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Tu Z, Zhang Y, Lv X, Wang Y, Zhang T, Wang J, Yu X, Chen P, Pang S, Li S, Yu X, Zhao X. Accurate Machine Learning-based Monitoring of Anesthesia Depth with EEG Recording. Neurosci Bull 2024:10.1007/s12264-024-01297-w. [PMID: 39289330 DOI: 10.1007/s12264-024-01297-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: 04/08/2024] [Accepted: 05/05/2024] [Indexed: 09/19/2024] Open
Abstract
General anesthesia, pivotal for surgical procedures, requires precise depth monitoring to mitigate risks ranging from intraoperative awareness to postoperative cognitive impairments. Traditional assessment methods, relying on physiological indicators or behavioral responses, fall short of accurately capturing the nuanced states of unconsciousness. This study introduces a machine learning-based approach to decode anesthesia depth, leveraging EEG data across different anesthesia states induced by propofol and esketamine in rats. Our findings demonstrate the model's robust predictive accuracy, underscored by a novel intra-subject dataset partitioning and a 5-fold cross-validation method. The research diverges from conventional monitoring by utilizing anesthetic infusion rates as objective indicators of anesthesia states, highlighting distinct EEG patterns and enhancing prediction accuracy. Moreover, the model's ability to generalize across individuals suggests its potential for broad clinical application, distinguishing between anesthetic agents and their depths. Despite relying on rat EEG data, which poses questions about real-world applicability, our approach marks a significant advance in anesthesia monitoring.
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Affiliation(s)
- Zhiyi Tu
- Department of Anesthesiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Yuehan Zhang
- Department of Anesthesiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Xueyang Lv
- Department of Anesthesiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Yanyan Wang
- Department of Anesthesiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Tingting Zhang
- Department of Anesthesiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Juan Wang
- Department of Anesthesiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Xinren Yu
- Department of Anesthesiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Pei Chen
- Department of Anesthesiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Suocheng Pang
- Department of Anesthesiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Shengtian Li
- Bio-X Institutes, Key Laboratory for the Genetics of Development and Neuropsychiatric Disorders (Ministry of Education), Shanghai Jiao Tong University, Shanghai, 200240, China
| | - Xiongjie Yu
- Department of Anesthesia, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, China.
- Zhejiang Key Laboratory of Precision Diagnosis and Therapy for Major Gynecological Diseases, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, 310027, China.
| | - Xuan Zhao
- Department of Anesthesiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China.
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Lütze C, Weber TP, Lücke T, Gude P, Georgevici AI. Incidence of emergence delirium after homeostasis-guided pediatric anesthesia for ear-nose-throat surgery. Minerva Anestesiol 2024; 90:644-653. [PMID: 39021140 DOI: 10.23736/s0375-9393.24.17847-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2024]
Abstract
BACKGROUND Emergence delirium is a complication of pediatric anesthesia during the early recovery period. Children undergoing ear, nose, and throat surgery are at high risk. The Pediatric Assessment of Emergence Delirium (PAED) scale is used for diagnosis and founded to specify the degree of emergence delirium. However, there is no consensus regarding a threshold value for emergence delirium diagnosis. Homeostasis-guided pediatric general anesthesia aims to maintain physiological parameters within normal ranges. In this prospective, observational study we evaluated the incidence of emergence delirium in children undergoing elective ear, nose, and throat surgery under standardized homeostasis-guided general anesthesia. Secondarily, we identified risk factors associated with an increased PAED score. METHODS In children aged 0-6 years, we collected data from standard monitoring, depth of anesthesia, and preoperative glucose and ketone body levels. These variables were studied as risk or protective factors for increased PAED >0 scores using multivariate logistic regression. RESULTS Of the 105 children analyzed, only five children (4.7%) had emergence delirium according to a threshold PAED score ≥10, while 37 children (35%) had PAED scores >0. Statistical analysis of the PAED outcome identified two significant positive associations with pain (P<0.001) and preoperative blood glucose levels (P=0.006) and one negative association with preoperative ketone body levels (P<0.001). CONCLUSIONS Our cohort observed a lower incidence of emergence delirium than in the literature. Higher pain intensity and lower blood glucose levels were risk factors for PAED > 0, whereas preoperative ketone body levels were protective.
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Affiliation(s)
- Christian Lütze
- Department of Anesthesiology, St. Josef and St. Elisabeth Hospital, Ruhr University Bochum, Bochum, Germany -
| | - Thomas P Weber
- Department of Anesthesiology, St. Josef and St. Elisabeth Hospital, Ruhr University Bochum, Bochum, Germany
| | - Thomas Lücke
- University Children's Hospital, St. Josef and St. Elisabeth Hospital, Ruhr University Bochum, Bochum, Germany
| | - Philipp Gude
- Department of Anesthesiology, St. Josef and St. Elisabeth Hospital, Ruhr University Bochum, Bochum, Germany
| | - Adrian-Iustin Georgevici
- Department of Anesthesiology, St. Josef and St. Elisabeth Hospital, Ruhr University Bochum, Bochum, Germany
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Franka M, Edthofer A, Körner A, Widmann S, Fenzl T, Schneider G, Kreuzer M. An in-depth analysis of parameter settings and probability distributions of specific ordinal patterns in the Shannon permutation entropy during different states of consciousness in humans. J Clin Monit Comput 2024; 38:385-397. [PMID: 37515662 PMCID: PMC10995010 DOI: 10.1007/s10877-023-01051-z] [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: 02/23/2023] [Accepted: 06/20/2023] [Indexed: 07/31/2023]
Abstract
As electrical activity in the brain has complex and dynamic properties, the complexity measure permutation entropy (PeEn) has proven itself to reliably distinguish consciousness states recorded by the EEG. However, it has been shown that the focus on specific ordinal patterns instead of all of them produced similar results. Moreover, parameter settings influence the resulting PeEn value. We evaluated the impact of the embedding dimension m and the length of the EEG segment on the resulting PeEn. Moreover, we analysed the probability distributions of monotonous and non-occurring ordinal patterns in different parameter settings. We based our analyses on simulated data as well as on EEG recordings from volunteers, obtained during stable anaesthesia levels at defined, individualised concentrations. The results of the analysis on the simulated data show a dependence of PeEn on different influencing factors such as window length and embedding dimension. With the EEG data, we demonstrated that the probability P of monotonous patterns performs like PeEn in lower embedding dimension (m = 3, AUC = 0.88, [0.7, 1] in both), whereas the probability P of non-occurring patterns outperforms both methods in higher embedding dimensions (m = 5, PeEn: AUC = 0.91, [0.77, 1]; P(non-occurring patterns): AUC = 1, [1, 1]). We showed that the accuracy of PeEn in distinguishing consciousness states changes with different parameter settings. Furthermore, we demonstrated that for the purpose of separating wake from anaesthesia EEG solely pieces of information used for PeEn calculation, i.e., the probability of monotonous patterns or the number of non-occurring patterns may be equally functional.
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Affiliation(s)
- Michelle Franka
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Rechts Der Isar, Technical University of Munich, Munich, Germany
- Department Biology, Ludwig-Maximilians University of Munich, LMU Biocenter, Planegg-Martinsried, Munich, Germany
| | - Alexander Edthofer
- Institute of Analysis and Scientific Computing, TU Wien, Vienna, Austria
| | - Andreas Körner
- Institute of Analysis and Scientific Computing, TU Wien, Vienna, Austria
| | - Sandra Widmann
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Rechts Der Isar, Technical University of Munich, Munich, Germany
| | - Thomas Fenzl
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Rechts Der Isar, Technical University of Munich, Munich, Germany
| | - Gerhard Schneider
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Rechts Der Isar, Technical University of Munich, Munich, Germany
| | - Matthias Kreuzer
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Rechts Der Isar, Technical University of Munich, Munich, Germany.
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Tang Y, Gao X, Xu J, Ren L, Qi H, Li R, Shu H, Zou X, Yuan S, Yang X, Shang Y. Remimazolam besylate versus propofol for deep sedation in critically ill patients: a randomized pilot study. Crit Care 2023; 27:474. [PMID: 38049909 PMCID: PMC10694930 DOI: 10.1186/s13054-023-04760-8] [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: 08/17/2023] [Accepted: 11/27/2023] [Indexed: 12/06/2023] Open
Abstract
OBJECTIVE To compare the efficacy and safety of remimazolam besylate and propofol for deep sedation in critically ill patients. METHODS In this single-center, prospective, randomized, controlled pilot study, patients in the intensive care unit (ICU) requiring deep sedation were randomized to receive remimazolam besylate or propofol intravenously. Deep sedation was defined as a Richmond Agitation and Sedation Scale (RASS) score of - 4 or - 5. Sedation depth was monitored using RASS and Narcotrend Index (NI). The primary outcome was the percentage of time within the target sedation range without rescue sedation. The secondary outcomes included ventilator-free hours within 7 days, successful extubation, length of ICU stay, and 28-day mortality. Adverse events during the interventional period were also recorded. RESULTS Thirty patients were assigned to each group. The median (IQR) RASS score was - 5.0 (- 5.0, - 4.0), and the median (IQR) NI value was 29.0 (21.0, 37.0) during the intervention period. Target RASS was reached a median of 100% of the sedation time in the two groups. No significant differences were observed in ventilator-free hours within 7 days, successful extubation, length of ICU stay, or 28-day mortality among groups. Hypotension occurred in 16 (53.3%) patients of remimazolam group and 18 (60.0%) patients of propofol group (p > 0.05). No patient experienced bradycardia. CONCLUSIONS Remimazolam besylate appears to be an effective and safe agent for short-term deep sedation in critically ill patients. Our findings warrant large sample-sized randomized clinical trials.
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Affiliation(s)
- Yun Tang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xuehui Gao
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jiqian Xu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lehao Ren
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hong Qi
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ruiting Li
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Huaqing Shu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaojing Zou
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shiying Yuan
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaobo Yang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - You Shang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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Hu J, Gu X, Zhu W, Zhu X, Ji F, Luo Y, Liu N. Comparison of anesthetic effects of different doses of alfentanil combined with ciprofol in elderly patients undergoing ERCP: a randomized controlled trial. BMC Anesthesiol 2023; 23:353. [PMID: 37907835 PMCID: PMC10617131 DOI: 10.1186/s12871-023-02325-4] [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: 05/14/2023] [Accepted: 10/26/2023] [Indexed: 11/02/2023] Open
Abstract
BACKGROUND AND OBJECTS Patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) are often old and poor in physical fitness. The purpose of this study was to investigate the anesthetic effect of different doses of alfentanil combined with ciprofol in elderly patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). METHODS In this clinical trial, 137 patients, who were candidates for ERCP were randomly divided into three groups. Group A were given 0.15 μg/kg/min of alfentanil in maintenance stage, Group B were given 0.25 μg/kg/min and Group C were given 0.35 μg/kg/min. Mean arterial pressure (MAP), heart rate (HR), oxygen saturation (SpO2) of the patients at each time point including the entry into the operation room (T0), at the beginning of surgery(T1), 10 min after surgery(T2), 20 min after surgery(T3), 30 min after surgery(T4),endoscopy withdrawal (T5) were recorded. Adverse events(including respiratory depression, body movement and hypoxemia),the dosage of ciprofol, the time of operation time and awakening were recorded. RESULTS Compared with Group A, MAP and HR in Group B and Group C was decreased during T1-T5 (P < 0.05). Compared with group B, MAP and HR in group C was decreased during T1-T5 (P < 0.05). Compared with Group A and Group C,the number of adverse reactions of Group B was decreased(P < 0.05). There was no statistical difference in surgical time among the three groups(P > 0.05),but a statistically significant difference in recovery time (P < 0.05). CONCLUSION The adverse events of alfentanil 0.25μg/kg/min combined with ciprofol were low, and the anesthetic effect was the best.
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Affiliation(s)
- Jun Hu
- Department of Anesthesiology, Weifang People's Hospital, Weifang, 261000, China
| | - Xiuxia Gu
- Department of Anesthesiology, Weifang People's Hospital, Weifang, 261000, China
| | - Wenhao Zhu
- Department of Anesthesiology, Dongying Shengli Oilfield Central Hospital, Dongying, China
| | - Xiuli Zhu
- Department of Anesthesiology, Weifang People's Hospital, Weifang, 261000, China
| | - Fanceng Ji
- Department of Anesthesiology, Weifang People's Hospital, Weifang, 261000, China
| | - Yanhua Luo
- Department of Anesthesiology, Weifang People's Hospital, Weifang, 261000, China
| | - Ning Liu
- Department of Anesthesiology, Weifang People's Hospital, Weifang, 261000, China.
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Fehrlin ES, Hight D, Kaiser HA, Luedi MM, Huber M, Zubler F, Lersch F. A Pilot Investigation Evaluating Relative Changes in Fronto-Occipital Alpha and Beta Spectral Power as Measurement of Anesthesia Hypnotic Depth. Anesth Analg 2023; 137:656-664. [PMID: 36961823 PMCID: PMC10408731 DOI: 10.1213/ane.0000000000006398] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2022] [Indexed: 03/25/2023]
Abstract
BACKGROUND Other than clinical observation of a patient's vegetative response to nociception, monitoring the hypnotic component of general anesthesia (GA) and unconsciousness relies on electroencephalography (EEG)-based indices. These indices exclusively based on frontal EEG activity neglect an important observation. One of the main hallmarks of transitions from wakefulness to GA is a shift in alpha oscillations (7.5-12.5 Hz activity) from occipital brain regions toward anterior brain regions ("alpha anteriorization"). Monitoring the degree of this alpha anteriorization may help to guide induction and maintenance of hypnotic depth and prevent intraoperative awareness. However, the occipital region of the brain is completely disregarded and occipital alpha as characteristic of wakefulness and its posterior-to-anterior shift during induction are missed. Here, we propose an application of Narcotrend's reduced power alpha beta (RPAB) index, originally developed to monitor differences in hemispheric perfusion, for determining the ratio of alpha and beta activity in the anterior-posterior axis. METHODS Perioperative EEG data of 32 patients undergoing GA in the ophthalmic surgery department of Bern University Hospital were retrospectively analyzed. EEG was recorded with the Narcotrend® monitor using a frontal (Fp1-Fp2) and a posterior (T9-Oz) bipolar derivation with reference electrode over A2. The RPAB index was computed between both bipolar signals, defining the fronto-occipital RPAB (FO-RPAB). FO-RPAB was analyzed during wakefulness, GA maintenance, and emergence, as well as before and after the intraoperative administration of a ketamine bolus. FO-RPAB was compared with a classical quantitative EEG measure-the spectral edge frequency 95% (SEF-95). RESULTS A significant shift of the FO-RPAB was observed during both induction of and emergence from GA ( P < .001). Interestingly, the additional administration of ketamine during GA did not lead to a significant change in FO-RPAB ( P = 0.81). In contrast, a significant increase in the SEF-95 in the frontal channel was observed during the 10-minute period after ketamine administration ( P < .001). CONCLUSIONS FO-RPAB appears to qualify as a marker of unconsciousness, reflecting physiological fronto-occipital activity differences during GA. In contrast to frontal SEF-95, it is not disturbed by additional administration of ketamine for analgesia.
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Affiliation(s)
- Eloy S. Fehrlin
- From the Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Darren Hight
- From the Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Heiko A. Kaiser
- From the Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Sleep-Wake-Epilepsy-Center, Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Markus M. Luedi
- From the Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Markus Huber
- From the Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Frédéric Zubler
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Friedrich Lersch
- From the Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Chen X, Zhang J, Yuan S, Huang H. Remimazolam besylate for the sedation of postoperative patients undergoing invasive mechanical ventilation in the ICU: a prospective dose‒response study. Sci Rep 2022; 12:19022. [PMID: 36347892 PMCID: PMC9643476 DOI: 10.1038/s41598-022-20946-6] [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: 05/21/2022] [Accepted: 09/21/2022] [Indexed: 11/09/2022] Open
Abstract
This single-center study aimed to determine the effective dose and safety of remimazolam besylate for the sedation of postoperative patients undergoing invasive mechanical ventilation in the intensive care unit (ICU). Mechanically ventilated patients admitted to the ICU after surgery were included. The Narcotrend index (NTI) was used to assess the depth of sedation, and the Richmond Agitation-Sedation Scale (RASS) score was also recorded. Remimazolam besylate was administered initially at a loading dose of 0.02 mg/kg, followed by a gradual increase of 0.005 mg/kg each time until the targeted depth of sedation was achieved (NTI 65-94). A maintenance dose of remimazolam besylate was administered starting at 0.2 mg/kg/h, followed by increments or subtractions of 0.05 mg/kg/h each time until a satisfactory depth of sedation was achieved and maintained for at least 30 min. The demographic data, anesthesia, surgery types, hemodynamics and respiratory parameters were recorded. Adverse events and adverse drug reactions were monitored for safety. Twenty-three patients were eventually included in this study covering a period of 1 year. A satisfactory depth of sedation was achieved by a single intravenous infusion of remimazolam besylate at a loading dose of 0.02-0.05 mg/kg followed by a maintenance dose of 0.20-0.35 mg/kg/h. There were no significant changes in hemodynamic and respiratory parameters within 10 min after the administration of remimazolam besylate. In addition, a significant correlation was observed between the NTI and the RASS score for assessing sedation (r = 0.721, P < 0.001). The NTI showed a predictive probability for a RASS score of 0.817. Remimazolam besylate was effective for mild/moderate sedation of invasively mechanically ventilated postoperative patients in the ICU while maintaining excellent respiratory and hemodynamic stability. The NTI can be used as a good tool for the objective evaluation of the depth of sedation and agitation.
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Affiliation(s)
- Xiaoyan Chen
- grid.33199.310000 0004 0368 7223Department of Critical Care Medicine, Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022 China ,grid.33199.310000 0004 0368 7223Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022 China
| | - Jiancheng Zhang
- grid.33199.310000 0004 0368 7223Department of Critical Care Medicine, Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022 China ,grid.33199.310000 0004 0368 7223Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022 China
| | - Shiying Yuan
- grid.33199.310000 0004 0368 7223Department of Critical Care Medicine, Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022 China ,grid.33199.310000 0004 0368 7223Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022 China
| | - Haiyan Huang
- grid.33199.310000 0004 0368 7223Department of Critical Care Medicine, Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022 China ,grid.33199.310000 0004 0368 7223Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022 China
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Han Y, Miao M, Li P, Yang Y, Zhang H, Zhang B, Sun M, Zhang J. EEG-Parameter-Guided Anesthesia for Prevention of Emergence Delirium in Children. Brain Sci 2022; 12:brainsci12091195. [PMID: 36138931 PMCID: PMC9496666 DOI: 10.3390/brainsci12091195] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 08/27/2022] [Accepted: 08/29/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Emergence delirium (ED) usually occurs in children after surgery with an incidence of 10−80%. Though ED is mostly self-limited, its potential injuries cannot be ignored. Whether electroencephalography (EEG)-parameter-guided anesthesia could reduce the incidence of ED in pediatric surgery has not been fully discussed to date. Methods: Fifty-four boys aged 2−12 years undergoing elective hypospadias surgery under sevoflurane anesthesia were selected. In the EEG-parameter-guided group (E group), sevoflurane was used for anesthesia induction and was maintained by titrating the spectral edge frequency (SEF) to 10−15 and combining the monitoring of density spectral array (DSA) power spectra and raw EEG. While in the control group (C group), anesthesiologists were blinded to the SedLine screen (including SEF, DSA, and raw EEG) and adjusted the intraoperative drug usage according to their experience. Patients with a Pediatric Anesthesia Emergence Delirium (PAED) score > 10 were diagnosed with ED, while patients with a PAED score > 2 were diagnosed with emergence agitation (EA). Results: Finally, a total of 37 patients were included in this trial. The incidence of ED in the E group was lower than in the C group (5.6% vs. 36.8%; p = 0.04), while the incidence of EA was similar in the two groups (61% vs. 78.9%; p = 0.48). Intraoperative parameters including remifentanil dosage and the decrease in mean arterial pressure (MAP) were not different between the two groups (p > 0.05), but the mean end-tidal sevoflurane concentration (EtSevo) was lower in the E group than in the C group (p > 0.05). Moreover, during PACU stay, the extubation time and discharge time of the groups were similar, while the PAED scores within 5 min from extubation and the Face, Legs, Activity, Cry, and Consolability (FLACC) scores within 30 min from extubation were lower in the E group than in the C group. Conclusion: EEG-parameter-guided anesthesia management reduced the incidence of ED in children. Studies with larger sample sizes are needed to obtain more convincing results.
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Affiliation(s)
- Yaqian Han
- Department of Anesthesiology and Perioperative Medicine, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Zhengzhou 450003, China
- Department of Anesthesiology and Perioperative Medicine, People’s Hospital of Zhengzhou University, Zhengzhou 450003, China
| | - Mengrong Miao
- Department of Anesthesiology and Perioperative Medicine, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Zhengzhou 450003, China
- Department of Anesthesiology and Perioperative Medicine, People’s Hospital of Zhengzhou University, Zhengzhou 450003, China
| | - Pule Li
- Department of Anesthesiology, Tengzhou Central People’s Hospital, Jining Medical College, Tengzhou 277522, China
| | - Yitian Yang
- Department of Anesthesiology and Perioperative Medicine, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Zhengzhou 450003, China
- Department of Anesthesiology and Perioperative Medicine, People’s Hospital of Zhengzhou University, Zhengzhou 450003, China
| | - Hui Zhang
- Department of Anesthesiology and Perioperative Medicine, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Zhengzhou 450003, China
- Department of Anesthesiology and Perioperative Medicine, People’s Hospital of Zhengzhou University, Zhengzhou 450003, China
| | - Beibei Zhang
- Department of Anesthesiology and Perioperative Medicine, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Zhengzhou 450003, China
- Department of Anesthesiology and Perioperative Medicine, People’s Hospital of Zhengzhou University, Zhengzhou 450003, China
| | - Mingyang Sun
- Department of Anesthesiology and Perioperative Medicine, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Zhengzhou 450003, China
- Correspondence: (M.S.); (J.Z.); Tel.: +86-0371-65580728 (M.S. & J.Z.)
| | - Jiaqiang Zhang
- Department of Anesthesiology and Perioperative Medicine, People’s Hospital of Zhengzhou University, Zhengzhou 450003, China
- Correspondence: (M.S.); (J.Z.); Tel.: +86-0371-65580728 (M.S. & J.Z.)
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Jang YE, Kim EH, Lee JH, Kim JT, Kim HS. Usefulness of bispectral index and patient state index during sevoflurane anesthesia in children: A prospective observational study. Medicine (Baltimore) 2022; 101:e29925. [PMID: 35905224 PMCID: PMC9333493 DOI: 10.1097/md.0000000000029925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Cortical electroencephalography-based devices are used to monitor the depth of anesthesia. In this study, we evaluated the values of bispectral index (BIS) and patient state index (PSI) during sevoflurane anesthesia in children. The ability/accuracy of BIS and PSI to predict the maintenance and recovery state of anesthesia was evaluated based on prediction probability (Pk) values and the secondary outcomes were agreement and correlation of 2 monitors. Fifty children (3-12 years old) were enrolled and the patients received sevoflurane anesthesia with remifentanil followed by propofol administration. Before the induction of anesthesia, BIS and PSI sensors were simultaneously placed on the forehead, and data were collected until the end of anesthesia. Maintenance state was defined as the period following intubation until the cessation of sevoflurane, while recovery state was defined as the period following the cessation of sevoflurane until awake. Pk, agreement or correlation of BIS and PSI in different anesthesia state were calculated. Anesthesia reduced mean BIS and PSI values. Pk of BIS (95% confidential interval [CI]: 0.78-0.91) and PSI (95% CI: 0.82-0.91) for anesthesia were 0.85 and 0.87, respectively. Agreement was 0.79 for recovery state and 0.73 for maintenance state. Pk values were comparable for BIS and PSI. Agreement between BIS and PSI measurements in the same state was relatively good. Therefore, these monitors are appropriate for monitoring for different state of anesthesia in pediatric population.
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Affiliation(s)
- Young-Eun Jang
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Eun-Hee Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Ji-Hyun Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jin-Tae Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, Seoul, Republic of Korea
| | - Hee-Soo Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, Seoul, Republic of Korea
- * Correspondence: Hee-Soo Kim, MD, PhD, Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, #101 Daehak-ro, Jongno-gu, 03080 Seoul, Republic of Korea (e-mail address: )
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Hight D, Schanderhazi C, Huber M, Stüber F, Kaiser HA. Age, minimum alveolar concentration and choice of depth of sedation monitor: examining the paradox of age when using the Narcotrend monitor: A secondary analysis of an observational study. Eur J Anaesthesiol 2022; 39:305-314. [PMID: 34313611 DOI: 10.1097/eja.0000000000001576] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND With an ageing global population, it is important to individualise titration of anaesthetics according to age and by measuring their effect on the brain. A recent study reported that during general surgery, the given concentration of volatile anaesthetics, expressed as a fraction of the minimum alveolar concentration (MAC fraction), decreases by around only 3% per age-decade, which is less than the 6% expected from age-adjusted MAC. Paradoxically, despite the excessive dosing, Bispectral index (BIS) values also increased. OBJECTIVE We planned to investigate the paradox of age when using the Narcotrend depth of anaesthesia monitor. DESIGN Secondary analyses of a prospective observational study. SETTING Tertiary hospital in Switzerland, recordings took place during 2016 and 2017. PATIENTS One thousand and seventy-two patients undergoing cardiac surgery entered the study, and 909 with noise-free recordings and isoflurane anaesthesia were included in this analysis. INTERVENTION We calculated mean end-tidal MAC fraction and mean index value of the Narcotrend depth of sedation monitor used in the study during the prebypass period. Statistical associations were modelled using linear regression, local weighted regression (LOESS) and a generalised additive model (GAM). MAIN OUTCOME MEASURES Primary endpoints in this study were the change in end-tidal MAC fraction and mean Narcotrend index values, both measured per age-decade. RESULTS We observed a linear decrease in end-tidal MAC fraction of 3.2% per age-decade [95% confidence interval (CI) -3.97% to -2.38%, P < 0.001], consistent with previous findings. In contrast to the BIS, mean Narcotrend index values decreased with age at 3.0 index points per age-decade (95% CI, -3.55 points to -2.36 points, P < 0.001), a direction of change commensurate with the increasing age-adjusted MAC fraction with patient age. These relationships were consistent regardless of whether age-adjusted MAC was displayed on the anaesthetic machine. CONCLUSIONS We caution that the 'paradox of age' may in part depend on the choice of depth of sedation monitor. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02976584.
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Affiliation(s)
- Darren Hight
- From the Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern (DH, CS, MH, FS, HAK) and Department of General Internal Medicine, Canton Hospital Frauenfeld, Frauenfeld, Switzerland (CS)
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Bi H, Cao S, Yan H, Jiang Z, Zhang J, Zou L. Resting State Functional Connectivity Analysis During General Anesthesia: A High-Density EEG Study. IEEE/ACM TRANSACTIONS ON COMPUTATIONAL BIOLOGY AND BIOINFORMATICS 2022; 19:3-13. [PMID: 34156946 DOI: 10.1109/tcbb.2021.3091000] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
The depth of anesthesia monitoring is helpful to guide administrations of general anesthetics during surgical procedures,however, the conventional 2-4 channels electroencephalogram (EEG) derived monitors have their limitations in monitoring conscious states due to low spatial resolution and suboptimal algorithm. In this study, 256-channel high-density EEG signals in 24 subjects receiving three types of general anesthetics (propofol, sevoflurane and ketamine) respectively were recorded both before and after anesthesia. The raw EEG signals were preprocessed by EEGLAB 14.0. Functional connectivity (FC) analysis by traditional coherence analysis (CA) method and a novel sparse representation (SR) method. And the network parameters, average clustering coefficient (ACC) and average shortest path length (ASPL) before and after anesthesia were calculated. The results show SR method find more significant FC differences in frontal and occipital cortices, and whole brain network (p<0.05). In contrast, CA can hardly obtain consistent ASPL in the whole brain network (p>0.05). Further, ASPL calculated by SR for whole brain connections in all of three anesthesia groups increased, which can be a unified EEG biomarker of general anesthetics-induced loss of consciousness (LOC). Therefore FC analysis based on SR analysis has better performance in distinguishing anesthetic-induced LOC from awake state.
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Emergence agitation in paediatric day case surgery: A randomised, single-blinded study comparing narcotrend and heart rate variability with standard monitoring. Eur J Anaesthesiol 2021; 39:261-268. [PMID: 34923564 DOI: 10.1097/eja.0000000000001649] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Postoperative emergence agitation remains a significant challenge in paediatric anaesthesia. Although short-lived, it may cause harm to the patient and negative experiences for all. Differentiating agitation, delirium and pain is difficult. Electroencephalography allows precise titration of anaesthetic depth, and heart rate variability monitoring permits immediate intervention regarding nociception and pain. We examined if one of these measures could be used to reduce postoperative agitation in an unselected paediatric day surgical population. OBJECTIVE The primary outcome was postoperative agitation with a Richmond Agitation-Sedation Scale greater than 0. Secondary outcomes were: length of stay, postoperative nausea and vomiting, fentanyl and propofol consumption, pain scores and use of postoperative analgesics. DESIGN A randomised, single-blinded study constituting children aged 1 to 6 years, undergoing minor general day surgical procedures. SETTING Paediatric day surgical department 29th March 2019 to 12th June 2020. PATIENTS Ninety-eight children (ASA 1 or 2) were enrolled, and 93 children were included in the final analysis. INTERVENTIONS Children received standard monitoring (n=31), standard monitoring plus either Narcotrend (n=31), or Anaesthesia Nociception Index monitoring (n=31). Sevoflurane or fentanyl was titrated immediately according to monitor thresholds. RESULTS Kaplan-Meier analysis yielded a statistically significant difference between the groups (P = 0.016) with the lowest agitation levels in the Anaesthesia Nociception Index group, intermediate levels in the control group and the highest agitation levels in the Narcotrend monitored group. Intergroup pairwise comparison however, showed no difference. The Anaesthesia Nocioception Index group received slightly more fentanyl (P = 0.277). The control group patients had the highest pain scores despite receiving more caudal blocks and the Narcotrend group had more sevoflurane adjustments. Other secondary outcomes were comparable. CONCLUSION Children in the Anaesthesia Nociception Index group were the least agitated with the highest fentanyl doses, without increasing the length of stay in the PACU or postoperative nausea and vomiting. CLINICAL REGISTRATION The study was registered in RedCAP online trial database 1/11/2018 trial registration nr. OP720. https://open.rsyd.dk/OpenProjects/openProject.jsp?openNo=720&lang=da.
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Dagnall C, Khenissi L, Love E. Monitoring techniques for equine anaesthesia. EQUINE VET EDUC 2021. [DOI: 10.1111/eve.13581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- C. Dagnall
- Faculty of Health Sciences The University of Bristol Bristol UK
| | | | - E. Love
- Faculty of Health Sciences The University of Bristol Bristol UK
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Shen JH, Ye M, Chen Q, Chen Y, Zhao HL, Khan A, Yi B, Ning JL, Lu KZ, Gu JT. Effects of circadian rhythm on Narcotrend index and target-controlled infusion concentration of propofol anesthesia. BMC Anesthesiol 2021; 21:215. [PMID: 34488646 PMCID: PMC8419887 DOI: 10.1186/s12871-021-01445-z] [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: 10/06/2020] [Accepted: 08/28/2021] [Indexed: 01/13/2023] Open
Abstract
Background The effects of circadian rhythms on drug metabolism and efficacy are being increasingly recognized. However, the extent to which they affect general anesthesia remains unclear. This study aims to investigate the effects of circadian rhythms on anesthetic depth and the concentrations of propofol target-controlled infusion (TCI). Methods Sixty patients undergoing laparoscopic surgeries were sequentially assigned to four groups. Group ND (n = 15): Propofol TCI with Narcotrend monitor during the day (8:00–18:00), Group NN (n = 15): Propofol TCI with Narcotrend monitor during the night (22:00–5:00), Group CLTD (n = 15): Propofol closed-loop TCI guided by bispectral index (BIS) during the day (8:00–18:00), Group CLTN (n = 15): Propofol closed-loop TCI guided by BIS during the night (22:00–5:00). The Narcotrend index, mean arterial pressure (MAP) and heart rate (HR) were compared between group ND and NN at 7 time points, from 5 min before induction to the end of operation. The propofol TCI concentrations, MAP and HR were compared between group CLTD and CLTN at 7 time points, from 5 min after induction to the end of operation. Results The Narcotrend index, MAP, and HR in group NN were lower than those in group ND from the beginning of mechanical ventilation to the end of operation (p < 0.05). The propofol TCI concentrations in group CLTN were lower than those in group CLTD from the beginning of operation to the end of operation (p < 0.05). Conclusion Circadian rhythms have a significant effect on the depth of anesthesia and drug infusion concentrations during propofol TCI. When using general anesthesia during night surgery, the propofol infusion concentration should be appropriately reduced compared to surgery during the day. Trial registration The present study was registered on the ClinicalTrials.gov website (NCT02440269) and approved by the Medical Ethics Committee of Southwest Hospital of Third Military Medical University (ethics lot number: 2016 Research No. 93). All patients provided informed written consent to participate in the study.
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Affiliation(s)
- Jiang-Hua Shen
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University (Army Medical University), No.30 Gaotanyan Road, Shapingba district, Chongqing, China
| | - Min Ye
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University (Army Medical University), No.30 Gaotanyan Road, Shapingba district, Chongqing, China
| | - Qian Chen
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University (Army Medical University), No.30 Gaotanyan Road, Shapingba district, Chongqing, China.,Division of Anesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea & Westminster Hospital, London, UK
| | - Yan Chen
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University (Army Medical University), No.30 Gaotanyan Road, Shapingba district, Chongqing, China
| | - Hai-Lin Zhao
- Division of Anesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea & Westminster Hospital, London, UK
| | - Ameena Khan
- Division of Anesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea & Westminster Hospital, London, UK
| | - Bin Yi
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University (Army Medical University), No.30 Gaotanyan Road, Shapingba district, Chongqing, China
| | - Jiao-Lin Ning
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University (Army Medical University), No.30 Gaotanyan Road, Shapingba district, Chongqing, China
| | - Kai-Zhi Lu
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University (Army Medical University), No.30 Gaotanyan Road, Shapingba district, Chongqing, China.
| | - Jian-Teng Gu
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University (Army Medical University), No.30 Gaotanyan Road, Shapingba district, Chongqing, China.
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Time-Frequency Analysis of EEG Signals and GLCM Features for Depth of Anesthesia Monitoring. COMPUTATIONAL INTELLIGENCE AND NEUROSCIENCE 2021; 2021:8430565. [PMID: 34422035 PMCID: PMC8376433 DOI: 10.1155/2021/8430565] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 07/26/2021] [Accepted: 08/04/2021] [Indexed: 11/28/2022]
Abstract
One of the important tasks in the operating room is monitoring the depth of anesthesia (DoA) during surgery, and noninvasive techniques are very popular. Hence, we propose a new scheme for DoA monitoring considering the time-frequency analysis of electroencephalography (EEG) signals and GLCM features extracted from them. To this end, at first, the time-frequency map (TFM) of each channel of each EEG is computed by smoothed pseudo-Wigner–Ville distribution (SPWVD), where the EEG signal used in this paper is recorded in 15 channels. After that, we consider the gray-level co-occurrence matrix (GLCM) to obtain the content of TFM, and after that, four features such as homogeneity, correlation, energy, and contrast are obtained for each GLCM. Finally, after the selection of efficient features using the minimum redundancy maximum relevance (MRMR) method, the K-nearest neighbor (KNN) classifier is utilized to determine the DoA. Here, we consider the three states, namely, deep hypnotic, surgical anesthesia, and sedation and awake states according to bispectral index (BIS), and each EEG epoch is classified to these states. We also employ data augmentation to enhance the training phase and increase accuracy. We obtain the accuracy and confusion matrix of the proposed method. We also analyze the effects of a number of gray levels of GLCM, distance measure in KNN classifier, and parameters of data augmentation on the performance of the proposed method. Results indicate the efficiency of the proposed method to determine the DoA during surgery.
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Obert DP, Schweizer C, Zinn S, Kratzer S, Hight D, Sleigh J, Schneider G, García PS, Kreuzer M. The influence of age on EEG-based anaesthesia indices. J Clin Anesth 2021; 73:110325. [PMID: 33975095 DOI: 10.1016/j.jclinane.2021.110325] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 04/07/2021] [Accepted: 04/21/2021] [Indexed: 02/06/2023]
Abstract
STUDY OBJECTIVE In the upcoming years there will be a growing number of elderly patients requiring general anaesthesia. As age is an independent risk factor for postoperative delirium (POD) the incidence of POD will increase concordantly. One approach to reduce the risk of POD would be to avoid excessively high doses of anaesthetics by using neuromonitoring to guide anaesthesia titration. Therefore, we evaluated the influence of patient's age on various electroencephalogram (EEG)-based anaesthesia indices. DESIGN AND PATIENTS We conducted an analysis of previously published data by replaying single electrode EEG episodes of maintenance of general anaesthesia from 180 patients (18-90 years; ASA I-IV) into the five different commercially available monitoring systems and evaluated their indices. We included the State/Response Entropy, Narcotrend, qCON/qNOX, bispectral index (BIS), and Treaton MGA-06. For a non-commercial comparison, we extracted the spectral edge frequency (SEF) from the BIS. To evaluate the influence of the age we generated linear regression models. We also assessed the correlation between the various indices. MAIN RESULTS During anaesthetic maintenance the values of the SEF, State/Response Entropy, qCON/qNOX and BIS all significantly increased (0.05 Hz/0.19-0.26 index points per year) with the patient's age (p < 0.001); whereas the Narcotrend did not change significantly with age (0.06 index points per year; p = 0.28). The index values of the Treaton device significantly decreased with age (-0.09 index points per year; p < 0.001). These findings were independent of the administered dose of anaesthetics. CONCLUSIONS Almost all current neuromonitoring devices are influenced by age, with the potential to result in inappropriately high dosage of anaesthetics. Therefore, anaesthesiologists should be aware of this phenomenon, and the next generation of monitors should correct for these changes.
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Affiliation(s)
- David P Obert
- Department of Anesthesiology and Intensive Care Medicine, Technical University of Munich, School of Medicine, Munich, Germany
| | - Catrin Schweizer
- Department of Anesthesiology and Intensive Care Medicine, Technical University of Munich, School of Medicine, Munich, Germany
| | - Sebastian Zinn
- Department of Anesthesiology, Goethe University, Frankfurt am Main, Germany
| | - Stephan Kratzer
- Department of Anesthesiology and Intensive Care Medicine, Technical University of Munich, School of Medicine, Munich, Germany
| | - Darren Hight
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Jamie Sleigh
- Department of Anaesthesia, Waikato Clinical School, University of Auckland, Hamilton, New Zealand
| | - Gerhard Schneider
- Department of Anesthesiology and Intensive Care Medicine, Technical University of Munich, School of Medicine, Munich, Germany
| | - Paul S García
- Department of Anesthesiology, Columbia University, New York, NY, USA
| | - Matthias Kreuzer
- Department of Anesthesiology and Intensive Care Medicine, Technical University of Munich, School of Medicine, Munich, Germany.
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Nguyen-Ky T, Tuan HD, Savkin A, Do MN, Van NTT. Real-Time EEG Signal Classification for Monitoring and Predicting the Transition Between Different Anaesthetic States. IEEE Trans Biomed Eng 2021; 68:1450-1458. [PMID: 33471747 DOI: 10.1109/tbme.2021.3053019] [Citation(s) in RCA: 6] [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
Quantitative identification of the transitions between anaesthetic states is very essential for optimizing patient safety and quality care during surgery but poses a very challenging task. The state-of-the-art monitors are still not capable of providing their manifest variables, so the practitioners must diagnose them based on their own experience. The present paper proposes a novel real-time method to identify these transitions. Firstly, the Hurst method is used to pre-process the de-noised electro-encephalograph (EEG) signals. The maximum of Hurst's ranges is then accepted as the EEG real-time response, which induces a new real-time feature under moving average framework. Its maximum power spectral density is found to be very differentiated into the distinct transitions of anaesthetic states and thus can be used as the quantitative index for their identification.
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Kermad A, Appenzeller M, Morinello E, Schneider SO, Kleinschmidt S, O'Gara B, Volk T, Meiser A. Reflection Versus Rebreathing for Administration of Sevoflurane During Minor Gynecological Surgery. Anesth Analg 2021; 132:1042-1050. [PMID: 32701542 DOI: 10.1213/ane.0000000000005074] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Contemporary anesthetic circle systems, when used at low fresh gas flows (FGF) to allow rebreathing of anesthetic, lack the ability for rapid dose titration. The small-scale anesthetic reflection device Anaesthetic Conserving Device (50mL Version; AnaConDa-S) permits administration of volatile anesthetics with high-flow ventilators. We compared washin, washout, and sevoflurane consumption using AnaConDa-S versus a circle system with low and minimal FGF. METHODS Forty patients undergoing breast surgery were randomized to receive 0.5 minimal alveolar concentration (MAC) sevoflurane with AnaConDa-S (21 patients, reflection group) or with a circle system (low flow: FGF = 0.2 minute ventilation [V'E], 9 patients; or minimal flow: 0.1 V'E, 10 patients). In the reflection group, syringe pump boluses were given for priming and washin; to simulate an open system, the FGF of the anesthesia ventilator was set to 18 L·min-1 with the soda lime removed. In the other groups, the FGF was increased for washin (1 V'E for 8 minutes) and washout (3 V'E). For all patients, tidal volume was 7 mL·kg-1 and the respiratory rate adjusted to ensure normoventilation. Analgesia was attained with remifentanil 0.3 µg·kg-1·min-1. Sevoflurane consumption was compared between the reflection group and the low- and minimal-flow groups, respectively, using a post hoc test (Fisher Least Significant Difference). To compare washin and washout (half-life), the low- and minimal-flow groups were combined. RESULTS Sevoflurane consumption was reduced in the reflection group (9.4 ± 2.0 vs 15.0 ± 3.5 [low flow, P < .001] vs 11.6 ± 2.3 mL·MAC h-1 [minimal flow, P = .02]); washin (33 ± 15 vs 49 ± 12 seconds, P = .001) and washout (28 ± 15 vs 55 ± 19 seconds, P < .001) times were also significantly shorter. CONCLUSIONS In this clinical setting with short procedures, low anesthetic requirements, and low tidal volumes, AnaConDa-S decreased anesthetic consumption, washin, and washout times compared to a circle system.
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Affiliation(s)
- Azzeddine Kermad
- From the Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, Saarland University Hospital Medical Center, Homburg/Saar, Germany
| | - Madeleine Appenzeller
- From the Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, Saarland University Hospital Medical Center, Homburg/Saar, Germany
| | - Emanuela Morinello
- From the Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, Saarland University Hospital Medical Center, Homburg/Saar, Germany
| | - Sven Oliver Schneider
- From the Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, Saarland University Hospital Medical Center, Homburg/Saar, Germany
| | - Stefan Kleinschmidt
- From the Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, Saarland University Hospital Medical Center, Homburg/Saar, Germany
| | - Brian O'Gara
- Department of Anesthesiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Thomas Volk
- From the Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, Saarland University Hospital Medical Center, Homburg/Saar, Germany
| | - Andreas Meiser
- From the Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, Saarland University Hospital Medical Center, Homburg/Saar, Germany
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Garbe J, Eisenmann S, Kantelhardt JW, Duenninghaus F, Michl P, Rosendahl J. Capability of processed EEG parameters to monitor conscious sedation in endoscopy is similar to general anaesthesia. United European Gastroenterol J 2021; 9:354-361. [PMID: 32921270 PMCID: PMC8259428 DOI: 10.1177/2050640620959153] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 08/20/2020] [Indexed: 11/23/2022] Open
Abstract
Background Reliable and safe sedation is a prerequisite for endoscopic interventions. The current standard is rather safe, yet, an objective device to measure sedation depth is missing. To date, anaesthesia monitors based on processed electroencephalogram (EEG) have not been utilised in conscious sedation. Objective To investigate EEG parameters to differentiate consciousness in endoscopic propofol sedation. Methods In total, 171 patients aged 21–83 years (ASA I–III) undergoing gastrointestinal and bronchial endoscopy were enrolled. Standard monitoring and a frontotemporal two‐channel EEG were recorded. The state of consciousness was identified by repeated requests to squeeze the investigator's hand. Results In total, 1132 state‐of‐consciousness (SOC) transitions were recorded in procedures ranging from 5 to 69 min. Thirty‐four EEG parameters from the frequency domain, time‐frequency domain and complexity measures were calculated. Area under the curve ranged from 0.51 to 0.82 with complexity and optimised frequency domain parameters yielding the best results. Conclusion Prediction of the SOC with processed EEG parameters is feasible, and the results for sedation in endoscopic procedures are similar to those reported from general anaesthesia. These results are insufficient for a clinical application, but prediction capability may be increased with optimisation and modelling. Electroencephalogram (EEG)‐based anaesthesia monitors, like the Bispectral Index, have been investigated as an adjunct to monitor propofol sedation in the endoscopy ward. These studies showed very limited benefit. Capability of processed EEG parameters to differentiate the state of consciousness (SOC) in endoscopy is similar to general anaesthesia. However, artefacts arising from the less controlled endoscopy environment as compared to anaesthesia limit their use in sedation monitoring. The Bispectral Index and its underlying parameters are ineffective in the determination of the SOC in sedation during endoscopic procedures.
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Affiliation(s)
- Jakob Garbe
- Department of Internal Medicine I, University Hospital Halle, Halle (Saale), Germany
| | - Stephan Eisenmann
- Department of Internal Medicine I, University Hospital Halle, Halle (Saale), Germany
| | - Jan W Kantelhardt
- Institute of Physics, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Florian Duenninghaus
- Department of Internal Medicine I, University Hospital Halle, Halle (Saale), Germany
| | - Patrick Michl
- Department of Internal Medicine I, University Hospital Halle, Halle (Saale), Germany
| | - Jonas Rosendahl
- Department of Internal Medicine I, University Hospital Halle, Halle (Saale), Germany
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Rogobete AF, Bedreag OH, Papurica M, Popovici SE, Bratu LM, Rata A, Barsac CR, Maghiar A, Garofil DN, Negrea M, Petcu LB, Toma D, Dumbuleu CM, Rimawi S, Sandesc D. Multiparametric Monitoring of Hypnosis and Nociception-Antinociception Balance during General Anesthesia-A New Era in Patient Safety Standards and Healthcare Management. ACTA ACUST UNITED AC 2021; 57:medicina57020132. [PMID: 33540844 PMCID: PMC7913052 DOI: 10.3390/medicina57020132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 01/27/2021] [Accepted: 01/28/2021] [Indexed: 11/16/2022]
Abstract
The development of general anesthesia techniques and anesthetic substances has opened new horizons for the expansion and improvement of surgical techniques. Nevertheless, more complex surgical procedures have brought a higher complexity and longer duration for general anesthesia, which has led to a series of adverse events such as hemodynamic instability, under- or overdosage of anesthetic drugs, and an increased number of post-anesthetic events. In order to adapt the anesthesia according to the particularities of each patient, the multimodal monitoring of these patients is highly recommended. Classically, general anesthesia monitoring consists of the analysis of vital functions and gas exchange. Multimodal monitoring refers to the concomitant monitoring of the degree of hypnosis and the nociceptive-antinociceptive balance. By titrating anesthetic drugs according to these parameters, clinical benefits can be obtained, such as hemodynamic stabilization, the reduction of awakening times, and the reduction of postoperative complications. Another important aspect is the impact on the status of inflammation and the redox balance. By minimizing inflammatory and oxidative impact, a faster recovery can be achieved that increases patient safety. The purpose of this literature review is to present the most modern multimodal monitoring techniques to discuss the particularities of each technique.
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Affiliation(s)
- Alexandru Florin Rogobete
- Faculty of Medicine, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (A.F.R.); (O.H.B.); (M.P.); (C.R.B.); (A.M.); (D.S.)
- Anaesthesia and Intensive Care Research Center, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (D.T.); (C.M.D.)
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital “Pius Brinzeu”, 300723 Timisoara, Romania;
| | - Ovidiu Horea Bedreag
- Faculty of Medicine, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (A.F.R.); (O.H.B.); (M.P.); (C.R.B.); (A.M.); (D.S.)
- Anaesthesia and Intensive Care Research Center, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (D.T.); (C.M.D.)
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital “Pius Brinzeu”, 300723 Timisoara, Romania;
| | - Marius Papurica
- Faculty of Medicine, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (A.F.R.); (O.H.B.); (M.P.); (C.R.B.); (A.M.); (D.S.)
- Anaesthesia and Intensive Care Research Center, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (D.T.); (C.M.D.)
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital “Pius Brinzeu”, 300723 Timisoara, Romania;
| | - Sonia Elena Popovici
- Faculty of Medicine, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (A.F.R.); (O.H.B.); (M.P.); (C.R.B.); (A.M.); (D.S.)
- Anaesthesia and Intensive Care Research Center, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (D.T.); (C.M.D.)
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital “Pius Brinzeu”, 300723 Timisoara, Romania;
- Correspondence: (S.E.P.); (L.M.B.); Tel.: +40-728-001-971
| | - Lavinia Melania Bratu
- Faculty of Medicine, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (A.F.R.); (O.H.B.); (M.P.); (C.R.B.); (A.M.); (D.S.)
- Correspondence: (S.E.P.); (L.M.B.); Tel.: +40-728-001-971
| | - Andreea Rata
- Department of Vascular Surgery, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania;
- Clinic of Vascular Surgery, Emergency County Hospital “Pius Brinzeu”, 300723 Timisoara, Romania
| | - Claudiu Rafael Barsac
- Faculty of Medicine, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (A.F.R.); (O.H.B.); (M.P.); (C.R.B.); (A.M.); (D.S.)
- Anaesthesia and Intensive Care Research Center, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (D.T.); (C.M.D.)
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital “Pius Brinzeu”, 300723 Timisoara, Romania;
| | - Andra Maghiar
- Faculty of Medicine, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (A.F.R.); (O.H.B.); (M.P.); (C.R.B.); (A.M.); (D.S.)
- Anaesthesia and Intensive Care Research Center, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (D.T.); (C.M.D.)
| | - Dragos Nicolae Garofil
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
| | - Mihai Negrea
- Faculty of Political, Administrative and Communication Sciences, Babes-Bolyai University, 400376 Cluj Napoca, Romania;
| | - Laura Bostangiu Petcu
- Faculty of Management, The Bucharest University of Economic Studies, 020021 Bucharest, Romania;
| | - Daiana Toma
- Anaesthesia and Intensive Care Research Center, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (D.T.); (C.M.D.)
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital “Pius Brinzeu”, 300723 Timisoara, Romania;
| | - Corina Maria Dumbuleu
- Anaesthesia and Intensive Care Research Center, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (D.T.); (C.M.D.)
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital “Pius Brinzeu”, 300723 Timisoara, Romania;
| | - Samir Rimawi
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital “Pius Brinzeu”, 300723 Timisoara, Romania;
| | - Dorel Sandesc
- Faculty of Medicine, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (A.F.R.); (O.H.B.); (M.P.); (C.R.B.); (A.M.); (D.S.)
- Anaesthesia and Intensive Care Research Center, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (D.T.); (C.M.D.)
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital “Pius Brinzeu”, 300723 Timisoara, Romania;
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Garbe J, Garbe V, Kantelhardt JW, Michl P, Eisenmann S, Rosendahl J, Krug S. Überwachung der Sedierung in der Endoskopie mit künstlicher Intelligenz. DER GASTROENTEROLOGE 2021; 16:17-24. [DOI: 10.1007/s11377-020-00494-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/30/2020] [Indexed: 08/30/2023]
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Montupil J, Defresne A, Bonhomme V. The Raw and Processed Electroencephalogram as a Monitoring and Diagnostic Tool. J Cardiothorac Vasc Anesth 2020; 33 Suppl 1:S3-S10. [PMID: 31279351 DOI: 10.1053/j.jvca.2019.03.038] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
In this narrative review, different aspects of electroencephalogram (EEG) monitoring during anesthesia are approached, with a special focus on cardiothoracic and vascular anesthesia, from the basic principles to more sophisticated diagnosis and monitoring utilities. The available processed EEG-derived indexes of the depth of the hypnotic component of anesthesia have well-defined limitations and usefulness. They prevent intraoperative awareness with recall in specific patient populations and under a specific anesthetic regimen. They prevent intraoperative overdose, and they shorten recovery times. They also help to avoid lengthy intraoperative periods of suppression activity, which are known to be deleterious in terms of outcome. Other than those available indexes, the huge amount of information contained in the EEG currently is being used only partially. Several other areas of interest regarding EEG during anesthesia have emerged in terms of anesthesia mechanisms elucidation, nociception monitoring, and diagnosis or prevention of brain insults.
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Affiliation(s)
- Javier Montupil
- University Department of Anesthesia and Intensive Care Medicine, CHR Citadelle, Liège, Belgium
| | - Aline Defresne
- Department of Anesthesia and Intensive Care Medicine, CHU Liege, Liège, Belgium
| | - Vincent Bonhomme
- Anesthesia and Intensive Care Laboratory, GIGA-Consciousness Thematic Unit, GIGA Research, Liege University, Liège, Belgium.
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Affiliation(s)
- Susana Vacas
- Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, Los Angeles, CA.
| | - Maxime Cannesson
- Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, Los Angeles, CA
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Kaiser HA, Hirschi T, Sleigh C, Reineke D, Hartwich V, Stucki M, Rummel C, Sleigh J, Hight D. Comorbidity-dependent changes in alpha and broadband electroencephalogram power during general anaesthesia for cardiac surgery. Br J Anaesth 2020; 125:456-465. [DOI: 10.1016/j.bja.2020.06.054] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 05/12/2020] [Accepted: 06/03/2020] [Indexed: 01/21/2023] Open
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Raue JF, Tünsmeyer J, Kästner SBR. Effects of isoflurane, remifentanil and dexmedetomidine on selected EEG parameters derived from a Narcotrend Monitor before and after nociceptive stimulation at different MAC multiples in cats. BMC Vet Res 2020; 16:332. [PMID: 32928231 PMCID: PMC7489203 DOI: 10.1186/s12917-020-02532-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 08/19/2020] [Indexed: 11/19/2022] Open
Abstract
Background The aim of this prospective and complete cross-over study was to evaluate the effects of isoflurane, remifentanil and dexmedetomidine on EEG parameters derived from the Narcotrend® Monitor before and after nociceptive stimulation at different isoflurane MAC (minimal alveolar concentration) multiples. Seven adult European Domestic Short Hair cats were used. Each cat went through 3 experimental treatments. Group I received isoflurane, group IR received isoflurane and a constant rate infusion (CRI) of remifentanil (18 μg/kg/h IV), and group ID received isoflurane and a CRI of dexmedetomidine (3 μg/kg/h IV). The isoflurane MAC in each group was determined via supramaximal electrical stimulation. The EEG parameters were derived by a Narcotrend Monitor at specific time points before and after nociceptive stimulation at 0.75, 1.0 and 1.5 MAC. The depth of anaesthesia was also assessed by a clinical score. Results The mean MAC sparing effects in group IR and group ID were 9.8 and 55.2%, respectively. The best correlation of EEG and MAC multiples was found for the Narcotrend Index (NI) in group I (r = − 0.67). The NI was also able to differentiate between 0.75 MAC and 1.5 MAC in group IR. Spectral edge frequency had a lower correlation with MAC multiples in group I (r = − 0.62) but was able to differentiate between 0.75 MAC and 1.5 MAC in groups I and IR, and between 1.0 MAC and 1.5 MAC in group IR. Narcotrend Index, SEF 95 and MF increased significantly after nociceptive stimulation at 1.0 MAC in group I, and SEF 95 increased significantly at 0.75 MAC in group ID. The clinical score correlated closer than any of the EEG parameters with MAC in all groups, with highest correlation values in group I (r = − 0.89). Noxious stimulation led to a significant increase of the clinical score at 0.75 MAC and 1.0 MAC in group I. Conclusions The EEG parameters derived from the Narcotrend Monitor show correlation to isoflurane MAC multiples in cats, but the anaesthetic protocol and especially the addition of dexmedetomidine have great influence on the reliability. The Narcotrend Monitor can be used as an additional tool to assess anesthetic depth in cats.
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Affiliation(s)
- Jonathan F Raue
- Small Animal Clinic, University of Veterinary Medicine Hannover, Foundation, Bünteweg 9, 30559, Hannover, Germany.
| | - Julia Tünsmeyer
- Small Animal Clinic, University of Veterinary Medicine Hannover, Foundation, Bünteweg 9, 30559, Hannover, Germany
| | - Sabine B R Kästner
- Small Animal Clinic, University of Veterinary Medicine Hannover, Foundation, Bünteweg 9, 30559, Hannover, Germany.,Center for Systems Neuroscience Hannover, University of Veterinary Medicine Hannover, Foundation, Bünteweg 9, 30559, Hannover, Germany
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Pharmacokinetics and Pharmacodynamics of Remimazolam (CNS 7056) after Continuous Infusion in Healthy Male Volunteers: Part II. Pharmacodynamics of Electroencephalogram Effects. Anesthesiology 2020; 132:652-666. [PMID: 31972657 DOI: 10.1097/aln.0000000000003102] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Remimazolam (CNS 7056) is a new ultra-short acting benzodiazepine for IV sedation. This study aimed to investigate the electroencephalogram (EEG) pharmacodynamics of remimazolam infusion. METHODS Twenty healthy male volunteers received remimazolam as continuous IV infusion of 5 mg/min for 5 min, 3 mg/min for the next 15 min, and 1 mg/min for further 15 min. Continuous EEG monitoring was performed by a neurophysiologic system with electrodes placed at F3, F4, C3, C4, O1, O2, Cz, and Fp1 (10/20 system) and using the Narcotrend Index. Sedation was assessed clinically by using the Modified Observer's Assessment of Alertness and Sedation scale. Pharmacodynamic models were developed for selected EEG variables and Narcotrend Index. RESULTS EEG changes during remimazolam infusion were characterized by an initial increase in beta frequency band and a late increase in delta frequency band. The EEG beta ratio showed a prediction probability of Modified Observer's Assessment of Alertness and Sedation score of 0.79, and could be modeled successfully using a standard sigmoid Emax model. Narcotrend Index showed a prediction probability of Modified Observer's Assessment of Alertness and Sedation score of 0.74. The time course of Narcotrend Index was described by an extended sigmoid Emax model with two sigmoid terms and different plasma-effect equilibration times. CONCLUSIONS Beta ratio was identified as a suitable EEG variable for monitoring remimazolam sedation. Narcotrend Index appeared less suitable than the beta ratio for monitoring the sedative effect if remimazolam is administered alone.
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Affiliation(s)
- Rossella Garra
- Institute of Anesthesia and Intensive Care, IRCCS A. Gemelli University Polyclinic Foundation, Sacred Heart Catholic University, Rome, Italy -
| | - Carmela Riso
- Institute of Anesthesia and Intensive Care, IRCCS A. Gemelli University Polyclinic Foundation, Sacred Heart Catholic University, Rome, Italy
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Chan MTV, Hedrick TL, Egan TD, García PS, Koch S, Purdon PL, Ramsay MA, Miller TE, McEvoy MD, Gan TJ. American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on the Role of Neuromonitoring in Perioperative Outcomes. Anesth Analg 2020; 130:1278-1291. [DOI: 10.1213/ane.0000000000004502] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Monitoring the level of hypnosis using a hierarchical SVM system. J Clin Monit Comput 2020; 34:331-338. [PMID: 30982945 DOI: 10.1007/s10877-019-00311-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 04/04/2019] [Indexed: 10/27/2022]
Abstract
Monitoring level of hypnosis is a major ongoing challenge for anesthetists to reduce anesthetic drug consumption, avoiding intraoperative awareness and prolonged recovery. This paper proposes a novel automated method for accurate assessing of the level of hypnosis with sevoflurane in 17 patients using the electroencephalogram signal. In this method, a set of distinctive features and a hierarchical classification structure based on support vector machine (SVM) methods, is proposed to discriminate the four levels of anesthesia (awake, light, general and deep states). The first stage of the hierarchical SVM structure identifies the awake state by extracting Shannon Permutation Entropy, Detrended Fluctuation Analysis and frequency features. Then deep state is identified by extracting the sample entropy feature; and finally light and general states are identified by extracting the three mentioned features of the first step. The accuracy of the proposed method of analyzing the brain activity during anesthesia is 94.11%; which was better than previous studies and also a commercial monitoring system (Response Entropy Index).
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Puchner WF, Dünser MW, Paulus P, Neuner MP, Mayer CL, Pomberger IM, Hackl R, Meier JM. A comparative study on adequate anesthesia depth: clinical judgement and the Narcotrend® measurement. Can J Anaesth 2020; 67:664-673. [PMID: 32128723 PMCID: PMC7214482 DOI: 10.1007/s12630-020-01602-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 11/26/2019] [Accepted: 12/04/2019] [Indexed: 12/19/2022] Open
Abstract
Purpose To compare the clinical judgement of electroencephalogram (EEG)-naïve anesthesiologists with an EEG-based measurement of anesthetic depth (AD) using the Narcotrend® monitor. Methods In this prospective cohort study including 600 patients, AD during stable anesthesia was assessed by clinical judgement of the attending, EEG-blinded anesthesiologist (using a scale staging the AD as mid-adequate, adequate but fairly deep, or adequate but fairly light) and by simultaneously recorded Narcotrend measurements. Results In 42% of patients (n = 250), the anesthesiologist’s clinical judgement was in agreement with anesthetic levels as measured by the Narcotrend monitor. In 46% of patients (n = 274), the anesthesiologist’s judgement and the Narcotrend monitor differed by one AD level (minor discordance). Major discordance was observed in 76 (13%) measurements (judged deeper than measured, n = 29 [5%]; judged lighter than measured, n = 47 [8%]). In 7% of patients (n = 44), the Narcotrend index was outside the limits of adequate AD (too deep, n = 28 [5%]; too superficial, n = 16 [3%]). The overall level of agreement between the anesthesiologist’s judgement and the Narcotrend monitor was not statistically significant (Cohen’s kappa, −0.039; P = 0.17). Using a random forests algorithm, age, mean blood pressure, the American Society of Anesthesiologists classification, body mass index, and frailty were the variables with the highest relative feature importance to predict the level of agreement. Conclusion These results suggest that clinical judgement of AD during stable anesthesia was not in agreement with EEG-based assessment of anesthetic depth in 58% of cases. Nevertheless, this finding could be influenced by the lack of validated scales to clinically judge AD. Trial registration www.clinicaltrials.gov (NCT02766894); registered 10 May, 2016.
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Affiliation(s)
- Wolfgang F Puchner
- Department of Anesthesiology and Intensive Care, Kepler University Hospital and Johannes Kepler University, Krankenhausstraße 9, 4021, Linz, Austria.
| | - Martin W Dünser
- Department of Anesthesiology and Intensive Care, Kepler University Hospital and Johannes Kepler University, Krankenhausstraße 9, 4021, Linz, Austria
| | - Patrick Paulus
- Department of Anesthesiology and Intensive Care, Kepler University Hospital and Johannes Kepler University, Krankenhausstraße 9, 4021, Linz, Austria
| | - Markus P Neuner
- Department of Anesthesiology and Intensive Care, Kepler University Hospital and Johannes Kepler University, Krankenhausstraße 9, 4021, Linz, Austria
| | - Charlotte L Mayer
- Department of Anesthesiology and Intensive Care, Kepler University Hospital and Johannes Kepler University, Krankenhausstraße 9, 4021, Linz, Austria
| | - Irmgard M Pomberger
- Department of Anesthesiology and Intensive Care, Kepler University Hospital and Johannes Kepler University, Krankenhausstraße 9, 4021, Linz, Austria
| | - Ruth Hackl
- Department of Anesthesiology and Intensive Care, Kepler University Hospital and Johannes Kepler University, Krankenhausstraße 9, 4021, Linz, Austria
| | - Jens M Meier
- Department of Anesthesiology and Intensive Care, Kepler University Hospital and Johannes Kepler University, Krankenhausstraße 9, 4021, Linz, Austria
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Villa EK, Villa D, Bundoc RC. Narcotrend-guided intraoperative care of a Trisomy 21 paediatric patient who underwent occipitocervical fusion. BMJ Case Rep 2020; 13:13/2/e231276. [PMID: 32051155 DOI: 10.1136/bcr-2019-231276] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
A 9-year-old female with Trisomy 21 with complex craniovertebral instability causing severe cervicomedullary compression underwent occipitocervical fusion. This paper will discuss the anaesthetic management and highlight the use of the Narcotrend monitor not only as a depth of consciousness monitor but more importantly as a tool to detect surgery-induced cerebral hypoperfusion by monitoring the right and left cerebral hemispheres independently and simultaneously.
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Affiliation(s)
- Evangeline Ko Villa
- Department of Anesthesiology Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Dominic Villa
- Department of Anesthesiology Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Rafael C Bundoc
- Department of Orthopedics Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
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Time delay of the qCON monitor and its performance during state transitions. J Clin Monit Comput 2020; 35:379-386. [PMID: 32040794 PMCID: PMC7943427 DOI: 10.1007/s10877-020-00480-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 01/31/2020] [Indexed: 01/16/2023]
Abstract
We investigated the performance of the qCON index regarding its time delay for sudden changes in the anesthetic level as well as to separate responsiveness from unresponsiveness during loss and return of responsiveness (LOR and ROR). For evaluation of the time delay, we replayed relevant EEG episodes to the qCON to simulate sudden changes between the states (i) awake/sedation, (ii) adequate anesthesia, or (iii) suppression. We also replayed EEG from 40 patients during LOR and ROR to evaluate the qCON’s ability to separate responsiveness from unresponsiveness. The time delays depended on the type of transition. The delays for the important transition between awake/sedation and adequate anesthesia were 21(5) s from awake/sedation to adequate anesthesia and 26(5) s in the other direction. The performance of the qCON to separate responsiveness from unresponsiveness depended on signal quality, the investigation window, i.e. ± 30 s or ± 60 s around LOR/ROR, and the specific transition being tested. AUC was 0.63–0.90 for LOR and 0.61–0.79 for ROR. Time delay and performance during state transitions of the qCON were similar to other monitoring systems such as bispectral index. The better performance of qCON during LOR than ROR probably reflects the sudden change in EEG activity during LOR and the more heterogeneous EEG during ROR.
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Scheeren TWL, Kuizenga MH, Maurer H, Struys MMRF, Heringlake M. Electroencephalography and Brain Oxygenation Monitoring in the Perioperative Period. Anesth Analg 2019; 128:265-277. [PMID: 29369096 DOI: 10.1213/ane.0000000000002812] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Maintaining brain function and integrity is a pivotal part of anesthesiological practice. The present overview aims to describe the current role of the 2 most frequently used monitoring methods for evaluation brain function in the perioperative period, ie, electroencephalography (EEG) and brain oxygenation monitoring. Available evidence suggests that EEG-derived parameters give additional information about depth of anesthesia for optimizing anesthetic titration. The effects on reduction of drug consumption or recovery time are heterogeneous, but most studies show a reduction of recovery times if anesthesia is titrated along processed EEG. It has been hypothesized that future EEG-derived indices will allow a better understanding of the neurophysiological principles of anesthetic-induced alteration of consciousness instead of the probabilistic approach most often used nowadays.Brain oxygenation can be either measured directly in brain parenchyma via a surgical burr hole, estimated from the venous outflow of the brain via a catheter in the jugular bulb, or assessed noninvasively by near-infrared spectroscopy. The latter method has increasingly been accepted clinically due to its ease of use and increasing evidence that near-infrared spectroscopy-derived cerebral oxygen saturation levels are associated with neurological and/or general perioperative complications and increased mortality. Furthermore, a goal-directed strategy aiming to avoid cerebral desaturations might help to reduce these complications. Recent evidence points out that this technology may additionally be used to assess autoregulation of cerebral blood flow and thereby help to titrate arterial blood pressure to the individual needs and for bedside diagnosis of disturbed autoregulation.
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Affiliation(s)
- Thomas W L Scheeren
- From the Department of Anaesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Merel H Kuizenga
- From the Department of Anaesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Holger Maurer
- Department of Anesthesiology and Intensive Care Medicine, University of Lübeck, Lübeck, Germany
| | - Michel M R F Struys
- From the Department of Anaesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Matthias Heringlake
- Department of Anesthesiology and Intensive Care Medicine, University of Lübeck, Lübeck, Germany
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Sponholz C, Schuwirth C, Koenig L, Hoyer H, Coldewey SM, Schelenz C, Doenst T, Kortgen A, Bauer M. Intraoperative reduction of vasopressors using processed electroencephalographic monitoring in patients undergoing elective cardiac surgery: a randomized clinical trial. J Clin Monit Comput 2019; 34:71-80. [PMID: 30784008 DOI: 10.1007/s10877-019-00284-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 02/13/2019] [Indexed: 01/13/2023]
Abstract
Intraoperative vasopressor and fluid application are common strategies against hypotension. Use of processed electroencephalographic monitoring (pEEG) may reduce vasopressor application, a known risk factor for organ dysfunction, in elective cardiac surgery patients. Randomized single-centre clinical trial at Jena University Hospital. Adult patients operated on cardiopulmonary bypass or off-pump coronary artery bypass grafting were randomised to receive anesthesia with visible or blinded pEEG using Narcotrend™. In blinded-Narcotrend (NT) depth of anesthesia was extrapolated from clinical signs, hemodynamic response and anesthetic concentration, supplemented by target indices between 37 and 64 in the visible-NT group. Intraoperative norepinephrine requirement (primary endpoint), fluid balance, extubation time, delirium occurrence and adverse events were evaluated. Patients of the intent-to-treat population (visible-NT: n = 123, blinded-NT: n = 122) had similar patient and procedural characteristics. Adjusted for type of surgery intraoperative Norepinephrine application was significantly reduced in visible-NT (n = 120, robust mean of cumulative dose 4.71 µg/kg bodyweight) compared to blinded-NT patients (n = 119, 6.14 µg/kg bodyweight) (adjusted robust mean difference 1.71 (95% CI 0.33-3.10) µg/kg bodyweight). Although reduction in patients operated on cardiopulmonary bypass was higher the interaction was not significant in post-hoc subgroup analysis. Intraoperative fluid balance was similar among both groups and strata. Extubation time was non-significantly lower in visible than in blinded-NT group. Overall postoperative delirium risk was 16.4% without differences among the groups. Adverse events-sudden movement/coughing, perspiration or hypertension-occurred more often with visible-NT, while one blinded-NT patient experienced intraoperative awareness. Titration of depth of anesthesia in elective cardiac surgery patients using pEEG allows to reduce application of norepinephrine.
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Affiliation(s)
- C Sponholz
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany.
| | - C Schuwirth
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - L Koenig
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - H Hoyer
- Institute of Medical Statistics, Computer Sciences and Data Sciences, Jena University Hospital, Jena, Germany
| | - S M Coldewey
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany.,ZIK Septomics Research Centre, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - C Schelenz
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - T Doenst
- Department of Cardiothoracic Surgery, Jena University Hospital, Jena, Germany
| | - A Kortgen
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - M Bauer
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
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Shander A, Lobel GP, Mathews DM. Brain Monitoring and the Depth of Anesthesia: Another Goldilocks Dilemma. Anesth Analg 2018; 126:705-709. [PMID: 28787338 DOI: 10.1213/ane.0000000000002383] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Aryeh Shander
- From the Englewood Hospital and Medical Center, TeamHealth Research Institute, Englewood, New Jersey
| | - Gregg P Lobel
- From the Englewood Hospital and Medical Center, TeamHealth Research Institute, Englewood, New Jersey
| | - Donald M Mathews
- Department of Anesthesiology, University of Vermont College of Medicine, Burlington, Vermont
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Li BL, Yuen VM, Zhou JL, Zhang N, Huang JX, Tian H, Song XR. A randomized controlled trial of oral chloral hydrate vs intranasal dexmedetomidine plus buccal midazolam for auditory brainstem response testing in children. Paediatr Anaesth 2018; 28:1022-1028. [PMID: 30281180 DOI: 10.1111/pan.13498] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 08/27/2018] [Accepted: 08/27/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Moderate to deep sedation is required for an auditory brainstem response test when high-intensity stimulation is used. Chloral hydrate is the most commonly used sedative, whereas intranasal dexmedetomidine is increasingly used in pediatric non-painful procedural sedations. OBJECTIVE The aim of this study was to compare the sedation success rate after oral chloral hydrate at 50 mg kg-1 and intranasal dexmedetomidine at 3 μg kg-1 plus buccal midazolam at 0.1 mg kg-1 for an auditory brainstem response test. METHODS Children who required an auditory brainstem response test were recruited and randomly assigned to receive oral chloral hydrate at 50 mg kg-1 and intranasal placebo, or intranasal dexmedetomidine at 3 μg kg-1 with buccal midazolam 0.1 mg kg-1 . The primary outcome was the rate of successful sedation for auditory brainstem response tests. RESULTS Fifty-seven out of 82 (69.5%) were successfully sedated after chloral hydrate, while 70 out of 78 (89.7%) children were successfully sedated with dexmedetomidine plus midazolam combination, with the odd ratio (95% CI) for successful sedation between dexmedetomidine plus midazolam combination and chloral hydrate estimated to be 3.84 (1.61-9.16), P = 0.002. Dexmedetomidine plus midazolam was associated with quicker onset with median onset time 15 (IQR 11.0-19.8) for dexmedetomidine plus midazolam and 20 (IQR 15.0-27.0) for chloral hydrate respectively, with difference between median (95% CI) of 5 [3-8], P < 0.0001). The behavior observed during drug administration of intranasal dexmedetomidine and buccal midazolam was better that of the children who had oral chloral hydrate. No children required oxygen therapy or medical intervention for hemodynamic disturbances in this study and the incidence of hypotension and bradycardia was similar. CONCLUSION Intranasal dexmedetomidine plus buccal midazolam was associated with higher sedation success with deeper level of sedation, with similar discharge time and adverse event rate when compared to chloral hydrate.
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Affiliation(s)
- Bi L Li
- Department of Anaesthesiology, Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Vivian M Yuen
- Department of Anaesthesiology, Hong Kong Children's Hospital and Queen Mary Hospital, Hong Kong, Hong Kong
| | - Jia L Zhou
- Department of Anaesthesiology, Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Na Zhang
- Department of Anaesthesiology, Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Jun X Huang
- Department of Anaesthesiology, Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Hang Tian
- Department of Anaesthesiology, Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Xing R Song
- Department of Anaesthesiology, Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, Guangzhou, Guangdong, China
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Fahy BG, Chau DF. The Technology of Processed Electroencephalogram Monitoring Devices for Assessment of Depth of Anesthesia. Anesth Analg 2018; 126:111-117. [DOI: 10.1213/ane.0000000000002331] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Dennhardt N, Beck C, Boethig D, Heiderich S, Horke A, Tiedge S, Boehne M, Sümpelmann R. Impact of temperature on the Narcotrend Index during hypothermic cardiopulmonary bypass in children with sevoflurane anesthesia. Perfusion 2017; 33:303-309. [DOI: 10.1177/0267659117746234] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: During cardiopulmonary bypass (CPB) in children, anesthesia maintained by sevoflurane administered via the oxygenator is increasingly common. Anesthetic uptake and requirement may be influenced by the non-physiological conditions during hypothermic CPB. Narcotrend-processed EEG monitoring may, therefore, be useful to guide the administration of sevoflurane during this phase. Objective: The objective of this prospective, clinical, observational study was to assess the correlation between body temperature, Narcotrend Index (NI) and administered sevoflurane in children during CPB. Methods: Forty-four children aged 0 to 10 years undergoing hypothermic cardiac surgery were studied. On bypass, anesthesia was maintained with sevoflurane administered via the oxygenator of the heart-lung machine. Nasopharyngeal temperature, NI and minimum alveolar concentration (MAC) of sevoflurane were recorded in intervals of 10 minutes. Expiratory gas was sampled from the oxygenator’s sole expiratory port via a separate connecting line and the MAC was measured by the agent analyzer of the anesthesia machine. Results: Raw (r = 0.74) and corrected (r = 0.73) r-values show that narcosis depth (as indicated by NI) can primarily be explained by the interaction of MAC and temperature. The analysis of variance (without the interaction term) confirms the significant and independent association of both factors, MAC (p<0.004, 95%CI: 0.19 to 0.46) and temperature (p<0.0001, 95%CI: 0.68 to 0.78), with the NI. During hypothermia, sevoflurane had been reduced significantly (r = 0.41, p<0.0001, 95%CI: 0.33 to 0.48). Conclusion: Perfusionists and anesthetists should be aware of the results of processed electroencephalograph (EEG) monitoring during CPB. Sevoflurane requirements differ inter-individually; they may decrease during cooling and increase during rewarming. Therefore, it seems reasonable to include the results of processed EEG monitoring when administering sevoflurane during CPB in children, but further studies are necessary to confirm this thesis.
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Affiliation(s)
- Nils Dennhardt
- Clinic for Anesthesiology and Intensive Care Medicine, Hanover Medical School, Hanover, Germany
| | - Christiane Beck
- Clinic for Anesthesiology and Intensive Care Medicine, Hanover Medical School, Hanover, Germany
| | - Dietmar Boethig
- Clinic for Cardiac, Thoracic, Transplant and Vascular Surgery, Hanover Medical School, Hanover, Germany
| | - Sebastian Heiderich
- Clinic for Anesthesiology and Intensive Care Medicine, Hanover Medical School, Hanover, Germany
| | - Alexander Horke
- Clinic for Cardiac, Thoracic, Transplant and Vascular Surgery, Hanover Medical School, Hanover, Germany
| | - Sebastian Tiedge
- Clinic for Cardiac, Thoracic, Transplant and Vascular Surgery, Hanover Medical School, Hanover, Germany
| | - Martin Boehne
- Clinic for Pediatric Cardiology and Pediatric Intensive Care Medicine, Hanover Medical School, Hanover, Germany
| | - Robert Sümpelmann
- Clinic for Anesthesiology and Intensive Care Medicine, Hanover Medical School, Hanover, Germany
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Intraoperative Noninvasive Cardiovascular and Brain Monitoring in the Elderly. CURRENT ANESTHESIOLOGY REPORTS 2017. [DOI: 10.1007/s40140-017-0237-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Vacas S, McInrue E, Gropper MA, Maze M, Zak R, Lim E, Leung JM. The Feasibility and Utility of Continuous Sleep Monitoring in Critically Ill Patients Using a Portable Electroencephalography Monitor. Anesth Analg 2017; 123:206-12. [PMID: 27159066 DOI: 10.1213/ane.0000000000001330] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Sleep disruption in critically ill adults can result in acute decrements in cognitive function, including delirium, but it is underdiagnosed in the setting of the intensive care unit (ICU). Although sleep stages can be assessed by polysomnography (PSG), acquisition and interpretation of PSG is costly, is labor intensive, is difficult to do over an extended period of time with critically ill patients (multiple days of continuous recording), and may interfere with patient care. In this pilot study, we investigated the feasibility and utility of monitoring sleep in the ICU setting using a portable electroencephalography (EEG) monitor, the SedLine brain monitor. METHODS We first performed a baseline comparison study of the SedLine brain monitor by comparing its recordings to PSG recorded in a sleep laboratory (n = 3). In a separate patient cohort, we enrolled patients in the ICU who were monitored continuously with the SedLine monitor for sleep disruption (n = 23). In all enrolled patients, we continuously monitored their EEG. The raw EEG was retrieved and sleep stages and arousals were analyzed by a board-certified technologist. Delirium was measured by a trained research nurse using the Confusion Assessment Method developed for the ICU. RESULTS For all enrolled patients, we continuously monitored their EEGs and were able to retrieve the raw EEGs for analysis of sleep stages. Overall, the SedLine brain monitor was able to differentiate sleep stages, as well as capture arousals and transitions between sleep stages compared with the PSG performed in the sleep laboratory. The percentage agreement was 67% for the wake stage, 77% for the non-rapid eye movement (REM) stage (N1 = 29%, N2 = 88%, and N3 = 6%), and 89% for the REM stage. The overall agreement was measured with the use of weighted kappa, which was 0.61, 95% confidence interval, 0.58 to 0.64. In the ICU study, the mean recording time for the 23 enrolled patients was 19.10 hours. There were several signs indicative of poor-quality sleep, where sleep was distributed throughout the day, with reduced time spent in REM (1.38% ± 2.74% of total sleep time), and stage N3 (2.17% ± 5.53% of total sleep time) coupled with a high arousal index (34.63 ± 19.04 arousals per hour). The occurrence of ICU delirium was not significantly different between patients with and without sleep disruption. CONCLUSIONS Our results suggest the utility of a portable EEG monitor to measure different sleep stages, transitions, and arousals; however, the accuracy in measuring different sleep stages by the SedLine monitor varies compared with PSG. Our results also support previous findings that sleep is fragmented in critically ill patients. Further research is necessary to develop portable EEG monitors that have higher agreement with PSG.
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Affiliation(s)
- Susana Vacas
- From the Departments of *Anesthesia and Perioperative Care and †Medicine, University of California San Francisco, San Francisco, California; and ‡Office of Biostatistics & Quantitative Health Sciences, University of Hawaii John A. Burns School of Medicine, Honolulu, Hawaii
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Kreuzer M. EEG Based Monitoring of General Anesthesia: Taking the Next Steps. Front Comput Neurosci 2017; 11:56. [PMID: 28690510 PMCID: PMC5479908 DOI: 10.3389/fncom.2017.00056] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 06/07/2017] [Indexed: 01/19/2023] Open
Affiliation(s)
- Matthias Kreuzer
- Department of Anesthesiology, Emory University School of MedicineAtlanta, GA, United States.,Research Division, Atlanta VA Medical CenterAtlanta, GA, United States
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Patel PA, Ackermann AM, Augoustides JG, Ender J, Gutsche JT, Giri J, Vallabhajosyula P, Desai ND, Kostibas M, Brady MB, Eoh EJ, Gaca JG, Thompson A, Fitzsimons MG. Anesthetic Evolution in Transcatheter Aortic Valve Replacement: Expert Perspectives From High-Volume Academic Centers in Europe and the United States. J Cardiothorac Vasc Anesth 2017; 31:777-790. [DOI: 10.1053/j.jvca.2017.02.051] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Indexed: 11/11/2022]
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Shalbaf A, Saffar M, Sleigh JW, Shalbaf R. Monitoring the Depth of Anesthesia Using a New Adaptive Neurofuzzy System. IEEE J Biomed Health Inform 2017; 22:671-677. [PMID: 28574372 DOI: 10.1109/jbhi.2017.2709841] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Accurate and noninvasive monitoring of the depth of anesthesia (DoA) is highly desirable. Since the anesthetic drugs act mainly on the central nervous system, the analysis of brain activity using electroencephalogram (EEG) is very useful. This paper proposes a novel automated method for assessing the DoA using EEG. First, 11 features including spectral, fractal, and entropy are extracted from EEG signal and then, by applying an algorithm according to exhaustive search of all subsets of features, a combination of the best features (Beta-index, sample entropy, shannon permutation entropy, and detrended fluctuation analysis) is selected. Accordingly, we feed these extracted features to a new neurofuzzy classification algorithm, adaptive neurofuzzy inference system with linguistic hedges (ANFIS-LH). This structure can successfully model systems with nonlinear relationships between input and output, and also classify overlapped classes accurately. ANFIS-LH, which is based on modified classical fuzzy rules, reduces the effects of the insignificant features in input space, which causes overlapping and modifies the output layer structure. The presented method classifies EEG data into awake, light, general, and deep states during anesthesia with sevoflurane in 17 patients. Its accuracy is 92% compared to a commercial monitoring system (response entropy index) successfully. Moreover, this method reaches the classification accuracy of 93% to categorize EEG signal to awake and general anesthesia states by another database of propofol and volatile anesthesia in 50 patients. To sum up, this method is potentially applicable to a new real-time monitoring system to help the anesthesiologist with continuous assessment of DoA quickly and accurately.
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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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Dennhardt N, Boethig D, Beck C, Heiderich S, Boehne M, Leffler A, Schultz B, Sümpelmann R. Optimization of initial propofol bolus dose for EEG Narcotrend Index-guided transition from sevoflurane induction to intravenous anesthesia in children. Paediatr Anaesth 2017; 27:425-432. [PMID: 28213945 DOI: 10.1111/pan.13118] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/08/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND Sevoflurane induction followed by intravenous anesthesia is a widely used technique to combine the benefits of an easier and less traumatic venipuncture after sevoflurane inhalation with a recovery with less agitation, nausea, and vomiting after total intravenous anesthesia (TIVA). Combination of two different anesthetics may lead to unwanted burst suppression in the electroencephalogram (EEG) during the transition phase. OBJECTIVE The objective of this prospective clinical observational study was to identify the optimal initial propofol bolus dose for a smooth transition from sevoflurane induction to TIVA using the EEG Narcotrend Index (NI). METHODS Fifty children aged 1-8 years scheduled for elective pediatric surgery were studied. After sevoflurane induction and establishing of an intravenous access, a propofol bolus dose range 0-5 mg·kg-1 was administered at the attending anesthetist's discretion to maintain a NI between 20 and 64, and sevoflurane was stopped. Anesthesia was continued as TIVA with a propofol infusion dose of 15 mg·kg-1 ·h-1 for the first 15 min, followed by stepwise reduction according to McFarlan's pediatric infusion regime, and remifentanil 0.25 μg·kg-1 ·min-1 . Endtidal concentration of sevoflurane, NI, and hemodynamic data were recorded during the whole study period using a standardized case report form. Propofol plasma concentrations were calculated using the paedfusor dataset and a TIVA simulation program. RESULTS Median endtidal concentration of sevoflurane at the time of administration of the propofol bolus was 5.1 [IQR 4.7-5.9] Vol%. The median propofol bolus dose was 1.2 [IQR 0.9-2.5] mg·kg-1 and median NI thereafter was 33 [IQR 23-40]. Nine children presented with a NI 13-20 and three children with burst suppression in the EEG (NI 0-12); all of them received an initial propofol bolus dose >2 mg·kg-1 . Regression equation demonstrated that NI 20-64 was achieved with a 95% probability when using a propofol bolus dose of 1 mg·kg-1 after sevoflurane induction. Decrease in mean arterial blood pressure correlated significantly with propofol bolus dose (P = 0.038). After 25 min of TIVA, children younger than 2 years had a higher NI (median difference 14.0, 95%CI: 6.0-20.0, P = 0.001), higher deviations from the expected Narcotend Index (median difference 4.1, 95%CI: 3.9-4.2, P < 0.001) and lower calculated propofol plasma concentrations (median difference 0.2 μg·ml-1 , 95% CI: 0.1-0.3 μg·ml-1 , P < 0.001) than older children. CONCLUSION After sevoflurane induction, a reduced propofol bolus dose of 1 mg·kg-1 followed by TIVA according to McFarlan's regime resulted in a NI within the recommended range in children aged 1-8 years. During the course of TIVA, children younger than 2 years displayed higher NI values and more pronounced interindividual variation. Processed EEG monitoring is recommended to find adequate individual age-dependent doses.
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Affiliation(s)
- Nils Dennhardt
- Clinic for Anesthesiology and Intensive Care Medicine, Hanover Medical School, Hanover, Germany
| | - Dietmar Boethig
- Clinic for Cardiac, Thoracic, Transplant and Vascular Surgery, Hanover Medical School, Hanover, Germany
| | - Christiane Beck
- Clinic for Anesthesiology and Intensive Care Medicine, Hanover Medical School, Hanover, Germany
| | - Sebastian Heiderich
- Clinic for Anesthesiology and Intensive Care Medicine, Hanover Medical School, Hanover, Germany
| | - Martin Boehne
- Clinic for Pediatric Cardiology and Pediatric Intensive Care Medicine, Hanover Medical School, Hanover, Germany
| | - Andreas Leffler
- Clinic for Anesthesiology and Intensive Care Medicine, Hanover Medical School, Hanover, Germany
| | - Barbara Schultz
- Clinic for Anesthesiology and Intensive Care Medicine, Hanover Medical School, Hanover, Germany
| | - Robert Sümpelmann
- Clinic for Anesthesiology and Intensive Care Medicine, Hanover Medical School, Hanover, Germany
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Şerban CA, Barborică A, Roceanu AM, Mîndruță IR, Ciurea J, Zăgrean AM, Zăgrean L, Moldovan M. EEG Assessment of Consciousness Rebooting from Coma. THE PHYSICS OF THE MIND AND BRAIN DISORDERS 2017. [DOI: 10.1007/978-3-319-29674-6_16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Zhang Y, Duan G, Guo S, Ying Y, Huang P, Zhang M, Li N, Zhang X. To predict sufentanil requirement for postoperative pain control using a real-time method: A prospective observational cohort study. Medicine (Baltimore) 2016; 95:e3915. [PMID: 27336880 PMCID: PMC4998318 DOI: 10.1097/md.0000000000003915] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Preoperative identification of individual sensitivity to opioid analgesics could improve the quality of postoperative analgesia. We explored the feasibility and utility of a real-time assessment of sufentanil sensitivity in predicting postoperative analgesic requirement.Our primary study included 111 patients who underwent measurements of pressure and quantitative pricking pain thresholds before and 5 minutes after sufentanil infusion. Pain intensity was assessed during the first 24-hour postsurgery, and patients who reported inadequate levels of analgesia were excluded from the study. The sufentanil requirement for patient-controlled analgesia was recorded, and a subsequent exploratory study of 20 patients facilitated the interpretation of the primary study results. In the primary study, experimental pain thresholds increased (P < 0.001) 5 minutes after sufentanil infusion, and the percent change in pricking pain threshold was positively associated with sufentanil requirement at 12 and 24 hours after surgery (β = 0.318, P = 0.001; and β = 0.335, P = 0.001). A receiver-operating characteristic curve analysis showed that patients with a change in pricking pain threshold >188% were >50% likely to require more sufentanil for postoperative pain control. In the exploratory study, experimental pain thresholds significantly decreased after the operation (P < 0.001), and we observed a positive correlation (P < 0.001) between the percent change in pricking pain threshold before and after surgery. Preoperative detection of individual sensitivity to sufentanil via the above described real-time method was effective in predicting postoperative sufentanil requirement. Thus, percent change in pricking pain threshold might be a feasible predictive marker of postoperative analgesia requirement.
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Affiliation(s)
- Yuhao Zhang
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Guangyou Duan
- Department of Anesthesiology, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Shanna Guo
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ying Ying
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Penghao Huang
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Mi Zhang
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ningbo Li
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xianwei Zhang
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Cascella M. Mechanisms underlying brain monitoring during anesthesia: limitations, possible improvements, and perspectives. Korean J Anesthesiol 2016; 69:113-20. [PMID: 27066200 PMCID: PMC4823404 DOI: 10.4097/kjae.2016.69.2.113] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 12/13/2015] [Accepted: 12/31/2015] [Indexed: 12/18/2022] Open
Abstract
Currently, anesthesiologists use clinical parameters to directly measure the depth of anesthesia (DoA). This clinical standard of monitoring is often combined with brain monitoring for better assessment of the hypnotic component of anesthesia. Brain monitoring devices provide indices allowing for an immediate assessment of the impact of anesthetics on consciousness. However, questions remain regarding the mechanisms underpinning these indices of hypnosis. By briefly describing current knowledge of the brain's electrical activity during general anesthesia, as well as the operating principles of DoA monitors, the aim of this work is to simplify our understanding of the mathematical processes that allow for translation of complex patterns of brain electrical activity into dimensionless indices. This is a challenging task because mathematical concepts appear remote from clinical practice. Moreover, most DoA algorithms are proprietary algorithms and the difficulty of exploring the inner workings of mathematical models represents an obstacle to accurate simplification. The limitations of current DoA monitors — and the possibility for improvement — as well as perspectives on brain monitoring derived from recent research on corticocortical connectivity and communication are also discussed.
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Affiliation(s)
- Marco Cascella
- Department of Anesthesia, Endoscopy and Cardiology, National Cancer Institute 'G Pascale' Foundation, Naples, Italy
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Otto KA. Differential effects of propofol and isoflurane on the relationship between EEG Narcotrend index and clinical stages of anaesthetic depth in sheep undergoing experimental cardiac surgery. Vet J 2016; 208:87-9. [DOI: 10.1016/j.tvjl.2015.10.049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Revised: 10/21/2015] [Accepted: 10/22/2015] [Indexed: 10/22/2022]
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Jia L, Dong R, Zhang F, Wang W, Lu H, Luo Y, Xue Q, Yu B. Propofol Provides More Effective Protection for Circulating Lymphocytes Than Sevoflurane in Patients Undergoing Off-Pump Coronary Artery Bypass Graft Surgery. J Cardiothorac Vasc Anesth 2015. [DOI: 10.1053/j.jvca.2015.01.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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