Controversies in the perioperative management of the vulnerable brain

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Controversies in the perioperative management of the vulnerable brain – ATOTW 572

06 June 2026

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1) Extended preoperative assessment in vulnerable individuals can prevent postoperative Neuro Cognitive Disorders (NCD’s).

True False

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Extended preoperative assessment alone cannot prevent NCD’s. It may help identify high risk individuals and direct the anaesthesiologist to adopt brain protective strategies in perioperative period.

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2) Months backward test (MBT), Short-Blessed Test, Telephone Interview of Cognitive status (TICS), Time & Change (T&C) test are validated tests to be used for cognitive screening in preoperative assessment.

True False

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Only Mini-Mental status examination (MMSE), Clock drawing test (CDT) and Mini-Cog are validated to be used by anaesthesiologists in preoperative assessment.

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3) Perioperative Brain Health Initiative (PBHI) recommends the 4 A’s assessment (Arousal, Attention, Abbreviated mental test and Acute change) test or Confusion assessment Method (CAM) in all high risk older patients before emergency surgery.

True False

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4 A’s test or CAM test should ideally be performed in all high risk older patients before emergency surgery and at time of discharge from recovery room and twice daily till Day 5 or discharge.

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4) Diagnosis of cognitive impairment in the preoperative period can be achieved with Mini-Cog.

True False

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Mini-Cog is only a screening test. It is not a diagnostic test. Moreover, the results have to be interpreted with caution.

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5) Cognitive prehabilitation improves post operative cognitive outcomes in high-risk vulnerable individuals.

True False

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Currently there is no conclusive proof of the efficacy of Cognitive prehabilitation in improving cognitive outcomes.

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6) Dexmedetomidine is neuroprotective drug and has to be used in all high-risk patients for prevention of Delirium

True False

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Though Dexmedetomidine is neuroprotective drug, it should be used cautiously because of its known side effects of Hypotension and Bradycardia. Moreover, the current evidence for routine use of Dexmedetomidine is very low.

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7) Neuraxial Anaesthesia is better than General Anaesthesia for prevention of neurocognitive disorders.

True False

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Multiple RCT’s and meta- analyses have shown that neither type of anaesthesia are better in prevention of neurocognitive disorders. However, the final choice of primary anaesthetic technique should be based on type of surgery, patient condition, practitioner and patient preferences with shared decision making.

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8) TIVA is better than Inhalational agents in prevention of perioperative neurocognitive disorders.

True False

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Multiple RCT’s and meta-analyses have shown neither are better in prevention of neurocognitive disorders. Peri operative Brain Health initiative, ASA 2025 practice guidelines advocate both techniques.

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9) Hypothermia is neuroprotective and hence Intraoperative hypothermia must be maintained.

True False

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Hypothermia is a risk factor for delirium. Recent meta-analysis on effect of temperature on postoperative neurocognitive disorders supported Normothermia.

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10) Short acting benzodiazepines like Midazolam can be used as premedication in high risk vulnerable individuals.

True False

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American geriatric society and European Society of Anesthesiologists advocate guarded use of short acting benzodiazepines as premedication and the ASA (2025) practical guidelines advise weighing individual risk vs benefit.

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11) Remimazolam is recommended for prevention of postoperative neurocognitive disorders.

True False

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Remimazolam is a newer agent with much research yet to be conducted to define its role. There is currently no consensus recommendation for regular use of Remimazolam in high-risk individuals. Recent metanalyses showed Remimazolam was beneficial in preventing post operative NCD’s but currently with a low level of evidence.

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12) Esketamine is a neuroprotective drug and can prevent Postoperative Delirium.

True False

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Esketamine, is a S-enantiomer of ketamine and a NMDA antagonist. It is known to have a profound effect on hippocampal synaptic plasticity, minimising surgical stress response and decreasing neuroinflammatory markers. However, there is no current consensus for use of Esketamine for POD prevention.

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13) Processed EEG indices like Bispectral index are more useful than interpretation of raw EEG in elderly individuals.

True False

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Processed EEG indices such as Bispectral Index(BIS), Entropy and Patient safety Index (PSI) provide information about depth of anaesthesia. However, interpretation is not reliable in older and vulnerable individuals because of reduced cortical activity and low EEG power.

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14) Scottish Intercollegiate Guidelines Network (SIGN) guidelines recommend depth of anaesthesia monitoring in all patients over 60 years under GA for surgery expected to last for more than one hour.

True False

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SIGN guidelines recommend for mandatory depth anaesthesia monitoring in high risk vulnerable individuals in order to avoid excessive depth of anaesthesia.

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15) Near infrared spectrograph(NIRS) monitoring is recommended for all elderly patients intraoperatively for the prevention of Postoperative Delirium.

True False

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Near infrared spectrograph (NIRS) monitoring is used as routine monitoring technique in cardiac patients. Its use in all elderly patients intraoperatively for prevention of POD is not recommended by Perioperative Brain Health Initiative.

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16) Steroids like dexamethasone are advocated for prevention of Postoperative Delirium.

True False

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Though steroids can reduce inflammation and thereby inhibit pain pathways, currently the fifth International Perioperative Neurotoxicity Working Group does not support the use of steroids for preventing neurocognitive disorders.

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17) Pethidine is contraindicated in high-risk vulnerable individuals in view of the risk of Delirium.

True False

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Pethidine is known to have high risk of Delirium.

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18) Anticholinergic drugs prevent post operative delirium.

True False

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Anticholinergics like Diphenhydramine, Promethazine and Atropine aggravate delirium and are contraindicated.

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19) Preventing burst suppression in EEG is beneficial for better cognitive outcomes.

True False

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Intraoperative burst suppression must be avoided or the duration of burst suppression minimised in high risk vulnerable individuals to prevent long PND’s.

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20) Antipsychotics like Haloperidol are the mainstay in management of postoperative Delirium.

True False

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Non-pharmacologic interventions are the first choice for prevention and management of post operative delirium. Antipsychotics like Haloperidol and Risperidone can be used only in the setting of violent behaviour or severe hallucinations.

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