Abstract
During emergence from anesthesia patients regain their muscle tone (EMG). In a typical population of surgical patients the actual volatile gas anesthetic concentrations in the brain (CeMAC) at which EMG activation occurs remains unknown, as is whether EMG activation at higher CeMACs is correlated with subsequent severe pain, or with cortical activation. Electroencephalographic (EEG) and EMG activity was recorded from the forehead of 273 patients emerging from general anesthesia following surgery. We determined CeMAC at time of EMG activation and at return of consciousness. Pain was assessed immediately after return of consciousness using an 11 point numerical rating scale. The onset of EMG activation during emergence was associated with neither discernible muscle movement nor with the presence of exogenous stimulation in half the patients. EMG activation could be modelled as two distinct processes; termed high- and low-CeMAC (occurring higher or lower than 0.07 CeMAC). Low-CeMAC activation was typically associated with simultaneous EMG activation and consciousness, and the presence of a laryngeal mask. In contrast, high-CeMAC EMG activation occurred independently of return of consciousness, and was not associated with severe post-operative pain, but was more common in the presence of an endotracheal tube. Patients emerging from general anesthesia with an endotracheal tube in place are more likely to have an EMG activation at higher CeMAC concentrations. These activations are not associated with subsequent high-pain, nor with cortical arousal, as evidenced by continuing delta waves in the EEG. Conversely, patients emerging from general anesthesia with a laryngeal mask demonstrate marked neural inertia—EMG activation occurs at a low CeMAC, and is closely temporally associated with return of consciousness.
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Acknowledgments
This project has been funded with funds from the James S. McDonnell Foundation under Grant Award No. 220020346. The results were independently derived and do not reflect any endorsement on the part of the James S. McDonnell Foundation.
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All procedures performed in this study involving human participants were in accordance with the ethical standards of the Northern Y Regional Ethics Committee of New Zealand (NTY/11/EXP/077) and the New Zealand Health and Disability Ethics Committee (12/CEN/56) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
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Informed consent was obtained from all individual participants included in the study. This article does not contain any studies with animals performed by any of the authors.
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Hight, D.F., Voss, L.J., García, P.S. et al. Electromyographic activation reveals cortical and sub-cortical dissociation during emergence from general anesthesia. J Clin Monit Comput 31, 813–823 (2017). https://doi.org/10.1007/s10877-016-9911-z
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DOI: https://doi.org/10.1007/s10877-016-9911-z