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.

Effects of Dexmedetomidine Anesthesia on Early Postoperative Cognitive Dysfunction in Elderly Patients

“…The occurrence of POCD is the result of multifactor synergy. 19 Accumulating studies have demonstrated the important role that anesthesia plays in the occurrence and development of POCD. 20 Anesthetics can activate inositol triphosphate receptors and ryanodine receptors on the endoplasmic reticulum membrane of nerve cells, thereby inducing the pathology and death of neurons.…”

“…The occurrence of POCD is the result of multifactor synergy . Accumulating studies have demonstrated the important role that anesthesia plays in the occurrence and development of POCD .…”

Protective effect of Houttuynia cordata extract on propofol-induced injury of rat hippocampal neurons by regulating PI3K/Akt and Toll-like receptor 4/NF-κB signaling pathway

“…Previous study showed RTA-408 protected against propofol-induced cognitive impairment in neonatal mice [ 4 ]. Additionally, repeated propofol exposure could induce neuronal damage and cognitive impairment in aged rats [ 16 ]. Similarly, propofol was successfully used to induce inflammation and apoptosis of hippocampal neurons in rats [ 17 ].…”

A Century of Technology in Anesthesia & Analgesia

“…216,217 Numerous manuscripts on fully automated anesthetic delivery have also been published, 218 from automated general anesthesia 219,220,206 to automated sedation for transcatheter aortic valve replacement, 221 and from simple pilot studies 222 to randomized controlled trials. 223,224 At the same time, Anesthesia & Analgesia has also led the way in publishing articles from US Food and Drug Administration (FDA) authors that delineate the regulatory pathways that need to be passed to make automated anesthesia systems commercially available. 225 Although it is unclear when these systems will be able to enter clinical practice, regulatory barriers have now been identified and discussed extensively.…”

“…216,217 Numerous manuscripts on fully automated anesthetic delivery have also been published, 218 from automated general anesthesia 219,220,206 to automated sedation for transcatheter aortic valve replacement, 221 and from simple pilot studies 222 to randomized controlled trials. 223,224…”