A AE EP P MMo on ni it to or r 麻麻醉醉知知覺覺/ /深深度度監監測測儀儀( (A Au ud di it to or ry y E Ev vo ok ke ed d P Po ot te en nt ti ia al l) )台台大大醫醫學學系系六六年年級級 全全以以祖祖C Co on nt te en nt ts s1 1、前前言言2 2、A AE EP P MMo on ni it to or r的的理理論論及及臨臨床床應應用用3 3、A AE EP P v v. .s s. . B BI IS S4 4、WWH HY Y A AE EP P？有有人人說說：麻麻醉醉醫醫師師的的工工作作流流程程非非常常類類似似P Pi il lo ot t不不同同的的是是 - - - p pi il lo ot t 已已有有非非常常精精確確及及直直接接且且即即時時的的自自動動導導航航系系統統、全全球球衛衛星星定定位位系系統統e et tc c. .。- - - p pi il lo ot t有有非非常常嚴嚴格格的的工工作作時時間間限限制制。然然而而 - - - 麻麻醉醉醫醫師師只只有有一一些些輔輔助助儀儀器器間間接接且且非非即即時時來來提提供供病病患患麻麻醉醉深深度度/ /知知覺覺的的判判斷斷。- - - 麻麻醉醉醫醫師師常常o ov ve er rt ti im me e。有有人人說說：麻麻醉醉是是一一種種 S Sc ci ie en nc ce e更更是是一一種種 A Ar rt t如如何何在在安安全全、品品質質、成成本本間間取取得得最最佳佳的的 R Re es su ul lt t，仍仍是是最最主主要要的的目目 標標？各各位位麻麻醉醉醫醫師師在在過過去去的的經經驗驗中中，是是否否仍仍有有一一些些有有待待挑挑戰戰的的 S Su ub bj je ec ct t呢呢？例例如如：1、在Induction時，提供的劑量是否夠或不夠？可否 intubation了或再等一下？2、多種藥物的交互作用下，對麻醉深度的影響到底為何？3、在maintenance期，血壓亦或心跳升高，是否深度不夠，亦或其他原因呢？4、在reversing期，如何判斷病患意識已開始恢復，可被喚醒 了？5、在maintenance期，何時可減量麻醉氣體，以提早reversepatient？各各位位麻麻醉醉醫醫師師在在過過去去的的經經驗驗中中，是是否否仍仍有有一一些些有有待待挑挑戰戰的的 S Su ub bj je ec ct t呢呢？例例如如：6、如何在OB或 Truma Cases中，更能掌握病患麻醉深度呢？7、如何在低溫Open-Heart中，更能掌握病患麻醉深度呢？8、做Low-Flow時，能否告知麻醉深度，以便更能掌握呢？9、目前麻醉環境中，是否就是缺少一個直接且即時告知麻醉深度的設備呢？2.AEP Monitor理論 及臨床應用T Th he e p pa at ti ie en nt tThe patient has 2 worries:1: Will he sleep during the operation?2. Will he wake up after the operation?B Ba as si ic c b ba as si ic c b ba as si ic c b ba as si ic c b ba as si ic c T Th he e h he ea ar ri in ng g i is s t th he e l la as st t s se en ns se e t th ha at t l le ea av ve es s a an nd d t th he e f fi ir rs st t t th ha at t r re et tu ur rn ns s d du ur ri in ng g a an na ae es st th he es si ia a. .A AE EP P i is s j ju us st t t th he e b br ra ai in n r re es sp po on ns se e t to o a a c cl li ic ck k s st ti im mu ul li i t th hr ro ou ug gh h t th he e h he ea ar ri in ng g n ne er rv ve eA AE EP P i is s a a v ve er ry y w we ea ak k e el le ec ct tr ri ic ca al l s si ig gn na al l w wr ra ap pp pe ed d i in n t th he e E EE EG G b ba ac ck kg gr ro ou un nd d a ac ct tv vi it ty y. .L Le et t s s l lo oo ok k a at t h ho ow w t ti in ny y t ti in ny y t th hi is s s si ig gn na al l i is s. .The implications of undersedation Patient remainsimmobilized but feels pain Although it is occurs in only 0.1% - 0.2% of all surgeries, 23 million surgeries are performed in the U.S. each year Resulting in 35,000 cases of surgical awarenessThe implications of oversedation To avoid the possibility of surgical awareness too much hypnotics and analgesics may be administered The patients recovery time is extended: higher room cost More drugs than necessary are used: higher drug costWWh hy y m mo on ni it to or r s sl le ee ep p? ? It is important to think about this.B Bu ur rs st t S Su up pp pr re es ss si io on nWe look at spikes 3,5 uV.In contrast: An awake Pa amplitude is typically 0.7 uV.And, an asleep amplitude is typically 0.4 uVE EC CG G s si ig gn na al l h ha as sa ap pp pr ro ox x. . 4 40 00 0 x x a am mp pl li it tu ud de e t th ha an n t th he e A AE EP P s si ig gn na al ls s. . E EE EG G s si ig gn na al l h ha as s a ap pp pr ro ox x. . 4 40 0 x x a am mp pl li it tu ud de e t th ha an n t th he e A AE EP P s si ig gn na al l4 40 00 0 x x4 40 0 x xE Ex xt tr ra ac ct ti in ng g t th he e e ev vo ok ke ed d r re es sp po on ns se eBefore A-Line it took too long to ”detect and present” (extract)this weak signal, because it requires advanced signal processing1 click128 clicks256 clicks1024 clicks100 msclickB Bu ut t, , l le et ts s m ma ak ke e t th hi is s m mo or re e v vi is si ib bl le eLets see what happens when we send a click through the ear.A deviation in the positioning of the electrodes up to 2 cm does not have significant influence on the ARX-index.To MonitorSom e pref erto wai tw i t h t he headphones unt i lel ect rodes are connected2The auditory PathwayF FI IG GU UR RE E 3 35 5 1 10 0S Sc ch he em ma at ti ic c o of f a au ud di it to or ry y n ne eu ur ra al l p pa at th hw wa ay y. . T Th he e B BA AE EP P i is s i in ni it ti ia at te ed d b by y s st ti im mu ul la at ti io on n o of ft th he e c co oc ch hl le ea a w wi it th h a a b br ro oa ad db ba an nd d c cl li ic ck k s st ti im mu ul lu us s g gi iv ve en n v vi ia a a an n e ea ar r i in ns se er rt ti in n t th he e e ex xt te er rn na al l a au ud di it to or ry y c ca an na al l. . N Ne eu ur ra al l g ge en ne er ra at to or rs s o of ft th he e B BA AE EP P p pe ea ak ks s a ar re e s sh ho ow wn n. .A Au ud di it to or ry y E Ev vo ok ke ed d P Po ot te en nt ti ia al ls sClassLatency (MS)Best ResponseSourceEra ValueCochlear0 1-4SP(DC)CM(A C); AP(N1)Hair cells VIII? *Fast2-12P6-SN10Brainstem VIII*Middle12-50P35Brainstem,Mid brain,Cortex I*? ?Slow50-300 200-800N90-P180- N250Cortex II(awake) Cortex III (asleep)*? *Late260-600 DC-shiftP300,p350,CN VCortex IV (event related)?Acoustic nerve and brainstemMMe