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Evered LA, Chan MTV, Han R, Chu MHM, Cheng BP, Scott DA, Pryor KO, Sessler DI, Veselis R, Frampton C, Sumner M, Ayeni A, Myles PS, Campbell D, Leslie K, Short TG. Anaesthetic depth and delirium after major surgery: a randomised clinical trial. Br J Anaesth 2021; 127:704-712. [PMID: 34465469 PMCID: PMC8579421 DOI: 10.1016/j.bja.2021.07.021] [Citation(s) in RCA: 146] [Impact Index Per Article: 48.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 06/11/2021] [Accepted: 07/05/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Postoperative delirium is a serious complication of surgery associated with prolonged hospitalisation, long-term cognitive decline, and mortality. This study aimed to determine whether targeting bispectral index (BIS) readings of 50 (light anaesthesia) was associated with a lower incidence of POD than targeting BIS readings of 35 (deep anaesthesia). METHODS This multicentre randomised clinical trial of 655 at-risk patients undergoing major surgery from eight centres in three countries assessed delirium for 5 days postoperatively using the 3 min confusion assessment method (3D-CAM) or CAM-ICU, and cognitive screening using the Mini-Mental State Examination at baseline and discharge and the Abbreviated Mental Test score (AMTS) at 30 days and 1 yr. Patients were assigned to light or deep anaesthesia. The primary outcome was the presence of postoperative delirium on any of the first 5 postoperative days. Secondary outcomes included mortality at 1 yr, cognitive decline at discharge, cognitive impairment at 30 days and 1 yr, unplanned ICU admission, length of stay, and time in electroencephalographic burst suppression. RESULTS The incidence of postoperative delirium in the BIS 50 group was 19% and in the BIS 35 group was 28% (odds ratio 0.58 [95% confidence interval: 0.38-0.88]; P=0.010). At 1 yr, those in the BIS 50 group demonstrated significantly better cognitive function than those in the BIS 35 group (9% with AMTS ≤6 vs 20%; P<0.001). CONCLUSIONS Among patients undergoing major surgery, targeting light anaesthesia reduced the risk of postoperative delirium and cognitive impairment at 1 yr. CLINICAL TRIAL REGISTRATION ACTRN12612000632897.
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Affiliation(s)
- Lisbeth A Evered
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA; Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital, Melbourne, VIC, Australia; Department of Critical Care Medicine, University of Melbourne, Melbourne, VIC, Australia.
| | - Matthew T V Chan
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Ruquan Han
- Department of Anesthesiology, Beijing Tiantan Hospital and Capital Medical University, Beijing, China
| | - Mandy H M Chu
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Benny P Cheng
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - David A Scott
- Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital, Melbourne, VIC, Australia; Department of Critical Care Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Kane O Pryor
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Robert Veselis
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA; Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Matthew Sumner
- Department of Anaesthesiology, Auckland City Hospital, Auckland, New Zealand
| | - Ade Ayeni
- Department of Anaesthesiology, Auckland City Hospital, Auckland, New Zealand
| | - Paul S Myles
- Department of Anaesthesia and Perioperative Medicine, Alfred Hospital and Monash University, Melbourne, VIC, Australia
| | - Douglas Campbell
- Department of Anaesthesiology, Auckland City Hospital, Auckland, New Zealand; Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| | - Kate Leslie
- Department of Critical Care Medicine, University of Melbourne, Melbourne, VIC, Australia; Department of Anaesthesia and Pain Medicine, Royal Melbourne Hospital, Melbourne, VIC, Australia; Monash University, Melbourne, VIC, Australia
| | - Timothy G Short
- Department of Anaesthesiology, Auckland City Hospital, Auckland, New Zealand; Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
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