Editorial
Don’t turn-off the brain
No apague el cerebro
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Terada, S. Inoue, M. Konda, J. Egawa, J. Ueda, T. Kirita, M. Kawaguchi" "autores" => array:7 [ 0 => array:2 [ "nombre" => "Y." "apellidos" => "Terada" ] 1 => array:2 [ "nombre" => "S." "apellidos" => "Inoue" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "Konda" ] 3 => array:2 [ "nombre" => "J." "apellidos" => "Egawa" ] 4 => array:2 [ "nombre" => "J." "apellidos" => "Ueda" ] 5 => array:2 [ "nombre" => "T." "apellidos" => "Kirita" ] 6 => array:2 [ "nombre" => "M." "apellidos" => "Kawaguchi" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572719300104?idApp=WMIE" "url" => "/21735727/0000004300000001/v1_201901260634/S2173572719300104/v1_201901260634/en/main.assets" ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>" "titulo" => "Don’t turn-off the brain" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "1" "paginaFinal" => "2" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "C. Chamorro-Jambrina, C. Chamorro-Falero" "autores" => array:2 [ 0 => array:4 [ "nombre" => "C." "apellidos" => "Chamorro-Jambrina" "email" => array:1 [ 0 => "carlos.chamorro@salud.madrid.org" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "C." "apellidos" => "Chamorro-Falero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Intensiva, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Gestión Clínica de Anestesiología y Reanimación, Hospital Universitario Virgen del Rocío, Sevilla, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "No apague el cerebro" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Paradoxically, the analgesics and/or sedatives used to improve the comfort and wellbeing of critical patients can have a negative impact upon their clinical course in the Intensive Care Unit (ICU) or in hospital, with consequences that may even hinder patient return to normal life. Important steps have been taken over the last 20 years to avoid such serious complications. On one hand, the doses and indications of sedative agents have been adjusted. As examples, etomidate is no longer used in continuous infusion; benzodiazepines are increasingly restricted to only concrete indications; and propofol for sedation in critical patients is rarely used at doses above 4.5<span class="elsevierStyleHsp" style=""></span>mg/kg/h. On the other hand, the complications resulting from a poor sedoanalgesic strategy are known. The non-monitored administration of certain sedatives inevitably results in overdose and drug accumulation, and this in turn prolongs mechanical ventilation (MV) and intubation – with the associated morbidity implied. With the new available drugs, including the incorporation of remifentanil, dexmedetomidine or new anesthetic gases; the application of sedoanalgesia scales; and the use of cooperative and dynamic sedoanalgesic strategies adapted to the clinical situation of the patient, the prolongation of MV as a consequence of the sedoanalgesic strategy used should be regarded as a serious adverse event and, indeed, as malpractice on the part of the healthcare professional.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">However, in recent years a new issue has emerged, with physiopathological implications. The administration of sedating agents for the sedation of critical patients in the ICU, or for carrying out an anesthetic procedure, can cause delirium – with all its associated undesirable consequences – and can give rise to long-term cognitive impairment (LTCI).<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Such problems in turn are more common when the drugs used induce deep sedation. The main factor limiting our understanding of this phenomenon is the current lack of knowledge on how the brain works. Achieving such understanding is the aim of the American Brain Research Through Advancing Innovative (BRAIN) project, which includes the participation of hundreds of professionals (physicians, neurobiologists, physicists and engineers), with a budget running into the hundreds of millions of dollars. The director of this project, the Spanish neurobiologist Rafael Yuste, was recently interviewed on television. In reply to the question of how the brain works, the investigator explained that “<span class="elsevierStyleItalic">We don’t know… In fact there is a mystery in neurobiology which we have been unable to explain for over 80 years: the brain is always turned on, always triggering…</span>”.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Interesting studies have recently appeared – mostly conducted in the experimental setting – that show the importance of having the brain “<span class="elsevierStyleItalic">always turned on”</span> as a fundamental factor for neuroregeneration,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> neuroprotection,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> and even the control and regulation of phenomena such as inflammation.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> We therefore must consider whether the fact of reducing or “<span class="elsevierStyleItalic">turning off</span>” patient brain activity for sedation or anesthesia – whether for a few minutes, hours or even days – can induce changes in brain function that might have a negative impact upon neurotransmitter balance, neuronal apoptosis and cerebral inflammation, and thus upon the induction of delirium and LTCI. Since 2005 it has been suggested that keeping the bispectral index (BIS<span class="elsevierStyleSup">®</span>) to under 40/45 during anesthesia may increase the long-term mortality rate.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> Later studies in anesthesia and also in critical patients have shown excessive neuronal depression to exert a decisive influence upon the appearance of delirium and LTCI. Deep sedation has its indications and is necessary during general anesthesia or for the sedation of a patient receiving neuromuscular blocker drugs. However, it is essential to distinguish between deep sedation and oversedation, and there monitoring techniques are available for doing so. Sedation scales do not help to discriminate deep sedation levels, and use must be made of electroencephalographic (EEG) processing systems at the patient bedside – BIS<span class="elsevierStyleSup">®</span> being the most widely used option.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> Oversedation is to cause greater sedation than the patient needs. Keeping BIS<span class="elsevierStyleSup">®</span> to under 40/45 affords no advantages during general anesthesia, and obviously also not for critical patient sedation. Maintaining values of under 40 can trigger the appearance of episodes of brain electrical silence, with suppression rates (SR) on the monitor, and these circumstances in turn are associated to an increased incidence of delirium following either anesthesia<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> or sedation of the critically ill patient.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The study published in this number of <span class="elsevierStyleSmallCaps">Medicina</span> I<span class="elsevierStyleSmallCaps">ntensiva</span> addresses this interesting issue, and the authors conclude that cognitive function over the middle term may be affected in some patients subjected to deep sedation for several days.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> Unfortunately, with the methodology used, it is not possible to deduce whether the observed LTCI is attributable to the long anesthetic procedure or to the subsequent deep sedation episode during MV in the ICU. Likewise, the authors did not use EEG monitoring in the operating room or ICU, and we therefore cannot know whether the applied deep sedation could be regarded as oversedation. Prolonged deep sedation (for over 24<span class="elsevierStyleHsp" style=""></span>h), particularly in tracheostomized patients, is not a routine procedure, and its usefulness in preserving graft integrity after microvascular reconstruction is very debatable. For this reason, it would have been a good opportunity for the authors to design a comparative study between groups with BIS<span class="elsevierStyleSup">®</span> values above or under 40 versus a control group without postoperative deep sedation, in order to either confirm or refute the current evidence. In any case, we congratulate the authors on their article, since it causes us to ponder the importance and impact of deep sedation.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The BRAIN project is an ambitious scientific initiative, and in a period of time which we hope will be as short as possible, it will help us to understand how and why certain neurological disorders develop, and to know why delirium and LTCI occur. Until then, and with the existing knowledge, we can recommend the following in order to reduce the incidence of these two serious complications in the event deep sedation is required: “<span class="elsevierStyleItalic">Doctor, please don’t turn your patients’ brain off</span>”.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Chamorro-Jambrina C, Chamorro-Falero C. No apague el cerebro. Med Intensiva. 2019;43:1–2.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Is failure to awaken and wean malpractice?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "C.A. Manthous" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jcrc.2016.04.029" "Revista" => array:6 [ "tituloSerie" => "J Crit Care" "fecha" => "2016" "volumen" => "36" "paginaInicial" => "306" "paginaFinal" => "310" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27745945" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0060" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Do sedation and analgesia contribute to long-term cognitive dysfunction in critical care survivors?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "S. Fernandez-Gonzalo" 1 => "M. Turon" 2 => "C. de Haro" 3 => "J. López-Aguilar" 4 => "M. Jodar" 5 => "L. Blanch" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.medin.2017.06.010" "Revista" => array:6 [ "tituloSerie" => "Med Intensiva" "fecha" => "2018" "volumen" => "42" "paginaInicial" => "114" "paginaFinal" => "128" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28851588" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0065" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Use it or lose it: how neurogenesis keeps the brain fit for learning" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "T.J. Shors" 1 => "M.L. Anderson" 2 => "D.M. Curlik 2nd" 3 => "M.S. Nokia" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.bbr.2011.04.023" "Revista" => array:6 [ "tituloSerie" => "Behav Brain Res" "fecha" => "2012" "volumen" => "227" "paginaInicial" => "450" "paginaFinal" => "458" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21536076" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0070" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Depression of neuronal activity by sedatives is associated with adverse effects after brain injury" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "D. Hertle" 1 => "L. Werhahn" 2 => "C. Beynon" 3 => "K. Zweckberger" 4 => "B. Vienenkötter" 5 => "C.S. Jung" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.brainres.2013.03.009" "Revista" => array:6 [ "tituloSerie" => "Brain Res" "fecha" => "2013" "volumen" => "1510" "paginaInicial" => "1" "paginaFinal" => "9" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23524191" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0075" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Neural control of inflammation: implications for perioperative and critical care" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "B.E. Steinberg" 1 => "E. Sundman" 2 => "N. Terrando" 3 => "L.I. Eriksson" 4 => "P.S. Olofsson" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Anesthesiology" "fecha" => "2016" "volumen" => "124" "paginaInicial" => "1174" "paginaFinal" => "1189" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0080" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anesthetic management and one-year mortality after noncardiac surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "T.G. Monk" 1 => "V. Saini" 2 => "B.C. Weldon" 3 => "J.C. Sigl" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1213/01.ANE.0000147519.82841.5E" "Revista" => array:6 [ "tituloSerie" => "Anesth Analg" "fecha" => "2005" "volumen" => "100" "paginaInicial" => "4" "paginaFinal" => "10" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15616043" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0085" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "32 Spec No.1:45-52" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Grupo de Trabajo de Analgesia y Sedación de la SEMICYUC. Monitoring of sedation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "C. Chamorro" 1 => "J.L. Martínez-Melgar" 2 => "R. Barrientos" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:2 [ "tituloSerie" => "Med Intensiva" "fecha" => "2008" ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0090" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Monitoring depth of anaesthesia in a randomized trial decreases the rate of postoperative delirium but not postoperative cognitive dysfunction" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "F.M. Radtke" 1 => "M. Franck" 2 => "J. Lendner" 3 => "S. Krüger" 4 => "K.D. Wernecke" 5 => "C.D. Spies" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/bja/aet055" "Revista" => array:6 [ "tituloSerie" => "Br J Anaesth" "fecha" => "2013" "volumen" => "110" "paginaInicial" => "i98" "paginaFinal" => "i105" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23539235" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0095" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Burst suppression on processed electroencephalography as a predictor of postcoma delirium in mechanically ventilated ICU patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J.M. Andresen" 1 => "T.D. Girard" 2 => "P.P. Pandharipande" 3 => "M.A. Davidson" 4 => "E.W. Ely" 5 => "P.L. Watson" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/CCM.0000000000000522" "Revista" => array:6 [ "tituloSerie" => "Crit Care Med" "fecha" => "2014" "volumen" => "42" "paginaInicial" => "2244" "paginaFinal" => "2251" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25072756" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0100" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effects of deep sedation under mechanical ventilation on cognitive outcome in patients undergoing surgery for oral and maxillofacial cancer and microvascular reconstruction" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "Y. Terada" 1 => "S. Inoue" 2 => "M. Konda" 3 => "J. Egawa" 4 => "J. Ueda" 5 => "T. 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| 2023 December | 22 | 30 | 52 |
| 2023 November | 24 | 39 | 63 |
| 2023 October | 23 | 28 | 51 |
| 2023 September | 21 | 35 | 56 |
| 2023 August | 18 | 13 | 31 |
| 2023 July | 24 | 24 | 48 |
| 2023 June | 26 | 17 | 43 |
| 2023 May | 28 | 31 | 59 |
| 2023 April | 26 | 18 | 44 |
| 2023 March | 53 | 23 | 76 |
| 2023 February | 39 | 25 | 64 |
| 2023 January | 24 | 12 | 36 |
| 2022 December | 51 | 20 | 71 |
| 2022 November | 52 | 30 | 82 |
| 2022 October | 49 | 30 | 79 |
| 2022 September | 37 | 21 | 58 |
| 2022 August | 32 | 34 | 66 |
| 2022 July | 24 | 28 | 52 |
| 2022 June | 17 | 20 | 37 |
| 2022 May | 27 | 32 | 59 |
| 2022 April | 22 | 27 | 49 |
| 2022 March | 27 | 40 | 67 |
| 2022 February | 22 | 23 | 45 |
| 2022 January | 19 | 32 | 51 |
| 2021 December | 28 | 29 | 57 |
| 2021 November | 29 | 29 | 58 |
| 2021 October | 37 | 55 | 92 |
| 2021 September | 29 | 28 | 57 |
| 2021 August | 18 | 39 | 57 |
| 2021 July | 10 | 20 | 30 |
| 2021 June | 21 | 18 | 39 |
| 2021 May | 28 | 33 | 61 |
| 2021 April | 48 | 62 | 110 |
| 2021 March | 63 | 30 | 93 |
| 2021 February | 69 | 23 | 92 |
| 2021 January | 39 | 13 | 52 |
| 2020 December | 48 | 11 | 59 |
| 2020 November | 25 | 19 | 44 |
| 2020 October | 28 | 38 | 66 |
| 2020 September | 22 | 10 | 32 |
| 2020 August | 19 | 14 | 33 |
| 2020 July | 26 | 18 | 44 |
| 2020 June | 16 | 5 | 21 |
| 2020 May | 25 | 9 | 34 |
| 2020 April | 16 | 8 | 24 |
| 2020 March | 9 | 21 | 30 |
| 2020 February | 32 | 51 | 83 |
| 2020 January | 21 | 21 | 42 |
| 2019 December | 36 | 18 | 54 |
| 2019 November | 23 | 16 | 39 |
| 2019 October | 28 | 19 | 47 |
| 2019 September | 38 | 23 | 61 |
| 2019 August | 38 | 21 | 59 |
| 2019 July | 25 | 21 | 46 |
| 2019 June | 16 | 14 | 30 |
| 2019 May | 33 | 26 | 59 |
| 2019 April | 5 | 8 | 13 |
| 2019 March | 0 | 3 | 3 |
| 2019 February | 3 | 9 | 12 |
| 2019 January | 0 | 2 | 2 |
Show all
