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Laferrière-Langlois P, Morisson L, Jeffries S, Duclos C, Espitalier F, Richebé P. Depth of Anesthesia and Nociception Monitoring: Current State and Vision For 2050. Anesth Analg 2024; 138:295-307. [PMID: 38215709 DOI: 10.1213/ane.0000000000006860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2024]
Abstract
Anesthesia objectives have evolved into combining hypnosis, amnesia, analgesia, paralysis, and suppression of the sympathetic autonomic nervous system. Technological improvements have led to new monitoring strategies, aimed at translating a qualitative physiological state into quantitative metrics, but the optimal strategies for depth of anesthesia (DoA) and analgesia monitoring continue to stimulate debate. Historically, DoA monitoring used patient's movement as a surrogate of awareness. Pharmacokinetic models and metrics, including minimum alveolar concentration for inhaled anesthetics and target-controlled infusion models for intravenous anesthesia, provided further insights to clinicians, but electroencephalography and its derivatives (processed EEG; pEEG) offer the potential for personalization of anesthesia care. Current studies appear to affirm that pEEG monitoring decreases the quantity of anesthetics administered, diminishes postanesthesia care unit duration, and may reduce the occurrence of postoperative delirium (notwithstanding the difficulties of defining this condition). Major trials are underway to further elucidate the impact on postoperative cognitive dysfunction. In this manuscript, we discuss the Bispectral (BIS) index, Narcotrend monitor, Patient State Index, entropy-based monitoring, and Neurosense monitor, as well as middle latency evoked auditory potential, before exploring how these technologies could evolve in the upcoming years. In contrast to developments in pEEG monitors, nociception monitors remain by comparison underdeveloped and underutilized. Just as with anesthetic agents, excessive analgesia can lead to harmful side effects, whereas inadequate analgesia is associated with increased stress response, poorer hemodynamic conditions and coagulation, metabolic, and immune system dysregulation. Broadly, 3 distinct monitoring strategies have emerged: motor reflex, central nervous system, and autonomic nervous system monitoring. Generally, nociceptive monitors outperform basic clinical vital sign monitoring in reducing perioperative opioid use. This manuscript describes pupillometry, surgical pleth index, analgesia nociception index, and nociception level index, and suggest how future developments could impact their use. The final section of this review explores the profound implications of future monitoring technologies on anesthesiology practice and envisages 3 transformative scenarios: helping in creation of an optimal analgesic drug, the advent of bidirectional neuron-microelectronic interfaces, and the synergistic combination of hypnosis and virtual reality.
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Affiliation(s)
- Pascal Laferrière-Langlois
- From the Maisonneuve-Rosemont Research Center, CIUSSS de l'Est de L'Ile de Montréal, Montreal, Quebec, Canada
- Department of Anesthesiology and Pain Medicine, Montreal University, Montreal, Quebec, Canada
| | - Louis Morisson
- Department of Anesthesiology and Pain Medicine, Montreal University, Montreal, Quebec, Canada
| | - Sean Jeffries
- Department of Experimental Surgery, McGill University, Montreal, Quebec, Canada
| | - Catherine Duclos
- Department of Anesthesiology and Pain Medicine, Montreal University, Montreal, Quebec, Canada
| | - Fabien Espitalier
- Department of Anesthesia and Intensive Care, University Hospitals of Tours, Tours, France
| | - Philippe Richebé
- From the Maisonneuve-Rosemont Research Center, CIUSSS de l'Est de L'Ile de Montréal, Montreal, Quebec, Canada
- Department of Anesthesiology and Pain Medicine, Montreal University, Montreal, Quebec, Canada
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Sevenius Nilsen A, Juel BE, Thürer B, Aamodt A, Storm JF. Are we really unconscious in “unconscious” states? Common assumptions revisited. Front Hum Neurosci 2022; 16:987051. [PMID: 36277049 PMCID: PMC9581328 DOI: 10.3389/fnhum.2022.987051] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 09/08/2022] [Indexed: 12/05/2022] Open
Abstract
In the field of consciousness science, there is a tradition to categorize certain states such as slow-wave non-REM sleep and deep general anesthesia as “unconscious”. While this categorization seems reasonable at first glance, careful investigations have revealed that it is not so simple. Given that (1) behavioral signs of (un-)consciousness can be unreliable, (2) subjective reports of (un-)consciousness can be unreliable, and, (3) states presumed to be unconscious are not always devoid of reported experience, there are reasons to reexamine our traditional assumptions about “states of unconsciousness”. While these issues are not novel, and may be partly semantic, they have implications both for scientific progress and clinical practice. We suggest that focusing on approaches that provide a more pragmatic and nuanced characterization of different experimental conditions may promote clarity in the field going forward, and help us build stronger foundations for future studies.
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Affiliation(s)
- Andre Sevenius Nilsen
- Department of Physiology, Institute of Basic Medicine, University of Oslo, Oslo, Norway
- *Correspondence: Andre Sevenius Nilsen,
| | - Bjørn E. Juel
- Department of Physiology, Institute of Basic Medicine, University of Oslo, Oslo, Norway
- School of Medicine and Public Health, Wisconsin Institute for Sleep and Consciousness, University of Wisconsin-Madison, Madison, WI, United States
- Bjørn E. Juel,
| | - Benjamin Thürer
- Department of Physiology, Institute of Basic Medicine, University of Oslo, Oslo, Norway
| | - Arnfinn Aamodt
- Department of Physiology, Institute of Basic Medicine, University of Oslo, Oslo, Norway
| | - Johan F. Storm
- Department of Physiology, Institute of Basic Medicine, University of Oslo, Oslo, Norway
- Johan F. Storm,
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Rasulo FA, Hopkins P, Lobo FA, Pandin P, Matta B, Carozzi C, Romagnoli S, Absalom A, Badenes R, Bleck T, Caricato A, Claassen J, Denault A, Honorato C, Motta S, Meyfroidt G, Radtke FM, Ricci Z, Robba C, Taccone FS, Vespa P, Nardiello I, Lamperti M. Processed Electroencephalogram-Based Monitoring to Guide Sedation in Critically Ill Adult Patients: Recommendations from an International Expert Panel-Based Consensus. Neurocrit Care 2022; 38:296-311. [PMID: 35896766 PMCID: PMC10090014 DOI: 10.1007/s12028-022-01565-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 06/20/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND The use of processed electroencephalography (pEEG) for depth of sedation (DOS) monitoring is increasing in anesthesia; however, how to use of this type of monitoring for critical care adult patients within the intensive care unit (ICU) remains unclear. METHODS A multidisciplinary panel of international experts consisting of 21 clinicians involved in monitoring DOS in ICU patients was carefully selected on the basis of their expertise in neurocritical care and neuroanesthesiology. Panelists were assigned four domains (techniques for electroencephalography [EEG] monitoring, patient selection, use of the EEG monitors, competency, and training the principles of pEEG monitoring) from which a list of questions and statements was created to be addressed. A Delphi method based on iterative approach was used to produce the final statements. Statements were classified as highly appropriate or highly inappropriate (median rating ≥ 8), appropriate (median rating ≥ 7 but < 8), or uncertain (median rating < 7) and with a strong disagreement index (DI) (DI < 0.5) or weak DI (DI ≥ 0.5 but < 1) consensus. RESULTS According to the statements evaluated by the panel, frontal pEEG (which includes a continuous colored density spectrogram) has been considered adequate to monitor the level of sedation (strong consensus), and it is recommended by the panel that all sedated patients (paralyzed or nonparalyzed) unfit for clinical evaluation would benefit from DOS monitoring (strong consensus) after a specific training program has been performed by the ICU staff. To cover the gap between knowledge/rational and routine application, some barriers must be broken, including lack of knowledge, validation for prolonged sedation, standardization between monitors based on different EEG analysis algorithms, and economic issues. CONCLUSIONS Evidence on using DOS monitors in ICU is still scarce, and further research is required to better define the benefits of using pEEG. This consensus highlights that some critically ill patients may benefit from this type of neuromonitoring.
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Affiliation(s)
- Frank A Rasulo
- Department of Anesthesiology and Intensive Care, Spedali Civili Hospital, Brescia, Italy. .,Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy.
| | - Philip Hopkins
- Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - Francisco A Lobo
- Institute of Anesthesiology, Cleveland Clinic, Abu Dhabi, United Arab Emirates
| | - Pierre Pandin
- Department of Anesthesia and Intensive Care, Erasme Hospital, Universitè Libre de Bruxelles, Brussels, Belgium
| | - Basil Matta
- Department of Anaesthesia and Intensive Care, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Carla Carozzi
- Department of Anesthesia and Intensive Care, Istituto Neurologico C. Besta, Milan, Italy
| | - Stefano Romagnoli
- Department of Anesthesia and Intensive Care, Careggi University Hospital, Florence, Italy
| | - Anthony Absalom
- Department of Anesthesiology, University Medical Center Groningen, Groningen, Netherlands
| | - Rafael Badenes
- Department of Anesthesia and Intensive Care, University of Valencia, Valencia, Spain
| | - Thomas Bleck
- Division of Stroke and Neurocritical Care, Department of Neurology, Northwestern University, Evanston, IL, USA
| | - Anselmo Caricato
- Department of Anesthesia and Intensive Care, Gemelli University Hospital, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Jan Claassen
- Department of Neurocritical Care, Columbia University Irving Medical Center, New York, NY, USA
| | - André Denault
- Critical Care Division, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Cristina Honorato
- Department of Anesthesiology and Critical Care, Universidad de Navarra, Pamplona, Spain
| | - Saba Motta
- Scientific Library, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Geert Meyfroidt
- Department of Intensive Care, University Hospitals Leuven and Laboratory of Intensive Care Medicine, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Finn Michael Radtke
- Department of Anesthesiology IRS, Nykøbing F. Hospital, Nykøbing Falster, Denmark
| | - Zaccaria Ricci
- Department of Pediatric Anesthesia, Meyer University Hospital of Florence, University of Florence, Florence, Italy
| | - Chiara Robba
- Department of Anesthesia and Intensive Care, Policlinico San Martino and University of Genoa, Genoa, Italy
| | - Fabio S Taccone
- Department of Anesthesia and Intensive Care, Erasme Hospital, Universitè Libre de Bruxelles, Brussels, Belgium
| | - Paul Vespa
- Department of Neurosurgery and Neurocritical Care, Los Angeles Medical Center, Ronald Reagan University of California, Los Angeles, CA, USA
| | - Ida Nardiello
- Department of Anesthesiology and Intensive Care, Spedali Civili Hospital, Brescia, Italy
| | - Massimo Lamperti
- Institute of Anesthesiology, Cleveland Clinic, Abu Dhabi, United Arab Emirates
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End-tidal Anesthetic Concentration: Monitoring, Interpretation, and Clinical Application. Anesthesiology 2022; 136:985-996. [PMID: 35483048 DOI: 10.1097/aln.0000000000004218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Age-adjusted fraction of minimum alveolar concentration derived from end-tidal anesthetic partial pressure measurement remains a useful drug advisory display to help prevent awareness if interpreted with proper understanding of the quantal and probabilistic nature of minimum alveolar concentration, semantics, drug interactions, and hysteresis.
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Kaiser HA, Knapp J, Sleigh J, Avidan MS, Stüber F, Hight D. [The quantitative EEG in electroencephalogram-based brain monitoring during general anesthesia]. Anaesthesist 2021; 70:531-547. [PMID: 33970302 PMCID: PMC8108440 DOI: 10.1007/s00101-021-00960-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2021] [Indexed: 11/12/2022]
Abstract
The electroencephalogram (EEG) is increasingly being used in the clinical routine of anesthesia in German-speaking countries. In over 90% of patients the frontal EEG changes somewhat predictably in response to administration of the normally used anesthetic agents (propofol and volatile gasses). An adequate depth of anesthesia and appropriate concentrations of anesthetics in the brain generate mostly frontal oscillations between 8 and 12 Hz as well as slow delta waves between 0.5 and 4 Hz. The frontal EEG channel is well-suited for avoidance of insufficient depth of anesthesia and excessive administration of anesthetics. This article explains the clinical interpretation of the most important EEG patterns and the biophysical background. Also discussed are important limitations and pitfalls for the clinical routine, which the anesthetist should know in order to utilize the EEG as an admittedly incomplete but clinically extremely important parameter for the level of consciousness.
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Affiliation(s)
- H A Kaiser
- Universitätsklinik für Anästhesiologie und Schmerztherapie, Inselspital, Universitätsspital Bern, Freiburgstr., 3010, Bern, Schweiz.
| | - J Knapp
- Universitätsklinik für Anästhesiologie und Schmerztherapie, Inselspital, Universitätsspital Bern, Freiburgstr., 3010, Bern, Schweiz
| | - J Sleigh
- Department of Anaesthesia, Waikato Clinical School, University of Auckland, Hamilton, Neuseeland
| | - M S Avidan
- Department of Anesthesiology, Washington University School of Medicine, 660 S. Euclid Ave., MO 63110, St. Louis, USA
| | - F Stüber
- Universitätsklinik für Anästhesiologie und Schmerztherapie, Inselspital, Universitätsspital Bern, Freiburgstr., 3010, Bern, Schweiz
| | - D Hight
- Universitätsklinik für Anästhesiologie und Schmerztherapie, Inselspital, Universitätsspital Bern, Freiburgstr., 3010, Bern, Schweiz
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Odor PM, Bampoe S, Lucas DN, Moonesinghe SR, Andrade J, Pandit JJ. Incidence of accidental awareness during general anaesthesia in obstetrics: a multicentre, prospective cohort study. Anaesthesia 2021; 76:759-776. [PMID: 33434945 DOI: 10.1111/anae.15385] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2020] [Indexed: 12/11/2022]
Abstract
General anaesthesia for obstetric surgery has distinct characteristics that may contribute towards a higher risk of accidental awareness during general anaesthesia. The primary aim of this study was to investigate the incidence, experience and psychological implications of unintended conscious awareness during general anaesthesia in obstetric patients. From May 2017 to August 2018, 3115 consenting patients receiving general anaesthesia for obstetric surgery in 72 hospitals in England were recruited to the study. Patients received three repetitions of standardised questioning over 30 days, with responses indicating memories during general anaesthesia that were verified using interviews and record interrogation. A total of 12 patients had certain/probable or possible awareness, an incidence of 1 in 256 (95%CI 149-500) for all obstetric surgery. The incidence was 1 in 212 (95%CI 122-417) for caesarean section surgery. Distressing experiences were reported by seven (58.3%) patients, paralysis by five (41.7%) and paralysis with pain by two (16.7%). Accidental awareness occurred during induction and emergence in nine (75%) of the patients who reported awareness. Factors associated with accidental awareness during general anaesthesia were: high BMI (25-30 kg.m-2 ); low BMI (<18.5 kg.m-2 ); out-of-hours surgery; and use of ketamine or thiopental for induction. Standardised psychological impact scores at 30 days were significantly higher in awareness patients (median (IQR [range]) 15 (2.7-52.0 [2-56]) than in patients without awareness 3 (1-9 [0-64]), p = 0.010. Four patients had a provisional diagnosis of post-traumatic stress disorder. We conclude that direct postoperative questioning reveals high rates of accidental awareness during general anaesthesia for obstetric surgery, which has implications for anaesthetic practice, consent and follow-up.
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Affiliation(s)
- P M Odor
- Centre for Anaesthesia and Peri-operative Medicine, University College London Hospital, London, UK
| | - S Bampoe
- Centre for Anaesthesia and Peri-operative Medicine, University College London Hospital, London, UK
| | - D N Lucas
- Department of Anaesthesia, Northwick Park Hospital, London, UK
| | - S R Moonesinghe
- Centre for Peri-operative Medicine, Research Department for Targeted Intervention, University College London, London, UK
| | - J Andrade
- School of Psychology, University of Plymouth, Plymouth, UK
| | - J J Pandit
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Trust, Oxford, UK.,University of Oxford, Oxford, UK
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Continuing professional development module : An updated introduction to electroencephalogram-based brain monitoring during intended general anesthesia. Can J Anaesth 2020; 67:1858-1878. [PMID: 33190217 PMCID: PMC7666718 DOI: 10.1007/s12630-020-01820-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 07/25/2019] [Accepted: 07/13/2020] [Indexed: 10/27/2022] Open
Abstract
The electroencephalogram (EEG) provides a reliable reflection of the brain's electrical state, so it can reassure us that the anesthetic agents are actually reaching the patient's brain, and are having the desired effect. In most patients, the EEG changes somewhat predictably in response to propofol and volatile agents, so a frontal EEG channel can guide avoidance of insufficient and excessive administration of general anesthesia. Persistent alpha-spindles (around 10 Hz) phase-amplitude coupled with slow delta waves (around 1 Hz) are commonly seen during an "appropriate hypnotic state of general anesthesia". Such patterns can be appreciated from the EEG waveform or from the spectrogram (a colour-coded display of how the power in the various EEG frequencies changes with time). Nevertheless, there are exceptions to this. For example, administration of ketamine and nitrous oxide is generally not associated with the aforementioned alpha-spindle coupled with delta wave pattern. Also, some patients, including older adults and those with neurodegenerative disorders, are less predisposed to generate a strong electroencephalographic "alpha-spindle" pattern during general anesthesia. There might also be some rare instances when the frontal EEG shows a pattern suggestive of general anesthesia, while the patient has some awareness and is able to follow simple commands, albeit this is typically without obvious distress or memory formation. Thus, the frontal EEG alone, as currently analyzed, is an imperfect but clinically useful mirror, and more scientific insights will be needed before we can claim to have a reliable readout of brain "function" during general anesthesia.
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Pandit JJ, Odor PM. Author's reply: the 5th National Audit Project Handbook and the realities of the dynamic phases of (dys)anaesthesia and
EEG
limitations. Anaesthesia 2019; 74:1333-1334. [DOI: 10.1111/anae.14801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- J. J. Pandit
- Oxford University Hospitals NHS Foundation Trust OxfordUK
| | - P. M. Odor
- University College London Hospital London UK
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Rimbert S, Schmartz D, Bougrain L, Meistelman C, Baumann C, Guerci P. MOTANA: study protocol to investigate motor cerebral activity during a propofol sedation. Trials 2019; 20:534. [PMID: 31455386 PMCID: PMC6712668 DOI: 10.1186/s13063-019-3596-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 07/18/2019] [Indexed: 11/17/2022] Open
Abstract
Background Accidental Accidental awareness during general anesthesia (AAGA) occurs in 1–2% of high-risk practice patients and is a cause of severe psychological trauma, termed post-traumatic stress disorder (PTSD). However, no monitoring techniques can accurately predict or detect AAGA. Since the first reflex for a patient during AAGA is to move, a passive brain-computer interface (BCI) based on the detection of an intention of movement would be conceivable to alert the anesthetist. However, the way in which propofol (i.e., an anesthetic commonly used for the general anesthesia induction) affects motor brain activity within the electroencephalographic (EEG) signal has been poorly investigated and is not clearly understood. For this reason, a detailed study of the motor activity behavior with a step-wise increasing dose of propofol is required and would provide a proof of concept for such an innovative BCI. The main goal of this study is to highlight the occurrence of movement attempt patterns, mainly changes in oscillations called event-related desynchronization (ERD) and event-related synchronization (ERS), in the EEG signal over the motor cortex, in healthy subjects, without and under propofol sedation, during four different motor tasks. Methods MOTANA is an interventional, prospective, exploratory, physiological, monocentric, and randomized study conducted in healthy volunteers under light anesthesia, involving EEG measurements before and after target-controlled infusion of propofol at three different effect-site concentrations (0 μg.ml −1, 0.5 μg.ml −1, and 1.0 μg.ml −1). In this exploratory study, 30 healthy volunteers will perform 50 trials for the four motor tasks (real movement, motor imagery, motor imagery with median nerve stimulation, and median nerve stimulation alone) in a randomized sequence. In each conditions and for each trial, we will observe changes in terms of ERD and ERS according to the three propofol concentrations. Pre- and post-injection comparisons of propofol will be performed by paired series tests. Discussion MOTANA is an exploratory study aimed at designing an innovative BCI based on EEG-motor brain activity that would detect an attempt to move by a patient under anesthesia. This would be of interest in the prevention of AAGA. Trial registration Agence Nationale de Sécurité du Médicament (EUDRACT 2017-004198-1), NCT03362775. Registered on 29 August 2018. https://clinicaltrials.gov/ct2/show/NCT03362775?term=03362775&rank=1 Electronic supplementary material The online version of this article (10.1186/s13063-019-3596-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sébastien Rimbert
- Université de Lorraine, Inria, LORIA, Neurosys team, 615 rue du Jardin Botanique, Vandoeuvre-lès-Nancy, France.
| | - Denis Schmartz
- CHU Brugmann, Université Libre de Bruxelles, Place A.Van Gehuchten 4, Bruxelles, 1020, Belgium
| | - Laurent Bougrain
- Université de Lorraine, Inria, LORIA, Neurosys team, 615 rue du Jardin Botanique, Vandoeuvre-lès-Nancy, France
| | - Claude Meistelman
- Department of Anesthesiology and Critical Care Medicine, Universisty Hospital of Nancy, 9 Avenue de la Forêt de Haye, Vandoeuvre-lès-Nancy, 54500, France
| | - Cédric Baumann
- CHRU Nancy, plateforme d'aide à la recherche clinique, UMDS, Vandoeuvre-lès-Nancy, 54500, France
| | - Philippe Guerci
- Department of Anesthesiology and Critical Care Medicine, Universisty Hospital of Nancy, 9 Avenue de la Forêt de Haye, Vandoeuvre-lès-Nancy, 54500, France.,INSERM, U1116, Université de Lorraine, 615 rue du Jardin Botanique, Vandoeuvre-lès-Nancy, France
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Sinmyee S, Pandit VJ, Pascual JM, Dahan A, Heidegger T, Kreienbühl G, Lubarsky DA, Pandit JJ. Legal and ethical implications of defining an optimum means of achieving unconsciousness in assisted dying. Anaesthesia 2019; 74:630-637. [PMID: 30786320 DOI: 10.1111/anae.14532] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2018] [Indexed: 01/15/2023]
Abstract
A decision by a society to sanction assisted dying in any form should logically go hand-in-hand with defining the acceptable method(s). Assisted dying is legal in several countries and we have reviewed the methods commonly used, contrasting these with an analysis of capital punishment in the USA. We expected that, since a common humane aim is to achieve unconsciousness at the point of death, which then occurs rapidly without pain or distress, there might be a single technique being used. However, the considerable heterogeneity in methods suggests that an optimum method of achieving unconsciousness remains undefined. In voluntary assisted dying (in some US states and European countries), the common method to induce unconsciousness appears to be self-administered barbiturate ingestion, with death resulting slowly from asphyxia due to cardiorespiratory depression. Physician-administered injections (a combination of general anaesthetic and neuromuscular blockade) are an option in Dutch guidelines. Hypoxic methods involving helium rebreathing have also been reported. The method of capital punishment (USA) resembles the Dutch injection technique, but specific drugs, doses and monitoring employed vary. However, for all these forms of assisted dying, there appears to be a relatively high incidence of vomiting (up to 10%), prolongation of death (up to 7 days), and re-awakening from coma (up to 4%), constituting failure of unconsciousness. This raises a concern that some deaths may be inhumane, and we have used lessons from the most recent studies of accidental awareness during anaesthesia to describe an optimal means that could better achieve unconsciousness. We found that the very act of defining an 'optimum' itself has important implications for ethics and the law.
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Affiliation(s)
- S Sinmyee
- Department of Anaesthesia, Northwick Park Hospital, London North West Healthcare NHS Trust, London, UK
| | - V J Pandit
- University of Kent, UK.,l'Aix-Marseille Université, Marseille, France
| | - J M Pascual
- Department of Neurology and Neurotherapeutics, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - A Dahan
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - T Heidegger
- Department of Anaesthesia, Intensive Care and Resuscitation Spitalregion Rheintal Werdenberg Sarganserland, Grabs, Switzerland.,University of Bern, Bern, Switzerland
| | - G Kreienbühl
- Kantonsspital St. Gallen and Former Head of Research Ethics Committee, Kanton St Gallen, Switzerland
| | - D A Lubarsky
- Human Health Sciences and Chief Executive Officer, University of California, UC Davis Health, USA
| | - J J Pandit
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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12
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The Isolated Forearm Paradox: Why Never a Response to Command in the Completely Unparalyzed? Anesthesiology 2017; 127:722-723. [PMID: 28926451 DOI: 10.1097/aln.0000000000001799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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13
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Checketts MR, Jenkins B, Pandit JJ. Implications of the 2015 AAGBI recommendations for standards of monitoring during anaesthesia and recovery. Anaesthesia 2017; 72 Suppl 1:3-6. [DOI: 10.1111/anae.13736] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
| | | | - J. J. Pandit
- Nuffield Department of Anaesthetics; Oxford University Hospitals NHS Foundation Trust; Oxford UK
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Hajat Z, Ahmad N, Andrzejowski J. The role and limitations of EEG-based depth of anaesthesia monitoring in theatres and intensive care. Anaesthesia 2017; 72 Suppl 1:38-47. [DOI: 10.1111/anae.13739] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2016] [Indexed: 12/14/2022]
Affiliation(s)
- Z. Hajat
- Sheffield Teaching Hospitals NHS Trust; Sheffield UK
| | - N. Ahmad
- Sheffield Teaching Hospitals NHS Trust; Sheffield UK
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15
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Hamp T, Mairweck M, Schiefer J, Krammel M, Pablik E, Wolzt M, Plöchl W. Feasibility of a 'reversed' isolated forearm technique by regional antagonization of rocuronium-induced neuromuscular block: a pilot study. Br J Anaesth 2016; 116:797-803. [PMID: 26934944 DOI: 10.1093/bja/aew018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2015] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The isolated forearm technique is used to monitor intraoperative awareness. However, this technique cannot be applied to patients who must be kept deeply paralysed for >1h, because the tourniquet preventing the neuromuscular blocking agent from paralysing the forearm must be deflated from time to time. To overcome this problem, we tested the feasibility of a 'reversed' isolated forearm technique. METHODS Patients received rocuronium 0.6 mg kg(-1) i.v. to achieve muscle paralysis. A tourniquet was then inflated around one upper arm to prevent further blood supply to the forearm. Sugammadex was injected into a vein of this isolated forearm to antagonize muscle paralysis regionally. A dose titration of sugammadex to antagonize muscle paralysis in the isolated forearm was performed in 10 patients, and the effects of the selected dose were observed in 10 additional patients. RESULTS The sugammadex dose required to antagonize muscle paralysis in the isolated forearm was 0.03 mg kg(-1) in 30 ml of 0.9% saline. Muscle paralysis was antagonized in the isolated forearm within 3.2 min in nine of 10 patients; the rest of the patients' bodies remained paralysed. Releasing the tourniquet 15 min later did not affect the train-of-four count in the isolated forearm but significantly increased the train-of-four count in the other arm by 7%. CONCLUSIONS Regional antagonization of rocuronium-induced muscle paralysis using a sugammadex dose of 0.03 mg kg(-1) injected into an isolated forearm was feasible and did not have relevant systemic effects. CLINICAL TRIAL REGISTRATION The trial was registered at EudraCT (ref. no. 2013-002164-53) before patient enrolment began.
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Affiliation(s)
- T Hamp
- Department of General Anaesthesia and Intensive Care Medicine
| | - M Mairweck
- Department of General Anaesthesia and Intensive Care Medicine
| | - J Schiefer
- Department of General Anaesthesia and Intensive Care Medicine
| | - M Krammel
- Department of General Anaesthesia and Intensive Care Medicine
| | - E Pablik
- Centre for Medical Statistics, Informatics, and Intelligent Systems, Section for Medical Statistics
| | - M Wolzt
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - W Plöchl
- Department of General Anaesthesia and Intensive Care Medicine
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Pandit JJ. The isolated forearm technique in non-paralysed patients - a reply. Anaesthesia 2016; 71:344-5. [DOI: 10.1111/anae.13381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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17
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Wang M, Russell I. The isolated forearm technique in non-paralysed patients. Anaesthesia 2016; 71:343-4. [DOI: 10.1111/anae.13365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- M. Wang
- University of Leicester; Leicester UK
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18
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Checketts MR, Alladi R, Ferguson K, Gemmell L, Handy JM, Klein AA, Love NJ, Misra U, Morris C, Nathanson MH, Rodney GE, Verma R, Pandit JJ. Recommendations for standards of monitoring during anaesthesia and recovery 2015: Association of Anaesthetists of Great Britain and Ireland. Anaesthesia 2016; 71:85-93. [PMID: 26582586 PMCID: PMC5063182 DOI: 10.1111/anae.13316] [Citation(s) in RCA: 309] [Impact Index Per Article: 38.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2015] [Indexed: 12/17/2022]
Abstract
This guideline updates and replaces the 4th edition of the AAGBI Standards of Monitoring published in 2007. The aim of this document is to provide guidance on the minimum standards for physiological monitoring of any patient undergoing anaesthesia or sedation under the care of an anaesthetist. The recommendations are primarily aimed at anaesthetists practising in the United Kingdom and Ireland. Minimum standards for monitoring patients during anaesthesia and in the recovery phase are included. There is also guidance on monitoring patients undergoing sedation and also during transfer of anaesthetised or sedated patients. There are new sections discussing the role of monitoring depth of anaesthesia, neuromuscular blockade and cardiac output. The indications for end-tidal carbon dioxide monitoring have been updated.
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Affiliation(s)
| | - R Alladi
- Department of Anaesthesia, Tameside Hospital, Ashton-under-Lyne, UK
- Royal College of Anaesthetists
| | | | - L Gemmell
- Department of Anaesthesia, North Wales Trust, North Wales, UK
| | - J M Handy
- Department of Anaesthesia and Intensive Care, Chelsea and Westminster Hospital, London, UK
| | - A A Klein
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, UK
| | - N J Love
- AAGBI
- Department of Anaesthesia and Intensive Care Medicine, North Devon District Hospital, Barnstaple, Devon, UK
| | - U Misra
- Department of Anaesthesia, Sunderland Royal Hospital, Sunderland, UK
| | - C Morris
- Department of Anaesthesia and Intensive Care, Royal Derby Hospital, Derby, UK
| | - M H Nathanson
- Department of Anaesthesia, Nottingham University Hospitals, Nottingham, UK
| | - G E Rodney
- Department of Anaesthesia, Ninewells Hospital and Medical School, Dundee, UK
| | - R Verma
- Department of Anaesthesia, Derby Teaching Hospitals, Derby, UK
| | - J J Pandit
- Department of Anaesthesia, Nuffield Department of Anaesthetics, Oxford University Hospitals, Oxford, UK
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Nunes RR, Fonseca NM, Simões CM, Rosa DM, Silva ED, Cavalcante SL, Lopes CG, Stefani LC. [Brazilian consensus on anesthetic depth monitoring]. Rev Bras Anestesiol 2015; 65:427-36. [PMID: 26553813 DOI: 10.1016/j.bjan.2015.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Indexed: 12/20/2022] Open
Affiliation(s)
- Rogean Rodrigues Nunes
- Curso de Graduação em Medicina, Centro Universitário Christus (Unichristus), Fortaleza, CE, Brasil; CET, Hospital Geral de Fortaleza, Fortaleza, CE, Brasil; Sociedade Brasileira de Anestesiologia (SBA), Rio de Janeiro, RJ, Brasil.
| | - Neuber Martins Fonseca
- Sociedade Brasileira de Anestesiologia (SBA), Rio de Janeiro, RJ, Brasil; Disciplina de Anestesiologia, Faculdade de Medicina, Universidade Federal de Uberlândia (UFU), Uberlândia, MG, Brasil; CET, Faculdade de Medicina, Universidade Federal de Uberlândia (UFU), Uberlândia, MG, Brasil
| | - Claudia Marques Simões
- Sociedade Brasileira de Anestesiologia (SBA), Rio de Janeiro, RJ, Brasil; Serviço de Anestesiologia, Instituto do Câncer do Estado de São Paulo (Icesp), São Paulo, SP, Brasil
| | - Deise Martins Rosa
- Serviço de Anestesia da Unidade II, Instituto Nacional do Câncer (Inca), Rio de Janeiro, RJ, Brasil; CET, Instituto Nacional do Câncer (Inca), Rio de Janeiro, RJ, Brasil; Curso Suporte Avançado de Vida em Anestesia (Sava), Sociedade Brasileira de Anestesiologia (SBA), Rio de Janeiro, RJ, Brasil
| | - Enis Donizete Silva
- Sociedade de Anestesiologia do Estado de São Paulo (Saesp), São Paulo, SP, Brasil
| | - Sara Lúcia Cavalcante
- CET, Hospital Geral de Fortaleza, Fortaleza, CE, Brasil; Hospital São Carlos, Fortaleza, CE, Brasil
| | - Cristiane Gurgel Lopes
- CET, Hospital Geral de Fortaleza, Fortaleza, CE, Brasil; Hospital Haroldo Juaçaba, Instituto do Câncer do Ceará, Fortaleza, CE, Brasil; Serviço de Oncologia, Hospital São Carlos, Fortaleza, CE, Brasil
| | - Luciana Cadore Stefani
- Departamento de Cirurgia, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brasil; CET, Serviço de Anestesia e Medicina Perioperatória, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brasil
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20
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Brazilian consensus on anesthetic depth monitoring. Braz J Anesthesiol 2015; 65:427-36. [PMID: 26614137 DOI: 10.1016/j.bjane.2015.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Indexed: 12/20/2022] Open
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21
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Pandit JJ. An observational study of the 'isolated forearm technique' in unparalysed, spontaneously breathing patients. Anaesthesia 2015; 70:1369-74. [PMID: 26443293 DOI: 10.1111/anae.13242] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2015] [Indexed: 11/27/2022]
Abstract
The isolated forearm technique enables a patient, otherwise paralysed by neuromuscular blockade, to communicate by movement if wakeful during surgery. The positive response rate to verbal command is high (~32%). The 5th National Audit Project recommended that this monitoring technique should become more widely taught and considered, so this study was designed to assess its utility as a standard of care in unparalysed patients. A positive response rate as high as in the paralysed would justify local adoption. Therefore, 100 consecutive patients undergoing urology surgery were given verbal commands to move at two-minute intervals from induction of anaesthesia (fentanyl and propofol) to full emergence and extubation of the supraglottic airway. Anaesthesia was maintained with isoflurane in oxygen/nitrous oxide. Although 24 patients moved during surgery (and therefore needed additional anaesthetic), none moved to verbal command. Even at extubation, when patients moved to expel the airway, there was no response to command until after wakening. These results suggest that in contrast to its use in paralysed patients, the isolated forearm technique does not yield useful information about the patient's state of wakefulness in the unparalysed. Another interpretation is that unparalysed patients are less prone to wakefulness than the paralysed.
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Affiliation(s)
- J J Pandit
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Trust, Oxford, UK
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Affiliation(s)
- J Kurata
- Department of Anesthesiology and Pain Clinic, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo City, Tokyo 113-8519, Japan
| | - H C Hemmings
- Departments of Anesthesiology and Pharmacology, Weill Cornell Medical College, 1300 York Avenue, New York, NY 10065, USA
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