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doi: 10.1093/bja/aev212
Review Article
REVIEW ARTICLE
Abstract
The use of EEG monitors to assess the level of hypnosis during anaesthesia has become widespread. Anaesthetists, however,
do not usually observe the raw EEG data: they generally pay attention only to the Bispectral Index (BIS) and other indices
calculated by EEG monitors. This abstracted information only partially characterizes EEG features. To properly appreciate the
availability and reliability of EEG-derived indices, it is necessary to understand how raw EEG changes during anaesthesia.
With hemi-frontal lead EEGs obtained under volatile anaesthesia or propofol anaesthesia, the dominant EEG frequency
decreases and the amplitude increases with increasing concentrations of anaesthetic. Looking more closely, the EEG
changes are more complicated. At surgical concentrations of anaesthesia, spindle waves (alpha range) become dominant. At
deeper levels, this activity decreases, and theta and delta waves predominate. At even deeper levels, EEG waveform changes
into a burst and suppression pattern, and nally becomes at. EEG waveforms vary in the presence of noxious stimuli
(surgical skin incision), which is not always reected in BIS, or other processed EEG indices. Spindle waves are adequately
sensitive, however, to noxious stimuli: under surgical anaesthesia they disappear when noxious stimuli are applied, and
reappear when adequate analgesia is obtained. To prevent awareness during anaesthesia, I speculate that the most effective
strategy is to administer anaesthetic agents in such a way as to maintain anaesthesia at a level where spindle waves
predominate.
During the past few decades, EEG monitors, such as the BIS
Editors key points
monitor (Covidien, Boulder, CO USA), have become widely used.
Anaesthetists commonly use processed electroencephalo- These devices calculate proprietary indices that purportedly
graphic data to guide anaesthesia, but the raw EEG can be show levels of hypnosis as numerical values. Most anaesthetists
more informative. normally pay attention only to the indices and rarely take interest
The raw EEG changes in a characteristic dose-dependent in the raw EEG. While it is true that EEG indices are convenient to
manner for both volatile and i.v. anaesthetics, probably as use, they reveal only some aspects of raw EEG. Indeed, raw EEG,
a result of enhanced inhibitory effects. presenting richly complete data, initially seem more difcult to
Processed EEG indices such as BIS are not as sensitive to interpret. It is easy, however, to observe dramatic changes in
noxious stimuli as the raw EEG; use of the raw EEG is a more the raw EEG as the administered concentration of anaesthetic in-
sensitive way to monitor anaesthesia during surgery. creases.1 While raw EEG patterns are anaesthetic-specic, con-
centration-related changes in EEG waveforms are quite similar
i27
i28 | Hagihira
25 0.0
0.5
0.3%
Relative b ratio
15
0.5% 1.0
0.7%
(m V2)
10 0.9% 1.5
1.1%
2.0
5
2.5
Awake 0.3 0.5 0.7 0.9 1.1 1.3 1.5
Isoflurane (%)
0 10 20 30
(Hz)
Fig 3 Relative ratio (RBR) changes during isourane anaesthesia. RBR
values were calculated from stored data used in a previous report.
Fig 2 Power spectrum changes during isourane anaesthesia in a 43-
(Source: ref.8).
year-old female patient undergoing resection for colon cancer.
dependently hyperpolarize the membrane potential of TC neu- the EEG pattern changed to show a predominance of large delta
rones, decreasing the frequency of pBIC-high. The changing waves, so called paradoxical arousal14 marked by dips in BIS or
power spectrum pattern in Figure 2 also seems to reect a transi- SEF or other EEG index values. Kochs and colleagues15 have re-
ent increase in spindle activity and concentration-related ported that noxious stimuli promptly decreased alpha activity
changes in delta activity. in 53% and increased delta activity in 44% of instances during
1.2% isourane with 66% nitrous oxide. Such EEG power spec-
trum changes seem to caused BIS or SEF values to decrease.
Inuence of noxious stimuli on the EEG The situation is further complicated in that the EEG involved a
mixed pattern of these two patterns in some patients. Currently,
So far, only the effects on the EEG of varying anaesthetic concen-
there is little information about what situations give rise to
trations have been discussed. EEG is also inuenced, however, by
paradoxical arousal. Using an anaesthetized cat model, Kaada
noxious stimuli.
and colleagues16 have reported on the effect on EEG of high-
Changes in EEG bicoherence and BIS or other EEG-derived
frequency electrical stimulation to the midbrain reticular forma-
parameters have been reported in 12 subjects at incision and at
tion. Their results suggest that EEG changes depend on both on
5 min after administration of 3 g kg1 of fentanyl during admin-
the concentration of anaesthetic and the intensity of stimulus,
istration of 1.0% isourane.13 After initial skin incision (noxious
even when stimulation was intensied at the same neurone.
stimulus), the EEG frequency increased and the amplitude de-
When noxious stimulation is applied, BIS shows variable
creased. In other words, the EEG pattern was desynchronized.
changes: in some patients, the BIS value increases after incision;
This pattern was different, however, to those obtained with iso-
in others, it decreases; and in others, BIS remains unchanged.
urane at lower concentrations. Furthermore, in some patients
Interestingly, when BIS changed, administration of fentanyl
restored BIS values to those before incision in a sample of 12 sub-
jects.13 SEF95 values show a tendency to change in the same way
as BIS values. These results indicate that it is imprudent to assess
analgesia using BIS or SEF95 values. Going further, it is rst ne-
Pyramidal neuron GABA cessary to ensure adequate analgesia before assessing the level
Glu of hypnosis using BIS or SEF95 values. Changes in EEG after nox-
Ach Ach ious stimuli during sevourane anaesthesia have also been in-
Excitatory synapse vestigated and the results were quite similar to those obtained
Inhibitory synapse
during isourane anaesthesia.13 Furthermore, similarities are
Glu also apparent during propofol anaesthesia (data not published).
Ach
On the other hand, pBIC-high decreased after incision and, in
Basal ganglia Glu all patients, rose to previous values after administration of
GABA TC neuron
fentanyl (Fig. 5). Meanwhile, spindle activity disappeared after
RE neuron incision and, in all patients, re-appeared after fentanyl adminis-
Ach Ach tration. This correspondence indicates that pBIC-high is likely to
be a good indicator of adequate analgesia. As pBIC-high seems
PPT/LDT to indicate spindle activity, spindle patterns observed in raw
EEG or in the power spectrum might also provide a basis for as-
sessing adequacy of analgesia. This hypothesis warrants further
Fig 4 Scheme of neuronal circuits related to spindle generation GABA,
gamma-amino butyric acid; Ach, acetylcholine; Glu, glutamate; PPT/LDT,
study.
pedunculopontine tegmental/laterodorsal tegmental nuclei. (Source: During more than 15 years of clinical practice, I have observed
compiled from refs.10 11). the raw EEG during anaesthesia in more than 10 000 surgeries,
and I have managed many patients using pBIC-high as an indica-
tor of adequacy of analgesia. A limitation of my strategy is inter-
individual variation in the raw EEG during anaesthesia. Some
patients do not manifest high spindle activity at any level of
anaesthesia. Generally speaking, this absence is more frequent
50 in elderly patients but, even so, some patients aged more than
1.0% isoflurane 80 or 85 still show predominant spindle activity. At the same
40 time, some younger patients, even in the 30 to 40 year range, do
not show predominant spindle activity. The variation cannot be
30 solely attributed to aging. What we can conclude is that absence
of spindle activity does not necessarily indicate insufcient
(%)
0 Conclusion
Control After incision After fentanyl
Although the raw EEG varies widely from individual to individual,
the way the EEG patterns change when differing concentrations
Fig 5 Effect of surgical incision (noxious stimuli) on pBIC-high in 12 patients
during isourane anaesthesia (Source: Plotter data from ref.13). of anaesthetic are administered is quite similar among patients.
While it is easier to refer to EEG indices, they might not adequately
Changes in EEG during anaesthesia | i31
convey the information necessary to control anaesthesia. In par- 7. Rampil IJ. A primer for EEG signal processing in anesthesia.
ticular, adequate analgesia is required before the indices can be Anesthesiology 1998; 89: 9801002
used as indicators of level of hypnosis. As it is relatively easy to 8. Hagihira S, Takashina M, Mori T, Mashimo T, Yoshiya I.
interpret raw EEG changes during anaesthesia, all anaesthetists Changes of electroencephalographic bicoherence during iso-
should acquire the ability to interpret raw EEG. urane anesthesia combined with epidural anesthesia.
Anesthesiology 2002; 97: 140915
9. Hagihira S, Takashina M, Mori T, Mashimo T, Yoshiya I. Prac-
Authors contribution
tical issues in bispectral analysis of electroencephalographic
S.H. is the sole author of this paper, accountable for accuracy and signals. Anesth Analg 2001; 93: 96670
integrity of the paper. 10. Steriade M, Nuez A, Amzica F. Intracellular analysis of rela-
tions between the slow (<1 Hz) neocortical oscillation and
Declaration of interest other sleep rhythms of the electroencephalogram. J Neurosci
1993; 13: 326683
None declared.
11. Steriade M, Contreras D, Dossi RC, Nuez A. The slow (<1 Hz)
oscillation in reticular thalamic and thalamocortical neu-
Funding rons: Scenario of sleep rhythm generation in interacting
This study was funded by the Department of Anesthesiology and thalamic and neocortical networks. J Neurosci 1993; 13:
Intensive Care Medicine, Osaka University Graduate School of 328499
Medicine, Suita, Osaka, Japan. 12. Nuez A, Dossi CC, Contreras D, Steriade M. Intracellular evi-
dence for incompatibility between spindle and delta oscilla-
tions in thalamocortical neurons of cat. Neuroscience 1992; 48:
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