Effect of Targeting Mean Arterial Pressure during Cardiopulmonary Bypass by Monitoring Cerebral Autoregulation on Postsurgical Delirium among Older Patients: A Nested Randomized Clinical Trial

the Cerebral Autoregulation Study Group

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Abstract

Importance: Delirium occurs in up to 52% of patients after cardiac surgery and may result from changes in cerebral perfusion. Using intraoperative cerebral autoregulation monitoring to individualize and optimize cerebral perfusion may be a useful strategy to reduce the incidence of delirium after cardiac surgery. Objective: To determine whether targeting mean arterial pressure during cardiopulmonary bypass (CPB) using cerebral autoregulation monitoring reduces the incidence of delirium compared with usual care. Design, Setting, and Participants: This randomized clinical trial nested within a larger trial enrolled patients older than 55 years who underwent nonemergency cardiac surgery at a single US academic medical center between October 11, 2012, and May 10, 2016, and had a high risk for neurologic complications. Patients, physicians, and outcome assessors were masked to the assigned intervention. A total of 2764 patients were screened, and 199 were eligible for analysis in this study. Intervention: In the intervention group, the patient's lower limit of cerebral autoregulation was identified during surgery before CPB. On CPB, the patient's mean arterial pressure was targeted to be greater than that patient's lower limit of autoregulation. In the control group, mean arterial pressure targets were determined according to institutional practice. Main Outcomes and Measures: The main outcome was any incidence of delirium on postoperative days 1 through 4, as adjudicated by a consensus expert panel. Results: Among the 199 participants in this study, mean (SD) age was 70.3 (7.5) years and 150 (75.4%) were male. One hundred sixty-two (81.4%) were white, 26 (13.1%) were black, and 11 (5.5%) were of other race. Of 103 patients randomized to usual care, 94 were analyzed, and of 102 patients randomized to the intervention 105 were analyzed. Excluding 5 patients with coma, delirium occurred in 48 of the 91 patients (53%) in the usual care group compared with 39 of the 103 patients (38%) in the intervention group (P =.04). The odds of delirium were reduced by 45% in patients randomized to the autoregulation group (odds ratio, 0.55; 95% CI, 0.31-0.97; P =.04). Conclusions and Relevance: The results of this study suggest that optimizing mean arterial pressure to be greater than the individual patient's lower limit of cerebral autoregulation during CPB may reduce the incidence of delirium after cardiac surgery, but further study is needed.

Original languageEnglish (US)
JournalJAMA surgery
DOIs
StatePublished - Jan 1 2019

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Delirium
Cardiopulmonary Bypass
Arterial Pressure
Homeostasis
Randomized Controlled Trials
Thoracic Surgery
Incidence
Perfusion
Institutional Practice
Coma
Nervous System
Consensus

ASJC Scopus subject areas

  • Surgery

Cite this

@article{d10a250d534a4539aeecb12c02c4e969,
title = "Effect of Targeting Mean Arterial Pressure during Cardiopulmonary Bypass by Monitoring Cerebral Autoregulation on Postsurgical Delirium among Older Patients: A Nested Randomized Clinical Trial",
abstract = "Importance: Delirium occurs in up to 52{\%} of patients after cardiac surgery and may result from changes in cerebral perfusion. Using intraoperative cerebral autoregulation monitoring to individualize and optimize cerebral perfusion may be a useful strategy to reduce the incidence of delirium after cardiac surgery. Objective: To determine whether targeting mean arterial pressure during cardiopulmonary bypass (CPB) using cerebral autoregulation monitoring reduces the incidence of delirium compared with usual care. Design, Setting, and Participants: This randomized clinical trial nested within a larger trial enrolled patients older than 55 years who underwent nonemergency cardiac surgery at a single US academic medical center between October 11, 2012, and May 10, 2016, and had a high risk for neurologic complications. Patients, physicians, and outcome assessors were masked to the assigned intervention. A total of 2764 patients were screened, and 199 were eligible for analysis in this study. Intervention: In the intervention group, the patient's lower limit of cerebral autoregulation was identified during surgery before CPB. On CPB, the patient's mean arterial pressure was targeted to be greater than that patient's lower limit of autoregulation. In the control group, mean arterial pressure targets were determined according to institutional practice. Main Outcomes and Measures: The main outcome was any incidence of delirium on postoperative days 1 through 4, as adjudicated by a consensus expert panel. Results: Among the 199 participants in this study, mean (SD) age was 70.3 (7.5) years and 150 (75.4{\%}) were male. One hundred sixty-two (81.4{\%}) were white, 26 (13.1{\%}) were black, and 11 (5.5{\%}) were of other race. Of 103 patients randomized to usual care, 94 were analyzed, and of 102 patients randomized to the intervention 105 were analyzed. Excluding 5 patients with coma, delirium occurred in 48 of the 91 patients (53{\%}) in the usual care group compared with 39 of the 103 patients (38{\%}) in the intervention group (P =.04). The odds of delirium were reduced by 45{\%} in patients randomized to the autoregulation group (odds ratio, 0.55; 95{\%} CI, 0.31-0.97; P =.04). Conclusions and Relevance: The results of this study suggest that optimizing mean arterial pressure to be greater than the individual patient's lower limit of cerebral autoregulation during CPB may reduce the incidence of delirium after cardiac surgery, but further study is needed.",
author = "{the Cerebral Autoregulation Study Group} and Charles Brown and Neufeld, {Karin Jane} and Jing Tian and Julia Probert and Andrew Laflam and Laura Max and Daijiro Hori and Yohei Nomura and Kaushik Mandal and Ken Brady and Hogue, {Charles W.} and Ashish Shah and Zehr, {Kenton J} and Duke Cameron and John Conte and Bienvenu, {Oscar J} and Gottesman, {Rebecca F} and Atsushi Yamaguchi and Kraut, {Michael A}",
year = "2019",
month = "1",
day = "1",
doi = "10.1001/jamasurg.2019.1163",
language = "English (US)",
journal = "JAMA Surgery",
issn = "2168-6254",
publisher = "American Medical Association",

}

TY - JOUR

T1 - Effect of Targeting Mean Arterial Pressure during Cardiopulmonary Bypass by Monitoring Cerebral Autoregulation on Postsurgical Delirium among Older Patients

T2 - A Nested Randomized Clinical Trial

AU - the Cerebral Autoregulation Study Group

AU - Brown, Charles

AU - Neufeld, Karin Jane

AU - Tian, Jing

AU - Probert, Julia

AU - Laflam, Andrew

AU - Max, Laura

AU - Hori, Daijiro

AU - Nomura, Yohei

AU - Mandal, Kaushik

AU - Brady, Ken

AU - Hogue, Charles W.

AU - Shah, Ashish

AU - Zehr, Kenton J

AU - Cameron, Duke

AU - Conte, John

AU - Bienvenu, Oscar J

AU - Gottesman, Rebecca F

AU - Yamaguchi, Atsushi

AU - Kraut, Michael A

PY - 2019/1/1

Y1 - 2019/1/1

N2 - Importance: Delirium occurs in up to 52% of patients after cardiac surgery and may result from changes in cerebral perfusion. Using intraoperative cerebral autoregulation monitoring to individualize and optimize cerebral perfusion may be a useful strategy to reduce the incidence of delirium after cardiac surgery. Objective: To determine whether targeting mean arterial pressure during cardiopulmonary bypass (CPB) using cerebral autoregulation monitoring reduces the incidence of delirium compared with usual care. Design, Setting, and Participants: This randomized clinical trial nested within a larger trial enrolled patients older than 55 years who underwent nonemergency cardiac surgery at a single US academic medical center between October 11, 2012, and May 10, 2016, and had a high risk for neurologic complications. Patients, physicians, and outcome assessors were masked to the assigned intervention. A total of 2764 patients were screened, and 199 were eligible for analysis in this study. Intervention: In the intervention group, the patient's lower limit of cerebral autoregulation was identified during surgery before CPB. On CPB, the patient's mean arterial pressure was targeted to be greater than that patient's lower limit of autoregulation. In the control group, mean arterial pressure targets were determined according to institutional practice. Main Outcomes and Measures: The main outcome was any incidence of delirium on postoperative days 1 through 4, as adjudicated by a consensus expert panel. Results: Among the 199 participants in this study, mean (SD) age was 70.3 (7.5) years and 150 (75.4%) were male. One hundred sixty-two (81.4%) were white, 26 (13.1%) were black, and 11 (5.5%) were of other race. Of 103 patients randomized to usual care, 94 were analyzed, and of 102 patients randomized to the intervention 105 were analyzed. Excluding 5 patients with coma, delirium occurred in 48 of the 91 patients (53%) in the usual care group compared with 39 of the 103 patients (38%) in the intervention group (P =.04). The odds of delirium were reduced by 45% in patients randomized to the autoregulation group (odds ratio, 0.55; 95% CI, 0.31-0.97; P =.04). Conclusions and Relevance: The results of this study suggest that optimizing mean arterial pressure to be greater than the individual patient's lower limit of cerebral autoregulation during CPB may reduce the incidence of delirium after cardiac surgery, but further study is needed.

AB - Importance: Delirium occurs in up to 52% of patients after cardiac surgery and may result from changes in cerebral perfusion. Using intraoperative cerebral autoregulation monitoring to individualize and optimize cerebral perfusion may be a useful strategy to reduce the incidence of delirium after cardiac surgery. Objective: To determine whether targeting mean arterial pressure during cardiopulmonary bypass (CPB) using cerebral autoregulation monitoring reduces the incidence of delirium compared with usual care. Design, Setting, and Participants: This randomized clinical trial nested within a larger trial enrolled patients older than 55 years who underwent nonemergency cardiac surgery at a single US academic medical center between October 11, 2012, and May 10, 2016, and had a high risk for neurologic complications. Patients, physicians, and outcome assessors were masked to the assigned intervention. A total of 2764 patients were screened, and 199 were eligible for analysis in this study. Intervention: In the intervention group, the patient's lower limit of cerebral autoregulation was identified during surgery before CPB. On CPB, the patient's mean arterial pressure was targeted to be greater than that patient's lower limit of autoregulation. In the control group, mean arterial pressure targets were determined according to institutional practice. Main Outcomes and Measures: The main outcome was any incidence of delirium on postoperative days 1 through 4, as adjudicated by a consensus expert panel. Results: Among the 199 participants in this study, mean (SD) age was 70.3 (7.5) years and 150 (75.4%) were male. One hundred sixty-two (81.4%) were white, 26 (13.1%) were black, and 11 (5.5%) were of other race. Of 103 patients randomized to usual care, 94 were analyzed, and of 102 patients randomized to the intervention 105 were analyzed. Excluding 5 patients with coma, delirium occurred in 48 of the 91 patients (53%) in the usual care group compared with 39 of the 103 patients (38%) in the intervention group (P =.04). The odds of delirium were reduced by 45% in patients randomized to the autoregulation group (odds ratio, 0.55; 95% CI, 0.31-0.97; P =.04). Conclusions and Relevance: The results of this study suggest that optimizing mean arterial pressure to be greater than the individual patient's lower limit of cerebral autoregulation during CPB may reduce the incidence of delirium after cardiac surgery, but further study is needed.

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U2 - 10.1001/jamasurg.2019.1163

DO - 10.1001/jamasurg.2019.1163

M3 - Article

C2 - 31116358

AN - SCOPUS:85066156791

JO - JAMA Surgery

JF - JAMA Surgery

SN - 2168-6254

ER -