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End-Tidal Hypocapnia Under Anesthesia Predicts Postoperative Delirium.

ABSTRACT: Background: Postoperative delirium (POD) might be associated with anesthetic management, but research has focused on choice or dosage of anesthetic drugs. We examined potential contributions of intraoperative ventilatory and hemodynamic management to POD. Methods: This was a sub-study of the ENGAGES-Canada trial (NCT02692300) involving non-cardiac surgery patients enrolled in Winnipeg, Canada. Patients received preoperative psychiatric and cognitive assessments, and intraoperatively underwent high-fidelity data collection of blood pressure, end-tidal respiratory gases and anesthetic agent concentration. POD was assessed by peak and mean POD scores using the Confusion Assessment Method-Severity (CAM-S) tool. Bivariate and multiple linear regression models were constructed controlling for age, psychiatric illness, and cognitive dysfunction in the examination of deviations in intraoperative end-tidal carbon dioxide (areas over (AOC) and under the curve (AUC)) on POD severity scores. Results: A total of 101 subjects [69 (6) years of age] were studied; 89 had comprehensive intraoperative hemodynamic and end-tidal gas measurements (data recorded at 1 Hz). The incidence of POD was 11.9% (12/101). Age, cognitive dysfunction, anxiety, depression, and intraoperative end-tidal CO2 (AUC) were significant correlates of POD severity. In the multiple regression model, cognitive dysfunction and AUC end-tidal CO2 (0.67 kPa below median intra-operative value) were the only independent significant predictors across both POD severity (mean and peak) scores. There was no association between cumulative anesthetic agent exposure and POD. Conclusions: POD was associated with intraoperative ventilatory management, reflected by low end-tidal CO2 concentrations, but not with cumulative anesthetic drug exposure. These findings suggest that maintenance of intraoperative normocapnia might benefit patients at risk of POD.

SUBMITTER: Mutch WAC

PROVIDER: S-EPMC6108130 | biostudies-literature | 2018

REPOSITORIES: biostudies-literature

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End-Tidal Hypocapnia Under Anesthesia Predicts Postoperative Delirium.

Mutch W Alan C WAC El-Gabalawy Renée R Girling Linda L Kilborn Kayla K Jacobsohn Eric E

Frontiers in neurology 20180817

<b>Background:</b> Postoperative delirium (POD) might be associated with anesthetic management, but research has focused on choice or dosage of anesthetic drugs. We examined potential contributions of intraoperative ventilatory and hemodynamic management to POD. <b>Methods:</b> This was a sub-study of the ENGAGES-Canada trial (NCT02692300) involving non-cardiac surgery patients enrolled in Winnipeg, Canada. Patients received preoperative psychiatric and cognitive assessments, and intraoperativel ...[more]

PMID: 30174647

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Project description: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.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.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 (?(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.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).

Project description:Study objectivesDelirium is a postoperative complication accompanied by disturbances in attention, cognition, arousal, and psychomotor activity. Wrist actigraphy has been advocated to study inactivity and inferred sleep patterns during delirium. We hypothesized that altered patterns of motor activity or immobility, reflective of disordered sleep and wakefulness patterns, would serve as predictive markers of hypoactive postoperative delirium.MethodsEighty-four elderly surgical patients were classified into three groups based on the timing of hypoactive delirium following surgery: intact with no delirium throughout postoperative days (POD) 0-5 (n = 51), delirium during POD 0-1 (n = 24), and delirium during POD 2-5 (n = 13). Delirium was detected on daily Confusion Assessment Method evaluations and chart review. Actigraphy measures were calculated from accelerometry signals acquired on the first postoperative day (POD 0, 16:00-23:00) and night (POD 0, 23:00-POD 1, 06:00).ResultsActigraphy metrics showed substantial interpatient variability. Among the three patient groups, only those without delirium showed greater movement during the day compared to night and also fewer minutes of night immobility (P = .03 and P = .02, Wilcoxon rank-sum tests). These patients were poorly discriminated from those with delirium during either POD 0-1 or POD 2-5, using differences in day and night activity (C-statistic, 95% confidence interval [CI]: 0.66 [0.53-0.79] and C-statistic, 95% CI: 0.71 [0.55-0.87], respectively). Inclusion of low-frequency signals improved performance of immobility measures without affecting those based on activity. Cognitively intact patients during POD 0-5 were distinguished from those with delirium during POD 0-1, based on differences in the number of day and night immobile minutes (C-statistic 0.65, 95% CI: [0.53-0.78]). Actigraphy metrics with the strongest association to delirium incidence were not reliably correlated with an increased risk during POD 0-5, when accounting for patient age, sex, intensive care unit admission, and Charlson Comorbidity Index (adjusted odds ratio of 1.7, 95% CI: [1.0-3.0], P = .09, likelihood ratio test).ConclusionsEarly postoperative wrist actigraphy metrics that serve as markers of sleep and wakefulness offer limited capacity as sole predictors or markers of hypoactive delirium.Clinical trial registrationRegistry: ClinicalTrials.gov; Title: Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes (ENGAGES) Study; Identifier: NCT02241655; URL: https://clinicaltrials.gov/ct2/show/NCT02241655.

Project description:Delirium after surgery or Postoperative delirium (POD) is an underdiagnosed entity, despite its severity and high incidence. Patients with delirium require a longer hospital stay and present more postoperative complications, which also increases hospital costs. Given its importance and the lack of specific treatment, multifactorial preventive strategies are evidenced based. Our hypothesis is that using general anaesthesia and avoiding the maximum time in excessively deep anaesthetic planes through BIS neuromonitoring device will reduce the incidence of postoperative delirium in patients over the age of 65 and their hospitalization stay. Patients were randomly assigned to two groups: The visible BIS group and the hidden BIS neuromonitoring group. In the visible BIS group, the depth of anaesthesia was sustained between 40 and 60, while in the other group the depth of anaesthesia was guided by hemodynamic parameters and the Minimum Alveolar Concentration value. Patients were assessed three times a day by research staff fully trained during the 72 h after the surgery to determine the presence of POD, and there was follow-up at 30 days. Patients who developed delirium (n = 69) was significantly lower in the visible BIS group (n = 27; 39.1%) than in the hidden BIS group (n = 42, 60.9%; p = 0.043). There were no differences between the subtypes of delirium in the two groups. Patients in the hidden BIS group were kept for 26.6 ± 14.0 min in BIS values < 40 versus 11.6 ± 10.9 min (p < 0.001) for the patients in the visible BIS group. The hospital stay was lower in the visible BIS group 6.56 ± 6.14 days versus the 9.30 ± 7.11 days (p < 0.001) for the hidden BIS group, as well as mortality; hidden BIS 5.80% versus visible BIS 0% (p = 0.01). A BIS-guided depth of anaesthesia is associated with a lower incidence of delirium. Patients with intraoperative neuromonitoring stayed for a shorter time in excessively deep anaesthetic planes and presented a reduction in hospital stay and mortality.

Project description:Background:Several studies have identified side effects of general anesthesia with endotracheal intubation, such as laryngeal pain, dysphonia, and postoperative nausea and vomiting (PONV). The laryngeal mask airway (LMAw) is believed to decrease these side effects. The aim of this trial was to compare postoperative discomfort, emergence delirium, and recovery time of patients who received either an LMAw or nasotracheal intubation (NTI). Patients and methods:A total of 70 children were randomly assigned to the LMAw group (n=35) or the NTI group (n=35). Both groups underwent mask induction with 8% sevoflurane. The NTI group received muscle relaxant, whereas the LMAw group did not. Postoperative laryngeal pain, dental pain, dysphonia, and PONV were assessed immediately and at 1 hour and 6 hours postoperatively. The Wong-Baker Faces Scale was used to evaluate the patients' self-reported pain. In addition, decayed, missing, and filled teeth (dft/DMFT) values, dental procedure type, number of dental procedures, duration of the dental operation, duration of anesthesia, recovery time, emergence delirium, pediatric dentist's access to the mouth, and parents' satisfaction levels were recorded. Data were analyzed using descriptive statistics, chi-square tests, and two-sample t-tests. Results:The incidence of postoperative laryngeal pain was significantly higher in the NTI group immediately (97.2% vs. 8.5%, P=0.00), 1 hour (94.2% vs. 0%, P=0.00), and 6 hours postoperatively (25.7% vs. 0%, P=0.00). There were no statistically significant differences between the two groups in dental pain scores, dft/DMFT values, duration of anesthesia, duration of the dental operation, number of dental procedures, the incidence of PONV, or pediatric dentist's access to the mouth (P>0.05). Emergence delirium and recovery time were significantly higher in the NTI group (P<0.05). Conclusion:The LMAw provided a more comfortable postoperative period than NTI for children who underwent full-mouth dental rehabilitation under general anesthesia.

Project description:BackgroundFrailty has been associated with postoperative delirium (POD). Studies suggest that the Fried phenotype has a stronger association with POD than the Edmonton Frailty Scale (EFS) criteria. Although phenotypic frailty is recognized as a good predictor of delirium, the EFS has higher ratings for feasibility in the surgical setting. Thus, our aim was to determine the association between EFS-assessed vulnerability and POD in an elective surgical population of older adults. A secondary aim was to determine which domains assessed by the EFS were closely associated with POD.MethodsAfter IRB approval was received, electronic medical records of surgical patients at our institution were downloaded from 12/1/2018 to 3/1/2020. Inclusion criteria included age ≥ 65 years, preoperative EFS assessment within 6 months of surgery, elective surgery not scheduled for intensive care unit (ICU) stay but followed by at least 1 day postoperative stay, and at least two in-hospital evaluations with the 4 A's test (arousal, attention, abbreviated mental test-4, acute change [4AT]) on the surgical ward. Vulnerability was determined by EFS score ≥ 6. Patients were stratified into two groups according to highest postoperative 4AT score: 0-3 (no POD) and ≥ 4 (POD). Odds of POD associated with EFS score ≥ 6 were evaluated by using logistic regression adjusted for potential confounders.ResultsThe dataset included 324 patients. Vulnerability was associated with higher incidence of POD (p = 0.0007, Fisher's exact). EFS ≥6 was consistently associated with POD in all bivariate models. Vulnerability predicted POD in multivariable modeling (OR = 3.5, 95% CI 1.1 to 11.5). Multivariable analysis of EFS domains revealed an overall trend in which higher scores per domain had a higher odds for POD. The strongest association occurred with presence of incontinence (OR = 3.8, 95% CI 1.2 to 11.0).ConclusionsEFS criteria for vulnerability predict POD in older, non-ICU patients undergoing elective surgery.

Project description:BackgroundChanges in the direct current (DC) electroencephalography (EEG), so-called DC shifts, are observed during hypoxia, hypo-/hypercapnia, anesthetic administration, epileptic seizures, and spreading depolarizations. They are associated with altered cerebral ion currents across cell membranes and/or the blood-brain barrier (BBB). Here, we measured DC shifts in clinical practice during hyperventilation (HV) and anesthesia induction, and investigated whether such DC shifts correlate with the occurrence of postoperative delirium (POD) in older patients.MethodsIn this prospective observational study (subproject of the BioCog study, NCT02265263; EA2/092/14), a continuous pre- and perioperative DC-EEG was recorded in patients aged ≥65 years. The preoperative DC-EEG included a 2 min HV with simultaneous measurement of end-tidal CO2. Of the perioperative recordings, DC-EEG segments were chosen from a 30 s period at the start of induction of anesthesia (IOA), loss of consciousness (LOC), and during a stable anesthetic phase 30 min after skin incision (intraOP). The DC shift at Cz was determined in μV/s. All patients were screened twice daily for the first seven postoperative days for the occurrence of POD. DC-EEG shifts were compared in patients with (POD) and without postoperative delirium (noPOD).ResultsFifteen patients were included in this subproject of the BioCog study. DC shifts correlated significantly with concurrent HV, with DC shifts increasing the more end-tidal CO2 decreased (P = 0.001, Spearman's rho 0.862). During the perioperative DC-EEG, the largest DC shift was observed at LOC during IOA. POD patients (n = 8) presented with significantly larger DC shifts at LOC [POD 31.6 (22.7; 38.9) μV/s vs. noPOD 4.7 (2.2; 12.5) μV/s, P = 0.026].ConclusionDC shifts can be observed during HV and IOA in routine clinical practice. At anesthesia induction, the DC shift was greatest at the time of LOC, with POD patients presenting with significantly stronger DC shifts. This could indicate larger changes in gas tensions, hypotension and impaired cerebral autoregulation or BBB dysfunction in these patients.Clinical trial registrationwww.clinicaltrials.gov, identifier NCT02265263.

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End-Tidal Hypocapnia Under Anesthesia Predicts Postoperative Delirium.

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End-Tidal Hypocapnia Under Anesthesia Predicts Postoperative Delirium.

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