Monitoring in TIVA

This can be done by:

•Clinical Monitoring
•Special Monitoring
 Clinical Monitoring
► Standard ASA recommended monitoring plus as per requirement of
surgery/ individual patient. MONITORS-ECG , PULSE OXYMETRY,
NIBP, ETCO2, TEMP
SUBJECTIVE METHOD:
1}AUTONOMIC RESPONSE-hemodynamic changes, lacrimation,
sweating, pupillary dilatation
2}ISOLATED FOREARM TECHNIQUE-
 Short Coming of Clinical
Monitoring
Clinical assessment of anaesthetic depth has
become more challenging because IV
anaesthetic techniques involve combination of
hypnotics, Opioids, muscle relaxants and
adjuvant drugs.

The interaction between these drugs result in

additive, supra additive, infra-additive, or even
antagonist effects making clinical monitoring
alone unreliable leading to the chances of
“Awareness or Delayed awakening”
 Special Monitoring

Two simple noninvasive monitor to measure

depth on anaesthesia could be:
• EEG & DERIVED INDICES
1. Bispectral index(BIS)
2.Entropy
3.Patient State Index (PSI)
4.Narcotrend
5.Cerebral State Index
6.SNAP index

•EVOKED POTENTIALS.
1.MLAEP- AEP index
Definitions of Awareness and Memory
► Awareness—Postoperative recall of events
  
occurring during general anesthesia . 
► Amnesic wakefulness—Responsiveness during
general anesthesia without postoperative recall
►   Dreaming—Any experience (excluding awareness)
that patients are able to recall postoperatively that
they think occurred during general anesthesia and
that they believe is dreaming.
►    Explicit memory—Conscious recollection of
previous experiences (“awareness” is evidence of
explicit memory)
► Implicit memory—Changes in performance or
behavior that are produced by previous experiences
but without any conscious recollection of those
experiences (“unconscious memory formation”
during general anesthesia).
High Risk Patient Characteristics

 Substance use or abuse

 Limited hemodynamic reserve
 ASA IV – V
 Previous episode of intraoperative awareness
 Chronic pain patients
 Younger age
 Tobacco smoking
High Risk Anesthetic Techniques

Reduced anesthetic doses in presence

of paralysis

Total intravenous anesthesia

Nitrous oxide-opioid anesthesia

Rapid sequence induction

 TIVA and Awareness
► TIVA – independent high risk for awareness
► TIVA recipe: Propofol/opioid +/- ketamine
 Ketamine is controversial since Ketamine (as well
as Etomidate) enhance both SSEP’s and MEP’s
► Wake up test (rarely done anymore!)
► BIS monitoring
► Small bolus (eg, 1-2mg) of Midazolam intraop
(too much will affect monitoring!!)
SEA # 32 – Reducing risk of awareness
► Pre operative amnestics
► Deeper anesthesia during intubation
► Appropriate use of narcotics to prevent pain – separate
recall of events from pain
► Less profound muscle relaxation
► Appropriate considerations for substance-tolerant patients
► Maintain accuracy of anesthesia delivery systems
► Brain monitoring
► Better OR decorum – less talking and loud music at times
of expected light anesthesia
► Post op review and counseling
► Informed consent?

10
 EEG monitoring limitations:

 Insensitive to nitrous oxide, ketamine, xenon

 Sensitive to Beta- blockers, muscle relaxants
 Hypothermia, hypoglycemia can affect the
reading
 5-10% of normal population has congenitally
low-voltage EEG
 Subject to artifact from other electrical
equipment in the OR.
 Practical Problems with
EEG/BIS/Entropy…
►Algorithmic
 Artifacts (diathermy, eye-
movements etc…)
 EMG and Burst Suppression
►Inherent
 Prediction of movement /MAC
 Other drugs… atropine…
 Disease…CNS… Systemic…
 Awake ()

Drowsy

Spindle Light GA

Deeper
GA ()

Burst
Burst suppression
 EEG analysis
3 predominant methods
► time domain analysis methods: analyse the
changes in the EEG signal in respect to time,
► frequency domain analysis methods: analyse
the changes in the EEG potentials in respect to
frequency
► bispectral analysis methods: analyse EEG
signal in respect to its amplitude, its frequency
and its correlation between phase angle and the
frequency range of the included waves.
Bispectral Index (BIS)
 Bispectral Index
► BIS is a proprietary that converts a single channel of frontal EEG
into an index of hypnotic level (BIS).
► To compute the BIS, several variables derived from the EEG
time domain (burst-suppression analysis), frequency domain
(power spectrum, bispectrum: inter-frequency phase
relationships) are combined into a single index of hypnotic level.
► A multivariate logistic regression was used in offline analysis
and identified those features of the EEG recordings that best
correlated with clinical depth of sedation/anaesthesia, and these
were then fitted to a model. The resulting algorithm generates
the BIS.
► BIS model accounts for the nonlinear stages of EEG activity by
allowing different parameters to dominate the resulting BIS as
the EEG changes its character with increasing plasma
concentrations of various anaesthetics, resulting in a linear
decrease in BIS.
► It is suggested that routine intraoperative events (e.g.,
administration of depolarizing muscle relaxants, activation of
electromagnetic equipment or devices, patient warming or
planned hypothermia)may interfere with BIS functioning.
 BIS Range Guidelines

Titration of sedatives to BIS ranges should be dependent upon the individual goals
for sedation that have been established for each patient.
These goals and associated BIS ranges may vary over time, in the context of patient
status and treatment plan.
 Bispectral Index (BIS)

Proprietary algorithm converts a single channel of

frontal EEG into an index of hypnotic level

BIS values scaled from 0-100

Specific range of 40-60 = low probability of

consciousness under GA
Entropy
 ENTROPY
► Based on acquisition and processing of raw
EEG and FEMG signals
► describes the irregularity, complexity, or
unpredictability characteristics of a signal.
► EEG recordings change from irregular to
more regular patterns when anaesthesia
deepens.
 Entropy
 Describes the irregularity, complexity or
unpredictable characteristics of a signal
 Single sine wave represents a completely
predictable signal (entropy = 0)
 Noise represents entropy = 1
 State entropy: cortical state (hypnosis)
 Response entropy: EMG activity from inadequate
analgesia
 Entropy and Anaesthesia
►Awake brain = High Entropy =>
‘Freedom’ “Boiling Brain”
 there are many available microstates
 energy spreads out easily spatial coherence or
decoherence?
 accurate & fast cortical information processing
►Comatose brain = Low Entropy =>
‘Prison’
“Frozen Brain”
 few microstates
 slow inaccurate information processing
ENTROPY AND ANAESTHESIA
Deep GA

Awake 0.74(0.02)
0.90(0.03)

Loss-of-Consciousness
0.69(0.06)

Increasing Anaesthetic Effect

EEG & Power Spectrum - Alert
Patient

Spectral Entropy = 0.9

EEG & Power Spectrum - Anaesthetised

Spectral Entropy = 0.4

 State/ Response entropy
► State entropy (SE) is an index ranging from 0 to 91
(awake)-- the frequency range from 0.8 to 32 Hz,
reflecting the cortical state of the patient.
► Response entropy (RE) is an index ranging from 0 to
100 (awake)--a frequency range from 0.8 to 47 Hz,
containing the higher EMG-dominated frequencies, and
will thus also respond to the increased EMG activity
resulting from inadequate analgesia.
► Vakkuri A et al have been reported that entropy
monitoring assists better titration of propofol especially
during the last part of the procedures, as indicated by
higher entropy values, decreased consumption of
propofol, and shorter recovery times in the entropy
group.
 PSI(PATIENT STATE INDEX)
► The PSI monitor is based on a quantitative analysis of
the α, β, Δ, and θ frequency bands as revealed by fast
Fourier transformation, recorded from anterior and
posterior scalp sites, as input to a multivariate algorithm
that quantifies the most probable level of hypnosis.
► 4-channel EEG
Patient State Analyzer: self-norming technique
values: 0 to 100
► faster emergence and recovery from propofol-alfentanil-
nitrous oxide anesthesia, with modest decrease in the
amount of propofol delivered.
► useful in assessing patients receiving a combination of
propofol and sufentanil.
► the influence of muscle activity: uncertain.
► less interference with the PSI readings during
electrocautery use
PSI VALUES
AUDITORY EVOKED POTENTIALS
► The AEP is defined as the passage of electrical activity from the
cochlea to the cortex, which produces a waveform consisting of 15
waves. The waveform can be divided into three parts:
 Brainstem Auditory Evoked Potential (BAEP) from brainstem,
 Middle Latency Auditory Evoked Potential (MLAEP) from medial
geniculate body and the primary auditory cortex and
 Long Latency Auditory Evoked Potential (LLAEP) from frontal cortex
and association areas.
► Measures the brain’s reaction to acoustic stimuli.
► Hearing,a natural choice for measuring patient consciousness under
anaesthetic
► The brainstem response is relatively insensitive to anaesthetics,
whereas early cortical responses (MLAEPs), change predictably with
increasing concentrations of both volatile and intravenous
anaesthetics
 AEP monitoring
► From a mathematical analysis of the AEP waveform, the device
generates an “AEP index” {from 0-100} or A-line ARX Index(AAI)
{0–60 range }
► Re-usable headphones/earphones deliver the active stimulation,
cost-effective disposable surface electrodes are used to measure
the AEP.
► The AAI index is calculated in the 20–80 ms window of the AEP and
latency and amplitude changes in the AEP are weighted equally.
► The typical AEP response to increasing anaesthetic concentrations is
increased latency and decreased amplitude of the various waveform
components.
► AAI responded to LMA insertion or surgical incision, but not the BIS,
and the AAI had smaller variations.
► AAI recovered faster from the disturbance by electrocautery than
theBIS and the AAI may be a more sensitive and useful detector of
arousal than the BIS.
 AEP monitoring-
A-line ARX Index(AAI)
 NARCOTREND
► Frontal EEG monitor to measure the depth of anaesthesia
► recorded by standard ECG electrodes for single- and double-channel
registration.
► After artifact exclusion and Fourier transformation EEG data classified
as:
A(awake), B(sedated), C (light anaesthesia), D (general
anaesthesia), E (general anaesthesia with deep hypnosis), F
(general anaesthesia with increasing burst suppression).
► 14 possible sub-stages: A, B0–2, C0–2, D0–2, E0–1, and F0–1
► In the most recent version it is “translated” into a numerical scaling
index system which called as the Narcotrend®index.
► This is scaled quantitatively similar to BIS scale viz. 0 (deeply
anaesthetized) to 100(awake).
 NARCOTREND
► No clinical trials or other comparative
studies were found that examine the
impact of Narcotrend®monitoring on the
incidence of intraoperative awareness.
► found to reduce propofol consumption
compared to a conventional clinical practice.
► unable to differentiate reliably between
conscious and unconscious patients during
general anaesthesia when neuromuscular
blocking agentsare used
SNAP index
 SNAP index
► Raw EEG signals used by unique algorithm, which analyses
both high(80-420 Hz) and low (0-20 Hz) frequency
components of the signal and results ranges from 100
(arbitrarily representing the fully awake state)to 0. This is
termed the SNAP index.
► SNAP index returns to baseline before awakening,
whereas the BIS index remains below baseline at
awakening, suggesting that the SNAP index may be more
sensitive to unintentional awareness.
► there is no evidence that SNAP is superior to others in
generating more specific information about ‘depth of
sedation’
► Still being researched.
 Cerebral State Monitor/Cerebral
State Index (CSI)
► The EEG waveform is derived from the signal recorded between the
frontal and mastoid electrodes. The frequency content is 2-35 Hz.
► CSI is based on the analysis of the frequency content of the EEG
signal. It analyses the frequency shifts that take place in the EEG
signal as the level of consciousness changes.
► The energy of the EEG is evaluated in specific frequency bands. These
are used to define two energy ratios called α and β.
► Both of these show a shift in energy content from the higher to the
lower frequencies during anaesthesia. The relationship between these
quantities is also analyzed as a separate parameter (β-α).
► The monitor incorporates an EMG filter.
 Cerebral State Monitor/Cerebral
State Index (CSI)
► The monitor also evaluates the amount of instantaneous burst
suppression (BS) in each thirty-second period of the EEG.
► The four parameters (α ratio, β ratio, β-α shift & BS) are used as input
to a fuzzy logic classifier system that calculates the CSI.
► The CSI is a unit-less scale from 0 to 100,where 0 indicates a flat EEG
and 100 indicate EEG activity corresponding to the awake state. The
range of adequate anaesthesia is designed to be between 40 and 60.
► CSI detects well the graduated levels of propofol anaesthesia when
compared with the propofol effect site concentration and the OAAS
score
► It behaves as other depth of anaesthesia monitors with a progressive
decrease during propofol induction but loss of consciousness with N2O
results no change in CSI.
► No published literature was found for impact on intraoperative
awareness.
 ASA Practice Advisory
 The decision to administer benzodiazepine
prophylactically should be made on a case-by-
case basis for selected patients

 Intraoperative monitoring of depth of anesthesia

should rely on multiple modalities, including
clinical techniques and conventional monitoring
systems( ECG, BP, end-tidal gas analyzer)
 ASA Practice Advisory
The decision to use a brain function monitor
should be made on a case-by-case basis.

Cautions!!!
Maintaining low brain function monitor values
in an attempt to prevent intraoperative
awareness may conflict with other anesthesia
goals (preservation vital functions)
Opioid in tiva