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

• Published in: JAMA : the journal of the American Medical Association Vol. 321; no. 5; pp. 473 - 483
• Main Authors: Wildes, Troy S, Mickle, Angela M, Ben Abdallah, Arbi, Maybrier, Hannah R, Oberhaus, Jordan, Budelier, Thaddeus P, Kronzer, Alex, McKinnon, Sherry L, Park, Daniel, Torres, Brian A, Graetz, Thomas J, Emmert, Daniel A, Palanca, Ben J, Goswami, Shreya, Jordan, Katherine, Lin, Nan, Fritz, Bradley A, Stevens, Tracey W, Jacobsohn, Eric, Schmitt, Eva M, Inouye, Sharon K, Stark, Susan, Lenze, Eric J, Avidan, Michael S
• Format: Journal Article
• Language: English
• Published: United States American Medical Association 05.02.2019
• Subjects: Adults; Aged; Aged, 80 and over; Algorithms; Alveoli; Anesthesia; Anesthesia, General - adverse effects; Anesthetics, General - administration & dosage; Anesthetics, General - adverse effects; Blood pressure; Cardiotonic Agents - therapeutic use; Clinical trials; Complications; Delirium; EEG; Electroencephalography; Emergence Delirium - epidemiology; Emergence Delirium - prevention & control; Female; Humans; Hypotension; Hypotension - chemically induced; Hypotension - drug therapy; Incidence; Intraoperative Complications - chemically induced; Male; Mental disorders; Mercury; Middle Aged; Monitoring, Intraoperative - methods; Nausea; Older people; Original Investigation; Patients; Phenylephrine - therapeutic use; Postoperative Nausea and Vomiting; Surgery; Surgical Procedures, Operative - adverse effects; Surgical Procedures, Operative - mortality; Vomiting
• ISSN: 0098-7484; 1538-3598; 1538-3598
• DOI: 10.1001/jama.2018.22005

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