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Electroencephalography-Guided Minimisation of Anaesthetic Administration to Prevent Post-Operative Delirium: A Randomised, Pragmatic Trial

34 Pages Posted: 17 Oct 2018

See all articles by Troy S Wildes

Troy S Wildes

Washington University in St. Louis - School of Medicine

Angela M Mickle

Washington University in St. Louis - School of Medicine

Arbi Ben Abdallah

Washington University in St. Louis - School of Medicine

Hannah R Maybrier

Washington University in St. Louis - School of Medicine

Jordan Oberhaus

Washington University in St. Louis - School of Medicine

Alex Kronzer

Washington University in St. Louis - School of Medicine

Sherry L McKinnon

Washington University in St. Louis - School of Medicine

Brian A Torres

Washington University in St. Louis - School of Medicine

Thaddeus P Budelier

Washington University in St. Louis - School of Medicine

Daniel Park

Washington University in St. Louis - School of Medicine

Thomas J Graetz

Washington University in St. Louis - School of Medicine

Daniel A Emmert

Washington University in St. Louis - School of Medicine

Ben J Palanca

Washington University in St. Louis - School of Medicine

Shreya Goswami

Washington University in St. Louis - School of Medicine

Katherine Jordan

Washington University in St. Louis - School of Medicine

Nan Lin

Washington University in St. Louis - School of Medicine

Bradley A Fritz

Washington University in St. Louis - School of Medicine

Tracey W Stevens

Washington University in St. Louis - School of Medicine

Eric Jacobsohn

University of Manitoba

Eva M Schmitt

Harvard University - Harvard Medical School

Sharon K Inouye

Harvard University - Harvard Medical School; Hebrew SeniorLife

Susan Stark

Washington University in St. Louis - School of Medicine

Eric J Lenze

Washington University in St. Louis - School of Medicine

Michael Avidan

Washington University in St. Louis - Department of Anesthesiology

ENGAGES Research Group

Independent

More...

Abstract

Background: Intraoperative electroencephalogram suppression, suggesting excessive general anaesthesia, predicts postoperative delirium. The primary purpose of this trial was to assess the effectiveness of electroencephalography-guided minimisation of anaesthetic administration and electroencephalogram suppression to prevent postoperative delirium in older adults.

Methods: The Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes [ENGAGES] study enrolled adults older than 60 undergoing major surgery under general anaesthesia at Barnes-Jewish Hospital in Saint Louis. Using a computer-generated randomisation sequence we randomly assigned patients in blocks of 20 in four strata (cardiac or non-cardiac surgery; positive or negative recent fall history) to electroencephalography-guided or usual anaesthetic care. Participants and investigators were blinded to group assignment. Delirium was assessed for 5 postoperative days, using structured chart review and daily Confusion Assessment Method. We analysed by intention-to-treat and assessed adverse events.

Findings: Between Jan 16, 2015 and May 7, 2018, 39144 patients were screened, and 1232 patients were randomly assigned, with 614 in the electroencephalography-guided and 618 in the usual care group. Compared with usual care, the guided group had a 14% median decrease in volatile anaesthetic administration, and a 46% reduction in the median [interquartile range] intraoperative time with electroencephalogram suppression (7 [1 to 23] vs 13 [2 to 58] minutes, p<0·001). However, there was no significant difference between groups in delirium incidence: 157/604 in the guided compared with 140/609 in the usual care group (26·0% vs 23·0%; absolute difference 3·0%, 95% CI -2·0 to 8·0, P=0·224). No patients reported intraoperative awareness, but patient movement occurred in 22·3% of patients in the guided and 15·4% in the usual care group (absolute difference 6·9%, 95% CI 2·6 to 11·3, P=0·002). Duration of hypotension and overall occurrence of serious adverse events were similar in the groups.

Interpretation: Electroencephalography-guidance of anaesthesia with the aim of minimising suppression and anaesthetic administration is unlikely to prevent postoperative delirium, and might instead promote undesirable patient movement during surgery.

Trial Registry Number: The trial is registered with clinicaltrials.gov, number NCT02241655.

Funding: This study was funded by a National Institutes of Health grant to support pragmatic trials ((1 UH2 HL125141, 5 UH3 AG050312). This study was also funded by the National Institutes of Health NIDUS Grant (NIA R24AG054259) and the Dr Seymour and Rose T. Brown Endowed Chair at Washington University.

Declaration of Interests: The authors have no conflicts of interest to report.

Ethical Approval Statement: The ethics committee at Washington University School of Medicine approved the study, and all patients provided written informed consent.

Suggested Citation

Wildes, Troy S and Mickle, Angela M and Abdallah, Arbi Ben and Maybrier, Hannah R and Oberhaus, Jordan and Kronzer, Alex and McKinnon, Sherry L and Torres, Brian A and Budelier, Thaddeus P and Park, Daniel and Graetz, Thomas J and Emmert, Daniel A and Palanca, Ben J and Goswami, Shreya and Jordan, Katherine and Lin, Nan and Fritz, Bradley A and Stevens, Tracey W and Jacobsohn, Eric and Schmitt, Eva M and Inouye, Sharon K and Stark, Susan and Lenze, Eric J and Avidan, Michael and Group, ENGAGES Research, Electroencephalography-Guided Minimisation of Anaesthetic Administration to Prevent Post-Operative Delirium: A Randomised, Pragmatic Trial (September 18, 2018). Available at SSRN: https://ssrn.com/abstract=3251500 or http://dx.doi.org/10.2139/ssrn.3251500

Troy S Wildes

Washington University in St. Louis - School of Medicine

660 S. Euclid Ave., Third Floor McMillan
St. Louis, MO 63110-1010
United States

Angela M Mickle

Washington University in St. Louis - School of Medicine

660 S. Euclid Ave., Third Floor McMillan
St. Louis, MO 63110-1010
United States

Arbi Ben Abdallah

Washington University in St. Louis - School of Medicine

660 S. Euclid Ave., Third Floor McMillan
St. Louis, MO 63110-1010
United States

Hannah R Maybrier

Washington University in St. Louis - School of Medicine

660 S. Euclid Ave., Third Floor McMillan
St. Louis, MO 63110-1010
United States

Jordan Oberhaus

Washington University in St. Louis - School of Medicine

660 S. Euclid Ave., Third Floor McMillan
St. Louis, MO 63110-1010
United States

Alex Kronzer

Washington University in St. Louis - School of Medicine

660 S. Euclid Ave., Third Floor McMillan
St. Louis, MO 63110-1010
United States

Sherry L McKinnon

Washington University in St. Louis - School of Medicine

660 S. Euclid Ave., Third Floor McMillan
St. Louis, MO 63110-1010
United States

Brian A Torres

Washington University in St. Louis - School of Medicine

660 S. Euclid Ave., Third Floor McMillan
St. Louis, MO 63110-1010
United States

Thaddeus P Budelier

Washington University in St. Louis - School of Medicine

660 S. Euclid Ave., Third Floor McMillan
St. Louis, MO 63110-1010
United States

Daniel Park

Washington University in St. Louis - School of Medicine

660 S. Euclid Ave., Third Floor McMillan
St. Louis, MO 63110-1010
United States

Thomas J Graetz

Washington University in St. Louis - School of Medicine

660 S. Euclid Ave., Third Floor McMillan
St. Louis, MO 63110-1010
United States

Daniel A Emmert

Washington University in St. Louis - School of Medicine

660 S. Euclid Ave., Third Floor McMillan
St. Louis, MO 63110-1010
United States

Ben J Palanca

Washington University in St. Louis - School of Medicine

660 S. Euclid Ave., Third Floor McMillan
St. Louis, MO 63110-1010
United States

Shreya Goswami

Washington University in St. Louis - School of Medicine

660 S. Euclid Ave., Third Floor McMillan
St. Louis, MO 63110-1010
United States

Katherine Jordan

Washington University in St. Louis - School of Medicine

660 S. Euclid Ave., Third Floor McMillan
St. Louis, MO 63110-1010
United States

Nan Lin

Washington University in St. Louis - School of Medicine

660 S. Euclid Ave., Third Floor McMillan
St. Louis, MO 63110-1010
United States

Bradley A Fritz

Washington University in St. Louis - School of Medicine

660 S. Euclid Ave., Third Floor McMillan
St. Louis, MO 63110-1010
United States

Tracey W Stevens

Washington University in St. Louis - School of Medicine

660 S. Euclid Ave., Third Floor McMillan
St. Louis, MO 63110-1010
United States

Eric Jacobsohn

University of Manitoba

501 F.A. Bldg
Winnipeg R3T 5V4, Manitoba R3T 5V5
Canada

Eva M Schmitt

Harvard University - Harvard Medical School

25 Shattuck St
Boston, MA 02115
United States

Sharon K Inouye

Harvard University - Harvard Medical School

25 Shattuck St
Boston, MA 02115
United States

Hebrew SeniorLife

Boston, MA
United States

Susan Stark

Washington University in St. Louis - School of Medicine

660 S. Euclid Ave., Third Floor McMillan
St. Louis, MO 63110-1010
United States

Eric J Lenze

Washington University in St. Louis - School of Medicine

660 S. Euclid Ave., Third Floor McMillan
St. Louis, MO 63110-1010
United States

Michael Avidan (Contact Author)

Washington University in St. Louis - Department of Anesthesiology ( email )

Campus Box 8054
660 S. Euclid Ave
St. Louis, MO 63110
United States