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Fuller BM, Driver BE, Roberts MB, Schorr CA, Thompson K, Faine B, Yeary J, Mohr NM, Pappal RD, Stephens RJ, Yan Y, Johnson NJ, Roberts BW. Awareness with paralysis and symptoms of post-traumatic stress disorder among mechanically ventilated emergency department survivors (ED-AWARENESS-2 Trial): study protocol for a pragmatic, multicenter, stepped wedge cluster randomized trial. Trials 2023; 24:753. [PMID: 38001507 PMCID: PMC10675941 DOI: 10.1186/s13063-023-07764-5] [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: 09/21/2023] [Accepted: 10/30/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Awareness with paralysis (AWP) is memory recall during neuromuscular blockade (NMB) and can cause significant psychological harm. Decades of effort and rigorous trials have been conducted to prevent AWP in the operating room, where prevalence is 0.1-0.2%. By contrast, AWP in mechanically ventilated emergency department (ED) patients is common, with estimated prevalence of 3.3-7.4% among survivors given NMB. Longer-acting NMB use is a critical risk for AWP, and we have shown an association between ED rocuronium use and increased AWP prevalence. As NMB are given to more than 90% of ED patients during tracheal intubation, this trial provides a platform to test an intervention aimed at reducing AWP. The overall objective is to test the hypothesis that limiting ED rocuronium exposure will significantly reduce the proportion of patients experiencing AWP. METHODS This is a pragmatic, stepped wedge cluster randomized trial conducted in five academic EDs, and will enroll 3090 patients. Per the design, all sites begin in a control phase, under observational conditions. At 6-month intervals, sites sequentially enter a 2-month transition phase, during which we will implement the multifaceted intervention, which will rely on use of nudges and defaults to change clinician decisions regarding ED NMB use. During the intervention phase, succinylcholine will be the default NMB over rocuronium. The primary outcome is AWP, assessed with the modified Brice questionnaire, adjudicated by three independent, blinded experts. The secondary outcome is the proportion of patients developing clinically significant symptoms of post-traumatic stress disorder at 30 and 180 days after hospital discharge. We will also assess for symptoms of depression and anxiety, and health-related quality of life. A generalized linear model, adjusted for time and cluster interactions, will be used to compare AWP in control versus intervention phases, analyzed by intention-to-treat. DISCUSSION The ED-AWARENESS-2 Trial will be the first ED-based trial aimed at preventing AWP, a critical threat to patient safety. Results could shape clinical use of NMB in the ED and prevent more than 10,000 annual cases of AWP related to ED care. TRIAL REGISTRATION ClinicalTrials.gov identifier NCT05534243 . Registered 06, September 2022.
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Affiliation(s)
- Brian M Fuller
- Department of Anesthesiology, Division of Critical Care, Department of Emergency Medicine, Washington University in St. Louis School of Medicine, St. Louis, MO, 63110, USA.
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN, 55415, USA
| | - Michael B Roberts
- Department of Institutional Research, Department of Psychology, Philadelphia College of Osteopathic Medicine, Rowland Hall, 514B, 4190 City Avenue, Philadelphia, PA, 19131, USA
| | - Christa A Schorr
- Cooper Research Institute, Cooper University Health Care, One Cooper Plaza, Dorrance, Camden, NJ, 08103, USA
| | - Kathryn Thompson
- Department of Emergency Medicine, University of Washington/Harborview Medical Center, 325 9th Avenue, Seattle, WA, 98104, USA
| | - Brett Faine
- Departments of Emergency Medicine and Pharmacy, Roy J. and Lucille A. Carver College of Medicine, University of Iowa College of Pharmacy, 200 Hawkins Drive, 1008 RCP, Iowa City, IA, 52242, USA
| | - Julianne Yeary
- Emergency Department, Charles F. Knight Emergency and Trauma Center, Barnes-Jewish Hospital, 1 Barnes Jewish Hospital Plaza, St. Louis, MO, 63110, USA
| | - Nicholas M Mohr
- Departments of Emergency Medicine and Anesthesiology, Division of Critical Care, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, 200 Hawkins Drive, 1008 RCP, Iowa City, IA, 52242, USA
| | - Ryan D Pappal
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Robert J Stephens
- Department of Medicine, Division of Critical Care Medicine, University of Maryland School of Medicine, 655 W. Baltimore Street, Baltimore, MD, 21201, USA
| | - Yan Yan
- Division of Public Health Sciences, Department of Surgery, Division of Biostatistics, Washington University School of Medicine, 418E, 2Nd Floor, 600 South Taylor Ave., St. Louis, MO, 63110, USA
| | - Nicholas J Johnson
- Departments of Emergency Medicine and Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington/Harborview Medical Center, 325 9th Avenue, Seattle, WA, 98104, USA
| | - Brian W Roberts
- Department of Emergency Medicine, Cooper Medical School of Rowan University, One Cooper Plaza, K152, Camden, NJ, 08103, USA
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2
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Carlson RT, Shah S, Wells E, Fertel BS, Campbell MJ. Post-intubation analgesia and sedation following succinylcholine vs. rocuronium in the emergency department. Am J Emerg Med 2023; 71:99-103. [PMID: 37356339 DOI: 10.1016/j.ajem.2023.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 06/07/2023] [Accepted: 06/11/2023] [Indexed: 06/27/2023] Open
Abstract
BACKGROUND Succinylcholine and rocuronium are the most commonly utilized neuromuscular blocker agents (NMBAs) for rapid sequence intubation (RSI) in the emergency department (ED). The duration of action of rocuronium is significantly longer (∼30 min) compared to succinylcholine (∼10 min) and previous studies have shown that patients receiving rocuronium are more likely to have longer time to sedation initiation following RSI. Furthermore, patients receiving rocuronium may be more likely to experience awareness with paralysis than those receiving succinylcholine. The primary goal for this study was to evaluate the association between NMBA use during RSI and post-intubation sedation and analgesia practices in the ED. METHODS This was a retrospective, multicenter cohort study including patients 18 years and older that received succinylcholine or rocuronium during RSI in the ED between September 1, 2020 and August 31, 2021. Patients were excluded if they were intubated prior to ED arrival, experienced an out-of-hospital or in ED cardiac arrest, or received sugammadex within 60 min of rocuronium administration. Patients were screened in reverse chronological order until the targeted sample size was achieved and all data was abstracted from the electronic health record. The primary outcome was the time to initiation of analgesia or sedation. Secondary outcomes included dose of sedatives or analgesia administered at 30- and 60 min, and medications administered for post-intubation sedation or analgesia. FINDINGS A total of 200 ED patients were included of which 100 received succinylcholine and 100 received rocuronium. There was no difference in the median time to initiation of analgesia or sedation between the succinylcholine and rocuronium groups (10 vs 8.5 min, p = 0.82) or in Kaplan-Meier cumulative probabilities (p = 0.17). At 60 min post-RSI, those receiving succinylcholine received significantly higher median doses of propofol (20 μg/kg/min vs. 10 μg/kg/min; p = 0.02) and fentanyl [100 μg vs. 84.2 μg; p = 0.02]. CONCLUSION While no differences were observed in the time to initiation of post-intubation sedation or analgesia in ED patients receiving succinylcholine compared to rocuronium, differences in the intensity of post-intubation regimens was observed. Further investigation is needed to evaluate the adequacy of sedation following RSI in the ED.
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Affiliation(s)
- Rick T Carlson
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, United States of America; Emergency Services Institute, Cleveland Clinic, Cleveland, OH, United States of America; Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA, United States of America; Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, United States of America.
| | - Sneha Shah
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, United States of America; Department of Pharmacy, Massachusetts General Hospital, Boston, MA, United States of America
| | - Elizabeth Wells
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, United States of America; Emergency Services Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Baruch S Fertel
- Emergency Services Institute, Cleveland Clinic, Cleveland, OH, United States of America; Department of Emergency Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States of America; Quality and Patient Safety, New York - Presbyterian Hospital, New York, NY, United States of America
| | - Matthew J Campbell
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, United States of America; Emergency Services Institute, Cleveland Clinic, Cleveland, OH, United States of America
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3
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Hight D, Kreuzer M, Ugen G, Schuller P, Stüber F, Sleigh J, Kaiser HA. Five commercial 'depth of anaesthesia' monitors provide discordant clinical recommendations in response to identical emergence-like EEG signals. Br J Anaesth 2023; 130:536-545. [PMID: 36894408 DOI: 10.1016/j.bja.2022.12.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 12/16/2022] [Accepted: 12/18/2022] [Indexed: 03/09/2023] Open
Abstract
BACKGROUND 'Depth of anaesthesia' monitors claim to measure hypnotic depth during general anaesthesia from the EEG, and clinicians could reasonably expect agreement between monitors if presented with the same EEG signal. We took 52 EEG signals showing intraoperative patterns of diminished anaesthesia, similar to those that occur during emergence (after surgery) and subjected them to analysis by five commercially available monitors. METHODS We compared five monitors (BIS, Entropy-SE, Narcotrend, qCON, and Sedline) to see if index values remained within, or moved out of, each monitors' recommended index range for general anaesthesia for at least 2 min during a period of supposed lighter anaesthesia, as observed by changes in the EEG spectrogram obtained in a previous study. RESULTS Of the 52 cases, 27 (52%) had at least one monitor warning of potentially inadequate hypnosis (index above range) and 16 of the 52 cases (31%) had at least one monitor signifying excessive hypnotic depth (index below clinical range). Of the 52 cases, only 16 (31%) showed concordance between all five monitors. Nineteen cases (36%) had one monitor discordant compared with the remaining four, and 17 cases (33%) had two monitors in disagreement with the remaining three. CONCLUSIONS Many clinical providers still rely on index values and manufacturer's recommended ranges for titration decision making. That two-thirds of cases showed discordant recommendations given identical EEG data, and that one-third signified excessive hypnotic depth where the EEG would suggest a lighter hypnotic state, emphasizes the importance of personalised EEG interpretation as an essential clinical skill.
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Affiliation(s)
- Darren Hight
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Matthias Kreuzer
- Department of Anesthesiology and Intensive Care Medicine, Technical University of Munich, School of Medicine, Munich, Germany
| | - Gesar Ugen
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Peter Schuller
- Department of Anaesthesia, Cairns Hospital, Cairns, QLD, Australia
| | - Frank Stüber
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jamie Sleigh
- Department of Anaesthesia, Waikato Clinical School, University of Auckland, Hamilton, New Zealand
| | - Heiko A Kaiser
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Centre for Anaesthesiology and Intensive Care Medicine, Hirslanden Klinik Aarau, Hirslanden Group, Aarau, Switzerland
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4
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Driver BE, Prekker ME, Wagner E, Cole JB, Puskarich MA, Stang J, DeVries P, Maruggi E, Miner JR. Recall of Awareness During Paralysis Among ED Patients Undergoing Tracheal Intubation. Chest 2023; 163:313-323. [PMID: 36089069 DOI: 10.1016/j.chest.2022.08.2232] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 08/16/2022] [Accepted: 08/31/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Critically ill patients sometimes remember periods of neuromuscular blockade. RESEARCH QUESTION What is the prevalence of recalled awareness during paralysis in patients who underwent emergency tracheal intubation and mechanical ventilation, and what clinical variables are associated with this outcome? STUDY DESIGN AND METHODS This study analyzed data from a prospectively collected continuous quality improvement database of emergency tracheal intubation in an urban, county hospital. Patients who received a neuromuscular blocking agent to facilitate emergency tracheal intubation in the ED were included. The database contained details of intubation management, including medications received and patient mental status prior to intubation. Patient recall of awareness of paralysis was assessed by trained staff during an in-person interview following extubation using a modified Brice questionnaire. For this analysis, three expert reviewers used these data to adjudicate whether patients may have had awareness of paralysis, the primary outcome. A logistic regression model was constructed to determine whether clinical variables were associated with the primary outcome. RESULTS A total of 886 patients were analyzed. There were 66 patients (7.4%; 95% CI, 5.8-9.4) determined to possibly (61 patients) or definitely (5 patients) have experienced and recalled awareness of paralysis. A logistic regression model revealed that a decreased level of consciousness prior to intubation was associated with lower odds of awareness (adjusted OR, 0.39; 95% CI, 0.22-0.69), whereas the class of neuromuscular blocking agent used, sedative used, preintubation shock index, and postintubation sedation were not significantly associated with recall of this outcome. INTERPRETATION Among patients intubated emergently using a neuromuscular blocking agent, 7.4% of patients recalled awareness without being able to move, which was more likely when patients had a normal level of consciousness prior to intubation.
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Affiliation(s)
- Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA.
| | - Matthew E Prekker
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA; Department of Medicine, Division of Pulmonary and Critical Care, Hennepin County Medical Center, Minneapolis, MN
| | - Emily Wagner
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Jon B Cole
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Michael A Puskarich
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Jamie Stang
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Paige DeVries
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Ellen Maruggi
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - James R Miner
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
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5
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Nawafleh S, Alrawashdeh A, Ababneh O, Bani-Hani M, Al Modanat Z, Hani DB, Bataineh A, Al-Salameh F, Abuzaid S, Yasser O, Khairallah K. Perception and practices of depth of anesthesia monitoring and intraoperative awareness event rate among Jordanian anesthesiologists: a cross-sectional study. BMC Anesthesiol 2022; 22:402. [PMID: 36575378 PMCID: PMC9793501 DOI: 10.1186/s12871-022-01941-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 12/12/2022] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Intraoperative awareness is the second most common complication of surgeries, and it negatively affects patients and healthcare professionals. Based on the limited previous studies, there is a wide variation in the incidence of intraoperative awareness and in the practices and attitudes toward depth of anesthesia (DoA) monitoring among healthcare systems and anesthesiologists. This study aimed to evaluate the Jordanian anesthesiologists' practice and attitudes toward DoA monitoring and estimate the event rate of intraoperative awareness among the participating anesthesiologists. METHODS A descriptive cross-sectional survey of Jordanian anesthesiologists working in public, private, and university hospitals was utilized using a questionnaire developed based on previous studies. Practice and attitude in using DoA monitors were evaluated. Anesthesiologists were asked to best estimate the number of anesthesia procedures and frequency of intraoperative awareness events in the year before. Percentages and 95% Confidence Intervals (95%CI) were reported and compared between groups using chi-square tests. RESULTS A total of 107 anesthesiologists responded and completed the survey. About one-third of the respondents (34.6%; 95% CI 26.1-44.2) had never used a DoA monitor and only 6.5% (95% CI 3.1-13.2) reported using it as a "daily practice". The use of a DoA monitor was associated with experience and type of health sector. However, 81.3% (95% CI 66.5-83.5) believed that currently available DoA monitors are effective for DoA monitoring and only 4.7% (95%CI 1.9-10.8) reported it as being "invalid". Most respondents reported that the main purpose of using a DoA monitor was to prevent awareness (86.0%; 95%CI 77.9-91.4), guide the delivery of anesthetics (63.6%; 95%CI 53.9-72.2), and reduce recovery time (57%; 95%CI 47.4-66.1). The event rate of intraoperative awareness was estimated at 0.4% among participating anesthesiologists. Most Jordanian hospitals lacked policy intending to prevent intraoperative awareness. CONCLUSIONS Most anesthesiologists believed in the role of DoA monitors in preventing intraoperative awareness, however, their attitudes and knowledge are inadequate, and few use DoA monitors in routine practices. In Jordan, large efforts are needed to regulate the use of DoA monitoring and reduce the incidence of intraoperative awareness.
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Affiliation(s)
- Sager Nawafleh
- grid.33801.390000 0004 0528 1681Department of General Surgery, Urology and Anesthesia, Faculty of Medicine, The Hashemite University, Zarqa, 13115 Jordan
| | - Ahmad Alrawashdeh
- grid.37553.370000 0001 0097 5797Department of Allied Medical Science, Faculty of Applied Medical Science, Jordan University of Science and Technology, Irbid, 22110 Jordan
| | - Omar Ababneh
- grid.9670.80000 0001 2174 4509Department of Anesthesia and Intensive Care, School of Medicine, The University of Jordan, Amman, 11942 Jordan
| | - Morad Bani-Hani
- grid.33801.390000 0004 0528 1681Department of General Surgery, Urology and Anesthesia, Faculty of Medicine, The Hashemite University, Zarqa, 13115 Jordan
| | - Zaid Al Modanat
- grid.14440.350000 0004 0622 5497Faculty of Medicine, Yarmouk University, Irbid, 21110 Jordan
| | - Diab Bani Hani
- grid.37553.370000 0001 0097 5797Department of Anesthesia and Recovery, Faculty of Medicine, Jordan University of Science and Technology, Irbid, 21110 Jordan
| | - Adel Bataineh
- grid.37553.370000 0001 0097 5797Department of Anesthesia and Recovery, Faculty of Medicine, Jordan University of Science and Technology, Irbid, 21110 Jordan
| | | | - Sajeda Abuzaid
- Department of Research and Data Analytics, Kernel Center, Irbid, 21110 Jordan
| | - Omer Yasser
- grid.37553.370000 0001 0097 5797Department of Anesthesia and Recovery, Faculty of Medicine, Jordan University of Science and Technology, Irbid, 21110 Jordan
| | - Khaled Khairallah
- grid.37553.370000 0001 0097 5797Department of Public Health and Community Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, 22110 Jordan
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6
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Hampton JP, Hommer K, Musselman M, Bilhimer M. Rapid sequence intubation and the role of the emergency medicine pharmacist: 2022 update. Am J Health Syst Pharm 2022; 80:182-195. [PMID: 36306474 PMCID: PMC9620375 DOI: 10.1093/ajhp/zxac326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Indexed: 12/05/2022] Open
Abstract
PURPOSE The dosing, potential adverse effects, and clinical outcomes of the most commonly utilized pharmacologic agents for rapid sequence intubation (RSI) are reviewed for the practicing emergency medicine pharmacist (EMP). SUMMARY RSI is the process of establishing a safe, functional respiratory system in patients unable to effectively breathe on their own. Various medications are chosen to sedate and even paralyze the patient to facilitate an efficient endotracheal intubation. The mechanism of action and pharmacokinetic/pharmacodynamic profiles of these agents were described in a 2011 review. Since then, the role of the EMP as well as the published evidence regarding RSI agents, including dosing, adverse effects, and clinical outcomes, has grown. It is necessary for the practicing EMP to update previous practice patterns in order to continue to provide optimal patient care. CONCLUSION While the agents used in RSI have changed little, knowledge regarding optimal dosing, appropriate patient selection, and possible adverse effects continues to be gained. The EMP is a key member of the bedside care team and uniquely positioned to communicate this evolving data.
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Affiliation(s)
- Jeremy P Hampton
- University of Missouri-Kansas City School of Pharmacy, Kansas City, MO, and University Health Kansas City, Kansas City, MO, USA
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7
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Accidental Awareness With Recall During Pharmacologic Neuromuscular Blockade in Emergency Department Settings: Challenges, Opportunities, and Lessons for Intensive Care*. Crit Care Med 2022; 50:1541-1544. [PMID: 36106974 DOI: 10.1097/ccm.0000000000005653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Fuller BM, Pappal RD, Mohr NM, Roberts BW, Faine B, Yeary J, Sewatsky T, Johnson NJ, Driver BE, Ablordeppey E, Drewry AM, Wessman BT, Yan Y, Kollef MH, Carpenter CR, Avidan MS. Awareness With Paralysis Among Critically Ill Emergency Department Patients: A Prospective Cohort Study. Crit Care Med 2022; 50:1449-1460. [PMID: 35866657 PMCID: PMC10040234 DOI: 10.1097/ccm.0000000000005626] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES In mechanically ventilated patients, awareness with paralysis (AWP) can have devastating consequences, including post-traumatic stress disorder (PTSD), depression, and thoughts of suicide. Single-center data from the emergency department (ED) demonstrate an event rate for AWP factors higher than that reported from the operating room. However, there remains a lack of data on AWP among critically ill, mechanically ventilated patients. The objective was to assess the proportion of ED patients experiencing AWP and investigate modifiable variables associated with its occurrence. DESIGN An a priori planned secondary analysis of a multicenter, prospective, before-and-after clinical trial. SETTING The ED of three academic medical centers. PATIENTS Mechanically ventilated adult patients that received neuromuscular blockers. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS All data related to sedation and analgesia were collected. AWP was the primary outcome, assessed with the modified Brice questionnaire, and was independently adjudicated by three expert reviewers. Perceived threat, in the causal pathway for PTSD, was the secondary outcome. A total of 388 patients were studied. The proportion of patients experiencing AWP was 3.4% ( n = 13), the majority of whom received rocuronium ( n = 12/13; 92.3%). Among patients who received rocuronium, 5.5% ( n = 12/230) experienced AWP, compared with 0.6% ( n = 1/158) among patients who did not receive rocuronium in the ED (odds ratio, 8.64; 95% CI, 1.11-67.15). Patients experiencing AWP had a higher mean ( sd ) threat perception scale score, compared with patients without AWP (15.6 [5.8] vs 7.7 [6.0]; p < 0.01). CONCLUSIONS AWP was present in a concerning proportion of mechanically ventilated ED patients, was associated with rocuronium exposure in the ED, and led to increased levels of perceived threat, placing patients at greater risk for PTSD. Studies that aim to further quantify AWP in this vulnerable population and eliminate its occurrence are urgently needed.
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Affiliation(s)
- Brian M Fuller
- Departments of Anesthesiology and Emergency Medicine, Division of Critical Care, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Ryan D Pappal
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Nicholas M Mohr
- Departments of Emergency Medicine and Anesthesiology, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA
| | - Brian W Roberts
- Department of Emergency Medicine, Cooper University Hospital, Camden, NJ
| | - Brett Faine
- Departments of Emergency Medicine and Pharmacy, Roy J. and Lucille A. Carver College of Medicine, University of Iowa College of Pharmacy, Iowa City, IA
| | - Julianne Yeary
- Emergency Department, Charles F. Knight Emergency and Trauma Center, Barnes Jewish Hospital, St. Louis, MO
| | - Thomas Sewatsky
- Department of Emergency Medicine, Cooper University Hospital, Camden, NJ
| | - Nicholas J Johnson
- Departments of Emergency Medicine and Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington/Harborview Medical Center, Seattle, WA
| | - Brian E Driver
- Department of Emergency Medicine, University of Minnesota School of Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Enyo Ablordeppey
- Departments of Anesthesiology and Emergency Medicine, Division of Critical Care, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Anne M Drewry
- Department of Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Brian T Wessman
- Departments of Anesthesiology and Emergency Medicine, Division of Critical Care, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Yan Yan
- Division of Public Health Sciences, Department of Surgery, Division of Biostatistics, Washington University School of Medicine, St. Louis, MO
| | - Marin H Kollef
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Christopher R Carpenter
- Department of Emergency Medicine, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Michael S Avidan
- Department of Anesthesiology, Washington University in St. Louis School of Medicine, St. Louis, MO
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Heavner MS, Gorman EF, Linn DD, Yeung SYA, Miano TA. Systematic review and meta‐analysis of the correlation between bispectral index (
BIS
) and clinical sedation scales: Toward defining the role of
BIS
in critically ill patients. Pharmacotherapy 2022; 42:667-676. [PMID: 35707961 PMCID: PMC9671609 DOI: 10.1002/phar.2712] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 05/13/2022] [Accepted: 05/21/2022] [Indexed: 11/09/2022]
Abstract
INTRODUCTION The bispectral index (BIS) is an attractive approach for monitoring level of consciousness in critically ill patients, particularly during paralysis, when commonly used sedation scales cannot be used. OBJECTIVES As a first step toward establishing the utility of BIS during paralysis, this review examines the strength of correlation between BIS and clinical sedation scales in a broad population of non-paralyzed, critically ill adults. METHODS We included studies evaluating the strength of correlation between concurrent assessments of BIS and Richmond Agitation Sedation Scale (RASS), Ramsay Sedation Scale (RSS), or Sedation Agitation Scale (SAS) in critically ill adult patients. Studies involving assessment of depth sedation periperative or procedural time periods, and those reporting BIS and sedation scale assessments conducted >5 min apart or while neuromuscular blocking agents (NMBA) were administered, were excluded. Data were abstracted on sedation scale, correlation coefficients, setting, patient characteristics, and BIS assessment characteristics that could impact the quality of the studies. RESULTS Twenty-four studies which enrolled 1235 patients met inclusion criteria. The correlation between BIS and RASS, RSS, and SAS overall was 0.68 (95% confidence interval, 0.61-0.74, Ƭ2 = 0.06 I2 = 71.26%). Subgroup analysis by sedation scale indicated that the correlation between BIS and RASS, RSS, and SAS were 0.66 (95% confidence interval 0.58-0.73, Ƭ2 = 0.01 I2 = 30.20%), 0.76 (95% confidence interval 0.69-0.82, Ƭ2 = 0.04 I2 = 67.15%), and 0.53 (95% confidence interval 0.42-0.63, Ƭ2 = 0.01 I2 = 26.59%), respectively. Factors associated with significant heterogeneity included comparator clinical sedation scale, neurologic injury, and the type of intensive care unit (ICU) population. CONCLUSIONS BIS demonstrated moderate to strong correlation with clinical sedation scales in adult ICU patients, providing preliminary evidence for the validity of BIS as a measure of sedation intensity when clinical scales cannot be used. Future studies should determine whether BIS monitoring is safe and effective in improving outcomes in patients receiving NMBA treatment.
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Affiliation(s)
- Mojdeh S. Heavner
- Department of Pharmacy Practice and Science University of Maryland School of Pharmacy Baltimore Maryland USA
| | - Emily F. Gorman
- Health Sciences and Human Services Library University of Maryland Baltimore Maryland USA
| | - Dustin D. Linn
- Medical Science Liaison Philips North America Cambridge Massachusetts USA
| | - Siu Yan Amy Yeung
- Medical Intensive Care Unit, Department of Pharmacy Services University of Maryland Medical Center Baltimore Maryland USA
| | - Todd A. Miano
- Department of Biostatistics, Epidemiology, and Informatics Perelman School of Medicine at the University of Pennsylvania Philadelphia Pennsylvania USA
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10
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Jarvis JL, Lyng JW, Miller BL, Perlmutter MC, Abraham H, Sahni R. Prehospital Drug Assisted Airway Management: An NAEMSP Position Statement and Resource Document. PREHOSP EMERG CARE 2022; 26:42-53. [PMID: 35001829 DOI: 10.1080/10903127.2021.1990447] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Airway management is a critical intervention for patients with airway compromise, respiratory failure, and cardiac arrest. Many EMS agencies use drug-assisted airway management (DAAM) - the administration of sedatives alone or in combination with neuromuscular blockers - to facilitate advanced airway placement in patients with airway compromise or impending respiratory failure who also have altered mental status, agitation, or intact protective airway reflexes. While DAAM provides several benefits including improving laryngoscopy and making insertion of endotracheal tubes and supraglottic airways easier, DAAM also carries important risks. NAEMSP recommends:DAAM is an appropriate tool for EMS clinicians in systems with clear guidelines, sufficient training, and close EMS physician oversight. DAAM should not be used in settings without adequate resources.EMS physicians should develop clinical guidelines informed by evidence and oversee the training and credentialing for safe and effective DAAM.DAAM programs should include best practices of airway management including patient selection, assessmenct and positioning, preoxygenation strategies including apneic oxygenation, monitoring and management of physiologic abnormalities, selection of medications, post-intubation analgesia and sedation, equipment selection, airway confirmation and monitoring, and rescue airway techniques.Post-DAAM airway placement must be confirmed and continually monitored with waveform capnography.EMS clinicians must have the necessary equipment and training to manage patients with failed DAAM, including bag mask ventilation, supraglottic airway devices and surgical airway approaches.Continuous quality improvement for DAAM must include assessment of individual and aggregate performance metrics. Where available for review, continuous physiologic recordings (vital signs, pulse oximetry, and capnography), audio and video recordings, and assessment of patient outcomes should be part of DAAM continuous quality improvement.
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11
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Radek L, Koskinen L, Sandman N, Laaksonen L, Kallionpää RE, Scheinin A, Rajala V, Maksimow A, Laitio T, Revonsuo A, Scheinin H, Valli K. On no man's land: Subjective experiences during unresponsive and responsive sedative states induced by four different anesthetic agents. Conscious Cogn 2021; 96:103239. [PMID: 34801782 DOI: 10.1016/j.concog.2021.103239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 10/19/2021] [Accepted: 10/30/2021] [Indexed: 10/19/2022]
Abstract
To understand how anesthetics with different molecular mechanisms affect consciousness, we explored subjective experiences recalled after responsive and unresponsive sedation induced with equisedative doses of dexmedetomidine, propofol, sevoflurane, and S-ketamine in healthy male participants (N = 140). The anesthetics were administered in experimental setting using target-controlled infusion or vapouriser for one hour. Interviews conducted after anesthetic administration revealed that 46.9% (n = 46) of arousable participants (n = 98) reported experiences, most frequently dreaming or memory incorporation of the setting. Participants receiving dexmedetomidine reported experiences most often while S-ketamine induced the most multimodal experiences. Responsiveness at the end of anesthetic administration did not affect the prevalence or content of reported experiences. These results demonstrate that subjective experiences during responsive and unresponsive sedation are common and anesthetic agents with different molecular mechanisms of action may have different effects on the prevalence and complexity of the experiences, albeit in the present sample the differences between drugs were minute.
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Affiliation(s)
- Linda Radek
- Turku PET Centre, Turku University Hospital and University of Turku, PO Box 52, FI-20521 Turku, Finland.
| | - Lauri Koskinen
- Department of Psychology and Speech-Language Pathology, and Turku Brain and Mind Center, University of Turku, FI-20014 Turun yliopisto, Finland
| | - Nils Sandman
- Department of Psychology and Speech-Language Pathology, and Turku Brain and Mind Center, University of Turku, FI-20014 Turun yliopisto, Finland
| | - Lauri Laaksonen
- Turku PET Centre, Turku University Hospital and University of Turku, PO Box 52, FI-20521 Turku, Finland; Department of Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital and University of Turku, PO Box 52, FI-20521 Turku, Finland
| | - Roosa E Kallionpää
- Department of Psychology and Speech-Language Pathology, and Turku Brain and Mind Center, University of Turku, FI-20014 Turun yliopisto, Finland
| | - Annalotta Scheinin
- Turku PET Centre, Turku University Hospital and University of Turku, PO Box 52, FI-20521 Turku, Finland; Department of Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital and University of Turku, PO Box 52, FI-20521 Turku, Finland
| | - Ville Rajala
- Department of Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital and University of Turku, PO Box 52, FI-20521 Turku, Finland
| | - Anu Maksimow
- Department of Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital and University of Turku, PO Box 52, FI-20521 Turku, Finland
| | - Timo Laitio
- Department of Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital and University of Turku, PO Box 52, FI-20521 Turku, Finland
| | - Antti Revonsuo
- Department of Psychology and Speech-Language Pathology, and Turku Brain and Mind Center, University of Turku, FI-20014 Turun yliopisto, Finland; Department of Cognitive Neuroscience and Philosophy, School of Bioscience, University of Skövde, PO Box 408, 541 28 Skövde, Sweden
| | - Harry Scheinin
- Turku PET Centre, Turku University Hospital and University of Turku, PO Box 52, FI-20521 Turku, Finland; Department of Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital and University of Turku, PO Box 52, FI-20521 Turku, Finland; Institute of Biomedicine and Unit of Clinical Pharmacology, University of Turku and Turku University Hospital, FI-20014 Turun yliopisto, Finland
| | - Katja Valli
- Department of Psychology and Speech-Language Pathology, and Turku Brain and Mind Center, University of Turku, FI-20014 Turun yliopisto, Finland; Department of Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital and University of Turku, PO Box 52, FI-20521 Turku, Finland; Department of Cognitive Neuroscience and Philosophy, School of Bioscience, University of Skövde, PO Box 408, 541 28 Skövde, Sweden
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12
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Chen YF, Fan SZ, Abbod MF, Shieh JS, Zhang M. Electroencephalogram variability analysis for monitoring depth of anesthesia. J Neural Eng 2021; 18. [PMID: 34695812 DOI: 10.1088/1741-2552/ac3316] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 10/25/2021] [Indexed: 12/27/2022]
Abstract
Objective. In this paper, a new approach of extracting and measuring the variability in electroencephalogram (EEG) was proposed to assess the depth of anesthesia (DOA) under general anesthesia.Approach. The EEG variability (EEGV) was extracted as a fluctuation in time interval that occurs between two local maxima of EEG. Eight parameters related to EEGV were measured in time and frequency domains, and compared with state-of-the-art DOA estimation parameters, including sample entropy, permutation entropy, median frequency and spectral edge frequency of EEG. The area under the receiver-operator characteristics curve (AUC) and Pearson correlation coefficient were used to validate its performance on 56 patients.Main results. Our proposed EEGV-derived parameters yield significant difference for discriminating between awake and anesthesia stages at a significance level of 0.05, as well as improvement in AUC and correlation coefficient on average, which surpasses the conventional features of EEG in detection accuracy of unconscious state and tracking the level of consciousness.Significance. To sum up, EEGV analysis provides a new perspective in quantifying EEG and corresponding parameters are powerful and promising for monitoring DOA under clinical situations.
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Affiliation(s)
- Yi-Feng Chen
- Academy for Advanced Interdisciplinary Studies, Southern University of Science and Technology, ShenZhen, GuangDong, 518055, People's Republic of China.,Shenzhen Key Laboratory of Smart Healthcare Engineering, the Department of Biomedical Engineering, Southern University of Science and Technology, ShenZhen, GuangDong, 518055, People's Republic of China
| | - Shou-Zen Fan
- Department of Anesthesiology, College of Medicine, National Taiwan University, Taipei, 100, Taiwan
| | - Maysam F Abbod
- College of Engineering, Design and Physical Sciences, Brunel University London, Uxbridge, UB8 3PH, United Kingdom
| | - Jiann-Shing Shieh
- Department of Mechanical Engineering, Yuan Ze University, Taoyuan 32003, Taiwan
| | - Mingming Zhang
- Shenzhen Key Laboratory of Smart Healthcare Engineering, the Department of Biomedical Engineering, Southern University of Science and Technology, ShenZhen, GuangDong, 518055, People's Republic of China
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13
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Li F, Li Y, Zheng H, Jiang L, Gao D, Li C, Peng Y, Cao Z, Zhang Y, Yao D, Xu T, Yuan TF, Xu P. Identification of the General Anesthesia Induced Loss of Consciousness by Cross Fuzzy Entropy-Based Brain Network. IEEE Trans Neural Syst Rehabil Eng 2021; 29:2281-2291. [PMID: 34705652 DOI: 10.1109/tnsre.2021.3123696] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Although the spatiotemporal complexity and network connectivity are clarified to be disrupted during the general anesthesia (GA) induced unconsciousness, it remains to be difficult to exactly monitor the fluctuation of consciousness clinically. In this study, to track the loss of consciousness (LOC) induced by GA, we first developed the multi-channel cross fuzzy entropy method to construct the time-varying networks, whose temporal fluctuations were then explored and quantitatively evaluated. Thereafter, an algorithm was further proposed to detect the time onset at which patients lost their consciousness. The results clarified during the resting state, relatively stable fuzzy fluctuations in multi-channel network architectures and properties were found; by contrast, during the LOC period, the disrupted frontal-occipital connectivity occurred at the early stage, while at the later stage, the inner-frontal connectivity was identified. When specifically exploring the early LOC stage, the uphill of the clustering coefficients and the downhill of the characteristic path length were found, which might help resolve the propofol-induced consciousness fluctuation in patients. Moreover, the developed detection algorithm was validated to have great capacity in exactly capturing the time point (in seconds) at which patients lost consciousness. The findings demonstrated that the time-varying cross-fuzzy networks help decode the GA and are of great significance for developing anesthesia depth monitoring technology clinically.
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14
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Li Y, Li F, Zheng H, Jiang L, Peng Y, Zhang Y, Yao D, Xu T, Yuan T, Xu P. Recognition of general anesthesia-induced loss of consciousness based on the spatial pattern of the brain networks. J Neural Eng 2021; 18. [PMID: 34534980 DOI: 10.1088/1741-2552/ac27fc] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 09/17/2021] [Indexed: 11/11/2022]
Abstract
Objective.Unconsciousness is a key feature related to general anesthesia (GA) but is difficult to be evaluated accurately by anesthesiologists clinically.Approach.To tracking the loss of consciousness (LOC) and recovery of consciousness (ROC) under GA, in this study, by investigating functional connectivity of the scalp electroencephalogram, we explore any potential difference in brain networks among anesthesia induction, anesthesia recovery, and the resting state.Main results.The results of this study demonstrated significant differences among the three periods, concerning the corresponding brain networks. In detail, the suppressed default mode network, as well as the prolonged characteristic path length and decreased clustering coefficient, during LOC was found in the alpha band, compared to the Resting and the ROC state. When to further identify the Resting and LOC states, the fused network topologies and properties achieved the highest accuracy of 95%, along with a sensitivity of 93.33% and a specificity of 96.67%.Significance.The findings of this study not only deepen our understanding of propofol-induced unconsciousness but also provide quantitative measurements subserving better anesthesia management.
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Affiliation(s)
- Yuqin Li
- The Clinical Hospital of Chengdu Brain Science Institute, MOE Key Lab for Neuroinformation, University of Electronic Science and Technology of China, Chengdu 611731, People's Republic of China.,School of Life Science and Technology, Center for Information in Medicine, University of Electronic Science and Technology of China, Chengdu 611731, People's Republic of China
| | - Fali Li
- The Clinical Hospital of Chengdu Brain Science Institute, MOE Key Lab for Neuroinformation, University of Electronic Science and Technology of China, Chengdu 611731, People's Republic of China.,School of Life Science and Technology, Center for Information in Medicine, University of Electronic Science and Technology of China, Chengdu 611731, People's Republic of China
| | - Hui Zheng
- Shanghai Key Laboratory of Psychotic Disorders, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, People's Republic of China
| | - Lin Jiang
- The Clinical Hospital of Chengdu Brain Science Institute, MOE Key Lab for Neuroinformation, University of Electronic Science and Technology of China, Chengdu 611731, People's Republic of China.,School of Life Science and Technology, Center for Information in Medicine, University of Electronic Science and Technology of China, Chengdu 611731, People's Republic of China
| | - Yueheng Peng
- The Clinical Hospital of Chengdu Brain Science Institute, MOE Key Lab for Neuroinformation, University of Electronic Science and Technology of China, Chengdu 611731, People's Republic of China.,School of Life Science and Technology, Center for Information in Medicine, University of Electronic Science and Technology of China, Chengdu 611731, People's Republic of China
| | - Yangsong Zhang
- School of Computer Science and Technology, Southwest University of Science and Technology, Mianyang 621010, People's Republic of China
| | - Dezhong Yao
- The Clinical Hospital of Chengdu Brain Science Institute, MOE Key Lab for Neuroinformation, University of Electronic Science and Technology of China, Chengdu 611731, People's Republic of China.,School of Life Science and Technology, Center for Information in Medicine, University of Electronic Science and Technology of China, Chengdu 611731, People's Republic of China
| | - Tao Xu
- Department of Anesthesiology, Affiliated Shanghai Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai 200233, People's Republic of China.,Department of Anesthesiology, Tongzhou People's Hospital, Nantong 226300, People's Republic of China
| | - Tifei Yuan
- Shanghai Key Laboratory of Psychotic Disorders, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, People's Republic of China.,Co-innovation Center of Neuroregeneration, Nantong University, Nantong 226001, People's Republic of China
| | - Peng Xu
- The Clinical Hospital of Chengdu Brain Science Institute, MOE Key Lab for Neuroinformation, University of Electronic Science and Technology of China, Chengdu 611731, People's Republic of China.,School of Life Science and Technology, Center for Information in Medicine, University of Electronic Science and Technology of China, Chengdu 611731, People's Republic of China
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15
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Abstract
The electroencephalogram (EEG) can be analyzed in its raw form for characteristic drug-induced patterns of change or summarized using mathematical parameters as a processed electroencephalogram (pEEG). In this article we aim to summarize the contemporary literature pertaining to the commonly available pEEG monitors including the effects of commonly used anesthetic drugs on the EEG and pEEG parameters, pEEG monitor pitfalls, and the clinical implications of pEEG monitoring for anesthesia, pediatrics, and intensive care.
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Affiliation(s)
- David Roche
- Department of Anaesthesiology and Critical Care, Cork University Hospital, Wilton Road, Wilton, Cork T12 DC4A, Ireland.
| | - Padraig Mahon
- Department of Anaesthesiology and Critical Care, Cork University Hospital, Wilton Road, Wilton, Cork T12 DC4A, Ireland
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16
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Neurons in the Nonhuman Primate Amygdala and Dorsal Anterior Cingulate Cortex Signal Aversive Memory Formation under Sedation. Anesthesiology 2021; 134:734-747. [PMID: 33684203 DOI: 10.1097/aln.0000000000003732] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Anesthetics aim to prevent memory of unpleasant experiences. The amygdala and dorsal anterior cingulate cortex participate in forging emotional and valence-driven memory formation. It was hypothesized that this circuitry maintains its role under sedation. METHODS Two nonhuman primates underwent aversive tone-odor conditioning under sedative states induced by ketamine or midazolam (1 to 8 and 0.1 to 0.8 mg/kg, respectively). The primary outcome was behavioral and neural evidence suggesting memory formation. This study simultaneously measured conditioned inspiratory changes and changes in firing rate of single neurons in the amygdala and the dorsal anterior cingulate cortex in response to an expected aversive olfactory stimulus appearing during acquisition and tested their retention after recovery. RESULTS Aversive memory formation occurred in 26 of 59 sessions under anesthetics (16 of 29 and 10 of 30, 5 of 30 and 21 of 29 for midazolam and ketamine at low and high doses, respectively). Single-neuron responses in the amygdala and dorsal anterior cingulate cortex were positively correlated between acquisition and retention (amygdala, n = 101, r = 0.51, P < 0.001; dorsal anterior cingulate cortex, n = 121, r = 0.32, P < 0.001). Neural responses during acquisition under anesthetics were stronger in sessions exhibiting memory formation than those that did not (amygdala median response ratio, 0.52 versus 0.33, n = 101, P = 0.021; dorsal anterior cingulate cortex median response ratio, 0.48 versus 0.32, n = 121, P = 0.012). The change in firing rate of amygdala neurons during acquisition was correlated with the size of stimuli-conditioned inspiratory response during retention (n = 101, r = 0.22 P = 0.026). Thus, amygdala and dorsal anterior cingulate cortex responses during acquisition under anesthetics predicted retention. Respiratory unconditioned responses to the aversive odor anesthetics did not differ from saline controls. CONCLUSIONS These results suggest that the amygdala-dorsal anterior cingulate cortex circuit maintains its role in acquisition and maintenance of aversive memories in nonhuman primates under sedation with ketamine and midazolam and that the stimulus valence is sufficient to drive memory formation. EDITOR’S PERSPECTIVE
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17
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Abstract
Inhalational anesthetics have been used for induction and maintenance of general anesthesia for more than 150 years. All of the currently used inhalational anesthetics are chlorinated and fluorinated derivatives of ether. Dosing is carried out using the minimal alveolar concentration (MAC) concept. The pharmacokinetic properties of the various inhalational anesthetics are governed by the specific distribution coefficients. Mechanisms of action include specific modulations of various receptors of the central nervous system as well as an unspecific interaction with the cell membrane. Organ toxicity of modern inhalational anesthetics is considered to be minimal. The role of inhalational anesthetics in the context of postoperative nausea and vomiting (PONV) has been reassessed in recent years. The superiority of inhalational anesthetics over intravenous hypnotics with respect to intraoperative awareness is undisputed. The organ protective mechanism of preconditioning is an exclusive property of inhalational anesthetics among all the currently available hypnotics.
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Affiliation(s)
- Jan Jedlicka
- Klinik für Anaesthesiologie, Chirurgische Klinik Nußbaumstraße, LMU Klinikum, Campus Innenstadt, Nußbaumstr. 20, 80336, München, Deutschland.
| | - Philipp Groene
- Klinik für Anaesthesiologie, Chirurgische Klinik Nußbaumstraße, LMU Klinikum, Campus Innenstadt, Nußbaumstr. 20, 80336, München, Deutschland
| | - Julia Linhart
- Klinik für Anaesthesiologie, Chirurgische Klinik Nußbaumstraße, LMU Klinikum, Campus Innenstadt, Nußbaumstr. 20, 80336, München, Deutschland
| | - Elisabeth Raith
- Klinik für Anaesthesiologie, Chirurgische Klinik Nußbaumstraße, LMU Klinikum, Campus Innenstadt, Nußbaumstr. 20, 80336, München, Deutschland
| | - Da Vy Mu Stapha
- Klinik für Anaesthesiologie, Chirurgische Klinik Nußbaumstraße, LMU Klinikum, Campus Innenstadt, Nußbaumstr. 20, 80336, München, Deutschland
| | - Peter Conzen
- Klinik für Anaesthesiologie, Chirurgische Klinik Nußbaumstraße, LMU Klinikum, Campus Innenstadt, Nußbaumstr. 20, 80336, München, Deutschland
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18
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Cyr S, Guo DX, Marcil MJ, Dupont P, Jobidon L, Benrimoh D, Guertin MC, Brouillette J. Posttraumatic stress disorder prevalence in medical populations: A systematic review and meta-analysis. Gen Hosp Psychiatry 2021; 69:81-93. [PMID: 33582645 DOI: 10.1016/j.genhosppsych.2021.01.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 01/19/2021] [Accepted: 01/19/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE PTSD is increasingly recognized following medical traumas although is highly heterogeneous. It is difficult to judge which medical contexts have the most traumatic potential and where to concentrate further research and clinical attention for prevention, early detection and treatment. The objective of this study was to compare PTSD prevalence in different medical populations. METHODS A systematic review of the literature on PTSD following medical traumas was conducted as well as a meta-analysis with final pooled result and 95% confidence intervals presented. A meta-regression was used to investigate the impact of potential effect modifiers (PTSD severity, age, sex, timeline) on study effect size between prevalence studies. RESULTS From 3278 abstracts, the authors extracted 292 studies reporting prevalence. Using clinician-administered reports, the highest 24 month or longer PTSD prevalence was found for intraoperative awareness (18.5% [95% CI=5.1%-36.6%]) and the lowest was found for epilepsy (4.5% [95% CI=0.2%-12.6%]). In the overall effect of the meta-regression, only medical events or procedures emerged as significant (p = 0.006) CONCLUSION: This review provides clinicians with greater awareness of medical contexts most associated with PTSD, which may assist them in the decision to engage in more frequent, earlier screening and referral to mental health services.
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Affiliation(s)
- Samuel Cyr
- Research Center, Montreal Heart Institute, Montreal, Quebec, Canada; Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada
| | - De Xuan Guo
- Research Center, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Marie-Joëlle Marcil
- Research Center, Montreal Heart Institute, Montreal, Quebec, Canada; Department of Psychiatry and Addiction, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Patrice Dupont
- Health Sciences Library, Université de Montréal, Montreal, Quebec, Canada
| | - Laurence Jobidon
- Department of Psychiatry and Addiction, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - David Benrimoh
- Department of Psychiatry, McGill University, Montreal, Canada
| | - Marie-Claude Guertin
- Montreal Health Innovations Coordinating Center, Montreal, Montreal, Quebec, Canada
| | - Judith Brouillette
- Research Center, Montreal Heart Institute, Montreal, Quebec, Canada; Department of Psychiatry and Addiction, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada.
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19
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Pappal RD, Roberts BW, Winkler W, Yaegar LH, Stephens RJ, Fuller BM. Awareness With Paralysis in Mechanically Ventilated Patients in the Emergency Department and ICU: A Systematic Review and Meta-Analysis. Crit Care Med 2021; 49:e304-e314. [PMID: 33566462 PMCID: PMC7902430 DOI: 10.1097/ccm.0000000000004824] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Awareness with paralysis is a devastating complication for mechanically ventilated patients and can carry long-term psychologic sequelae. Hundreds of thousands of patients require mechanical ventilation in the emergency department and ICU annually, yet awareness has only been rigorously examined in the operating room (incidence ~0.1%). This report collates the global literature regarding the incidence of awareness with paralysis outside of the operating room. DATA SOURCES We searched OvidMedline, Embase, Scopus, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, conference proceedings, and reference lists. STUDY SELECTION Randomized or nonrandomized studies (except single case studies) reporting on awareness with paralysis in the emergency department or ICU were eligible. DATA EXTRACTION Two independent reviewers screened abstracts for eligibility. DATA SYNTHESIS The search identified 4,454 potentially eligible studies. Seven studies (n = 941 patients) were included for analysis. A random effects meta-analysis of proportions along with multiple subgroup analyses was performed. Significant between-study heterogeneity in reporting of awareness with paralysis was noted, and the quality of the evidence was low. Analyses stratified by: 1) good-quality studies and 2) use of the modified Brice questionnaire to detect awareness revealed estimates of 3.4% (95% CI, 0-10.2%) and 1.9% (95% CI, 1.0-3.0%), respectively. CONCLUSIONS The incidence of awareness with paralysis in mechanically ventilated patients in the emergency department and ICU, as evaluated in a small number of qualifying studies from this comprehensive systematic review, appears much higher than that reported from the operating room. Given the clinical and statistical heterogeneity, caution is warranted in the interpretation of these findings. Further high-quality studies are needed to both define the true incidence and to target the prevention of awareness with paralysis in this vulnerable patient cohort.
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Affiliation(s)
- Ryan D Pappal
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Brian W Roberts
- Department of Emergency Medicine, Cooper University Hospital, Camden, NJ
| | - Winston Winkler
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Lauren H Yaegar
- Bernard Becker Medical Library, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Robert J Stephens
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Brian M Fuller
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
- Division of Critical Care Medicine, Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, MO
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20
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Hayase K, Kainuma A, Akiyama K, Kinoshita M, Shibasaki M, Sawa T. Poincaré Plot Area of Gamma-Band EEG as a Measure of Emergence From Inhalational General Anesthesia. Front Physiol 2021; 12:627088. [PMID: 33633587 PMCID: PMC7900422 DOI: 10.3389/fphys.2021.627088] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 01/05/2021] [Indexed: 12/18/2022] Open
Abstract
The Poincaré plot obtained from electroencephalography (EEG) has been used to evaluate the depth of anesthesia. A standalone EEG Analyzer application was developed; raw EEG signals obtained from a bispectral index (BIS) monitor were analyzed using an on-line monitoring system. Correlations between Poincaré plot parameters and other measurements associated with anesthesia depth were evaluated during emergence from inhalational general anesthesia. Of the participants, 20 were adults anesthetized with sevoflurane (adult_SEV), 20 were adults anesthetized with desflurane (adult_DES), and 20 were pediatric patients anesthetized with sevoflurane (ped_SEV). EEG signals were preprocessed through six bandpass digital filters (f0: 0.5–47 Hz, f1: 0.5–8 Hz, f2: 8–13 Hz, f3: 13–20 Hz, f4: 20–30 Hz, and f5: 30–47 Hz). The Poincaré plot-area ratio (PPAR = PPA_fx/PPA_f0, fx = f1∼f5) was analyzed at five frequency ranges. Regardless of the inhalational anesthetic used, there were strong linear correlations between the logarithm of PPAR at f5 and BIS (R2 = 0.67, 0.79, and 0.71, in the adult_SEV, adult_DES, and ped_SEV groups, respectively). As an additional observation, a part of EMG activity at the gamma range of 30–47 Hz probably influenced the calculations of BIS and PPAR_f5 with a non-negligible level. The logarithm of PPAR in the gamma band was most sensitive to state changes during the emergence process and could provide a new non-proprietary parameter that correlates with changes in BIS during measurement of anesthesia depth.
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Affiliation(s)
- Kazuma Hayase
- Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Atsushi Kainuma
- Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Koichi Akiyama
- Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Mao Kinoshita
- Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masayuki Shibasaki
- Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Teiji Sawa
- Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
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21
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Pappal RD, Roberts BW, Mohr NM, Ablordeppey E, Wessman BT, Drewry AM, Winkler W, Yan Y, Kollef MH, Avidan MS, Fuller BM. The ED-AWARENESS Study: A Prospective, Observational Cohort Study of Awareness With Paralysis in Mechanically Ventilated Patients Admitted From the Emergency Department. Ann Emerg Med 2021; 77:532-544. [PMID: 33485698 DOI: 10.1016/j.annemergmed.2020.10.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 10/12/2020] [Accepted: 10/14/2020] [Indexed: 12/20/2022]
Abstract
STUDY OBJECTIVE Awareness with paralysis is a devastating complication for patients receiving mechanical ventilation and risks long-term psychological morbidity. Data from the emergency department (ED) demonstrate a high rate of longer-acting neuromuscular blocking agent use, delayed analgosedation, and a lack of sedation depth monitoring. These practices are discordant with recommendations for preventing awareness with paralysis. Despite this, awareness with paralysis has not been rigorously studied in the ED population. Our objective is to assess the prevalence of awareness with paralysis in ED patients receiving mechanical ventilation. METHODS This was a single-center, prospective, observational cohort study on 383 mechanically ventilated ED patients. After extubation, we assessed patients for awareness with paralysis by using the modified Brice questionnaire. Three expert reviewers independently adjudicated awareness with paralysis. We report the prevalence of awareness with paralysis (primary outcome); the secondary outcome was perceived threat, a mediator for development of posttraumatic stress disorder. RESULTS The prevalence of awareness with paralysis was 2.6% (10/383). Exposure to rocuronium at any point in the ED was significantly different between patients who experienced awareness with paralysis (70%) versus the rest of the cohort (31.4%) (unadjusted odds ratio 5.1; 95% confidence interval 1.30 to 20.1). Patients experiencing awareness with paralysis had higher mean values on the threat perception scale, denoting a higher degree of perceived threat, compared with patients who did not experience awareness with paralysis (13.4 [SD 7.7] versus 8.5 [SD 6.2]; mean difference 4.9; 95% confidence interval 0.94 to 8.8). CONCLUSION Awareness with paralysis occurs in a significant minority of ED patients who receive mechanical ventilation. Potential associations of awareness with paralysis with ED care and increased perceived threat warrant further evaluation.
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Affiliation(s)
- Ryan D Pappal
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Brian W Roberts
- Department of Emergency Medicine, Cooper University Hospital, Camden, NJ
| | - Nicholas M Mohr
- Departments of Emergency Medicine and Anesthesiology, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA
| | - Enyo Ablordeppey
- Department of Emergency Medicine, St. Louis, MO; Department of Anesthesiology, St. Louis, MO
| | - Brian T Wessman
- Department of Emergency Medicine, St. Louis, MO; Department of Anesthesiology, St. Louis, MO
| | | | - Winston Winkler
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Yan Yan
- Public Health Sciences, St. Louis, MO; Clinical Epidemiology Center, VA St. Louis Health Care System, St. Louis, MO
| | | | | | - Brian M Fuller
- Department of Emergency Medicine, St. Louis, MO; Department of Anesthesiology, St. Louis, MO.
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22
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Odor PM, Bampoe S, Lucas DN, Moonesinghe SR, Andrade J, Pandit JJ. Incidence of accidental awareness during general anaesthesia in obstetrics: a multicentre, prospective cohort study. Anaesthesia 2021; 76:759-776. [PMID: 33434945 DOI: 10.1111/anae.15385] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2020] [Indexed: 12/11/2022]
Abstract
General anaesthesia for obstetric surgery has distinct characteristics that may contribute towards a higher risk of accidental awareness during general anaesthesia. The primary aim of this study was to investigate the incidence, experience and psychological implications of unintended conscious awareness during general anaesthesia in obstetric patients. From May 2017 to August 2018, 3115 consenting patients receiving general anaesthesia for obstetric surgery in 72 hospitals in England were recruited to the study. Patients received three repetitions of standardised questioning over 30 days, with responses indicating memories during general anaesthesia that were verified using interviews and record interrogation. A total of 12 patients had certain/probable or possible awareness, an incidence of 1 in 256 (95%CI 149-500) for all obstetric surgery. The incidence was 1 in 212 (95%CI 122-417) for caesarean section surgery. Distressing experiences were reported by seven (58.3%) patients, paralysis by five (41.7%) and paralysis with pain by two (16.7%). Accidental awareness occurred during induction and emergence in nine (75%) of the patients who reported awareness. Factors associated with accidental awareness during general anaesthesia were: high BMI (25-30 kg.m-2 ); low BMI (<18.5 kg.m-2 ); out-of-hours surgery; and use of ketamine or thiopental for induction. Standardised psychological impact scores at 30 days were significantly higher in awareness patients (median (IQR [range]) 15 (2.7-52.0 [2-56]) than in patients without awareness 3 (1-9 [0-64]), p = 0.010. Four patients had a provisional diagnosis of post-traumatic stress disorder. We conclude that direct postoperative questioning reveals high rates of accidental awareness during general anaesthesia for obstetric surgery, which has implications for anaesthetic practice, consent and follow-up.
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Affiliation(s)
- P M Odor
- Centre for Anaesthesia and Peri-operative Medicine, University College London Hospital, London, UK
| | - S Bampoe
- Centre for Anaesthesia and Peri-operative Medicine, University College London Hospital, London, UK
| | - D N Lucas
- Department of Anaesthesia, Northwick Park Hospital, London, UK
| | - S R Moonesinghe
- Centre for Peri-operative Medicine, Research Department for Targeted Intervention, University College London, London, UK
| | - J Andrade
- School of Psychology, University of Plymouth, Plymouth, UK
| | - J J Pandit
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Trust, Oxford, UK.,University of Oxford, Oxford, UK
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23
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McIsaac DI, Boet S. Can we sooth the subconscious during general anaesthesia? BMJ 2020; 371:m4547. [PMID: 33599624 DOI: 10.1136/bmj.m4547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Daniel I McIsaac
- Departments of Anesthesiology & Pain Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Sylvain Boet
- Departments of Anesthesiology & Pain Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Francophone Affairs, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Department of Innovation in Medical Education, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
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24
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Awareness with Recall After Neuromuscular Blockade—Lessons on Anesthetic Awareness from the UK and Ireland National Audit Project 5 (NAP5). CURRENT ANESTHESIOLOGY REPORTS 2020. [DOI: 10.1007/s40140-020-00426-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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25
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Tomczyk M, Schumacher BN. Nurses' experience with palliative sedation procedures in line with the 2005 Swiss guidelines: an exploratory study. Can Oncol Nurs J 2020; 30:261-268. [PMID: 33165398 DOI: 10.5737/23688076304261268] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Many international studies have shown that the process of palliative sedation in an end-of-life context can be an adverse, even emotionally distressing experience for nurses. However, to the best of our knowledge, the experience of nurses working in palliative care in Switzerland has never been explored. The purpose of our study was, therefore, to understand and describe nurses' experience with the process of palliative sedation in line with the Swiss guidelines developed in 2005. We opted for an exploratory qualitative monocentric study using comprehensive individual interviews to achieve this objective. A total of 10 nurses were approached, and nine agreed to take part. After the interviews were transcribed, eight were ultimately included in the analysis. This analysis shows that nurses' attitudes toward the process of palliative sedation tended to be hesitant, resistant, or confident and that this was linked to the length of time they had worked in palliative care. These findings suggest that the 2005 Swiss guidelines do not protect nurses against the uncertainty related to process of palliative sedation. A national comprehensive multicentric study therefore needs to be developed to consolidate these results.
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Affiliation(s)
- Martyna Tomczyk
- Medical Ethics Researcher, PhD, Postdoctoral Fellow, Institute of Humanities in Medicine, Lausanne University Hospital (CHUV), Avenue de Provence 82, CH-1007 Lausanne, Switzerland, , +33 (0)6 95 11 86 45
| | - Bernard N Schumacher
- Philosopher, Professor, PhD-HDR, Coordinator, Interdisciplinary Institute of Ethics and Human Rights, University of Fribourg, Switzerland. Avenue de Beauregard 13, CH-1700 Fribourg, Switzerland,
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Bombardieri AM, Wildes TS, Stevens T, Wolfson M, Steinhorn R, Ben Abdallah A, Sleigh J, Avidan MS. Practical Training of Anesthesia Clinicians in Electroencephalogram-Based Determination of Hypnotic Depth of General Anesthesia. Anesth Analg 2020; 130:777-786. [PMID: 31880629 DOI: 10.1213/ane.0000000000004537] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Electroencephalographic (EEG) brain monitoring during general anesthesia provides information on hypnotic depth. We hypothesized that anesthesia clinicians could be trained rapidly to recognize typical EEG waveforms occurring with volatile-based general anesthesia. METHODS This was a substudy of a trial testing the hypothesis that EEG-guided anesthesia prevents postoperative delirium. The intervention was a 35-minute training session, summarizing typical EEG changes with volatile-based anesthesia. Participants completed a preeducational test, underwent training, and completed a posteducational test. For each question, participants indicated whether the EEG was consistent with (1) wakefulness, (2) non-slow-wave anesthesia, (3) slow-wave anesthesia, or (4) burst suppression. They also indicated whether the processed EEG (pEEG) index was discordant with the EEG waveforms. Four clinicians, experienced in intraoperative EEG interpretation, independently evaluated the EEG waveforms, resolved disagreements, and provided reference answers. Ten questions were assessed in the preeducational test and 9 in the posteducational test. RESULTS There were 71 participants; 13 had previous anesthetic-associated EEG interpretation training. After training, the 58 participants without prior training improved at identifying dominant EEG waveforms (median 60% with interquartile range [IQR], 50%-70% vs 78% with IQR, 67%-89%; difference: 18%; 95% confidence interval [CI], 8-27; P < .001). In contrast, there was no significant improvement following the training for the 13 participants who reported previous training (median 70% with IQR, 60%-80% vs 67% with IQR, 67%-78%; difference: -3%; 95% CI, -18 to 11; P = .88). The difference in the change between the pre- and posteducational session for the previously untrained versus previously trained was statistically significant (difference in medians: 21%; 95% CI, 2-28; P = .005). Clinicians without prior training also improved in identifying discordance between the pEEG index and the EEG waveform (median 60% with IQR, 40%-60% vs median 100% with IQR, 75%-100%; difference: 40%; 95% CI, 30-50; P < .001). Clinicians with prior training showed no significant improvement (median 60% with IQR, 60%-80% vs 75% with IQR, 75%-100%; difference: 15%; 95% CI, -16 to 46; P = .16). Regarding the identification of discordance, the difference in the change between the pre- and posteducational session for the previously untrained versus previously trained was statistically significant (difference in medians: 25%; 95% CI, 5-45; P = .012). CONCLUSIONS A brief training session was associated with improvements in clinicians without prior EEG training in (1) identifying EEG waveforms corresponding to different hypnotic depths and (2) recognizing when the hypnotic depth suggested by the EEG was discordant with the pEEG index.
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Affiliation(s)
- Anna Maria Bombardieri
- From the Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Troy S Wildes
- From the Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Tracey Stevens
- From the Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Maxim Wolfson
- From the Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Rachel Steinhorn
- Department of Anesthesiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Arbi Ben Abdallah
- From the Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Jamie Sleigh
- Department of Anesthesiology, Waikato Clinical School, University of Auckland, Hamilton, New Zealand
| | - Michael S Avidan
- From the Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
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Deis AS, Schnetz MP, Ibinson JW, Vogt KM. Retrospective analysis of cases of intraoperative awareness in a large multi-hospital health system reported in the early postoperative period. BMC Anesthesiol 2020; 20:62. [PMID: 32151241 PMCID: PMC7061486 DOI: 10.1186/s12871-020-00974-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 02/28/2020] [Indexed: 12/17/2022] Open
Abstract
Background Awareness with recall under general anesthesia remains a rare but important issue that warrants further study. Methods We present a series of seven cases of awareness that were identified from provider-reported adverse event data from the electronic anesthesia records of 647,000 general anesthetics. Results The low number of identified cases suggests an under-reporting bias. Themes that emerge from this small series can serve as important reminders to anesthesia providers to ensure delivery of an adequate anesthetic for each patient. Commonalities between a majority of our identified anesthetic awareness cases include: obesity, use of total intravenous anesthesia, use of neuromuscular blockade, and either a lack of processed electroencephalogram (EEG) monitoring or documented high depth of consciousness index values. An interesting phenomenon was observed in one case, where adequately-dosed anesthesia was delivered without technical issue, processed EEG monitoring was employed, and the index value suggested an adequate depth of consciousness throughout the case. Conclusions Provider-reported adverse event data in the immediate post-operative period are likely insensitive for detecting cases of intraoperative awareness. Though causation cannot firmly be established from our data, themes identified in this series of cases of awareness with recall under general anesthesia provide important reminders for anesthesia providers to maintain vigilance in monitoring depth and dose of anesthesia, particularly with total intravenous anesthesia.
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Affiliation(s)
- Amanda S Deis
- Department of Anesthesiology & Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Michael P Schnetz
- Department of Anesthesiology & Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - James W Ibinson
- Department of Anesthesiology & Perioperative Medicine, University of Pittsburgh School of Medicine, 3459 Fifth Avenue, UPMC Montefiore, Suite 467, Pittsburgh, PA, 15213, USA.,Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, USA.,Department of Anesthesiology, Surgical Service Line, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, USA
| | - Keith M Vogt
- Department of Anesthesiology & Perioperative Medicine, University of Pittsburgh School of Medicine, 3459 Fifth Avenue, UPMC Montefiore, Suite 467, Pittsburgh, PA, 15213, USA. .,Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, USA. .,Center for the Neural Basis of Cognition, Pittsburgh, USA.
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28
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Pappal RD, Roberts BW, Winkler W, Yaegar LH, Stephens RJ, Fuller BM. Awareness and bispectral index (BIS) monitoring in mechanically ventilated patients in the emergency department and intensive care unit: a systematic review protocol. BMJ Open 2020; 10:e034673. [PMID: 32139489 PMCID: PMC7059542 DOI: 10.1136/bmjopen-2019-034673] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Accidental awareness with recall is one of the most feared complications for patients undergoing general anaesthesia and can lead to post-traumatic stress disorder in up to 70% of patients experiencing it. To reduce the incidence of awareness with recall, the bispectral index monitor is recommended for patients receiving total intravenous anaesthetics, especially those receiving neuromuscular blockers. While extensive investigation into awareness and bispectral index monitoring has occurred for operating room patients, this has not extended to other clinical arenas where sedated and mechanically ventilated patients are cared for, namely the intensive care unit and emergency department. The purpose of this systematic review is to assess the world's literature to determine the incidence of awareness with paralysis in mechanically ventilated patients and the impact of bispectral index monitoring for reducing this complication. METHODS AND ANALYSIS Randomised trials and non-randomised studies are eligible for inclusion. With aid from a medical librarian, an electronic search will include Ovid Medline, Embase.com, Scopus, Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials. To find data published in abstract form, literature from professional society conferences (2010-2019) will be manually searched. Two authors will independently review search results and consensus will be reached with assistance from a third author, as needed. Heterogeneity and publication bias will be assessed and reported. If possible and appropriate, a meta-analysis of the data will be conducted for quantitative data analysis. ETHICS AND DISSEMINATION The proposed systematic review does not require ethical approval, as it is conducted at the study level and does not involve individual patient-level data. Results will be disseminated by data sharing via academically established means, presentation at local and national scientific meetings and publication as a peer-reviewed manuscript. PROSPERO REGISTRATION NUMBER The protocol has been submitted to International Prospective Register of Systematic Reviews and is awaiting registration.
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Affiliation(s)
- Ryan D Pappal
- Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Brian W Roberts
- Emergency Medicine, Cooper Medical School of Rowan University, Camden, New Jersey, USA
| | - Winston Winkler
- Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Lauren H Yaegar
- Bernard Becker Medical Library, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Robert J Stephens
- Emergency Medicine, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Brian M Fuller
- Emergency Medicine and Anesthesiology, Washington University, Saint Louis, Missouri, USA
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29
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Lai HC, Wu KL, Wu ZF, Lai MF, Huang YH, Tseng WC, Chen JY. A 10-year retrospective analysis on the incidence of anesthesia awareness with recall in adult patients under total intravenous anesthesia. JOURNAL OF MEDICAL SCIENCES 2020. [DOI: 10.4103/1011-4564.282530] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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30
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Lai HC, Wu KL, Wu ZF, Lai MF, Huang YH, Tseng WC, Chen JY. A 10-year retrospective analysis on the incidence of anesthesia awareness with recall in adult patients under total intravenous anesthesia. JOURNAL OF MEDICAL SCIENCES 2020. [DOI: 10.4103/jmedsci.jmedsci_224_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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31
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Bombardieri AM, Mathur S, Soares A, Sharma A, Ben Abdallah A, Wildes TS, Avidan MS. Intraoperative Awareness With Recall. Anesth Analg 2019; 129:1291-1297. [DOI: 10.1213/ane.0000000000004358] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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32
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Ferreira AL, Mendes JG, Nunes CS, Amorim P. [Evaluation of Bispectral Index time delay in response to anesthesia induction: an observational study]. Rev Bras Anestesiol 2019; 69:377-382. [PMID: 31371175 DOI: 10.1016/j.bjan.2019.03.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 02/16/2019] [Accepted: 03/03/2019] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND OBJECTIVES According to the manufacturer, the Bispectral Index (BIS) has a processing time delay of 5-10s. Studies addressing this have suggested longer delays. We evaluated the time delay in the Bispectral Index response. METHODS Based on clinical data from 45 patients, using the difference between the predicted and the real BIS, calculated during a fixed 3minutes period after the moment the Bispectral Index dropped below 80 during the induction of general anesthesia with propofol and remifentanil. RESULTS The difference between the predicted and the real BIS was in average 30.09±18.73s. CONCLUSION Our results may be another indication that the delay in BIS processing may be much longer than stated by the manufacture, a fact with clinical implications.
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Affiliation(s)
- Ana Leitão Ferreira
- Universidade do Porto, Faculdade de Engenharia, Porto, Portugal; Centro Hospitalar do Porto, Serviço de Anestesiologia, Centro de Investigação Clínica em Anestesiologia, Porto, Portugal.
| | | | - Catarina Sofia Nunes
- Centro Hospitalar do Porto, Serviço de Anestesiologia, Centro de Investigação Clínica em Anestesiologia, Porto, Portugal; Universidade Aberta, Departamento de Ciências e Tecnologia, Delegação do Porto, Porto, Portugal
| | - Pedro Amorim
- Centro Hospitalar do Porto, Serviço de Anestesiologia, Centro de Investigação Clínica em Anestesiologia, Porto, Portugal
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Ferreira AL, Mendes JG, Nunes CS, Amorim P. Evaluation of Bispectral Index time delay in response to anesthesia induction: an observational study. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2019. [PMID: 31371175 PMCID: PMC9391904 DOI: 10.1016/j.bjane.2019.04.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background and objectives According to the manufacturer, the Bispectral Index (BIS) has a processing time delay of 5–10 s. Studies addressing this have suggested longer delays. We evaluated the time delay in the Bispectral Index response. Methods Based on clinical data from 45 patients, using the difference between the predicted and the real BIS, calculated during a fixed 3 minutes period after the moment the Bispectral Index dropped below 80 during the induction of general anesthesia with propofol and remifentanil. Results The difference between the predicted and the real BIS was in average 30.09 ± 18.73 s. Conclusion Our results may be another indication that the delay in BIS processing may be much longer than stated by the manufacture, a fact with clinical implications.
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Diaz Milian R. Propofol and Outcome from Colon Cancer Surgery: Comment. Anesthesiology 2019; 131:218-219. [PMID: 31219866 DOI: 10.1097/aln.0000000000002788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Rimbert S, Riff P, Gayraud N, Schmartz D, Bougrain L. Median Nerve Stimulation Based BCI: A New Approach to Detect Intraoperative Awareness During General Anesthesia. Front Neurosci 2019; 13:622. [PMID: 31275105 PMCID: PMC6593137 DOI: 10.3389/fnins.2019.00622] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 05/29/2019] [Indexed: 11/24/2022] Open
Abstract
Hundreds of millions of general anesthesia are performed each year on patients all over the world. Among these patients, 0.1–0.2% are victims of Accidental Awareness during General Anesthesia (AAGA), i.e., an unexpected awakening during a surgical procedure under general anesthesia. Although anesthesiologists try to closely monitor patients using various techniques to prevent this terrifying phenomenon, there is currently no efficient solution to accurately detect its occurrence. We propose the conception of an innovative passive brain-computer interface (BCI) based on an intention of movement to prevent AAGA. Indeed, patients typically try to move to alert the medical staff during an AAGA, only to discover that they are unable to. First, we examine the challenges of such a BCI, i.e., the lack of a trigger to facilitate when to look for an intention to move, as well as the necessity for a high classification accuracy. Then, we present a solution that incorporates Median Nerve Stimulation (MNS). We investigate the specific modulations that MNS causes in the motor cortex and confirm that they can be altered by an intention of movement. Finally, we perform experiments on 16 healthy participants to assess whether an MI-based BCI using MNS is able to generate high classification accuracies. Our results show that MNS may provide a foundation for an innovative BCI that would allow the detection of AAGA.
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Affiliation(s)
| | - Pierre Riff
- Université de Lorraine, CNRS, Inria, LORIA, Nancy, France
| | - Nathalie Gayraud
- Université Côte d'Azur, Inria, Sophia-Antipolis Méditerrannée, Athena Team, Nice, France
| | - Denis Schmartz
- Le Centre Hospitalier Universitaire (CHU) Brugmann, Université Libre de Bruxelles, Brussels, Belgium
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El-Gabalawy R, Sommer JL, Pietrzak R, Edmondson D, Sareen J, Avidan MS, Jacobsohn E. Post-traumatic stress in the postoperative period: current status and future directions. Can J Anaesth 2019; 66:1385-1395. [DOI: 10.1007/s12630-019-01418-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Revised: 04/19/2019] [Accepted: 04/22/2019] [Indexed: 11/24/2022] Open
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Wang G, Liu Z, Feng Y, Li J, Dong H, Wang D, Li J, Yan N, Liu T, Yan X. Monitoring the Depth of Anesthesia Through the Use of Cerebral Hemodynamic Measurements Based on Sample Entropy Algorithm. IEEE Trans Biomed Eng 2019; 67:807-816. [PMID: 31180830 DOI: 10.1109/tbme.2019.2921362] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE The aim of this study is to explore the relationship between the depth of anesthesia and the cerebral hemodynamic variables during the complete anesthesia process. METHODS In this study, near-infrared spectroscopy signals were used to record eight kinds of cerebral hemodynamic variables, including left, right, proximal, distal deoxygenated (Hb) and oxygenated (HbO2) hemoglobin concentration changes. Then, by measuring the complexity information of cerebral hemodynamic variables, the sample entropy was calculated as a new index of monitoring the depth of anesthesia. RESULTS By means of receiver operating characteristic curve analysis, the sample entropy approach was proved to effectively discriminate anesthesia maintenance and waking phases. The discriminatory ability of HbO2 signals was stronger than that of Hb signals and the distal signals had weaker discrimination capability when compared with the proximal signals. In addition, there was statistical consistency between the bispectral index and sample entropy of cerebral hemodynamic variables during the complete anesthesia process. Moreover, the cerebral hemodynamic signals could not be interfered by clinical electrical devices. CONCLUSION The sample entropy of cerebral hemodynamic variables could be suitable as a new index for monitoring the depth of anesthesia. SIGNIFICANCE This study is very meaningful for developing new modality and decoding methods in perspective of anesthesia surveillance and may result in the anesthesia monitoring system with high performance.
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Aggarwal A, Brennan C, Shortal B, Contreras D, Kelz MB, Proekt A. Coherence of Visual-Evoked Gamma Oscillations Is Disrupted by Propofol but Preserved Under Equipotent Doses of Isoflurane. Front Syst Neurosci 2019; 13:19. [PMID: 31139058 PMCID: PMC6519322 DOI: 10.3389/fnsys.2019.00019] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 04/18/2019] [Indexed: 12/15/2022] Open
Abstract
Previous research demonstrates that the underlying state of the brain influences how sensory stimuli are processed. Canonically, the state of the brain has been defined by quantifying the spectral characteristics of spontaneous fluctuations in local field potentials (LFP). Here, we utilized isoflurane and propofol anesthesia to parametrically alter the spectral state of the murine brain. With either drug, we produce slow wave activity, with low anesthetic doses, or burst suppression, with higher doses. We find that while spontaneous LFP oscillations were similar, the average visual-evoked potential (VEP) was always smaller in amplitude and shorter in duration under propofol than under comparable doses of isoflurane. This diminished average VEP results from increased trial-to-trial variability in VEPs under propofol. One feature of single trial VEPs that was consistent in all animals was visual-evoked gamma band oscillation (20-60 Hz). This gamma band oscillation was coherent between trials in the early phase (<250 ms) of the visual evoked potential under isoflurane. Inter trial phase coherence (ITPC) of gamma oscillations was dramatically attenuated in the same propofol anesthetized mice despite similar spontaneous oscillations in the LFP. This suggests that while both anesthetics lead to loss of consciousness (LOC), elicit slow oscillations and burst suppression, only the isoflurane permits phase resetting of gamma oscillations by visual stimuli. These results demonstrate that accurate characterization of a brain state must include both spontaneous as well as stimulus-induced perturbations of brain activity.
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Affiliation(s)
- Adeeti Aggarwal
- Department of Neuroscience, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Connor Brennan
- Department of Neuroscience, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Brenna Shortal
- Department of Neuroscience, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Diego Contreras
- Department of Neuroscience, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Max B Kelz
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Alex Proekt
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
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Tasbihgou SR, Vogels MF, Absalom AR. Accidental awareness during general anaesthesia - a narrative review. Anaesthesia 2018; 73:112-122. [PMID: 29210043 DOI: 10.1111/anae.14124] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2017] [Indexed: 11/30/2022]
Abstract
Unintended accidental awareness during general anaesthesia represents failure of successful anaesthesia, and so has been the subject of numerous studies during the past decades. As return to consciousness is both difficult to describe and identify, the reported incidence rates vary widely. Similarly, a wide range of techniques have been employed to identify cases of accidental awareness. Studies which have used the isolated forearm technique to identify responsiveness to command during intended anaesthesia have shown remarkably high incidences of awareness. For example, the ConsCIOUS-1 study showed an incidence of responsiveness around the time of laryngoscopy of 1:25. On the other hand, the 5th Royal College of Anaesthetists National Audit Project, which reported the largest ever cohort of patients who had experienced accidental awareness, used a system to identify patients who spontaneously self-reported accidental awareness. In this latter study, the incidence of accidental awareness was 1:19,600. In the recently published SNAP-1 observational study, in which structured postoperative interviews were performed, the incidence was 1:800. In almost all reported cases of intra-operative responsiveness, there was no subsequent explicit recall of intra-operative events. To date, there is no evidence that this occurrence has any psychological consequences. Among patients who experience accidental awareness and can later remember details of their experience, the consequences are better known. In particular, when awareness occurs in a patient who has been given neuromuscular blocking agents, it may result in serious sequelae such as symptoms of post-traumatic stress disorder and a permanent aversion to surgery and anaesthesia, and is feared by patients and anaesthetists. In this article, the published literature on the incidence, consequences and management of accidental awareness under general anaesthesia with subsequent recall will be reviewed.
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Affiliation(s)
- S R Tasbihgou
- Department of Anesthesiology, University Medical Centre Groningen, University of Groningen, the Netherlands
| | - M F Vogels
- Department of Anesthesiology, University Medical Centre Groningen, University of Groningen, the Netherlands
| | - A R Absalom
- Department of Anesthesiology, University Medical Centre Groningen, University of Groningen, the Netherlands
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Samuel N, Taub A, Paz R, Raz A. Implicit aversive memory under anaesthesia in animal models: a narrative review. Br J Anaesth 2018; 121:219-232. [DOI: 10.1016/j.bja.2018.05.046] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 05/15/2018] [Accepted: 05/15/2018] [Indexed: 12/23/2022] Open
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Altıparmak B, Çelebi N, Canbay Ö, Toker MK, Kılıçarslan B, Aypar Ü. Effect of magnesium sulfate on anesthesia depth, awareness incidence, and postoperative pain scores in obstetric patients. A double-blind randomized controlled trial. Saudi Med J 2018; 39:579-585. [PMID: 29915852 PMCID: PMC6058748 DOI: 10.15537/smj.2018.6.22376] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Objectives: To assess the effects of magnesium on the depth of anesthesia and to determine the effects of magnesium on incidence of awareness and postoperative pain after caesarean section. Methods: The study was designed as a double-blind, controlled, randomized study and conducted in Hacettepe University Hospital, Ankara, Turkey between January 2015 and March 2016. A total of 100 pregnant healthy women who were between 17 and 41 years old, ASA II, and scheduled for an elective cesarean section with general anesthesia were included in the study. After induction, sevoflurane was used for maintenance in Group S and desflurane in Group D (control groups). At Group S-M and Group D-M (study groups), magnesium infusion was started with sevoflurane and desflurane anesthesia respectively. Minimum alveolar concentration of sevoflurane and desflurane were kept constant. Bispectral index scores (BIS), fentanyl consumption and postoperative visual analogue scale (VAS) values were recorded. All of the patients had been followed-up for awareness until the postoperative first year. Results: Demographic variables of the patients were similar. BIS values were significantly higher in control groups throughout the operation (p<0.001). No significant difference was detected for intraoperative fentanyl consumption and awareness incidence. VAS values were significantly lower in study groups (p<0.05). Conclusion: Magnesium infusion provided significantly lower intraoperative BIS values and lower postoperative VAS scores. We believe that magnesium can be useful as an adjuvant to general anesthesia.
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Affiliation(s)
- Başak Altıparmak
- Department of Anesthesiology and Reanimation, Training and Research Hospital, Muğla Sıtkı Koçman University, Muğla, Turkey. E-mail.
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Szostakiewicz K, Rybicki Z, Tomaszewski D. Non-instrumental clinical monitoring does not guarantee an adequate course of general anesthesia. A prospective clinical study. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2018; 162:198-205. [PMID: 29568123 DOI: 10.5507/bp.2018.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 03/02/2018] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Clinical monitoring is the most common method of adjusting the appropriate level of general anesthesia. However, episodes of intraoperative awareness (AWR) are still reported, suggesting that clinical observations may not be sufficient in some cases. The objective of this study was to compare the efficacy of clinical and instrumental neuromonitoring with auditory evoked potentials (AEP) in an intraoperative analysis of the proper level of general anesthesia. METHODS Patients scheduled for elective surgery were randomly divided into two groups. Subjects in the first group underwent intravenous, in the second group volatile anesthesia. The adequacy of anesthesia was analyzed using clinical parameters. All the participants were instrumentally monitored with the autoregressive AEP index (AAI). After the anesthesia, patients filled out a questionnaire on possible AWR. RESULTS Data of 208 patients (87 in the first, and 121 in the second group) were analyzed. Before surgery there were no changes in AAI values between groups (80 vs. 78, P=0.5192). The mean values of clinical parameters changed, but five minutes after the nociceptive stimuli. The mean values of AAI at analyzed time points were specific for general anesthesia. In patients under intravenous anesthesia, we found more episodes of too low (46/608 vs.15/847, P<0.000) anesthesia. One case of AWR was found in the TIVA group. CONCLUSIONS AAI index is good indicator of patients' level of consciousness during general anesthesia. Standard clinical monitoring provides appropriate level of the procedure. However, it is insufficient during TIVA and does not prevent episodes of AWR.
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Affiliation(s)
- Katarzyna Szostakiewicz
- Department of Anesthesiology and Intensive Therapy, Military Institute of Medicine, 128 Szaserow Str., 04141 Warsaw, Poland
| | - Zbigniew Rybicki
- Department of Anesthesiology and Intensive Therapy, Military Institute of Medicine, 128 Szaserow Str., 04141 Warsaw, Poland
| | - Dariusz Tomaszewski
- Department of Anesthesiology and Intensive Therapy, Military Institute of Medicine, 128 Szaserow Str., 04141 Warsaw, Poland
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Hounsome J, Greenhalgh J, Schofield-Robinson OJ, Lewis SR, Cook TM, Smith AF. Nitrous oxide-based vs. nitrous oxide-free general anaesthesia and accidental awareness in surgical patients: an abridged Cochrane systematic review. Anaesthesia 2017; 73:365-374. [PMID: 29034449 DOI: 10.1111/anae.14065] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2017] [Indexed: 12/29/2022]
Abstract
Accidental awareness during general anaesthesia can arise from a failure to deliver sufficient anaesthetic agent, or from a patient's resistance to an expected sufficient dose of such an agent. Awareness is 'explicit' if the patient is subsequently able to recall the event. We conducted a systematic review into the effect of nitrous oxide used as part of a general anaesthetic on the risk of accidental awareness in people over the age of five years undergoing general anaesthesia for surgery. We included 15 randomised controlled trials, 14 of which, representing a total of 3439 participants, were included in our primary analysis of the frequency of accidental awareness events. The awareness incidence rate was rare within these studies, and all were considered underpowered with respect to this outcome. The risk of bias across all studies was judged to be high, and 76% of studies failed adequately to conceal participant allocation. We considered the available evidence to be of very poor quality. There were a total of three accidental awareness events reported in two studies, one of which reported that the awareness was the result of a kink in a propofol intravenous line. There were insufficient data to conduct a meta- or sub-group analysis and there was insufficient evidence to draw outcome-related conclusions. We can, however, recommend that future studies focus on potentially high-risk groups such as obstetric or cardiac surgery patients, or those receiving neuromuscular blocking drugs or total intravenous anaesthesia.
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Affiliation(s)
- J Hounsome
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - J Greenhalgh
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - O J Schofield-Robinson
- Patient Safety Research Unit, Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK
| | - S R Lewis
- Patient Safety Research Unit, Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK
| | - T M Cook
- Royal United Hospital Bath NHS Foundation Trust, Bath, UK
- School of Clinical Sciences, University of Bristol, Bristol, UK
| | - A F Smith
- Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK
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Abstract
The purpose of the study was to investigate the effects of total intravenous anesthesia (TIVA) and combined of intravenous and inhaled anesthesia (CIIA) on intraoperative awareness in surgical patients.A total of 678 patients were recruited in the CIIA group, while TIVA group included 566 patients. The clinical characteristics and the occurrence of intraoperative awareness were compared between the groups. Mini-Mental State Examination, Generalized Anxiety Disorder 7, and Patient Health Questionnaire 9 tests were performed to estimate cognitive and psychological functions of the patients. In addition, logistic regression analysis was applied to identify the risk factors for intraoperative awareness in surgical patients.In CIIA group, 3 patients (0.44%) were confirmed with intraoperative awareness, while 11 patients (1.94%) in TIVA group underwent intraoperative awareness. The occurrence rate of intraoperative awareness was significantly higher in VITA group than that in the CIIA group (P = .029). Awareness classification demonstrated that intraoperative awareness mainly included auditory, tactile, and pain perceptions. Moreover, 4 patients showed distress after operation. Patients with intraoperative awareness exhibited poor performance in cognitive and psychological tests (P < .001 for all). Logistic regression analysis demonstrated that CIIA (odds ratio [OR] = 0.198, 95% confidence interval [CI] = 0.047-0.827), age (OR = 0.951, 95% CI = 0.908-0.997), midazolam application (OR = 0.158, 95% CI = 0.034-0.736), awareness history (OR = 10.131, 95% CI = 2.206-45.517), and duration of surgery (OR = 1.016, 95% CI = 1.001-1.032) were significantly associated with intraoperative awareness.Intraoperative awareness can significantly influence the cognitive and psychological functions of surgical patients. CIIA and midazolam application may lower the risk of intraoperative awareness.
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MESH Headings
- Adult
- Anesthesia, General/adverse effects
- Anesthesia, General/methods
- Anesthesia, General/psychology
- Anesthesia, Inhalation/adverse effects
- Anesthesia, Inhalation/psychology
- Anesthesia, Intravenous/adverse effects
- Anesthesia, Intravenous/psychology
- Anesthetics, Inhalation/administration & dosage
- Anesthetics, Inhalation/adverse effects
- Female
- Humans
- Intraoperative Awareness/psychology
- Logistic Models
- Male
- Methyl Ethers/administration & dosage
- Methyl Ethers/adverse effects
- Middle Aged
- Operative Time
- Postoperative Complications/chemically induced
- Postoperative Complications/psychology
- Postoperative Period
- Propofol/administration & dosage
- Propofol/adverse effects
- Sevoflurane
- Stress, Psychological/chemically induced
- Stress, Psychological/psychology
- Treatment Outcome
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Leslie K, Culwick MD, Reynolds H, Hannam JA, Merry AF. Awareness during General Anaesthesia in the First 4,000 Incidents Reported to webairs. Anaesth Intensive Care 2017; 45:441-447. [DOI: 10.1177/0310057x1704500405] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The aim of this study was to analyse the incidents related to awareness during general anaesthesia in the first 4,000 cases reported to webAIRS—an anaesthetic incident reporting system established in Australia and New Zealand in 2009. Included incidents were those in which the reporter selected “neurological” as the main category and “awareness/dreaming/ nightmares” as a subcategory, those where the narrative report included the word “awareness” and those identified by the authors as possibly relevant to awareness. Sixty-one awareness-related incidents were analysed: 16 were classified as “awareness”, 31 were classified as “no awareness but increased risk of awareness” and 14 were classified as “no awareness and no increased risk of awareness”. Among 47 incidents in the former two categories, 42 (89%) were associated with low anaesthetic delivery and 24 (51%) were associated with signs of intraoperative wakefulness. Memory of intraoperative events caused significant ongoing distress for five of the 16 awareness patients. Patients continue to be put at risk of awareness by a range of well-described errors (such as syringe swaps) but also by some new errors related to recently introduced anaesthetic equipment, such as electronic anaesthesia workstations.
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Affiliation(s)
- K. Leslie
- Head of Research, Department of Anaesthesia and Pain Management, Royal Melbourne Hospital; Honorary Professorial Fellow, Anaesthesia, Perioperative and Pain Medicine Unit, Melbourne Medical School, Department of Pharmacology and Therapeutics, University of Melbourne; Honorary Adjunct Professor, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria
| | - M. D. Culwick
- Medical Director, Australian and New Zealand Tripartite Anaesthesia Data Committee, Anaesthetist, Department of Anaesthesia, Royal Brisbane and Women's Hospital, The University of Queensland, Brisbane, Queensland
| | - H. Reynolds
- Data Analyst, Australian and New Zealand Tripartite Anaesthesia Data Committee, Brisbane, Queensland
| | - J. A. Hannam
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| | - A. F. Merry
- Head of Research, Department of Anaesthesia and Pain Management, Royal Melbourne Hospital; Honorary Professorial Fellow, Anaesthesia, Perioperative and Pain Medicine Unit, Melbourne Medical School, Department of Pharmacology and Therapeutics, University of Melbourne; Honorary Adjunct Professor, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria
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46
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Liu Q, Chen YF, Fan SZ, Abbod MF, Shieh JS. Quasi-Periodicities Detection Using Phase-Rectified Signal Averaging in EEG Signals as a Depth of Anesthesia Monitor. IEEE Trans Neural Syst Rehabil Eng 2017; 25:1773-1784. [PMID: 28391200 DOI: 10.1109/tnsre.2017.2690449] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Phase-rectified signal averaging (PRSA) has been known to be a useful method to detect periodicities in non-stationary biological signals. Determination of quasi-periodicities in electroencephalogram (EEG) is a candidate for quantifying the changes in the depth of anesthesia (DOA). In this paper, DOA monitoring capacity of periodicities detected using PRSA was quantified by assessing EEG signals collected from 56 patients during surgery. The method is compared with sample entropy (SampEn), detrended fluctuation analysis (DFA), and permutation entropy (PE). The performance of quasi-periodicities defined by deceleration capacity and acceleration capacity was tested using the area under the receiver operating characteristic curve (AUC) and Pearson correlation coefficient. During the surgery, a significant difference ( ) in the quasi-periodicities was observed among three different stages under general anesthesia. There is a larger mean AUC and correlation coefficient of quasi-periodicities compared with SampEn, DFA, and PE using expert assessment of conscious level and bispectral index as the gold standard, respectively. Quasi-periodicities detected using PRSA in EEG signals are a powerful monitor of DOA and perform more accurate and robust results compared with SampEn, DFA, and PE. The results do provide a valuable reference to researchers in the field of clinical applications.
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Singla D, Mangla M. Incidence of Awareness with Recall under General Anesthesia in Rural India: An Observational Study. Anesth Essays Res 2017; 11:489-494. [PMID: 28663647 PMCID: PMC5490134 DOI: 10.4103/aer.aer_44_17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Context: Awareness under anesthesia is a rare but extremely unpleasant phenomenon. There are very few studies in the developing world and none from rural areas where incidence of intraoperative awareness may be higher due to increased patient load, limited patient knowledge and lack of trained hospital staff, reliance on older, cheaper but less effective drugs, and lack of proper equipment both for providing anesthesia, as well as monitoring the patient. Aims: To assess the incidence of intraoperative awareness during general anesthesia among patients in rural India and any factors associated with the same. Settings and Design: Prospective, nonrandomized, observational study. Subjects and Methods: Patients undergoing elective surgical procedures in various specialties under general anesthesia from over a period of 1 year were considered for this study. Approximately, after 1 h of arrival in postanaesthesia care unit, anesthesiologist (not involved in administering anesthesia) assessed intraoperative awareness using a modified form of Brice questionnaire. Statistical Analysis Used: Data were collected on a Microsoft Excel® sheet and analyzed using Statistical Package for the Social Sciences® version 23 (SPSS Inc., Chicago, IL, USA) for windows. Results: A total of 896 patients completed the questionnaire. Postoperatively, in response to the questionnaire, seven patients reported to have remembered something under anesthesia. Out of these, three patients described events that were confirmed by operation theater staff to have occurred whereas they were under anesthesia. Conclusions: Incidence of definite awareness under anesthesia with postoperative recall was found to be 0.33% (three patients out of total 896) in our study.
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Affiliation(s)
- Deepak Singla
- Department of Anaesthesia, AIIMS, Rishikesh, Uttarakhand, India
| | - Mishu Mangla
- Department of Obstetrics and Gynaecology, Himalayan Hospital, Dehradun, Uttarakhand, India
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Liu Q, Chen YF, Fan SZ, Abbod MF, Shieh JS. Improved spectrum analysis in EEG for measure of depth of anesthesia based on phase-rectified signal averaging. Physiol Meas 2016; 38:116-138. [PMID: 28033111 DOI: 10.1088/1361-6579/38/2/116] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The definition of the depth of anesthesia (DOA) is still controversial and its measurement is not completely standardized in modern anesthesia. Power spectral analysis is an important method for feature detection in electroencephalogram (EEG) signals. Several spectral parameters derived from EEG have been proposed for measuring DOA in clinical applications. In the present paper, an improved method based on phase-rectified signal averaging (PRSA) is designed to improve the predictive accuracy of relative alpha and beta power, a frequency band power ratio, total power, median frequency (MF), spectral edge frequency 95 (SEF95), and spectral entropy for assessing anesthetic drug effects. Fifty-six patients undergoing general anesthesia in an operating theatre are studied. All EEG signals are continuously recorded from the awake state to the end of the recovery state and then filtered using multivariate empirical mode decomposition (MEMD). All parameters are evaluated using the commercial bispectral index (BIS) and expert assessment of conscious level (EACL), respectively. The ability to predict DOA is estimated using the area under the receiver-operator characteristics curve (AUC). All indicators based on the improved method can clearly discriminate the conscious state from the anesthetized state after filtration (p < 0.05). A significantly larger mean AUC (p < 0.05) shows that the improved method performs better than the conventional method to measure the DOA in most circumstances. Especially for raw EEG contaminated by artifacts, when the BIS index is used to indicate the consciousness level, the improvement is 7.37% (p < 0.05), 9.04% (p < 0.05), 18.46% (p < 0.05), 27.73% (p < 0.05), 14.65% (p < 0.05), 2.52%, 5.38% and 6.24% (p < 0.05) for relative alpha and beta power, power ratio, total power, MF, SEF, RE and SE, respectively. However, when the EACL is used to indicate the consciousness level, the improvement is 3.30% (p < 0.05), 16.69% (p < 0.05), 15.08% (p < 0.05), 34.83% (p < 0.05), 27.78% (p < 0.05), 5.89% (p < 0.05), 26.05% (p < 0.05) and 23.42% (p < 0.05). Spectral parameters derived from PRSA are more useful to measure the DOA in noisy cases.
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Affiliation(s)
- Quan Liu
- Key Laboratory of Fiber Optic Sensing Technology and Information Processing, Ministry of Education, Wuhan University of Technology, Wuhan, Hubei 430070 People's Republic of China. School of Information Engineering, Wuhan University of Technology, Wuhan, Hubei 430070, People's Republic of China
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Calvo Vecino JM, Bergese S, Casans Francés R. Consciousness versus memory and intraoperative pain. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2016; 63:433-437. [PMID: 27568286 DOI: 10.1016/j.redar.2016.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 07/18/2016] [Indexed: 06/06/2023]
Affiliation(s)
- J M Calvo Vecino
- Hospital Universitario Infanta Leonor, Departamento de Farmacología, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, España.
| | - S Bergese
- Wexner Medical Center, Ohio State University, Columbus, Ohio, Estados Unidos de América
| | - R Casans Francés
- Servicio de Anestesiología y Reanimación, Hospital Clínico de Zaragoza, Zaragoza, España
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Hounsome J, Nicholson A, Greenhalgh J, Cook TM, Smith AF, Lewis SR. Nitrous oxide-based versus nitrous oxide-free general anaesthesia and accidental awareness during general anaesthesia in surgical patients. Cochrane Database Syst Rev 2016; 2016:CD011052. [PMID: 27508523 PMCID: PMC9284342 DOI: 10.1002/14651858.cd011052.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Accidental awareness during general anaesthesia (AAGA) is when a patient unintentionally becomes conscious during a procedure performed with general anaesthesia and subsequently has explicit recall of this event. Incidence estimates for AAGA vary, with the most common estimate being one to two cases per 1000 general anaesthetics. Evidence linking nitrous oxide use and an increased risk of AAGA has come from observational studies data but the literature is contradictory, with some studies finding a protective effect of nitrous oxide. OBJECTIVES To assess the effect of general anaesthesia including nitrous oxide on the risk of AAGA in patients aged five years and over. SEARCH METHODS We searched the following databases: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and trial registers ((www.clinicaltrials.gov), the WHO International Clinical Trials Registry Platform (www.who.int/ictrp/network/en/) and Current Controlled Trials (www.isrctn.com/)) for eligible studies on December 9 2015. In addition, we conducted forward and backward citation searching using key identified papers. SELECTION CRITERIA We considered all randomized controlled trials (RCTs), including quasi-randomized studies and cluster-randomized studies, of participants aged five years or older receiving general anaesthesia for any type of surgery.We included trials in which participants receiving general anaesthesia that included nitrous oxide for maintenance at a concentration of at least 30% were compared with participants receiving no nitrous oxide during general anaesthesia. The intervention group must have received nitrous oxide in conjunction with an additional anaesthetic. We excluded studies where the depth of anaesthesia differed between the study arms. For inclusion in the review, studies needed to state in their methods that they planned to assess AAGA. We defined this as when a patient becomes conscious during a procedure performed with general anaesthesia and subsequently has explicit recall of this event. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane to identify studies. We extracted data and conducted 'Risk of bias' assessment using the Covidence database. MAIN RESULTS We included 15 studies. The total number of participants included in the analyses was 3520. Most studies were small with fewer than 120 participants, although two larger studies with 2012 and 671 participants were included. There was considerable variation in many of the study characteristics, including the anaesthetics used. The concentrations of nitrous oxide varied between 50% and 70%, and half of the studies used clinical signs and haemodynamic changes to monitor depth of anaesthesia.As it was not possible to blind the anaesthetist to the anaesthetic used, we rated all studies at high risk of performance bias and we therefore downgraded the quality of evidence by one level for risk of bias using the GRADE approach. Other types of bias were generally low, or were rated unclear due to missing information.No studies were designed to measure AAGA as the primary outcome, and were therefore statistically underpowered to answer this review question. Despite the inclusion of 3520 participants, only three awareness events were reported by two studies. In one study the event was due to technical failure. Due to the rarity of the events, we did not consider it appropriate to pool the data, and we therefore downgraded the quality of evidence by a further level for imprecision using GRADE. AUTHORS' CONCLUSIONS It is not possible to draw any conclusions from this review. The included studies were mainly small (fewer than 120 participants) and there were limited estimates of effect, with only two studies reporting any events. We cannot therefore determine whether the use of nitrous oxide in general anaesthesia increases, decreases or has no effect on the risk of accidental awareness.
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Affiliation(s)
- Juliet Hounsome
- University of LiverpoolLiverpool Reviews and Implementation GroupSherrington BuildingAshton StreetLiverpoolUKL69 3GE
| | - Amanda Nicholson
- University of LiverpoolLiverpool Reviews and Implementation GroupSherrington BuildingAshton StreetLiverpoolUKL69 3GE
- Q Medical Technologies LimitedUnit 1A Summerlands Trading EstateEndmoorKendalUKLA8 0FB
| | - Janette Greenhalgh
- University of LiverpoolLiverpool Reviews and Implementation GroupSherrington BuildingAshton StreetLiverpoolUKL69 3GE
| | - Tim M Cook
- Royal United HospitalDepartment of AnaesthesiaCombe ParkBathUKBA1 3NG
| | - Andrew F Smith
- Royal Lancaster InfirmaryDepartment of AnaesthesiaAshton RoadLancasterLancashireUKLA1 4RP
| | - Sharon R Lewis
- Royal Lancaster InfirmaryPatient Safety Research DepartmentPointer Court 1, Ashton RoadLancasterUKLA1 1RP
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