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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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Ning M, Rodionov A, Ross JM, Ozdemir RA, Burch M, Lian SJ, Alsop D, Cavallari M, Dickerson BC, Fong TG, Jones RN, Libermann TA, Marcantonio ER, Santarnecchi E, Schmitt EM, Touroutoglou A, Travison TG, Acker L, Reese M, Sun H, Westover B, Berger M, Pascual-Leone A, Inouye SK, Shafi MM. Prediction of Post-Operative Delirium in Older Adults from Preoperative Cognition and Alpha Power from Resting-State EEG. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.08.15.24312053. [PMID: 39185530 PMCID: PMC11343253 DOI: 10.1101/2024.08.15.24312053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 08/27/2024]
Abstract
Postoperative Delirium (POD) is the most common complication following surgery among older adults, and has been consistently associated with increased mortality and morbidity, cognitive decline, and loss of independence, as well as markedly increased health-care costs. The development of new tools to identify individuals at high risk for POD could guide clinical decision-making and enable targeted interventions to potentially decrease delirium incidence and POD-related complications. In this study, we used machine learning techniques to evaluate whether baseline (pre-operative) cognitive function and resting-state electroencephalography could be used to identify patients at risk for POD. Pre-operative resting-state EEGs and the Montreal Cognitive Assessment (MoCA) were collected from 85 patients (age = 73 ± 6.4 years) undergoing elective surgery, 12 of whom subsequently developed POD. The model with the highest f1-score for predicting delirium, a linear-discriminant analysis (LDA) model incorporating MoCA scores and occipital alpha-band EEG features, was subsequently validated in an independent, prospective cohort of 51 older adults (age ≥ 60) undergoing elective surgery, 6 of whom developed POD. The LDA-based model, with a total of 7 features, was able to predict POD with area under the receiver operating characteristic curve, specificity and accuracy all >90%, and sensitivity > 80%, in the validation cohort. Notably, models incorporating both resting-state EEG and MoCA scores outperformed those including either EEG or MoCA alone. While requiring prospective validation in larger cohorts, these results suggest that prediction of POD with high accuracy may be feasible in clinical settings using simple and widely available clinical tools. Highlights Predict postoperative delirium using pre-operative EEG alpha power and MoCA scores.Prediction performance improves over cognitive assessment alone.ROC-AUC, specificity, accuracy >90%, and sensitivity > 80%, in a validation cohort.Abnormalities in baseline EEG are a risk factor for postoperative delirium.
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Affiliation(s)
- Matthew Ning
- Berenson-Allen Center for Noninvasive Brain Stimulation, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Andrei Rodionov
- Berenson-Allen Center for Noninvasive Brain Stimulation, Beth Israel Deaconess Medical Center, Boston, MA, USA
- BioMag Laboratory, HUS Medical Imaging Center, Helsinki University Hospital, Helsinki, Finland
- Faculty of Educational Sciences, University of Helsinki, University of Helsinki, Finland
| | - Jessica M. Ross
- Berenson-Allen Center for Noninvasive Brain Stimulation, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Veterans Affairs Palo Alto Healthcare System, and the Sierra Pacific Mental Illness, Research, Education, and Clinical Center, Palo Alto, CA, USA
- Department of Psychiatry and Behavioral Sciences, Stanford Medical School, Stanford, CA, USA
| | - Recep A. Ozdemir
- Berenson-Allen Center for Noninvasive Brain Stimulation, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Maja Burch
- Berenson-Allen Center for Noninvasive Brain Stimulation, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Shu Jing Lian
- Berenson-Allen Center for Noninvasive Brain Stimulation, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - David Alsop
- Harvard Medical School, Boston, MA, USA
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Michele Cavallari
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Center for Neurological Imaging, Department of Radiology, Brigham and Women’s Hospital, Boston, MA, USA
| | - Bradford C. Dickerson
- Harvard Medical School, Boston, MA, USA
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Tamara G. Fong
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - Richard N. Jones
- Department of Psychiatry and Human Behavior, Department of Neurology, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Towia A. Libermann
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Edward R. Marcantonio
- Harvard Medical School, Boston, MA, USA
- Divisions of General Medicine and Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Emiliano Santarnecchi
- Berenson-Allen Center for Noninvasive Brain Stimulation, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Precision Neuroscience & Neuromodulation Program (PNN), Gordon Center for Medical Imaging, Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Eva M. Schmitt
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - Alexandra Touroutoglou
- Harvard Medical School, Boston, MA, USA
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Thomas G. Travison
- Harvard Medical School, Boston, MA, USA
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - Leah Acker
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC, USA
- Duke Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC, USA
- Center for Cognitive Neuroscience, Duke University, Durham, NC, USA
| | - Melody Reese
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC, USA
- Duke Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC, USA
| | - 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 at Mass General
| | - 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 at Mass General
| | - Miles Berger
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC, USA
- Duke Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC, USA
- Center for Cognitive Neuroscience, Duke University, Durham, NC, USA
- Duke-UNC Alzheimer’s Disease Research Center, Durham, NC, USA
| | - Alvaro Pascual-Leone
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - Sharon K. Inouye
- Harvard Medical School, Boston, MA, USA
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Mouhsin M. Shafi
- Berenson-Allen Center for Noninvasive Brain Stimulation, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Bruzzone MJ, Chapin B, Walker J, Santana M, Wang Y, Amini S, Kimmet F, Perera E, Rubinos C, Arias F, Price C. Electroencephalographic Measures of Delirium in the Perioperative Setting: A Systematic Review. Anesth Analg 2024:00000539-990000000-00887. [PMID: 39088366 DOI: 10.1213/ane.0000000000007079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2024]
Abstract
Postoperative delirium (POD) is frequent in older adults and is associated with adverse cognitive and functional outcomes. In the last several decades, there has been an increased interest in exploring tools that easily allow the early recognition of patients at risk of developing POD. The electroencephalogram (EEG) is a widely available tool used to understand delirium pathophysiology, and its use in the perioperative setting has grown exponentially, particularly to predict and detect POD. We performed a systematic review to investigate the use of EEG in the pre-, intra-, and postoperative settings. We identified 371 studies, and 56 met the inclusion criteria. A range of techniques was used to obtain EEG data, from limited 1-4 channel setups to complex 256-channel systems. Power spectra were often measured preoperatively, yet the outcomes were inconsistent. During surgery, the emphasis was primarily on burst suppression (BS) metrics and power spectra, with a link between the frequency and timing of BS, and POD. The EEG patterns observed in POD aligned with those noted in delirium in different contexts, suggesting a reduction in EEG activity. Further research is required to investigate preoperative EEG indicators that may predict susceptibility to delirium.
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Affiliation(s)
- Maria J Bruzzone
- From the Department of Neurology, University of Florida, Gainesville, Florida
| | - Benjamin Chapin
- Department of Anesthesia, University of Florida, Gainesville, Florida
| | - Jessie Walker
- From the Department of Neurology, University of Florida, Gainesville, Florida
| | - Marcos Santana
- From the Department of Neurology, University of Florida, Gainesville, Florida
| | - Yue Wang
- From the Department of Neurology, University of Florida, Gainesville, Florida
| | - Shawna Amini
- Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - Faith Kimmet
- Department of Clinical and Health Psychology, University of Florida, Gainesville, Florida
| | - Estefania Perera
- Department of Clinical and Health Psychology, University of Florida, Gainesville, Florida
| | - Clio Rubinos
- Department of Neurology, University of North Carolina, Chapel Hill, North Carolina
| | - Franchesca Arias
- Department of Clinical and Health Psychology, University of Florida, Gainesville, Florida
| | - Catherine Price
- Department of Clinical and Health Psychology, University of Florida, Gainesville, Florida
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4
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Berger M, Neuman MD. Anesthesia Dose and Delirium-A Picture Coming Into Focus. JAMA 2024; 332:107-108. [PMID: 38857024 DOI: 10.1001/jama.2023.26819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/11/2024]
Affiliation(s)
- Miles Berger
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
- Center for Cognitive Neuroscience, Duke University Medical Center, Durham, North Carolina
- Center for the Study of Aging and Human Development and the Duke/UNC Alzheimer's Disease Research Center, Duke University Medical Center, Durham, North Carolina
| | - Mark D Neuman
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Penn Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania Perelman School of Medicine, Philadelphia
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Kim YS, Kim J, Park S, Kim KN, Ha Y, Yi S, Shin DA, Kuh SU, Lee CK, Koo BN, Kim SE. Differential effects of sevoflurane and desflurane on frontal intraoperative electroencephalogram dynamics associated with postoperative delirium. J Clin Anesth 2024; 93:111368. [PMID: 38157663 DOI: 10.1016/j.jclinane.2023.111368] [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: 04/16/2023] [Revised: 11/23/2023] [Accepted: 12/18/2023] [Indexed: 01/03/2024]
Abstract
STUDY OBJECTIVE Intraoperative electroencephalogram (EEG) patterns associated with postoperative delirium (POD) development have been studied, but the differences in EEG recordings between sevoflurane- and desflurane-induced anesthesia have not been clarified. We aimed to distinguish the EEG characteristics of sevoflurane and desflurane in relation to POD development. DESIGN AND PATIENTS We collected frontal four-channel EEG data during the maintenance of anesthesia from 148 elderly patients who received sevoflurane (n = 77) or desflurane (n = 71); 30 patients were diagnosed with delirium postoperatively. The patients were divided into four subgroups based on anesthetics and delirium status: sevoflurane delirium (n = 17), sevoflurane non-delirium (n = 60), desflurane delirium (n = 13), and desflurane non-delirium (n = 58). We compared spectral power, coherence, and pairwise phase consistency (PPC) between sevoflurane and desflurane, and between non-delirium and delirium groups for each anesthetic. MAIN RESULTS In patients without POD, the sevoflurane non-delirium group exhibited higher EEG spectral power across 8.5-35 Hz (99.5% CI bootstrap analysis) and higher PPC from alpha to gamma bands (p < 0.005) compared to the desflurane non-delirium group. Conversely, in patients with POD, no significant EEG differences were observed between the sevoflurane and desflurane delirium groups. For the sevoflurane-induced patients, the sevoflurane delirium group had significantly lower power within 7.5-31.5 Hz (99.5% CI bootstrap analysis), reduced coherence over 8.9-23.8 Hz (99.5% CI bootstrap analysis), and lower PPC values in the alpha band (p < 0.005) compared with the sevoflurane non-delirium group. For the desflurane-induced patients, there were no significant differences in the EEG patterns between delirium and non-delirium groups. CONCLUSIONS In normal patients without POD, sevoflurane demonstrates a higher power spectrum and prefrontal connectivity than desflurane. Furthermore, reduced frontal alpha power, coherence, and connectivity of intraoperative EEG could be associated with an increased risk of POD. These intraoperative EEG characteristics associated with POD are more noticeable in sevoflurane-induced anesthesia than in desflurane-induced anesthesia.
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Affiliation(s)
- Yeon-Su Kim
- Department of Applied Artificial Intelligence, Seoul National University of Science and Technology, Seoul 01811, Republic of Korea
| | - Jeongmin Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Sujung Park
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Keung Nyun Kim
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, 03722, Republic of Korea
| | - Yoon Ha
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, 03722, Republic of Korea; POSTECH Biotech Center, Pohang University of Science and Technology, Pohang, Gyeongbuk 37673, Republic of Korea
| | - Seong Yi
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, 03722, Republic of Korea
| | - Dong Ah Shin
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, 03722, Republic of Korea
| | - Sung Uk Kuh
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, 03722, Republic of Korea
| | - Chang Kyu Lee
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, 03722, Republic of Korea
| | - Bon-Nyeo Koo
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul 03722, Republic of Korea.
| | - Seong-Eun Kim
- Department of Applied Artificial Intelligence, Seoul National University of Science and Technology, Seoul 01811, Republic of Korea.
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6
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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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7
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Wang Y, Jiang Y, Fu H, Zhao Y, Xu Z. The clinical value of the Duke Anesthesia Resistance Scale in predicting postoperative delirium after hip fracture surgery: a retrospective study. PeerJ 2023; 11:e16535. [PMID: 38077438 PMCID: PMC10704981 DOI: 10.7717/peerj.16535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 11/07/2023] [Indexed: 12/18/2023] Open
Abstract
Aim This study aims to investigate the clinical value of the Duke Anesthesia Resistance Scale (DARS) in predicting postoperative delirium (POD) after hip fracture surgery. Methods A retrospective study was conducted. Clinical data were collected from the patients who had hip fracture and underwent elective total hip arthroplasty in Shaanxi Provincial People's Hospital, Third Affiliated Hospital of Xi'an Jiaotong University between January 2022 and June 2023. The Consciousness Fuzzy Assessment Scale was used to evaluate the occurrence of POD on postoperative day 3 (POD 3). The enrolled patients were divided into the POD group (n = 26) and the non-POD group (n = 125). Baseline characteristics, surgical data, postoperative information, and laboratory test results were collected. DARS scores were calculated using the minimum alveolar concentration, end-tidal concentration average (ETAC), and bispectral index (BIS). Multivariate logistic regression analysis was conducted to recognize the independent risk factors for POD after hip fracture surgery. Receiver operating characteristic (ROC) curve was plotted to evaluate the value of DARS in POD prediction. Results The average age of POD group was significantly higher, comparing to non-POD group (P < 0.05). DARS scores were statistically lower in the POD group compared to non-POD group (P < 0.05). Multivariate logistic regression analysis found that age and DARS scores were factors impacting post-operative delirium occurrence after hip fracture surgery (P < 0.05). ROC showed that the area under the curve for DARS in predicting POD after hip fracture surgery was 0.929 (95% CI [0.861-0.997]). The optimal cutoff value was 30. The sensitivity was 95.45%, while the specificity was 84.09%. Conclusion DARS score demonstrates good predictive value in hip fracture patients and is feasible in clinical practice, making it suitable for clinical application and promotion.
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Affiliation(s)
- Yaya Wang
- Department of Anesthesiology, Shaanxi Provincial People’s Hospital, Third Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Yan’an Jiang
- Department of Anesthesiology, Shaanxi Provincial People’s Hospital, Third Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Huajun Fu
- Department of Anesthesiology, Shaanxi Provincial People’s Hospital, Third Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Yikang Zhao
- Department of Anesthesiology, Shaanxi Provincial People’s Hospital, Third Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Zhao Xu
- Department of Anesthesiology, Shaanxi Provincial People’s Hospital, Third Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
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8
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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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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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10
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Cao SJ, Zhang Y, Zhang YX, Zhao W, Pan LH, Sun XD, Jia Z, Ouyang W, Ye QS, Zhang FX, Guo YQ, Ai YQ, Zhao BJ, Yu JB, Liu ZH, Yin N, Li XY, Ma JH, Li HJ, Wang MR, Sessler DI, Ma D, Wang DX. Delirium in older patients given propofol or sevoflurane anaesthesia for major cancer surgery: a multicentre randomised trial. Br J Anaesth 2023; 131:253-265. [PMID: 37474241 DOI: 10.1016/j.bja.2023.04.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 04/04/2023] [Accepted: 04/14/2023] [Indexed: 07/22/2023] Open
Abstract
BACKGROUND Delirium is a common and disturbing postoperative complication that might be ameliorated by propofol-based anaesthesia. We therefore tested the primary hypothesis that there is less delirium after propofol-based than after sevoflurane-based anaesthesia within 7 days of major cancer surgery. METHODS This multicentre randomised trial was conducted in 14 tertiary care hospitals in China. Patients aged 65-90 yr undergoing major cancer surgery were randomised to either propofol-based anaesthesia or to sevoflurane-based anaesthesia. The primary endpoint was the incidence of delirium within 7 postoperative days. RESULTS A total of 1228 subjects were enrolled and randomised, with 1195 subjects included in the modified intention-to-treat analysis (mean age 71 yr; 422 [35%] women); one subject died before delirium assessment. Delirium occurred in 8.4% (50/597) of subjects given propofol-based anaesthesia vs 12.4% (74/597) of subjects given sevoflurane-based anaesthesia (relative risk 0.68 [95% confidence interval {CI}: 0.48-0.95]; P=0.023; adjusted relative risk 0.59 [95% CI: 0.39-0.90]; P=0.014). Delirium reduction mainly occurred on the first day after surgery, with a prevalence of 5.4% (32/597) with propofol anaesthesia vs 10.7% (64/597) with sevoflurane anaesthesia (relative risk 0.50 [95% CI: 0.33-0.75]; P=0.001). Secondary endpoints, including ICU admission, postoperative duration of hospitalisation, major complications within 30 days, cognitive function at 30 days and 3 yr, and safety outcomes, did not differ significantly between groups. CONCLUSIONS Delirium was a third less common after propofol than sevoflurane anaesthesia in older patients having major cancer surgery. Clinicians might therefore reasonably select propofol-based anaesthesia in patients at high risk of postoperative delirium. CLINICAL TRIAL REGISTRATION Chinese Clinical Trial Registry (ChiCTR-IPR-15006209) and ClinicalTrials.gov (NCT02662257).
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Affiliation(s)
- Shuang-Jie Cao
- Department of Anesthesiology, Peking University First Hospital, Beijing, China
| | - Yue Zhang
- Department of Anesthesiology, Peking University First Hospital, Beijing, China; Clinical Research Institute, Shenzhen Peking University-The Hong Kong University of Science and Technology Medical Center, Shenzhen, Guangdong, China
| | - Yu-Xiu Zhang
- Department of Anesthesiology, Peking University First Hospital, Beijing, China
| | - Wei Zhao
- Department of Anesthesiology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Ling-Hui Pan
- Department of Anesthesiology, Guangxi Medical University Cancer Hospital, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Xu-De Sun
- Department of Anesthesiology, Tangdu Hospital, Air Force Medical University (Fourth Military Medical University), Xi'an, Shaanxi, China
| | - Zhen Jia
- Department of Anesthesiology, Affiliated Hospital of Qinghai University, Xining, Qinghai, China
| | - Wen Ouyang
- Department of Anesthesiology, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Qing-Shan Ye
- Department of Anesthesiology, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan, Ningxia Hui Autonomous Region, China
| | - Fang-Xiang Zhang
- Department of Anesthesiology, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China
| | - Yong-Qing Guo
- Department of Anesthesiology, Shanxi Provincial People's Hospital, Taiyuan, Shanxi, China
| | - Yan-Qiu Ai
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Bin-Jiang Zhao
- Department of Anesthesiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Jian-Bo Yu
- Department of Anesthesiology and Critical Care Medicine, Tianjin Nankai Hospital, Tianjin Medical University, Tianjin, China
| | - Zhi-Heng Liu
- Department of Anesthesiology, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen, Guangdong, China
| | - Ning Yin
- Department of Anesthesiology, Zhongda Hospital, Medical School of Southeast University, Nanjing, Jiangsu, China; Department of Anesthesiology, Sir Run Run Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Xue-Ying Li
- Department of Biostatistics, Peking University First Hospital, Beijing, China
| | - Jia-Hui Ma
- Department of Anesthesiology, Peking University First Hospital, Beijing, China
| | - Hui-Juan Li
- Peking University Clinical Research Institute, Peking University Health Science Center, Beijing, China
| | - Mei-Rong Wang
- Peking University Clinical Research Institute, Peking University Health Science Center, Beijing, China
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Outcomes Research Consortium, Cleveland, OH, USA
| | - Daqing Ma
- Division of Anesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea and Westminster Hospital, London, UK; The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Dong-Xin Wang
- Department of Anesthesiology, Peking University First Hospital, Beijing, China; Outcomes Research Consortium, Cleveland, OH, USA.
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11
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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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12
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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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13
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Röhr V, Blankertz B, Radtke FM, Spies C, Koch S. Machine-learning model predicting postoperative delirium in older patients using intraoperative frontal electroencephalographic signatures. Front Aging Neurosci 2022; 14:911088. [PMID: 36313029 PMCID: PMC9614270 DOI: 10.3389/fnagi.2022.911088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 09/27/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveIn older patients receiving general anesthesia, postoperative delirium (POD) is the most frequent form of cerebral dysfunction. Early identification of patients at higher risk to develop POD could provide the opportunity to adapt intraoperative and postoperative therapy. We, therefore, propose a machine learning approach to predict the risk of POD in elderly patients, using routine intraoperative electroencephalography (EEG) and clinical data that are readily available in the operating room.MethodsWe conducted a retrospective analysis of the data of a single-center study at the Charité-Universitätsmedizin Berlin, Department of Anesthesiology [ISRCTN 36437985], including 1,277 patients, older than 60 years with planned surgery and general anesthesia. To deal with the class imbalance, we used balanced ensemble methods, specifically Bagging and Random Forests and as a performance measure, the area under the ROC curve (AUC-ROC). We trained our models including basic clinical parameters and intraoperative EEG features in particular classical spectral and burst suppression signatures as well as multi-band covariance matrices, which were classified, taking advantage of the geometry of a Riemannian manifold. The models were validated with 10 repeats of a 10-fold cross-validation.ResultsIncluding EEG data in the classification resulted in a robust and reliable risk evaluation for POD. The clinical parameters alone achieved an AUC-ROC score of 0.75. Including EEG signatures improved the classification when the patients were grouped by anesthetic agents and evaluated separately for each group. The spectral features alone showed an AUC-ROC score of 0.66; the covariance features showed an AUC-ROC score of 0.68. The AUC-ROC scores of EEG features relative to patient data differed by anesthetic group. The best performance was reached, combining both the EEG features and the clinical parameters. Overall, the AUC-ROC score was 0.77, for patients receiving Propofol it was 0.78, for those receiving Sevoflurane it was 0.8 and for those receiving Desflurane 0.73. Applying the trained prediction model to an independent data set of a different clinical study confirmed these results for the combined classification, while the classifier on clinical parameters alone did not generalize.ConclusionA machine learning approach combining intraoperative frontal EEG signatures with clinical parameters could be an easily applicable tool to early identify patients at risk to develop POD.
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Affiliation(s)
- Vera Röhr
- Neurotechnology Group, Technische Universität Berlin, Berlin, Germany
- *Correspondence: Vera Röhr
| | | | - Finn M. Radtke
- Department of Anaesthesia, Hospital of Nykobing, University of Southern Denmark, Odense, Denmark
| | - Claudia Spies
- Department of Anaesthesiology and Operative Intensive Care Medicine, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Susanne Koch
- Department of Anaesthesiology and Operative Intensive Care Medicine, Charité—Universitätsmedizin Berlin, Berlin, Germany
- Susanne Koch
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14
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Fong TG, Inouye SK. The inter-relationship between delirium and dementia: the importance of delirium prevention. Nat Rev Neurol 2022; 18:579-596. [PMID: 36028563 PMCID: PMC9415264 DOI: 10.1038/s41582-022-00698-7] [Citation(s) in RCA: 76] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2022] [Indexed: 12/30/2022]
Abstract
Delirium and dementia are two frequent causes of cognitive impairment among older adults and have a distinct, complex and interconnected relationship. Delirium is an acute confusional state characterized by inattention, cognitive dysfunction and an altered level of consciousness, whereas dementia is an insidious, chronic and progressive loss of a previously acquired cognitive ability. People with dementia have a higher risk of developing delirium than the general population, and the occurrence of delirium is an independent risk factor for subsequent development of dementia. Furthermore, delirium in individuals with dementia can accelerate the trajectory of the underlying cognitive decline. Delirium prevention strategies can reduce the incidence of delirium and associated adverse outcomes, including falls and functional decline. Therefore, delirium might represent a modifiable risk factor for dementia, and interventions that prevent or minimize delirium might also reduce or prevent long-term cognitive impairment. Additionally, understanding the pathophysiology of delirium and the connection between delirium and dementia might ultimately lead to additional treatments for both conditions. In this Review, we explore mechanisms that might be common to both delirium and dementia by reviewing evidence on shared biomarkers, and we discuss the importance of delirium recognition and prevention in people with dementia. In this Review, Fong and Inouye explore mechanisms that might be common to both delirium and dementia. They present delirium as a possible modifiable risk factor for dementia and discuss the importance of delirium prevention strategies in reducing this risk. Delirium and dementia are frequent causes of cognitive impairment among older adults and have a distinct, complex and interconnected relationship. Delirium prevention strategies have been shown to reduce not only the incidence of delirium but also the incidence of adverse outcomes associated with delirium such as falls and functional decline. Adverse outcomes associated with delirium, such as the onset of dementia symptoms in individuals with preclinical dementia, and/or the acceleration of cognitive decline in individuals with dementia might also be delayed by the implementation of delirium prevention strategies. Evidence regarding the association of systemic inflammatory and neuroinflammatory biomarkers with delirium is variable, possibly as a result of co-occurring dementia pathology or disruption of the blood–brain barrier. Alzheimer disease pathology, even prior to the onset of symptoms, might have an effect on delirium risk, with potential mechanisms including neuroinflammation and gene–protein interactions with the APOE ε4 allele. Novel strategies, including proteomics, multi-omics, neuroimaging, transcranial magnetic stimulation and EEG, are beginning to reveal how changes in cerebral blood flow, spectral power and connectivity can be associated with delirium; further work is needed to expand these findings to patients with delirium superimposed upon dementia.
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Affiliation(s)
- Tamara G Fong
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA. .,Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.
| | - Sharon K Inouye
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA.,Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
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15
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Berger M, Eleswarpu SS, Cooter M, Ray AM, Wingfield SA, Heflin MT, Bengali S, Udani AD. Developing a Real-Time Electroencephalogram-Guided Anesthesia-Management Curriculum for Educating Residents: A Single-Center Randomized Controlled Trial. Anesth Analg 2022; 134:159-170. [PMID: 34709008 PMCID: PMC8678191 DOI: 10.1213/ane.0000000000005677] [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: 01/03/2023]
Abstract
BACKGROUND Different anesthetic drugs and patient factors yield unique electroencephalogram (EEG) patterns. Yet, it is unclear how best to teach trainees to interpret EEG time series data and the corresponding spectral information for intraoperative anesthetic titration, or what effect this might have on outcomes. METHODS We developed an electronic learning curriculum (ELC) that covered EEG spectrogram interpretation and its use in anesthetic titration. Anesthesiology residents at a single academic center were randomized to receive this ELC and given spectrogram monitors for intraoperative use versus standard residency curriculum alone without intraoperative spectrogram monitors. We hypothesized that this intervention would result in lower inhaled anesthetic administration (measured by age-adjusted total minimal alveolar concentration [MAC] fraction and age-adjusted minimal alveolar concentration [aaMAC]) to patients ≥60 old during the postintervention period (the primary study outcome). To study this effect and to determine whether the 2 groups were administering similar anesthetic doses pre- versus postintervention, we compared aaMAC between control versus intervention group residents both before and after the intervention. To measure efficacy in the postintervention period, we included only those cases in the intervention group when the monitor was actually used. Multivariable linear mixed-effects modeling was performed for aaMAC fraction and hospital length of stay (LOS; a non-prespecified secondary outcome), with a random effect for individual resident. A multivariable linear mixed-effects model was also used in a sensitivity analysis to determine if there was a group (intervention versus control group) by time period (post- versus preintervention) interaction for aaMAC. Resident EEG knowledge difference (a prespecified secondary outcome) was compared with a 2-sided 2-group paired t test. RESULTS Postintervention, there was no significant aaMAC difference in patients cared for by the ELC group (n = 159 patients) versus control group (N = 325 patients; aaMAC difference = -0.03; 95% confidence interval [CI], -0.09 to 0.03; P =.32). In a multivariable mixed model, the interaction of time period (post- versus preintervention) and group (intervention versus control) led to a nonsignificant reduction of -0.05 aaMAC (95% CI, -0.11 to 0.01; P = .102). ELC group residents (N = 19) showed a greater increase in EEG knowledge test scores than control residents (N = 20) from before to after the ELC intervention (6-point increase; 95% CI, 3.50-8.88; P < .001). Patients cared for by the ELC group versus control group had a reduced hospital LOS (median, 2.48 vs 3.86 days, respectively; P = .024). CONCLUSIONS Although there was no effect on mean aaMAC, these results demonstrate that this EEG-ELC intervention increased resident knowledge and raise the possibility that it may reduce hospital LOS.
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Affiliation(s)
| | | | - Mary Cooter
- Duke University Medical Center, Durham, NC, USA
| | - Anna M. Ray
- Brigham and Women’s Hospital, Boston, MA, USA
| | | | | | - Shahrukh Bengali
- University of Texas Southwestern Medical Center, Dallas, TX, USA
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