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Excelente artículo!

In previous posts, we discussed the synergy between propofol, remifentanil, and dexmedetomidine, and the impact of dexmedetomidine on alpha band power over time. The tendency that I have observed in my patients is a progressive decrease in alpha band power, which is more accentuated in fragile brains.
The big question remains as to why this happening?
Is this an indirect effect of dexmedetomidine on oscillatory states? or
This means that when the Cp of propofol decreases due to the synergistic effect of dexmedetomidine, the activation of GABAergic neurons in the anterior thalamic reticular nucleus promotes arousal from propofol.
Recently I read an article related to the topic, where they compared the perioperative EEG signatures, drug-induced changes, and neurocognitive outcomes between two anesthetic regimens in geriatric patients (Propofol-Remifentanil vs Propofol-Remifentanil-Dexmedetomidine), and at the end, they proposed the following question: “alpha band power per se is a valid predictor of frailty or is that only in the case of GABAergic anesthetics1.”
Two days ago, I had two 48-year-old patients. The first one was a female ASA I patient, under general anesthesia with Propofol-Remifentanil and Dexmedetomidine (0.2 mcg/kg/hour), with a typical DSA signature of propofol (“rail pattern”), adequate alpha power.
The second, female ASA II patient with history of breast cancer, autoimmune hypothyroidism being treated with tamoxifen and euthirox, ex-smoker, under general anesthesia with Propofol-Remifentanil and Dexmedetomidine (0.2 mcg/kg/hour), with a DSA typical of a fragil brain. After the first hour of anesthesia, the alpha band power decreased even more, with doses of propofol (5.5 mg/kg/hour and remifentanil (0.18 mcg/kg/hour). I decided to perform a 30 mg bolus of propofol at 12:35 (see DSA case 2), and a few seconds later, I recovered the alpha power that I had after LOC. The patient had adequate NMB, adequate analgesia, SEF trend towards 20 Hz, and after the bolus, it decreased to 16 Hz.
Although there is much left to know, I am still thinking that the most important thing is to titrate appropriately and not lose the power of alpha.
I have attached the DSAs processed with Python and the DSAs downloaded from the BIS monitor.
Reference
1.Mehler DM, Kreuzer M, Obert DP, Cardenas LF, Barra I, Zurita F, Lobo FA, Kratzer S, Schneider G, Sepúlveda PO. Electroencephalographic guided propofol-remifentanil TCI anesthesia with and without dexmedetomidine in a geriatric population: electroencephalographic signatures and clinical evaluation. J Clin Monit Comput. 2024 Mar 7. doi: 10.1007/s10877-024-01127-4. Epub ahead of print. PMID: 38451341.

Por ejemplo:
«Hypnotic depth was targeted to a bispectral index (BIS) of 40-60, or to clinical judgement when BIS monitoring was unavailable». Me gustaría saber ¿en cuantos casos no se uso BIS? ¿Usaron matriz de densidad espectral (DSA/SEF/MF? No veo correlación entre Burst suppression e incidencia de Delirium. Sabemos que no debemos desestimar los indices derivados del EEG, pero no son suficientes para titular adecuadamente la hipnosis, y también sabemos que muchos estudios han demostrado que a mayor Burst suppression mayor incidencia de delirium.
Con respecto al propofol, ¿que modelo TCI usaron?, sabemos que los modelos no son perfectos y fueron diseñados para una población particular, las diferencias las encontraremos en la inducción, pero las fases de mantenimiento se parecen. ¿Cuanta masa de droga dieron en la inducción? ¿como ocurrió la desconexión de los circuitos corticales y cortico-talámicos?
No usaron dexmedetomidine ni bloqueos neuroaxiales/AR, sabemos que la combinacion TIVA y Regional es ideal en este tipo de pacientes ya que el dolor es uno de los desencadenantes de delirium, fué suficiente la analgesia?
Sigo creyendo que podemos hacer bien ambas técnicas, TIVA o Inhalatoria, tomando en cuenta todas las variables necesarias y aprendiendo a usar los monitores adecuadamente.

Les dejamos el Programa científico de un curso de TIVA TCI, el cual se celebra anualmente en el Hospital Ángeles Pedregal, del 2 al 6 de Octubre 2023, Modalidad Híbrida.

Ignacio Cortínez, Mauricio Ibacache y Juan Cristobal Pedemonte. Completando el equipo de Profesores de la 2da Jornada Iberoamericana de TIVA y Neurociencias, Barcelona 16 y 17 de Junio 2023.