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Lipp M, Schneider G, Kreuzer M, Pilge S. Substance-dependent EEG during recovery from anesthesia and optimization of monitoring. J Clin Monit Comput 2024; 38:603-612. [PMID: 38108943 PMCID: PMC11164797 DOI: 10.1007/s10877-023-01103-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 10/28/2023] [Indexed: 12/19/2023]
Abstract
The electroencephalographic (EEG) activity during anesthesia emergence contains information about the risk for a patient to experience postoperative delirium, but the EEG dynamics during emergence challenge monitoring approaches. Substance-specific emergence characteristics may additionally limit the reliability of commonly used processed EEG indices during emergence. This study aims to analyze the dynamics of different EEG indices during anesthesia emergence that was maintained with different anesthetic regimens. We used the EEG of 45 patients under general anesthesia from the emergence period. Fifteen patients per group received sevoflurane, isoflurane (+ sufentanil) or propofol (+ remifentanil) anesthesia. One channel EEG and the bispectral index (BIS A-1000) were recorded during the study. We replayed the EEG back to the Conox, Entropy Module, and the BIS Vista to evaluate and compare the index behavior. The volatile anesthetics induced significantly higher EEG frequencies, causing higher indices (AUC > 0.7) over most parts of emergence compared to propofol. The median duration of "awake" indices (i.e., > 80) before the return of responsiveness (RoR) was significantly longer for the volatile anesthetics (p < 0.001). The different indices correlated well under volatile anesthesia (rs > 0.6), with SE having the weakest correlation. For propofol, the correlation was lower (rs < 0.6). SE was significantly higher than BIS and, under propofol anesthesia, qCON. Systematic differences of EEG-based indices depend on the drugs and devices used. Thus, to avoid early awareness or anesthesia overdose using an EEG-based index during emergence, the anesthetic regimen, the monitor used, and the raw EEG trace should be considered for interpretation before making clinical decisions.
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Affiliation(s)
- Marlene Lipp
- Department of Anesthesiology and Intensive Care, School of Medicine, Technical University of Munich, Ismaningerstr 22, 81675, Munich, Germany.
| | - Gerhard Schneider
- Department of Anesthesiology and Intensive Care, School of Medicine, Technical University of Munich, Ismaningerstr 22, 81675, Munich, Germany
| | - Matthias Kreuzer
- Department of Anesthesiology and Intensive Care, School of Medicine, Technical University of Munich, Ismaningerstr 22, 81675, Munich, Germany
| | - Stefanie Pilge
- Department of Anesthesiology and Intensive Care, School of Medicine, Technical University of Munich, Ismaningerstr 22, 81675, Munich, Germany
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Lichtenfeld F, Kratzer S, Hinzmann D, García PS, Schneider G, Kreuzer M. The Influence of Electromyographic on Electroencephalogram-Based Monitoring: Putting the Forearm on the Forehead. Anesth Analg 2024; 138:1285-1294. [PMID: 37756246 DOI: 10.1213/ane.0000000000006652] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2023]
Abstract
BACKGROUND Monitoring the electroencephalogram (EEG) during general anesthesia can help to safely navigate the patient through the procedure by avoiding too deep or light anesthetic levels. In daily clinical practice, the EEG is recorded from the forehead and available neuromonitoring systems translate the EEG information into an index inversely correlating with the anesthetic level. Electrode placement on the forehead can lead to an influence of electromyographic (EMG) activity on the recorded signal in patients without neuromuscular blockade (NMB). A separation of EEG and EMG in the clinical setting is difficult because both signals share an overlapping frequency range. Previous research showed that indices decreased when EMG was absent in awake volunteers with NMB. Here, we investigated to what extent the indices changed, when EEG recorded during surgery with NMB agents was superimposed with EMG. METHODS We recorded EMG from the flexor muscles of the forearm of 18 healthy volunteers with a CONOX monitor during different activity settings, that is, during contraction using a grip strengthener and during active diversion (relaxed arm). Both the forehead and forearm muscles are striated muscles. The recorded EMG was normalized by z -scoring and added to the EEG in different amplification steps. The EEG was recorded during anesthesia with NMB. We replayed these combined EEG and EMG signals to different neuromonitoring systems, that is, bispectral index (BIS), CONOX with qCON and qNOX, and entropy module with state entropy (SE) and response entropy (RE). We used the Friedman test and a Tukey-Kramer post hoc correction for statistical analysis. RESULTS The indices of all neuromonitoring systems significantly increased when the EEG was superimposed with the contraction EMG and with high EMG amplitudes, the monitors returned invalid values, representative of artifact contamination. When replaying the EEG being superimposed with "relaxed" EMG, the qCON and BIS showed significant increases, but not SE and RE. For SE and RE, we observed an increased number of invalid values. CONCLUSIONS With our approach, we could show that EMG activity during contraction and resting state can influence the neuromonitoring systems. This knowledge may help to improve EEG-based patient monitoring in the future and help the anesthesiologist to use the neuromonitoring systems with more knowledge regarding their function.
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Affiliation(s)
- Felicitas Lichtenfeld
- From the Department of Anesthesiology and Intensive Care Medicine, Technical University of Munich, School of Medicine, Munich, Germany
| | - Stephan Kratzer
- From the Department of Anesthesiology and Intensive Care Medicine, Technical University of Munich, School of Medicine, Munich, Germany
- Department of Anesthesia and Intensive Care Medicine, Hessing Foundation, Augsburg, Germany
| | - Dominik Hinzmann
- From the Department of Anesthesiology and Intensive Care Medicine, Technical University of Munich, School of Medicine, Munich, Germany
| | - Paul S García
- Department of Anesthesiology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Gerhard Schneider
- From the Department of Anesthesiology and Intensive Care Medicine, Technical University of Munich, School of Medicine, Munich, Germany
| | - Matthias Kreuzer
- From the Department of Anesthesiology and Intensive Care Medicine, Technical University of Munich, School of Medicine, Munich, Germany
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Rogozov V, Vanek T, Maly M, Rocek J, Kacer P. The nociceptive response during adult cardiac surgery measured by the qNOX index: A feasibility study. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2024; 168:62-67. [PMID: 36321735 DOI: 10.5507/bp.2022.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 10/18/2022] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Monitoring nociception during general anaesthesia remains a substantial challenge. The Conox monitor uses two EEG indices, the qCon and the qNox. The qNox refers to the probability that a nociceptive stimulation triggers a movement of the patient and the response probability of reaction to nociceptive stimulation. We decided to test the feasibility of monitoring the qNOX index during adult cardiac surgery and to investigate whether this index correlates with hemodynamic and hormonal signs of nociceptive stimulation. METHOD We enrolled 19 patients undergoing elective cardiac surgery. These were randomised to 2 groups receiving different doses of sufentanil via target controlled infusion: group A (n=9) 0.25 ng/mL and group B (n=10) 0.75 ng/mL. All patients were maintained at the same depth of anaesthesia. We recorded the Conox monitor indices (qNOX, qCON, electromyographic), hemodynamic variables and plasmatic levels of cortisol and noradrenaline. RESULTS There was significantly higher blood pressure (P=0.013) and plasmatic cortisol (P=0.003) in group A and a significant increase in plasmatic noradrenaline with increasing intensity of surgical stimulation in both groups: A (P=0.001), B (P=0.008). We found no significant corresponding changes in the qNOX index. There was a positive correlation between qNOX and hemodynamic signs of stimulation (P=0.012) and between the qNOX and EMG indices (P=0.013) after endotracheal intubation, but not later after EMG index dropped. CONCLUSION Our results do not support the assumption that signs of nociceptive stimulation during adult cardiac surgery will be reflected by the qNOX index. This may be related to compounding of qNOX processing and use of muscle relaxants. Further investigation on this field is needed.
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Affiliation(s)
- Vladislav Rogozov
- Department of Cardiac Surgery, 3rd Faculty of Medicine, Charles University, Prague and University Hospital Kralovske Vinohrady, Prague, Czech Republic
- Department of Anaesthesia, Leeds Teaching Hospitals, United Kingdom
| | - Tomas Vanek
- Department of Cardiac Surgery, 3rd Faculty of Medicine, Charles University, Prague and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Marek Maly
- National Institute of Public Health, Prague, Czech Republic
| | - Jan Rocek
- Department of Cardiac Surgery, 3rd Faculty of Medicine, Charles University, Prague and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Petr Kacer
- Department of Cardiac Surgery, 3rd Faculty of Medicine, Charles University, Prague and University Hospital Kralovske Vinohrady, Prague, Czech Republic
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Dragovic S, Schneider G, García PS, Hinzmann D, Sleigh J, Kratzer S, Kreuzer M. Predictors of Low Risk for Delirium during Anesthesia Emergence. Anesthesiology 2023; 139:757-768. [PMID: 37616326 DOI: 10.1097/aln.0000000000004754] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
BACKGROUND Processed electroencephalography (EEG) is used to monitor the level of anesthesia, and it has shown the potential to predict the occurrence of delirium. While emergence trajectories of relative EEG band power identified post hoc show promising results in predicting a risk for a delirium, they are not easily transferable into an online predictive application. This article describes a low-resource and easily applicable method to differentiate between patients at high risk and low risk for delirium, with patients at low risk expected to show decreasing EEG power during emergence. METHODS This study includes data from 169 patients (median age, 61 yr [49, 73]) who underwent surgery with general anesthesia maintained with propofol, sevoflurane, or desflurane. The data were derived from a previously published study. The investigators chose a single frontal channel, calculated the total and spectral band power from the EEG and calculated a linear regression model to observe the parameters' change during anesthesia emergence, described as slope. The slope of total power and single band power was correlated with the occurrence of delirium. RESULTS Of 169 patients, 32 (19%) showed delirium. Patients whose total EEG power diminished the most during emergence were less likely to screen positive for delirium in the postanesthesia care unit. A positive slope in total power and band power evaluated by using a regression model was associated with a higher risk ratio (total, 2.83 [95% CI, 1.46 to 5.51]; alpha/beta band, 7.79 [95% CI, 2.24 to 27.09]) for delirium. Furthermore, a negative slope in multiple bands during emergence was specific for patients without delirium and allowed definition of a test for patients at low risk. CONCLUSIONS This study developed an easily applicable exploratory method to analyze a single frontal EEG channel and to identify patterns specific for patients at low risk for delirium. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Srdjan Dragovic
- Department for Anesthesiology and Intensive Care, School of Medicine, Technical University of Munich, Munich, Germany
| | - Gerhard Schneider
- Department for Anesthesiology and Intensive Care, School of Medicine, Technical University of Munich, Munich, Germany
| | - Paul S García
- Department of Anesthesiology, Columbia University, New York, New York
| | - Dominik Hinzmann
- Department for Anesthesiology and Intensive Care, School of Medicine, Technical University of Munich, Munich, Germany
| | - Jamie Sleigh
- Waikato Clinical Campus, University of Auckland, Auckland, New Zealand
| | - Stephan Kratzer
- Department for Anesthesiology and Intensive Care, School of Medicine, Technical University of Munich, Munich, Germany; and Hessing Clinic for Anesthesiology, Intensive Care and Pain Medicine, Augsburg, Germany
| | - Matthias Kreuzer
- Department for Anesthesiology and Intensive Care, School of Medicine, Technical University of Munich, Munich, Germany
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Lutz R, Müller C, Dragovic S, Schneider F, Ribbe K, Anders M, Schmid S, García PS, Schneider G, Kreuzer M, Kratzer S. The absence of dominant alpha-oscillatory EEG activity during emergence from delta-dominant anesthesia predicts neurocognitive impairment- results from a prospective observational trial. J Clin Anesth 2022; 82:110949. [PMID: 36049381 DOI: 10.1016/j.jclinane.2022.110949] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 08/02/2022] [Accepted: 08/04/2022] [Indexed: 11/24/2022]
Abstract
STUDY OBJECTIVE Postoperative neurocognitive disorders (PND) are common complications after surgery under general anesthesia. In our aging society the incidence of PND will increase. Hence, interdisciplinary efforts should be taken to minimize the occurrence of PND. Electroencephalographic (EEG) monitoring of brain activity during anesthesia or emergence from anesthesia is a promising tool to identify patients at risk. We therefore investigated whether we could identify specific EEG signatures during emergence of anesthesia that are associated with the occurrence of PND. DESIGN AND PATIENTS We performed a prospective observational investigation on 116 patients to evaluate the EEG features during emergence from general anesthesia dominated by slow delta waves in patients with and without delirium in the postoperative care unit (PACU-D) as assessed by the CAM-ICU and the RASS. MAIN RESULTS During emergence both the frontal and global EEG of patients with PACU-D were significantly different from patients without PACU-D. PACU-D patients had lower relative alpha power and reduced fronto-parietal alpha coherence. CONCLUSIONS With our analysis we show differences in EEG features associated with anesthesia emergence in patients with and without PACU-D. Frontal and global EEG alpha-band features could help to identify patients with PACU-D. CLINICAL TRIAL NUMBER NCT03287401.
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Affiliation(s)
- Rieke Lutz
- Department of Anaesthesiology and Intensive Care, Technical University of Munich, School of Medicine, Munich, Germany
| | - Claudia Müller
- Department of Anaesthesiology and Intensive Care, Technical University of Munich, School of Medicine, Munich, Germany
| | - Srdjan Dragovic
- Department of Anaesthesiology and Intensive Care, Technical University of Munich, School of Medicine, Munich, Germany
| | - Frederick Schneider
- Department of Anaesthesiology and Intensive Care, Technical University of Munich, School of Medicine, Munich, Germany
| | - Katharina Ribbe
- Department of Anaesthesiology and Intensive Care, Technical University of Munich, School of Medicine, Munich, Germany
| | - Malte Anders
- Early Clinical Development and Human Pain Models, Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Frankfurt am Main, Germany
| | - Sebastian Schmid
- Department of Anaesthesiology and Intensive Care, Technical University of Munich, School of Medicine, Munich, Germany; Department of Anaesthesiology and Intensive Care, Universitätsklinikum Ulm, Ulm, Germany
| | - Paul S García
- Department of Anaesthesiology, Columbia University, New York, NY, USA
| | - Gerhard Schneider
- Department of Anaesthesiology and Intensive Care, Technical University of Munich, School of Medicine, Munich, Germany
| | - Matthias Kreuzer
- Department of Anaesthesiology and Intensive Care, Technical University of Munich, School of Medicine, Munich, Germany.
| | - Stephan Kratzer
- Department of Anaesthesiology and Intensive Care, Technical University of Munich, School of Medicine, Munich, Germany
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Evaluation of Anesthetic Specific EEG Dynamics during State Transitions between Loss and Return of Responsiveness. Brain Sci 2021; 12:brainsci12010037. [PMID: 35053781 PMCID: PMC8773581 DOI: 10.3390/brainsci12010037] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 12/21/2021] [Accepted: 12/23/2021] [Indexed: 11/17/2022] Open
Abstract
Purpose: electroencephalographic (EEG) information is used to monitor the level of cortical depression of a patient undergoing surgical intervention under general anesthesia. The dynamic state transitions into and out of anesthetic-induced loss and return of responsiveness (LOR, ROR) present a possibility to evaluate the dynamics of the EEG induced by different substances. We evaluated changes in the EEG power spectrum during anesthesia emergence for three different anesthetic regimens. We also assessed the possible impact of these changes on processed EEG parameters such as the permutation entropy (PeEn) and the cerebral state index (CSI). Methods: we analyzed the EEG from 45 patients, equally assigned to three groups. All patients were induced with propofol and the groups differed by the maintenance anesthetic regimen, i.e., sevoflurane, isoflurane, or propofol. We evaluated the EEG and parameter dynamics during LOR and ROR. For the emergence period, we focused on possible differences in the EEG dynamics in the different groups. Results: depending on the substance, the EEG emergence patterns showed significant differences that led to a substance-specific early activation of higher frequencies as indicated by the “wake” CSI values that occurred minutes before ROR in the inhalational anesthetic groups. Conclusion: our results highlight substance-specific differences in the emergence from anesthesia that can influence the EEG-based monitoring that probably have to be considered in order to improve neuromonitoring during general anesthesia.
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Affiliation(s)
- T. Ezri
- Kaplan Medical Center Rehovot Israel
| | - A. Dukhan
- Kaplan Medical Center Rehovot Israel
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Permutation entropy in intraoperative ECoG of brain tumour patients in awake tumour surgery- a robust parameter to separate consciousness from unconsciousness. Sci Rep 2019; 9:16482. [PMID: 31712616 PMCID: PMC6848144 DOI: 10.1038/s41598-019-52949-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 10/25/2019] [Indexed: 01/10/2023] Open
Abstract
Awake craniotomies represent an essential opportunity in the case of lesions in eloquent areas. Thus, optimal surveillance of the patient during different stages of sedation, as well as the detection of seizure activity during brain surgery, remains difficult, as skin electrodes for electroencephalographic (EEG) analysis are not applicable in most cases. We assessed the applicability of ECoG to monitor different stages of sedation, as well as the influence of different patient characteristics, such as tumour volume, size, entity, and age or gender on permutation entropy (PeEn). We conducted retrospective analysis of the ECoG data of 16 patients, who underwent awake craniotomies because of left-sided brain tumours at our centre between 2014 and 2016. PeEn could be easily calculated and compared using frontal and parietal cortical electrodes. A comparison of PeEn scores showed significantly higher values in awake patients than in patients under anaesthesia (p ≤ 0.004) and significantly higher ones in the state of transition than under general anaesthesia (p = 0.023). PeEn scores in frontal and parietal leads did not differ significantly, making them both applicable for continuous surveillance during brain surgery. None of the following clinical characteristics showed significant correlation with PeEn scores: tumour volume, WHO grade, first or recurrent tumour, gender, and sex. Being 50 years or older led to significantly lower values in parietal leads but not in frontal leads. ECoG and a consecutive analysis of PeEn are feasible and suitable for the continuous surveillance of patients during awake craniotomies. Hence, the analysis is not influenced by patients' clinical characteristics.
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Fleischmann A, Pilge S, Kiel T, Kratzer S, Schneider G, Kreuzer M. Substance-Specific Differences in Human Electroencephalographic Burst Suppression Patterns. Front Hum Neurosci 2018; 12:368. [PMID: 30297992 PMCID: PMC6160564 DOI: 10.3389/fnhum.2018.00368] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 08/28/2018] [Indexed: 12/17/2022] Open
Abstract
Different anesthetic agents induce burst suppression in the electroencephalogram (EEG) at very deep levels of general anesthesia. EEG burst suppression has been identified to be a risk factor for postoperative delirium (POD). EEG based automated detection algorithms are used to detect burst suppression patterns during general anesthesia and a burst suppression ratio (BSR) is calculated. Unfortunately, applied algorithms do not give information as precisely as suggested, often resulting in an underestimation of the patients’ burst suppression level. Additional knowledge of substance-specific burst suppression patterns could be of great importance to improve the ability of EEG based monitors to detect burst suppression. In a re-analysis of EEG recordings obtained from a previous study, we analyzed EEG data of 45 patients undergoing elective surgery under general anesthesia. The patients were anesthetized with sevoflurane, isoflurane or propofol (n = 15, for each group). After skin incision, the used agent was titrated to a level when burst suppression occurred. In a visual analysis of the EEG, blinded to the used anesthetic agent, we included the first distinct burst in our analysis. To avoid bias through changing EEG dynamics throughout the burst, we only focused on the first 2 s of the burst. These episodes were analyzed using the power spectral density (PSD) and normalized PSD, the absolute burst amplitude and absolute burst slope, as well as permutation entropy (PeEn). Our results show significant substance-specific differences in the architecture of the burst. Volatile-induced bursts showed higher burst amplitudes and higher burst power. Propofol-induced bursts had significantly higher relative power in the EEG alpha-range. Further, isoflurane-induced bursts had the steepest burst slopes. We can present the first systematic comparison of substance-specific burst characteristics during anesthesia. Previous observations, mostly derived from animal studies, pointing out the substance-specific differences in bursting behavior, concur with our findings. Our findings of substance-specific EEG characteristics can provide information to help improve automated burst suppression detection in monitoring devices. More specific detection of burst suppression may be helpful to reduce excessive EEG effects of anesthesia and therefore the incidence of adverse outcomes such as POD.
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Affiliation(s)
- Antonia Fleischmann
- Department of Anesthesiology and Intensive Care, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany
| | - Stefanie Pilge
- Department of Anesthesiology and Intensive Care, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany
| | - Tobias Kiel
- Department of Anesthesiology and Intensive Care, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany
| | - Stephan Kratzer
- Department of Anesthesiology and Intensive Care, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany
| | - Gerhard Schneider
- Department of Anesthesiology and Intensive Care, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany
| | - Matthias Kreuzer
- Department of Anesthesiology and Intensive Care, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany
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Zaouter C, Hemmerling TM, Mion S, Leroux L, Remy A, Ouattara A. Feasibility of Automated Propofol Sedation for Transcatheter Aortic Valve Implantation. Anesth Analg 2017; 125:1505-1512. [DOI: 10.1213/ane.0000000000001737] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Kuhlmann L, Liley DTJ. Assessing nitrous oxide effect using electroencephalographically-based depth of anesthesia measures cortical state and cortical input. J Clin Monit Comput 2017; 32:173-188. [DOI: 10.1007/s10877-017-9978-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 01/02/2017] [Indexed: 12/19/2022]
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Hight DF, Voss LJ, García PS, Sleigh JW. Electromyographic activation reveals cortical and sub-cortical dissociation during emergence from general anesthesia. J Clin Monit Comput 2016; 31:813-823. [PMID: 27444893 DOI: 10.1007/s10877-016-9911-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 07/19/2016] [Indexed: 12/17/2022]
Abstract
During emergence from anesthesia patients regain their muscle tone (EMG). In a typical population of surgical patients the actual volatile gas anesthetic concentrations in the brain (CeMAC) at which EMG activation occurs remains unknown, as is whether EMG activation at higher CeMACs is correlated with subsequent severe pain, or with cortical activation. Electroencephalographic (EEG) and EMG activity was recorded from the forehead of 273 patients emerging from general anesthesia following surgery. We determined CeMAC at time of EMG activation and at return of consciousness. Pain was assessed immediately after return of consciousness using an 11 point numerical rating scale. The onset of EMG activation during emergence was associated with neither discernible muscle movement nor with the presence of exogenous stimulation in half the patients. EMG activation could be modelled as two distinct processes; termed high- and low-CeMAC (occurring higher or lower than 0.07 CeMAC). Low-CeMAC activation was typically associated with simultaneous EMG activation and consciousness, and the presence of a laryngeal mask. In contrast, high-CeMAC EMG activation occurred independently of return of consciousness, and was not associated with severe post-operative pain, but was more common in the presence of an endotracheal tube. Patients emerging from general anesthesia with an endotracheal tube in place are more likely to have an EMG activation at higher CeMAC concentrations. These activations are not associated with subsequent high-pain, nor with cortical arousal, as evidenced by continuing delta waves in the EEG. Conversely, patients emerging from general anesthesia with a laryngeal mask demonstrate marked neural inertia-EMG activation occurs at a low CeMAC, and is closely temporally associated with return of consciousness.
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Affiliation(s)
- Darren F Hight
- Department of Anaesthesiology, Waikato Clinical Campus, University of Auckland, Pembroke Street, Hamilton, 3240, New Zealand
| | - Logan J Voss
- Waikato District Health Board, Hamilton, 3240, New Zealand
| | - Paul S García
- Department of Anesthesiology, Atlanta VA Medical Center/Emory University, 1670 Clairmont Road, Atlanta, GA, 30033, USA
| | - Jamie W Sleigh
- Department of Anaesthesiology, Waikato Clinical Campus, University of Auckland, Pembroke Street, Hamilton, 3240, New Zealand.
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Kuhlmann L, Manton JH, Heyse B, Vereecke HEM, Lipping T, Struys MMRF, Liley DTJ. Tracking Electroencephalographic Changes Using Distributions of Linear Models: Application to Propofol-Based Depth of Anesthesia Monitoring. IEEE Trans Biomed Eng 2016; 64:870-881. [PMID: 27323352 DOI: 10.1109/tbme.2016.2562261] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Tracking brain states with electrophysiological measurements often relies on short-term averages of extracted features and this may not adequately capture the variability of brain dynamics. The objective is to assess the hypotheses that this can be overcome by tracking distributions of linear models using anesthesia data, and that anesthetic brain state tracking performance of linear models is comparable to that of a high performing depth of anesthesia monitoring feature. METHODS Individuals' brain states are classified by comparing the distribution of linear (auto-regressive moving average-ARMA) model parameters estimated from electroencephalographic (EEG) data obtained with a sliding window to distributions of linear model parameters for each brain state. The method is applied to frontal EEG data from 15 subjects undergoing propofol anesthesia and classified by the observers assessment of alertness/sedation (OAA/S) scale. Classification of the OAA/S score was performed using distributions of either ARMA parameters or the benchmark feature, Higuchi fractal dimension. RESULTS The highest average testing sensitivity of 59% (chance sensitivity: 17%) was found for ARMA (2,1) models and Higuchi fractal dimension achieved 52%, however, no statistical difference was observed. For the same ARMA case, there was no statistical difference if medians are used instead of distributions (sensitivity: 56%). CONCLUSION The model-based distribution approach is not necessarily more effective than a median/short-term average approach, however, it performs well compared with a distribution approach based on a high performing anesthesia monitoring measure. SIGNIFICANCE These techniques hold potential for anesthesia monitoring and may be generally applicable for tracking brain states.
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Kim E, Ryu JH, Byun SH. Effect of neuromuscular blockade reversal by pyridostigmine on spectral entropy values during recovery from desflurane anesthesia: a prospective, randomized, double-blind, controlled trial. Korean J Anesthesiol 2016; 69:227-33. [PMID: 27274366 PMCID: PMC4891533 DOI: 10.4097/kjae.2016.69.3.227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Revised: 01/30/2016] [Accepted: 02/03/2016] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND According to several studies investigating the relationship between muscle activity and electroencephalogram results, reversal of neuromuscular blockade (NMB) may affect depth of anesthesia indices. Therefore, we investigated the effect of pyridostigmine on these indices via spectral entropy. METHODS Fifty-six patients scheduled for thyroidectomy or parotidectomy were included in this study and randomized into two groups. At the start of skin suturing, the desflurane concentration was adjusted to 4.2 vol% in both groups. Following this, the pyridostigmine group (group P, n = 28) was administered pyridostigmine 0.2 mg/kg mixed with glycopyrrolate 0.04 mg/kg, while the control group (group C, n = 28) received normal saline. Entropy values (response entropy [RE] and state entropy [SE]), train of four (TOF) ratio, and end-tidal desflurane concentration were recorded from point of drug administration to 15 minutes post-drug administration. RESULTS Mean RE values at 15 minutes, when the maximum effect of pyridostigmine was anticipated, showed a statistically significant difference between groups (53.8 ± 10.5 in group P and 48.0 ± 8.8 in group C; P = 0.030). However, mean SE at 15 minutes showed no significant difference between the two groups (P = 0.066). At 15 minutes, there were significant differences in the TOF ratio between the two groups (P < 0.001). CONCLUSIONS NMB reversal by pyridostigmine significantly increased RE values but not SE values. This finding suggests that spectral entropy may be a useful alternative tool for monitoring anesthetic depth during recovery from anesthesia in the presence of electromyogram activity.
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Affiliation(s)
- Eugene Kim
- Department of Anesthesiology and Pain Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Jae Hun Ryu
- Department of Anesthesiology and Pain Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Sung Hye Byun
- Department of Anesthesiology and Pain Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
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Iturri Clavero F, Tamayo Medel G, de Orte Sancho K, González Uriarte A, Iglesias Martínez A, Martínez Ruíz A. Use of BIS VISTA bilateral monitor for diagnosis of intraoperative seizures, a case report. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2015; 62:590-595. [PMID: 25944463 DOI: 10.1016/j.redar.2015.03.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Revised: 02/28/2015] [Accepted: 03/02/2015] [Indexed: 06/04/2023]
Abstract
Changes in BIS (bispectral index) VISTA bilateral monitoring system associated with intraoperative episodes of generalized and focal seizures, during total intravenous anesthesia for resection of a left frontal parasagittal meningioma, are herein described.
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Affiliation(s)
- F Iturri Clavero
- Servicio de Anestesiología y Reanimación del Hospital Universitario de Cruces, Plaza de Cruces s/n, 48903 Barakaldo, Bizkaia, Spain.
| | - G Tamayo Medel
- Servicio de Anestesiología y Reanimación del Hospital Universitario de Cruces, Plaza de Cruces s/n, 48903 Barakaldo, Bizkaia, Spain; Departamento de Farmacología de la Universidad del País Vasco, Campus de Bizkaia, Barrio Sarriena, s/n, 48940 Leioa, Bizkaia, Spain
| | - K de Orte Sancho
- Servicio de Anestesiología y Reanimación del Hospital Universitario de Cruces, Plaza de Cruces s/n, 48903 Barakaldo, Bizkaia, Spain
| | - A González Uriarte
- Servicio de Anestesiología y Reanimación del Hospital Universitario de Cruces, Plaza de Cruces s/n, 48903 Barakaldo, Bizkaia, Spain
| | - A Iglesias Martínez
- Servicio de Neurofisiología clínica del Hospital Universitario de Cruces, Plaza de Cruces s/n Cruces, 48903 Barakaldo, Bizkaia, Spain
| | - A Martínez Ruíz
- Servicio de Anestesiología y Reanimación del Hospital Universitario de Cruces, Plaza de Cruces s/n, 48903 Barakaldo, Bizkaia, Spain; Departamento de Departamento: Cirugía, Radiología y Medicina Física, Área de Cirugía, Universidad del País Vasco, Campus de Bizkaia, Barrio Sarriena, s/n, 48940 Leioa, Bizkaia, Spain
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Automation of anaesthesia: a review on multivariable control. J Clin Monit Comput 2014; 29:231-9. [DOI: 10.1007/s10877-014-9590-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Accepted: 06/03/2014] [Indexed: 12/19/2022]
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Monitoring depth of anesthesia utilizing a combination of electroencephalographic and standard measures. Anesthesiology 2014; 120:819-28. [PMID: 24694845 DOI: 10.1097/aln.0000000000000151] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND For decades, monitoring depth of anesthesia was mainly based on unspecific effects of anesthetics, for example, blood pressure, heart rate, or drug concentrations. Today, electroencephalogram-based monitors promise a more specific assessment of the brain function. To date, most approaches were focused on a "head-to-head" comparison of either electroencephalogram- or standard parameter-based monitoring. In the current study, a multimodal indicator based on a combination of both electro encephalographic and standard anesthesia monitoring parameters is defined for quantification of "anesthesia depth." METHODS Two hundred sixty-three adult patients from six European centers undergoing surgery with general anesthesia were assigned to 1 of 10 anesthetic combinations according to standards of the enrolling hospital. The anesthesia multimodal index of consciousness was developed using a data-driven approach, which maps standard monitoring and electroencephalographic parameters into an output indicator that separates different levels of anesthesia from awake to electroencephalographic burst suppression. Obtained results were compared with either a combination of standard monitoring parameters or the electroencephalogram-based bispectral index. RESULTS The anesthesia multimodal index of consciousness showed prediction probability (P(K)) of 0.96 (95% CI, 0.95 to 0.97) to separate different levels of anesthesia (wakefulness to burst suppression), whereas the bispectral index had significantly lower PK of 0.80 (0.76 to 0.81) at corrected threshold P value of less than 0.05. At the transition between consciousness and unconsciousness, anesthesia multimodal index of consciousness yielded a PK of 0.88 (0.85 to 0.91). CONCLUSION A multimodal integration of both standard monitoring and electroencephalographic parameters may more precisely reflect the level of anesthesia compared with monitoring based on one of these aspects alone.
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Marchant N, Sanders R, Sleigh J, Vanhaudenhuyse A, Bruno MA, Brichant JF, Laureys S, Bonhomme V. How electroencephalography serves the anesthesiologist. Clin EEG Neurosci 2014; 45:22-32. [PMID: 24415399 DOI: 10.1177/1550059413509801] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Major clinical endpoints of general anesthesia, such as the alteration of consciousness, are achieved through effects of anesthetic agents on the central nervous system, and, more precisely, on the brain. Historically, clinicians and researchers have always been interested in quantifying and characterizing those effects through recordings of surface brain electrical activity, namely electroencephalography (EEG). Over decades of research, the complex signal has been dissected to extract its core substance, with significant advances in the interpretation of the information it may contain. Methodological, engineering, statistical, mathematical, and computer progress now furnishes advanced tools that not only allow quantification of the effects of anesthesia, but also shed light on some aspects of anesthetic mechanisms. In this article, we will review how advanced EEG serves the anesthesiologist in that respect, but will not review other intraoperative utilities that have no direct relationship with consciousness, such as monitoring of brain and spinal cord integrity. We will start with a reminder of anesthestic effects on raw EEG and its time and frequency domain components, as well as a summary of the EEG analysis techniques of use for the anesthesiologist. This will introduce the description of the use of EEG to assess the depth of the hypnotic and anti-nociceptive components of anesthesia, and its clinical utility. The last part will describe the use of EEG for the understanding of mechanisms of anesthesia-induced alteration of consciousness. We will see how, eventually in association with transcranial magnetic stimulation, it allows exploring functional cerebral networks during anesthesia. We will also see how EEG recordings during anesthesia, and their sophisticated analysis, may help corroborate current theories of mental content generation.
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Affiliation(s)
- Nicolas Marchant
- Department of Anesthesia and Intensive Care Medicine, CHU Liege, Liege, Belgium
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Fuzzy logic model to describe anesthetic effect and muscular influence on EEG Cerebral State Index. Res Vet Sci 2013; 94:735-42. [DOI: 10.1016/j.rvsc.2012.12.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Revised: 12/11/2012] [Accepted: 12/23/2012] [Indexed: 11/17/2022]
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20
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van Kralingen S, Diepstraten J, Peeters MYM, Deneer VHM, van Ramshorst B, Wiezer RJ, van Dongen EPA, Danhof M, Knibbe CAJ. Population pharmacokinetics and pharmacodynamics of propofol in morbidly obese patients. Clin Pharmacokinet 2012; 50:739-50. [PMID: 21973271 DOI: 10.2165/11592890-000000000-00000] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND OBJECTIVES In view of the increasing prevalence of morbidly obese patients, the influence of excessive total bodyweight (TBW) on the pharmacokinetics and pharmacodynamics of propofol was characterized in this study using bispectral index (BIS) values as a pharmacodynamic endpoint. METHODS A population pharmacokinetic and pharmacodynamic model was developed with the nonlinear mixed-effects modelling software NONMEM VI, on the basis of 491 blood samples from 20 morbidly obese patients (TBW range 98-167 kg) and 725 blood samples from 44 lean patients (TBW range 55-98 kg) from previously published studies. In addition, 2246 BIS values from the 20 morbidly obese patients were available for pharmacodynamic analysis. RESULTS In a three-compartment pharmacokinetic model, TBW proved to be the most predictive covariate for clearance from the central compartment (CL) in the 20 morbidly obese patients (CL 2.33 L/min × [TBW/70]^[0.72]). Similar results were obtained when the morbidly obese patients and the 44 lean patients were analysed together (CL 2.22 L/min × [TBW/70]^[0.67]). No covariates were identified for other pharmacokinetic parameters. The depth of anaesthesia in the morbidly obese patients was adequately described by a two-compartment biophase-distribution model with a sigmoid maximum possible effect (E(max)) pharmacodynamic model (concentration at half-maximum effect [EC(50)] 2.12 mg/L) without covariates. CONCLUSION We developed a pharmacokinetic and pharmacodynamic model of propofol in morbidly obese patients, in which TBW proved to be the major determinant of clearance, using an allometric function with an exponent of 0.72. For the other pharmacokinetic and pharmacodynamic parameters, no covariates could be identified. Trial registration number (clinicaltrials.gov): NCT00395681.
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Affiliation(s)
- Simone van Kralingen
- Department of Anesthesiology and Intensive Care, St Antonius Hospital, Nieuwegein, the Netherlands
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Brás S, Ferreira DA, Antunes L, Ribeiro L, Nunes CS, Gouveia S. EMG contributes to improve Cerebral State Index modeling in dogs anesthesia. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2012; 2011:6593-6. [PMID: 22255850 DOI: 10.1109/iembs.2011.6091626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Cerebral State Index (CSI) is a measure of depth of anesthesia (DoA) developed for humans, which is traditionally modeled with the Hill equation and the propofol effect-site concentration (Ce). The CSI has been studied in dogs and showed several limitations related to the interpretation of EEG data. Nevertheless, the CSI has a lot of potential for DoA monitoring in dogs, it just needs to be adjusted for this species. In this work, an adapted CSI model is presented for dogs considering a) both Ce and EMG as inputs and b) a fuzzy logic structure with parameters optimized using the ANFIS method. The new model is compared with traditional Hill model using data from dogs in routine surgery. The results showed no significant impact in the model performance with the change of model structure (Fuzzy instead of Hill). The residuals of the Hill model were significantly correlated with the EMG, indicating that the latter should be considered in the model. In fact, the EMG introduction in CSI model significantly decreased the modeling error: 11.8 [8.6; 15.2] (fuzzy logic) versus 20.9 [16.4; 29.0] (Hill). This work shows that CSI modeling in dogs can be improved using the current human anesthesia set-up, once the EMG signal is acquired simultaneously with the CSI index. However, it does not invalidate the search of new DoA indices more adjusted to use in dog's anesthesia.
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Affiliation(s)
- Susana Brás
- Instituto de Ciências Biomédicas Abel Salazar da Universidade do Porto.
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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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Abstract
In recent years, the importance of appropriate intra-operative anesthesia and analgesia during cardiac surgery has become recognized as a factor in postoperative recovery. This includes the early perioperative management of the neonate undergoing radical surgery and more recently the care surrounding fast-track and ultra fast-track surgery. However, outside these areas, relatively little attention has focused on postoperative sedation and analgesia within the pediatric intensive care unit (PICU). This reflects perceived priorities of the primary disease process over the supporting structure of PICU, with a generic approach to sedation and analgesia that can result in additional morbidities and delayed recovery. Management of the marginal patient requires optimisation of not only cardiac and other attendant pathophysiology, but also every aspect of supportive care. Individualized sedation and analgesia strategies, starting in the operating theater and continuing through to hospital discharge, need to be regarded as an important aspect of perioperative care, to speed the process of recovery.
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Affiliation(s)
- Andrew R Wolf
- Paediatric Intensive Care Unit, Bristol Children's Hospital, Upper Maudlin Street, Bristol, UK.
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Sieber FE, Gottshalk A, Zakriya KJ, Mears SC, Lee H. General anesthesia occurs frequently in elderly patients during propofol-based sedation and spinal anesthesia. J Clin Anesth 2011; 22:179-83. [PMID: 20400003 DOI: 10.1016/j.jclinane.2009.06.005] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2008] [Revised: 06/16/2009] [Accepted: 06/22/2009] [Indexed: 12/25/2022]
Abstract
STUDY OBJECTIVE To test the hypothesis that sedation in elderly patients is often electrophysiologically equivalent to general anesthesia (GA). DESIGN Prospective, observational study. SETTING Operating room of a university medical center. PATIENTS 40 elderly patients (>or=65 yrs of age) undergoing hip fracture repair with spinal anesthesia and propofol-based sedation. INTERVENTIONS In the routine practice group (RP; n = 15), propofol sedation was administered per the usual routine of the anesthesiologist. In the targeted sedation group (TS; n = 25), sedation was titrated to an observer's assessment of alertness/sedation (OAA/S) score of 4 (ie, lethargic in response to name called) to 5 (ie, awake and alert). MEASUREMENTS Both patient groups underwent processed electroencephalographic monitoring using bispectral index (BIS) intraoperatively. BIS levels were compared between groups to determine amount of surgical time spent in GA (BIS <or= 60). MAIN RESULTS In the RP group, subjects spent 32.2% of surgical time at BIS levels consistent with GA. Although averaged BIS values during surgery increased from (mean +/- SD) 71 +/- 16 to 88 +/- 9 (P < 0.001), GA was still observed during 5% of surgical time in the TS group. Overall, 13 of 15 (87%) RP group patients and 11 of 25 (44%) TS group patients (P < 0.010) experienced some period of GA. CONCLUSIONS BIS levels consistent with GA occur frequently in elderly patients during propofol-based sedation for spinal anesthesia. Altering routine practice such that sedation is titrated to a targeted clinically-determined sedation level reduces - but does not eliminate - this incidence.
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Affiliation(s)
- Frederick E Sieber
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD 21224, USA.
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25
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Weber F, Kriek N, Blussé van Oud-Alblas HJ. The effects of mivacurium-induced neuromuscular block on Bispectral Index and Cerebral State Index in children under propofol anesthesia - a prospective randomized clinical trial. Paediatr Anaesth 2010; 20:697-703. [PMID: 20670234 DOI: 10.1111/j.1460-9592.2010.03327.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND In adults anesthetized with propofol, muscle relaxants may decrease the Bispectral Index (BIS). The aim of this prospective randomized trial was to detect the influence of a muscle relaxant bolus on the BIS and the Cerebral State Index (CSI) in children under propofol anesthesia. METHODS Forty pediatric patients, age 6.6 +/- 3.3 years, weight 24 +/- 9 kg, scheduled for surgical procedures requiring general anesthesia were enrolled. Two minutes after i.v. injection of 0.3 mcg.kg(-1) of sufentanil, general anesthesia was induced by an initial bolus of 3 mg.kg(-1) of propofol, followed by a continuous infusion titrated to achieve a stable BIS value of 50 +/- 5. Patients received either mivacurium 0.25 mg.kg(-1) (Group Miva) or NaCl 0.9% 0.12 ml.kg(-1) (Group Control). Mean BIS and CSI values per minute were compared between (Miva vs. Control) and within groups (Baseline vs 5 min. after study drug administration). RESULTS The observed changes in BIS and CSI values before and after administration of study drugs revealed no differences between the study groups. Mean baseline BIS and CSI values were lower than 5 min after study drug administration. There were no intergroup differences with respect to BIS and CSI values at any time point. CONCLUSIONS These data suggest that in pediatric patients anesthetized with propofol, administration of mivacurium has no impact on BIS and CSI values.
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Affiliation(s)
- Frank Weber
- Department of Anaesthesia, Erasmus University Medical Center Rotterdam, Sophia Children's Hospital, Rotterdam, The Netherlands.
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Fakhari S, Bilehjani E, Azarfarin R, Kianfar AA, Mirinazhad M, Negargar S. Anesthesia in adult cardiac surgery without maintenance of muscle relaxants: a randomized clinical trial. Pak J Biol Sci 2009; 12:1111-1118. [PMID: 19899321 DOI: 10.3923/pjbs.2009.1111.1118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
There may be no need for muscle paralysis during cardiac surgery when adequate anesthesia is provided. We studied intra- and post-operative conditions during cardiac surgery without maintenance muscle relaxant therapy. Eighty adult patients who were candidates for elective coronary artery bypass graft surgery were randomly allocated into two groups. In the noMR or study group (noMR group; n = 40) only an intubation dose of cisatracurium (0.15 mg kg(-1)) was administrated, as opposed to the control group (MR group; n = 40), who had a continuous infusion added to the intubation dose. The anesthesia level was maintained at a Bispectral score of 40-50 using a propofol infusion. A remifentanil infusion was titrated to control patient hemodynamic response. During surgery, any minor (fine body or respiratory muscle movements) or major (coarse body movements or bucking/caught) movements were recorded. Postoperatively, analgesia was provided by remifentanil. The surgical condition was classified into three states: good (no movement), acceptable (minor movements), or poor (major movements). Anesthesia, surgery and postoperative characteristics were compared between the two groups. Statistical analysis was performed in only 78 patients (noMR = 38, MR = 40). The demographic and preoperative characteristics of the two groups were comparable. Intra-operative propofol consumption was the same, but significantly more remifentanil was used in the noMR group (p = 0.001). Post-operative characteristics and complication rates did not differ between the two groups. There were no movements in the MR group patients, while in the noMR group one patient had major movement and three had minor movements. We concluded that omitting maintenance muscle relaxants in adult cardiac surgery or eliminating residual muscle paralysis at the end of the surgery without improving early outcome can increase patient intra-operative movement risk.
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Affiliation(s)
- S Fakhari
- Madani Heart Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
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Odri A, Cavalcanti A, Billard V. Un indice bispectral étrangement élevé. ACTA ACUST UNITED AC 2008; 27:945-8. [DOI: 10.1016/j.annfar.2008.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2008] [Accepted: 08/25/2008] [Indexed: 12/20/2022]
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Borjian Boroojeny S. The effect of facial muscle contractions on the cerebral state index in an ICU patient: A case report. CASES JOURNAL 2008; 1:167. [PMID: 18803822 PMCID: PMC2561013 DOI: 10.1186/1757-1626-1-167] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2008] [Accepted: 09/19/2008] [Indexed: 11/23/2022]
Abstract
Introduction Cerebral state monitor is a monitor which shows depth of anesthesia in a number between 0–100 as cerebral state index, in which 40–60 is appropriate for general anesthesia. The effect of electromyogram on cerebral state index has not been shown yet. Case report A 24-year-old Iranian-balooch man admitted in the intensive care unit because of head injury in a car accident. In spite of sustained low level of consciousness, his cerebral state index had significant fluctuations coordinated with electromyogram resulted from facial muscle contractions. After neuromuscular blocking agent prescription, cerebral state index was decreased from about 90 to 40, directly followed the changes in electromyogram.
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Sim JY, Ahn W. Electric signal composed of electroencephalogram and electromyogram. Korean J Anesthesiol 2008. [DOI: 10.4097/kjae.2008.55.2.263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Ji-Yeon Sim
- Department of anesthesiology and pain medicine, Asan medical center, Korea
| | - Wonsik Ahn
- Department of anesthesiology and pain medicine, Seoul National University Hospital, Korea
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Andrzejowski J, Carroll T. Inappropriate elevation of bispectral index and disruption of neurosurgery after irrigation-induced facial nerve irritation. Br J Anaesth 2007; 99:750-1. [DOI: 10.1093/bja/aem289] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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