监测麻醉与镇静深度的新方法-ARX模式听觉诱发电位指数
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摘要
Background: The rapidly extracted auditory evoked potentials index (A-lineTM ARX Index or AAI) has been proposed as a method to measure the depth of anaesthesia. In an attempt to give some guidance for clinical monitoring, prospective studies were designed: ⑴ to assess the performance of AAI for measuring the depth of sedation induced by propofol or midazolam under epidural block; ⑵ to assess the performance of AAI to detect the recovery and loss of wakefulness in anaesthetized and paralysed patients; ⑶ to test whether neuromuscular block with vecuronium can reduce AAI.
Methods: ⑴ Thirty-two adult patients undergoing elective gynaecological surgery under low-thoracolumbar epidural block were studied to assess the performance of AAI for measuring the depth of sedation induced by propofol or midazolam. Eighteen patients received propofol (Group P: 20mg bolus every 3 min) and fourteen received midazolam (Group M: 0.5mg bolus every 5 min) until the observer's assessment of alertness/sedation (OAA/S) scale score of 1 was achieved. AAI and the bispectal index (BIhx, Huaxiang Technology Co. Ltd, Heilongjiang, China) were monitored for different OAA/S scores. ⑵ Fourteen adult patients undergoing elective surgery were anaesthetized with propofol 1.5 mg·kg-1, vecuronium 0.1 mg·kg-1 and another propofol 1.0 mg·kg-1. Wakefulness was measured by the ability of the patient to respond to command using the isolated forearm technique (IFT). After the patient responded, propofol was infused at 10 mg·kg-1·h-1 until wakefulness was lost. AAI was recorded continuously throughout the study and analysed off-line. ⑶ Forty adult patients undergoing elective surgery were studied. After tracheal intubation, anaesthesia was maintained with an end-tidal isoflurane concentration (FETISO) of 1.0% for 20 min, then a 10 ml dose of either vecuronium 0.05 mg·kg-1, 0.1 mg·kg-1, 0.2 mg·kg-1 or saline was randomly administered. AAI and BIhx were monitored throughout the study and analysed off-line.
Results: ⑴ AAI and BIhx decreased and increased following the changes on the patients' OAA/S scores and correlated with sedation significantly. During the onset phase, the coefficients of Spearman's rank correlation for AAI and BIhx were respectively 0.958 and 0.898 (P < 0.001) for Group P, and 0.973 and 0.945 (P < 0.001) for Group M. During the recovery phase in Group P, the coefficients were respectively 0.946 and 0.702 (P < 0.001). The coefficients of Spearman's rank correlation and linear regression for AAI were all greater comparing with the corresponding ones for BIhx (P < 0.05). ⑵ AAI showed a significant difference between the values registered during, 30 s before and 30 s after the recovery, and also between 30 s before and 30 s after the loss of wakefulness. The prediction probability (Pk) values for AAI were 0.786 and 0.864 during the transitions from unresponsiveness to responsiveness and from responsiveness to unresponsiveness. The area under the receiver operating characteristic curve for the responsive and unresponsive values was 0.926 (SE 0.002, 95% CI 0.922-0.931), and the AAI values of approximately 5%, 50% and 95% predicted
probability of wakefulness were 19, 29 and 39, respectively. ⑶ BIhx was unaltered after the administration of saline or vecuronium. The mean of the averaged (per patient) AAI values recorded from 2 min to 10 min after the administration of saline or vecuronium 0.05 mg.kg-1 did not differ significantly from the corresponding mean recorded from 15 min to 20 min after FETISO maintained 1.0% (P > 0.05). However, after the administration of vecuronium 0.1 mg.kg-1 or 0.2 mg.kg-1, the mean showed a significant reduction (P < 0.05). The mean percentages of decrease of AAI in the vecuronium 0.1 mg.kg-1 and 0.2 mg.kg-1 groups (16.3% and 21.6%) were also significantly greater than that in the saline group (0.3%) (P < 0.05).
Conclusions: ⑴ Both AAI and BIhx correlate well with the depth of sedation induced by propofol or midazolam under epidural block. AAI may be more valuable to monitor the dept
引文
1. Stanski DR. Monitoring depth of anesthesia. In: Miller RD (Ed.). Anesthesia, 5th ed., Beijing: Science Press, 2001: 1087-1116.
2. Rosow CE. Can we measure depth of anesthesia? In: Schwartz AJ, Matjasko J, Otto C, eds. 50th Annual Refresher Course Lectures and Clinical Update Program. Philadelphia: Lippincott Williams & Wilkins, 1999: 114.
3. Capitanio L, Jensen EW, Filligoi GC, et al. On-line analysis of averaged AEP, autoregressive (ARX) modeled AEP and spectral edge frequency of EEG for monitoring depth of anaesthesia. Methods Inf Med 1997; 36: 311-314.
4. Urhonen E, Jensen EW, Lund J. Changes in rapidly extracted auditory evoked potentials during tracheal intubation. Acta Anaesthesiol Scand 2000; 44: 743-748.
5. Thornton C. Evoked potentials in anaesthesia. Eur J Anaesthesiol 1991; 8: 89-107.
6. Drummond JC. Monitoring depth of anesthesia. Anesthesiology 2000; 93; 876-882.
7. Thornton C, Sharpe RM. Evoked responses in anaesthesia. Br J Anaesth 1998; 81: 771-781.
8. Jensen EW, Lindholm P, Henneberg SW. Autoregressive modeling with exogenous input of middle-latency auditory-evoked potentials to measure rapid changes in depth of anesthesia. Methods Inf Med 1996; 35: 256-260.
9. Litvan H, Jensen EW, Galan J, et al. Comparison of conventional averaged and rapid averaged, autoregressive-based extracted auditory evoked potentials for monitoring the hypnotic level during propofol induction. Anesthesiology 2002; 97: 351-358.
10. Struys MMRF, Jensen EW, Smith W, et al. Performance of the ARX-derived auditory evoked potential as an indicator of anesthetic depth: a comparison with BIS and hemodynamic measures during propofol administration. Anesthesiology 2002; 96: 803-816.
11. Alpiger S, Helbo-Hansen HS, Jensen EW. Effect of sevoflurane on the mid-latency auditory evoked potentials measured by a new fast extracting monitor. Acta Anaesthesiol Scand 2002; 46: 252-256.
12. Litvan H, Jensen EW, Revuelta M, et al. Comparison of auditory evoked potentials and the A-line ARX Index for monitoring the hypnotic level during sevoflurane and propofol induction. Acta Anaesthesiol Scand 2002; 46: 245-251.
13. Ge SJ, Zhuang XL, Wang YT, et al. Changes in the rapidly extracted auditory evoked potentials index and the bispectral index during sedation induced by propofol or midazolam under epidural block. Br J Anaesth 2002; 89: 260-264.
14. Richmond CE, Matson A, Thornton C, et al. Effect of neuromuscular block on depth of anaesthesia as measured by the auditory evoked response. Br J Anaesth 1996; 76: 446-448.
15. Greif R, Greenwald S, Schweitzer E, et al. Muscle relaxation does not alter hypnotic level during propofol anesthesia. Anesth Analg 2002; 94: 604-608.
16. Kearse L, Rosow C, Sebel P, et al. The bispectral index correlate with sedation/hypnosis and recall: comparison using multiple agents. Anesthesiology 1995; 83: A507.
17. Chernik DA, Gillings D, Laine H, et al. Validity and reliability of the observer's assessment of alertness/sedation scale: study with intravenous midazolam. J Clin P sychopharmacol 1990; 10: 244-251.
18. Li JC, Zhuang XL, Kong L, et al. Correlation analysis of bispectral index, spectral edge frequency of electroencephalogram with midazolam-induced sedation. Chin J Anesthesiol 1998; 18: 141-143.
19. Liu J, Singh H, White PF. Electroencephalogram bispectral analysis predicts the depth of midazolam-induced sedation. Anesthesiology 1996; 84: 64-69.
20. Liu J, Singh H, White PF. Electroencephalographic bispectral index correlates with intraoperative recall and depth of propofol-induced sedation. Anesth Analg 1997; 84: 185-189.
21. Glass PS, Bloom M, Kearse L, et al. Bispectral analysis measures sedation and memory effects of propofol, midazolam, isoflurane, and alfentanil in healthy volunteers. Anesthesiology 1997; 86: 836-847.
22. Bailey AR, Jones JG. Patients' memories of events during general anaesthesia. Anaesthesia 1997; 52: 460-476.
23. Mantzaridis H, Kenny GN. Auditory evoked potential index: a quantitative measure of changes in auditory evoked potentials during general anaesthesia. Anaesthesia 1997; 52: 1030-1036.
24. Jensen EW, Nebot A, Caminal P, et al. Identification of causal relations between haemodynamic parameters, auditory evoked potentials and isoflurane by means of fuzzy logic. Br J Anaesth 1999; 82: 25-32.
25. McLeskey CH. Awareness during anesthesia. Can J Anaesth 1999; 46: R80-87.
26. Jessop J, Jones JG. Conscious awareness during general anaesthesia-What are we attempting to monitor? Br J Anaesth 1991; 66: 635-637.
27. Russell IF, Wang M. Intraoperative awareness and the isolated forearm technique. Br J Anaesth 1995; 75: 819-821.
28. Russell IF, Wang M. Absence of memory for intra-operative information during surgery with total intravenous anaesthesia. Br J Anaesth 2001; 86: 196-202.
29. Breckenridege J, Aitkenhead AR. Isolated forearm technique for detection of wakefulness during general anaesthesia. Br J Anaesth 1981; 53: 665P-666P.
30. Schwender D, Daunderer M, Klasing S, et al. Monitoring intraoperative awareness. Vegetative signs, isolated forearm technique, electroencephalogram, and acute evoked potentials. Anaesthesist 1996; 45: 708-721.
31. Hooper MB. Absence of memory for intraoperative information. Br J Anaesth 1997; 79: 143.
32. Smith WD, Dutton RC, Smith NT. Measuring the performance of anesthetic depth indictors. Anesthesiology 1996; 84: 38-51.
33. Tunstall ME. Detecting wakefulness during general anesthesia for caesarian section. BMJ 1977; 1: 1321.
34. Tunstall ME. The reduction of amnesic wakefulness during caesarean section. Anaesthesia 1979; 34: 316-319.
35. Russell IF. Comparison of wakefulness with two anaesthetic regimens. Total i.v. v. balanced anaesthesia. Br J Anaesth 1986; 58: 965-968.
36. Byers GF, Muir JG. Detecting wakefulness in anaesthetised children. Can J Anaesth 1997; 44: 486-488.
37. Flaishon R, Windsor A, Sigl J, et al. Recovery of consciousness after thiopental or propofol. Bispectral index and isolated forearm technique. Anesthesiology 1997; 86: 613-619.
38. Loveman E, Van Hooff JC, Smith DC. The auditory evoked response as an awareness monitor during anaesthesia. Br J Anaesth 2001; 86: 513-518.
39. McGillem CD, Aunon JI, Pomalaza CA. Improved waveform estimation procedures for event-related potentials. IEEE Trans Biomed Eng 1985; 32: 371-379.
40. Thornton C, Konieczko K, Jones JG, et al. Effect of surgical stimulation on the auditory evoked response. Br J Anaesth 1988; 60: 372-378.
41. Lanier WL, Iaizzo PA, Milde JH, et al. The cerebral and systemic effects of movement in response to a noxious stimulus in lightly anesthetized dogs: possible modulation of cerebral function by muscle afferents. Anesthesiology 1994; 80: 392-401.
2. Rosow CE. Can we measure depth of anesthesia? In: Schwartz AJ, Matjasko J, Otto C, eds. 50th Annual Refresher Course Lectures and Clinical Update Program. Philadelphia: Lippincott Williams & Wilkins, 1999: 114.
3. Capitanio L, Jensen EW, Filligoi GC, et al. On-line analysis of averaged AEP, autoregressive (ARX) modeled AEP and spectral edge frequency of EEG for monitoring depth of anaesthesia. Methods Inf Med 1997; 36: 311-314.
4. Urhonen E, Jensen EW, Lund J. Changes in rapidly extracted auditory evoked potentials during tracheal intubation. Acta Anaesthesiol Scand 2000; 44: 743-748.
5. Thornton C. Evoked potentials in anaesthesia. Eur J Anaesthesiol 1991; 8: 89-107.
6. Drummond JC. Monitoring depth of anesthesia. Anesthesiology 2000; 93; 876-882.
7. Thornton C, Sharpe RM. Evoked responses in anaesthesia. Br J Anaesth 1998; 81: 771-781.
8. Jensen EW, Lindholm P, Henneberg SW. Autoregressive modeling with exogenous input of middle-latency auditory-evoked potentials to measure rapid changes in depth of anesthesia. Methods Inf Med 1996; 35: 256-260.
9. Litvan H, Jensen EW, Galan J, et al. Comparison of conventional averaged and rapid averaged, autoregressive-based extracted auditory evoked potentials for monitoring the hypnotic level during propofol induction. Anesthesiology 2002; 97: 351-358.
10. Struys MMRF, Jensen EW, Smith W, et al. Performance of the ARX-derived auditory evoked potential as an indicator of anesthetic depth: a comparison with BIS and hemodynamic measures during propofol administration. Anesthesiology 2002; 96: 803-816.
11. Alpiger S, Helbo-Hansen HS, Jensen EW. Effect of sevoflurane on the mid-latency auditory evoked potentials measured by a new fast extracting monitor. Acta Anaesthesiol Scand 2002; 46: 252-256.
12. Litvan H, Jensen EW, Revuelta M, et al. Comparison of auditory evoked potentials and the A-line ARX Index for monitoring the hypnotic level during sevoflurane and propofol induction. Acta Anaesthesiol Scand 2002; 46: 245-251.
13. Ge SJ, Zhuang XL, Wang YT, et al. Changes in the rapidly extracted auditory evoked potentials index and the bispectral index during sedation induced by propofol or midazolam under epidural block. Br J Anaesth 2002; 89: 260-264.
14. Richmond CE, Matson A, Thornton C, et al. Effect of neuromuscular block on depth of anaesthesia as measured by the auditory evoked response. Br J Anaesth 1996; 76: 446-448.
15. Greif R, Greenwald S, Schweitzer E, et al. Muscle relaxation does not alter hypnotic level during propofol anesthesia. Anesth Analg 2002; 94: 604-608.
16. Kearse L, Rosow C, Sebel P, et al. The bispectral index correlate with sedation/hypnosis and recall: comparison using multiple agents. Anesthesiology 1995; 83: A507.
17. Chernik DA, Gillings D, Laine H, et al. Validity and reliability of the observer's assessment of alertness/sedation scale: study with intravenous midazolam. J Clin P sychopharmacol 1990; 10: 244-251.
18. Li JC, Zhuang XL, Kong L, et al. Correlation analysis of bispectral index, spectral edge frequency of electroencephalogram with midazolam-induced sedation. Chin J Anesthesiol 1998; 18: 141-143.
19. Liu J, Singh H, White PF. Electroencephalogram bispectral analysis predicts the depth of midazolam-induced sedation. Anesthesiology 1996; 84: 64-69.
20. Liu J, Singh H, White PF. Electroencephalographic bispectral index correlates with intraoperative recall and depth of propofol-induced sedation. Anesth Analg 1997; 84: 185-189.
21. Glass PS, Bloom M, Kearse L, et al. Bispectral analysis measures sedation and memory effects of propofol, midazolam, isoflurane, and alfentanil in healthy volunteers. Anesthesiology 1997; 86: 836-847.
22. Bailey AR, Jones JG. Patients' memories of events during general anaesthesia. Anaesthesia 1997; 52: 460-476.
23. Mantzaridis H, Kenny GN. Auditory evoked potential index: a quantitative measure of changes in auditory evoked potentials during general anaesthesia. Anaesthesia 1997; 52: 1030-1036.
24. Jensen EW, Nebot A, Caminal P, et al. Identification of causal relations between haemodynamic parameters, auditory evoked potentials and isoflurane by means of fuzzy logic. Br J Anaesth 1999; 82: 25-32.
25. McLeskey CH. Awareness during anesthesia. Can J Anaesth 1999; 46: R80-87.
26. Jessop J, Jones JG. Conscious awareness during general anaesthesia-What are we attempting to monitor? Br J Anaesth 1991; 66: 635-637.
27. Russell IF, Wang M. Intraoperative awareness and the isolated forearm technique. Br J Anaesth 1995; 75: 819-821.
28. Russell IF, Wang M. Absence of memory for intra-operative information during surgery with total intravenous anaesthesia. Br J Anaesth 2001; 86: 196-202.
29. Breckenridege J, Aitkenhead AR. Isolated forearm technique for detection of wakefulness during general anaesthesia. Br J Anaesth 1981; 53: 665P-666P.
30. Schwender D, Daunderer M, Klasing S, et al. Monitoring intraoperative awareness. Vegetative signs, isolated forearm technique, electroencephalogram, and acute evoked potentials. Anaesthesist 1996; 45: 708-721.
31. Hooper MB. Absence of memory for intraoperative information. Br J Anaesth 1997; 79: 143.
32. Smith WD, Dutton RC, Smith NT. Measuring the performance of anesthetic depth indictors. Anesthesiology 1996; 84: 38-51.
33. Tunstall ME. Detecting wakefulness during general anesthesia for caesarian section. BMJ 1977; 1: 1321.
34. Tunstall ME. The reduction of amnesic wakefulness during caesarean section. Anaesthesia 1979; 34: 316-319.
35. Russell IF. Comparison of wakefulness with two anaesthetic regimens. Total i.v. v. balanced anaesthesia. Br J Anaesth 1986; 58: 965-968.
36. Byers GF, Muir JG. Detecting wakefulness in anaesthetised children. Can J Anaesth 1997; 44: 486-488.
37. Flaishon R, Windsor A, Sigl J, et al. Recovery of consciousness after thiopental or propofol. Bispectral index and isolated forearm technique. Anesthesiology 1997; 86: 613-619.
38. Loveman E, Van Hooff JC, Smith DC. The auditory evoked response as an awareness monitor during anaesthesia. Br J Anaesth 2001; 86: 513-518.
39. McGillem CD, Aunon JI, Pomalaza CA. Improved waveform estimation procedures for event-related potentials. IEEE Trans Biomed Eng 1985; 32: 371-379.
40. Thornton C, Konieczko K, Jones JG, et al. Effect of surgical stimulation on the auditory evoked response. Br J Anaesth 1988; 60: 372-378.
41. Lanier WL, Iaizzo PA, Milde JH, et al. The cerebral and systemic effects of movement in response to a noxious stimulus in lightly anesthetized dogs: possible modulation of cerebral function by muscle afferents. Anesthesiology 1994; 80: 392-401.