Daniel Shmukler
@DrShmuk
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Anaesthetist, foodie, still dreaming of being a tennis pro! Passionate EEG in anaesthesia advocate. ❤️TIVA. Views my own.
Johannesburg, South Africa
Joined October 2015
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As an acknowledgement of the problem that's out there, but denied, not screened or looked for, or just sent home....some articles to highlight the multi-factorial problem, pathophysiology and prevention/treatment(?) options regarding delirium.
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Show off support for our murdered colleague. Dr Abdulhay Munshi
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TIPS for TIVA: Where to put the electrodes edition. Forehead not available? No problem. Pretty good trace and display. Nice gas induction to TIVA Eleveld model without opioid.great wake up. 👍😊
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Tips for EEG Part 2: Alternative Placements of electrodes during anaesthesia.
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TIPS for TIVA: Planet edition 🌎🌍 Based on clinical studies, we should be looking at 6 litres/mn total flow to hit the sweet spot between soda lime usage/canister longevity, oxygen use and production costs and global warming potential of all of the above. Is it your routine?
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TIPS for TIVA: If you loved the soda lime tweet, you gonna do your mind for this one Edition! more reasons why TIVA trumps GAS. From a costing perspective, and regarding climate impact, the evidence is clear. European parliament looking at limiting volatile use in near future...
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What to do with a tiny forehead? Make it work... Nasal bridge placement of EEG sensor allowing cerebral oximetry to be placed as well. Good trace and DSA
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This picture should make you uncomfortable....
71 years, Parkinson's dz, dementia
Awake EEG before anaesthesia commenced did not look much different.
-loss of frontal alpha power = poor preoperative cognition
-this is a vulnerable brain
#avoidburstsuppression
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Mandibular placement of eeg electrodes... Forehead unavailable
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EEG Spectrograms for practice : patient awake, talking... But delta dominant picture. What drug group typically gives delta wave increase alone? 🙂
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🧵TIPS for TIVA 2nd edition: Tiny Edition👶 It’s all about titration, right? But BIS has not been validated in neonates/infants, right? Yes.but who is still only using the index in 2022?!😳 40-60 is so 1996! It’s all about EEG and Spectrograms - SEF95/MF/alpha-delta dominance!
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EEG Spectrograms for practice : It's Nociception again! Some lovely DSA images showing one of the expected responses to pain. Beta waves clearly seen in response to surgical stimulation. Treatment? Analgesia! This is not treated with more propofol......
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Drug signatures: Typical Propofol vs Sevoflurane spectrograms
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EEG Spectrograms for practice : Nociception again. Seen nicely here with beta wave increased activity and small alpha dropout. MF remained low while SEF increased in keeping with Nociceptive response. Treatment... Analgesia
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EEG SPECTROGRAMS for practice: The brain is an organ too edition! If you think EEG monitoring is just about the index you are WRONG. Compare these DSA's from young and old. It's a window into brain health and pre operative cognition+marking those at risk for DELIRIUM.
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Hey Doc..how do I read the BIS?🤦🏼♂️
Cover the number and start with this must read article.
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EEG spectrograms meets TIPS 4 TIVA!😊fun today with iTIVA app and Eleveld in young patient. EEG monitoring for seamless transition from inhalational to TIVA. NO BS. Loved the BIS prediction as well. Probably most useful if no eeg available. Don't you love technology?!
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🧵EEG in clinical practice: know your evidence. A common question seems to be "where is the evidence of harm for deep hypnosis?" I'll do my best to cover them all! Apologies to any of the authors I may have left out who continue to do great work in this area.😀
@AAAanesthesiol1
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TIPS for EEG monitoring: Out of the box edition. As a follow up to a recent post, sharing some interesting articles to read through when frontal EEG placement is not possible. There are limitations of course: strength of signal, negating anteriorisation of EEG during anaesthesia.
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TIPS for TIVA: I'll show you mine if you show me yours Edition. Tweeted before but worth sharing again.Forgetting the environmental benefits, there are so many other reasons to totally TIVA. I'm still waiting for the Volatile Vehements to share their list😀
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Open access, interesting read. More reasons to use eeg monitoring, with ALL anaesthesia techniques. MAC is a poor indicator of unconsciousness and doesn't allow titration to any end point. We need to be aiming for thalamo- cortical disruption and slow wave saturation.
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EEG SPECTROGRAMS FOR PRACTICE: Where does your faith lie edition?! BIS number 50.. but SR 2...DSA in keeping with deep patient with very poorly developed alpha band, MF 01 What's your next step? How old is the patient? Why is BIS 50 with SR OF 2? Does it matter? Answers to follow
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EEG Spectrograms for practice : It's a cognitive function monitor! Love these cases.. Mini cog 5/5 80years orif shoulder. Tci prop and block. BS zero.Awake+orientated in recovery. Even remembered the 3 mini cog words after 2 hours under GA!
#EEG4ALL
#DELIRIUMPREVENTION
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EEG Spectrograms for Practice: It's for everyone edition! Looking for some good reads to get you going in using available EEG monitors (BIS/Narcotrend/Sedline) in the tiniest of tots? These will help
@napen_icr
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Tips for TIVA : small paediatric case today.. Really amazing to see the BIS prediction from iTiva app
@deramirezmd
.. Pretty much spot on today. No excuse... TIVA can be done anywhere
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EEG SPECTROGRAMS FOR PRACTICE: lessons galore edition. So much to unpack here.70+with dementia, almost non verbal. Easily burst suppressed on slow induction but recovered. DSA in keeping with poor preop cog. LOW SEF pre induction.poor alpha band. Lastly,maybe decent emergence DSA
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Very exciting day.. Pump is all mine for a week... Eleveld here we come.
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TIPS for TIVA: It's the CONTEXT! The pharmacokinetics are important of course. Propofol can reach 20 mns after 4 hours, double the adult population. With Remifentanil the context is always relevant. Recent case needing high target effect site [ ] of 8ng/ml. Decrement time 15mns!
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EEG Spectrograms: Dive deeper edition. Great, now that we have mastered the DSA, its time to really look closely at emergence patterns when you are waking patients up. This article is fascinating. Some personal examples added that match the different emergence trajectories.
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Got asked today, why do you do TIVA?!😯
Did I leave anything out?
Could you compile a similar list for volatile-based anaesthesia?
Mostly I do TIVA just so I can use my EEG Monitor!😂
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TIPS for TIVA: Make your life easier edition! TCI is there to simplify things for many reasons. Interestingly, there are studies to show manual TIVA with EEG monitoring (BIS) approximate TCI and BIS in dosages, emergence and extubation times.Of course..its about the PDynamics.
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EEG Spectrograms for practice : Dexmed sedation for revision total hip. Initially patient obstructing on propofol TCI for sedation, made the switch to dexmed, obstruction much improved. Next time I'll use "new" dexmed TCI model by Hannivoort
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EEG SPECTROGRAMS FOR PRACTICE : Anteriorisation is real edition. Just for fun... Occipital and frontal comparison.. Nicely shown in DSA.
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Delirium Debates: do you know what midazolam is doing to your patients? This in 40 years old.. Spinal with sedation, 1.5mgs plus propofol tci initially. Benzos can give very deep sedation.. Imagine the effect in your elderly patients?!
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Some nice benefits including decreasing emergence agitation. No increase in time in PACU. IMO personalisation of dose might avoid hypotension and bradycardia.
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Tips for TIVA: TCI - Its elegant and easy...just do it! With your TCI pumps or with an app and old volumetric pumps - there should be no obstruction to TCIs no matter where you are! USA or rural Kwazulu-Natal!
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Great reminder to think of other costs/equipment when performing TIVA. 6 litres FGF is the sweet spot!
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Sedation to general anaesthetic so nicely seen in this spectrogram.
#whentheblockdoesntwork
😉 Propofol TCI
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🧵EEG Spectrograms for Practice: It's all in the context edition! 90 yrs old for knee scope. Slow Propof induction , sevo maintenance. 13h37 still no strong alpha power and SEF increasing, some patient movement. no noxious stimulus yet. Maybe to slow on the volatile🤷♂️
#mindthegap
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EEG Spectrograms for Practice: Benefits in TIVA edition For the haters😜who deny the dose-response relationship between Propofol and BIS/DSA/EEG oscillations. Beyond the obvious benefits, EEG monitoring also alerts if you forget to restart an infusion, shown very clearly
@8h08
!
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EEG Spectrograms for practice: Newbie edition! Really good (hopefully!) TCI/TIVA-Pain management workshop yesterday, with support as always from Fresenius Kabi. Anyone want to comment on which drug was given? Appropriate hypnosis? SEF?MF? Nice zipper opening for emergence shown.
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EEG spectrograms for practice: packed full of useful info edition: sedation quick case... patient having pain.. deepened to GA... K-wires in... emergence and beautiful sleep spindles towards the end. Propofol/Midazolam young patient.
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Tips for TIVA: Today's patient 🚺40 years... Eleveld+ op with new Bbraun space plus. Wake up concentration 3.1!! Pharmacodynamic prediction can only take you so far... Real time PD monitoring the way to go.
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3year old for removal of TENS femur. Had fun with inhalational induction, change to Eleveld TCI Propofol . Made possible with iTIVA app. Lovely wake-up .
@deramirezmd
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Another really satisfying case. 93 with dementia.Fracture NOF. TCI Propofol and US fascia iliaca block. 2 hours. Only 1mn41s suppression. Was aiming for zero 😆Spectrograms from beginning to recovery area.Awake, pain free and talking to me 5 mns after surgery ended.
#eegforelderly
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🧵Perioperative Delirium: The Safe Brain Initiative (SBI)masterclass Medtronic IC Istanbul: Personalised precision anaesthesia is where it's headed. This means ALL physiological systems including the 🧠! We have monitors available right now to guide our care of patients. USE THEM
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Really enjoying my new toy.. Easy solution to bumbling hospital administrators trying to sort out labels for theatre
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EEG Spectrograms for practice : Dementia/delirium A brain in distress edition. Drugs used in order from top 1) prop 2), sufenta 3) norad. Spectrogram correlates with mini cog done before. Lovely gentleman answered my questions but boy is this a fragile brain.
#eegmonitoringforall
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Really happy with this case. 84 years, preop mini cog 0/5. Starting spectrogram SEF =14 prior to induction. Spinal plus eeg titrated TIVA/TCI. woke up beautifully after 3 hours revision THR. orientated.. Having tea at the moment 🙏😊
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EEG spectrograms for practice : It's nociception fool (!) edition. TCI PROPOFOL with patient displaying DSA consistent with appropriate hypnosis. Still moving foot with incision on plantar surface. Treatment? ⬆️Remi... NOT PROPOFOL OR PARALYSE!
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EEG SPECTROGRAMS for practice. Just for fun edition.
1) What drug for hypnosis?
2) Age of patient? Closest guess wins free coffee in Johannesburg! 😊
Clue: between 20 and 40
3) yes... That's really my own coffee and artwork!
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EEG spectrograms for practice: who needs midazolam edition. Love dexmedetomidine sedation. Young patient, increasing Prop often causes restless over sedated pt. Small dex dose in ringers Infusion (20ug) often lovely choice to achieve good sedation with no respiratory compromise
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EEG SPECTROGRAMS FOR PRACTICE: Using all the info edition. Lots of interference- cautery. Index suggests too light but DSA shows alpha/delta dominance, with 50% at least delta. Alpha decreasing.. Suggesting ⬇️hypnosis might be more appropriate. MF consistently low
#NOTJUST40
-60!
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EEG Spectrograms for Practice: No spectrogram edition! Are these resources in your folder?
#EEGmonitoringforall
#EEG4volatile
#EEGforTIVA
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"Ultimately, there are no indispensable qualities of Desflurane (sympathetic tone stimulation, rapid emergence) that cannot be achieved using other means, and with less environmental impact"
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EEG spectrograms for practice: I'm ashamed edition😅even the surgeon couldn't believe I used volatile! it was only to show people the overlap on DSA and that drug signatures aren't always that easy. basal flows, monitored oxygen conc. Good block. Patient happy. Nice raw EEG
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TIPS 4 TIVA: Outliers edition. Today's wake up concentrations! You just don't know where you are without the pharmacodynamic feedback from real time eeg and spectrograms.
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EEG Spectrograms for practice: Up or Down edition! Alpha oscillations can disappear if too deep or if anaesthetic plane is too light. How to know the difference? CONTEXT! Use all the other information available. EEG trace, SEF, patient parameters, level of noxious stimulation../2
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Did you TOF someone today? With
@ESAIC_org
and
@ASALifeline
having clear guidelines published this year, there's no excuse for not monitoring your patients properly. What are you doing for patient safety?
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EEG spectrograms for practice: which one is it edition? GA or sedation..70yrs male, spinal block in situ. Some good learning points.neuraxial effect on blocking neuronal input=sedation effect.Elderly sensitivity/PK effects. Be careful.very easy to tip these patients + oversedate
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Delirium Discussions: 1st Edition did you mini cog anyone today? This 83 year old scored 5/5.👍Accompanying Spectrogram shown. Sedation for small procedure. Remember good cognition doesn't nullify increased sensitivity to hypnotic agents. Start low go slow.
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EEG Spectrograms for Practice: What’s your next course of action? Breast surgery, young patient. TIVA. Want to know anything else?
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Tips for TIVA : start right to finish right! The equipment matters. A simple thing like non-luer lock syringe can cause pressure alarms to trigger. Especially with induction and high flow rates. Whenever possible use luer lock syringes and dedicated TIVA sets.
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More EEG studies and validation of the monitoring. EEG waveforms, together with spectrograms, and actively aiming to avoid burst supression...just as useful in paediatric population with volatile based anaesthesia, where varying anaesthetic requirements are all seen. Nice work
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Delirium debates: more food for thought with the choices we make for our patients. I have tried hard to convince people that a quick wake up does not = a good wake up! open access article by some big names in POD research
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EEG Spectrograms for practice : get the dose right. Really enjoyed using all parameters available to find right dose for this young patient. Lost alpha, SF+MF down, small amount BS. Reduced hypnotic component to get alpha back. And 50% power of EEG <1hz so happy
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Today's patient.. Young male.. High hypnotic/analgesic requirements. Guided by EEG of course. You don't get any of this pharmacodynamic feedback if you don't monitor! Propofol's "MAC" equivalent range is much greater than volatile,and can be in the order of several hundred %
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EEG Monitoring in 2023: This is what it's about. Awareness prevention(important) is so 1996☺️.Drag yourself into the 21st century, to deliver personalised modern anaesthesia tailored to each individual patient.NOT monitoring the brain should NOT be tolerated anymore.
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Tips for TIVA : start right to finish right! The equipment matters. A simple thing like non-luer lock syringe can cause pressure alarms to trigger. Especially with induction and high flow rates. Whenever possible use luer lock syringes and dedicated TIVA sets.
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EEG Spectrograms for practice: Finesse edition! It's not just about awareness. This particular patient on drugs that could affect drug metabolism in either direction. Don't guess on the dose.. Use PD FEEDBACK and get it right... Each time. TIVA(PROP/REMI) same goes for volatile!
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EEG Spectrograms for practice : greyhair edition. Which one of these patients is 84 years old?
Picture 1 or
Picture 2?
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For the BIS haters who give me a hard time... I've found a worse display 😅. No decent scale for oscillations.. No MF or SEF to assist in assessing slow wave saturation. And the qNOX just seems to track the qCON index or give unhelpful info.. This patient under spinal/sedation
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Delirium Debates: typical case, 93 years.. Failed 4AT..fracture femur. Of note: low SEF PRE induction, very sensitive to hypnotic, poor alpha band. 230mgs only of Propofol needed for 90mns.Priorities =avoid burst suppression/normothermia/normotension/good pain control.
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EEG Spectrograms for Practice: Super brain edition! When I grow up I want a brain like this😍. 78 yrs female for sedation. What lovely activity.. And in all the right places! EEG/DSA are a window into brain health.
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Tips for TIVA Sedation: Monitoring effectively for personalised anaesthesia and improved patient safety. BIS of course... but really enjoying Cap35 (medtronic) with microstream co2 monitoring.
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@SIVATrainees
This is a must read when starting out. In fact it should be in the curriculum of all FCA programs... But change takes time. Small progress is better than no progress!
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EEG Spectrograms for practice: Scale is Significant edition. The one time Drager improves things 😂With our slave cable we can now adjust BIS scale on the monitor. Watch what a difference it makes to EEG interpretation.
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It’s not even a debate!😀
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Delirium debates: 82 years . Mini cog 2/5 frailty score 5. 4AT neg Second operative procedure in 3 months. DSA picture from awake to GA and probable pain response shown as well. Slow titration of anaesthetic to achieve zero BS. Quick wake up, orientated in recovery.
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Ultrasound Imaging of the Spine for Central Neuraxial Blockade: a Technical Description and Evidence Update | SpringerLink
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🧵EEG spectrograms for practice: Nociception edition part 2!Nice examples of alpha dropout, beta activation. Will continue looking for example of delta increase, the third EEG change one can look for. Remember, it is still contextual and requires looking at your patient +surgery
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EEG Monitoring in Anaesthesia/Critical Care: Where to in 2023 (?) edition. If you are still going on about the number and awareness, you are stuck in the late 1990's! We have moved on from the number...to raw EEG trace...to density spectral array. Get with the programme!
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Nice study... gives further impetus to why I call EEG MONITORS haemodynamic stability monitors! (Not Always🤫). It's so much more than depth or awareness... monitoring personalised response to our drugs is the future of anaesthesia..EEG is going to play a big part in this...
🔥 New trial results hot off the press: Processed EEG-guided (compared to non-pEEG-guided) general anesthesia reduces the amount of norepinephrine needed to keep intraoperative mean arterial pressure above 65 mmHg by about a third.
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EEG Spectrograms for Practice: ADD edition! (its not attention deficit disorder!☺️) alpha/delta dominant EEG is currently the most reliable (but sensitivity not 100%) way to reach plane of anaesthesia where the patient is unconscious or disconnected🤞this can be seen on EEG +DSA
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EEG Spectrograms for practice: Geriatric edition. Maybe the Titration paradox in action? Spinal in elderly patient with propofol sedation. TCI Schnider starting around 1.2 mcg/ml and reduced to 0.7 . EEG very suggestive of deep hypnosis. Its very easy to oversedate the elderly!
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Pro-con debate of TIVA/EEG versus volatile.nice read and stimulating debate. I know which camp I'm in! Personally, I think we should be debating should all GA'S be done with pEEG as separate issue.TIVA rules already 😊
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You can see clearly as dexmed starts to kick in.. Beta oscillations disappear,sleep spindles make their appearance (can you see them in the video? 🙂) Often looks like very deep patient.. But you won't get burst suppression and patients are rousable. Love it!
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Delirium Debates: 72 years.. Mini cog 5/5 nice looking DSA in keeping with preserved preoperative cognitive function. Titration of anesthesia to EEG plus regional. Pt awake in 5 mns,pain free, 4AT zero in PACU. 🥳
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This year we will be celebrating 100 yr anniversary of first EEG recording. And yet we are nowhere near 100% clinician use... Or 100% patient application. Lots of work to be done.
#EEGmonitoringforall
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Great example of personalised anaesthesia. Would you be happy for your elderly relative to undergo surgery/anaesthesia without EEG monitoring? I wouldn't......
#EEGmonitoringforall
1/ Geriatric Anesthesia -
90yo lady for laparoscopic procedure. ASA PS 3 , Mini-Cog 1/5 , Clinical Frailty Scale 4/9 , FRAIL 4/5.
BIS 93 pre-induction. Midazolam not given for anxiolysis.
Anesthesiologist
#1
did great but w/o DSA or SR .. What do we know about these number?
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Young male teen. Spinal with sedation. One of few scenarios where I might combine TCI Propofol with midazolam.Easy to push Propofol up and have very restless/talkative/uncooperative patient. Nice progression from light to moderate/deep sedation. Prop target 1. Midaz 1mg
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TIPS for TIVA: Always have a Plan B edition! What to do if pump fails (not common) , data resets, battery expires (your own fault🫣) or things just go 🍐shaped.
1st...don't panic . Try one of the below..and if all else fails just switch on the volatile🤫
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EEG Spectrograms for Practice: GOT/Greyjoy edition . Some really interesting features here. Lovely active brain, 91 years old! Spinal with sedation for
#NOF
. Wanted to achieve appropriate sedation without HD/resp compromise from excessive Propofol. Sedation plan changed 17h00
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EEG Spectrograms for practice : does Connox work edition: IMHO it's a resounding no! At least the Nociception index. Patient moved in response to stimulus.. No discernible change in index. Now tourniquet pain and no change either...
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86 years, mini cog 2/5. Starting SEF95 15Hz BIS 81.Vulnerable brain. Spinal and sedation with TCI Schn Propofol 0,3-0.4. Sedation so easy to get wrong in these patients with either wrong choice of drugs/over sedated. Use your EEG Monitor!
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