Intraoperative electroencephalogram suppression at lower volatile anaesthetic concentrations predicts postoperative delirium occurring in the intensive care unit

• Published in: British journal of anaesthesia : BJA Vol. 121; no. 1; pp. 241 - 248
• Main Authors: Fritz, B.A., Maybrier, H.R., Avidan, M.S.
• Format: Journal Article
• Language: English
• Published: England Elsevier Ltd 01.07.2018; Elsevier
• Subjects: Adolescent; Adult; Aged; Aged, 80 and over; Algorithms; anaesthesia; Anesthetics, Inhalation - administration & dosage; Anesthetics, Inhalation - pharmacology; brain waves/drug effects; Cohort Studies; Consciousness Monitors; Critical Care; delirium/aetiology; Electroencephalography - drug effects; electroencephalography/instrumentation; Emergence Delirium - chemically induced; Emergence Delirium - diagnosis; Emergence Delirium - epidemiology; Female; Humans; Incidence; Intensive Care Units; Male; Middle Aged; Predictive Value of Tests; Retrospective Studies; Young Adult; brain waves/drug effects; delirium/aetiology; electroencephalography/instrumentation; anaesthesia
• ISSN: 0007-0912; 1471-6771
• DOI: 10.1016/j.bja.2017.10.024

Postoperative delirium is a common complication associated with increased morbidity and mortality. A recently-reported association between intraoperative electroencephalogram suppression and postoperative delirium might be mediated in some patients by a heightened sensitivity to volatile anaesthetics. This retrospective cohort study included 618 elective surgery patients with planned intensive care unit admission, who also received intraoperative electroencephalogram monitoring and had delirium assessments documented in the medical record. Sensitivity to volatile anaesthetics was assessed using a mixed effects model predicting the likelihood of electroencephalogram suppression at each time point based on the current end-tidal anaesthetic concentration. Patients with a random intercept above the population median (electroencephalogram suppression at lower anaesthetic concentrations) were classified as having heightened sensitivity to volatile anaesthetics. Delirium was defined as a positive Confusion Assessment Method for the Intensive Care Unit assessment anytime in the first five postoperative days. Postoperative delirium was observed in 162 of 618 patients (26%). Patients who experienced electroencephalogram suppression at lower volatile anaesthetic concentrations had a higher incidence of postoperative delirium [109/309 (35%)] than other patients [53/309 (17%)] [unadjusted odds ratio 2.63; 95% confidence interval (CI), 1.81–3.84, P<0.001]. This association remained significant after adjusting for patient characteristics, surgical variables, and duration of electroencephalogram suppression (adjusted odds ratio 2.13; 95% CI 1.24–3.65, P=0.006). These data support the hypothesis that patients with electroencephalogram suppression at lower volatile anaesthetic concentrations have an increased incidence of postoperative delirium. Such patients appear to exhibit a phenotype of anaesthetic sensitivity, which might predispose them to adverse cognitive outcomes.