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Legriel S. Burst Suppression as a Treatment Goal in Refractory Status Epilepticus. Neurocrit Care 2024; 40:847-848. [PMID: 37921931 DOI: 10.1007/s12028-023-01880-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 10/06/2023] [Indexed: 11/05/2023]
Affiliation(s)
- Stephane Legriel
- Intensive Care Unit, Centre Hospitalier de Versailles, 78150, Le Chesnay, France.
- IctalGroup, Le Chesnay, France.
- University Paris-Saclay, UVSQ, INSERM, CESP, Villejuif, France.
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2
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Schoknecht K, Maechler M, Wallach I, Dreier JP, Liotta A, Berndt N. Isoflurane lowers the cerebral metabolic rate of oxygen and prevents hypoxia during cortical spreading depolarization in vitro: An integrative experimental and modeling study. J Cereb Blood Flow Metab 2024; 44:1000-1012. [PMID: 38140913 PMCID: PMC11318408 DOI: 10.1177/0271678x231222306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 10/23/2023] [Accepted: 11/29/2023] [Indexed: 12/24/2023]
Abstract
Cortical spreading depolarization (SD) imposes a massive increase in energy demand and therefore evolves as a target for treatment following acute brain injuries. Anesthetics are empirically used to reduce energy metabolism in critical brain conditions, yet their effect on metabolism during SD remains largely unknown. We investigated oxidative metabolism during SD in brain slices from Wistar rats. Extracellular potassium ([K+]o), local field potential and partial tissue oxygen pressure (ptiO2) were measured simultaneously. The cerebral metabolic rate of oxygen (CMRO2) was calculated using a reaction-diffusion model. By that, we tested the effect of clinically relevant concentrations of isoflurane on CMRO2 during SD and modeled tissue oxygenation for different capillary pO2 values. During SD, CMRO2 increased 2.7-fold, resulting in transient hypoxia in the slice core. Isoflurane decreased CMRO2, reduced peak [K+]o, and prolonged [K+]o clearance, which indicates reduced synaptic transmission and sodium-potassium ATPase inhibition. Modeling tissue oxygenation during SD illustrates the need for increased capillary pO2 levels to prevent hypoxia. In the absence thereof, isoflurane could improve tissue oxygenation by lowering CMRO2. Therefore, isoflurane is a promising candidate for pre-clinical studies on neuronal survival in conditions involving SD.
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Affiliation(s)
- Karl Schoknecht
- Carl-Ludwig-Institute of Physiology, Medical Faculty, Leipzig University, Leipzig, Germany
| | - Mathilde Maechler
- Department of Anesthesiology and Intensive Care, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Institute of Neurophysiology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Institute of Computer-Assisted Cardiovascular Medicine, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
| | - Iwona Wallach
- Institute of Computer-Assisted Cardiovascular Medicine, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Jens P Dreier
- Centre for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Experimental Neurology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Neurology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Bernstein Centre for Computational Neuroscience Berlin, Berlin, Germany
- Einstein Centre for Neurosciences Berlin, Berlin, Germany
| | - Agustin Liotta
- Department of Anesthesiology and Intensive Care, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Institute of Neurophysiology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Institute of Computer-Assisted Cardiovascular Medicine, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- Department of Experimental Neurology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Institute of Health at Charité – Universitätsmedizin Berlin, Berlin
- Neuroscience Research Center, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Nikolaus Berndt
- Institute of Computer-Assisted Cardiovascular Medicine, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- German Institute of Human Nutrition Potsdam-Rehbruecke (DIfE), Department of Molecular Toxicology, Nuthetal, Germany
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3
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Hawkes MA, Eliliwi M, Wijdicks EFM. The Origin of the Burst-Suppression Paradigm in Treatment of Status Epilepticus. Neurocrit Care 2024; 40:849-854. [PMID: 37921932 DOI: 10.1007/s12028-023-01877-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 09/26/2023] [Indexed: 11/05/2023]
Abstract
After electroencephalography (EEG) was introduced in hospitals, early literature recognized burst-suppression pattern (BSP) as a distinctive EEG pattern characterized by intermittent high-power oscillations alternating with isoelectric periods in coma and epileptic encephalopathies of childhood or the pattern could be induced by general anesthesia and hypothermia. The term was introduced by Swank and Watson in 1949 but was initially described by Derbyshire et al. in 1936 in their study about the anesthetic effects of tribromoethanol. Once the EEG/BSP pattern emerged in the literature as therapeutic goal in refractory status epilepticus, researchers began exploring whether the depth of EEG suppression correlated with improved seizure control and clinical outcomes. We can conclude that, from a historical perspective, the evidence to suppress the brain to a BSP when treating status epilepticus is inconclusive.
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Affiliation(s)
- Maximiliano A Hawkes
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, USA
| | - Mouhanned Eliliwi
- Division of Pulmonary Critical Care, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Eelco F M Wijdicks
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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4
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Sexton MT, Kim A, McGonigle T, Mihalko S, Vandekar SN, Brummel NE, Patel MB, Dittus RS, Heckers S, Pandharipande PP, Ely EW, Wilson JE. In-hospital catatonia, delirium, and coma and mortality: Results from the delirium and catatonia prospective cohort investigation. Schizophr Res 2024; 263:223-228. [PMID: 37580182 PMCID: PMC10843668 DOI: 10.1016/j.schres.2023.07.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 07/25/2023] [Accepted: 07/27/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND Catatonia, a form of acute brain dysfunction typically linked with severe affective and psychotic disorders, occurs in critical illness with delirium and coma. Delirium and coma are associated with mortality, though catatonia's relationship with mortality is unclear. We aim to describe whether catatonia, delirium, and coma are associated with mortality. METHODS We enrolled a convenience cohort of critically ill adults (N = 378) at an academic medical center. We assessed catatonia, delirium, and coma using the Bush-Francis Catatonia Rating Scale, the Confusion Assessment Method for the Intensive Care Unit and the Richmond Agitation-Sedation Scale, respectively. We tested the associations between previous day brain dysfunction state occurrence with in-hospital and one-year mortality using multivariable time-dependent risk models. Additionally, we tested the association between brain dysfunction duration and one-year mortality. RESULTS Catatonia was not associated with death on the day after diagnosis during hospitalization, and neither previous catatonia occurrence nor duration was associated with one-year mortality. Delirium was not associated with death on any day following diagnosis during hospitalization, and neither previous delirium occurrence nor duration was associated with one-year mortality. The occurrence of coma was associated with death on any day after diagnosis during hospitalization (HR 2.30,CI 1.19-4.44,p = 0.014), as well as through one year following hospital discharge (HR 1.68,CI 1.09-2.59,p = 0.02). CONCLUSIONS Coma, but neither catatonia nor delirium, was associated with future day in-hospital and one-year mortality. More research is needed to understand catatonia's clinical impact. Delirium results differ from existing literature likely due to cohort demographics and size. Coma results highlight the prognostic significance of suppressed arousal while critically ill.
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Affiliation(s)
- Morgan T Sexton
- Critical Illness, Brain Dysfunction, and Survivorship Center, Center for Health Services Research, Nashville, TN, United States of America; Vanderbilt University School of Medicine, Nashville, TN, United States of America
| | - Ahra Kim
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Trey McGonigle
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Sarasota Mihalko
- Critical Illness, Brain Dysfunction, and Survivorship Center, Center for Health Services Research, Nashville, TN, United States of America
| | - Simon N Vandekar
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Nathan E Brummel
- Critical Illness, Brain Dysfunction, and Survivorship Center, Center for Health Services Research, Nashville, TN, United States of America; Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, United States of America
| | - Mayur B Patel
- Critical Illness, Brain Dysfunction, and Survivorship Center, Center for Health Services Research, Nashville, TN, United States of America; Division of Acute Care Surgery, Departments of Surgery, Neurosurgery, and Hearing and Speech Sciences, Section of Surgical Sciences, Vanderbilt Brain Institute, Vanderbilt University Medical Center, Nashville, TN, United States of America; Geriatric Research, Education, and Clinical Center Service, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN, United States of America
| | - Robert S Dittus
- Critical Illness, Brain Dysfunction, and Survivorship Center, Center for Health Services Research, Nashville, TN, United States of America; Geriatric Research, Education, and Clinical Center Service, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN, United States of America; Department of Medicine, Division of General Internal Medicine and Public Health, Center for Health Services Research and Quality Aging, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Stephan Heckers
- Critical Illness, Brain Dysfunction, and Survivorship Center, Center for Health Services Research, Nashville, TN, United States of America; Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Pratik P Pandharipande
- Critical Illness, Brain Dysfunction, and Survivorship Center, Center for Health Services Research, Nashville, TN, United States of America; Division of Anesthesiology Critical Care, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - E Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship Center, Center for Health Services Research, Nashville, TN, United States of America; Geriatric Research, Education, and Clinical Center Service, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN, United States of America; Division of Allergy, Pulmonary and Critical Care, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Jo Ellen Wilson
- Critical Illness, Brain Dysfunction, and Survivorship Center, Center for Health Services Research, Nashville, TN, United States of America; Geriatric Research, Education, and Clinical Center Service, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN, United States of America; Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN, United States of America.
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5
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Dolmans RG, Nahed BV, Robertson FC, Peul WC, Rosenthal ES, Broekman ML. Practice-Pattern Variation in Sedation of Neurotrauma Patients in the Intensive Care Unit: An International Survey. J Intensive Care Med 2023; 38:1143-1150. [PMID: 37415510 PMCID: PMC10616999 DOI: 10.1177/08850666231186563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 06/21/2023] [Indexed: 07/08/2023]
Abstract
Background: Analgo-sedation plays an important role during intensive care management of traumatic brain injury (TBI) patients, however, limited evidence is available to guide practice. We sought to quantify practice-pattern variation in neurotrauma sedation management, surveying an international sample of providers. Methods: An electronic survey consisting of 56 questions was distributed internationally to neurocritical care providers utilizing the Research Electronic Data Capture platform. Descriptive statistics were used to quantitatively describe and summarize the responses. Results: Ninety-five providers from 37 countries responded. 56.8% were attending physicians with primary medical training most commonly in intensive care medicine (68.4%) and anesthesiology (26.3%). Institutional sedation guidelines for TBI patients were available in 43.2%. Most common sedative agents for induction and maintenance, respectively, were propofol (87.5% and 88.4%), opioids (60.2% and 70.5%), and benzodiazepines (53.4% and 68.4%). Induction and maintenance sedatives, respectively, are mostly chosen according to provider preference (68.2% and 58.9%) rather than institutional guidelines (26.1% and 35.8%). Sedation duration for patients with intracranial hypertension ranged from 24 h to 14 days. Neurological wake-up testing (NWT) was routinely performed in 70.5%. The most common NWT frequency was every 24 h (47.8%), although 20.8% performed NWT at least every 2 h. Richmond Agitation and Sedation Scale targets varied from deep sedation (34.7%) to alert and calm (17.9%). Conclusions: Among critically ill TBI patients, sedation management follows provider preference rather than institutional sedation guidelines. Wide practice-pattern variation exists for the type, duration, and target of sedative management and NWT performance. Future comparative effectiveness research investigating these differences may help optimize sedation strategies to promote recovery.
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Affiliation(s)
- Rianne G.F. Dolmans
- Department of Neurosurgery, Leiden University Medical Center, Leiden, the Netherlands
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Brian V. Nahed
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Faith C. Robertson
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Wilco C. Peul
- Department of Neurosurgery, Haaglanden Medical Centre, The Hague, the Netherlands
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Neurosurgery, Leiden, the Netherlands
| | - Eric S. Rosenthal
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Marike L.D. Broekman
- Department of Neurosurgery, Leiden University Medical Center, Leiden, the Netherlands
- Department of Neurosurgery, Haaglanden Medical Centre, The Hague, the Netherlands
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Favre E, Bernini A, Miroz JP, Abed-Maillard S, Ramelet AS, Oddo M. Early processed electroencephalography for the monitoring of deeply sedated mechanically ventilated critically ill patients. Nurs Crit Care 2023. [PMID: 37997530 DOI: 10.1111/nicc.13009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 10/22/2023] [Accepted: 11/01/2023] [Indexed: 11/25/2023]
Abstract
BACKGROUND Deep sedation may be indicated in the intensive care unit (ICU) for the management of acute organ failure, but leads to sedative-induced delirium. Whether processed electroencephalography (p-EEG) is useful in this setting is unclear. METHODS We conducted a single-centre observational study of non-neurological ICU patients sedated according to a standardized guideline of deep sedation (Richmond Agitation Sedation Scale [RASS] between -5 and -4) during the acute phase of respiratory and/or cardio-circulatory failure. The SedLine (Masimo Incorporated, Irvine, California) was used to monitor the Patient State Index (PSI) (ranging from 0 to 100, <25 = very deep sedation and >50 = light sedation to full awareness) during the first 72 h of care. Delirium was assessed with the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). RESULTS The median duration of PSI monitoring was 43 h. Patients spent 49% in median of the total PSI monitoring duration with a PSI <25. Patients with delirium (n = 41/97, 42%) spent a higher percentage of total monitored time with PSI <25 (median 67% [19-91] vs. 47% [12.2-78.9]) in non-delirious patients (p .047). After adjusting for the cumulative dose of analgesia and sedation, increased time spent with PSI <25 was associated with higher delirium (odds ratio 1.014; 95% CI 1.001-1.027, p = .036). CONCLUSIONS A clinical protocol of deep sedation targeted to RASS at the acute ICU phase may be associated with prolonged EEG suppression and increased delirium. Whether PSI-targeted sedation may help reducing sedative dose and delirium deserves further clinical investigation. RELEVANCE TO CLINICAL PRACTICE Patients requiring deep sedation are at high risk of being over-sedated and developing delirium despite the application of an evidence-based sedation guideline. Development of early objective measures are essential to improve sedation management in these critically ill patients.
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Affiliation(s)
- Eva Favre
- Department of Intensive Care, Centre Hospitalier Universitaire Vaudois (CHUV)-Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Institute of Higher Education and Research in Healthcare, CHUV-Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Adriano Bernini
- Department of Intensive Care, Centre Hospitalier Universitaire Vaudois (CHUV)-Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - John-Paul Miroz
- Department of Intensive Care, Centre Hospitalier Universitaire Vaudois (CHUV)-Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Samia Abed-Maillard
- Department of Intensive Care, Centre Hospitalier Universitaire Vaudois (CHUV)-Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Anne-Sylvie Ramelet
- Institute of Higher Education and Research in Healthcare, CHUV-Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Mauro Oddo
- Medical Directorate for Research, Education and Innovation, CHUV-Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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7
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Ren S, Zang C, Yuan F, Yan X, Zhang Y, Yuan S, Sun Z, Lang B. Correlation between burst suppression and postoperative delirium in elderly patients: a prospective study. Aging Clin Exp Res 2023; 35:1873-1879. [PMID: 37479909 DOI: 10.1007/s40520-023-02460-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 05/29/2023] [Indexed: 07/23/2023]
Abstract
OBJECTIVE To explore the correlation between intraoperative burst suppression (BS) and postoperative delirium (POD) in elderly patients, and provide more ideas for reducing POD in clinical. METHODS Ninety patients, aged over 60 years, who underwent lumbar internal fixation surgery in our hospital were selected. General information of patients was obtained and informed consent was signed during preoperative visits. Patients were divided into burst suppression (BS) group and non-burst suppression (NBS) group by intraoperative electroencephalogram monitoring. Intraoperative systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), and heart rate (HR) were recorded, and the variation and minimum value were obtained by calculating. Hemoglobin (HGB), C-reactive protein (CRP), system immune inflammatory index (SII) at 24 and 72 h after surgery, the incidence of postoperative adverse reactions, postoperative hospital stay, and total cost were recorded after operation. POD assessment was performed using CAM within 7 days after surgery or until discharge. SPSS25.0 was used for statistical analysis. RESULTS Compared with the NBS group, the number of elderly patients with high frailty level in BS group was more (P = 0.048). There is correlation between BS and POD (OR: 4.954, 95%CI 1.034-23.736, P = 0.045), and most of the POD patients in BS group behave as hyperactive type. CONCLUSION The occurrence of intraoperative BS is associated with POD, and elderly patients with frailty are more likely to have intraoperative BS. BS can be used as a predictor of POD.
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Affiliation(s)
- Shengjie Ren
- School of Anesthesiology, Weifang Medical University, Weifang, 261053, China
- Department of Anesthesiology, Weifang Second People's Hospital, Weifang, 261041, China
| | - Chuanbo Zang
- School of Anesthesiology, Weifang Medical University, Weifang, 261053, China
| | - Fang Yuan
- Department of Anesthesiology, Zibo Central Hospital, Zibo, 255020, China
| | - Xuemei Yan
- Department of Anesthesiology, Weifang People's Hospital, Weifang, 261041, China
| | - Yanan Zhang
- School of Anesthesiology, Weifang Medical University, Weifang, 261053, China
| | - Shu Yuan
- School of Anesthesiology, Weifang Medical University, Weifang, 261053, China
| | - Zenggang Sun
- School of Anesthesiology, Weifang Medical University, Weifang, 261053, China
| | - Bao Lang
- Department of Anesthesiology, Weifang People's Hospital, Weifang, 261041, China.
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Berger M, Ryu D, Reese M, McGuigan S, Evered LA, Price CC, Scott DA, Westover MB, Eckenhoff R, Bonanni L, Sweeney A, Babiloni C. A Real-Time Neurophysiologic Stress Test for the Aging Brain: Novel Perioperative and ICU Applications of EEG in Older Surgical Patients. Neurotherapeutics 2023; 20:975-1000. [PMID: 37436580 PMCID: PMC10457272 DOI: 10.1007/s13311-023-01401-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2023] [Indexed: 07/13/2023] Open
Abstract
As of 2022, individuals age 65 and older represent approximately 10% of the global population [1], and older adults make up more than one third of anesthesia and surgical cases in developed countries [2, 3]. With approximately > 234 million major surgical procedures performed annually worldwide [4], this suggests that > 70 million surgeries are performed on older adults across the globe each year. The most common postoperative complications seen in these older surgical patients are perioperative neurocognitive disorders including postoperative delirium, which are associated with an increased risk for mortality [5], greater economic burden [6, 7], and greater risk for developing long-term cognitive decline [8] such as Alzheimer's disease and/or related dementias (ADRD). Thus, anesthesia, surgery, and postoperative hospitalization have been viewed as a biological "stress test" for the aging brain, in which postoperative delirium indicates a failed stress test and consequent risk for later cognitive decline (see Fig. 3). Further, it has been hypothesized that interventions that prevent postoperative delirium might reduce the risk of long-term cognitive decline. Recent advances suggest that rather than waiting for the development of postoperative delirium to indicate whether a patient "passed" or "failed" this stress test, the status of the brain can be monitored in real-time via electroencephalography (EEG) in the perioperative period. Beyond the traditional intraoperative use of EEG monitoring for anesthetic titration, perioperative EEG may be a viable tool for identifying waveforms indicative of reduced brain integrity and potential risk for postoperative delirium and long-term cognitive decline. In principle, research incorporating routine perioperative EEG monitoring may provide insight into neuronal patterns of dysfunction associated with risk of postoperative delirium, long-term cognitive decline, or even specific types of aging-related neurodegenerative disease pathology. This research would accelerate our understanding of which waveforms or neuronal patterns necessitate diagnostic workup and intervention in the perioperative period, which could potentially reduce postoperative delirium and/or dementia risk. Thus, here we present recommendations for the use of perioperative EEG as a "predictor" of delirium and perioperative cognitive decline in older surgical patients.
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Affiliation(s)
- Miles Berger
- Department of Anesthesiology, Duke University Medical Center, Duke South Orange Zone Room 4315B, Box 3094, Durham, NC, 27710, USA.
- Duke Aging Center, Duke University Medical Center, Durham, NC, USA.
- Duke/UNC Alzheimer's Disease Research Center, Duke University Medical Center, Durham, NC, USA.
| | - David Ryu
- School of Medicine, Duke University, Durham, NC, USA
| | - Melody Reese
- Department of Anesthesiology, Duke University Medical Center, Duke South Orange Zone Room 4315B, Box 3094, Durham, NC, 27710, USA
- Duke Aging Center, Duke University Medical Center, Durham, NC, USA
| | - Steven McGuigan
- Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital, Melbourne, VIC, Australia
- Department of Critical Care, School of Medicine, University of Melbourne, Melbourne, Australia
| | - Lisbeth A Evered
- Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital, Melbourne, VIC, Australia
- Department of Critical Care, School of Medicine, University of Melbourne, Melbourne, Australia
- Weill Cornell Medicine, New York, NY, USA
| | - Catherine C Price
- Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
- Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
| | - David A Scott
- Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital, Melbourne, VIC, Australia
- Department of Critical Care, School of Medicine, University of Melbourne, Melbourne, Australia
| | - M Brandon Westover
- Department of Neurology, Beth Israel Deaconess Hospital, Boston, MA, USA
| | - Roderic Eckenhoff
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Laura Bonanni
- Department of Medicine and Aging Sciences, University G d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Aoife Sweeney
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Claudio Babiloni
- Department of Physiology and Pharmacology "Vittorio Erspamer", Sapienza University of Rome, Rome, Italy
- San Raffaele of Cassino, Cassino, FR, Italy
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9
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Jones KG, Lybbert C, Euler MJ, Huang J, Lunt S, Richards SV, Jessop JE, Larson A, Odell DH, Kuck K, Tadler SC, Mickey BJ. Diversity of electroencephalographic patterns during propofol-induced burst suppression. Front Syst Neurosci 2023; 17:1172856. [PMID: 37397237 PMCID: PMC10309040 DOI: 10.3389/fnsys.2023.1172856] [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: 02/23/2023] [Accepted: 05/23/2023] [Indexed: 07/04/2023] Open
Abstract
Burst suppression is a brain state consisting of high-amplitude electrical activity alternating with periods of quieter suppression that can be brought about by disease or by certain anesthetics. Although burst suppression has been studied for decades, few studies have investigated the diverse manifestations of this state within and between human subjects. As part of a clinical trial examining the antidepressant effects of propofol, we gathered burst suppression electroencephalographic (EEG) data from 114 propofol infusions across 21 human subjects with treatment-resistant depression. This data was examined with the objective of describing and quantifying electrical signal diversity. We observed three types of EEG burst activity: canonical broadband bursts (as frequently described in the literature), spindles (narrow-band oscillations reminiscent of sleep spindles), and a new feature that we call low-frequency bursts (LFBs), which are brief deflections of mainly sub-3-Hz power. These three features were distinct in both the time and frequency domains and their occurrence differed significantly across subjects, with some subjects showing many LFBs or spindles and others showing very few. Spectral-power makeup of each feature was also significantly different across subjects. In a subset of nine participants with high-density EEG recordings, we noted that each feature had a unique spatial pattern of amplitude and polarity when measured across the scalp. Finally, we observed that the Bispectral Index Monitor, a commonly used clinical EEG monitor, does not account for the diversity of EEG features when processing the burst suppression state. Overall, this study describes and quantifies variation in the burst suppression EEG state across subjects and repeated infusions of propofol. These findings have implications for the understanding of brain activity under anesthesia and for individualized dosing of anesthetic drugs.
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Affiliation(s)
- Keith G. Jones
- Interdepartmental Program in Neuroscience, The University of Utah, Salt Lake City, UT, United States
- Department of Psychiatry, Huntsman Mental Health Institute, The University of Utah, Salt Lake City, UT, United States
| | - Carter Lybbert
- Department of Biomedical Engineering, The University of Utah, Salt Lake City, UT, United States
- Department of Anesthesiology, The University of Utah, Salt Lake City, UT, United States
| | - Matthew J. Euler
- Department of Psychology, The University of Utah, Salt Lake City, UT, United States
| | - Jason Huang
- Department of Biomedical Engineering, The University of Utah, Salt Lake City, UT, United States
| | - Seth Lunt
- Department of Psychiatry, Huntsman Mental Health Institute, The University of Utah, Salt Lake City, UT, United States
| | - Sindhu V. Richards
- Department of Neurology, The University of Utah, Salt Lake City, UT, United States
| | - Jacob E. Jessop
- Department of Anesthesiology, The University of Utah, Salt Lake City, UT, United States
| | - Adam Larson
- Department of Anesthesiology, The University of Utah, Salt Lake City, UT, United States
| | - David H. Odell
- Department of Psychiatry, Huntsman Mental Health Institute, The University of Utah, Salt Lake City, UT, United States
- Department of Anesthesiology, The University of Utah, Salt Lake City, UT, United States
| | - Kai Kuck
- Department of Biomedical Engineering, The University of Utah, Salt Lake City, UT, United States
- Department of Anesthesiology, The University of Utah, Salt Lake City, UT, United States
| | - Scott C. Tadler
- Department of Psychiatry, Huntsman Mental Health Institute, The University of Utah, Salt Lake City, UT, United States
- Department of Anesthesiology, The University of Utah, Salt Lake City, UT, United States
| | - Brian J. Mickey
- Interdepartmental Program in Neuroscience, The University of Utah, Salt Lake City, UT, United States
- Department of Psychiatry, Huntsman Mental Health Institute, The University of Utah, Salt Lake City, UT, United States
- Department of Biomedical Engineering, The University of Utah, Salt Lake City, UT, United States
- Department of Anesthesiology, The University of Utah, Salt Lake City, UT, United States
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10
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Fong MWK, Pu K, Jadav R, Khan T, Hirsch LJ, Zaveri HP. Quantitative assessment of burst suppression as a predictor of seizure recurrence in refractory status epilepticus. Clin Neurophysiol 2023; 150:98-105. [PMID: 37060844 PMCID: PMC11265649 DOI: 10.1016/j.clinph.2023.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 02/15/2023] [Accepted: 03/11/2023] [Indexed: 03/31/2023]
Abstract
OBJECTIVE To determine whether quantitative EEG analysis of burst suppression can predict seizure recurrence in patients with refractory status epilepticus (RSE) being treated with anesthetic doses of continuous IV antiseizure medications (cIVASM). METHODS Quantitative assessment of burst suppression (including epileptiform discharges [EDs] and evolution) in 31 occasions (from 27 patients), and correlation with seizure recurrence up to 48 hours post sedative wean. RESULTS Occasions resulting in seizure recurrence (vs. no seizure recurrence) had lower burst (8.4 vs. 10.6 µV) and interburst interval (IBI) (4.2 vs. 4.8 µV) average amplitude, duration (bursts 2.8 vs. 3.6 s: IBIs 3.6 vs. 4.4 s); and burst total power (0.4 vs. 0.7 µV2). Bursts (0.86 vs. 0.60) and IBIs (0.28 vs. 0.07) with EDs, higher number of EDs within bursts (mean 2.1 vs. 1.4) and IBIs (0.6 vs. 0.2), and positive evolution measures all predicted seizure recurrence, although EDs had the greatest adjusted odds ratio on multivariate analysis. CONCLUSIONS For patients in burst suppression, successful wean of cIVASM was not determined by classical burst suppression measures, but instead how "epileptiform" bursts and IBIs were, as determined by EDs in both bursts and IBIs and surrogates for evolution within bursts. SIGNIFICANCE If confirmed, these objective measures could be used during clinical care to help determine when to wean cIVASM in patients with RSE.
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Affiliation(s)
- Michael W K Fong
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA; Westmead Comprehensive Epilepsy Unit, Westmead Hospital, University of Sydney, Sydney, Australia.
| | - Kelly Pu
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Rakesh Jadav
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA; Department of Neurology, Manipal Hospitals, Bengaluru, India
| | - Tasleema Khan
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA; University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Lawrence J Hirsch
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Hitten P Zaveri
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
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11
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Zafar A. Prevalence, electroclinical spectrum and effect on the outcome of non-convulsive status epilepticus in critically ill patients; the utility of routine electroencephalogram. Epilepsy Behav 2023; 141:109144. [PMID: 36863137 DOI: 10.1016/j.yebeh.2023.109144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 02/12/2023] [Accepted: 02/12/2023] [Indexed: 03/04/2023]
Abstract
OBJECTIVES To highlight the importance of routine electroencephalogram (rEEG) in detecting non-convulsive status epilepticus (NCSE), describing the electroclinical spectrum and effect on outcome in critically ill patients with altered mental status (CIPAMS). METHODS This retrospective study was conducted at King Fahd University Hospital. Clinical data and EEG recordings of CIPAMS to rule out NCSE were reviewed. All patients had at least 30 minutes of EEG recording. The Salzburg Consensus criteria (SCC) were applied to diagnose NCSE. The data analysis was performed using SPSS version 22.0. The chi-squared test was used to compare categorical variables such as etiologies, EEG findings, and functional outcomes. Multivariable analysis was performed to identify the predictors of unfavorable outcomes. RESULTS A total of 323 CIPAMS referred to rule out NCSE were enrolled (mean age 57.8 ± 20 years). Nonconvulsive status epilepticus was diagnosed in 54 (16.7%) patients. A significant association was found between subtle clinical features and NCSE (P =< 0.01). Acute ischemic stroke (18.5%), sepsis (18.5%), and hypoxic brain injury (22.2%) were the main etiologies. The previous history of epilepsy was significantly associated with NCSE (P = 0.01). Acute stroke, cardiac arrest, mechanical ventilation, and NCSE were statistically associated with unfavorable outcomes. Nonconvulsive status epilepticus was an independent predictor of unfavorable outcomes (P = 0.02, OR = 2.75, CI = 1.16-6.48) during multivariable analysis. Sepsis was associated with higher mortality (P =< 0.01, OR = 2.4, CI = 1.4-4.0). SIGNIFICANCE Our study findings suggest that the utility of rEEG in detecting NCSE in CIPAMS should not be underestimated. Important observations further indicate that repeating rEEG is advisable, as this would increase the likelihood of identifying NCSE. Thus, physicians should consider and repeat rEEG when evaluating CIPAMS in order to detect NCSE, which is an independent predictor of unfavorable outcomes. Nonetheless, further studies comparing rEEG and cEEG yields are required to augment the current understanding of the electroclinical spectrum and better describe NCSE in CIPAMS.
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Affiliation(s)
- Azra Zafar
- Department of Neurology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam 34212, Saudi Arabia.
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12
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Williams Roberson S, Azeez NA, Fulton JN, Zhang KC, Lee AXT, Ye F, Pandharipande P, Brummel NE, Patel MB, Ely EW. Quantitative EEG signatures of delirium and coma in mechanically ventilated ICU patients. Clin Neurophysiol 2023; 146:40-48. [PMID: 36529066 PMCID: PMC9889081 DOI: 10.1016/j.clinph.2022.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 11/18/2022] [Accepted: 11/25/2022] [Indexed: 12/05/2022]
Abstract
OBJECTIVE To identify quantitative electroencephalography (EEG)-based indicators of delirium or coma in mechanically ventilated patients. METHODS We prospectively enrolled 28 mechanically ventilated intensive care unit (ICU) patients to undergo 24-hour continuous EEG, 25 of whom completed the study. We assessed patients twice daily using the Richmond Agitation-Sedation Scale (RASS) and Confusion Assessment Method for the ICU (CAM-ICU). We evaluated the spectral profile, regional connectivity and complexity of 5-minute EEG segments after each assessment. We used penalized regression to select EEG metrics associated with delirium or coma, and compared mixed-effects models predicting delirium with and without the selected EEG metrics. RESULTS Delta variability, high-beta variability, relative theta power, and relative alpha power contributed independently to EEG-based identification of delirium or coma. A model with these metrics achieved better prediction of delirium or coma than a model with clinical variables alone (Akaike Information Criterion: 36 vs 43, p = 0.006 by likelihood ratio test). The area under the receiver operating characteristic curve for an ad hoc hypothetical delirium score using these metrics was 0.94 (95%CI 0.83-0.99). CONCLUSIONS We identified four EEG metrics that, in combination, provided excellent discrimination between delirious/comatose and non-delirious mechanically ventilated ICU patients. SIGNIFICANCE Our findings give insight to neurophysiologic changes underlying delirium and provide a basis for pragmatic, EEG-based delirium monitoring technology.
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Affiliation(s)
- Shawniqua Williams Roberson
- Critical Illness, Brain dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Neurology, Epilepsy Division, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, USA.
| | - Naureen A Azeez
- Critical Illness, Brain dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Neurology, Epilepsy Division, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jenna N Fulton
- Critical Illness, Brain dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Neurology, Epilepsy Division, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kevin C Zhang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Aaron X T Lee
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Fei Ye
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Pratik Pandharipande
- Critical Illness, Brain dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Nathan E Brummel
- Critical Illness, Brain dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pulmonary Critical Care, The Ohio State University, Columbus, OH, USA
| | - Mayur B Patel
- Critical Illness, Brain dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA; Departments of Surgery, Neurosurgery, and Hearing & Speech Sciences, Vanderbilt University Medical Center, Nashville, TN, USA; Vanderbilt Brain Institute, Vanderbilt University, Nashville, TN, USA; Department of General Surgery, VA Tennessee Valley Healthcare System, Nashville, TN, USA; Geriatric Research, Education and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, TN, USA
| | - E Wesley Ely
- Critical Illness, Brain dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA; Geriatric Research, Education and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, TN, USA; Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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13
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Tobar E, Farías JI, Rojas V, Penna A, Egaña JI, Ponce D, Bravo D, Maldonado F, Gajardo A, Gutiérrez R. Electroencephalography spectral edge frequency and suppression rate-guided sedation in patients with COVID-19: A randomized controlled trial. Front Med (Lausanne) 2022; 9:1013430. [DOI: 10.3389/fmed.2022.1013430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 10/07/2022] [Indexed: 11/06/2022] Open
Abstract
BackgroundSedation in coronavirus disease 2019 (COVID-19) patients has been identified as a major challenge. We aimed to investigate whether the use of a multiparameter electroencephalogram (EEG) protocol to guide sedation in COVID-19 patients would increase the 30-day mechanical ventilation-free days (VFD).MethodsWe conducted a double-blind randomized clinical trial. We included patients with severe pneumonia due to COVID-19 who required mechanical ventilation (MV) and deep sedation. We randomized to the control (n = 25) or multiparameter group (n = 25). Sedation in the intervention group was administered following the standard institutional protocols together with a flow chart designed to reduce the propofol administration dose if the EEG suppression rate was over 2% or the spectral edge frequency 95 (SEF95) was below 10 Hz. We performed an intention-to-treat analysis to evaluate our primary outcome (30-day VFD).ResultsThere was no difference in VFD at day 30 (median: 11 [IQR 0–20] days in the control group vs. 0 [IQR 0–21] days in the BIS multiparameter group, p = 0.87). Among secondary outcomes, we documented a 17% reduction in the total adjusted propofol administered during the first 5 days of the protocol [median: 2.3 (IQR 1.9–2.8) mg/k/h in the control group vs. 1.9(IQR 1.5–2.2) mg/k/h in the MP group, p = 0.005]. This was accompanied by a higher average BIS value in the intervention group throughout the treatment period.ConclusionA sedation protocol guided by multivariate EEG-derived parameters did not increase the 30-day VFD. However, the intervention led to a reduction in total propofol administration.
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Kafashan M, Brian Hickman L, Labonte AK, Huels ER, Maybrier H, Guay CS, Subramanian S, Farber NB, Ching S, Hogan RE, Kelz MB, Avidan MS, Mashour GA, Palanca BJA. Quiescence during burst suppression and postictal generalized EEG suppression are distinct patterns of activity. Clin Neurophysiol 2022; 142:125-132. [PMID: 36030576 PMCID: PMC10287541 DOI: 10.1016/j.clinph.2022.07.493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 06/15/2022] [Accepted: 07/17/2022] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Periods of low-amplitude electroencephalographic (EEG) signal (quiescence) are present during both anesthetic-induced burst suppression (BS) and postictal generalized electroencephalographic suppression (PGES). PGES following generalized seizures induced by electroconvulsive therapy (ECT) has been previously linked to antidepressant response. The commonality of quiescence during both BS and PGES motivated trials to recapitulate the antidepressant effects of ECT using high doses of anesthetics. However, there have been no direct electrographic comparisons of these quiescent periods to address whether these are distinct entities. METHODS We compared periods of EEG quiescence recorded from two human studies: BS induced in 29 healthy adult volunteers by isoflurane general anesthesia and PGES in 11 patients undergoing right unilateral ECT for treatment-resistant depression. An automated algorithm allowed detection of EEG quiescence based on a 10-microvolt amplitude threshold. Spatial, spectral, and temporal analyses compared quiescent epochs during BS and PGES. RESULTS The median (interquartile range) voltage for quiescent periods during PGES was greater than during BS (1.81 (0.22) microvolts vs 1.22 (0.33) microvolts, p < 0.001). Relative power was greater for quiescence during PGES than BS for the 1-4 Hz delta band (p < 0.001), at the expense of power in the theta (4-8 Hz, p < 0.001), beta (13-30 Hz, p = 0.04) and gamma (30-70 Hz, p = 0.006) frequency bands. Topographic analyses revealed that amplitude across the scalp was consistently higher for quiescent periods during PGES than BS, whose voltage was within the noise floor. CONCLUSIONS Quiescent epochs during PGES and BS have distinct patterns of EEG signals across voltage, frequency, and spatial domains. SIGNIFICANCE Quiescent epochs during PGES and BS, important neurophysiological markers for clinical outcomes, are shown to have distinct voltage and frequency characteristics.
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Affiliation(s)
- MohammadMehdi Kafashan
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - L Brian Hickman
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA; Department of Neurology, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA, USA
| | - Alyssa K Labonte
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA; Neuroscience Graduate Program, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Emma R Huels
- Neuroscience Graduate Program, University of Michigan, Ann Arbor, MI, USA; Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Hannah Maybrier
- Psychological & Brain Sciences Department, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Christian S Guay
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA; Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Picower Institute for Learning & Memory, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Subha Subramanian
- Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Nuri B Farber
- Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - ShiNung Ching
- Department of Electrical & Systems Engineering, Washington University in St. Louis, St. Louis, MO, USA; Division of Biology and Biomedical Sciences, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - R Edward Hogan
- Department of Neurology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Max B Kelz
- Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA; Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - George A Mashour
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Ben J A Palanca
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA; Department of Electrical & Systems Engineering, Washington University in St. Louis, St. Louis, MO, USA; Division of Biology and Biomedical Sciences, Washington University School of Medicine in St. Louis, St. Louis, MO, USA; Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, USA.
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15
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Krishna B. Inhaled Anesthetics for Sedation in ICU: Widening Horizons! Indian J Crit Care Med 2022; 26:889-891. [PMID: 36042759 PMCID: PMC9363807 DOI: 10.5005/jp-journals-10071-24295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
How to cite this article: Krishna B. Inhaled Anesthetics for Sedation in ICU: Widening Horizons! Indian J Crit Care Med 2022;26(8):889–891.
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Affiliation(s)
- Bhuvana Krishna
- Department of Critical Care Medicine, St John's Medical College and Hospital, Bengaluru, Karnataka, India
- Bhuvana Krishna, Department of Critical Care Medicine, St John's Medical College and Hospital, Bengaluru, Karnataka, India, Phone: +91 9945693221, e-mail:
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Rasulo FA, Hopkins P, Lobo FA, Pandin P, Matta B, Carozzi C, Romagnoli S, Absalom A, Badenes R, Bleck T, Caricato A, Claassen J, Denault A, Honorato C, Motta S, Meyfroidt G, Radtke FM, Ricci Z, Robba C, Taccone FS, Vespa P, Nardiello I, Lamperti M. Processed Electroencephalogram-Based Monitoring to Guide Sedation in Critically Ill Adult Patients: Recommendations from an International Expert Panel-Based Consensus. Neurocrit Care 2022; 38:296-311. [PMID: 35896766 PMCID: PMC10090014 DOI: 10.1007/s12028-022-01565-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 06/20/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND The use of processed electroencephalography (pEEG) for depth of sedation (DOS) monitoring is increasing in anesthesia; however, how to use of this type of monitoring for critical care adult patients within the intensive care unit (ICU) remains unclear. METHODS A multidisciplinary panel of international experts consisting of 21 clinicians involved in monitoring DOS in ICU patients was carefully selected on the basis of their expertise in neurocritical care and neuroanesthesiology. Panelists were assigned four domains (techniques for electroencephalography [EEG] monitoring, patient selection, use of the EEG monitors, competency, and training the principles of pEEG monitoring) from which a list of questions and statements was created to be addressed. A Delphi method based on iterative approach was used to produce the final statements. Statements were classified as highly appropriate or highly inappropriate (median rating ≥ 8), appropriate (median rating ≥ 7 but < 8), or uncertain (median rating < 7) and with a strong disagreement index (DI) (DI < 0.5) or weak DI (DI ≥ 0.5 but < 1) consensus. RESULTS According to the statements evaluated by the panel, frontal pEEG (which includes a continuous colored density spectrogram) has been considered adequate to monitor the level of sedation (strong consensus), and it is recommended by the panel that all sedated patients (paralyzed or nonparalyzed) unfit for clinical evaluation would benefit from DOS monitoring (strong consensus) after a specific training program has been performed by the ICU staff. To cover the gap between knowledge/rational and routine application, some barriers must be broken, including lack of knowledge, validation for prolonged sedation, standardization between monitors based on different EEG analysis algorithms, and economic issues. CONCLUSIONS Evidence on using DOS monitors in ICU is still scarce, and further research is required to better define the benefits of using pEEG. This consensus highlights that some critically ill patients may benefit from this type of neuromonitoring.
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Affiliation(s)
- Frank A Rasulo
- Department of Anesthesiology and Intensive Care, Spedali Civili Hospital, Brescia, Italy. .,Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy.
| | - Philip Hopkins
- Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - Francisco A Lobo
- Institute of Anesthesiology, Cleveland Clinic, Abu Dhabi, United Arab Emirates
| | - Pierre Pandin
- Department of Anesthesia and Intensive Care, Erasme Hospital, Universitè Libre de Bruxelles, Brussels, Belgium
| | - Basil Matta
- Department of Anaesthesia and Intensive Care, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Carla Carozzi
- Department of Anesthesia and Intensive Care, Istituto Neurologico C. Besta, Milan, Italy
| | - Stefano Romagnoli
- Department of Anesthesia and Intensive Care, Careggi University Hospital, Florence, Italy
| | - Anthony Absalom
- Department of Anesthesiology, University Medical Center Groningen, Groningen, Netherlands
| | - Rafael Badenes
- Department of Anesthesia and Intensive Care, University of Valencia, Valencia, Spain
| | - Thomas Bleck
- Division of Stroke and Neurocritical Care, Department of Neurology, Northwestern University, Evanston, IL, USA
| | - Anselmo Caricato
- Department of Anesthesia and Intensive Care, Gemelli University Hospital, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Jan Claassen
- Department of Neurocritical Care, Columbia University Irving Medical Center, New York, NY, USA
| | - André Denault
- Critical Care Division, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Cristina Honorato
- Department of Anesthesiology and Critical Care, Universidad de Navarra, Pamplona, Spain
| | - Saba Motta
- Scientific Library, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Geert Meyfroidt
- Department of Intensive Care, University Hospitals Leuven and Laboratory of Intensive Care Medicine, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Finn Michael Radtke
- Department of Anesthesiology IRS, Nykøbing F. Hospital, Nykøbing Falster, Denmark
| | - Zaccaria Ricci
- Department of Pediatric Anesthesia, Meyer University Hospital of Florence, University of Florence, Florence, Italy
| | - Chiara Robba
- Department of Anesthesia and Intensive Care, Policlinico San Martino and University of Genoa, Genoa, Italy
| | - Fabio S Taccone
- Department of Anesthesia and Intensive Care, Erasme Hospital, Universitè Libre de Bruxelles, Brussels, Belgium
| | - Paul Vespa
- Department of Neurosurgery and Neurocritical Care, Los Angeles Medical Center, Ronald Reagan University of California, Los Angeles, CA, USA
| | - Ida Nardiello
- Department of Anesthesiology and Intensive Care, Spedali Civili Hospital, Brescia, Italy
| | - Massimo Lamperti
- Institute of Anesthesiology, Cleveland Clinic, Abu Dhabi, United Arab Emirates
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Kotfis K, van Diem-Zaal I, Williams Roberson S, Sietnicki M, van den Boogaard M, Shehabi Y, Ely EW. The future of intensive care: delirium should no longer be an issue. Crit Care 2022; 26:200. [PMID: 35790979 PMCID: PMC9254432 DOI: 10.1186/s13054-022-04077-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 06/30/2022] [Indexed: 01/02/2023] Open
Abstract
In the ideal intensive care unit (ICU) of the future, all patients are free from delirium, a syndrome of brain dysfunction frequently observed in critical illness and associated with worse ICU-related outcomes and long-term cognitive impairment. Although screening for delirium requires limited time and effort, this devastating disorder remains underestimated during routine ICU care. The COVID-19 pandemic brought a catastrophic reduction in delirium monitoring, prevention, and patient care due to organizational issues, lack of personnel, increased use of benzodiazepines and restricted family visitation. These limitations led to increases in delirium incidence, a situation that should never be repeated. Good sedation practices should be complemented by novel ICU design and connectivity, which will facilitate non-pharmacological sedation, anxiolysis and comfort that can be supplemented by balanced pharmacological interventions when necessary. Improvements in the ICU sound, light control, floor planning, and room arrangement can facilitate a healing environment that minimizes stressors and aids delirium prevention and management. The fundamental prerequisite to realize the delirium-free ICU, is an awake non-sedated, pain-free comfortable patient whose management follows the A to F (A-F) bundle. Moreover, the bundle should be expanded with three additional letters, incorporating humanitarian care: gaining (G) insight into patient needs, delivering holistic care with a 'home-like' (H) environment, and redefining ICU architectural design (I). Above all, the delirium-free world relies upon people, with personal challenges for critical care teams to optimize design, environmental factors, management, time spent with the patient and family and to humanize ICU care.
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Affiliation(s)
- Katarzyna Kotfis
- Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University in Szczecin, Szczecin, Poland.
| | - Irene van Diem-Zaal
- Department of Intensive Care, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands.,Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Shawniqua Williams Roberson
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Center for Health Services Research, Nashville, TN, USA.,Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, USA
| | - Marek Sietnicki
- Department of Architecture, West Pomeranian University of Technology in Szczecin, Szczecin, Poland
| | - Mark van den Boogaard
- Department of Intensive Care, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Yahya Shehabi
- Monash Health School of Clinical Sciences, Monash University, Melbourne, VIC, Australia.,School of Clinical Medicine, University of New South Wales, Sydney, NSW, Australia
| | - E Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Center for Health Services Research, Nashville, TN, USA.,Division of Allergy, Department of Medicine, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Geriatric Research, Education and Clinical Center (GRECC) Service, Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
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Sevoflurane Effects on Neuronal Energy Metabolism Correlate with Activity States While Mitochondrial Function Remains Intact. Int J Mol Sci 2022; 23:ijms23063037. [PMID: 35328453 PMCID: PMC8949020 DOI: 10.3390/ijms23063037] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 03/04/2022] [Accepted: 03/09/2022] [Indexed: 12/04/2022] Open
Abstract
During general anesthesia, alterations in neuronal metabolism may induce neurotoxicity and/or neuroprotection depending on the dose and type of the applied anesthetic. In this study, we investigate the effects of clinically relevant concentrations of sevoflurane (2% and 4%, i.e., 1 and 2 MAC) on different activity states in hippocampal slices of young Wistar rats. We combine electrophysiological recordings, partial tissue oxygen (ptiO2) measurements, and flavin adenine dinucleotide (FAD) imaging with computational modeling. Sevoflurane minimally decreased the cerebral metabolic rate of oxygen (CMRO2) while decreasing synaptic transmission in naive slices. During pharmacologically induced gamma oscillations, sevoflurane impaired network activity, thereby decreasing CMRO2. During stimulus-induced neuronal activation, sevoflurane decreased CMRO2 and excitability while basal metabolism remained constant. In this line, stimulus-induced FAD transients decreased without changes in basal mitochondrial redox state. Integration of experimental data and computer modeling revealed no evidence for a direct effect of sevoflurane on key enzymes of the citric acid cycle or oxidative phosphorylation. Clinically relevant concentrations of sevoflurane generated a decent decrease in energy metabolism, which was proportional to the present neuronal activity. Mitochondrial function remained intact under sevoflurane, suggesting a better metabolic profile than isoflurane or propofol.
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Coeckelenbergh S, Richebé P, Longrois D, Joosten A, De Hert S. Current trends in anesthetic depth and antinociception monitoring: an international survey. J Clin Monit Comput 2021; 36:1407-1422. [PMID: 34826017 DOI: 10.1007/s10877-021-00781-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 11/21/2021] [Indexed: 12/19/2022]
Abstract
Current trends in anesthetic depth (i.e., hypnosis) and antinociception monitoring are unclear. We thus aimed to determine contemporary perspectives on monitoring these components of anesthesia during general anesthesia. Participants received and responded anonymously to an internet-based international survey supported by the European Society of Anaesthesiology and Intensive Care. Comparisons, when applicable, were carried out using Chi2 analysis or Fischer's exact test. A total of 564 respondents, predominantly from Europe (80.1%), participated. There was a strong participation from Belgium (11.5%). A majority (70.9%) of anesthetists considered hypnotic monitoring important on most occasions to always. In contrast, a majority (62.6%) never or only occasionally considered antinociception monitoring important. This difference in the perceived importance of anesthetic depth versus antinociception monitoring was significant (p < 0.0001). A majority of respondents (70.1%) believed that guiding hypnosis and antinociception using these monitors would improve patient care on most occasions to always. Nonetheless, a substantial number of participants were unsure if hypnotic (23%) or antinociception (32%) monitoring were recommended and there was a lack of knowledge (58%) of any published algorithms to titrate hypnotic and/or antinociceptive drugs based on the information provided by the monitors. In conclusion, current trends in European academic centers prioritize anesthesia depth over antinociception monitoring. Despite an agreement among respondents that applying strategies that optimize anesthetic depth and antinociception could improve outcome, there remains a lack of knowledge of appropriate algorithms. Future studies and recommendations should focus on clarifying goal-directed anesthetic strategies and determine their impact on perioperative patient outcome.
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Affiliation(s)
- Sean Coeckelenbergh
- Department of Anesthesiology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium.
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, Ghent University, Ghent, Belgium.
| | - Philippe Richebé
- Department of Anesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital, CIUSSS de L'Est de L'Ile de Montréal (CEMTL), University of Montreal, Montreal, Canada
| | - Dan Longrois
- Department of Anesthesiology and Intensive Care, Hôpital Bichat-Claude-Bernard, AP-HP. Nord-Université de Paris, Paris, France
| | - Alexandre Joosten
- Department of Anesthesiology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
- Department of Anesthesiology, Hôpital-Paul Brousse, Université Paris-Saclay, Villejuif, France
| | - Stefan De Hert
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, Ghent University, Ghent, Belgium
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20
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Responsiveness Index versus the RASS-Based Method for Adjusting Sedation in Critically Ill Patients. Crit Care Res Pract 2021; 2021:6621555. [PMID: 34659830 PMCID: PMC8516552 DOI: 10.1155/2021/6621555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 08/09/2021] [Accepted: 09/02/2021] [Indexed: 11/18/2022] Open
Abstract
Background Sedation of intensive care patients is needed for patient safety, but deep sedation is associated with adverse outcomes. Frontal electromyogram-based Responsiveness Index (RI) aims to quantify the level of sedation and is scaled 0-100 (low index indicates deep sedation). We compared RI-based sedation to Richmond Agitation-Sedation Scale- (RASS-) based sedation. Our hypothesis was that RI-controlled sedation would be associated with increased total time alive without mechanical ventilation at 30 days without an increased number of adverse events. Methods 32 critically ill adult patients with mechanical ventilation and administration of sedation were randomized to either RI- or RASS-guided sedation. Patients received propofol and oxycodone, if possible. The following standardized sedation protocol was utilized in both groups to achieve the predetermined target sedation level: either RI 40-80 (RI group) or RASS -3 to 0 (RASS group). RI measurement was blinded in the RASS group, and the RI group was blinded to RASS assessments. State Entropy (SE) values were registered in both groups. Results RI and RASS groups did not differ in total time alive in 30 days without mechanical ventilation (p=0.72). The incidence of at least one sedation-related adverse event did not differ between the groups. Hypertension was more common in the RI group (p=0.01). RI group patients were in the target RI level 22% of the time and RASS group patients had 57% of scores within the target RASS level. The RI group spent significantly more time in their target sedation level than the RASS group spent in the corresponding RI level (p=0.03). No difference was observed between the groups (p=0.13) in the corresponding analysis for RASS. Propofol and oxycodone were administered at higher RI and SE values and lower RASS values in the RI group than in the RASS group. Conclusion Further studies with a larger sample size are warranted to scrutinize the optimal RI level during different phases of critical illness.
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21
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Wang D, Guo Q, Liu D, Kong XX, Xu Z, Zhou Y, Su Y, Dai F, Ding HL, Cao JL. Association Between Burst-Suppression Latency and Burst-Suppression Ratio Under Isoflurane or Adjuvant Drugs With Isoflurane Anesthesia in Mice. Front Pharmacol 2021; 12:740012. [PMID: 34646140 PMCID: PMC8504134 DOI: 10.3389/fphar.2021.740012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 08/24/2021] [Indexed: 11/13/2022] Open
Abstract
The same doses of anesthesia may yield varying depths of anesthesia in different patients. Clinical studies have revealed a possible causal relationship between deep anesthesia and negative short- and long-term patient outcomes. However, a reliable index and method of the clinical monitoring of deep anesthesia and detecting latency remain lacking. As burst-suppression is a characteristic phenomenon of deep anesthesia, the present study investigated the relationship between burst-suppression latency (BSL) and the subsequent burst-suppression ratio (BSR) to find an improved detection for the onset of intraoperative deep anesthesia. The mice were divided young, adult and old group treated with 1.0% or 1.5% isoflurane anesthesia alone for 2 h. In addition, the adult mice were pretreated with intraperitoneal injection of ketamine, dexmedetomidine, midazolam or propofol before they were anesthetized by 1.0% isoflurane for 2 h. Continuous frontal, parietal and occipital electroencephalogram (EEG) were acquired during anesthesia. The time from the onset of anesthesia to the first occurrence of burst-suppression was defined as BSL, while BSR was calculated as percentage of burst-suppression time that was spent in suppression periods. Under 1.0% isoflurane anesthesia, we found a negative correlation between BSL and BSR for EEG recordings obtained from the parietal lobes of young mice, from the parietal and occipital lobes of adult mice, and the occipital lobes of old mice. Under 1.5% isoflurane anesthesia, only the BSL calculated from EEG data obtained from the occipital lobe was negatively correlated with BSR in all mice. Furthermore, in adult mice receiving 1.0% isoflurane anesthesia, the co-administration of ketamine and midazolam, but not dexmedetomidine and propofol, significantly decreased BSL and increased BSR. Together, these data suggest that BSL can detect burst-suppression and predict the subsequent BSR under isoflurane anesthesia used alone or in combination with anesthetics or adjuvant drugs. Furthermore, the consistent negative correlation between BSL and BSR calculated from occipital EEG recordings recommends it as the optimal position for monitoring burst-suppression.
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Affiliation(s)
- Di Wang
- Jiangsu Province Key Laboratory of Anesthesiology, Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application Technology, Xuzhou Medical University, Xuzhou, China.,Department of Anesthesiology and Perioperative Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Qingchen Guo
- Jiangsu Province Key Laboratory of Anesthesiology, Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application Technology, Xuzhou Medical University, Xuzhou, China
| | - Di Liu
- Jiangsu Province Key Laboratory of Anesthesiology, Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application Technology, Xuzhou Medical University, Xuzhou, China
| | - Xiang-Xi Kong
- Jiangsu Province Key Laboratory of Anesthesiology, Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application Technology, Xuzhou Medical University, Xuzhou, China
| | - Zheng Xu
- Jiangsu Province Key Laboratory of Anesthesiology, Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application Technology, Xuzhou Medical University, Xuzhou, China
| | - Yu Zhou
- Jiangsu Province Key Laboratory of Anesthesiology, Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application Technology, Xuzhou Medical University, Xuzhou, China
| | - Yan Su
- Jiangsu Province Key Laboratory of Anesthesiology, Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application Technology, Xuzhou Medical University, Xuzhou, China
| | - Feng Dai
- Jiangsu Province Key Laboratory of Anesthesiology, Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application Technology, Xuzhou Medical University, Xuzhou, China
| | - Hai-Lei Ding
- Jiangsu Province Key Laboratory of Anesthesiology, Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application Technology, Xuzhou Medical University, Xuzhou, China.,NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou, China
| | - Jun-Li Cao
- Jiangsu Province Key Laboratory of Anesthesiology, Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application Technology, Xuzhou Medical University, Xuzhou, China.,NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou, China.,Department of Anesthesiology Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
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22
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Berndt N, Kovács R, Schoknecht K, Rösner J, Reiffurth C, Maechler M, Holzhütter HG, Dreier JP, Spies C, Liotta A. Low neuronal metabolism during isoflurane-induced burst suppression is related to synaptic inhibition while neurovascular coupling and mitochondrial function remain intact. J Cereb Blood Flow Metab 2021; 41:2640-2655. [PMID: 33899556 PMCID: PMC8504408 DOI: 10.1177/0271678x211010353] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Deep anaesthesia may impair neuronal, vascular and mitochondrial function facilitating neurological complications, such as delirium and stroke. On the other hand, deep anaesthesia is performed for neuroprotection in critical brain diseases such as status epilepticus or traumatic brain injury. Since the commonly used anaesthetic propofol causes mitochondrial dysfunction, we investigated the impact of the alternative anaesthetic isoflurane on neuro-metabolism. In deeply anaesthetised Wistar rats (burst suppression pattern), we measured increased cortical tissue oxygen pressure (ptiO2), a ∼35% drop in regional cerebral blood flow (rCBF) and burst-associated neurovascular responses. In vitro, 3% isoflurane blocked synaptic transmission and impaired network oscillations, thereby decreasing the cerebral metabolic rate of oxygen (CMRO2). Concerning mitochondrial function, isoflurane induced a reductive shift in flavin adenine dinucleotide (FAD) and decreased stimulus-induced FAD transients as Ca2+ influx was reduced by ∼50%. Computer simulations based on experimental results predicted no direct effects of isoflurane on mitochondrial complexes or ATP-synthesis. We found that isoflurane-induced burst suppression is related to decreased ATP consumption due to inhibition of synaptic activity while neurovascular coupling and mitochondrial function remain intact. The neurometabolic profile of isoflurane thus appears to be superior to that of propofol which has been shown to impair the mitochondrial respiratory chain.
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Affiliation(s)
- Nikolaus Berndt
- Institute for Imaging Science and Computational Modelling in Cardiovascular Medicine Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Richard Kovács
- Institute for Neurophysiology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Karl Schoknecht
- Carl-Ludwig-Institute for Physiology, University Leipzig, Leipzig, Germany
| | - Jörg Rösner
- Neuroscience Research Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Clemens Reiffurth
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Mathilde Maechler
- Institute for Neurophysiology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Hermann-Georg Holzhütter
- Institute of Biochemistry, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Jens P Dreier
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Bernstein center for Computational Neuroscience, Charité - Universitätsmedizin, Humboldt-Universität zu Berlin and Technische Universität Berlin, Berlin, Germany.,Einstein Center for Neuroscience, Charité - Universitätsmedizin Berlin, the Freie Universität Berlin, the Humboldt-Universität zu Berlin and the Technische Universität Berlin, Berlin, Germany
| | - Claudia Spies
- Department of Anesthesiology and Intensive Care, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany.,Berlin Institute of Health, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Agustin Liotta
- Institute for Neurophysiology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany.,Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Anesthesiology and Intensive Care, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany.,Berlin Institute of Health, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
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23
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Eskioglou E, Iaquaniello C, Alvarez V, Rüegg S, Schindler K, Rossetti AO, Oddo M. Electroencephalography of mechanically ventilated patients at high risk of delirium. Acta Neurol Scand 2021; 144:296-302. [PMID: 33950516 PMCID: PMC8453526 DOI: 10.1111/ane.13447] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/30/2021] [Accepted: 04/15/2021] [Indexed: 01/03/2023]
Abstract
Objective Neurophysiological exploration of ICU delirium is limited. Here, we examined EEG characteristics of medical‐surgical critically ill patients with new‐onset altered consciousness state at high risk for ICU delirium. Materials and methods Pre‐planned analysis of non‐neurological mechanically ventilated medical‐surgical ICU subjects, who underwent a prospective multicenter randomized, controlled EEG study (NCT03129438, April 2017–November 2018). EEG characteristics, according to the 2012 ACNS nomenclature, included background activity, rhythmic periodic patterns/epileptic activity, amplitude, frequency, stimulus‐induced discharges, triphasic waves, reactivity, and NREM sleep. We explored EEG findings in delirious versus non‐delirious patients, specifically focusing on the presence of burst‐suppression and rhythmic periodic patterns (ictal‐interictal continuum), and ictal activity. Results We analyzed 91 patients (median age, 66 years) who underwent EEG because of new‐onset altered consciousness state at a median 5 days from admission; 42 patients developed delirium (46%). Burst‐suppression (10 vs 0%, p = .02), rhythmic/periodic patterns (43% vs 22%, p = .03) and epileptiform activity (7 vs 0%, p = .05) were more frequent in delirious versus non‐delirious patients. The presence of at least one of these abnormal EEG findings (32/91 patients; 35%) was associated with a significant increase in the likelihood of delirium (42 vs 15%, p = .006). Cumulative dose of sedatives and analgesics, as well as all other EEG characteristics, did not differ significantly between the two groups. Conclusion In mechanically ventilated non‐neurological critically ill patients with new‐onset alteration of consciousness, EEG showing burst‐suppression, rhythmic or periodic patterns, or seizures/status epilepticus indicate an increased risk of ICU delirium.
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Affiliation(s)
- Elissavet Eskioglou
- Department of Intensive Care Medicine University Hospital (CHUV) and University of Lausanne Lausanne Switzerland
| | - Carolina Iaquaniello
- Department of Intensive Care Medicine University Hospital (CHUV) and University of Lausanne Lausanne Switzerland
- School of Medicine and Surgery University of Milan Monza Italy
| | - Vincent Alvarez
- Department of Clinical Neuroscience University Hospital (CHUV) and University of Lausanne Lausanne Switzerland
- Department of Neurology Hôpital du Valais Sion Switzerland
| | - Stephan Rüegg
- Department of Neurology University Hospital Basel and University of Basel Basel Switzerland
| | - Kaspar Schindler
- Sleep‐Wake‐Epilepsy‐Center Department of Neurology, Inselspital Bern University Hospital University of Bern Bern Switzerland
| | - Andrea O. Rossetti
- Department of Clinical Neuroscience University Hospital (CHUV) and University of Lausanne Lausanne Switzerland
| | - Mauro Oddo
- Department of Intensive Care Medicine University Hospital (CHUV) and University of Lausanne Lausanne Switzerland
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24
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Wingert T, Lee C, Cannesson M. Machine Learning, Deep Learning, and Closed Loop Devices-Anesthesia Delivery. Anesthesiol Clin 2021; 39:565-581. [PMID: 34392886 PMCID: PMC9847584 DOI: 10.1016/j.anclin.2021.03.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
With the tremendous volume of data captured during surgeries and procedures, critical care, and pain management, the field of anesthesiology is uniquely suited for the application of machine learning, neural networks, and closed loop technologies. In the past several years, this area has expanded immensely in both interest and clinical applications. This article provides an overview of the basic tenets of machine learning, neural networks, and closed loop devices, with emphasis on the clinical applications of these technologies.
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Affiliation(s)
- Theodora Wingert
- University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA, USA,Department of Anesthesiology and Perioperative Medicine, Ronald Reagan UCLA Medical Center, 757 Westwood Plaza, Suite 3325, Los Angeles, CA 90095-7403, USA,Corresponding author. Department of Anesthesiology and Perioperative Medicine, Ronald Reagan UCLA Medical Center, 757 Westwood Plaza, Suite 3325, Los Angeles, CA 90095-7403.
| | - Christine Lee
- Edwards Lifesciences, Irvine, CA, USA,Critical Care R&D, 1 Edwards Way, Irvine, CA 92614, USA
| | - Maxime Cannesson
- University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA, USA,Department of Anesthesiology and Perioperative Medicine, Ronald Reagan UCLA Medical Center, 757 Westwood Plaza, Suite 3325, Los Angeles, CA 90095-7403, USA
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25
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Mauritz MD, Uhlenberg F, Vettorazzi E, Ebenebe CU, Singer D, Deindl P. Impact of Propofol Bolus Administration on the Nociceptive Flexion Reflex Threshold and Bispectral Index in Children—A Case Series. CHILDREN 2021; 8:children8080639. [PMID: 34438531 PMCID: PMC8393661 DOI: 10.3390/children8080639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/20/2021] [Accepted: 07/22/2021] [Indexed: 11/16/2022]
Abstract
We analyzed the impact of propofol administration during continuous sedation and analgesia on the nociceptive flexion reflex threshold (NFRT) and Bispectral Index (BIS) in ventilated children. We examined patients who received propofol before planned endotracheal suctioning. Patients were clinically assessed using the modified Face, Legs, Activity, Cry, Consolability (mFLACC) scale and COMFORT-B (Comfort Behavior) scale. We continuously recorded the NFRT and BIS. We recorded 23 propofol administrations in eight patients with an average age of 8.6 ± 3.5 years. The median (minimum-maximum) scores for the mFLACC scale and COMFORT-B scale were 0 (0–5) and 6 (6–17), respectively, before the bolus. The administration of a weight-adjusted propofol bolus of 1.03 ± 0.31 mg/kg resulted in an increase in NFRT and burst-suppression ratio; BIS and electromyogram values decreased. Changes from baseline (95% CI) after propofol bolus administration were BIS −23.9 (−30.8 to −17.1), EMG -10.5 dB (−13.3 to −7.7), SR 14.8 % (5.6 to 24.0) and NFRT 13.6 mA (5.5 to 21.7). Further studies are needed to determine whether sedated children may benefit from objective pain and sedation monitoring with BIS and NFRT.
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Affiliation(s)
- Maximilian David Mauritz
- Department of Neonatology and Pediatric Intensive Care Medicine, University Children’s Hospital, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (F.U.); (C.U.E.); (D.S.); (P.D.)
- Department of General Pediatrics and Adolescent Medicine, Children’s and Adolescents’ Hospital Datteln, Witten/Herdecke University, 45711 Datteln, Germany
- Correspondence: ; Tel.: +49-2363-9750
| | - Felix Uhlenberg
- Department of Neonatology and Pediatric Intensive Care Medicine, University Children’s Hospital, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (F.U.); (C.U.E.); (D.S.); (P.D.)
- Department of Pediatrics and Adolescent Medicine, Neonatology and Pediatric Intensive Care Medicine, Itzehoe Medical Center, 25524 Itzehoe, Germany
| | - Eik Vettorazzi
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany;
| | - Chinedu Ulrich Ebenebe
- Department of Neonatology and Pediatric Intensive Care Medicine, University Children’s Hospital, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (F.U.); (C.U.E.); (D.S.); (P.D.)
| | - Dominique Singer
- Department of Neonatology and Pediatric Intensive Care Medicine, University Children’s Hospital, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (F.U.); (C.U.E.); (D.S.); (P.D.)
| | - Philipp Deindl
- Department of Neonatology and Pediatric Intensive Care Medicine, University Children’s Hospital, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (F.U.); (C.U.E.); (D.S.); (P.D.)
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26
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Nazish S, Zafar A, Shariff E, Shahid R, Alamri S, Albakr A. Clinical Correlates of Electroencephalographic Patterns in Critically Ill Patients. Clin EEG Neurosci 2021; 52:287-295. [PMID: 33104405 DOI: 10.1177/1550059420966844] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The objective of this study was to determine the frequency and clinical correlates of different electroencephalographic patterns and their association with clinical outcomes in critically ill patients. SUBJECTS AND METHODS This retrospective cross-sectional study was performed in the Neurology Department of King Fahd Hospital of the University, Kingdom of Saudi Arabia and involved a review and analysis of medical records pertaining to 179 intensive care unit patients who underwent electroencephalography (EEG) in the June to November 2018 period. RESULTS Among the different etiologies, presence of spike and wave or sharp wave (SWs) was associated with encephalitis (P = .01) and large artery stroke (P = .01), whereas markedly attenuated EEG activity (p = .04) and burst suppression (P = .01) were associated with large artery stroke and hypoxic ischemic encephalopathy (HIE), respectively. Generalized theta activity (P = .01) was significantly found in patients of septic encephalopathy, while generalized delta activity (P = .02) and asymmetrical background (P = .04) were significantly associated with traumatic brain injury. Presence of periodic discharges in EEG was significantly associated with more adverse clinical outcomes (P = .001), whereas rhythmic delta activity (RDA) (P = .03), persistent focal slow wave activity (P = .01), and asymmetric background (P = .002) were found in patients who were discharged from hospital with sequelae of current illness. CONCLUSION Certain EEG patterns are associated with particular underlying etiologies like SWs for encephalitis, markedly attenuated EEG activity and burst suppression with large artery stroke and HIE, respectively. Whereas few EEG patterns, including periodic discharges, RDA, persistent focal slow wave activity have some prognostic value in critically ill patients. However, they cannot be used as markers for prognostic assessment of patients without considering other clinical and diagnostic variables. Further larger prospective studies with continuous EEG monitoring with control of confounding factors are needed.
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Affiliation(s)
- Saima Nazish
- Department of Neurology, College of Medicine, 48135Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Azra Zafar
- Department of Neurology, College of Medicine, 48135Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Erum Shariff
- Department of Neurology, College of Medicine, 48135Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Rizwana Shahid
- Department of Neurology, College of Medicine, 48135Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Sara Alamri
- Department of Neurology, College of Medicine, 48135Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Aisha Albakr
- Department of Neurology, College of Medicine, 48135Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
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27
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Jones JH, Nittur VR, Fleming N, Applegate RL. Simultaneous comparison of depth of sedation performance between SedLine and BIS during general anesthesia using custom passive interface hardware: study protocol for a prospective, non-blinded, non-randomized trial. BMC Anesthesiol 2021; 21:105. [PMID: 33823811 PMCID: PMC8022390 DOI: 10.1186/s12871-021-01326-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 03/29/2021] [Indexed: 11/10/2022] Open
Abstract
Background Intraoperative brain function monitoring with processed electroencephalogram (EEG) indices, such as the bispectral index (BIS) and patient state index (PSI), may improve characterization of the depth of sedation or anesthesia when compared to conventional physiologic monitors, such as heart rate and blood pressure. However, the clinical assessment of anesthetic depth may not always agree with available processed EEG indices. To concurrently compare the performance of BIS and SedLine monitors, we present a data collection system using shared individual generic sensors connected to a custom-built passive interface box. Methods This prospective, non-blinded, non-randomized study will enroll 100 adult American Society of Anesthesiologists (ASA) class I-III patients presenting for elective procedures requiring general anesthesia. BIS and SedLine electrodes will be placed preoperatively according to manufacturer recommendations and their respective indices tracked throughout anesthesia induction, maintenance and emergence. The concordance between processed EEG indices and clinical assessments of anesthesia depth will be analyzed with chi-square and kappa statistic. Discussion Prior studies comparing brain function monitoring devices have applied both sensors on the forehead of study subjects simultaneously. With limited space and common sensor locations between devices, it is not possible to place both commercial sensor arrays according to the manufacturer’s recommendations, thus compromising the validity of these comparisons. This trial utilizes a custom interface allowing signals from sensors to be shared between BIS and SedLine monitors to provide an accurate comparison. Our results will also characterize the degree of agreement between processed EEG indices and clinical assessments of anesthetic depth as determined by the anesthesiologists’ interpretations of acute changes in blood pressure and heart rate as well as the administration, or change to the continuous delivery, of medications at these timepoints. Patient factors (such as burst suppression state or low power EEG conditions from aging brain), surgical conditions (such as use of electrocautery), artifacts (such as electromyography), and anesthesia medications and doses (such as end-tidal concentration of volatile anesthetic or hypnotic infusion dose) that lead to lack of agreement will be explored as well. Trial registration Clinical Trials (ClinicalTrials.gov), NCT03865316. Registered on 4 February 2019 – retrospectively registered. Sponsor: Masimo Corporation.
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Affiliation(s)
- James Harvey Jones
- Department of Anesthesiology and Pain Medicine, University of California Davis Medical Center, 4150 V Street, PSSB Suite 1200, Sacramento, CA, 95817, USA.
| | - Vinay Ravikumar Nittur
- Department of Anesthesiology and Pain Medicine, University of California Davis Medical Center, 4150 V Street, PSSB Suite 1200, Sacramento, CA, 95817, USA.,School of Medicine, University of California Davis, Sacramento, CA, USA
| | - Neal Fleming
- Department of Anesthesiology and Pain Medicine, University of California Davis Medical Center, 4150 V Street, PSSB Suite 1200, Sacramento, CA, 95817, USA
| | - Richard L Applegate
- Department of Anesthesiology and Pain Medicine, University of California Davis Medical Center, 4150 V Street, PSSB Suite 1200, Sacramento, CA, 95817, USA
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Wood MD, Boyd JG, Wood N, Frank J, Girard TD, Ross-White A, Chopra A, Foster D, Griesdale DEG. The Use of Near-Infrared Spectroscopy and/or Transcranial Doppler as Non-Invasive Markers of Cerebral Perfusion in Adult Sepsis Patients With Delirium: A Systematic Review. J Intensive Care Med 2021; 37:408-422. [PMID: 33685273 PMCID: PMC8772019 DOI: 10.1177/0885066621997090] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background: Several studies have previously reported the presence of altered cerebral perfusion during sepsis. However, the role of non-invasive neuromonitoring, and the impact of altered cerebral perfusion, in sepsis patients with delirium remains unclear. Methods: We performed a systematic review of studies that used near-infrared spectroscopy (NIRS) and/or transcranial Doppler (TCD) to assess adults (≥18 years) with sepsis and delirium. From study inception to July 28, 2020, we searched the following databases: Ovid MedLine, Embase, Cochrane Library, and Web of Science. Results: Of 1546 articles identified, 10 met our inclusion criteria. Although NIRS-derived regional cerebral oxygenation was consistently lower, this difference was only statistically significant in one study. TCD-derived cerebral blood flow velocity was inconsistent across studies. Importantly, both impaired cerebral autoregulation during sepsis and increased cerebrovascular resistance were associated with delirium during sepsis. However, the heterogeneity in NIRS and TCD devices, duration of recording (from 10 seconds to 72 hours), and delirium assessment methods (e.g., electronic medical records, confusion assessment method for the intensive care unit), precluded meta-analysis. Conclusion: The available literature demonstrates that cerebral perfusion disturbances may be associated with delirium in sepsis. However, future investigations will require consistent definitions of delirium, delirium assessment training, harmonized NIRS and TCD assessments (e.g., consistent measurement site and length of recording), as well as the quantification of secondary and tertiary variables (i.e., Cox, Mxa, MAPOPT), in order to fully assess the relationship between cerebral perfusion and delirium in patients with sepsis.
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Affiliation(s)
- Michael D Wood
- Department of Anesthesiology, Pharmacology and Therapeutics, 8166University of British Columbia, Vancouver, British Columbia, Canada
| | - J Gordon Boyd
- Department of Critical Care Medicine, 4257Queen's University, Kingston, Ontario, Canada
| | - Nicole Wood
- Department of Physics, 8430University of Waterloo, Waterloo, Ontario, Canada
| | - James Frank
- Department of Physics, 7497Brock University, St. Catharines, Ontario, Canada
| | - Timothy D Girard
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Akash Chopra
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Denise Foster
- Division of Critical Care Medicine, Department of Medicine, 8166University of British Columbia, Vancouver, British Columbia, Canada
| | - Donald E G Griesdale
- Department of Anesthesiology, Pharmacology and Therapeutics, 8166University of British Columbia, Vancouver, British Columbia, Canada.,Division of Critical Care Medicine, Department of Medicine, 8166University of British Columbia, Vancouver, British Columbia, Canada.,Center for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
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Michalak AJ, Mendiratta A, Eliseyev A, Ramnath B, Chung J, Rasnow J, Reid L, Salerno S, García PS, Agarwal S, Roh D, Park S, Bazil C, Claassen J. Frontotemporal EEG to guide sedation in COVID-19 related acute respiratory distress syndrome. Clin Neurophysiol 2021; 132:730-736. [PMID: 33567379 PMCID: PMC7817418 DOI: 10.1016/j.clinph.2021.01.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 12/08/2020] [Accepted: 01/06/2021] [Indexed: 12/14/2022]
Abstract
Objective To study if limited frontotemporal electroencephalogram (EEG) can guide sedation changes in highly infectious novel coronavirus disease 2019 (COVID-19) patients receiving neuromuscular blocking agent. Methods 98 days of continuous frontotemporal EEG from 11 consecutive patients was evaluated daily by an epileptologist to recommend reduction or maintenance of the sedative level. We evaluated the need to increase sedation in the 6 h following this recommendation. Post-hoc analysis of the quantitative EEG was correlated with the level of sedation using a machine learning algorithm. Results Eleven patients were studied for a total of ninety-eight sedation days. EEG was consistent with excessive sedation on 57 (58%) and adequate sedation on 41 days (42%). Recommendations were followed by the team on 59% (N = 58; 19 to reduce and 39 to keep the sedation level). In the 6 h following reduction in sedation, increases of sedation were needed in 7 (12%). Automatized classification of EEG sedation levels reached 80% (±17%) accuracy. Conclusions Visual inspection of a limited EEG helped sedation depth guidance. In a secondary analysis, our data supported that this determination may be automated using quantitative EEG analysis. Significance Our results support the use of frontotemporal EEG for guiding sedation in patients with COVID-19.
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Affiliation(s)
- Andrew J Michalak
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | - Anil Mendiratta
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | - Andrey Eliseyev
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | | | - Jane Chung
- NewYork Presbyterian Hospital, New York, NY, USA
| | | | | | | | - Paul S García
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY, USA
| | - Sachin Agarwal
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | - David Roh
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | - Soojin Park
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | - Carl Bazil
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | - Jan Claassen
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA.
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30
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Gong C, Zhang D, Ou W, Ou M, Liang P, Liao D, Zhang W, Zhu T, Liu J, Zhou C. Deficiency of Mitochondrial Functions and Peroxidation of Frontoparietal Cortex Enhance Isoflurane Sensitivity in Aging Mice. Front Aging Neurosci 2020; 12:583542. [PMID: 33343330 PMCID: PMC7744615 DOI: 10.3389/fnagi.2020.583542] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 11/09/2020] [Indexed: 02/05/2023] Open
Abstract
Background: Hypersensitivity to general anesthetics may predict poor postoperative outcomes, especially among the older subjects. Therefore, it is essential to elucidate the mechanism underlying hypersensitivity to volatile anesthetics in the aging population. Given the fact that isoflurane sensitivity increases with aging, we hypothesized that deficiencies of mitochondrial function and elevated oxidative levels in the frontoparietal cortex may contribute to the enhanced sensitivity to isoflurane in aging mice. Methods: Isoflurane sensitivity in aging mice was determined by the concentration of isoflurane that is required for loss of righting reflex (LORR). Mitochondrial bioenergetics of the frontoparietal cortex was measured using a Seahorse XFp analyzer. Protein oxidation and lipid oxidation in the frontoparietal cortex were assessed using the Oxyblot protein oxidation detection kit and thiobarbituric acid reactive substance (TBARS) assay, respectively. Contributions of mitochondrial complex II inhibition by malonate and peroxidation by ozone to isoflurane sensitivity were tested in vivo. Besides, effects of antioxidative therapy on mitochondrial function and isoflurane sensitivity in mice were also measured. Results: The mean concentration of isoflurane that is required for LORR in aging mice (14-16 months old) was 0.83% ± 0.13% (mean ± SD, n = 80). Then, the mice were divided into three groups as sensitive group (S group, mean - SD), medium group (M group), and resistant group (R group, mean + SD) based on individual concentrations of isoflurane required for LORR. Activities of mitochondrial complex II and complex IV in mice of the S group were significantly lower than those of the R group, while frontoparietal cortical malondialdehyde (MDA) levels were higher in the mice of S group. Both inhibition of mitochondrial complexes and peroxidation significantly decreased the concentration of isoflurane that is required for LORR in vivo. After treatment with idebenone, the levels of lipid oxidation were alleviated and mitochondrial function was restored in aging mice. The concentration of isoflurane that required for LORR was also elevated after idebenone treatment. Conclusions: Decreased mitochondrial functions and higher oxidative stress levels in the frontoparietal cortex may contribute to the hypersensitivity to isoflurane in aging mice.
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Affiliation(s)
- Cansheng Gong
- Laboratory of Anesthesia & Critical Care Medicine, Translational Neuroscience Center, National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Chengdu, China.,Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China.,Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, China
| | - Donghang Zhang
- Laboratory of Anesthesia & Critical Care Medicine, Translational Neuroscience Center, National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Chengdu, China.,Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
| | - Wei Ou
- Laboratory of Anesthesia & Critical Care Medicine, Translational Neuroscience Center, National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Chengdu, China.,Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
| | - Mengchan Ou
- Laboratory of Anesthesia & Critical Care Medicine, Translational Neuroscience Center, National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Chengdu, China.,Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
| | - Peng Liang
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
| | - Daqing Liao
- Laboratory of Anesthesia & Critical Care Medicine, Translational Neuroscience Center, National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Chengdu, China
| | - Weiyi Zhang
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
| | - Tao Zhu
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
| | - Jin Liu
- Laboratory of Anesthesia & Critical Care Medicine, Translational Neuroscience Center, National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Chengdu, China.,Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
| | - Cheng Zhou
- Laboratory of Anesthesia & Critical Care Medicine, Translational Neuroscience Center, National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Chengdu, China.,Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
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Alkhamis F, Nazish S. Electroencephalographic Grading of Neuronal Dysfunction in Various Etiologies of Encephalopathy. Clin EEG Neurosci 2020; 51:420-425. [PMID: 32483980 DOI: 10.1177/1550059420925962] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE The objective of this work was to study the electroencephalographic (EEG) grading of neuronal dysfunction in encephalopathy of various etiologies and assess their association with clinical outcomes. SUBJECTS AND METHODS This retrospective cross-sectional study was performed between June and November 2018 at the Neurology Department of King Fahd Hospital of University, Kingdom of Saudi Arabia (KSA) and involved a review and analysis of EEG and medical records pertaining to 222 patients in whom encephalopathy was diagnosed. RESULTS In patients suffering from encephalopathy, advanced age (P = .01), low Glasgow Coma Scale (GCS) scores (P = .00), and certain etiologies, namely hypoxic-ischemic encephalopathy (HIE) (P = .00), septic encephalopathy (P = .01), and other illnesses (P = .00), were significantly associated with unfavorable clinical outcomes, whereas traumatic brain injury (TBI) (P = .01) and GCS >7 (P = .00) were associated with favorable outcomes. Among different etiologies, EEG grade I (P = .02) and grade IV (P = .04) neuronal dysfunction was significantly associated with TBI while grade III (P = .05) and grade V (P = .02) neuronal dysfunction was significantly associated with HIE. Grade I (P = .03) neuronal dysfunction was mostly observed in septic encephalopathy cases, while patients suffering from other illnesses were also found to have grade I (P = .04) and grade IV (P = .05) neuronal dysfunction based on their EEG. CONCLUSION EEG is being conducted routinely to determine the course and severity of various forms of encephalopathy. However, the clinical implications of EEG grading for neuronal dysfunction are largely dependent on underlying etiology and other clinical parameters, such as age and GCS score. Further larger prospective cohort studies involving other important prognostic parameters and continuous EEG monitoring are thus needed.
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Affiliation(s)
- Fahad Alkhamis
- Department of Neurology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Saima Nazish
- Department of Neurology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
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32
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Lobo FA, Vacas S, Rossetti AO, Robba C, Taccone FS. Does electroencephalographic burst suppression still play a role in the perioperative setting? Best Pract Res Clin Anaesthesiol 2020; 35:159-169. [PMID: 34030801 DOI: 10.1016/j.bpa.2020.10.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 10/21/2020] [Accepted: 10/27/2020] [Indexed: 12/18/2022]
Abstract
With the widespread use of electroencephalogram [EEG] monitoring during surgery or in the Intensive Care Unit [ICU], clinicians can sometimes face the pattern of burst suppression [BS]. The BS pattern corresponds to the continuous quasi-periodic alternation between high-voltage slow waves [the bursts] and periods of low voltage or even isoelectricity of the EEG signal [the suppression] and is extremely rare outside ICU and the operative room. BS can be secondary to increased anesthetic depth or a marker of cerebral damage, as a therapeutic endpoint [i.e., refractory status epilepticus or refractory intracranial hypertension]. In this review, we report the neurophysiological features of BS to better define its role during intraoperative and critical care settings.
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Affiliation(s)
- Francisco Almeida Lobo
- Anesthesiology Department, Centro Hospitalar de Trás-os-Montes e Alto Douro, Avenida da Noruega, Lordelo, 5000-508, Vila Real, Portugal.
| | - Susana Vacas
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, Reagan UCLA Medical Center, 757 Westwood Plaza #3325, Los Angeles, CA, 90095, USA.
| | - Andrea O Rossetti
- Department of Neurology, Lausanne University Hospital and University of Lausanne, CH-1011, Lausanne, Switzerland.
| | - Chiara Robba
- Azienda Ospedaliera Universitaria San Martino di Genova, Largo Rosanna Benzi,15, 16100, Genova, Italy.
| | - Fabio Silvio Taccone
- Hopital Érasme, Université Libre de Bruxelles, Department of Intensive Care Medicine, Route de Lennik, 808 1070, Brussels, Belgium.
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Weeden M, Desai N, Sriram S, Swami Palaniswami M, Wang B, Talbot L, Deane A, Bellomo R, Yan B. A pilot study of high frequency accelerometry-based sedation and agitation monitoring in critically ill patients. CRIT CARE RESUSC 2020; 22:245-252. [PMID: 32900331 PMCID: PMC10699079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
OBJECTIVE The degree of sedation or agitation in critically ill patients is typically assessed with the Richmond Agitation and Sedation Scale (RASS). However, this approach is intermittent and subject to unrecognised variation between assessments. High frequency accelerometry may assist in achieving a quantitative and continuous assessment of sedation while heralding imminent agitation. DESIGN We undertook a prospective, observational pilot study. SETTING An adult tertiary intensive care unit in Melbourne, Australia. PARTICIPANTS 20 patients with an admission diagnosis of trauma. MAIN OUTCOME MEASURES Accelerometers were applied to patients' wrists and used to continuously record patient movement. Video data of patient behaviour were simultaneously collected, and observers blinded to accelerometry data were adjudicated the RASS score every 30 seconds. Exploratory analyses were undertaken. RESULTS Patients were enrolled for a median duration of 9.7 hours (interquartile range [IQR], 0-22.8) and a total of 160 hours. These patients had a median RASS score of 0 (IQR, -4 to 0). A 2-minute moving window of amplitude variance was seen to reflect contemporaneous fluctuations in motor activity and was proportional to the RASS score. Furthermore, the moving window of amplitude variance was observed to spike immediately before ≥ 2 point increases in the RASS score. CONCLUSIONS We describe a novel approach to the analysis of wrist accelerometry data in critically ill patients. This technique not only appears to provide novel and continuous information about the depth of sedation or degree of agitation, it is also notable in its aptitude to anticipate impending transitions to higher RASS values.
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Affiliation(s)
- Mark Weeden
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia.
| | - Nandakishor Desai
- Department of Electrical and Electronic Engineering, The University of Melbourne, Melbourne, VIC, Australia
| | - Shyamala Sriram
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | | | - Bo Wang
- Melbourne Brain Centre at Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Lachlan Talbot
- Department of Neuroscience, University of Melbourne, Melbourne, VIC, Australia
| | - Adam Deane
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Bernard Yan
- Melbourne Brain Centre at Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
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Double standard: why electrocardiogram is standard care while electroencephalogram is not? Curr Opin Anaesthesiol 2020; 33:626-632. [PMID: 32769746 DOI: 10.1097/aco.0000000000000902] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW Major adverse cardiovascular and cerebrovascular events (MACCE) significantly affect the surgical outcomes. Electrocardiogram (ECG) has been a standard intraoperative monitor for 30 years. Electroencephalogram (EEG) can provide valuable information about the anesthetized state and guide anesthesia management during surgery. Whether EEG should be a standard intraoperative monitor is discussed in this review. RECENT FINDINGS Deep anesthesia has been associated with postoperative delirium, especially in elderly patients. Intraoperative EEG monitoring has been demonstrated to reduce total anesthesia drug use during general anesthesia and postoperative delirium. SUMMARY Unlike ECG monitoring, the EEG under general anesthesia has not been designated as a standard monitor by anesthesiologist societies around the world. The processed EEG technology has been commercially available for more than 25 years and EEG technology has significantly facilitated its intraoperative use. It is time to consider EEG as a standard anesthesia monitor during surgery.
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Savoca A, van Heusden K, Manca D, Ansermino JM, Dumont GA. The effect of cardiac output on the pharmacokinetics and pharmacodynamics of propofol during closed-loop induction of anesthesia. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2020; 192:105406. [PMID: 32155533 DOI: 10.1016/j.cmpb.2020.105406] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 01/31/2020] [Accepted: 02/17/2020] [Indexed: 06/10/2023]
Abstract
BACKGROUND AND OBJECTIVE Intraoperative hemodynamic stability is essential to safety and post-operative well-being of patients and should be optimized in closed-loop control of anesthesia. Cardiovascular changes inducing variations in pharmacokinetics may require dose modification. Rigorous investigational tools can strengthen current knowledge of the anesthesiologists and support clinical practice. We quantify the cardiovascular response of high-risk patients to closed-loop anesthesia and propose a new application of physiologically-based pharmacokinetic-pharmacodynamic (PBPK-PD) simulations to examine the effect of hemodynamic changes on the depth of hypnosis (DoH). METHODS We evaluate clinical hemodynamic changes in response to anesthesia induction in high-risk patients from a study on closed-loop anesthesia. We develop and validate a PBPK-PD model to simulate the effect of changes in cardiac output (CO) on plasma levels and DoH. The wavelet-based anesthetic value for central nervous system monitoring index (WAVCNS) is used as clinical end-point of propofol hypnotic effect. RESULTS The median (interquartile range, IQR) changes in CO and arterial pressure (AP), 3 min after induction of anesthesia, are 22.43 (14.82-36.0) % and 26.60 (22.39-35.33) % respectively. The decrease in heart rate (HR) is less marked, i.e. 8.82 (4.94-12.68) %. The cardiovascular response is comparable or less enhanced than in manual propofol induction studies. PBPK simulations show that the marked decrease in CO coincides with high predicted plasma levels and deep levels of hypnosis, i.e. WAVCNS < 40. PD model identification is improved using the PBPK model rather than a standard three-compartment PK model. PD simulations reveal that a 30% drop in CO can cause a 30% change in WAVCNS. CONCLUSIONS Significant CO drops produce increased predicted plasma concentrations corresponding to deeper anesthesia, which is potentially dangerous for elderly patients. PBPK-PD model simulations allow studying and quantifying these effects to improve clinical practice.
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Affiliation(s)
- A Savoca
- PSE-Lab, Process Systems Engineering Laboratory, Dipartimento di Chimica, Materiali e Ingegneria Chimica "Giulio Natta", Politecnico di Milano, Piazza Leonardo da Vinci 32, Milano 20133, Italy
| | - K van Heusden
- Department of Electrical & Computer Engineering, The University of British Columbia, Vancouver, British Columbia, Canada
| | - D Manca
- PSE-Lab, Process Systems Engineering Laboratory, Dipartimento di Chimica, Materiali e Ingegneria Chimica "Giulio Natta", Politecnico di Milano, Piazza Leonardo da Vinci 32, Milano 20133, Italy.
| | - J M Ansermino
- Department of Anesthesiology, Pharmacology & Therapeutics, The University of British Columbia, Vancouver, British Columbia, Canada
| | - G A Dumont
- Department of Electrical & Computer Engineering, The University of British Columbia, Vancouver, British Columbia, Canada; Department of Anesthesiology, Pharmacology & Therapeutics, The University of British Columbia, Vancouver, British Columbia, Canada
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Kreuzer M, Stern MA, Hight D, Berger S, Schneider G, Sleigh JW, García PS. Spectral and Entropic Features Are Altered by Age in the Electroencephalogram in Patients under Sevoflurane Anesthesia. Anesthesiology 2020; 132:1003-1016. [PMID: 32108685 PMCID: PMC7159998 DOI: 10.1097/aln.0000000000003182] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Preexisting factors such as age and cognitive performance can influence the electroencephalogram (EEG) during general anesthesia. Specifically, spectral EEG power is lower in elderly, compared to younger, subjects. Here, the authors investigate age-related changes in EEG architecture in patients undergoing general anesthesia through a detailed examination of spectral and entropic measures. METHODS The authors retrospectively studied 180 frontal EEG recordings from patients undergoing general anesthesia, induced with propofol/fentanyl and maintained by sevoflurane at the Waikato Hospital in Hamilton, New Zealand. The authors calculated power spectral density and normalized power spectral density, the entropic measures approximate and permutation entropy, as well as the beta ratio and spectral entropy as exemplary parameters used in current monitoring systems from segments of EEG obtained before the onset of surgery (i.e., with no noxious stimulation). RESULTS The oldest quartile of patients had significantly lower 1/f characteristics (P < 0.001; area under the receiver operating characteristics curve, 0.84 [0.76 0.92]), indicative of a more uniform distribution of spectral power. Analysis of the normalized power spectral density revealed no significant impact of age on relative alpha (P = 0.693; area under the receiver operating characteristics curve, 0.52 [0.41 0.63]) and a significant but weak effect on relative beta power (P = 0.041; area under the receiver operating characteristics curve, 0.62 [0.52 0.73]). Using entropic parameters, the authors found a significant age-related change toward a more irregular and unpredictable EEG (permutation entropy: P < 0.001, area under the receiver operating characteristics curve, 0.81 [0.71 0.90]; approximate entropy: P < 0.001; area under the receiver operating characteristics curve, 0.76 [0.66 0.85]). With approximate entropy, the authors could also detect an age-induced change in alpha-band activity (P = 0.002; area under the receiver operating characteristics curve, 0.69 [0.60 78]). CONCLUSIONS Like the sleep literature, spectral and entropic EEG features under general anesthesia change with age revealing a shift toward a faster, more irregular, oscillatory composition of the EEG in older patients. Age-related changes in neurophysiological activity may underlie these findings however the contribution of age-related changes in filtering properties or the signal to noise ratio must also be considered. Regardless, most current EEG technology used to guide anesthetic management focus on spectral features, and improvements to these devices might involve integration of entropic features of the raw EEG.
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Affiliation(s)
- Matthias Kreuzer
- From the Department of Anaesthesiology and Intensive Care, Klinikum rechts der Isar, Technical University Munich, Munich, Germany (M.K., S.B., G.S.) the Department of Anesthesiology (M.K., M.A.S., P.S.G.) the Medical Scientist Training Program (M.A.S.), Emory University School of Medicine, Atlanta, Georgia the Anesthesiology and Research Divisions, Atlanta Veterans Affairs Medical Center, (M.K., M.A.S., P.S.G.) Atlanta, Georgia the Department of Anaesthesia, Waikato Clinical School, University of Auckland, Hamilton, New Zealand (D.H., J.W.S.) the Waikato District Health Board, Hamilton, New Zealand (D.H., J.W.S.) the Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (D.H.) the Department of Anesthesiology, Columbia University Irving Medical Center, New York, New York (P.S.G.)
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Rasulo FA, Togni T, Romagnoli S. Essential Noninvasive Multimodality Neuromonitoring for the Critically Ill Patient. Crit Care 2020; 24:100. [PMID: 32204723 PMCID: PMC7092614 DOI: 10.1186/s13054-020-2781-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2020. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2020. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.
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Affiliation(s)
- Frank A Rasulo
- Division of Anesthesiology, Intensive Care & Emergency Medicine, University of Brescia at Spedali Civili Hospital, Brescia, Italy.
| | - Tommaso Togni
- Division of Anesthesiology, Intensive Care & Emergency Medicine, University of Brescia at Spedali Civili Hospital, Brescia, Italy
| | - Stefano Romagnoli
- Department of Health Science, University of Florence, Florence, Italy
- Department of Anesthesiology and Intensive Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
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Hogan J, Sun H, Aboul Nour H, Jing J, Tabaeizadeh M, Shoukat M, Javed F, Kassa S, Edhi MM, Bordbar E, Gallagher J, Junior VM, Ghanta M, Shao YP, Akeju O, Cole AJ, Rosenthal ES, Zafar S, Westover MB. Burst Suppression: Causes and Effects on Mortality in Critical Illness. Neurocrit Care 2020; 33:565-574. [PMID: 32096120 DOI: 10.1007/s12028-020-00932-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Burst suppression in mechanically ventilated intensive care unit (ICU) patients is associated with increased mortality. However, the relative contributions of propofol use and critical illness itself to burst suppression; of burst suppression, propofol, and critical illness to mortality; and whether preventing burst suppression might reduce mortality, have not been quantified. METHODS The dataset contains 471 adults from seven ICUs, after excluding anoxic encephalopathy due to cardiac arrest or intentional burst suppression for therapeutic reasons. We used multiple prediction and causal inference methods to estimate the effects connecting burst suppression, propofol, critical illness, and in-hospital mortality in an observational retrospective study. We also estimated the effects mediated by burst suppression. Sensitivity analysis was used to assess for unmeasured confounding. RESULTS The expected outcomes in a "counterfactual" randomized controlled trial (cRCT) that assigned patients to mild versus severe illness are expected to show a difference in burst suppression burden of 39%, 95% CI [8-66]%, and in mortality of 35% [29-41]%. Assigning patients to maximal (100%) burst suppression burden is expected to increase mortality by 12% [7-17]% compared to 0% burden. Burst suppression mediates 10% [2-21]% of the effect of critical illness on mortality. A high cumulative propofol dose (1316 mg/kg) is expected to increase burst suppression burden by 6% [0.8-12]% compared to a low dose (284 mg/kg). Propofol exposure has no significant direct effect on mortality; its effect is entirely mediated through burst suppression. CONCLUSIONS Our analysis clarifies how important factors contribute to mortality in ICU patients. Burst suppression appears to contribute to mortality but is primarily an effect of critical illness rather than iatrogenic use of propofol.
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Affiliation(s)
- Jacob Hogan
- Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.,Department of Biology, Brigham Young University, Provo, UT, USA
| | - Haoqi Sun
- Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Hassan Aboul Nour
- Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.,Department of Neurology, Henry Ford Hospital, Detroit, MI, USA
| | - Jin Jing
- Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.,School of Electrical and Electronic Engineering, Nanyang Technological University, Singapore, Singapore
| | - Mohammad Tabaeizadeh
- Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Maryum Shoukat
- Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Farrukh Javed
- Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Solomon Kassa
- Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Muhammad M Edhi
- Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.,Brown Institute for Brain Science, Providence, RI, 02903, USA
| | - Elahe Bordbar
- Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Justin Gallagher
- Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Valdery Moura Junior
- Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Manohar Ghanta
- Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Yu-Ping Shao
- Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Oluwaseun Akeju
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Andrew J Cole
- Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Eric S Rosenthal
- Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Sahar Zafar
- Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - M Brandon Westover
- Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
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Romagnoli S, Franchi F, Ricci Z. Processed EEG monitoring for anesthesia and intensive care practice. Minerva Anestesiol 2019; 85:1219-1230. [PMID: 31630505 DOI: 10.23736/s0375-9393.19.13478-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Individual response to sedatives and hypnotics is characterized by high variability and the identification of a personalized dose during anesthesia in the operating room and during sedation in the intensive care unit may have beneficial effects. Although the brain is the main target of general intravenous and inhaled anesthetic agents, electroencephalography (EEG) is not routinely utilized to explore cerebral response to sedation and anesthesia probably because EEG trace reading is complex and requires encephalographers' skills. Automated processing algorithms (processed EEG, pEEG) of raw EEG traces provide easy-to-use indices that can be utilized to optimize anesthetic management. A large number of high-quality studies and the recommendations of international scientific societies have confirmed the deleterious consequences of inadequate or excessively deep anesthesia (and sedation) level. In this context, anesthesia in the operating rooms and moderate/deep sedation in intensive care units driven by pEEG monitors could become a standard practice in the near future. The aim of the present review was to provide an overview of current knowledge and debate on available technologies for pEEG monitoring and their role in clinical practice for anesthesia and sedation.
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Affiliation(s)
- Stefano Romagnoli
- Section of Anesthesiology and Intensive Care, Department of Health Science, University of Florence, Florence, Italy - .,Department of Anesthesiology and Intensive Care, Careggi University Hospital, Florence, Italy -
| | - Federico Franchi
- Department of Medicine, Surgery and Neuroscience, Anesthesiology and Intensive Care, University Hospital of Siena, Siena, Italy
| | - Zaccaria Ricci
- Unit of Pediatric Cardiac Intensive Care, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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Cartailler J, Parutto P, Touchard C, Vallée F, Holcman D. Alpha rhythm collapse predicts iso-electric suppressions during anesthesia. Commun Biol 2019; 2:327. [PMID: 31508502 PMCID: PMC6718680 DOI: 10.1038/s42003-019-0575-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 07/29/2019] [Indexed: 02/07/2023] Open
Abstract
Could an overly deep sedation be anticipated from ElectroEncephaloGram (EEG) patterns? We report here motifs hidden in the EEG signal that predict the appearance of Iso-Electric Suppressions (IES), observed during epileptic encephalopathies, drug intoxications, comatose, brain death or during anesthetic over-dosage that are considered to be detrimental. To show that IES occurrences can be predicted from EEG traces dynamics, we focus on transient suppression of the alpha rhythm (8-14 Hz) recorded for 80 patients, that had a Propofol target controlled infusion of 5 μg/ml during a general anesthesia. We found that the first time of appearance as well as changes in duration of these Alpha-Suppressions (αS) are two parameters that anticipate the appearance of IES. Using machine learning, we predicted IES appearance from the first 10 min of EEG (AUC of 0.93). To conclude, transient motifs in the alpha rhythm predict IES during anesthesia and can be used to identify patients, with higher risks of post-operative complications.
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Affiliation(s)
- Jérôme Cartailler
- 1Group of Data Modeling, Computational Biology and Predictive Medicine, Institut de Biologie de l'École Normale Supérieure (IBENS); École Normale Supérieure CNRS/INSERM, Université PSL, Paris, France
| | - Pierre Parutto
- 1Group of Data Modeling, Computational Biology and Predictive Medicine, Institut de Biologie de l'École Normale Supérieure (IBENS); École Normale Supérieure CNRS/INSERM, Université PSL, Paris, France
| | - Cyril Touchard
- 2Department of Anesthesiology and Critical Care, St-Louis- Lariboisière-Fernand Widal University Hospitals, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
| | - Fabrice Vallée
- 2Department of Anesthesiology and Critical Care, St-Louis- Lariboisière-Fernand Widal University Hospitals, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
| | - David Holcman
- 1Group of Data Modeling, Computational Biology and Predictive Medicine, Institut de Biologie de l'École Normale Supérieure (IBENS); École Normale Supérieure CNRS/INSERM, Université PSL, Paris, France.,3Department of Biochemistry and DAMPT, University of Cambridge and Churchill College, Cambridge, UK
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Jung D, Yang S, Lee MS, Lee Y. Remifentanil Alleviates Propofol-Induced Burst Suppression without Affecting Bispectral Index in Female Patients: A Randomized Controlled Trial. J Clin Med 2019; 8:jcm8081186. [PMID: 31398849 PMCID: PMC6722898 DOI: 10.3390/jcm8081186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 08/05/2019] [Accepted: 08/06/2019] [Indexed: 01/27/2023] Open
Abstract
The bispectral index is affected by various factors, such as noxious stimuli and other drugs, such as muscle relaxants. The burst suppression ratio from bispectral index monitoring is correlated with electroencephalographic burst suppression, which is associated with deep anesthesia, metabolic disorders, and brain injury. We assessed patients undergoing total intravenous anesthesia and examined the effects of remifentanil on the bispectral index, burst suppression ratio, and hemodynamic changes immediately after loss of consciousness with propofol. Seventy American Society of Anesthesiologists physical status class I and II Korean female patients scheduled for general anesthesia were administered propofol with an effect-site concentration of 5 μg/mL, using a target-controlled infusion (TCI). After losing consciousness, patients received either saline or remifentanil at an effect-site concentration of 5 ng/mL for 10 min. During this period, we recorded the bispectral index values, including burst suppression ratio, blood pressure, and heart rate. With remifentanil infusion, burst suppression ratios were lower (p < 0.01) but bispectral values were not different. The burst suppression ratio was significantly different at 6, 7, 8, and 10 min after remifentanil infusion (p < 0.05). In female patients with propofol-induced unconsciousness, remifentanil alleviated the burst suppression ratio without affecting the bispectral value.
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Affiliation(s)
- Dahye Jung
- Department of Anesthesiology and Pain Medicine, Changwon Fatima Hospital, Changwon 51394, Korea
- Department of Anesthesiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Banpo-daero, Seocho-gu, Seoul 06591, Korea
| | - Sungwon Yang
- Department of Anesthesiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Banpo-daero, Seocho-gu, Seoul 06591, Korea
| | - Min Soo Lee
- Department of Anesthesiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Banpo-daero, Seocho-gu, Seoul 06591, Korea
| | - Yoonki Lee
- Department of Anesthesiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Banpo-daero, Seocho-gu, Seoul 06591, Korea.
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Shortal BP, Hickman LB, Mak-McCully RA, Wang W, Brennan C, Ung H, Litt B, Tarnal V, Janke E, Picton P, Blain-Moraes S, Maybrier HR, Muench MR, Lin N, Avidan MS, Mashour GA, McKinstry-Wu AR, Kelz MB, Palanca BJ, Proekt A. Duration of EEG suppression does not predict recovery time or degree of cognitive impairment after general anaesthesia in human volunteers. Br J Anaesth 2019; 123:206-218. [PMID: 31202561 DOI: 10.1016/j.bja.2019.03.046] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 02/14/2019] [Accepted: 03/08/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Burst suppression occurs in the EEG during coma and under general anaesthesia. It has been assumed that burst suppression represents a deeper state of anaesthesia from which it is more difficult to recover. This has not been directly demonstrated, however. Here, we test this hypothesis directly by assessing relationships between EEG suppression in human volunteers and recovery of consciousness. METHODS We recorded the EEG of 27 healthy humans (nine women/18 men) anaesthetised with isoflurane 1.3 minimum alveolar concentration (MAC) for 3 h. Periods of EEG suppression and non-suppression were separated using principal component analysis of the spectrogram. After emergence, participants completed the digit symbol substitution test and the psychomotor vigilance test. RESULTS Volunteers demonstrated marked variability in multiple features of the suppressed EEG. In order to test the hypothesis that, for an individual subject, inclusion of features of suppression would improve accuracy of a model built to predict time of emergence, two types of models were constructed: one with a suppression-related feature included and one without. Contrary to our hypothesis, Akaike information criterion demonstrated that the addition of a suppression-related feature did not improve the ability of the model to predict time to emergence. Furthermore, the amounts of EEG suppression and decrements in cognitive task performance relative to pre-anaesthesia baseline were not significantly correlated. CONCLUSIONS These findings suggest that, in contrast to current assumptions, EEG suppression in and of itself is not an important determinant of recovery time or the degree of cognitive impairment upon emergence from anaesthesia in healthy adults.
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Affiliation(s)
- B P Shortal
- Neuroscience Graduate Group, University of Pennsylvania, Philadelphia, PA, USA
| | - L B Hickman
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO, USA
| | - R A Mak-McCully
- Center for Sleep and Circadian Neurobiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - W Wang
- Department of Mathematics, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - C Brennan
- Neuroscience Graduate Group, University of Pennsylvania, Philadelphia, PA, USA
| | - H Ung
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA
| | - B Litt
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA; Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - V Tarnal
- Center for Consciousness Science, Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - E Janke
- Center for Consciousness Science, Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - P Picton
- Center for Consciousness Science, Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - S Blain-Moraes
- School of Physical and Occupational Therapy, McGill University, Montreal, QC, Canada
| | - H R Maybrier
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO, USA
| | - M R Muench
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO, USA
| | - N Lin
- Department of Mathematics, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - M S Avidan
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO, USA
| | - G A Mashour
- Center for Consciousness Science, Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - A R McKinstry-Wu
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - M B Kelz
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - B J Palanca
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO, USA
| | - A Proekt
- School of Physical and Occupational Therapy, McGill University, Montreal, QC, Canada; Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | -
- Department of Anesthesiology and Critical Care, University of Pennsylvania, USA; Department of Anesthesiology, Washington University, St. Louis, MO, USA; Center for Consciousness Science, Department of Anesthesiology, Ann Arbor, MI, USA
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Rengel KF, Hayhurst CJ, Pandharipande PP, Hughes CG. Long-term Cognitive and Functional Impairments After Critical Illness. Anesth Analg 2019; 128:772-780. [DOI: 10.1213/ane.0000000000004066] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Lee S, Ko A, Sol IS, Kim KW, Kang HC, Lee JS, Kim HD, Kim SH. Predicting the Outcome of Critically Ill Children and Adolescents with Electroencephalography. ANNALS OF CHILD NEUROLOGY 2019. [DOI: 10.26815/acn.2019.00010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Koyama C, Haruna T, Hagihira S, Yamashita K. New criteria of burst suppression on electroencephalogram in dogs anesthetized with sevoflurane. Res Vet Sci 2019; 123:171-177. [PMID: 30677617 DOI: 10.1016/j.rvsc.2019.01.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 01/12/2019] [Accepted: 01/13/2019] [Indexed: 11/26/2022]
Abstract
Burst suppression on electroencephalogram (EEG) is defined as suppression periods longer than 0.5 s during which the amplitude does not exceed 5 μV in human. The aims of this study were; 1) an attempt of creating new criteria of burst suppression in dogs; and 2) a survey on accuracy of sub-parameter of Bispectral index (BIS). Using a BIS monitor, suppression ratio (SRBIS) and raw-EEG data were recorded at 2.0%, 2.5%, 3.0%, 3.5%, 4.0%, and 5.0% end-tidal sevoflurane concentration (ETSEV) in 6 beagle dogs. The minimum ETSEV at which burst suppression was visually confirmed (ETSEVBS) was determined. By applying various duration and voltage threshold to criteria, suppression ratio was calculated (SR). Using the minimum balanced error rate (BER), new criteria consisting of the minimum duration of 0.35 s and the maximum threshold of 2.25 μV that provided SR > 0 above ETSEVBS was screened. SR was set by these criteria (SRBER) and by manual inspection (SRTRUE). The median detection rate of SRBER/SRTRUE was a statistically significant increase (p < .01) compared to that of SRBIS/SRTRUE (77% and 17% at 3.5% ETSEV, 89% and 19% at 4.0% ETSEV, and 86% and 84% at 5.0% ETSEV, respectively). In addition, between SRBER and SRTRUE evaluated by regression and Bland-Altman analyses, there was a strong correlation (r = 0.967, p < .001) and a moderate agreement (Limits of agreement: -7.14 ± 13.95). The method using BER may help to establish new criteria of burst suppression to grasp the excessive deep level of anesthesia.
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Affiliation(s)
- Chika Koyama
- Department of Small Animal Clinical Sciences, School of Veterinary Medicine, Rakuno Gakuen University, Midorimachi 582, Bunkyodai, Ebetsu-shi, Hokkaido 069-8591, Japan; Japan Animal Referral Medical Center, 3-1-7 Hitotsuya, Adachi-ku, Tokyo 121-0075, Japan.
| | - Taichi Haruna
- Department of Information and Sciences, Tokyo Woman's Christian University, 2-6-1, Zenpukuji, Suginami-ku, Tokyo 167-8585, Japan
| | - Satoshi Hagihira
- Department of Anesthesiology, Kansai Medical University, 2-5-1, Shinmachi, Hirakata-shi, Osaka 573-1010, Japan; Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-2, Yamadaoka, Suita-shi, Osaka 565-0871, Japan
| | - Kazuto Yamashita
- Department of Small Animal Clinical Sciences, School of Veterinary Medicine, Rakuno Gakuen University, Midorimachi 582, Bunkyodai, Ebetsu-shi, Hokkaido 069-8591, Japan
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Lamperti M, Jain A, Dharmalingam S. Neuroanesthesia and Coexisting Cardiac Problems: Acquired. CO-EXISTING DISEASES AND NEUROANESTHESIA 2019:37-62. [DOI: 10.1007/978-981-13-2086-6_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
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Electroencephalographic Abnormalities in Sepsis Patients in Correlation to the Calculated Prognostic Scores: A Case Series. J Transl Int Med 2018; 6:176-180. [PMID: 30637204 PMCID: PMC6326033 DOI: 10.2478/jtim-2018-0032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Objective To evaluate the electroencephalographic (EEG) findings and correlate EEG findings with inflammatory biomarkers and the sepsis prognostic scores SOFA, SAPS II and APACHE II in patients who present in the Emergency Department with sepsis without clinical central nervous system involvement. Methods The study included seventeen patients (< 70 years old) with sepsis without central nervous system involvement presenting in the Emergency Department of the University Hospital of Patras, Greece. All patients underwent neurologic examination and EEG analysis on admission to the hospital and were treated according to the international guideline protocols for sepsis. Results Six of seventeen sepsis patients had mild or moderate EEG abnormalities. We did not find any significant correlation between EEG abnormalities and inflammatory biomarkers (CRP, WBC) or commonly used prognostic sepsis scores. Conclusions EEG could serve as a useful tool to identify brain alterations at an early stage in sepsis, before clinical sings of encephalopathy can be detected. However, the presence of EEG abnormalities does not correlate with sepsis severity as measured by the commonly used prognostic sepsis scores SOFA, APACHE II or SAPS II. Because this was a small single center observational study, large multi-center studies are warranted to confirm these findings.
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Muhlhofer WG, Zak R, Kamal T, Rizvi B, Sands LP, Yuan M, Zhang X, Leung JM. Burst-suppression ratio underestimates absolute duration of electroencephalogram suppression compared with visual analysis of intraoperative electroencephalogram. Br J Anaesth 2018; 118:755-761. [PMID: 28486575 DOI: 10.1093/bja/aex054] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2017] [Indexed: 12/21/2022] Open
Abstract
Background Machine-generated indices based on quantitative electroencephalography (EEG), such as the patient state index (PSI™) and burst-suppression ratio (BSR), are increasingly being used to monitor intraoperative depth of anaesthesia in the endeavour to improve postoperative neurological outcomes, such as postoperative delirium (POD). However, the accuracy of the BSR compared with direct visualization of the EEG trace with regard to the prediction of POD has not been evaluated previously. Methods Forty-one consecutive patients undergoing non-cardiac, non-intracranial surgery with general anaesthesia wore a SedLine ® monitor during surgery and were assessed after surgery for the presence of delirium with the Confusion Assessment Method. The intraoperative EEG was scanned for absolute minutes of EEG suppression and correlated with the incidence of POD. The BSR and PSI™ were compared between patients with and without POD. Results Visual analysis of the EEG by neurologists and the SedLine ® -generated BSR provided a significantly different distribution of estimated minutes of EEG suppression ( P =0.037). The Sedline ® system markedly underestimated the amount of EEG suppression. The number of minutes of suppression assessed by visual analysis of the EEG was significantly associated with POD ( P =0.039), whereas the minutes based on the BSR generated by SedLine ® were not associated with POD ( P =0.275). Conclusions Our findings suggest that SedLine ® (machine)-generated indices might underestimate the minutes of EEG suppression, thereby reducing the sensitivity for detecting patients at risk for POD. Thus, the monitoring of machine-generated BSR and PSI™ might benefit from the addition of a visual tracing of the EEG to achieve a more accurate and real-time guidance of anaesthesia depth monitoring and the ultimate goal, to reduce the risk of POD.
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Affiliation(s)
- W G Muhlhofer
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA.,Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - R Zak
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - T Kamal
- Department of Anaesthesia, University of California San Francisco, San Francisco, CA, USA
| | - B Rizvi
- Department of Anaesthesia, University of California San Francisco, San Francisco, CA, USA
| | | | - M Yuan
- Department of Biostatistics, Virginia Tech, Blacksburg, VA, USA
| | - X Zhang
- Department of Anaesthesia, University of California San Francisco, San Francisco, CA, USA
| | - J M Leung
- Department of Anaesthesia, University of California San Francisco, San Francisco, CA, USA
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An J, Jonnalagadda D, Moura V, Purdon PL, Brown EN, Westover MB. Variability in pharmacologically-induced coma for treatment of refractory status epilepticus. PLoS One 2018; 13:e0205789. [PMID: 30379935 PMCID: PMC6209214 DOI: 10.1371/journal.pone.0205789] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 10/02/2018] [Indexed: 12/16/2022] Open
Abstract
Objective To characterize the amount of EEG suppression achieved in refractory status epilepticus (RSE) patients treated with pharmacologically-induced coma (PIC). Methods We analyzed EEG recordings from 35 RSE patients between 21–84 years-old who received PIC that target burst suppression and quantified the amount of EEG suppression using the burst suppression probability (BSP). Then we measured the variability of BSPs with respect to a reference level of BSP 0.8 ± 0.15. Finally, we also measured the variability of BSPs with respect to the amount of intravenous anesthetic drugs (IVADs) received by the patients. Results Patients remained in the reference BSP range for only 8% (median, interquartile range IQR [0, 29] %) of the total time under treatment. The median time with BSP below the reference range was 84% (IQR [37, 100] %). BSPs in some patients drifted significantly over time despite constant infusion rates of IVADs. Similar weight-normalized infusion rates of IVADs in different patients nearly always resulted in distinct BSPs (probability 0.93 (IQR [0.82, 1.0]). Conclusion This study quantitatively identified high variability in the amount of EEG suppression achieved in clinical practice when treating RSE patients. While some of this variability may arise from clinicians purposefully deviating from clinical practice guidelines, our results show that the high variability also arises in part from significant inter- and intra- individual pharmacokinetic/pharmacodynamic variation. Our results indicate that the delicate balance between maintaining sufficient EEG suppression in RSE patients and minimizing IVAD exposure in clinical practice is challenging to achieve. This may affect patient outcomes and confound studies seeking to determine an optimal amount of EEG suppression for treatment of RSE. Therefore, our analysis points to the need for developing an alternative paradigm, such as vigilant anesthetic management as happens in operating rooms, or closed-loop anesthesia delivery, for investigating and providing induced-coma therapy to RSE patients.
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Affiliation(s)
- Jingzhi An
- Massachusetts Institute of Technology, Cambridge, Massachusetts, United States of America.,Harvard-MIT Division of Health Science and Technology, Cambridge, Massachusetts, United States of America
| | - Durga Jonnalagadda
- Massachusetts General Hospital, Harvard Medical School, Cambridge, Massachusetts, United States of America
| | - Valdery Moura
- Massachusetts General Hospital, Harvard Medical School, Cambridge, Massachusetts, United States of America
| | - Patrick L Purdon
- Massachusetts General Hospital, Harvard Medical School, Cambridge, Massachusetts, United States of America
| | - Emery N Brown
- Massachusetts Institute of Technology, Cambridge, Massachusetts, United States of America.,Harvard-MIT Division of Health Science and Technology, Cambridge, Massachusetts, United States of America.,Massachusetts General Hospital, Harvard Medical School, Cambridge, Massachusetts, United States of America.,MIT Department of Brain and Cognitive Sciences, Cambridge, Massachusetts, United States of America.,Institute of Medical Engineering and Sciences, Cambridge, Massachusetts, United States of America
| | - M Brandon Westover
- Massachusetts General Hospital, Harvard Medical School, Cambridge, Massachusetts, United States of America
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