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Neuromonitoring Michel MRF Struys, MD, PhD, FRCA Professor and Chair, Department of Anesthesia University Medical Center Groningen Groningen, The Netherlands Professor of Anesthesia, Ghent University, Gent, Belgium Afdeling Anesthesiologie

Afdeling Anesthesiologie · The mechanism explaining this association, however, is yet to be determined. The data are insufficient to assess the relationship between processed electroencephalogram

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  • Neuromonitoring

    Michel MRF Struys, MD, PhD, FRCA

    Professor and Chair, Department of Anesthesia University Medical Center GroningenGroningen, The Netherlands

    Professor of Anesthesia, Ghent University, Gent, Belgium

    Afdeling Anesthesiologie

  • Conflicts of interest

    My research group/department received grants, funding, honoraria from The Medicines Company (Parsippany, NJ, USA), Masimo (Irvine, CA, USA), Fresenius (Bad Homburg, Germany), Acacia Design (Maastricht, The Netherlands), Medtronic (Dublin, Ireland) and

    honoraria from The Medicines Company (Parsippany, NJ, USA), Masimo (Irvine, CA, USA), Fresenius (Bad Homburg, Germany), Baxter (Deerfield, IL, USA), Medtronic (Dublin, Ireland), Demed Medical (Temse, Belgium).

    I serve as a Director and editorial board member of the British Journal of Anesthesia and as a Senior Editor for Anesthesia & Analgesia.

  • Brain monitoring (during anesthesia)

    Michel MRF Struys, MD, PhD, FRCA

    Professor and Chair, Department of Anesthesia University Medical Center GroningenGroningen, The Netherlands

    Professor of Anesthesia, Ghent University, Gent, Belgium

    Afdeling Anesthesiologie

    Acknowledgement : Prof TWL Scheeren, UMC Groningen for the slides on NIRS

  • The brain is the most important organ to care for during anesthesia…..

    Let’s care for oxygen homeostasis !

    Statement

  • Oxygen homeostasis in the brain

    Important components …

    - Oxygen delivery- Oxygen content- Cerebral blood flow

    …. Blood pressure …. The heart !

    - Oxygen consumption (CMR02)- effects of anesthesia

    Source : https://aneskey.com/organ-system-considerations-that-affect-anesthetic-management/

  • Source : Miller’s Anesthesia, 8th edition, 2015

    Relation between CMRO2 and depth of anesthesia ?

  • So..it might be good to monitor the brain for electrical activity and oxygen homeostasis?

  • Measuring “cerebral drug effect”

    EEG

  • Why using brain function monitoring?

    Side-effectsCostsAdverse Outcomes

    - delirium- cognitive decline- mortality

    ComplicationsAdverse Outcomes

    - awareness

    “ANESTHETIC DEPTH”

    OVERDOSING UNDERDOSINGADEQUATE/OPTIMAL

    BEST OUTCOMESQuality + Safety

    Anesthetic Effect Management

  • Anesthesia

    Hypnotic componentof anesthesia

    Mediated at supra-spinal level

    Amnesia(Loss of Memory

    Formation)

    Hypnosis(Loss of Consciousness)

    Analgesic componentof anesthesia

    Mediated at Spinal level LOR to noxious stimulus

    Nociception/ Antinociception

    (Arousal Response)

    Immobility(no reflex movement)

    Inhibition Stress response

    Components of anesthesia

    Courtesy of Hugo Vereecke, MD, PhD

  • Sahinovic MM, Absalom AR, Struys MM: Administration and monitoring of intravenous anesthetics, Curr Opin Anaesthesiol 23:734-734, 2010.

    Dose - response relationship

  • Interindividual Pharmacokinetic-dynamic variability

    Effect

    Dose

    Pharmacodynamic variability

    Pharmacokinetic variability

  • A population model

    Averaged

    0

    10

    20

    30

    40

    50

    60

    70

    80

    90

    100

    0 1 2 3 4 5 6 7 8 9 10

    Average curve :Ce50 = 4.17 µg/ml ; γ = 5.21 ; E0 = 95 ; Emax = 12

    Mortier et al. Anaesthesia 1998; 53: 749-54.

    BIS

    CePROP

    Chart1

    0

    0.05

    0.1

    0.15

    0.2

    0.25

    0.3

    0.35

    0.4

    0.45

    0.5

    0.55

    0.6

    0.65

    0.7

    0.75

    0.8

    0.85

    0.9

    0.95

    1

    1.05

    1.1

    1.15

    1.2

    1.25

    1.3

    1.35

    1.4

    1.45

    1.5

    1.55

    1.6

    1.65

    1.7

    1.75

    1.8

    1.85

    1.9

    1.95

    2

    2.05

    2.1

    2.15

    2.2

    2.25

    2.3

    2.35

    2.4

    2.45

    2.5

    2.55

    2.6

    2.65

    2.7

    2.75

    2.8

    2.85

    2.9

    2.95

    3

    3.05

    3.1

    3.15

    3.2

    3.25

    3.3

    3.35

    3.4

    3.45

    3.5

    3.55

    3.6

    3.65

    3.7

    3.75

    3.8

    3.85

    3.9

    3.95

    4

    4.05

    4.1

    4.15

    4.2

    4.25

    4.3

    4.35

    4.4

    4.45

    4.5

    4.55

    4.6

    4.65

    4.7

    4.75

    4.8

    4.85

    4.9

    4.95

    5

    5.05

    5.1

    5.15

    5.2

    5.25

    5.3

    5.35

    5.4

    5.45

    5.5

    5.55

    5.6

    5.65

    5.7

    5.75

    5.8

    5.85

    5.9

    5.95

    6

    6.05

    6.1

    6.15

    6.2

    6.25

    6.3

    6.35

    6.4

    6.45

    6.5

    6.55

    6.6

    6.65

    6.7

    6.75

    6.8

    6.85

    6.9

    6.95

    7

    7.05

    7.1

    7.15

    7.2

    7.25

    7.3

    7.35

    7.4

    7.45

    7.5

    7.55

    7.6

    7.65

    7.7

    7.75

    7.8

    7.85

    7.9

    7.95

    8

    8.05

    8.1

    8.15

    8.2

    8.25

    8.3

    8.35

    8.4

    8.45

    8.5

    8.55

    8.6

    8.65

    8.7

    8.75

    8.8

    8.85

    8.9

    8.95

    9

    9.05

    9.1

    9.15

    9.2

    9.25

    9.3

    9.35

    9.4

    9.45

    9.5

    9.55

    9.6

    9.65

    9.7

    9.75

    9.8

    9.85

    9.9

    9.95

    10

    Averaged

    95.256

    95.255999992

    95.2559997036

    95.2559975429

    95.2559889819

    95.255964715

    95.2559086729

    95.2557959233

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    95.2552430134

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    95.2538439627

    95.2526056627

    95.2508469419

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    Sheet1

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    y2.8211.055.1713.112.458.393.313.092.413.092.652.168.096.024.435.216

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    9.4516.0734636816.040077585116.775255121215.935825577821.05804762620.17462952534.9065351820.781264172634.709781717215.43688508113.666030040325.861076938110.64239866215.494935032624.084543802212.5399943433

    9.515.988531618916.040073190416.753264944415.934099817720.87272379940.17442903584.825780336420.68535037434.607411596915.358978055513.531706744125.762217203710.640627616615.462964513223.916642074412.5088541938

    9.5515.905105532216.040069065716.731965911315.932497514120.68976776250.17423821344.746700529820.591240989634.506537746815.282580042913.39951096825.664720654610.638939234215.432130117623.752716179612.4786940179

    9.615.823153498616.040065193316.71133314415.931009260820.5091467960.17405654494.669254693920.498896349534.407134137315.207656360413.269403274625.568564111510.637329256715.40238653323.592667143712.4494786591

    9.6515.742644357616.040061556416.691342766315.929626411720.3308285650.17388354694.593402895820.408277739534.309175233215.134173221113.141345011625.473724844710.635793665515.373690431523.436398263412.4211743633

    9.715.663547690816.040058139616.671971859615.928341015320.15478112020.17371876394.519106302220.319347378134.212635984315.062097709613.015298297225.380180565110.634328667115.346000376723.283815077812.3937487181

    9.7515.585833802616.040054928716.653198420815.927145756319.9809728980.17356176654.446327146920.232068393334.117491816714.991397757212.891226005325.28790941510.632930679215.319276734723.134825339112.3671705949

    9.815.509473702516.040051910116.635001322415.926033901519.80937272030.17341214964.37502869920.146404800334.023718623414.922042119412.769091751325.196889959410.631596318415.293481589622.98933898112.3414100931

    9.8515.434439087116.040049071516.617360273515.924999251119.63994979460.17326953144.305175232620.0623214833.931292756114.85400035312.648859877825.10710117710.630322387915.268578663322.847268086112.3164384877

    9.915.360702322516.040046401416.600255784315.924036094119.47267371260.17313355144.236731996719.97978415733.840191016414.787242793812.530495440425.018522452110.629105866315.244533239222.708526852112.292228179

    9.9515.288236427516.040043888916.583669130915.923139167519.30751445010.17300386944.169665186619.898759379133.750390647214.721740535312.413964194224.931133565610.627943897515.221312089422.573031556512.2687526439

    1015.217015057316.040041524116.567582321915.92230361919.14444236520.17288016424.10394191619.819214496933.661869324214.657465407912.299232579624.844914687710.626833780515.198883405722.440700520812.2459863907

    Sheet2

    Sheet3

  • Interindividual variability ineffect/effect-site concentration relation

    0

    10

    20

    30

    40

    50

    60

    70

    80

    90

    100

    0 1 2 3 4 5 6 7 8 9 10

    Average curve :Ce50 = 4.17 µg/ml ; γ = 5.21 ; E0 = 95 ; Emax = 12

    Mortier et al. Anaesthesia 1998; 53: 749-54.

    BIS

    CePROP

    Chart1

    0000000000000000

    0.050.050.050.050.050.050.050.050.050.050.050.050.050.050.050.05

    0.10.10.10.10.10.10.10.10.10.10.10.10.10.10.10.1

    0.150.150.150.150.150.150.150.150.150.150.150.150.150.150.150.15

    0.20.20.20.20.20.20.20.20.20.20.20.20.20.20.20.2

    0.250.250.250.250.250.250.250.250.250.250.250.250.250.250.250.25

    0.30.30.30.30.30.30.30.30.30.30.30.30.30.30.30.3

    0.350.350.350.350.350.350.350.350.350.350.350.350.350.350.350.35

    0.40.40.40.40.40.40.40.40.40.40.40.40.40.40.40.4

    0.450.450.450.450.450.450.450.450.450.450.450.450.450.450.450.45

    0.50.50.50.50.50.50.50.50.50.50.50.50.50.50.50.5

    0.550.550.550.550.550.550.550.550.550.550.550.550.550.550.550.55

    0.60.60.60.60.60.60.60.60.60.60.60.60.60.60.60.6

    0.650.650.650.650.650.650.650.650.650.650.650.650.650.650.650.65

    0.70.70.70.70.70.70.70.70.70.70.70.70.70.70.70.7

    0.750.750.750.750.750.750.750.750.750.750.750.750.750.750.750.75

    0.80.80.80.80.80.80.80.80.80.80.80.80.80.80.80.8

    0.850.850.850.850.850.850.850.850.850.850.850.850.850.850.850.85

    0.90.90.90.90.90.90.90.90.90.90.90.90.90.90.90.9

    0.950.950.950.950.950.950.950.950.950.950.950.950.950.950.950.95

    1111111111111111

    1.051.051.051.051.051.051.051.051.051.051.051.051.051.051.051.05

    1.11.11.11.11.11.11.11.11.11.11.11.11.11.11.11.1

    1.151.151.151.151.151.151.151.151.151.151.151.151.151.151.151.15

    1.21.21.21.21.21.21.21.21.21.21.21.21.21.21.21.2

    1.251.251.251.251.251.251.251.251.251.251.251.251.251.251.251.25

    1.31.31.31.31.31.31.31.31.31.31.31.31.31.31.31.3

    1.351.351.351.351.351.351.351.351.351.351.351.351.351.351.351.35

    1.41.41.41.41.41.41.41.41.41.41.41.41.41.41.41.4

    1.451.451.451.451.451.451.451.451.451.451.451.451.451.451.451.45

    1.51.51.51.51.51.51.51.51.51.51.51.51.51.51.51.5

    1.551.551.551.551.551.551.551.551.551.551.551.551.551.551.551.55

    1.61.61.61.61.61.61.61.61.61.61.61.61.61.61.61.6

    1.651.651.651.651.651.651.651.651.651.651.651.651.651.651.651.65

    1.71.71.71.71.71.71.71.71.71.71.71.71.71.71.71.7

    1.751.751.751.751.751.751.751.751.751.751.751.751.751.751.751.75

    1.81.81.81.81.81.81.81.81.81.81.81.81.81.81.81.8

    1.851.851.851.851.851.851.851.851.851.851.851.851.851.851.851.85

    1.91.91.91.91.91.91.91.91.91.91.91.91.91.91.91.9

    1.951.951.951.951.951.951.951.951.951.951.951.951.951.951.951.95

    2222222222222222

    2.052.052.052.052.052.052.052.052.052.052.052.052.052.052.052.05

    2.12.12.12.12.12.12.12.12.12.12.12.12.12.12.12.1

    2.152.152.152.152.152.152.152.152.152.152.152.152.152.152.152.15

    2.22.22.22.22.22.22.22.22.22.22.22.22.22.22.22.2

    2.252.252.252.252.252.252.252.252.252.252.252.252.252.252.252.25

    2.32.32.32.32.32.32.32.32.32.32.32.32.32.32.32.3

    2.352.352.352.352.352.352.352.352.352.352.352.352.352.352.352.35

    2.42.42.42.42.42.42.42.42.42.42.42.42.42.42.42.4

    2.452.452.452.452.452.452.452.452.452.452.452.452.452.452.452.45

    2.52.52.52.52.52.52.52.52.52.52.52.52.52.52.52.5

    2.552.552.552.552.552.552.552.552.552.552.552.552.552.552.552.55

    2.62.62.62.62.62.62.62.62.62.62.62.62.62.62.62.6

    2.652.652.652.652.652.652.652.652.652.652.652.652.652.652.652.65

    2.72.72.72.72.72.72.72.72.72.72.72.72.72.72.72.7

    2.752.752.752.752.752.752.752.752.752.752.752.752.752.752.752.75

    2.82.82.82.82.82.82.82.82.82.82.82.82.82.82.82.8

    2.852.852.852.852.852.852.852.852.852.852.852.852.852.852.852.85

    2.92.92.92.92.92.92.92.92.92.92.92.92.92.92.92.9

    2.952.952.952.952.952.952.952.952.952.952.952.952.952.952.952.95

    3333333333333333

    3.053.053.053.053.053.053.053.053.053.053.053.053.053.053.053.05

    3.13.13.13.13.13.13.13.13.13.13.13.13.13.13.13.1

    3.153.153.153.153.153.153.153.153.153.153.153.153.153.153.153.15

    3.23.23.23.23.23.23.23.23.23.23.23.23.23.23.23.2

    3.253.253.253.253.253.253.253.253.253.253.253.253.253.253.253.25

    3.33.33.33.33.33.33.33.33.33.33.33.33.33.33.33.3

    3.353.353.353.353.353.353.353.353.353.353.353.353.353.353.353.35

    3.43.43.43.43.43.43.43.43.43.43.43.43.43.43.43.4

    3.453.453.453.453.453.453.453.453.453.453.453.453.453.453.453.45

    3.53.53.53.53.53.53.53.53.53.53.53.53.53.53.53.5

    3.553.553.553.553.553.553.553.553.553.553.553.553.553.553.553.55

    3.63.63.63.63.63.63.63.63.63.63.63.63.63.63.63.6

    3.653.653.653.653.653.653.653.653.653.653.653.653.653.653.653.65

    3.73.73.73.73.73.73.73.73.73.73.73.73.73.73.73.7

    3.753.753.753.753.753.753.753.753.753.753.753.753.753.753.753.75

    3.83.83.83.83.83.83.83.83.83.83.83.83.83.83.83.8

    3.853.853.853.853.853.853.853.853.853.853.853.853.853.853.853.85

    3.93.93.93.93.93.93.93.93.93.93.93.93.93.93.93.9

    3.953.953.953.953.953.953.953.953.953.953.953.953.953.953.953.95

    4444444444444444

    4.054.054.054.054.054.054.054.054.054.054.054.054.054.054.054.05

    4.14.14.14.14.14.14.14.14.14.14.14.14.14.14.14.1

    4.154.154.154.154.154.154.154.154.154.154.154.154.154.154.154.15

    4.24.24.24.24.24.24.24.24.24.24.24.24.24.24.24.2

    4.254.254.254.254.254.254.254.254.254.254.254.254.254.254.254.25

    4.34.34.34.34.34.34.34.34.34.34.34.34.34.34.34.3

    4.354.354.354.354.354.354.354.354.354.354.354.354.354.354.354.35

    4.44.44.44.44.44.44.44.44.44.44.44.44.44.44.44.4

    4.454.454.454.454.454.454.454.454.454.454.454.454.454.454.454.45

    4.54.54.54.54.54.54.54.54.54.54.54.54.54.54.54.5

    4.554.554.554.554.554.554.554.554.554.554.554.554.554.554.554.55

    4.64.64.64.64.64.64.64.64.64.64.64.64.64.64.64.6

    4.654.654.654.654.654.654.654.654.654.654.654.654.654.654.654.65

    4.74.74.74.74.74.74.74.74.74.74.74.74.74.74.74.7

    4.754.754.754.754.754.754.754.754.754.754.754.754.754.754.754.75

    4.84.84.84.84.84.84.84.84.84.84.84.84.84.84.84.8

    4.854.854.854.854.854.854.854.854.854.854.854.854.854.854.854.85

    4.94.94.94.94.94.94.94.94.94.94.94.94.94.94.94.9

    4.954.954.954.954.954.954.954.954.954.954.954.954.954.954.954.95

    5555555555555555

    5.055.055.055.055.055.055.055.055.055.055.055.055.055.055.055.05

    5.15.15.15.15.15.15.15.15.15.15.15.15.15.15.15.1

    5.155.155.155.155.155.155.155.155.155.155.155.155.155.155.155.15

    5.25.25.25.25.25.25.25.25.25.25.25.25.25.25.25.2

    5.255.255.255.255.255.255.255.255.255.255.255.255.255.255.255.25

    5.35.35.35.35.35.35.35.35.35.35.35.35.35.35.35.3

    5.355.355.355.355.355.355.355.355.355.355.355.355.355.355.355.35

    5.45.45.45.45.45.45.45.45.45.45.45.45.45.45.45.4

    5.455.455.455.455.455.455.455.455.455.455.455.455.455.455.455.45

    5.55.55.55.55.55.55.55.55.55.55.55.55.55.55.55.5

    5.555.555.555.555.555.555.555.555.555.555.555.555.555.555.555.55

    5.65.65.65.65.65.65.65.65.65.65.65.65.65.65.65.6

    5.655.655.655.655.655.655.655.655.655.655.655.655.655.655.655.65

    5.75.75.75.75.75.75.75.75.75.75.75.75.75.75.75.7

    5.755.755.755.755.755.755.755.755.755.755.755.755.755.755.755.75

    5.85.85.85.85.85.85.85.85.85.85.85.85.85.85.85.8

    5.855.855.855.855.855.855.855.855.855.855.855.855.855.855.855.85

    5.95.95.95.95.95.95.95.95.95.95.95.95.95.95.95.9

    5.955.955.955.955.955.955.955.955.955.955.955.955.955.955.955.95

    6666666666666666

    6.056.056.056.056.056.056.056.056.056.056.056.056.056.056.056.05

    6.16.16.16.16.16.16.16.16.16.16.16.16.16.16.16.1

    6.156.156.156.156.156.156.156.156.156.156.156.156.156.156.156.15

    6.26.26.26.26.26.26.26.26.26.26.26.26.26.26.26.2

    6.256.256.256.256.256.256.256.256.256.256.256.256.256.256.256.25

    6.36.36.36.36.36.36.36.36.36.36.36.36.36.36.36.3

    6.356.356.356.356.356.356.356.356.356.356.356.356.356.356.356.35

    6.46.46.46.46.46.46.46.46.46.46.46.46.46.46.46.4

    6.456.456.456.456.456.456.456.456.456.456.456.456.456.456.456.45

    6.56.56.56.56.56.56.56.56.56.56.56.56.56.56.56.5

    6.556.556.556.556.556.556.556.556.556.556.556.556.556.556.556.55

    6.66.66.66.66.66.66.66.66.66.66.66.66.66.66.66.6

    6.656.656.656.656.656.656.656.656.656.656.656.656.656.656.656.65

    6.76.76.76.76.76.76.76.76.76.76.76.76.76.76.76.7

    6.756.756.756.756.756.756.756.756.756.756.756.756.756.756.756.75

    6.86.86.86.86.86.86.86.86.86.86.86.86.86.86.86.8

    6.856.856.856.856.856.856.856.856.856.856.856.856.856.856.856.85

    6.96.96.96.96.96.96.96.96.96.96.96.96.96.96.96.9

    6.956.956.956.956.956.956.956.956.956.956.956.956.956.956.956.95

    7777777777777777

    7.057.057.057.057.057.057.057.057.057.057.057.057.057.057.057.05

    7.17.17.17.17.17.17.17.17.17.17.17.17.17.17.17.1

    7.157.157.157.157.157.157.157.157.157.157.157.157.157.157.157.15

    7.27.27.27.27.27.27.27.27.27.27.27.27.27.27.27.2

    7.257.257.257.257.257.257.257.257.257.257.257.257.257.257.257.25

    7.37.37.37.37.37.37.37.37.37.37.37.37.37.37.37.3

    7.357.357.357.357.357.357.357.357.357.357.357.357.357.357.357.35

    7.47.47.47.47.47.47.47.47.47.47.47.47.47.47.47.4

    7.457.457.457.457.457.457.457.457.457.457.457.457.457.457.457.45

    7.57.57.57.57.57.57.57.57.57.57.57.57.57.57.57.5

    7.557.557.557.557.557.557.557.557.557.557.557.557.557.557.557.55

    7.67.67.67.67.67.67.67.67.67.67.67.67.67.67.67.6

    7.657.657.657.657.657.657.657.657.657.657.657.657.657.657.657.65

    7.77.77.77.77.77.77.77.77.77.77.77.77.77.77.77.7

    7.757.757.757.757.757.757.757.757.757.757.757.757.757.757.757.75

    7.87.87.87.87.87.87.87.87.87.87.87.87.87.87.87.8

    7.857.857.857.857.857.857.857.857.857.857.857.857.857.857.857.85

    7.97.97.97.97.97.97.97.97.97.97.97.97.97.97.97.9

    7.957.957.957.957.957.957.957.957.957.957.957.957.957.957.957.95

    8888888888888888

    8.058.058.058.058.058.058.058.058.058.058.058.058.058.058.058.05

    8.18.18.18.18.18.18.18.18.18.18.18.18.18.18.18.1

    8.158.158.158.158.158.158.158.158.158.158.158.158.158.158.158.15

    8.28.28.28.28.28.28.28.28.28.28.28.28.28.28.28.2

    8.258.258.258.258.258.258.258.258.258.258.258.258.258.258.258.25

    8.38.38.38.38.38.38.38.38.38.38.38.38.38.38.38.3

    8.358.358.358.358.358.358.358.358.358.358.358.358.358.358.358.35

    8.48.48.48.48.48.48.48.48.48.48.48.48.48.48.48.4

    8.458.458.458.458.458.458.458.458.458.458.458.458.458.458.458.45

    8.58.58.58.58.58.58.58.58.58.58.58.58.58.58.58.5

    8.558.558.558.558.558.558.558.558.558.558.558.558.558.558.558.55

    8.68.68.68.68.68.68.68.68.68.68.68.68.68.68.68.6

    8.658.658.658.658.658.658.658.658.658.658.658.658.658.658.658.65

    8.78.78.78.78.78.78.78.78.78.78.78.78.78.78.78.7

    8.758.758.758.758.758.758.758.758.758.758.758.758.758.758.758.75

    8.88.88.88.88.88.88.88.88.88.88.88.88.88.88.88.8

    8.858.858.858.858.858.858.858.858.858.858.858.858.858.858.858.85

    8.98.98.98.98.98.98.98.98.98.98.98.98.98.98.98.9

    8.958.958.958.958.958.958.958.958.958.958.958.958.958.958.958.95

    9999999999999999

    9.059.059.059.059.059.059.059.059.059.059.059.059.059.059.059.05

    9.19.19.19.19.19.19.19.19.19.19.19.19.19.19.19.1

    9.159.159.159.159.159.159.159.159.159.159.159.159.159.159.159.15

    9.29.29.29.29.29.29.29.29.29.29.29.29.29.29.29.2

    9.259.259.259.259.259.259.259.259.259.259.259.259.259.259.259.25

    9.39.39.39.39.39.39.39.39.39.39.39.39.39.39.39.3

    9.359.359.359.359.359.359.359.359.359.359.359.359.359.359.359.35

    9.49.49.49.49.49.49.49.49.49.49.49.49.49.49.49.4

    9.459.459.459.459.459.459.459.459.459.459.459.459.459.459.459.45

    9.59.59.59.59.59.59.59.59.59.59.59.59.59.59.59.5

    9.559.559.559.559.559.559.559.559.559.559.559.559.559.559.559.55

    9.69.69.69.69.69.69.69.69.69.69.69.69.69.69.69.6

    9.659.659.659.659.659.659.659.659.659.659.659.659.659.659.659.65

    9.79.79.79.79.79.79.79.79.79.79.79.79.79.79.79.7

    9.759.759.759.759.759.759.759.759.759.759.759.759.759.759.759.75

    9.89.89.89.89.89.89.89.89.89.89.89.89.89.89.89.8

    9.859.859.859.859.859.859.859.859.859.859.859.859.859.859.859.85

    9.99.99.99.99.99.99.99.99.99.99.99.99.99.99.99.9

    9.959.959.959.959.959.959.959.959.959.959.959.959.959.959.959.95

    10101010101010101010101010101010

    StudCL1120000111

    studcl119990521

    studcl219990521

    CLSTUD1019991103

    CLstud1220000215

    CLSTUD1320000223

    CLSTUD1420000228

    CLSTUD1520000306

    clstud319990607

    clstud4

    CLSTUD519990616

    CLSTUD619990618

    CLSTUD719990702

    CLSTUD819991001

    CLSTUD919991103

    Averaged

    92

    95.79

    96.9

    97.7

    90.37

    96.22

    97.53

    95.66

    97.66

    93.8

    95.66

    97.25

    88.89

    97.59

    95.82

    95.256

    91.9996180643

    95.79

    96.8999999866

    97.7

    90.3691163866

    96.22

    97.5299462974

    95.659912514

    97.6584008304

    93.7998820698

    95.6593541954

    97.2429202054

    88.89

    97.5899999999

    95.8199999416

    95.255999992

    91.99730299

    95.79

    96.8999995187

    97.7

    90.3651720117

    96.2199999999

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    95.6592550659

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    93.7989958397

    95.6559466443

    97.2183689007

    88.89

    97.5899999915

    95.8199987411

    95.2559997036

    91.9915388492

    95.79

    96.8999960843

    97.7

    90.3569638595

    96.2199999984

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    97.6374248517

    93.796485108

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    97.1741012181

    88.8899999996

    97.5899999029

    95.8199924129

    95.2559975429

    91.9809585191

    95.79

    96.8999826724

    97.7

    90.3436255935

    96.2199999822

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    95.6536573516

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    96.899945076

    97.7

    90.3244470019

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    97.7

    90.2988157895

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    88.8899998907

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    91.9078105963

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    96.8996872171

    97.7

    90.2661895309

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    97.7

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    97.7

    90.178041785

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    97.7

    90.1216684205

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    95.5525108477

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    93.6551656591

    95.3724202736

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    97.7

    90.0565849518

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    93.6056802204

    95.2901182261

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    97.6999999999

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    93.5459191329

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