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Schwerin S, Schneider G, Kreuzer M, Kratzer S. Impact of Age on the Occurrence of Processed Electroencephalographic Burst Suppression. Anesth Analg 2024:00000539-990000000-00915. [PMID: 39178156 DOI: 10.1213/ane.0000000000007143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2024]
Abstract
BACKGROUND Patient age is assumed to be an important risk factor for the occurrence of burst suppression, yet this has still to be confirmed by large datasets. METHODS In this single-center retrospective analysis at a university hospital, the electronic patient records of 38,628 patients (≥18 years) receiving general anesthesia between January 2016 and December 2018 were analyzed. Risk factors for burst suppression were evaluated using univariate and multivariable analysis. We measured the incidence of burst suppression as indicated by the burst suppression ratio (BSR) of the Entropy Module, the maximum and mean BSR values, relative burst suppression duration, mean volatile anesthetic concentrations, and mean age-adjusted minimum alveolar concentrations (aaMAC) at burst suppression, and cases of potentially misclassified burst suppression episodes. Analyses were done separately for the total anesthesia period, as well as for the Induction and Maintenance phase. The association with age was evaluated using linear and polynomial fits and by calculating correlation coefficients. RESULTS Of the 54,266 patients analyzed, 38,628 were included, and 19,079 patients exhibited episodes with BSR >0. Patients with BSR >0 were significantly older, and age had the highest predictive power for BSR >0 (area under the receiving operating characteristic [AUROC] = 0.646 [0.638-0.654]) compared to other patient or procedural factors. The probability of BSR >0 increased linearly with patient age (ρ = 0.96-0.99) between 1.9% and 9.8% per year. While maximal and mean BSR showed a nonlinear relationship with age, relative burst suppression duration also increased linearly during maintenance (ρ = 0.83). Further, episodes potentially indicating burst suppression that were not detected by the Entropy BSR algorithm also became more frequent with age. Volatile anesthetic concentrations sufficient to induce BSR >0 were negatively correlated with age (sevoflurane: ρ = -0.71), but remained close to an aaMAC of 1.0. CONCLUSIONS The probability of burst suppression during general anesthesia increases linearly with age in adult patients, while lower anesthetic concentrations induce burst suppression with increasing patient age. Simultaneously, algorithm-based burst suppression detection appears to perform worse in older patients. These findings highlight the necessity to further enhance EEG application and surveillance strategies in anesthesia.
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Affiliation(s)
- Stefan Schwerin
- From the Department of Anesthesiology and Intensive Care Medicine, Technical University of Munich School of Medicine and Health, Munich, Germany
| | - Gerhard Schneider
- From the Department of Anesthesiology and Intensive Care Medicine, Technical University of Munich School of Medicine and Health, Munich, Germany
| | - Matthias Kreuzer
- From the Department of Anesthesiology and Intensive Care Medicine, Technical University of Munich School of Medicine and Health, Munich, Germany
| | - Stephan Kratzer
- Department of Anesthesia and Intensive Care Medicine, Hessing Foundation, Augsburg, Germany
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Aldecoa C, Bettelli G, Bilotta F, Sanders RD, Aceto P, Audisio R, Cherubini A, Cunningham C, Dabrowski W, Forookhi A, Gitti N, Immonen K, Kehlet H, Koch S, Kotfis K, Latronico N, MacLullich AMJ, Mevorach L, Mueller A, Neuner B, Piva S, Radtke F, Blaser AR, Renzi S, Romagnoli S, Schubert M, Slooter AJC, Tommasino C, Vasiljewa L, Weiss B, Yuerek F, Spies CD. Update of the European Society of Anaesthesiology and Intensive Care Medicine evidence-based and consensus-based guideline on postoperative delirium in adult patients. Eur J Anaesthesiol 2024; 41:81-108. [PMID: 37599617 PMCID: PMC10763721 DOI: 10.1097/eja.0000000000001876] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2023]
Abstract
Postoperative delirium (POD) remains a common, dangerous and resource-consuming adverse event but is often preventable. The whole peri-operative team can play a key role in its management. This update to the 2017 ESAIC Guideline on the prevention of POD is evidence-based and consensus-based and considers the literature between 01 April 2015, and 28 February 2022. The search terms of the broad literature search were identical to those used in the first version of the guideline published in 2017. POD was defined in accordance with the DSM-5 criteria. POD had to be measured with a validated POD screening tool, at least once per day for at least 3 days starting in the recovery room or postanaesthesia care unit on the day of surgery or, at latest, on postoperative day 1. Recent literature confirmed the pathogenic role of surgery-induced inflammation, and this concept reinforces the positive role of multicomponent strategies aimed to reduce the surgical stress response. Although some putative precipitating risk factors are not modifiable (length of surgery, surgical site), others (such as depth of anaesthesia, appropriate analgesia and haemodynamic stability) are under the control of the anaesthesiologists. Multicomponent preoperative, intra-operative and postoperative preventive measures showed potential to reduce the incidence and duration of POD, confirming the pivotal role of a comprehensive and team-based approach to improve patients' clinical and functional status.
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Affiliation(s)
- César Aldecoa
- From the Department of Anaesthesia and Postoperative Critical Care, Hospital Universitario Rio Hortega, Valladolid, Spain (CA), Department of Biomedical Studies, University of the Republic of San Marino, San Marino (GB), Department of Anesthesiology, Critical Care and Pain Medicine, 'Sapienza' University of Rome, Rome, Italy (FB, AF, LM), Specialty of Anaesthetics & NHMRC Clinical Trials Centre, University of Sydney & Department of Anaesthetics and Institute of Academic Surgery, Royal Prince Alfred Hospital (RDS), Department of Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, and Humboldt Universität zu Berlin, Campus Charité Mitte, and Campus Virchow Klinikum (CDS, SK, AM, BN, LV, BW, FY), Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy (PA), Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy (PA), Department of Surgery, Institute of Clinical Sciences, Sahlgrenska University Hospital, Göteborg, Sweden (RA), Geriatria, Accettazione Geriatrica e Centro di ricerca per l'invecchiamento, IRCCS INRCA, Ancona, Italy (AC), School of Biochemistry and Immunology and Trinity College Institute of Neuroscience, Trinity College, Dublin, Ireland (CC), First Department of Anaesthesiology and Intensive Care Medical University of Lublin, Poland (WD), Research Unit of Nursing Science and Health Management, University of Oulu, Oulu, Finland (KI), Section of Surgical Pathophysiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (HK), Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University in Szczecin, Poland (KK), Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia (NG, NL, SP, SR), Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy (NL, SP), Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Edinburgh, United Kingdom (AMJM), Department of Anaesthesia and Intensive Care, Nykoebing Hospital; University of Southern Denmark, SDU (SK, FR), Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia (ARB), Center for Intensive Care Medicine, Luzerner Kantonsspital, Lucerne, Switzerland (ARB), Department of Health Science, Section of Anesthesiology, University of Florence (SR), Department of Anaesthesia and Critical Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy (SR), School of Health Sciences, Institute of Nursing, ZHAW Zurich University of Applied Science, Winterthur, Switzerland (MS), Departments of Psychiatry and Intensive Care Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands (AJCS), Department of Neurology, UZ Brussel and Vrije Universiteit Brussel, Brussels, Belgium (AJCS) and Dental Anesthesia and Intensive Care Unit, Polo Universitario Ospedale San Paolo, Department of Biomedical, Surgical and Odontoiatric Sciences, University of Milano, Milan, Italy (CT)
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Kreuzer M, Schneider G, García PS. Using Spectral Edge Frequency to Target Equivalent Brain States Under General Anesthesia Is Like Asking for Apples and Getting Oranges. Anesth Analg 2023; 137:e49-e50. [PMID: 37973136 DOI: 10.1213/ane.0000000000006615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Affiliation(s)
- Matthias Kreuzer
- School of Medicine, Department of Anesthesiology and Intensive Care Medicine, Technical University of Munich, Munich, Germany,
| | - Gerhard Schneider
- School of Medicine, Department of Anesthesiology and Intensive Care Medicine, Technical University of Munich, Munich, Germany,
| | - Paul S García
- Department of Anesthesiology, Columbia University, New York, New York
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Obert DP, Schneider F, Schneider G, von Dincklage F, Sepulveda P, García PS, Kratzer S, Kreuzer M. Performance of the SEDLine Monitor: Age Dependency and Time Delay. Anesth Analg 2023; 137:887-895. [PMID: 36727845 DOI: 10.1213/ane.0000000000006369] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Devices monitoring the hypnotic component of general anesthesia can help to guide anesthetic management. The main purposes of these devices are the titration of anesthesia dose. While anesthesia at low doses can result in awareness with intraoperative memory formation, excessive administration of anesthetics may be associated with an increased risk of postoperative neurocognitive disorder. We have previously shown for various indices that they are significantly influenced by the patient's age and that the monitors have a significant time delay. Here, we evaluated the influence of patient's age and time delay on the patient state index (PSI) of the SEDLine monitor. METHODS To analyze the influence of the patient's age, we replayed 2 minutes of electroencephalography (EEG) of 141 patients (19-88 years, ASA I-IV) undergoing general anesthesia maintained with desflurane, sevoflurane, or propofol to the SEDLine monitor. We extracted the PSI as well as the spectral edge frequency (SEF) and performed a linear regression analysis. For evaluation of the time delay, we replayed 5 minutes of EEG of stable episodes of adequate anesthesia (PSI between 25 and 50) or light sedation/wake (PSI >70) in different orders to the SEDLine to simulate sudden changes between the states. Time delays were defined as the required time span of the monitor to reach the stable target index. RESULTS PSI and SEF increased significantly with the patient's age. These findings did not depend on the administered anesthetic. The evaluation of the correlation between SEF and PSI showed a strong correlation with Spearman's correlation coefficient of ρ = 0.86 (0.82; 0.89). The time delays depended on the type of transition. We found a median time delay of 54 (Min: 46; Max: 61) seconds for the important transition between adequate anesthesia and awake and 55 (Min: 50; Max: 67) seconds in the other direction. CONCLUSIONS With our analyses, we show that the indices presented on the SEDLine display, the PSI and the SEF, increase with age for patients under general anesthesia. Additionally, a delay of the PSI to react to sudden neurophysiologic changes due to dose of the maintenance anesthetic is of a time course that is clinically significant. These factors should be considered when navigating anesthesia relying on only the proprietary index for the SEDLine monitor.
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Affiliation(s)
- David P Obert
- From the Department of Anesthesiology and Intensive Care Medicine, Technical University of Munich School of Medicine, Munich, Germany
| | - Frederick Schneider
- From the Department of Anesthesiology and Intensive Care Medicine, Technical University of Munich School of Medicine, Munich, Germany
| | - Gerhard Schneider
- From the Department of Anesthesiology and Intensive Care Medicine, Technical University of Munich School of Medicine, Munich, Germany
| | - Falk von Dincklage
- Department of Anesthesia, Intensive Care, Emergency and Pain Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Pablo Sepulveda
- Department of Anesthesiology, Hospital Base San José, Osorno/Universidad Austral, Valdivia, Chile
| | - Paul S García
- Department of Anesthesiology, Columbia University, New York, New York
| | - Stephan Kratzer
- From the Department of Anesthesiology and Intensive Care Medicine, Technical University of Munich School of Medicine, Munich, Germany
| | - Matthias Kreuzer
- From the Department of Anesthesiology and Intensive Care Medicine, Technical University of Munich School of Medicine, Munich, Germany
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5
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Hight D, Obert DP, Kratzer S, Schneider G, Sepulveda P, Sleigh J, García PS, Kreuzer M. Permutation entropy is not an age-independent parameter for EEG-based anesthesia monitoring. Front Aging Neurosci 2023; 15:1173304. [PMID: 37396663 PMCID: PMC10308118 DOI: 10.3389/fnagi.2023.1173304] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 05/30/2023] [Indexed: 07/04/2023] Open
Abstract
Background An optimized anesthesia monitoring using electroencephalographic (EEG) information in the elderly could help to reduce the incidence of postoperative complications. Processed EEG information that is available to the anesthesiologist is affected by the age-induced changes of the raw EEG. While most of these methods indicate a "more awake" patient with age, the permutation entropy (PeEn) has been proposed as an age-independent measure. In this article, we show that PeEn is also influenced by age, independent of parameter settings. Methods We retrospectively analyzed the EEG of more than 300 patients, recorded during steady state anesthesia without stimulation, and calculated the PeEn for different embedding dimensions m that was applied to the EEG filtered to a wide variety of frequency ranges. We constructed linear models to evaluate the relationship between age and PeEn. To compare our results to published studies, we also performed a stepwise dichotomization and used non-parametric tests and effect sizes for pairwise comparisons. Results We found a significant influence of age on PeEn for all settings except for narrow band EEG activity. The analysis of the dichotomized data also revealed significant differences between old and young patients for the PeEn settings used in published studies. Conclusion Based on our findings, we could show the influence of age on PeEn. This result was independent of parameter, sample rate, and filter settings. Hence, age should be taken into consideration when using PeEn to monitor patient EEG.
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Affiliation(s)
- Darren Hight
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - David P. Obert
- Department of Anesthesiology and Intensive Care Medicine, School of Medicine, Technical University of Munich, Munich, Germany
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, United States
- Department of Anesthesia, Harvard Medical School, Boston, MA, United States
| | - Stephan Kratzer
- Department of Anesthesiology and Intensive Care Medicine, School of Medicine, Technical University of Munich, Munich, Germany
- Department of Anesthesia and Intensive Care Medicine, Hessing Foundation, Augsburg, Germany
| | - Gerhard Schneider
- Department of Anesthesiology and Intensive Care Medicine, School of Medicine, Technical University of Munich, Munich, Germany
| | - Pablo Sepulveda
- Department of Anesthesiology, Hospital Base San José, Osorno/Universidad Austral, Valdivia, Chile
| | - Jamie Sleigh
- Department of Anaesthesia, Waikato Clinical School, University of Auckland, Hamilton, New Zealand
| | - Paul S. García
- Department of Anesthesiology, Columbia University, New York, NY, United States
| | - Matthias Kreuzer
- Department of Anesthesiology and Intensive Care Medicine, School of Medicine, Technical University of Munich, Munich, Germany
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Ito T, Utsumi N, Baba Y, Matsumura T, Wakita R, Maeda S. Considerations for Satisfactory Sedation during Dental Implant Surgery. J Pers Med 2023; 13:461. [PMID: 36983643 PMCID: PMC10054855 DOI: 10.3390/jpm13030461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 02/22/2023] [Accepted: 02/28/2023] [Indexed: 03/05/2023] Open
Abstract
Implant surgery is a lengthy dental procedure, and sedation is often used to reduce discomfort. The effectiveness of sedation has traditionally been evaluated in terms of patient and surgeon satisfaction, but the most important goal is not to induce a deep sleep in the patient, but rather to ensure that the surgery is performed safely and as planned. Additionally, adequate pain control is a necessary requirement for patient and surgeon satisfaction. Most patients undergoing implant surgery are middle-aged or older, and a relatively large number of them have cardiovascular disease. Infiltration anesthesia using articaine or lidocaine in combination with adrenaline is widely used, but its use in patients with cardiovascular disease is limited because of adrenaline's effects on the cardiovascular system. The use of long-acting local anesthetics and the potential efficacy of ultrasound-guided jaw nerve block have been investigated to enhance analgesia without resorting to adrenaline. Midazolam and propofol are usually used for sedation, but dexmedetomidine, which causes less respiratory depression, and the ultrashort-acting benzodiazepine remimazolam are emerging as potential alternatives. Monitoring of anesthetic depth using electroencephalography is effective in maintaining a constant level of sedation. In addition, sedation promotes the stabilization of heart rate and blood pressure, reducing the risks associated with adrenaline and allowing for safer management.
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Affiliation(s)
| | | | | | | | | | - Shigeru Maeda
- Department of Dental Anesthesiology and Orofacial Pain Management, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan
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Li F, Dang Y, Zhang X, Chen H, Lu Y, Yu Y. Age-dependent Electroencephalogram Characteristics During Different Levels of Anesthetic Depth. Clin EEG Neurosci 2022:15500594221142680. [PMID: 36503267 DOI: 10.1177/15500594221142680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Objective The monitoring of anesthetic depth based on electroencephalogram derivation is not currently adjusted for age. Here we analyze the influence of age factors on electroencephalogram characteristics. Methods Frontal electroencephalogram recordings were obtained from 80 adults during routine clinical anesthesia. The characteristics of electroencephalogram with age and anesthesia were observed during four kinds of anesthesia. Results The slow wave power, δ power, Bispectral Index (BIS) and approximate entropy can be used to distinguish different states of anesthesia (P < 0.05). In the deep and very deep anesthesia states, δ power decreased with age (P < 0.0001). In the very deep anesthesia state, θ power decreased with age (P < 0.05). In the deep and very deep anesthesia states, α power decreased with age (P = 0.0002). In the light and deep anesthesia states, β power decreased with age (P = 0.003). In the deep anesthesia state, γ power decreased with age (P = 0.002). In the very deep anesthesia state, permutation entropy increased significantly with age (P = 0.0001). In the very deep anesthesia state, BIS value increased with age (P = 0.006). The slow wave power, approximate entropy, and sample entropy did not show age-dependent changes. Conclusions The influence of age should be considered when using BIS and δ power to monitor the depth of anesthesia, while the influence of age should not be considered when using slow wave power and approximate entropy to monitor the depth of anesthesia.
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Affiliation(s)
- Feixiang Li
- Department of Anesthesiology, 74671Tianjin Medical University General Hospital, Tianjin Research Institute of Anesthesiology, Tianjin, China
- Department of Anesthesiology, 117865The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Yaoyao Dang
- Department of Anesthesiology, 117865The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Xuan Zhang
- Tianjin Medical University Cancer Institute and Hospital, 74675National Clinical Research Center for Cancer, Tianjin's Clinical Research Center for Cancer, Tianjin, China
| | - Huimin Chen
- Department of Anesthesiology, 117865The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Yuechun Lu
- Department of Anesthesiology, 117865The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Yonghao Yu
- Department of Anesthesiology, 74671Tianjin Medical University General Hospital, Tianjin Research Institute of Anesthesiology, Tianjin, China
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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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Barreto Chang OL, Kreuzer M, Morgen DF, Possin KL, García PS. Ketamine Associated Intraoperative Electroencephalographic Signatures of Elderly Patients With and Without Preoperative Cognitive Impairment. Anesth Analg 2022; 135:683-692. [PMID: 35051953 DOI: 10.1213/ane.0000000000005875] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Ketamine is typically used by anesthesiologists as an adjunct for general anesthesia and as a nonopioid analgesic. It has been explored for prevention of postoperative delirium, although results have been contradictory. In this study, we investigated the association of ketamine with postoperative delirium and specific encephalographic signatures. Furthermore, we examined these associations in the context of baseline neurocognition as measured by a validated assessment. METHODS We conducted a prospective observational study from January 2019 to December 2020. Ninety-eight patients aged ≥65 years and undergoing spine surgery scheduled for ≥3 hours were included in the study. All participants who completed the University of California San Francisco (UCSF) Brain Health Assessment preoperatively and postoperatively were assessed with the confusion assessment method for intensive care unit (CAM-ICU) and/or the Nursing Delirium Screening Scale (NuDESC). Patients had frontal electroencephalogram (EEG) recordings (SedLine Root, Masimo, Corp) quantitatively analyzed. We used 60 seconds of artifact-free EEG (without burst suppression) extracted from the middle of the maintenance period to calculate the normalized power spectral density (PSD). Comparisons were made between those who did or did not receive ketamine and according to results from neurocognitive assessments. RESULTS Ninety-eight patients (of a total of 155, enrolled and consented) had EEG of sufficient quality for analysis (42 women). Overall, we found a significant increase in the EEG power in the moderate frequency range (10-20 Hz) in patients that received ketamine. When the patients were divided by their preoperative cognitive status, this result in the ketamine group only held true for the cognitively normal patients. Patients that were cognitively impaired at baseline did not demonstrate a significant change in EEG characteristics based on ketamine administration, but impaired patients that received ketamine had a significantly higher rate of postoperative delirium (52% ketamine versus 20% no ketamine) (odds ratio [OR], 4.36; confidence interval [CI], 1.02-18.22; P = .048). In patients determined to be preoperatively cognitively normal, the incidence of postoperative delirium was not significantly associated with ketamine administration (19% ketamine versus 17% no ketamine) (OR, 1.10; CI, 0.30-4.04; P = .5833). CONCLUSIONS Ketamine-related changes in EEG are observed in a heterogeneous group of patients receiving spine surgery. This result was driven primarily by the effect of ketamine on cognitively normal patients and not observed in patients that were cognitively impaired at baseline. Furthermore, patients who were cognitively impaired at baseline and who had received ketamine were more likely to develop postoperative delirium, suggesting that cognitive vulnerability might be predicted by the lack of a neurophysiologic response to ketamine.
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Affiliation(s)
- Odmara L Barreto Chang
- From the Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California
| | - Matthias Kreuzer
- Department of Anesthesiology and Intensive Care, Technical University of Munich, School of Medicine, Munich, Germany
| | - Danielle F Morgen
- From the Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California
| | - Katherine L Possin
- Memory and Aging Center, Department of Neurology, University of California, San Francisco, San Francisco, California.,Global Brain Health Institute, University of California, San Francisco, San Francisco, California
| | - Paul S García
- Department of Anesthesiology, Columbia University Medical Center New York Presbyterian Hospital, New York, New York
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10
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Wright MC, Bunning T, Eleswarpu SS, Heflin MT, McDonald S, Lagoo-Deenadalayan S, Whitson H, Martinez-Camblor P, Deiner SG, Berger M. A Processed Electroencephalogram-Based Brain Anesthetic Resistance Index Is Associated With Postoperative Delirium in Older Adults: A Dual Center Study. Anesth Analg 2022; 134:149-158. [PMID: 34252066 PMCID: PMC8678136 DOI: 10.1213/ane.0000000000005660] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Some older adults show exaggerated responses to drugs that act on the brain. The brain's response to anesthetic drugs is often measured clinically by processed electroencephalogram (EEG) indices. Thus, we developed a processed EEG-based measure of the brain's resistance to volatile anesthetics and hypothesized that low scores on it would be associated with postoperative delirium risk. METHODS We defined the Duke Anesthesia Resistance Scale (DARS) as the average bispectral index (BIS) divided by the quantity (2.5 minus the average age-adjusted end-tidal minimum alveolar concentration [aaMAC] inhaled anesthetic fraction). The relationship between DARS and postoperative delirium was analyzed in 139 older surgical patients (age ≥65) from Duke University Medical Center (n = 69) and Mt Sinai Medical Center (n = 70). Delirium was assessed by geriatrician interview at Duke, and by research staff utilizing the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) instrument at Mt Sinai. We examined the relationship between DARS and delirium and used the Youden index to identify an optimal low DARS threshold (for delirium risk), and its associated 95% bootstrap confidence bounds. We used multivariable logistic regression to examine the relationship between low DARS and delirium risk. RESULTS The relationship between DARS and delirium risk was nonlinear, with higher delirium risk at low DARS scores. A DARS threshold of 28.755 maximized the Youden index for the association between low DARS and delirium, with bootstrap 95% confidence bounds of 26.18 and 29.80. A low DARS (<28.755) was associated with increased delirium risk in multivariable models adjusting for site (odds ratio [OR] [95% confidence interval {CI}] = 4.30 [1.89-10.01]; P = .001), or site-plus-patient risk factors (OR [95% CI] = 3.79 [1.63-9.10]; P = .003). These associations with postoperative delirium risk remained significant when using the 95% bootstrap confidence bounds for the low DARS threshold (P < .05 for all). Further, a low DARS (<28.755) was associated with delirium risk after accounting for opioid, midazolam, propofol, phenylephrine, and ketamine dosage as well as site (OR [95% CI] = 4.21 [1.80-10.16]; P = .002). This association between low DARS and postoperative delirium risk after controlling for these other medications remained significant (P < .05) when using either the lower or the upper 95% bootstrap confidence bounds for the low DARS threshold. CONCLUSIONS These results demonstrate that an intraoperative processed EEG-based measure of lower brain anesthetic resistance (ie, low DARS) is independently associated with increased postoperative delirium risk in older surgical patients.
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Affiliation(s)
| | - Thomas Bunning
- Anesthesiology Department, Duke University Medical Center, Durham NC
| | | | - Mitchell T. Heflin
- Geriatrics Division, Department of Medicine, Duke University Medical Center, Durham NC
| | - Shelley McDonald
- Geriatrics Division, Department of Medicine, Duke University Medical Center, Durham NC
| | | | - Heather Whitson
- Geriatrics Division, Department of Medicine, Duke University Medical Center, Durham NC,Center for the Study of Aging and Human Development, Duke University Medical Center, Durham NC
| | | | - Stacie G Deiner
- Geriatrics and Palliative Care Medicine, Department of Medicine, Mount Sinai Medical Center, New York, NY,Anesthesiology Department, Mount Sinai Medical Center, New York, NY,Neurosurgery Department, Mount Sinai Medical Center, New York, NY,Geisel School of Medicine, Dartmouth College, New Hanover, New Hampshire
| | - Miles Berger
- Anesthesiology Department, Duke University Medical Center, Durham NC,Center for the Study of Aging and Human Development, Duke University Medical Center, Durham NC,Center for Cognitive Neuroscience, Duke University, Durham NC
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11
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Evaluation of Anesthetic Specific EEG Dynamics during State Transitions between Loss and Return of Responsiveness. Brain Sci 2021; 12:brainsci12010037. [PMID: 35053781 PMCID: PMC8773581 DOI: 10.3390/brainsci12010037] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 12/21/2021] [Accepted: 12/23/2021] [Indexed: 11/17/2022] Open
Abstract
Purpose: electroencephalographic (EEG) information is used to monitor the level of cortical depression of a patient undergoing surgical intervention under general anesthesia. The dynamic state transitions into and out of anesthetic-induced loss and return of responsiveness (LOR, ROR) present a possibility to evaluate the dynamics of the EEG induced by different substances. We evaluated changes in the EEG power spectrum during anesthesia emergence for three different anesthetic regimens. We also assessed the possible impact of these changes on processed EEG parameters such as the permutation entropy (PeEn) and the cerebral state index (CSI). Methods: we analyzed the EEG from 45 patients, equally assigned to three groups. All patients were induced with propofol and the groups differed by the maintenance anesthetic regimen, i.e., sevoflurane, isoflurane, or propofol. We evaluated the EEG and parameter dynamics during LOR and ROR. For the emergence period, we focused on possible differences in the EEG dynamics in the different groups. Results: depending on the substance, the EEG emergence patterns showed significant differences that led to a substance-specific early activation of higher frequencies as indicated by the “wake” CSI values that occurred minutes before ROR in the inhalational anesthetic groups. Conclusion: our results highlight substance-specific differences in the emergence from anesthesia that can influence the EEG-based monitoring that probably have to be considered in order to improve neuromonitoring during general anesthesia.
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12
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The Strength of Alpha Oscillations in the Electroencephalogram Differently Affects Algorithms Used for Anesthesia Monitoring. Anesth Analg 2021; 133:1577-1587. [PMID: 34543237 DOI: 10.1213/ane.0000000000005704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Intraoperative patient monitoring using the electroencephalogram (EEG) can help to adequately adjust the anesthetic level. Therefore, the processed EEG (pEEG) provides the anesthesiologist with the estimated anesthesia level. The commonly used approaches track the changes from a fast- and a low-amplitude EEG during wakefulness to a slow- and a high-amplitude EEG under general anesthesia. However, besides these changes, another EEG feature, a strong oscillatory activity in the alpha band (8-12 Hz), develops in the frontal EEG. Strong alpha-band activity during general anesthesia seems to reflect an appropriate anesthetic level for certain anesthetics, but the way the common pEEG approaches react to changes in the alpha-band activity is not well explained. Hence, we investigated the impact of an artificial alpha-band modulation on pEEG approaches used in anesthesia research. METHODS We performed our analyses based on 30 seconds of simulated sedation (n = 25) EEG, simulated anesthesia (n = 25) EEG, and EEG episodes from 20 patients extracted from a steady state that showed a clearly identifiable alpha peak in the density spectral array (DSA) and a state entropy (GE Healthcare) around 50, indicative of adequate anesthesia. From these traces, we isolated the alpha activity by band-pass filtering (8-12 Hz) and added this alpha activity to or subtracted it from the signals in a stepwise manner. For each of the original and modified signals, the following pEEG values were calculated: (1) spectral edge frequency (SEF95), (2) beta ratio, (3) spectral entropy (SpEntr), (4) approximate entropy (ApEn), and (5) permutation entropy (PeEn). RESULTS The pEEG approaches showed different reactions to the alpha-band modification that depended on the data set and the amplification step. The beta ratio and PeEn decreased with increasing alpha activity for all data sets, indicating a deepening of anesthesia. The other pEEG approaches behaved nonuniformly. SEF95, SpEntr, and ApEn decreased with increasing alpha for the simulated anesthesia data (arousal) but decreased for simulated sedation. For the patient EEG, ApEn indicated an arousal, and SEF95 and SpEntr showed a nonuniform change. CONCLUSIONS Changes in the alpha-band activity lead to different reactions for different pEEG approaches. Hence, the presence of strong oscillatory alpha activity that reflects an adequate level of anesthesia may be interpreted differently, by an either increasing (arousal) or decreasing (deepening) pEEG value. This could complicate anesthesia navigation and prevent the adjustment to an adequate, alpha-dominant anesthesia level, when titrating by the pEEG values.
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13
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Koch S, Windmann V, Chakravarty S, Kruppa J, Yürek F, Brown EN, Winterer G, Spies C. Perioperative Electroencephalogram Spectral Dynamics Related to Postoperative Delirium in Older Patients. Anesth Analg 2021; 133:1598-1607. [PMID: 34591807 DOI: 10.1213/ane.0000000000005668] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Intraoperative electroencephalography (EEG) signatures related to the development of postoperative delirium (POD) in older patients are frequently studied. However, a broad analysis of the EEG dynamics including preoperative, postinduction, intraoperative and postoperative scenarios and its correlation to POD development is still lacking. We explored the relationship between perioperative EEG spectra-derived parameters and POD development, aiming to ascertain the diagnostic utility of these parameters to detect patients developing POD. METHODS Patients aged ≥65 years undergoing elective surgeries that were expected to last more than 60 minutes were included in this prospective, observational single center study (Biomarker Development for Postoperative Cognitive Impairment [BioCog] study). Frontal EEGs were recorded, starting before induction of anesthesia and lasting until recovery of consciousness. EEG data were analyzed based on raw EEG files and downloaded excel data files. We performed multitaper spectral analyses of relevant EEG epochs and further used multitaper spectral estimate to calculate a corresponding spectral parameter. POD assessments were performed twice daily up to the seventh postoperative day. Our primary aim was to analyze the relation between the perioperative spectral edge frequency (SEF) and the development of POD. RESULTS Of the 237 included patients, 41 (17%) patients developed POD. The preoperative EEG in POD patients was associated with lower values in both SEF (POD 13.1 ± 4.6 Hz versus no postoperative delirium [NoPOD] 17.4 ± 6.9 Hz; P = .002) and corresponding γ-band power (POD -24.33 ± 2.8 dB versus NoPOD -17.9 ± 4.81 dB), as well as reduced postinduction absolute α-band power (POD -7.37 ± 4.52 dB versus NoPOD -5 ± 5.03 dB). The ratio of SEF from the preoperative to postinduction state (SEF ratio) was ~1 in POD patients, whereas NoPOD patients showed a SEF ratio >1, thus indicating a slowing of EEG with loss of unconscious. Preoperative SEF, preoperative γ-band power, and SEF ratio were independently associated with POD (P = .025; odds ratio [OR] = 0.892, 95% confidence interval [CI], 0.808-0.986; P = .029; OR = 0.568, 95% CI, 0.342-0.944; and P = .009; OR = 0.108, 95% CI, 0.021-0.568, respectively). CONCLUSIONS Lower preoperative SEF, absence of slowing in EEG while transitioning from preoperative state to unconscious state, and lower EEG power in relevant frequency bands in both these states are related to POD development. These findings may suggest an underlying pathophysiology and might be used as EEG-based marker for early identification of patients at risk to develop POD.
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Affiliation(s)
- Susanne Koch
- From the Department of Anesthesiology and Intensive Care Medicine, Campus Virchow-Klinikum and Campus Charité Mitte, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Technical Transfer Department, Berlin Institute of Health (BIH), Berlin, Germany
| | - Victoria Windmann
- From the Department of Anesthesiology and Intensive Care Medicine, Campus Virchow-Klinikum and Campus Charité Mitte, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Sourish Chakravarty
- Harvard-MIT, Division of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Jochen Kruppa
- Technical Transfer Department, Berlin Institute of Health (BIH), Berlin, Germany.,Department of Biometry and Clinical Epidemiology, Charité-Universitätsmedizin Berlin, Campus Charité Mitte, Berlin, Germany
| | - Fatima Yürek
- From the Department of Anesthesiology and Intensive Care Medicine, Campus Virchow-Klinikum and Campus Charité Mitte, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Emery N Brown
- Harvard-MIT, Division of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, Massachusetts.,Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Georg Winterer
- From the Department of Anesthesiology and Intensive Care Medicine, Campus Virchow-Klinikum and Campus Charité Mitte, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Claudia Spies
- From the Department of Anesthesiology and Intensive Care Medicine, Campus Virchow-Klinikum and Campus Charité Mitte, Charité-Universitätsmedizin Berlin, Berlin, Germany
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14
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Obert DP, Hight D, Sleigh J, Kaiser HA, García PS, Schneider G, Kreuzer M. The First Derivative of the Electroencephalogram Facilitates Tracking of Electroencephalographic Alpha Band Activity During General Anesthesia. Anesth Analg 2021; 134:1062-1071. [PMID: 34677164 DOI: 10.1213/ane.0000000000005783] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Intraoperative neuromonitoring can help to navigate anesthesia. Pronounced alpha oscillations in the frontal electroencephalogram (EEG) appear to predict favorable perioperative neurocognitive outcomes and may also provide a measure of intraoperative antinociception. Monitoring the presence and strength of these alpha oscillations can be challenging, especially in elderly patients, because the EEG in these patients may be dominated by oscillations in other frequencies. Hence, the information regarding alpha oscillatory activity may be hidden and hard to visualize on a screen. Therefore, we developed an effective approach to improve the detection and presentation of alpha activity in the perioperative setting. METHODS We analyzed EEG records of 180 patients with a median age of 60 years (range, 18-90 years) undergoing noncardiac, nonneurologic surgery under general anesthesia with propofol induction and sevoflurane maintenance. We calculated the power spectral density (PSD) for the unprocessed EEG as well as for the time-discrete first derivative of the EEG (diffPSD) from 10-second epochs. Based on these data, we estimated the power-law coefficient κ of the PSD and diffPSD, as the EEG coarsely follows a 1/fκ distribution when displayed in double logarithmic coordinates. In addition, we calculated the alpha (7.8-12.1 Hz) to delta (0.4-4.3 Hz) ratio from the PSD as well as diffPSD. RESULTS The median κ was 0.899 [first and third quartile: 0.786, 0.986] for the unaltered PSD, and κ = -0.092 [-0.202, -0.013] for the diffPSD, corresponding to an almost horizontal PSD of the differentiated EEG. The alpha-to-delta ratio of the diffPSD was strongly increased (median ratio = -8.0 dB [-10.5, -4.7 dB] for the unaltered PSD versus 30.1 dB [26.1, 33.8 dB] for the diffPSD). A strong narrowband oscillatory alpha power component (>20% of total alpha power) was detected in 23% using PSD, but in 96% of the diffPSD. CONCLUSIONS We demonstrated that the calculation of the diffPSD from the time-discrete derivative of the intraoperative frontal EEG is a straightforward approach to improve the detection of alpha activity by eliminating the broadband background noise. This improvement in alpha peak detection and visualization could facilitate the guidance of general anesthesia and improve patient outcome.
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Affiliation(s)
- David P Obert
- From the 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, Bern, Switzerland
| | - Jamie Sleigh
- Department of Anaesthesia, Waikato Clinical School, University of Auckland, Hamilton, New Zealand
| | - Heiko A Kaiser
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Paul S García
- Department of Anesthesiology, Columbia University, New York, New York
| | - Gerhard Schneider
- From the Department of Anesthesiology and Intensive Care Medicine, Technical University of Munich, School of Medicine, Munich, Germany
| | - Matthias Kreuzer
- From the Department of Anesthesiology and Intensive Care Medicine, Technical University of Munich, School of Medicine, Munich, Germany
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15
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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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16
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García PS, Kreuzer M, Hight D, Sleigh JW. Effects of noxious stimulation on the electroencephalogram during general anaesthesia: a narrative review and approach to analgesic titration. Br J Anaesth 2021; 126:445-457. [PMID: 33461725 DOI: 10.1016/j.bja.2020.10.036] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 10/01/2020] [Accepted: 10/24/2020] [Indexed: 01/10/2023] Open
Abstract
Electroencephalographic (EEG) activity is used to monitor the neurophysiology of the brain, which is a target organ of general anaesthesia. Besides its use in evaluating hypnotic states, neurophysiologic reactions to noxious stimulation can also be observed in the EEG. Recognising and understanding these responses could help optimise intraoperative analgesic management. This review describes three types of changes in the EEG induced by noxious stimulation when the patient is under general anaesthesia: (1) beta arousal, (2) (paradoxical) delta arousal, and (3) alpha dropout. Beta arousal is an increase in EEG power in the beta-frequency band (12-25 Hz) in response to noxious stimulation, especially at lower doses of anaesthesia drugs in the absence of opioids. It is usually indicative of a cortical depolarisation and increased cortical activity. At higher concentrations of anaesthetic drug, and with insufficient opioids, delta arousal (increased power in the delta band [0.5-4 Hz]) and alpha dropout (decreased alpha power [8-12 Hz]) are associated with noxious stimuli. The mechanisms of delta arousal are not well understood, but the midbrain reticular formation seems to play a role. Alpha dropout may indicate a return of thalamocortical communication, from an idling mode to an operational mode. Each of these EEG changes reflect an incomplete modulation of pain signals and can be mitigated by administration of opioid or the use of regional anaesthesia techniques. Future studies should evaluate whether titrating analgesic drugs in response to these EEG signals reduces postoperative pain and influences other postoperative outcomes, including the potential development of chronic pain.
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Affiliation(s)
- Paul S García
- Department of Anesthesiology, Columbia University, New York, NY, USA.
| | - Matthias Kreuzer
- Department of Anesthesiology and Intensive Care, Technical University of Munich School of Medicine, Munich, Germany
| | - Darren Hight
- Department of Anaesthesiology, Waikato Clinical School, University of Auckland, Hamilton, New Zealand; Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - James W Sleigh
- Department of Anaesthesiology, Waikato Clinical School, University of Auckland, Hamilton, New Zealand
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17
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Kratzer S, Schneider M, Obert DP, Schneider G, García PS, Kreuzer M. Age-Related EEG Features of Bursting Activity During Anesthetic-Induced Burst Suppression. Front Syst Neurosci 2020; 14:599962. [PMID: 33343307 PMCID: PMC7744408 DOI: 10.3389/fnsys.2020.599962] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 11/09/2020] [Indexed: 12/19/2022] Open
Abstract
Electroencephalographic (EEG) Burst Suppression (BSUPP) is a discontinuous pattern characterized by episodes of low voltage disrupted by bursts of cortical synaptic activity. It can occur while delivering high-dose anesthesia. Current research suggests an association between BSUPP and the occurrence of postoperative delirium in the post-anesthesia care unit (PACU) and beyond. We investigated burst micro-architecture to further understand how age influences the neurophysiology of this pharmacologically-induced state. We analyzed a subset of EEG recordings (n = 102) taken from a larger data set previously published. We selected the initial burst that followed a visually identified “silent second,” i.e., at least 1 s of iso-electricity of the EEG during propofol induction. We derived the (normalized) power spectral density [(n)PSD], the alpha band power, the maximum amplitude, the maximum slope of the EEG as well as the permutation entropy (PeEn) for the first 1.5 s of the initial burst of each patient. In the old patients >65 years, we observed significantly lower (p < 0.001) EEG power in the 1–15 Hz range. In general, their EEG contained a significantly higher amount of faster oscillations (>15 Hz). Alpha band power (p < 0.001), EEG amplitude (p = 0.001), and maximum EEG slope (p = 0.045) all significantly decreased with age, whereas PeEn increased (p = 0.008). Hence, we can describe an age-related change in features during EEG burst suppression. Sub-group analysis revealed no change in results based on pre-medication. These EEG changes add knowledge to the impact of age on cortical synaptic activity. In addition to a reduction in EEG amplitude, age-associated burst features can complicate the identification of excessive anesthetic administration in patients under general anesthesia. Knowledge of these neurophysiologic changes may not only improve anesthesia care through improved detection of burst suppression but might also provide insight into changes in neuronal network organization in patients at risk for age-related neurocognitive problems.
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Affiliation(s)
- Stephan Kratzer
- Department of Anesthesiology and Intensive Care Medicine, School of Medicine, Technical University Munich, Munich, Germany
| | - Michael Schneider
- Department of Anesthesiology and Intensive Care Medicine, School of Medicine, Technical University Munich, Munich, Germany
| | - David P Obert
- Department of Anesthesiology and Intensive Care Medicine, School of Medicine, Technical University Munich, Munich, Germany
| | - Gerhard Schneider
- Department of Anesthesiology and Intensive Care Medicine, School of Medicine, Technical University Munich, Munich, Germany
| | - Paul S García
- Department of Anesthesiology, Columbia University, New York, NY, United States
| | - Matthias Kreuzer
- Department of Anesthesiology and Intensive Care Medicine, School of Medicine, Technical University Munich, Munich, Germany
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18
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Linassi F, Kreuzer M, Maran E, Farnia A, Zanatta P, Navalesi P, Carron M. Age influences on Propofol estimated brain concentration and entropy during maintenance and at return of consciousness during total intravenous anesthesia with target-controlled infusion in unparalyzed patients: An observational prospective trial. PLoS One 2020; 15:e0244145. [PMID: 33351856 PMCID: PMC7755218 DOI: 10.1371/journal.pone.0244145] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 12/03/2020] [Indexed: 12/27/2022] Open
Abstract
PURPOSE Aging affects pharmacodynamics/pharmacokinetics of anesthetics, but age effects on Entropy-guided total intravenous anesthesia with target-controlled infusions (TIVA-TCI) are not fully characterized. We compared aging effects on effective estimated brain concentration of Propofol (CeP) during TIVA-TCI Entropy-guided anesthesia, without neuromuscular blockade (NMB). METHODS We performed an observational, prospective, single-center study enrolling 75 adult women undergoing Entropy-guided Propofol-Remifentanil TIVA-TCI for breast surgery. Primary endpoint was the relationship between age and CeP at maintenance of anesthesia (MA) during Entropy-guided anesthesia. Secondary endpoints were relationships between age and CeP at arousal reaction (AR), return of consciousness (ROC) and explicit recall evenience. We calculated a linear model to evaluate the age's impact on observational variable and performed pairwise tests to compare old (≥65 years, n = 50) and young (<65 years, n = 25) patients or patients with and without an AR. RESULTS We did not observe age-related differences in CeP during MA, but CeP significantly (p = 0,01) decreased with age at ROC. Entropy values during MA increased with age and were significantly higher in the elderly (RE: median 56[IQR49.3-61] vs 47.5[42-52.5],p = 0.001; SE: 51.6[45-55.5] vs 44[IQR40-50],p = 0.005). 18 patients had an AR, having higher maximum RE (92.5[78-96.3] vs 65[56.5-80.5],p<0.001), SE (79[64.8-84] vs 61[52.5-69],p = 0.03, RE-SE (12.5[9.5-16.5] vs 6 [3-9],p<0.001. CONCLUSION Older age was associated with lower CeP at ROC, but not during MA in unparalysed patients undergoing breast surgery. Although RE and SE during MA, at comparable CeP, were higher in the elderly, Entropy, and in particular an increasing RE-SE, is a reliable index to detect an AR.
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Affiliation(s)
- Federico Linassi
- Department of Medicine—DIMED, Section of Anesthesiology and Intensive Care, University of Padova, Padova, Italy
- Department of Anesthesiology and Intensive Care, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Matthias Kreuzer
- Department of Anesthesiology and Intensive Care, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Eleonora Maran
- Department of Medicine—DIMED, Section of Anesthesiology and Intensive Care, University of Padova, Padova, Italy
| | - Antonio Farnia
- Department of Anesthesia and Intensive Care, Treviso Regional Hospital, Piazzale Ospedale, Treviso, Italy
| | - Paolo Zanatta
- Department of Anesthesia and Intensive Care, Integrated University Hospital of Verona, Piazzale Aristide Stefani, Verona, Italy
| | - Paolo Navalesi
- Department of Medicine—DIMED, Section of Anesthesiology and Intensive Care, University of Padova, Padova, Italy
| | - Michele Carron
- Department of Medicine—DIMED, Section of Anesthesiology and Intensive Care, University of Padova, Padova, Italy
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Sleep/Wake Behavior and EEG Signatures of the TgF344-AD Rat Model at the Prodromal Stage. Int J Mol Sci 2020; 21:ijms21239290. [PMID: 33291462 PMCID: PMC7730237 DOI: 10.3390/ijms21239290] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 11/26/2020] [Accepted: 12/02/2020] [Indexed: 12/27/2022] Open
Abstract
Transgenic modification of the two most common genes (APPsw, PS1ΔE9) related to familial Alzheimer's disease (AD) in rats has produced a rodent model that develops pathognomonic signs of AD without genetic tau-protein modification. We used 17-month-old AD rats (n = 8) and age-matched controls (AC, n = 7) to evaluate differences in sleep behavior and EEG features during wakefulness (WAKE), non-rapid eye movement sleep (NREM), and rapid eye movement sleep (REM) over 24-h EEG recording (12:12h dark-light cycle). We discovered that AD rats had more sleep-wake transitions and an increased probability of shorter REM and NREM bouts. AD rats also expressed a more uniform distribution of the relative spectral power. Through analysis of information content in the EEG using entropy of difference, AD animals demonstrated less EEG information during WAKE, but more information during NREM. This seems to indicate a limited range of changes in EEG activity that could be caused by an AD-induced change in inhibitory network function as reflected by increased GABAAR-β2 expression but no increase in GAD-67 in AD animals. In conclusion, this transgenic rat model of Alzheimer's disease demonstrates less obvious EEG features of WAKE during wakefulness and less canonical features of sleep during sleep.
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Abstract
Purpose of Review Processed electroencephalography (pEEG) is widely used in clinical practice. Few clinicians utilize the full potential of these devices. This brief review will address the improvements in patient management available from the utilization of all pEEG data. Recent Findings Anesthesiologists easily learn to recognize raw pEEG patterns that are consistent with an appropriate level of hypnotic effect. Power distribution within the waveform can be displayed in a visual format that identifies signatures of the principal anesthetic hypnotics. Opinion on the benefit of pEEG data in the mitigation of postoperative neurological impairment remains divided. Summary Looking beyond the index number can aid clinical decision making and improve confidence in the benefits of this monitoring modality.
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Age-related effects of three inhalational anesthetics at one minimum alveolar concentration on electroencephalogram waveform. Aging Clin Exp Res 2020; 32:1857-1864. [PMID: 31650503 DOI: 10.1007/s40520-019-01378-1] [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] [Received: 08/14/2019] [Accepted: 10/05/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND The characteristics of electroencephalogram (EEG) profiles under general anesthesia may depend on age and type of anesthetic. AIM This study investigated age-related differences in EEG waveforms between three inhalational anesthetics used at the same minimum alveolar concentration (MAC), which indicates the level of analgesia. METHODS Patients with American Society of Anesthesiologists physical status I-II were divided into three groups according to age: pediatric (≦ 15 years); adult (16-64 years); and elderly (≧ 65 years). Each group was divided into three subgroups according to the inhalational anesthetic used: sevoflurane, isoflurane, and desflurane. Anesthesia was maintained at 1 MAC, followed by assessment of 95% spectral edge frequency (SEF95) values and amplitude of EEG waveform. RESULTS The 3 age groups comprised a total of 180 patients. The mean (± SD) EEG waveform amplitude and SEF95 values for sevoflurane in the pediatric, adult, and elderly age groups, respectively, were: 32.9 ± 2.9 µV and 16.7 ± 2.4 Hz; 16.4 ± 3.6 µV and 12.2 ± 1.3 Hz; and 11.0 ± 2.1 µV and 13.6 ± 1.6 Hz. EEG waveform amplitude and SEF95 values were significantly higher in the pediatric group than in the other groups. SEF95 value was higher in the elderly group than in the adult group. Similar results were obtained for isoflurane and desflurane. CONCLUSION The amplitude of the EEG waveform and SEF95 values varied with age, even at the same analgesic state in patients under general anesthesia. This age-dependent change in EEG waveform was observed for all three inhalational anesthetics, and should be considered in procedures requiring general anesthesia.
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Hayashi K, Indo K, Sawa T. Anaesthesia-dependent oscillatory EEG features in the super-elderly. Clin Neurophysiol 2020; 131:2150-2157. [PMID: 32682243 DOI: 10.1016/j.clinph.2020.05.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 05/06/2020] [Accepted: 05/23/2020] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Although the characteristics of electroencephalograms (EEGs) have been reported to change with age, anaesthesia-dependent oscillatory features and reactivity of the super-elderly EEG to anaesthesia have not been examined in detail. METHODS Participants comprised 20 super-elderly patients (age; mean ± standard deviation, 87.1 ± 3.8 years) and 20 young adult patients (35.5 ± 8.5 years). At three levels of sevoflurane anaesthesia (minimum alveolar concentration [MAC] of 0.3, 0.7, and 1.4), oscillatory features of the frontal EEG were examined by analysing quadratic phase coupling (bicoherence) and power spectrum in α and δ-θ areas and compared in an anaesthesia-dependent manner, using the Friedman test. RESULTS Among super-elderly individuals, bicoherences in the δ-θ area showed anaesthesia-dependent increases (median [interquartile range], 12.9% [5.2%], 19.2% [9.1%], 23.3% [8.7%]; 0.3, 0.7, 1.4 MAC sevoflurane, p = 0.000), whereas bicoherence in the α area did not change at these different anaesthesia levels (11.2% [3.9%], 12.5% [4.4%], 14.1% [5.7%], respectively; p = 0.142), counter to the results found in young adult patients, where both δ-θ and α bicoherences changed with anaesthesia. CONCLUSIONS In the super-elderly, δ-θ bicoherence of EEG shows anaesthesia- dependent changes, whereas α activity remains small irrespective of anaesthesia level. SIGNIFICANCE Quantification of δ-θ bicoherence is a candidate for anaesthesia monitoring in the super-elderly.
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Affiliation(s)
- K Hayashi
- Department of Anesthesiology, Kyoto Chubu Medical Center, Yagi, Ueno 25, Nantan City, Kyoto, Japan; Medical Education and Research Center, Meiji University of Integrative Medicine, Kyoto, Japan.
| | - K Indo
- Department of Anesthesiology, Kyoto Chubu Medical Center, Yagi, Ueno 25, Nantan City, Kyoto, Japan.
| | - T Sawa
- Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan.
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Kreuzer M, Stern MA, Hight D, Berger S, Schneider G, Sleigh JW, García PS. Spectral and Entropic Features Are Altered by Age in the Electroencephalogram in Patients under Sevoflurane Anesthesia. Anesthesiology 2020; 132:1003-1016. [PMID: 32108685 PMCID: PMC7159998 DOI: 10.1097/aln.0000000000003182] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Preexisting factors such as age and cognitive performance can influence the electroencephalogram (EEG) during general anesthesia. Specifically, spectral EEG power is lower in elderly, compared to younger, subjects. Here, the authors investigate age-related changes in EEG architecture in patients undergoing general anesthesia through a detailed examination of spectral and entropic measures. METHODS The authors retrospectively studied 180 frontal EEG recordings from patients undergoing general anesthesia, induced with propofol/fentanyl and maintained by sevoflurane at the Waikato Hospital in Hamilton, New Zealand. The authors calculated power spectral density and normalized power spectral density, the entropic measures approximate and permutation entropy, as well as the beta ratio and spectral entropy as exemplary parameters used in current monitoring systems from segments of EEG obtained before the onset of surgery (i.e., with no noxious stimulation). RESULTS The oldest quartile of patients had significantly lower 1/f characteristics (P < 0.001; area under the receiver operating characteristics curve, 0.84 [0.76 0.92]), indicative of a more uniform distribution of spectral power. Analysis of the normalized power spectral density revealed no significant impact of age on relative alpha (P = 0.693; area under the receiver operating characteristics curve, 0.52 [0.41 0.63]) and a significant but weak effect on relative beta power (P = 0.041; area under the receiver operating characteristics curve, 0.62 [0.52 0.73]). Using entropic parameters, the authors found a significant age-related change toward a more irregular and unpredictable EEG (permutation entropy: P < 0.001, area under the receiver operating characteristics curve, 0.81 [0.71 0.90]; approximate entropy: P < 0.001; area under the receiver operating characteristics curve, 0.76 [0.66 0.85]). With approximate entropy, the authors could also detect an age-induced change in alpha-band activity (P = 0.002; area under the receiver operating characteristics curve, 0.69 [0.60 78]). CONCLUSIONS Like the sleep literature, spectral and entropic EEG features under general anesthesia change with age revealing a shift toward a faster, more irregular, oscillatory composition of the EEG in older patients. Age-related changes in neurophysiological activity may underlie these findings however the contribution of age-related changes in filtering properties or the signal to noise ratio must also be considered. Regardless, most current EEG technology used to guide anesthetic management focus on spectral features, and improvements to these devices might involve integration of entropic features of the raw EEG.
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Affiliation(s)
- Matthias Kreuzer
- From the Department of Anaesthesiology and Intensive Care, Klinikum rechts der Isar, Technical University Munich, Munich, Germany (M.K., S.B., G.S.) the Department of Anesthesiology (M.K., M.A.S., P.S.G.) the Medical Scientist Training Program (M.A.S.), Emory University School of Medicine, Atlanta, Georgia the Anesthesiology and Research Divisions, Atlanta Veterans Affairs Medical Center, (M.K., M.A.S., P.S.G.) Atlanta, Georgia the Department of Anaesthesia, Waikato Clinical School, University of Auckland, Hamilton, New Zealand (D.H., J.W.S.) the Waikato District Health Board, Hamilton, New Zealand (D.H., J.W.S.) the Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (D.H.) the Department of Anesthesiology, Columbia University Irving Medical Center, New York, New York (P.S.G.)
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Age progression from vicenarians (20-29 year) to nonagenarians (90-99 year) among a population pharmacokinetic/pharmacodynamic (PopPk-PD) covariate analysis of propofol-bispectral index (BIS) electroencephalography. J Pharmacokinet Pharmacodyn 2020; 47:145-161. [PMID: 32100175 DOI: 10.1007/s10928-020-09678-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 02/03/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Pharmacokinetic/pharmacodynamic (PK/PD) modeling has made an enormous contribution to intravenous anesthesia. Because of their altered physiological, pharmacological and pathological aspects, titrating general anesthesia in the elderly is a challenging task. METHODS Eighty patients were consecutively enrolled divided by decades from vicenarians (20-29 year) to nonagenarians (90-99 year) into eight groups. Using target controlled infusion (TCI) and electroencephalographic (EEG)-derived bispectral index (BIS) we set propofol plasma concentration (Cp) to gradually reach 3.5 μg mL-1 over 3.5-min. In each patient, we constructed a PK/PD model and conducted a population PK/PD (PopPK-PD) covariate analysis. RESULTS Age was significant covariate for baseline BIS effect (E0), inhibitory propofol concentration at 50% BIS decline (IC50) and maximum BIS decline (Emax). First-order rate constant Ke0 of 0.47 min-1 in vicenarians (20-29 year) gradually increased with age-progression to 1.85 min-1 in nonagenarians (90-99 year). Simulation modelling showed that clinically recommended Cp of 3.5 μg mL-1 for 20-29 year BIS 50 should be reduced to 3.0 for 30-49 year, 2.5 for 50-69 year and 2.0 for 80-89 year. CONCLUSION We quantified and graded EEG-BIS age-progression among different age groups divided by decades. We demonstrated deeper BIS values with decades' age progression. Our data has important implications for propofol dosing. The practical information for physicians in their daily clinical practice is using propofol Cp of 3.5 μg mL-1 might not yield BIS value of 50 in elderly patients. Our simulations showed that the recommended regimen of Cp 3.5 μg mL-1 for 20-29 year should be gradually decreased to 2.0 μg mL-1 for 80-89 year. CLINICAL TRIAL REGISTRY NUMBERS European Community Clinical Trials Database EudraCT (http://eudract.emea.eu) initial trial registration number: 2011-002847-81, and subsequently registered at www.clinicaltrials.gov; trial registration number: NCT02585284. Xijing Hospital of Fourth Military Medical University ethics committee approval number 20110707-4.
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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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Jia L, Hou J, Zheng H, Sun L, Fan Y, Wang X, Hao M, Li Y, Yang T. Study of the rational dose of propofol in elderly patients under bispectral index monitoring during total intravenous anesthesia: A PRISMA-compliant systematic review. Medicine (Baltimore) 2020; 99:e19043. [PMID: 32000452 PMCID: PMC7004673 DOI: 10.1097/md.0000000000019043] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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
BACKGROUND Propofol has been used widely as an anesthetic for elderly patients; however, the drug instructions only indicate that the need for maintenance of general anesthesia in elderly patients is reduced, and not the extent of the reduction. This study has summarized the usage of propofol in total intravenous anesthesia under bispectral index (BIS) monitoring and determined the optimum dosage of propofol for elderly patients. METHODS The study comprised 156 patients undergoing elective surgery under general anesthesia divided into 2 groups according to their age: the elderly group (O group) and nonelderly group (Y group). BIS monitoring was used in both groups during the operation, and propofol and remifentanil were used to maintain anesthesia. The preoperative special conditions, intraoperative maintenance of propofol, remifentanil, fentanyl, cis-atracurium, vasoactive drug use, and hemodynamic changes were summarized. RESULTS Propofol maintenance in the O group was 3.372 ± 0.774 mg/(kg h), which was significantly lesser than that in Y group (P < 0.05). The incidence of cardiovascular and cerebrovascular diseases and the use rate of vasoactive drugs in the O group were significantly higher than in the Y group (P < 0.05). CONCLUSION Propofol maintenance in the O group was significantly lower than that in the nonelderly group; this indicates that the anesthetic drug delivery rate for elderly patients should be reduced.
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Affiliation(s)
| | - Jiachen Hou
- Department of Surgery, the Second Hospital of Jilin University, Changchun City, Jilin Province, China
| | | | | | | | - Xu Wang
- Department of Anesthesiology
| | | | - Yue Li
- Department of Anesthesiology
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Ni K, Cooter M, Gupta DK, Thomas J, Hopkins TJ, Miller TE, James ML, Kertai MD, Berger M. Paradox of age: older patients receive higher age-adjusted minimum alveolar concentration fractions of volatile anaesthetics yet display higher bispectral index values. Br J Anaesth 2019; 123:288-297. [PMID: 31279479 DOI: 10.1016/j.bja.2019.05.040] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 04/26/2019] [Accepted: 05/06/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Minimum alveolar concentration (MAC) and MAC-awake decrease with age. We hypothesised that, in clinical practice, (i) end-tidal MAC fraction in older patients would decline by less than the predicted age-dependent MAC decrease (i.e. older patients would receive relatively excessive anaesthetic concentrations), and (ii) bispectral index (BIS) values would therefore be lower in older patients. METHODS We examined the relationship between end-tidal MAC fraction, BIS values, and age in 4699 patients > 30 yr in age at a single centre using unadjusted local regression (locally estimated scatterplot smoothing), Spearman's correlation, stratification, and robust univariable and multivariable linear regression. RESULTS The end-tidal MAC fraction in older patients declined by 3.01% per decade (95% confidence interval [CI]: 2.56-3.45; P<0.001), less than the 6.47% MAC decrease per decade that we found in a meta-regression analysis of published studies of age-dependent changes in MAC (P<0.001), and less than the age-dependent decrease in MAC-awake. The BIS values correlated positively with age (ρ=0.15; 95% CI: 0.12-0.17; P<0.001), and inversely with the age-adjusted end-tidal MAC (aaMAC) fraction (ρ= -0.13; 95% CI: -0.16, -0.11; P<0.001). CONCLUSIONS The age-dependent decline in end-tidal MAC fraction delivered in clinical practice at our institution was less than the age-dependent percentage decrease in MAC and MAC-awake determined from published studies. Despite receiving higher aaMAC fractions, older patients paradoxically showed higher BIS values. This most likely suggests that the BIS algorithm is inaccurate in older adults.
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Affiliation(s)
- Katherine Ni
- Mount Sinai School of Medicine, New York, NY, USA
| | - Mary Cooter
- Anesthesiology Department, Duke University Medical Center, Durham, NC, USA
| | - Dhanesh K Gupta
- Anesthesiology Department, Duke University Medical Center, Durham, NC, USA
| | - Jake Thomas
- Anesthesiology Department, Duke University Medical Center, Durham, NC, USA; Trinity College of Arts and Sciences, Duke University, Durham, NC, USA
| | - Thomas J Hopkins
- Anesthesiology Department, Duke University Medical Center, Durham, NC, USA
| | - Timothy E Miller
- Anesthesiology Department, Duke University Medical Center, Durham, NC, USA
| | - Michael L James
- Trinity College of Arts and Sciences, Duke University, Durham, NC, USA; Neurology Department, Duke University Medical Center, Durham, NC, USA
| | - Miklos D Kertai
- Division of Cardiothoracic Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Miles Berger
- Anesthesiology Department, Duke University Medical Center, Durham, NC, USA.
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Abstract
An aging worldwide population demands that anesthesiologists consider geriatrics a unique subset of patients requiring customization of practice. This article reviews the current literature investigating physiologic changes of the elderly that affect pharmacokinetics and pharmacodynamics. Changes in drug absorption, distribution, metabolism, and excretion are discussed as well as the ultimate effects of medications. Implications for practice regarding specific anesthetic and analgesic drugs are addressed. Despite the immense body of research that contributes to understanding of geriatric pharmacology, elderly patients often are excluded from rigorous research trials, and further scientific investigation to inform best practices for this group of patients is needed.
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Affiliation(s)
- Tate M Andres
- Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, 4648 TVC, Nashville, TN, USA.
| | - Tracy McGrane
- Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, 4648 TVC, Nashville, TN 37232, USA
| | - Matthew D McEvoy
- Perioperative Consult Service, Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, 4648 TVC, Nashville, TN 37232, USA
| | - Brian F S Allen
- Regional and Acute Pain Medicine Fellowship, Regional and Acute Pain Medicine Service, Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, 4648 TVC, Nashville, TN 37232, USA
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Abstract
PURPOSE OF REVIEW To summarize recent recommendations on intraoperative electroencephalogram (EEG) neuromonitoring in the elderly aimed at the prevention of postoperative delirium and long-term neurocognitive decline. We discuss recent perioperative EEG investigations relating to aging and cognitive dysfunction, and their implications on intraoperative EEG neuromonitoring in elderly patients. RECENT FINDINGS The incidence of postoperative delirium in elderly can be reduced by monitoring depth of anesthesia, using an index number (0-100) derived from processed frontal EEG readings. The recently published European Society of Anaesthesiology guideline on postoperative delirium in elderly now recommends guiding general anesthesia with such indices (Level A). However, intraoperative EEG signatures are heavily influenced by age, cognitive function, and choice of anesthetic agents. Detailed spectral EEG analysis and research on EEG-based functional connectivity provide new insights into the pathophysiology of neuronal excitability, which is seen in elderly patients with postoperative delirium. SUMMARY Anesthesiologists should become acquainted with intraoperative EEG signatures and their relation to age, anesthetic agents, and the risk of postoperative cognitive complications. A working knowledge would allow an optimized and individualized provision of general anesthesia for the elderly.
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Gaskell A, Pullon R, Hight D, Termaat J, Mans G, Voss L, Kreuzer M, Schmid S, Kratzer S, Rodriguez A, Schneider G, Garcia P, Sleigh J. Modulation of frontal EEG alpha oscillations during maintenance and emergence phases of general anaesthesia to improve early neurocognitive recovery in older patients: protocol for a randomised controlled trial. Trials 2019; 20:146. [PMID: 30795794 PMCID: PMC6387545 DOI: 10.1186/s13063-019-3178-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 01/03/2019] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Postoperative delirium may manifest in the immediate post-anaesthesia care period. Such episodes appear to be predictive of further episodes of inpatient delirium and associated adverse outcomes. Frontal electroencephalogram (EEG) findings of suppression patterns and low proprietary index values have been associated with postoperative delirium and poor outcomes. However, the efficacy of titrating anaesthesia to proprietary index targets for preventing delirium remains contentious. We aim to assess the efficacy of two strategies which we hypothesise could prevent post-anaesthesia care unit (PACU) delirium by maximising the alpha oscillation observed in frontal EEG channels during the maintenance and emergence phases of anaesthesia. METHODS This is a 2 × 2 factorial, double-blind, stratified, randomised control trial of 600 patients. Eligible patients are those aged 60 years or over who are undergoing non-cardiac, non-intracranial, volatile-based anaesthesia of expected duration of more than 2 h. Patients will be stratified by pre-operative cognitive status, surgery type and site. For the maintenance phase of anaesthesia, patients will be randomised (1:1) to an alpha power-maximisation anaesthesia titration strategy versus standard care avoiding suppression patterns in the EEG. For the emergence phase of anaesthesia, patients will be randomised (1:1) to early cessation of volatile anaesthesia and emergence from an intravenous infusion of propofol versus standard emergence from volatile anaesthesia only. The primary study outcomes are the power of the frontal alpha oscillation during the maintenance and emergence phases of anaesthesia. Our main clinical outcome of interest is PACU delirium. DISCUSSION This is a largely exploratory study; the extent to which EEG signatures can be modified by titration of pharmacological agents is not known. The underlying concept is maximisation of anaesthetic efficacy by individualised drug titration to a clearly defined EEG feature. The interventions are already clinically used strategies in anaesthetic practice, but have not been formally evaluated. The addition of propofol during the emergence phase of volatile-based general anaesthesia is known to reduce emergence delirium in children; however, the efficacy of this strategy in older patients is not known. TRIAL REGISTRATION Australian and New Zealand Clinical Trial Registry, ID: 12617001354370 . Registered on 27/09/2017.
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Affiliation(s)
- Amy Gaskell
- Department of Anaesthesiology, Waikato Clinical Campus, University of Auckland, Hamilton, New Zealand
- Department of Anaesthesia and Pain Medicine, Waikato District Health Board, Hamilton, New Zealand
| | - Rebecca Pullon
- Department of Anaesthesiology, Waikato Clinical Campus, University of Auckland, Hamilton, New Zealand
| | - Darren Hight
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jonathan Termaat
- Department of Anaesthesia and Pain Medicine, Waikato District Health Board, Hamilton, New Zealand
| | - Gay Mans
- Department of Anaesthesia and Pain Medicine, Waikato District Health Board, Hamilton, New Zealand
| | - Logan Voss
- Department of Anaesthesiology, Waikato Clinical Campus, University of Auckland, Hamilton, New Zealand
- Department of Anaesthesia and Pain Medicine, Waikato District Health Board, Hamilton, New Zealand
| | - Matthias Kreuzer
- Department for Anesthesiology and Critical Care, Technische Universität München, Munich, Germany
| | - Sebastian Schmid
- Department for Anesthesiology and Critical Care, Technische Universität München, Munich, Germany
| | - Stephan Kratzer
- Department for Anesthesiology and Critical Care, Technische Universität München, Munich, Germany
| | - Amy Rodriguez
- Center for Visual and Neurocognitive Rehabilitation, Atlanta VA Medical Center, Atlanta, GA USA
- Department of Neurology, Emory University School of Medicine, Atlanta, GA USA
| | - Gerhard Schneider
- Department for Anesthesiology and Critical Care, Technische Universität München, Munich, Germany
| | - Paul Garcia
- Department of Bioinformatics, Emory University School of Medicine, Atlanta, GA USA
- Department of Anesthesiology, Columbia University, New York, USA
- Neuroanaesthesia Division, Columbia University Medical Center, New York, USA
- New York Presbyterian Hospital, Irving, New York, USA
| | - Jamie Sleigh
- Department of Anaesthesiology, Waikato Clinical Campus, University of Auckland, Hamilton, New Zealand
- Department of Anaesthesia and Pain Medicine, Waikato District Health Board, Hamilton, New Zealand
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Asahi Y, Kubota K, Omichi S. Dose Requirements for Propofol Anaesthesia for Dental Treatment for Autistic Patients Compared with Intellectually Impaired Patients. Anaesth Intensive Care 2019; 37:70-3. [DOI: 10.1177/0310057x0903700101] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Y. Asahi
- Department of Dentistry, Bobath Memorial Hospital, Osaka, Japan
- Department of Dentistry, Morinomiya Hospital and Bobath Memorial Hospital
| | - K. Kubota
- Department of Dentistry, Morinomiya Hospital and Graduate School of Management Development and Information Sciences, Nihon Fukushi University, Aichi
| | - S. Omichi
- Department of Dentistry, Bobath Memorial Hospital and Part-time Dentist, Department of Dentistry, Morinomiya Hospital
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Koch S, Feinkohl I, Chakravarty S, Windmann V, Lichtner G, Pischon T, Brown EN, Spies C. Cognitive Impairment Is Associated with Absolute Intraoperative Frontal α-Band Power but Not with Baseline α-Band Power: A Pilot Study. Dement Geriatr Cogn Disord 2019; 48:83-92. [PMID: 31578031 PMCID: PMC7367434 DOI: 10.1159/000502950] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 08/26/2019] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Cognitive abilities decline with aging, leading to a higher risk for the development of postoperative delirium or postoperative neurocognitive disorders after general anesthesia. Since frontal α-band power is known to be highly correlated with cognitive function in general, we hypothesized that preoperative cognitive impairment is associated with lower baseline and intraoperative frontal α-band power in older adults. METHODS Patients aged ≥65 years undergoing elective surgery were included in this prospective observational study. Cognitive function was assessed on the day before surgery using six age-sensitive cognitive tests. Scores on those tests were entered into a principal component analysis to calculate a composite "g score" of global cognitive ability. Patient groups were dichotomized into a lower cognitive group (LC) reaching the lower 1/3 of "g scores" and a normal cognitive group (NC) consisting of the upper 2/3 of "g scores." Continuous pre- and intraoperative frontal electroencephalograms (EEGs) were recorded. EEG spectra were analyzed at baseline, before start of anesthesia medication, and during a stable intraoperative period. Significant differences in band power between the NC and LC groups were computed by using a frequency domain (δ 0.5-3 Hz, θ 4-7 Hz, α 8-12 Hz, β 13-30 Hz)-based bootstrapping algorithm. RESULTS Of 38 included patients (mean age 72 years), 24 patients were in the NC group, and 14 patients had lower cognitive abilities (LC). Intraoperative α-band power was significantly reduced in the LC group compared to the NC group (NC -1.6 [-4.48/1.17] dB vs. LC -6.0 [-9.02/-2.64] dB), and intraoperative α-band power was positively correlated with "g score" (Spearman correlation: r = 0.381; p = 0.018). Baseline EEG power did not show any associations with "g." CONCLUSIONS Preoperative cognitive impairment in older adults is associated with intraoperative absolute frontal α-band power, but not baseline α-band power.
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Affiliation(s)
- Susanne Koch
- Department of Anaesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany, .,Berlin Institute of Health (BIH), Berlin, Germany,
| | - Insa Feinkohl
- Molecular Epidemiology Research Group, Max-Delbrueck Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
| | | | - Victoria Windmann
- Department of Anaesthesiology and Intensive Care Medicine, Charité – Universitätsmedizin Berlin, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany
| | - Gregor Lichtner
- Department of Anaesthesiology and Intensive Care Medicine, Charité – Universitätsmedizin Berlin, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany
| | - Tobias Pischon
- Berlin Institute of Health (BIH), Berlin, Germany;,Molecular Epidemiology Research Group, Max-Delbrueck Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany;,MDC/BIH Biobank, Max-Delbrueck Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
| | - Emery N. Brown
- Picower Institute for Learning and Memory, MIT, Cambridge, MA, USA;,Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA;,Institute for Medical Engineering and Science, MIT, Cambridge, MA, USA;,Institute for Data, Systems and Society, MIT, Cambridge, MA, USA;,Harvard-MIT Health Sciences and Technology Program, Massachusetts Institute of Technology, Cambridge, MA, USA;,Department of Brain and Cognitive Sciences, MIT, Cambridge, MA, USA
| | - Claudia Spies
- Department of Anaesthesiology and Intensive Care Medicine, Charité – Universitätsmedizin Berlin, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany
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Association of electroencephalogram trajectories during emergence from anaesthesia with delirium in the postanaesthesia care unit: an early sign of postoperative complications. Br J Anaesth 2018; 122:622-634. [PMID: 30915984 DOI: 10.1016/j.bja.2018.09.016] [Citation(s) in RCA: 122] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 08/21/2018] [Accepted: 09/11/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Postoperative delirium is associated with an increased risk of morbidity and mortality, especially in the elderly. Delirium in the postanaesthesia care unit (PACU) could predict adverse clinical outcomes. METHODS We investigated a potential link between intraoperative EEG patterns and PACU delirium as well as an association of PACU delirium with perioperative outcomes, readmission and length of hospital stay. The risk factors for PACU delirium were also explored. Data were collected from 626 patients receiving general anaesthesia for procedures that would not interfere with frontal EEG recording. RESULTS Of the 626 subjects enrolled, 125 tested positive for PACU delirium. Whilst age, renal failure, and pre-existing neurological disease were associated with PACU delirium in the univariable analysis, the multivariable analysis revealed the importance of information derived from the EEG, anaesthetic technique, anaesthesia duration, and history of stroke or neurodegenerative disease. The occurrence of EEG burst suppression during maintenance [odds ratio (OR)=1.86 (1.13-3.05)] and the type of EEG emergence trajectory may be predictive of PACU delirium. Specifically, EEG emergence trajectories lacking significant spindle power were strongly associated with PACU delirium, especially in cases that involved ketamine or nitrous oxide [OR=6.51 (3.00-14.12)]. Additionally, subjects with PACU delirium were at an increased risk for readmission [OR=2.17 (1.13-4.17)] and twice as likely to stay >6 days in the hospital. CONCLUSIONS Specific EEG patterns were associated with PACU delirium. These findings provide valuable information regarding how the brain reacts to surgery and anaesthesia that may lead to strategies to predict PACU delirium and identify key areas of investigation for its prevention.
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Ke JD, Xu M, Wang PP, Wang M, Tian M, Chen ACN. Influence of propofol on the electroencephalogram default mode network in patients of advanced age. J Int Med Res 2018; 46:4660-4668. [PMID: 30246583 PMCID: PMC6259396 DOI: 10.1177/0300060518788241] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Objective This study was performed to evaluate the effects of propofol on the electroencephalogram (EEG) default mode network (DMN) in patients of advanced age. Methods Fifteen men aged >60 years (mean, 70 years) were selected. Propofol target-controlled infusion was performed under EEG bispectral index monitoring. The propofol target effect-site concentration, blood pressure, heart rate, and distributions and powers of the EEG spectrum were recorded in an awake state and under anesthesia. The EEG included seven bands: delta (0.5–3.5 Hz), theta (4.0–7.0 Hz), alpha-1 (7.5–9.5 Hz), alpha-2 (10–12 Hz), beta-1 (13–23 Hz), beta-2 (24–34 Hz), and gamma (35–45 Hz). Results From an awake state to anesthesia, the brain topographic map showed that the energies of delta, theta, alpha-1, alpha-2, and beta-1 were concentrated in the frontoparietal site, and the power increased significantly. The energy distribution of beta-2 was significantly decreased and the power significantly reduced. The energy distribution of gamma in the temporal lobe was also markedly decreased and the power significantly reduced. Conclusions This study revealed the changes in the spatial distribution and regional energy of the EEG DMD in men of advanced age from the awake state to the anesthetized state.
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Affiliation(s)
- Jing-Dong Ke
- 1 Center for Higher Brain Functions, Department of Neurobiology, Capital Medical University, Beijing, China.,2 Department of Anesthesiology, Friendship Hospital, Capital Medical University, Beijing, China
| | - Min Xu
- 1 Center for Higher Brain Functions, Department of Neurobiology, Capital Medical University, Beijing, China
| | - Pei-Pei Wang
- 1 Center for Higher Brain Functions, Department of Neurobiology, Capital Medical University, Beijing, China
| | - Min Wang
- 2 Department of Anesthesiology, Friendship Hospital, Capital Medical University, Beijing, China
| | - Ming Tian
- 2 Department of Anesthesiology, Friendship Hospital, Capital Medical University, Beijing, China
| | - Andrew C N Chen
- 1 Center for Higher Brain Functions, Department of Neurobiology, Capital Medical University, Beijing, China
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So E, Kim HJ, Karm MH, Seo KS, Chang J, Lee JH. A retrospective analysis of outpatient anesthesia management for dental treatment of patients with severe Alzheimer's disease. J Dent Anesth Pain Med 2017; 17:271-280. [PMID: 29349349 PMCID: PMC5766088 DOI: 10.17245/jdapm.2017.17.4.271] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 12/22/2017] [Accepted: 12/26/2017] [Indexed: 01/25/2023] Open
Abstract
Background The number of patients with Alzheimer's disease is growing worldwide, and the proportion of patients requiring dental treatment under general anesthesia increases with increasing severity of the disease. However, outpatient anesthesia management for these patients involves great risks, as most patients with Alzheimer's disease are old and may show reduced cardiopulmonary functions and have cognitive disorders. Methods This study retrospectively investigated 43 patients with Alzheimer's disease who received outpatient anesthesia for dental treatment between 2012–2017. Pre-anesthesia patient evaluation, dental treatment details, anesthetics dose, blood pressure, duration and procedure of anesthesia, and post-recovery management were analyzed and compared between patients who underwent general anesthesia or intravenous sedation. Results Mean age of patients was about 70 years; mean duration of Alzheimer's disease since diagnosis was 6.3 years. Severity was assessed using the global deterioration scale; 62.8% of patients were in level ≥ 6. Mean duration of anesthesia was 178 minutes for general anesthesia and 85 minutes for intravenous sedation. Mean recovery time was 65 minutes. Eleven patients underwent intravenous sedation using propofol, and 22/32 cases involved total intravenous anesthesia using propofol and remifentanil. Anesthesia was maintained with desflurane for other patients. While maintaining anesthesia, inotropic and atropine were used for eight and four patients, respectively. No patient developed postoperative delirium. All patients were discharged without complications. Conclusion With appropriate anesthetic management, outpatient anesthesia was successfully performed without complications for dental treatment for patients with severe Alzheimer's disease.
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Affiliation(s)
- Eunsun So
- Department of Dental Anesthesiology, Seoul National University Dental Hospital, Seoul, Korea
| | - Hyun Jeong Kim
- Department of Dental Anesthesiology, Seoul National University Dental Hospital, Seoul, Korea
| | - Myong-Hwan Karm
- Department of Dental Anesthesiology, Seoul National University Dental Hospital, Seoul, Korea
| | - Kwang-Suk Seo
- Department of Dental Anesthesiology, Seoul National University Dental Hospital, Seoul, Korea
| | - Juhea Chang
- Special Care Clinic, Seoul National University Dental Hospital, Seoul, Korea
| | - Joo Hyung Lee
- Department of anesthesiology and pain medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea
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Escontrela Rodríguez B, Gago Martínez A, Merino Julián I, Martínez Ruiz A. Spectral entropy in monitoring anesthetic depth. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2016; 63:471-478. [PMID: 26431743 DOI: 10.1016/j.redar.2015.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2015] [Revised: 06/30/2015] [Accepted: 07/14/2015] [Indexed: 06/05/2023]
Abstract
Monitoring the brain response to hypnotics in general anesthesia, with the nociceptive and hemodynamic stimulus interaction, has been a subject of intense investigation for many years. Nowadays, monitors of depth of anesthesia are based in processed electroencephalogram by different algorithms, some of them unknown, to obtain a simplified numeric parameter approximate to brain activity state in each moment. In this review we evaluate if spectral entropy suitably reflects the brain electric behavior in response to hypnotics and the different intensity nociceptive stimulus effect during a surgical procedure.
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Affiliation(s)
- B Escontrela Rodríguez
- Servicio Anestesiología y Reanimación, Hospital Universitario de Cruces, Barakaldo, Vizcaya, España.
| | - A Gago Martínez
- Servicio Anestesiología y Reanimación, Hospital Universitario de Cruces, Barakaldo, Vizcaya, España
| | - I Merino Julián
- Servicio Anestesiología y Reanimación, Hospital Universitario de Cruces, Barakaldo, Vizcaya, España
| | - A Martínez Ruiz
- Servicio Anestesiología y Reanimación, Hospital Universitario de Cruces, Barakaldo, Vizcaya, España; Facultad de Medicina, Universidad del País Vasco, Leioa, Vizcaya, España
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Mensen A, Poryazova R, Huegli G, Baumann CR, Schwartz S, Khatami R. The Roles of Dopamine and Hypocretin in Reward: A Electroencephalographic Study. PLoS One 2015; 10:e0142432. [PMID: 26599765 PMCID: PMC4658140 DOI: 10.1371/journal.pone.0142432] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 10/21/2015] [Indexed: 11/19/2022] Open
Abstract
The proper functioning of the mesolimbic reward system is largely dependent on the neurotransmitter dopamine. Recent evidence suggests that the hypocretin system has significant projections to this reward system. We examined the distinct effects of reduced dopamine or reduced hypocretin levels on reward activity in patients with Parkinson’s disease, dopamine deficient, as well as patients with narcolepsy-cataplexy, hypocretin depleted, and healthy controls. Participants performed a simple game-like task while high-density electroencephalography was recorded. Topography and timing of event-related potentials for both reward cue, and reward feedback was examined across the entire dataset. While response to reward cue was similar in all groups, two distinct time points were found to distinguish patients and controls for reward feedback. Around 160ms both patient groups had reduced ERP amplitude compared to controls. Later at 250ms, both patient groups also showed a clear event-related potential (ERP), which was absent in controls. The initial differences show that both patient groups show a similar, blunted response to reward delivery. The second potential corresponds to the classic feedback-related negativity (FRN) potential which relies on dopamine activity and reflects reward prediction-error signaling. In particular the mismatch between predicted reward and reward subsequently received was significantly higher in PD compared to NC, independent of reward magnitude and valence. The intermediate FRN response in NC highlights the contribution of hypocretin in reward processing, yet also shows that this is not as detrimental to the reward system as in Parkinson’s. Furthermore, the inability to generate accurate predictions in NC may explain why hypocretin deficiency mediates cataplexy triggered by both positive and negative emotions.
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Affiliation(s)
- Armand Mensen
- Department of Sleep Medicine, Clinic Barmelweid, 5017 Aargau, Switzerland
| | - Rositsa Poryazova
- Department of Neurology, University Hospital Zurich, 8006 Zurich, Switzerland
| | - Gordana Huegli
- Department of Sleep Medicine, Clinic Barmelweid, 5017 Aargau, Switzerland
| | | | - Sophie Schwartz
- Department of Neuroscience, University of Geneva, 1211 Geneva, Switzerland
| | - Ramin Khatami
- Department of Sleep Medicine, Clinic Barmelweid, 5017 Aargau, Switzerland
- * E-mail:
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Purdon PL, Pavone KJ, Akeju O, Smith AC, Sampson AL, Lee J, Zhou DW, Solt K, Brown EN. The Ageing Brain: Age-dependent changes in the electroencephalogram during propofol and sevoflurane general anaesthesia. Br J Anaesth 2015; 115 Suppl 1:i46-i57. [PMID: 26174300 DOI: 10.1093/bja/aev213] [Citation(s) in RCA: 230] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Anaesthetic drugs act at sites within the brain that undergo profound changes during typical ageing. We postulated that anaesthesia-induced brain dynamics observed in the EEG change with age. METHODS We analysed the EEG in 155 patients aged 18-90 yr who received propofol (n=60) or sevoflurane (n=95) as the primary anaesthetic. The EEG spectrum and coherence were estimated throughout a 2 min period of stable anaesthetic maintenance. Age-related effects were characterized by analysing power and coherence as a function of age using linear regression and by comparing the power spectrum and coherence in young (18- to 38-yr-old) and elderly (70- to 90-yr-old) patients. RESULTS Power across all frequency bands decreased significantly with age for both propofol and sevoflurane; elderly patients showed EEG oscillations ∼2- to 3-fold smaller in amplitude than younger adults. The qualitative form of the EEG appeared similar regardless of age, showing prominent alpha (8-12 Hz) and slow (0.1-1 Hz) oscillations. However, alpha band dynamics showed specific age-related changes. In elderly compared with young patients, alpha power decreased more than slow power, and alpha coherence and peak frequency were significantly lower. Older patients were more likely to experience burst suppression. CONCLUSIONS These profound age-related changes in the EEG are consistent with known neurobiological and neuroanatomical changes that occur during typical ageing. Commercial EEG-based depth-of-anaesthesia indices do not account for age and are therefore likely to be inaccurate in elderly patients. In contrast, monitoring the unprocessed EEG and its spectrogram can account for age and individual patient characteristics.
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Affiliation(s)
- P L Purdon
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA Harvard Medical School, Boston, MA, USA Department of Brain and Cognitive Science
| | - K J Pavone
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - O Akeju
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA Harvard Medical School, Boston, MA, USA
| | - A C Smith
- Department of Brain and Cognitive Science
| | - A L Sampson
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - J Lee
- Harvard-Massachusetts Institute of Technology Division of Health Sciences and Technology
| | - D W Zhou
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - K Solt
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA Harvard Medical School, Boston, MA, USA
| | - E N Brown
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA Harvard Medical School, Boston, MA, USA Department of Brain and Cognitive Science Harvard-Massachusetts Institute of Technology Division of Health Sciences and Technology Institute for Medical Engineering and Sciences, Massachusetts Institute of Technology, Cambridge, MA, USA
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Chemali JJ, Kenny JD, Olutola O, Taylor NE, Kimchi EY, Purdon PL, Brown EN, Solt K. Ageing delays emergence from general anaesthesia in rats by increasing anaesthetic sensitivity in the brain. Br J Anaesth 2015; 115 Suppl 1:i58-i65. [PMID: 26174302 DOI: 10.1093/bja/aev112] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Little is known about ageing-related changes in the brain that affect emergence from general anaesthesia. We used young adult and aged Fischer 344 rats to test the hypothesis that ageing delays emergence from general anaesthesia by increasing anaesthetic sensitivity in the brain. METHODS Time to emergence was determined for isoflurane (1.5 vol% for 45 min) and propofol (8 mg kg(-1) i.v.). The dose of isoflurane required to maintain loss of righting (LOR) was established in young adult and aged rats. The efficacy of methylphenidate to reverse LOR from general anaesthesia was tested. Separate young adult and aged rats with implanted electroencephalogram (EEG) electrodes were used to test whether ageing increases sensitivity to anaesthetic-induced burst suppression. RESULTS Mean time to emergence from isoflurane anaesthesia was 47 s [95% CI 33, 60; young adult) compared with 243 s (95% CI 185, 308; aged). For propofol, mean time to emergence was 13.1 min (95% CI 11.9, 14.0; young adult) compared with 23.1 min (95% CI 18.8, 27.9; aged). These differences were statistically significant. When methylphenidate was administered after propofol, the mean time to emergence decreased to 6.6 min (95% CI 5.9, 7.1; young adult) and 10.2 min (95% CI 7.9, 12.3; aged). These reductions were statistically significant. Methylphenidate restored righting in all rats during continuous isoflurane anaesthesia. Aged rats had lower EEG power and were more sensitive to anaesthetic-induced burst suppression. CONCLUSIONS Ageing delays emergence from general anaesthesia. This is due, at least in part, to increased anaesthetic sensitivity in the brain. Further studies are warranted to establish the underlying causes.
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Affiliation(s)
- J J Chemali
- Department of Anaesthesia, Critical Care, and Pain Medicine and
| | - J D Kenny
- Department of Anaesthesia, Critical Care, and Pain Medicine and
| | - O Olutola
- Department of Anaesthesia, Critical Care, and Pain Medicine and
| | - N E Taylor
- Department of Anaesthesia, Critical Care, and Pain Medicine and Department of Anaesthesia, Harvard Medical School and
| | - E Y Kimchi
- Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA Department of Neurology, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - P L Purdon
- Department of Anaesthesia, Critical Care, and Pain Medicine and Department of Anaesthesia, Harvard Medical School and
| | - E N Brown
- Department of Anaesthesia, Critical Care, and Pain Medicine and Department of Anaesthesia, Harvard Medical School and Department of Brain and Cognitive Sciences Institute for Medical Engineering and Science, Massachusetts Institute of Technology, 77 Massachusetts Avenue, Cambridge, MA 02139, USA
| | - K Solt
- Department of Anaesthesia, Critical Care, and Pain Medicine and Department of Anaesthesia, Harvard Medical School and
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Rao AK, Gurajala I, Gopinath R. Comparison of electroencephalogram entropy versus loss of verbal response to determine the requirement of propofol for induction of general anaesthesia. Indian J Anaesth 2015. [PMID: 26195830 PMCID: PMC4481753 DOI: 10.4103/0019-5049.158738] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Background and Aims: Propofol causes dose-dependent reduction in blood pressure (BP). This study was done to evaluate the use of spectral entropy on the dose of propofol required and the haemodynamic stability during induction of general anaesthesia (GA). Methods: In this randomised controlled study, 72 American Society of Anesthesiologists’ physical status I and II patients undergoing general and orthopaedic surgeries were divided into Group S (n-36) and Group C (n-36). Patients in Group C were induced with propofol till loss of response to verbal commands and in Group S until the state entropy was <50 and state and response entropy difference was <10. The induction dose of propofol, haemodynamic parameters and the entropy values were recorded. Numerical data were expressed as a mean ± standard deviation and analysed using unpaired, two-tailed t-test. Categorical data were compared using Chi-square test. P < 0.05 value was considered significant. Results: The dose of propofol per kg was significantly more in the entropy group (1.80 ± 0.23 mg/kg in the Group C and 1.98 ± 0.217 mg/kg in the Group S [P < 0.05]). After induction, at intubation and 1 min after intubation, entropy values were lower in Group S than Group C (P < 0.05). The BP decreased significantly after induction compared with the baseline (P < 0.05), but there was no difference between the groups. Conclusion: Propofol required for induction of GA when guided by electroencephalogram entropy was significantly higher than the induction dose based on loss of verbal response. Both conventional induction and induction with entropy as the endpoint resulted in similar haemodynamic profile.
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Affiliation(s)
- Akasapu Karunakara Rao
- Department of Anaesthesiology, Rajiv Gandhi Institute of Medical Sciences, Srikakulam, Andhra Pradesh, India
| | - Indira Gurajala
- Department of Anaesthesiology and Critical Care, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Ramachandran Gopinath
- Department of Anaesthesiology and Critical Care, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
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Abstract
Aging involves changes in several physiologic processes that lead to decreased volumes of distribution, slowed metabolism, and increased end-organ sensitivity to anesthetics. These changes generally result in increased potency. Elderly patients require less anesthetic medication, but the true extent of reduction is underappreciated and less uniformly practiced. The impact of potential anesthetic drug overdosing on intermediate and long-term outcomes is not fully appreciated. It may be necessary to consider age as a continuous variable for anesthetic drug dosing in older patients rather than treating adult versus elderly patients. Further pharmacologic studies are required in people more than 85 years old.
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Affiliation(s)
- Shamsuddin Akhtar
- Department of Anesthesiology, Yale University School of Medicine, 333 Cedar Street, Tompkins # 3, New Haven, CT 06520, USA.
| | - Ramachandran Ramani
- Department of Anesthesiology, Yale University School of Medicine, 333 Cedar Street, Tompkins # 3, New Haven, CT 06520, USA
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Chilkoti G, Wadhwa R, Saxena AK. Technological advances in perioperative monitoring: Current concepts and clinical perspectives. J Anaesthesiol Clin Pharmacol 2015; 31:14-24. [PMID: 25788767 PMCID: PMC4353146 DOI: 10.4103/0970-9185.150521] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Minimal mandatory monitoring in the perioperative period recommended by Association of Anesthetists of Great Britain and Ireland and American Society of Anesthesiologists are universally acknowledged and has become an integral part of the anesthesia practice. The technologies in perioperative monitoring have advanced, and the availability and clinical applications have multiplied exponentially. Newer monitoring techniques include depth of anesthesia monitoring, goal-directed fluid therapy, transesophageal echocardiography, advanced neurological monitoring, improved alarm system and technological advancement in objective pain assessment. Various factors that need to be considered with the use of improved monitoring techniques are their validation data, patient outcome, safety profile, cost-effectiveness, awareness of the possible adverse events, knowledge of technical principle and ability of the convenient routine handling. In this review, we will discuss the new monitoring techniques in anesthesia, their advantages, deficiencies, limitations, their comparison to the conventional methods and their effect on patient outcome, if any.
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Affiliation(s)
- Geetanjali Chilkoti
- Department of Anaesthesiology and Critical Care, University College of Medical Sciences and Guru Teg Bahadur Hospital, Shahdara, New Delhi, India
| | - Rachna Wadhwa
- Department of Anaesthesiology and Critical Care, University College of Medical Sciences and Guru Teg Bahadur Hospital, Shahdara, New Delhi, India
| | - Ashok Kumar Saxena
- Department of Anaesthesiology and Critical Care, University College of Medical Sciences and Guru Teg Bahadur Hospital, Shahdara, New Delhi, India
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Aimé I, Gayat E, Fermanian C, Cook F, Peuch C, Laloë P, Mantz J, Fischler M. Effect of age on the comparability of bispectral and state entropy indices during the maintenance of propofol–sufentanil anaesthesia. Br J Anaesth 2012; 108:638-43. [DOI: 10.1093/bja/aer457] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Fu Y, Cui J, Ma Y. Differential effects of aging on EEG after baclofen administration. SCIENCE CHINA. LIFE SCIENCES 2011; 54:459-465. [PMID: 21574046 DOI: 10.1007/s11427-011-4170-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2010] [Accepted: 02/21/2011] [Indexed: 05/30/2023]
Abstract
Baclofen is a selective gamma-aminobutyric acid (GABA) type B agonist that may have important medicinal uses, such as in analgesics and drug addiction treatment. In addition, evidence is accumulating that suggests GABAergic-mediated neurotransmission is altered during aging. This study investigated whether baclofen administration (5 mg kg(-1)) induces differential effects on cortical electrical activity with age. Electroencephalograms (EEGs) were recorded from young (3-4 months) and aged (15-17 months) rats, and both the absolute and relative powers in five frequency bands (delta: 2-4 Hz; theta: 4-8 Hz; alpha: 8-12 Hz; beta: 12-20 Hz; gamma: 20-100 Hz) were analyzed. Before administration of baclofen, we found that the EEG relative power in the beta band was higher in the aged than that in the young rats. After administration of baclofen, there was a slower increase in the relative power in the delta band in the aged than that in the young rats. Moreover, there was no significant difference between the two age groups in absolute power in any frequency band. These findings indicate that baclofen treatment appears to differentially modify cortical EEG activity as a function of age. Our data further elucidate the relationship between GABA(B) receptor-mediated neurotransmission and aging.
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Affiliation(s)
- Yu Fu
- Department of Electronic Engineering, Information School, Yunnan University, Kunming, 650091, China.
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46
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Effects of isoflurane upon minimum alveolar concentration and cerebral cortex depression in pigs and goats: An interspecies comparison. Vet J 2011; 187:217-20. [DOI: 10.1016/j.tvjl.2009.11.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2009] [Revised: 11/12/2009] [Accepted: 11/17/2009] [Indexed: 11/21/2022]
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Monitoring the depth of anaesthesia. SENSORS 2010; 10:10896-935. [PMID: 22163504 PMCID: PMC3231065 DOI: 10.3390/s101210896] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/01/2010] [Revised: 09/29/2010] [Accepted: 11/22/2010] [Indexed: 11/25/2022]
Abstract
One of the current challenges in medicine is monitoring the patients’ depth of general anaesthesia (DGA). Accurate assessment of the depth of anaesthesia contributes to tailoring drug administration to the individual patient, thus preventing awareness or excessive anaesthetic depth and improving patients’ outcomes. In the past decade, there has been a significant increase in the number of studies on the development, comparison and validation of commercial devices that estimate the DGA by analyzing electrical activity of the brain (i.e., evoked potentials or brain waves). In this paper we review the most frequently used sensors and mathematical methods for monitoring the DGA, their validation in clinical practice and discuss the central question of whether these approaches can, compared to other conventional methods, reduce the risk of patient awareness during surgical procedures.
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Pritchett S, Zilberg E, Xu ZM, Myles P, Brown I, Burton D. Peak and averaged bicoherence for different EEG patterns during general anaesthesia. Biomed Eng Online 2010; 9:76. [PMID: 21092128 PMCID: PMC2998515 DOI: 10.1186/1475-925x-9-76] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2009] [Accepted: 11/20/2010] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Changes in nonlinear neuronal mechanisms of EEG generation in the course of general anaesthesia have been extensively investigated in research literature. A number of EEG signal properties capable of tracking these changes have been reported and employed in anaesthetic depth monitors. The degree of phase coupling between different spectral components is a marker of nonlinear EEG generators and is claimed to be an important aspect of BIS. While bicoherence is the most direct measure of phase coupling, according to published research it is not directly used in the calculation of BIS, and only limited studies of its association with anaesthetic depth and level of consciousness have been published. This paper investigates bicoherence parameters across equal band and unequal band bifrequency regions, during different states of anaesthetic depth relating to routine clinical anaesthesia, as determined by visual inspection of EEG. METHODS 41 subjects scheduled for day surgery under general anaesthesia were recruited into this study. EEG bicoherence was analysed using average and smoothed-peak estimates calculated over different regions on the bifrequency plane. Statistical analysis of associations between anaesthetic depth/state of consciousness and bicoherence estimates included linear regression using generalised linear mixed effects models (GLMs), ROC curves and prediction probability (Pk). RESULTS Bicoherence estimates for the δ_θ region on the bifrequency plane were more sensitive to anaesthetic depth changes compared to other bifrequency regions. Smoothed-peak bicoherence displayed stronger associations than average bicoherence. Excluding burst suppression and large transients, the δ_θ peak bicoherence was significantly associated with level of anaesthetic depth (z = 25.74, p < 0.001 and R2 = 0.191). Estimates of Pk for this parameter were 0.889(0.867-0.911) and 0.709(0.689-0.729) respectively for conscious states and anaesthetic depth levels (comparable BIS estimates were 0.928(0.905-0.950) and 0.801(0.786-0.816)). Estimates of linear regression and areas under ROC curves supported Pk findings. Bicoherence for eye movement artifacts were the most distinctive with respect to other EEG patterns (average |z| value 13.233). CONCLUSIONS This study quantified associations between deepening anaesthesia and increase in bicoherence for different frequency components and bicoherence estimates. Increase in bicoherence was also established for eye movement artifacts. While identified associations extend earlier findings of bicoherence changes with increases in anaesthetic drug concentration, results indicate that the unequal band bifrequency region, δ_θ, provides better predictive capabilities than equal band bifrequency regions.
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Affiliation(s)
- Stacey Pritchett
- Electrical and Computer Science Engineering, Monash University, Clayton, Vic, Australia
- Medical Innovations, Compumedics Pty Ltd, Abbotsford, Vic, Australia
| | - Eugene Zilberg
- Medical Innovations, Compumedics Pty Ltd, Abbotsford, Vic, Australia
| | - Zheng Ming Xu
- Medical Innovations, Compumedics Pty Ltd, Abbotsford, Vic, Australia
| | - Paul Myles
- Anaesthesia and Perioperative Medicine, Alfred Hospital, Prahran, Vic, Australia
- Medicine, Nursing and Health Sciences (Central Clinical School), Monash University, Clayton, Vic, Australia
| | - Ian Brown
- Electrical and Computer Science Engineering, Monash University, Clayton, Vic, Australia
| | - David Burton
- Medical Innovations, Compumedics Pty Ltd, Abbotsford, Vic, Australia
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Propofol and the electroencephalogram. Clin Neurophysiol 2010; 121:998-1006. [DOI: 10.1016/j.clinph.2009.12.016] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2009] [Revised: 12/01/2009] [Accepted: 12/13/2009] [Indexed: 11/15/2022]
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50
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Lysakowski C, Elia N, Czarnetzki C, Dumont L, Haller G, Combescure C, Tramèr M. Bispectral and spectral entropy indices at propofol-induced loss of consciousness in young and elderly patients. Br J Anaesth 2009; 103:387-93. [DOI: 10.1093/bja/aep162] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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