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array:24 [ "pii" => "S2341192921000135" "issn" => "23411929" "doi" => "10.1016/j.redare.2020.02.005" "estado" => "S300" "fechaPublicacion" => "2021-02-01" "aid" => "1136" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "copyrightAnyo" => "2020" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Revista Española de Anestesiología y Reanimación (English Version). 2021;68:82-98" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0034935620300712" "issn" => "00349356" "doi" => "10.1016/j.redar.2020.02.010" "estado" => "S300" "fechaPublicacion" => "2021-02-01" "aid" => "1136" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Rev Esp Anestesiol Reanim. 2021;68:82-98" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">ARTÍCULO ESPECIAL</span>" "titulo" => "Documento de consenso para la monitorización neurofisiológica intraoperatoria multimodal en procedimientos neuroquirúrgicos. Fundamentos básicos" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "82" "paginaFinal" => "98" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Consensus document for multimodal intraoperatory neurophisiological monitoring in neurosurgical procedures. Basic fundamentals" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2789 "Ancho" => 3167 "Tamanyo" => 848504 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Registro de la fase reversa de los PESS. A) Registro en córtex cerebral de la fase inversa de los PESS. Paciente con tumor parietal izquierdo. Figura izquierda: imagen in vivo de la craneotomía con exposición del córtex frontoparietal izquierdo del paciente. Tira de electrodos de seis contactos colocada sobre el córtex. Figura derecha: registro de la fase reserva de los PESS del nervio mediano derecho con la tira de electrodos. Estimulación del nervio mediano derecho en muñeca y registro de los contactos 1-2-3-4 de la tira cortical. Flecha roja: se objetiva un cambio de fase de los PESS entre los electrodos 3 y 4, localizando el surco central (línea azul) entre dichos contactos (3 motor y 4 sensitivo). B) Mapeo de raíces. Figura izquierda: imagen del microscopio quirúrgico del paciente con tumor intrarraquídeo extramedular a nivel de L1-2 sugestivo de neurinoma. Estimulación de raíz con estimulador monopolar y referencia externa. Imagen derecha: PEM registrados en músculos dependientes de L1 a S2-3 izquierdos. Se objetiva respuesta con 0,6 mA en raíz S1 (flecha roja).</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">AH I: músculo abductor hallucis longua izquierdo; E1: electrodo 1; E 2: electrodo 2; E3: electrodo 3; E4: electrodo 4; GAS I: músculo gastroenemio medial izquierdo; QI: músculo cuádriceps izquierdo; PEM: potenciales evocados motores; PESS: potenciales evocados somatosensoriales; Psoas I: músculo iliopsoas izquierdo; SFI: músculo esfínter anal izquierdo; TA I: músculo tibialis anterior izquierdo. El color de las figuras solo puede apreciarse en la versión electrónica del artículo.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "E. Aldana, N. Álvarez López-Herrero, H. Benito, M.J. Colomina, J. Fernández-Candil, M. García-Orellana, B. Guzmán, I. Ingelmo, F. Iturri, B. Martín Huerta, A. León, P.J. Pérez-Lorensu, L. Valencia, J.L. Valverde" "autores" => array:15 [ 0 => array:2 [ "nombre" => "E." "apellidos" => "Aldana" ] 1 => array:2 [ "nombre" => "N." "apellidos" => "Álvarez López-Herrero" ] 2 => array:2 [ "nombre" => "H." "apellidos" => "Benito" ] 3 => array:2 [ "nombre" => "M.J." "apellidos" => "Colomina" ] 4 => array:2 [ "nombre" => "J." "apellidos" => "Fernández-Candil" ] 5 => array:2 [ "nombre" => "M." "apellidos" => "García-Orellana" ] 6 => array:2 [ "nombre" => "B." "apellidos" => "Guzmán" ] 7 => array:2 [ "nombre" => "I." "apellidos" => "Ingelmo" ] 8 => array:2 [ "nombre" => "F." "apellidos" => "Iturri" ] 9 => array:2 [ "nombre" => "B." "apellidos" => "Martín Huerta" ] 10 => array:2 [ "nombre" => "A." "apellidos" => "León" ] 11 => array:2 [ "nombre" => "P.J." "apellidos" => "Pérez-Lorensu" ] 12 => array:2 [ "nombre" => "L." "apellidos" => "Valencia" ] 13 => array:2 [ "nombre" => "J.L." "apellidos" => "Valverde" ] 14 => array:1 [ "colaborador" => "Grupo de Trabajo de la Sección de Neurociencias de la Sociedad Española de Anestesiología y Reanimación (SEDAR) y la Asociación de Monitorización Intraquirúrgica Neurofisiológica Española (AMINE)" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2341192921000135" "doi" => "10.1016/j.redare.2020.02.005" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192921000135?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935620300712?idApp=UINPBA00004N" "url" => "/00349356/0000006800000002/v2_202102140648/S0034935620300712/v2_202102140648/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2341192921000172" "issn" => "23411929" "doi" => "10.1016/j.redare.2020.05.017" "estado" => "S300" "fechaPublicacion" => "2021-02-01" "aid" => "1170" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Revista Española de Anestesiología y Reanimación (English Version). 2021;68:99-102" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Hip fracture in elderly and COVID-19 infection. Report of 3 cases" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "99" "paginaFinal" => "102" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Fractura de cadera en el anciano e infección por COVID-19. Descripción de 3 casos" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J.M. Rabanal LLevot, F.M. Moreno Suarez, A. Merodio Gómez, A. Solar Herrera, G. Tejón Pérez" "autores" => array:5 [ 0 => array:2 [ "nombre" => "J.M." "apellidos" => "Rabanal LLevot" ] 1 => array:2 [ "nombre" => "F.M." "apellidos" => "Moreno Suarez" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Merodio Gómez" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "Solar Herrera" ] 4 => array:2 [ "nombre" => "G." "apellidos" => "Tejón Pérez" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0034935620301481" "doi" => "10.1016/j.redar.2020.05.015" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935620301481?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192921000172?idApp=UINPBA00004N" "url" => "/23411929/0000006800000002/v1_202103160736/S2341192921000172/v1_202103160736/en/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S2341192921000202" "issn" => "23411929" "doi" => "10.1016/j.redare.2020.08.008" "estado" => "S300" "fechaPublicacion" => "2021-02-01" "aid" => "1233" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Revista Española de Anestesiología y Reanimación (English Version). 2021;68:73-81" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "A multicenter and observational study of the Ambu™ AuraGain™ laryngeal mask in adult patients" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "73" "paginaFinal" => "81" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Estudio multicéntrico observacional de la mascarilla Ambu® AuraGain® en pacientes adultos" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2945 "Ancho" => 2349 "Tamanyo" => 286574 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0050" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Flow chart of patient recruitment and follow-up.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M. Zaballos, F. Escribá, S. López, J. Zaballos, J. Montero, I. Fernández, A.M. López" "autores" => array:7 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "Zaballos" ] 1 => array:2 [ "nombre" => "F." "apellidos" => "Escribá" ] 2 => array:2 [ "nombre" => "S." "apellidos" => "López" ] 3 => array:2 [ "nombre" => "J." "apellidos" => "Zaballos" ] 4 => array:2 [ "nombre" => "J." "apellidos" => "Montero" ] 5 => array:2 [ "nombre" => "I." "apellidos" => "Fernández" ] 6 => array:2 [ "nombre" => "A.M." "apellidos" => "López" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192921000202?idApp=UINPBA00004N" "url" => "/23411929/0000006800000002/v1_202103160736/S2341192921000202/v1_202103160736/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Special article</span>" "titulo" => "Consensus document for multimodal intraoperatory neurophisiological monitoring in neurosurgical procedures. Basic fundamentals" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "82" "paginaFinal" => "98" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "E. Aldana, N. Álvarez López-Herrero, H. Benito, M.J. Colomina, J. Fernández-Candil, M. García-Orellana, B. Guzmán, I. Ingelmo, F. Iturri, B. Martín Huerta, A. León, P.J. Pérez-Lorensu, L. Valencia, J.L. Valverde" "autores" => array:15 [ 0 => array:3 [ "nombre" => "E." "apellidos" => "Aldana" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "N." "apellidos" => "Álvarez López-Herrero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "H." "apellidos" => "Benito" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "M.J." "apellidos" => "Colomina" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 4 => array:4 [ "nombre" => "J." "apellidos" => "Fernández-Candil" "email" => array:1 [ 0 => "jfcandil@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 5 => array:3 [ "nombre" => "M." "apellidos" => "García-Orellana" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">f</span>" "identificador" => "aff0030" ] ] ] 6 => array:3 [ "nombre" => "B." "apellidos" => "Guzmán" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">g</span>" "identificador" => "aff0035" ] ] ] 7 => array:3 [ "nombre" => "I." "apellidos" => "Ingelmo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">h</span>" "identificador" => "aff0040" ] ] ] 8 => array:3 [ "nombre" => "F." "apellidos" => "Iturri" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">i</span>" "identificador" => "aff0045" ] ] ] 9 => array:3 [ "nombre" => "B." "apellidos" => "Martín Huerta" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">j</span>" "identificador" => "aff0050" ] ] ] 10 => array:3 [ "nombre" => "A." "apellidos" => "León" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">k</span>" "identificador" => "aff0055" ] ] ] 11 => array:3 [ "nombre" => "P.J." "apellidos" => "Pérez-Lorensu" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">l</span>" "identificador" => "aff0060" ] ] ] 12 => array:3 [ "nombre" => "L." "apellidos" => "Valencia" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">m</span>" "identificador" => "aff0065" ] ] ] 13 => array:3 [ "nombre" => "J.L." "apellidos" => "Valverde" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 14 => array:1 [ "colaborador" => "Working Group of the Neuroscience Section of the Spanish Society of Anesthesiology and Resuscitation (SEDAR) and the Spanish Neurophysiological Intra-surgical Monitoring Association (AMINE)" ] ] "afiliaciones" => array:13 [ 0 => array:3 [ "entidad" => "Anestesiología y Reanimación, Hospital Vithas Xanit Internacional, Benalmádena, Málaga, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Neurofisiología, Servicio de Neurocirugía, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Anestesiología y Reanimación, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Anestesiología y Reanimación, Hospital Universitari Bellvitge, L’Hospitalet de Llobregat, Universitat de Barcelona, Barcelona, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Anestesiología y Reanimación, Parc de Salut Mar, Barcelona, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Anestesiología y Reanimación, Hospital Clínic de Barcelona, Barcelona, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Neurofisiología clínica, Hospital Clínico Universitario Lozano de Blesa, Zaragoza, Spain" "etiqueta" => "g" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "Anestesiología y Reanimación, Hospital Universitario Ramón y Cajal, Madrid, Spain" "etiqueta" => "h" "identificador" => "aff0040" ] 8 => array:3 [ "entidad" => "Anestesiología y Reanimación, Hospital Universitario de Cruces, Baracaldo, Vizcaya, Spain" "etiqueta" => "i" "identificador" => "aff0045" ] 9 => array:3 [ "entidad" => "Anestesiología y Reanimación, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain" "etiqueta" => "j" "identificador" => "aff0050" ] 10 => array:3 [ "entidad" => "Neurofisiología, Servicio de Neurología, Parc de Salut Mar, Barcelona, Spain" "etiqueta" => "k" "identificador" => "aff0055" ] 11 => array:3 [ "entidad" => "Neurofisiología Clínica, Unidad de Monitorización Neurofisiológica Intraoperatoria, Hospital Universitario de Canarias, Tenerife, Spain" "etiqueta" => "l" "identificador" => "aff0060" ] 12 => array:3 [ "entidad" => "Anestesiología y Reanimación, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain" "etiqueta" => "m" "identificador" => "aff0065" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Documento de consenso para la monitorización neurofisiológicaintraoperatoria multimodal en procedimientos neuroquirúrgicos. Fundamentos básicos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1881 "Ancho" => 3169 "Tamanyo" => 686150 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Examples of brain stem electrocorticography, electromyography, and auditory evoked potentials. (A) EcoG. Patient with left frontal astrocytoma. Surgery in patient under conscious sedation. Language mapping with bipolar stimulation using the Montreal procedure (7<span class="elsevierStyleHsp" style=""></span>mA) and electrocorticography co-recording with electrode strip (electrodes 1, 2 and 3 and external reference. Fz) Red arrow: stimulus artifact. After the stimulus artifact, post-discharges (spikes and polyspikes) are observed for about 30<span class="elsevierStyleHsp" style=""></span>s, then subside spontaneously. (B) EMG. Continuous electromyographic recording in bilateral L2 to S2 muscles in a patient undergoing surgery for a tumour in L3-4, suggestive of neurinoma. During L2-4 laminotomy, and after retraction of the dura from the right side, abrupt neurotonic discharges appear in both SF, in the form of trains on the right side and irregular on the left side, as well as in the left HA and GAS. (C) Short latency BAEP. Schwannoma of the right VIII cranial nerve. Right ear click stimulation and recording in A2 (active) and Cz (reference). During traction of the cerebellum with retractors, an increase in latency of waves III and V (red arrow) is observed corresponding to responses from the VIII cranial nerve at the base of the trunk and pons. The surgeon is advised to decrease traction, showing a decrease in latencies, returning to baseline values. (D) Somatosensory evoked potentials of the bilateral posterior tibial nerve and transcranial motor potentials evoked by transcranial direct current stimulation. Bilateral SEP PT. Right: surgical microscope image of the posterior part of the spinal cord at the level of C2-3 during the myelotomy manoeuvre in the central part of the cord. Left: Bilateral SEP PT. Posterior tibial nerve stimulation and transcranial recording with active Cz and reference Fpz electrodes. At the beginning of myelotomy, we observe an increase in latency and a decrease in the amplitude of the left SEP PT (red arrow), and at the beginning of tumour resection also on the right side (blue arrow), without return of responses. The patient presented postoperative posterior cord involvement. (E) tcMEP: myogenic potentials recorded from the left-side muscles in a patient with C4-C5 disc herniation and symptoms of mild myelopathy who underwent C4-5 and C5-6 anterior cervical arthrodesis. Red arrow, spinal contusion with the Kerrison punch on the left side. Sudden disappearance of tcMEPs in muscles ADM, TA and AH. Surgery is stopped, MAP is increased to 100<span class="elsevierStyleHsp" style=""></span>mmHg, followed by full return of response within 15<span class="elsevierStyleHsp" style=""></span>min.ADM: abductor digiti minimi; AH: abductor hallucis muscle; BI: biceps; DEL: deltoids; EcoG: electromyography; EMG: continuous electromyography; GAS: medial gastrocnemius muscle; MAP: mean arterial pressure; tcMEP: transcranial motor evoked potentials; PESS PT: somatosensory evoked potentials from posterior tibial nerve; Psoas: iliopsoas muscle; Q: quadriceps muscle; muscle; SF: external anal sphincter muscle; TA: anterior tibialis.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The introduction of multimodal intraoperative neurophysiological monitoring (IONMm) has led to an increase in the quality, safety and efficacy of neurosurgical procedures, particularly spinal, spinal cord, cranioencephalic and peripheral nerve surgeries with a risk of nerve sequelae, since it offers real-time intraoperative functional assessment of neural pathways.<a class="elsevierStyleCrossRefs" href="#bib0530"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Recent years have seen a considerable increase in the number of procedures involving IONMm and in the use of techniques for reducing the incidence of intraoperative neural injuries in patients and/or high-risk surgeries.<a class="elsevierStyleCrossRefs" href="#bib0540"><span class="elsevierStyleSup">3,4</span></a> This, in turn, has made it even more essential for surgeons, neurophysiologists and anaesthesiologists to work together and communicate effectively.<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The quality of IONMm can be significantly affected by several modifiable factors, such as patient core temperature, systemic blood pressure, and the depth and type of general anaesthesia.<a class="elsevierStyleCrossRefs" href="#bib0555"><span class="elsevierStyleSup">6,7</span></a> In patients with existing neurological involvement, moreover, neurophysiological recordings may be altered and anaesthesia may further distort signals and recordings.<a class="elsevierStyleCrossRefs" href="#bib0565"><span class="elsevierStyleSup">8,9</span></a> Despite major technological advances in IONMm devices and considerable improvements in anaesthesia techniques, the reliability and accuracy of IONMm to signal changes can be difficult to interpret. The anaesthesiologist plays a crucial role in identifying and correcting modifiable risk factors in order to prevent neurological injuries and optimise neurological outcomes.<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">10</span></a> Understanding the limitations of IONMm and the evidence supporting its use is therefore of great importance. For this reason, consensus clinical practice guidelines drawn up by clinicians involved in this type of monitoring should be used to minimise the occurrence of postoperative neurological dysfunction.<a class="elsevierStyleCrossRefs" href="#bib0550"><span class="elsevierStyleSup">5,11,12</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">A multidisciplinary approach to the evaluation of potential damage to different neural pathways allows the surgical team to promptly implement treatment or therapeutic measures that will improve patient outcomes. The number of indications for these techniques has increased as their use has become more widespread. It is essential, therefore, to review and update the pharmacological and non-pharmacological factors affecting these indications, and to put forward recommendations for different scenarios in both neurosurgery and procedures (surgical, diagnostic or therapeutic) with a risk for neurological sequelae.</p><p id="par0025" class="elsevierStylePara elsevierViewall">For all these reasons, the main aims of this study have been to describe the latest IONMm techniques, to clarify issues arising in different clinical practice settings, and to standardise different multidisciplinary criteria. For this purpose, we have drawn up guidelines for effective intraoperative electrophysiological recording that will facilitate early detection of reversible nerve injury and reduce neurological sequelae.<a class="elsevierStyleCrossRefs" href="#bib0590"><span class="elsevierStyleSup">13,14</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect1010">Material and method</span><p id="par0030" class="elsevierStylePara elsevierViewall">This narrative review is based on a literature search in PubMed for original articles, clinical practice guidelines and consensus documents written in English or Spanish published from 2000 to the present day, selecting the most relevant in all population groups. The main search terms were “Neurophysiological monitoring”, “Intraoperative neurophysiologic monitoring”, “general anesthesia”, “blood pressure”, “temperature”, “Spinal cord surgery”; “Spinal cord monitoring”; “Motor evoked potentials”; “Preventive medicine”; “Physical injuries”; “propofol”; “remifentanil”, “Somatosensory evoked potentials”; “intraoperative mapping”; “practice guidelines”.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Articles were selected by 6 reviewers (EA, HB, MGO, II, PJPL, JLV). They were then discussed with 5 other reviewers (NA, BG, FI, BM, LV), and re-read by 3 final reviewers (AL, MJC, JFC). The suitability of the articles was based on the abstract and full text. Articles were chosen if the aforementioned search terms appeared in the title or abstract.</p><p id="par0040" class="elsevierStylePara elsevierViewall">No articles were deliberately excluded in order to bias the result of this review. However, the authors took the liberty of not citing articles that do not contribute to understanding or improve the state of the knowledge on any specific technique. Although the review was comprehensive, our aim is not to discuss all aspects of IONMm, but to provide specific, practical solutions to different issues.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Current neurophysiological techniques used in multimodal intraoperative neurophysiological monitoring</span><p id="par0045" class="elsevierStylePara elsevierViewall">IONMm can improve the neurological prognosis of patients and contribute to patient safety. However, its use in surgery in general, and in the operating room in particular, calls for certain changes. Patient preparation, for example, will take longer. Setting up the device is also complex: the electrodes must be correctly placed, and the signal must be correctly recorded. The monitors must be strategically place in the operating room - far enough away to minimise potential artifacts (or electrical noise), yet close enough to allow adequate visibility of the surgical field and quick communication between anaesthesiologists and surgeons.<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">15</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The main neurophysiological techniques used in IONMm are divided into monitoring techniques and mapping techniques. Monitoring techniques give a continuous record of neurophysiological responses throughout surgery, with no need for intervention by the surgeon. Mapping techniques can identify, locate and evaluate the functional status of a particular nerve structure. Neurophysiological recordings are analysed using 3 main parameters: the amplitude of the signal (distance from the peak to the adjacent trough), the latency or time from the stimulus to the start of the response, and signal morphology.<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">8</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Monitoring techniques</span><p id="par0055" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Somatosensory evoked potentials (SEP)</span>: these assess the function of the somaesthetic pathway after electrical stimulation of a peripheral nerve (posterior tibial nerve for lower limbs and median or ulnar nerve for upper limbs). The response is recorded at different points along the pathway (nerve, plexus, posterior roots of the spinal cord and the sensory cortex of the brain). The intraoperative alarm criterion is traditionally defined as >50% decrease in amplitude in cortical SEPs and/or >10% increase in latency over baseline value.<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">16</span></a> These criteria were recently revised, and the new alarm criterion is a visually obvious reduction in amplitude, particularly when abrupt and focal.<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">17</span></a> SEPs can be used to monitor cortical and subcortical structures and have good interobserver reproducibility and reliability. However, being low amplitude responses they must be recorded using signal averaging, which can cause a delay between onset of the functional alteration and its detection.</p><p id="par0060" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Visual evoked potentials (VEP):</span> these responses are recorded in the occipital lobe after an ocular stimulus. VEPs are used to evaluate the functional integrity of the optic pathways. They are very useful for evaluating and detecting optic nerve injuries in patients undergoing pituitary gland surgery,<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">18</span></a> skull base surgery or vascular surgery.</p><p id="par0065" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Brainstem auditory evoked potentials (BAEP):</span> these record changes produced in the auditory nerve and brainstem in response to an auditory stimulus. They are used to evaluate the auditory pathway to the midbrain. The signals must be recorded using averaging techniques.</p><p id="par0070" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Electroencephalogram (EEG):</span> the EEG records brain electrical activity using electrodes placed either on the scalp or directly on the cerebral cortex (electrocorticography). EEG allows early detection of cerebral ischaemia in carotid and cardiac surgery. Although there is no consensus regarding the alarm criterion, a decrease in amplitude greater than 60%, a decrease in alpha and beta activity, as well as an increase in slow activity (delta, theta) are generally accepted.<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">19</span></a> In supratentorial surgery with cortical stimulation and in epilepsy surgery EEG can detect epileptiform activity and seizures. EEG can provide real-time, continuous monitoring of anaesthesia depth, and does not require averaging; however, interpretation of EEG recording is prone to interobserver variability.</p><p id="par0075" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Transcranial motor evoked potentials (tcMEP):</span> responses recorded at the level of different muscles of the extremities (muscle action potentials or M waves), cranial muscles (corticobulbar MEPs) or epidural potentials (D waves) after transcranial direct-current stimulation (TDS). They are used to study both the corticospinal and corticobulbar tracts of the pyramidal pathway, and therefore assess the function of the motor cortex, subcortical motor pathway, spinal cord and its pathway to the peripheral muscles. They provide immediate assessment without the need for averaging, but present a certain degree of inter-recording variability. The alarm criteria vary depending on the type of response monitored and the surgery performed.<a class="elsevierStyleCrossRefs" href="#bib0585"><span class="elsevierStyleSup">12,20</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Direct cortical motor evoked potentials (dcMEP)</span>: these responses are registered at the muscular level after direct stimulation of the motor cortex using a strip of electrodes placed at the epidural or subdural level. They detect direct or ischaemic injury to the motor cortex and subcortical motor pathways in supratentorial surgery.<a class="elsevierStyleCrossRef" href="#bib0630"><span class="elsevierStyleSup">21</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Electromyography (EMG):</span> continuous recording of electrical activity of muscles caused by irritation of the roots and/or nerves that innervate them. Motor unit potentials discharged when a neural structure is irritated by manoeuvres such as ischaemia, manipulation, irrigation, compression or traction can be registered in the muscles innervated by that nerve. The EMG recording is very sensitive but not very specific, and an absence of abnormal signals does not always indicate indemnity of the neural tissue.<a class="elsevierStyleCrossRef" href="#bib0635"><span class="elsevierStyleSup">22</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Bulbocavernosus and anal reflex</span>: this is performed by stimulating the clitoral nerve in women and the dorsal nerve of the penis in men and recording the response in the bulbocavernosus muscle or external anal sphincter. The technique evaluates the sacral roots involved in urination, defecation, and erection, and is highly sensitive to anaesthesia.</p><p id="par0095" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Blink reflex:</span> register of muscle activity in the orbicularis oculi muscle after supraorbital nerve stimulation.<a class="elsevierStyleCrossRef" href="#bib0640"><span class="elsevierStyleSup">23</span></a> It evaluates alterations in the trigeminal nerve, and signals between trigeminal and facial nuclei in the brain stem and facial nerve.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Mapping techniques</span><p id="par0100" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Stimulation electromyography (sEMG):</span> an electrical stimulus is sent to a motor or mixed nerve and the motor response is registered using subdermal needles in the tributary muscle. A variant of this technique involves stimulation of pedicle screws during spinal fusion surgery to evaluate their correct implantation.</p><p id="par0105" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Cortical and subcortical mapping of eloquent areas:</span> technique based on stimulating an eloquent area (motor, sensory or language) in the cortex or at the subcortical level in order to correctly locate and identify it in a patient under general anaesthesia or conscious sedation.</p><p id="par0110" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Brain stem mapping to locate motor nuclei on the floor of the IV ventricle</span>: this technique is used to locate motor nuclei on the floor of the IV ventricle in brain stem surgeries in which it is exposed.</p><p id="par0115" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Nerve conduction studies (NCS):</span> these are techniques to evaluate the integrity and function of nerve fibres (motor, sensory and mixed) during peripheral nerve surgery.</p><p id="par0120" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">SEP phase-reversal technique:</span> these are used to identify the central sulcus that separates the sensory and motor cortex by stimulating a peripheral nerve (median or ulnar) and recording the response using a strip of electrodes placed at the cortical level.</p><p id="par0125" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a> show various examples of techniques and abnormal recordings.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">In what type of surgery is multimodal intraoperative neurophysiological monitoring indicated?</span><p id="par0130" class="elsevierStylePara elsevierViewall">The diagnostic and prognostic value of IONMm in spinal surgery has been demonstrated with type A level of evidence,<a class="elsevierStyleCrossRef" href="#bib0645"><span class="elsevierStyleSup">24</span></a> but there are still too few class I studies to show the efficacy of this technique, so its use is not standardized. Its application and indications in different surgeries are based on numerous class II and class III studies, cost-effectiveness evaluations, historical comparator studies, guidelines and expert consensus documents.<a class="elsevierStyleCrossRef" href="#bib0650"><span class="elsevierStyleSup">25</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the different IONMm techniques recommended according to the type of surgery. New IONMm techniques and indications are constantly emerging, so the recommendations given here are for general use, and are susceptible to change. Experts continue to recommend that IONMm should be indicated in all surgical procedures with risk of neurological deficit.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">What should be taken into account when performing this monitoring technique?</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Non-pharmacological factors affecting multimodal intraoperative neurophysiological monitoring</span><p id="par0140" class="elsevierStylePara elsevierViewall">Changes in electrolyte balance or homoeostasis, as well as haemodynamic or ventilatory changes, can affect intraoperative neurophysiological recording.<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">6</span></a></p><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Haemodynamic changes: blood flow and blood pressure</span><p id="par0145" class="elsevierStylePara elsevierViewall">Changes in blood pressure and cerebral blood flow can affect the quality of the recordings. For example, cranial EEG and SEP recordings are normally unaffected until cerebral blood flow (CBF) is reduced to 22<span class="elsevierStyleHsp" style=""></span>ml/min/100<span class="elsevierStyleHsp" style=""></span>g and 20<span class="elsevierStyleHsp" style=""></span>ml/min/100<span class="elsevierStyleHsp" style=""></span>g, respectively. CBF below these levels results in changes in the amplitude of the EEG and in the amplitude and latency of the SEP, and the responses disappear completely when CBF thresholds are even lower.<a class="elsevierStyleCrossRefs" href="#bib0560"><span class="elsevierStyleSup">7,26</span></a> The degree and duration of blood flow below this alert threshold appears to be related to the appearance of permanent neurological damage. Some brain and spinal cord injuries caused by alterations in blood flow and/or spinal cord or cerebral perfusion pressure can be detected using IONMm techniques.<a class="elsevierStyleCrossRefs" href="#bib0660"><span class="elsevierStyleSup">27,28</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">In other techniques, such as SEPs or MEPs, the extent to which a drop in blood pressure will affect recordings varies from patient to patient. The critical value for most patients is a mean arterial pressure (MAP) below 60<span class="elsevierStyleHsp" style=""></span>mmHg. Autoregulation is traditionally thought to occur at between 50–60 and 120–150<span class="elsevierStyleHsp" style=""></span>mmHg. However, the lower limit of autoregulation varies from 33<span class="elsevierStyleHsp" style=""></span>mmHg to 113<span class="elsevierStyleHsp" style=""></span>mmHg, and some authors recommend an “average” limit of 70<span class="elsevierStyleHsp" style=""></span>mmHg.<a class="elsevierStyleCrossRefs" href="#bib0585"><span class="elsevierStyleSup">12,26</span></a> Additional factors can increase this limit or hamper autoregulation, such as advanced age, hypertension, or diabetes, making tissue perfusion more linear and dependent on MAP.<a class="elsevierStyleCrossRefs" href="#bib0660"><span class="elsevierStyleSup">27,28</span></a> MAP, therefore, is critical when it is too low to maintain adequate cerebral perfusion pressure, causing ischaemic distress and impairing both EEG, SEP, and MEP recordings.<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">7</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">In spinal surgery, specifically, evidence has shown that both MEPs and SEPs may show different sensitivity to an identical episode of locally diminished blood flow. It is thought that this may be secondary to intraoperative mechanical stress combined with a drop in MAP. This may produce a greater effect than would be expected from a single change, since in most cases both recordings are fully recovered by reversing the surgical manoeuvre and/or increasing the patient's MAP.<a class="elsevierStyleCrossRefs" href="#bib0560"><span class="elsevierStyleSup">7,26</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">Transient, potentially reversible changes in SEP amplitude can sometimes occur even when MAP is within the autoregulatory range. For example, haemorrhagic shock is associated with a transient increase in SEP amplitude that is probably related to the phenomenon of anoxic activation followed by decreased amplitude and loss of SEPs.<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">6</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">It is also important to bear in mind that consistent changes in amplitude between MAP and MEP do not necessarily point to ischaemia, and that the cause of this change may be due to a “third factor” that directly affects both. Some vasoactive drugs administered to control MAP could alter MEP amplitude through changes in the affinity mechanisms of certain neuromodulators.<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">12</span></a> For example, alpha-2 antagonists or ketanserin-derived antihypertensives may reduce MEPs, and phenylephrine, ephedrine, and vasopressin may increase motor neuron excitability.<a class="elsevierStyleCrossRefs" href="#bib0670"><span class="elsevierStyleSup">29,30</span></a> Magnesium sulphate reduces blood pressure, and can also reduce MEPs through a mechanism that enhances neuromuscular blockade.<a class="elsevierStyleCrossRefs" href="#bib0575"><span class="elsevierStyleSup">10,26,31</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Ventilatory changes: hypoxaemia</span><p id="par0170" class="elsevierStylePara elsevierViewall">Moderate hypoxaemia does not normally alter SEPs, but severe and progressive hypoxia (arterial oxygen pressure [PaO<span class="elsevierStyleInf">2</span>] 48<span class="elsevierStyleHsp" style=""></span>mmHg) is associated with a decrease in SEP amplitude and an increase in latency that ultimately leads to a complete loss of both at the cranial level. Cortical SEPs are more sensitive than subcortical and spinal potentials, presumably due to their higher metabolic rate.<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">6</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">The MEPs are less affected by hypoxaemia until PaO<span class="elsevierStyleInf">2</span> reaches levels associated with metabolic acidosis. This is associated with the phenomenon of anoxic activation/depolarization, which is attributed to an early loss of function due to the inhibition of cortical neurons (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Carbon dioxide</span><p id="par0180" class="elsevierStylePara elsevierViewall">Hypocapnia (partial pressure of carbon dioxide [PaCO<span class="elsevierStyleInf">2</span>]<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>25<span class="elsevierStyleHsp" style=""></span>mmHg) shortens latency by 2%–4% over total potentials in awake healthy volunteers, as well as in patients anaesthetised with isoflurane. In awake volunteers with hyperventilation, however, an improvement in cortical amplitude of up to 70% has been observed; but no increase in amplitude has been observed in anaesthetised hypocapnic patients.<a class="elsevierStyleCrossRefs" href="#bib0555"><span class="elsevierStyleSup">6,10</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">Shortened latency induced by hypocapnia is usually reflected in an increase in conduction speed, probably due to secondary alteration in plasma pH, ionized calcium levels, etc., which enhance neural excitability. In contrast, no effects on SEPs have been recorded in humans with a PaCO level<span class="elsevierStyleInf">2</span> of 50<span class="elsevierStyleHsp" style=""></span>mmHg. CO levels<span class="elsevierStyleInf">2</span> below 20<span class="elsevierStyleHsp" style=""></span>mmHg can result in vasoconstriction ischaemia and lead to significant changes in SEPs.<a class="elsevierStyleCrossRefs" href="#bib0555"><span class="elsevierStyleSup">6,10,11</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Intracranial pressure</span><p id="par0190" class="elsevierStylePara elsevierViewall">Increased intracranial pressure leads to reduced amplitude and increased latency in cortical SEPs. Intracranial hypertension can affect cortical structures and diminish responses. In MEPs, meanwhile, the onset of response gradually increases to the point that the potential can no longer be produced.<a class="elsevierStyleCrossRefs" href="#bib0555"><span class="elsevierStyleSup">6,11</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Blood rheology</span><p id="par0195" class="elsevierStylePara elsevierViewall">An increase in the amplitude of SEPs with mild anaemia and an increase in latency with haematocrit values of around 10%–15% has been observed. These changes were partially restored by raising haematocrit levels. We found no studies on the effects of haemodilution on MEPs.<a class="elsevierStyleCrossRefs" href="#bib0555"><span class="elsevierStyleSup">6,7</span></a></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Temperature</span><p id="par0200" class="elsevierStylePara elsevierViewall">Hypothermia to 35<span class="elsevierStyleHsp" style=""></span>°C decreases central and peripheral nerve conduction velocities, while SEP latency and central conduction time increases by10%–20%. These hypothermia-induced changes may be reversed after 3<span class="elsevierStyleHsp" style=""></span>min of re-warming. Regional temperature changes can also alter evoked potentials. Irrigation of the spinal cord, brainstem, etc. with cold saline causes alterations in evoked potentials. For the same reason, limb cooling (from infusion of cold fluids) can change baseline SEPs. Hypothermia can also increase the stimulation threshold.<a class="elsevierStyleCrossRefs" href="#bib0555"><span class="elsevierStyleSup">6,7,12</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">Another effect of lowering body temperature is a decrease in neural conduction velocity with a resulting gradual increase in maximum SEP latencies (an increase of approximately 0.75–1.0<span class="elsevierStyleHsp" style=""></span>ms in cortical potential latency for every 1<span class="elsevierStyleHsp" style=""></span>°C decrease in nasopharyngeal temperature). This occurs without significant changes in amplitude. With very low temperatures, approximately 22<span class="elsevierStyleHsp" style=""></span>°C, the cortical evoked potentials disappear while the subcortical, spinal and peripheral SEPs are preserved with increased latencies. At even lower temperatures, subcortical potentials also disappear.<a class="elsevierStyleCrossRef" href="#bib0685"><span class="elsevierStyleSup">32</span></a></p></span></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Pharmacological factors affecting multimodal intraoperative neurophysiological monitoring</span><p id="par0210" class="elsevierStylePara elsevierViewall">General anaesthesia is an induced, reversible state that depresses neurotransmission and evoked potentials. IONMm is affected by anaesthetic drugs, as these modify neural networks, and directly intervene in synaptic pathways. This is why responses recorded from pathways with multiple synapses are affected more than those from paucisynaptic pathways, and explains why cortical responses are more sensitive to anaesthesia than subcortical responses. Modification of excitatory and inhibitory responses<a class="elsevierStyleCrossRef" href="#bib0690"><span class="elsevierStyleSup">33</span></a> ultimately causes loss of consciousness.<a class="elsevierStyleCrossRef" href="#bib0695"><span class="elsevierStyleSup">34</span></a> Three research groups have shown that propofol, ketamine, and sevoflurane use a similar neural mechanism to inhibit connectivity during loss of consciousness.<a class="elsevierStyleCrossRefs" href="#bib0700"><span class="elsevierStyleSup">35–39</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">The importance of IONMm lies in its capacity to identify the responses most easily suppressed by each anaesthetic.</p><p id="par0220" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRefs" href="#tbl0015">Tables 3 and 4</a> describe the most commonly used anaesthetic drugs, the most relevant recommendations in relation to the use of IONMm, and the studies that support these actions.</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">What complications can occur with different intraoperative neuromonitoring techniques?</span><p id="par0225" class="elsevierStylePara elsevierViewall">IONMm is a safe tool in expert hands when all necessary precautions have been taken. These include adhering to electrical safety principles, reserving the most invasive methods for justified indications, taking basic measures to reduce the risk of infection, and implementing correct waste management strategies.</p><p id="par0230" class="elsevierStylePara elsevierViewall">However, some adverse effects have been described in IONMm, mainly:</p><p id="par0235" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Bite injuries</span><span class="elsevierStyleItalic">(tongue/lip)</span>: incidence is estimated at between 0.13% and 0.69%, and such reflexes are due to the contraction of the masseter muscles during stimulation. Because of this, it is important to use bite blocks. Most bite injuries are small lesions that heal spontaneously and rarely needing to be sutured. Isolated cases of fractures (teeth or jaw) or breakage of endotracheal tubes have also been published.<a class="elsevierStyleCrossRef" href="#bib0875"><span class="elsevierStyleSup">70</span></a></p><p id="par0240" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Surgical field injuries</span> caused by patient movement after electrical stimulation: contraction of the axial muscles and the extremities during TDS can result in injury to vital structures near the surgical field, due either to direct manipulation or due to the surgical instruments used. It is essential for the surgical team to agree on the ideal moment to deliver the stimuli.</p><p id="par0245" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Epileptic seizures</span>: incidence is 5%–20%,<a class="elsevierStyleCrossRef" href="#bib0880"><span class="elsevierStyleSup">71</span></a> being more frequent after direct cortical stimulus, mainly during the Montreal procedure used in language mapping. They are usually self-limiting when the electrical stimulus ceases; if not, they must be treated promptly. As soon as an epileptic episode is observed, the surgical team should be notified and the cortical surface irrigated with cold serum. If this is not effective, increase propofol infusion or administer anticonvulsants (benzodiazepines, barbiturates or others), bearing in mind that they may interfere with subsequent neuromonitoring. However, stopping the seizure must take priority. Paradoxically, some authors have reported that a short burst of cortical electrical stimulation could stop a seizure.<a class="elsevierStyleCrossRef" href="#bib0885"><span class="elsevierStyleSup">72</span></a> No increase in the usual pattern of seizures has been reported in epileptic patients after the use of transcranial electrical stimulation.</p><p id="par0250" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Bruising and/or bleeding</span><span class="elsevierStyleItalic">due to needle placement</span>: usually of minor importance, these injuries usually occur on the scalp, palms and soles of the feet during the withdrawal of needles; they may be important if they appear in relation to the intraorbital musculature. Cases of significant haematomas have been published, and these can have important consequences in patients with coagulopathy.<a class="elsevierStyleCrossRef" href="#bib0885"><span class="elsevierStyleSup">72</span></a></p><p id="par0255" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Interaction with implantable electronic medical devices</span>: these include deep brain stimulators (DBS), pacemakers, vagal nerve stimulators (VNS), and cochlear implants, among others, because the current used in TDS can alter the electrical system of these devices. It is essential to assess the risk–benefit of IONMm individually. Avoid or limit stimulation in the presence of a pacemaker.<a class="elsevierStyleCrossRefs" href="#bib0875"><span class="elsevierStyleSup">70,73</span></a> If IONMm interferes with these devices, they should be turned off, if possible, and if not, IONMm should be interrupted.</p><p id="par0260" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Burns</span>: though infrequent, burns can be caused by high radiofrequency currents generated by the monopolar electrosurgery unit or by direct current (battery or equipment malfunction). To prevent burns, the IONMm equipment should be inspected and properly maintained, ensuring the system is grounded, limiting the use of needles or electrodes with collodion (unless unavoidable), making sure the cable do not form loops that can come into contact with the patient, and using the lowest possible stimulation threshold.</p><p id="par0265" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Skin or musculoskeletal involvement</span>: exceptional, although a case of compartment syndrome has been described<a class="elsevierStyleCrossRef" href="#bib0895"><span class="elsevierStyleSup">74</span></a> together with a case of necrotizing fasciitis<a class="elsevierStyleCrossRef" href="#bib0900"><span class="elsevierStyleSup">75</span></a> associated with the placement of intradermal needles. To avoid these complications, it is important to insert the needles at a certain angle and withdraw them carefully, following the insertion direction and applying aseptic measures. The skin should be swabbed with disinfectant before inserting the needles and/or placing the electrodes (avoiding dermabrasion injury).</p><p id="par0270" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Cardiovascular disorders</span>: rare, and mainly involve arrhythmias associated with the duration of the stimulation pulse. Artifacts and interferences frequently appear in monitoring waveforms, and these must be distinguished from real disturbances.</p><p id="par0275" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Complications associated with epidural electrodes</span>: few have been described – there is a risk of infection, nerve injury and haematoma due to involvement of epidural vessels that could be associated with the introduction of the electrode.</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">What anaesthetic technique should be used?</span><p id="par0280" class="elsevierStylePara elsevierViewall">Surgical procedures requiring IONMm require a well-coordinated multidisciplinary team to maintain good communication between the surgeon, anaesthesiologist and neurophysiologist at all times.<a class="elsevierStyleCrossRef" href="#bib0905"><span class="elsevierStyleSup">76</span></a> The preoperative period will be crucial for planning the anaesthesia, taking into account the modalities of IONMm to be used and the surgical objectives.<a class="elsevierStyleCrossRefs" href="#bib0530"><span class="elsevierStyleSup">1,15,77</span></a></p><p id="par0285" class="elsevierStylePara elsevierViewall">Once anaesthesia has been induced and the patient has been placed in the surgical position, before the surgical incision, it is advisable to establish and evaluate the baseline post-anaesthesia responses that will serve as a reference for the neurophysiological record throughout surgery.<a class="elsevierStyleCrossRefs" href="#bib0915"><span class="elsevierStyleSup">78,79</span></a></p><p id="par0290" class="elsevierStylePara elsevierViewall">It will sometimes be necessary to re-establish baseline values if changes are detected in drug administration or other physiological parameters during surgery.<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">17</span></a></p><p id="par0295" class="elsevierStylePara elsevierViewall">Although not strictly necessary, in patients with myopathy, neuromuscular disease or previous sensory-motor deficits, preoperative neurophysiological studies could be useful to assess the degree of baseline involvement and, if necessary, modify the setup and recording parameters to optimize responses. These studies could also help interpret post-induction and intraoperative changes in these parameters.<a class="elsevierStyleCrossRef" href="#bib0925"><span class="elsevierStyleSup">80</span></a></p><p id="par0300" class="elsevierStylePara elsevierViewall">In patients undergoing cervical spine surgery with symptoms or risk of cervical spinal cord involvement, it is advisable to obtain baseline parameters before placing the patient on the table in the surgical position.<a class="elsevierStyleCrossRef" href="#bib0930"><span class="elsevierStyleSup">81</span></a></p><p id="par0305" class="elsevierStylePara elsevierViewall">It is also important to bear in mind that intraoperative recording can produce artifacts in anaesthesia measurements or equipment (such as the arterial line tracing artifact produced by median nerve stimulation for SEP monitoring<a class="elsevierStyleCrossRef" href="#bib0935"><span class="elsevierStyleSup">82</span></a>), and certain anaesthesia monitoring equipment can produce artifacts in intraoperative recordings.</p><p id="par0310" class="elsevierStylePara elsevierViewall">So far, the best anaesthesia approach for effective IONMm monitoring is pure total intravenous anaesthesia (TIVA) (without anaesthetic gases) with propofol and remifentanil in continuous and variable perfusion, and without the use of any type of neuromuscular blockade (NMB).<a class="elsevierStyleCrossRef" href="#bib0750"><span class="elsevierStyleSup">45</span></a> However, some authors have obtained good monitoring results with propofol/remifentanil and low-dose (0.5 minimum alveolar concentration [MAC]) of inhalation anaesthetics (sevoflurane or desflurane).<a class="elsevierStyleCrossRefs" href="#bib0590"><span class="elsevierStyleSup">13,83–86</span></a> Guidelines and consensus documents do not recommend the use of inhalational agents for general anaesthesia in routine practice, but we believe they can be considered in certain cases.<a class="elsevierStyleCrossRefs" href="#bib0595"><span class="elsevierStyleSup">14,12,42,85,86</span></a></p><p id="par0315" class="elsevierStylePara elsevierViewall">IONMm can also be used with TIVA “manually administered” by volumetric infusion pumps, but the use of automated systems with target controlled infusion (TCI) and guided by processed electroencephalography, such as Sedline (Masimo), Entropy (Datex Ohmeda), BIS (Medtronic)<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">14</span></a> is currently recommended in order to avoid deep anaesthetic planes (hypnotic/nociceptive) with respect to the surgical stimulus.</p><p id="par0320" class="elsevierStylePara elsevierViewall">Intravenous bolus administration of anaesthetic agents should be avoided as far as possible. If anaesthesia needs to be deepened, it is best to gradually increase the opioid dose (remifentanil) and not the hypnotic (propofol) dose, since the former interferes to a lesser extent than the latter with neurophysiological recording. Other opioids such as fentanyl and alpha-2 agonists such as dexmedetomidine can be used as adjuvants. This will allow the hypnotic dose (propofol) to be reduced and will avoid propofol infusion syndrome in prolonged surgeries.</p><p id="par0325" class="elsevierStylePara elsevierViewall">It is very important to note that even constant anaesthesia levels can give rise to a phenomenon called “anaesthetic fade” that is inversely proportional to the duration of anaesthesia. This means that the longer the patient remains anaesthetised, the more MEP amplitude will decrease and the more the voltage threshold will need to be increased to evoke them (this is not a dose-dependent effect).<a class="elsevierStyleCrossRefs" href="#bib0840"><span class="elsevierStyleSup">63,87–89</span></a></p><p id="par0330" class="elsevierStylePara elsevierViewall">Current recommendations are to avoid the use of anaesthetic gases (N<span class="elsevierStyleInf">2</span>O, Xe), since they can affect neurophysiological recordings (MEP<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>SEP).<a class="elsevierStyleCrossRef" href="#bib0975"><span class="elsevierStyleSup">90</span></a> If propofol is contraindicated (for example, allergy to egg protein), sevoflurane and desflurane could be used at doses lower than 0.5 MAC and anaesthesia depth monitoring. In these difficult cases, signal-enhancing adjuvant drugs, such as ketamine, should be used.<a class="elsevierStyleCrossRefs" href="#bib0950"><span class="elsevierStyleSup">85,91</span></a></p><p id="par0335" class="elsevierStylePara elsevierViewall">If muscle MEP monitoring is performed, it is preferable to avoid the use of NMB after orotracheal intubation. If NMB is unavoidable, for example, when patient immobility is hard to achieve, it can be delivered in continuous perfusion while monitoring blockade depth to ensure it does not exceed 2/4 train of four (TOF) responses.<a class="elsevierStyleCrossRef" href="#bib0760"><span class="elsevierStyleSup">47</span></a> When NMB is unavoidable and optimal responses cannot be obtained, tetanic stimulation of the motor nerves will facilitate response.<a class="elsevierStyleCrossRef" href="#bib0985"><span class="elsevierStyleSup">92</span></a></p><p id="par0340" class="elsevierStylePara elsevierViewall">BAEPs and the epidural component of tcMEPs (D wave) are resistant to the effects of anaesthetic drugs (intravenous, inhalation) and NMB. SEPs and VEPs are not attenuated by NMB; in fact, NMB facilitates recording by reducing the muscle contraction artifact.</p><p id="par0345" class="elsevierStylePara elsevierViewall">During the intraoperative period, hypotension, hypoxia, hypo- and hypercapnia, anaemia, hypothermia, and fluid and electrolyte disorders should be avoided, since they can interfere with neurophysiological recording.</p><p id="par0350" class="elsevierStylePara elsevierViewall">Some procedures, such as epilepsy surgery, require a specific IONMm with intracranial electroencephalography. In addition to the general recommendations for this technique, dexmedetomidine should be used and barbiturates and benzodiazepines, which depress brain electrical activity, should be avoided.</p><p id="par0355" class="elsevierStylePara elsevierViewall">In IONMm of the vagus nerve (X), it is important to use a specific endotracheal tube equipped with electrodes that are placed at the level of the vocal cords to monitor the recurrent laryngeal nerve. The following factors must be taken into account during insertion: the electrodes must be placed at the level of the vocal cords, they must not be rotated, and the reference mark must be on the posterior cricoarytenoid muscle. If monitoring of the glossopharyngeal (IX) and hypoglossal (XII) nerves is performed, the anaesthesiologist should place the needle electrodes on the soft palate on both sides of the uvula and on either side of the base of the tongue under direct vision.<a class="elsevierStyleCrossRef" href="#bib0815"><span class="elsevierStyleSup">58</span></a></p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">What steps should be taken when unexpected changes appear in the intraoperative neurophysiological monitoring record?</span><p id="par0360" class="elsevierStylePara elsevierViewall">Given the risk of false positives, the neurophysiologist should be advised of any changes in the anaesthesia regimen that could interfere with recording.<a class="elsevierStyleCrossRef" href="#bib0905"><span class="elsevierStyleSup">76</span></a> If, after having ruled out technical, anaesthesia-induced, and physiological factors, etc., the neurophysiologist observes changes in the recording (decrease in amplitude, increase in latency, change in morphology and/or an increase in the stimulation threshold), he or she must alert the team so that they can take steps to avoid irreversible nerve damage.<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">1</span></a></p><p id="par0365" class="elsevierStylePara elsevierViewall">If abnormalities are observed in the recordings, the following measures should be taken:</p><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">General measures<a class="elsevierStyleCrossRefs" href="#bib0670"><span class="elsevierStyleSup">29,93,94</span></a></span><p id="par0370" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0375" class="elsevierStylePara elsevierViewall">First, the neurophysiologist must rapidly check whether the equipment is working correctly, whether there any technical problems, artifacts, or whether the electrodes have been displaced since the start of surgery.<a class="elsevierStyleCrossRef" href="#bib1000"><span class="elsevierStyleSup">95</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0380" class="elsevierStylePara elsevierViewall">Evaluate the surgical position of the patient to ensure there is no vascular and nerve compression.<a class="elsevierStyleCrossRefs" href="#bib1005"><span class="elsevierStyleSup">96,97</span></a></p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0385" class="elsevierStylePara elsevierViewall">Allow the cerebrospinal fluid (CSF) to circulate freely around the brain and spinal cord: abdominal compression, neck turned, head lowered with respect to the thorax, Trendelenburg position, etc.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0390" class="elsevierStylePara elsevierViewall">In surgery involving supratentorial lesions, if the MEP threshold increases, evaluate the possible presence of pneumocephalus.<a class="elsevierStyleCrossRef" href="#bib1015"><span class="elsevierStyleSup">98</span></a> If pneumocephalus is suspected, new baseline potentials should be elicited after opening the dura.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0395" class="elsevierStylePara elsevierViewall">In the case of spinal and/or spinal cord surgery, consider lowering CSF pressure by controlled external drainage.<a class="elsevierStyleCrossRef" href="#bib1020"><span class="elsevierStyleSup">99</span></a></p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0400" class="elsevierStylePara elsevierViewall">Optimize the patient's physical status. Correct, if appropriate:</p></li></ul></p><p id="par0405" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">–</span><p id="par0410" class="elsevierStylePara elsevierViewall">Hypovolaemia (goal-directed fluid therapy) and/or anaemia (haemoglobin<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>8<span class="elsevierStyleHsp" style=""></span>g/dl).</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">–</span><p id="par0415" class="elsevierStylePara elsevierViewall">Low blood pressure. Maintain good spinal and brain perfusion pressure (MAP of around 60–70<span class="elsevierStyleHsp" style=""></span>mmHg). If potential recordings are altered, MAP should be increased >80<span class="elsevierStyleHsp" style=""></span>mmHg, to rule out arterial involvement. MAP can be increased by decreasing the depth of anaesthesia, goal-directed fluid loading, favouring venous return (avoid abdominal compression of the cava) and/or administering pharmacological hemodynamic support.</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">–</span><p id="par0420" class="elsevierStylePara elsevierViewall">Oxygenation and ventilation problems – maintain normocapnia and slight hyperoxia.</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">–</span><p id="par0425" class="elsevierStylePara elsevierViewall">Alterations in blood glucose, ion and/or acid–base balance, plasma osmolarity, and temperature (central and peripheral).</p></li></ul></p><p id="par0430" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Local measures:</span> “Time, Irrigation, Pressure, Papaverine (TIPP)”<a class="elsevierStyleCrossRefs" href="#bib0585"><span class="elsevierStyleSup">12,100–102</span></a></p><p id="par0435" class="elsevierStylePara elsevierViewall">If response changes are maintained over time, once all causes not directly related to the surgical manoeuvres have been ruled out the surgeon should be immediately alerted and corrective measures started.<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">-</span><p id="par0440" class="elsevierStylePara elsevierViewall">The most important and effective measure is to stop the ongoing surgical manoeuvre. The time required for this will depend on the type of surgery, the manoeuvre, and the type and severity of changes in the monitored responses. The area undergoing dissection or resection can also be changed while awaiting the return of responses.</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">-</span><p id="par0445" class="elsevierStylePara elsevierViewall">Irrigate the field with warmed saline in order to dilute the metabolites that accumulate in the extracellular space.</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">-</span><p id="par0450" class="elsevierStylePara elsevierViewall">Increase MAP to at least 80<span class="elsevierStyleHsp" style=""></span>mmHg. Consider administering vasoactive drugs, such as phenylephrine or ephedrine.</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">-</span><p id="par0455" class="elsevierStylePara elsevierViewall">Local irrigation with papaverine<a class="elsevierStyleCrossRef" href="#bib1030"><span class="elsevierStyleSup">101</span></a> to improve local perfusion and counteract incipient ischaemia. Some studies in cerebellopontine angle surgery have reported papaverine toxicity on the VIII nerve, and instead have used calcium blockers.</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">-</span><p id="par0460" class="elsevierStylePara elsevierViewall">If the changes persist, or responses do not return completely, corticosteroid bolus may be administered in some cases. The administration of high-dose corticosteroids is controversial, although recent reports suggest that it may do more harm than good.<a class="elsevierStyleCrossRefs" href="#bib1030"><span class="elsevierStyleSup">101,103</span></a></p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">-</span><p id="par0465" class="elsevierStylePara elsevierViewall">If, despite all the measures mentioned above, responses do not return, the surgical manoeuvres performed prior to changes should be reversed (for example: removal of osteosynthesis material in spinal surgery, removal of temporary clamps in cerebral vascular surgery, removal of spatulas, etc.), as loss of response can be slightly delayed.<a class="elsevierStyleCrossRefs" href="#bib0545"><span class="elsevierStyleSup">4,104,105</span></a></p></li></ul></p></span></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conclusion</span><p id="par0470" class="elsevierStylePara elsevierViewall">For neurophysiologists, IONMm has proven to be an indispensable tool for aiding intraoperative decision-making and thus avoiding postoperative neurological deficits. The choice of IONMm technique will depend on the type of surgical procedure to be performed and the nervous structure at risk of injury. Success depends on correctly analysing and interpreting any changes in neurophysiological responses that may be related to the drugs administered or to physiological or pathophysiological factors, among others.</p><p id="par0475" class="elsevierStylePara elsevierViewall">The presence of the neurophysiologist is essential to avoid functional nerve injury during surgery, while the anaesthesiologist plays an important role in optimising IONMm recordings. Surgeons, neurophysiologists and anaesthesiologists must work together to maximise the effectiveness of these monitoring techniques and increase patient safety during surgical procedures.</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflict of interests</span><p id="par0480" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:18 [ 0 => array:3 [ "identificador" => "xres1480708" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1348412" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1480709" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1348411" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and method" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Current neurophysiological techniques used in multimodal intraoperative neurophysiological monitoring" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Monitoring techniques" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Mapping techniques" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "In what type of surgery is multimodal intraoperative neurophysiological monitoring indicated?" ] 10 => array:3 [ "identificador" => "sec0035" "titulo" => "What should be taken into account when performing this monitoring technique?" "secciones" => array:1 [ 0 => array:3 [ "identificador" => "sec0040" "titulo" => "Non-pharmacological factors affecting multimodal intraoperative neurophysiological monitoring" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0045" "titulo" => "Haemodynamic changes: blood flow and blood pressure" ] 1 => array:2 [ "identificador" => "sec0050" "titulo" => "Ventilatory changes: hypoxaemia" ] 2 => array:2 [ "identificador" => "sec0055" "titulo" => "Carbon dioxide" ] 3 => array:2 [ "identificador" => "sec0060" "titulo" => "Intracranial pressure" ] 4 => array:2 [ "identificador" => "sec0065" "titulo" => "Blood rheology" ] 5 => array:2 [ "identificador" => "sec0070" "titulo" => "Temperature" ] ] ] ] ] 11 => array:2 [ "identificador" => "sec0075" "titulo" => "Pharmacological factors affecting multimodal intraoperative neurophysiological monitoring" ] 12 => array:2 [ "identificador" => "sec0080" "titulo" => "What complications can occur with different intraoperative neuromonitoring techniques?" ] 13 => array:2 [ "identificador" => "sec0085" "titulo" => "What anaesthetic technique should be used?" ] 14 => array:3 [ "identificador" => "sec0090" "titulo" => "What steps should be taken when unexpected changes appear in the intraoperative neurophysiological monitoring record?" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0095" "titulo" => "General measures" ] ] ] 15 => array:2 [ "identificador" => "sec0100" "titulo" => "Conclusion" ] 16 => array:2 [ "identificador" => "sec0105" "titulo" => "Conflict of interests" ] 17 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-01-24" "fechaAceptado" => "2020-02-18" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1348412" "palabras" => array:6 [ 0 => "Intraoperative neurophysiological monitoring" 1 => "Neurosurgical procedures" 2 => "Surgery" 3 => "Anesthesia" 4 => "Intravenous anaesthesia" 5 => "General anaesthesia" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1348411" "palabras" => array:6 [ 0 => "Monitorización neurofisiológica intraoperatoria" 1 => "Procedimientos neuroquirúrgicos" 2 => "Cirugía" 3 => "Anestesia" 4 => "Anestesia intravenosa" 5 => "Anestesia general" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar1005" class="elsevierStyleSimplePara elsevierViewall">The present work aims to establish a guide to action, agreed by anaesthesiologists and neurophysiologists alike, to perform effective intraoperative neurophysiological monitoring for procedures presenting a risk of functional neurological injury, and neurosurgical procedures. The first section discusses the main techniques currently used for intraoperative neurophysiological monitoring. The second exposes the anaesthetic and non-anaesthetic factors that are likely to affect the electrical records of the nervous system structures. This section is followed by an analysis detailing the adverse effects associated with the most common techniques and their use. Finally, the last section describes a series of guidelines to be followed upon the various intraoperative clinical events.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar1010" class="elsevierStyleSimplePara elsevierViewall">El presente trabajo pretende establecer una guía de actuación consensuada entre anestesiólogos y neurofisiólogos para realizar una monitorización neurofisiológica intraoperatoria efectiva en procedimientos tanto neuroquirúrgicos, como en aquellos en los que existe un riesgo de lesión neurológica funcional. En la primera parte, se describen las principales técnicas utilizadas en la actualidad para la monitorización neurofisiológica intraoperatoria. En segundo lugar, se describen los factores anestésicos y no anestésicos que pueden afectar al registro eléctrico de las estructuras del sistema nervioso. Posteriormente, se analizan los efectos adversos de las técnicas más comunes derivados de su utilización. Y, por último, se describen las diferentes pautas a seguir tras la aparición de los diferentes eventos clínicos intraoperatorios.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Aldana E, Álvarez López-Herrero N, Benito H, Colomina MJ, Fernández-Candil J, García-Orellana M, et al. Documento de consenso para la monitorización neurofisiológica intraoperatoria multimodal en procedimientos neuroquirúrgicos. Fundamentos básicos. Rev Esp Anestesiol Reanim. 2021;68:82–98.</p>" ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2789 "Ancho" => 3167 "Tamanyo" => 854210 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">SEP phase reversal recording. (A) SEP phase reversal recording in the cerebral cortex. Patient with a left parietal tumour. Left: in vivo image of craniotomy with exposure of the patient's left frontoparietal cortex. Six-contact strip electrode placed over the cortex. Right: SEP phase reversal recording of the right median nerve using the electrode strip. Stimulation of the right median nerve in the wrist and recording from contacts 1-2-3-4 of the cortical strip. Red arrow: SEP phase reversal between electrodes 3 and 4 is observed, locating the central sulcus (blue line) between these contacts (3 motor and 4 sensory). (B) Root mapping. Left: surgical microscope image of a patient with an extramedullary intraspinal tumour at the level of L1-2, suggestive of neurinoma. Root stimulation with monopolar stimulator and external reference. Right: MEP recordings in left L1 to S2-3 muscles. A response is observed with 0.6 mA in root S1 (red arrow).</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">AH I: left abductor hallucis longus muscle; E1: electrode 1; E2: electrode 2; E3: electrode 3; E4: electrode 4; GAS I: left medial gastrocnemius muscle; QI: left quadriceps muscle; PEM: motor evoked potentials; PESS: somatosensory evoked potentials; Psoas I: left iliopsoas muscle; SFI: left anal sphincter muscle; TA I: left anterior tibialis muscle. Images are only seen in colour in the electronic version of the article.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1881 "Ancho" => 3169 "Tamanyo" => 686150 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Examples of brain stem electrocorticography, electromyography, and auditory evoked potentials. (A) EcoG. Patient with left frontal astrocytoma. Surgery in patient under conscious sedation. Language mapping with bipolar stimulation using the Montreal procedure (7<span class="elsevierStyleHsp" style=""></span>mA) and electrocorticography co-recording with electrode strip (electrodes 1, 2 and 3 and external reference. Fz) Red arrow: stimulus artifact. After the stimulus artifact, post-discharges (spikes and polyspikes) are observed for about 30<span class="elsevierStyleHsp" style=""></span>s, then subside spontaneously. (B) EMG. Continuous electromyographic recording in bilateral L2 to S2 muscles in a patient undergoing surgery for a tumour in L3-4, suggestive of neurinoma. During L2-4 laminotomy, and after retraction of the dura from the right side, abrupt neurotonic discharges appear in both SF, in the form of trains on the right side and irregular on the left side, as well as in the left HA and GAS. (C) Short latency BAEP. Schwannoma of the right VIII cranial nerve. Right ear click stimulation and recording in A2 (active) and Cz (reference). During traction of the cerebellum with retractors, an increase in latency of waves III and V (red arrow) is observed corresponding to responses from the VIII cranial nerve at the base of the trunk and pons. The surgeon is advised to decrease traction, showing a decrease in latencies, returning to baseline values. (D) Somatosensory evoked potentials of the bilateral posterior tibial nerve and transcranial motor potentials evoked by transcranial direct current stimulation. Bilateral SEP PT. Right: surgical microscope image of the posterior part of the spinal cord at the level of C2-3 during the myelotomy manoeuvre in the central part of the cord. Left: Bilateral SEP PT. Posterior tibial nerve stimulation and transcranial recording with active Cz and reference Fpz electrodes. At the beginning of myelotomy, we observe an increase in latency and a decrease in the amplitude of the left SEP PT (red arrow), and at the beginning of tumour resection also on the right side (blue arrow), without return of responses. The patient presented postoperative posterior cord involvement. (E) tcMEP: myogenic potentials recorded from the left-side muscles in a patient with C4-C5 disc herniation and symptoms of mild myelopathy who underwent C4-5 and C5-6 anterior cervical arthrodesis. Red arrow, spinal contusion with the Kerrison punch on the left side. Sudden disappearance of tcMEPs in muscles ADM, TA and AH. Surgery is stopped, MAP is increased to 100<span class="elsevierStyleHsp" style=""></span>mmHg, followed by full return of response within 15<span class="elsevierStyleHsp" style=""></span>min.ADM: abductor digiti minimi; AH: abductor hallucis muscle; BI: biceps; DEL: deltoids; EcoG: electromyography; EMG: continuous electromyography; GAS: medial gastrocnemius muscle; MAP: mean arterial pressure; tcMEP: transcranial motor evoked potentials; PESS PT: somatosensory evoked potentials from posterior tibial nerve; Psoas: iliopsoas muscle; Q: quadriceps muscle; muscle; SF: external anal sphincter muscle; TA: anterior tibialis.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "fx1.jpeg" "imagenAlto" => 4333 "imagenAncho" => 3049 "imagenTamanyo" => 1115209 ] ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Different IONMm techniques by type of surgery.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">IONMm: multimodal intraoperative neurophysiological monitoring; MEP: motor evoked potentials; PaCO<span class="elsevierStyleInf">2</span>: partial pressure of carbon dioxide; PaO<span class="elsevierStyleInf">2</span>: arterial oxygen pressure; SEP: somatosensory evoked potentials; ↓: decrease; ↑: increase; −: no involvement; −/+: doubtful involvement; +: mild involvement; ++: moderate involvement.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Body temperature</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Blood flow</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mean arterial pressure</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">PaO<span class="elsevierStyleInf">2</span></th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">PaCO<span class="elsevierStyleInf">2</span></th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Intracranial pressure</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">↑ \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">↓ \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">↓ \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">↑ \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">↓ \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">↑ \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">↓ \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">↓ \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">↑ \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">↓ \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">↑ \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">↓ \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SEP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">− \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">++ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">++ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">++ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">− \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">++ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">− \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−/+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">++ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MEP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">− \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">++ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">++ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">++ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">++ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">− \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">++ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Mapping</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−/+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">++ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">++ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−/+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2547769.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Summary of the main changes in IONMm recordings with respect to systemic variables.</p>" ] ] 4 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">EMG: electromyography; IONMm: multimodal intraoperative neurophysiological monitoring; NMB: neuromuscular blockade; MAC: minimum alveolar concentration; MEP: motor evoked potentials; Rc: receptors; SEP: somatosensory evoked potentials; TCI: target controlled infusion.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Drug \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Overview \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SevofluraneDesflurane \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mechanism of action on GABA Rc similar to propofol, differing in their effect on cortical or spinal glycine Rc, dose-dependent depressant effect.<a class="elsevierStyleCrossRef" href="#bib0725"><span class="elsevierStyleSup">40</span></a>They mainly affect amplitude by reducing it and lengthening the latency of the MEPs by inhibiting pyramidal neurons at the level of the anterior horn, thus increasing the number of false positives in IONMm recordings.<a class="elsevierStyleCrossRefs" href="#bib0725"><span class="elsevierStyleSup">40,41</span></a>The use of desflurane/remifentanil and propofol/remifentanil in patients with no preoperative neurological deficit and depressed MEP amplitudes was recently compared with desflurane in patients who presented a lower amplitude base wave before surgery.A comparative study of incremental doses of desflurane and sevoflurane added to propofol/remifentanil showed significant dose-dependent depression of MEP amplitudes. Desflurane at 0.3 MAC provides acceptable MEP recordings for clinical interpretation; lower concentrations of sevoflurane depressed MEP amplitudes.<a class="elsevierStyleCrossRef" href="#bib0735"><span class="elsevierStyleSup">42</span></a>Isoflurane and halothane appear to have a greater inhibitory effect. They should be avoided in IONMm of MEPs and continuous EMG. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nitrous oxide (N<span class="elsevierStyleInf">2</span>O) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">N<span class="elsevierStyleInf">2</span>O, has a discrete action in the spinal cord, distinct from the effects of volatile anaesthetics, consisting of inhibition of excitation in SG neurons by acting on ionotropic glutamatergic receptors and potentiating inhibition through the descending noradrenergic system.<a class="elsevierStyleCrossRef" href="#bib0740"><span class="elsevierStyleSup">43</span></a>When used at concentrations <40%, without adding other drugs, it does not seem to affect SEPs.<a class="elsevierStyleCrossRef" href="#bib0745"><span class="elsevierStyleSup">44</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Propofol \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Propofol acts as a presynaptic agonist of GABA Rc, subunit β, by increasing their release and increasing the flow of Cl currents at the postsynaptic level, which produces hyperpolarization and a global inhibitory effect. It also modulates voltage-depending K and Na channels.It is important to adapt the pharmacokinetic system (TCI) to deliver the minimum possible dose of propofol, and thus optimize IONMm.<a class="elsevierStyleCrossRef" href="#bib0750"><span class="elsevierStyleSup">45</span></a> The hypnotic depth of anaesthesia should be monitored.<a class="elsevierStyleCrossRefs" href="#bib0730"><span class="elsevierStyleSup">41,46</span></a>At high and/or prolonged doses, propofol infusion syndrome may appear. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Etomidate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Increases the SEP amplitudes in cases where recording is difficult. Bear in mind its potentially inhibitory effect on the cortico-adrenal axis.The combination of etomidate in TCI of dexmedetomidine–fentanyl does not seem to affect SEP and MEP monitoring during spinal surgery.<a class="elsevierStyleCrossRef" href="#bib0760"><span class="elsevierStyleSup">47</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ketamine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ketamine facilitates MEPs, so it can be administered in patients with a history of neurological damage.<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">14</span></a> More studies are needed on its use as an adjunct to general anaesthesia. Administration of 1<span class="elsevierStyleHsp" style=""></span>mg/kg induces analgesia.<a class="elsevierStyleCrossRef" href="#bib0765"><span class="elsevierStyleSup">48</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dexmedetomidine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">An α-2 agonist with subcortical action, not related to GABA.When used as an adjunctive anaesthetic it appears to be effective and does not interfere with IONMm recordings.<a class="elsevierStyleCrossRef" href="#bib0770"><span class="elsevierStyleSup">49</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Benzodiazepines and barbiturates \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">They act at the cortical level on GABAergic receptors.They should be avoided in IONMm because they significantly depress SEP and MEP amplitudes, although to a lesser degree than the previous drugs. Few subcortical effects.<a class="elsevierStyleCrossRefs" href="#bib0595"><span class="elsevierStyleSup">14,29,37</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Neuromuscular blockers (NMB) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Their use is controversial due to their effect on the neuromuscular plate, but some recent studies support their use, although it is essential to use an objective method for monitoring blockade depth.<a class="elsevierStyleCrossRefs" href="#bib0730"><span class="elsevierStyleSup">41,50</span></a> Some authors recommend monitoring responses in both upper and lower limbs. When NMB is unavoidable, tetanic stimulation should be performed to amplify the responses. Post-tetanic facilitation does not occur in the presence of sensory or motor deficit. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sugammadex \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sugammadex can rapidly optimise IONMm when non-depolarizing, aminosteroidal-type (rocuronium) NMB is interfering with the accuracy of recordings.<a class="elsevierStyleCrossRef" href="#bib0780"><span class="elsevierStyleSup">51</span></a> Neostigmine requires a longer period of action and some metabolism of non-depolarizing NMB for effective reversal of blockade.<a class="elsevierStyleCrossRefs" href="#bib0730"><span class="elsevierStyleSup">41,52</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Remifentanil \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Opioids have minimal effect on spinal and subcortical MEPs and SEPs; they can cause a slight decrease in amplitude and an increase in late cortical latencies. Remifentanil is the opioid of choice in IONMm, along with intravenous hypnotic anaesthetics (propofol) and inhalation (sevoflurane or desflurane).A recent study showed that there are no significant differences between remifentanil and fentanyl infusion in terms of their effect on SEPs, although the pharmacokinetic characteristics of remifentanil make it easily metabolized and eliminated, so its use is more predictable than fentanyl, which is more lipid-soluble and accumulative.<a class="elsevierStyleCrossRef" href="#bib0790"><span class="elsevierStyleSup">53</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Fentanyl \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A lipophilic μ Rc agonist with a tendency to accumulate.It slightly increases cortical latencies of SEPS and decreases their amplitude.<a class="elsevierStyleCrossRef" href="#bib0795"><span class="elsevierStyleSup">54</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sufentanil \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">More potent than fentanyl, with high μ receptor affinity. It reaches evenly distributed steady state levels to a greater extent than fentanyl, so has less tendency to accumulate. It has a shorter context-sensitive half-life than fentanyl, which is why it is eliminated more rapidly from plasma.<a class="elsevierStyleCrossRef" href="#bib0800"><span class="elsevierStyleSup">55</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2547768.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Description of commonly used anaesthetic drugs and their main pharmacological characteristics.</p>" ] ] 5 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">BAEP: short-latency brainstem auditory evoked potentials; EMG: electromyography; EP: evoked potential; IONMm: multimodal intraoperative neurophysiological monitoring; NMB: neuromuscular blockade; MAC: minimum alveolar concentration; MEP: motor evoked potentials; Rc: receptors; SEP: somatosensory evoked potentials; TCI, target controlled infusion; TIVA: total intravenous anaesthesia; TOF: train of four.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Drug \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Recommendations \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">MEP \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">SEP \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Study \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SevofluraneDesflurane \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cause increased latency and decreased SEP amplitudes, with more cortical than subcortical impact, and MEP amplitudes. They can be used at MAC <0.5. Above this, loss of MEP is more frequent.They should be avoided. If used, anaesthetic depth and MAC should be monitored.<a class="elsevierStyleCrossRef" href="#bib0730"><span class="elsevierStyleSup">41</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">↓↓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">↓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Chong et al.<a class="elsevierStyleCrossRef" href="#bib0735"><span class="elsevierStyleSup">42</span></a>Malcharek et al.<a class="elsevierStyleCrossRef" href="#bib0750"><span class="elsevierStyleSup">45</span></a>Kawaguchi et al.<a class="elsevierStyleCrossRef" href="#bib0730"><span class="elsevierStyleSup">41</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nitrous oxide (N<span class="elsevierStyleInf">2</span>O) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Can be used in addition to inhalational anaesthetics to lower MAC. Additive effect with halogenated anaesthetics, enhancing their amplitude depressant effect in IONMm recordings. They should be avoided. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">↓↓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">↓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sloan et al.<a class="elsevierStyleCrossRef" href="#bib0805"><span class="elsevierStyleSup">56</span></a>Da Costa et al.<a class="elsevierStyleCrossRef" href="#bib0810"><span class="elsevierStyleSup">57</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Propofol \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Drug of choice in IONMm.<a class="elsevierStyleCrossRef" href="#bib0730"><span class="elsevierStyleSup">41</span></a>During IONMm, levels of hypnosis and neuromuscular block (if the latter are used) should be kept at constant levels by monitoring.TIVA with TCI recommended, minimizing bolus use.TCI propofol infusion, Schnider model at effect site concentrations of 4<span class="elsevierStyleHsp" style=""></span>μg/ml, does not appear to have any clinically relevant effect on the characteristics of MEP or SEP recordings.Lidocaine in continuous infusion or dexmedetomidine appears to reduce propofol requirements without affecting evoked potentials. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">↓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">↓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Scheufler et al.<a class="elsevierStyleCrossRef" href="#bib0815"><span class="elsevierStyleSup">58</span></a>Absalom et al.<a class="elsevierStyleCrossRef" href="#bib0820"><span class="elsevierStyleSup">59</span></a>Valverde et al.<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">10</span></a>Urban et al.<a class="elsevierStyleCrossRef" href="#bib0825"><span class="elsevierStyleSup">60</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Etomidate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Doses of less than 0.3<span class="elsevierStyleHsp" style=""></span>mg/kg have amplified SEPs.Infusion at 0.5–1<span class="elsevierStyleHsp" style=""></span>mg/ml can be used in severely impaired MEPs. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">↑ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">↑ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Meng et al.<a class="elsevierStyleCrossRef" href="#bib0830"><span class="elsevierStyleSup">61</span></a>Liu et al.<a class="elsevierStyleCrossRef" href="#bib0835"><span class="elsevierStyleSup">62</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ketamine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Amplify MEPs and SEPs. In a recent review, the authors advised against ketamine as the main anaesthetic due to its side effects, such as delirium, confusion, hallucinations<a class="elsevierStyleCrossRef" href="#bib0730"><span class="elsevierStyleSup">41</span></a>. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">↑ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">↑ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Stoicea et al.<a class="elsevierStyleCrossRef" href="#bib0765"><span class="elsevierStyleSup">48</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dexmedetomidine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Infusion at 0.6–0.5<span class="elsevierStyleHsp" style=""></span>μg/kg for 10<span class="elsevierStyleHsp" style=""></span>min, followed by 0.6–0.5<span class="elsevierStyleHsp" style=""></span>μg/kg/h as an adjuvant in propofol/remifentanil TIVA, did not significantly alter MEP and SEP recordings.It could be used in “opiate-sparing” anaesthesia without affecting EPs.In deep brain stimulation surgery, local field potentials or recordings are not affected by perfusion of 0.2<span class="elsevierStyleHsp" style=""></span>μg/kg/h. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Rozet et al.<a class="elsevierStyleCrossRef" href="#bib0840"><span class="elsevierStyleSup">63</span></a>Li et al.<a class="elsevierStyleCrossRef" href="#bib0845"><span class="elsevierStyleSup">64</span></a>Martinez Simon et al.<a class="elsevierStyleCrossRef" href="#bib0770"><span class="elsevierStyleSup">49</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Benzodiazepines and barbiturates \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Significant dose-dependent depression of MEP and SEP amplitudes.Not recommended in IONMm.3–5<span class="elsevierStyleHsp" style=""></span>mg/kg thiopental causes significant impairment of SEPs and MEPs. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">↓↓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">↓↓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lotto et al.<a class="elsevierStyleCrossRef" href="#bib0670"><span class="elsevierStyleSup">29</span></a>Valverde et al.<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">10</span></a>Nunes et al.<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">14</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Neuromuscular blockers (non-depolarizing) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Significant effect on myogenic MEPs (M-wave) and continuous EMG, with little effect on: SEPs, MEP D wave, BAEP, VEPs and evoked EMG. It is best to avoid them;if they must be used, NMB will be partial. Blockade depth should be accurately and effectively monitored, and the drug should be administered by continuous and variable infusion (avoid iv boluses) to ensure a balanced and constant level of partial blockade, maintaining 2 TOF responses or a recording at 10%–20% of baseline T1.For MEPs in extremities, 3 responses out of 4 are needed for bladder and gastrointestinal studies.It best not to use them in patients with a history previous myogenic and/or neurogenic pathology.Succinylcholine causes depression or suppression of responses on IONMm, although these are of short duration (if there is no cholinesterase deficiency). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">↓↓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+/− \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sloan et al.<a class="elsevierStyleCrossRef" href="#bib0760"><span class="elsevierStyleSup">47</span></a>Kim et al.<a class="elsevierStyleCrossRef" href="#bib0850"><span class="elsevierStyleSup">65</span></a>Hernández Palazón et al.<a class="elsevierStyleCrossRef" href="#bib0855"><span class="elsevierStyleSup">66</span></a>Kawaguchi et al.<a class="elsevierStyleCrossRef" href="#bib0730"><span class="elsevierStyleSup">41</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sugammadex \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Reversal agent of choice for non-depolarizing NMB by administration of aminosteroids (rocuronium), It will minimize false positives when myogenic transcranial MEPs (M wave) and/or continuous EMG present intraoperative alterations (stimulation threshold, amplitude, latency, morphology). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Trifa et al.<a class="elsevierStyleCrossRef" href="#bib0785"><span class="elsevierStyleSup">52</span></a>Errando et al.<a class="elsevierStyleCrossRef" href="#bib0860"><span class="elsevierStyleSup">67</span></a>Kawaguchi et al.<a class="elsevierStyleCrossRef" href="#bib0730"><span class="elsevierStyleSup">41</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Remifentanil \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The combination of propofol (low dose) and remifentanil (high dose) has been shown to be beneficial in the absence of neuromuscular block for IONMm recordings.Remifentanil can be used at high doses, and has little effect on IONMm.TCI of propofol/remifentanil with an inhalation anaesthetic (Sevo- or desflurane at doses <0.5 MAC) has shown acceptable EP recordings.The Minto TCI model of remifentanil with effect concentration 3–5<span class="elsevierStyleHsp" style=""></span>ng/ml is effective in minimizing the amount of drug administered, and favours IONMm. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">↓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">↓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cho et al.<a class="elsevierStyleCrossRef" href="#bib0865"><span class="elsevierStyleSup">68</span></a>Kim et al.<a class="elsevierStyleCrossRef" href="#bib0850"><span class="elsevierStyleSup">65</span></a>Hernández-Palazón et al.<a class="elsevierStyleCrossRef" href="#bib0855"><span class="elsevierStyleSup">66</span></a>Kawaguchi et al.<a class="elsevierStyleCrossRef" href="#bib0730"><span class="elsevierStyleSup">41</span></a>Valverde et al.<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">10</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Fentanyl \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">At doses of 3–8<span class="elsevierStyleHsp" style=""></span>μg/kg it decreases EP peaks.Fentanyl be used at high doses, and has little effect on IONMm. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">↓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">↓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Samra et al.<a class="elsevierStyleCrossRef" href="#bib0790"><span class="elsevierStyleSup">53</span></a>Kawaguchi et al.<a class="elsevierStyleCrossRef" href="#bib0730"><span class="elsevierStyleSup">41</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sufentanil \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">There are few studies on its efficacy in IONMm, but its pharmacokinetic profile suggests it could be useful when administered in continuous infusion at TCI doses of 0.3–0.4<span class="elsevierStyleHsp" style=""></span>ng/ml according to the Gept model.Infusion of 1<span class="elsevierStyleHsp" style=""></span>mg/kg/h lidocaine can reduce sufentanil requirements. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">↓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">↓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Jeleazcov et al.<a class="elsevierStyleCrossRef" href="#bib0870"><span class="elsevierStyleSup">69</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2547770.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Main effect of IONMm of drugs most commonly used in anaesthesia.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:105 [ 0 => array:3 [ "identificador" => "bib0530" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Intraoperative neurophysiological monitoring team's communique with anesthesia professionals" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4103/joacp.JOACP_315_17" "Revista" => array:6 [ "tituloSerie" => "J Anaesthesiol Clin Pharmacol" "fecha" => "2018" "volumen" => "34" "paginaInicial" => "84" "paginaFinal" => "93" "link" => array:1 [ …1] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0535" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Somatosensory and motor evoked potentials as biomarkers for post-operative neurological status" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.clinph.2014.11.009" "Revista" => array:6 [ "tituloSerie" => "Clin Neurophysiol" "fecha" => "2015" "volumen" => "126" "paginaInicial" => "857" "paginaFinal" => "865" "link" => array:1 [ …1] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0540" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Does intraoperative neurophysiologic monitoring matter in noncomplex spine surgeries?" 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