Anesthesia Clinical Trial
— Balanced-2Official title:
Preserving Brain Health After Surgery: Does Light General Anesthesia Reduce Postoperative Delirium and Cognitive Decline Compared With Deep General Anesthesia in Older Adults?
The goal of this clinical trial (Balanced-2 study) is to compare light to deep general anesthesia using widely available brain monitors, to see if 'light' anesthesia could reduce rates of delirium, cognitive decline, and disability in older adults undergoing major surgery. Delirium is the most common serious surgical complication, occurring in an estimated one in four older adults undergoing major surgery. Delirium causes significant distress to patients and family, and is associated with prolonged hospital stay, physical disability, progression to dementia-like illnesses, and discharge to long-term care. Between 10 - 30% of adults aged 70 years and above have surgery every year, and preserving brain health and wellbeing is an important priority during this time. Older adults (aged ≥65 years, or Indigenous, Pasific patients aged ≥55 years) undergoing major surgery with general anesthesia (excluding heart and brain surgery) and able to provide consent will be able to participate. Participants will be randomized to two groups - a lighter general anesthesia group and a deeper general anesthesia group using processed electroencephalography (a brain monitor that provides information on depth of anesthesia using brain waves). The anesthesiologist will titrate anesthetic drugs according to the brain monitor. Participants will be followed up to determine if they experience delirium after surgery, and longer term impact of delirium such as cognitive and physical decline will also be measured. If found to be effect, this simple, cheap, and widely available treatment could reduce disability, preserve brain health and wellbeing of many older adults undergoing surgery worldwide, and save millions in healthcare dollars.
Status | Not yet recruiting |
Enrollment | 2766 |
Est. completion date | December 31, 2028 |
Est. primary completion date | December 31, 2027 |
Accepts healthy volunteers | No |
Gender | All |
Age group | 55 Years and older |
Eligibility | Inclusion Criteria: - Patients aged = 65 years, and Maori, Pacific or Indigenous participants aged = 55 years who are undergoing major elective or non-elective surgery with expected surgical duration = 2 hours and postoperative hospital stay = 2 nights. - Having general anesthesia using total intravenous anesthesia (TIVA) with pEEG monitoring - Able to provide informed consent (including patients with mild preoperative neurocognitive disorders) Exclusion Criteria: - Intracranial or cardiac surgery - Undergoing surgery with 'wake up' test - Previous enrollment in Balanced-2 study - Terminal illness with expected survival <3 months - Emergency surgery within 6 hours of presentation to hospital - Cognitive impairment with no capacity to consent or activated enduring power of attorney - Clinically impaired and unable to consent due to acute pathology or preoperative delirium |
Country | Name | City | State |
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n/a |
Lead Sponsor | Collaborator |
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Auckland City Hospital |
Deng C, Sidebotham D. Using the Delphi process to determine the minimum clinically important effect size for the Balanced-2 randomised controlled trial. Clin Trials. 2023 Oct;20(5):473-478. doi: 10.1177/17407745231173058. Epub 2023 May 5. — View Citation
Evered L, Silbert B, Knopman DS, Scott DA, DeKosky ST, Rasmussen LS, Oh ES, Crosby G, Berger M, Eckenhoff RG; Nomenclature Consensus Working Group. Recommendations for the nomenclature of cognitive change associated with anaesthesia and surgery-2018. Br J Anaesth. 2018 Nov;121(5):1005-1012. doi: 10.1016/j.bja.2017.11.087. Epub 2018 Jun 15. — View Citation
Evered LA, Chan MTV, Han R, Chu MHM, Cheng BP, Scott DA, Pryor KO, Sessler DI, Veselis R, Frampton C, Sumner M, Ayeni A, Myles PS, Campbell D, Leslie K, Short TG. Anaesthetic depth and delirium after major surgery: a randomised clinical trial. Br J Anaesth. 2021 Nov;127(5):704-712. doi: 10.1016/j.bja.2021.07.021. Epub 2021 Aug 28. — View Citation
Sumner M, Deng C, Evered L, Frampton C, Leslie K, Short T, Campbell D. Processed electroencephalography-guided general anaesthesia to reduce postoperative delirium: a systematic review and meta-analysis. Br J Anaesth. 2023 Feb;130(2):e243-e253. doi: 10.1016/j.bja.2022.01.006. Epub 2022 Feb 17. — View Citation
Type | Measure | Description | Time frame | Safety issue |
---|---|---|---|---|
Other | Incidence of awareness | Assessed using Brice questionnaire | Assessed once, between postoperative days 1 to 3 | |
Other | Adverse and serious adverse events | Up to 1 year | ||
Primary | Incidence of postoperative delirium (POD) | Assessed using the three-minute diagnostic interview for the confusion assessment method (CAM)-defined POD (3D-CAM) or if patients are in the intensive care unit (ICU), the CAM-ICU. Delirium testing will occur between 0600 and 1000 and 1800 to 2200 daily including weekends. | Administered twice a daily for up to 3 postoperative days or until discharge if discharge occurs before day 3, including weekends. Further once daily testing from days 4 to 7 if screens positive. | |
Secondary | Incidence of severe delirium | Assessed using 3D-CAM-S tool | 7 days after surgery | |
Secondary | Incidence of new mild and major postoperative neurocognitive disorders | Diagnosis of new postoperative neurocognitive disorder requires 1) subjective complaint using standardized questionnaire, 2) objective testing using Mini-Addenbrook's Cognitive Examination (ACE), and for a diagnosis of major postoperative neurocognitive disorder, 3) evidence of functional decline using Lawton-Brody's instrumental activities of daily living (ADL) scale | Assessed at 90 days and 1 year after surgery | |
Secondary | Postoperative cognitive decline | Defined by a 2 or more-point drop in Mini-ACE scores | Assessed at 90 days and 1 year after surgery | |
Secondary | Functional decline | As measured by the change in Lawton-Brody's instrumental ADL scores | Assessed at 90 days and 1 year after surgery | |
Secondary | All-cause mortality | Assessed at 1 year after surgery | ||
Secondary | Duration of delirium | Duration of delirium for the first 7 days after surgery | 7 days after surgery |
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