The Electroencephalogram in Anesthesia: Fundamentals, Practical Applications, Examples

218 Pages·1984·5.7 MB·English

by  Professor Dr. Ina Pichlmayr

I. Pichlmayr . U. Lips' H. Kunkel
The Electroencephalogram
in Anesthesia
Fundamentals, Practical Applications, Examples
Translated by E. Bonatz and T. Masyk-Iversen
With 70 Figures
Springer-Verlag
Berlin Heidelberg New York Tokyo 1984
Professor Dr. INA PICHLMA YR
Privat-Oozent Dr. ULRICH LIps
Zentrum fUr Anasthesiologie der Medizinischen Hochschule Hannover, Abt. IV
Krankenhaus Oststadt, Podbielskistr. 380, 0-3000 Hannover 51
Professor Dr. HELMUT KUNKEL
Zentrum Neurologische Medizin, Abt. II - Institut fUr Klinische Neurophysiologie
und Experimentelle Neurologie, Konstanty-Gutschow-Str. 8, 0-3000 Hannover 61
Translators:
E. BONATZ
T. MASYK-IvERSEN
Zentrum fUr Anasthesiologie der Medizinischen Hochschule Hannover, Abt. IV
Krankenhaus Oststadt, Podbielskistr. 380, 0-3000 Hannover 51
Title of the original German edition 1983:
Das Elektroenzephalogramm in der Anasthesie
ISBN-13: 978-3-642-69564-3 e-ISBN-13: 978-3-642-69562-9
001: 10.1007/978-3-642-69562-9
Library of Congress Cataloging in Publication Data. Pichlmayr. I. (Ina). 1932-. The electroencephalogram
in anesthesia. Translation of: Das Elektroenzephalogramm in der Anlisthesie. Includes bibliographies and
index. I. Anesthesiology. 2. Encephalography. 3. Patient monitoring. I. Lips. u. (Ulrich). 1948-. II. KUnkel.
Helmut. III. Title. [DNLM: I. Anesthesia. 2. Electroencephalography. 3. Monitoring. Physiologic methods.
WL 150 P592ej RD82.P513 1984 617'.96 84-5569
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(EJ by Springer-Verlag Berlin Heidelberg 1984
Softcover reprint of the hardcover I st edition 1984
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2119/3130-543210
Preface
Neurological, neurovegetative, and psychic changes following surgery or in
tensive care indicate alterations in cerebral function. When these changes
are analyzed exactly, they are found to be by no means rare; at the same
time, they present a wide spectrum of clinical manifestations. While optimal
circulatory monitoring - including continuous EEG recording during anes
thesia or intensive care - is today regarded as routine, the problem of objec
tive and continuous monitoring of cerebral function under various forms of
anesthesia, surgery, and intensive care has not been solved.
Considerable improvements in clinical neurophysiology, mainly
through visual and spectral analytic evaluations of the EEG, show func
tional neurophysiological changes to be equivalent to, or the cause of,
clinical, neurological, and psychic changes. The question of current interest,
therefore, is whether anesthesiological EEG monitoring is able, both theo
retically and practically, to detect and adequately interpret cerebral altera
tions following perioperative measures such that these alterations can be
treated or avoided accordingly. In the long run, the basic questions are to
what extent can anesthesiological measures be guided by the EEG pattern
and managed effectively, and can EEG analysis be significant both for the
individual patient and in the general interpretation of the effect of anes
thesiological procedures?
Questions of the relevance and practicability of anesthesiological EEG
monitoring are dealt with in this book. This study is based on an analysis of
more than 1500 EEGs of patients who underwent anesthesia during surgery.
The effects of premedication, anesthesia, events during the perioperative
period, and intensive care are analyzed separately. Theoretical and practical
aspects of anesthesiological EEG monitoring are outlined in the Introduc
tion. Results and practical experience from all sources give a perspective on
the routine use ofEEG monitoring in the future.
We would like to thank the Volkswagenwerk Foundation for their gen
erous support of the clinical studies. We are grateful to our assistants Mrs.
U. LESSING, Mrs. K. REDEKER, Mrs. H. SCHULZE, and Mrs. K. SCHWEDHELM.
INA PICHLMA YR, ULRICH LIPS, HELMUT KUNKEL
Contents
Detailed contents are found at the beginning of each chapter
A. Introduction to Electroencephalography in Anesthesiology
I. Development and Application of Electroencephalography 2
II. Fundamentals of Electroencephalographic Analysis 12
III. Technical Requirements for Electroencephalography in the
Operating Area. . . . . . . . . . . . . . . . 22
IV. Initial Electroencephalographic Findings in Patients
Undergoing Anesthesia . . . . . . . . . . . . . . . .. 33
B. Electroencephalographic Patterns Induced by Various
Anesthetics and Perioperative Influences
I. Premedication.... 44
II. Stages of Anesthesia 65
III. Inhalation Anesthetics . 72
IV. Intravenous Anesthetics 90
V. Muscle Relaxants . . . 124
VI. Analgetics in the Postoperative Phase 128
VII. Anesthesiological and Operative Procedures with Potential
Cerebral Effects . . . . . . . . . . . . . . 146
VIII. Perioperative Disturbances with Cerebral Effects 154
IX. Special Considerations in Old Patients .... 164
X. Special Considerations in Patients with Seizure Disorders 168
C. Electroencephalography as a Method of Anesthesiological
Monitoring
I. Electroencephalographic Monitoring During Anesthesia l74
II. Electroencephalographic Monitoring During the Immediate
Postoperative Phase. . . . . . . . . . . . . . . 192
III. Electroencephalographic Monitoring in Intensive Care 197
Final Remarks . 208
Subject Index . 211
A. Introduction to Electroencephalography
in Anesthesiology
I. Development and Application
of Electroencephalography
The electroencephalogram is a neurophysiological technique for examining
cerebral electric activity; it can be applied to many medical fields and has
allowed considerable advances to be made. This has been due to the devel
opment of data processing and signal analysis as well as to experience in the
clinical application of the findings (JUNG 1953; COPPER et al. 1974; DOLCE
and KONKEL 1975; REMOND 1977). Berger, whose name is linked insepa
rably with the history of electroencephalography, hoped to determine the
mechanisms of psychic processes with this new harmless method (KOLLE
1965). His expectations were not fulfilled, but he did recognize the value of
electroencephalography as an experimental method in the study of drug-in
duced changes of consciousness. In 1933, he performed the first elec
troencephalogram (EEG) recording under chloroform anesthesia. Sub
sequently, barbiturates, synthesized in 1932, were thoroughly studied with
the EEG [27]. This led to the development of EEG-controlled dosage ma
chines [23]. Research in clinical neurophysiology with respect to the tech
nique and validity of electroencephalography revealed further possibilities
for application. In anesthesiology, the EEG has proven useful in special
indications (e.g., open heart surgery, intra- and postoperative cerebral
emergency). Monographs about the application and value of the EEG,
especially for the anesthesiologist, were published by BRECHNER et al.
(1962), SADOVE et al. (1967), PRIOR (1979), and GRABOW (1981). In the light
of the, on the whole, promising advances that have been made, the desir
able routine EEG monitoring of anesthesiological measures would appear
to be practicable in the near future. Milestones in the historical devel
opment of electroencephalography, briefly summarized and without claim
ing completeness, are given below, outlining the development to date.
1875 R. CATON (London) [30]
First tracing of cerebral electric potentials in animal exper
iments by galvanometry with optical amplification.
1890-1893 B. DANILEWSKI (Charkow) [34], F. VON MARXOW (Vienna) [64,
65], A. BECK, N. M. CYBULSKI (Krakau) [4, 5]
Tracings of electric processes in various animal species with in
consistent results, due to poor technical conditions. In 1890,
von Marxhow studied the effect of chloroform anesthesia on
the animal EEG.
Development and Application of Electroencephalography 3
1904 S. TSCHIRIEV (Kiev) [78]
Hypothesis about the origin of electric potentials through vari
able cerebral congestion.
1912 P. I. KAUFMANN (St. Pe,tersburg) [56]
Final refutation ofTschiriev's theory.
1913-1925 N. W. PRAWDlCZ-NEMINSKI (Kiev) [66, 67]
Experimental elaboration on recordings of the EEG back
ground activity in animals; his results are still valid today.
1914 N. M. CYBULSKI (Krakau) [33]
Description of EEG recordings during epileptic seizures
brought about by electric stimulation of the canine cortex.
1924 H. BERGER (Jena) (BRAZIER 1961)
First EEG recording on a human subject performed using sil
ver-needle electrodes. Discovery of the alpha activity over the
occipital region.
1929 H. BERGER (lena) [7]
First publication on the EEG in man.
1930-1938 H. BERGER (lena) [8-21]
The results of 13 further papers and one publication summariz
ing the fundamentals, criteria for assessment, and possibilities
for development of the EEG; some of the results are still valid
today.
1932 G. DIETSCH, H. BERGER (Jena) [35]
First application of the Fourier analysis in short EEG record
mgs.
1932-1933 J. F. TONNIES (Berlin) [74-76]
Development of the "neurograph". This EEG apparatus with
continuous registration by means of pen replaced the com
plicated photographic documentation that had previously been
used.
1933 H. BERGER (lena) [12]
First EEG recordings during chloroform anesthesia in man.
1934 E. D. ADRIAN, A. MATTHEWS (Cambridge) [l]
Acknowledgement of Berger's discoveries and scientific
studies, which led to the final recognition of Berger's work in
1937 during the psychology congress in Paris. Improvement of
the EEG recording technique by means of a Faraday cage.
1932-1937 A. E. KORNMULLER (Berlin) [58, 59]
Discovery of various activities in the cortical fields in animal
experiments.
1934-1935 J. F. TONNIES, D. FORSTER, H. ALTENBURGER (Berlin) [44, 76]
First EEG recordings from the cortex during craniocerebral
surgery.
4 Introduction to Electroencephalography in Anesthesiology
1934-1937 H. ROHRACHER (Vienna) [69-71]
Postulation of the so-called alpha-wave theory for explaining
psychiatric disorders.
1935 F. A. GIBBS, H. DAVIES, W. G. LENNOX (Boston) [45]
First description of spike-wave patterns in the EEG of patients
with clinical signs of petit mal epilepsy.
1936 W. G. WALTER (Bristol) [81, 82]
Demonstration of parameters for tumor localization 10 the
brain.
1937 F. A. GIBBS, E. L. GIBBS, W. G. LENNOX (Boston) [46]
First extensive study on the correlation of anesthesia and EEG
changes.
1938 H. A. GRASS, F. A. GIBBS (Boston) [50]
Elaboration of a method for applying the Fourier transforma
tion to the EEG.
1938 Z. DROHOCKI, J. DROHOCKA (Brussels) [37]
Animal experiments revealing severe impairment by anesthe
sia of the cortical area of the brain as opposed to deeper cer
ebral areas.
1939 Z. DROHOCKI (Brussels) [36]
Quantification of the EEG by means ofa graphic amplitude in
tegration.
1943-1946 G. R. BALDOCK, W. C. WALTER (Bristol) [3]
Extension of frequency analysis of the EEG by use of electron
ic filters; the further development of this method was hindered
initially by problems with electronic technology.
1945 M. A. B. BRAZIER, J. E. FINESINGER (Los Angeles) [27]
Studies on the effect of barbiturates on the EEG.
1950 R. F. COURTlN, R. G. BICKFORD, A. FAULCONER (Rochester) [32]
Findings indicating a correlation between EEG changes and
depth of anesthesia using combined nitrous oxide/oxygen/
ether anesthesia.
1949-1951 R. G. BICKFORD (Rochester) [22-24]
Development of a device for automatic control of anesthesia,
based on EEG changes determined in animal experiments and
occasionally used clinically.
1951 D. K. KIERSEY, R. G. BICKFORD, A. FAULCONER (Rochester)
[57]
Definition of stages of anesthesia by means of specific EEG
changes.
1951-1952 W. G. WALTER and H. W. SHIPTON (Bristol) [83], A. REMOND
and F. OFFNER (Paris) [68]
Development of the "toposcope", a device for optically con
trolled topographical recording ofEEG frequency distribution.
Development and Application of Electroencephalography 5
1952 J. SCHNEIDER et al. (Colmar) [73]
Further differentiation of the classification of stages of anes
thesia according to EEG pattern, today still valid for bartiturates.
1952 M. A. B. BRAZIER, J. U. CASBY (Los Angeles) [28]
First statistical processing of EEG parameters by auto- and
cross-correlation functions.
195711959 B. SALTZBERG, A. R. BURCH (New Orleans) [29, 72]
Use of periodic EEG analysis. After initial technical problems,
this method has become established especially in psy
chopharmacology by Fink and Itil.
1959 J. T. MARTIN, A. FAULCONER, R. G. BICKFORD (Rochester) [63]
Summary of the correlation between anesthesia and EEG
changes, based on studies between 1933 and 1959.
1959 M. FINK, B. BENTE, T. M. ITIL (New York) [6, 39]
First systematic listing of EEG effects after application of
phenothiazines. The basic work was carried out independently
by the different authors.
1959-1960 ST. KUBICKI, M. TREDE, O. JUST (Berlin) [60]
Use of EEG monitoring in open heart surgery with ex
tracorporal circulation.
Since 1961 T. M. ITIL (New York) [53-55]
EEG classification of psychopharmacological agents, first the
group of phenothiazines, then the psychotropic drugs. Period
ical EEG analyses are used for quantification of the EEG data.
1961-1969 M. FINK, P. BORENSTEIN et al.; L. GOLDSTEIN et al. (Mas
sachusetts) [25, 26,40-43,48,49]
Development of various EEG classifications for psychotropic
drugs on the basis of different qualitative and quantitative
properties.
1963 D. O. WALTER (Los Angeles) [80]
Further development of EEG spectral analysis.
1965 J. W. COOLEY, J. W. TUKEY [31]
Introduction of the fast Fourier transform with a reduction in
the calculating effort required for Fourier analysis.
1967 G. DUMERMUTH, H. FLUHLER (Zurich) [38]
Use of the fast Fourier transform (FFT) for the spectral analy
sis of the EEG. With the introduction of better computers and
the reduction in the effort required to calculate the FFT, wide
application ofEEG spectral analysis becomes possible.
1967 M. S. SADOVE, D. BECKA, F. A. GIBBS (Rochester) (SADOVE et
al. 1967)
Publication of the applications of the EEG in surgery. Despite
technical difficulties, the application in anesthesiology and
open heart surgery is strongly suggested.