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Propofol… Less Confusion after Surgery

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The injected anesthetic propofol seems to be less likely to cause cognitive difficulties after surgery than inhaled anesthetics.

The People’s Pharmacy October 26, 2014
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heart surgeryQ. After reading your column on the aftereffects of anesthesia, I want to share my own experience.

I had severe memory lapses for months after undergoing anesthesia. It was like knowing something was in a filing cabinet, but not being able to see what is in the folder. It is frustrating to know the information is there, but you can’t access it.

Thankfully, my brain function did return to normal, but it took months. My physician suggested propofol for future surgeries. I have needed anesthesia a few more times over the last several years and have not experienced aftereffects again.

A. Post-operative cognitive decline is surprisingly common, though the cause remains controversial. Propofol is an injectable anesthetic. One study showed less impairment among patients getting propofol compared to those getting the inhaled anesthetic sevoflurane (Clinical Interventions in Aging, online Sept. 24, 2014).

It makes sense to ask the surgeon ahead of time if a peripheral nerve block would be appropriate. In some cases, such as knee surgery, that may be another option (Clinical Interventions in Aging, online Feb. 18, 2014).

People who find that they are spacey or forgetful after surgery should be patient with themselves. In most cases, the cognitive problems (which may also be linked to insomnia) will disappear over time.

 

Thoughts Shared

  1. Barry
    Corona del Mar, CA

Anesthesia providers can only guess how much anesthetic you might need. Without a brain monitor, one American patient dies every day from anesthesia over medication. Prior to 1996, to insure an adequate experience, we tend to err on the side of too much. Since the FDA approval of the BIS brain monitor, it is now not only possible but also highly desirable to directly measure individual response to avoid brain fog (aka postoperative cognitive dysfunction or POCD). Watch You Tube ‘Going under with Goldilocks anesthesia.’ Learn what you need to know by reading ‘Getting Over Going Under.’ Complimentary copies from www.goldilocksfoundation.org. DISCLAIMER: Neither I, nor my non-profit Goldilocks Anesthesia Foundation, receive financial support from makers of the BIS monitor.

Goldilocks anesthesia postoperative delirium concerns validated again by brain monitor maker, Covidien

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Evidence and Supporting Resources

Delirium: Prevalence

Ten percent of patients over 50 will experience some level of delirium postoperatively, and the incidence increases up to 60% for those over 65. In young adults, the occurrence of emergence delirium in the PACU ranges from 3 to 20%.1

In an article published in the International Journal of Geriatric Psychiatry, the authors conclude: “In long-term care, prevalence ranges between 1.4% and 70%, depending on diagnostic criteria and on the prevalence of dementia. Most studies agree that older people who previously experienced delirium have a higher risk of dementia and a higher mortality rate. Population and long-term care studies show the same tendency.”2

Delirium: Risks to Healthcare Providers

In an era of increasing accountability and a focus on outcomes-based medicine, the risk to HCPs is high.According to Dr. Sharon K. lnnoye, a professor of medicine at Harvard Medical School and director of the Aging Brain Center at Hebrew Seniorlife in Boston, “Not only do patients have a 25-70% higher chance of dying during their hospital stay, but they are also at a 62% higher risk of mortality in the following year.”3

The American Geriatrics Society now believes there is sufficient peer-reviewed published data on levels of anesthesia as an independent predictor of delirium in the postsurgical setting. Their Expert Panel on Postoperative Delirium in Older Adults consensus statement on intraoperative monitoring asserts that practitioners may use “processed electroencephalographic monitors of anesthetic depth during intravenous sedation or general anesthesia of older patients to reduce postoperative delirium.”4

Delirium: Costs to Hospitals

Numerous studies have shown an increased risk of institutionalization, dementia and death in patients with postoperative delirium5 as well as increases in hospital length of stay by up to six days.6 Moreover, “total cost estimates attributable to delirium ranged from $16,303 to $64,421 per patient”.5

According to a study in The Journal of American Geriatric Society, post-hospital treatment for delirium costs $143-$152 billion per year,5 which includes additional rehabilitation services, home health care and nursing home care.7

Delirium: How BIS™ monitoring can help mitigate risk

Postoperative delirium is preventable in up to 40% of such cases,6 with a proper screening program, the identification of risk factors and the implementation of evidence-based monitoring methods within the OR.

Brain function monitoring-guided anesthesia dosing may decrease the rate of postoperative delirium.6,7,11,12 Monitoring with Bispectral Index™ (BIS™’) technology during surgical procedures gives anesthesia providers the ability to directly monitor the anesthetic effect on the patient’s brain to optimize the anesthetic dosing for the individual.

Peer-reviewed literature has shown BIS-guided anesthetic titration may aid in a reduction in the incidence of delirium in elderly and other patient populations at increased risk.5

BIS monitoring has also been clinically shown to reduce primary anesthetic delivery (as much as 50%) and promote faster wake-up, recovery and discharge from the PACU.11,12,13,14 BIS also reduces the risk of awareness or ”wake-up” during surgery by up to 80%.14

BIS™ monitoring ensures a more positive experience for patients

Brain function monitoring with Bispectral lndexn. (BIS™) technology during surgical procedures gives anesthesiologists the ability to directly monitor the anesthetic effect on the patient’s brain to optimize dosing,which can result in:

  • Improved safety: Helps the anesthesia professional optimize the anesthetic dosing for each patient
  • Reduced postoperative delirium: Research has now shown that monitoring brain function monitoring-guided anesthesia dosing may decrease the rate of postoperative delirium11,12
  • Reduced costs: Reduction in primary anesthetic delivery of up to 50%; fewer delirium episodes may reduce treatment costs6,13
  • Improved patient satisfaction: Faster wake-up, recovery and discharge from PACU; 80% less risk of patient awareness during surgery14,15,16

View the statistics: Incidence of post-operative delirium

References
  1. Lepouse, C., Lautner, C., et al. Emergence delirium in adults in postanaesthesia care unit. British Journal Anaesthesia. May 2, 2006;(96) 747-53
  2. de Lange, E., Verhaak, P.F., van der Meer, K. Prevalence, presentation and prognosis of delirium in older people in the population, at home and in long term care: a review. Int J Geriatr Psychiatry. Feb 28, 2013.
  3. Selinger, S. Preventing Hospital Delirium. The New Old Age blog. New York Times Website. November 11,2011. Accessed March 6, 2015.
  4. Inouye, Sharon K. et al. Postoperative Delirium in Older Adults: Best Practice Statement from the American Geriatrics Society. lntraoperative Measures to Prevent Delirium. J Am Coll Surg. 2014;220;2 ,136-148.e1.
  5. Leslie, D.L., Marcantonio, E.R., Zhang, Y., Leo-Summers, L., & Inouye, S.K. (2008). One-year health care costs associated with delirium in the elderly population. Archives of Internal Medicine. 168(1), 27-32.
  6. Whitlock, E.L., Torres, B.A., Lin, N., Helsten, D.L., Nadelson, M.R., & Mashour, G.A. (2014). Postoperative delirium in a substudy of cardiothorac ic surgical patients in the BAG-RECALL clinical trial. Anesthesia & Analegesia. 118(4),809-817.
  7. Sieber, F.E., Zakriya, K.J., Gottschalk, A., Blute, M.R., Lee, H.B., Rosenberg, P.B., Mears S.C. Sedation depth during spinal anesthesia and the development of postoperative delirium in elderly patients undergoing hip fracture repair. Mayo Clin Proc. 2010 Jan;85(1):18-26.
  8. Inouye, S.K., Bogardus, S.T. Jr., Charpentier, P.A. et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med. 1999;340:669-676. (ET)
  9. Marcantonio, E.R., Flacker, J.M., Wright, R.J. et al. Reducing delirium after hip fracture: A randomized trial. J Am Geriatr Soc. 2001;49:516-522.(ET)
  10. Rubin, F.H., Neal, K., Fenlon, K., Hassan, S., Inouye, S.K. Sustainability and scalability of the hospital elder life program at a community hospital. J Am Geriatr Soc. Feb 2011;59(2):359-65.
  11. Chan, M.T., Cheng, B.C., Lee, T.M. et al. BIS-guided anesthesia decreases postoperative delirium and cognitive decline. J Neurosurg Anesthesiol. 2013; 25: 33-42
  12. Radtke, F. M., Franck, M., Lendner, J., Kruger, S., Wernecke, K. D., & Spies, C. D. (2013). Monitoring depth of anaesthesia in a randomized trial decreases the rate of postoperative delirium but not postoperative cognitive dysfunction. Br J Anaesth. 2013; 110: i98-105.
  13. Kaplan, L.J., Bailey, H. Bispectral index (BIS) monitoring of ICU patients on continuous infusion of sedatives and paralytics reduces sedative drug utilization and cost. Crit Care Med. 2000;4(Suppl):S110.
  14. Gan, T.J., Glass, P. S., Windsor, A., Payne, F., Rosow, C., Sebel, P., & Manberg, P. (1997). Bispectral index monitoring allows faster emergence and improved recovery from propofol, alfentanil, and nitrous oxide anesthesia. Anesthesiology. 87(4), 808-815.
  15. Myles P.S., Leslie, K., McNeil, J., Forbes, A., Chan, M.T. Bispectral index monitoring to prevent awareness during anaesthesia: the B-Aware randomised controlled trial. Lancet. 2004;363(9423):1757-1763.
  16. White, P.F., Ma, H., Tang, J., Wender, R.H., Sloninsky, A., Kariger, R. Does the use of electroencephalographic bispectral index or auditory evoked potential index monitoring facilitate recovery after desflurane anesthesia in the ambulatory setting?Anesthesiology. 2004; 100(4):811-817.

????? or Paula’s anesthesia quandary

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Hi Dr Friedberg.

I wrote you awhile ago with questions about my son and his surgery. I have a few more questions about his surgery. Which was yesterday.

Joan Rivers’ Needless death

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Re: propofol dose… Body weight is a standard 20th century method of ‘guesstimating’ propofol dose. Ultimately, it is still a guess.*

MEASURING the direct brain response with a brain monitor is the 21st century
approach.

Preventing postoperative delirium

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Dr. Friedberg, a board certified anesthesiologist and author of “Getting Over Going Under: 5 Things You Must Know Before Anesthesia,” applauds the American Geriatrics Society guidelines to prevent postoperative delirium: “Brain monitoring is the best available technology to reduce or eliminate anesthesia brain fog after surgery and it needs to be more widely used as the study suggests. The vast majority of Americans are routinely over-medicated during surgery because their anesthesiologist is not measuring their brain.

 

New Study Concludes: Postoperative Delirium Can be Avoided by Using a Brain Monitor

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Los Angeles, CA — The American Geriatrics Society (AGS) recently released its new Clinical Practice Guideline for Postoperative Delirium in Older Adults for providing essential guidance to clinicians to prevent and treat postoperative delirium in older patients. Delirium, an episode of sudden confusion, is a serious medical condition that can occur following surgery and is associated with complications resulting in longer hospital stays, delayed rehabilitation, and other factors that can adversely affect an older person’s surgical recovery and longer-term mental and physical health.

Dr. Friedberg, a board certified anesthesiologist and author of Getting Over Going Under: 5 Things You Must Know Before Anesthesia applauds the American Geriatrics Society guidelines to prevent postoperative delirium. Website: http://www.DrFriedberg.com

“Brain monitoring is the best available technology to reduce or eliminate anesthesia brain fog after surgery and it needs to be more widely used as the study suggests,” says Friedberg. “The vast majority of Americans are routinely over-medicated during surgery because their anesthesiologist is not measuring their brain. There are cases every day where families are trying to determine what happened to their loved one’s personality and cognitive skills after a surgery. Sadly, some of these patients will never be the same. The key is to monitor the brain during the surgical procedure.”

Dr. Friedberg is the developer of propofol ketamine (PK) technique designed to maximize patient safety by minimizing the degree to which patients need to be medicated to create the illusion of general anesthesia, i.e., “no hear, no feel.” Located in Los Angeles, Dr. Friedberg has been interviewed by FOX, CNN, truTV, Nancy Grace and People magazine, and commented throughout the Michael Jackson murder trial regarding the use of propofol.

Two decades ago, Dr. Friedberg developed a safer anesthesia protocol, subsequently made numerically reproducible with the brain monitor and earning him a U.S. Congressional award. Among the findings in Getting Over Going Under is that about 80 percent of the surgeries in the U.S. put patients at risk of being afflicted with delirium, POCD or even permanent brain damage because a brain monitor is not used.

“The bottom line,” says Friedberg, “Don’t let your parents, your spouse or anybody you love over 50 years old get general anesthesia without a brain monitor or you may NEVER speak to that SAME person again.”

About Barry Friedberg, M.D.

Dr. Barry Friedberg has been interviewed extensively on the subject of anesthesia and propofol by FOX, CNN, True TV, and People Magazine during the Michael Jackson murder trial. A Board Certified Anesthesiologist for more than three decades, Dr. Friedberg developed the Friedberg Method for administering anesthesia in 1992 and the Goldilocks Anesthesia protocol in 1997. He has been published and cited in several medical journals and textbooks and was honored with a U.S. Congressional award for applying his methods on wounded soldiers in Afghanistan and Iraq. Website: http://www.drfriedberg.com