Anaesthetic management of a pregnant patient in a persistent vegetative state

EEG Changes during Propofol Anesthesia Induction in Vegetative State Patients Undergoing Spinal Cord Stimulation Implantation Surgery

OBJECTIVE

To compare the EEG changes in vegetative state (VS) patients and non-craniotomy, non-vegetative state (NVS) patients during general anesthesia with low-dose propofol and to find whether it affects the arousal rate of VS patients.

METHODS

Seven vegetative state patients (VS group: five with traumatic brain injury, two with ischemic-hypoxic VS) and five non-craniotomy, non-vegetative state patients (NVS group) treated in the Department of Neurosurgery, Peking University International Hospital from January to May 2022 were selected. All patients were induced with 0.5 mg/kg propofol, and the Bispectral Index (BIS) changes within 5 min after administration were observed. Raw EEG signals and perioperative EEG signals were collected and analyzed using EEGLAB in the MATLAB software environment, time-frequency spectrums were calculated, and EEG changes were analyzed using power spectrums.

RESULTS

There was no significant difference in the general data before surgery between the two groups (p > 0.05); the BIS reduction in the VS group was significantly greater than that in the NVS group at 1 min, 2 min, 3 min, 4 min, and 5 min after 0.5 mg/kg propofol induction (p < 0.05). Time-frequency spectrum analysis showed the following: prominent α band energy around 10 Hz and decreased high-frequency energy in the NVS group, decreased high-frequency energy and main energy concentrated below 10 Hz in traumatic brain injury VS patients, higher energy in the 10-20 Hz band in ischemic-hypoxic VS patients. The power spectrum showed that the brain electrical energy of the NVS group was weakened R5 min after anesthesia induction compared with 5 min before induction, mainly concentrated in the small wave peak after 10 Hz, i.e., the α band peak; the energy of traumatic brain injury VS patients was weakened after anesthesia induction, but no α band peak appeared; and in ischemic-hypoxic VS patients, there was no significant change in low-frequency energy after anesthesia induction, high-frequency energy was significantly weakened, and a clear α band peak appeared slightly after 10 Hz. Three months after the operation, follow-up visits were made to the VS group patients who had undergone SCS surgery. One patient with traumatic brain injury VS was diagnosed with MCS-, one patient with ischemic-hypoxic VS had increased their CRS-R score by 1 point, and the remaining five patients had no change in their CRS scores.

CONCLUSIONS

Low doses of propofol cause great differences in the EEG of different types of VS patients, which may be the unique response of damaged nerve cell residual function to propofol, and these weak responses may also be the basis of brain recovery.

Management of the unconscious pregnant patient

The management of the unconscious pregnant patient encompasses many aspects of obstetrics and critical care. It is not uncommon to have to manage such a patient, therefore one needs to be well prepared. There is a spectrum of altered consciousness, brain death being the most extreme. The causes of unconsciousness can be general or pregnancy specific. It is important to consider the physiological changes in pregnancy when managing these patients. The immediate resuscitative measures are mostly the same as for the nonpregnant with a few modifications. It is important to remember that there are two patients involved and this can complicate management issues. A multidisciplinary approach would be prudent. The intermediate and long-term management should also involve the family. The issues of perimortem and somatic support for foetal maturity are also discussed.

Successful neonatal outcome in 2 cases of maternal persistent vegetative state treated in a labor and delivery suite

Two cases of maternal vegetative state after motor vehicle accidents are presented. Aggressive support allowed the prolongation of both pregnancies into the third trimester without neonatal compromise. After initial medical stabilization in intensive care unit environments, both patients were treated in a labor and delivery setting with consultative supports from various subspecialists.

Pregnancy in a persistent vegetative state: case report, comparison to brain death, and review of the literature

Severe maternal neurologic injury during pregnancy has the potential for fetal demise without advanced critical care support to the mother. Brain death is the unequivocal and irreversible loss of total brain function, whereas patients in a vegetative state, by contrast, have preserved brain stem function but lack cerebral function. They can appear to be awake, have sleep-wake cycles, be capable of swallowing, and have normal respiratory control, but there are no purposeful interactions. These conditions have different maternal prognoses, but both have resulted in near-normal neonatal outcomes with long latencies from maternal injury to delivery in previously published cases. This article compares and contrasts the 11 cases of brain death with 15 cases of persistent vegetative state in pregnancy. We found that the mean latency between maternal brain injury and delivery was significantly shorter in the brain-dead patients as compared with those in a vegetative state (46 days vs. 124 days, P </=.001). Correspondingly, the gestational ages at delivery (29.7 weeks vs. 33.2 weeks, P </=.01) and the birth weights (1380 g vs. 2145 g, P </=.01) were shorter in duration and smaller in size in the brain-dead group. We also present a case of persistent vegetative state in pregnancy at our institution with both maternal and neonatal death in the context of previously published literature with a focus on obstetric and ethical management. We hope this information will help elucidate the issues for providers confronted with these unique and challenging cases.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to state the difference between coma, persistent vegetative state and brain death, to describe the neurologic aspects of a patient in a persistent vegetative state, and to list the fetal effects of maternal brain injury.

Bispectral index-guided management of anaesthesia in permanent vegetative state

A patient in a permanent vegetative state required general anaesthesia for dental surgery. Because of the uncertainties involved in the appropriate monitoring and assessment of the conscious level of patients in a permanent vegetative state, it was decided to use the bispectral index to help guide the anaesthetic depth during surgery. We found that the bispectral index profile during anaesthesia and surgery was similar to that of a normal subject. The findings raise the possibility that patients in permanent vegetative states might sense noxious stimuli at a cortical level.