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Brook K, Agarwala AV, Li F, Purdon PL. Depth of anesthesia monitoring: an argument for its use for patient safety. Curr Opin Anaesthesiol 2024:00001503-990000000-00230. [PMID: 39248004 DOI: 10.1097/aco.0000000000001430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2024]
Abstract
PURPOSE OF REVIEW There have been significant advancements in depth of anesthesia (DoA) technology. The Anesthesia Patient Safety Foundation recently published recommendations to use a DoA monitor in specific patient populations receiving general anesthesia. However, the universal use of DoA monitoring is not yet accepted. This review explores the current state of DoA monitors and their potential impact on patient safety. RECENT FINDINGS We reviewed the current evidence for using a DoA monitor and its potential role in preventing awareness and preserving brain health by decreasing the incidence of postoperative delirium and postoperative cognitive dysfunction or decline (POCD). We also explored the evidence for use of DoA monitors in improving postoperative clinical indicators such as organ dysfunction, mortality and length of stay. We discuss the use of DoA monitoring in the pediatric population, as well as highlight the current limitations of DoA monitoring and the path forward. SUMMARY There is evidence that DoA monitoring may decrease the incidence of awareness, postoperative delirium, POCD and improve several postoperative outcomes. In children, DoA monitoring may decrease the incidence of awareness and emergence delirium, but long-term effects are unknown. While there are key limitations to DoA monitoring technology, we argue that DoA monitoring shows great promise in improving patient safety in most, if not all anesthetic populations.
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Affiliation(s)
- Karolina Brook
- Department of Anesthesiology, Boston Medical Center
- Department of Anesthesiology, Boston University Chobanian & Avedisian School of Medicine
| | - Aalok V Agarwala
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital
- Harvard Medical School, Boston, Massachusetts
| | - Fenghua Li
- Department of Anesthesiology, Norton College of Medicine, SUNY Upstate Medical University, Syracuse, New York
| | - Patrick L Purdon
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford Medicine, Palo Alto, California, USA
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Yu R, Zhou Z, Xu M, Gao M, Zhu M, Wu S, Gao X, Bin G. SQI-DOANet: electroencephalogram-based deep neural network for estimating signal quality index and depth of anaesthesia. J Neural Eng 2024; 21:046031. [PMID: 39029477 DOI: 10.1088/1741-2552/ad6592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 07/19/2024] [Indexed: 07/21/2024]
Abstract
Objective. Monitoring the depth of anaesthesia (DOA) during surgery is of critical importance. However, during surgery electroencephalography (EEG) is usually subject to various disturbances that affect the accuracy of DOA. Therefore, accurately estimating noise in EEG and reliably assessing DOA remains an important challenge. In this paper, we proposed a signal quality index (SQI) network (SQINet) for assessing the EEG signal quality and a DOA network (DOANet) for analyzing EEG signals to precisely estimate DOA. The two networks are termed SQI-DOANet.Approach. The SQINet contained a shallow convolutional neural network to quickly determine the quality of the EEG signal. The DOANet comprised a feature extraction module for extracting features, a dual attention module for fusing multi-channel and multi-scale information, and a gated multilayer perceptron module for extracting temporal information. The performance of the SQI-DOANet model was validated by training and testing the model on the large VitalDB database, with the bispectral index (BIS) as the reference standard.Main results. The proposed DOANet yielded a Pearson correlation coefficient with the BIS score of 0.88 in the five-fold cross-validation, with a mean absolute error (MAE) of 4.81. The mean Pearson correlation coefficient of SQI-DOANet with the BIS score in the five-fold cross-validation was 0.82, with an MAE of 5.66.Significance. The SQI-DOANet model outperformed three compared methods. The proposed SQI-DOANet may be used as a new deep learning method for DOA estimation. The code of the SQI-DOANet will be made available publicly athttps://github.com/YuRui8879/SQI-DOANet.
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Affiliation(s)
- Rui Yu
- Department of Biomedical Engineering, College of Chemistry and Life Science, Beijing University of Technology, Beijing 100124, People's Republic of China
| | - Zhuhuang Zhou
- Department of Biomedical Engineering, College of Chemistry and Life Science, Beijing University of Technology, Beijing 100124, People's Republic of China
| | - Meng Xu
- Faculty of Information Technology, Beijing University of Technology, Beijing 100124, People's Republic of China
| | - Meng Gao
- Department of Biomedical Engineering, College of Chemistry and Life Science, Beijing University of Technology, Beijing 100124, People's Republic of China
| | - Meitong Zhu
- Department of Biomedical Engineering, College of Chemistry and Life Science, Beijing University of Technology, Beijing 100124, People's Republic of China
| | - Shuicai Wu
- Department of Biomedical Engineering, College of Chemistry and Life Science, Beijing University of Technology, Beijing 100124, People's Republic of China
| | - Xiaorong Gao
- Department of Biomedical Engineering, Tsinghua University, Beijing 100084, People's Republic of China
| | - Guangyu Bin
- Department of Biomedical Engineering, College of Chemistry and Life Science, Beijing University of Technology, Beijing 100124, People's Republic of China
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Ren L, Yang J, Li Y, Wang Y. Effect of Continuous Infusion of Different Doses of Esketamine on the Bispectral Index During Sevoflurane Anesthesia: A Randomized Controlled Trial. Drug Des Devel Ther 2024; 18:1727-1741. [PMID: 38803563 PMCID: PMC11129705 DOI: 10.2147/dddt.s457625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 05/13/2024] [Indexed: 05/29/2024] Open
Abstract
Purpose To investigate and quantify the effect of continuous esketamine infusion at different doses on the bispectral index (BIS) during sevoflurane anesthesia. Methods A total of 120 patients scheduled for elective laparoscopic renal surgery were randomly divided into three groups. Under steady anesthesia and surgical situations, the patient was started on continuous infusion of the study drug: 0.125 mg/kg/h esketamine (group E1), 0.25 mg/kg/h esketamine (group E2), and the same volume of saline (group C). The primary outcome was changes in BIS value after 15 min (T15), 30 min (T30), 45 min (T45), and 60 min (T60) of drug infusion. The secondary outcomes were 95% spectral edge frequency (SEF95), electromyogram (EMG), heart rate (HR), and mean arterial pressure (MAP) from T0 to T60. Furthermore, postoperative pain, postoperative recovery, and perioperative adverse events were evaluated. Results Compared with group C, group E1 exhibited significant BIS elevation at T30-T60 and group E2 at T15-T60 (P < 0.001). Compared with group E1, group E2 showed a more significant BIS elevation at T15-T60 (P < 0.001). The area under the curve (AUC) of BIS and SEF95 were significantly higher in group E2 than in groups C and E1 (P < 0.05). BIS value for any of the three groups was significantly correlated with SEF95 (P < 0.001). No significant differences were observed in the AUC of EMG, HR, and MAP among the three groups. Intraoperative remifentanil consumption and postoperative NRS of pain on movement were significantly reduced in group E2 compared with groups C and E1 (P < 0.05). Conclusion Continuous infusion of both 0.125 and 0.25 mg/kg/h of esketamine increased the BIS value during sevoflurane anesthesia, and the BIS value gradually stabilized with the prolongation of the infusion time.
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Affiliation(s)
- Liyuan Ren
- Department of Anesthesiology, Pain and Perioperative Medicine, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, People’s Republic of China
| | - Jinjin Yang
- Department of Anesthesiology, Pain and Perioperative Medicine, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, People’s Republic of China
| | - Yanshuang Li
- Department of Anesthesiology, Pain and Perioperative Medicine, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, People’s Republic of China
| | - Yanping Wang
- Department of Anesthesiology, Pain and Perioperative Medicine, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, People’s Republic of China
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Huang WK, Lian WY, Zhuo XY, Kang SY, Luo WC, Xie YS, Xi GY, Liu KX, Liu WF. Association between cumulative duration of deep anesthesia and postoperative acute kidney injury after noncardiac surgeries: a retrospective observational study. Ren Fail 2023; 45:2287130. [PMID: 38031451 PMCID: PMC11001356 DOI: 10.1080/0886022x.2023.2287130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 11/19/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND Bispectral index (BIS) is a processed electroencephalography monitoring tool and is widely used in anesthetic depth monitoring. Deep anesthesia exposure may be associated with multiple adverse outcomes. However, the relationship between anesthetic depth and postoperative acute kidney injury (AKI) remains unclear. We sought to determine the effect of BIS-based deep anesthesia duration on postoperative AKI following noncardiac surgery. METHODS This retrospective study used data from the Vital Signs DataBase, including patients undergoing noncardiac surgeries with BIS monitoring. The BIS values were collected every second during anesthesia. Restricted cubic splines and logistic regression were used to assess the association between the cumulative duration of deep anesthesia and postoperative AKI. RESULTS 4774 patients were eligible, and 129 (2.7%) experienced postoperative AKI. Restricted cubic splines showed that a cumulative duration of BIS < 45 was nonlinearly associated with postoperative AKI (P-overall = 0.033 and P-non-linear = 0.023). Using the group with the duration of BIS < 45 less than 15 min as the reference, ORs of postoperative AKI were 2.59 (95% confidence interval [CI]:0.60 to 11.09, p = 0.200) in the 15-100 min group, and 4.04 (95%CI:0.92 to 17.76, p = 0.064) in the ≥ 100 min group after adjusting for preoperative and intraoperative covariates in multivariable logistic regression. CONCLUSIONS The cumulative duration of BIS < 45 was independently and nonlinearly associated with the risk of postoperative AKI in patients undergoing noncardiac surgery.
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Affiliation(s)
- Wen-Kao Huang
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Wan-Yi Lian
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xiao-Yu Zhuo
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Song-Yun Kang
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Wen-Chi Luo
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yi-Shan Xie
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Gui-Yang Xi
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Ke-Xuan Liu
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Wei-Feng Liu
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
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Payne T, Braithwaite H, McCulloch T, Paleologos M, Johnstone C, Wehrman J, Taylor J, Loadsman J, Wang AY, Sanders RD. Depth of anaesthesia and mortality after cardiac or noncardiac surgery: a systematic review and meta-analysis of randomised controlled trials. Br J Anaesth 2023; 130:e317-e329. [PMID: 36210184 DOI: 10.1016/j.bja.2022.08.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 07/25/2022] [Accepted: 08/24/2022] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Recent randomised controlled trials have failed to show a benefit in mortality by using processed electroencephalography (pEEG) to guide lighter anaesthesia. We performed a meta-analysis of mortality data from randomised trials of pEEG monitoring to assess the evidence of any protective effect of pEEG-guided light anaesthesia compared with deep anaesthesia in adults aged ≥18 yr. METHODS Our study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. In February 2022, we searched three databases (Cochrane CENTRAL, OVID Medline, EMBASE) for RCTs of pEEG monitoring that provided mortality data at 30 days, 90 days, and/or 1 yr or longer. RESULTS We included 16 articles from 12 RCTs with 48 827 total participants. We observed no statistically significant mortality reduction with light anaesthesia compared with deep anaesthesia in patients aged ≥18 yr when all studies were pooled (odds ratio [OR]=0.99; 95% confidence interval (CI), 0.92-1.08). This result did not change significantly when analysing mortality at 30 days, 90 days, 1 yr or longer. We observed no mortality benefit for pEEG monitoring compared with usual care (OR=1.02; 95% CI, 0.89-1.18), targeting higher pEEG index values compared with lower values (OR=0.89; 95% CI, 0.60-1.32), or low pEEG index value alerts compared with no alerts (OR=1.02; 95% CI, 0.41-2.52). CONCLUSIONS pEEG-guided lighter anaesthesia does not appear to reduce the risk of postoperative mortality. The absence of a plausible rationale for why deeper anaesthesia should increase mortality has hampered appropriate design of definitive clinical trials. CLINICAL TRIAL REGISTRATION CRD42022285195 (PROSPERO).
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Affiliation(s)
- Thomas Payne
- Central Clinical School Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, NSW, Australia.
| | - Hannah Braithwaite
- Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, NSW, Australia
| | - Tim McCulloch
- Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, NSW, Australia
| | - Michael Paleologos
- Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, NSW, Australia
| | - Charlotte Johnstone
- Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, NSW, Australia
| | - Jordan Wehrman
- Central Clinical School Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Jennifer Taylor
- Central Clinical School Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - John Loadsman
- Central Clinical School Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, NSW, Australia
| | - Andy Y Wang
- Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, NSW, Australia; Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, NSW, Australia
| | - Robert D Sanders
- Central Clinical School Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, NSW, Australia; NHMRC Clinical Trials Centre, University of Sydney, New South Wales, Australia; Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, NSW, Australia.
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Zhao S, Huang S, Zhong Q, Han L, Wang Y, Xu F, Ma L, Ding Y, Xia L, Chen X. Study of the Association of Single Nucleotide Polymorphisms in Candidate Genes With Sevoflurane. J Clin Pharmacol 2023; 63:91-104. [PMID: 35943164 DOI: 10.1002/jcph.2138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 08/03/2022] [Indexed: 01/07/2023]
Abstract
The susceptibility of different individuals to anesthetics varies widely, and sevoflurane is no exception. We hypothesized that polymorphisms in genes involved in pharmacokinetics and pharmacodynamics may explain this variation. A total of 151 individuals undergoing otorhinolaryngology surgery were included. The influence of genetic polymorphisms on sevoflurane sensitivity were investigated through SNaPshot technology. Individuals carrying KCNK2 rs6686529 G > C, MTRR rs3733784 TT, rs2307116 GG, or rs1801394 AA polymorphisms had a higher sensitivity to the sedative effect of sevoflurane than those without those polymorphisms. The univariate linear regression analysis indicated that MTRR rs3733784 TT, rs2307116 GG, and rs1801394 AA were potentially significant predictors of higher sensitivity to the sedative effect of sevoflurane. Moreover, CYP2E1 rs3813867 G > C and rs2031920 C > T, GABRG1 rs279858 T > C, KCNK3 rs1275988 CC, GRIN2B rs1806201 GG, MTRR rs2307116 G > A, and rs1801394 A > G were associated with a higher sensitivity to the cardiovascular effect of sevoflurane. Our results suggested that 9 single nucleotide polymorphisms in genes involved in metabolizing enzymes, transport proteins, target proteins of sevoflurane and folate metabolism may help to explain individual differences in the susceptibility to the sedative or cardiovascular effect of sevoflurane.
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Affiliation(s)
- Shuai Zhao
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Department of Anesthesiology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Shiqian Huang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qi Zhong
- Department of Anesthesiology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Linlin Han
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yafeng Wang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Feng Xu
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lulin Ma
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yuanyuan Ding
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Leiming Xia
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiangdong Chen
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Effects of anesthetic depth on postoperative pain and delirium: a meta-analysis of randomized controlled trials with trial sequential analysis. Chin Med J (Engl) 2022; 135:2805-2814. [PMID: 36728598 PMCID: PMC9944713 DOI: 10.1097/cm9.0000000000002449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Whether anesthetic depth affects postoperative outcomes remains controversial. This meta-analysis aimed to evaluate the effects of deep vs. light anesthesia on postoperative pain, cognitive function, recovery from anesthesia, complications, and mortality. METHODS PubMed, EMBASE, and Cochrane CENTRAL databases were searched until January 2022 for randomized controlled trials comparing deep and light anesthesia in adult surgical patients. The co-primary outcomes were postoperative pain and delirium (assessed using the confusion assessment method). We conducted a meta-analysis using a random-effects model. We assessed publication bias using the Begg's rank correlation test and Egger's linear regression. We evaluated the evidence using the trial sequential analysis and Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. We conducted subgroup analyses for pain scores at different postoperative time points and delirium according to cardiac or non-cardiac surgery. RESULTS A total of 26 trials with 10,743 patients were included. Deep anesthesia compared with light anesthesia (a mean difference in bispectral index of -12 to -11) was associated with lower pain scores at rest at 0 to 1 h postoperatively (weighted mean difference = -0.72, 95% confidence interval [CI] = -1.25 to -0.18, P = 0.009; moderate-quality evidence) and an increased incidence of postoperative delirium (24.95% vs. 15.92%; risk ratio = 1.57, 95% CI = 1.28-1.91, P < 0.0001; high-quality evidence). No publication bias was detected. For the exploratory secondary outcomes, deep anesthesia was associated with prolonged postoperative recovery, without affecting neurocognitive outcomes, major complications, or mortality. In the subgroup analyses, the deep anesthesia group had lower pain scores at rest and on movement during 24 h postoperatively, without statistically significant subgroup differences, and deep anesthesia was associated with an increased incidence of delirium after non-cardiac and cardiac surgeries, without statistically significant subgroup differences. CONCLUSIONS Deep anesthesia reduced early postoperative pain but increased postoperative delirium. The current evidence does not support the use of deep anesthesia in clinical practice.
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Ling L, Yang TX, Lee SWK. Effect of Anaesthesia Depth on Postoperative Delirium and Postoperative Cognitive Dysfunction in High-Risk Patients: A Systematic Review and Meta-Analysis. Cureus 2022; 14:e30120. [DOI: 10.7759/cureus.30120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2022] [Indexed: 11/07/2022] Open
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Ning M, Sun Y, Zhang H, Chen C, Sun L, Chen L, Xia Z, Lu Y. Effects of different anesthetic depth during propofol anesthesia on postoperative recovery 24 h after arthroscopic day surgery: A randomized clinical trial. Front Pharmacol 2022; 13:972793. [PMID: 36188531 PMCID: PMC9523434 DOI: 10.3389/fphar.2022.972793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 09/02/2022] [Indexed: 12/05/2022] Open
Abstract
Background: This study aimed to compare the effects of different depths of sedation during propofol anesthesia on postoperative recovery 24 h after knee arthroscopy day surgery in adult patients. Methods: This prospective randomized controlled trial involved 126 patients (ASA physical status 1–2) who were scheduled to undergo arthroscopic day surgery. Patients were randomly divided into two groups: the light-sedation (L-Group) or deep-sedation (D-Group). In the L-group, the bispectral index values were kept in the range of 50–59; in the D-group, the bispectral index values were maintained in the range of 40–49. The Quality of Recovery-15 (QoR-15) score assessed 24 h postoperatively using a 15-item questionnaire was the primary outcome. Secondary outcomes included Athens Insomnia Scale scores, postoperative pain scores, nausea or vomiting. Results: The total QoR-15 score 24 h postoperatively was similar in the two groups (L-group median:130, IQR [127–132] vs. D-group median:131, IQR [126–135], p = 0.089). But among the five dimensions of the QoR-15, physiological comfort was significantly better in the D-group than L-group (p < 0.001). The time to open eyes (p < 0.001), follow the command (p < 0.001) and to extubation (p < 0.001) after surgery in the L-group were shorter than the D-group. The Athens Insomnia Scale scores (p < 0.001) and incidence of dreaming (p = 0.041) at the first postoperative night in the L-group was significantly higher than those in the D-group. Propofol consumption in the L-group was less than D-group (p < 0.001). Conclusion: For patients undergoing arthroscopic day surgery, general anesthesia with high-bispectral-index (50–59) cannot improve the total QoR-15 score 24 h postoperatively after surgery, but can lessen propofol consumption, reduce the time of extubation and anesthesia recovery period, compared with low-bispectral-index (40–49). Patients exposed to general anesthesia with low-bispectral-index values (40–49) may have better quality sleep and physical comfort than those with high-bispectral-index values (50–59). Clinical Trial Registration:http://www.chictr.org.cn/showproj.aspx?proj=126526, identifier ChiCTR2100046340
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Affiliation(s)
- Meng Ning
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Yue Sun
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Hao Zhang
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Caiyun Chen
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Linglu Sun
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Lijian Chen
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
- *Correspondence: Yao Lu, ; Zhengyuan Xia, ; Lijian Chen,
| | - Zhengyuan Xia
- State Key Laboratory of Pharmaceutical Biotechnology, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
- Department of Anesthesiology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
- *Correspondence: Yao Lu, ; Zhengyuan Xia, ; Lijian Chen,
| | - Yao Lu
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
- Ambulatory Surgery Center, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
- *Correspondence: Yao Lu, ; Zhengyuan Xia, ; Lijian Chen,
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Li A, He Q, Li R, Chen Y, Xu W. Effect of Carbon Dioxide on Bispectral Index of EEG under Intravenous Target-Controlled Anesthesia Based on Intelligent Medical Treatment. JOURNAL OF HEALTHCARE ENGINEERING 2022; 2022:4696128. [PMID: 35388314 PMCID: PMC8977325 DOI: 10.1155/2022/4696128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 02/18/2022] [Accepted: 02/21/2022] [Indexed: 11/17/2022]
Abstract
Laparoscopic surgery has the advantages of less trauma and quick recovery, and it is more and more favored by surgeons and patients in clinical practice. However, the impact of carbon dioxide pneumoperitoneum on the body during laparoscopic surgery has attracted the attention of many scholars. Pneumoperitoneum can cause increased cerebral blood flow and increased intracranial pressure, cerebral metabolic rate is highly correlated with blood carbon dioxide partial pressure, and cerebral metabolism without cardiopulmonary bypass is linearly correlated with the depth of anesthesia. Electroencephalographic (EEG) bispectral index (BIS) is a signal analysis method, which can directly measure the effect of drugs on the cerebral cortex and reflect the depth of anesthesia. Based on this, this study takes smart medical treatment as the background and uses the improved BP neural network as a tool to explore the effect of carbon dioxide on EEG bispectral index under intravenous target-controlled anesthesia. The main purpose is to observe the correlation between arterial blood carbon dioxide partial pressure and EEG bispectral index under propofol target-controlled anesthesia during retroperitoneal laparoscopic surgery. The experimental results show that the model proposed in this study can efficiently and accurately obtain the size of the influencing factors, which provides a clinical basis for the anesthesia management and anesthesia depth regulation of carbon dioxide pneumoperitoneum laparoscopic surgery.
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Affiliation(s)
- Aizhi Li
- Yantai Yuhuangding Hospital, Anesthesiology Department, 264000 Shan Dong, China
| | - Qunhui He
- Yantai Yuhuangding Hospital, Anesthesiology Department, 264000 Shan Dong, China
| | - Rulin Li
- Yantai Zhifu Hospital, Anesthesiology Department, 264000 Shan Dong, China
| | - Yu Chen
- Yantai Yuhuangding Hospital, Anesthesiology Department, 264000 Shan Dong, China
| | - Weiwei Xu
- Yantai Yuhuangding Hospital, Anesthesiology Department, 264000 Shan Dong, China
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11
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Wei Y, Zhang D, Zuo Y. Metabolomics and Whole-Exome Sequencing in Patients with Differential Sensitivity to Sevoflurane: A Protocol for a Prospective Observational Trial. Front Pharmacol 2021; 12:621159. [PMID: 34790114 PMCID: PMC8591073 DOI: 10.3389/fphar.2021.621159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 10/18/2021] [Indexed: 02/05/2023] Open
Abstract
Introduction: Different sensitivity to volatile anesthetics in Drosophila, nematodes and mice is related to mutation of energy metabolism genes. In clinical practice, we find that the end-tidal sevoflurane concentration (ETsevo) differs among patients at the same depth of anesthesia, indicating that the sensitivity to sevoflurane varies among patients. However, the underlying mechanism remains unclear. The sensitivity of an anesthetic is associated with the postoperative outcomes of patients and the mechanism of action of volatile anesthetics. We therefore propose this protocol to determine whether differences in metabolite profile and genetic variations contribute to patients' sensitivity to volatile anesthetics. Methods and Analysis: This is a single-centre, prospective observational study. 720 patients undergoing abdominal surgery were included. General anesthesia was induced with inhaled sevoflurane, a bolus of sufentanil (0.2-0.4 μg/kg) and cis-atracurium (0.2-0.3 mg/kg). The end-tidal sevoflurane concentration (ETsevo) was adjusted to maintain a BIS (bispectral index) value between 40-60. The mean ETsevo from 20 min after endotracheal intubation to 2 h after the beginning of surgery (steady state) was calculated for each patient. Patients were further divided into a high-sensitivity group (mean ETsevo - SD) and a low-sensitivity group (mean ETsevo + SD) to investigate the sensitivity to sevoflurane. Cases were paired from the high-sensitivity group (group H) and low-sensitivity group (group L) according to age, sex, body mass index (BMI), ASA physical status classification, vital signs, BIS, ephedrine use, sufentanildose, and cis-atracurium dose at anesthesia induction and steady state. Differences in metabolite levels, single nucleotide polymorphisms (SNPs) and protein-coding gene sequence variations between group H and group L will be determined through plasma metabolomics, whole-exome sequencing (WES), genome-wide association study (GWAS), and bioinformatics analyses. These results will be analysed to determine the reasons for the differential sensitivity to sevoflurane in humans. Ethics and Dissemination: This prospective observational study protocol has received ethical approval from the Ethical Committee of West China Hospital of Sichuan University on May 19, 2017 (Approval No. 78). Informed consent will be obtained before patient enrolment. The results will be submitted to international peer-review journals. Trial Registration Number: ChiCTR1800014327.
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Affiliation(s)
- Yiyong Wei
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China.,Department of Anesthesiology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Donghang Zhang
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
| | - Yunxia Zuo
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
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12
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Origin of post-ictal and post-anesthesia adverse effects and possibly of SUDEP. Med Hypotheses 2021; 151:110591. [PMID: 33873149 DOI: 10.1016/j.mehy.2021.110591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 03/10/2021] [Accepted: 04/05/2021] [Indexed: 11/20/2022]
Abstract
The origin of post-ictal malfunctions is debatable. We want to propose a novel idea of a cause of these adverse results occurring following epileptic seizures and anesthesia. Previously we have put forward the idea that epileptic seizures termination is caused by the function of the glymphatic system in the brain. A new measurement shows that this system can be much faster than what was estimated before. Moreover, the method enabling this speeding was actually measured in brains of epilepsy subjects. So, the main objection to our model is relegated. As a possible consequence of the glymphatic process, there can be an excess cleaning of the brain's interstitial fluid. We discuss possible adverse results of this process. This over-cleaning (that can, to a lower extent, occur also during anesthesia) which results post-ictally from the previous overexpression of fluid materials by the neurons during their seizure operation, can reduce ingredients essential for regular neuronal functioning, thereby leading to function reduction and EEG suppression which last until those materials are replenished. We argue that this ingredients' scarcity is the cause of post-ictal generalized EEG suppression (PGES), of post-ictal immobility (PI) and possibly of Sudden Unexpected Death in Epilepsy Patients (SUDEP). Similarly, such cleaning can lead to morbidity and even mortality problems following anesthesia. If our assumption is correct, this understanding of the process of the problems' origin can lead to a method to remedy them by judicial supplement of the lost materials.
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Li J, Wei YY, Zhang DH. Postoperative recovery of patients with differential requirements for sevoflurane after abdominal surgery: A prospective observational clinical study. Medicine (Baltimore) 2021; 100:e24842. [PMID: 33663105 PMCID: PMC7909113 DOI: 10.1097/md.0000000000024842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 01/26/2021] [Indexed: 02/05/2023] Open
Abstract
An association between animals and volatile anaesthetic requirements has been shown; however, evidence related to the postoperative outcome of human patients is lacking. Our aim was to investigate whether there is a difference in the requirement for sevoflurane among people undergoing gastrointestinal surgery.We observed 390 adult patients who underwent gastrointestinal surgery with an American Society of Anesthesiologists physical status of I or II with an expected surgery duration of > 2 hours. We used the bispectral index (BIS) to guide the regulation of end-tidal sevoflurane concentration (ETsevo). The mean ETsevo from 20 minutes after endotracheal intubation to 2 hours after the start of surgery was calculated for all patients. Differential sevoflurane requirements were identified according to ETsevo. The BIS, ETsevo, heart rate, mean arterial pressure, dose of sufentanil and cisatracurium, tracheal extubation time, incidence of intraoperative awareness, and incidence of postoperative nausea and vomiting were compared between patients with a low requirement for sevoflurane (group L) and patients with a high requirement for sevoflurane (group H).The mean ETsevo of the 390 patients was 1.55% ± 0.26%. Based on our definition, patients with an ETsevo of < 1.29% were allocated to the low requirement group (group L; n = 69), while patients with an ETsevo of > 1.81% were allocated to the high requirement group (group H; n = 78). The ETsevo of group L was significantly lower than the ETsevo of group H (1.29% ± 0.014% vs 1.82% ± 0.017%, P < .001). There was no significant difference in the ETsevo, BIS, heart rate, mean arterial pressure, dose of sufentanil and cisatracurium, tracheal extubation time, incidence of intraoperative awareness, and incidence of postoperative nausea and vomiting. The tracheal extubation time in the L group was significantly shorter than that in the H group. No intraoperative awareness occurred.There was a significant difference in the requirement for sevoflurane in adult patients. The tracheal extubation time in group L was significantly shorter than that in group H.
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Affiliation(s)
- Jia Li
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Yi Yong Wei
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
- Department of Anesthesiology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Dong Hang Zhang
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
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14
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Wang D, Song Z, Zhang C, Chen P. Bispectral index monitoring of the clinical effects of propofol closed-loop target-controlled infusion: Systematic review and meta-analysis of randomized controlled trials. Medicine (Baltimore) 2021; 100:e23930. [PMID: 33530193 PMCID: PMC7850716 DOI: 10.1097/md.0000000000023930] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 10/07/2020] [Accepted: 11/27/2020] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND To investigate whether closed-loop systems under bispectral index anesthesia depth monitoring can reduce the intraoperative propofol dosage. METHODS All randomized controlled trials (RCTs) on reducing propofol dosage under closed-loop systems were collected, and the literature was screened out, the abstracts and full texts were carefully read, and the references were tracked, data extraction and quality evaluation were conducted on the included research, and the RevMan5.3 software was used for meta-analysis. The main results were propofol and the incidence of adverse reactions such as hypertensive hypotension and postoperative cognitive dysfunction. A total of 879 cases were included in 8 articles, including 450 occurrences in the closed-loop system group and 429 cases in the open-loop system group. RESULTS Compared with manual control, closed-loop systems under bispectral index anesthesia depth monitoring reduced the dose of propofol (MD: -0.62, 95% CI: -1.08--0.16, P = .008), with heterogeneity (I2 = 80%). Closed-loop systems significantly reduced the incidence of abnormal blood pressure (MD: -0.02, 95%CI: -0.05-0.01, P = .15, I2 = 74%) and postoperative cognitive dysfunction (MD: -0.08, 95% CI: -0.14 -0.01, P = .02, I2 = 94%). CONCLUSION Bispectral index monitoring of propofol closed-loop target-controlled infusion system can reduce the amount of propofol, reduce the incidence of adverse reactions such as hypertensive or hypotension and postoperative cognitive dysfunction.
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15
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Bienert A, Sobczyński P, Młodawska K, Hartmann-Sobczyńska R, Grześkowiak E, Wiczling P. The influence of cardiac output on propofol and fentanyl pharmacokinetics and pharmacodynamics in patients undergoing abdominal aortic surgery. J Pharmacokinet Pharmacodyn 2020; 47:583-596. [PMID: 32840723 PMCID: PMC7652808 DOI: 10.1007/s10928-020-09712-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 08/13/2020] [Indexed: 12/27/2022]
Abstract
Cardiac output (CO) is expected to affect elimination and distribution of highly extracted and perfusion rate-limited drugs. This work was undertaken to quantify the effect of CO measured by the pulse pressure method on pharmacokinetics and pharmacodynamics of propofol and fentanyl administrated during total intravenous anesthesia (TIVA). The data were obtained from 22 ASA III patients undergoing abdominal aortic surgery. Propofol was administered via target-controlled infusion system (Diprifusor) and fentanyl was administered at a dose of 2-3 µg/kg each time analgesia appeared to be inadequate. Hemodynamic measurements as well as bispectral index were monitored and recorded throughout the surgery. Data analysis was performed by using a non-linear mixed-effect population modeling (NONMEM 7.4 software). Three compartment models that incorporated blood flows as parameters were used to describe propofol and fentanyl pharmacokinetics. The delay of the anesthetic effect, with respect to plasma concentrations, was described using a biophase (effect) compartment. The bispectral index was linked to the propofol and fentanyl effect site concentrations through a synergistic Emax model. An empirical linear model was used to describe CO changes observed during the surgery. Cardiac output was identified as an important predictor of propofol and fentanyl pharmacokinetics. Consequently, it affected the depth of anesthesia and the recovery time after propofol-fentanyl TIVA infusion cessation. The model predicted (not observed) CO values correlated best with measured responses. Patients' age was identified as a covariate affecting the rate of CO changes during the anesthesia leading to age-related difference in individual patient's responses to both drugs.
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Affiliation(s)
- Agnieszka Bienert
- Department of Clinical Pharmacy and Biopharmacy, Poznan University of Medical Sciences, Sw. Marii Magdaleny 14 Street, 61-861, Poznan, Poland.
| | - Paweł Sobczyński
- Department of Anesthesiology and Intensive Therapy, Poznan University of Medical Sciences, 1/2 Długa Str., 61-848, Poznań, Poland
| | - Katarzyna Młodawska
- Department of Clinical Pharmacy and Biopharmacy, Poznan University of Medical Sciences, Sw. Marii Magdaleny 14 Street, 61-861, Poznan, Poland
| | - Roma Hartmann-Sobczyńska
- Department of Experimental Anaesthesiology, Poznan University of Medical Sciences, Sw. Marii Magdaleny 14 Street, 61-861, Poznan, Poland
| | - Edmund Grześkowiak
- Department of Clinical Pharmacy and Biopharmacy, Poznan University of Medical Sciences, Sw. Marii Magdaleny 14 Street, 61-861, Poznan, Poland
| | - Paweł Wiczling
- Department of Biopharmacy and Pharmacodynamics, Medical University of Gdansk, Hallera 107 Street, 80-416, Gdansk, Poland
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16
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Yoon S, Yoo S, Hur M, Park SK, Lee HC, Jung CW, Bahk JH, Kim JT. The cumulative duration of bispectral index less than 40 concurrent with hypotension is associated with 90-day postoperative mortality: a retrospective study. BMC Anesthesiol 2020; 20:200. [PMID: 32795266 PMCID: PMC7427057 DOI: 10.1186/s12871-020-01122-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 08/09/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The relationship between intraoperative low bispectral index (BIS) values and poor clinical outcomes has been controversial. Intraoperative hypotension is associated with postoperative complication. The purpose of this study was to investigate the influence of intraoperative low BIS values and hypotension on postoperative mortality in patients undergoing major abdominal surgery. METHODS This retrospective study analyzed 1862 cases of general anesthesia. We collected the cumulative time of BIS values below 20 and 40 as well as electroencephalographic suppression and documented the incidences in which these states were maintained for at least 5 min. Durations of intraoperative mean arterial pressures (MAP) less than 50 mmHg were also recorded. Multivariable logistic regression was used to evaluate the association between suspected risk factors and postoperative mortality. RESULTS Ninety-day mortality and 180-day mortality were 1.5 and 3.2% respectively. The cumulative time in minutes for BIS values falling below 40 coupled with MAP falling below 50 mmHg was associated with 90-day mortality (odds ratio, 1.26; 95% confidence interval, 1.04-1.53; P = .019). We found no association between BIS related values and 180-day mortality. CONCLUSIONS The cumulative duration of BIS values less than 40 concurrent with MAP less than 50 mmHg was associated with 90-day postoperative mortality, not 180-day postoperative mortality.
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Affiliation(s)
- Soohyuk Yoon
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Seokha Yoo
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Min Hur
- Department of Anesthesiology and Pain Medicine, Ajou University Hospital, 164 World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea
| | - Sun-Kyung Park
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Hyung-Chul Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Chul-Woo Jung
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Jae-Hyon Bahk
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Jin-Tae Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
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Charier D, Longrois D, Chapelle C, Salaün JP, Molliex S. Deep anaesthesia and postoperative death: Is the matter resolved? Anaesth Crit Care Pain Med 2020; 39:21-23. [PMID: 31891774 DOI: 10.1016/j.accpm.2019.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- David Charier
- Department of Anaesthesiology and Intensive Care, Jean-Monnet University, Saint-Etienne University Hospital, 42055 Saint-Etienne cedex 2, France
| | - Dan Longrois
- Department of Anaesthesiology and Intensive Care,Paris-Diderot University, Bichat-Claude Bernard Hospital, Paris Nord Val de Seine University Hospitals, Paris, France
| | - Celine Chapelle
- Clinical Research, Innovation and Pharmacology Unit, Jean-Monnet University, Saint-Etienne University Hospital, Saint-Etienne, France
| | - Jean Philippe Salaün
- Department of Anaesthesiology and Intensive Care, Caen Normandie University, Caen University Hospital, Caen, France; Junior Group - French Society of Anaesthesia and Intensive Care Medicine (SFAR), Paris, France
| | - Serge Molliex
- Department of Anaesthesiology and Intensive Care, Jean-Monnet University, Saint-Etienne University Hospital, 42055 Saint-Etienne cedex 2, France.
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18
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Galley HF, Webster NR. Deep anaesthesia and poor outcomes: the jury is still out. Lancet 2019; 394:1881-1882. [PMID: 31645289 DOI: 10.1016/s0140-6736(19)32465-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 10/09/2019] [Indexed: 12/26/2022]
Affiliation(s)
- Helen F Galley
- Institute of Medical Sciences, University of Aberdeen, Aberdeen AB25 2ZD, UK.
| | - Nigel R Webster
- Institute of Medical Sciences, University of Aberdeen, Aberdeen AB25 2ZD, UK
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