Human Physiology and Electrophysiology

Electrophysics and Electromechanics

Lab 03: Anaesthesia Monitoring

Lab Instructor: Dr. Paulo Navas MD. / Diego Almeida Ph.D.

Developed by: Paulo Navas / Diego Almeida / Brenda Guanulema / Gabriela González

Group: Darwin Quinteros, Leslie Espinoza and Stefany Cuenca.

1. Introduction

1.1. CONOX Smart Anaesthesia Monitoring

Conox is a non-invasive depth of anesthesia monitor designed to help the anesthesiologists assess
patient brain activity and to rapidly detect how certain drugs are affecting the patient. It captures
the EEG signal from the brain to measure the depth level of anesthesia and guide intraoperative
hypnosis drug and opioid administration. The Conox monitor differentiates itself from the other
brain monitor by calculating two EEG indexes, the qCON and the qNOX.

Figure 1. Conox: Smart Anaesthesia Monitoring

1.2. CONOX parameters

1.2.1. qCON index
The qCON index corresponds to the depth of the sedation. It is based on a combination of different
EEG frequency bands obtained from frontal lobe, which are inserted into the Adaptive Neuro-Fuzzy
Inference System (ANFIS), which produces output on a scale between 99 (completely awake) and 0
(isoelectric EEG) that reflex the level of anesthesia. Index qCON ≥ 80 is associated with a conscious

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state or mild sedation, and the range of the index from 60 to 40 relates to the adequate level of
anesthesia for surgery.

Table 1. qCON score interpretation

Score qCON

80-90 Full Awareness

75 Sedation

40-60 General Anesthesia

20 Deep Anesthesia

0 Isoelectric EEG

1.2.2. qNOX index

The qNOX is based on low and high frequency EEG in order to detect any changes related to surgical
stimuli. The EEG signal is recorded from frontal lobe through a single channel. The acquired EEG
signal, with sampling frequency of 1024 Hz undergoes signal preprocessing to eliminate noise
through morphological filters.
Table 2. qNOX score interpretation

Score qNOX

60-99 Patient is likely to respond to

nociceptive stimuli.

40-60 Patienent is unlikely to respond to

nociceptive stimuli.

0-40 There is verly low probability that

the patient will responde to
nociceptive stimuli.

Both the qCON and qNOX indices can detect movement in response to noxious stimuli, although the
response is greater on qNOX than on qCON. It can occur because an increase in qNOX is the effect of
EEG directly from dangerous stimulation, while qCON increased due to the secondary effect of
dangerous stimulation.
1.2.3. Burst suppression ratio (BSR)
BSR is a parameter that evaluates the presence and relationship between periods of brain electrical
activity called "bursts" and periods of inactivity or suppression of activity. A higher BSR value
generally indicates greater cerebral suppression and a deeper level of anesthesia.
1.2.4. Electromyogram (EMG)
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EMG is a technique used to measure muscle response or electrical activity when a nerve stimulates
the muscle. The EMG index refers to the component of facial muscle electrical activity, it is in a
frequency range of 30-42 Hz in dB. EMG activity could increased due to reflex reactions or painful
stimuli during surgery.
1.2.5. Signal Quality Index (SQI)
SQI is a dimensional scale from 0 to 100 represents the quality of the EEG signal that is calculated
based on device.
1.2.6. EEG signal
The electroencephalogram (EEG) is a diagnostic technique that records the electrical activity of the
brain. To analyze the brain signals during anesthesia it is important to understand the properties of
EEG signals such as frequencies, amplitudes, and internal and external effects that change the shape
of these signals.The EEG signal is traditionally divided into spectral broad frequency bands related
to EEG generators and rhythms: delta, theta, alpha, and beta.

Figure 2. EGG frequency bands

Electroencephalogram (EEG) shows dramatic changes with increase of the concentration of

anesthetic. In light anesthetic level, high frequency with low amplitude waves are dominant. With
increase of anesthetic concentration, waves in alpha range (8-13 Hz) become dominant. In deeper
levels, powers in alpha range then become smaller and theta or delta powers become dominant.
With further deeper levels, EEG waveform changes into specific pattern so-called "burst and
suppression", and finally it becomes flat.

1.3. CONOX operation and qNOX and qCON obtaining.

The qNOX index comes from the frontal EEG signal, as shown in Figure 3, the EEG obtained from the
monitor has a test frequency of 1024Hz, which is preprocessed to eliminate noise through a
low-pass filter, eliminating high frequencies. Each EEG sequence is subjected to fast Fourier
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transform (FFT) spectral analysis. From the spectral analysis different normalized frequency bands
are obtained, also called ratios.
The qNOX index is based on the incorporation of four frequency relationships derived from spectral
analysis into a fuzzy logic model. It uses an ANFIS (Adaptive Neuro Fuzzy Inference System).
Subsequently, the index is rectified according to the value of the index qCON.

Figure 3. Flowchart corresponding to obtain qNOX and qCON indices.

1.4. CONOX sensor

The CONOX monitor relies on the qCON and qNOX indices, derived from EEG signals captured by a
sensor consisting of three electrodes that have gel and transduction pads, that placed on the
patient's forehead, as illustrated in Figure 4. reference electrode is usually distinguished by its
yellow color (2) . Importantly, electrode placement is independent of the specific side of the head, as
it assumes symmetry between both hemispheres, unless there are underlying pathological factors.

Figure 4. Location of CONOX’s electrodes.

The Conox Anesthetic Depth Monitor automatically measures the impedance of the sensor
connections at power up and every 15 minutes during operation. If the impedance is less than 10, it

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is considered good, if it exceeds this limit, a "PH" is displayed. For the correct operation of the
device, it is suggested that in each electrode, the impedance is less than 5.

2. Objectives:
● Know the operation of the CONOX equipment.
● Understand the qNOX and qCON parameters and their relationship to the depth of
anesthesia.
● Perform measurements using the CONOX in different stimulus.

3. Materials and Methods

3.1. Materials
● CONOX anaesthesia monitor
● Head band with electrodes
● CONOX View app
Download the APK file "Conox view app.apk" on an Android phone. (One per group).
Connect with the monitor using Bluetooth.

Figure 5. Conox view app interface.

3.2. Methodology

3.2.1. Manipulation of CONOX monitor.

3.2.1.1. Create a flow diagram of the operation of CONOX monitor.

a. Add the type of sensors of the equipment.
b. Add the impedance value of the three electrodes

Electrode 1 (red) Electrode 2 (yellow) Electrode 3 (green)

c. Add CONOX parameters.

o BSR
o EMG
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o SQI

Include figure

3.2.1.2. Describe the clinical state of the patient in the three states of general
anesthesia according to the values of qNOX and qCON, SQI indexes.

a.Induction

The induction stage begins when anesthesia is administered to the patient. The patient passes from
a waking state to a state of loss of consciousness, where he may experience decreased reflexes and
muscle relaxation.

In this stage, the qCON is above 80 given the degree of consciousness of the patient; the qNOX is
between 61 and 99 due to its high probability of response to reflexes and stimuli; and the SQI
presents a better quality and clarity of the EEG signal.

b.Maintenance

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During the maintenance stage, the patient is maintained in a suitable state of anesthesia for the
surgical procedure. During this phase, the medical team monitors and controls the patient's vital
signs, including heart rate, blood pressure, oxygen saturation, and pulmonary ventilation.

In this stage, the qCON is between 40 to 60 due to the continuous administration of anesthesia; the
qNOX would be less than 39 because the response to stimuli decreases or becomes null and it is
unlikely to have reflexes; and the SQI presents a medium quality of the EEG signal.

c.Emergence

The recovery stage begins when the administration of anesthetic agents is discontinued. The patient
soon begins to regain consciousness. Vital signs stabilize again and reflexes recover.

In this stage, the qCON is between 60 to 80 due to the gradual recovery of consciousness; the qNOX
is between 40 and 60 because the response to stimuli gradually increases; and the SQI increases the
quality of the EEG signal.

3.2.2. Measurements using CONOX in differents stimulus.

3.2.2.1. Perform measurements using the CONOX in the following situation: Low
blood sugar (hypoglycemia) caused by fasting.
a. Discuss the changes of qCON and qNOX indexes.
b. Discuss the changes of EEG signal.

Hypoglycemia can affect the normal functioning of the brain due to the decrease in glucose levels,
which is the main source of energy for it. Regarding qCON, the patient may experience a decreased
level of consciousness and present symptoms such as confusion, disorientation, slurred speech, and
slow or clumsy movements. Regarding qNOX, the patient can still respond to painful stimuli,
although their response may be reduced or decreased compared to a person with normal blood
glucose levels. Therefore, both qCON and qNOX will register levels between 40 to 60.

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The signal recorded on the EEG may present slow or abnormal waves, as well as a decrease in the
amplitude of normal waves. These changes reflect the alteration in brain function due to lack of
energy.

Include figure

3.2.2.2. Perform measurements using the CONOX in the following situation: Exercise
or body movement during the test.
a. Discuss the changes of qCON and qNOX indexes.
b. Discuss the changes of EEG signal.

Regarding the degree of consciousness qCON, exercise or body movement can increase the patient's
alertness and attention. Physical activity stimulates the central nervous system, which can result in
heightened alertness and a higher level of consciousness. This can translate into increased
responsiveness to external stimuli, including qNOX nociceptive stimuli.

During exercise or body movements, muscles contract and generate electrical activity that is
recorded on the EEG. These artifacts can appear as waveform interference and irregular spikes in
the signal.

Include figure
3.2.2.3. Perform measurements using the CONOX in the following situation: Presence
of lights, especially bright or flashing ones.
a. Discuss the changes of qCON and qNOX indexes.
b. Discuss the changes of EEG signal.
In terms of consciousness, bright or flashing lights can provide intense visual stimulation and
significantly engage the patient's attention. In some cases, this can increase alertness and vigilance,
which can result in a heightened degree of awareness and an increased ability to respond to
external stimuli, including nociceptive stimuli.

Bright or flashing lights can generate neural responses and electrical activity in the brain that will
be reflected in the EEG signal. Depending on the intensity and frequency of the lights, patterns of
activity may appear on the EEG that correspond to visual stimulation.

Include figure

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3.2.2.4. Perform measurements using the CONOX in the following situation: Drinking
1 cup of coffee before the test.
a. Discuss the changes of qCON and qNOX indexes.
b. Discuss the changes of EEG signal.

Drinking a cup of coffee before a test can increase the level of consciousness and, in some cases,
have a mild analgesic effect on the response to nociceptive stimuli.

Drinking coffee before a test can increase the frequency of brain waves, reduce the amplitude of
lower frequency waves, and increase overall activity in the EEG signal.

Include figure

3.2.2.5. Perform measurements using the CONOX in the following situation: Drinking
1 cup of valerian tea before the test. Administer 2 to 6 ml (40-120 drops) of
valerian.
a. Discuss the changes of qCON and qNOX indexes.
b. Discuss the changes of EEG signal.

Valerian has relaxing properties and can promote a sense of tranquility and calm. As a result, there
may be decreased alertness and a feeling of sleepiness or relaxation. Valerian may have
pain-relieving or analgesic effects in some individuals, which may modulate pain perception and
reduce sensitivity to nociceptive stimuli. Therefore, the levels of qCON and qNOX are expected to
decrease slightly.

The EEG signal can lead to an increase in lower frequency waves, suppression of higher frequency
waves, and stability and regularity of the EEG signal.

Include figure

3.2.2.6. Perform measurements using the CONOX in the following situation: Presence
of hair spray or oily hair.
a. Discuss the changes of qCON and qNOX indexes.
b. Discuss the changes of EEG signal.

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The presence of hairspray or greasy hair does not have a significant effect on the level of
consciousness or on the response to nociceptive stimuli.

These products are not directly related to brain activity and are not expected to drastically alter the
EEG signal.

Include figure
3.2.3. Drugs used Anesthesia
3.2.3.1. In the following table, indicate 5 drugs that are used for sedation and
analgesia for surgical procedures.

Drug Type of drug Dose Route of Mechanism of action

administration

Propofol Intravenous 2 to 2.5 mg/kg Intravenous (IV) Enhances the inhibitory

general anesthetic injection or effects of
and infusion gamma-aminobutyric
sedative-hypnotic acid (GABA), a
neurotransmitter that
reduces neuronal activity,
leading to sedation and
anesthesia.

Midazolam Benzodiazepine 0.3 to 0.35 Intravenous (IV) Enhances the effects of

sedative and mg/kg injection or oral GABA, resulting in
anxiolytic administration sedative, anxiolytic, and
amnesic effects.

Fentanyl Opioid analgesic 25-100 Intravenous (IV) Binds to opioid receptors

mcg/dose injection, in the central nervous
transdermal system, producing
patch, or analgesic effects and
intranasal spray. reducing the perception
of pain.

Dexmedetomid Alpha-2 adrenergic 0.5 mcg/kg Intravenous (IV) Activates alpha-2

ine agonist sedative infusion adrenergic receptors in
the brain, leading to
sedation, anxiolysis, and
analgesia.

Ketamine Dissociative 1-4.5 mg/kg Intravenous (IV) Blocks

anesthetic and injection N-methyl-D-aspartate
analgesic (NMDA) receptors,

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leading to dissociative
anesthesia, analgesia, and
sedation.

3.2.3.2. Answer the following question: What could be the clinical consequences of
an overdose of anesthesia?
An anesthesia overdose can result in respiratory depression, compromising oxygenation and
ventilation and leading to respiratory arrest. It can also cause cardiovascular effects like decreased
blood pressure and bradycardia, potentially leading to cardiac arrest and inadequate blood flow to
vital organs. Excessive anesthesia can suppress the central nervous system, inducing deep
unconsciousness and interfering with vital reflexes, posing a risk of aspiration and respiratory
complications. Overdose can extend sedation and recovery time, increasing the likelihood of
postoperative complications such as respiratory issues and confusion. Additionally, there is a higher
risk of drug interactions and toxicity, as combining anesthesia agents or other medications can
intensify their effects and trigger adverse reactions like arrhythmias, seizures, or allergies.

4. Conclusions

The Conox monitor is a non-invasive anesthesia depth monitor that integrates two EEG-based
indices: the qCON index and the qNOX index. The qCON index indicates the patient's level of
consciousness, while the qNOX index can be used to measure the probability that a patient will
respond to noxious stimuli. The Conox monitor is designed to monitor the combination of hypnotic
and analgesic effects in patients undergoing anesthesia. The qCON index is based on an easily
readable 0-99 scale, resulting from processing EEG readings, and a qCON index between 40 and 60
points for an adequate level of anesthesia, while 0 points for an isoelectric EEG. The Conox monitor
is applicable under general anesthesia and ICU settings. The Conox monitor is a useful tool for
monitoring the depth of anesthesia and analgesia in patients undergoing surgery.

5. References

● Salgado,C., Antonio, & Montoya Pedrón, Arquímedes. (2016). Técnicas para el monitoreo de
los niveles de profundidad anestésica. MEDISAN, 20(6).
● Jensen, E. W., Valencia, J. F., López, A., Anglada, T., Agustí, M., Ramos, Y., Serra, R., Jospin, M.,
Pineda, P., & Gambus, P. (2014). Monitoring hypnotic effect and nociception with two
EEG-derived indices, qCON and qNOX, during general anaesthesia: Monitoring anaesthesia
with qCON and qNOX. Acta Anaesthesiologica Scandinavica, 58(8), 933–941.
https://doi.org/10.1111/aas.12359

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● Morgaz Rodríguez, J. (2008). Evaluación del índice biespectral y la entropía como monitores
de profundidad anestésica en beagles. Servicio de Publicaciones, Universidad de Córdoba.
● Toar, B. J., Suarjaya, I. P. P., Hartawan, I. U., & Senapathi, T. G. A. (2021). The use of CONOX as a
guide to the general anesthesia on laparotomy patients compared with standard clinical
care – A pilot study. Neurologico Spinale Medico Chirurgico, 4(2), 51–54.
https://doi.org/10.36444/nsmc.v4i2.158
● Zanner R, Kreuzer M, Meyer A, Kochs E, Schneider G.(2015). Evaluation of the qCON, a novel
monitor of the hypnotic component of anaesthesia.

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