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Willingham M, Avidan M. Triple low, double low: it’s time to deal Achilles heel a single deadly blow. Br J Anaesth 2017; 119:1-4. [DOI: 10.1093/bja/aex132] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Abstract
PURPOSE OF REVIEW Initial studies suggested that the use of processed electroencephalogram technology could significantly decrease the incidence of unintended intraoperative awareness events during general anesthesia. Subsequent work has cast doubts on these findings. This review will examine the current state of awareness monitoring. RECENT FINDINGS Recently published randomized controlled trials examining the use of the bispectral index during general anesthesia have not been able to show superiority over other forms of monitoring depth of anesthesia, such as end-tidal anesthetic-agent concentration. Additionally, there is current interest in utilizing the unprocessed electroencephalogram to ascertain depth of anesthesia and recent studies have demonstrated its use in preventing postoperative delirium. SUMMARY Although awareness monitors such as the bispectral index monitor may have benefit in patients in whom volatile anesthetic agents must be minimized - such as in hemodynamically unstable patients, or patients undergoing total intravenous anesthesia - these monitors do not appear to be useful for all patients.
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Wildes TS, Winter AC, Maybrier HR, Mickle AM, Lenze EJ, Stark S, Lin N, Inouye SK, Schmitt EM, McKinnon SL, Muench MR, Murphy MR, Upadhyayula RT, Fritz BA, Escallier KE, Apakama GP, Emmert DA, Graetz TJ, Stevens TW, Palanca BJ, Hueneke RL, Melby S, Torres B, Leung J, Jacobsohn E, Avidan MS. Protocol for the Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes (ENGAGES) study: a pragmatic, randomised clinical trial. BMJ Open 2016; 6:e011505. [PMID: 27311914 PMCID: PMC4916634 DOI: 10.1136/bmjopen-2016-011505] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Postoperative delirium, arbitrarily defined as occurring within 5 days of surgery, affects up to 50% of patients older than 60 after a major operation. This geriatric syndrome is associated with longer intensive care unit and hospital stay, readmission, persistent cognitive deterioration and mortality. No effective preventive methods have been identified, but preliminary evidence suggests that EEG monitoring during general anaesthesia, by facilitating reduced anaesthetic exposure and EEG suppression, might decrease incident postoperative delirium. This study hypothesises that EEG-guidance of anaesthetic administration prevents postoperative delirium and downstream sequelae, including falls and decreased quality of life. METHODS AND ANALYSIS This is a 1232 patient, block-randomised, double-blinded, comparative effectiveness trial. Patients older than 60, undergoing volatile agent-based general anaesthesia for major surgery, are eligible. Patients are randomised to 1 of 2 anaesthetic approaches. One group receives general anaesthesia with clinicians blinded to EEG monitoring. The other group receives EEG-guidance of anaesthetic agent administration. The outcomes of postoperative delirium (≤5 days), falls at 1 and 12 months and health-related quality of life at 1 and 12 months will be compared between groups. Postoperative delirium is assessed with the confusion assessment method, falls with ProFaNE consensus questions and quality of life with the Veteran's RAND 12-item Health Survey. The intention-to-treat principle will be followed for all analyses. Differences between groups will be presented with 95% CIs and will be considered statistically significant at a two-sided p<0.05. ETHICS AND DISSEMINATION Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes (ENGAGES) is approved by the ethics board at Washington University. Recruitment began in January 2015. Dissemination plans include presentations at scientific conferences, scientific publications, internet-based educational materials and mass media. TRIAL REGISTRATION NUMBER NCT02241655; Pre-results.
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Affiliation(s)
- T S Wildes
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - A C Winter
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - H R Maybrier
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - A M Mickle
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - E J Lenze
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA
| | - S Stark
- Department of Occupational Therapy, Washington University Institute for Public Health, School of Medicine, St. Louis, Missouri, USA
- Department of Neurology, Washington University Institute for Public Health, School of Medicine, St. Louis, Missouri, USA
| | - N Lin
- Department of Mathematics, Biostatistics Division, Washington University in St. Louis, St. Louis, Missouri, USA
| | - S K Inouye
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
- Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - E M Schmitt
- Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - S L McKinnon
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - M R Muench
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - M R Murphy
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - R T Upadhyayula
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - B A Fritz
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - K E Escallier
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - G P Apakama
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - D A Emmert
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - T J Graetz
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - T W Stevens
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - B J Palanca
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - R L Hueneke
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - S Melby
- Department of Surgery, Cardiothoracic Division, Washington University School of Medicine, St. Louis, Missouri, USA
| | - B Torres
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - J Leung
- Department of Anesthesia & Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - E Jacobsohn
- Department of Anesthesia, University of Manitoba/Winnipeg Regional Health Authority Anesthesia Program, Winnipeg, Manitoba, Canada
| | - M S Avidan
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
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Wickham A, Highton D, Martin D. Care of elderly patients: a prospective audit of the prevalence of hypotension and the use of BIS intraoperatively in 25 hospitals in London. Perioper Med (Lond) 2016; 5:12. [PMID: 27239298 PMCID: PMC4882849 DOI: 10.1186/s13741-016-0036-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 05/09/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Anaesthesia is frequently complicated by intraoperative hypotension (IOH) in the elderly, and this is associated with adverse outcome. The definition of IOH is controversial, and although management guidelines for IOH in the elderly exist, the frequency of IOH and typical clinically applied treatment thresholds are largely unknown in the UK. METHODS We audited frequency of intraoperative blood pressure against national guidelines in elderly patients undergoing surgery. Depth of anaesthesia (DOA) monitoring was also audited due to the association between low DOA values and IOH with increased mortality (as part of "double" and "triple low" phenomena) and because it is a suggested management strategy to reduce IOH. RESULTS Twenty-five hospitals submitted data on 481 patients. Hypotension varied depending on the definition, but affected 400 patients (83.3 %) using the AAGBI standard. Furthermore, 2.9, 13.5, and 24.6 % had mean arterial blood pressures <50, <60, and <70 mmHg for 20 min, respectively, and 136 (28.4 %) had systolic blood pressure decrease by 20 % for 20 min. DOA monitors were used for 45 (9.4 %) patients. CONCLUSIONS IOH is common and use of DOA monitors is less than implied by guidelines. Improved management of IOH may be a simple intervention with real potential to reduce morbidity in this vulnerable group.
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Affiliation(s)
- Alex Wickham
- Department of Anaesthetics, Imperial College Healthcare NHS Trust, London, UK
| | - David Highton
- Neurocritical Care, the National Hospital for Neurology and Neurosurgery, University College London Hospitals, Queen Square, London, UK
| | - Daniel Martin
- Division of Surgery and Interventional Science, Royal Free Hospital, University College London, Pond Street, London, NW3 2QG UK ; Royal Free Perioperative Research, Department of Anaesthesia, Royal Free Hospital, Pond Street, London, NW3 2QG UK
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Kowalczyk AK, Bachar BJ, Liu H. Neuromonitoring during adult cardiac surgery. J Biomed Res 2016; 30:171-3. [PMID: 27533926 PMCID: PMC4885162 DOI: 10.7555/jbr.30.20150159] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Revised: 12/08/2015] [Accepted: 02/03/2016] [Indexed: 11/03/2022] Open
Affiliation(s)
- Anna K Kowalczyk
- Department of Anesthesiology and Pain Medicine, University of California Davis, Sacramento, CA 95817, USA
| | - Bradlee J Bachar
- Department of Anesthesiology and Pain Medicine, University of California Davis, Sacramento, CA 95817, USA
| | - Hong Liu
- Department of Anesthesiology and Pain Medicine, University of California Davis, Sacramento, CA 95817, USA.
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Fritz BA, Kalarickal PL, Maybrier HR, Muench MR, Dearth D, Chen Y, Escallier KE, Ben Abdallah A, Lin N, Avidan MS. Intraoperative Electroencephalogram Suppression Predicts Postoperative Delirium. Anesth Analg 2016; 122:234-42. [PMID: 26418126 DOI: 10.1213/ane.0000000000000989] [Citation(s) in RCA: 192] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Postoperative delirium is a common complication associated with increased morbidity and mortality, longer hospital stays, and greater health care expenditures. Intraoperative electroencephalogram (EEG) slowing has been associated previously with postoperative delirium, but the relationship between intraoperative EEG suppression and postoperative delirium has not been investigated. METHODS In this observational cohort study, 727 adult patients who received general anesthesia with planned intensive care unit admission were included. Duration of intraoperative EEG suppression was recorded from a frontal EEG channel (FP1 to F7). Delirium was assessed twice daily on postoperative days 1 through 5 with the Confusion Assessment Method for the intensive care unit. Thirty days after surgery, quality of life, functional independence, and cognitive ability were measured using the Veterans RAND 12-item survey, the Barthel index, and the PROMIS Applied Cognition-Abilities-Short Form 4a survey. RESULTS Postoperative delirium was observed in 162 (26%) of 619 patients assessed. When we compared patients with no EEG suppression with those divided into quartiles based on duration of EEG suppression, patients with more suppression were more likely to experience delirium (χ(4) = 25, P < 0.0001). This effect remained significant after we adjusted for potential confounders (odds ratio for log(EEG suppression) 1.22 [99% confidence interval, 1.06-1.40, P = 0.0002] per 1-minute increase in suppression). EEG suppression may have been associated with reduced functional independence (Spearman partial correlation coefficient -0.15, P = 0.02) but not with changes in quality of life or cognitive ability. Predictors of EEG suppression included greater end-tidal volatile anesthetic concentration and lower intraoperative opioid dose. CONCLUSIONS EEG suppression is an independent risk factor for postoperative delirium. Future studies should investigate whether anesthesia titration to minimize EEG suppression decreases the incidence of postoperative delirium. This is a substudy of the Systematic Assessment and Targeted Improvement of Services Following Yearlong Surgical Outcomes Surveys (SATISFY-SOS) surgical outcomes registry (NCT02032030).
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Affiliation(s)
- Bradley A Fritz
- From the *Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri; and †Department of Mathematics, Washington University, St. Louis, Missouri
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Short TG, Leslie K, Chan MTV, Campbell D, Frampton C, Myles P. Rationale and Design of the Balanced Anesthesia Study: A Prospective Randomized Clinical Trial of Two Levels of Anesthetic Depth on Patient Outcome After Major Surgery. Anesth Analg 2015; 121:357-65. [PMID: 25993386 DOI: 10.1213/ane.0000000000000797] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND An association between relatively deep anesthesia, as guided by the bispectral index (BIS), and increased postoperative mortality has been demonstrated in 6 of 8 published observational studies, but association does not necessarily mean causality. Small clinical trials of anesthetic depth have demonstrated increased delirium and postoperative cognitive dysfunction in patients who were relatively deeply anesthetized, but have been inadequately powered to study mortality. A large-scale randomized study is required to determine whether causality exists. METHODS The primary hypothesis of our study is that "light" anesthesia, defined as a BIS target of 50, will reduce all-cause mortality within 1 year of surgery in comparison with "deep" anesthesia, defined as a BIS target of 35, in patients aged ≥60 years presenting for major surgery under general anesthesia. The trial is an international multicenter, randomized, parallel-group, double-blind (patients and investigators) prospective, intention-to-treat, safety and efficacy study. The relative reduction in mortality in the light anesthesia group is expected to be 20%, giving an absolute risk reduction from 10% to 8%. Power analysis using a = 0.049 and b = 0.2 indicates that 3250 patients are required in each group. RESULTS The study is underway, and 1325 patients have been recruited in 40 centers in 5 countries. It is anticipated that the study will be completed in 3 years. CONCLUSIONS This randomized controlled trial should definitively answer the question of whether titrating anesthetic depth makes a difference to patient outcome in a vulnerable patient group.
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Affiliation(s)
- Timothy G Short
- From the *Department of Anaesthesia and Perioperative Medicine, Auckland City Hospital, Auckland, New Zealand; †Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Victoria, Australia; ‡Anaesthesia, Perioperative and Pain Medicine Unit, Department of Pharmacology, University of Melbourne, Melbourne, Victoria, Australia; §Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; ∥Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, People's Republic of China; ¶Department of Statistics, University of Otago, Christchurch, New Zealand; #Department of Anaesthesia and Perioperative Medicine, Alfred Hospital, Melbourne, Victoria, Australia; and **Academic Board of Anaesthesia and Perioperative Medicine, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Willingham MD, Karren E, Shanks AM, O'Connor MF, Jacobsohn E, Kheterpal S, Avidan MS. Concurrence of Intraoperative Hypotension, Low Minimum Alveolar Concentration, and Low Bispectral Index Is Associated with Postoperative Death. Anesthesiology 2015; 123:775-85. [PMID: 26267244 PMCID: PMC4573282 DOI: 10.1097/aln.0000000000000822] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND An intraoperative concurrence of mean arterial pressure less than 75 mmHg, minimum alveolar concentration less than 0.8, and bispectral index less than 45 has been termed a "triple low" state. An association between triple low and postoperative mortality has been reported but was not replicated in a subsequent study. The authors pooled existing data from clinical trials to further evaluate the purported association in an observational study. METHODS This retrospective observational study included 13,198 patients from three clinical trials: B-Unaware, BAG-RECALL, and Michigan Awareness Control Study. Patients with greater than 15 not necessarily consecutive minutes of triple low were propensity matched to controls with similar characteristics and comorbidities. A multivariable Cox proportional hazards model was used to evaluate the association between triple low duration and postoperative mortality. RESULTS Thirty-day mortality was 0.8% overall, 1.9% in the triple low cohort, and 0.4% in the nontriple low cohort (odds ratio, 5.16; 95% CI, 4.21 to 6.34). After matching and adjusting for comorbidities, cumulative duration of triple low was significantly associated with an increased risk of mortality at 30 days (hazard ratio, 1.09; 95% CI, 1.07 to 1.11, per 15 min) and 90 days (hazard ratio, 1.09; 95% CI, 1.08 to 1.11, per 15 min). CONCLUSION There is a weak independent association between the triple low state and postoperative mortality, and the propensity-matched analysis does not suggest that this is an epiphenomenon.
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Affiliation(s)
- Mark D Willingham
- From the Department of Anesthesiology, Washington University in Saint Louis School of Medicine, St. Louis, Missouri (M.D.W., M.S.A.); Department of Anesthesiology, University of Utah Medical School, Salt Lake City, Utah (E.K.); Center for Perioperative Outcomes Research, and Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan (A.M.S., S.K.); Department of Anesthesiology, University of Chicago, Chicago, Illinois (M.F.O.); and Department of Anesthesiology, University of Manitoba, Winnipeg, Manitoba, Canada (E.J.)
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Bharath S, Chakrabarti D, Umamaheswara Rao GS. Does anaesthetic dose really not contribute to mortality? Br J Anaesth 2015; 115:638. [PMID: 26385677 DOI: 10.1093/bja/aev315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Leslie K, Short TG. Anesthetic depth and long-term survival: an update. Can J Anaesth 2015; 63:233-40. [DOI: 10.1007/s12630-015-0490-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Revised: 05/20/2015] [Accepted: 09/10/2015] [Indexed: 01/12/2023] Open
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Chana AS, Mahajan RP. BJA 2014; An overview. Br J Anaesth 2015; 114:ix-xvi. [PMID: 25500411 DOI: 10.1093/bja/aeu455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- A S Chana
- Anaesthesia and Critical Care, Division of Clinical Neurosciences, Queen's Medical Centre, University of Nottingham, Nottingham NG7 2UK, UK
| | - R P Mahajan
- Anaesthesia and Critical Care, Division of Clinical Neurosciences, Queen's Medical Centre, University of Nottingham, Nottingham NG7 2UK, UK
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Short T, Leslie K. ‘Known unknowns and unknown unknowns': electroencephalographic burst suppression and mortality. Br J Anaesth 2014; 113:897-9. [DOI: 10.1093/bja/aeu147] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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