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.

[A Case Series of Elderly Patients with Aortic Stenosis (AS) Undergoing Conscious Glaucoma Surgery in Sub-Tenon's or Subconjunctival Anaesthesia]. / Eine Fallserie wacher Glaukomoperationen mittels Sub-Tenon- oder subkonjunktivaler Anästhesie bei älteren PatientInnen mit Aortenklappenstenose.

With the current demographic changes, an increasing number of patients scheduled for glaucoma surgery presents with aortic sclerosis (AS) as part of their list of systemic diseases. This presents a definite challenge for anaesthesiologists and eye surgeons alike. We illustrate 6 cases of patients with aortic sclerosis undergoing glaucoma surgery in subconjunctival local anaesthesia or sub-Tenon block (STB). In one patient, due to discomfort, local anaesthesia had to be given repeatedly. Her blood pressure rose permanently to hypertensive values. During surgery, localised, temporal choroidal bleeding was noticed. The follow-up was complicated by exorbitant intraocular pressure swings and secondary localised choroidal bleeding. Anaesthesiologist and ophthalmic surgeon must harmonise their strategy to provide optimal transmural pressure across choroidal vessels and stenotic aortic valve outlet. Clinicians are often not aware of the core principals of each other's speciality. Our discussion considers different approaches for both disciplines to safely reduce the risk of suprachoroidal bleeding for this high-risk patient population with aortic stenosis.

Atypical trigeminocardiac reflex during intranasal dexmedetomidine sedation of a 6-month-old premature baby.

The trigeminocardiac reflex (TCR) is an established brainstem reflex leading to parasympathetic dysrhythmias-including haemodynamic irregularities, apnoea and gastric hypermotility-during stimulation of any sensory branches of the trigeminal nerve. Most of the clinical knowledge about TCR was gathered from general anaesthesia observations, not from procedural sedation.We present a case of a 6-month-old premature baby experiencing the reflex twice under dexmedetomidine-propofol-sedation while undergoing ophthalmic and ear examination. This was interpreted as cross-over sensitisation between the facial and trigeminal cranial nerve (N V and N VII).The present case demonstrates that different TCR subtypes can occur during the same anaesthetic procedure. Triggering TCR seems to be based on several factors and not just on a single stimulus as often presumed. Therefore, for premature babies, there is a risk for TCR under procedural sedation, and we recommend using glycopyrrolate as preventive treatment.