• Alexandre Joosten, Joseph Rinehart, Aurélie Bardaji, Philippe Van der Linden, Vincent Jame, Luc Van Obbergh, Brenton Alexander, Maxime Cannesson, Susana Vacas, Ngai Liu, Hichem Slama, and Luc Barvais.
• From the Department of Anesthesiology (A.J., A.B., V.J., L.V.O, L.B.) Department of Clinical and Cognitive Neuropsychology (H.S.) Erasme Hospital, and Department of Anesthesiology, Brugmann Hospital (P.V.d.L.), Université Libre de Bruxelles, Brussels, Belgium Department of Anesthesiology and Intensive Care, University of Paris-Saclay, Bicetre Hospital, Le Kremlin-Bicêtre, Paris, France (A.J.) Department of Anesthesiology and Perioperative Care, University of California, Irvine, Irvine, California (J.R.) Department of Anesthesiology, University of California, San Diego, San Diego, California (B.A.) Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California (M.C., S.V.) Department of Anesthesiology, Foch Hospital, Suresnes, Paris, France (N.L.) Outcome Research Consortium, Cleveland Clinic, Cleveland, Ohio (N.L.).
• Anesthesiology. 2020 Feb 1; 132 (2): 253266253-266.

BackgroundCognitive changes after anesthesia and surgery represent a significant public health concern. We tested the hypothesis that, in patients 60 yr or older scheduled for noncardiac surgery, automated management of anesthetic depth, cardiac blood flow, and protective lung ventilation using three independent controllers would outperform manual control of these variables. Additionally, as a result of the improved management, patients in the automated group would experience less postoperative neurocognitive impairment compared to patients having standard, manually adjusted anesthesia.MethodsIn this single-center, patient-and-evaluator-blinded, two-arm, parallel, randomized controlled, superiority study, 90 patients having noncardiac surgery under general anesthesia were randomly assigned to one of two groups. In the control group, anesthesia management was performed manually while in the closed-loop group, the titration of anesthesia, analgesia, fluids, and ventilation was performed by three independent controllers. The primary outcome was a change in a cognition score (the 30-item Montreal Cognitive Assessment) from preoperative values to those measures 1 week postsurgery. Secondary outcomes included a battery of neurocognitive tests completed at both 1 week and 3 months postsurgery as well as 30-day postsurgical outcomes.ResultsForty-three controls and 44 closed-loop patients were assessed for the primary outcome. There was a difference in the cognition score compared to baseline in the control group versus the closed-loop group 1 week postsurgery (-1 [-2 to 0] vs. 0 [-1 to 1]; difference 1 [95% CI, 0 to 3], P = 0.033). Patients in the closed-loop group spent less time during surgery with a Bispectral Index less than 40, had less end-tidal hypocapnia, and had a lower fluid balance compared to the control group.ConclusionsAutomated anesthetic management using the combination of three controllers outperforms manual control and may have an impact on delayed neurocognitive recovery. However, given the study design, it is not possible to determine the relative contribution of each controller on the cognition score.

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