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Cui Q, Peng Y, Liu X, Jia B, Dong J, Han R. Effect of anesthesia depth on postoperative clinical ou tcome in patients with supratentorial tumor (DEPTH): study protocol for a randomized controlled trial. BMJ Open 2017; 7:e016521. [PMID: 28899891 PMCID: PMC5595190 DOI: 10.1136/bmjopen-2017-016521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Recent studies have shown that deep anaesthesia is associated with poor outcomes. However, no randomised controlled trials have been conducted to test the causality in patients undergoing brain tumour resection. METHODS AND ANALYSIS DEPTH is a multicenter, randomised, parallel-group, blind trial. The depth of general anaesthesia will be monitored using the bispectral index (BIS). Patients elected for supratentorial tumour resection will be randomly allocated to the deep or the light anaesthesia group in which the target BIS value is 35 or 50, respectively. BIS will be maintained at the target value for more than 90% of the total anaesthesia period. The primary outcome is the disability-free survival rate at postoperative 30 days and 1 year. The secondary outcomes are the mortality and morbidity within 30 days after surgery. ETHICS APPROVAL AND DISSEMINATION Ethical approval has been granted by the Medical Ethics Committee of Beijing Tiantan Hospital, Capital Medicine University. The reference number is KY2016-059-02. The results of this study will be disseminated through presentations at scientific conferences and publication in scientific journals. TRIAL REGISTRATION NCT03033693.
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Affiliation(s)
- Qianyu Cui
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuming Peng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaoyuan Liu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Bo Jia
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jia Dong
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ruquan Han
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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A Prospective Study of Age-dependent Changes in Propofol-induced Electroencephalogram Oscillations in Children. Anesthesiology 2017; 127:293-306. [PMID: 28657957 DOI: 10.1097/aln.0000000000001717] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND In adults, frontal electroencephalogram patterns observed during propofol-induced unconsciousness consist of slow oscillations (0.1 to 1 Hz) and coherent alpha oscillations (8 to 13 Hz). Given that the nervous system undergoes significant changes during development, anesthesia-induced electroencephalogram oscillations in children may differ from those observed in adults. Therefore, we investigated age-related changes in frontal electroencephalogram power spectra and coherence during propofol-induced unconsciousness. METHODS We analyzed electroencephalogram data recorded during propofol-induced unconsciousness in patients between 0 and 21 yr of age (n = 97), using multitaper spectral and coherence methods. We characterized power and coherence as a function of age using multiple linear regression analysis and within four age groups: 4 months to 1 yr old (n = 4), greater than 1 to 7 yr old (n = 16), greater than 7 to 14 yr old (n = 30), and greater than 14 to 21 yr old (n = 47). RESULTS Total electroencephalogram power (0.1 to 40 Hz) peaked at approximately 8 yr old and subsequently declined with increasing age. For patients greater than 1 yr old, the propofol-induced electroencephalogram structure was qualitatively similar regardless of age, featuring slow and coherent alpha oscillations. For patients under 1 yr of age, frontal alpha oscillations were not coherent. CONCLUSIONS Neurodevelopmental processes that occur throughout childhood, including thalamocortical development, may underlie age-dependent changes in electroencephalogram power and coherence during anesthesia. These age-dependent anesthesia-induced electroencephalogram oscillations suggest a more principled approach to monitoring brain states in pediatric patients.
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Ramírez MIG, Rodríguez-Arias LR, Santiago AO, Pizano AL, Zamora RL, Gregorio RV, Trenado C, Sánchez HMG, San-Juan D. Correlation Between Bispectral Index and Electrocorticographic Features During Epilepsy Surgery. Clin EEG Neurosci 2017; 48:272-279. [PMID: 27325591 DOI: 10.1177/1550059416654850] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Surgical resection guided by intraoperative electrocorticography (iECoG) has been in clinical use for many decades. The use of the bispectral index (BIS) for monitoring depth of anesthesia during different types of surgery, including epilepsy surgery, is increasing nowadays. The BIS is an EEG-derived variable indicating cortical electrical activity. However, the correlation between the BIS score and the iECoG score, with the purpose of optimizing the quality and time of the iECoG recordings in epilepsy surgery is unknown. The goal of this study was to evaluate the correlation between BIS values and iECoG parameters during the epilepsy surgery under anesthesia with propofol and fentanyl. This is a prospective study that included patients with epilepsy who underwent epilepsy surgery guided by BIS and iECoG (September 2008 to October 2013). Clinical, physiological, and sociodemographic characteristics are shown. We correlated the iECoG parameters (presence of burst suppressions [BS], suppression time [seconds], background frequency [Hz], and type of iECoG score by Mathern et al) with BIS values. We included 28 patients, 15/28 (53.5%) female, general mean age of 30.5 years (range 13-56 years). Patients underwent epilepsy surgery: 22/28 (79%) temporal and 6/28 (21%) extratemporal. We found a nonlinear polynomial cubic relationship between the mentioned variables noting that a BIS range of 40 to 60 gave the following results: iECoG BS periods <5 seconds, background frequency 10 to 17 Hz, and iECoG score 2 characterized by lack of >20-Hz background frequencies. No BS were observed with a BIS > 60. In conclusion BIS values and iECoG parameters during the epilepsy surgery under anesthesia with propofol and fentanyl have a nonlinear correlation. BS patterns were not found with a BIS > 60. These findings show that BIS is a nonlinear multidimensional measure, which possesses high variability with the iECoG parameters. BS patterns are not found with BIS > 60.
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Affiliation(s)
| | | | - Areli O Santiago
- 1 Neuroanesthesiology Department. National Institute of Neurology, Mexico City, Mexico
| | | | | | - Rafael V Gregorio
- 3 Clinical Neurophysiology Department, National Institute of Neurology, Mexico City, Mexico
| | - Carlos Trenado
- 4 Institute of Clinical Neuroscience and Medical Psychology, University Hospital Düsseldorf, Dusseldorf, Germany
| | - Héctor Manuel G Sánchez
- 5 Faculty of Medicine of the Autonomous University of Baja California, Campus of Mexicali, Mexicali, Baja California, Mexico
| | - Daniel San-Juan
- 3 Clinical Neurophysiology Department, National Institute of Neurology, Mexico City, Mexico
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Willingham M, Avidan M. Triple low, double low: it’s time to deal Achilles heel a single deadly blow. Br J Anaesth 2017; 119:1-4. [DOI: 10.1093/bja/aex132] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Hagihira S. Brain Mechanisms during Course of Anesthesia: What We Know from EEG Changes during Induction and Recovery. Front Syst Neurosci 2017; 11:39. [PMID: 28611602 PMCID: PMC5447006 DOI: 10.3389/fnsys.2017.00039] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 05/11/2017] [Indexed: 12/11/2022] Open
Affiliation(s)
- Satoshi Hagihira
- Department of Anesthesiology, Kansai Medical UniversityOsaka, Japan.,Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of MedicineOsaka, Japan
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Idiopathic decreased bispectral index during anaesthesia emergence: Possible causes for the phenomenon of paradoxical arousal. ACTA ACUST UNITED AC 2017; 64:472-475. [PMID: 28347549 DOI: 10.1016/j.redar.2017.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 01/09/2017] [Accepted: 02/13/2017] [Indexed: 11/23/2022]
Abstract
In a small percentage of patients, sound, touch and even nociceptive stimulation in the presence of a light anaesthetic depth does not cause an electroencephalogram wave pattern of cortical activation (α, β waves) as would be expected, but leads to a slowed electroencephalogram pattern instead. We report the case of a patient who on emerging from anaesthesia showed very slowed brain activity on the electroencephalogram and reduced algorithmic value, that lasted approximately 5min coinciding with sound and tactile stimulation. After keeping her under observation for 24h during the postoperative period she did not present any brain disorder that could justify that event.
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Abstract
PURPOSE OF REVIEW Initial studies suggested that the use of processed electroencephalogram technology could significantly decrease the incidence of unintended intraoperative awareness events during general anesthesia. Subsequent work has cast doubts on these findings. This review will examine the current state of awareness monitoring. RECENT FINDINGS Recently published randomized controlled trials examining the use of the bispectral index during general anesthesia have not been able to show superiority over other forms of monitoring depth of anesthesia, such as end-tidal anesthetic-agent concentration. Additionally, there is current interest in utilizing the unprocessed electroencephalogram to ascertain depth of anesthesia and recent studies have demonstrated its use in preventing postoperative delirium. SUMMARY Although awareness monitors such as the bispectral index monitor may have benefit in patients in whom volatile anesthetic agents must be minimized - such as in hemodynamically unstable patients, or patients undergoing total intravenous anesthesia - these monitors do not appear to be useful for all patients.
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Kang H, Mohamed HMH, Takashina M, Mori T, Fujino Y, Hagihira S. Individual indicators of appropriate hypnotic level during propofol anesthesia: highest alpha power and effect-site concentrations of propofol at loss of response. J Anesth 2017; 31:502-509. [PMID: 28197775 DOI: 10.1007/s00540-017-2319-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 02/01/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Electroencephalogram (EEG) waveforms vary widely among individuals, this decreases the usefulness of BIS™ monitors for assessing the effects of propofol. Practically, anesthesia is only seen as too deep when evidence of burst-suppression is seen. We designed an experiment to help towards better assessment of individual anesthetic needs. First, to mark the Ce (effect-site concentration) of propofol at loss of response to calling name and gently shaking shoulders (LOR), we defined Ce-LOR. To mark the transient power increase in the alpha range (9-14 Hz), common to all patients, when propofol concentration gradually increases, we defined Ce-alpha as the highest recorded alpha power for Ce. We also defined Ce-OBS as the Ce of propofol at initial observation of burst-suppression. Then we tried to predict Ce-LOR and Ce-alpha from Ce-OBS, vice versa, and considered the significance of these parameters. METHODS We enrolled 26 female patients (age 33-65) who were undergoing scheduled mastectomy. During anesthesia, we recorded all raw EEG packets as well as EEG-derived parameters on a computer from BIS-XP™ monitor. Propofol was infused using a TCI pump. Target concentration was adjusted so that Ce of propofol was gradually increased. RESULTS We obtained the following regression equation; Ce-alpha or Ce-OBS = Ce-LOR × 0.87 + 1.06 + dummy × 0.83 (for Ce-alpha dummy = 0, and for Ce-OBS = 1; adjusted r = 0.90, p < 2.2e-16) by ANCOVA. At Ce-alpha, BIS was 50.2 ± 7.7. CONCLUSION Ce-alpha and Ce-OBS could be estimated from Ce-LOR. Based on Ce-LOR it is possible to manage the hypnotic level of individual patients.
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Affiliation(s)
- Hongling Kang
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita City, 565-0871, Osaka, Japan
| | | | - Masaki Takashina
- Surgical Center, Osaka University Hospital, 2-15 Yamadaoka, Suita City, 565-0871, Osaka, Japan
| | - Takahiko Mori
- Department of Anesthesilogy, Surgical Center, Osaka General Medical Center, 3-1-56 Bandai-higashi, Sumiyoshi-ku, Osaka, 558-8558, Japan
| | - Yuji Fujino
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita City, 565-0871, Osaka, Japan
| | - Satoshi Hagihira
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita City, 565-0871, Osaka, Japan. .,Department of Anesthesilogy, Surgical Center, Osaka General Medical Center, 3-1-56 Bandai-higashi, Sumiyoshi-ku, Osaka, 558-8558, Japan.
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Yang N, Yue Y, Pan JZ, Zuo MZ, Shi Y, Zhou SZ, Peng WP, Gao JD. Changes in the Bispectral Index in Response to Loss of Consciousness and No Somatic Movement to Nociceptive Stimuli in Elderly Patients. Chin Med J (Engl) 2017; 129:410-6. [PMID: 26879014 PMCID: PMC4800841 DOI: 10.4103/0366-6999.176083] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background: Bispectral index (BIS) is considered very useful to guide anesthesia care in elderly patients, but its use is controversial for the evaluation of the adequacy of analgesia. This study compared the BIS changes in response to loss of consciousness (LOC) and loss of somatic response (LOS) to nociceptive stimuli between elderly and young patients receiving intravenous target-controlled infusion (TCI) of propofol and remifentanil. Methods: This study was performed on 52 elderly patients (aged 65–78 years) and 52 young patients (aged 25–58 years), American Society of Anesthesiologists physical status I or II. Anesthesia was induced with propofol administered by TCI. A standardized noxious electrical stimulus (transcutaneous electrical nerve stimulation, [TENS]) was applied (50 Hz, 80 mA, 0.25 ms pulses for 4 s) to the ulnar nerve at increasing remifentanil predicted effective-site concentration (Ce) until patients lost somatic response to TENS. Changes in awake, prestimulus, poststimulus BIS, heart rate, mean arterial pressure, pulse oxygen saturation, predicted plasma concentration, Ce of propofol, and remifentanil at both LOC and LOS clinical points were investigated. Results: BISLOC in elderly group was higher than that in young patient group (65.4 ± 9.7 vs. 57.6 ± 12.3) (t = 21.58, P < 0.0001) after TCI propofol, and the propofol Ce at LOC was 1.6 ± 0.3 μg/ml in elderly patients, which was significantly lower than that in young patients (2.3 ± 0.5 μg/ml) (t = 7.474, P < 0.0001). As nociceptive stimulation induced BIS to increase, the mean of BIS maximum values after TENS was significantly higher than that before TENS in both age groups (t = 8.902 and t = 8.019, P < 0.0001). With increasing Ce of remifentanil until patients lost somatic response to TENS, BISLOS was the same as the BISLOC in elderly patients (65.6 ± 10.7 vs. 65.4 ± 9.7), and there were no marked differences between elderly and young patient groups in BISawake, BISLOS, and Ce of remifentanil required for LOS. Conclusion: In elderly patients, BIS can be used as an indicator for hypnotic-analgesic balance and be helpful to guide the optimal administration of propofol and remifentanil individually. Trial Registration: CTRI Reg. No: ChiCTR-OOC-14005629; http://www.chictr.org.cn/showproj.aspx?proj=9875.
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Affiliation(s)
| | - Yun Yue
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
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Escontrela Rodríguez B, Gago Martínez A, Merino Julián I, Martínez Ruiz A. Spectral entropy in monitoring anesthetic depth. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2016; 63:471-478. [PMID: 26431743 DOI: 10.1016/j.redar.2015.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2015] [Revised: 06/30/2015] [Accepted: 07/14/2015] [Indexed: 06/05/2023]
Abstract
Monitoring the brain response to hypnotics in general anesthesia, with the nociceptive and hemodynamic stimulus interaction, has been a subject of intense investigation for many years. Nowadays, monitors of depth of anesthesia are based in processed electroencephalogram by different algorithms, some of them unknown, to obtain a simplified numeric parameter approximate to brain activity state in each moment. In this review we evaluate if spectral entropy suitably reflects the brain electric behavior in response to hypnotics and the different intensity nociceptive stimulus effect during a surgical procedure.
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Affiliation(s)
- B Escontrela Rodríguez
- Servicio Anestesiología y Reanimación, Hospital Universitario de Cruces, Barakaldo, Vizcaya, España.
| | - A Gago Martínez
- Servicio Anestesiología y Reanimación, Hospital Universitario de Cruces, Barakaldo, Vizcaya, España
| | - I Merino Julián
- Servicio Anestesiología y Reanimación, Hospital Universitario de Cruces, Barakaldo, Vizcaya, España
| | - A Martínez Ruiz
- Servicio Anestesiología y Reanimación, Hospital Universitario de Cruces, Barakaldo, Vizcaya, España; Facultad de Medicina, Universidad del País Vasco, Leioa, Vizcaya, España
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Short TG, Campbell D, Leslie K. Response of bispectral index to neuromuscular block in awake volunteers. Br J Anaesth 2016; 116:725-6. [PMID: 27106988 DOI: 10.1093/bja/aew089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Fritz BA, Kalarickal PL, Maybrier HR, Muench MR, Dearth D, Chen Y, Escallier KE, Ben Abdallah A, Lin N, Avidan MS. Intraoperative Electroencephalogram Suppression Predicts Postoperative Delirium. Anesth Analg 2016; 122:234-42. [PMID: 26418126 DOI: 10.1213/ane.0000000000000989] [Citation(s) in RCA: 192] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Postoperative delirium is a common complication associated with increased morbidity and mortality, longer hospital stays, and greater health care expenditures. Intraoperative electroencephalogram (EEG) slowing has been associated previously with postoperative delirium, but the relationship between intraoperative EEG suppression and postoperative delirium has not been investigated. METHODS In this observational cohort study, 727 adult patients who received general anesthesia with planned intensive care unit admission were included. Duration of intraoperative EEG suppression was recorded from a frontal EEG channel (FP1 to F7). Delirium was assessed twice daily on postoperative days 1 through 5 with the Confusion Assessment Method for the intensive care unit. Thirty days after surgery, quality of life, functional independence, and cognitive ability were measured using the Veterans RAND 12-item survey, the Barthel index, and the PROMIS Applied Cognition-Abilities-Short Form 4a survey. RESULTS Postoperative delirium was observed in 162 (26%) of 619 patients assessed. When we compared patients with no EEG suppression with those divided into quartiles based on duration of EEG suppression, patients with more suppression were more likely to experience delirium (χ(4) = 25, P < 0.0001). This effect remained significant after we adjusted for potential confounders (odds ratio for log(EEG suppression) 1.22 [99% confidence interval, 1.06-1.40, P = 0.0002] per 1-minute increase in suppression). EEG suppression may have been associated with reduced functional independence (Spearman partial correlation coefficient -0.15, P = 0.02) but not with changes in quality of life or cognitive ability. Predictors of EEG suppression included greater end-tidal volatile anesthetic concentration and lower intraoperative opioid dose. CONCLUSIONS EEG suppression is an independent risk factor for postoperative delirium. Future studies should investigate whether anesthesia titration to minimize EEG suppression decreases the incidence of postoperative delirium. This is a substudy of the Systematic Assessment and Targeted Improvement of Services Following Yearlong Surgical Outcomes Surveys (SATISFY-SOS) surgical outcomes registry (NCT02032030).
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Affiliation(s)
- Bradley A Fritz
- From the *Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri; and †Department of Mathematics, Washington University, St. Louis, Missouri
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Pana R, Hornby L, Shemie SD, Dhanani S, Teitelbaum J. Time to loss of brain function and activity during circulatory arrest. J Crit Care 2016; 34:77-83. [PMID: 27288615 DOI: 10.1016/j.jcrc.2016.04.001] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Revised: 04/03/2016] [Accepted: 04/04/2016] [Indexed: 11/18/2022]
Abstract
PURPOSE Brain function during the dying process and around the time of cardiac arrest is poorly understood. To better inform the clinical physiology of the dying process and organ donation practices, we performed a scoping review of the literature to assess time to loss of brain function and activity after circulatory arrest. MATERIALS AND METHODS Medline and Embase databases were searched from inception to June 2014 for articles reporting the time interval to loss of brain function or activity after loss of systemic circulation. RESULTS Thirty-nine studies met selection criteria. Seven human studies and 10 animal studies reported that electroencephalography (EEG) activity is lost less than 30seconds after abrupt circulatory arrest. In the setting of existing brain injury, with progressive loss of oxygenated circulation, loss of EEG may occur before circulatory arrest. Cortical evoked potentials may persist for several minutes after loss of circulation. CONCLUSION The time required to lose brain function varied according to clinical context and method by which this function is measured. Most studies show that clinical loss of consciousness and loss of EEG activity occur within 30seconds after abrupt circulatory arrest and may occur before circulatory arrest after progressive hypoxia-ischemia. Prospective clinical studies are required to confirm these observations.
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Affiliation(s)
- R Pana
- Division of Neurology, McGill University Health Center, Montreal, QC, Canada.
| | - L Hornby
- Division of Pediatric Critical Care, Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada; Deceased Donation, Canadian Blood Services, Ottawa, ON, Canada
| | - S D Shemie
- Deceased Donation, Canadian Blood Services, Ottawa, ON, Canada; Division of Critical Care, Montreal Children's Hospital, McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - S Dhanani
- Children's Hospital of Eastern Ontario, Children's Hospital of Eastern Ontario Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - J Teitelbaum
- Division of Neurology and Neurosurgery, McGill University Health Center, Montreal Neurological Institute, Montreal, QC, Canada
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Bresson J, Gayat E, Agrawal G, Chazot T, Liu N, Hausser-Haw C, Fischler M. A Randomized Controlled Trial Comparison of NeuroSENSE and Bispectral Brain Monitors During Propofol-Based Versus Sevoflurane-Based General Anesthesia. Anesth Analg 2015; 121:1194-201. [DOI: 10.1213/ane.0000000000000922] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Purdon PL, Sampson A, Pavone KJ, Brown EN. Clinical Electroencephalography for Anesthesiologists: Part I: Background and Basic Signatures. Anesthesiology 2015; 123:937-60. [PMID: 26275092 PMCID: PMC4573341 DOI: 10.1097/aln.0000000000000841] [Citation(s) in RCA: 460] [Impact Index Per Article: 51.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
The widely used electroencephalogram-based indices for depth-of-anesthesia monitoring assume that the same index value defines the same level of unconsciousness for all anesthetics. In contrast, we show that different anesthetics act at different molecular targets and neural circuits to produce distinct brain states that are readily visible in the electroencephalogram. We present a two-part review to educate anesthesiologists on use of the unprocessed electroencephalogram and its spectrogram to track the brain states of patients receiving anesthesia care. Here in part I, we review the biophysics of the electroencephalogram and the neurophysiology of the electroencephalogram signatures of three intravenous anesthetics: propofol, dexmedetomidine, and ketamine, and four inhaled anesthetics: sevoflurane, isoflurane, desflurane, and nitrous oxide. Later in part II, we discuss patient management using these electroencephalogram signatures. Use of these electroencephalogram signatures suggests a neurophysiologically based paradigm for brain state monitoring of patients receiving anesthesia care.
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Affiliation(s)
- Patrick L. Purdon
- Associate Bioengineer, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts; Assistant Professor of Anaesthesia, Department of Anesthesia, Harvard Medical School, Boston, Massachusetts
| | - Aaron Sampson
- Research Assistant, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Kara J. Pavone
- Research Assistant, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Emery N. Brown
- Anesthetist, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts; Warren M. Zapol Professor of Anesthesia, Department of Anesthesia, Harvard Medical School, Boston, Massachusetts; Edward Hood Taplin Professor of Medical Engineering, Institute for Medical Engineering and Science and Harvard-Massachusetts Institute of Technology, Health Sciences and Technology Program, Professor of Computational Neuroscience, Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, Massachusetts
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Purdon PL, Pavone KJ, Akeju O, Smith AC, Sampson AL, Lee J, Zhou DW, Solt K, Brown EN. The Ageing Brain: Age-dependent changes in the electroencephalogram during propofol and sevoflurane general anaesthesia. Br J Anaesth 2015; 115 Suppl 1:i46-i57. [PMID: 26174300 DOI: 10.1093/bja/aev213] [Citation(s) in RCA: 227] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Anaesthetic drugs act at sites within the brain that undergo profound changes during typical ageing. We postulated that anaesthesia-induced brain dynamics observed in the EEG change with age. METHODS We analysed the EEG in 155 patients aged 18-90 yr who received propofol (n=60) or sevoflurane (n=95) as the primary anaesthetic. The EEG spectrum and coherence were estimated throughout a 2 min period of stable anaesthetic maintenance. Age-related effects were characterized by analysing power and coherence as a function of age using linear regression and by comparing the power spectrum and coherence in young (18- to 38-yr-old) and elderly (70- to 90-yr-old) patients. RESULTS Power across all frequency bands decreased significantly with age for both propofol and sevoflurane; elderly patients showed EEG oscillations ∼2- to 3-fold smaller in amplitude than younger adults. The qualitative form of the EEG appeared similar regardless of age, showing prominent alpha (8-12 Hz) and slow (0.1-1 Hz) oscillations. However, alpha band dynamics showed specific age-related changes. In elderly compared with young patients, alpha power decreased more than slow power, and alpha coherence and peak frequency were significantly lower. Older patients were more likely to experience burst suppression. CONCLUSIONS These profound age-related changes in the EEG are consistent with known neurobiological and neuroanatomical changes that occur during typical ageing. Commercial EEG-based depth-of-anaesthesia indices do not account for age and are therefore likely to be inaccurate in elderly patients. In contrast, monitoring the unprocessed EEG and its spectrogram can account for age and individual patient characteristics.
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Affiliation(s)
- P L Purdon
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA Harvard Medical School, Boston, MA, USA Department of Brain and Cognitive Science
| | - K J Pavone
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - O Akeju
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA Harvard Medical School, Boston, MA, USA
| | - A C Smith
- Department of Brain and Cognitive Science
| | - A L Sampson
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - J Lee
- Harvard-Massachusetts Institute of Technology Division of Health Sciences and Technology
| | - D W Zhou
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - K Solt
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA Harvard Medical School, Boston, MA, USA
| | - E N Brown
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA Harvard Medical School, Boston, MA, USA Department of Brain and Cognitive Science Harvard-Massachusetts Institute of Technology Division of Health Sciences and Technology Institute for Medical Engineering and Sciences, Massachusetts Institute of Technology, Cambridge, MA, USA
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68
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Akeju O, Pavone KJ, Thum JA, Firth PG, Westover MB, Puglia M, Shank ES, Brown EN, Purdon PL. Age-dependency of sevoflurane-induced electroencephalogram dynamics in children. Br J Anaesth 2015; 115 Suppl 1:i66-i76. [PMID: 26174303 DOI: 10.1093/bja/aev114] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND General anaesthesia induces highly structured oscillations in the electroencephalogram (EEG) in adults, but the anaesthesia-induced EEG in paediatric patients is less understood. Neural circuits undergo structural and functional transformations during development that might be reflected in anaesthesia-induced EEG oscillations. We therefore investigated age-related changes in the EEG during sevoflurane general anaesthesia in paediatric patients. METHODS We analysed the EEG recorded during routine care of patients between 0 and 28 yr of age (n=54), using power spectral and coherence methods. The power spectrum quantifies the energy in the EEG at each frequency, while the coherence measures the frequency-dependent correlation or synchronization between EEG signals at different scalp locations. We characterized the EEG as a function of age and within 5 age groups: <1 yr old (n=4), 1-6 yr old (n=12), >6-14 yr old (n=14), >14-21 yr old (n=11), >21-28 yr old (n=13). RESULTS EEG power significantly increased from infancy through ∼6 yr, subsequently declining to a plateau at approximately 21 yr. Alpha (8-13 Hz) coherence, a prominent EEG feature associated with sevoflurane-induced unconsciousness in adults, is absent in patients <1 yr. CONCLUSIONS Sevoflurane-induced EEG dynamics in children vary significantly as a function of age. These age-related dynamics likely reflect ongoing development within brain circuits that are modulated by sevoflurane. These readily observed paediatric-specific EEG signatures could be used to improve brain state monitoring in children receiving general anaesthesia.
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Affiliation(s)
- O Akeju
- Department of Anesthesia, Critical Care and Pain Medicine Harvard Medical School, Boston, MA, USA
| | - K J Pavone
- Department of Anesthesia, Critical Care and Pain Medicine
| | - J A Thum
- Harvard Medical School, Boston, MA, USA Harvard-Massachusetts Institute of Technology Division of Health Sciences and Technology
| | - P G Firth
- Department of Anesthesia, Critical Care and Pain Medicine Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - M B Westover
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA Harvard Medical School, Boston, MA, USA
| | - M Puglia
- Department of Anesthesia, Critical Care and Pain Medicine Harvard Medical School, Boston, MA, USA
| | - E S Shank
- Department of Anesthesia, Critical Care and Pain Medicine Harvard Medical School, Boston, MA, USA
| | - E N Brown
- Department of Anesthesia, Critical Care and Pain Medicine Harvard Medical School, Boston, MA, USA Department of Brain and Cognitive Science Harvard-Massachusetts Institute of Technology Division of Health Sciences and Technology Institute for Medical Engineering and Sciences, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - P L Purdon
- Department of Anesthesia, Critical Care and Pain Medicine Harvard Medical School, Boston, MA, USA Department of Brain and Cognitive Science
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69
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Leslie K, Short TG. Anesthetic depth and long-term survival: an update. Can J Anaesth 2015; 63:233-40. [DOI: 10.1007/s12630-015-0490-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Revised: 05/20/2015] [Accepted: 09/10/2015] [Indexed: 01/12/2023] Open
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70
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Luk TTH, Jia B, Pang EYT, Lau VNM, Lam CKM, Chu MHM, Han R, Chan MTV. Depth of Anesthesia and Postoperative Delirium. CURRENT ANESTHESIOLOGY REPORTS 2015. [DOI: 10.1007/s40140-014-0088-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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71
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Hight DF, Dadok VM, Szeri AJ, García PS, Voss L, Sleigh JW. Emergence from general anesthesia and the sleep-manifold. Front Syst Neurosci 2014; 8:146. [PMID: 25165436 PMCID: PMC4131673 DOI: 10.3389/fnsys.2014.00146] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 07/24/2014] [Indexed: 12/17/2022] Open
Abstract
The electroencephalogram (EEG) during the re-establishment of consciousness after general anesthesia and surgery varies starkly between patients. Can the EEG during this emergence period provide a means of estimating the underlying biological processes underpinning the return of consciousness? Can we use a model to infer these biological processes from the EEG patterns? A frontal EEG was recorded from 84 patients. Ten patients were chosen for state-space analysis. Five showed archetypal emergences; which consisted of a progressive decrease in alpha power and increase peak alpha frequency before return of responsiveness. The five non-archetypal emergences showed almost no spectral EEG changes (even as the volatile general anesthetic decreased) and then an abrupt return of responsiveness. We used Bayesian methods to estimate the likelihood of an EEG pattern corresponding to the position of the patient on a 2-dimensional manifold in a state space of excitatory connection strength vs. change in intrinsic resting neuronal membrane conductivity. We could thus visualize the trajectory of each patient in the state-space during their emergence period. The patients who followed an archetypal emergence displayed a very consistent pattern; consisting of progressive increase in conductivity, and a temporary period of increased connection strength before return of responsiveness. The non-archetypal emergence trajectories remained fixed in a region of phase space characterized by a relatively high conductivity and low connection strength throughout emergence. This unexpected progressive increase in conductivity during archetypal emergence may be due to an abating of the surgical stimulus during this period. Periods of high connection strength could represent forays into dissociated consciousness, but the model suggests all patients reposition near the fold in the state space to take advantage of bi-stable cortical dynamics before transitioning to consciousness.
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Affiliation(s)
- Darren F Hight
- Department of Anaesthesiology, Waikato Clinical School, University of Auckland Hamilton, New Zealand
| | - Vera M Dadok
- Department of Mechanical Engineering and Center for Neural Engineering and Prostheses, University of California Berkeley, CA, USA
| | - Andrew J Szeri
- Department of Mechanical Engineering and Center for Neural Engineering and Prostheses, University of California Berkeley, CA, USA
| | - Paul S García
- Department of Anesthesiology, Atlanta VA Medical Center/Emory University Atlanta, GA, USA
| | - Logan Voss
- Department of Anaesthesiology, Waikato Clinical School, University of Auckland Hamilton, New Zealand
| | - Jamie W Sleigh
- Department of Anaesthesiology, Waikato Clinical School, University of Auckland Hamilton, New Zealand
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72
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Escallier KE, Nadelson MR, Zhou D, Avidan MS. Monitoring the brain: processed electroencephalogram and peri‐operative outcomes. Anaesthesia 2014; 69:899-910. [DOI: 10.1111/anae.12711] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2014] [Indexed: 11/29/2022]
Affiliation(s)
- K. E. Escallier
- Washington University School of Medicine Saint Louis Missouri USA
| | - M. R. Nadelson
- Washington University School of Medicine Saint Louis Missouri USA
| | - D. Zhou
- Washington University School of Medicine Saint Louis Missouri USA
| | - M. S. Avidan
- Washington University School of Medicine Saint Louis Missouri USA
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73
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Ingrande J, Lemmens HJ. Medical devices for the anesthetist: current perspectives. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2014; 7:45-53. [PMID: 24707188 PMCID: PMC3971909 DOI: 10.2147/mder.s43428] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Anesthesiologists are unique among most physicians in that they routinely use technology and medical devices to carry out their daily activities. Recently, there have been significant advances in medical technology. These advances have increased the number and utility of medical devices available to the anesthesiologist. There is little doubt that these new tools have improved the practice of anesthesia. Monitoring has become more comprehensive and less invasive, airway management has become easier, and placement of central venous catheters and regional nerve blockade has become faster and safer. This review focuses on key medical devices such as cardiovascular monitors, airway equipment, neuromonitoring tools, ultrasound, and target controlled drug delivery software and hardware. This review demonstrates how advances in these areas have improved the safety and efficacy of anesthesia and facilitate its administration. When applicable, indications and contraindications to the use of these novel devices will be explored as well as the controversies surrounding their use.
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Affiliation(s)
- Jerry Ingrande
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Hendrikus Jm Lemmens
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
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74
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Nicolaou N, Georgiou J. Neural network-based classification of anesthesia/awareness using Granger causality features. Clin EEG Neurosci 2014; 45:77-88. [PMID: 23820086 DOI: 10.1177/1550059413486271] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
This article investigates the signal processing part of a future system for monitoring awareness during surgery. The system uses features from the patients' electrical brain activity (EEG) to discriminate between "anesthesia" and "awareness." We investigate the use of a neural network classifier and Granger causality (GC) features for this purpose. GC captures anesthetic-induced changes in the causal relationships between pairs of signals from different brain areas. The differences in the pairwise causality estimated from the EEG activity are used as features for subsequent classification between "awake" and "anesthetized" states. EEG data from 31 subjects obtained during surgery and maintenance of anesthesia with propofol, sevoflurane, or desflurane, are classified using a neural network with one layer of hidden units. An average accuracy of 96% is obtained.
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Affiliation(s)
- Nicoletta Nicolaou
- KIOS Research Centre, Department of Electrical and Computer Engineering, University of Cyprus, Nicosia, Cyprus
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75
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Abstract
How does general anesthesia (GA) work? Anesthetics are pharmacological agents that target specific central nervous system receptors. Once they bind to their brain receptors, anesthetics modulate remote brain areas and end up interfering with global neuronal networks, leading to a controlled and reversible loss of consciousness. This remarkable manipulation of consciousness allows millions of people every year to undergo surgery safely most of the time. However, despite all the progress that has been made, we still lack a clear and comprehensive insight into the specific neurophysiological mechanisms of GA, from the molecular level to the global brain propagation. During the last decade, the exponential progress in neuroscience and neuro-imaging led to a significant step in the understanding of the neural correlates of consciousness, with direct consequences for clinical anesthesia. Far from shutting down all brain activity, anesthetics lead to a shift in the brain state to a distinct, highly specific and complex state, which is being increasingly characterized by modern neuro-imaging techniques. There are several clinical consequences and challenges that are arising from the current efforts to dissect GA mechanisms: the improvement of anesthetic depth monitoring, the characterization and avoidance of intra-operative awareness and post-anesthesia cognitive disorders, and the development of future generations of anesthetics.
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Affiliation(s)
- L Uhrig
- CEA, NeuroSpin center, 91191 Gif-sur-Yvette, France; Avenir-Bettencourt-Schueller, Inserm, 91191 Gif-sur-Yvette, France; Cognitive neuroimaging unit, Inserm, U992, 91191 Gif-sur-Yvette, France.
| | - S Dehaene
- CEA, NeuroSpin center, 91191 Gif-sur-Yvette, France; Cognitive neuroimaging unit, Inserm, U992, 91191 Gif-sur-Yvette, France; Collège de France, 75231 Paris, France; Université Paris-Sud, 91405 Orsay, France
| | - B Jarraya
- CEA, NeuroSpin center, 91191 Gif-sur-Yvette, France; Avenir-Bettencourt-Schueller, Inserm, 91191 Gif-sur-Yvette, France; Neuromodulation unit, department of neurosurgery, Foch Hospital, 92150 Suresnes, France; Université Versailles Saint-Quentin-en-Yvelines, 78000 Versailles, France
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76
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Anestesia total intravenosa en un sistema de lazo cerrado: reporte del primer caso en Colombia. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2013. [DOI: 10.1016/j.rca.2013.05.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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77
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Gómez Oquendo FJ, Casas Arroyave FD, Fernández JM, Guarín Grisales Á. Total intravenous anesthesia in a closed loop system: Report of the first case in Colombia. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2013. [DOI: 10.1016/j.rcae.2013.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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78
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Anderson BJ. La farmacología de la anestesia total intravenosa en pediatría. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2013. [DOI: 10.1016/j.rca.2013.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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79
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80
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Jäntti V. Do we need more anesthesia EEG indexes? J Clin Monit Comput 2013; 27:105-6. [DOI: 10.1007/s10877-012-9421-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Accepted: 12/06/2012] [Indexed: 11/28/2022]
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81
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Avidan MS, Mashour GA. II. The incidence of intraoperative awareness in the UK: under the rate or under the radar? Br J Anaesth 2013; 110:494-7. [DOI: 10.1093/bja/aet012] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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82
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Avidan MS, Mashour GA. The incidence of intra-operative awareness in the UK: under the rate or under the radar? Anaesthesia 2013; 68:334-8. [DOI: 10.1111/anae.12215] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- M. S. Avidan
- Department of Anesthesiology; Washington University School of Medicine; Saint Louis Missouri USA
| | - G. A. Mashour
- Department of Anesthesiology; University of Michigan; Ann Arbor Michigan USA
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83
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Hyder F, Fulbright RK, Shulman RG, Rothman DL. Glutamatergic function in the resting awake human brain is supported by uniformly high oxidative energy. J Cereb Blood Flow Metab 2013; 33:339-47. [PMID: 23299240 PMCID: PMC3587823 DOI: 10.1038/jcbfm.2012.207] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Rodent (13)C magnetic resonance spectroscopy studies show that glutamatergic signaling requires high oxidative energy in the awake resting state and allowed calibration of functional magnetic resonance imaging (fMRI) signal in terms of energy relative to the resting energy. Here, we derived energy used for glutamatergic signaling in the awake resting human. We analyzed human data of electroencephalography (EEG), positron emission tomography (PET) maps of oxygen (CMR(O2)) and glucose (CMR(glc)) utilization, and calibrated fMRI from a variety of experimental conditions. CMR(glc) and EEG in the visual cortex were tightly coupled over several conditions, showing that the oxidative demand for signaling was four times greater than the demand for nonsignaling events in the awake state. Variations of CMR(O2) and CMR(glc) from gray-matter regions and networks were within ±10% of means, suggesting that most areas required similar energy for ubiquitously high resting activity. Human calibrated fMRI results suggest that changes of fMRI signal in cognitive studies contribute at most ±10% CMR(O2) changes from rest. The PET data of sleep, vegetative state, and anesthesia show metabolic reductions from rest, uniformly >20% across, indicating no region is selectively reduced when consciousness is lost. Future clinical investigations will benefit from using quantitative metabolic measures.
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Affiliation(s)
- Fahmeed Hyder
- Magnetic Resonance Research Center, Yale University, New Haven, Connecticut 06520, USA.
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84
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AHO AJ, YLI-HANKALA A, LYYTIKÄINEN LP, KAMATA K, JÄNTTI V. Can electromyographic arousal be detected visually on the Datex-Ohmeda S/5™ anesthesia monitor? Acta Anaesthesiol Scand 2013; 57:364-72. [PMID: 22928590 DOI: 10.1111/j.1399-6576.2012.02761.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND Electroencephalogram (EEG)-based depth of anaesthesia monitoring is susceptible to contaminating electromyographic (EMG) activity. Many authorities have suggested that anaesthesiologists using these monitors should interpret the raw EEG waveform seen on the anaesthesia monitor. METHODS In 34 patients anaesthetized with propofol using two doses of rocuronium (0.6 and 1.2 mg/kg), we studied whether the EMG arousal can be detected visually on the anaesthesia monitor. The Bispectral Index (BIS) and Entropy biosignals on the monitor were recorded with a video camera, and the one-channel EEG recorded by the Entropy strip was collected on a laptop computer. The recordings and the one-channel EEG were analyzed offline by two experts (anaesthesiologist and neurophysiologist), both with a long experience on anaesthesia-related EEG. RESULTS EMG arousal existed in 14/34 and 13/33 patients in the BIS and Entropy biosignals, respectively. The anaesthesiologist detected EMG on the monitor in 7/14 patients with BIS (sensitivity 50%) and in 4/13 patients with Entropy (31%). The clinical neurophysiologist detected EMG in 6/14 (43%) patients with BIS and in 5/13 (38%) with Entropy. The specificity of the EMG analyses was 55 and 65% with BIS, and 85 and 90% with Entropy. EMG arousal was detected in BIS biosignal in 10/17 and 4/17 patients with 0.6 and 1.2 mg/kg doses of rocuronium (P = 0.04). CONCLUSIONS In contrast to many EEG phenomena, EMG activity cannot be accurately detected visually from the raw EEG on the anaesthesia monitor. Further development in the quality of the anaesthesia monitors is warranted.
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Affiliation(s)
- A. J. AHO
- Coxa Ltd, Hospital for Joint Replacement; Tampere; Finland
| | | | - L.-P. LYYTIKÄINEN
- Department of Clinical Chemistry; Tampere University Hospital; Tampere; Finland
| | - K. KAMATA
- Department of Anaesthesia; Tampere University Hospital; Tampere; Finland
| | - V. JÄNTTI
- Department of Clinical Neurophysiology; Seinäjoki Central Hospital; Seinäjoki; Finland
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85
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Jagadeesan N, Wolfson M, Chen Y, Willingham M, Avidan MS. Brain monitoring during general anesthesia. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2013. [DOI: 10.1016/j.tacc.2012.12.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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86
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Foster BL, Liley DT. Effects of nitrous oxide sedation on resting electroencephalogram topography. Clin Neurophysiol 2013; 124:417-23. [DOI: 10.1016/j.clinph.2012.08.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2012] [Revised: 08/10/2012] [Accepted: 08/14/2012] [Indexed: 11/30/2022]
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87
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Total intravenous anesthesia in a closed loop system: Report of the first case in Colombia☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2013. [DOI: 10.1097/01819236-201341040-00014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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88
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Pharmacology of paediatric total intravenous anaesthesia☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2013. [DOI: 10.1097/01819236-201341030-00007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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89
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Rapid fragmentation of neuronal networks at the onset of propofol-induced unconsciousness. Proc Natl Acad Sci U S A 2012; 109:E3377-86. [PMID: 23129622 DOI: 10.1073/pnas.1210907109] [Citation(s) in RCA: 274] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The neurophysiological mechanisms by which anesthetic drugs cause loss of consciousness are poorly understood. Anesthetic actions at the molecular, cellular, and systems levels have been studied in detail at steady states of deep general anesthesia. However, little is known about how anesthetics alter neural activity during the transition into unconsciousness. We recorded simultaneous multiscale neural activity from human cortex, including ensembles of single neurons, local field potentials, and intracranial electrocorticograms, during induction of general anesthesia. We analyzed local and global neuronal network changes that occurred simultaneously with loss of consciousness. We show that propofol-induced unconsciousness occurs within seconds of the abrupt onset of a slow (<1 Hz) oscillation in the local field potential. This oscillation marks a state in which cortical neurons maintain local patterns of network activity, but this activity is fragmented across both time and space. Local (<4 mm) neuronal populations maintain the millisecond-scale connectivity patterns observed in the awake state, and spike rates fluctuate and can reach baseline levels. However, neuronal spiking occurs only within a limited slow oscillation-phase window and is silent otherwise, fragmenting the time course of neural activity. Unexpectedly, we found that these slow oscillations occur asynchronously across cortex, disrupting functional connectivity between cortical areas. We conclude that the onset of slow oscillations is a neural correlate of propofol-induced loss of consciousness, marking a shift to cortical dynamics in which local neuronal networks remain intact but become functionally isolated in time and space.
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90
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REBOSO JA, MÉNDEZ JA, REBOSO HJ, LEÓN AM. Design and implementation of a closed-loop control system for infusion of propofol guided by bispectral index (BIS). Acta Anaesthesiol Scand 2012; 56:1032-41. [PMID: 22834710 DOI: 10.1111/j.1399-6576.2012.02738.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND This study describes the design of a hypnosis closed-loop control system with propofol. The controller used a proportional-integral (PI) algorithm with the bispectral index (BIS) as the feedback signal. Our hypothesis was that a PI closed-loop control could be applied in clinical practice safely keeping the BIS within a pre-determined target range. METHODS The adjustment of the PI parameters was based on simulation. The procedure had three steps: obtaining a patient model using data from 12 patients, designing and adjusting the controller in simulation, and fine tuning the PI parameters in a pilot study (10 patients). The resulting controller was tested in 24 American Society of Anesthesiology (ASA) I-II patients. The controller directly decides the infusion rate of propofol, and no model is necessary in its online operation. The BIS target was set to 50. Remifentanil was used for analgesia. RESULTS We evaluated the efficiency and safety of the automatic feedback system. It worked properly in all the patients. The median performance error was -1.62, and the median absolute performance error was 11.03. Average propofol-normalized consumption was 5.3 ± 1.8 mg/kg/h. Mean percentage of BIS in the range 40-60 was 83%. Mean time to open eyes was 8 ± 4 min. Time to extubation was 9 ± 5 min. Hemodynamic adverse event or intraoperative awareness were not recorded. CONCLUSIONS The closed-loop system was able to maintain the BIS within an acceptable range of levels. The control of a propofol infusion guided by the BIS is feasible without hemodynamic instability in ASA I/II patients.
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Affiliation(s)
- J. A. REBOSO
- Department of Anesthesiology and Reanimation; Hospital Universitario de Canarias; La Laguna; Spain
| | - J. A. MÉNDEZ
- Department of Systems Engineering and Automation and Computer Architecture and Technology; University of La Laguna; La Laguna; Spain
| | - H. J. REBOSO
- Department of Systems Engineering and Automation and Computer Architecture and Technology; University of La Laguna; La Laguna; Spain
| | - A. M. LEÓN
- Department of Anesthesiology and Reanimation; Hospital Universitario de Canarias; La Laguna; Spain
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91
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Nicolaou N, Hourris S, Alexandrou P, Georgiou J. EEG-based automatic classification of 'awake' versus 'anesthetized' state in general anesthesia using Granger causality. PLoS One 2012; 7:e33869. [PMID: 22457797 PMCID: PMC3310868 DOI: 10.1371/journal.pone.0033869] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Accepted: 02/20/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND General anesthesia is a reversible state of unconsciousness and depression of reflexes to afferent stimuli induced by administration of a "cocktail" of chemical agents. The multi-component nature of general anesthesia complicates the identification of the precise mechanisms by which anesthetics disrupt consciousness. Devices that monitor the depth of anesthesia are an important aide for the anesthetist. This paper investigates the use of effective connectivity measures from human electrical brain activity as a means of discriminating between 'awake' and 'anesthetized' state during induction and recovery of consciousness under general anesthesia. METHODOLOGY/PRINCIPAL FINDINGS Granger Causality (GC), a linear measure of effective connectivity, is utilized in automated classification of 'awake' versus 'anesthetized' state using Linear Discriminant Analysis and Support Vector Machines (with linear and non-linear kernel). Based on our investigations, the most characteristic change of GC observed between the two states is the sharp increase of GC from frontal to posterior regions when the subject was anesthetized, and reversal at recovery of consciousness. Features derived from the GC estimates resulted in classification of 'awake' and 'anesthetized' states in 21 patients with maximum average accuracies of 0.98 and 0.95, during loss and recovery of consciousness respectively. The differences in linear and non-linear classification are not statistically significant, implying that GC features are linearly separable, eliminating the need for a complex and computationally expensive non-linear classifier. In addition, the observed GC patterns are particularly interesting in terms of a physiological interpretation of the disruption of consciousness by anesthetics. Bidirectional interaction or strong unidirectional interaction in the presence of a common input as captured by GC are most likely related to mechanisms of information flow in cortical circuits. CONCLUSIONS/SIGNIFICANCE GC-based features could be utilized effectively in a device for monitoring depth of anesthesia during surgery.
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Affiliation(s)
- Nicoletta Nicolaou
- Department of Electrical and Computer Engineering, KIOS Research Centre, University of Cyprus, Nicosia, Cyprus.
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92
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Mathews DM, Clark L, Johansen J, Matute E, Seshagiri CV. Increases in electroencephalogram and electromyogram variability are associated with an increased incidence of intraoperative somatic response. Anesth Analg 2012; 114:759-70. [PMID: 22344241 DOI: 10.1213/ane.0b013e3182455ac2] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND sBIS, the variability of the Bispectral Index (BIS), sEMG, the variability of facial electromyogram power (EMG), and the Composite Variability Index (CVI) are 3 new measures of electroencephalogram and EMG variability. CVI is a single measure of the combined variability in BIS and EMG. We investigated whether increases in these variables are associated with intraoperative somatic responses. METHODS This multicenter study included 120 patients undergoing elective, noncardiac surgery from 4 different sites. General anesthesia was maintained using propofol and remifentanil at 2 of the sites and sevoflurane and remifentanil at the 2 other sites. Propofol or sevoflurane was adjusted to maintain BIS between 45 and 60. Clinicians were blinded to CVI (v2.0) at all times, and remifentanil infusions were adjusted at the discretion of the clinician. The times of all intraoperative somatic events, defined as movement, grimacing, or eye opening, were recorded. Offline, the maintenance phase of each case was divided into consecutive, nonoverlapping, 10-minute segments. Segments were identified as containing a somatic event or containing no events. For each segment, mean sBIS, sEMG, and CVI and the heart rate (HR) range and mean arterial blood pressure range were calculated. To quantify how effectively each variable discriminated between somatic event segments and nonevent segments, we computed the area under the receiver operating characteristic (ROC) curve for each variable. Finally, we observed the time course of sBIS, sEMG, CVI, and the HR range before each somatic event and characterized the earliest time before the somatic event at which each variable was able to discriminate between the somatic events and a specified set of nonevents. RESULTS The analysis included 33 somatic event segments and 829 nonevent segments from 105 surgical cases. The areas under the ROC curve (±SE) for sBIS, sEMG, and CVI were 0.83 ± 0.04, 0.92 ± 0.02, and 0.89 ± 0.03, respectively. The areas under the ROC curve for HR range and mean arterial blood pressure range were 0.77 ± 0.03 and 0.68 ± 0.05, respectively. CVI, sBIS, and sEMG all demonstrated higher average values before upcoming somatic events when compared with nonevents. HR range only showed a difference within a few seconds before the somatic event. CONCLUSION sBIS, sEMG, and CVI, measures of electroencephalogram and EMG variability, increased when intraoperative somatic events occurred. sBIS, sEMG, and CVI discriminated between 10-minute segments that contained a somatic event and those segments that did not contain an event better than changes in HR and mean arterial blood pressure. Furthermore, CVI increases before somatic events began earlier than HR changes and may provide caregivers with an early warning of potentially inadequate antinociception.
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Affiliation(s)
- Donald M Mathews
- Department of Clinical Anesthesiology, Vermont College of Medicine, Burlington, Vermont, USA
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Paisansathan C, Ozcan MD, Khan QS, Baughman VL, Ozcan MS. Signal persistence of bispectral index and state entropy during surgical procedure under sedation. ScientificWorldJournal 2012; 2012:272815. [PMID: 22454604 PMCID: PMC3289978 DOI: 10.1100/2012/272815] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2011] [Accepted: 12/07/2011] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Bispectral index (BIS) and state entropy (SE) are prone to artifacts, especially due to electrocautery (EC). We compared the incidence of artifacts in BIS and SE during surgery under local anesthesia and sedation. METHODS 28 females undergoing breast surgery under local anesthesia and sedation were studied. Simultaneous BIS and SE measurements were recorded every 10 seconds. Artifact was defined as a failure of the device to display a numerical value while the electrodes remained appropriately attached to the patient's forehead. Ratio of artifact to good signal was compared between BIS and SE in the presence or absence of EC use. RESULTS 7679 data points were collected from 28 patients. Overall, artifact incidence was similar in BIS and SE (6.2% and 6.3%, resp.). In the presence of EC (1370 data points), BIS had significantly more artifact compared to SE (18.6% versus 6.4%, P < 0.0001). Without EC (6309 data points), BIS had significantly less artifact compared to SE (4.1% versus 7.3%, P < 0.0001). DISCUSSION BIS and SE were comparable for incidence of artifacts in patients under sedation. Use of EC lead to more artifact in BIS than SE. Conversely, BIS had fewer artifacts than SE when there was no EC use.
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Affiliation(s)
- Chanannait Paisansathan
- Department of Anesthesiology, University of Illinois at Chicago, 1740 West Taylor Street, Suite 3200W, Chicago, IL 60612, USA
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Kertai MD, Whitlock EL, Avidan MS. Brain monitoring with electroencephalography and the electroencephalogram-derived bispectral index during cardiac surgery. Anesth Analg 2012; 114:533-46. [PMID: 22253267 DOI: 10.1213/ane.0b013e31823ee030] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Cardiac surgery presents particular challenges for the anesthesiologist. In addition to standard and advanced monitors typically used during cardiac surgery, anesthesiologists may consider monitoring the brain with raw or processed electroencephalography (EEG). There is strong evidence that a protocol incorporating the processed EEG bispectral index (BIS) decreases the incidence intraoperative awareness in comparison with standard practice. However, there is conflicting evidence that incorporating the BIS into cardiac anesthesia practice improves "fast-tracking," decreases anesthetic drug use, or detects cerebral ischemia. Recent research, including many cardiac surgical patients, shows that a protocol based on BIS monitoring is not superior to a protocol based on end-tidal anesthetic concentration monitoring in preventing awareness. There has been a resurgence of interest in the anesthesia literature in limited montage EEG monitoring, including nonproprietary processed indices. This has been accompanied by research showing that with structured training, anesthesiologists can glean useful information from the raw EEG trace. In this review, we discuss both the hypothesized benefits and limitations of BIS and frontal channel EEG monitoring in the cardiac surgical population.
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Affiliation(s)
- Miklos D Kertai
- Duke University Medical Center, 2301 Erwin Road, 5693 HAFS Bldg., DUMC 3094 Durham, NC 27710, USA.
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95
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Sneyd JR. Depth-of-anaesthesia monitoring. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2012. [DOI: 10.1080/22201173.2012.10872820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Foster BL, Liley DTJ. Nitrous Oxide Paradoxically Modulates Slow Electroencephalogram Oscillations. Anesth Analg 2011; 113:758-65. [DOI: 10.1213/ane.0b013e318227b688] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Affiliation(s)
- Joseph T Daley
- Department of Internal Medicine, Center for Sleep and Respiratory Neurobiology, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA
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Slow wave sleep in patients with respiratory failure. Sleep Med 2011; 12:378-83. [PMID: 21377420 DOI: 10.1016/j.sleep.2011.01.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2010] [Revised: 01/12/2011] [Accepted: 01/14/2011] [Indexed: 11/23/2022]
Abstract
BACKGROUND Slow wave sleep (SWS) has been theorized as reflecting a homeostatic sleep process and is considered a state of recuperation. SWS is reduced in obstructive sleep apnea (OSA) patients, but SWS has not been specifically studied in respiratory failure patients. The aim of this study is to investigate SWS in predominantly hypercapnic respiratory failure patients. METHODS We analyzed sleep and arterial blood gas records of all 97 respiratory failure patients who underwent polysomnography and bilevel non-invasive ventilation (NIV) treatment in our laboratory from 2008 to July 2009. We also analyzed 32 initial diagnostic study data from these 97 patients. RESULTS The 97 patients had an average age of 58±15 (SD) years. Total sleep time was 320.3±82.8 (SD) min of which 32.9%±15.4 (%) was spent in SWS. This high percentage SWS correlated positively with awake arterial CO(2) pressure (PCO(2)) in both the 97 treatment studies (r=0.35, p=0.001) and the 32 initial diagnostic studies (r=0.40, p=0.025). The relationship was particularly apparent in patients with obesity hypoventilation syndrome or overlap syndrome. Statistical modelling identified three significant predictor variables for SWS across both diagnostic and NIV nights: PCO(2), arousal index and female gender. CONCLUSIONS Patients with respiratory failure have a high percentage of EEG assessed SWS which is in part determined by disease specific variables such as hypercapnia as well as by traditional SWS determinants such as sleep fragmentation and gender.
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Aho A, Lyytikäinen LP, Yli-Hankala A, Kamata K, Jäntti V. Explaining Entropy responses after a noxious stimulus, with or without neuromuscular blocking agents, by means of the raw electroencephalographic and electromyographic characteristics. Br J Anaesth 2011; 106:69-76. [DOI: 10.1093/bja/aeq300] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
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