Proceedings of the 29th Annual International

Conference of the IEEE EMBS

Cit Internationale, Lyon, France
August 23-26, 2007.

FrP2A1.18

Automated Estimation of Sedation depth from the EEG

B.R. Greene, P. Mahon, B. McNamara, G.B. Boylan, G. Shorten,

Abstract A method is presented for the automatic

determination of a patients level of sedation from the EEG. Six
bipolar channels of EEG recorded from 12 adult patients
sedated with low-dose propofol (2, 6-disopropylphenol) were
used to develop a linear discriminant based system for depth of
sedation monitoring using a number of quantitative EEG
measures. A cross fold validation estimate of the performance
of the algorithm as a patient independent system yielded a
sensitivity of 74.70% and a specificity of 81.67%. It is hoped
that the methodology reported here could lead to fully
automated systems for depth of sedation monitoring.

I. INTRODUCTION

ONCIOUS sedation allows patients to tolerate

unpleasant procedures by alleviating anxiety and
discomfort. Sedation may also expedite the conduct of
procedures particularly those that require the patient does not
move [1]. With sedation comes risk, in particular those of
cardiovascular and respiratory compromise that accompany
excess hypnotic drug use [2]. Currently many practitioners
rely on intuition and experience to judge depth of sedation.
In the research setting sedation scales [such as the Modified
Observers Assessment of Alertness/Sedation Score
(MOAA/S)] [3] are used to quantify depth of sedation. The
disadvantage of this method when applied to clinical practice
is that it requires continuous stimulation (verbal or tactile) of
the patient. Paradoxically this may increase the amount of
hypnotic drug used. Thus the need exists for a reliable,
passive depth-of-sedation monitor.
The electroencephalographic (EEG) is the obvious starting
point. The changes that occur in the EEG during
pharmacologic or physiologic drowsiness, when viewed by
an experienced clinician are unequivocal and objective [4,
5]. These changes include alpha wave drop out in the
posterior brain regions and increased frontal beta activity
during propofol sedation (Table 1) [6, 7]. A number of
commercially available devices including BIS, Entropy,
Manuscript received April 2nd 2007. This work was supported in part by
Science Foundation Ireland (SFI/05/PICA/1836).
B.R. Greene is with the Department of Electrical & Electronic
Engineering, University College Cork, Ireland (phone +353-21-490-3793; email: barryg@rennes.ucc.ie).
P. Mahon is with the department of Anaesthesia and Intensive Care
Medicine, Cork University Hospital, Cork, Ireland. (e-mail:
rsimahon@hotmail.com).
B. McNamara is with the department of Clinical Neurophysiology, Cork
University Hospital, Cork, Ireland.
G.B. Boylan is with the School of Medicine, University College Cork,
Ireland (e-mail: g.boylan@ucc.ie).
G. Shorten is with the department of Anaesthesia and Intensive Care
Medicine, Cork University Hospital, Cork, Ireland. (e-mail:
George.Shorten@mailp.hse.ie).

1-4244-0788-5/07/$20.00 2007 IEEE

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and Narcotrend are used in the context of depth-ofanesthesia monitoring. Each of these monitors is based on
the calculation of one or more quantitative EEG measures [8,
9], that are thought to contain anesthesia/sedation-specific
information. General anesthesia is very deep sedation with
the absence of a cortical response to pain. Some of these
devices [particularly the Bispectral or BIS monitor
(Aspect Medical)] have been studied in the context of light
sedation and are unable to reliably distinguish between light
and deep sedation [1]. We set out to determine if the
combination of a number of quantitative EEG measures or
features could be used to automatically determine a
patients level of sedation.
Grade
0
1

Criterion
Awake alpha rhythm
Decrease in amplitude and drop out
/ activity theta activity
2
Theta wave activity, sleep spindles / K
complexes
3
Generalised delta activity 20-50%
epoch duration
Table 1: EEG criteria for assignment of sedation grade

II. METHOD
A. Data set
We used an independently validated dataset of EEG
recordings from 12 healthy patients aged 37+/-9yrs
(M:F::4:8), who underwent sedation prior to anesthesia using
propofol (2,6-disopropylphenol). The study protocol was
approved by the Clinical Research Ethics Committee of the
Cork Teaching Hospitals. All patients gave prior written
informed consent.
B. Clinical Protocol
A target-effect site propofol infusion was commenced to
provide a target-effect site concentration of 0.5 gml-1. The
target-effect site was brain. The target effect concentration
was increased in 0.5 gml-1 increments every four minutes to
a maximum of 2 gml-1. A period of 4 minutes was allowed
at each concentration level to allow adequate equilibrium to
be achieved across the blood-brain-barrier. For each patient
the data acquisition period was thus 16 minutes.
C. EEG Acquisition
Nineteen channels of EEG were recorded for each patient
using a NicVue digital EEG machine. For the purposes of
analysis and comparison we calculated each quantitative
EEG measure or feature in the following bipolar channels:

 'P4-O2'
'P3-O1'
'Fp1-Fp2'
'F3-C3'
'F4-C4'
'F3-F4'
Even numbers by convention refer to electrodes placed on
the right side of the scalp. The occipito-parietal leads were
chosen as alpha rhythm which originates in the posterior
cortex is best seen in these leads. Fp1 Fp2 represents a
prefrontal location likely to be contaminated by EMG
artifact from the frontalis muscle. Activity in the three other
channels is representative of frontal and central lobe activity.
D. Sedation Measurement
The EEG recordings were retrospectively assessed by a
clinical neurophysiologist blinded to the clinical sedation
score. A sedation grade was assigned to each time period of
four minutes corresponding to a set propofol concentration.
The sedation grade was assigned according to preset criteria
set out in table 1. For the purposes of this analysis any four
minute period in which the sedation score was greater then
zero was deemed to be sedated. There were 48 four minute
intervals in twelve patients. Twenty nine had evidence of
sedation with 19 non-sedated. Each record contained 19
EEG channels and was sampled at 250Hz. Records had a
mean duration of 19.8 minutes. The dataset contained a total
of 192 minutes of 19 channel EEG. 116 minutes of EEG
were assigned the labeled sedated while 76 minutes of
EEG were assigned the label non-sedated. Table 2
summarizes the characteristics of each of the recordings.
Patient
#
1
2
3
4
5
6
7
8
9
10
11
12

Record
Length
(mins)

16.3
16.6
16.6
16.2
16.3
17.6
22.6
21.6
17.0
19.8
22.7
34.9
Mean:
19.8
Table 2: Record information

Sedated
Time (mins)
16
4
4
8
12
8
16
12
0
12
12
12
Total:
116

Nonsedated
time (mins)
0
12
12
8
4
8
0
4
16
4
4
4
Total:
76

E. Feature Extraction
The EEG for each channel was low-pass filtered using a
type II Chebyshev IIR filter with a corner frequency of 34Hz
to remove power line noise along with out-of-band noise.
The EEG for each channel was then considered in epochs of
2 seconds duration. The following features were extracted

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for each 2 s EEG epoch for each channel.

Spectral Entropy (HS)
Spectral Edge frequency (SEF)
Relative Alpha band power (P)
Relative Beta band power (P)
Relative Delta band power (P)
Relative Theta band power (P)
Many of these measures have been used in previously
reported studies [7, 10] and are currently in use in
commercially available depth of anesthesia monitors [9, 11].
The EEG spectral entropy (HS) was calculated for 2 second
epoch using Eqn.1, which normalizes HS to the range 0-1
[9].

HS ( X ) =

1
log N f

P ( X ) log
f

Pf ( X ) (1)

Pf(X) is an estimate of the probability density function

(PDF) and is calculated by normalizing the power spectral
density (PSD) estimate with respect to the total spectral
power. The PSD is calculated in the range 0.5-32Hz for each
epoch using a 500-point fast fourier transform (FFT). Nf is
the number of frequency components in the PSD estimate.
Spectral Edge frequency (SEF) was calculated according
to the methodology discussed by a number of authors [1214]. The total EEG power in the range 0.5-32Hz was
calculated for each 2 second EEG epoch. The SEF was then
calculated as that frequency (in Hertz) below which 90% of
the total spectral power resides. The SEF features for each
channel and for each patient were then normalized to have
zero mean and unity standard deviation.
A number of authors have investigated the variation of
EEG power bands with sedation and anesthesia [7, 15]. The
spectral power in a number of EEG sub-bands was then
calculated as the total spectral power in a given frequency
range from the power spectral density estimate for each
epoch. The relative power feature for each band was then the
ratio of the power in a given sub-band to the total power in
the 0.5-32 Hz band. The Alpha sub-band is defined as the
spectral power in the range 8-13Hz, similarly the Beta subband is defined in the range 14-40Hz. The Delta and Theta
sub-bands are defined in the ranges 0.5- 4Hz and 4-7Hz
respectively [16].
Six features for each of the six channels were then
combined into a feature vector (of length 36) which was then
applied to the classifier.
F. EEG Artifact Rejection
The EEG signal often contains variety of biological and
non-biological artifacts [17]. In this paper we have attempted
to reject two kinds of artifact from subsequent analysis,
namely: movement artifacts which are large signal spikes
caused by movement of the electrodes, and zero-signal
artifact caused by the amplifier being powered-off in the
course of a recording.
To identify the artifact sections of each EEG channel a

zero mean EEG signal was first calculated by subtracting the

mean of the EEG from each sample and then processing this
signal as follows:
The standard deviation of the absolute value of
signal was calculated and any signal samples
greater than six times the standard deviation were
flagged as movement artifact.
Any 10 sample epoch whose mean was 100 times
smaller than the 5% trimmed mean of the signal
was flagged zero-signal artifact
Any 10 sample epoch on a given channel containing
artifact was assigned the value 1. All epochs for each
channel that did not contain artifact was assigned the value
0. If the mean artifact value across all channels exceeded an
empirically derived threshold, the epoch was considered to
contain artifact.
G. Classifier Model
A linear discriminant (LD) based classifier model was
employed in this study. A linear discriminant classifier
model, (based on the Mahalanobis distance), is defined
completely by a mean vector for each class and a common
covariance matrix. An LD model assumes normal class
distributions and the same variance across classes. The class
conditional mean vectors and a common covariance matrix
were estimated entirely from the training data. Weighting of
the class conditional mean vectors and common covariance
matrix by the duration of each record was implemented as
discussed by Greene et al. [18]. This ensures that records of
differing lengths contribute equally to the training of the
classifier.
Feature

I. Algorithm Performance Measures

The classification accuracy (Acc) is defined as the
percentage of 2 s epochs correctly classified by the system.
The sensitivity (Sens) is defined as the percentage of
sedated
epochs
(as
labeled
by
a
Clinical
Neurophysiologist) correctly identified as sedated epochs
by the system. Similarly, the specificity (Spec) is defined as
the percentage of epochs labeled non-sedated correctly
classified as non-sedated by the system. A receiver
operating characteristic (ROC) curve is a graphical
representation of class sensitivity against specificity as a
threshold parameter is varied. The area under the ROC curve
(ROC Area), is used as an index of sedated/non-sedated
class discrimination for the patient independent classifier. A
random discrimination will give an area of 0.5 under the
curve while perfect discrimination between the two classes
will give unity area under the ROC curve.
III. RESULTS
Table 3 gives the classification performance for each
feature taken individually as well as all features combined, in
classifying epochs of EEG as sedated or non-sedated. On
a patient independent basis using the combined features,
74.70% of sedated epochs were correctly classified as
sedated (sensitivity of 74.70%) while 81.67% of non-sedated
epochs were correctly classified as non-sedated (specificity
of 81.67%).
Fig.1 shows an ROC plot for the output discriminant value
of the patient independent classifier. The area under the

Combined

SEF

Acc (%)

77.45

61.28

67.89

70.27

66.21

69.38

60.90

Sens (%)

74.70

62.32

75.28

69.07

65.49

70.98

65.52

Spec (%)

81.67

59.70

56.55

72.10

67.32

66.92

53.81

ROC Area

0.86

0.63

0.71

0.77

0.71

0.77

0.63

Measure

Table 3: Overall performance results for each feature taken individually as well as all features combined together and classified
using a linear discriminant classifier model.

H. Classifier Performance Estimation

The automated depth of sedation monitoring system was
considered as a patient-independent or generalized
classifier. The performance of the patient-independent
system was estimated using cross validation across all
records. This involved training the classifier model on 11 of
the 12 records and using the 12th record to test the classifier
performance and then rotating through the 12 possible
combinations of training and test sets. The mean of the
results for all iterations is taken as a patient-independent
classifier performance estimate. This test provides a measure
of the systems ability to generalize from the training set and
classify unseen records as sedated or non-sedated.

3190

ROC curve was 0.86.

REFERENCES
Patient Independent ROC curve

[1]

100
90
80

[2]

Sensitivity [%]

70
60
50

[3]

40
30
20

[4]

10
0

10

20

30

40
50
60
Specificity [%]

70

80

90

100

Figure 1: Receiver operating characteristic curve for all

features combined into a patient independent classifier. Area
under the ROC curve was 0.86.

[5]
[6]

Table 4 gives the individual cross-validated performances

for each of the twelve patient recordings. Patients 1 and 7
contained no non-sedated epochs and so have no associated
specificity metric, while patient 9 contained no sedated
epochs and so has no associated sensitivity metric.
Patient #

Acc (%)

Sens (%)

[8]

Spec (%)

82.18

82.18

85.92

58.82

94.96

76.42

20.83

95.21

77.47

73.95

81.01

66.18

59.22

87.29

67.78

55.65

79.92

98.12

98.12

78.24

71.31

99.16

74.58

74.58

10

75.10

78.55

64.71

11

71.85

72.91

68.64

12

75.52

86.87

41.67

[7]

[9]

[10]
[11]

[12]
[13]

Table 4: Patient independent classifier results for each patient.

Six features were extracted for six EEG channels and classified
as sedated or non-sedated using a linear discriminant classifier
model.

[14]

IV. DISCUSSION
A system for the automated estimation of a patients level
of consciousness is presented here. The EEG for each patient
was
dichotomized
by
an
experienced
Clinical
Neurophysiologist into two classes, sedated and non-sedated.
Six quantitative EEG measures per EEG channel were used
in this study. Each quantitative EEG measure has been used
previously in depth of sedation / anesthesia research.
Classifying each epoch using a LD classifier model led to a
sedation sensitivity of 74.70% with an associated specificity
of 81.67%.

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