Processed Multiparameter Electroencephalogram-Guided General Anesthesia Management Can Reduce Postoperative Delirium Following Carotid Endarterectomy: A Randomized Clinical Trial

Na Xu, Li-Xia Li, Tian-Long Wang, Li-Qun Jiao, Yang Hua, Dong-Xu Yao, Jie Wu, Yan-Hui Ma, Tian Tian, Xue-Li Sun, Na Xu, Li-Xia Li, Tian-Long Wang, Li-Qun Jiao, Yang Hua, Dong-Xu Yao, Jie Wu, Yan-Hui Ma, Tian Tian, Xue-Li Sun

Abstract

Background: Patients undergoing carotid endarterectomy (CEA) for severe carotid stenosis are vulnerable to postoperative delirium, a complication frequently associated with poor outcome. This study investigated the impact of processed electroencephalogram (EEG)-guided anesthesia management on the incidence of postoperative delirium in patients undergoing CEA. Methods: This single-center, prospective, randomized clinical trial on 255 patients receiving CEA under general anesthesia compared the outcomes of patient state index (PSI) monitoring [SEDLine Brain Function Monitor (Masimo, Inc, Irvine, CA)] (standard group, n = 128) with PSI combined with density spectral array(DSA) -guided monitoring (intervention group, n = 127) to reduce the risk of intraoperative EEG burst suppression. All patients were monitored by continuous transcranial Doppler ultrasound (TCD) and near-infrared spectroscopy (NIRS) to avoid perioperative cerebral hypoperfusion or hyperperfusion. According to the surgical process, EEG suppression time was calculated separately for three stages: S1 (from anesthesia induction to carotid artery clamping), S2 (from clamping to declamping), and S3 (from declamping to the end of surgery). The primary outcome was incidence of postoperative delirium according to the Confusion Assessment Method algorithm during the first 3 days post-surgery, and secondary outcomes were other neurologic complications and length of hospital stay. Results: There were no episodes of cerebral hypoperfusion or hyperperfusion according to TCD and NIRS monitoring in either group during surgery. The incidence of postoperative delirium within 3 days post-surgery was significantly lower in the intervention group than the standard group (7.87 vs. 28.91%, P < 0.01). In the intervention group, the total EEG suppression time and the EEG suppression time during S2 and S3 were shorter (Total, 0 "0" vs. 0 "1.17" min, P = 0.04; S2, 0 "0" vs. 0 "0.1" min, P < 0.01; S3, 0 "0" vs. 0 "0" min, P = 0.02). There were no group differences in incidence of neurologic complications and length of postoperative hospital stay. Conclusion: Processed electroencephalogram-guided general anesthesia management, consisting of PSI combined with DSA monitoring, can significantly reduce the risk of postoperative delirium in patients undergoing CEA. Patients, especially those exhibiting hemodynamic fluctuations or receiving surgical procedures that disrupt cerebral perfusion, may benefit from the monitoring of multiple EEG parameters during surgery. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT03622515.

Keywords: carotid endarterectomy; cerebral perfusion; delirium; electroencephalogram-guided; general anesthesia; monitoring.

Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2021 Xu, Li, Wang, Jiao, Hua, Yao, Wu, Ma, Tian and Sun.

Figures

Figure 1
Figure 1
Flow diagram depicting patient recruitment for this clinical trial. EEG, electroencephalography.
Figure 2
Figure 2
MAP over time. MAP, mean arterial blood pressure. The measurement time interval after general anesthesia but before clamping the carotid artery was recorded as baseline reference T1, the time interval after clamping but before declamping was recorded as T2, and the time interval after the declamping and stabilization of cerebral perfusion but before completion of surgery was recorded as T3.
Figure 3
Figure 3
PETCO2 over time. PETCO2, end-expiratory carbon dioxide partial pressure. The measurement time interval after general anesthesia but before clamping the carotid artery was recorded as baseline reference T1, the time interval after clamping but before declamping was recorded as T2, and the time interval after the declamping and stabilization of cerebral perfusion but before completion of surgery was recorded as T3.
Figure 4
Figure 4
Ipsilateral rSO2 over time. rSO2, regional cerebral oxygenation. The measurement time interval after general anesthesia but before clamping the carotid artery was recorded as baseline reference T1, the time interval after clamping but before declamping was recorded as T2, and the time interval after the declamping and stabilization of cerebral perfusion but before completion of surgery was recorded as T3.
Figure 5
Figure 5
Contralateral rSO2 over time. rSO2, regional cerebral oxygenation. The measurement time interval after general anesthesia but before clamping the carotid artery was recorded as baseline reference T1, the time interval after clamping but before declamping was recorded as T2, and the time interval after the declamping and stabilization of cerebral perfusion but before completion of surgery was recorded as T3.
Figure 6
Figure 6
Ipsilateral MFVMAC over time. MFVMAC, mean flow velocity of middle cerebral artery. The measurement time interval after general anesthesia but before clamping the carotid artery was recorded as baseline reference T1, the time interval after clamping but before declamping was recorded as T2, and the time interval after the declamping and stabilization of cerebral perfusion but before completion of surgery was recorded as T3. MFVMAC, bilateral mean flow velocity of middle cerebral artery.
Figure 7
Figure 7
Contralateral MFVMAC over time. MFVMAC, mean flow velocity of middle cerebral artery. The measurement time interval after general anesthesia but before clamping the carotid artery was recorded as baseline reference T1, the time interval after clamping but before declamping was recorded as T2, and the time interval after the declamping and stabilization of cerebral perfusion but before completion of surgery was recorded as T3. MFVMAC, bilateral mean flow velocity of middle cerebral artery.
Figure 8
Figure 8
PSI at corresponding time points. PSI, patient state index, *P < 0.05 from standard group (statistically significant). The measurement time interval after general anesthesia but before clamping the carotid artery was recorded as baseline reference T1, the time interval after clamping but before declamping was recorded as T2, and the time interval after the declamping and stabilization of cerebral perfusion but before completion of surgery was recorded as T3.

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