Postgraduate Course of Anesthesiology What does anesthesia do with the brain? September 23, 2013 UZ Leuven

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1 Postgraduate Course of Anesthesiology What does anesthesia do with the brain? September 23, 2013 UZ Leuven

2 Vincent Bonhomme CHU Liege and CHR Citadelle MONITORING DEPTH OF ANESTHESIA: WHY? WHEN?

3 WHY?

4 1. Individual titration of anesthesia 2. Prevention of failure WHY?

5 1. Individual titration of anesthesia Dose Concentration Response Pharmacodynamic effects Consciousness alteration/hypnosis Muscle relaxation Anti-nociception WHY? Inter-individual variability Pharmacokinetics Pharmacodynamics Interactions

6 2. Prevention of failure Disconnections Empty vaporizer Failure of pump Overdose WHY?

7 Measure something Alarms Individual balance Too light Too deep WHY?

8 Is it worth? Anti-nociception Too light Hemodynamic repercussions Increased surgical stress Movements Too deep Delayed recovery Acute tolerance Long term effects (immunity?) WHY?

9 Is it worth? Too light = unintentional awareness Type of surgery Incidence Overall 0.2 % High risk Fragile C-section Trauma Hemodynamic instability WHY?

10 Is it worth? Too light = unintentional awareness Consequences Movements Psychological Hemodynamic rep. PTSD WHY?

11 Is it worth? Too deep? Long cumulative deep hypnotic time (BIS < 45) 1 2 year morbidity - mortality MI cerebrovascular accident Independent of hypotension Not related to increased anesthetic dose WHY?

12

13 1. The past 2. The present 3. The future

14 1. The past Clinical evaluation Guedel 1937

15 1. The past Clinical evaluation Poor sensitivity Poor specificity

16 Depth of sedation 2. The present EEG Awake state Beta activation Delta slowing Burst-suppression Flat Tonner et Bein Best Pract Res Clin Anaesthesiol 2006

17 2. The present Analysis Algorithm Number 0-100

18 2. The present Bispectral Index

19 x * log(1/x) Normalisation SN(fi ) = S(fi) / ln(n(fi)) 2. The present M-Entropy - Spectral Entropy of the EEG State Entropy (SE) Response Entropy (RE) Raw EEG Power spectrum x ln(1/x) Entropy x * log(1/x) FFT x * log(1/x) x * log(1/x)

20 2. The present SedLine Patient State Index (PSI)

21 2. The present Cerebral State Monitor (CSM) Cerebral State Index (CSI) Pilge et al Anesth Analg 2011

22 2. The present Narcotrend Schultz et al J Clin Monit Comp 2008

23 2. The present NeuroSense - WAV CNS

24 2. The present aepex

25 BIS 2. The present Utilization mode Loss of responsiveness Laryngoscopy Delta-BIS Time (hh:mm:ss)

26 2. The present Do we achieve our goals? Prevention of awareness with recall Not straightforward Avidan et al Anesthesiology 2013

27 2. The present Do we achieve our goals? Prevention of awareness with recall Not straightforward Avidan et al Anesthesiology 2013

28 2. The present Do we achieve our goals? Prevention of awareness with recall Reasons Relatively low incidence Several confounding factors Electrical artifacts, inter-individual variability, site of recording, hypothermia, hypoglycemia, cortical atrophy, cerebral ischemia, interactions Endpoint definition Consciousness Connectedness Responsiveness

29 2. The present Do we achieve our goals? Prevention of awareness with recall Current recommendations Avidan et al Anesthesiology 2013

30 2. The present Do we achieve our goals? Individual titration Large scale randomized studies not convincing, but Avidan et al Anesthesiology 2013

31 2. The present Do we achieve our goals? Individual titration Hasten recovery El Hor et al Anesthesiology 2013

32 2. The present Do we achieve our goals? Individual titration Avoid over dosing El Hor et al Anesthesiology 2013

33 2. The present Nociception

34 2. The present Nociception Commercially available monitors Algiscan

35 2. The present Nociception Commercially available monitors Surgical Pleth Index (SPI)

36 2. The present Nociception Commercially available monitors Analgesia Nociception Index (ANI)

37 2. The present Nociception Demonstrated benefits Sensitive to nociception-anti-nociception balance Prediction of movement in response to stimulation Reduce remifentanil consumption Reduce undesired events Better prediction of recovery Chen et al Anesthesiology 2010

38 2. The present Nociception Confounding factors PCMK non-sinus rhythm Atropine amines Sensor position Ventilation mode Hypothermia Intravascular volume status Thresholds? Hans et al Acta Anaesthesiol Scand 2012 Bonhomme et al BJA 2010

39 3. The future Consciousness networks Heine et al Front Neurol 2012

40 3. The future Semantic precisions Consciousness - Connectedness - Responsiveness? Sanders et al Anesthesiology 2012

41 3. The future Consciousness networks Alteration by anesthesia Boveroux et al Anesthesiology 2010

42 3. The future Consciousness networks Fronto-parietal connectivity Parietal cortex Thalamus Prefrontal cortex

43 3. The future Functional correlates Feedback and feed-forward fronto-parietal connectivity Symbolic Transfer Entropy (STE) Consciousness not necessarily connectedness Ku et al PlosOne 2011

44 3. The future Functional correlates Feedback and feed-forward fronto-parietal connectivity Symbolic Transfer Entropy (STE) Consciousness not necessarily connectedness Lee et al Anesthesiology 2013

45 3. The future Functional correlates Feedback and feed-forward fronto-parietal connectivity Permutation Entropy (PeEn) Consciousness not necessarily connectedness Jordan et al Anesthesiology 2008

46 3. The future Functional correlates Feedback and feed-forward fronto-parietal connectivity High density EEG - TMS Consciousness not necessarily connectedness Ferrarelli et al PNAS 2010

47 3. The future Functional correlates Late latency evoked responses Connectedness Bell et al Anesth Analg 2006

48 3. The future Functional correlates Phase amplitude - distribution Responsiveness Purdon et al PNAS 2013

49 3. The future Nociception Individual calibration? Removal of confounding factors Specific cortical witness?

50 WHEN?

51 1. Hypnotic component Prevention of AWR High risk patients Long procedures TIVA Individual titration All patients WHEN?

52 2. Nociception Large scale studies still needed Improved titration Limitation of surgical stress Prediction of pain on recovery WHEN?

53 THANK YOU

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