Postoperative Delirium Severity and Recovery Correlate With Electroencephalogram Spectral Features

BACKGROUND

Delirium is an acute syndrome characterized by inattention, disorganized thinking, and an altered level of consciousness. A reliable biomarker for tracking delirium does not exist, but oscillations in the electroencephalogram (EEG) could address this need. We evaluated whether the frequencies of EEG oscillations are associated with delirium onset, severity, and recovery in the postoperative period.

METHODS

Twenty-six adults enrolled in the Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes (ENGAGES; ClinicalTrials.gov NCT02241655) study underwent major surgery requiring general anesthesia, and provided longitudinal postoperative EEG recordings for this prespecified substudy. The presence and severity of delirium were evaluated with the confusion assessment method (CAM) or the CAM-intensive care unit. EEG data obtained during awake eyes-open and eyes-closed states yielded relative power in the delta (1-4 Hz), theta (4-8 Hz), and alpha (8-13 Hz) bands. Discriminability for delirium presence was evaluated with c-statistics. To account for correlation among repeated measures within patients, mixed-effects models were generated to assess relationships between: (1) delirium severity and EEG relative power (ordinal), and (2) EEG relative power and time (linear). Slopes of ordinal and linear mixed-effects models are reported as the change in delirium severity score/change in EEG relative power, and the change in EEG relative power/time (days), respectively. Bonferroni correction was applied to confidence intervals (CIs) to account for multiple comparisons.

RESULTS

Occipital alpha relative power during eyes-closed states offered moderate discriminability (c-statistic, 0.75; 98% CI, 0.58-0.87), varying inversely with delirium severity (slope, -0.67; 98% CI, -1.36 to -0.01; P = .01) and with severity of inattention (slope, -1.44; 98% CI, -2.30 to -0.58; P = .002). Occipital theta relative power during eyes-open states correlated directly with severity of delirium (slope, 1.28; 98% CI, 0.12-2.44; P = .007), inattention (slope, 2.00; 98% CI, 0.48-3.54; P = .01), and disorganized thinking (slope, 3.15; 98% CI, 0.66-5.65; P = .01). Corresponding frontal EEG measures recapitulated these relationships to varying degrees. Severity of altered level of consciousness correlated with frontal theta relative power during eyes-open states (slope, 11.52; 98% CI, 6.33-16.71; P < .001). Frontal theta relative power during eyes-open states correlated inversely with time (slope, -0.05; 98% CI, -0.12 to -0.04; P = .002).

CONCLUSIONS

Presence, severity, and core features of postoperative delirium covary with spectral features of the EEG. The cost and accessibility of EEG facilitate the translation of these findings to future mechanistic and interventional trials.

Preoperative Cognitive Abnormality, Intraoperative Electroencephalogram Suppression, and Postoperative Delirium: A Mediation Analysis

BACKGROUND

Postoperative delirium is a common complication that hinders recovery after surgery. Intraoperative electroencephalogram suppression has been linked to postoperative delirium, but it is unknown if this relationship is causal or if electroencephalogram suppression is merely a marker of underlying cognitive abnormalities. The hypothesis of this study was that intraoperative electroencephalogram suppression mediates a nonzero portion of the effect between preoperative abnormal cognition and postoperative delirium.

METHODS

This is a prespecified secondary analysis of the Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes (ENGAGES) randomized trial, which enrolled patients age 60 yr or older undergoing surgery with general anesthesia at a single academic medical center between January 2015 and May 2018. Patients were randomized to electroencephalogram-guided anesthesia or usual care. Preoperative abnormal cognition was defined as a composite of previous delirium, Short Blessed Test cognitive score greater than 4 points, or Eight Item Interview to Differentiate Aging and Dementia score greater than 1 point. Duration of intraoperative electroencephalogram suppression was defined as number of minutes with suppression ratio greater than 1%. Postoperative delirium was detected via Confusion Assessment Method or chart review on postoperative days 1 to 5.

RESULTS

Among 1,113 patients, 430 patients showed evidence of preoperative abnormal cognition. These patients had an increased incidence of postoperative delirium (151 of 430 [35%] vs.123 of 683 [18%], P < 0.001). Of this 17.2% total effect size (99.5% CI, 9.3 to 25.1%), an absolute 2.4% (99.5% CI, 0.6 to 4.8%) was an indirect effect mediated by electroencephalogram suppression, while an absolute 14.8% (99.5% CI, 7.2 to 22.5%) was a direct effect of preoperative abnormal cognition. Randomization to electroencephalogram-guided anesthesia did not change the mediated effect size (P = 0.078 for moderation).

CONCLUSIONS

A small portion of the total effect of preoperative abnormal cognition on postoperative delirium was mediated by electroencephalogram suppression. Study precision was too low to determine if the intervention changed the mediated effect.

Chromatic techniques for in vivo monitoring jaundice in neonate tissues

OBJECTIVE

A chromatic method is described for providing a preliminary indication of unacceptable bilirubin levels in a newly born baby in order to avoid the development of serious mental deficiencies. The aim was to investigate the reliability of a new chromatic approach using a novel template unit for a preliminary, non-invasive monitoring of the skin tissue of newly born babies with jaundice and its capability for use with different mobile phone cameras.

APPROACH

A description of the monitoring system is given along with an explanation of the monitoring technique used. Preliminary tests have been performed on 48 different neonates each being addressed by one of six different mobile phone cameras, which were randomly available to the operating clinicians.

MAIN RESULTS

The test results have a correlation (R ²) of 0.81, a sensitivity (Sn) of 0.97, a specificity (Sp) of 0.82, a positive predictive value (PPV) of 0.95 and a negative predictive value (NPV) of 0.9.

SIGNIFICANCE

The significance of the results obtained is that they show the approach to have a high level of fail-safe reliability in indicating the bilirubin levels when compared with blood test results. The results also show that the approach can be used with a few different mobile phone cameras and that because of its non-invasive nature and its cost effectiveness, has the potential for remote use from a medical hospital to provide an immediate preliminary diagnosis.

Asbestos fiber release from the brake pads of overhead industrial cranes

The purpose of this evaluation was to determine the actual contribution of airborne asbestos fibers to the work environment from the operation of overhead cranes and hoists that use asbestos composition brake pads. The evaluation was conducted in a working manufacturing facility. Other potential sources of asbestos were accounted for by visual inspection and background air monitoring. An overhead crane assembly comprised of a trolley and two hoists was employed for this study. The crane was operated for two consecutive eight-hour shifts representative of a heavy-duty cycle. Forty-four personal and area air samples were collected during the assessment. Asbestos fibers were analyzed for by phase contrast (NIOSH 7400), and transmission electron (NIOSH 7402) microscopy methods. Eight-hour time-weighted average (TWA) asbestos fiber concentrations ranged from < 0.005 to 0.011 fibers/cc (PCM), and < 0.0026 to < 0.0094 f/cc (TEM). There were no asbestos fibers detected by the TEM method from air samples collected during the operation of the cranes.

Procaine-induced increases in limbic rCBF correlate positively with increases in occipital and temporal EEG fast activity

Previous independent EEG and PET studies suggest that administration of intravenous procaine hydrochloride selectively activates limbic brain structures. To further elucidate procaine's effects and explore the relationship between quantitative EEG (qEEG) and regional cerebral blood flow (rCBF), we simultaneously recorded qEEG and sampled rCBF using O-15 water PET in 20 healthy volunteers during single-blind injections of saline (baseline condition) followed by intravenous procaine (1.84 mg/kg). After thorough screening of EEG records, a subgroup of 7 subjects with EEG data relatively free of both muscle and movement artifacts was selected for analysis. Quantitative spectral EEG data from right occipital and temporal leads were then correlated with each subject's PET rCBF values on a pixel by pixel basis, both at baseline and after procaine. The most striking finding was that the increases in occipital and temporal omega activity from baseline to procaine positively correlated with rCBF increases in the amygdala and its efferents (p < .05), in a pattern very similar to the rCBF increases seen after procaine administration. This suggests that omega activity may reflect activation of deeper brain limbic structures. Also, the convergence of EEG and PET data further supports procaine's selective limbic activation.

Cognitive brain potential alterations in boys exposed to opiates: in utero and lifestyle comparisons

Several studies have observed that intrauterine exposure to opiates results in emotional and cognitive complications for the child, but genetic and postnatal social-environmental factors may also affect the CNS development of these children. To assess the relative contribution of the in utero and social-environmental (lifestyle) effects of opiate exposure, event-related potentials (ERPs) and performance were studied in three groups of 7- to 12-year-old boys: (1) the in utero/lifestyle group (IU/LS) contained 16 boys who were exposed to opiates (in utero and lived with opiate-abusing mothers, (2) the lifestyle group (LS) included 14 boys who lived with opiate-abusing mothers, and (3) the control group (CON) composed of 13 boys. The cognitive ERP components and task performance were recorded in the Auditory Rare Event Monitoring (AREM) task and the Sternberg Memory task (Sternberg, 1975). On the AREM and Sternberg Memory tasks, P200 component was significantly decreased for the IU/LS and LS groups. On the Sternberg Memory task, percent correct was also significantly impaired in IU/LS and LS groups. The ERP alterations in the boys living with opiate-abusing mothers with and without intrauterine opiate exposure were similar. A dysfunctional social environment may contribute to the cognitive deficits seen in the sons of opiate-abusing mothers.

A comparison of chorionic villi sampling and amniocentesis: acceptability of procedure and maternal attachment to pregnancy

Sixty-one women with high-risk pregnancies participated in a clinical trial comparing chorionic villi sampling and amniocentesis. They were assessed initially on five background measures and maternal attachment to the fetus, then were randomly assigned to either chorionic villi sampling or an amniocentesis group. Women were further assessed for maternal attachment three times during pregnancy. During the final assessment, those who were planning future pregnancies were asked which of the two procedures they would prefer. No differences between groups were found on any of the five background measures. All 31 women who considered future pregnancies indicated a preference for chorionic villi sampling, regardless of the procedure they underwent during the study. Women receiving chorionic villi sampling reported significantly greater attachment during the second trimester than did women receiving amniocentesis, who viewed themselves as being less attached than other pregnant women during this period. The findings were interpreted as evidence for attachment suppression among women undergoing amniocentesis.

Emotional responses of pregnant women to chorionic villi sampling or amniocentesis

Seventy-four "high-risk" pregnant women interested in participating in a clinical trial comparing chorionic villi sampling and amniocentesis were initially assessed on five background measures and for anxiety, depression, hostility, and concern about abortion. The 61 women who then agreed to be randomized into the chorionic villi sampling and amniocentesis groups were assessed three additional times between 9 and 22 weeks' gestational age. Physical discomfort experienced during the diagnostic procedure was also assessed. Women in the chorionic villi sampling group underwent a reduction in anxiety up to 10 weeks earlier and reported less procedure-related discomfort than women in the amniocentesis group. The group X time interaction for depression was also significant, with women undergoing chorionic villi sampling reporting an earlier decrease in depression than women undergoing amniocentesis. No differences were found between the two groups in hostility or concern about abortion. Findings were discussed in the context of evidence linking prenatal maternal emotionality to an increased risk of obstetric complications.

5-O-Alkylated derivatives of 5-hydroxy-2'-deoxyuridine as potential antiviral agents. Anti-herpes activity of 5-propynyloxy-2'-deoxyuridine

Alkylation of 5-hydroxyuridine or 5-hydroxy-2'-deoxyuridine with various activated alkylating agents in the presence of 1 equiv of NaOH gave a series of new nucleoside analogues which were evaluated for antiviral activity against vaccinia virus, herpes simplex-1 virus, and vesicular stomatitis virus in both primary rabbit kidney cells and human skin fibroblasts. One of these analogues, 5-propynyloxy-2'-deoxyuridine, was a potent inhibitor of herpes simplex virus. Structure-activity considerations suggest that the anti-herpes activity is dependent on the integrity of the acetylene group since substitution of phenyl, p-nitrophenyl, vinyl, carboxamido, or carboxyl for the triple bond led to diminished antiviral activity.

Brain stimulation in rats exposed to hyperbaric environments

Six rats were trained to make an operant response to receive brief trains of electrical current to the lateral hypothalamus (self-stimulation). All animals were then randomly exposed to pressures of 4.03, 5.51, 7.06, or 10.1 ATA breathing either compressed air or N2-O2 and 13.1 ATA (N2-O2 only). When the subjects breathed air at pressures of 7.06 and 10.1 ATA, rate of self-stimulation decreased by 32 and 43%, respectively. No differences were observed in rate of response at any pressure when the animals breathed N2-O2 with the partial pressure of oxygen maintained at 0.2 ATA. When an oxygen-nitrogen mixture was breathed at 3 ATA in which the PO2 was similar to compressed air at 10.1 ATA, self-stimulation rate was decreased by 40%; this suggests that PO2 is a critical variable influencing behavior mediated by brain stimulation. Results are discussed in terms of the use of self-stimulation as one tool for better understanding the neuronal mechanisms of behavior as they relate to breathing-gas mixtures at increased pressures.