• Troy S Wildes, Angela M Mickle, Ben Abdallah Arbi A Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri., Hannah R Maybrier, Jordan Oberhaus, Thaddeus P Budelier, Alex Kronzer, Sherry L McKinnon, Daniel Park, Brian A Torres, Thomas J Graetz, Daniel A Emmert, Ben J Palanca, Shreya Goswami, Katherine Jordan, Nan Lin, Bradley A Fritz, Tracey W Stevens, Eric Jacobsohn, Eva M Schmitt, Sharon K Inouye, Susan Stark, Eric J Lenze, Michael S Avidan, and ENGAGES Research Group.
• Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri.
• JAMA. 2019 Feb 5; 321 (5): 473-483.

ImportanceIntraoperative electroencephalogram (EEG) waveform suppression, often suggesting excessive general anesthesia, has been associated with postoperative delirium.ObjectiveTo assess whether EEG-guided anesthetic administration decreases the incidence of postoperative delirium.Design, Setting, And ParticipantsRandomized 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.InterventionsPatients 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 MeasuresThe 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.ResultsOf 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 RelevanceAmong 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 RegistrationClinicalTrials.gov Identifier: NCT02241655.

This article appears in the collection: Does anesthesia cause post-operative delirium and post-operative cognitive decline?.

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