce intraoperative hypotension and the need for vasopressors. We tested the hypothesis that pEEG-guided - compared to non-pEEG-guided - general anesthesia reduces the amount of norepinephrine needed to keep intraoperative mean arterial pressure above 65 mmHg in patients having vascular surgery. DESIGN Randomized controlled clinical trial. SETTING University Medical Center Hamburg-Eppendorf, Hamburg, Germany. PATIENTS 110 patients having vascular surgery. INTERVENTIONS pEEG-guided general anesthesia. MEASUREMENTS Our primary endpoint was the average norepinephrine infusion rate from the beginning of induction of anesthesia until the end of surgery. MAIN RESULT 96 patients were analyzed. The mean ± standard deviation average norepinephrine infusion rate was 0.08 ± 0.04 μg kg-1 min-1 in patients assigned to pEEG-guided and 0.12 ± 0.09 μg kg-1 min-1 in patients assigned to non-pEEG-guided general anesthesia (mean difference 0.04 μg kg-1 min-1, 95% confidence interval 0.01 to 0.07 μg kg-1 min-1, p = 0.004). Patients assigned to pEEG-guided versus non-pEEG-guided general anesthesia, had a median time-weighted minimum alveolar concentration of 0.7 (0.6, 0.8) versus 0.8 (0.7, 0.8) (p = 0.006) and a median percentage of time Patient State Index was <25 of 12 (1, 41) % versus 23 (3, 49) % (p = 0.279). CONCLUSION pEEG-guided - compared to non-pEEG-guided - general anesthesia reduced the amount of norepinephrine needed to keep mean arterial pressure above 65 mmHg by about a third in patients having vascular surgery. Whether reduced intraoperative norepinephrine requirements resulting from pEEG-guided general anesthesia translate into improved patient-centered outcomes remains to be determined in larger trials.
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Affiliation(s)
- Kristen K Thomsen
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Daniel I Sessler
- OutcomesResearch Consortium, Department of Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
| | - Linda Krause
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Phillip Hoppe
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Benjamin Opitz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Till Kessler
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Viorel Chindris
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alina Bergholz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Moritz Flick
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Karim Kouz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; OutcomesResearch Consortium, Cleveland, OH, USA
| | - Christian Zöllner
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Leonie Schulte-Uentrop
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; OutcomesResearch Consortium, Cleveland, OH, USA
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Huang Y, Huang L, Xu J, Bao Y, Qu Y, Huang Y. Bispectral Index Monitoring Effect on Delirium Occurrence and Nursing Quality Improvement in Post-anesthesia Care Unit Patients Recovering From General Anesthesia: A Randomized Controlled Trial. Cureus 2024; 16:e66348. [PMID: 39246973 PMCID: PMC11377963 DOI: 10.7759/cureus.66348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/06/2024] [Indexed: 09/10/2024] Open
Abstract
BACKGROUND The effect of intraoperative anesthesia depth monitoring on delirium occurrence and improvement of nursing quality in the post-anesthesia care unit (PACU) remains unclear. We aimed to explore the effect of intraoperative anesthesia bispectral index (BIS) monitoring on delirium occurrence and improvement of nursing quality in the PACU for patients recovering from general anesthesia. METHODS This randomized controlled trial included 120 patients, aged 20-80 years, classified as grades I-III according to the American Society of Anesthesiologists. The BIS-guided group (group B) underwent intraoperative monitoring of BIS anesthesia depth (maintained within the anesthetic range (40-60)). The depth of anesthesia was not monitored in the non-BIS-guided group (group C). The patient's vital signs were recorded at the beginning of the operation (T0), upon entering the PACU (T1), 15 min after extubation (T2), and after leaving the PACU (T3). Delirium score, emergence period (extubation and PACU observation times), and adverse events in the PACU were monitored. The nursing activity score (NAS) was used to evaluate the quality of care. RESULTS Group B exhibited significantly lower heart rate and mean arterial pressure at T1 and T2, shorter time to extubation and PACU observation time, and a significantly lower incidence of adverse events than group C. Group B had significantly lower Ricker sedation-agitation scores and a lower incidence of delirium than group C. The NAS was significantly lower for group B than for group C. Patients aged 60-80 years in group C experienced agitation, requiring 30% more frequent assistance from one or two nurses than those in group B. CONCLUSION Intraoperative BIS monitoring can reduce the incidence of adverse events in the PACU, diminish the incidence of delirium during the recovery period in elderly patients, lessen the nursing workload, improve nursing quality, and promote patient rehabilitation, thus meriting clinical application.
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Affiliation(s)
- Yi'an Huang
- Department of Nursing, First Affiliated Hospital, Zhejiang University School of Medicine, Yiwu, CHN
- Department of Nursing, Fourth Affiliated Hospital of School of Medicine, International School of Medicine, International Institutes of Medicine, Zhejiang University, Huangzhou, CHN
| | - Lihua Huang
- Department of Nursing, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, CHN
| | - Jianhong Xu
- Department of Anesthesiology, Fourth Affiliated Hospital of School of Medicine, International School of Medicine, International Institutes of Medicine, Zhejiang University, Yiwu, CHN
| | - Yangjuan Bao
- Department of Nursing, Fourth Affiliated Hospital of School of Medicine, International School of Medicine, International Institutes of Medicine, Zhejiang University, Yiwu, CHN
| | - Ying Qu
- Department of Nursing, Fourth Affiliated Hospital of School of Medicine, International School of Medicine, International Institutes of Medicine, Zhejiang University, Yiwu, CHN
| | - Yanzi Huang
- Department of Nursing, Fourth Affiliated Hospital of School of Medicine, International School of Medicine, International Institutes of Medicine, Zhejiang University, Yiwu, CHN
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Mehler DM, Kreuzer M, Obert DP, Cardenas LF, Barra I, Zurita F, Lobo FA, Kratzer S, Schneider G, Sepúlveda PO. Electroencephalographic guided propofol-remifentanil TCI anesthesia with and without dexmedetomidine in a geriatric population: electroencephalographic signatures and clinical evaluation. J Clin Monit Comput 2024; 38:803-815. [PMID: 38451341 DOI: 10.1007/s10877-024-01127-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 01/17/2024] [Indexed: 03/08/2024]
Abstract
Elderly and multimorbid patients are at high risk for developing unfavorable postoperative neurocognitive outcomes; however, well-adjusted and EEG-guided anesthesia may help titrate anesthesia and improve postoperative outcomes. Over the last decade, dexmedetomidine has been increasingly used as an adjunct in the perioperative setting. Its synergistic effect with propofol decreases the dose of propofol needed to induce and maintain general anesthesia. In this pilot study, we evaluate two highly standardized anesthetic regimens for their potential to prevent burst suppression and postoperative neurocognitive dysfunction in a high-risk population. Prospective, randomized clinical trial with non-blinded intervention. Operating room and post anesthesia care unit at Hospital Base San José, Osorno/Universidad Austral, Valdivia, Chile. 23 patients with scheduled non-neurologic, non-cardiac surgeries with age > 69 years and a planned intervention time > 60 min. Patients were randomly assigned to receive either a propofol-remifentanil based anesthesia or an anesthetic regimen with dexmedetomidine-propofol-remifentanil. All patients underwent a slow titrated induction, followed by a target controlled infusion (TCI) of propofol and remifentanil (n = 10) or propofol, remifentanil and continuous dexmedetomidine infusion (n = 13). We compared the perioperative EEG signatures, drug-induced changes, and neurocognitive outcomes between two anesthetic regimens in geriatric patients. We conducted a pre- and postoperative Montreal Cognitive Assessment (MoCa) test and measured the level of alertness postoperatively using a sedation agitation scale to assess neurocognitive status. During slow induction, maintenance, and emergence, burst suppression was not observed in either group; however, EEG signatures differed significantly between the two groups. In general, EEG activity in the propofol group was dominated by faster rhythms than in the dexmedetomidine group. Time to responsiveness was not significantly different between the two groups (p = 0.352). Finally, no significant differences were found in postoperative cognitive outcomes evaluated by the MoCa test nor sedation agitation scale up to one hour after extubation. This pilot study demonstrates that the two proposed anesthetic regimens can be safely used to slowly induce anesthesia and avoid EEG burst suppression patterns. Despite the patients being elderly and at high risk, we did not observe postoperative neurocognitive deficits. The reduced alpha power in the dexmedetomidine-treated group was not associated with adverse neurocognitive outcomes.
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Affiliation(s)
- Dominik M Mehler
- Department of Anesthesiology and Intensive Care, School of Medicine, Technical University of Munich, Munich, Germany
| | - Matthias Kreuzer
- Department of Anesthesiology and Intensive Care, School of Medicine, Technical University of Munich, Munich, Germany
| | - David P Obert
- Department of Anesthesiology and Intensive Care, School of Medicine, Technical University of Munich, Munich, Germany
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts's General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Luis F Cardenas
- Department of Anesthesiology, Hospital Base San José, Osorno/Universidad Austral, Valdivia, Chile
| | - Ignacio Barra
- Department of Anesthesiology, Hospital Base San José, Osorno/Universidad Austral, Valdivia, Chile
| | - Fernando Zurita
- Department of Anesthesiology, Hospital Base San José, Osorno/Universidad Austral, Valdivia, Chile
| | - Francisco A Lobo
- Anesthesiology Institute, Cleveland Clinic Abu Dhabi, United Arab Emirates, Abu Dhabi, UAE
| | - Stephan Kratzer
- Department of Anesthesiology and Intensive Care, School of Medicine, Technical University of Munich, Munich, Germany
| | - Gerhard Schneider
- Department of Anesthesiology and Intensive Care, School of Medicine, Technical University of Munich, Munich, Germany
| | - Pablo O Sepúlveda
- Department of Anesthesiology, Hospital Base San José, Osorno/Universidad Austral, Valdivia, Chile.
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Deschamps A, Ben Abdallah A, Jacobsohn E, Saha T, Djaiani G, El-Gabalawy R, Overbeek C, Palermo J, Courbe A, Cloutier I, Tanzola R, Kronzer A, Fritz BA, Schmitt EM, Inouye SK, Avidan MS. Electroencephalography-Guided Anesthesia and Delirium in Older Adults After Cardiac Surgery: The ENGAGES-Canada Randomized Clinical Trial. JAMA 2024; 332:112-123. [PMID: 38857019 PMCID: PMC11165413 DOI: 10.1001/jama.2024.8144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 04/18/2024] [Indexed: 06/11/2024]
Abstract
Importance Intraoperative electroencephalogram (EEG) waveform suppression, suggesting excessive general anesthesia, has been associated with postoperative delirium. Objective To assess whether EEG-guided anesthesia decreases the incidence of delirium after cardiac surgery. Design, Setting, and Participants Randomized, parallel-group clinical trial of 1140 adults 60 years or older undergoing cardiac surgery at 4 Canadian hospitals. Recruitment was from December 2016 to February 2022, with follow-up until February 2023. Interventions Patients were randomized in a 1:1 ratio (stratified by hospital) to receive EEG-guided anesthesia (n = 567) or usual care (n = 573). Patients and those assessing outcomes were blinded to group assignment. Main Outcomes and Measures The primary outcome was delirium during postoperative days 1 through 5. Intraoperative measures included anesthetic concentration and EEG suppression time. Secondary outcomes included intensive care and hospital length of stay. Serious adverse events included intraoperative awareness, medical complications, and 30-day mortality. Results Of 1140 randomized patients (median [IQR] age, 70 [65-75] years; 282 [24.7%] women), 1131 (99.2%) were assessed for the primary outcome. Delirium during postoperative days 1 to 5 occurred in 102 of 562 patients (18.15%) in the EEG-guided group and 103 of 569 patients (18.10%) in the usual care group (difference, 0.05% [95% CI, -4.57% to 4.67%]). In the EEG-guided group compared with the usual care group, the median volatile anesthetic minimum alveolar concentration was 0.14 (95% CI, 0.15 to 0.13) lower (0.66 vs 0.80) and there was a 7.7-minute (95% CI, 10.6 to 4.7) decrease in the median total time spent with EEG suppression (4.0 vs 11.7 min). There were no significant differences between groups in median length of intensive care unit (difference, 0 days [95% CI, -0.31 to 0.31]) or hospital stay (difference, 0 days [95% CI, -0.94 to 0.94]). No patients reported intraoperative awareness. Medical complications occurred in 64 of 567 patients (11.3%) in the EEG-guided group and 73 of 573 (12.7%) in the usual care group. Thirty-day mortality occurred in 8 of 567 patients (1.4%) in the EEG-guided group and 13 of 573 (2.3%) in the usual care group. Conclusions and Relevance Among older adults undergoing cardiac surgery, EEG-guided anesthetic administration to minimize EEG suppression, compared with usual care, did not decrease the incidence of postoperative delirium. This finding does not support EEG-guided anesthesia for this indication. Trial Registration ClinicalTrials.gov Identifier: NCT02692300.
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Affiliation(s)
- Alain Deschamps
- Montreal Heart Institute, Department of Anesthesiology and Pain Medicine, Université de Montreal, Montreal, Quebec, Canada
| | - Arbi Ben Abdallah
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Eric Jacobsohn
- Department of Anesthesiology Perioperative and Pain Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Tarit Saha
- Department of Anesthesiology and Perioperative Medicine, Queen’s University, Kingston, Ontario, Canada
| | - George Djaiani
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Renée El-Gabalawy
- Departments of Clinical Health Psychology and Anesthesiology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Charles Overbeek
- Montreal Heart Institute, Department of Anesthesiology and Pain Medicine, Université de Montreal, Montreal, Quebec, Canada
| | - Jennifer Palermo
- Montreal Heart Institute, Department of Anesthesiology and Pain Medicine, Université de Montreal, Montreal, Quebec, Canada
| | - Athanase Courbe
- Montreal Heart Institute, Department of Anesthesiology and Pain Medicine, Université de Montreal, Montreal, Quebec, Canada
| | - Isabelle Cloutier
- Montreal Health Innovations Coordinating Center, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Rob Tanzola
- Department of Anesthesiology and Perioperative Medicine, Queen’s University, Kingston, Ontario, Canada
| | - Alex Kronzer
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Bradley A. Fritz
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Eva M. Schmitt
- Department of Medicine, Beth Israel-Deaconess Medical Center and the Marcus Institute for Aging Research, Hebrew Senior Life, Harvard Medical School, Boston, Massachusetts
| | - Sharon K. Inouye
- Department of Medicine, Beth Israel-Deaconess Medical Center and the Marcus Institute for Aging Research, Hebrew Senior Life, Harvard Medical School, Boston, Massachusetts
| | - Michael S. Avidan
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
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8
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Aldana EM, Pérez de Arriba N, Valverde JL, Aldecoa C, Fábregas N, Fernández-Candil JL. National survey on perioperative cognitive dysfunction. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024:S2341-1929(24)00122-7. [PMID: 38972351 DOI: 10.1016/j.redare.2024.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 11/29/2023] [Accepted: 02/15/2024] [Indexed: 07/09/2024]
Abstract
BACKGROUND 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. MATERIAL AND METHODS Prospective online survey conducted by the Neurosciences Section and distributed by SEDAR. RESULTS 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. CONCLUSIONS 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.
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Affiliation(s)
- E M Aldana
- Anestesiología y Reanimación, Hospital Vithas Xanit Internacional, Benalmádena, Málaga, Spain.
| | - N Pérez de Arriba
- Anestesiología y Reanimación, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - J L Valverde
- Anestesiología y Reanimación, Hospital Vithas Xanit Internacional, Benalmádena, Málaga, Spain
| | - C Aldecoa
- Anestesiología y Reanimación, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - N Fábregas
- Anestesiología y Reanimación, Hospital Clínic, Universidad de Barcelona, Barcelona, Spain
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9
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Aasheim A, Rosseland LA, Leonardsen ACL, Romundstad L. Depth of anesthesia monitoring in Norway-A web-based survey. Acta Anaesthesiol Scand 2024; 68:781-787. [PMID: 38551019 DOI: 10.1111/aas.14420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Revised: 01/16/2024] [Accepted: 03/18/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND The bispectral index (BIS) monitor is the most frequently used electroencephalogram (EEG)-based depth of anesthesia (DoA) technology in Norwegian hospitals. However, there is limited knowledge regarding the extent and clinical impact of its use and how anesthesiologists and nurse anesthetists use the information provided by the DoA monitors in their clinical practice. METHODS This cross-sectional survey on the use of DoA monitors in Norway used a web-based questionnaire distributed to anesthesia personnel in all hospitals in Norway. Participation was voluntary and anonymized, and the web form could not track IP sources or respondents' locations. RESULTS Three hundred and ninety-one nurse anesthetists (n = 324) and anesthesiologists (n = 67) responded. Among the EEG-based DoA monitoring tools, BIS was most often used to observe and assess patients' DoA (98%). Raw EEG waveform analysis (10%), EEG-spectrogram (9%), and suppression rate (10%) were seldom used. Twenty-seven percent of the anesthesia personnel were able to recognize a burst suppression pattern on EEG and its significance. Fifty-eight percent of the respondents considered clinical observations more reliable than BIS. Almost all respondents reported adjusting anesthetic dosage based on the BIS index values (80%). However, the anesthetic dose was more often increased (90%) because of high BIS index values than lowered (55%) because of low BIS index values. CONCLUSION Despite our respondents' extensive use of DoA monitoring, the anesthesia personnel in our survey did not use all the information and the potential to guide the titration of anesthetics the DoA monitors provide. Thus, anesthesia personnel could generally benefit from increased knowledge of how EEG-based DoA monitoring can be used to assess and determine individual patients' need for anesthetic medication.
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Affiliation(s)
- Anders Aasheim
- Department of Research and Development, Division of Emergencies and Critical care, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Leiv Arne Rosseland
- Department of Research and Development, Division of Emergencies and Critical care, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Ann-Chatrin Linqvist Leonardsen
- Department of Nursing, Health and Bioengineering, University of Southeastern Norway, Fredrikstad, Norway
- Department of Anesthesia, Østfold Hospital Trust, Kalnes, Norway
| | - Luis Romundstad
- Department of Anesthesia and Intensive Care medicine, Division of Emergencies and Critical care, Oslo University Hospital, Oslo, Norway
- Lovisenberg Diaconal University College, Oslo, Norway
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10
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Lütze C, Weber TP, Lücke T, Gude P, Georgevici AI. Incidence of emergence delirium after homeostasis-guided pediatric anesthesia for ear-nose-throat surgery. Minerva Anestesiol 2024; 90:644-653. [PMID: 39021140 DOI: 10.23736/s0375-9393.24.17847-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2024]
Abstract
BACKGROUND Emergence delirium is a complication of pediatric anesthesia during the early recovery period. Children undergoing ear, nose, and throat surgery are at high risk. The Pediatric Assessment of Emergence Delirium (PAED) scale is used for diagnosis and founded to specify the degree of emergence delirium. However, there is no consensus regarding a threshold value for emergence delirium diagnosis. Homeostasis-guided pediatric general anesthesia aims to maintain physiological parameters within normal ranges. In this prospective, observational study we evaluated the incidence of emergence delirium in children undergoing elective ear, nose, and throat surgery under standardized homeostasis-guided general anesthesia. Secondarily, we identified risk factors associated with an increased PAED score. METHODS In children aged 0-6 years, we collected data from standard monitoring, depth of anesthesia, and preoperative glucose and ketone body levels. These variables were studied as risk or protective factors for increased PAED >0 scores using multivariate logistic regression. RESULTS Of the 105 children analyzed, only five children (4.7%) had emergence delirium according to a threshold PAED score ≥10, while 37 children (35%) had PAED scores >0. Statistical analysis of the PAED outcome identified two significant positive associations with pain (P<0.001) and preoperative blood glucose levels (P=0.006) and one negative association with preoperative ketone body levels (P<0.001). CONCLUSIONS Our cohort observed a lower incidence of emergence delirium than in the literature. Higher pain intensity and lower blood glucose levels were risk factors for PAED > 0, whereas preoperative ketone body levels were protective.
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Affiliation(s)
- Christian Lütze
- Department of Anesthesiology, St. Josef and St. Elisabeth Hospital, Ruhr University Bochum, Bochum, Germany -
| | - Thomas P Weber
- Department of Anesthesiology, St. Josef and St. Elisabeth Hospital, Ruhr University Bochum, Bochum, Germany
| | - Thomas Lücke
- University Children's Hospital, St. Josef and St. Elisabeth Hospital, Ruhr University Bochum, Bochum, Germany
| | - Philipp Gude
- Department of Anesthesiology, St. Josef and St. Elisabeth Hospital, Ruhr University Bochum, Bochum, Germany
| | - Adrian-Iustin Georgevici
- Department of Anesthesiology, St. Josef and St. Elisabeth Hospital, Ruhr University Bochum, Bochum, Germany
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11
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Han C, Kim HI, Soh S, Choi JW, Song JW, Yoon D. Machine learning with clinical and intraoperative biosignal data for predicting postoperative delirium after cardiac surgery. iScience 2024; 27:109932. [PMID: 38799563 PMCID: PMC11126810 DOI: 10.1016/j.isci.2024.109932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 02/25/2024] [Accepted: 05/05/2024] [Indexed: 05/29/2024] Open
Abstract
Early identification of patients at high risk of delirium is crucial for its prevention. Our study aimed to develop machine learning models to predict delirium after cardiac surgery using intraoperative biosignals and clinical data. We introduced a novel approach to extract relevant features from continuously measured intraoperative biosignals. These features reflect the patient's overall or baseline status, the extent of unfavorable conditions encountered intraoperatively, and beat-to-beat variability within the data. We developed a soft voting ensemble machine learning model using retrospective data from 1,912 patients. The model was then prospectively validated with data from 202 additional patients, achieving a high performance with an area under the receiver operating characteristic curve of 0.887 and an accuracy of 0.881. According to the SHapley Additive exPlanation method, several intraoperative biosignal features had high feature importance, suggesting that intraoperative patient management plays a crucial role in preventing delirium after cardiac surgery.
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Affiliation(s)
- Changho Han
- Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Yongin, Republic of Korea
| | - Hyun Il Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sarah Soh
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ja Woo Choi
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jong Wook Song
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dukyong Yoon
- Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Yongin, Republic of Korea
- Center for Digital Health, Yongin Severance Hospital, Yonsei University Health System, Yongin, Republic of Korea
- Institute for Innovation in Digital Healthcare (IIDH), Severance Hospital, Seoul, Republic of Korea
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12
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Lipp M, Schneider G, Kreuzer M, Pilge S. Substance-dependent EEG during recovery from anesthesia and optimization of monitoring. J Clin Monit Comput 2024; 38:603-612. [PMID: 38108943 PMCID: PMC11164797 DOI: 10.1007/s10877-023-01103-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 10/28/2023] [Indexed: 12/19/2023]
Abstract
The electroencephalographic (EEG) activity during anesthesia emergence contains information about the risk for a patient to experience postoperative delirium, but the EEG dynamics during emergence challenge monitoring approaches. Substance-specific emergence characteristics may additionally limit the reliability of commonly used processed EEG indices during emergence. This study aims to analyze the dynamics of different EEG indices during anesthesia emergence that was maintained with different anesthetic regimens. We used the EEG of 45 patients under general anesthesia from the emergence period. Fifteen patients per group received sevoflurane, isoflurane (+ sufentanil) or propofol (+ remifentanil) anesthesia. One channel EEG and the bispectral index (BIS A-1000) were recorded during the study. We replayed the EEG back to the Conox, Entropy Module, and the BIS Vista to evaluate and compare the index behavior. The volatile anesthetics induced significantly higher EEG frequencies, causing higher indices (AUC > 0.7) over most parts of emergence compared to propofol. The median duration of "awake" indices (i.e., > 80) before the return of responsiveness (RoR) was significantly longer for the volatile anesthetics (p < 0.001). The different indices correlated well under volatile anesthesia (rs > 0.6), with SE having the weakest correlation. For propofol, the correlation was lower (rs < 0.6). SE was significantly higher than BIS and, under propofol anesthesia, qCON. Systematic differences of EEG-based indices depend on the drugs and devices used. Thus, to avoid early awareness or anesthesia overdose using an EEG-based index during emergence, the anesthetic regimen, the monitor used, and the raw EEG trace should be considered for interpretation before making clinical decisions.
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Affiliation(s)
- Marlene Lipp
- Department of Anesthesiology and Intensive Care, School of Medicine, Technical University of Munich, Ismaningerstr 22, 81675, Munich, Germany.
| | - Gerhard Schneider
- Department of Anesthesiology and Intensive Care, School of Medicine, Technical University of Munich, Ismaningerstr 22, 81675, Munich, Germany
| | - Matthias Kreuzer
- Department of Anesthesiology and Intensive Care, School of Medicine, Technical University of Munich, Ismaningerstr 22, 81675, Munich, Germany
| | - Stefanie Pilge
- Department of Anesthesiology and Intensive Care, School of Medicine, Technical University of Munich, Ismaningerstr 22, 81675, Munich, Germany
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13
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Yuan I, Bong CL, Chao JY. Intraoperative pediatric electroencephalography monitoring: an updated review. Korean J Anesthesiol 2024; 77:289-305. [PMID: 38228393 PMCID: PMC11150110 DOI: 10.4097/kja.23843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 12/05/2023] [Accepted: 01/16/2024] [Indexed: 01/18/2024] Open
Abstract
Intraoperative electroencephalography (EEG) monitoring under pediatric anesthesia has begun to attract increasing interest, driven by the availability of pediatric-specific EEG monitors and the realization that traditional dosing methods based on patient movement or changes in hemodynamic response often lead to imprecise dosing, especially in younger infants who may experience adverse events (e.g., hypotension) due to excess anesthesia. EEG directly measures the effects of anesthetics on the brain, which is the target end-organ responsible for inducing loss of consciousness. Over the past ten years, research on anesthesia and computational neuroscience has improved our understanding of intraoperative pediatric EEG monitoring and expanded the utility of EEG in clinical practice. We now have better insights into neurodevelopmental changes in the developing pediatric brain, functional connectivity, the use of non-proprietary EEG parameters to guide anesthetic dosing, epileptiform EEG changes during induction, EEG changes from spinal/regional anesthesia, EEG discontinuity, and the use of EEG to improve clinical outcomes. This review article summarizes the recent literature on EEG monitoring in perioperative pediatric anesthesia, highlighting several of the topics mentioned above.
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Affiliation(s)
- Ian Yuan
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Choon L. Bong
- Department of Pediatric Anesthesia, KK Women’s and Children’s Hospital, Duke-NUS Medical School, Singapore
| | - Jerry Y. Chao
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
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14
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Likhvantsev VV, Berikashvili LB, Smirnova AV, Polyakov PA, Yadgarov MY, Gracheva ND, Romanova OE, Abramova IS, Shemetova MM, Kuzovlev AN. Intraoperative electroencephalogram patterns as predictors of postoperative delirium in older patients: a systematic review and meta-analysis. Front Aging Neurosci 2024; 16:1386669. [PMID: 38803541 PMCID: PMC11128674 DOI: 10.3389/fnagi.2024.1386669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 04/30/2024] [Indexed: 05/29/2024] Open
Abstract
Background Postoperative delirium (POD) significantly affects patient outcomes after surgery, leading to increased morbidity, extended hospital stays, and potential long-term cognitive decline. This study assessed the predictive value of intraoperative electroencephalography (EEG) patterns for POD in adults. Methods This systematic review and meta-analysis followed the PRISMA and Cochrane Handbook guidelines. A thorough literature search was conducted using PubMed, Medline, and CENTRAL databases focusing on intraoperative native EEG signal analysis in adult patients. The primary outcome was the relationship between the burst suppression EEG pattern and POD development. Results From the initial 435 articles identified, 19 studies with a total of 7,229 patients were included in the systematic review, with 10 included in the meta-analysis (3,705 patients). In patients exhibiting burst suppression, the POD incidence was 22.1% vs. 13.4% in those without this EEG pattern (p=0.015). Furthermore, an extended burst suppression duration associated with a higher likelihood of POD occurrence (p = 0.016). Interestingly, the burst suppression ratio showed no significant association with POD. Conclusions This study revealed a 41% increase in the relative risk of developing POD in cases where a burst suppression pattern was present. These results underscore the clinical relevance of intraoperative EEG monitoring in predicting POD in older patients, suggesting its potential role in preventive strategies. Systematic Review Registration This study was registered on International Platform for Registered Protocols for Systematic Reviews and Meta-Analyses: INPLASY202420001, https://doi.org/10.37766/inplasy2024.2.0001.
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Affiliation(s)
- Valery V. Likhvantsev
- Federal Research and Clinical Centre of Intensive Care Medicine and Rehabilitology, Department of Clinical Trials, Moscow, Russia
- Department of Anesthesiology, First Moscow State Medical University, Moscow, Russia
| | - Levan B. Berikashvili
- Federal Research and Clinical Centre of Intensive Care Medicine and Rehabilitology, Department of Clinical Trials, Moscow, Russia
| | - Anastasia V. Smirnova
- Federal Research and Clinical Centre of Intensive Care Medicine and Rehabilitology, Department of Clinical Trials, Moscow, Russia
| | - Petr A. Polyakov
- Federal Research and Clinical Centre of Intensive Care Medicine and Rehabilitology, Department of Clinical Trials, Moscow, Russia
| | - Mikhail Ya Yadgarov
- Federal Research and Clinical Centre of Intensive Care Medicine and Rehabilitology, Department of Clinical Trials, Moscow, Russia
| | - Nadezhda D. Gracheva
- Federal Research and Clinical Centre of Intensive Care Medicine and Rehabilitology, Department of Clinical Trials, Moscow, Russia
| | - Olga E. Romanova
- Federal Research and Clinical Centre of Intensive Care Medicine and Rehabilitology, Department of Clinical Trials, Moscow, Russia
| | - Irina S. Abramova
- Department of Anesthesiology, City Clinical Oncological Hospital No. 1, Moscow, Russia
| | - Maria M. Shemetova
- Federal Research and Clinical Centre of Intensive Care Medicine and Rehabilitology, Department of Clinical Trials, Moscow, Russia
| | - Artem N. Kuzovlev
- Federal Research and Clinical Centre of Intensive Care Medicine and Rehabilitology, Department of Clinical Trials, Moscow, Russia
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15
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Hight D, Ehrhardt A, Lersch F, Luedi MM, Stüber F, Kaiser HA. Lower alpha frequency of intraoperative frontal EEG is associated with postoperative delirium: A secondary propensity-matched analysis. J Clin Anesth 2024; 93:111343. [PMID: 37995609 DOI: 10.1016/j.jclinane.2023.111343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 10/23/2023] [Accepted: 11/15/2023] [Indexed: 11/25/2023]
Abstract
BACKGROUND Postoperative delirium (POD) is a serious complication of surgery, especially in the elderly patient population. It has been proposed that decreasing the amount of anesthetics by titrating to an EEG index will lower POD rate, but clear evidence is missing. A strong age-dependent negative correlation has been reported between the peak oscillatory frequency of alpha waves and end-tidal anesthetic concentration, with older patients generating slower alpha frequencies. We hypothesized, that slower alpha oscillations are associated with a higher rate of POD. METHOD Retrospective analysis of patients` data from a prospective observational study in cardiac surgical patients approved by the Bernese Ethics committee. Frontal EEG was recorded during Isoflurane effect-site concentrations of 0.7 to 0.8 and peak alpha frequency was measured at highest power between 6 and 17 Hz. Delirium was assessed by chart review. Demographic and clinical characteristics were compared between POD and non-POD groups. Selection bias was addressed using nearest neighbor propensity score matching (PSM) for best balance. This incorporated 18 variables, whereas patients with missing variable information or without an alpha oscillation were excluded. RESULT Of the 1072 patients in the original study, 828 were included, 73 with POD, 755 without. PSM allowed 328 patients into the final analysis, 67 with, 261 without POD. Before PSM, 8 variables were significantly different between POD and non-POD groups, none thereafter. Mean peak alpha frequency was significantly lower in the POD in contrast to non-POD group before and after matching (7.9 vs 8.9 Hz, 7.9 vs 8.8 Hz respectively, SD 1.3, p < 0.001). CONCLUSION Intraoperative slower frontal peak alpha frequency is independently associated with POD after cardiac surgery and may be a simple intraoperative neurophysiological marker of a vulnerable brain for POD. Further studies are needed to investigate if there is a causal link between alpha frequency and POD.
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Affiliation(s)
- Darren Hight
- Inselspital, Bern University Hospital, University of Bern, Department of Anaesthesiology & Pain Medicine, Bern, Switzerland
| | - Alexander Ehrhardt
- Inselspital, Bern University Hospital, University of Bern, Department of Anaesthesiology & Pain Medicine, Bern, Switzerland; Hirslanden Clinic Aarau, Center for Anaesthesiology and Intensive Care Medicine, Aarau, Switzerland
| | - Friedrich Lersch
- Inselspital, Bern University Hospital, University of Bern, Department of Anaesthesiology & Pain Medicine, Bern, Switzerland
| | - Markus M Luedi
- Inselspital, Bern University Hospital, University of Bern, Department of Anaesthesiology & Pain Medicine, Bern, Switzerland; Department for Anesthesiology, Intensive, Rescue and Pain medicine, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Frank Stüber
- Inselspital, Bern University Hospital, University of Bern, Department of Anaesthesiology & Pain Medicine, Bern, Switzerland
| | - Heiko A Kaiser
- Inselspital, Bern University Hospital, University of Bern, Department of Anaesthesiology & Pain Medicine, Bern, Switzerland; Hirslanden Clinic Aarau, Center for Anaesthesiology and Intensive Care Medicine, Aarau, Switzerland.
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16
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Wang YP, Li L, Jin H, Chen Y, Jiang Y, Liu WX, Xue YX, Huang L, Wang DJ. Relative band power in assessing temporary neurological dysfunction post- type A aortic dissection surgery: a prospective study. Sci Rep 2024; 14:7845. [PMID: 38570622 PMCID: PMC10991486 DOI: 10.1038/s41598-024-58557-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 04/01/2024] [Indexed: 04/05/2024] Open
Abstract
Temporary neurological dysfunction (TND), a common complication following surgical repair of Type A Aortic Dissection (TAAD), is closely associated with increased mortality and long-term cognitive impairment. Currently, effective treatment options for TND remain elusive. Therefore, we sought to investigate the potential of postoperative relative band power (RBP) in predicting the occurrence of postoperative TND, with the aim of identifying high-risk patients prior to the onset of TND. We conducted a prospective observational study between February and December 2022, involving 165 patients who underwent surgical repair for TAAD at our institution. Bedside Quantitative electroencephalography (QEEG) was utilized to monitor the post-operative brain electrical activity of each participant, recording changes in RBP (RBP Delta, RBP Theta, RBP Beta and RBP Alpha), and analyzing their correlation with TND. Univariate and multivariate analyses were employed to identify independent risk factors for TND. Subsequently, line graphs were generated to estimate the incidence of TND. The primary outcome of interest was the development of TND, while secondary outcomes included intensive care unit (ICU) admission and length of hospital stay. A total of 165 patients were included in the study, among whom 68 (41.2%) experienced TND. To further investigate the independent risk factors for postoperative TND, we conducted both univariate and multivariate logistic regression analyses on all variables. In the univariate regression analysis, we identified age (Odds Ratio [OR], 1.025; 95% CI, 1.002-1.049), age ≥ 60 years (OR, 2.588; 95% CI, 1.250-5.475), hemopericardium (OR, 2.767; 95% CI, 1.150-7.009), cardiopulmonary bypass (CPB) (OR, 1.007; 95% CI, 1.001-1.014), RBP Delta (OR, 1.047; 95% CI, 1.020-1.077), RBP Alpha (OR, 0.853; 95% CI, 0.794-0.907), and Beta (OR, 0.755; 95% CI, 0.649-0.855) as independent risk factors for postoperative TND. Further multivariate regression analyses, we discovered that CPB time ≥ 180 min (OR, 1.021; 95% CI, 1.011-1.032), RBP Delta (OR, 1.168; 95% CI, 1.105-1.245), and RBP Theta (OR, 1.227; 95% CI, 1.135-1.342) emerged as independent risk factors. TND patients had significantly longer ICU stays (p < 0.001), and hospital stays (p = 0.002). We obtained the simplest predictive model for TND, consisting of three variables (CPB time ≥ 180 min, RBP Delta, RBP Theta, upon which we constructed column charts. The areas under the receiver operating characteristic (AUROC) were 0.821 (0.755, 0.887). Our study demonstrates that postoperative RBP monitoring can detect changes in brain function in patients with TAAD during the perioperative period, providing clinicians with an effective predictive method that can help improve postoperative TND in TAAD patients. These findings have important implications for improving clinical care in this population.Trial registration ChiCTR2200055980. Registered 30th Jan. 2022. This trial was registered before the first participant was enrolled.
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Affiliation(s)
- Ya-Peng Wang
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Li Li
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Afliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Hua Jin
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Afliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Yang Chen
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Afliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Yi Jiang
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Wen-Xue Liu
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Afliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Yun-Xing Xue
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Afliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Li Huang
- Department of Critical Care Medicine, Xiangya Hospital of Central South University, Changsha, 410008, Hunan, People's Republic of China.
| | - Dong-Jin Wang
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Afliated Hospital of Nanjing University Medical School, Nanjing, China.
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17
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Xue S, Xu AX, Liu H, Zhang Y. Electroencephalography Monitoring for Preventing Postoperative Delirium and Postoperative Cognitive Decline in Patients Undergoing Cardiothoracic Surgery: A Meta-Analysis. Rev Cardiovasc Med 2024; 25:126. [PMID: 39076572 PMCID: PMC11264044 DOI: 10.31083/j.rcm2504126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 11/26/2023] [Accepted: 12/06/2023] [Indexed: 07/31/2024] Open
Abstract
Background Patients undergoing cardiothoracic surgery frequently encounter perioperative neurocognitive disorders (PND), which can include postoperative delirium (POD) and postoperative cognitive decline (POCD). Currently, there is not enough evidence to support the use of electroencephalograms (EEGs) in preventing POD and POCD among cardiothoracic surgery patients. This meta-analysis examined the importance of EEG monitoring in POD and POCD. Methods Cochrane Library, PubMed, and EMBASE databases were searched to obtain the relevant literature. This analysis identified trials based on the inclusion and exclusion criteria. The Cochrane tool was used to evaluate the methodological quality of the included studies. Review Manager software (version 5.3) was applied to analyze the data. Results Four randomized controlled trials (RCTs) were included in this meta-analysis, with 1096 participants. Our results found no correlation between EEG monitoring and lower POD risk (relative risk (RR): 0.81; 95% CI: 0.55-1.18; p = 0.270). There was also no statistically significant difference between the EEG group and the control group in the red cell transfusions (RR: 0.86; 95% CI: 0.51-1.46; p = 0.590), intensive care unit (ICU) stay (mean deviation (MD): -0.46; 95% CI: -1.53-0.62; p = 0.410), hospital stay (MD: -0.27; 95% CI: -2.00-1.47; p = 0.760), and mortality (RR: 0.33; 95% CI: 0.03-3.59; p = 0.360). Only one trial reported an incidence of POCD, meaning we did not conduct data analysis on POCD risk. Conclusions This meta-analysis did not find evidence supporting EEG monitoring as a potential method to reduce POD incidence in cardiothoracic surgery patients. In the future, more high-quality RCTs with larger sample sizes are needed to validate the relationship between EEG monitoring and POD/POCD further.
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Affiliation(s)
- Song Xue
- Department of Anesthesiology and Perioperative Medicine, The Second
Hospital of Anhui Medical University, 230061 Hefei, Anhui, China
- Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui
Higher Education Institutes, Anhui Medical University, 230038 Hefei, Anhui, China
| | - Ao-xue Xu
- Department of Anesthesiology and Perioperative Medicine, The Second
Hospital of Anhui Medical University, 230061 Hefei, Anhui, China
- Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui
Higher Education Institutes, Anhui Medical University, 230038 Hefei, Anhui, China
| | - Hong Liu
- Department of Anesthesiology and Pain Medicine, University of California
Davis Health, Sacramento, CA 95817, USA
| | - Ye Zhang
- Department of Anesthesiology and Perioperative Medicine, The Second
Hospital of Anhui Medical University, 230061 Hefei, Anhui, China
- Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui
Higher Education Institutes, Anhui Medical University, 230038 Hefei, Anhui, China
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18
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Ryalino C, Sahinovic MM, Drost G, Absalom AR. Intraoperative monitoring of the central and peripheral nervous systems: a narrative review. Br J Anaesth 2024; 132:285-299. [PMID: 38114354 DOI: 10.1016/j.bja.2023.11.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 11/03/2023] [Accepted: 11/03/2023] [Indexed: 12/21/2023] Open
Abstract
The central and peripheral nervous systems are the primary target organs during anaesthesia. At the time of the inception of the British Journal of Anaesthesia, monitoring of the central nervous system comprised clinical observation, which provided only limited information. During the 100 yr since then, and particularly in the past few decades, significant progress has been made, providing anaesthetists with tools to obtain real-time assessments of cerebral neurophysiology during surgical procedures. In this narrative review article, we discuss the rationale and uses of electroencephalography, evoked potentials, near-infrared spectroscopy, and transcranial Doppler ultrasonography for intraoperative monitoring of the central and peripheral nervous systems.
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Affiliation(s)
- Christopher Ryalino
- Department of Anaesthesiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Marko M Sahinovic
- Department of Anaesthesiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Gea Drost
- Department of Neurology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands; Department of Neurosurgery, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Anthony R Absalom
- Department of Anaesthesiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands.
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19
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Aldecoa C, Bettelli G, Bilotta F, Sanders RD, Aceto P, Audisio R, Cherubini A, Cunningham C, Dabrowski W, Forookhi A, Gitti N, Immonen K, Kehlet H, Koch S, Kotfis K, Latronico N, MacLullich AMJ, Mevorach L, Mueller A, Neuner B, Piva S, Radtke F, Blaser AR, Renzi S, Romagnoli S, Schubert M, Slooter AJC, Tommasino C, Vasiljewa L, Weiss B, Yuerek F, Spies CD. Update of the European Society of Anaesthesiology and Intensive Care Medicine evidence-based and consensus-based guideline on postoperative delirium in adult patients. Eur J Anaesthesiol 2024; 41:81-108. [PMID: 37599617 PMCID: PMC10763721 DOI: 10.1097/eja.0000000000001876] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2023]
Abstract
Postoperative delirium (POD) remains a common, dangerous and resource-consuming adverse event but is often preventable. The whole peri-operative team can play a key role in its management. This update to the 2017 ESAIC Guideline on the prevention of POD is evidence-based and consensus-based and considers the literature between 01 April 2015, and 28 February 2022. The search terms of the broad literature search were identical to those used in the first version of the guideline published in 2017. POD was defined in accordance with the DSM-5 criteria. POD had to be measured with a validated POD screening tool, at least once per day for at least 3 days starting in the recovery room or postanaesthesia care unit on the day of surgery or, at latest, on postoperative day 1. Recent literature confirmed the pathogenic role of surgery-induced inflammation, and this concept reinforces the positive role of multicomponent strategies aimed to reduce the surgical stress response. Although some putative precipitating risk factors are not modifiable (length of surgery, surgical site), others (such as depth of anaesthesia, appropriate analgesia and haemodynamic stability) are under the control of the anaesthesiologists. Multicomponent preoperative, intra-operative and postoperative preventive measures showed potential to reduce the incidence and duration of POD, confirming the pivotal role of a comprehensive and team-based approach to improve patients' clinical and functional status.
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Affiliation(s)
- César Aldecoa
- From the Department of Anaesthesia and Postoperative Critical Care, Hospital Universitario Rio Hortega, Valladolid, Spain (CA), Department of Biomedical Studies, University of the Republic of San Marino, San Marino (GB), Department of Anesthesiology, Critical Care and Pain Medicine, 'Sapienza' University of Rome, Rome, Italy (FB, AF, LM), Specialty of Anaesthetics & NHMRC Clinical Trials Centre, University of Sydney & Department of Anaesthetics and Institute of Academic Surgery, Royal Prince Alfred Hospital (RDS), Department of Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, and Humboldt Universität zu Berlin, Campus Charité Mitte, and Campus Virchow Klinikum (CDS, SK, AM, BN, LV, BW, FY), Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy (PA), Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy (PA), Department of Surgery, Institute of Clinical Sciences, Sahlgrenska University Hospital, Göteborg, Sweden (RA), Geriatria, Accettazione Geriatrica e Centro di ricerca per l'invecchiamento, IRCCS INRCA, Ancona, Italy (AC), School of Biochemistry and Immunology and Trinity College Institute of Neuroscience, Trinity College, Dublin, Ireland (CC), First Department of Anaesthesiology and Intensive Care Medical University of Lublin, Poland (WD), Research Unit of Nursing Science and Health Management, University of Oulu, Oulu, Finland (KI), Section of Surgical Pathophysiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (HK), Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University in Szczecin, Poland (KK), Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia (NG, NL, SP, SR), Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy (NL, SP), Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Edinburgh, United Kingdom (AMJM), Department of Anaesthesia and Intensive Care, Nykoebing Hospital; University of Southern Denmark, SDU (SK, FR), Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia (ARB), Center for Intensive Care Medicine, Luzerner Kantonsspital, Lucerne, Switzerland (ARB), Department of Health Science, Section of Anesthesiology, University of Florence (SR), Department of Anaesthesia and Critical Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy (SR), School of Health Sciences, Institute of Nursing, ZHAW Zurich University of Applied Science, Winterthur, Switzerland (MS), Departments of Psychiatry and Intensive Care Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands (AJCS), Department of Neurology, UZ Brussel and Vrije Universiteit Brussel, Brussels, Belgium (AJCS) and Dental Anesthesia and Intensive Care Unit, Polo Universitario Ospedale San Paolo, Department of Biomedical, Surgical and Odontoiatric Sciences, University of Milano, Milan, Italy (CT)
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20
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Ma ZM, Hu JH, Ying YY, Chen X, Xu JY, Huo WW, Liu H, Ji FH, Peng K. Effect of remimazolam on electroencephalogram burst suppression in elderly patients undergoing cardiac surgery: Protocol for a randomized controlled noninferiority trial. Heliyon 2024; 10:e23879. [PMID: 38192765 PMCID: PMC10772712 DOI: 10.1016/j.heliyon.2023.e23879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 12/06/2023] [Accepted: 12/14/2023] [Indexed: 01/10/2024] Open
Abstract
Background Postoperative delirium (POD) is a common complication following cardiac surgery and increases postoperative morbidity and mortality. Intraoperative electroencephalogram (EEG) burst suppression suggests excessively deep anesthesia and predicts POD. Use of remimazolam provides a stable hemodynamic status and an appropriate depth of anesthesia. We aim to assess remimazolam administered for anesthesia and sedation in elderly patients having cardiac surgery. Methods This is a randomized controlled clinical trial with noninferiority design. A total of 260 elderly patients aged equal to or greater than 60 years undergoing cardiac surgery will be randomly allocated to receive remimazolam or propofol (1:1) for general anesthesia and postoperative sedation until extubation. The primary outcome is the cumulative time with EEG burst suppression which is obtained from the SedLine system. The noninferiority margin is 2.0 min. The secondary outcomes include the POD occurrence within the first 5 days postoperatively and the duration of perioperative hypotension. Discussion This noninferiority trial is the first to evaluate the effect of perioperative remimazolam administration on EEG burst suppression, POD occurrence, and duration of hypotension in elderly patients who undergo cardiac surgery. Trial registration Chinese Clinical Trial Registry (ChiCTR2200056353).
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Affiliation(s)
- Zheng-min Ma
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Jing-hui Hu
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Yao-yu Ying
- Department of Medical Affairs, The Second Affiliated Hospital of Soochow University, Suzhou, China
- Department of Epidemiology and Biostatistics, Soochow University Medical College, Suzhou, China
| | - Xian Chen
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Jing-ya Xu
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Wen-wen Huo
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Hong Liu
- Department of Anesthesiology and Pain Medicine, University of California Davis Health, Sacramento, CA, USA
| | - Fu-hai Ji
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Ke Peng
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
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21
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Loison V, Voskobiynyk Y, Lindquist B, Necula D, Longrois D, Paz J, Holcman D. Mapping general anesthesia states based on electro-encephalogram transition phases. Neuroimage 2024; 285:120498. [PMID: 38135170 PMCID: PMC10792552 DOI: 10.1016/j.neuroimage.2023.120498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 12/08/2023] [Accepted: 12/11/2023] [Indexed: 12/24/2023] Open
Abstract
Cortical electro-encephalography (EEG) served as the clinical reference for monitoring unconsciousness during general anesthesia. The existing EEG-based monitors classified general anesthesia states as underdosed, adequate, or overdosed, lacking predictive power due to the absence of transition phases among these states. In response to this limitation, we undertook an analysis of the EEG signal during isoflurane-induced general anesthesia in mice. Adopting a data-driven approach, we applied signal processing techniques to track θ- and δ-band dynamics, along with iso-electric suppressions. Combining this approach with machine learning, we successfully developed an automated algorithm. The findings of our study revealed that the dampening of the δ-band occurred several minutes before the onset of significant iso-electric suppression episodes. Furthermore, a distinct γ-frequency oscillation was observed, persisting for several minutes during the recovery phase subsequent to isoflurane-induced overdose. As a result of our research, we generated a map summarizing multiple brain states and their transitions, offering a tool for predicting and preventing overdose during general anesthesia. The transition phases identified, along with the developed algorithm, have the potential to be generalized, enabling clinicians to prevent inadequate anesthesia and, consequently, tailor anesthetic regimens to individual patients.
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Affiliation(s)
- V Loison
- Group of Data Modeling and Computational Biology, Institut de Biologie (IBENS), École Normale Supérieure CNRS, Université PSL Paris, France
| | - Y Voskobiynyk
- Gladstone Institutes, USA; Gladstone Institute of Neurological Disease, University of California, San Francisco, USA
| | - B Lindquist
- Gladstone Institutes, USA; Gladstone Institute of Neurological Disease, University of California, San Francisco, USA
| | - D Necula
- Gladstone Institutes, USA; Gladstone Institute of Neurological Disease, University of California, San Francisco, USA
| | - D Longrois
- Département d'Anesthésie-Réanimation, Hôpital Bichat-Claude Bernard, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - J Paz
- Gladstone Institutes, USA; Gladstone Institute of Neurological Disease, University of California, San Francisco, USA
| | - D Holcman
- Group of Data Modeling and Computational Biology, Institut de Biologie (IBENS), École Normale Supérieure CNRS, Université PSL Paris, France; DAMPT, University of Cambridge and Churchill College, CB30DS, Cambridge, UK.
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22
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Astalosch M, Mousavi M, Ribeiro LM, Schneider GH, Stuke H, Haufe S, Borchers F, Spies C, von Hofen-Hohloch J, Al-Fatly B, Ebersbach G, Franke C, Kühn AA, Kübler-Weller D. Risk Factors for Postoperative Delirium Severity After Deep Brain Stimulation Surgery in Parkinson's Disease. JOURNAL OF PARKINSON'S DISEASE 2024; 14:1175-1192. [PMID: 39058451 PMCID: PMC11380232 DOI: 10.3233/jpd-230276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/28/2024]
Abstract
Background Postoperative delirium (POD) is a serious complication following deep brain stimulation (DBS) but only received little attention. Its main risk factors are higher age and preoperative cognitive deficits. These are also main risk factors for long-term cognitive decline after DBS in Parkinson's disease (PD). Objective To identify risk factors for POD severity after DBS surgery in PD. Methods 57 patients underwent DBS (21 female; age 60.2±8.2; disease duration 10.5±5.9 years). Preoperatively, general, PD- and surgery-specific predictors were recorded. Montreal Cognitive Assessment and the neuropsychological test battery CANTAB ConnectTM were used to test domain-specific cognition. Volumes of the cholinergic basal forebrain were calculated with voxel-based morphometry. POD severity was recorded with the delirium scales Confusion Assessment Method for Intensive Care Unit (CAM-ICU) and Nursing Delirium Scale (NU-DESC). Spearman correlations were calculated for univariate analysis of predictors and POD severity and linear regression with elastic net regularization and leave-one-out cross-validation was performed to fit a multivariable model. Results 21 patients (36.8%) showed mainly mild courses of POD following DBS. Correlation between predicted and true POD severity was significant (spearman rho = 0.365, p = 0.001). Influential predictors were age (p < 0.001), deficits in attention and motor speed (p = 0.002), visual learning (p = 0.036) as well as working memory (p < 0.001), Nucleus basalis of Meynert volumes (p = 0.003) and burst suppression (p = 0.005). Conclusions General but also PD- and surgery-specific factors were predictive of POD severity. These findings underline the multifaceted etiology of POD after DBS in PD. Valid predictive models must therefore consider general, PD- and surgery-specific factors.
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Affiliation(s)
- Melanie Astalosch
- Department of Neurology and Experimental Neurology, Movement Disorder and Neuromodulation Unit, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Luísa Martins Ribeiro
- Department of Neurology and Experimental Neurology, Movement Disorder and Neuromodulation Unit, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Gerd-Helge Schneider
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Heiner Stuke
- Department of Psychiatry, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Robert Koch-Institute, Berlin, Germany
- Centre for Artificial Intelligence in Public Health Research, Germany; Berlin Center for Advanced Neuroimaging (BCAN), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Stefan Haufe
- Technische Universität, Berlin, Germany
- Robert Koch-Institute, Berlin, Germany
- Physikalisch-Technische Bundesanstalt, Berlin, Germany
| | - Friedrich Borchers
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Claudia Spies
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | - Bassam Al-Fatly
- Department of Neurology and Experimental Neurology, Movement Disorder and Neuromodulation Unit, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Georg Ebersbach
- Movement Disorders Clinic, Kliniken Beelitz GmbH, Beelitz-Heilstätten, Germany
| | - Christiana Franke
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Andrea A Kühn
- Department of Neurology and Experimental Neurology, Movement Disorder and Neuromodulation Unit, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin School of Mind and Brain, Humboldt - Universität zu Berlin, Berlin, Germany
- Deutsches Zentrum für Neurodegenerative Erkrankungen, Berlin, Germany
| | - Dorothee Kübler-Weller
- Department of Neurology and Experimental Neurology, Movement Disorder and Neuromodulation Unit, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
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23
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Dragovic S, Schneider G, García PS, Hinzmann D, Sleigh J, Kratzer S, Kreuzer M. Predictors of Low Risk for Delirium during Anesthesia Emergence. Anesthesiology 2023; 139:757-768. [PMID: 37616326 DOI: 10.1097/aln.0000000000004754] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
BACKGROUND Processed electroencephalography (EEG) is used to monitor the level of anesthesia, and it has shown the potential to predict the occurrence of delirium. While emergence trajectories of relative EEG band power identified post hoc show promising results in predicting a risk for a delirium, they are not easily transferable into an online predictive application. This article describes a low-resource and easily applicable method to differentiate between patients at high risk and low risk for delirium, with patients at low risk expected to show decreasing EEG power during emergence. METHODS This study includes data from 169 patients (median age, 61 yr [49, 73]) who underwent surgery with general anesthesia maintained with propofol, sevoflurane, or desflurane. The data were derived from a previously published study. The investigators chose a single frontal channel, calculated the total and spectral band power from the EEG and calculated a linear regression model to observe the parameters' change during anesthesia emergence, described as slope. The slope of total power and single band power was correlated with the occurrence of delirium. RESULTS Of 169 patients, 32 (19%) showed delirium. Patients whose total EEG power diminished the most during emergence were less likely to screen positive for delirium in the postanesthesia care unit. A positive slope in total power and band power evaluated by using a regression model was associated with a higher risk ratio (total, 2.83 [95% CI, 1.46 to 5.51]; alpha/beta band, 7.79 [95% CI, 2.24 to 27.09]) for delirium. Furthermore, a negative slope in multiple bands during emergence was specific for patients without delirium and allowed definition of a test for patients at low risk. CONCLUSIONS This study developed an easily applicable exploratory method to analyze a single frontal EEG channel and to identify patterns specific for patients at low risk for delirium. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Srdjan Dragovic
- Department for Anesthesiology and Intensive Care, School of Medicine, Technical University of Munich, Munich, Germany
| | - Gerhard Schneider
- Department for Anesthesiology and Intensive Care, School of Medicine, Technical University of Munich, Munich, Germany
| | - Paul S García
- Department of Anesthesiology, Columbia University, New York, New York
| | - Dominik Hinzmann
- Department for Anesthesiology and Intensive Care, School of Medicine, Technical University of Munich, Munich, Germany
| | - Jamie Sleigh
- Waikato Clinical Campus, University of Auckland, Auckland, New Zealand
| | - Stephan Kratzer
- Department for Anesthesiology and Intensive Care, School of Medicine, Technical University of Munich, Munich, Germany; and Hessing Clinic for Anesthesiology, Intensive Care and Pain Medicine, Augsburg, Germany
| | - Matthias Kreuzer
- Department for Anesthesiology and Intensive Care, School of Medicine, Technical University of Munich, Munich, Germany
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Kinoshita H, Saito J, Kushikata T, Oyama T, Takekawa D, Hashiba E, Sawa T, Hirota K. The Perioperative Frontal Relative Ratio of the Alpha Power of Electroencephalography for Predicting Postoperative Delirium After Highly Invasive Surgery: A Prospective Observational Study. Anesth Analg 2023; 137:1279-1288. [PMID: 36917508 DOI: 10.1213/ane.0000000000006424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/15/2023]
Abstract
BACKGROUND We investigated the associations between postoperative delirium (POD) and both the relative ratio of the alpha (α)-power of electroencephalography (EEG) and inflammatory markers in a prospective, single-center observational study. METHODS We enrolled 84 patients who underwent radical cancer surgeries with reconstruction for esophageal cancer, oral floor cancer, or pharyngeal cancer under total intravenous anesthesia. We collected the perioperative EEG data and the perioperative data of the inflammatory markers, including neutrophil gelatinase-associated lipocalin, presepsin, procalcitonin, C-reactive protein, and the neutrophil-lymphocyte ratio (NLR). The existence of POD was evaluated based on the Intensive Care Delirium Screening Checklist. We compared the time-dependent changes in the relative ratio of the EEG α-power and inflammatory markers between the patients with and without POD. RESULTS Four of the 84 patients were excluded from the analysis. Of the remaining 80 patients, 25 developed POD and the other 55 did not. The relative ratio of the α-power at baseline was significantly lower in the POD group than the non-POD group (0.18 ± 0.08 vs 0.28 ± 0.11, P < .001). A time-dependent decline in the relative ratio of α-power in the EEG during surgery was observed in both groups. There were significant differences between the POD and non-POD groups in the baseline, 3-h, 6-h, and 9-h values of the relative ratio of α-power. The preoperative NLR of the POD group was significantly higher than that of the non-POD group (2.88 ± 1.04 vs 2.22 ± 1.00, P < .001), but other intraoperative inflammatory markers were comparable between the groups. Two multivariable logistic regression models demonstrated that the relative ratio of the α-power at baseline was significantly associated with POD. CONCLUSIONS Intraoperative frontal relative ratios of the α-power of EEG were associated with POD in patients who underwent radical cancer surgery. Intraoperative EEG monitoring could be a simple and more useful tool for predicting the development of postoperative delirium than measuring perioperative acute inflammatory markers. A lower relative ratio of α-power might be an effective marker for vulnerability of brain and ultimately for the development of POD.
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Affiliation(s)
- Hirotaka Kinoshita
- From the Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Junichi Saito
- From the Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Tetsuya Kushikata
- From the Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Tasuku Oyama
- From the Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Daiki Takekawa
- From the Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Eiji Hashiba
- Division of Intensive Care, Hirosaki University Medical Hospital, Hirosaki, Japan
| | - Teiji Sawa
- Department of Anesthesiology, School of Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kazuyoshi Hirota
- From the Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
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25
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Suzuki Y, Miyasaka KW, Hayashi K, Takahashi O, Nagasaka Y. Protocol for a randomized controlled trial to reduce pediatric anesthesia emergence delirium by titration of sevoflurane anesthesia using brain function monitoring. Trials 2023; 24:734. [PMID: 37974297 PMCID: PMC10655373 DOI: 10.1186/s13063-023-07785-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Accepted: 11/06/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Emergence agitation or emergence delirium is a common complication of unknown etiology in pediatric anesthesia. Pediatric anesthesia emergence delirium (PAED) has been reported most commonly in younger children and may occur in about 30% of children up to 5-6 years old. Exposure to anesthetic agents may contribute to PAED, and we hypothesized that a management strategy to minimize exposure to volatile anesthetics may reduce PAED. Electroencephalography (EEG) signatures captured and displayed by brain function monitors during anesthesia change with concentration of sevoflurane and level of unconsciousness, and these EEG signatures may be used to inform titration of anesthetics. METHODS A single-center, parallel-group, two-arm, superiority trial with a 1:1 allocation ratio will be performed to compare the incidence of PAED following standard sevoflurane anesthesia (maintained at 1.0MAC) and EEG-guided anesthesia (minimum concentration to sustain surgical anesthesia as determined by monitoring of EEG signatures). Participants between 1 and 6 years of age undergoing surgical procedures involving minimal postoperative pain will be randomly assigned to receive standard (n = 90) or EEG-guided (n = 90) anesthesia. PAED score will be assessed by a blinded observer in the PACU on arrival and after 5, 10, 15, and 30 min. DISCUSSION Anesthesia management with proactive use of brain function monitoring is expected to reduce exposure to sevoflurane without compromising surgical anesthesia. We expect this reduced exposure should help prevent PAED. Routinely administering what may be considered standard levels of anesthetic such as 1.0 MAC sevoflurane may be excessive and potentially associated with unfavorable sequelae such as PAED. TRIAL REGISTRATION Japan Registry of Clinical Trials (jRCT) jRCTs032210248. Prospectively registered on 17 August 2021.
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Affiliation(s)
- Yasuyuki Suzuki
- National Center for Child Health and Development, Tokyo, Japan
- Tokyo Women's Medical University, Tokyo, Japan
| | - Kiyoyuki W Miyasaka
- National Center for Child Health and Development, Tokyo, Japan.
- Tokyo Women's Medical University, Tokyo, Japan.
- St. Luke's International University, Tokyo, Japan.
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26
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Vlisides PE, Li D, Maywood M, Zierau M, Lapointe AP, Brooks J, McKinney AM, Leis AM, Mentz G, Mashour GA. Electroencephalographic Biomarkers, Cerebral Oximetry, and Postoperative Cognitive Function in Adult Noncardiac Surgical Patients: A Prospective Cohort Study. Anesthesiology 2023; 139:568-579. [PMID: 37364282 PMCID: PMC10592490 DOI: 10.1097/aln.0000000000004664] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023]
Abstract
BACKGROUND Perioperative neurocognitive disorders are a major public health issue, although there are no validated neurophysiologic biomarkers that predict cognitive function after surgery. This study tested the hypothesis that preoperative posterior electroencephalographic alpha power, alpha frontal-parietal connectivity, and cerebral oximetry would each correlate with postoperative neurocognitive function. METHODS This was a single-center, prospective, observational study of adult (older than 18 yr) male and female noncardiac surgery patients. Whole-scalp, 16-channel electroencephalography and cerebral oximetry were recorded in the preoperative, intraoperative, and immediate postoperative settings. The primary outcome was the mean postoperative T-score of three National Institutes of Health Toolbox Cognition tests-Flanker Inhibitory Control and Attention, List Sorting Working Memory, and Pattern Comparison Processing Speed. These tests were obtained at preoperative baseline and on the first two postoperative mornings. The lowest average score from the first two postoperative days was used for the primary analysis. Delirium was a secondary outcome (via 3-min Confusion Assessment Method) measured in the postanesthesia care unit and twice daily for the first 3 postoperative days. Last, patient-reported outcomes related to cognition and overall well-being were collected 3 months postdischarge. RESULTS Sixty-four participants were recruited with a median (interquartile range) age of 59 (48 to 66) yr. After adjustment for baseline cognitive function scores, no significant partial correlation (ρ) was detected between postoperative cognition scores and preoperative relative posterior alpha power (%; ρ = -0.03, P = 0.854), alpha frontal-parietal connectivity (via weight phase lag index; ρ = -0.10, P = 0.570, respectively), or preoperative cerebral oximetry (%; ρ = 0.21, P = 0.246). Only intraoperative frontal-parietal theta connectivity was associated with postoperative delirium (F[1,6,291] = 4.53, P = 0.034). No electroencephalographic or oximetry biomarkers were associated with cognitive or functional outcomes 3 months postdischarge. CONCLUSIONS Preoperative posterior alpha power, frontal-parietal connectivity, and cerebral oximetry were not associated with cognitive function after noncardiac surgery. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Phillip E. Vlisides
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI USA
- Center for Consciousness Science, University of Michigan, Ann Arbor, MI USA
| | - Duan Li
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI USA
| | - Michael Maywood
- Department of Ophthalmology, William Beaumont Hospital, Royal Oak, MI, USA
| | - Mackenzie Zierau
- College of Health Professions, University of Detroit Mercy, Detroit, MI USA
| | - Andrew P. Lapointe
- Department of Radiology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Joseph Brooks
- Department of Orthopaedic Surgery, Michigan Medicine, Ann Arbor, MI USA
| | - Amy M. McKinney
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI USA
| | - Aleda M. Leis
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI USA
| | - Graciela Mentz
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI USA
| | - George A. Mashour
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI USA
- Center for Consciousness Science, University of Michigan, Ann Arbor, MI USA
- Neuroscience Graduate Program, University of Michigan Medical School, Ann Arbor, MI USA
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Hao D, Fritz BA, Saddawi-Konefka D, Palanca BJA. Pro-Con Debate: Electroencephalography-Guided Anesthesia for Reducing Postoperative Delirium. Anesth Analg 2023; 137:976-982. [PMID: 37862399 DOI: 10.1213/ane.0000000000006399] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2023]
Abstract
Postoperative delirium (POD) has significant implications on morbidity, mortality, and health care expenditures. Monitoring electroencephalography (EEG) to adjust anesthetic management has gained interest as a strategy to mitigate POD. In this Pro-Con commentary article, the pro side supports the use of EEG to reduce POD, citing an empiric reduction in POD with processed EEG (pEEG)-guided general anesthesia found in several studies and recent meta-analysis. The Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes (ENGAGES) trial is the exception to this, and issues with methods and achieved depths are discussed. Meanwhile, the Con side advocates that the use of EEG to reduce POD is not yet certain, citing that there is a lack of evidence that associations between anesthetic depth and POD represent causal relationships. The Con side also contends that the ideal EEG signatures to guide anesthetic titration are currently unknown, and the potential benefits of reduced anesthesia levels may be outweighed by the risks of potentially insufficient anesthetic administration. As the public health burden of POD increases, anesthesia clinicians will be tasked to consider interventions to mitigate risk such as EEG. This Pro-Con debate will provide 2 perspectives on the evidence and rationales for using EEG to mitigate POD.
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Affiliation(s)
- David Hao
- From the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Bradley A Fritz
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Daniel Saddawi-Konefka
- From the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ben Julian A Palanca
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
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Neuner B, Wolter S, McCarthy WJ, Spies C, Cunningham C, Radtke FM, Franck M, Koenig T. EEG microstate quantifiers and state space descriptors during anaesthesia in patients with postoperative delirium: a descriptive analysis. Brain Commun 2023; 5:fcad270. [PMID: 37942086 PMCID: PMC10629467 DOI: 10.1093/braincomms/fcad270] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 08/21/2023] [Accepted: 10/16/2023] [Indexed: 11/10/2023] Open
Abstract
Postoperative delirium is a serious sequela of surgery and surgery-related anaesthesia. One recommended method to prevent postoperative delirium is using bi-frontal EEG recording. The single, processed index of depth of anaesthesia allows the anaesthetist to avoid episodes of suppression EEG and excessively deep anaesthesia. The study data presented here were based on multichannel (19 channels) EEG recordings during anaesthesia. This enabled the analysis of various parameters of global electrical brain activity. These parameters were used to compare microstate topographies under anaesthesia with those in healthy volunteers and to analyse changes in microstate quantifiers and EEG global state space descriptors with increasing exposure to anaesthesia. Seventy-three patients from the Surgery Depth of Anaesthesia and Cognitive Outcome study (SRCTN 36437985) received intraoperative multichannel EEG recordings. Altogether, 720 min of artefact-free EEG data, including 210 min (29.2%) of suppression EEG, were analysed. EEG microstate topographies, microstate quantifiers (duration, frequency of occurrence and global field power) and the state space descriptors sigma (overall EEG power), phi (generalized frequency) and omega (number of uncorrelated brain processes) were evaluated as a function of duration of exposure to anaesthesia, suppression EEG and subsequent development of postoperative delirium. The major analyses involved covariate-adjusted linear mixed-effects models. The older (71 ± 7 years), predominantly male (60%) patients received a median exposure of 210 (range: 75-675) min of anaesthesia. During seven postoperative days, 21 patients (29%) developed postoperative delirium. Microstate topographies under anaesthesia resembled topographies from healthy and much younger awake persons. With increasing duration of exposure to anaesthesia, single microstate quantifiers progressed differently in suppression or non-suppression EEG and in patients with or without subsequent postoperative delirium. The most pronounced changes occurred during enduring suppression EEG in patients with subsequent postoperative delirium: duration and frequency of occurrence of microstates C and D progressed in opposite directions, and the state space descriptors showed a pattern of declining uncorrelated brain processes (omega) combined with increasing EEG variance (sigma). With increasing exposure to general anaesthesia, multiple changes in the dynamics of microstates and global EEG parameters occurred. These changes varied partly between suppression and non-suppression EEG and between patients with or without subsequent postoperative delirium. Ongoing suppression EEG in patients with subsequent postoperative delirium was associated with reduced network complexity in combination with increased overall EEG power. Additionally, marked changes in quantifiers in microstate C and in microstate D occurred. These putatively adverse intraoperative trajectories in global electrical brain activity may be seen as preceding and ultimately predicting postoperative delirium.
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Affiliation(s)
- Bruno Neuner
- Department of Anaesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, 10117 Berlin, Germany
| | - Simone Wolter
- Department of Anaesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, 10117 Berlin, Germany
| | - William J McCarthy
- Centre for Cancer Prevention and Control Research, Fielding School of Public Health and Jonsson Comprehensive Cancer Centre, University of California Los Angeles (UCLA), Los Angeles, CA 90095-1781, USA
| | - Claudia Spies
- Department of Anaesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, 10117 Berlin, Germany
| | - Colm Cunningham
- School of Biochemistry and Immunology, Trinity Biomedical Sciences Institute & Trinity College Institute of Neuroscience, Trinity College Dublin, 2 D02 R590 Dublin, Ireland
| | - Finn M Radtke
- Department of Anaesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, 10117 Berlin, Germany
- Department of Anaesthesia and Intensive Care, Hospital of Nykøbing Falster, Fjordvej 15, 4800 Nykøbing Falster, Denmark
- University of Southern Denmark (SDU), Campusvej 55, 5230 Odense, Denmark
| | - Martin Franck
- Department of Anaesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, 10117 Berlin, Germany
- Department of Anaesthesia, Alexianer St.Hedwig Hospital, 10115 Berlin, Germany
| | - Thomas Koenig
- University Hospital of Psychiatry, Translational Research Centre, University of Bern, 3000 Bern, Switzerland
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He Z, Zhang H, Xing Y, Liu J, Gao Y, Gu E, Zhang L, Chen L. Effect of raw electroencephalogram-guided anesthesia administration on postoperative outcomes in elderly patients undergoing abdominal major surgery: a randomized controlled trial. BMC Anesthesiol 2023; 23:337. [PMID: 37803259 PMCID: PMC10557275 DOI: 10.1186/s12871-023-02297-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 09/27/2023] [Indexed: 10/08/2023] Open
Abstract
BACKGROUND EEG monitoring techniques are receiving increasing clinical attention as a common method of reflecting the depth of sedation in the perioperative period. The influence of depth of sedation indices such as the bispectral index (BIS) generated by the processed electroencephalogram (pEEG) machine to guide the management of anesthetic depth of sedation on postoperative outcome remains controversial. This research was designed to decide whether an anesthetic agent exposure determined by raw electroencephalogram (rEEG) can influence anesthetic management and cause different EEG patterns and affect various patient outcomes. METHODS A total of 141 participants aged ≥ 60 years undergoing abdominal major surgery were randomized to rEEG-guided anesthesia or routine care group. The rEEG-guided anesthesia group had propofol titrated to keep the rEEG waveform at the C-D sedation depth during surgery, while in the routine care group the anesthetist was masked to the patient's rEEG waveform and guided the anesthetic management only through clinical experience. The primary outcome was the presence of postoperative complications, the secondary outcomes included intraoperative anesthetic management and different EEG patterns. RESULTS There were no statistically significant differences in the occurrence of postoperative respiratory, circulatory, neurological and gastrointestinal complications. Further EEG analysis revealed that lower frontal alpha power was significantly associated with a higher incidence of POD, and that rEEG-guidance not only reduced the duration of deeper anesthesia in patients with lower frontal alpha power, but also allowed patients with higher frontal alpha power to receive deeper and more appropriate depths of anesthesia than in the routine care group. CONCLUSIONS In elderly patients undergoing major abdominal surgery, rEEG-guided anesthesia did not reduce the incidence of postoperative respiratory, circulatory, neurological and gastrointestinal complications. rEEG-guided anesthesia management reduced the duration of intraoperative BS in patients and the duration of over-deep sedation in patients with lower frontal alpha waves under anesthesia, and there was a strong association between lower frontal alpha power under anesthesia and the development of POD. rEEG-guided anesthesia may improve the prognosis of patients with vulnerable brains by improving the early identification of frail elderly patients and providing them with a more effective individualized anesthetic managements.
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Affiliation(s)
- Ziqing He
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, Anhui Province, 230022, China
| | - Hao Zhang
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, Anhui Province, 230022, China
| | - Yahui Xing
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, Anhui Province, 230022, China
| | - Jia Liu
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, Anhui Province, 230022, China
| | - Yang Gao
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, Anhui Province, 230022, China
| | - Erwei Gu
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, Anhui Province, 230022, China
| | - Lei Zhang
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, Anhui Province, 230022, China
| | - Lijian Chen
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, Anhui Province, 230022, China.
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Chen YC, Hung IY, Hung KC, Chang YJ, Chu CC, Chen JY, Ho CH, Yu CH. Incidence change of postoperative delirium after implementation of processed electroencephalography monitoring during surgery: a retrospective evaluation study. BMC Anesthesiol 2023; 23:330. [PMID: 37794315 PMCID: PMC10548752 DOI: 10.1186/s12871-023-02293-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 09/26/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND Postoperative delirium (POD) is a common complication in the elderly, which is associated with poor outcomes after surgery. Recognized as predisposing factors for POD, anesthetic exposure and burst suppression during general anesthesia can be minimized with intraoperative processed electroencephalography (pEEG) monitoring. In this study, we aimed to evaluate whether implementation of intraoperative pEEG-guided anesthesia is associated with incidence change of POD. METHODS In this retrospective evaluation study, we analyzed intravenous patient-controlled analgesia (IVPCA) dataset from 2013 to 2017. There were 7425 patients using IVPCA after a noncardiac procedure under general anesthesia. Patients incapable of operating the device independently, such as cognitive dysfunction or prolonged sedation, were declined and not involved in the dataset. After excluding patients who opted out within three days (N = 110) and those with missing data (N = 24), 7318 eligible participants were enrolled. Intraoperative pEEG has been implemented since July 2015. Participants having surgery after this time point had intraoperative pEEG applied before induction until full recovery. All related staff had been trained in the application of pEEG-guided anesthesia and the assessment of POD. Patients were screened twice daily for POD within 3 days after surgery by staff in the pain management team. In the first part of this study, we compared the incidence of POD and its trend from 2013 January-2015 July with 2015 July-2017 December. In the second part, we estimated odds ratios of risk factors for POD using multivariable logistic regression in case-control setting. RESULTS The incidence of POD decreased from 1.18 to 0.41% after the administration of intraoperative pEEG. For the age group ≧ 75 years, POD incidence decreased from 5.1 to 1.56%. Further analysis showed that patients with pEEG-guided anesthesia were associated with a lower odd of POD (aOR 0.33; 95% CI 0.18-0.60) than those without after adjusting for other covariates. CONCLUSIONS Implementation of intraoperative pEEG was associated with a lower incidence of POD within 3 days after surgery, particularly in the elderly. Intraoperative pEEG might be reasonably considered as part of the strategy to prevent POD in the elder population. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Yi-Chen Chen
- Department of Medical Research, Chi Mei Medical Center, 901 Zhonghua Road, Yongkang District, Tainan, Taiwan
| | - I-Yin Hung
- Department of Anesthesiology, Chi Mei Medical Center, 901 Zhonghua Road, Yongkang District, Tainan, Taiwan
| | - Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical Center, 901 Zhonghua Road, Yongkang District, Tainan, Taiwan
- Department of Hospital and Health Care Administration, College of Recreation and Health Management, Chia Nan University of Pharmacy and Science, 60 Erren Road, Rende District, Tainan, Taiwan
| | - Ying-Jen Chang
- Department of Anesthesiology, Chi Mei Medical Center, 901 Zhonghua Road, Yongkang District, Tainan, Taiwan
- Department of Recreation and Health Care Management, College of Recreation and Health Management, Chia Nan University of Pharmacy and Science, 60 Erren Road, Rende District, Tainan, Taiwan
| | - Chin-Chen Chu
- Department of Anesthesiology, Chi Mei Medical Center, 901 Zhonghua Road, Yongkang District, Tainan, Taiwan
| | - Jen-Yin Chen
- Department of Anesthesiology, Chi Mei Medical Center, 901 Zhonghua Road, Yongkang District, Tainan, Taiwan
| | - Chung-Han Ho
- Department of Medical Research, Chi Mei Medical Center, 901 Zhonghua Road, Yongkang District, Tainan, Taiwan
- Department of Information Management, Southern Taiwan University of Science and Technology, 1 Nantai St, Yongkang District, Tainan, Taiwan
| | - Chia-Hung Yu
- Department of Anesthesiology, Chi Mei Medical Center, 901 Zhonghua Road, Yongkang District, Tainan, Taiwan.
- Department of Computer Science and Information Engineering, Southern Taiwan University of Science and Technology, 1 Nantai St, Yongkang District, Tainan, Taiwan.
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Amirfarzan H, Azocar RJ, Shapeton AD. "The Big Three" of geriatrics: A review of perioperative cognitive impairment, frailty and malnutrition. Saudi J Anaesth 2023; 17:509-516. [PMID: 37779565 PMCID: PMC10540988 DOI: 10.4103/sja.sja_532_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 06/20/2023] [Accepted: 06/21/2023] [Indexed: 10/03/2023] Open
Abstract
Cognitive impairment, frailty, and malnutrition are three of the most impactful pathologies facing an aging population, having dramatic effects on morbidity and mortality across nearly all facets of medical care and intervention. By 2050, the World Health Organization estimates that the population of individuals over the age of sixty worldwide will nearly double, and the public health toll of these demographic changes cannot be understated. With these changing demographics comes a need for a sharpened focus on the care and management of this vulnerable population. The average patient presenting for surgery is getting older, and this necessitates that clinicians understand the implications of these pathologies for both their immediate medical care needs and for appropriate procedural selection and prognostication of surgical outcomes. We believe it is incumbent on clinicians to consider the frailty, nutritional status, and cognitive function of each individual patient when offering a surgical intervention, as well as consider interventions that may delay the progression of these pathologies. Unfortunately, despite excellent evidence supporting things like routine pre-operative frailty screening and nutritional optimization, many interventions that would specifically benefit this population still have not been integrated into routine practice. In this review, we will synthesize the existing literature on these topics to provide a pragmatic approach and understanding for anesthesiologists and intensivists faced with this complex population.
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Affiliation(s)
- Houman Amirfarzan
- Department of Anesthesia, Critical Care and Pain Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Ruben J. Azocar
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Alexander D. Shapeton
- Department of Anesthesia, Critical Care and Pain Medicine, Tufts University School of Medicine, Boston, MA, USA
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Consales G, Cappellini I, Freschi B, Campiglia L, Parise M, Zamidei L. Sevoflurane sedation in COVID-19 acute respiratory distress syndrome: an observational study with a propensity score matching model. Front Med (Lausanne) 2023; 10:1267691. [PMID: 37780555 PMCID: PMC10540812 DOI: 10.3389/fmed.2023.1267691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 09/04/2023] [Indexed: 10/03/2023] Open
Abstract
Introduction The management of severe COVID-19-induced acute respiratory distress syndrome (C-ARDS) often involves deep sedation. This study evaluated the efficacy of sevoflurane, a volatile anesthetic, as an alternative to traditional intravenous sedation in this patient population. Methods This single-center, retrospective cohort study enrolled 112 patients with C-ARDS requiring invasive mechanical ventilation. A propensity score matching model was utilized to pair 56 patients receiving sevoflurane sedation with 56 patients receiving intravenous sedation. The primary outcome was mortality, with secondary outcomes being changes in oxygenation (PaO2/FiO2 ratio), pulmonary compliance, and levels of D-Dimer, CRP, and creatinine. Results The use of sevoflurane was associated with a statistically significant reduction in mortality (OR 0.40, 95% CI 0.18-0.87, beta = -0.9, p = 0.02). In terms of secondary outcomes, an increase in the PaO2/FiO2 ratio and pulmonary static compliance was observed, although the results were not statistically significant. No significant differences were noted in the levels of D-Dimer, CRP, and creatinine between the two groups. Conclusion Our findings suggest an association between the use of sevoflurane and improved outcomes in C-ARDS patients requiring invasive mechanical ventilation. However, due to the single-center, retrospective design of the study, caution should be taken in interpreting these results, and further research is needed to corroborate these findings. The study offers promising insights into potential alternative sedation strategies in the management of severe C-ARDS.
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Affiliation(s)
- Guglielmo Consales
- Department of Critical Care, Section of Anesthesiology and Critical Care Azienda USL Toscana Centro, Ospedale Santo Stefano, Prato, Italy
| | - Iacopo Cappellini
- Department of Critical Care, Section of Anesthesiology and Critical Care Azienda USL Toscana Centro, Ospedale Santo Stefano, Prato, Italy
| | - Benedetta Freschi
- Department of Critical Care, Section of Anesthesiology and Critical Care Azienda USL Toscana Centro, Ospedale Santo Stefano, Prato, Italy
| | - Laura Campiglia
- Department of Critical Care, Section of Anesthesiology and Critical Care Azienda USL Toscana Centro, Ospedale Santo Stefano, Prato, Italy
| | - Maddalena Parise
- Anesthesia Unit, Castellanza Hospital, Multimedica Group, Milan, Italy
| | - Lucia Zamidei
- Department of Critical Care, Section of Anesthesiology and Critical Care Azienda USL Toscana Centro, Ospedale Santo Stefano, Prato, Italy
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Reese M, Christensen S, Anolick H, Roberts KC, Wong MK, Wright MC, Acker L, Browndyke JN, Woldorff MG, Berger M. EEG pre-burst suppression: characterization and inverse association with preoperative cognitive function in older adults. Front Aging Neurosci 2023; 15:1229081. [PMID: 37711992 PMCID: PMC10499509 DOI: 10.3389/fnagi.2023.1229081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 08/01/2023] [Indexed: 09/16/2023] Open
Abstract
The most common complication in older surgical patients is postoperative delirium (POD). POD is associated with preoperative cognitive impairment and longer durations of intraoperative burst suppression (BSup) - electroencephalography (EEG) with repeated periods of suppression (very low-voltage brain activity). However, BSup has modest sensitivity for predicting POD. We hypothesized that a brain state of lowered EEG power immediately precedes BSup, which we have termed "pre-burst suppression" (preBSup). Further, we hypothesized that even patients without BSup experience these preBSup transient reductions in EEG power, and that preBSup (like BSup) would be associated with preoperative cognitive function and delirium risk. Data included 83 32-channel intraoperative EEG recordings of the first hour of surgery from 2 prospective cohort studies of patients ≥age 60 scheduled for ≥2-h non-cardiac, non-neurologic surgery under general anesthesia (maintained with a potent inhaled anesthetic or a propofol infusion). Among patients with BSup, we defined preBSup as the difference in 3-35 Hz power (dB) during the 1-s preceding BSup relative to the average 3-35 Hz power of their intraoperative EEG recording. We then recorded the percentage of time that each patient spent in preBSup, including those without BSup. Next, we characterized the association between percentage of time in preBSup and (1) percentage of time in BSup, (2) preoperative cognitive function, and (3) POD incidence. The percentage of time in preBSup and BSup were correlated (Spearman's ρ [95% CI]: 0.52 [0.34, 0.66], p < 0.001). The percentage of time in BSup, preBSup, or their combination were each inversely associated with preoperative cognitive function (β [95% CI]: -0.10 [-0.19, -0.01], p = 0.024; -0.04 [-0.06, -0.01], p = 0.009; -0.04 [-0.06, -0.01], p = 0.003, respectively). Consistent with prior literature, BSup was significantly associated with POD (odds ratio [95% CI]: 1.34 [1.01, 1.78], p = 0.043), though this association did not hold for preBSup (odds ratio [95% CI]: 1.04 [0.95, 1.14], p = 0.421). While all patients had ≥1 preBSup instance, only 20.5% of patients had ≥1 BSup instance. These exploratory findings suggest that future studies are warranted to further study the extent to which preBSup, even in the absence of BSup, can identify patients with impaired preoperative cognition and/or POD risk.
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Affiliation(s)
- Melody Reese
- Department of Anesthesiology, School of Medicine, Duke University, Durham, NC, United States
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, NC, United States
| | | | - Harel Anolick
- Pratt School of Engineering, Duke University, Durham, NC, United States
| | - Kenneth C. Roberts
- Center for Cognitive Neuroscience, Duke University, Durham, NC, United States
| | - Megan K. Wong
- School of Medicine, Duke University, Durham, NC, United States
| | - Mary Cooter Wright
- Department of Anesthesiology, School of Medicine, Duke University, Durham, NC, United States
| | - Leah Acker
- Department of Anesthesiology, School of Medicine, Duke University, Durham, NC, United States
| | | | - Marty G. Woldorff
- Center for Cognitive Neuroscience, Duke University, Durham, NC, United States
- Department of Psychiatry, Duke University, Durham, NC, United States
- Department of Psychology and Neuroscience, Duke University, Durham, NC, United States
| | - Miles Berger
- Department of Anesthesiology, School of Medicine, Duke University, Durham, NC, United States
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, NC, United States
- Center for Cognitive Neuroscience, Duke University, Durham, NC, United States
- Alzheimer’s Disease Research Center, Duke University, Durham, NC, United States
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Rios RL, Kafashan M, Hyche O, Lenard E, Lucey BP, Lenze EJ, Palanca BJA. Targeting Slow Wave Sleep Deficiency in Late-Life Depression: A Case Series With Propofol. Am J Geriatr Psychiatry 2023; 31:643-652. [PMID: 37105885 PMCID: PMC10544727 DOI: 10.1016/j.jagp.2023.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 03/14/2023] [Accepted: 03/16/2023] [Indexed: 04/29/2023]
Abstract
Slow wave sleep (SWS), characterized by large electroencephalographic oscillations, facilitates crucial physiologic processes that maintain synaptic plasticity and overall brain health. Deficiency in older adults is associated with depression and cognitive dysfunction, such that enhancing sleep slow waves has emerged as a promising target for novel therapies. Enhancement of SWS has been noted after infusions of propofol, a commonly used anesthetic that induces electroencephalographic patterns resembling non-rapid eye movement sleep. This paper 1) reviews the scientific premise underlying the hypothesis that sleep slow waves are a novel therapeutic target for improving cognitive and psychiatric outcomes in older adults, and 2) presents a case series of two patients with late-life depression who each received two propofol infusions. One participant, a 71-year-old woman, had a mean of 2.8 minutes of evening SWS prior to infusions (0.7% of total sleep time). SWS increased on the night after each infusion, to 12.5 minutes (5.3% of total sleep time) and 24 minutes (10.6% of total sleep time), respectively. Her depression symptoms improved, reflected by a reduction in her Montgomery-Asberg Depression Rating Scale (MADRS) score from 26 to 7. In contrast, the other participant, a 77-year-old man, exhibited no SWS at baseline and only modest enhancement after the second infusion (3 minutes, 1.3% of total sleep time). His MADRS score increased from 13 to 19, indicating a lack of improvement in his depression. These cases provide proof-of-concept that propofol can enhance SWS and improve depression for some individuals, motivating an ongoing clinical trial (ClinicalTrials.gov NCT04680910).
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Affiliation(s)
- Rachel L Rios
- Department of Anesthesiology (RLR, MK, OH, EJL, BJAP), Washington University School of Medicine in St. Louis, St. Louis, MO
| | - MohammadMehdi Kafashan
- Department of Anesthesiology (RLR, MK, OH, EJL, BJAP), Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Orlandrea Hyche
- Department of Anesthesiology (RLR, MK, OH, EJL, BJAP), Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Emily Lenard
- Department of Psychiatry (EL, EJL, BJAP), Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Brendan P Lucey
- Center on Biological Rhythms and Sleep (BPL, BJAP), Washington University School of Medicine in St. Louis, St. Louis, MO; Department of Neurology (BPL), Washington University in St. Louis, MO
| | - Eric J Lenze
- Department of Anesthesiology (RLR, MK, OH, EJL, BJAP), Washington University School of Medicine in St. Louis, St. Louis, MO; Department of Psychiatry (EL, EJL, BJAP), Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Ben Julian A Palanca
- Department of Anesthesiology (RLR, MK, OH, EJL, BJAP), Washington University School of Medicine in St. Louis, St. Louis, MO; Department of Psychiatry (EL, EJL, BJAP), Washington University School of Medicine in St. Louis, St. Louis, MO; Center on Biological Rhythms and Sleep (BPL, BJAP), Washington University School of Medicine in St. Louis, St. Louis, MO; Department of Biomedical Engineering (BJAP), Washington University in St. Louis, St. Louis, MO; Division of Biology and Biomedical Sciences (BJAP), Washington University School of Medicine in St. Louis, St. Louis, MO.
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Xu Q, Zhang J, Gao Z, Li S, Li G. Analysis of the relationship between EEG burst suppression and poor prognosis in children under general anaesthesia: study protocol for a prospective, observational, single-centre study. Trials 2023; 24:481. [PMID: 37501064 PMCID: PMC10375778 DOI: 10.1186/s13063-023-07478-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 06/26/2023] [Indexed: 07/29/2023] Open
Abstract
BACKGROUND Emergence delirium (ED) in children refers to the immediate postoperative period when children experience decreased perception of their surroundings, accompanied by disorientation and altered perception. Burst suppression (BS) is recognised as periods longer than 0.50 s during which the EEG does not exceed approximately + 5.0 mV, which is an electroencephalographic state associated with profound inactivation of the brain. Our primary objective was to determine the association between BS on electroencephalogram (EEG) under general anaesthesia with postoperative wake-up delirium and multiple adverse outcomes, such as prolonged awakening and extubation. METHODS In this prospective, observational cohort study at Beijing Children's Hospital, Capital Medical University, Beijing, China, children aged 6 months to 9 years who underwent surgery under general anaesthesia and underwent EEG monitoring between January 2022 and January 2023 were included. Patients' prefrontal EEGs were recorded intraoperatively as well as analysed for the occurrence and duration of BS and scored postoperatively for delirium by the PAED scale, with a score of no less than 10 considered as having developed wake-up delirium. DISCUSSION This study identified a relationship between EEG BS and postoperative awakening delirium under general anaesthesia in children and provides a novel preventive strategy for postoperative awakening delirium and multiple adverse outcomes in paediatric patients. TRIAL REGISTRATION Chinese Clinical Trial Registry, ChiCTR2200055256. Registered on January 5, 2022.
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Affiliation(s)
- Qian Xu
- Department of Anesthesiology, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, No.56, South Lishi Road, Beijing, 100045, China
| | - Jianmin Zhang
- Department of Anesthesiology, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, No.56, South Lishi Road, Beijing, 100045, China.
| | - Zhengzheng Gao
- Department of Anesthesiology, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, No.56, South Lishi Road, Beijing, 100045, China
| | - Shanshan Li
- Department of Anesthesiology, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, No.56, South Lishi Road, Beijing, 100045, China
| | - Gan Li
- Department of Anesthesiology, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, No.56, South Lishi Road, Beijing, 100045, China
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Berger M, Ryu D, Reese M, McGuigan S, Evered LA, Price CC, Scott DA, Westover MB, Eckenhoff R, Bonanni L, Sweeney A, Babiloni C. A Real-Time Neurophysiologic Stress Test for the Aging Brain: Novel Perioperative and ICU Applications of EEG in Older Surgical Patients. Neurotherapeutics 2023; 20:975-1000. [PMID: 37436580 PMCID: PMC10457272 DOI: 10.1007/s13311-023-01401-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2023] [Indexed: 07/13/2023] Open
Abstract
As of 2022, individuals age 65 and older represent approximately 10% of the global population [1], and older adults make up more than one third of anesthesia and surgical cases in developed countries [2, 3]. With approximately > 234 million major surgical procedures performed annually worldwide [4], this suggests that > 70 million surgeries are performed on older adults across the globe each year. The most common postoperative complications seen in these older surgical patients are perioperative neurocognitive disorders including postoperative delirium, which are associated with an increased risk for mortality [5], greater economic burden [6, 7], and greater risk for developing long-term cognitive decline [8] such as Alzheimer's disease and/or related dementias (ADRD). Thus, anesthesia, surgery, and postoperative hospitalization have been viewed as a biological "stress test" for the aging brain, in which postoperative delirium indicates a failed stress test and consequent risk for later cognitive decline (see Fig. 3). Further, it has been hypothesized that interventions that prevent postoperative delirium might reduce the risk of long-term cognitive decline. Recent advances suggest that rather than waiting for the development of postoperative delirium to indicate whether a patient "passed" or "failed" this stress test, the status of the brain can be monitored in real-time via electroencephalography (EEG) in the perioperative period. Beyond the traditional intraoperative use of EEG monitoring for anesthetic titration, perioperative EEG may be a viable tool for identifying waveforms indicative of reduced brain integrity and potential risk for postoperative delirium and long-term cognitive decline. In principle, research incorporating routine perioperative EEG monitoring may provide insight into neuronal patterns of dysfunction associated with risk of postoperative delirium, long-term cognitive decline, or even specific types of aging-related neurodegenerative disease pathology. This research would accelerate our understanding of which waveforms or neuronal patterns necessitate diagnostic workup and intervention in the perioperative period, which could potentially reduce postoperative delirium and/or dementia risk. Thus, here we present recommendations for the use of perioperative EEG as a "predictor" of delirium and perioperative cognitive decline in older surgical patients.
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Affiliation(s)
- Miles Berger
- Department of Anesthesiology, Duke University Medical Center, Duke South Orange Zone Room 4315B, Box 3094, Durham, NC, 27710, USA.
- Duke Aging Center, Duke University Medical Center, Durham, NC, USA.
- Duke/UNC Alzheimer's Disease Research Center, Duke University Medical Center, Durham, NC, USA.
| | - David Ryu
- School of Medicine, Duke University, Durham, NC, USA
| | - Melody Reese
- Department of Anesthesiology, Duke University Medical Center, Duke South Orange Zone Room 4315B, Box 3094, Durham, NC, 27710, USA
- Duke Aging Center, Duke University Medical Center, Durham, NC, USA
| | - Steven McGuigan
- Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital, Melbourne, VIC, Australia
- Department of Critical Care, School of Medicine, University of Melbourne, Melbourne, Australia
| | - Lisbeth A Evered
- Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital, Melbourne, VIC, Australia
- Department of Critical Care, School of Medicine, University of Melbourne, Melbourne, Australia
- Weill Cornell Medicine, New York, NY, USA
| | - Catherine C Price
- Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
- Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
| | - David A Scott
- Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital, Melbourne, VIC, Australia
- Department of Critical Care, School of Medicine, University of Melbourne, Melbourne, Australia
| | - M Brandon Westover
- Department of Neurology, Beth Israel Deaconess Hospital, Boston, MA, USA
| | - Roderic Eckenhoff
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Laura Bonanni
- Department of Medicine and Aging Sciences, University G d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Aoife Sweeney
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Claudio Babiloni
- Department of Physiology and Pharmacology "Vittorio Erspamer", Sapienza University of Rome, Rome, Italy
- San Raffaele of Cassino, Cassino, FR, Italy
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Bong CL, Balanza GA, Khoo CEH, Tan JSK, Desel T, Purdon PL. A Narrative Review Illustrating the Clinical Utility of Electroencephalogram-Guided Anesthesia Care in Children. Anesth Analg 2023; 137:108-123. [PMID: 36729437 DOI: 10.1213/ane.0000000000006267] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The major therapeutic end points of general anesthesia include hypnosis, amnesia, and immobility. There is a complex relationship between general anesthesia, responsiveness, hemodynamic stability, and reaction to noxious stimuli. This complexity is compounded in pediatric anesthesia, where clinicians manage children from a wide range of ages, developmental stages, and body sizes, with their concomitant differences in physiology and pharmacology. This renders anesthetic requirements difficult to predict based solely on a child's age, body weight, and vital signs. Electroencephalogram (EEG) monitoring provides a window into children's brain states and may be useful in guiding clinical anesthesia management. However, many clinicians are unfamiliar with EEG monitoring in children. Young children's EEGs differ substantially from those of older children and adults, and there is a lack of evidence-based guidance on how and when to use the EEG for anesthesia care in children. This narrative review begins by summarizing what is known about EEG monitoring in pediatric anesthesia care. A key knowledge gap in the literature relates to a lack of practical information illustrating the utility of the EEG in clinical management. To address this gap, this narrative review illustrates how the EEG spectrogram can be used to visualize, in real time, brain responses to anesthetic drugs in relation to hemodynamic stability, surgical stimulation, and other interventions such as cardiopulmonary bypass. This review discusses anesthetic management principles in a variety of clinical scenarios, including infants, children with altered conscious levels, children with atypical neurodevelopment, children with hemodynamic instability, children undergoing total intravenous anesthesia, and those undergoing cardiopulmonary bypass. Each scenario is accompanied by practical illustrations of how the EEG can be visualized to help titrate anesthetic dosage to avoid undersedation or oversedation when patients experience hypotension or other physiological challenges, when surgical stimulation increases, and when a child's anesthetic requirements are otherwise less predictable. Overall, this review illustrates how well-established clinical management principles in children can be significantly complemented by the addition of EEG monitoring, thus enabling personalized anesthesia care to enhance patient safety and experience.
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Affiliation(s)
- Choon Looi Bong
- From the Department of Pediatric Anesthesia, KK Women's and Children's Hospital, Duke-NUS Medical School, Singapore
| | - Gustavo A Balanza
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Charis Ern-Hui Khoo
- From the Department of Pediatric Anesthesia, KK Women's and Children's Hospital, Duke-NUS Medical School, Singapore
| | - Josephine Swee-Kim Tan
- From the Department of Pediatric Anesthesia, KK Women's and Children's Hospital, Duke-NUS Medical School, Singapore
| | - Tenzin Desel
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Patrick Lee Purdon
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Shaf A, Khodarahmi A, Shahhosseini S. Comparative Study of the Effect of Oral Chloral Hydrate and Intranasal Fentanyl on Sedation in Children for Electroencephalography. IRANIAN JOURNAL OF CHILD NEUROLOGY 2023; 17:99-107. [PMID: 37637784 PMCID: PMC10448842 DOI: 10.22037/ijcn.v17i2.36019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 05/15/2022] [Indexed: 08/29/2023]
Abstract
Objectives Sedation and stability during electroencephalography (EEG) in pediatrics have high clinical importance. This study compares the sedative properties of oral chloral hydrate (OCH) and intranasal fentanyl (INF). Materials & Methods This study was a randomized clinical trial conducted in 2020 in Isfahan City on sixty-two pediatric candidates for EEG. Patients were randomized into two groups receiving 50 mg/kg OCH and 2 μg/kg INF thirty minutes before the process. The heart rate (HR), mean arterial pressure (MAP), respiratory rate (RR), and oxygen saturation (O2 sat) of patients, sedation, and physician's satisfaction were measured and compared between groups. Results The HR of patients decreased significantly in both groups (P< 0.001), and the patients that received INF had significantly lower HR 15, 30, 45, and 60 minutes after drug administrations (P< 0.05). RR evaluation indicated significantly decreased RR in both groups (P< 0.001), and patients receiving INF had lower RR 30, 45, and 60 per minutes after drug administrations (P< 0.001). Both groups showed significantly increased sedation levels during the study (P< 0.001), and patients treated with INF had higher sedation levels 15, 30, and 45 minutes after drug administration. Satisfaction rates were higher among the group that received INF (P= 0.020). Conclusion The use of INF had significant analgesic and sedative effects on pediatrics undergoing EEG.
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Affiliation(s)
- Amir Shaf
- Anesthesiology Department, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Amir Khodarahmi
- School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Sedighe Shahhosseini
- Anesthesiology Department, Isfahan University of Medical Sciences, Isfahan, Iran
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Jones KG, Lybbert C, Euler MJ, Huang J, Lunt S, Richards SV, Jessop JE, Larson A, Odell DH, Kuck K, Tadler SC, Mickey BJ. Diversity of electroencephalographic patterns during propofol-induced burst suppression. Front Syst Neurosci 2023; 17:1172856. [PMID: 37397237 PMCID: PMC10309040 DOI: 10.3389/fnsys.2023.1172856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 05/23/2023] [Indexed: 07/04/2023] Open
Abstract
Burst suppression is a brain state consisting of high-amplitude electrical activity alternating with periods of quieter suppression that can be brought about by disease or by certain anesthetics. Although burst suppression has been studied for decades, few studies have investigated the diverse manifestations of this state within and between human subjects. As part of a clinical trial examining the antidepressant effects of propofol, we gathered burst suppression electroencephalographic (EEG) data from 114 propofol infusions across 21 human subjects with treatment-resistant depression. This data was examined with the objective of describing and quantifying electrical signal diversity. We observed three types of EEG burst activity: canonical broadband bursts (as frequently described in the literature), spindles (narrow-band oscillations reminiscent of sleep spindles), and a new feature that we call low-frequency bursts (LFBs), which are brief deflections of mainly sub-3-Hz power. These three features were distinct in both the time and frequency domains and their occurrence differed significantly across subjects, with some subjects showing many LFBs or spindles and others showing very few. Spectral-power makeup of each feature was also significantly different across subjects. In a subset of nine participants with high-density EEG recordings, we noted that each feature had a unique spatial pattern of amplitude and polarity when measured across the scalp. Finally, we observed that the Bispectral Index Monitor, a commonly used clinical EEG monitor, does not account for the diversity of EEG features when processing the burst suppression state. Overall, this study describes and quantifies variation in the burst suppression EEG state across subjects and repeated infusions of propofol. These findings have implications for the understanding of brain activity under anesthesia and for individualized dosing of anesthetic drugs.
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Affiliation(s)
- Keith G. Jones
- Interdepartmental Program in Neuroscience, The University of Utah, Salt Lake City, UT, United States
- Department of Psychiatry, Huntsman Mental Health Institute, The University of Utah, Salt Lake City, UT, United States
| | - Carter Lybbert
- Department of Biomedical Engineering, The University of Utah, Salt Lake City, UT, United States
- Department of Anesthesiology, The University of Utah, Salt Lake City, UT, United States
| | - Matthew J. Euler
- Department of Psychology, The University of Utah, Salt Lake City, UT, United States
| | - Jason Huang
- Department of Biomedical Engineering, The University of Utah, Salt Lake City, UT, United States
| | - Seth Lunt
- Department of Psychiatry, Huntsman Mental Health Institute, The University of Utah, Salt Lake City, UT, United States
| | - Sindhu V. Richards
- Department of Neurology, The University of Utah, Salt Lake City, UT, United States
| | - Jacob E. Jessop
- Department of Anesthesiology, The University of Utah, Salt Lake City, UT, United States
| | - Adam Larson
- Department of Anesthesiology, The University of Utah, Salt Lake City, UT, United States
| | - David H. Odell
- Department of Psychiatry, Huntsman Mental Health Institute, The University of Utah, Salt Lake City, UT, United States
- Department of Anesthesiology, The University of Utah, Salt Lake City, UT, United States
| | - Kai Kuck
- Department of Biomedical Engineering, The University of Utah, Salt Lake City, UT, United States
- Department of Anesthesiology, The University of Utah, Salt Lake City, UT, United States
| | - Scott C. Tadler
- Department of Psychiatry, Huntsman Mental Health Institute, The University of Utah, Salt Lake City, UT, United States
- Department of Anesthesiology, The University of Utah, Salt Lake City, UT, United States
| | - Brian J. Mickey
- Interdepartmental Program in Neuroscience, The University of Utah, Salt Lake City, UT, United States
- Department of Psychiatry, Huntsman Mental Health Institute, The University of Utah, Salt Lake City, UT, United States
- Department of Biomedical Engineering, The University of Utah, Salt Lake City, UT, United States
- Department of Anesthesiology, The University of Utah, Salt Lake City, UT, United States
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Boncompte G, Sun H, Elgueta MF, Benavides J, Carrasco M, Morales MI, Calderón N, Contreras V, Westover MB, Cortínez LI, Akeju O, Pedemonte JC. Intraoperative electroencephalographic marker of preoperative frailty: A prospective cohort study. J Clin Anesth 2023; 86:111069. [PMID: 36738630 PMCID: PMC10074446 DOI: 10.1016/j.jclinane.2023.111069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 01/25/2023] [Accepted: 01/27/2023] [Indexed: 02/05/2023]
Affiliation(s)
- Gonzalo Boncompte
- Neurodynamics of Cognition Laboratory, Department of Psychiatry, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile; División de Anestesiología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Haoqi Sun
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA; Department of Neurology, Massachusetts General Hospital, Boston, MA, USA; Henry and Allison McCance Center for Brain Health, Boston, MA, USA; Clinical Data Animation Center (CDAC), Massachusetts General Hospital, Boston, MA, USA
| | - María F Elgueta
- División de Anestesiología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Javiera Benavides
- División de Anestesiología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Marcela Carrasco
- Sección de Geriatría, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - María I Morales
- Sección de Geriatría, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Natalia Calderón
- División de Anestesiología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Victor Contreras
- División de Anestesiología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; Departamento del Adulto, Escuela de Enfermería, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - M Brandon Westover
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA; Department of Neurology, Massachusetts General Hospital, Boston, MA, USA; Henry and Allison McCance Center for Brain Health, Boston, MA, USA; Clinical Data Animation Center (CDAC), Massachusetts General Hospital, Boston, MA, USA
| | - Luis I Cortínez
- División de Anestesiología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Oluwaseun Akeju
- Department of Anesthesia, Critical Care and Pain Medicine, Boston, MA, USA; Henry and Allison McCance Center for Brain Health, Boston, MA, USA
| | - Juan C Pedemonte
- División de Anestesiología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; Programa de Farmacología y Toxicología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.
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Wakabayashi R. Anesthetic management of a patient with an electroencephalogram phenotype for a "vulnerable brain": a case report. JA Clin Rep 2023; 9:25. [PMID: 37193855 DOI: 10.1186/s40981-023-00616-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 04/28/2023] [Accepted: 05/06/2023] [Indexed: 05/18/2023] Open
Abstract
BACKGROUND Low frontal alpha power is an electroencephalogram phenotype suggesting vulnerability to anesthetics. This phenotype for a "vulnerable brain" carries risks for burst suppression at lower-than-expected anesthetic concentrations and therefore for postoperative delirium. CASE PRESENTATION A 73-year-old man underwent a laparoscopic Miles' operation. He was monitored with a bispectral index monitor. Before the skin incision, the fraction of age-adjusted minimum alveolar concentration of desflurane was 0.48, and a spectrogram showed slow-delta oscillation despite a bispectral index value of 38-48. Although the fraction of age-adjusted minimum alveolar concentration of desflurane decreased to 0.33, the EEG signature remained unchanged, along with a similar bispectral index value. No burst suppression patterns were observed throughout the whole procedure, and he did not experience postoperative delirium. CONCLUSIONS This case suggests that monitoring of electroencephalogram signatures is helpful for detecting patients with a "vulnerable brain" and for providing optimal anesthetic depth in such patients.
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Affiliation(s)
- Ryo Wakabayashi
- Department of Anesthesia, Nagano Red Cross Hospital, 5-22-1, Wakasato, Nagano, 380-8582, Japan.
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42
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Hight D, Kreuzer M, Ugen G, Schuller P, Stüber F, Sleigh J, Kaiser HA. Five commercial 'depth of anaesthesia' monitors provide discordant clinical recommendations in response to identical emergence-like EEG signals. Br J Anaesth 2023; 130:536-545. [PMID: 36894408 DOI: 10.1016/j.bja.2022.12.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 12/16/2022] [Accepted: 12/18/2022] [Indexed: 03/09/2023] Open
Abstract
BACKGROUND 'Depth of anaesthesia' monitors claim to measure hypnotic depth during general anaesthesia from the EEG, and clinicians could reasonably expect agreement between monitors if presented with the same EEG signal. We took 52 EEG signals showing intraoperative patterns of diminished anaesthesia, similar to those that occur during emergence (after surgery) and subjected them to analysis by five commercially available monitors. METHODS We compared five monitors (BIS, Entropy-SE, Narcotrend, qCON, and Sedline) to see if index values remained within, or moved out of, each monitors' recommended index range for general anaesthesia for at least 2 min during a period of supposed lighter anaesthesia, as observed by changes in the EEG spectrogram obtained in a previous study. RESULTS Of the 52 cases, 27 (52%) had at least one monitor warning of potentially inadequate hypnosis (index above range) and 16 of the 52 cases (31%) had at least one monitor signifying excessive hypnotic depth (index below clinical range). Of the 52 cases, only 16 (31%) showed concordance between all five monitors. Nineteen cases (36%) had one monitor discordant compared with the remaining four, and 17 cases (33%) had two monitors in disagreement with the remaining three. CONCLUSIONS Many clinical providers still rely on index values and manufacturer's recommended ranges for titration decision making. That two-thirds of cases showed discordant recommendations given identical EEG data, and that one-third signified excessive hypnotic depth where the EEG would suggest a lighter hypnotic state, emphasizes the importance of personalised EEG interpretation as an essential clinical skill.
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Affiliation(s)
- Darren Hight
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Matthias Kreuzer
- Department of Anesthesiology and Intensive Care Medicine, Technical University of Munich, School of Medicine, Munich, Germany
| | - Gesar Ugen
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Peter Schuller
- Department of Anaesthesia, Cairns Hospital, Cairns, QLD, Australia
| | - Frank Stüber
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jamie Sleigh
- Department of Anaesthesia, Waikato Clinical School, University of Auckland, Hamilton, New Zealand
| | - Heiko A Kaiser
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Centre for Anaesthesiology and Intensive Care Medicine, Hirslanden Klinik Aarau, Hirslanden Group, Aarau, Switzerland
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Rengel KF, Boncyk CS, DiNizo D, Hughes CG. Perioperative Neurocognitive Disorders in Adults Requiring Cardiac Surgery: Screening, Prevention, and Management. Semin Cardiothorac Vasc Anesth 2023; 27:25-41. [PMID: 36137773 DOI: 10.1177/10892532221127812] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Neurocognitive changes are the most common complication after cardiac surgery, ranging from acute postoperative delirium to prolonged postoperative neurocognitive disorder. Changes in cognition are distressing to patients and families and associated with worse outcomes overall. This review outlines definitions and diagnostic criteria, risk factors for, and mechanisms of Perioperative Neurocognitive Disorders and offers strategies for preoperative screening and perioperative prevention and management of neurocognitive complications.
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Affiliation(s)
- Kimberly F Rengel
- Division of Anesthesia Critical Care Medicine, Department of Anesthesiology, 12328Vanderbilt University Medical Center, Nashville, TN, USA.,Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christina S Boncyk
- Division of Anesthesia Critical Care Medicine, Department of Anesthesiology, 12328Vanderbilt University Medical Center, Nashville, TN, USA.,Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Daniella DiNizo
- Scope Anesthesia of North Carolina, Charlotte, NC, USA.,Pulmonary and Critical Care Consultants, Carolinas Medical Center, 2351Atrium Health, Charlotte, NC, USA
| | - Christopher G Hughes
- Division of Anesthesia Critical Care Medicine, Department of Anesthesiology, 12328Vanderbilt University Medical Center, Nashville, TN, USA.,Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, 12328Vanderbilt University Medical Center, Nashville, TN, USA.,Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
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Lapointe AP, Li D, Hudetz AG, Vlisides PE. Microstate analyses as an indicator of anesthesia-induced unconsciousness. Clin Neurophysiol 2023; 147:81-87. [PMID: 36739618 DOI: 10.1016/j.clinph.2023.01.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 12/21/2022] [Accepted: 01/06/2023] [Indexed: 01/26/2023]
Abstract
OBJECTIVE The objective of this study was to identify differences in electroencephalographic microstate topographies across three perioperative phases: anesthetic pre-induction, surgical anesthesia, and post-anesthesia care unit (PACU) admission. METHODS Whole-scalp 16-channel electroencephalographic recordings were taken throughout the perioperative period on n = 22 adult, non-cardiac surgical patients. RESULTS Several differences between perioperative periods were identified. Most notably, during surgical anesthesia, patients demonstrated increased mean duration and, consequently, a reduction in the occurrence of microstates when compared to both preoperative baseline and PACU admission. We also observed the presence of microstate F with propofol anesthesia during surgery, which had been previously identified with propofol infusion in laboratory settings using human volunteers. Finally, we observed inverse age effects with mean occurrence and duration of microstates, particularly during PACU recovery. CONCLUSIONS Microstate duration is significantly increased during surgery compared to both pre-induction and PACU recovery. These data suggest that microstate topographies may be useful in monitoring anesthetic depth. SIGNIFICANCE This work highlights the potential for microstate analysis in the perioperative setting. We identified distinct topographical signatures across perioperative periods and with increasing age, which is predictive of post-operative delirium.
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Affiliation(s)
- Andrew P Lapointe
- Hotchkiss Brain Institute, Cummins School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB T2N 4N1, Canada; Department of Radiology, Cummins School of Medicine, University of Calgary, Teaching Research and Wellness Building, Experimental Imaging Centre (Level P2E), 3280 Hospital Drive NW, Calgary, AB T2N 4Z6, Canada; Department of Anesthesiology, Center for Consciousness Science, University of Michigan, USA.
| | - Duan Li
- Department of Anesthesiology, Center for Consciousness Science, University of Michigan, USA
| | - Anthony G Hudetz
- Department of Anesthesiology, Center for Consciousness Science, University of Michigan, USA
| | - Phillip E Vlisides
- Department of Anesthesiology, Center for Consciousness Science, University of Michigan, USA
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Rengel KF, Wahl LA, Sharma A, Lee H, Hayhurst CJ. Delirium Prevention and Management in Frail Surgical Patients. Anesthesiol Clin 2023; 41:175-189. [PMID: 36871998 DOI: 10.1016/j.anclin.2022.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
Delirium, an acute, fluctuating impairment in cognition and awareness, is one of the most common causes of postoperative brain dysfunction. It is associated with increased hospital length of stay, health care costs, and mortality. There is no FDA-approved treatment of delirium, and management relies on symptomatic control. Several preventative techniques have been proposed, including the choice of anesthetic agent, preoperative testing, and intraoperative monitoring. Frailty, a state of increased vulnerability to adverse events, is an independent and potentially modifiable risk factor for the development of delirium. Diligent preoperative screening techniques and implementation of prevention strategies could help improve outcomes in high-risk patients.
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Affiliation(s)
- Kimberly F Rengel
- Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, 1211 21st Avenue South, 422 MAB, Nashville, TN 37212, USA
| | - Lindsay A Wahl
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Northwestern Memorial Hospital, 251 East Huron, Suite 5-704, Chicago, IL 60611, USA
| | - Archit Sharma
- Division of Cardiothoracic Anesthesia, Solid Organ Transplant, and Critical Care, Department of Anesthesia, University of Iowa Carver College of Medicine, 200 Hawkins Drive, 6512 JCP, Iowa City, IA 52242, USA
| | - Howard Lee
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Northwestern Memorial Hospital, 251 East Huron, Suite 5-704, Chicago, IL 60611, USA
| | - Christina J Hayhurst
- Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, 1211 21st Avenue South, 422 MAB, Nashville, TN 37212, USA.
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Contribution of intraoperative electroencephalogram suppression to frailty-associated postoperative delirium: mediation analysis of a prospective surgical cohort. Br J Anaesth 2023; 130:e263-e271. [PMID: 36503826 DOI: 10.1016/j.bja.2022.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 11/02/2022] [Accepted: 11/04/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Frailty is a risk factor for postoperative delirium (POD), and has led to preoperative interventions that have reduced, but not eliminated, the risk. We hypothesised that EEG suppression, another risk factor for POD, mediates some of the frailty risk for POD. METHODS A prospective cohort study enrolled patients aged 65 yr or older, scheduled for noncardiac surgery under total intravenous anaesthesia. Frailty was assessed using the FRAIL scale. Cumulative duration of EEG suppression, defined as an amplitude between -5 and 5 μV for >0.5 s during anaesthesia, was measured. POD was diagnosed by either confusion assessment method (CAM), CAM-ICU, or medical records. The severity of POD was assessed using the Delirium Rating Scale - Revised-98 (DRS). Mediation analysis was used to estimate the relationships between frailty, EEG suppression, and severity of POD. RESULTS Among 252 enrolled patients, 51 were robust, 129 were prefrail, and 72 were frail. Patients classified as frail had higher duration of EEG suppression than either the robust (19 vs 0.57 s, P<0.001) or prefrail groups (19 vs 3.22 s, P<0.001). Peak delirium score was higher in the frail group than either the robust (17 vs 15, P<0.001) or prefrail groups (17 vs 16, P=0.007). EEG suppression time mediated 24.2% of the frailty-DRS scores association. CONCLUSION EEG suppression time mediated a statistically significant portion of the frailty-POD association in older noncardiac surgery patients. Trials directed at reducing EEG suppression time could result in intraoperative interventions to reduce POD in frail patients. CLINICAL TRIAL REGISTRATION ChiCTR2000041092 (Chinese Clinical Trial Registry).
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Fleischmann A, Georgii MT, Schuessler J, Schneider G, Pilge S, Kreuzer M. Always Assess the Raw Electroencephalogram: Why Automated Burst Suppression Detection May Not Detect All Episodes. Anesth Analg 2023; 136:346-354. [PMID: 35653440 DOI: 10.1213/ane.0000000000006098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Electroencephalogram (EEG)-based monitors of anesthesia are used to assess patients' level of sedation and hypnosis as well as to detect burst suppression during surgery. One of these monitors, the Entropy module, uses an algorithm to calculate the burst suppression ratio (BSR) that reflects the percentage of suppressed EEG. Automated burst suppression detection monitors may not reliably detect this EEG pattern. Hence, we evaluated the detection accuracy of BSR and investigated the EEG features leading to errors in the identification of burst suppression. METHODS With our study, we were able to compare the performance of the BSR to the visual burst suppression detection in the raw EEG and obtain insights on the architecture of the unrecognized burst suppression phases. RESULTS We showed that the BSR did not detect burst suppression in 13 of 90 (14%) patients. Furthermore, the time comparison between the visually identified burst suppression duration and elevated BSR values strongly depended on the BSR value being used as a cutoff. A possible factor for unrecognized burst suppression by the BSR may be a significantly higher suppression amplitude ( P = .002). Six of the 13 patients with undetected burst suppression by BSR showed intraoperative state entropy values >80, indicating a risk of awareness while being in burst suppression. CONCLUSIONS Our results complement previous results regarding the underestimation of burst suppression by other automated detection modules and highlight the importance of not relying solely on the processed index, but to assess the native EEG during anesthesia.
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Affiliation(s)
- Antonia Fleischmann
- From the Department of Anesthesiology and Intensive Care, School of Medicine, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
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Koch S, Blankertz B, Windmann V, Spies C, Radtke FM, Röhr V. Desflurane is risk factor for postoperative delirium in older patients' independent from intraoperative burst suppression duration. Front Aging Neurosci 2023; 15:1067268. [PMID: 36819718 PMCID: PMC9929347 DOI: 10.3389/fnagi.2023.1067268] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 01/09/2023] [Indexed: 02/04/2023] Open
Abstract
Background Postoperative Delirium (POD) is the most frequent neurocognitive complication after general anesthesia in older patients. The development of POD is associated with prolonged periods of burst suppression activity in the intraoperative electroencephalogram (EEG). The risk to present burst suppression activity depends not only on the age of the patient but is also more frequent during propofol anesthesia as compared to inhalative anesthesia. The aim of our study is to determine, if the risk to develop POD differs depending on the anesthetic agent given and if this correlates with a longer duration of intraoperative burst suppression. Methods In this secondary analysis of the SuDoCo trail [ISRCTN 36437985] 1277 patients, older than 60 years undergoing general anesthesia were included. We preprocessed and analyzed the raw EEG files from each patient and evaluated the intraoperative burst suppression duration. In a logistic regression analysis, we assessed the impact of burst suppression duration and anesthetic agent used for maintenance on the risk to develop POD. Results 18.7% of patients developed POD. Burst suppression duration was prolonged in POD patients (POD 27.5 min ± 21.3 min vs. NoPOD 21.4 ± 16.2 min, p < 0.001), for each minute of prolonged intraoperative burst suppression activity the risk to develop POD increased by 1.1% (OR 1.011, CI 95% 1.000-1.022, p = 0.046). Burst suppression duration was prolonged under propofol anesthesia as compared to sevoflurane and desflurane anesthesia (propofol 32.5 ± 20.3 min, sevoflurane 17.1 ± 12.6 min and desflurane 20.1 ± 16.0 min, p < 0.001). However, patients receiving desflurane anesthesia had a 1.8fold higher risk to develop POD, as compared to propofol anesthesia (OR 1.766, CI 95% 1.049-2.974, p = 0.032). Conclusion We found a significantly increased risk to develop POD after desflurane anesthesia in older patients, even though burst suppression duration was shorter under desflurane anesthesia as compared to propofol anesthesia. Our finding might help to explain some discrepancies in studies analyzing the impact of burst suppression duration and EEG-guided anesthesia on the risk to develop POD.
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Affiliation(s)
- Susanne Koch
- Department of Anaesthesiology and Operative Intensive Care Medicine, Charité – Universitätsmedizin Berlin, Berlin, Germany,*Correspondence: Susanne Koch, ✉
| | | | - Victoria Windmann
- Department of Anaesthesiology and Operative Intensive Care Medicine, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Claudia Spies
- Department of Anaesthesiology and Operative Intensive Care Medicine, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Finn M. Radtke
- Department of Anesthesia, Hospital of Nykobing, University of Southern Denmark, Odense, Denmark
| | - Vera Röhr
- Neurotechnology Group, Technische Universität Berlin, Berlin, Germany
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Leroy S, Major S, Bublitz V, Dreier JP, Koch S. Unveiling age-independent spectral markers of propofol-induced loss of consciousness by decomposing the electroencephalographic spectrum into its periodic and aperiodic components. Front Aging Neurosci 2023; 14:1076393. [PMID: 36742202 PMCID: PMC9889977 DOI: 10.3389/fnagi.2022.1076393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 12/05/2022] [Indexed: 01/19/2023] Open
Abstract
Background Induction of general anesthesia with propofol induces radical changes in cortical network organization, leading to unconsciousness. While perioperative frontal electroencephalography (EEG) has been widely implemented in the past decades, validated and age-independent EEG markers for the timepoint of loss of consciousness (LOC) are lacking. Especially the appearance of spatially coherent frontal alpha oscillations (8-12 Hz) marks the transition to unconsciousness.Here we explored whether decomposing the EEG spectrum into its periodic and aperiodic components unveiled markers of LOC and investigated their age-dependency. We further characterized the LOC-associated alpha oscillations by parametrizing the adjusted power over the aperiodic component, the center frequency, and the bandwidth of the peak in the alpha range. Methods In this prospective observational trial, EEG were recorded in a young (18-30 years) and an elderly age-cohort (≥ 70 years) over the transition to propofol-induced unconsciousness. An event marker was set in the EEG recordings at the timepoint of LOC, defined with the suppression of the lid closure reflex. Spectral analysis was conducted with the multitaper method. Aperiodic and periodic components were parametrized with the FOOOF toolbox. Aperiodic parametrization comprised the exponent and the offset. The periodic parametrization consisted in the characterization of the peak in the alpha range with its adjusted power, center frequency and bandwidth. Three time-segments were defined: preLOC (105 - 75 s before LOC), LOC (15 s before to 15 s after LOC), postLOC (190 - 220 s after LOC). Statistical significance was determined with a repeated-measures ANOVA. Results Loss of consciousness was associated with an increase in the aperiodic exponent (young: p = 0.004, elderly: p = 0.007) and offset (young: p = 0.020, elderly: p = 0.004) as well as an increase in the adjusted power (young: p < 0.001, elderly p = 0.011) and center frequency (young: p = 0.008, elderly: p < 0.001) of the periodic alpha peak. We saw age-related differences in the aperiodic exponent and offset after LOC as well as in the power and bandwidth of the periodic alpha peak during LOC. Conclusion Decomposing the EEG spectrum over induction of anesthesia into its periodic and aperiodic components unveiled novel age-independent EEG markers of propofol-induced LOC: the aperiodic exponent and offset as well as the center frequency and adjusted power of the power peak in the alpha range.
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Affiliation(s)
- Sophie Leroy
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Sebastian Major
- Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany,Department of Experimental Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany,Department of Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Viktor Bublitz
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Jens P. Dreier
- Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany,Department of Experimental Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany,Department of Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany,Bernstein Center for Computational Neuroscience Berlin, Berlin, Germany,Einstein Center for Neurosciences Berlin, Berlin, Germany
| | - Susanne Koch
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany,*Correspondence: Susanne Koch, ✉
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Deschamps A, Saha T, El-Gabalawy R, Jacobsohn E, Overbeek C, Palermo J, Robichaud S, Dumont AA, Djaiani G, Carroll J, Kavosh MS, Tanzola R, Schmitt EM, Inouye SK, Oberhaus J, Mickle A, Ben Abdallah A, Avidan MS, Clinical Trials Group CPA. Protocol for the electroencephalography guidance of anesthesia to alleviate geriatric syndromes (ENGAGES-Canada) study: A pragmatic, randomized clinical trial. F1000Res 2023; 8:1165. [PMID: 31588356 PMCID: PMC6760454 DOI: 10.12688/f1000research.19213.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/09/2023] [Indexed: 01/15/2023] Open
Abstract
Background: There is some evidence that electroencephalography guidance of general anesthesia can decrease postoperative delirium after non-cardiac surgery. There is limited evidence in this regard for cardiac surgery. A suppressed electroencephalogram pattern, occurring with deep anesthesia, is associated with increased incidence of postoperative delirium (POD) and death. However, it is not yet clear whether this electroencephalographic pattern reflects an underlying vulnerability associated with increased incidence of delirium and mortality, or whether it is a modifiable risk factor for these adverse outcomes. Methods: The Electroe ncephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes ( ENGAGES-Canada) is an ongoing pragmatic 1200 patient trial at four Canadian sites. The study compares the effect of two anesthetic management approaches on the incidence of POD after cardiac surgery. One approach is based on current standard anesthetic practice and the other on electroencephalography guidance to reduce POD. In the guided arm, clinicians are encouraged to decrease anesthetic administration, primarily if there is electroencephalogram suppression and secondarily if the EEG index is lower than the manufacturers recommended value (bispectral index (BIS) or WAVcns below 40 or Patient State Index below 25). The aim in the guided group is to administer the minimum concentration of anesthetic considered safe for individual patients. The primary outcome of the study is the incidence of POD, detected using the confusion assessment method or the confusion assessment method for the intensive care unit; coupled with structured delirium chart review. Secondary outcomes include unexpected intraoperative movement, awareness, length of intensive care unit and hospital stay, delirium severity and duration, quality of life, falls, and predictors and outcomes of perioperative distress and dissociation. Discussion: The ENGAGES-Canada trial will help to clarify whether or not using the electroencephalogram to guide anesthetic administration during cardiac surgery decreases the incidence, severity, and duration of POD. Registration: ClinicalTrials.gov ( NCT02692300) 26/02/2016.
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Affiliation(s)
- Alain Deschamps
- Department of Anesthesiology and Pain Medicine, Montreal Heart Institute and Universite de Montreal, Montreal, Quebec, H1T 1C8, Canada,
| | - Tarit Saha
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Kingston, Ontario, Canada
| | - Renée El-Gabalawy
- Department of Clinical Health Psychology, Anesthesiology, Perioperative and Pain Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Eric Jacobsohn
- Departments of Anesthesia and Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Charles Overbeek
- Department of Anesthesiology and Pain Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Jennifer Palermo
- Department of Anesthesiology and Pain Medicine, University of Montreal, Montreal, Quebec, Canada
| | | | - Andrea Alicia Dumont
- Montreal Health Innovation Coordinating Center, Montreal Heart Institute, Montreal, Quebec, Canada
| | - George Djaiani
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Jo Carroll
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Morvarid S. Kavosh
- Department of Anesthesiology, Perioperative and Pain Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rob Tanzola
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Kingston, Ontario, Canada
| | - Eva M. Schmitt
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachussetts, USA
| | - Sharon K. Inouye
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachussetts, USA
| | - Jordan Oberhaus
- Department of Anesthesiology, Washington University School of Medicine, St-Louis, Missouri, USA
| | - Angela Mickle
- Department of Anesthesiology, Washington University School of Medicine, St-Louis, Missouri, USA
| | - Arbi Ben Abdallah
- Department of Anesthesiology, Washington University School of Medicine, St-Louis, Missouri, USA
| | - Michael S. Avidan
- Department of Anesthesiology, Washington University School of Medicine, St-Louis, Missouri, USA
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