FEATURED ARTICLE

Perioperative Brain Health: A New Multi-Stakeholder Initiative Led by the American Society of Anesthesiologists

By Stacie G. Deiner, MD
The Icahn School of Medicine at Mount Sinai, New York, New York
Carol J. Peden, MD, MB, ChB, MPH
University of Southern California, Los Angeles, California
Lee A. Fleisher, MD
Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 
Roderic G. Eckenhoff, MD
Perelman School of Medicine,  University of Pennsylvania, Philadelphia, Pennsylvania 

The American Society of Anesthesiologists (ASA) convened an ad-hoc committee, Brain Health Initiative (BHI), in 2016 to address perioperative cognition in older adults after surgery. The committee (listed at the end of this article) has formed a multi-stakeholder group which includes specialty societies that care for older patients undergoing surgery, including, but not limited to: the American College of Surgeons, the American Association of Orthopedic Surgeons, the American Geriatric Society, payers (e.g. Centers for Medicare and Medicaid Services, Veterans Affairs), public advocacy groups (e.g. American Association of Retired Persons, IHI) and federal funders (National Institute of Aging, Patient Centered Outcomes Research Institute). 

The Mission of the BHI is:

  • To create a low barrier access program to minimize the impact of preexisting cognitive deficits, and optimize the cognitive recovery and perioperative experience for older (>65) adults undergoing surgery.
  • To make available a three-year comprehensive plan that anesthesiology departments can follow to become centers of excellence.
  • To create a campaign through which all anesthesiologists have greater awareness of the importance of pre-operative screening for cognitive deficit and of appropriate protective measures to minimize impact on cognitive function during the perioperative period.
  • To provide a stepped implementation program supported by tools. Some departments may choose to implement years one to three at an accelerated pace, including consideration of intraoperative monitoring of the brain.  However, the intention of this campaign is to ensure widespread early adoption of the simplest evidence-based methods of cognitive protection.

Since its inception in 2016, the group has created a website with tips and tools for providers, links to research and publications, as well as advice about how to create change in your health system. The committee created a model recommended process to begin to advise patients about cognitive change and implement best practice. The three-year phase includes:

First Phase PrioritiesEducate Patients and Providers 

  • Identify patients at high risk for delirium: provide tools for simple preoperative screening for cognitive impairment and risk factors including past history of confusion or disorientation.
  • Assist providers in talking with patients about delirium through the provision of checklists covering risk factors and the promotion of orientation through hearing aids, glasses, importance of family/friends bedside presence and reassurance. 
  • Educate perioperative providers regarding perioperative anesthetic sedative and analgesic drug choices, including medications to be avoided.

Second Phase – Implementation of Recommendations for Geriatric Surgical Patients

  • Development of a Patient Screening Program for delirium which hospitals can implement in the PACU, on the ward and ICU using a validated tool (CAM versions). Posters/flyers will be developed for PACU staff. Resident and student projects will be encouraged to accelerate the initiative.
  • Utilize regular pain assessments to adjust pain regimen as needed.
  • Screen preoperative patients for polypharmacy and Beers List medications.

Medication Recommendations Might Include:

  • Do not routinely give benzodiazepines as a pre-sedative or sedation to patients greater than 70 years old; impact can be very long lasting.  If these drugs are given, document justification. 
  • Use dexmedetomidine instead of opioids, benzodiazepines, and propofol in the ICU for sedation. Benzodiazepines should never be used for infusion.
  • Do not give diphenhydramine for sedation or sleep.
  • Remove meperidine from order sets.
  • Low dose first or second generation antipsychotics (haloperidol or risperdone/olanzapine) only for delirium (not for prevention); never as a standing order and for agitated delirium only.
  • Distinguish agitation from pain or anxiety. If patient is delirious look for underlying causes, re-orient, utilize family. Use medication and restraint as a last resort.

Third Phase – Proactive Risk Modification

  • Develop a paradigm for early assessment of patients with cognitive impairment or history of delirium, followed by appropriate consultation, which might include geriatric and neuropsychology referral prior to surgery and/or specialized services after the procedure. 
  • Provide an orientation program to include environmental cues (white boards) and support of sleep/wake cycles (timing of vital signs, blood draws, ear plugs, eye shades).
  • Develop protocols for early mobilization and early physical therapy consult, including in the ICU.
  • Evaluate of the role of intraoperative brain function monitoring as a means of reducing delirium in those at risk.

In recognition of the fact that hospitals may adapt these recommendations to be most effective for their practice situation, the BHI collects and publishes provider experiences to decrease postoperative delirium and optimize cognitive function after review by an editorial committee.

The BHI also intends to collect patient experiences with delirium and postoperative cognitive change; some are currently posted. If you or your patients would like to share their experience, please contact: brainhealth@asahq.org.

In June 2018, the ASA and AARP will sponsor a summit on Capitol Hill with the multi-stakeholder group and leading scientists in the field, the goals of which will be to refine the recommendations for patients and providers, to develop strategies for implementation and to identify critical knowledge gaps for further research.

ASA Ad Hoc Committee

Lee A. Fleisher, MD, Chair
Stacie G. Deiner, MD, Vice Chair for Clinical Activities
Roderic G. Eckenhoff, MD, Vice Chair for Scientific Activities
Carol J. Peden, MB, ChB, MD, MPH, Vice Chair for Performance Improvement
Alexander A. Hannenberg, MD, ASA Interim Chief Quality Officer
Daniel J. Cole, MD, FASA, Member
James C. Eisenach, MD, Member
Hugh C. Hemmings, MD, PhD, Member
Keith A. Jones, MD, Member
Evan D. Kharasch, MD, PhD, Member
Jeffrey R. Kirsch, MD, FASA, Member
Aman Mahajan, MD, PhD, Member
Jeanine P. Wiener-Kronish, MD, Member

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