Episode #47 Brain Safety: Then, Now, and Beyond

June 1, 2021

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Welcome to the next installment of the Anesthesia Patient Safety podcast hosted by Alli Bechtel.  This podcast will be an exciting journey towards improved anesthesia patient safety.

For this show, we are returning to the October 2020 ASPF Newsletter for a “What Then” and “What Now” look at brain health and safety.

The original top 10 article is from the February 2019 APSF Newsletter. It is called “Perioperative Brain Health –It’s Not All Positive Attitude, Exercise, and Superfoods” by Nirav Kamdar, MD, MPP; Lee A. Fleisher, MD; Daniel Cole, MD. You can find the article here. https://www.apsf.org/article/perioperative-brain-health-its-not-all-positive-attitude-exercise-and-superfoods/

Here are some ideas that the authors report from 2019 for opportunities and challenges related to patient brain health going forward.

Audience Generated Reflections

Patient advocacy societies must maintain an active list of the most frequent and pertinent questions from patients.

Specialty organizations, such as the APSF, need to invest in developing and evaluating screening tools for brain health, including future technologies such as machine learning-based risk assessment.

There is a need to establish intraoperative brain monitoring standards linked to improved outcomes that can be implemented directly in our operating rooms (i.e., processed electroencephalogram).

The updated article from the October 2020 article is “Brain Safety: The Next Frontier for Our Specialty” by Nirav Kamdar, MD, MPP, MBA; Phillip E. Vlisides, MD; Daniel J. Cole, MD. You can find the article here. https://www.apsf.org/article/brain-safety-the-next-frontier-for-our-specialty/

For more information about the Mini-Cog Test which may be used for preoperative screening for patients at higher risk for postoperative delirium, check out https://mini-cog.com/

Special thanks to Nirav Kamdar for his contributions to the show today.

This is a two part show and we hope that you will join us next week when we will discuss future research ideas and consider the role for Implementation Science and Quality Improvement.

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© 2021, The Anesthesia Patient Safety Foundation

Hello and welcome back to the Anesthesia Patient Safety Podcast.  My name is Alli Bechtel and I am your host. Thank you for joining us for another show.  We will be discussing the June 2021 APSF Newsletter articles before we know it, but first there is another article from the October 2020 APSF Newsletter that we haven’t talked about yet.

Before we dive into today’s episode, we’d like to recognize Medtronic, a major corporate supporter of APSF. Medtronic has generously provided unrestricted support as well as research and educational grants to further our vision that “no one shall be harmed by anesthesia care”. Thank you, Medtronic – we wouldn’t be able to do all that we do without you!”

Some people consider space the next frontier…

[Space audio clip]

For our guest author today, Brain Safety is the next Frontier. I will let him introduce himself. Let’s take a listen.

[Kamdar] Hi my name is Nirav Kamdar. I’m an associate professor of anesthesiology at UCLA and director of quality and innovation.

[Bechtel] We are so excited to have Kamdar send in some audio clips. To get us started today, I asked Kamdar why he wrote this article. So, sit back and relax as he kicks off the show.

[Kamdar] With increasing frequency our patients enquire about the neurocognitive effects when they undergo general anesthesia. Parents often ask these questions before their children undergo general anesthesia and the elderly in particular are curious about their brain safety and fear the post-surgical brain fog that they may have experienced in a previous surgical episode or they fear their own neurocognitive decline from delirium after surgery. With my own interest in public policy, I could not ignore this problem as more than one third of our population will be over the age of 65 and will be accessing healthcare and surgical services with greater frequency and all the while neurocognitive and delirium associated healthcare costs are rising with heavy price tags. With my own scientific interests that falls into neurobiology, there is a vast intersection of hypothesis that contribute that make avenues for scientific discovery an exciting arena of research. Without one unifying biomarker to follow or a single intervention to implement, brain safety in anesthesia is a complex problem, requiring both scientific investigation and human factors driven interventions. That makes this an exciting place for scientific discovery, challenging patient care, and implementation science to intersect.”

[Bechtel] Thank you to Kamdar for kicking off the show. Now it is time to get into the article or rather articles. Our featured article today is “Brain Safety: The Next Frontier for Our Specialty” by Kamdar and colleagues. This article was published in the October 2020 APSF Newsletter. To follow along with us, head over to APSF.org and click on the Newsletter heading. Fourth one down is Newsletter Archives. Then click on October 2020. Then, scroll down looking at the left hand column until you come to our featured article. The October 2020 APSF newsletter had a special theme of “What then and What now” and included a review of the Top 10 most impactful anesthesia patient safety articles with a recent update.

The original article was published in the February 2018 APSF Newsletter. It was called “Perioperative Brain Health –It’s Not All Positive Attitude, exercise, and Superfoods by Kamdar, Fleisher, and Cole. I will include a link to the article in the show notes and you can find the article by clicking on the link at the top of our featured article as well.

So, before we get to the next frontier, we need to start with Perioperative Brain Health. This is such an important topic. Patients may come in for surgery and be more worried about the effects of surgery and anesthesia on their brain health than the surgery itself. Anesthesia professionals are responsible for administering medications and monitoring patients and want to help keep patients safe and this includes their cognitive function as well. So, the authors start with the very important questions, “What can be done to protect my perioperative brain health?” This article provides insight into a panel presentation sponsored by the APSF that included academic anesthesiologists, researchers, patient engagement and public policy representatives. This multidisciplinary team evaluated the following 3 questions:

(1) What do patients want to know about preserving brain health before upcoming surgery?

(2) What can clinicians do to address brain health perioperatively?

(3) How do clinician’s and patient’s goals align with smart public policy?

These are really great questions that highlight this important area of anesthesia patient safety. We have already talked about the safety of anesthesia with pediatric patients and neurocognitive developmental outcomes on the podcast for episodes #27 and #28 when we talked about Anesthesia and the Developing Brain. Today, we are going to take a closer look at the cognitive effects of anesthesia for elderly patients.  This is a common question that is asked during preop and post op patient evaluations. “When will I start to feel like myself again” or “Will I have any difficulty concentrating or reading?” Patients may also ask if there is anything that they can do to decrease their risk for cognitive dysfunction and what kind of cognitive effects may occur as a result of the surgery and anesthesia and what is the expected time frame for symptoms resolution. Brain health is not just an important anesthesia patient safety concern, but it is also costly since postoperative delirium and cognitive dysfunction occurs with an incidence of 5-50% with a cost to the health care system of an impressive $150 billion.

Now that we understand the scope of the problem. What can we do about it? There are screening tools that can be used to assess patients before and after surgery to evaluate cognitive function and discover the impact of surgery and anesthesia. Some of these tools include The Mini-cognition questionnaire and the Frailty Scoring Scale. Both of these tools are included in the article, so click over there to take a look at it when you are done listening to the show. These screening tools may be something that you want to include in your department’s practice, but protecting patients’ brain health involves many more components and requires input from the patients, providers, and policy makers. What does this look like? The authors report that working with geriatric societies and federal partners may allow for top-down leadership with a well thought out strategic agenda to prioritize brain health while at the same time invested clinicians may be able to  change clinical practice to inform a bottom-up cultural change as well. The geriatric societies are important resources to provide information about brain health initiatives for patients and clinicians. Lee Fleisher also included an important call to action for financial incentives that allow medical professionals the opportunity to participate in brain health research and developing programs. From back in 2019, the authors provide ideas and challenges for protecting brain health of patients undergoing surgery and anesthesia going forward.

First, patient advocacy societies must maintain an active list of the most frequent and pertinent questions from patients. This will be helpful for anesthesia professionals to be prepared to answer these important questions so that patients are armed with knowledge and engaged in their medical care.

Second, Specialty organizations including the APSF, must invest in developing and evaluating screening tools for brain health and this will likely include future advanced medical technologies such as machine learning based risk assessment.

Finally, there was a call to action to develop intraoperative brain monitoring standards that can help lead to improved patient outcomes and are able to be implemented in the operating room. The example that they give is the processed EEG.

It has been fun learning about what was happening in 2019 but now it is time to explore the new frontier of brain safety with the updated October 2020 APSF Newsletter article.

The authors start with a reminder about where the APSF started with the mission that no patient shall be harmed by anesthesia care. 35 years ago, this meant working to improve events related to cardiac arrest, hypoxia, and human error. The working definition of patient safety is much broader in scope and reach now. Here is an updated definition that the authors modified from Gaba and Weinger:

“Safety is how we deliver care in a way that prevents harm from the processes of care, and the behavior of the humans embedded in the system of care. Safety is an emergent property of the system that occurs when we actively try to achieve it.”

Advances in patient safety over the years can be attributed to standards and guidelines, advances in medical technology and devices, focus on human factors, and the development of a culture of safety within institutions. This new frontier takes the initial goal, to see patients safely through surgery and anesthesia care, to a whole new vision of safe patient care that brings them out of surgery and anesthesia safely with improved functional, psychological, and cognitive health in the postoperative phase and beyond. One of the threats to this goal is postoperative delirium and we need more information about the pathophysiology, diagnosis and identification, and tools for monitoring and effective treatment. With the large percentage of older patients in the United states which predicts that over 1/3rd of patients will be older than 65 in the US, this is a big problem and the good news is that many of these cases can be prevented with care pathways designed to decrease the risk for postoperative delirium.

What do we know about postoperative delirium? According to the 2018 Perioperative Brain Health Initiative Summit Report, risk factors for development of postoperative delirium include baseline cognitive decline, dementia, poor vision, poor hearing, severe illness and underlying infection. In addition, the summit report provides information about the pathophysiology of postop delirium which appears to be related to neurotransmitter imbalance, inflammation and related changes due to aging, epigenetic change, and microglial priming, stress response, cellular metabolism, pre-existing neurologic vulnerability and changes in network neurobiology. Before patients even come in to the OR, we can begin the evaluation to assess the risk for postop delirium. This is in-line with the recommendations from the 2015 American Geriatrics Society Guidelines which includes pre-op cognitive screening. Screening may include the Mental Status Exam or a shortened version of the mini-cognition questionnaire. The mini cog includes a three step exam. The first step is 3 Word Registration. The second step is Clock Drawing and the third step is 3 Word Recall. For more information you can check out the website, mini-cog.com and I will include a link in the show notes.

As we move from screening to testing, there are additional tools to help make the diagnosis for postoperative delirium including the following:

The Confusion Assessment Method (CAM)
The Confusion Assessment Method that has been modified for the ICU (CAM-ICU)
Nursing Delirium Screening Scale
Delirium Symptom Interview

There is no consensus for which tool is the single best tool at this time. It is important that healthcare professionals receive training and have experience using the tools to improve diagnosis rates and accuracy especially since patients with postop delirium often have changes in severity over time.

Patients and family members may ask questions about what can be done to minimize the risk for postoperative delirium. Prevention strategies at this time include Minimizing use of or avoidance of high-risk medications such as benzodiazepines, anticholinergic medications, higher dose corticosteroids, and meperidine as well as decreasing polypharmacy if possible.

Treatment for postop delirium starts with non-pharmacologic therapy.

There is still so much to learn about this area. One idea was that if we could closely monitor the depth of anesthesia with technology such as cerebral blood flow and EEG-based monitoring and then provide adequate anesthesia, but at a reduced depth of anesthesia then perhaps this could help to decrease the risk for postop delirium. Results from the ENGAGES trial published in 2019 in JAMA revealed no difference in rates of postoperative delirium in patients over 60 years old undergoing major surgery with EEG monitoring for depth of anesthesia compared to usual anesthesia care.

We have learned a lot about postoperative delirium but there is still so much to learn and do to help keep our patients safe. And that is why I hope you will join us next week for part 2 about Brain Health. Thank you so much to Kamdar for his contributions to the show today and we are looking forward to hearing more next week. We will also discuss future research ideas and we will consider the role for Implementation Science and Quality Improvement. You will not want to miss it!

If you have any questions or comments from today’s show, please email us at [email protected].

Visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.  Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. Have you joined the conversation on twitter? If so, we would love for you to tag us in a tweet using #ASPF podcast and tell us where you like to listen to the show. Thanks for listening and we can’t wait to hear from you soon!

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

© 2021, The Anesthesia Patient Safety Foundation