AEP Monitor 麻醉知覺/深度監測儀 ( Auditory Evoked Potential)

AEP Monitor麻醉知覺 /深度監測儀(Auditory Evoked Potential)

台大醫學系六年級全以祖

Contents

1 、前言2、 AEP Monitor 的理論及臨床應用3、 AEP v.s. BIS

4、WHY AEP？

有人說：有人說：麻醉醫師的工作流程非常類似〝 Pilot〞

不同的是 -- pilot 已有非常精確及〝直接〞且〝即時〞的自動導航系統、全球衛星定位系統… etc.。

-- pilot 有非常嚴格的工作時間限制。

然而 -- 麻醉醫師只有一些輔助儀器〝間接〞且〝非即時〞來提供病患麻醉深度 / 知覺的判斷。 -- 麻醉醫師常 overtime。

有人說：有人說：麻醉是一種 Science

更是一種 Art

如何在安全、品質、成本間取得最佳的 Result ，仍是最主要的目標？

各位麻醉醫師在過去的經驗中，是否仍有一些有待挑戰的Subject 呢？例如：

1 、在 Induction 時，提供的劑量是否夠或不夠？可否 intubation了或再等一下？2 、多種藥物的交互作用下，對麻醉深度的影響到底為何？3 、在 maintenance 期，血壓亦或心跳升高，是否深度不夠，亦或其他原因呢？4 、在 reversing 期，如何判斷病患意識已開始恢復，可被喚醒了？5 、在 maintenance 期，何時可減量麻醉氣體，以提早 reverse

patient？

各位麻醉醫師在過去的經驗中，是否仍有一些有待挑戰的Subject 呢？例如：

6 、如何在 OB 或 Truma Cases 中，更能掌握病患麻醉深度呢？7 、如何在低溫 Open-Heart 中，更能掌握病患麻醉深度呢？8 、做 Low-Flow 時，能否告知麻醉深度，以便更能掌握呢？9 、目前麻醉環境中，是否就是缺少一個〝直接且即時〞告知麻醉深度的設備呢？

2.2.AEP MonitorAEP Monitor 理理論及臨床應用論及臨床應用

The patientThe patient

The patient has 2 worries:The patient has 2 worries:

1: Will he sleep during the 1: Will he sleep during the operation?operation?

2. Will he wake up after the 2. Will he wake up after the operation?operation?

Basic basic basic basic Basic basic basic basic basic basic The hearing is the The hearing is the last senselast sense that leaves and that leaves and

the first that returns during anaesthesia.the first that returns during anaesthesia.

AEP is just the brain response to a AEP is just the brain response to a click click stimulistimuli through the hearing nerve through the hearing nerve

AEP is a AEP is a very weak electrical signalvery weak electrical signal wrapped wrapped in the EEG background actvity.in the EEG background actvity.

Let’s look at how tiny tiny this signal is.Let’s look at how tiny tiny this signal is.

The implications of The implications of undersedationundersedation Patient remains immobilized but feels painPatient remains immobilized but feels pain Although it is occurs in only 0.1% - 0.2% of all surgeries, Although it is occurs in only 0.1% - 0.2% of all surgeries,

23 million surgeries are performed in the U.S. each year23 million surgeries are performed in the U.S. each year Resulting in 35,000 cases of surgical awareness Resulting in 35,000 cases of surgical awareness

The implications of The implications of oversedationoversedation To avoid the possibility of surgical awareness too much To avoid the possibility of surgical awareness too much

hypnotics and analgesics may be administered hypnotics and analgesics may be administered The patient’s recovery time is extended: higher room costThe patient’s recovery time is extended: higher room cost More drugs than necessary are used: higher drug costMore drugs than necessary are used: higher drug cost

Why monitor sleep?Why monitor sleep?It is important to think about this.It is important to think about this.

Burst SuppressionBurst Suppression

We look at spikes < 3,5 uV.

In contrast: An awake Pa amplitude is typically 0.7 uV.

And, an asleep amplitude is typically 0.4 uV

Dimensions of AEP, EEG & ECG

2,5

100

1000

1

10

100

1000

AEP EEG ECG

Norm

al D

imen

sion

Sca

le in

uV

(Log

aritm

ic)

ECG signal has approx. 400 x amplitude than the AEP signals.EEG signal has approx. 40 x amplitude than the AEP signal

400 x

40 x

Extracting the evoked responseExtracting the evoked response Before A-Line it took too long to ”detect and Before A-Line it took too long to ”detect and present” (extract) this weak signal, because it present” (extract) this weak signal, because it

requires advanced signal processingrequires advanced signal processing 1 click

128 clicks

256 clicks

1024 clicks

100 msclick

But, lets make But, lets make this more visiblethis more visible

Let’s see what happens Let’s see what happens when we send a click when we send a click

through the ear.through the ear.

A deviation in the positioning of the electrodes up to 2 cm does not have significant influence on the ARX-index.

To Monitor

Some prefer to wait with the headphones until electrodes are connected

Position Middle offorehead

Left side offorehead

Mastoid

Type Positive Ref. NegativeNo. 1 2 3Color White Green Black



Mastoid




Mastoid


2

The auditory Pathway

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FIGURE 35–10 Schematic of auditory neural pathway. The FIGURE 35–10 Schematic of auditory neural pathway. The BAEP is initiated by stimulation of the cochlea with a BAEP is initiated by stimulation of the cochlea with a

broadband click stimulus given via an ear insert in the broadband click stimulus given via an ear insert in the external auditory canal. Neural generators of the BAEP peaks external auditory canal. Neural generators of the BAEP peaks

are shown.are shown.

Auditory Evoked Auditory Evoked PotentialsPotentials

ClassClass LatencyLatency(MS)(MS)

Best Best ResponseResponse

SourceSource Era ValueEra Value

CochlearCochlear 001-41-4

SP(DC)CMSP(DC)CM(AC); (AC); AP(N1)AP(N1)

Hair cellsHair cellsVIIIVIII

??****

FastFast 2-122-12 P6-SN10P6-SN10 Brainstem Brainstem VIIIVIII

******MiddleMiddle 12-5012-50 P35P35 Brainstem,Brainstem,

Midbrain,CMidbrain,Cortex Iortex I

****????

SlowSlow 50-30050-300200-800200-800

N90-P180-N90-P180-N250N250

Cortex II Cortex II (awake)(awake)Cortex III Cortex III (asleep)(asleep)

**?**?**

LateLate 260-600260-600DC-shiftDC-shift

P300,p350,P300,p350,CNVCNV

Cortex IV Cortex IV (event (event related)related)

??

Acoustic nerveand brainstem

Medial geniculate and

primary auditory cortex

Frontal cortex andassociation areas

1 2 5 10 20 50 100 200 500 1000 msms

IIIIII

IIIIIIIVIV VV

VIVIPoPo

NaNa

PaPa

NbNb

PP11

NN11

PP22

NN22

vv

Brain stemBrain stemresponseresponse

Early corticalEarly corticalresponseresponse

Late cortical Late cortical responseresponse

msms

IIIIII

IIIIIIIVIV VV

VIVI

No

PoPo

NaNa

PaPa

NbNb

PP11

NN11

PP22

NN22

vv




What does the AEP Look What does the AEP Look Like?Like?

+0.1µV

100 msec

Pa

Nb

Pa latency

Pa amplitude

And, this is what And, this is what happenshappens

Acoustic nerveand brainstem

Medial geniculate and

primary auditory cortex

Frontal cortex andassociation areas

1 2 5 10 20 50 100 200 500 1000 msms

IIIIII

IIIIIIIVIV VV

VIVIPoPo

NaNa

PaPa

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PP11

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vv




msms

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VIVI

No

PoPo

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PaPa

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vv




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VIVIPoPo

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msms

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VIVI

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American Encephalography American Encephalography Society Criteria for Society Criteria for

Retrochochlear DysfunctionRetrochochlear Dysfunction 1. Abscencr of all waves1. Abscencr of all waves 2. Absence of all waves following 2. Absence of all waves following

wave I or IIwave I or II 3. Increase of I-V interpeak interval3. Increase of I-V interpeak interval 4. Decrease of 4. Decrease of V/I amplitude ratioV/I amplitude ratio 5. Interaural I-V interval asymmetry5. Interaural I-V interval asymmetry

Pa

Nb

And, of the opposite during awakening

NN11NN11

7NoNo

PoPo

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PaPa

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PP11PP

7NoNo

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Patient-Related FactorsPatient-Related Factors 1. Age1. Age 2. Temperature2. Temperature 3. Drug Effects3. Drug Effects - Barbiturates, Benzodiazepines- Barbiturates, Benzodiazepines - Fentanyl- Fentanyl - Ketamine, N- Ketamine, N22OO - Isoflurane- Isoflurane - Halothane, Enflurane- Halothane, Enflurane

Desflurane

1.5%

Pa

Nb3%

6%

The AEP during The AEP during AnaesthesiaAnaesthesia

With kind permission from Dr Christine Thornton, Northwick Park, London, UK.

Pre-intubation

100ms

0.1µV+

Pa

Nb Post-intubation

Effect of intubation on the AEPEffect of intubation on the AEP


The Effect of The Effect of Midazolam on the AEPMidazolam on the AEP

0 10050

Time (ms)

Awake

Nb Loss of eyelashresponse


The effect of propofol The effect of propofol on the AEPon the AEP

0 10050

Response to command

No response to command

Nb

Time (ms)With kind permission from Dr Christine Thornton, Northwick Park, London, UK.

ConclusionsConclusions

Graded changes with Graded changes with depth of depth of anaesthesiaanaesthesia

Similar changesSimilar changes for different anaesthetics for different anaesthetics Shows response to noxious stimulationShows response to noxious stimulation AEP indicates level of AEP indicates level of consciousnessconsciousness Technology has been studied since early Technology has been studied since early

1980’s1980’s

AEP signal processing?AEP signal processing?

How can it be so fast?How can it be so fast?

A-line signal processing v. 1.5

Signal OK?

YesBP filterAEP

25-65 Hz

Bandpass filterEMG

65-85 Hz

Bandpass filterBurst Suppr.

1-35 Hz

MTA256sweeps

MTA18sweeps

ARXMODEL

AAICalc.

No

EMGCalc.

BS%Calc.

A/DConverter

Signal OK?

Yes

No

AMP

900 xSec.

Reject

Reject

A-line Electrodes

If snr lowSmooth

signal

If snr lowSmooth signal

EstimateSNR

Show SNRbar

New elements to version 1.5 is marked with organge

12345678...........239...256

MTA 256sweeps

MTA 18sweeps

Moving time Averaging and ARX

ARX-model

257

Index calculation?

69

171

iii xxAEPindex

AEP window = 20-80 msxi xi+1

Index calculation?

mv 0,1mv 0,2mv 0,3mv 0,4Total 3,7 x factor = 100

Index calculationIndex calculation So, then you have a real curve, the So, then you have a real curve, the

index is highindex is high

And, an almost flat curve gives a low indexAnd, an almost flat curve gives a low index

= 93

= 16

What it isWhat it is AAI is typically higher than AAI is typically higher than 6060 when the when the

patient is awake and decreases when the patient is awake and decreases when the patient is anaesthetised; loss of patient is anaesthetised; loss of consciousness typically occurs when the consciousness typically occurs when the AAI is below 30AAI is below 30

The click detection is achieved by estimating the The click detection is achieved by estimating the Signal to Signal to Noise Ratio (SNR)Noise Ratio (SNR)..

The SNR is defined as the ratio between the measured signal The SNR is defined as the ratio between the measured signal and the noise.and the noise.

The SNR threshold is 1.45; this means that when the SNR is The SNR threshold is 1.45; this means that when the SNR is above 1.45above 1.45, the quality of the , the quality of the AEP is satisfactoryAEP is satisfactory..

On the other hand if the SNR is below 1.45, the signal quality On the other hand if the SNR is below 1.45, the signal quality is low, and a further averaging of the AEP is carried out.is low, and a further averaging of the AEP is carried out.

Yet if this does not improve the SNR, the symbol Yet if this does not improve the SNR, the symbol LOW AEP or NO AEP will appear on the monitor. LOW AEP or NO AEP will appear on the monitor.

What we didWhat we did

The symbol The symbol NO AEPNO AEP and and flashing AAIflashing AAI will appear will appear in one of the following situations:in one of the following situations:

The Headphones are disconnected or not working The Headphones are disconnected or not working properly.properly.

The subject may be hearing impaired.The subject may be hearing impaired. Too much noise is present. Check grounding of the AAI Too much noise is present. Check grounding of the AAI

monitor and the surrounding equipment. monitor and the surrounding equipment. The subject has very high levels of EMG activity, The subject has very high levels of EMG activity,

meaning that the AEP is embedded in an excessive meaning that the AEP is embedded in an excessive amount of noise, impeding the extraction of the AEP. amount of noise, impeding the extraction of the AEP.


The symbol The symbol LOW AEPLOW AEP will appear will appear frequently frequently during anaesthesiaduring anaesthesia in one of the in one of the following situations: following situations: both the both the AAIAAI and the and the SNRSNR are are lowlow. . a considerable suppression of the AEP is taking a considerable suppression of the AEP is taking

place caused by the effect of the anaesthetics. place caused by the effect of the anaesthetics.


Caution should be taken if Caution should be taken if LOW AEPLOW AEP appears in an appears in an awake subjectawake subject as this indicates one of following as this indicates one of following situations and renders the AAI unreliable: situations and renders the AAI unreliable:

The Headphones are disconnected or not working The Headphones are disconnected or not working properly.properly.

The subject may be hearing impaired.The subject may be hearing impaired. Too much noise is present. Check grounding of the Too much noise is present. Check grounding of the

AAI monitor and the surrounding equipment. AAI monitor and the surrounding equipment. The subject has very high levels of EMG activity, The subject has very high levels of EMG activity,

meaning that the AEP is embedded in an excessive meaning that the AEP is embedded in an excessive amount of noise, impeding the extraction of the AEP. amount of noise, impeding the extraction of the AEP.


For both LOW AEP and NO AEP: The response time For both LOW AEP and NO AEP: The response time after the headphones are disconnected until LOW AEP after the headphones are disconnected until LOW AEP or NO AEP appears in the display has a mean value of or NO AEP appears in the display has a mean value of 50 seconds and 97 % of the response times will 50 seconds and 97 % of the response times will typically be below 2 minutes. typically be below 2 minutes.


A good caseA good case Just to illustrate how important it is.Just to illustrate how important it is. Customer couldn’t understand why the index Customer couldn’t understand why the index

was high?was high? Complained that “something was wrong”Complained that “something was wrong” All details captured by our manAll details captured by our man After downloading and descriptions the After downloading and descriptions the

clinicians agreed the anaesthesia was not clinicians agreed the anaesthesia was not optimal.optimal.

They could actually see things they never seen They could actually see things they never seen beforebefore

Fentanyl 0,15 + Pentothal 250mg

Tracrium 15mg

Intubation. + Sevo FI 0,2 Moved Patient on table

Start surgery. Gyn. Lap. procedure . FI 1,0 + MAC 1,0

Induction started with normal dosesIndex dropped and NMB was given to prepare intubationIntubation too soon. Fentanyl had not reached peak effect. Penthotal dose was small for this patient. Gas conc. too lowTIVA with induction and Maintenance would have prevented thisPatient was not deep enough to be moved on table. Dose of gas too low.Patient still not deep enough and reacts. Remember: 50% sleep at 1 MAC

Put in trocar (insertion tube for scope) FI 1,8 + MAC 1,4

Sevo stopped FI 0,7 + MAC 0,9

At MAC 1,4 the patient is deep enough and all problems stops

3. AEP Monitor V.S. BIS

麻醉深度 ( 意識 ) 監視儀比較表AEP Monitor V.S. BIS

Why Bispectral IndexWhy Bispectral Index

Bispectral IndexBispectral Index

廠牌&型號

項目

ALARISAEP

ASPECTBIS 好處說明

測量原理及方式

Auditory EvokedPotential聽覺誘發電位

Bispectral EEG雙頻譜腦電波

1. 聽覺乃麻醉過程中最先恢復及最後失去的知覺，其理論及研究已超過 20年了。如能臨床應用于麻醉深度，乃甚佳的指標。

2. BIS會受藥物、溫度、移動及神經性病變…etc.影響其結果。

反應時間(指數 v.s.時

間)

2 ~ 6 sec幾乎 real-time 30秒 ~ 1分鐘以上

1. 幾乎〝即時〞的指數，較能提供麻醉醫師瞭解病患〝當時〞的深度狀況，臨床意義較大。

是否有〝灰色地帶〞

完全沒有指數 30以下適合手術

麻醉？

1. 根據報告及麻醉醫師使用 BIS經驗，常有指數與自己臨床經驗相〝矛盾〞現象及指數在60~80間有灰色地帶。

麻醉(安眠、止痛、肌肉鬆弛)綜合反映良好與否？

YES ？安眠表現上較佳

1. 由於 AEP利用聽覺乃是知覺，利用其麻醉落後及領先指標，固能除安眠外，止痛表現上也非常不錯。

2. AEP配合臉部 EMG可更能呈現真正的麻醉深度。


廠牌&型號

項目

ALARISAEP


在 Induction期反應良好與否？

YES ？ 1. 由於 AEP指數幾乎是 real-time，在induction其可迅速了解靜脈麻藥 v.s.深度的關係及提供可否 intubation的參考。

2. 由於 BIS乃是 delay-data(30秒~1分鐘)，對靜脈麻醉藥之反應，由於反應太慢，不太能做為參考指標。

在maintenance期反應良好與否？

YESexcellence

YESgood

1. 在 maintenance期，如血壓、心跳升高，由AEP指數來判斷，是否深度不夠亦或其他原因？

2. 做 low-Flow時，AEP更能即時提供麻醉深度的參考。

3. 手術結束前，更讓醫生有信心，提早減量，以縮短病患恢復意識時間。

在 reversing期反應良好與否？

YES ？ 1. AEP Monitor的指數配合臉部 EMG，可更精確掌握病患 reverse的狀況。

依賴藥物DataBase NO YES

1. 新藥出來時，原有BIS可能英雄無用武之地？2. BIS對藥物交互作用反應如何？


廠牌&型號

項目

ALARISAEP


外在刺激有否反應？

有真實呈現

？ 1. 麻醉就如同製造病患在沉睡狀態，但對 intubation、結石手術、腹腔鏡手術…etc. 不同大小的刺激真實呈現刺激大小對指數的影響，才真正呈現該病患麻醉深度之狀況。

是否有其他功能〝一起〞協助判斷麻醉深度的變化

1. 臉部 EMG2. BSR3. 5min Trend (almostsec by sec real-time)

1.臉部 EMG？2.BSR

1. 臉部 EMG變化幾乎與指數同步。(以 dB bar來顯示)

2. maintenance期，出現 BS rate太高及持續，可能麻醉深了點？

趨勢圖

5 min30 min60 min240 min

？

1. 5 min Trend可提供〝即時〞刺激對深度的影響，以避免發生強烈的連續性刺激突然超過臨界值，造成病患清醒。

2. 可提供 user在大部份 cases對過程中通盤的了解及掌握。

是否具事後編輯及統計利於研究

有PC版本軟體在

Windows3.1/95/98？

AEP 可提供3. 10個病患 15hr/per patient資料儲存及傳輸功能。

4. 具原廠軟體，可將 event與 Trend做報告，利於研究及報告。


結論1、 real-time v.s. Time-delay data ，那種較具臨床意義？2 、指數 v.s. 刺激，是否有反應，那種較具臨床意義？3 、除了全聾， AEP 不受人種、體質、 Database 、藥物、溫度… etc. 影響，真實呈現〝當時〞病患麻醉深度狀況，是否較方便及實用呢？4 、如果有機會選擇，您會選一個與經驗有〝矛盾〞及〝灰色地帶〞的產品嗎？5 、是否目前麻醉過程，其他設備均是輔助或間接性的資料，最終目的乃是確保麻醉深度正確與否？直接 v.s. 間接。6 、讓事實來證明， AEP 可能將是您得力的助手。Note： AEP 與 BIS 均無法對 Ketamine 類的麻醉藥有正確反應，此乃因此種藥物與其他麻醉藥作用機轉及 pathway 不一樣所致。

4.WHY AEP？

WHY AEP？由於 AEP Monitor 的推出1 、是否提供您一支大型探照燈，更能精確掌握病患的狀況呢？2 、是否提供〝即時〞且〝直接〞的指數，更具臨床實用呢？3 、是否對提升麻醉品質及精確使用藥物，有極大幫忙呢？4 、是否可避免因 under Sedation 造成 explicit Recall？

5 、是否可避免因 Over Sedation 造成成本的增加？ ( 特別在 daily surgery

Cases)

6 、是否讓麻醉醫生有 NEW & EXCITING 的挑戰呢？

在醫療糾紛日漸頻繁，利潤中心趨勢及總額預算將執行下， AEP Monitor

可提供麻醉醫生及院方一種不錯的解決方案。

AEP Monitor 麻醉知覺/深度監測儀 ( Auditory Evoked Potential)

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