Michel MRF Struys, MD, PhD, FRCA

Transcription

1 Afdeling Anesthesiologie Neuromonitoring Michel MRF Struys, MD, PhD, FRCA Professor and Chair, Department of Anesthesia University Medical Center Groningen Groningen, The Netherlands Professor of Anesthesia, Ghent University, Gent, Belgium

2

3

4 Conflicts of interest My research group/department received grants, funding, honoraria from The Medicines Company (Parsippany, NJ, USA), Masimo (Irvine, CA, USA), Fresenius (Bad Homburg, Germany), Acacia Design (Maastricht, The Netherlands), Medtronic (Dublin, Ireland) and honoraria from The Medicines Company (Parsippany, NJ, USA), Masimo (Irvine, CA, USA), Fresenius (Bad Homburg, Germany), Baxter (Deerfield, IL, USA), Medtronic (Dublin, Ireland), Demed Medical (Temse, Belgium). I serve as a Director and editorial board member of the British Journal of Anesthesia and as a Senior Editor for Anesthesia & Analgesia.

5 Afdeling Anesthesiologie Brain monitoring (during anesthesia) Michel MRF Struys, MD, PhD, FRCA Professor and Chair, Department of Anesthesia University Medical Center Groningen Groningen, The Netherlands Professor of Anesthesia, Ghent University, Gent, Belgium Acknowledgement : Prof TWL Scheeren, UMC Groningen for the slides on NIRS

6 Statement The brain is the most important organ to care for during anesthesia.. Let s care for oxygen homeostasis!

7 Oxygen homeostasis in the brain Important components - Oxygen delivery - Oxygen content - Cerebral blood flow. Blood pressure. The heart! - Oxygen consumption (CMR02) - effects of anesthesia Source :

8 Relation between CMRO2 and depth of anesthesia? Source : Miller s Anesthesia, 8th edition, 2015

9 So..it might be good to monitor the brain for electrical activity and oxygen homeostasis?

10 Measuring cerebral drug effect EEG

11 Why using brain function monitoring? Anesthetic Effect Management BEST OUTCOMES Quality + Safety Side-effects Costs Adverse Outcomes - delirium - cognitive decline - mortality Complications Adverse Outcomes - awareness OVERDOSING ADEQUATE/OPTIMAL UNDERDOSING ANESTHETIC DEPTH

12 Components of anesthesia Anesthesia Hypnotic component of anesthesia Analgesic component of anesthesia Mediated at supraspinal level Mediated at Spinal level LOR to noxious stimulus Amnesia (Loss of Memory Formation) Hypnosis (Loss of Consciousness) Nociception/ Antinociception (Arousal Response) Immobility (no reflex movement) Inhibition Stress response Courtesy of Hugo Vereecke, MD, PhD

13 Dose - response relationship Sahinovic MM, Absalom AR, Struys MM: Administration and monitoring of intravenous anesthetics, Curr Opin Anaesthesiol 23: , 2010.

14 Interindividual Pharmacokinetic-dynamic variability Effect Pharmacodynamic variability Dose Pharmacokinetic variability

15 A population model Averaged BIS CePROP Average curve : Ce 50 = 4.17 µg/ml ; γ = 5.21 ; E 0 = 95 ; E max = 12 Mortier et al. Anaesthesia 1998; 53:

16 Interindividual variability in effect/effect-site concentration relation BIS CePROP Average curve : Ce 50 = 4.17 µg/ml ; γ = 5.21 ; E 0 = 95 ; E max = 12 Mortier et al. Anaesthesia 1998; 53:

17 Drug concentrations + measuring drug effect

18 Measure the individual drug effect! Sahinovic MM, Absalom AR, Struys MM: Administration and monitoring of intravenous anesthetics, Curr Opin Anaesthesiol 23: , 2010.

19 Measuring the components of anesthesia BIS Vista Root- Entropy Narcotrend SedLine Module CONOX A.N.I. NeuroLight SPI PMD-200 AlgiScan Consciousness monitors Response to noxious stimuli EEG changes EEG/Arousal A.N.S

20 Measure the hypnotic component EEG

21 Ref.: Mashour et al. Anesthesiology 2011, 114,

22 Measuring the nociception-antinociception balance during anesthesia

23 Action and receptors and AROUSAL NOXIOUS STIMULUS propofol barbiturates benzodiazepines inhalational an. opiates Muscle relaxans AROUSAL Local an. NSAID S

24 Anesth &Analg 2014;119:

25 Measuring cerebral responsiveness U. Hypnotic component Responsiveness component qnox was able to predict the response to the LMA placement. Melia, E. Gabarron, M.Agustí, N. Souto, P. Pineda, J. Fontanet, M. Vallverdu, E. W. Jensen, P. Gambus Comparison of the qcon and qnox indices for the assessment of unconsciousness level and noxious stimulation response during surgery. Journal of Clinical Monitoring and Computing 2017, 31,

26

27 Clinical benefits of cerebral function monitors? EEG-derived indices improve peri-operative anesthetic drug titration and most indices closely correlate with hypnotic effects of most anesthetic drugs. Eleveld DJ, Colin P, Absalom AR, Struys M: Pharmacokinetic-pharmacodynamic model for propofol for broad application in anaesthesia and sedation. Br J Anaesth 2018 ; 120: Bruhn J, Myles PS, Sneyd R, Struys MM: Depth of anaesthesia monitoring: what's available, what's validated and what's next? Br J Anaesth 2006; 97: Struys MM, De Smet T, Versichelen LF, Van De Velde S, Van den Broecke R, Mortier EP: Comparison of closed-loop controlled administration of propofol using Bispectral Index as the controlled variable versus "standard practice" controlled administration. Anesthesiology 2001; 95: 6-17.

28 Clinical benefits of cerebral function monitors? Use of BIS could reduce intra-operative awareness in patients recieving TIVA. When inhaled anesthetics are used, BIS is as equal as ETAC Avidan MS, Mashour GA: Prevention of intraoperative awareness with explicit recall: making sense of the evidence. Anesthesiology 2013; 118: NICE guidelines in the UK recommend th use of EEG-based monitoring during anesthesia, especially in vulnerable patients. Significant cerebral ischemia or hypoperfusion can be detected by changes in EEG (shift in power to lower frequencies, progressive decrease in amplitude, burst suppression, isoelectricity). No change in EEG is not a garantee for no problem! Morimoto Y, Monden Y, Ohtake K, Sakabe T, Hagihira S: The detection of cerebral hypoperfusion with bispectral index monitoring during general anesthesia. Anesth Analg 2005; 100:

29 Clinical benefits of cerebral function monitors? BIS is able to reduce the incidence of postoperative delirium compared to routine care. Siddiqi N, Harrison JK, Clegg A, Teale EA, Young J, Taylor J, Simpkins SA: Interventions for preventing delirium in hospitalised non-icu patients. Cochrane Database Syst Rev; 2016, 3: CD Kristen K. MacKenzie, Angelitta M. Britt-Spells, Laura P. Sands, Jacqueline M. Leung. Processed Electroencephalogram Monitoring and Postoperative Delirium A Systematic Review and Meta-analysis. Anesthesiology 2018, 129: Conclusion : Processed electroencephalogram-guided anesthesia was associated with a decrease in postoperative delirium. The mechanism explaining this association, however, is yet to be determined. The data are insufficient to assess the relationship between processed electroencephalogram monitoring and postoperative cognitive dysfunction.

30 Clinical benefits of cerebral function monitors? peeg monitors, depth of anesthesia and long-term mortality CONTROVERSIAL!

31 Leslie et al : an update. All published studies used the bispectral index (BIS) monitor to measure anesthetic depth. The majority of the published observational studies were post hoc analyses of studies undertaken for other purposes. Most of these studies report a statistically significant association between deep general anesthesia (i.e., BIS values less than 45) and death. Some studies also suggest an association between deep general anesthesia and myocardial infarction or postoperative cognitive decline. The combination of low BIS values and low delivered anesthetic concentrations (thus defining increased anesthetic sensitivity) may identify patients at particularly high risk. One of the three available randomized controlled trials reports worse outcomes in the BIS = 50 group compared with the BIS >80 group (light sedation + spinal), and two report no difference in mortality between the BIS = 35 and BIS = groups.

32 Measure oxygen homeostasis Cerebral regional tissue saturation by near-infrared spectroscopy

33 Cerebral oxymetry : values SrcO 2 -value interpretation SaO 2 = 95% SjbO 2 = 50% Ratio between arterial and venous blood volume= 25:75 SrcO 2 = 95% x % x 0.75 = 61% (normal value) With SD of ± 5%: SrcO 2 < 51% (61% x 5%) = cerebral ischemia/hypoxia SrcO 2 >71% (61% x 5%) = safe range SrcO 2 51% - 71% = grey zone, inconclusive value Baseline value in green Obtained at room air!

34 Cerebral oxymetry by NIRS : practical Determine baseline value during room air respiration (recommended) Determine reaction at 100% oxygen respiration (recommended) Therapeutic Strategy: Maintain rso 2 -values above 75% of the initial value (for room air respiration) When no baseline value is available: Maintain Bilateral rso 2 - value above 50%

35 Cerebral oxymetry by NIRS Masimo O3 Covidien INVOS Casmed Fore-Sight Casmed Fore-sight Elite Nonin Equanox Advance Nonin Equanox 7600 (Classic) Technology LED-based LED-based laser-based LED-based LED-based LED-based # Wavelengths Absolute or Trend Both (unspecified) Absolute Absolute Absolute Absolute Tested A RMS 4.0% (abs) 2 2.1% (trend) Indications for Use 40 kg Adult, Ped, Neo Adult, Ped Adult, Ped, Neo Adult, Ped Adult, Ped 1 Bickler PE et al. Anesth Analg Oct; 117(4): Redford D et. al. Anesth Analg McLeaod D et. Al. Anesth Analg 2013;116(SCA Suppl):1-182,#40

36 NIRS during cardiac surgery 11 /15 Studies : association between low ScO 2 and adverse outcome 5 / 9 Studies ScO 2 - guided therapy results in better outcome Scheeren TWL, Kuizenga MH, Maurer H, Struys M, Heringlake M: Electroencephalography and Brain Oxygenation Monitoring in the Perioperative Period. Anesth Analg 2018, epub

37 NIRS during non-cardiac surgery Scheeren TWL, Kuizenga MH, Maurer H, Struys M, Heringlake M: Electroencephalography and Brain Oxygenation Monitoring in the Perioperative Period. Anesth Analg 2018, epub

38 Peri-operative NIRS and outcome 15 Studies, 1822 adult patients 10 Studies CABG 4 Studies orthopedic and general surgery 1 Study carotid surgery

39 Peri-operative NIRS and outcome Results : NIRS and stroke: uncertain (Risk reduction = 0.25, but large CI: 0-2,2) NIRS und Delirium: uncertain (Risk reduction =0.63, but large CI: 0,3-1,45) NIRS and POCD: positive effect (Risk reduction = 0.53, CI: 0,3-0,95) NIRS and Mortality: uncertain (Risk reduction =0.63, but large CI: 0,1-5,0) Results may change when results from 8 ongoing studies are known.

40 Conclusion Clinical decisions should be based on physiological and pharmacological principles. This decision should be based on information recieved from various online monitors, clinical evaluation, surgical and anesthetic conditions and drugs administered to the patient. Accurate brain monitoring should always be part of this.