Vol.:(0123456789) 1 3 Journal of Clinical Monitoring and Computing https://doi.org/10.1007/s10877-020-00593-w ORIGINAL RESEARCH Electromyographic assessment of blink reflex throughout the transition from responsiveness to unresponsiveness during induction with propofol and remifentanil Ana Ferreira 1,2  · Sérgio Vide 3  · João Felgueiras 4  · Márcio Cardoso 4  · Catarina Nunes 5  · Joaquim Mendes 1  · Pedro Amorim 3 Received: 20 February 2020 / Accepted: 16 September 2020 © Springer Nature B.V. 2020 Abstract General anesthesia is a reversible drug-induced state of altered arousal characterized by loss of responsiveness due to brainstem inactivation. Precise identification of the moment in which responsiveness is lost during the induction of general anesthesia is extremely important to provide information regarding an individual’s anesthetic requirements and help intra- operative drug titration. To characterize the transition from responsiveness to unresponsiveness more objectively, we studied neurophysiologic-derived parameters of electromyographic records of electrically evoked blink reflex as a means of identi- fying the precise moment of loss of responsiveness. Twenty-five patients received a slow infusion of propofol until loss of corneal reflex while successive blink reflexes were elicited and recorded every 6 s. The level of anesthesia was assessed using an adapted version of the Richmond Agitation-Sedation Scale. Different variables of the blink reflex components were calcu- lated and compared to the adapted version of the Richmond Agitation-Sedation score and the estimated effect-site propofol concentration. Baselines of the blink reflex responses were similar to those in literature. After propofol infusion started, the most susceptible component of the blink reflex to propofol was R 2 (EC 50 = 1.358 (95% CI 1.321, 1.396) µg/mL) and the most resistant was R 1 (EC 50 = 3.025 (95% CI 2.960, 3.090) µg/mL). Most of the patients (24 out of 25) lost the R 1 component when they were still responsive to shaking and shouting and corneal reflex could be elicited clinically (time = 102.48 ± 33.00 s). Habituation was present in R 2 but not in R 1 . The R 1 component of the blink reflex was found to have a strong correlation with the adapted version of the Richmond Agitation-Sedation Scale, with amplitude correlating better than areas (ρ = − 0.721 (0.123) versus ρ = − 0.688 (0.165)). We found a strong correlation between the R 1 component with the estimated propofol effect-site concentration, with amplitude correlating better than areas (ρ = − 0.838 (0.113) versus ρ = − 0.823 (0.153)) and between the clinical scale and the propofol concentration (ρ = 0.856 (0.060)). The area and amplitude of the R 1 component showed to be indicators of predicting different levels of anesthesia (P k = 0.672 (0.183) versus P k = 0.709 (0.134)) and these are connected to the propofol concentrations (P k = 0.593 (0.10)). Our results suggest that electrically evoked blink reflex could be used during the induction of anesthesia as a surrogate of the Richmond Agitation-Sedation Scale to provide an objective endpoint as far as a − 4. At this point, at the moment of loss of R 1 , the propofol infusion may be stopped, as overshooting increases slightly the effect-site concentration afterward and eventually reaching loss of responsiveness. If the desired target is not achieved, the infusion can then be resumed. Keywords Personalized anesthesia · Propofol · Blink reflex · Electromyography · Loss of responsiveness · Monitoring 1 Introduction To induce patient unconsciousness/unresponsiveness, anes- thesiologists use a variety of different drug combinations; however, synergisms and interpatient variability may lead to different dose requirements. Precise identification of the moment of loss of responsiveness during general anesthesia induction would allow for the determination of the amount Electronic supplementary material The online version of this article (https://doi.org/10.1007/s10877-020-00593-w) contains supplementary material, which is available to authorized users. * Ana Ferreira ana.leitao.ferreira@gmail.com Extended author information available on the last page of the article