Postoperative Neurocognitive Disorders After Closed-Loop Versus Manual Target Controlled-Infusion of Propofol and Remifentanil in Patients Undergoing Elective Major Noncardiac Surgery: The Randomized Controlled Postoperative Cognitive Dysfunction-Electroencephalographic-Guided Anesthetic Administration Trial.

Abstract

BACKGROUND:

The aim of the study was to investigate whether closed-loop compared to manual bispectral index (BIS)-guided target-controlled infusion of propofol and remifentanil could decrease the incidence of postoperative neurocognitive disorders after elective major noncardiac surgery.

METHODS:

Patients aged >50 admitted for elective major noncardiac surgery were included in a single-blind randomized (ratio 2:1) trial. The anesthetic protocol was allocated by randomization into either closed-loop or manual BIS-guided propofol and remifentanil titration. The BIS target range was 40-60. All patients had cognitive assessment the day before surgery and within 72 hours after surgery using a battery of neuropsychological tests. The primary outcome was the rate of postoperative neurocognitive disorders. Postoperative neurocognitive disorders were defined as a decrease >20% from baseline on at least 3 scores. Intergroup comparison of the primary outcome was performed using the χ2 test.

RESULTS:

A total of 143 and 61 patients were included in the closed-loop and manual groups, respectively (age: 66 [8] vs 66 [9] years). The primary outcome was observed in 18 (13%) and 10 (16%) patients of the closed-loop and manual groups, respectively (relative risk [95% confidence interval {CI}], 0.77 [0.38-1.57], P = .47). Intraoperative propofol consumption was lower (4.7 [1.4] vs 5.7 [1.4] mg·kg-1·h-1, mean difference [MD] [95% CI], -0.73 [-0.98 to -0.48], P < .0001) and the proportion of time within the BIS target range higher (84 [77-89] vs 74 [54-81]%, MD [95% CI], 0.94 [0.67-1.21], P < .0001) in the closed-loop group.

CONCLUSIONS:

Closed-loop compared to manual BIS-guided total intravenous anesthesia provided a significant reduction in episodes of an excessive depth of anesthesia while decreasing intraoperative propofol requirement but no evidence for a reduction of the incidence of postoperative neurocognitive disorders after elective major noncardiac surgery was observed.

• Authors: Nicolas Mahr, Yannis Bouhake, Gilles Chopard, Ngai Liu, Nathalie Boichut, Thierry Chazot, Melanie Claveau, Lucie Vettoretti, Gregory Tio, Sebastien Pili-Floury, Emmanuel Samain, Guillaume Besch
• Journal: Anesthesia and analgesia (Anesth Analg) Vol. 133 Issue 4 Pg. 837-847 (10 01 2021) ISSN: 1526-7598 [Electronic] United States
• PMID: 33181558 (Publication Type: Comparative Study, Journal Article, Randomized Controlled Trial, Research Support, Non-U.S. Gov't)
• Copyright: Copyright © 2020 International Anesthesia Research Society.

Chemical References

• Anesthetics, Intravenous
• Remifentanil
• Propofol

Topics

• Aged
• Anesthesia, Closed-Circuit (adverse effects)
• Anesthesia, Intravenous (adverse effects)
• Anesthetics, Intravenous (administration & dosage, adverse effects)
• Elective Surgical Procedures
• Electroencephalography
• Female
• France
• Humans
• Infusions, Intravenous
• Intraoperative Neurophysiological Monitoring
• Male
• Middle Aged
• Postoperative Cognitive Complications (chemically induced, diagnosis, physiopathology, prevention & control)
• Propofol (administration & dosage, adverse effects)
• Remifentanil (administration & dosage, adverse effects)
• Risk Factors
• Single-Blind Method
• Time Factors
• Treatment Outcome