ICPNT

Introducing Certification for Intraoperative Frontal EEG Interpretation for Pharmacologic Decision-making

 

Working Group Co-Chairs: Shobana Rajan, MD and Paul Garcia, MD, PhD

The brain is the target end-organ of our anesthetic drugs, and scalp EEG is the most convenient, non-invasive way to monitor the frontal cortex during surgery. During sleep, coma, and general anesthesia, predictable changes in signaling among brain networks are observed in this critical area, which is also important for working memory and executive functioning during wakeful behaviors. Certification in EEG interpretation is important as it standardizes and legitimizes the use of these technologies in clinical care. While caring for anesthetized patients, physician anesthesiologists must continuously adjust their pharmacologic treatment plan in response to subtle physiologic changes, and the EEG can aid in the subtle determinations of specific etiologies of common intraoperative scenarios: including plans for analgesia, treatment of hemodynamic fluctuations, and abnormal emergence/recovery.

Although intraoperative EEG monitoring technology has been available for several decades, its adoption as an ASA standard-required monitor has lagged. Most available devices recommend titration of anesthetic dose to a specified range of an EEG-based index derived through proprietary quantitative analysis of recent EEG information. Controversy surrounds the value of reducing the EEG information into a single number, the accuracy of this number in certain clinical situations (e.g., advanced age), and the utility of non-specific recommendations for adjustment of anesthetic dose. All FDA-approved devices are required to make the time-series EEG information accessible to the end user for assessment of the potential contribution of noise/artifact due to muscle activity, electrical interference, or movement. Unfortunately, few anesthesiologists are fully trained in interpreting the EEG time-series signals, and currently, no formal certification process exists. Several improvements in clinical outcomes have been attributed to the use of these devices, although in some studies, over-reliance on automatically interpreted EEG information has led to mixed results. Despite these challenges, recently published clinical guidelines and official recommendations support the use of these devices, and research continues to show promise for making anesthesia safer for patients with vulnerable brains through advanced knowledge of neurophysiology. It is imperative that SNACC/ICPNT use this opportunity to take the lead in this space, as it might be predicted that the future of brain function monitoring could be a standard for some or all general anesthetics.

Given this forecast, our motivation is to not only educate neuroanesthesiologists on the utility of EEG information for neurosurgical cases but also to establish educational standards for the intraoperative interpretation of frontal EEG for all interested anesthesiologists in every type of anesthetic situation. As a secondary effect, we expect that this will promote a common lexicon among interested clinicians and researchers. As demonstrated by the establishment of basic and advanced life support training (BLS/ACLS) as well as that of basic and advanced transesophageal (TEE) training, the establishment of these certifications can lead to changes in standard clinical practice, hospital protocols, definitive diagnostic criteria, as well as improvements in billing/coding/reimbursements. It is possible that people who are not SNACC members will want to learn this information and obtain certification. We have preliminarily outlined the educational content as well as the administrative components, including the certification/recertification process.

Completion of the Basic Certification as outlined would require a total of 24.0 CME hours. Each of these CME credits will require payment. We recognize that some anesthesiologists are already experts at EEG interpretation; therefore, for 2023- 2026, we recommend that ICPNT allow for SNACC members who can demonstrate significant EEG expertise (as determined by the EEG credentialing committee) to be exempted from online didactics and the in-person skills demonstration (if they choose). For these three years, basic certification could be obtained for some individuals, at the discretion of the credentialing committee, through the submission of a case log and successful passing of the examination. For exemption, the applicant merely has to describe their frontotemporal EEG experiences in a letter to the committee (i.e., history of national lectures, research, etc.). While attendance of the in-person demonstration of skills can also be exempted, it is recommended that all who wish to take the examination that year attend, as information on documenting case logs as well as case presentations will be reviewed in that session. Because EEG research is always changing, CME credits for Basic certification will expire after three years. And applicants may have to repeat coursework.

In summary, EEG monitoring is an important skill to learn to have an idea about the anesthetic effects on the brain. This certification is likely to improve the future for all physician anesthesiologists because the practice of medicine is defined as using clinical information to determine specific diagnoses and then deciding on an appropriate treatment plan. EEG can aid in defining diagnostic criteria for commonly encountered complications/clinical scenarios in the operating room. Additionally, the certification would add tremendous value to being affiliated with SNACC and to the role of being a neuroanesthesiologist.

Current Problems with EEG monitoring in Anesthesiology

  • Lack of standards
    • The nomenclature is inconsistent.
    • Most clinicians have received informal training.
  • Paucity of experts
    • Few anesthesiologists possess expertise in all necessary facets to integrate the available information, including an understanding of: quantitative EEG interpretation, systems neuroscience, clinical anesthesia, perioperative pharmacology, sleep, and geriatrics.
  • Oversimplification
    • There is a difference between using a proprietary index vs interpreting quantitative EEG information.
    • Grouping data from unrelated studies can obscure the utility of expert EEG information.
  • Hubris/Tradition in the field of Anesthesiology
    • Conventional perspective is a cardiopulmonary focus.
    • Criticisms of EEG devices include industry-sponsored research and training
      • The EEG can be harder to interpret in the brains that are most vulnerable and most important to titrate our medications.Challenges to Clinical Integration

Outline Of Training:

Criteria for certification in abbreviated frontotemporal EEG interpretation for perioperative pharmacologic decision-making and anesthetic management –

  1. Online content – 8 lectures with testing – (8 CME hours)
  2. attendance of skills demonstration, PBL case discussions, and Q & A with content experts offered at SNACC meeting (4.0 CME)
  3. Successful passing of a timed online examination (3.0 CME)
  4. Case log approval by ICPNT subcommittee for EEG certification (9.0 CME hours awarded after approval)

Online Content

  1. History, clinical context, & overview
  2. Origins of EEG signal generation (physics and mathematics)
  3. Towards a neurophysiologic understanding of unconsciousness
  4. Basics of quantitative EEG, spectral analysis & entropy
  5. Brain function monitoring devices and their features
  6. Commonly encountered frontal EEG waveforms in the perioperative period – Part 1
  • Induction, maintenance, and emergence
  • Spectral Edge, Low-frequency waves, high-frequency waves
  • Introduction to noise and artifact
  • Discontinuities and burst suppression
  1. Commonly encountered frontal EEG waveforms in the perioperative period – Part 2
    • Alpha power – sleep, pain, and the thalamus
    • Entropy, non-slow-wave anesthesia, and sedation
    • Special cases, symmetry, seizures, spines, & infarcts
  1. Effects of age, pharmacology, pain, metabolism, and temperature on EEG signals

Timeline

    • 2023 Website construction and online content for basic certification
    • 2024 Advanced Certification (pediatrics, ICU, alternate electrode configurations, training in billing codes)
    • 2025 and Beyond: Update billing codes and procedures considerations of remote consultation services

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