Francisco a Lobo

Cleveland Clinic Abu Dhabi · Institute of Anesthesiology

Different anesthetic techniques have been suggested for craniotomy with intraoperative awakening. We describe an asleep-awake-asleep technique with propofol and remifentanil infusions, with pharmacokinetic simulation to predict the effect-site concentrations and to modulate the infusion rates of both drugs, and bispectral index (BIS) monitoring. Fi...

We critically review brain function monitors based on the processed electroencephalogram with regards to signal quality, artefacts and other limitations in clinical performance. Several studies have been showing that depth of anaesthesia monitors based on processed electroencephalogram has limitations that can lead to a wrong interpretation of the...

Guidelines and Standard Operating Pro-cedures (SOPs) can help reduce mistakes during Total Intravenous Anesthesia (TIVA).When using infusion pumps, it is essential that clinical staff know how to use them, and their limitations. Safe and effective manage-ment of continuous drug infusions depends on the under-standing of the dynamics of the delivery...

Editorial on anesthetic management of awake neurosurgical procedures for brain tumors resection.

A tailored anesthesia is a major goal in the modern practice of total intravenous anesthesia (TIVA) and target-controlled infusion (TCI). The popularity of this technique is increasing along with the development of systems that allow their safe and accurate performance. To achieve better skills, the anesthesiologist should be familiarized with its...

BACKGROUND Packed red blood cell (pRBC) transfusions in patients undergoing surgery for cancer are given to treat anemia or acute hemorrhage. Evidence indicates that pRBC transfusions are associated with poor perioperative and oncological outcomes. The ARCA-1 (Perioperative Care in the Cancer Patient-1) study was designed to test the association be...

Damage to the brain can have disastrous and long-lasting consequences. The European Society of Anaesthesiology and Intensive Care (ESAIC) is aware of the importance of taking good care of the brain, both of patients and of anaesthesia and intensive care unit (ICU) caregivers, and has organised a complete learning track on brain health to bring this...

Although intraoperative electroencephalography (EEG) is not consensual among anesthesiologists, growing evidence supports its use to titrate anesthetic drugs, assess the level of arousal/consciousness, and detect ischemic cerebrovascular events; in addition, intraoperative EEG monitoring may decrease the incidence of postoperative neurocognitive di...

The main objective of this systematic review is to assess the reliability of alternative positions of processed electroencephalogram sensors for depth of anesthesia monitoring and its applicability in clinical practice. A systematic search was conducted in PubMed, Embase, Cochrane Library, Clinical trial.gov in accordance with reporting guidelines...

Technologies for monitoring organ function are rapidly advancing, aiding physicians in the care of patients in both operating rooms (ORs) and intensive care units (ICUs). Some of these emerging, minimally or non-invasive technologies focus on monitoring brain function and ensuring the integrity of its physiology. Generally, the central nervous syst...

Elderly and multimorbid patients are at high risk for developing unfavorable postoperative neurocognitive outcomes; however, well-adjusted and EEG-guided anesthesia may help titrate anesthesia and improve postoperative outcomes. Over the last decade, dexmedetomidine has been increasingly used as an adjunct in the perioperative setting. Its synergis...

Please confirm that an ethics committee approval has been applied for or granted Not relevant (see information at the bottom of this page) Application for ESRA Abstract Prizes I don’t wish to apply for the ESRA Prizes Background and Aims Peripheral neuropathies are a relatively common complication after CABG surgery, occurring in about 10-15%. Mo...

Background: Endovascular mechanical thrombectomy (EMT) for acute ischemic stroke can be conducted under conscious sedation (CS) or general anesthesia (GA). Emergency conversion from CS to GA during the procedure can occur, but its predictors and impact on clinical outcomes are not fully understood. Methods: A single centre retrospective analysis...

Multimodal intraoperative neurophysiological monitoring (IONM) is highly valuable in scoliosis surgeries for monitoring spinal cord function, particularly during instrumentation. Accurate timing of baseline recordings of TcMEP and SSEP is crucial, as any changes observed during surgery and instrumentation are compared to these baseline recordings....

The brain constitutes a good example of a chaotic, nonlinear biological system where large neuronal networks operate chaotically with random connectivity. This critical state is significantly affected by the anesthetic loss of consciousness induced by drugs whose pharmacological behavior has been classically based on linear kinetics and dynamics. R...

Over the past few years, the use of non-invasive neuromonitoring in non-brain injured patients has increased, as a result of the recognition that many of these patients are at risk of brain injury in a wide number of clinical scenarios and therefore may benefit from its application which allows interventions to prevent injury and improve outcome. A...

Background: Mild to moderate hyperoxia is potentially beneficial to patients undergoing open heart surgery. Oxygen Reserve Index (ORI) is a novel parameter that correlates to arterial oxygen tension (PaO2) in the hyperoxic range. This prospective study aimed to assess whether the relationship between ORI and PaO2 remains intact in the setting of o...

Background: When general anesthesia is used for endovascular thrombectomy (EVT) for acute ischemic stroke (AIS), the choice of anesthetic agents for maintenance remains inconclusive. The different effects of intravenous anesthetic and volatiles agents on cerebral hemodynamics are known and may explain differences in outcomes of patients with cereb...

The present case of a patient with several co-morbidities undergoing complex vitrectomy under peribulbar block and sedation with Target Controlled Infusion (TCI of propofol and dexmedetomidine with EEG and Analgesia Nociception Index (ANI) monitoring illustrates the benefits of multimodal monitoring to differentiate the effect of hypnotic and antin...

Editorial commenting the article by Idei et al. (PMID: 35661319) and globally addressing the value of the processed EEG monitoring to titrate sedative drugs dosing in the ICU

Background The use of processed electroencephalography (pEEG) for depth of sedation (DOS) monitoring is increasing in anesthesia; however, how to use of this type of monitoring for critical care adult patients within the intensive care unit (ICU) remains unclear. Methods A multidisciplinary panel of international experts consisting of 21 clinician...

Purpose of review: The aim of this review article is to present current recommendations regarding the use of hypertonic saline and mannitol for the treatment of intracranial hypertension. Recent findings: In recent years, a significant number of studies have been published comparing hypertonic saline with mannitol in patients with acute increase...

The clinical approach to sedation in critically ill patients has changed dramatically over the last two decades, moving to a regimen of light or non-sedation associated with adequate analgesia to guarantee the patient’s comfort, active interaction with the environment and family, and early mobilization and assessment of delirium. Although deep seda...

Background The literature related to the use of processed EEG (pEEG) for depth of sedation (DOS) monitoring is increasing, however it is unclear how to use this type of monitoring for critical care patients within the intensive care unit (ICU). Methods We performed a systematic review of the literature according to the Grade of Recommendation asses...

Purpose of Review We review the basic neurophysiological foundations of the adult electroencephalographic signal and how to apply the EEG to the modern anesthetic clinical practice, the different anesthetic drugs signatures, and their neurobiological background. We finally discuss how the intraoperative use of the EEG may be implemented eventually...

The electroencephalographic signatures of anesthetic drugs relate to a specific set of action mechanisms within the neural circuits. During intraoperative care, the recognition and correct interpretation of the EEG spectrogram can be used as a tool to guide anesthetic administration. For example, loss of alpha power during propofol anesthesia may b...

Background Propofol effect-site time course models included in TCI systems have been under discussion. We hypothesized that the rate of administration is a major contributor affecting the construction of a useful effect-site model: yielding different plasmatic concentrations, loss of consciousness may occur by different mechanisms more complex than...

The Analgesia Nociception Index is a dimensionless scale derived from the heart rate variability; by analyzing the heart rate variability oscillations, it reflects the activity of the sympathetic and parasympathetic nervous systems and ultimately helps to evaluate the Nociception–Antinociception balance during anesthesia and surgery. Drugs like eph...

Introduction Blood transfusion is still common in patients undergoing major cancer surgery. Blood transfusion can be associated with poor prognosis in patients with cancer. Perioperative Care in the Cancer Patient -1 (ARCA-1) aims to assess in a large cohort of patients the current incidence, pattern of practice and associations between perioperati...

Resumen Antecedentes Se han debatido los modelos de curso temporal del sitio de efecto del propofol. Nosotros supusimos que la tasa de administración es un gran factor contributivo que afecta a la construcción de un modelo de sitio de efecto útil: elaborando distintas concentraciones plasmáticas, la pérdida de consciencia puede producirse debido a...

Background: Pain assessment is a challenge in critically ill patients, in particular those who are unable to express movements in reaction to noxious stimuli. The purpose of the study was to compare the pupillary response and skin conductance to pain stimulation in critically ill unconscious patients. Methods: This observational study included a...

This review addresses the challenges of neuroanesthesiologic research: the population, the methodology and the outcomes. In addition we discuss the opportunities of adaptive trial designing neuroanesthesiologic research

With the wide spread of electroencephalogram [EEG] monitoring during surgery or in the Intensive Care Unit [ICU], clinicians can sometimes face the pattern of burst suppression [BS]. The BS pattern corresponds to the continuous quasi-periodic alternation between high-voltage slow waves [the bursts] and periods of low voltage or even isoelectricity...

This chapter compares anesthetic outcomes following the administration of volatile or intravenous agents in daily neuroanesthesiology practice. We also provide state-of-art understanding of the role of intravenous anesthetics as neuroprotectants. Intravenous drugs have demonstrated to be more specific for each component in anesthesia. Target-contro...

The advantages of TIVA with TCI over inhalation anesthesia for neurosurgical patients are reviewed including several tips and tricks about how to do safe TIVA-TCI

Introduction editorial of JCVA Supplement on noninvasive anesthetic monitoring (Editor Aryeh Shander; Guest Editor: Francisco A Lobo)

We criticized the article by Susano et al ( doi: 10.1097/ANA.0000000000000566), particularly the inclusion of the BIS monitor in the predictive model of Postoperative Delirium (the simple use of the monitor was predictive of POD).

Background: In Africa, most countries have fewer than 1 physician anesthesiologist (PA) per 100,000 population. Nonphysician anesthesia providers (NPAPs) play a large role in the workforce of many low- and middle-income countries (LMICs), but little information has been systematically collected to describe existing human resources for anesthesia c...

Why and how to to do TIVA for Neurosurgery

This lecture addresses the neurophysiological foundations of EEG and its application to anesthesia, highlighting the advantages of EEG peri-operative monitoring, using raw EEG and spectral analysis with appropriate monitors. This is a lecture that I am used to do and this is a version of a recent meeting.

Lecture exploring the advantages of Intravenous Anesthesia and the foundations of Target Controlled Infusion technique done in several conferences during the last 10 years

Chapter on foundations of anesthesia for neurological surgery and ECT included in the Oxford Textbook of Anaesthesia, a major Textbook of Anesthesiology

This movie was recorded and transmitted lively worldwide as a part of the project TCI IS NOW sponsored by Fresenius Kabi. The aim of this movie was to show how to induce general anesthesia using TCI of propofol and remifentanil guided by EEG (at the time we were using BIS monitor but we moved to use Sedline Monitor from Masimo as this one has bette...

Keywords: Colorectal Neoplasms; Hypnotics and Sedatives; Propofol; Endoscopy, Gastrointestinal; Colonoscopy.

This opinion article addresses the advantages of Intravenous Anesthesia with Target Controlled Infusions titrated by EEG monitoring

Opinion article discussing the role of EEG based monitors of level of anesthesia in the modern clinical practice

Chapter addressing the foundations of anesthesia for neurological surgery including neuroanatomy, neurophysiology, anesthesia for spine surgery, anesthesia for vascular neurosurgery, anesthesia for brain tumor surgery with a particular focus on anesthesia for awake neurosurgery and anesthesia and intensive care management of traumatic brain injury....

The effect of drugs' interaction on the brain signal Bispectral Index (BIS) of the EEG, is of great importance for an anesthesia control drug infusion system. In this study, the objective was to investigate if an autoregressive with exogenous inputs model (ARX) could be a suitable approach to predicting BIS according to the anesthetic drugs concent...

Our aim was to quantify the interaction between propofol and remifentanil on BIS for sedation, and analyse the effect on other clinical variables. Methods: Healthy unpremedicated volunteers participated in the study. BIS, systolic arterial pressure (SAP), heart rate (HR), ETCO2 and SpO2 were monitored. TCI was used for propofol (Schnider PK 1) and...

Background: High doses of remifentanil are often required to prevent autonomic responses to noxious stimuli, but causes changes in cerebral hemodynamics. Patients with intracranial pathologies may be more sensitive to the remifentanil induced hemodynamic effects. This study addresses the effect of high remifentanil doses in patients with brain tumo...

Patients with hypertension may be more prone to develop hypotension as a consequence of opioid administration under general anesthesia. The hemodynamic and bispectral index responses to a remifentanil bolus in neurosurgical hypertensive patients under target-controlled infusion with propofol and remifentanil are addressed. Ten healthy patients and...

To investigate whether a patient's propofol effect-site concentration at return to consciousness (ROC) was related to the propofol effect-site concentration at loss of consciousness (LOC) and to patients' individual demographic parameters. Prospective study. Operating room. 31 ASA physical status I and II neurosurgical patients with Glasgow Coma Sc...

Introduction: APOE-E4 allele is associated with Alzheimer disease (sup)1(/sup), worse outcome after brain injuries(sup)2-4(/sup), cognitive dysfunction following surgery(sup)5(/sup) and occurrence of delirium in critically ill patients (sup)6(/sup). We hypothesized that APOE-E4 allele could be related to the individual response to anesthetics and s...

In this study, we've found that patients who had anesthesia induction after 4 PM required less propofol to induce loss of consciousness

Introduction: Individual variability of anesthetic requirements is a common finding in routine practice. Factors that may change anesthetics pharmacokinetic and pharmacodynamic might be an explanation for that variability and can be incorporated in PK models.1 Since propofol effects on cerebral blood flow (CBF) velocity were described before,2 we a...

To compare propofol-predicted effect-site concentrations (PropCe) and bispectral index (BIS) of the electroencephalogram during induction of anesthesia in patients with small brain tumors and to analyze BIS and PropCe at loss of consciousness (LOC). Prospective investigation. Operating theater of a university hospital. 26 ASA physical status I and...

Introduction: APOE -E4 allele is associated with Alzheimer disease (sup)1(/sup), worse outcome after brain injuries(sup)2-4(/sup), cognitive dysfunction following surgery(sup)5(/sup) and occurrence of delirium in critically ill patients (sup)6(/sup). We hypothesized that APOE-E4 allele could be related to the individual response to anesthetics and...

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s published in the Journal of Neurosurgical Anesthesiology have been reviewed by the organizations or JNA Affiliate Societies at whose meetings the abstracts have been accepted for presentation. These abstracts have not undergone review by the Editorial Board of the Journal of Neurosurgical Anesthesiology.34th Annual Meeting of the Society of Neuro...

Hemodynamic profile of remifentanil in neurosurgical patients was studied in obese patients and patients with Arterial Hypertension. We conclude that remifentanil is a safe drug to be used by bolus in obese and hypertensive patients during neurosurgical anaesthesia.

Remifentanil boluses are used in different clinical situations and the effects on bispectral index monitoring are unclear. We analysed the effect of a remifentanil bolus on the bispectral index of the electroencephalogram (bispectral index) under total intravenous anaesthesia with propofol and remifentanil. ASA I-III patients were included in this...

Remifentanil has important side effects and it is not easy to know what remifentanil concentrations should be used during different endpoints of anaesthesia. We analyzed the remifentanil predicted effect-site concentrations (RemiCe) at different events during neurosurgical procedures and assessed if the concentrations used were clinically adequate....