Effect of Electroencephalography-Guided Anesthetic Administration on Postoperative Delirium Among Older Adults Undergoing Major Surgery: The ENGAGES Randomized Clinical Trial.

Autor:	Wildes TS; Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri., Mickle AM; Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri., Ben Abdallah A; Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri., Maybrier HR; Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri., Oberhaus J; Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri., Budelier TP; Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri., Kronzer A; Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri., McKinnon SL; Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri., Park D; Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri., Torres BA; Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri., Graetz TJ; Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri., Emmert DA; Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri., Palanca BJ; Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri., Goswami S; Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri., Jordan K; Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri., Lin N; Department of Mathematics, Washington University School of Medicine, St Louis, Missouri., Fritz BA; Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri., Stevens TW; Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri., Jacobsohn E; Department of Anesthesiology, University of Manitoba, Winnipeg, Canada., Schmitt EM; Department of Medicine, Beth Israel-Deaconess Medical Center, Hebrew Senior Life, Harvard Medical School, Boston, Massachusetts., Inouye SK; Department of Medicine, Beth Israel-Deaconess Medical Center, Hebrew Senior Life, Harvard Medical School, Boston, Massachusetts., Stark S; Department of Occupational Therapy, Washington University School of Medicine, St Louis, Missouri., Lenze EJ; Department of Psychiatry, Washington University School of Medicine, St Louis, Missouri., Avidan MS; Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri.
Jazyk:	angličtina
Zdroj:	JAMA [JAMA] 2019 Feb 05; Vol. 321 (5), pp. 473-483.
DOI:	10.1001/jama.2018.22005
Abstrakt:	Importance: Intraoperative electroencephalogram (EEG) waveform suppression, often suggesting excessive general anesthesia, has been associated with postoperative delirium. Objective: To assess whether EEG-guided anesthetic administration decreases the incidence of postoperative delirium. Design, Setting, and Participants: Randomized clinical trial of 1232 adults aged 60 years and older undergoing major surgery and receiving general anesthesia at Barnes-Jewish Hospital in St Louis. Recruitment was from January 2015 to May 2018, with follow-up until July 2018. Interventions: Patients were randomized 1:1 (stratified by cardiac vs noncardiac surgery and positive vs negative recent fall history) to receive EEG-guided anesthetic administration (n = 614) or usual anesthetic care (n = 618). Main Outcomes and Measures: The primary outcome was incident delirium during postoperative days 1 through 5. Intraoperative measures included anesthetic concentration, EEG suppression, and hypotension. Adverse events included undesirable intraoperative movement, intraoperative awareness with recall, postoperative nausea and vomiting, medical complications, and death. Results: Of the 1232 randomized patients (median age, 69 years [range, 60 to 95]; 563 women [45.7%]), 1213 (98.5%) were assessed for the primary outcome. Delirium during postoperative days 1 to 5 occurred in 157 of 604 patients (26.0%) in the guided group and 140 of 609 patients (23.0%) in the usual care group (difference, 3.0% [95% CI, -2.0% to 8.0%]; P = .22). Median end-tidal volatile anesthetic concentration was significantly lower in the guided group than the usual care group (0.69 vs 0.80 minimum alveolar concentration; difference, -0.11 [95% CI, -0.13 to -0.10), and median cumulative time with EEG suppression was significantly less (7 vs 13 minutes; difference, -6.0 [95% CI, -9.9 to -2.1]). There was no significant difference between groups in the median cumulative time with mean arterial pressure below 60 mm Hg (7 vs 7 minutes; difference, 0.0 [95% CI, -1.7 to 1.7]). Undesirable movement occurred in 137 patients (22.3%) in the guided and 95 (15.4%) in the usual care group. No patients reported intraoperative awareness. Postoperative nausea and vomiting was reported in 48 patients (7.8%) in the guided and 55 patients (8.9%) in the usual care group. Serious adverse events were reported in 124 patients (20.2%) in the guided and 130 (21.0%) in the usual care group. Within 30 days of surgery, 4 patients (0.65%) in the guided group and 19 (3.07%) in the usual care group died. Conclusions and Relevance: Among older adults undergoing major surgery, EEG-guided anesthetic administration, compared with usual care, did not decrease the incidence of postoperative delirium. This finding does not support the use of EEG-guided anesthetic administration for this indication. Trial Registration: ClinicalTrials.gov Identifier: NCT02241655.
Databáze:	MEDLINE
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