Anesthetic Management of a Patient with an Electroencephalogram Phenotype for a "vulnerable Brain": a Case Report

Overview

Journal JA Clin Rep

Date 2023 May 16

PMID 37193855

Authors

Ryo Wakabayashi

Affiliations

Soon will be listed here.

Abstract

Background: Low frontal alpha power is an electroencephalogram phenotype suggesting vulnerability to anesthetics. This phenotype for a "vulnerable brain" carries risks for burst suppression at lower-than-expected anesthetic concentrations and therefore for postoperative delirium.

Case Presentation: A 73-year-old man underwent a laparoscopic Miles' operation. He was monitored with a bispectral index monitor. Before the skin incision, the fraction of age-adjusted minimum alveolar concentration of desflurane was 0.48, and a spectrogram showed slow-delta oscillation despite a bispectral index value of 38-48. Although the fraction of age-adjusted minimum alveolar concentration of desflurane decreased to 0.33, the EEG signature remained unchanged, along with a similar bispectral index value. No burst suppression patterns were observed throughout the whole procedure, and he did not experience postoperative delirium.

Conclusions: This case suggests that monitoring of electroencephalogram signatures is helpful for detecting patients with a "vulnerable brain" and for providing optimal anesthetic depth in such patients.

References

Bakkour A, Morris J, Wolk D, Dickerson B . The effects of aging and Alzheimer's disease on cerebral cortical anatomy: specificity and differential relationships with cognition. Neuroimage. 2013; 76:332-44. PMC: 4098706. DOI: 10.1016/j.neuroimage.2013.02.059. View

Shafer S, Varvel J, Aziz N, Scott J . Pharmacokinetics of fentanyl administered by computer-controlled infusion pump. Anesthesiology. 1990; 73(6):1091-102. DOI: 10.1097/00000542-199012000-00005. View

Hendrickx J, De Wolf A . End-tidal Anesthetic Concentration: Monitoring, Interpretation, and Clinical Application. Anesthesiology. 2022; 136(6):985-996. DOI: 10.1097/ALN.0000000000004218. View

Scott J, Ponganis K, Stanski D . EEG quantitation of narcotic effect: the comparative pharmacodynamics of fentanyl and alfentanil. Anesthesiology. 1985; 62(3):234-41. DOI: 10.1097/00000542-198503000-00005. View

Mapleson W . Effect of age on MAC in humans: a meta-analysis. Br J Anaesth. 1996; 76(2):179-85. DOI: 10.1093/bja/76.2.179. View

Rampil I . A primer for EEG signal processing in anesthesia. Anesthesiology. 1998; 89(4):980-1002. DOI: 10.1097/00000542-199810000-00023. View

. Postoperative delirium in older adults: best practice statement from the American Geriatrics Society. J Am Coll Surg. 2014; 220(2):136-48.e1. DOI: 10.1016/j.jamcollsurg.2014.10.019. View

Foreman B, Claassen J . Quantitative EEG for the detection of brain ischemia. Crit Care. 2012; 16(2):216. PMC: 3681361. DOI: 10.1186/cc11230. View

Chung C, Poon C, Irwin M . Peri-operative neurological monitoring with electroencephalography and cerebral oximetry: a narrative review. Anaesthesia. 2022; 77 Suppl 1:113-122. DOI: 10.1111/anae.15616. View

10.

Mashour G, Orser B, Avidan M . Intraoperative awareness: from neurobiology to clinical practice. Anesthesiology. 2011; 114(5):1218-33. DOI: 10.1097/ALN.0b013e31820fc9b6. View

11.

Fritz B, Kalarickal P, Maybrier H, Muench M, Dearth D, Chen Y . Intraoperative Electroencephalogram Suppression Predicts Postoperative Delirium. Anesth Analg. 2015; 122(1):234-42. PMC: 4684753. DOI: 10.1213/ANE.0000000000000989. View

12.

Purdon P, Sampson A, Pavone K, Brown E . Clinical Electroencephalography for Anesthesiologists: Part I: Background and Basic Signatures. Anesthesiology. 2015; 123(4):937-60. PMC: 4573341. DOI: 10.1097/ALN.0000000000000841. View

13.

Shao Y, Kahali P, Houle T, Deng H, Colvin C, Dickerson B . Low Frontal Alpha Power Is Associated With the Propensity for Burst Suppression: An Electroencephalogram Phenotype for a "Vulnerable Brain". Anesth Analg. 2020; 131(5):1529-1539. PMC: 7553194. DOI: 10.1213/ANE.0000000000004781. View

14.

Egan T, Minto C, Hermann D, Barr J, Muir K, Shafer S . Remifentanil versus alfentanil: comparative pharmacokinetics and pharmacodynamics in healthy adult male volunteers. Anesthesiology. 1996; 84(4):821-33. DOI: 10.1097/00000542-199604000-00009. View

15.

Schmidt G, Bischoff P, Standl T, Lankenau G, Hilbert M, Am Esch J . Comparative evaluation of Narcotrend, Bispectral Index, and classical electroencephalographic variables during induction, maintenance, and emergence of a propofol/remifentanil anesthesia. Anesth Analg. 2004; 98(5):1346-53, table of contents. DOI: 10.1213/01.ane.0000111209.44119.30. View

16.

Eleveld D, Proost J, Vereecke H, Absalom A, Olofsen E, Vuyk J . An Allometric Model of Remifentanil Pharmacokinetics and Pharmacodynamics. Anesthesiology. 2017; 126(6):1005-1018. DOI: 10.1097/ALN.0000000000001634. View