Response of the GE Entropy™ monitor to neuromuscular block in awake volunteers.

BACKGROUND: The GE Entropy™ monitor analyses the frontal electroencephalogram (EEG) and generates two indices intended to represent the degree of anaesthetic drug effect on the brain. It is frequently used in the context of neuromuscular block. We have shown that a similar device, the Bispectral Index monitor (BIS), does not generate correct values in awake volunteers when neuromuscular blocking drugs are administered. METHODS: We replayed the EEGs recorded during awake paralysis from the original study to an Entropy monitor via a calibrated electronic playback system. Each EEG was replayed 30 times to evaluate the consistency of the Entropy output. RESULTS: Both State Entropy and Response Entropy decreased during periods of neuromuscular block to values consistent with anaesthesia, despite there being no change in conscious state (State Entropy <60 in eight of nine rocuronium trials and nine of 10 suxamethonium trials). Entropy values did not return to pre-test levels until after the return of movement. Entropy did not generate exactly the same results when the same EEG was replayed multiple times, which is primarily because of a cyclical state within the Entropy system itself. CONCLUSIONS: The GE Entropy™ monitor requires muscle activity to generate correct values in an awake subject. It could therefore be unreliable at detecting awareness in patients who have been given neuromuscular blocking drugs. In addition, Entropy does not generate the same result each time it is presented with the same EEG.

Five commercial 'depth of anaesthesia' monitors provide discordant clinical recommendations in response to identical emergence-like EEG signals.

BACKGROUND: 'Depth of anaesthesia' monitors claim to measure hypnotic depth during general anaesthesia from the EEG, and clinicians could reasonably expect agreement between monitors if presented with the same EEG signal. We took 52 EEG signals showing intraoperative patterns of diminished anaesthesia, similar to those that occur during emergence (after surgery) and subjected them to analysis by five commercially available monitors. METHODS: We compared five monitors (BIS, Entropy-SE, Narcotrend, qCON, and Sedline) to see if index values remained within, or moved out of, each monitors' recommended index range for general anaesthesia for at least 2 min during a period of supposed lighter anaesthesia, as observed by changes in the EEG spectrogram obtained in a previous study. RESULTS: Of the 52 cases, 27 (52%) had at least one monitor warning of potentially inadequate hypnosis (index above range) and 16 of the 52 cases (31%) had at least one monitor signifying excessive hypnotic depth (index below clinical range). Of the 52 cases, only 16 (31%) showed concordance between all five monitors. Nineteen cases (36%) had one monitor discordant compared with the remaining four, and 17 cases (33%) had two monitors in disagreement with the remaining three. CONCLUSIONS: Many clinical providers still rely on index values and manufacturer's recommended ranges for titration decision making. That two-thirds of cases showed discordant recommendations given identical EEG data, and that one-third signified excessive hypnotic depth where the EEG would suggest a lighter hypnotic state, emphasizes the importance of personalised EEG interpretation as an essential clinical skill.

Connected consciousness after tracheal intubation in young adults: an international multicentre cohort study.

BACKGROUND: Connected consciousness, assessed by response to command, occurs in at least 5% of general anaesthetic procedures and perhaps more often in young people. Our primary objective was to establish the incidence of connected consciousness after tracheal intubation in young people aged 18-40 yr. The secondary objectives were to assess the nature of these responses, identify relevant risk factors, and determine their relationship to postoperative outcomes. METHODS: This was an international, multicentre prospective cohort study using the isolated forearm technique to assess connected consciousness shortly after tracheal intubation. RESULTS: Of 344 enrolled subjects, 338 completed the study (mean age, 30 [standard deviation, 6.3] yr; 232 [69%] female). Responses after intubation occurred in 37/338 subjects (11%). Females (13%, 31/232) responded more often than males (6%, 6/106). In logistic regression, the risk of responsiveness was increased with female sex (odds ratio [ORadjusted]=2.7; 95% confidence interval [CI], 1.1-7.6; P=0.022) and was decreased with continuous anaesthesia before laryngoscopy (ORadjusted=0.43; 95% CI, 0.20-0.96; P=0.041). Responses were more likely to occur after a command to respond (and not to nonsense, 13 subjects) than after a nonsense statement (and not to command, four subjects, P=0.049). CONCLUSIONS: Connected consciousness occured after intubation in 11% of young adults, with females at increased risk. Continuous exposure to anaesthesia between induction of anaesthesia and tracheal intubation should be considered to reduce the incidence of connected consciousness. Further research is required to understand sex-related differences in the risk of connected consciousness.

Locked-in Guillain-Barré syndrome: 'my living nightmare'.

A 48-year-old man with severe Guillain-Barré syndrome suffered complete paralysis, and for 31 days could not communicate with the outside world, while remaining fully conscious. After recovery, he provided feedback on aspects of his care, such as mechanical ventilation, physical therapy, and communication. Conventional low tidal volume normocapnic ventilation induced ongoing and profound dyspnoea, occasionally relieved by modest increases in minute ventilation. Routine and apparently benign physical therapy was extremely painful, which was not reflected in heart rate or blood pressure changes. When he eventually re-established communication after many weeks, via slight eye movements, his first message was to express a particular distressing symptom. His case is a valuable reminder of the sometimes large gap between clinical measurements and assumptions and the subjective patient experience. We propose several approaches to address such issues in other paralysed but conscious patients.

Frequency response of EEG recordings from BIS and Entropy devices.

The BIS and Entropy systems are used as indicators of anaesthetic drug effect, and can also record EEGs in digital form. A number of studies have used such recordings for analysis, even though information about bandwidth and fidelity has not been provided by the manufacturers. In this study we consider these systems purely as EEG recording devices, and evaluate their suitability for quantitative analysis. Using a calibrated electronic testing system, we played an artificial test signal of known amplitude with frequency varying from 0.01 to 400 Hz into the BIS and Entropy EEG systems, and saved the recording in each of their supported recording modes. The amplitude of the recording at each frequency was then used to derive the frequency response curves, as well as the 3 dB and 0.5 dB points for each mode. There are important differences between the various BIS and Entropy recordings. The BIS 256 Hz and the Entropy 400 Hz recordings are broadly comparable, although Entropy has a slightly reduced response above 50 Hz and below 1 Hz. The BIS 128 Hz recording has a somewhat reduced bandwidth, due to its relatively low sampling rate. The Entropy 100 Hz recording in the Datex-Ohmeda S/5 monitor has a flawed implementation, leading to aliasing of signals over 50 Hz and potential distortion of the recording, while in the GE Carescape it has an uneven response and a narrowed bandwidth. Consequently, it is important to know which specific host monitor was used when an Entropy 100 Hz recording was made. In summary, the choice of recording device and host monitor may affect the results of some quantitative EEG analysis, and some previously published studies may need to be re-evaluated.

Combining Task and Motion Planning: Challenges and Guidelines.

Combined Task and Motion Planning (TAMP) is an area where no one-fits-all solution can exist. Many aspects of the domain, as well as operational requirements, have an effect on how algorithms and representations are designed. Frequently, trade-offs have to be made to build a system that is effective. We propose five research questions that we believe need to be answered to solve real-world problems that involve combined TAMP. We show which decisions and trade-offs should be made with respect to these research questions, and illustrate these on examples of existing application domains. By doing so, this article aims to provide a guideline for designing combined TAMP solutions that are adequate and effective in the target scenario.

[An overview on envenomings inflicted by the Common adder (Vipera berus) and their treatment in Hungary. Facts and beliefs -- part I]. / Górcso alatt a keresztes vipera (Vipera berus) által okozott marások és kezelésük Magyarországon. Tények és hiedelmek - I. rész.

Consequences of bites by the Common adder (Vipera berus) were reviewed in this study. Patients bitten by snakes from different populations may develop variable symptoms due to geographical venom variation. The correct diagnosis of snake bites and the knowledge of the distribution of venomous snake taxa have a crucial impact on snake bite therapy. The characteristic symptoms of patients bitten by V. berus in Hungary are highlighted. The habitat characteristics, seasonal activity and the Hungarian distribution of the adder are described based on literature data, museum specimens and field observations. However, envenomings are uncommon in Hungary, the annual 3 to 4 incidents have to be taken seriously, regardless of the age and actual health condition of the patients. Contrary to beliefs persisting both among laymen and professionals, the venom of V. berus is powerful. Medical observation of the patients is necessary in the first 5 to 6 hours. Any systemic symptom or progression of the edema requires hospital admission.

Ketamine sedation for patients with acute agitation and psychiatric illness requiring aeromedical retrieval.

OBJECTIVE: Aeromedical retrieval services face the difficult problem of appropriate levels of sedation for transport of acutely agitated patients to definitive care. This paper describes a technique using ketamine, which is titratable and avoids problems associated with airway management. METHOD: A 3-year review of a new technique of ketamine sedation by aeromedical retrieval teams from the Cairns base of the Queensland section of the Royal Flying Doctor Service of Australia. Clinical records were systematically reviewed for ketamine administration and signs of adverse events during transport and in the subsequent 72 h. RESULTS: 18 patients were sedated during retrieval with intravenous ketamine. Effective sedation was achieved in all cases, with no significant adverse events noted during retrieval or 72 h afterwards. CONCLUSION: Ketamine sedation is effective and safe in agitated patients with a psychiatric illness in the aeromedical setting and does not lead to worsening agitation in the subsequent 72-h period.

A statistical resampling method to calculate biomagnification factors exemplified with organochlorine data from herring (Clupea harengus) muscle and guillemot (Uria aalge) egg from the Baltic sea.

A novel method for calculating biomagnification factors is presented and demonstrated using contaminant concentration data from the Swedish national monitoring program regarding organochlorine contaminants (OCs) in herring (Clupea harengus) muscle and guillemot (Uria aalge) egg, sampled from 1996 to 1999 from the Baltic Sea. With this randomly sampled ratios (RSR) method, biomagnification factors (BMF(RSR)) were generated and denoted with standard deviation (SD) as a measure of the variation. The BMFRsR were calculated by randomly selecting one guillemot egg out of a total of 29 and one herring out of a total of 74, and the ratio was determined between the concentration of a given OC in that egg and the concentration of the same OC in that herring. With the resampling technique, this was performed 50 000 times for any given OC, and from this new distribution of ratios, BMF(RSR) for each OC were calculated and given as geometric mean (GM) with GM standard deviation (GMSD) range, arithmetic mean (AM) with AMSD range, and minimum (BMF(MIN)) as well as maximum (BMF(MAX)) biomagnification factors. The 14 analyzed OCs were p,p'DDT and its metabolites p,p'DDE and p,p'DDD, polychlorinated biphenyls (PCB congeners: CB28, CB52, CB101, CB118, CB138, CB153, and CB180), hexachlorocyclohexane isomers (alpha-, beta-, and gammaHCH), and hexachlorobenzene (HCB). Multivariate data analysis (MVDA) methods, including principal components analysis (PCA), partial least squares regression (PLS), and PLS discriminant analyses (PLS-DA), were first used to extract information from the complex biological and chemical data generated from each individual animal. MVDA were used to model similarities/dissimilarities regarding species (PCA, PLS-DA), sample years (PLS), and sample location (PLS-DA) to give a deeper understanding of the data that the BMF modeling was based upon. Contaminants that biomagnify, that had BMF(RSR) significantly higher than one, were p,p'DDE, CB118, HCB, CB138, CB180, CB153, ,betaHCH, and CB28. The contaminants that did not biomagnifywere p,p'DDT, p,p'DDD, alphaHCH, CB101, and CB52. Eventual biomagnification for gammaHCH could not be determined. The BMF(RSR) for OCs present in herring muscle and guillemot egg showed a broad span with large variations for each contaminant. To be able to make reliable calculations of BMFs for different contaminants, we emphasize the importance of using data based upon large numbers of, as well as well-defined, individuals.