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Xin Y, Ma L, Xie T, Liang Y, Ma M, Chu T, Liu C, Xu A. Comparative analysis of the effect of electromyogram to bispectral index and 95% spectral edge frequency under remimazolam and propofol anesthesia: a prospective, randomized, controlled clinical trial. Front Med (Lausanne) 2023; 10:1128030. [PMID: 37608826 PMCID: PMC10442164 DOI: 10.3389/fmed.2023.1128030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 07/25/2023] [Indexed: 08/24/2023] Open
Abstract
Background Bispectral index (BIS), an index used to monitor the depth of anesthesia, can be interfered with by the electromyogram (EMG) signal. The 95% spectral edge frequency (SEF95) also can reflect the sedation depth. Remimazolam in monitored anesthesia care results in higher BIS values than propofol, though in the same sedation level assessed by Modified Observers Assessment of Alertness and Sedation (MOAA/S). Our study aims to illustrate whether EMG is involved in remimazolam causing higher BIS value than propofol preliminarily and to explore the correlations among BIS, EMG, and SEF95 under propofol and remimazolam anesthesia. Patients and methods Twenty-eight patients were randomly divided into propofol (P) and remimazolam (RM) groups. Patients in the two groups received alfentanil 10 μg/kg, followed by propofol 2 mg/kg and remimazolam 0.15 mg/kg. Blood pressure (BP), heart rate (HR), and oxygen saturation (SpO2) were routinely monitored. The BIS, EMG, and SEF95 were obtained through BIS VISTATM. The primary outcomes were BIS, EMG, and the correlation between BIS and EMG in both groups. Other outcomes were SEF95, the correlation between BIS and SEF95, and the correlation between EMG and SEF95. And all the statistical and comparative analysis between these signals was conducted with SPSS 26.0 and GraphPad Prism 8. Results BIS values, EMG, and SEF95 were significantly higher in the RM group than in the P group (all p < 0.001). There was a strong positive correlation between BIS and EMG in the RM group (r = 0.416). Nevertheless, the BIS in the P group showed a weak negative correlation with EMG (r = -0.219). Both P (r = 0.787) and RM group (r = 0.559) had a reasonably significant correlation coefficient between BIS and SEF95. SEF95 almost did not correlate with EMG in the RM group (r = 0.101). Conclusion Bispectral index can be interfered with high EMG intensity under remimazolam anesthesia. However, EMG can hardly affect the accuracy of BIS under propofol anesthesia due to low EMG intensity and a weak negative correlation between EMG and BIS. Moreover, SEF95 may have a great application prospect in predicting the sedation condition of remimazolam.
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Affiliation(s)
- Yueyang Xin
- Department of Anesthesiology, Hubei Key Laboratory of Geriatric Anesthesia and Perioperative Brain Health, Wuhan Clinical Research Center for Geriatric Anesthesia, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Li Ma
- School of Information Engineering, Wuhan University of Technology, Wuhan, Hubei, China
| | - Tianli Xie
- School of Information Engineering, Wuhan University of Technology, Wuhan, Hubei, China
| | - Yuhui Liang
- School of Information Engineering, Wuhan University of Technology, Wuhan, Hubei, China
| | - Miao Ma
- School of Information Engineering, Wuhan University of Technology, Wuhan, Hubei, China
| | - Tiantian Chu
- Department of Anesthesiology, Hubei Key Laboratory of Geriatric Anesthesia and Perioperative Brain Health, Wuhan Clinical Research Center for Geriatric Anesthesia, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Cheng Liu
- Department of Anesthesiology, Hubei Key Laboratory of Geriatric Anesthesia and Perioperative Brain Health, Wuhan Clinical Research Center for Geriatric Anesthesia, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Aijun Xu
- Department of Anesthesiology, Hubei Key Laboratory of Geriatric Anesthesia and Perioperative Brain Health, Wuhan Clinical Research Center for Geriatric Anesthesia, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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Jin S, Baik HJ, Cho S, Chung RK, Kong KA, Kim YJ. The influence of neuromuscular blockade on phase lag entropy and bispectral index: A randomized, controlled trial. PLoS One 2021; 16:e0257467. [PMID: 34520506 PMCID: PMC8439464 DOI: 10.1371/journal.pone.0257467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 08/31/2021] [Indexed: 11/18/2022] Open
Abstract
The aim of this study is to compare the effects of neuromuscular blockade (NMB) on phase lag entropy (PLE) and the bispectral index (BIS). We recorded the BIS, electromyograph (EMG) activity on a BIS monitor (EMG_BIS), PLE, and EMG activity on a PLE monitor (EMG_PLE) in 40 patients receiving general anesthesia. During the awake state, we analyzed the changes in parameters before and 2 min after the eyes were closed. During sedation, we compared the changes in the parameters before and at 4 min after injecting rocuronium (group R) or normal saline (group C) between the two groups. During anesthesia, we compared the changes in parameters before and at 4 min after injecting sugammadex (group B) or normal saline (group D) between the two groups. During the awake state, the BIS, EMG_BIS, and EMG_PLE, but not PLE, decreased significantly with closed eyes. An effect of EMG on the BIS was evident, but not on PLE. During sedation, the BIS decreased with the decrease in EMG_BIS regardless of NMB caused by rocuronium, but NMB decreased PLE, although the degree of the decrease in EMG_PLE after NMB was similar to that after placebo. To determine the effect of NMB on electroencephalograms (EEGs) in groups R and C, we plotted the power spectra before and at 4 min after injecting rocuronium or normal saline. Changes in slow and delta frequency bands were observed at 4 min after injecting rocuronium relative to before injecting rocuronium. There was no effect of EMG on either the BIS or PLE during anesthesia. In conclusion, the effect of electromyograph activity and/or neuromuscular blockade on BIS or PLE depends on the level of consciousness.
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Affiliation(s)
- Sohee Jin
- Department of Anesthesiology and Pain Medicine, Yonsei Barun Hospital, Seoul, Republic of Korea
| | - Hee Jung Baik
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Ewha Womans University Mokdong Hospital, Seoul, Republic of Korea
| | - Sooyoung Cho
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Ewha Womans University Mokdong Hospital, Seoul, Republic of Korea
| | - Rack Kyung Chung
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Ewha Womans University Mokdong Hospital, Seoul, Republic of Korea
| | - Kyoung Ae Kong
- Department of Preventive Medicine, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Youn Jin Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Ewha Womans University Seoul Hospital, Seoul, Republic of Korea
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Na HS, Lim DJ, Koo BW, Oh AY, Lee PB. The influence of moderate or deep neuromuscular block status on anesthetic depth monitoring system during total intravenous anesthesia using propofol and remifentanil: A randomized trial. Sci Prog 2021; 104:368504211010629. [PMID: 33877942 PMCID: PMC10454749 DOI: 10.1177/00368504211010629] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The neuromuscular block state may affect the electroencephalogram-derived index representing the anesthetic depth. We applied an Anesthetic Depth Monitoring for Sedation (ADMS) to patients undergoing laparoscopic cholecystectomy under total intravenous anesthesia, and evaluated the requirement of propofol according to the different neuromuscular block state. Adult patients scheduled to undergo laparoscopic cholecystectomy were enrolled and randomly assigned to either the moderate (MB) or deep neuromuscular block (DB) group. The UniCon sensor of ADMS was applied to monitor anesthetic depth and the unicon value was maintained between 40 and 50 during the operation. According to the group assignment, intraoperative rocuronium was administered to maintain proper neuromuscular block state, moderate or deep block state. The unicon value, electromyography (EMG) index, and total dose of propofol and rocuronium were analyzed. At similar anesthetic depth, less propofol was used in the DB group compared to the MB group (6.19 ± 1.36 in the MB mg/kg/h group vs 4.93 ± 3.02 mg/kg/h in the DM group, p = 0.042). As expected, more rocuronium were used in the DB group than in the MB group (0.8 ± 0.2 mg/kg in the MB group vs 1.2 ± 0.2 mg/kg in the DB group, p = 0.023) and the EMG indices were lower in the DB group than in the MB group, at several time points as follows: at starting operation (p < 0.001); at 15 (p = 0.019), 45 (p = 0.011), and 60 min (p < 0.001) after the initiation of the operation; at the end of operation (p = 0.003); and at 5 min after the administration of sugammadex (p < 0.001). At similar anesthetic depth, patients under the deep neuromuscular block state required less propofol with lower intraoperative EMG indices compared to those under the moderate neuromuscular block state during general anesthesia.
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Affiliation(s)
- Hyo-Seok Na
- Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, South Korea
| | - Dae-Jin Lim
- Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, South Korea
| | - Bon-Wook Koo
- Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, South Korea
| | - Ah-Young Oh
- Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, South Korea
- Anesthesiology and Pain Medicine, Seoul National University, Seoul, South Korea
| | - Pyung-Bok Lee
- Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, South Korea
- Anesthesiology and Pain Medicine, Seoul National University, Seoul, South Korea
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Suzuki K, Sunaga H, Yamakawa K, Suga Y, Kondo I, Tsubokawa T, Uezono S. Intravenous infusion of rocuronium bromide prolongs emergence from propofol anesthesia in rats. PLoS One 2021; 16:e0246858. [PMID: 33571289 PMCID: PMC7877640 DOI: 10.1371/journal.pone.0246858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 01/27/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Neuromuscular blocking agents induce muscle paralysis via the prevention of synaptic transmission at the neuromuscular junction and may have additional effects at other sites of action. With regard to potential effects of neuromuscular blocking agents on the central nervous system, a definitive view has not been established. We investigated whether intravenous infusion of rocuronium bromide affects the emergence from propofol anesthesia. METHODS Using an in vivo rat model, we performed propofol infusion for 60 minutes, along with rocuronium bromide at various infusion rates or normal saline. Sugammadex or normal saline was injected at the end of the infusion period, and we evaluated the time to emergence from propofol anesthesia. We also examined the neuromuscular blocking, circulatory, and respiratory properties of propofol infusion along with rocuronium bromide infusion to ascertain possible factors affecting emergence. RESULTS Intravenous infusion of rocuronium bromide dose-dependently increased the time to emergence from propofol anesthesia. Sugammadex administered after propofol infusion not containing rocuronium bromide did not affect the time to emergence. Mean arterial pressure, heart rate, partial pressures of oxygen and carbon dioxide, and pH were not affected by rocuronium bromide infusion. Neuromuscular blockade induced by rocuronium bromide, even at the greatest infusion rate in the emergence experiment, was rapidly antagonized by sugammadex. CONCLUSIONS These results suggest that intravenous infusion of rocuronium bromide dose-dependently delays the emergence from propofol anesthesia in rats. Future studies, such as detection of rocuronium in the cerebrospinal fluid or central nervous system, electrophysiologic studies, microinjection of sugammadex into the brain, etc., are necessary to determine the mechanism of this effect.
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Affiliation(s)
- Kaoru Suzuki
- Department of Anesthesiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Hiroshi Sunaga
- Department of Anesthesiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Kentaro Yamakawa
- Department of Anesthesiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Yoshifumi Suga
- Department of Anesthesiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Ichiro Kondo
- Department of Anesthesiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Tsunehisa Tsubokawa
- Department of Anesthesiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Shoichi Uezono
- Department of Anesthesiology, The Jikei University School of Medicine, Tokyo, Japan
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Sanavia E, García M, del Castillo J, González R, López-Herce J, Mencía S. Efecto del bloqueo neuromuscular sobre la monitorización biespectral en los niños críticamente enfermos. An Pediatr (Barc) 2020; 93:251-256. [DOI: 10.1016/j.anpedi.2019.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 07/15/2019] [Accepted: 07/16/2019] [Indexed: 11/29/2022] Open
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A Review of Bispectral Index Utility in Neurocritical Care Patients. ARCHIVES OF NEUROSCIENCE 2020. [DOI: 10.5812/ans.96490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Context: Bispectral Index (BIS) was introduced in 1960 to monitor the depth of anesthesia in the operating rooms. It has been recently used to monitor the sedation in the critically ill patients hospitalized in intensive care and neurocritical care units (NCCU). Evidence Acquisition: Patients in the NCCU, particularly those with prolonged mechanical ventilation require appropriate adjustments in the administration of sedative drugs. Similarly, those who require neuro protection with barbiturates need to be closely monitored in the depth of their coma. Results: BIS may be a useful tool in this situation, and it can also help shorten the duration of mechanical ventilation by determining the appropriate time to eliminate patients from mechanical ventilation. We conducted a literature search to evaluate the utility of BIS monitoring in the NCCU patients with subarachnoid hemorrhage, intracranial hemorrhage, coma, cerebral hypoxia, status epilepticus and traumatic brain injury. Conclusions: BIS monitoring may be a useful adjunct to take care of the patients. However, further studies with a larger population and better design are required to substantiate the role of BIS monitoring in the care of NCCU patients.
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Sanavia E, García M, Castillo JD, González R, López-Herce J, Mencía S. Effect of neuromuscular blockade on the bispectral index in critically ill patients. An Pediatr (Barc) 2020; 93:251-256. [PMID: 34092338 DOI: 10.1016/j.anpede.2019.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 07/16/2019] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION It has been suggested that neuromuscular blockade (NMB) affects the capacity of bispectral index (BIS) monitoring to measure consciousness in sedated children. Our aim was to analyse the impact of NMB on BIS values in critically ill children. METHODS We conducted a prospective observational study of children monitored with a BIS system that received a continuous infusion of vecuronium. We analysed data on clinical, diagnostic and haemodynamic variables, sedatives, analgesics, muscle relaxants, and BIS parameters. We compared BIS parameters before the use of a muscle relaxant, during its administration, before its discontinuation and for the 24h following the end of the infusion. RESULTS The analysis included 35 patients (median age, 30 months). The most common diagnosis was heart disease (85%). The most frequent indication for initiation of NMB was low cardiac output (45%), followed by adaptation to mechanical ventilation (20%). Neuromuscular blockade did not produce a significant change in BIS values. We found a decrease was observed in electromyography (EMG) values at 6h (34.9±9.4 vs 31.2±7; P=.008) and 12h after initiation of NMB (34.9±9.4 vs 28.6±4.8; P =.006). We observed a small significant increase in BIS after discontinuation of NMB (from 42.7±11 to 48.4±14.5, P=.001), and 6 and 12h later (51.3±16.6; P=.015). There were no differences in the doses of sedatives or analgesics except for fentanyl, of which the dose was lowered after discontinuation of vecuronium. CONCLUSION Continuous NMB produces small changes on BIS values that are not clinically significant and therefore does not interfere with BIS consciousness monitoring in critically ill children.
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Affiliation(s)
- Eva Sanavia
- Servicio de Pediatría, Hospital Infanta Leonor, Madrid, Spain
| | - Mirian García
- Unidad de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Red de Salud Materno Infantil y del Desarrollo (RedSAMID), Madrid, Spain.
| | - Jimena Del Castillo
- Unidad de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Red de Salud Materno Infantil y del Desarrollo (RedSAMID), Madrid, Spain
| | - Rafael González
- Unidad de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Red de Salud Materno Infantil y del Desarrollo (RedSAMID), Madrid, Spain
| | - Jesús López-Herce
- Unidad de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Red de Salud Materno Infantil y del Desarrollo (RedSAMID), Madrid, Spain
| | - Santiago Mencía
- Unidad de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Red de Salud Materno Infantil y del Desarrollo (RedSAMID), Madrid, Spain
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Le Guen M, Roussel C, Chazot T, Dumont GA, Liu N, Fischler M. Reversal of neuromuscular blockade with sugammadex during continuous administration of anaesthetic agents: a double‐blind randomised crossover study using the bispectral index. Anaesthesia 2019; 75:583-590. [DOI: 10.1111/anae.14897] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2019] [Indexed: 12/17/2022]
Affiliation(s)
- M. Le Guen
- Department of Anaesthesiology Hospital Foch Suresnes and University Versailles Saint‐Quentin en Yvelines France
| | - C. Roussel
- Department of Anaesthesiology Hospital Foch Suresnes and University Versailles Saint‐Quentin en Yvelines France
| | - T. Chazot
- Department of Anaesthesiology Hospital Foch Suresnes and University Versailles Saint‐Quentin en Yvelines France
| | - G. A. Dumont
- Department of Electrical and Computer Engineering University of British Columbia Vancouver BC Canada
| | - N. Liu
- Department of Anaesthesiology Hospital Foch Suresnes and University Versailles Saint‐Quentin en Yvelines France
| | - M. Fischler
- Department of Anaesthesiology Hospital Foch Suresnes and University Versailles Saint‐Quentin en Yvelines France
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Xing Y, Xu D, Xu Y, Chen L, Wang H, Li S. Effects of Neuromuscular Blockages on Entropy Monitoring During Sevoflurane Anesthesia. Med Sci Monit 2019; 25:8610-8617. [PMID: 31729355 PMCID: PMC6873634 DOI: 10.12659/msm.917879] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background There are no data available on the effects of different degrees of neuromuscular blockade on spectral entropy during sevoflurane anesthesia. This study aimed to observe the effects of different degrees of neuromuscular blockade on state and response entropy during sevoflurane anesthesia. Material/Methods Eighty-one female patients were randomized to 9 groups (n=9 per group) according to the concentration of sevoflurane and degree of neuromuscular blockade. Response and state entropy were monitored. The endpoints were: 1) impact of neuromuscular blockade on state entropy and response entropy, and the difference between response entropy and state entropy; and 2) the response of entropy after cutaneous tetanic electrical noxious stimulation to the ulnar nerve under different degrees of neuromuscular blockade and concentrations of sevoflurane. Results These were no significant differences in response entropy or state entropy, or differences between response entropy and state entropy among the groups in the awake state (P>0.05). Without noxious stimulation, sevoflurane concentrations and neuromuscular blockade had no significant effects on response entropy or state entropy, or on the difference between response entropy and state entropy (all P>0.05), but sevoflurane concentrations showed a significant effect on state entropy (P<0.05). After noxious stimulation, sevoflurane concentrations and neuromuscular blockade had significant effects on response entropy and state entropy, and on the difference between response entropy and state entropy. Conclusions Response entropy and state entropy decreased with increasing sevoflurane concentration. Neuromuscular blockade did not affect entropy without noxious stimulation. With stimulation, muscle relaxants significantly reduced the changes in entropy, and there were significant effects of neuromuscular blockade and sevoflurane on entropy.
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Affiliation(s)
- Yian Xing
- Department of Anesthesiology, Shanghai General Hospital of Nanjing Medical University, Shanghai, China (mainland)
| | - Dian Xu
- Department of Anesthesiology, Shanghai General Hospital of Nanjing Medical University, Shanghai, China (mainland)
| | - Yanyifang Xu
- Department of Anesthesiology, Shanghai General Hospital of Nanjing Medical University, Shanghai, China (mainland)
| | - Lianhua Chen
- Department of Anesthesiology, Shanghai General Hospital of Nanjing Medical University, Shanghai, China (mainland)
| | - Hong Wang
- Department of Anesthesiology, Shanghai General Hospital of Nanjing Medical University, Shanghai, China (mainland)
| | - Shitong Li
- Department of Anesthesiology, Shanghai General Hospital of Nanjing Medical University, Shanghai, China (mainland)
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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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Choi JB, Na SH, Lee SY, Kim JY, Park SY, Kim JE, Hong S, An J, Park CH, Kim YC, Park WY. Suxamethonium induces a prompt increase in the bispectral index. Medicine (Baltimore) 2017; 96:e6670. [PMID: 28422877 PMCID: PMC5406093 DOI: 10.1097/md.0000000000006670] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Upon inducting general anesthesia in the operating room, we have observed a prompt increase in the bispectral index (BIS) after the intravenous injection of suxamethonium. We hypothesized that the cause of this BIS increase is muscle hyperactivity owing to fasciculation. However, no reports have been published regarding this abrupt increase in the BIS upon the induction of general anesthesia by suxamethonium. To investigate the degree of change in the BIS in patients receiving anesthesia with suxamethonium, we performed a prospective observational study of 63 participants who underwent closed reduction for nasal bone fracture. Anesthesia was induced by the total intravenous administration of anesthetics and 1.5 mg kg of suxamethonium was injected intravenously upon achieving BIS between 45 and 55. Intubation was performed after fasciculation. Electromyograms and BIS values were recorded from the induction of suxamethonium until 15 minutes after intubation. The mean BIS values were 95.4, 48.5, and 69.3 before induction, before the intravenous injection of suxamethonium, and immediately after fasciculation, respectively. The BIS value immediately after fasciculation (69.3 ± 10.6) was significantly higher than the cutoff BIS value of 60 (P < .001). Although fasciculation after the intravenous injection of suxamethonium resulted in the prompt increase of the BIS to values over 60, none of the participants was awake during surgery. In conclusion, the administration of suxamethonium resulted in the postfasciculation increase of the BIS to an average value of 69.3 without affecting the patient's state of consciousness.
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Affiliation(s)
- Jong Bum Choi
- Department of Anesthesiology and Pain Medicine, Ajou University, College of Medicine, Suwon
| | - Se Hee Na
- Department of Anesthesiology and Pain Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul
| | - Sook Young Lee
- Department of Anesthesiology and Pain Medicine, Ajou University, College of Medicine, Suwon
| | - Jong Yeop Kim
- Department of Anesthesiology and Pain Medicine, Ajou University, College of Medicine, Suwon
| | - Sung Yong Park
- Department of Anesthesiology and Pain Medicine, Ajou University, College of Medicine, Suwon
| | - Ji Eun Kim
- Department of Anesthesiology and Pain Medicine, Ajou University, College of Medicine, Suwon
| | - Seungbae Hong
- Department of Anesthesiology and Pain Medicine, Ajou University, College of Medicine, Suwon
| | - Jiwon An
- Department of Anesthesiology and Pain Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul
| | - Chung Hoon Park
- Department of Anesthesiology and Pain Medicine, Gwangmyeong Saeum Hospital, Gwangmyeong, Korea
| | - Yong Chan Kim
- Department of Anesthesiology and Pain Medicine, Gwangmyeong Saeum Hospital, Gwangmyeong, Korea
| | - Woo Young Park
- Department of Anesthesia, Sheikh Khalifa Specialty Hospital, Ras Al Khaimah, United Arab Emirates
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Korea
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Messina AG, Wang M, Ward MJ, Wilker CC, Smith BB, Vezina DP, Pace NL. Anaesthetic interventions for prevention of awareness during surgery. Cochrane Database Syst Rev 2016; 10:CD007272. [PMID: 27755648 PMCID: PMC6461159 DOI: 10.1002/14651858.cd007272.pub2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND General anaesthesia is usually associated with unconsciousness. 'Awareness' is when patients have postoperative recall of events or experiences during surgery. 'Wakefulness' is when patients become conscious during surgery, but have no postoperative recollection of the period of consciousness. OBJECTIVES To evaluate the efficacy of two types of anaesthetic interventions in reducing clinically significant awareness:- anaesthetic drug regimens; and- intraoperative anaesthetic depth monitors. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL, ISSUE 4 2016); PubMed from 1950 to April 2016; MEDLINE from 1950 to April 2016; and Embase from 1980 to April 2016. We contacted experts to identify additional studies. We performed a handsearch of the citations in the review. We did not search trial registries. SELECTION CRITERIA We included randomized controlled trials (RCTs) of either anaesthetic regimens or anaesthetic depth monitors. We excluded volunteer studies, studies of patients prior to skin incision, intensive care unit studies, and studies that only randomized different word presentations for memory tests (not anaesthetic interventions).Anaesthetic drug regimens included studies of induction or maintenance, or both. Anaesthetic depth monitors included the Bispectral Index monitor, M-Entropy, Narcotrend monitor, cerebral function monitor, cerebral state monitor, patient state index, and lower oesophageal contractility monitor. The use of anaesthetic depth monitors allows the titration of anaesthetic drugs to maintain unconsciousness. DATA COLLECTION AND ANALYSIS At least two authors independently scanned abstracts, extracted data from the studies, and evaluated studies for risk of bias. We made attempts to contact all authors for additional clarification. We performed meta-analysis statistics in packages of the R language. MAIN RESULTS We included 160 studies with 54,109 enrolled participants; 53,713 participants started the studies and 50,034 completed the studies or data analysis (or both). We could not use 115 RCTs in meta-analytic comparisons because they had zero awareness events. We did not merge 27 of the remaining 45 studies because they had excessive clinical and methodological heterogeneity. We pooled the remaining 18 eligible RCTs in meta-analysis. There are 10 studies awaiting classification which we will process when we update the review.The meta-analyses included 18 trials with 36,034 participants. In the analysis of anaesthetic depth monitoring (either Bispectral Index or M-entropy) versus standard clinical and electronic monitoring, there were nine trials with 34,744 participants. The overall event rate was 0.5%. The effect favoured neither anaesthetic depth monitoring nor standard clinical and electronic monitoring, with little precision in the odds ratio (OR) estimate (OR 0.98, 95% confidence interval (CI) 0.59 to 1.62).In a five-study subset of Bispectral Index monitoring versus standard clinical and electronic monitoring, with 34,181 participants, 503 participants gave awareness reports to a blinded, expert panel who adjudicated or judged the outcome for each patient after reviewing the questionnaires: no awareness, possible awareness, or definite awareness. Experts judged 351 patient awareness reports to have no awareness, 87 to have possible awareness, and 65 to have definite awareness. The effect size favoured neither Bispectral Index monitoring nor standard clinical and electronic monitoring, with little precision in the OR estimate for the combination of definite and possible awareness (OR 0.96, 95% CI 0.35 to 2.65). The effect size favoured Bispectral Index monitoring for definite awareness, but with little precision in the OR estimate (OR 0.60, 95% CI 0.13 to 2.75).We performed three smaller meta-analyses of anaesthetic drugs. There were nine studies with 1290 participants. Wakefulness was reduced by ketamine and etomidate compared to thiopental. Wakefulness was more frequent than awareness. Benzodiazepines reduces awareness compared to thiopental, ketamine, and placebo., Also, higher doses of inhaled anaesthetics versus lower doses reduced the risk of awareness.We graded the quality of the evidence as low or very low in the 'Summary of findings' tables for the five comparisons.Most of the secondary outcomes in this review were not reported in the included RCTs. AUTHORS' CONCLUSIONS Anaesthetic depth monitors may have similar effects to standard clinical and electrical monitoring on the risk of awareness during surgery. In older studies comparing anaesthetics in a smaller portion of the patient sample, wakefulness occurred more frequently than awareness. Use of etomidate and ketamine lowered the risk of wakefulness compared to thiopental. Benzodiazepines compared to thiopental and ketamine, or higher doses of inhaled anaesthetics versus lower doses, reduced the risk of awareness.
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Affiliation(s)
- Anthony G Messina
- School of Management, University of Texas at DallasThe Alliance for Medical Management EducationBox 2331920 N. Coit RoadRichardsonTXUSA75080
| | - Michael Wang
- University of LeicesterClinical Psychology UnitLancaster RoadLeicesterUKLE1 7HA
| | - Marshall J Ward
- Dartmouth‐Hitchcock Medical Center1 Medical Center DrLebanonNHUSA03766
| | - Chase C Wilker
- ARUP LaboratoriesClinical Toxicology IIISalt Lake CityUTUSA
| | - Brett B Smith
- University of UtahUniversity of Utah School of MedicineSalt Lake CityUTUSA84112
| | - Daniel P Vezina
- University of UtahDepartment of Anesthesiology, Department of Internal Medicine, Division of CardiologySalt Lake CityUTUSA
- Veteran's AdministrationEchocardiography LaboratorySalt Lake CityUTUSA
| | - Nathan Leon Pace
- University of UtahDepartment of Anesthesiology3C444 SOM30 North 1900 EastSalt Lake CityUTUSA84132‐2304
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Navarrete R, Quirós-Carmona S, Granados MDM, Gómez-Villamandos RJ, Domínguez JM, Férnandez-Sarmiento JA, Muñoz-Rascón P, Funes FJ, Morgaz J. Effect of dexmedetomidine constant rate infusion on the bispectral index during alfaxalone anaesthesia in dogs. Vet Anaesth Analg 2016; 43:397-404. [DOI: 10.1111/vaa.12323] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Accepted: 05/25/2015] [Indexed: 12/31/2022]
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Sugammadex at both high and low doses does not affect the depth of anesthesia or hemodynamics: a randomized double blind trial. J Clin Monit Comput 2016; 31:297-302. [DOI: 10.1007/s10877-016-9844-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Accepted: 02/15/2016] [Indexed: 12/17/2022]
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Schneider G, Pilge S. Restrict relaxants, be aware, and know the limitations of your depth of anaesthesia monitor. Br J Anaesth 2015; 115 Suppl 1:i11-i12. [PMID: 26174295 DOI: 10.1093/bja/aev148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- G Schneider
- Department of Anaesthesiology, HELIOS Clinic Wuppertal, Witten/Herdecke University, Heusnerstr. 40, Wuppertal 42283, Germany
| | - S Pilge
- Department of Anaesthesiology, HELIOS Clinic Wuppertal, Witten/Herdecke University, Heusnerstr. 40, Wuppertal 42283, Germany
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Arya S, Asthana V, Sharma JP. Clinical vs. bispectral index-guided propofol induction of anesthesia: A comparative study. Saudi J Anaesth 2013; 7:75-9. [PMID: 23717237 PMCID: PMC3657931 DOI: 10.4103/1658-354x.109819] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Clinically optimized focusing of drug administration to specific need of patient with bispectral index (BIS) monitoring results in reduced dose and faster recovery of consciousness. This study was planned with an aim to study and compare the conventional clinical end point or BIS on the requirement of dosage of propofol, hemodynamic effects, and BIS alterations following propofol induction. METHODS 70 patients, ASA I and II, 20-60 years undergoing elective surgical procedure under general anesthesia with endotracheal intubation were selected and divided into two groups. Group A received (inj.) fentanyl (2 μg/kg), followed 3 min later by inj. propofol at the rate of 30 mg/kg/hr infusion till the loss of response to verbal command while group B received inj. fentanyl (2 μg/kg), followed 3 min later by inj. propofol at the rate of 30 mg/kg/hr infusion. The end point of hypnosis was when the BIS value was sustained for 1 min at 48±2. The patients were intubated. Total induction dose of propofol was noted in each group. The value of BIS and hemodynamic parameters (heart rate, systolic/diastolic blood pressure) were noted at the time of loss of consciousness, at the time of intubation, and 1 min after intubation, thereafter every minute for first 10 min and thereafter every 10 min till end of surgery. Any involuntary muscle activity such as jerky movements, dystonic posturing, and opisthotonos were also recorded. RESULTS The mean dose of propofol used in groups A and B were 1.85±0.48 mg/kg and 1.79±0.41 mg/kg, respectively. The dosage used in group B were less but not clinically significant (P=0.575). On comparing the dosage of propofol in males among the groups there was a significantly lower dosage of propofol required in group B (2.06±0.45 mg/kg and 1.83±0.32 mg/kg, respectively, P=0.016). This decrease however was not seen in female patients dosage being 1.65±0.44 mg/kg and 1.75±0.49 mg/kg, respectively (P=0.372). The hemodynamic variables including heart rate, systolic/diastolic blood pressure and BIS were comparable within the group at induction, post-induction, and intubation. However, there was a significant increase in all the parameters at postintubation readings (P<0.001). CONCLUSION No significant difference in the induction dose of propofol was observed when assessed clinically (loss of verbal response) or by BIS monitoring. Traditional teaching to titrate the dose of propofol and depth of anesthesia during intubation by loss of verbal response is as good as BIS value monitoring.
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Affiliation(s)
- Snehdeep Arya
- Department of Anaesthesiology, Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand, India
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Russell IF. The ability of bispectral index to detect intra-operative wakefulness during total intravenous anaesthesia compared with the isolated forearm technique. Anaesthesia 2013; 68:502-11. [DOI: 10.1111/anae.12177] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2013] [Indexed: 11/28/2022]
Affiliation(s)
- I. F. Russell
- Department of Anaesthesia; Hull Royal Infirmary; Hull; UK
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Liu H, Liu Y, Xu Y, Xue Y. Prognostic evaluation of bispectral index in patients following cardiopulmonary resuscitation. Exp Ther Med 2013; 5:907-911. [PMID: 23407546 PMCID: PMC3570249 DOI: 10.3892/etm.2013.884] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Accepted: 12/17/2012] [Indexed: 12/25/2022] Open
Abstract
The aim of this study was to evaluate the prognosis of patients following cardiopulmonary resuscitation in an intensive care unit (ICU) using bispectral index (BIS) monitoring. The study was a prospective comparative study performed at the academic department of an ICU. A total of 33 adults who received cardiopulmonary resuscitation were enrolled and divided into the surviving and non-surviving groups according to their 7-day survival status. During their stay in the ICU, the BIS and arterial oxygen saturation (SaO2) levels of all the patients were continuously monitored. The neurological condition of the patients was measured according to the Glasgow coma scale (GCS). Acute physiological and chronic diseases were measured according to the acute physiology and chronic health evaluation II (APACHE II). SaO2 was monitored in all patients. The jugular bulb venous oxygen saturation (SjO2) levels were continuously monitored in 23 patients and the difference between the SaO2 and SjO2 values was used to indicate oxygen metabolism in the brain. The variables in the present study were compared between the 2 groups. The correlations between BIS values and GCS or APACHE II scores were analyzed. The BIS values were significantly higher in the surviving group than in the non-surviving group (P<0.01). The difference between the SaO2 and SjO2 was significant (P<0.01). There was a positive correlation between BIS values and GCS scores (r=0.821, P<0.01) and between BIS values and APACHE II scores (r=0.434, P<0.05). BIS values may be used to predict the post-resuscitative outcome of patients following cardiopulmonary resuscitation.
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Affiliation(s)
- Han Liu
- Departments of Intensive Care Unit, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu 210006, China
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Is It Simply a Good Spinal or Merely a Bad Anesthetic? Reg Anesth Pain Med 2013; 38:164. [DOI: 10.1097/aap.0b013e31827adc93] [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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Rivas G, Pacreu Terradas S, Garcia Aranda S, Fernández Galinski S. [Variation in the bispectral index during the Jannetta technique]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2012; 59:459-60. [PMID: 22748854 DOI: 10.1016/j.redar.2012.05.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2011] [Accepted: 05/08/2012] [Indexed: 11/25/2022]
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Belda E, Laredo FG, Lucas X, Agut A, Escobar M, Soler M. The effects of atracurium on bispectral index (BIS) values in dogs anaesthetized with isoflurane. Vet J 2012; 192:189-92. [DOI: 10.1016/j.tvjl.2011.05.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2010] [Revised: 05/23/2011] [Accepted: 05/25/2011] [Indexed: 10/17/2022]
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Abstract
PURPOSE OF REVIEW We critically review brain function monitors based on the processed electroencephalogram with regards to signal quality, artefacts and other limitations in clinical performance. RECENT FINDINGS Several studies have been showing that depth of anaesthesia monitors based on processed electroencephalogram has limitations that can lead to a wrong interpretation of the level of anaesthesia. Processed electroencephalogram indices can be altered by nonanaesthetic influences ranging from artefacts that affect signal quality and signal processing, adverse effects of some anaesthetic and nonanaesthetic drugs, neuromuscular blocking agents to conditions inherent to the patient such as cerebral tumours, brain ischemia and temperature. SUMMARY Clinicians should be aware of the several limitations of the commercial devices intending to monitor the depth of anaesthesia, which may not reflect the real underlying level of unconsciousness.
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AHO AJ, KAMATA K, YLI-HANKALA A, LYYTIKÄINEN LP, KULKAS A, JÄNTTI V. Elevated BIS and Entropy values after sugammadex or neostigmine: an electroencephalographic or electromyographic phenomenon? Acta Anaesthesiol Scand 2012; 56:465-73. [PMID: 22289106 DOI: 10.1111/j.1399-6576.2011.02647.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2011] [Indexed: 12/17/2022]
Abstract
BACKGROUND Sugammadex is designed to antagonize neuromuscular blockade (NMB) induced by rocuronium or vecuronium. In clinical practice, we have noticed a rise in the numerical values of bispectral index (BIS) and Entropy, two electroencephalogram (EEG) - based depth of anesthesia monitors, during the reversal of the NMB with sugammadex. The aim of this prospective, randomized, double-blind study was to test this impression and to compare the effects of sugammadex and neostigmine on the BIS and Entropy values during the reversal of the NMB. METHODS Thirty patients undergoing gynecological operations were studied. Patients were anesthetized with target-controlled infusions of propofol and remifentanil, and rocuronium was used to induce NMB. After operation, during light propofol-remifentanil anesthesia, NMB was antagonized with sugammadex or neostigmine. During the following 5 min, the numerical values of BIS, BIS electromyographic (BIS EMG) and Entropy were recorded on a laptop computer, as well as the biosignal recorded by the Entropy strip. The Entropy biosignal was studied off-line both in time and frequency domain to see if NMB reversal causes changes in EEG. RESULTS In some patients, administration of sugammadex or neostigmine caused a significant rise in the numerical values of BIS, BIS EMG and Entropy. This phenomenon was most likely caused by increased electromyographic (EMG) activity. The administration of sugammadex or neostigmine appeared to have only minimal effect on EEG. CONCLUSION The EMG contamination of EEG causes BIS and Entropy values to rise during reversal of rocuronium-induced NMB in light propofol-remifentanil anesthesia.
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Affiliation(s)
- A. J. AHO
- Coxa Ltd; Hospital for Joint Replacement; Tampere; Finland
| | - K. KAMATA
- Department of Anaesthesia; Tampere University Hospital; Tampere; Finland
| | | | | | - A. KULKAS
- Department of Clinical Neurophysiology; Seinäjoki Central Hospital; Seinäjoki; Finland
| | - V. JÄNTTI
- Department of Clinical Neurophysiology; Seinäjoki Central Hospital; Seinäjoki; Finland
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Dahaba A, Bornemann H, Hopfgartner E, Ohran M, Kocher K, Liebmann M, Wilfinger G, Metzler H. Effect of sugammadex or neostigmine neuromuscular block reversal on bispectral index monitoring of propofol/remifentanil anaesthesia. Br J Anaesth 2012; 108:602-606. [DOI: 10.1093/bja/aer495] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Kang MH, In CB, Kim MH, Lim KJ, Park EY, Lee HM, Lee SK. Inappropriate elevation of bispectral index values in robot assisted thyroidectomy with electromyographic endotracheal tube -A case report-. Korean J Anesthesiol 2011; 61:511-4. [PMID: 22220230 PMCID: PMC3249575 DOI: 10.4097/kjae.2011.61.6.511] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2011] [Revised: 08/09/2011] [Accepted: 08/25/2011] [Indexed: 12/04/2022] Open
Abstract
We report a case of an erroneously elevated bispectral index (BIS) during robot assisted thyroidectomy using an electromyographic endotracheal tube (EMG tube), which is safe and useful for laryngeal electromyographic monitoring. Ten minutes after start of the operation, a sudden increase of BIS value up to 98 was noticed. The BIS values were not decreased to < 65 with supplemental anesthetics. The anesthetic method was changed from total intravenous anesthesia to balanced anesthesia. The BIS sensor and monitor were changed and other models were used. These interventions did not alter BIS values. BIS levels remained between 60 and 70 throughout the main procedure and intermittently increased to the mid-90s without any trace of poor signal quality. At the end of the surgery, the BIS values returned to normal range. The patient did not complain of intraoperative recall. Knowledge of potential interference from the use of an EMG tube must be considered when interpreting BIS.
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Affiliation(s)
- Mae-Hwa Kang
- Department of Anesthesiology and Pain Medicine, College of Medicine, Hallym University, Anyang, Korea
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Jeong SJ, Han JI, Baik HJ, Lee H, Lee GY, Kim JH. The effect of pyridostigmine on bispectral index during recovery from sevoflurane anesthesia. Korean J Anesthesiol 2011; 61:460-4. [PMID: 22220221 PMCID: PMC3249566 DOI: 10.4097/kjae.2011.61.6.460] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Revised: 03/09/2011] [Accepted: 03/15/2011] [Indexed: 11/26/2022] Open
Abstract
Background There have been some conflicting reports showing that muscle relaxants and anticholinesterases affect the level of the bispectral index (BIS). The purpose of this study was to investigate whether pyridostigmine affects the level of the BIS during recovery from sevoflurane anesthesia. Methods Fifty-two adult patients scheduled for laparoscopic cholecystectomy and laparoscopic appendectomy. Anesthesia was induced with thiopental 4 mg/kg and rocuronium 0.6 mg/kg. The lung was mechanically ventilated with 1-3 vol% sevoflurane, 50% oxygen and 50% nitrous oxide. After a specimen was removed, the sevoflurane concentration was maintained at 1.5 vol%. When skin closure began, sevoflurane was stopped; however, 50% oxygen and 50% nitrous oxide were maintained. The patients then received either (1) a group that received an injection of glycopyrrolate 0.04 mg/kg and pyridostigmine 0.2 mg/kg (reverse (R) group, n = 26) or (2) a group that received normal saline (control (C) group, n = 26). Group assignment was random. Pyridostigmine, a reversible cholinesterase inhibitor, is a parasympathomimetic. End-tidal sevoflurane concentration, train of four (TOF) ratio, bispectral index (BIS), blood pressure and heart rate were measured from the end of the operation to 15 min after inject of pyridostigmine or placebo. Results There were no significant between group differences in the time dependent decrease in end-tidal sevoflurane concentration (P = 0.0642). There were significant differences between the two groups for the time course for increases in the TOF value (P < 0.0001). There were significant differences between the two groups for the time course for increases in the BIS value (P = 0.0107). There were no significant differences in the mean BIS value up to 10 minutes after administering drug, but 15 minutes after administrating the reverse drug or the control drug, the BIS value showed significantly different BIS values: 68.2 ± 6.2 (Group R) and 63.2 ± 6.2 (Group C) (P = 0.0058). Conclusions The finding that pyridostigmine increases TOF and BIS suggests that pyridostigmine may enhance recovery during recovery from sevoflurane anesthesia.
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Affiliation(s)
- Seol-Joo Jeong
- Department of Anesthesiology and Pain Medicine, School of Medicine, Ewha Womans University, Seoul, Korea
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Comparison of SNAP™ II and BIS Vista indices during normothermic cardiopulmonary bypass under isoflurane anesthesia. J Clin Monit Comput 2011; 25:365-70. [PMID: 22076615 DOI: 10.1007/s10877-011-9313-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2010] [Accepted: 10/12/2011] [Indexed: 10/15/2022]
Abstract
OBJECTIVE Processed EEG monitoring during cardiopulmonary bypass (CPB) may help determine loss of consciousness and depth of anesthesia. This study compared the SNAP(™) II and BIS Vista monitors in patients undergoing isoflurane anesthesia with normothermic CPB. METHODS 40 subjects undergoing CPB with isoflurane anesthesia were enrolled. Subjects were premedicated with 1-2 mg midazolam approximately 5 min prior to acquisition of baseline index values and anesthesia induced with midazolam and fentanyl. Anesthesia was maintained with isoflurane, midazolam, and fentanyl and a cis-atracurium infusion. SNAP(™) II (version 1.2.9 algorithm 1.88) and BIS Vista (application version 3.00 platform version 2.03) indices were recorded at baseline, pre-induction, post-intubation, incision, start of CPB, every 15 min during CPB, end of CPB, and end of case. Agreement between methods was determined using Pearson correlation and the Bland-Altman method with repeated observa- tions. RESULTS Twenty-four male and 12 female subjects completed the analysis. The correlation between SNAP(™) II and BIS Vista index values was 0.61 (P < 0.005). A linear relationship between the difference in the indices and the average index values was observed following the induction of anesthesia. In awake subjects, the bias between the SNAP(™) II and BIS Vista was 5 (95% CI 3-7). The limits of agreement were 23 (95% CI 19-26) and -13 (95% CI -9--16). During anesthesia, the mean difference on a log scale was 0.11 (95% CI 0.09-0.12). The limits of agreement were 0.43 (95% CI 0.40-0.45) and -0.21 (95% CI -0.18--0.24). The antilog of the mean difference demonstrated that the SNAP(™) II value was 28% (95% CI 24-33%) higher than the BIS Vista value following induction of anesthesia. CONCLUSIONS The SNAP(™) II monitor demonstrates a consistently positive bias during cardiopulmonary bypass under isoflurane anesthesia compared with the BIS Vista.
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de Mattos-Junior E, Ito KC, Conti-Patara A, da Silva de Carvalho H, Reinoldes A, de Araújo Caldeira J, Cortopassi SRG. Bispectral monitoring in dogs subjected to ovariohysterectomy and anesthetized with halothane, isoflurane or sevoflurane. Vet Anaesth Analg 2011; 38:475-83. [DOI: 10.1111/j.1467-2995.2011.00646.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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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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Aho A, Lyytikäinen LP, Yli-Hankala A, Kamata K, Jäntti V. Explaining Entropy responses after a noxious stimulus, with or without neuromuscular blocking agents, by means of the raw electroencephalographic and electromyographic characteristics. Br J Anaesth 2011; 106:69-76. [DOI: 10.1093/bja/aeq300] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
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Reversal of neuromuscular blockade by sugammadex does not affect EEG derived indices of depth of anesthesia. J Clin Monit Comput 2010; 24:371-6. [PMID: 20734116 DOI: 10.1007/s10877-010-9257-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2010] [Accepted: 08/06/2010] [Indexed: 01/13/2023]
Abstract
OBJECTIVE According to previous studies neuromuscular blockade may affect the depth of anesthesia. One theory states that neuromuscular blockade prevents disturbing EMG signals, arousing from the muscles of the forehead, from falsely elevating bispectral index (BIS)-levels. According to the afferentation theory signals generated in muscle stretch receptors, accessing the brain through afferent nerve pathways, induce arousal. By blocking these signals neuromuscular blockade would increase depth of anesthesia. Arousal has previously been associated with neostigmine reversal. This study investigates the possible effect of sugammadex on the level of anesthesia as defined by BIS and spectral entropy levels. METHODS Thirty elective patients were enrolled. All patients received propofol and remifentanil by target controlled infusion and an intermediate level neuromuscular blockade induced and maintained by bolus doses of rocuronium. Depth of anesthesia was monitored by BIS and spectral entropy. The patients were given 2 mg/kg sugammadex 5 min after finishing of surgery. Propofol and remifentanil infusions were kept unchanged for another 10 min while BIS and entropy values were recorded. RESULTS Mean BIS and Entropy™ values remained unchanged after reversal of the rocuronium block. The mean averaged BIS, state entropy and response entropy values were 31.7 ± 9.9, 35.3 ± 12.9 and 36.8 ± 13.3 before and 32.0 ± 11.9, 36.3 ± 15.9 and 38.4 ± 18.0 after sugammadex administration, respectively. CONCLUSIONS Sugammadex does not affect level of anesthesia as determined by BIS or entropy levels.
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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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Doufas AG, Komatsu R, Orhan-Sungur M, Sengupta P, Wadhwa A, Mascha E, Shafer SL, Sessler DI. Neuromuscular Block Differentially Affects Immobility and Cortical Activation at Near–Minimum Alveolar Concentration Anesthesia. Anesth Analg 2009; 109:1097-104. [DOI: 10.1213/ane.0b013e3181af631a] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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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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Morgaz J, Granados M, Domínguez J, Navarrete R, Galán A, Fernández J, Gómez-Villamandos R. Relationship of bispectral index to hemodynamic variables and alveolar concentration multiples of sevoflurane in puppies. Res Vet Sci 2009; 86:508-13. [DOI: 10.1016/j.rvsc.2008.09.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2008] [Revised: 08/05/2008] [Accepted: 09/15/2008] [Indexed: 10/21/2022]
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Is your patient sleeping? Eur J Anaesthesiol 2009; 26:704-6. [PMID: 19455043 DOI: 10.1097/eja.0b013e328329488e] [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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Kawaguchi M, Takamatsu I, Kazama T. Rocuronium dose-dependently suppresses the spectral entropy response to tracheal intubation during propofol anaesthesia. Br J Anaesth 2009; 102:667-72. [DOI: 10.1093/bja/aep040] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Kim BS, Lee SI, Choi SU, Shin HW, Lim HJ, Lee HW, Chang SH, Yoon SM. Effect of muscle relaxant on entropy during propofol anesthesia. Korean J Anesthesiol 2009; 56:381-386. [PMID: 30625757 DOI: 10.4097/kjae.2009.56.4.381] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose of this study was to investigate whether muscle relaxant affect the values of Entropy, response entropy (RE) or state entropy (SE) during propofol anesthesia. METHODS Eighty patients (ASA I) scheduled for elective surgery under general anesthesia were randomly assigned to four groups. Anesthesia was maintained at a SE value of 80 (80 +/- 2) using target controlled infusion (TCI) of propofol. After maintaining SE 80 for 5 min, vecuronium 0.1 mg/kg was injected intravenously in group I and same volume of normal saline was intravenously injected in group II. After maintaining SE 60 for 5 min, vecuronium 0.1 mg/kg was injected intravenously in group III and same volume of normal saline was injected intravenously in group IV. The mean arterial pressure, heart rate, SE and RE were measured before anesthetic induction and up to 5 min after vecuronium or normal saline injection in each group. RESULTS SE and RE were not changed in group II, but significantly decreased in group I (P < 0.05, respectively). In group III and IV, SE and RE were not changed in both groups. There were no significant hemodynamic changes among the four groups. CONCLUSIONS These results suggest that the effect of muscle relaxant on Entropy vary according to the baseline values of RE or SE during propofol anesthesia.
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Affiliation(s)
- Bo Song Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University, Seoul, Korea.
| | - Sang Ik Lee
- Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University, Seoul, Korea.
| | - Sung Uk Choi
- Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University, Seoul, Korea.
| | - Hye Won Shin
- Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University, Seoul, Korea.
| | - Hae Ja Lim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University, Seoul, Korea.
| | - Hye Won Lee
- Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University, Seoul, Korea.
| | - Seong Ho Chang
- Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University, Seoul, Korea.
| | - Suk Min Yoon
- Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University, Seoul, Korea.
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Shin YC, Kim SI, Ok SY, Kim SC. The Influence of a Muscle Relaxant on Bispectral Index during the Propofol Induction of Anesthesia. Korean J Anesthesiol 2008. [DOI: 10.4097/kjae.2008.54.4.373] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Yun Chul Shin
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Soon Im Kim
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Si Young Ok
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Sun Chong Kim
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University College of Medicine, Seoul, Korea
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Campagnol D, Teixeira Neto FJ, Giordano T, Ferreira TH, Monteiro ER. Effects of epidural administration of dexmedetomidine on the minimum alveolar concentration of isoflurane in dogs. Am J Vet Res 2007; 68:1308-18. [DOI: 10.2460/ajvr.68.12.1308] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Ekman A, Stålberg E, Sundman E, Eriksson LI, Brudin L, Sandin R. The Effect of Neuromuscular Block and Noxious Stimulation on Hypnosis Monitoring During Sevoflurane Anesthesia. Anesth Analg 2007; 105:688-95. [PMID: 17717224 DOI: 10.1213/01.ane.0000278117.31134.34] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND There are conflicting results on the influence of neuromuscular block (NMB) on the bispectral index (BIS). We investigated the influence of two degrees of NMB on BIS, Alaris auditory-evoked potential index (AAI), and the electromyogram (EMG) obtained with needle electrodes from the frontal and temporal muscles, immediately adjacent to the BIS-sensor. METHODS Twenty patients were anesthetized with sevoflurane, titrated for 30 min to an end-tidal concentration of 1.2% (baseline). Rocuronium was infused to 50% (partial) and 95% (profound) depression of the first twitch in a train-of-four response, the order being randomly chosen. Noxious tetanic electrical stimulation was applied at four occasions: 1) at baseline (control measurement), 2 and 3) at each degree of NMB, and 4) after neostigmine reversal. BIS, AAI, and EMG were obtained 2 min before and 2 min after each noxious stimulation. RESULTS Median BIS and AAI at baseline were 44 (39-50) and 15 (14-16), respectively. The two degrees of NMB did not affect BIS, AAI, and EMG before noxious stimulation. In contrast, profound NMB altered the BIS and AAI responses to noxious stimulation when compared with partial NMB, (BIS P = 0.01, AAI P < 0.01), after neostigmine reversal (BIS P < 0.01, AAI P = 0.01) and compared with baseline (BIS P = 0.08, AAI P = 0.02). No significant increase in EMG was found. CONCLUSION BIS and AAI responses to noxious tetanic electrical stimulation are affected by the degree of NMB during sevoflurane anesthesia whereas NMB does not affect BIS or AAI in the absence of noxious stimulation.
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Affiliation(s)
- Andreas Ekman
- Department of Physiology and Pharmacology, Section for Anesthesiology and Intensive Care Medicine, Karolinska Institute, Stockholm, Sweden.
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Bonhomme V, Hans P. Muscle relaxation and depth of anaesthesia: where is the missing link? Br J Anaesth 2007; 99:456-60. [PMID: 17704524 DOI: 10.1093/bja/aem243] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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Cortínez LI, Delfino AE, Fuentes R, Muñoz HR. Performance of the Cerebral State Index During Increasing Levels of Propofol Anesthesia: A Comparison with the Bispectral Index. Anesth Analg 2007; 104:605-10. [PMID: 17312217 DOI: 10.1213/01.ane.0000255152.96354.17] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The cerebral state monitor is a new device to measure depth of anesthesia. In this study we compared the cerebral state monitor with the bispectral index (BIS) monitor during propofol anesthesia. METHODS Fifteen healthy patients received a continuous infusion of propofol (300 mL/h). The cerebral state index (CSI) and the BIS values were recorded until burst suppression ratio > or =60%. Baseline variability, prediction probability, and agreement analysis between indices were evaluated. Clinical markers of loss of consciousness were also assessed. RESULTS Mean awake BIS and CSI values were 95.6 and 91.6, respectively (P = 0.01). BIS and CSI prediction probability values (mean +/- sd) were estimated to be 0.87 +/- 0.08 and 0.86 +/- 0.08, respectively (NS). The CSI tended to stabilize at values of 60-40 when estimated propofol concentrations at the effect site increased from 5 to 8 mug/mL. The BIS stabilized at values of 40-20 when the propofol concentrations at the effect site increased from 7 to 10 mug/mL. The mean BIS-CSI difference was -7.4 with 95% limits of agreement of 22.2 and -36.9. The BIS and CSI correlation with the burst suppression ratio was -0.60 and -0.97, respectively (P < 0.01). Predicted BIS and CSI values for loss of eyelash reflex in 50% and 95% of the patients were different (P < 0.05). CONCLUSION The overall performance of both monitors during propofol induction was similar. However, the different dynamic profiles of these monitors indicate that BIS may be a more useful index for evaluating intermediate anesthetic levels, whereas CSI may be better for evaluating deeper anesthetic levels.
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Affiliation(s)
- Luis I Cortínez
- Departamento de Anestesiología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.
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Oei-Lim VLB, Dijkgraaf MGW, de Smet MD, White M, Kalkman CJ. Does Cerebral Monitoring Improve Ophthalmic Surgical Operating Conditions During Propofol-Induced Sedation? Anesth Analg 2006; 103:1189-95. [PMID: 17056953 DOI: 10.1213/01.ane.0000244321.38023.92] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Sudden movements from over-sedation during ophthalmic surgery can be detrimental to the eye. Bispectral index (BIS) and middle-latency auditory-evoked potentials (Alaris AEP index, AAI) were reported to be accurate indicators for the level of sedation and loss of consciousness. We assessed these monitors during sedation with special emphasis on preventing over-sedation. One-hundred patients scheduled for elective eye surgery were sedated with target-controlled propofol infusion and randomly allocated to BIS-guided, AAI-guided, BIS/AAI-guided, or clinically guided groups (n = 25 each). The initial target concentration was 0.5 microg x mL(-1) in patients >70 yr and 1.0 microg x mL(-1) in all other patients. The concentration was increased every 3 min by 0.1 or 0.2 microg x mL(-1), respectively until the patient had reached a BIS value of 75 (range 70-90) or an AAI of 40 (range 35-60). The surgeon who was blinded to group allocation assessed treatment quality after the procedure. Sedation was converted into general anesthesia in four patients because of excessive head movements. BIS was out of range 7% of the time vs 58% for AAI. No significant differences in treatment quality were observed among the four groups. We conclude that propofol sedation, guided by BIS or AAI monitoring, did not enhance ophthalmic surgical operating conditions over sedation guided by clinical observation only.
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Chan MTV, Gin T. Changes of Bispectral Index After a Bolus Dose of Muscle Relaxant. Anesth Analg 2006; 103:776-7; author reply 777. [PMID: 16931696 DOI: 10.1213/01.ane.0000227160.25492.46] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Inoue S, Kawaguchi M, Sasaoka N, Hirai K, Furuya H. Effects of neuromuscular block on systemic and cerebral hemodynamics and bispectral index during moderate or deep sedation in critically ill patients. Intensive Care Med 2006; 32:391-7. [PMID: 16450097 DOI: 10.1007/s00134-005-0031-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2005] [Accepted: 12/12/2005] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To investigate whether neuromuscular block can affect bispectral index (BIS) or cerebral hemodynamics under moderate or deep sedation produced by propofol. DESIGN AND SETTING Prospective, controlled study in a university hospital affiliated intensive care unit. PATIENTS Seventeen surgical patients undergoing elective esophagectomy. INTERVENTIONS After stabilization with either light or deep sedation we investigated whether the BIS, electromyographic activity (EMG), or cerebral and systemic hemodynamic parameters were affected by administration of muscle relaxant. MEASUREMENTS AND MAIN RESULTS Neuromuscular block reduced the BIS during moderate sedation but not during deep sedation although the EMG at both levels of sedation was significantly reduced. No positive effects of neuromuscular block on cerebral hemodynamics were obtained with monitoring of regional cerebral oxygen saturation and middle cerebral artery blood velocity; however, significant effects on systemic hemodynamic parameters were observed only at moderate propofol sedation. The values of BIS and systemic hemodynamic variables with moderate sedation were also very similar to those with deep sedation and neuromuscular block although these values differed without neuromuscular block. CONCLUSIONS Neuromuscular block altered the BIS score in moderately sedated patients but not in deeply sedated patients although cerebral hemodynamics was not affected by neuromuscular block during either moderate or deep sedation. Muscular relaxant also enhanced cardiovascular stability with moderate sedation. These results suggest that level of consciousness may be decreased by neuromuscular block during moderate sedation but not affected during deep sedation.
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Affiliation(s)
- Satoki Inoue
- Nara Medical University, Division of Intensive Care, 840 Shijo-cho, Kashihara, Nara 634-8522, Japan.
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Ruiz-Gimeno P, Soro M, Pérez-Solaz A, Carrau M, Belda FJ, Jover JL, Aguilar G. Comparison of the EEG-based SNAP index and the Bispectral (BIS) index during sevoflurane-nitrous oxide anaesthesia. J Clin Monit Comput 2006; 19:383-9. [PMID: 16437288 DOI: 10.1007/s10877-005-5871-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2004] [Accepted: 04/04/2005] [Indexed: 12/23/2022]
Abstract
The BIS monitor (Aspect Medical Inc, Newton, USA) was the first electroencephalogram (EEG)-based monitor of the hypnotic effect reflected by a dimensionless figure ranging from 100 (awake state) to 0 (flat line EEG). Its widespread use makes it the most-studied and the best-known among same intended devices. Its algorithm processes low-frequency EEG oscillations in order to provide the Bispectral index. A BIS index ranging from 40 to 60 has been established as the proper for surgical performance. The BIS monitor permits a closer approach to the hypnotic component of anaesthesia beyond clinical signs and may reduce the probability of intraoperative awareness; therefore, it has become a recommended monitoring tool in routine practice. The SNAP monitor (Nicolet Biomedical, Madison WI, USA) is also intended for monitoring the hypnotic effect of anaesthetics, which is in turn displayed as an index ranging from 100 to 0, with 100 meaning a fully awake state and 0 meaning no brain activity. The algorithm of the SNAP monitor is featured by its additional processing of ultra-high EEG frequencies, which seem to be involved in the formation of consciousness. The use of these frequencies would theoretically improve responsiveness during increased brain activity. We studied its behaviour patterns and capability to monitor the hypnotic effect induced by sevoflurane-nitrous oxide by comparison with the BIS index. Seventy patients ASA I-III were induced with propofol, fentanyl and rocuronium, and maintained with sevoflurane-N(2)O. BIS and SNAP indices were simultaneously recorded before induction, after intubation, after incision, at the following 10, 30 and 50 minutes, awakening and extubation time points, together with heart rate and blood pressure. The Pearson correlation was R(2) = 0.68 (p < .05). The Bland and Altman test showed a bias of 14.3 for SNAP index values with respect to BIS index values. We concluded that the SNAP index correlates with variations in the hypnotic effect induced by sevoflurane-nitrous oxide anaesthesia when compared with the BIS index. In this context, a SNAP index ranging from 58 to 70 would be equivalent to the BIS index range 40 to 60 and, therefore, the accurate for surgical performance.
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Affiliation(s)
- P Ruiz-Gimeno
- Department of Anaesthesiology and Critical Care, Hospital Clínico Universitario, Av. Blasco Ibañez 17, 46010, Valencia, Spain.
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Liu N, Chazot T, Huybrechts I, Law-Koune JD, Barvais L, Fischler M. The Influence of a Muscle Relaxant Bolus on Bispectral and Datex-Ohmeda Entropy Values During Propofol-Remifentanil Induced Loss of Consciousness. Anesth Analg 2005; 101:1713-1718. [PMID: 16301247 DOI: 10.1213/01.ane.0000184038.49429.8f] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Studies investigating the influence of muscle relaxants on the bispectral index have yielded contradictory results. In our prospective, randomized, double-blind experiments, patients received a fixed target concentration of remifentanil along with a target-controlled infusion of propofol, titrated until loss of consciousness. Two minutes after loss of consciousness, the study group received a bolus injection of atracurium, whereas the control group received a placebo. The following variables were recorded: bispectral index, spectral edge frequency, electromyographic activity, state entropy, and response entropy provided by the Datex-Ohmeda Entropy monitor. Similar values were obtained in both groups at loss of consciousness. Placebo administration induced a decrease in bispectral index (P < 0.002), spectral edge frequency (P < 0.05), electromyographic activity (P < 0.02), state entropy (P < 0.05), and response entropy (P < 0.01) compared with the values measured at loss of consciousness. Atracurium administration induced a decrease in bispectral index (P < 0.0001), spectral edge frequency (P < 0.01), electromyographic activity (P < 0.0001), state entropy (P < 0.0001), and response entropy (P < 0.0001) values. Decreases in bispectral index (P < 0.05), electromyographic activity (P < 0.0001), and response entropy (P < 0.01) were larger after atracurium than placebo injection. In lightly anesthetized patients, myorelaxant administration decreases bispectral index and response entropy, but not state entropy values.
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Affiliation(s)
- Ngai Liu
- *Department of Anesthesiology, Hôpital Foch, Suresnes, France; †Department of Anesthesiology, Hôpital Erasme, ULB, Brussels, Belgium
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Dahaba AA. Different Conditions That Could Result in the Bispectral Index Indicating an Incorrect Hypnotic State. Anesth Analg 2005; 101:765-773. [PMID: 16115989 DOI: 10.1213/01.ane.0000167269.62966.af] [Citation(s) in RCA: 231] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Since its introduction in 1996, the Bispectral Index (BIS) has gained increasing popularity in daily anesthesia practice. However, numerous reports have been appearing in the literature of paradoxical BIS changes and inaccurate readings. The purpose of this review is to assess the utility of BIS monitoring through examining the various published reports of all BIS values not coinciding with a clinically judged sedative-hypnotic state, whether arising from an underlying pathophysiology of electroencephalographic (EEG) cerebral function or because of shortcomings in the performance and design of the BIS monitor. High electromyographic activity and electric device interference could create subtle artifact signal pollution without their necessarily being displayed as artifacts. This would be misinterpreted by the BIS algorithm as EEG activity and assigned a spuriously increased BIS value. Numerous clinical conditions that have a direct effect on EEG cerebral function could also directly influence the BIS value.
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Affiliation(s)
- Ashraf A Dahaba
- Department of Anaesthesiology and Intensive Care Medicine, Graz Medical University, Graz, Austria
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