Download PDF
CC BY-NC-ND 4.0 · J Neuroanaesth Crit Care 2014; 01(01): 002-012
DOI: 10.4103/2348-0548.124832
Review Article
Thieme Medical and Scientific Publishers Private Ltd.

Anaesthetic considerations for evoked potentials monitoring

Parmod Kumar Bithal
1   Department of Neuroanaesthesiology, Neurosciences Center, All India Institute of Medical Sciences, New Delhi, India
› Author Affiliations
Further Information

Publication History

Publication Date:
27 April 2018 (online)

   Permissions and Reprints

Abstract

Intra-operative neurophysiologic monitoring (IONM) under anaesthesia has achieved popularity because it helps prevent/ minimize neurologic morbidity from surgical manipulations of various neurologic structures. Neurologic functions in an anaesthetised patient can be monitored either by electroencephalography (EEG) or by evoked potentials. Whereas, EEG is difficult to analyse, evoked potentials, in contrast, are easy to interpret, they are either present or absent, delayed or not delayed, with normal or abnormal wave. The goal of IONM is to identify changes in nervous system function prior to irreversible damage. Many factors need consideration when selecting an anaesthetic regimen for intra-operative monitoring of evoked potentials. The very pathophysiological condition or the potential risks of the contemplated surgical procedure, which require evoked potentials monitoring, may place constraints on anaesthetic management as well. With the availability of numerous anaesthetic techniques, an appropriate plan for managing both anaesthesia and IONM in a patient should be organised. It is extremely essential not to alter the pharmacological state of the patient to avoid any changes in the recording of evoked responses. While an anaesthesiologist may alter plans for a patient in order to facilitate IONM, monitoring team too, sometimes may be required to modify plans for monitoring when a particular anaesthetic agent or technique is strongly indicated or contraindicated. At times, compromise may be required between an anaesthesia technique and a monitoring technique. To serve patients’ best interest, it is critical to have a team approach and good communication among the neurophysiologist, anaesthesiologist and surgeon.

Keywords

Anaesthetics - neurophysiologic monitoring - non-anaesthetic factors
 

  • REFERENCES

  • 1 Nuwer MR, Dawson EG, Carlson LG, Kanim LE, Sherman JE. Somatosensory evoked potential spinal cord monitoring reduces neurologic deficits after scoliosis surgery: Results of a large multicentre survey. Electroencephalogr Clin Neurophysiol 1995; 96: 6-11
    CrossrefPubMedGoogle Scholar
  • 2 Kelleher MO, Tan G, Sarjeant R, Fehlings MG. Predictive value of intraoperative neurophysiological monitoring during cervical spine surgery: A prospective analysis of 1055 consecutive patients. J Neurosurg Spine 2008; 8: 215-21
    CrossrefPubMedGoogle Scholar
  • 3 Chandanwale AS, Ramteke AA, Barhate S. Intraoperative somatosensory evoked potentials monitoring. J Orthop Surg (Hong-Kong) 2008; 16: 277-80
    CrossrefPubMedGoogle Scholar
  • 4 Vauzelle C, Stagnara P, Jouvinroux P. Functional monitoring of spinal cord activity during spinal surgery. Clin Orthop Relat Res 1973; 93: 173-8
    CrossrefPubMedGoogle Scholar
  • 5 Hoppenfield S, Gross A, Andrews C, Lonner B. The ankle clonus test for assessment of the integrity of the spinal cord during operation for scoliosis. J Bone Joint Surg Am 1997; 79: 208-12
    CrossrefPubMedGoogle Scholar
  • 6 King J, Sloan TB. Evoked potentials. Intraopeartive monitoring of the spinal cord and peripheral nerves. In: Domitru D. editor. Electrodiagnostic medicine. 2nd ed.. St Louis: Mosby; 2001
    Google Scholar
  • 7 Richard CD. Actions of general anaesthetics on synaptic transmission in the CNS. Br J Anaesth 1983; 55: 201-7
    CrossrefPubMedGoogle Scholar
  • 8 Sloan T. Anesthetics and the brain. Anesthesiol Clin North Am 2002; 20: 265-92
    CrossrefPubMedGoogle Scholar
  • 9 O'Shaughnessy CT, Lodge D. N- Methyl-D- Aspartate receptor mediated increase in calcium is reduced by ketamine and phencyclidine. Eur J Pharmacol 1988; 153: 175-88
    CrossrefPubMedGoogle Scholar
  • 10 Sloan T. Evoked potentials. In: Albin MS. editor. A Textbook of Neuroanesthesia with Neurosurgical and Neuroscience Perspectives. New York: McGraw-Hill; 1997. p. 221-76
    Google Scholar
  • 11 Fabrowski LW, Black S, Trankina MF, Pollard RJ, Clark RK, Mehta ME. Somatosensory evoked potentials during aortic coarctation repair. J Cardiothorac Vasc Anesth 1999; 13: 538-43
    CrossrefPubMedGoogle Scholar
  • 12 Lam AM, Manninen PH, Ferguson GG, Nantau W. Monitoring electrophysiologic function during carotid endarterectomy. A comparison of somatosensory evoked potentials and conventional electroencephalogram. Anesthesiology 1991; 75: 15-21
    CrossrefPubMedGoogle Scholar
  • 13 Calancie B, Harris W, Brindle GF, Green BA, Landly HJ. Threshold level repetitive transcranial electrical stimulationfor intraoperative monitoring of central motor conduction. J Neurosurg 2001; 95: 161-8
    PubMedGoogle Scholar
  • 14 Langeloo DD, Journee HL, de Kleuver M, Grotenhuis JA. Criteria for transcranial electrical motor evoked potential monitoring during spinal deformity surgery. A review and discussion of literature. Neurophysiol Clin 2007; 37: 431-9
    CrossrefPubMedGoogle Scholar
  • 15 Krammer MJ, Wolf S, Schull DB, Gerstner W, Lumeta CB. Significance of intraoperative motor function monitoring using transcranial electrical motor evoked potentials in patients with spinal and cranial lesions near the motor pathways. Br J Neurosurg 2009; 23: 48-55
    CrossrefPubMedGoogle Scholar
  • 16 Pathak KS, Amaddio BS, Scoles PV, Shffaer JW, Mackay W. Effects of halothane, enflurane, and isoflurane in nitrous oxide on multilevel somatosensory evoked potentials. Anesthesiology 1989; 70: 207-12
    CrossrefPubMedGoogle Scholar
  • 17 Sloan TB, Heyer EJ. Anesthesia for intraoperative neurophysiologic monitoring of spinal cord. J Clin Neurophysiol 2002; 19: 430-43
    CrossrefPubMedGoogle Scholar
  • 18 Kameyama Y. Effect of isoflurane and sevoflurane on evoked potentials and EEG. Masui 1994; 43: 657-64
    PubMedGoogle Scholar
  • 19 Wolfe DE, Drummond JC. Differental effects of isoflurane/nitrous oxide on posterior tibial somatosensory evoked responses of cortical and subcortical origin. Anesth Analg 1988; 67: 852-9
    PubMedGoogle Scholar
  • 20 Pechstein U, Nadstwek J, Zentner J, Schramm J. Isoflurane plus nitrous oxide versus propofol for recording of motor evoked potentials after high frequency repetitive electrical stimulation. Electroencepahalogr Clin Neurophysiol 1998; 108: 175-81
    PubMedGoogle Scholar
  • 21 Kawaguch M, Shimizu K, Furuya H, Sakamoto T, Ohnishi H, Karasawa J. Effects of isoflurane on motor evoked potentials induced by direct electrical stimulation of the exposed motor cortex with single, double and triple stimuli in rats. Anesthesiology 1996; 85: 1176-83
    CrossrefPubMedGoogle Scholar
  • 22 Zentner T, Albrecht T, Heuser D. Influence of halothane, enflurane, and isoflurane on motor evoked potentials. Neurosurgery 1992; 31: 298-305
    CrossrefPubMedGoogle Scholar
  • 23 Stecker MM. A review of intraoperative monitoring for spinal surgery. Surg Neurol Int Spine 2012; 3 Suppl (Suppl. 03) S174-87
    PubMedGoogle Scholar
  • 24 Schindler E, Muller M, Zickmann B, Osmer C, Wozniak G, Hempelmann G. Modulation of somatosensory evoked potentials under various concentrations of desflurane with or without nitrous oxide. J Neurosurg Anesthesiol 1998; 10: 218-23
    CrossrefPubMedGoogle Scholar
  • 25 da Costa VV, Saraiva RA, de Almeida AC, Rodrigues MR, Nunes LG, Ferreira JC. The effect of nitrous oxide on the inhibition of somatosensory evoked potentials by sevoflurane in children. Anaesthesia 2001; 56: 202-7
    CrossrefPubMedGoogle Scholar
  • 26 Kalkman CJ, ten Brink SA, Been HD, Bovill JG. Variability of somatosensory evoked potentials during spinal surgery: Effects of anesthetic techniques and high pass digital filtering. Spine (Phila Pa 1976) 1991; 16: 924-9
    CrossrefPubMedGoogle Scholar
  • 27 Koht A, Schutz W, Schmidt G, Schramm J, Watanabe E. Effects of etomidate, midazolam and thiopental on median nerve somatosensory evoked potential sand additive effects of fentanyl and nitrous oxide. Anesth Analg 1988; 67: 435-41
    PubMedGoogle Scholar
  • 28 Woodforth IJ, Hicks RG, Crawford MR, Stephen JP, Burke DJ. Variability of motor evoked potentials recorded during nitrous oxide anaesthesia from the tibialis anterior muscle after transcranial electrical stimulation. Anesth Analg 1996; 82: 744-9
    PubMedGoogle Scholar
  • 29 Zentner J, Kiss I, Ebner A. Influence of anesthesetics-nitrous oxide in particular-on electromyographic response evoked by transcranial electrical stimulation of the cortex. Neurosurgery 1989; 24: 253-6
    CrossrefPubMedGoogle Scholar
  • 30 Jellinek D, Platt M, Jewkes D, Symon L. Effects of nitrous oxide on motor evoked potentials recorded from skeletal muscle in patients under total anesthesia with intravenously administered propofol. Neurosurgery 1991; 29: 558-62
    CrossrefPubMedGoogle Scholar
  • 31 von Dongen EP, ter Beek HT, Schepens MA, Morshuis WJ, de Boer A, Aarts LP. et al. Effects of nitrous oxide on myogenic motor potentials evoked by a six pulse train of transcranial electrical stimuli: A possible monitor for aortic surgery. Br J Anaesth 1999; 82: 323-8
    CrossrefPubMedGoogle Scholar
  • 32 Sakamoto T, Kawaguchi M, Inoue S, Furuya H. Suppressive effect of nitrous oxide on motor evoked potentials can be reversed by train stimulation n rabbits under ketamine/fentanyl anaesthesia, but not with additional propofol. Br J Anaesth 2001; 86: 395-402
    CrossrefPubMedGoogle Scholar
  • 33 Glassman SD, Shields CB, Linden RD. Anesthetic effects on motor evoked potentials in dogs. Spine (Phila Pa 1976) 1993; 18: 1083-89
    CrossrefPubMedGoogle Scholar
  • 34 Kalkman CJ, Drummond JC, Ribberink AA, Patel PM, Sano T, Bickford RG. Effects of propofol, etomidate, midazolam and fentanyl on motor evoked responses to transcranial electrical or magnetic stimulation in humans. Anesthesiology 1992; 76: 502-9
    CrossrefPubMedGoogle Scholar
  • 35 Schwartz DM, Schwartz JA, Pratt Jr RE, Wierzbowski LR, Sestokas AK. Influence of nitrous oxide on posterior tibial nerve cortical somatosensory evoked potentials. J Spine Disord 1997; 10: 80-6
    PubMedGoogle Scholar
  • 36 Boisseau E, Madany M, Staccini P, Armando G, Martin F, Grimaud D. et al. Comparison of the effects of sevoflurane and propofol on cortical somatosensory evoked potentials. Br J Anaesth 2002; 88: 785-9
    CrossrefPubMedGoogle Scholar
  • 37 Calancie B, Harris W, Broton JG, Alexeeva N, Green BA. Threshold level multiple transcranial electrical stimulation of motor cortex for intraoperative monitoring of spinal motor tracts: Description of method and comparison to somatosensory evoked potential monitoring. J Neurosurg 1998; 88: 591-3
    PubMedGoogle Scholar
  • 38 Schubert A, Licina MG, Lineberry PJ. The effect of ketamine on human somatosensory evoked potentials and its modification by nitrous oxide. Anesthesiology 1990; 72: 33-9
    CrossrefPubMedGoogle Scholar
  • 39 Stone JL, Ghaly RF, Levy WJ, Kartha R, Krinsky L, Roccaforte P. A comparative analysis of enflurane, anaesthesia on primate motor and somatosensory evoked potentials. Encephalograph Clin Neurophysiol 1992; 84: 180-7
    PubMedGoogle Scholar
  • 40 Agarwal R, Roitman KJ, Stokes M. Improvement of intraoperative somatosensory evoked potentials by ketamine. Paediatr Anaesth 1998; 8: 263-6
    CrossrefPubMedGoogle Scholar
  • 41 Kawaguchi M, Sakamoto T, Inoue S, Kakimoto M, Furuya H, Moromoto T. et al. Low dose propofol as supplement to ketamine-based anesthesia during intraoperative monitoring of motor-evoked potentials. Spine (Phila Pa 1976) 2000; 25: 974-9
    CrossrefPubMedGoogle Scholar
  • 42 Inoue S, Kawaguchi M, Kakimoto T, Sakamoto T, Kitaguchi K, Furuya H. et al. Amplitudes and intrapatient variability of myogenic motor evoked potentials to transcranial electrical stimulation during ketamine/N2O and propofol/N2O based anesthesia. J Neurosurg Anesthesiol 2002; 14: 213-7
    CrossrefPubMedGoogle Scholar
  • 43 Kalkman CJ, Drummond JC, Patel PM, Sano T, Chestnut RM. Effects of droperidol, pentobarbital and ketamine on myogenic transcranial magnetic motor evoked responses in humans. Neurosurgery 1994; 35: 1066-71
    CrossrefPubMedGoogle Scholar
  • 44 Ghneim MM, Yameda T. Etomidate: A clinical and electroencephalographic comparison with thiopentone. Anesth Analg 1977; 56: 479-85
    PubMedGoogle Scholar
  • 45 Halliday AM. Cerebral evoked potentials in familial myoclonic progressive myoclonic epilepsy. J R Coll Physicians 1967; 1: 23-7
    PubMedGoogle Scholar
  • 46 Kochs E, Treede RD, Schulte am Esch J. Increase in somatosensory evoked potentials during anesthesia induction with etomidate. Anaesthesist 1986; 35: 359-64
    PubMedGoogle Scholar
  • 47 Samra SK, Sorkin LS. Enhancement of somatosensory evoked potentials by etomidate in cats: An investigation of its site of action. Anesthesiology 1991; 74: 499-503
    CrossrefPubMedGoogle Scholar
  • 48 Russ W, Theil A, Schwandt HJ, Hempelmann G. Somatosensory evoked potentials under thiopental and etomidate. Anaesthesist 1986; 35: 679-85
    PubMedGoogle Scholar
  • 49 Nagao S, Roccaforte P, Moody RA. The effects of isovolemic hemodynamic and reinfusion of packed erythrocytes on somatosensory and visual evoked potentials. J Surg Res 1978; 25: 530-7
    CrossrefPubMedGoogle Scholar
  • 50 McPherson RW, Sell B, Tryastman RJ. Effects of thiopental, fentanyl and etomidate on upper extremities SSEPs in humans. Anesthesiology 1986; 65: 584-9
    CrossrefPubMedGoogle Scholar
  • 51 Sloan TB, Ronal AK, Toleikis JR, Koht A. Improvement of intraoperative somatosensory evoked potentials by etomidate. Anesth Analg 1988; 67: 582-5
    PubMedGoogle Scholar
  • 52 Pathak KS, Brown RH, Casorbi HF, Nash Jr. CL. Effects of fentanyl and morphine on intraoperative somatosensory cortical-evoked potentials. Anesth Analg 1984; 63: 883-7
    PubMedGoogle Scholar
  • 53 Samra SK, Dy EA, Welch KB, Lovely LK, Grazino GP. Remifentanil and fentanyl base anesthesia for intraoperative monitoring of somatosensory evoked potentials. Anesth Analg 2001; 92: 1510-5
    PubMedGoogle Scholar
  • 54 Asouhidon I, Katsaridis V, Vaidis G, Ioannou P, Givissis P, Christodoulou A. et al. Somatosensory evoked potentails suppression due to remifentanil during spinal operation; a prospective study. Scoliosis 2010; 5: 8
    CrossrefPubMedGoogle Scholar
  • 55 Fernandez-Gallinski SM, Monells J, Espadaler JM, Pol O, Puig MM. Effects of subarachnoid lidocaine, meperidine and fentanyl on somatosensory and motor evoked responses in awake humans. Acta Anaesthesiol Scand 1996; 40: 39-46
    CrossrefPubMedGoogle Scholar
  • 56 Schmid UD, Boll J, Liechti S, Schmid J, Hess CW. Influence of some anesthetic agents on muscle responses to transcranial magnetic cortex stimulation: A pilot study in humans. Neurosurgery 1992; 30: 85-92
    CrossrefPubMedGoogle Scholar
  • 57 Sloan TB, Fugina ML, Toleikis JR. Effects of midazolam on median nerve somatosensory evoked potentials. Br J Anaesth 1990; 64: 590-3
    CrossrefPubMedGoogle Scholar
  • 58 Bala E, Sessler DI, Nair DR, McLain R, Dalton JE, Farag E. Motor and somatosensory evoked potentials are well maintained in patients given dexmedetomodine during spine surgery. Anesthesiology 2008; 109: 417-25
    CrossrefPubMedGoogle Scholar
  • 59 Mahmoud M, Sadhasivam S, Sestokas AK, Samuels P, McAuliffe J. Loss of transcranial electric motor evoked potentials during pediatric spine surgery. Anesthesiology 2007; 106: 393-6
    CrossrefPubMedGoogle Scholar
  • 60 Sloan TB. Non depolarizing neuromuscular blockade does not alter the sensory evoked potentials. J Clin Monit 1994; 10: 4-10
    CrossrefPubMedGoogle Scholar
  • 61 von Dongen EP, ter Beek HT, Schepen MA, Morshuis WJ, Langemeijer HJ, de Boer A. et al. Within patient variability of myogenic motor evoked potentials to multipulse transcranial electrical stimulation during two levels of partial neuromuscular blockade in aortic surgery. Anesth Analg 1999; 88: 22-7
    PubMedGoogle Scholar
  • 62 de Haan P, Kalkman CJ. Spinal cord monitoring: Somatosensory – and-motor evoked potentials. Anesth Clin North Am 2001; 19: 932-45
    PubMedGoogle Scholar
  • 63 Dolan EJ, Transfeld EE, Tator CH, Simmons EH, Hughes KF. The effects of spinal distraction on regional blood flow in cats. J Neurosurg 1980; 53: 756-64
    CrossrefPubMedGoogle Scholar
  • 64 McCutcheon EP, Frazier DT, Boyarsky LL. Changes in the somatosensory cortical evoked potentials produced by hypovolemic shock. Proc Soc Exp Biol Med 1971; 136: 1063-71
    CrossrefPubMedGoogle Scholar
  • 65 Ledsome JR, Cole C, Sharp-Kehl JM. Somatosensory evoked potentials during hypoxia and hypocapnia in conscious humans. Can J Anaesth 1996; 43: 1025-9
    CrossrefPubMedGoogle Scholar
  • 66 Colin F, Bourgain R, Manil J. Progressive alteration of somatosensory evoked potential waveforms with lowering of cerebral tissue pO2 in the rabbit. Arch Int Physiol Biochem 1978; 86: 677-9
    PubMedGoogle Scholar
  • 67 Kobrine AI, Evans DE, Rizzoli HV. Relative vulnerability of the brain and spinal cord to ischaemia. J Neurol Sci 1980; 45: 65-72
    CrossrefPubMedGoogle Scholar
  • 68 Mackey-Hargardine JR, Hall 3rd JW. Sensory evoked responses in head injury. Cent Nerv Syst Trauma 1985; 2: 187-206
    PubMedGoogle Scholar
  • 69 Schubert A, Drummond JC. The effects of acute hypocapnia on human median nerve somatosensory evoked responses. Anesth Analg 1986; 65: 240-4
    PubMedGoogle Scholar
  • 70 Kalkman CJ, Boezeman EH, Ribberink AA, Oosting J, Deen L, Bovill JG. Influence of changes in arterial carbon dioxide tension on the electroencephalogram and posterior tibial nerve somatosensory cortical evoked potentials during alfentanil/nitrous oxide anesthesia. Anesthesiology 1991; 75: 68-74
    CrossrefPubMedGoogle Scholar
  • 71 Browning JL, Heizer ML, Baskin DS. Variations in corticomotor and somatosensory evoked potentials. Effects of temperature, halothane anesthesia, and arterial partial pressure of CO2 . Anesth Analg 1992; 74: 643-8
    PubMedGoogle Scholar
  • 72 Grundy BL, Jannetta PJ, Procopio PT, Lina A, Boston JR, Doyle E. Intraoperative monitoring of brainstem auditory evoked potentials. J Neurosurg 1982; 57: 674-81
    CrossrefPubMedGoogle Scholar
  • 73 Aren C, Badar G, Feddersen K, Radegarn K. Somatosensory evoked potentials and cerebral metabolism during cardiopulmonary bypass with special reference to hypotension induced by prostacyclin infusion. J Thorac Cardiovasc Surg 1985; 90: 73-9
    PubMedGoogle Scholar
  • 74 MacKenzie MA, Vingerhoets DM, Colon EJ, Pinckers AJ, Notermans SL. Effects of steady hypothermia and normothermia on multimodality evoked potentials in human poikilothermia. Arch Neurol 1995; 52: 52-8
    CrossrefPubMedGoogle Scholar
  • 75 Kakimoto M, Kawaguchi M, Sakmoto T, Inoue S, Takahashi M, Furuya H. Effect of nitrous oxide on myogenic motor evoked potentials during hypothermia in rabbits anaesthetized with ketamine/fentanyl/propofol. Br J Anesth 2002; 88: 836-40
    CrossrefPubMedGoogle Scholar
  • 76 Leslie K, Sessler DI, Bjorksten AR, Moayyeri A. Mild hypothermia alters propofol pharmacokinetics and increases the duration of action of atracurium. Anesth Analg 1995; 80: 1007-14
    PubMedGoogle Scholar
  • 77 MacDonald DB. Safety of intraoperative transcranial electrical stimulation motor evoked potentials monitoring. J Clin Neurophysiol 2002; 19: 416-29
    CrossrefPubMedGoogle Scholar
  • 78 Sala F, Krzan MJ, Deletis V. Intraoperative neurophysiological monitoring in pediatric neurosurgery: Why, when and how?. Childs Nerv Syst 2002; 18: 264-87
    CrossrefPubMedGoogle Scholar
  • 79 Deiner S. Highlights of anesthetic considerations for intraoperative neuromonitoring. Semin Cardiothorac Vasc Surg 2010; 14: 51-3
    PubMedGoogle Scholar
  • 80 Deiner SG, Kwatra SG, Lin H, Weisz DJ. Patient characteristics and anesthetic technique are additive not synergistic predictors of successful motor evoked potential monitoring. Anesth Analg 2010; 111: 421-5
    CrossrefPubMedGoogle Scholar