Cerebral state index response to incision: a clinical study in day-surgical patients

Consciousness and depth of anesthesia assessment based on Bayesian analysis of EEG signals

This study applies Bayesian techniques to analyze EEG signals for the assessment of the consciousness and depth of anesthesia (DoA). This method takes the limiting large-sample normal distribution as posterior inferences to implement the Bayesian paradigm. The maximum a posterior (MAP) is applied to denoise the wavelet coefficients based on a shrinkage function. When the anesthesia states change from awake to light, moderate, and deep anesthesia, the MAP values increase gradually. Based on these changes, a new function B(DoA) is designed to assess the DoA. The new proposed method is evaluated using anesthetized EEG recordings and BIS data from 25 patients. The Bland-Alman plot is used to verify the agreement of B(DoA) and the popular BIS index. A correlation between B(DoA) and BIS was measured using prediction probability P(K). In order to estimate the accuracy of DoA, the effect of sample n and variance τ on the maximum posterior probability is studied. The results show that the new index accurately estimates the patient's hypnotic states. Compared with the BIS index in some cases, the B(DoA) index can estimate the patient's hypnotic state in the case of poor signal quality.

Comparison of two depth of anaesthesia monitors during general anaesthesia: electrophysiological and clinical assessment

Cerebral state monitor (CSM) is a recently developed anaesthesia depth monitor based on EEG measurement. Medline search confirmed that the accuracy of this monitor has already been compared with BIS monitoring; however, we did not find any studies comparing CSM monitor with AEP monitoring. Therefore, the aim of our study was to investigate the correlation between AAI using AEP monitor and CSI (cerebral state index) using CSM monitor.

METHODS

Prospective, observational study involving 39 ASA I-III patients undergoing lumbar discuss hernia operation. Simultaneous registration of CSI and AAI was performed during general anaesthesia. The identical values were off-line analysed. Additionally in 20 patients parallel registration of CSI and AAI was undertaken while anaesthesia was guided based on routine clinical signs.

RESULTS

While analysing the data in the superficial, ideal and deep anaesthesia zones, we found that a relationship between CSI and AAI is weak. Our patients spent roughly the half of the clinical anaesthesia in the ideal zone based on the AAI index and less than 50% based on CSI. Almost one fifth of clinical anaesthesia based on AAI and nearly 40% based on CSI was spent in the deep anaesthesia zones. A superficial anaesthesia has been detected in 27% of time based on AAI and 17% based on CSI.

CONCLUSIONS

CSI and AAI weakly correlated to each other. Depth of anaesthesia monitors may be useful in detecting patients who spend valuable time within the deep anaesthetic zone.

Electroencephalogram-based anaesthetic depth monitoring in laboratory animals

Objective measurements of physiological parameters controlled by the autonomic nervous system such as blood pressure, heart rate and respiration are easily obtained nowadays during anaesthesia by the use of monitors: oscillometers, pulseoximeters, electrocardiograms and capnographs are available for laboratory animals. However, the effect-site of hypnotic drugs that cause general anaesthesia is the central nervous system (the brain). In the present, the adjustment of hypnotic drugs in veterinary anaesthesia is performed according to subjective evaluation of clinical signs which are not direct reflexes of anaesthetic effects on the brain, making depth of anaesthesia (DoA) assessment a complicated task. The difficulties in assessing the real anaesthetic state of a laboratory animal may not only result in welfare-threatening situations, such as awareness and pain sensation during surgery, but also in a lack of standardization of experimental conditions, as it is not easy to keep all animals from an experiment in the same DoA without a measure of anaesthetic effect. A direct measure of this dose-effect relationship, although highly necessary, is still missing in the veterinary market. Meanwhile, research has been intense in this subject and methods based on the brain electrical activity (electroencephalogram) have been explored in laboratory animal species. The objective of this review is to explain the achievements made in this topic and clarify how far we are from an objective measure of DoA for animals.

Comparison between cerebral state index and bispectral index as measures of electroencephalographic effects of sevoflurane using combined sigmoidal E(max) model

AIM

The cerebral state index (CSI) was recently introduced as an electroencephalographic monitor for measuring the depth of anesthesia. We compared the performance of CSI to the bispectral index (BIS) as electroencephalographic measures of sevoflurane effect using two combined sigmoidal E(max) models.

METHODS

Twenty adult patients scheduled for laparotomy were studied. After induction of general anesthesia, sevoflurane concentrations were progressively increased and then decreased over 70 min. An analysis of the BIS and CSI with the sevoflurane effect-site concentration was conducted using two combined sigmoidal E(max) models.

RESULTS

The BIS and CSI decreased over the initial concentration range of sevoflurane and then reached a plateau in most patients. A further increase in sevoflurane concentration produced a secondary plateau in the pharmacodynamic response. The CSI was more strongly correlated with effect-site sevoflurane concentration (R(2)=0.95±0.04) than the BIS was (R(2)=0.87±0.07) (P<0.05). The individual E(max) and C(eff50) (effect-site concentration associated with 50% decrease from baseline to plateau) values for the upper and lower plateaus were significantly greater for BIS (12.7±7.3, 1.6±0.4, and 4.2±0.5, respectively) than for CSI (3.4±2.2, 1.2±0.4, and 3.8±0.5, respectively) (P<0.05). The remaining pharmacodynamic parameters for the BIS and CSI were similar.

CONCLUSION

The overall performance of the BIS and CSI during sevoflurane anesthesia was similar despite major differences in their algorithms. However, the CSI was more consistent and more sensitive to changes in sevoflurane concentration, whereas the measured BIS seemed to respond faster. The newly developed combined E(max) model adequately described the clinical data, including the pharmacodynamic plateau.

[Assessing the depth-of-hypnosis]

BACKGROUND

There has been a breakthrough in the understanding of anaesthetic drug effects during the last two decades, and new monitors aimed at quantifying such effects have been developed.

MATERIAL AND METHODS

This review is based on publications from the last 15 years, oral presentations, and rewritten parts of the author's PhD thesis.

RESULTS

General anaesthesia can be regarded as a combination of hypnosis (sleep), analgesia and muscle relaxation. Modern anaesthetic drugs aim at each of these effects separately. Pharmacological variation makes it impossible to find one dose suitable for all, so tools for measuring drug effects in the individual patient are warranted. Monitors for measuring depth-of-hypnosis and partly analgesic effect are commercially available. Among these, BIS (bispectral index), based on EEG, is by far the best documented. BIS is proven useful for preventing undesired awareness and overdosing, but there are major limitations. Use of such technology in clinical practice is under constant debate.

INTERPRETATION

Even though the BIS technology is promising and used widely, no health authorities have so far recommended that such monitors should be compulsory during general anaesthesia, but rather that it should be considered on an individual basis. So far, it seems like this is a sensible approach in Norway as well.