Monitoring of processed EEG under anesthesia I

Czech version

Authors: M. Horáček ^1,2
Authors‘ workplace: Klinika anesteziologie, resuscitace a intenzivní medicíny, 2. lékařská fakulta Univerzity Karlovy a Fakultní nemocnice v Motole, Praha ¹; Katedra anesteziologie a intenzivní medicíny, Institut postgraduálního vzdělávání ve zdravotnictví, Praha ²
Published in: Anest. intenziv. Med., 33, 2022, č. 2, s. 79-89
Category: Review Article

Overview

The target organ of most substances applied during general anesthesia is the brain. The manifestations of its function include, above all, consciousness. It is associated with the electrical activity of neurons, which can be easily recorded from the surface of the skull – electroencephalography (EEG). The electrical activity of the brain in anesthesia changes in a predictable way depending on the anesthetic used and its dose. EEG assessment is difficult but has been greatly simplified by computer development. Therefore, computer-processed EEG (pEEG) may soon become an integral part of monitoring patients under anesthesia. Anesthesiologists’ attention with EEG monitoring initially focused on anesthesia depth indices (eg. BIS, entropy, PSI, qCON, etc.), but brain function cannot be reduced to a single number. It is also necessary to monitor simultaneously the raw EEG curves and to assess the changes in their shape. When conducting anesthesia, it is important to avoid burst suppression because it is a risk factor for postoperative delirium. Evaluation of the phase-amplitude coupling makes it possible to quantify the depth of anesthesia in more detail. Processed EEG is used to prevent unattended awareness during anesthesia and to prevent too deep anesthesia, although the benefit has not yet been safely confirmed. However, pEEG has been shown to reduce recovery times and anesthetic doses. It allows also personalized management of anesthesia, relevant studies are underway. The most widespread monitors in the Czech Republic are probably BIS, GE Entropy, and Conox. The development of pEEG continues, but its understanding and application require increasing knowledge in many fields.

Keywords:

EEG – Entropy – Anesthesia – BIS – depth of anesthesia index

Sources

1. Brown EN, Lydic R, Schiff ND. General anesthesia, sleep, and coma. N Engl J Med. 2010 Dec 30;363(27):2638-50. doi: 10.1056/NEJMra0808281. PMID: 21190458.

2. Berger H. Über das Elektrenkephalogramm des Menschen. Archive für Psychiatre und Nervenkrankheiten, 1929, 87, p. 527-570.

3. https://en.wikipedia.org/wiki/Richard_Caton (poslední přístup 10. 1. 2022).

4. Gibbs FA,Gibbs EK, Lennox WG. Effect on the electroencephalogram of certain drugs which influence nervous activity. Arch Intern Med (Chic). 1937;60(1):154-166. doi:10.1001/archinte. 1937.00180010159012.

5. Aldecoa C, Bettelli G, Bilotta F, Sanders RD, Audisio R, Borozdina A, et al. European Society of Anaesthesiology evidence‑based and consensus‑based guideline on postoperative delirium. Eur J Anaesthesiol. 2017 Apr;34(4):192-214. doi: 10.1097/EJA.0000000000000594. PMID: 28187050.

6. Klein AA, Meek T, Allcock E, Cook TM, Mincher N, Morris C et al.: Recommendations for standards of monitoring during anaesthesia and recovery 2021: Guideline from the Association of Anaesthetists. Anaesthesia. 2021 Sep;76(9):1212-1223. doi: 10.1111/anae.15501. PMID: 34013531.

7. Doporučený postup ČSARIM: Zásady bezpečné anesteziologické péče. Dostupný na https://www.csarim.cz/getmedia/bf2afe85-bd5b-4050-acd6-0cd4583aff9b/doporuceny‑postup‑zasady‑bezpecne‑anesteziologicke‑pece- 2017.pdf.aspx (poslední přístup 10. 1. 2022).

8. Sigl JC, Chamoun NG. An introduction to bispectral analysis for the electroencephalogram. J Clin Monit 1994;10:392-404.

9. Montupil J, Defresne A, Bonhomme V. The Raw and Processed Electroencephalogram as a Monitoring and Diagnostic Tool. J Cardiothorac Vasc Anesth. 2019 Aug;33 Suppl 1:S3-S10. doi: 10.1053/j.jvca.2019. 03. 038. PMID: 31279351.

10. Ferreira AL, Mendes JG, Nunes CS, Amorim P. Evaluation of Bispectral Index time delay in response to anesthesia induction: an observational study. Braz J Anesthesiol. 2019 Jul‑Aug; 69(4):377-382. doi: 10.1016/j.bjan.2019. 03. 008. PMID: 31371175.

11. Kreuzer M, Zanner R, Pilge S, Paprotny S, Kochs EF, Schneider G. Time delay of monitors of the hypnotic component of anesthesia: analysis of state entropy and index of consciousness. Anesth Analg. 2012 Aug;115(2):315-9. doi: 10.1213/ANE.0b013e31825801ea. PMID: 22584557.

12. Monk TG, Saini V, Weldon BC, Sigl JC. Anesthetic management and one‑year mortality after noncardiac surgery. Anesth Analg. 2005 Jan;100(1):4-10. doi: 10.1213/01. ANE.0000147519.82841.5E.

13. Sessler DI, Sigl JC, Kelley SD, Chamoun NG, Manberg PJ, Saager L et al. Hospital stay and mortality are increased in patients having a „triple low“ of low blood pressure, low bispectral index, and low minimum alveolar concentration of volatile anesthesia. Anesthesiology. 2012 Jun;116(6):1195-203. doi: 10.1097/ALN.0b013e31825683dc.

14. Willingham MD, Karren E, Shanks AM, O’Connor MF, Jacobsohn E, Kheterpal S, et al. Concurrence of Intraoperative Hypotension, Low Minimum Alveolar Concentration, and Low Bispectral Index Is Associated with Postoperative Death. Anesthesiology. 2015 Oct;123(4):775- 85. doi: 10.1097/ALN.0000000000000822. PMID: 26267244.

15. Yoon S, Yoo S, Hur M, Park SK, Lee HC, Jung CW, et al. The cumulative duration of bispectral index less than 40 concurrent with hypotension is associated with 90-day postoperative mortality: a retrospective study. BMC Anesthesiol. 2020 Aug 14;20(1):200. doi: 10.1186/s12871-020-01122-7. PMID: 32795266.

16. Sessler DI, Turan A, Stapelfeldt WH, Mascha EJ, Yang D, Farag E, et al. Triple‑ low Alerts Do Not Reduce Mortality: A Real‑ time Randomized Trial. Anesthesiology. 2019 Jan;130(1):72-82. doi: 10.1097/ALN.0000000000002480. PMID: 30312182.

17. Ahuja S, Luedi MM. Too little or too much anesthesia: Age paradox of electroencephalogram indices. J Clin Anesth. 2021 Oct;73:110358. doi: 10.1016/j.jclinane. 2021.110358. PMID: 34082269.

18. Ellerkmann RK, Bruhn J, Soehle M, Kehrer M, Hoeft A, Kreuer S. Maximizing prediction probability PK as an alternative semiparametric approach to estimate the plasma effect‑ site equilibration rate constant ke0. Anesth Analg. 2009 Nov;109(5):1470- 8. doi: 10.1213/ANE.0b013e3181b61efd. PMID: 19713250.

19. Kim JK, Kim DK, Lee MJ. Relationship of bispectral index to minimum alveolar concentration during isoflurane, sevoflurane or desflurane anaesthesia. J Int Med Res. 2014 Feb;42(1):130-7.

20. Schuller PJ, Newell S, Strickland PA, Barry JJ: Response of bispectral index to neuromuscular block in awake volunteers. Br J Anaesth. 2015 Jul;115 Suppl 1:i95-i103. doi: 10.1093/bja/aev072.

21. Whitlock EL, Gross ER, King CR, Avidan MS. Anaesthetic depth and delirium: a challenging balancing act. Br J Anaesth. 2021 Nov;127(5):667-671. doi: 10.1016/j. bja.2021. 08. 003.

22. Dustin Boone M, Lin HM, Liu X, Kim J, Sano M, Baxter MG, et al. Processed intraoperative burst suppression and postoperative cognitive dysfunction in a cohort of older noncardiac surgery patients. J Clin Monit Comput. 2021 Dec 3. doi: 10.1007/ s10877-021-00783-0. Epub ahead of print. PMID: 34862586.

23. Purdon PL, Sampson A, Pavone KJ, Brown EN. Clinical Electroencephalography for Anesthesiologists: Part I: Background and Basic Signatures. Anesthesiology. 2015 Oct;123(4):937-60.

24. Barnard JP, Bennett C, Voss LJ, Sleigh JW. Can anaesthetists be taught to interpret the effects of general anaesthesia on the electroencephalogram? Comparison of performance with the BIS and spectral entropy. Br J Anaesth. 2007 Oct;99(4):532- 7. doi: 10.1093/bja/aem198.

25. Bombardieri AM, Wildes TS, Stevens T, Wolfson M, Steinhorn R, Ben Abdallah A, et al. Practical Training of Anesthesia Clinicians in Electroencephalogram‑ Based Determination of Hypnotic Depth of General Anesthesia. Anesth Analg. 2020 Mar;130(3):777-786. doi: 10.1213/ANE.00000000000045.

26. Bottros MM, Palanca BJ, Mashour GA, Patel A, Butler C, Taylor A, et al. Estimation of the bispectral index by anesthesiologists: an inverse turing test. Anesthesiology. 2011 May;114(5):1093-101. doi: 10.1097/ALN.0b013e31820e7c5c. PMID: 21460704.

27. Pawar N, Barreto Chang OL. Burst Suppression During General Anesthesia and Postoperative Outcomes: Mini Review. Front Syst Neurosci. 2022 Jan 7;15:767489. doi: 10.3389/fnsys.2021.767489. PMID: 35069132.

28. Fleischmann A, Pilge S, Kiel T, Kratzer S, Schneider G, Kreuzer M. Substance‑Specific Differences in Human Electroencephalographic Burst Suppression Patterns. Front Hum Neurosci. 2018 Sep 21;12:368. doi: 10.3389/fnhum.2018.00368. PMID: 30297992.

29. 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 Dec 3;14:599962. doi: 10.3389/fnsys.2020.599962.

30. Shanker A, Abel JH, Schamberg G, Brown EN. Etiology of Burst Suppression EEG Patterns. Front Psychol. 2021 Jun 10;12:673529. doi: 10.3389/fpsyg.2021.673529.

31. Fritz BA, Kalarickal PL, Maybrier HR, Muench MR, Dearth D, Chen Y, et al. Intraoperative Electroencephalogram Suppression Predicts Postoperative Delirium. Anesth Analg. 2016 Jan;122(1):234-42. doi: 10.1213/ANE.0000000000000989.

32. Deiner S, Luo X, Silverstein JH, Sano M. Can Intraoperative Processed EEG Predict Postoperative Cognitive Dysfunction in the Elderly? Clin Ther. 2015 Dec 1;37(12):2700- 5. doi: 10.1016/j.clinthera.2015. 11. 004.

33. Dustin Boone M, Lin HM, Liu X, Kim J, Sano M, Baxter MG, et al. Processed intraoperative burst suppression and postoperative cognitive dysfunction in a cohort of older noncardiac surgery patients. J Clin Monit Comput. 2021 Dec 3. doi: 10.1007/s10877- 021-00783-0.

34. Fritz BA, Budelier TP, Ben Abdallah A, Avidan MS. The Unbearableness of Being Light. Anesthesia & Analgesia: 2020; 131(3): 977-980 doi: 10.1213/ANE.0000000000004814.

35. Muhlhofer WG, Zak R, Kamal T, Rizvi B, Sands LP, Yuan Met al. Burst‑ suppression ratio underestimates absolute duration of electroencephalogram suppression compared with visual analysis of intraoperative electroencephalogram. Br J Anaesth. 2017;118:755- 61. https://doi.org/10.1093/bja/aex054.

36. Pleasants D, Zak R, Ashbrook LH, Zhang L, Tang C, Tran D, et al. Processed electroencephalography: impact of patient age and surgical position on intraoperative processed electroencephalogram monitoring of burst‑ suppression. J Clin Monit Comput. 2021 Jul 10. doi: 10.1007/s10877-021-00741-w.

37. Sleigh J, Scheib C, Sanders RD. General anaesthesia and electroencephalographic spindles. Trends in Anaesthesia and Critical Care 2011 (october): 1(5–6): 263-269. DOI: 10.1016/j.tacc.2011. 10. 001.

38. Purdon PL, Pierce ET, Mukamel EA, Prerau MJ, Walsh JL, Wong KF, et al. Electroencephalogram signatures of loss and recovery of consciousness from propofol. Proc Natl Acad Sci U S A. 2013 Mar 19;110(12):E1142-51. doi: 10.1073/pnas.1221180110.

39. Chamadia S, Pedemonte JC, Hahm EY, Mekonnen J, Ibala R, Gitlin J, et al. Delta oscillations phase limit neural activity during sevoflurane anesthesia. Commun Biol. 2019 Nov 15;2:415. doi: 10.1038/s42003-019-0664-3. eCollection 2019. PMID: 31754645.

40. Numan T, van Dellen E, Vleggaar FP, van Vlieberghe P, Stam CJ, Slooter AJC. Resting State EEG Characteristics During Sedation With Midazolam or Propofol in Older Subjects. Clin EEG Neurosci. 2019 Nov;50(6):436-443. doi: 10.1177/1550059419838938. PMID: 31106583.

41. Windmann V, Spies C, Brown EN, Kishnan D, Lichtner G, Koch S; BioCog Study Group. Influence of midazolam premedication on intraoperative EEG signatures in elderly patients. Clin Neurophysiol. 2019 Sep;130(9):1673-1681. doi: 10.1016/j.clinph. 2019. 05. 035. PMID: 31351371.

42. Gaskell A, Pullon R, Hight D, Termaat J, Mans G, Voss L, et al. 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 Feb 22;20(1):146. doi: 10.1186/s13063-019-3178-x.

43. Pears B. The short, sad life and tragic death of Hannah Greener. Dostupné z: https:// brianpearsblog.files.wordpress.com/2017/01/short_sad_life.pdf.

44. National Institute for Health and Clinical Excellence. Depth of anaesthesia monitors (E‐Entropy, BIS and Narcotrend). NICE Diagnostic Guideline No. 6. London: NICE 2012, 2012. Available at www.nice.org.uk/dg6.

45. Pandit JJ, Andrade J, Bogod DG, Hitchman JM, Jonker WR, Lucas N, et al; Royal College of Anaesthetists; Association of Anaesthetists of Great Britain and Ireland. 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: summary of main findings and risk factors. Br J Anaesth. 2014 Oct;113(4):549-59. doi: 10.1093/bja/aeu313. PMID: 25204697.

46. Messina AG, Wang M, Ward MJ, Wilker CC, Smith BB, Vezina DP, et al. Anaesthetic interventions for prevention of awareness during surgery. Cochrane Database Syst Rev. 2016 Oct 18;10(10):CD007272. doi: 10.1002/14651858.CD007272.pub2. PMID: 27755648.

47. Lewis SR, Pritchard MW, Fawcett LJ, Punjasawadwong Y. Bispectral index for improving intraoperative awareness and early postoperative recovery in adults. Cochrane Database Syst Rev. 2019 Sep 26;9(9):CD003843. doi: 10.1002/14651858.CD003843. pub4. PMID: 31557307.

48. Punjasawadwong Y, Chau‑ In W, Laopaiboon M, Punjasawadwong S, Pin‑On P. Processed electroencephalogram and evoked potential techniques for amelioration of postoperative delirium and cognitive dysfunction following non‑cardiac and non‑neurosurgical procedures in adults. Cochrane Database Syst Rev. 2018 May 15;5(5):CD011283. doi: 10.1002/14651858.CD011283.pub2. PMID: 29761891.

49. Wildes TS, Mickle AM, Ben Abdallah A, Maybrier HR, Oberhaus J, Budelier TP, et al.; ENGAGES Research Group. Effect of Electroencephalography‑Guided Anesthetic Administration on Postoperative Delirium Among Older Adults Undergoing Major Surgery: The ENGAGES Randomized Clinical Trial. JAMA. 2019 Feb 5;321(5):473-483. doi: 10.1001/ jama.2018.22005. PMID: 30721296.

50. Fritz BA, King CR, Mickle AM, Wildes TS, Budelier TP, Oberhaus J, et al.; ENGAGES Research Group. Effect of electroencephalogram‑guided anaesthesia administration on 1-yr mortality: follow‑up of a randomised clinical trial. Br J Anaesth. 2021 Sep;127(3):386-395. doi: 10.1016/j.bja.2021. 04. 036. Epub 2021 Jul 7. PMID: 34243940.

51. Evered LA, Goldstein PA. Reducing Perioperative Neurocognitive Disorders (PND) Through Depth of Anesthesia Monitoring: A Critical Review. Int J Gen Med. 2021 Jan 14;14:153- 162. doi: 10.2147/IJGM.S242230. eCollection 2021. PMID: 33469352.

52. Punjasawadwong Y, Boonjeungmonkol N, Phongchiewboon A. Bispectral index for improving anaesthetic delivery and postoperative recovery. Cochrane Database Syst Rev. 2007 Oct 17;(4):CD003843. doi: 10.1002/14651858.CD003843.pub2. PMID: 17943802.

53. Punjasawadwong Y, Phongchiewboon A, Bunchungmongkol N. Bispectral index for improving anaesthetic delivery and postoperative recovery. Cochrane Database Syst Rev. 2014 Jun 17;2014(6):CD003843. doi: 10.1002/14651858.CD003843.pub3. PMID: 24937564.

54. Lewis SR, Pritchard MW, Fawcett LJ, Punjasawadwong Y. Bispectral index for improving intraoperative awareness and early postoperative recovery in adults. Cochrane Database Syst Rev. 2019 Sep 26;9(9):CD003843. doi: 10.1002/14651858.CD003843.pub4. PMID: 31557307.

55. Chhabra A, Subramaniam R, Srivastava A, Prabhakar H, Kalaivani M, Paranjape S. Spectral entropy monitoring for adults and children undergoing general anaesthesia. Cochrane Database Syst Rev. 2016 Mar 14;3:CD010135. doi: 10.1002/14651858.CD010135. pub2. PMID: 26976247.

56. Dahaba AA. Different conditions that could result in the bispectral index indicating an incorrect hypnotic state. Anesth Analg. 2005 Sep;101(3):765-773. doi: 10.1213/01. ane.0000167269.62966.af. PMID: 16115989.

57. Viertiö‑Oja H, Maja V, Sarkela M, Talja P, Tenkanen N, Tolvanen‑Laakso H, et al. Description of the Entropy algorithm as applied in the Datex‑Ohmeda S/5 Entropy Module. Acta Anaesthesiol Scand. 2004;48:154-61. doi: 10.1111/j.0001-5172.2004.00322.x PMID: 14995936.

58. Drover DR, Lemmens HJ, Pierce ET, Plourde G, Loyd G, Ornstein E, et al. Patient State Index: titration of delivery and recovery from propofol, alfentanil, and nitrous oxide anesthesia. Anesthesiology. 2002 Jul;97(1):82-9. doi: 10.1097/00000542-200207000-00012. PMID: 12131107.

59. Ellerkmann RK, Soehle M, Kreuer S. Brain monitoring revisited: what is it all about? Best Pract Res Clin Anaesthesiol. 2013 Jun;27(2):225-33. doi: 10.1016/j.bpa.2013. 06. 006. PMID: 24012234.

60. Dahaba AA. Different conditions that could result in the bispectral index indicating an incorrect hypnotic state. Anesth Analg. 2005 Sep;101(3):765-773. doi: 10.1213/01. ane.0000167269.62966.af. PMID: 16115989.

61. Avendaňo DQ: BIS Índice Biespectral: Un nuevo „signo vital“. Slide 7. Dostupné z: http:// slideplayer.es/slide/1557150.