Intraoperative neurophysiological monitoring, personalized medicine and teamwork

Fàbregas Julià, N.
doi:10.1016/j.redare.2021.02.002
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">One of the aims of perioperative medicine is without a doubt the detection and prevention of events that can cause injury to both the central and peripheral nervous systems&#46; The more physiological parameters we record&#44; the more we appreciate the importance of monitoring and the more we improve patient safety&#46; Neuromuscular monitoring&#44; of paramount importance in anaesthesiology&#44; includes the monitoring of neuromuscular blockade &#40;NMB&#41;&#44; depth of hypnosis&#44; peripheral nervous system&#44; and also intraoperative neurophysiological monitoring&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">NMB monitoring has been part of our daily practice for many years&#44; although it is used less use than experts recommend<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46; It contributes to the safe use of NMB agents and reduces the risk of NMB-related respiratory complications&#46; In a recent consensus document&#44; both anaesthesiologists and surgeons recommended using NMB monitoring in procedures requiring deep prolonged nerve block<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Processing electroencephalographic signals to monitor the depth of hypnosis is now also part of routine clinical practice&#44; and allows us&#44; for example&#44; to reduce the risk of postoperative complications<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Anaesthesiologists are aware of the importance of preventing perioperative peripheral nerve injury due to extreme positions or nerve blockade&#46; Since 1990&#44; when records began&#44; perioperative peripheral nerve injuries have accounted for 12&#37; of claims for postoperative injury in the United States<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#46; The incidence of these injuries in the general surgical population is less than 1&#37;&#44; being more frequent after cardiac surgery&#44; neurosurgery and some orthopaedic procedures&#46; The aetiology is multifactorial&#44; including different stretch&#44; compression&#44; ischaemia&#44; and inflammation mechanisms&#46; The severity and duration of the injury together with each patient&#8217;s neural reserve will determine the extent of the neurological outcome<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#46; Patient positioning during surgery is the responsibility of the entire surgical team&#46; A recently developed automated system for monitoring somatosensory evoked potentials to detect nerve ischaemia and prevent peripheral neurological injury has been used in cardiac<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> and orthopaedic<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> surgery&#46; Many studies had been published on strategies to reduce the complications associated with nerve blocks performed for regional anaesthesia or analgesia<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#44; including nerve localisation methods&#44; timing of blocks&#44; needle techniques&#44; and the choice of local anaesthetic and adjunct&#46; It is difficult to ascertain the incidence of these complications&#44; as they are usually diagnosed with some delay and outcomes vary greatly according to the study and the type of surgery&#46; Anaesthesia-related nerve injury could affect up to 2&#46;2&#37; of patients 3 months after the procedure&#44; up to 0&#46;8&#37; at 6 months and 0&#46;2&#37; at 1 year<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#46; Several improvements are needed to reduce these complications&#44; including the widespread use of new techniques for locating nerve structures&#44; the use of new anaesthetic agents&#44; and the development of surgical techniques<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Intraoperative neurophysiological monitoring &#40;IONM&#41; involves the use of physiological monitoring techniques to assess neural integrity and&#47;or map or neuro-navigate within at-risk neural structures during various surgical procedures<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>&#46; It is routinely used in neurosurgery to treat brain conditions<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> &#40;brain and skull base&#41; and diseases of the spine&#44; spinal tumours and degenerative diseases such as scoliosis<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a>&#46; It is included in interventions involving lesions located close to eloquent areas or to ascending and descending sensory and motor tracts&#46; In these procedures&#44; IONM has proven useful in widening the extent of resection while preventing postoperative neurological deficits&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Although IONM is frequently associated with brain or spinal procedures&#44; it is now used in many different surgeries and surgical specialties&#44; such as cardiovascular surgery&#44; general and digestive surgery&#44; trauma&#44; and ear&#44; nose and throat surgery&#46; As described in the special article by Aldana et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>&#44; it is also used in thyroid and parotid surgery&#44; carotid endarterectomies&#44; open or minimally invasive thoracic aorta surgery&#44; hip surgery&#44; among others&#44; IONM is performed by a team made up of neurophysiologists and neurophysiology technicians who work closely with surgeons&#44; nurses&#44; and anaesthesiologists&#46; Multidisciplinary consensus documents&#44; such as the one prepared by the Neuroscience Section of SEDAR together with the Spanish Intraoperative Neurophysiological Monitoring Association &#40;<a href="https://monitorizacionintraoperatoria.com/">https&#58;&#47;&#47;monitorizacionintraoperatoria&#46;com&#47;</a>&#41; and published in this issue of the <span class="elsevierStyleSmallCaps">Spanish Journal of Anaesthesiology and Resuscitation</span><a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> play an important role in disseminating IONM protocols that can be followed by inexperienced surgical teams and teams that do not perform these procedures frequently enough&#46; Continuous professional training promoted by scientific societies improves patient safety&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The development of new monitoring devices that generate fewer artifacts has contributed to their increased presence in the operating room and contributes to patient safety&#59; however&#44; conclusive evidence of their impact on clinical outcomes is often missing&#46; Ongoing improvements in technology and accessories give more accurate recordings&#44; although some still need to be improved&#44; and more evidence is also needed to define the sensitivity and specificity of each monitoring technique used in different procedures&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In order for the surgical team to function correctly and achieve the best outcomes&#44; all team members needs know what role each of their colleagues plays&#46; The team needs to agree on the surgery plan&#44; communicate effectively&#44; and share information in order to create a climate of mutual trust and respect focussed on the patient&#46; The team must be aware of the different contexts and&#47;or events that can alter the quality of the recorded signals&#46; As Aldana et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> mention in their consensus document&#44; the reliability and accuracy of IONM to signal changes can be difficult to interpret&#46; Understanding the limitations of IONM and the evidence supporting its use is therefore of great importance&#46; The correct interpretation of neuromonitoring records will depend on the surgical team&#8217;s awareness of factors that can affect the recordings&#46; Some manoeuvres are more likely to cause injury&#44; and precautions must be taken to avoid iatrogenic lesions&#46; When there is evidence of an alteration in the neurophysiological signal&#44; each member of the team must question whether their actions might have contributed to the situation&#46; All those involved in the treatment of a specific patient during a specific intervention under the coordination of the neurophysiologist must take steps to avoid false positives&#46; Structured training in neurophysiological monitoring should be made available to surgeons and anaesthesiologists in order to reduce the generation of artifacts caused by certain surgical manipulations or anaesthetic techniques<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&#46; Anaesthesiologists are responsible for maintaining each patient&#8217;s vital signs within their &#34;personalized range&#34;&#46; As mentioned in the consensus document<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>&#44; there is a growing body of evidence that certain values that have hitherto been regarded as standard&#44; such as the lower limit of cerebral autoregulation&#44; vary from one patient to another&#46; In some patients there is no applicable standard of care&#44; so surgery must be guided by IONM on the basis of changes in post-induction recordings over baseline values&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Another factor to take into account is that technological advances have led to the widespread implementation of minimally invasive surgical techniques&#46; Although these can contribute to rapid postoperative recovery&#44; in certain cases they can lead to an increase in iatrogenesis&#46; One example of this is endoscopic microdiscectomy&#44; in which outcomes are similar to open microdiscectomy<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a>&#44; but limited anatomical exposure carries an increased risk of injury to nerve structures<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>&#46; IONM has becomes an essential tool for surgeons who in some procedures&#44; such as the latest percutaneous approaches&#44; do not have direct vision of nerve roots and are therefore unable to immediately detect direct or indirect injury that can cause a postoperative deficit&#46; Another example is robotic transaxillary thyroid surgery&#44; in which considerably shorter vagus nerve-evoked latencies have been observed in right-sided thyroid approaches compared to the open approach<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>&#46; IONM is recommended in complex high-risk hip surgeries&#44; such as those requiring prolonged surgical time&#44; and those performed in morbidly obese patients or with pre-existing neuropathies<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>&#46; In pelvic surgery in general and rectal cancer surgery in particular&#44; direct visualization may be compromised for a variety of reasons&#44; and IONM of pelvic autonomic nerves is performed in certain cases to avoid the risk of injury<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">As in other areas of medicine&#44; the automation and simplification of monitoring systems allows IONM techniques to be used without the physical presence of the neurophysiologist in certain procedures&#46; In these cases&#44; the technician can monitor the recordings telematically if required&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">There are several pressing questions anaesthesiologists will soon need to ask themselves&#58; Should we accept as inevitable the appearance of neurological lesions related to surgical positioning&#44; such as lithotomy or gynaecological surgery&#63; Will preoperative evaluations be generalized in high-risk populations&#63; Will patients undergoing different types of minimally invasive surgeries request perioperative IONM&#63; We are probably witnessing the start of a trend towards widespread neurophysiological monitoring in surgical patients&#46; We need to work closely with other clinicians to define the indications for IONM in different diseases and according to patient characteristics&#46; Articles such as those by Aldana et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> provide a valuable introduction to these technique and raise awareness of the importance of teamwork and shared decision-making&#46;</p></span>"
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