From the Maisonneuve-Rosemont Research Center, CIUSSS de l'Est de L'Ile de Montréal, Montreal, Quebec, Canada.
Department of Anesthesiology and Pain Medicine, Montreal University, Montreal, Quebec, Canada.
Anesth Analg. 2024 Feb 1;138(2):295-307. doi: 10.1213/ANE.0000000000006860. Epub 2024 Jan 12.
Anesthesia objectives have evolved into combining hypnosis, amnesia, analgesia, paralysis, and suppression of the sympathetic autonomic nervous system. Technological improvements have led to new monitoring strategies, aimed at translating a qualitative physiological state into quantitative metrics, but the optimal strategies for depth of anesthesia (DoA) and analgesia monitoring continue to stimulate debate. Historically, DoA monitoring used patient's movement as a surrogate of awareness. Pharmacokinetic models and metrics, including minimum alveolar concentration for inhaled anesthetics and target-controlled infusion models for intravenous anesthesia, provided further insights to clinicians, but electroencephalography and its derivatives (processed EEG; pEEG) offer the potential for personalization of anesthesia care. Current studies appear to affirm that pEEG monitoring decreases the quantity of anesthetics administered, diminishes postanesthesia care unit duration, and may reduce the occurrence of postoperative delirium (notwithstanding the difficulties of defining this condition). Major trials are underway to further elucidate the impact on postoperative cognitive dysfunction. In this manuscript, we discuss the Bispectral (BIS) index, Narcotrend monitor, Patient State Index, entropy-based monitoring, and Neurosense monitor, as well as middle latency evoked auditory potential, before exploring how these technologies could evolve in the upcoming years. In contrast to developments in pEEG monitors, nociception monitors remain by comparison underdeveloped and underutilized. Just as with anesthetic agents, excessive analgesia can lead to harmful side effects, whereas inadequate analgesia is associated with increased stress response, poorer hemodynamic conditions and coagulation, metabolic, and immune system dysregulation. Broadly, 3 distinct monitoring strategies have emerged: motor reflex, central nervous system, and autonomic nervous system monitoring. Generally, nociceptive monitors outperform basic clinical vital sign monitoring in reducing perioperative opioid use. This manuscript describes pupillometry, surgical pleth index, analgesia nociception index, and nociception level index, and suggest how future developments could impact their use. The final section of this review explores the profound implications of future monitoring technologies on anesthesiology practice and envisages 3 transformative scenarios: helping in creation of an optimal analgesic drug, the advent of bidirectional neuron-microelectronic interfaces, and the synergistic combination of hypnosis and virtual reality.
麻醉目标已经演变为结合催眠、遗忘、镇痛、麻痹和交感自主神经系统抑制。技术的进步带来了新的监测策略，旨在将定性的生理状态转化为定量指标，但最佳的麻醉深度（DoA）和镇痛监测策略仍在引发争议。历史上，DoA 监测使用患者的运动作为意识的替代指标。药代动力学模型和指标，包括吸入麻醉剂的最低肺泡浓度和静脉麻醉的靶控输注模型，为临床医生提供了进一步的见解，但脑电图及其衍生物（处理后的 EEG；pEEG）为麻醉护理的个性化提供了潜力。目前的研究似乎证实，pEEG 监测减少了麻醉剂的使用量，缩短了麻醉后护理单元的持续时间，并且可能降低术后谵妄的发生率（尽管定义这种情况存在困难）。正在进行的主要试验旨在进一步阐明其对术后认知功能障碍的影响。在本文中，我们讨论了双谱指数（BIS）、Narcotrend 监测仪、患者状态指数、基于熵的监测和 Neurosense 监测仪，以及中潜伏期听觉诱发电位，然后探讨了这些技术在未来几年可能如何发展。与 pEEG 监测仪的发展相比，疼痛监测仪相对而言仍未得到充分开发和利用。就像麻醉剂一样，过度镇痛会导致有害的副作用，而镇痛不足则与应激反应增加、血流动力学状况和凝血、代谢和免疫系统紊乱有关。广泛而言，出现了 3 种不同的监测策略：运动反射、中枢神经系统和自主神经系统监测。通常，疼痛监测仪在减少围手术期阿片类药物使用方面优于基本的临床生命体征监测。本文描述了瞳孔测量、手术 pleth 指数、镇痛痛觉指数和痛觉水平指数，并提出了未来发展如何影响它们的使用。本文的最后一部分探讨了未来监测技术对麻醉学实践的深远影响，并设想了 3 种变革性情景：帮助创建最佳镇痛药物、双向神经元-微电子界面的出现以及催眠和虚拟现实的协同结合。
