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Romagnoli S, Lobo FA, Picetti E, Rasulo FA, Robba C, Matta B. Non-invasive technology for brain monitoring: definition and meaning of the principal parameters for the International PRactice On TEChnology neuro-moniToring group (I-PROTECT). J Clin Monit Comput 2024; 38:827-845. [PMID: 38512360 PMCID: PMC11297817 DOI: 10.1007/s10877-024-01146-1] [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: 07/16/2023] [Accepted: 02/26/2024] [Indexed: 03/23/2024]
Abstract
Technologies for monitoring organ function are rapidly advancing, aiding physicians in the care of patients in both operating rooms (ORs) and intensive care units (ICUs). Some of these emerging, minimally or non-invasive technologies focus on monitoring brain function and ensuring the integrity of its physiology. Generally, the central nervous system is the least monitored system compared to others, such as the respiratory, cardiovascular, and renal systems, even though it is a primary target in most therapeutic strategies. Frequently, the effects of sedatives, hypnotics, and analgesics are entirely unpredictable, especially in critically ill patients with multiple organ failure. This unpredictability exposes them to the risks of inadequate or excessive sedation/hypnosis, potentially leading to complications and long-term negative outcomes. The International PRactice On TEChnology neuro-moniToring group (I-PROTECT), comprised of experts from various fields of clinical neuromonitoring, presents this document with the aim of reviewing and standardizing the primary non-invasive tools for brain monitoring in anesthesia and intensive care practices. The focus is particularly on standardizing the nomenclature of different parameters generated by these tools. The document addresses processed electroencephalography, continuous/quantitative electroencephalography, brain oxygenation through near-infrared spectroscopy, transcranial Doppler, and automated pupillometry. The clinical utility of the key parameters available in each of these tools is summarized and explained. This comprehensive review was conducted by a panel of experts who deliberated on the included topics until a consensus was reached. Images and tables are utilized to clarify and enhance the understanding of the clinical significance of non-invasive neuromonitoring devices within these medical settings.
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Affiliation(s)
- Stefano Romagnoli
- Department of Health Science, Section of Anesthesia and Critical Care, Department of Anesthesia and Critical Care, University of Florence, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
| | - Francisco A Lobo
- Anesthesiology Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Edoardo Picetti, Parma University Hospital, Parma, Italy
| | - Frank A Rasulo
- Neuroanesthesia and Neurocritical Care Unit, Spedali Civili University affiliated hospital of Brescia, Brescia, Italy
| | - Chiara Robba
- IRCCS Policlinico San Martino, Genova, Italy
- Dipartimento di Scienze Chirurgiche Diagnostiche ed Integrate, Università di Genova, Genova, Italy
| | - Basil Matta
- Consultant in Anaesthesia, Trauma and Critical Care, Cambridge University Hospitals, Cambridge, England
- Assistant Professor - University of Cambridge, Cambridge, England
- Global Senior Medical Director - Masimo International Irvine, Irvine, CA, United States
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Isik OG, Chauhan V, Ahmed MT, Chang BA, Cassim TZ, Graves MC, Rajan S, Garcia PS. Alternate Electrode Placements to Facilitate Frontal Electroencephalography Monitoring in Anesthetized and Critically Ill Patients. J Neurosurg Anesthesiol 2024:00008506-990000000-00098. [PMID: 38466565 DOI: 10.1097/ana.0000000000000955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 12/19/2023] [Indexed: 03/13/2024]
Abstract
BACKGROUND Frontal electroencephalography (EEG) monitoring can be useful in guiding the titration of anesthetics, but it is not always feasible to place electrodes in the standard configuration in some circumstances, including during neurosurgery. This study compares 5 alternate configurations of the Masimo Sedline Sensor. METHODS Ten stably sedated patients in the intensive care unit were recruited. Frontal EEG was monitored in the standard configuration (bifrontal upright) and 5 alternate configurations: bifrontal inverse, infraorbital, lateral upright, lateral inverse, and semilateral. Average power spectral densities (PSDs) with 95% CIs in the alternate configurations were compared to PSDs in the standard configuration. Two-one-sided-testing with Wilcoxon signed-rank tests assessed equivalence in the spectral edge frequency (SEF-95), EEG power, and relative delta (0.5 to 3.5 Hz), alpha (8 to 12 Hz), and beta (20 to 30 Hz) power between each alternate and standard configurations. RESULTS After the removal of unanalyzable tracings, 7 patients were included for analysis in the infraorbital configuration and 9 in all other configurations. In the lateral upright and lateral inverse configurations, PSDs significantly differed from the standard configuration within the 15 to 20 Hz band. The greatest decrease in EEG power was in the lateral inverse configuration (median: -97 dB; IQR: -130, -62 dB). The largest change in frequency distribution of EEG power was in the infraorbital configuration; median SEF-95 change of -1.4 Hz (IQR: -2.8, 0.7 Hz), median relative delta power change of +7.3% (IQR: 1.4%, 7.9%), and median relative alpha power change of -0.6% (IQR: -5.7%, 0.0%). CONCLUSIONS These 5 alternate Sedline electrode configurations are suitable options for monitoring frontal EEG when the standard configuration is not possible.
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Affiliation(s)
- Oliver G Isik
- Department of Anesthesiology, Columbia University Vagelos College of Physicians & Surgeons, New York, NY
| | - Vikas Chauhan
- Department of Anesthesiology, Columbia University Vagelos College of Physicians & Surgeons, New York, NY
| | - Meah T Ahmed
- Medical School, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Brian A Chang
- Department of Anesthesiology, Columbia University Vagelos College of Physicians & Surgeons, New York, NY
| | - Tuan Z Cassim
- Department of Psychology, School of Social and Behavioral Science, University of Utah, Salt Lake City, UT
| | - Morgan C Graves
- Department of Anesthesiology, Columbia University Vagelos College of Physicians & Surgeons, New York, NY
| | - Shobana Rajan
- Department of Anesthesiology, Cleveland Clinic, Cleveland, OH
| | - Paul S Garcia
- Department of Anesthesiology, Columbia University Vagelos College of Physicians & Surgeons, New York, NY
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Bi Y, Huang J, Li M, Li S, Lei H. Monitoring and evaluation of anesthesia depth status data based on neuroscience. Open Life Sci 2023; 18:20220719. [PMID: 38027229 PMCID: PMC10668331 DOI: 10.1515/biol-2022-0719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 07/26/2023] [Accepted: 08/13/2023] [Indexed: 12/01/2023] Open
Abstract
Monitoring and analysis of anesthesia depth status data refers to evaluating the anesthesia depth status of patients during the surgical process by monitoring their physiological index data, and conducting analysis and judgment. The depth of anesthesia is crucial for the safety and success of the surgical process. By monitoring the state of anesthesia depth, abnormal conditions of patients can be detected in a timely manner and corresponding measures can be taken to prevent accidents from occurring. Traditional anesthesia monitoring methods currently include computer tomography, electrocardiogram, respiratory monitoring, etc. In this regard, traditional physiological indicator monitoring methods have certain limitations and cannot directly reflect the patient's neural activity status. The monitoring and analysis methods based on neuroscience can obtain more information from the level of brain neural activity. PURPOSE In this article, the monitoring and analysis of anesthesia depth status data would be studied through neuroscience. METHODS Through a controlled experiment, the monitoring accuracy of traditional anesthesia status monitoring algorithm and neuroscience-based anesthesia status monitoring algorithm was studied, and the information entropy and oxygen saturation of electroencephalogram signals in patients with different anesthesia depth were explored. RESULTS The experiment proved that the average monitoring accuracy of the traditional anesthesia state monitoring algorithm in patients' blood drug concentration and oxygen saturation reached 95.55 and 95.00%, respectively. In contrast, the anesthesia state monitoring algorithm based on neuroscience performs better, with the average monitoring accuracy of drug concentration and oxygen saturation reaching 98.00 and 97.09%, respectively. This experimental result fully proved that the monitoring performance of anesthesia state monitoring algorithms based on neuroscience is better. CONCLUSION The experiment proved the powerful monitoring ability of the anesthesia state monitoring algorithm based on neuroscience used in this article, and explained the changing trend of brain nerve signals and oxygen saturation of patients with different anesthesia depth states, which provided a new research method for the monitoring and analysis technology of anesthesia depth state data.
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Affiliation(s)
- Yuhua Bi
- Department of Anesthesiology, Wuming Hospital Affiliated to Guangxi Medical University, Nanning530199, Guangxi, China
| | - Junping Huang
- Department of Anesthesiology, Wuming Hospital Affiliated to Guangxi Medical University, Nanning530199, Guangxi, China
| | - Mei Li
- Department of Anesthesiology, Wuming Hospital Affiliated to Guangxi Medical University, Nanning530199, Guangxi, China
| | - Siying Li
- Department of Anesthesiology, Wuming Hospital Affiliated to Guangxi Medical University, Nanning530199, Guangxi, China
| | - Heshou Lei
- Department of Anesthesiology, Wuming Hospital Affiliated to Guangxi Medical University, Nanning530199, Guangxi, China
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Neuner B, Wolter S, McCarthy WJ, Spies C, Cunningham C, Radtke FM, Franck M, Koenig T. EEG microstate quantifiers and state space descriptors during anaesthesia in patients with postoperative delirium: a descriptive analysis. Brain Commun 2023; 5:fcad270. [PMID: 37942086 PMCID: PMC10629467 DOI: 10.1093/braincomms/fcad270] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 08/21/2023] [Accepted: 10/16/2023] [Indexed: 11/10/2023] Open
Abstract
Postoperative delirium is a serious sequela of surgery and surgery-related anaesthesia. One recommended method to prevent postoperative delirium is using bi-frontal EEG recording. The single, processed index of depth of anaesthesia allows the anaesthetist to avoid episodes of suppression EEG and excessively deep anaesthesia. The study data presented here were based on multichannel (19 channels) EEG recordings during anaesthesia. This enabled the analysis of various parameters of global electrical brain activity. These parameters were used to compare microstate topographies under anaesthesia with those in healthy volunteers and to analyse changes in microstate quantifiers and EEG global state space descriptors with increasing exposure to anaesthesia. Seventy-three patients from the Surgery Depth of Anaesthesia and Cognitive Outcome study (SRCTN 36437985) received intraoperative multichannel EEG recordings. Altogether, 720 min of artefact-free EEG data, including 210 min (29.2%) of suppression EEG, were analysed. EEG microstate topographies, microstate quantifiers (duration, frequency of occurrence and global field power) and the state space descriptors sigma (overall EEG power), phi (generalized frequency) and omega (number of uncorrelated brain processes) were evaluated as a function of duration of exposure to anaesthesia, suppression EEG and subsequent development of postoperative delirium. The major analyses involved covariate-adjusted linear mixed-effects models. The older (71 ± 7 years), predominantly male (60%) patients received a median exposure of 210 (range: 75-675) min of anaesthesia. During seven postoperative days, 21 patients (29%) developed postoperative delirium. Microstate topographies under anaesthesia resembled topographies from healthy and much younger awake persons. With increasing duration of exposure to anaesthesia, single microstate quantifiers progressed differently in suppression or non-suppression EEG and in patients with or without subsequent postoperative delirium. The most pronounced changes occurred during enduring suppression EEG in patients with subsequent postoperative delirium: duration and frequency of occurrence of microstates C and D progressed in opposite directions, and the state space descriptors showed a pattern of declining uncorrelated brain processes (omega) combined with increasing EEG variance (sigma). With increasing exposure to general anaesthesia, multiple changes in the dynamics of microstates and global EEG parameters occurred. These changes varied partly between suppression and non-suppression EEG and between patients with or without subsequent postoperative delirium. Ongoing suppression EEG in patients with subsequent postoperative delirium was associated with reduced network complexity in combination with increased overall EEG power. Additionally, marked changes in quantifiers in microstate C and in microstate D occurred. These putatively adverse intraoperative trajectories in global electrical brain activity may be seen as preceding and ultimately predicting postoperative delirium.
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Affiliation(s)
- Bruno Neuner
- Department of Anaesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, 10117 Berlin, Germany
| | - Simone Wolter
- Department of Anaesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, 10117 Berlin, Germany
| | - William J McCarthy
- Centre for Cancer Prevention and Control Research, Fielding School of Public Health and Jonsson Comprehensive Cancer Centre, University of California Los Angeles (UCLA), Los Angeles, CA 90095-1781, USA
| | - Claudia Spies
- Department of Anaesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, 10117 Berlin, Germany
| | - Colm Cunningham
- School of Biochemistry and Immunology, Trinity Biomedical Sciences Institute & Trinity College Institute of Neuroscience, Trinity College Dublin, 2 D02 R590 Dublin, Ireland
| | - Finn M Radtke
- Department of Anaesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, 10117 Berlin, Germany
- Department of Anaesthesia and Intensive Care, Hospital of Nykøbing Falster, Fjordvej 15, 4800 Nykøbing Falster, Denmark
- University of Southern Denmark (SDU), Campusvej 55, 5230 Odense, Denmark
| | - Martin Franck
- Department of Anaesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, 10117 Berlin, Germany
- Department of Anaesthesia, Alexianer St.Hedwig Hospital, 10115 Berlin, Germany
| | - Thomas Koenig
- University Hospital of Psychiatry, Translational Research Centre, University of Bern, 3000 Bern, Switzerland
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Bong CL, Balanza GA, Khoo CEH, Tan JSK, Desel T, Purdon PL. A Narrative Review Illustrating the Clinical Utility of Electroencephalogram-Guided Anesthesia Care in Children. Anesth Analg 2023; 137:108-123. [PMID: 36729437 DOI: 10.1213/ane.0000000000006267] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The major therapeutic end points of general anesthesia include hypnosis, amnesia, and immobility. There is a complex relationship between general anesthesia, responsiveness, hemodynamic stability, and reaction to noxious stimuli. This complexity is compounded in pediatric anesthesia, where clinicians manage children from a wide range of ages, developmental stages, and body sizes, with their concomitant differences in physiology and pharmacology. This renders anesthetic requirements difficult to predict based solely on a child's age, body weight, and vital signs. Electroencephalogram (EEG) monitoring provides a window into children's brain states and may be useful in guiding clinical anesthesia management. However, many clinicians are unfamiliar with EEG monitoring in children. Young children's EEGs differ substantially from those of older children and adults, and there is a lack of evidence-based guidance on how and when to use the EEG for anesthesia care in children. This narrative review begins by summarizing what is known about EEG monitoring in pediatric anesthesia care. A key knowledge gap in the literature relates to a lack of practical information illustrating the utility of the EEG in clinical management. To address this gap, this narrative review illustrates how the EEG spectrogram can be used to visualize, in real time, brain responses to anesthetic drugs in relation to hemodynamic stability, surgical stimulation, and other interventions such as cardiopulmonary bypass. This review discusses anesthetic management principles in a variety of clinical scenarios, including infants, children with altered conscious levels, children with atypical neurodevelopment, children with hemodynamic instability, children undergoing total intravenous anesthesia, and those undergoing cardiopulmonary bypass. Each scenario is accompanied by practical illustrations of how the EEG can be visualized to help titrate anesthetic dosage to avoid undersedation or oversedation when patients experience hypotension or other physiological challenges, when surgical stimulation increases, and when a child's anesthetic requirements are otherwise less predictable. Overall, this review illustrates how well-established clinical management principles in children can be significantly complemented by the addition of EEG monitoring, thus enabling personalized anesthesia care to enhance patient safety and experience.
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Affiliation(s)
- Choon Looi Bong
- From the Department of Pediatric Anesthesia, KK Women's and Children's Hospital, Duke-NUS Medical School, Singapore
| | - Gustavo A Balanza
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Charis Ern-Hui Khoo
- From the Department of Pediatric Anesthesia, KK Women's and Children's Hospital, Duke-NUS Medical School, Singapore
| | - Josephine Swee-Kim Tan
- From the Department of Pediatric Anesthesia, KK Women's and Children's Hospital, Duke-NUS Medical School, Singapore
| | - Tenzin Desel
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Patrick Lee Purdon
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Crow J, Lindsley J, Cho SM, Wang J, Lantry JH, Kim BS, Tahsili-Fahadan P. Analgosedation in Critically Ill Adults Receiving Extracorporeal Membrane Oxygenation Support. ASAIO J 2022; 68:1419-1427. [PMID: 35593878 PMCID: PMC9675878 DOI: 10.1097/mat.0000000000001758] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is an increasingly utilized intervention for cardiopulmonary failure. Analgosedation during ECMO support is essential to ensure adequate pain and agitation control and ventilator synchrony, optimize ECMO support, facilitate patient assessment, and minimize adverse events. Although the principles of analgosedation are likely similar for all critically ill patients, ECMO circuitry alters medication pharmacodynamics and pharmacokinetics. The lack of clinical guidelines for analgosedation during ECMO, especially at times of medication shortage, can affect patient management. Here, we review pharmacological considerations, protocols, and special considerations for analgosedation in critically ill adults receiving ECMO support.
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Affiliation(s)
- Jessica Crow
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD
| | - John Lindsley
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD
| | - Sung-Min Cho
- Neurocritical Care Division, Departments of Neurology, Neurosurgery, and Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jing Wang
- Medical Critical Care Service, Department of Medicine, Inova Fairfax Medical Campus, Falls Church, VA
| | - James H Lantry
- Medical Critical Care Service, Department of Medicine, Inova Fairfax Medical Campus, Falls Church, VA
| | - Bo S. Kim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Pouya Tahsili-Fahadan
- Neurocritical Care Division, Departments of Neurology, Neurosurgery, and Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Medical Critical Care Service, Department of Medicine, Inova Fairfax Medical Campus, Falls Church, VA
- Department of Medical Education, University of Virginia, Inova Fairfax Medical Campus, Falls Church, VA
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Hernández-Hernández MA, Cherchi MS, Torres-Díez E, Orizaola P, Martín-Láez R, Fernández-Torre JL. Bispectral index monitoring to detect delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. J Crit Care 2022; 72:154154. [PMID: 36152563 DOI: 10.1016/j.jcrc.2022.154154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 09/07/2022] [Accepted: 09/07/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE Evaluate the bispectral index (BIS) monitoring to detect delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH). MATERIALS AND METHODS A single-center prospective study in patients with aSAH. BIS monitoring was recorded during 25-120 min in two periods, within the initial 72 h (BIS1) and between days 4 and 6 (BIS2) from admission. The median for each exported BIS parameter was analyzed. Transcranial Doppler (TCD) sonography was simultaneously performed with BIS1 (TCD1) and BIS2 (TCD2) monitoring. A multivariate logistic regression model was built to identify the variables associated with DCI. RESULTS Sixty-four patients were included and 16 (25%) developed DCI. During BIS2 monitoring, significant differences were found in BIS value (left, p = 0.01; right, p = 0.009), 95% spectral edge frequency (left and right, p = 0.04), and total power (left and right, p = 0.04). In multivariable analysis, vasospasm on TCD2 (OR 42.8 [95% CI 3.1-573]; p = 0.005), a median BIS2 value <85 in one or both sides (OR 6.2 [95% CI 1.28-30]; p = 0.023), and age (OR 1.08 [95% CI 1.00-1.17]; p = 0.04) were associated with the development of DCI. CONCLUSIONS BIS value is the most useful BIS parameter for detecting DCI after aSAH. Pending further validation, BIS monitoring might be even more accurate than TCD.
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Affiliation(s)
- Miguel A Hernández-Hernández
- Department of Intensive Medicine, Hospital Universitario Marqués de Valdecilla, Santander, Spain; Biomedical Research Institute (IDIVAL), Santander, Spain
| | - Marina S Cherchi
- Department of Intensive Medicine, Hospital Universitario Marqués de Valdecilla, Santander, Spain; Biomedical Research Institute (IDIVAL), Santander, Spain.
| | - Eduardo Torres-Díez
- Interventional Neuroradiology, Department of Radiology, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Pedro Orizaola
- Department of Clinical Neurophysiology, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Rubén Martín-Láez
- Biomedical Research Institute (IDIVAL), Santander, Spain; Department of Neurosurgery and Surgical Spine Unit, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - José L Fernández-Torre
- Biomedical Research Institute (IDIVAL), Santander, Spain; Department of Clinical Neurophysiology, Hospital Universitario Marqués de Valdecilla, Santander, Spain; Department of Physiology and Pharmacology, University of Cantabria (UNICAN), Santander, Spain
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Rasulo FA, Hopkins P, Lobo FA, Pandin P, Matta B, Carozzi C, Romagnoli S, Absalom A, Badenes R, Bleck T, Caricato A, Claassen J, Denault A, Honorato C, Motta S, Meyfroidt G, Radtke FM, Ricci Z, Robba C, Taccone FS, Vespa P, Nardiello I, Lamperti M. Processed Electroencephalogram-Based Monitoring to Guide Sedation in Critically Ill Adult Patients: Recommendations from an International Expert Panel-Based Consensus. Neurocrit Care 2022; 38:296-311. [PMID: 35896766 PMCID: PMC10090014 DOI: 10.1007/s12028-022-01565-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 06/20/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND The use of processed electroencephalography (pEEG) for depth of sedation (DOS) monitoring is increasing in anesthesia; however, how to use of this type of monitoring for critical care adult patients within the intensive care unit (ICU) remains unclear. METHODS A multidisciplinary panel of international experts consisting of 21 clinicians involved in monitoring DOS in ICU patients was carefully selected on the basis of their expertise in neurocritical care and neuroanesthesiology. Panelists were assigned four domains (techniques for electroencephalography [EEG] monitoring, patient selection, use of the EEG monitors, competency, and training the principles of pEEG monitoring) from which a list of questions and statements was created to be addressed. A Delphi method based on iterative approach was used to produce the final statements. Statements were classified as highly appropriate or highly inappropriate (median rating ≥ 8), appropriate (median rating ≥ 7 but < 8), or uncertain (median rating < 7) and with a strong disagreement index (DI) (DI < 0.5) or weak DI (DI ≥ 0.5 but < 1) consensus. RESULTS According to the statements evaluated by the panel, frontal pEEG (which includes a continuous colored density spectrogram) has been considered adequate to monitor the level of sedation (strong consensus), and it is recommended by the panel that all sedated patients (paralyzed or nonparalyzed) unfit for clinical evaluation would benefit from DOS monitoring (strong consensus) after a specific training program has been performed by the ICU staff. To cover the gap between knowledge/rational and routine application, some barriers must be broken, including lack of knowledge, validation for prolonged sedation, standardization between monitors based on different EEG analysis algorithms, and economic issues. CONCLUSIONS Evidence on using DOS monitors in ICU is still scarce, and further research is required to better define the benefits of using pEEG. This consensus highlights that some critically ill patients may benefit from this type of neuromonitoring.
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Affiliation(s)
- Frank A Rasulo
- Department of Anesthesiology and Intensive Care, Spedali Civili Hospital, Brescia, Italy. .,Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy.
| | - Philip Hopkins
- Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - Francisco A Lobo
- Institute of Anesthesiology, Cleveland Clinic, Abu Dhabi, United Arab Emirates
| | - Pierre Pandin
- Department of Anesthesia and Intensive Care, Erasme Hospital, Universitè Libre de Bruxelles, Brussels, Belgium
| | - Basil Matta
- Department of Anaesthesia and Intensive Care, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Carla Carozzi
- Department of Anesthesia and Intensive Care, Istituto Neurologico C. Besta, Milan, Italy
| | - Stefano Romagnoli
- Department of Anesthesia and Intensive Care, Careggi University Hospital, Florence, Italy
| | - Anthony Absalom
- Department of Anesthesiology, University Medical Center Groningen, Groningen, Netherlands
| | - Rafael Badenes
- Department of Anesthesia and Intensive Care, University of Valencia, Valencia, Spain
| | - Thomas Bleck
- Division of Stroke and Neurocritical Care, Department of Neurology, Northwestern University, Evanston, IL, USA
| | - Anselmo Caricato
- Department of Anesthesia and Intensive Care, Gemelli University Hospital, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Jan Claassen
- Department of Neurocritical Care, Columbia University Irving Medical Center, New York, NY, USA
| | - André Denault
- Critical Care Division, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Cristina Honorato
- Department of Anesthesiology and Critical Care, Universidad de Navarra, Pamplona, Spain
| | - Saba Motta
- Scientific Library, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Geert Meyfroidt
- Department of Intensive Care, University Hospitals Leuven and Laboratory of Intensive Care Medicine, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Finn Michael Radtke
- Department of Anesthesiology IRS, Nykøbing F. Hospital, Nykøbing Falster, Denmark
| | - Zaccaria Ricci
- Department of Pediatric Anesthesia, Meyer University Hospital of Florence, University of Florence, Florence, Italy
| | - Chiara Robba
- Department of Anesthesia and Intensive Care, Policlinico San Martino and University of Genoa, Genoa, Italy
| | - Fabio S Taccone
- Department of Anesthesia and Intensive Care, Erasme Hospital, Universitè Libre de Bruxelles, Brussels, Belgium
| | - Paul Vespa
- Department of Neurosurgery and Neurocritical Care, Los Angeles Medical Center, Ronald Reagan University of California, Los Angeles, CA, USA
| | - Ida Nardiello
- Department of Anesthesiology and Intensive Care, Spedali Civili Hospital, Brescia, Italy
| | - Massimo Lamperti
- Institute of Anesthesiology, Cleveland Clinic, Abu Dhabi, United Arab Emirates
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Hanidziar D, Westover MB. Monitoring of sedation in mechanically ventilated patients using remote technology. Curr Opin Crit Care 2022; 28:360-366. [PMID: 35653256 PMCID: PMC9434805 DOI: 10.1097/mcc.0000000000000940] [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: 02/04/2023]
Abstract
PURPOSE OF REVIEW Two years of coronavirus disease 2019 (COVID-19) pandemic highlighted that excessive sedation in the ICU leading to coma and other adverse outcomes remains pervasive. There is a need to improve monitoring and management of sedation in mechanically ventilated patients. Remote technologies that are based on automated analysis of electroencephalogram (EEG) could enhance standard care and alert clinicians real-time when severe EEG suppression or other abnormal brain states are detected. RECENT FINDINGS High rates of drug-induced coma as well as delirium were found in several large cohorts of mechanically ventilated patients with COVID-19 pneumonia. In patients with acute respiratory distress syndrome, high doses of sedatives comparable to general anesthesia have been commonly administered without defined EEG endpoints. Continuous limited-channel EEG can reveal pathologic brain states such as burst suppression, that cannot be diagnosed by neurological examination alone. Recent studies documented that machine learning-based analysis of continuous EEG signal is feasible and that this approach can identify burst suppression as well as delirium with high specificity. SUMMARY Preventing oversedation in the ICU remains a challenge. Continuous monitoring of EEG activity, automated EEG analysis, and generation of alerts to clinicians may reduce drug-induced coma and potentially improve patient outcomes.
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Affiliation(s)
- Dusan Hanidziar
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
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Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2022. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2022. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901.
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Affiliation(s)
- Denise Battaglini
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.,Department of Medicine, University of Barcelona, Barcelona, Spain
| | - Paolo Pelosi
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.,Department of Surgical Science and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Chiara Robba
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy. .,Department of Surgical Science and Integrated Diagnostics, University of Genoa, Genoa, Italy.
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11
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Davey Z, Gupta PB, Li DR, Nayak RU, Govindarajan P. Rapid Response EEG: Current State and Future Directions. Curr Neurol Neurosci Rep 2022; 22:839-846. [PMID: 36434488 PMCID: PMC9702853 DOI: 10.1007/s11910-022-01243-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW To critically appraise the literature on the application, methods, and advances in emergency electroencephalography (EEG). RECENT FINDINGS The development of rapid EEG (rEEG) technologies and other reduced montage approaches, along with advances in machine learning over the past decade, has increased the rate and access to EEG acquisition. These achievements have made EEG in the emergency setting a practical diagnostic technique for detecting seizures, suspected nonconvulsive status epilepticus (NCSE), altered mental status, stroke, and in the setting of sedation. Growing evidence supports using EEG to expedite medical decision-making in the setting of suspected acute neurological injury. This review covers approaches to acquiring EEG in the emergency setting in the adult and pediatric populations. We also cover the clinical impact of this data, the time associated with emergency EEG, and the costs of acquiring EEG in these settings. Finally, we discuss the advances in artificial intelligence for rapid electrophysiological interpretation.
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Affiliation(s)
- Zachary Davey
- grid.414467.40000 0001 0560 6544Department of Neurology, Walter Reed National Military Medical Center, Bethesda, MD USA
| | - Pranjal Bodh Gupta
- grid.240952.80000000087342732Department of Emergency Medicine, Stanford Medicine, Palo Alto, CA USA
| | - David R. Li
- grid.240952.80000000087342732Department of Emergency Medicine, Stanford Medicine, Palo Alto, CA USA
| | - Rahul Uday Nayak
- grid.240952.80000000087342732Department of Emergency Medicine, Stanford Medicine, Palo Alto, CA USA
| | - Prasanthi Govindarajan
- grid.240952.80000000087342732Department of Emergency Medicine, Stanford Medicine, Palo Alto, CA USA
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12
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Abstract
PURPOSE OF REVIEW To give an overview of cerebral monitoring techniques for surgical ICU patients. RECENT FINDINGS As the burden of postsurgical neurological and neurocognitive complications becomes increasingly recognized, cerebral monitoring in the surgical ICU might gain a relevant role in detecting and possibly preventing adverse outcomes. However, identifying neurological alterations in surgical ICU patients, who are often sedated and mechanically ventilated, can be challenging. Various noninvasive and invasive techniques are available for cerebral monitoring, providing an assessment of cortical electrical activity, cerebral oxygenation, blood flow autoregulation, intracranial pressure, and cerebral metabolism. These techniques can be used for the diagnosis of subclinical seizures, the assessment of sedation depth and delirium, the detection of an impaired cerebral blood flow, and the diagnosis of neurosurgical complications. SUMMARY Cerebral monitoring can be a valuable tool in the early detection of adverse outcomes in surgical ICU patients, but the evidence is limited, and clear clinical indications are still lacking.
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13
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Cavaliere F, Biancofiore G, Bignami E, De Robertis E, Giannini A, Piastra M, Scolletta S, Taccone FS, Terragni P. A year in review in Minerva Anestesiologica 2019. Critical care. Minerva Anestesiol 2020; 86:102-113. [PMID: 31994860 DOI: 10.23736/s0375-9393.20.14384-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Franco Cavaliere
- Institute of Anesthesia and Intensive Care, A. Gemelli University Polyclinic, IRCCS and Foundation, Sacred Heart Catholic University, Rome, Italy -
| | - Gianni Biancofiore
- Transplant Anesthesia and Critical Care, University School of Medicine, Pisa, Italy
| | - Elena Bignami
- Division of Anesthesiology, Critical Care and Pain Medicine, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Edoardo De Robertis
- Section of Anesthesia, Analgesia and Intensive Care, Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
| | - Alberto Giannini
- Unit of Pediatric Anesthesia and Intensive Care, ASST - Spedali Civili Children's Hospital, Brescia, Italy
| | - Marco Piastra
- Pediatric Intensive Care Unit and Trauma Center, A. Gemelli University Polyclinic, IRCCS and Foundation, Sacred Heart Catholic University, Rome, Italy
| | - Sabino Scolletta
- Department of Accident and Emergency, of Organ Transplantation, Anesthesia and Intensive Care, Siena University Hospital, Siena, Italy
| | - Fabio S Taccone
- Department of Intensive Care, Erasme Hospital, Free University of Brussels (ULB), Brussels, Belgium
| | - Pierpaolo Terragni
- Division of Anesthesia and General Intensive Care, Department of Medical, Surgical and Experimental Sciences, Sassari University Hospital, University of Sassari, Sassari, Italy
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14
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Demirel I, Yildiz Altun A, Bolat E, Kilinc M, Deniz A, Aksu A, Bestas A. Effect of Patient State Index Monitoring on the Recovery Characteristics in Morbidly Obese Patients: Comparison of Inhalation Anesthesia and Total Intravenous Anesthesia. J Perianesth Nurs 2020; 36:69-74. [PMID: 33012596 DOI: 10.1016/j.jopan.2020.07.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 07/03/2020] [Accepted: 07/05/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE Obese patients have a significantly higher risk of adverse effects associated with general anesthesia. The purpose of this study was to evaluate the effects of Patient State Index (PSI) monitoring on recovery from anesthesia and the incidence of any postoperative complications among patients undergoing bariatric surgery with total intravenous anesthesia (TIVA) and inhalational anesthesia. DESIGN This prospective, double-blind, and randomized controlled trial was conducted between February 2017 and August 2017 and included 120 morbidly obese patients (body mass index >40 kg/m2). METHODS Patients were randomly divided into four groups; group P-PSI (n = 30): TIVA with PSI monitoring; group P (n = 30): TIVA without PSI monitoring; group D-PSI (n = 30): desflurane with PSI monitoring; and group D (n = 30): desflurane without PSI monitoring. The discharge time from the postanesthesia care unit (PACU), postoperative complications, and hemodynamic parameters were recorded and evaluated. FINDINGS No significant differences were found in demographic data, duration of anesthesia, admittance to PACU, discharge from PACU, modified Aldrete scores, and perioperative mean blood pressure and heart rate. Nausea and vomiting scores were significantly lower in group P-PSI, group P, and group D-PSI compared with group D. CONCLUSIONS Although TIVA and inhalational anesthesia can be safely used for obese patients, intraoperative PSI monitoring may decrease the discharge time from PACU and reduces incidence of postoperative nausea and vomiting caused by inhalation anesthetics.
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Affiliation(s)
- Ismail Demirel
- Medicine Faculty, Anesthesiology and Reanimation Department, Firat University, Elazig, Turkey.
| | - Aysun Yildiz Altun
- Medicine Faculty, Anesthesiology and Reanimation Department, Firat University, Elazig, Turkey
| | - Esef Bolat
- Medicine Faculty, Anesthesiology and Reanimation Department, Firat University, Elazig, Turkey
| | - Mikail Kilinc
- Medicine Faculty, Anesthesiology and Reanimation Department, Firat University, Elazig, Turkey
| | - Ahmet Deniz
- Medicine Faculty, Anesthesiology and Reanimation Department, Firat University, Elazig, Turkey
| | - Ahmet Aksu
- Medicine Faculty, Anesthesiology and Reanimation Department, Firat University, Elazig, Turkey
| | - Azize Bestas
- Medicine Faculty, Anesthesiology and Reanimation Department, Firat University, Elazig, Turkey
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Sun Y, Wei C, Cui V, Xiu M, Wu A. Electroencephalography: Clinical Applications During the Perioperative Period. Front Med (Lausanne) 2020; 7:251. [PMID: 32582735 PMCID: PMC7296088 DOI: 10.3389/fmed.2020.00251] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 05/11/2020] [Indexed: 12/28/2022] Open
Abstract
Electroencephalography (EEG) monitoring has become technically feasible in daily clinical anesthesia practice. EEG is a sensitive method for detecting neurophysiological changes in the brain and represents an important frontier in the monitoring and treatment of patients in the perioperative period. In this review, we briefly introduce the essential principles of EEG. We review EEG application during anesthesia practice in the operating room, including the use of processed EEG in depth of anesthesia assessment, raw EEG monitoring in recognizing brain states under different anesthetic agents, the use of EEG in the prevention of perioperative neurocognitive disorders and detection of cerebral ischemia. We then discuss EEG utilization in the intensive care units, including the use of EEG in sedative level titration and prognostication of clinical outcomes. Existing literature provides insight into both the advances and challenges of the clinical applications of EEG. Future study is clearly needed to elucidate the precise EEG features that can reliably optimize perioperative care for individual patients.
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Affiliation(s)
- Yi Sun
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Changwei Wei
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Victoria Cui
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, United States
| | - Meihong Xiu
- Peking University HuiLongGuan Clinical Medical School, Beijing HuiLongGuan Hospital, Beijing, China
| | - Anshi Wu
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
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