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Habib A, Gouchoe DA, Rosenheck JP, Mokadam NA, Henn MC, Nunley DR, Ramsammy V, Whitson BA, Ganapathi AM. Early Extubation: Who Qualifies Postoperatively in Lung Transplantation? J Surg Res 2024; 299:303-312. [PMID: 38788467 DOI: 10.1016/j.jss.2024.04.061] [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: 09/25/2023] [Revised: 03/30/2024] [Accepted: 04/21/2024] [Indexed: 05/26/2024]
Abstract
INTRODUCTION Early extubation has been adopted in many settings within cardiothoracic surgery, with several advantages for patients. We sought to determine the association of timing of extubation in lung transplant recipients' short- and long-term outcomes. METHODS Adult, primary lung transplants were identified from the United Network for Organ Sharing database. Recipients were stratified based on the duration of postoperative ventilation: 1) None (NV); 2) <5 Days (<5D); and 3) 5+ Days (5+D). Comparative statistics were performed, and both unadjusted and adjusted survival were analyzed with Kaplan-Meier Methods and a Cox proportional hazard model. A multivariable model including recipient, donor, and transplant characteristics was created to examine factors associated with NV. RESULTS 28,575 recipients were identified (NV = 960, <5D = 21,959, 5+D = 5656). The NV group had shorter median length of stay (P < 0.01) and lower incidence of postoperative dialysis (P < 0.01). The NV and <5D groups had similar survival, while 5+D recipients had decreased survival (P < 0.01). The multivariable model demonstrated increased donor BMI, center volume, ischemic time, single lung transplant, and transplantation between 2011 and 2015 were associated with NV (P < 0.01 for all). Use of donation after cardiac death donors and transplantation between 2016 and 2021 was associated with postoperative ventilator use. CONCLUSIONS Patients extubated early after lung transplantation have a shorter median length of stay without an associated increase in mortality. While not all patients are appropriate for earlier extubation, it is possible to extubate patients early following lung transplant. Further efforts are necessary to help expand this practice and ensure its' success for recipients.
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Affiliation(s)
- Alim Habib
- The Ohio State University College of Medicine, Columbus, Ohio
| | - Doug A Gouchoe
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Justin P Rosenheck
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Nahush A Mokadam
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Matthew C Henn
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - David R Nunley
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Verai Ramsammy
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Bryan A Whitson
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Asvin M Ganapathi
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio.
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Xie T, Wang Y, Liu Y, Li J, Li W, Xu H. Accuracy of closed-loop and open-loop propofol delivery systems by bispectral index monitoring in breast surgery patients: a prospective randomized trial. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2024; 74:744438. [PMID: 37247817 DOI: 10.1016/j.bjane.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 05/14/2023] [Accepted: 05/18/2023] [Indexed: 05/31/2023]
Abstract
BACKGROUND This randomized and controlled prospective study tested the hypothesis that closed-loop Target-Controlled Infusion (TCI) of propofol would be associated with better system performance when compared with open-loop controlled delivery of propofol. METHODS Patients scheduled for elective breast surgery were randomly assigned to two groups: a closed-loop group, in which propofol infusion was performed by a closed-loop TCI system that used the Bispectral Index (BIS) as a feedback parameter to titrate the rate of propofol infusion, and an open-loop group, in which propofol infusion was performed manually and guided by the bispectral index. RESULTS A total of 156 patients were recruited for this study (closed-loop group n = 79; open-loop group n = 77). The Global Score (GS) of the closed-loop group was lower than that of the open-loop group (34.3 and 42.2) (p = 0.044). The proportions of time with a BIS value between 40 and 60 were almost identical in the closed-loop group and the open-loop group (68.7 ± 10.6% and 66.7 ± 13.3%) (p = 0.318). The individuals in the closed-loop group consumed more propofol compared with those in the open-loop group (7.20 ± 1.65 mg.kg-1.h-1 vs. 6.03 ± 1.31 mg.kg-1.h-1, p < 0.001). No intraoperative recall, somatic events or adverse events occurred. No significant difference in heart rate was observed between the two groups (p = 0.169). CONCLUSION The closed-loop protocol was associated with lower BIS variability and lower out-of-range BIS values, at the cost of a greater consumption of propofol when compared to the open loop group. REGISTER NUMBER ChiCTR-INR-17010399.
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Affiliation(s)
- Tian Xie
- Forth Hospital of Hebei Medical University, Department of Anesthesiology, Hebei, China
| | - Yong Wang
- Forth Hospital of Hebei Medical University, Department of Anesthesiology, Hebei, China
| | - Yuhua Liu
- Forth Hospital of Hebei Medical University, Department of Anesthesiology, Hebei, China
| | - Junjie Li
- Forth Hospital of Hebei Medical University, Department of Anesthesiology, Hebei, China
| | - Weijing Li
- Forth Hospital of Hebei Medical University, Department of Anesthesiology, Hebei, China
| | - Hongmeng Xu
- Forth Hospital of Hebei Medical University, Department of Anesthesiology, Hebei, China.
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Anesthetic management in lung transplantation: Our single-center experience. TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2021; 29:191-200. [PMID: 34104513 PMCID: PMC8167475 DOI: 10.5606/tgkdc.dergisi.2021.9490] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 06/16/2020] [Indexed: 11/25/2022]
Abstract
Background
In this study, we aimed to discuss our anesthesia management strategies, experiences, and outcomes in patients undergoing lung transplantation.
Methods
Between December 2016 and December 2018, a total of 53 patients (43 males, 10 females; mean age: 46.1±13 years; range, 14 to 64 years) undergoing lung transplantation in our center were included. The anesthesia technique, patients" characteristics, and perioperative clinical and follow-up data were recorded. The stage of lung disease was assessed using the New York Heart Association functional classification.
Results
Two patients underwent single lung transplantation, while 51 patients underwent double lung transplantation. Idiopathic pulmonary fibrosis was the most common indication in 41.5% of the patients. All patients had end-stage lung disease (Class IV) and 79% were oxygen-dependent. The extracorporeal membrane oxygenation support was given to 32 patients.
Conclusion
The anesthetic management of lung transplantation is challenging, either due to the deterioration of the recipient"s physical performance and the complexity of the surgical techniques used. In general, a kind of mechanical support may be needed and extracorporeal membrane oxygenation is the first choice in the majority of patients. A close communication should be maintained between the surgeons, perfusion technicians, and anesthesiologists to ensure an optimal multidisciplinary approach and to achieve successful outcomes.
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Roux A, Sage E, Cerf C, Le Guen M, Picard C, Hamid AM, Parquin F, Stern M, Bonnette P. [Evolution and progress of lung transplantation: An analysis of a cohort of 600 lung transplant patients at the Hospital Foch]. Rev Mal Respir 2019; 36:142-154. [PMID: 30686555 DOI: 10.1016/j.rmr.2018.02.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 02/24/2018] [Indexed: 10/27/2022]
Abstract
Lung transplantation is deemed to be the only effective therapy that improves survival for patients with end stage lung disease. The aim of our study was to examine the progress achieved over the last two decades and to demonstrate the effectiveness and safety of this treatment. METHODS A retrospective analysis of a cohort of 600 consecutive lung transplant patients treated at the hospital Foch (Suresnes, France) between 1988 and 2014. They were split into three groups of 200 patients each: 1988-2004, 2004-2011, 2011-2014. RESULTS Time and mortality on waiting list, perioperative mortality, the incidence of acute rejection in the first year and chronic lung allograft dysfunction (CLAD) at 5 years posttransplantation, have all decreased. Global survival at 1 and 5 years for the 600 patients increased from 78% and 57% to 86% and 75% respectively for the 200 last patients. Patients with cystic fibrosis have a better 5 year survival than those with emphysema or pulmonary fibrosis (68% vs. 54 % for emphysema and 37% for fibrosis). For the last 200 patients, 5 year survival is 81% for CF patients, 78 % for emphysema and 47% for fibrosis. Emergency transplantation had a 60% 5 years survival. Proliferative complications, arterial hypertension and renal function impairment are being monitored long term. CONCLUSION The twenty-five years experience shows a consistent improvement in the results of lung transplantation which is now accepted as the only effective curative treatment for end stage lung disease.
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Affiliation(s)
- A Roux
- Service de pneumologie, hôpital Foch, 40, rue Worth, 92150 Suresnes, France.
| | - E Sage
- Chirurgie thoracique, hôpital Foch, Suresnes, France
| | - C Cerf
- Réanimation, hôpital Foch, Suresnes, France
| | - M Le Guen
- Anesthésiologie, hôpital Foch, Suresnes, France
| | - C Picard
- Service de pneumologie, hôpital Foch, 40, rue Worth, 92150 Suresnes, France
| | - A M Hamid
- Service de pneumologie, hôpital Foch, 40, rue Worth, 92150 Suresnes, France
| | - F Parquin
- Chirurgie thoracique, hôpital Foch, Suresnes, France
| | - M Stern
- Service de pneumologie, hôpital Foch, 40, rue Worth, 92150 Suresnes, France
| | - P Bonnette
- Chirurgie thoracique, hôpital Foch, Suresnes, France
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Restoux A, Grassin-Delyle S, Liu N, Paugam-Burtz C, Mantz J, Le Guen M. Pilot study of closed-loop anaesthesia for liver transplantation. Br J Anaesth 2018; 117:332-40. [PMID: 27543528 DOI: 10.1093/bja/aew262] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2016] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Automated titration of propofol and remifentanil guided by the bispectral index (BIS) has been used for numerous surgical procedures. Orthotopic liver transplantation (OLT) uniquely combines major changes in circulating volume, an anhepatic phase, and ischaemia-reperfusion syndrome. We assessed the behaviour of this automated controller during OLT. METHODS Adult patients undergoing OLT were included in this pilot study. Consumption of propofol and remifentanil was calculated for each surgery period (dissection, anhepatic, and liver reperfusion phases). Arterial blood samples were collected at several time points to allow comparison of actual with calculated propofol and remifentanil concentrations. Data are presented as median [25th and 75th percentiles] or percentage (95% confidence interval). RESULTS Thirteen patients were studied. System performance, defined as the percentage of time with BIS in the range 40-60, was 88% (86-94) of the total duration of anaesthesia. Propofol requirement was decreased during the anhepatic phase compared with the dissection phase (2.9 [1.9-5.0] mg kg(-1) h(-1) and 4.6 [3.5-8.1] mg kg(-1) h(-1); P<0.03) while remifentanil consumption was unchanged (0.11 [0.09-0.19] µg kg- (1) min(-1)). Bland-Altman analysis showed a weak concordance for propofol (bias of 0.7 µg ml(-1) and limits of agreement of -2.2 to +3.7 µg ml(-1)) and remifentanil (bias of 1.3 ng ml(-1) and limits of agreement -4.3 to +6.8 ng ml(-1)). No adverse events were reported during anaesthesia. CONCLUSIONS This pilot study indicates that automated titration of propofol and remifentanil guided by the BIS is feasible during OLT.
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Affiliation(s)
- A Restoux
- Department of Anaesthesia and Critical Care, Hôpital Beaujon, Clichy, France Université Paris VII Denis Diderot, France
| | - S Grassin-Delyle
- Department of Pharmacology Mass Spectrometry Facility, UFR Sciences de la Santé Simone Veil, Université Versailles Saint-Quentin en Yvelines, France
| | - N Liu
- Department of Anaesthesia, Hôpital Foch, Suresnes, France Université Versailles Saint-Quentin en Yvelines, France
| | - C Paugam-Burtz
- Department of Anaesthesia and Critical Care, Hôpital Beaujon, Clichy, France Université Paris VII Denis Diderot, France
| | - J Mantz
- Department of Anaesthesia and Critical Care, Hôpital Européen Georges Pompidou, Paris, France Université Paris Descartes, France
| | - M Le Guen
- Department of Anaesthesia, Hôpital Foch, Suresnes, France Université Versailles Saint-Quentin en Yvelines, France
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Assenzo V, Assenzo C, Filippo R, Le Guen M, Sage E, Roux A, Fischler M, Liu N. The feasibility of extubation in the operating room after bilateral lung transplantation in adult emphysema patients: an observational retrospective study. Eur J Cardiothorac Surg 2018; 54:1128-1133. [DOI: 10.1093/ejcts/ezy196] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 04/16/2018] [Indexed: 12/31/2022] Open
Affiliation(s)
- Valentina Assenzo
- Department of Anaesthesia, Foch Hospital, Suresnes, France
- Outcomes Research Consortium, Cleveland Clinic, Cleveland, OH, USA
| | | | | | - Morgan Le Guen
- Department of Anaesthesia, Foch Hospital, Suresnes, France
| | - Edouard Sage
- Department of Thoracic Surgery, Foch Hospital, Suresnes, France
| | - Antoine Roux
- Department of Pneumology, Foch Hospital, Suresnes, France
| | - Marc Fischler
- Department of Anaesthesia, Foch Hospital, Suresnes, France
| | - Ngai Liu
- Department of Anaesthesia, Foch Hospital, Suresnes, France
- Outcomes Research Consortium, Cleveland Clinic, Cleveland, OH, USA
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Brodie SM, Görges M, Ansermino JM, Dumont GA, Merchant RN. Closed-Loop Control of Total Intravenous Anesthesia During Significant Intraoperative Blood Loss. ACTA ACUST UNITED AC 2017; 9:239-243. [DOI: 10.1213/xaa.0000000000000576] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Ing R, Liu N, Chazot T, Fessler J, Dreyfus JF, Fischler M, Le Guen M. Nociceptive stimulation during Macintosh direct laryngoscopy compared with McGrath Mac videolaryngoscopy: A randomized trial using indirect evaluation using an automated administration of propofol and remifentanil. Medicine (Baltimore) 2017; 96:e8087. [PMID: 28930848 PMCID: PMC5617715 DOI: 10.1097/md.0000000000008087] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Decrease of the nociceptive stimulation induced by laryngoscopy could be an advantage for patients without risk of difficult intubation. The present study aimed to compare the difference in nociceptive stimulation between the use of a conventional laryngoscope or of a videolaryngoscope. Amount of nociception was assessed indirectly using the peak remifentanil concentration determined by a closed-loop administration of propofol and remifentanil with bispectral index (BIS) as the input signal (target 50). METHODS A prospective single-center randomized study was performed including surgical patients without predictable risk of difficult mask ventilation or of difficult tracheal intubation. Forty consecutive surgery patients were randomly assigned to CL group (conventional laryngoscope) or VL group (McGrath Mac videolaryngoscope). Induction of anesthesia was performed automatically using the closed-loop system and myorelaxation with atracurium. The allocation was revealed just before tracheal intubation. The primary outcome was the peak plasma remifentanil concentration observed during the 5-minute period which followed intubation. RESULTS Sixteen patients in the CL group and 11 in the VL group were analyzed. Plasmatic remifentanil and propofol concentrations were similar in both groups either before tracheal intubation or during the 5 minutes following intubation. There was a nonsignificant between-group difference (P = .09) for the peak concentration of remifentanil. A comparable result was observed for other outcomes except for the heart rate which increased in the CL group. CONCLUSION Use of the videolaryngoscope McGrath Mac did not reduce the nociceptive stimulation induced during intubation as evaluated by the automatically administered remifentanil concentration. TRIAL REGISTRATION ClinicalTrials.gov, NCT02245789.
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Affiliation(s)
- Rathvirak Ing
- Department of Anesthesiology and Critical Care Medicine, Avicenne University Hospital, Bobigny, France
- Paris-13 University, France
| | - Ngai Liu
- Department of Anesthesiology, Hospital Foch, Suresnes, France
- University Versailles Saint-Quentin en Yvelines, France
- Outcomes Research Consortium, Cleveland, Ohio
| | - Thierry Chazot
- Department of Anesthesiology, Hospital Foch, Suresnes, France
- University Versailles Saint-Quentin en Yvelines, France
| | - Julien Fessler
- Department of Anesthesiology, Hospital Foch, Suresnes, France
- University Versailles Saint-Quentin en Yvelines, France
| | | | - Marc Fischler
- Department of Anesthesiology, Hospital Foch, Suresnes, France
- University Versailles Saint-Quentin en Yvelines, France
| | - Morgan Le Guen
- Department of Anesthesiology, Hospital Foch, Suresnes, France
- University Versailles Saint-Quentin en Yvelines, France
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Merigo L, Beschi M, Padula F, Latronico N, Paltenghi M, Visioli A. Event-Based control of depth of hypnosis in anesthesia. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2017; 147:63-83. [PMID: 28734531 DOI: 10.1016/j.cmpb.2017.06.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 06/10/2017] [Accepted: 06/20/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND AND OBJECTIVE In this paper, we propose the use of an event-based control strategy for the closed-loop control of the depth of hypnosis in anesthesia by using propofol administration and the bispectral index as a controlled variable. METHODS A new event generator with high noise-filtering properties is employed in addition to a PIDPlus controller. The tuning of the parameters is performed off-line by using genetic algorithms by considering a given data set of patients. RESULTS The effectiveness and robustness of the method is verified in simulation by implementing a Monte Carlo method to address the intra-patient and inter-patient variability. A comparison with a standard PID control structure shows that the event-based control system achieves a reduction of the total variation of the manipulated variable of 93% in the induction phase and of 95% in the maintenance phase. CONCLUSIONS The use of event based automatic control in anesthesia yields a fast induction phase with bounded overshoot and an acceptable disturbance rejection. A comparison with a standard PID control structure shows that the technique effectively mimics the behavior of the anesthesiologist by providing a significant decrement of the total variation of the manipulated variable.
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Affiliation(s)
- Luca Merigo
- Dipartimento di Ingegneria dell'Informazione, University of Brescia, Italy.
| | - Manuel Beschi
- Istituto di Tecnologie Industriali e Automazione, National Research Council Milan, Italy.
| | - Fabrizio Padula
- Department of Mathematics and Statistics, Curtin University, Australia.
| | - Nicola Latronico
- Department of Surgery, Radiology, and Public Health,University of Brescia, Italy.
| | | | - Antonio Visioli
- Dipartimento di Ingegneria Meccanica e Industriale, University of Brescia, Italy.
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Yang Y, Shanechi MM. An adaptive and generalizable closed-loop system for control of medically induced coma and other states of anesthesia. J Neural Eng 2016; 13:066019. [DOI: 10.1088/1741-2560/13/6/066019] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Closed-loop control better than open-loop control of profofol TCI guided by BIS: a randomized, controlled, multicenter clinical trial to evaluate the CONCERT-CL closed-loop system. PLoS One 2015; 10:e0123862. [PMID: 25886041 PMCID: PMC4401751 DOI: 10.1371/journal.pone.0123862] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 02/18/2015] [Indexed: 11/18/2022] Open
Abstract
Background The CONCERT-CL closed-loop infusion system designed by VERYARK Technology Co., Ltd. (Guangxi, China) is an innovation using TCI combined with closed-loop controlled intravenous anesthesia under the guide of BIS. In this study we performed a randomized, controlled, multicenter study to compare closed-loop control and open-loop control of propofol by using the CONCERT-CL closed-loop infusion system. Methods 180 surgical patients from three medical centers undergone TCI intravenous anesthesia with propofol and remifentanil were randomly assigned to propofol closed-loop group and propofol opened-loop groups. Primary outcome was global score (GS, GS = (MDAPE+Wobble)/% of time of bispectral index (BIS) 40-60). Secondary outcomes were doses of the anesthetics and emergence time from anesthesia, such as, time to tracheal extubation. Results There were 89 and 86 patients in the closed-loop and opened-loop groups, respectively. GS in the closed-loop groups (22.21±8.50) were lower than that in the opened-loop group (27.19±15.26) (p=0.009). The higher proportion of time of BIS between 40 and 60 was also observed in the closed-loop group (84.11±9.50%), while that was 79.92±13.17% in the opened-loop group, (p=0.016). No significant differences in propofol dose and time of tracheal extubation were observed. The frequency of propofol regulation in the closed-loop group (31.55±9.46 times/hr) was obverse higher than that in the opened-loop group (6.84±6.21 times/hr) (p=0.000). Conclusion The CONCERT-CL closed-loop infusion system can automatically regulate the TCI of propofol, maintain the BIS value in an adequate range and reduce the workload of anesthesiologists better than open-loop system. Trial Registration ChiCTR ChiCTR-OOR-14005551
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Liu N, Lory C, Assenzo V, Cocard V, Chazot T, Le Guen M, Sessler D, Journois D, Fischler M. Feasibility of closed-loop co-administration of propofol and remifentanil guided by the bispectral index in obese patients: a prospective cohort comparison †. Br J Anaesth 2015; 114:605-14. [DOI: 10.1093/bja/aeu401] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
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Shanechi MM, Chemali JJ, Liberman M, Solt K, Brown EN. A brain-machine interface for control of medically-induced coma. PLoS Comput Biol 2013; 9:e1003284. [PMID: 24204231 PMCID: PMC3814408 DOI: 10.1371/journal.pcbi.1003284] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Accepted: 08/07/2013] [Indexed: 11/19/2022] Open
Abstract
Medically-induced coma is a drug-induced state of profound brain inactivation and unconsciousness used to treat refractory intracranial hypertension and to manage treatment-resistant epilepsy. The state of coma is achieved by continually monitoring the patient's brain activity with an electroencephalogram (EEG) and manually titrating the anesthetic infusion rate to maintain a specified level of burst suppression, an EEG marker of profound brain inactivation in which bursts of electrical activity alternate with periods of quiescence or suppression. The medical coma is often required for several days. A more rational approach would be to implement a brain-machine interface (BMI) that monitors the EEG and adjusts the anesthetic infusion rate in real time to maintain the specified target level of burst suppression. We used a stochastic control framework to develop a BMI to control medically-induced coma in a rodent model. The BMI controlled an EEG-guided closed-loop infusion of the anesthetic propofol to maintain precisely specified dynamic target levels of burst suppression. We used as the control signal the burst suppression probability (BSP), the brain's instantaneous probability of being in the suppressed state. We characterized the EEG response to propofol using a two-dimensional linear compartment model and estimated the model parameters specific to each animal prior to initiating control. We derived a recursive Bayesian binary filter algorithm to compute the BSP from the EEG and controllers using a linear-quadratic-regulator and a model-predictive control strategy. Both controllers used the estimated BSP as feedback. The BMI accurately controlled burst suppression in individual rodents across dynamic target trajectories, and enabled prompt transitions between target levels while avoiding both undershoot and overshoot. The median performance error for the BMI was 3.6%, the median bias was -1.4% and the overall posterior probability of reliable control was 1 (95% Bayesian credibility interval of [0.87, 1.0]). A BMI can maintain reliable and accurate real-time control of medically-induced coma in a rodent model suggesting this strategy could be applied in patient care. Brain-machine interfaces (BMI) for closed-loop control of anesthesia have the potential to enable fully automated and precise control of brain states in patients requiring anesthesia care. Medically-induced coma is one such drug-induced state in which the brain is profoundly inactivated and unconscious and the electroencephalogram (EEG) pattern consists of bursts of electrical activity alternating with periods of suppression, termed burst suppression. Medical coma is induced to treat refractory intracranial hypertension and uncontrollable seizures. The state of coma is often required for days, making accurate manual control infeasible. We develop a BMI that can automatically and precisely control the level of burst suppression in real time in individual rodents. The BMI consists of novel estimation and control algorithms that take as input the EEG activity, estimate the burst suppression level based on this activity, and use this estimate as feedback to control the drug infusion rate in real time. The BMI maintains precise control and promptly changes the level of burst suppression while avoiding overshoot or undershoot. Our work demonstrates the feasibility of automatic reliable and accurate control of medical coma that can provide considerable therapeutic benefits.
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Affiliation(s)
- Maryam M. Shanechi
- School of Electrical and Computer Engineering, Cornell University, Ithaca, New York, United States of America
- Department of Electrical Engineering and Computer Science, University of California, Berkeley, California, United States of America
- * E-mail: (MMS); (ENB)
| | - Jessica J. Chemali
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Max Liberman
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Ken Solt
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Emery N. Brown
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts, United States of America
- Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, Massachusetts, United States of America
- * E-mail: (MMS); (ENB)
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Ching S, Liberman MY, Chemali JJ, Westover MB, Kenny J, Solt K, Purdon PL, Brown EN. Real-time closed-loop control in a rodent model of medically induced coma using burst suppression. Anesthesiology 2013; 119:848-60. [PMID: 23770601 PMCID: PMC3857134 DOI: 10.1097/aln.0b013e31829d4ab4] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND A medically induced coma is an anesthetic state of profound brain inactivation created to treat status epilepticus and to provide cerebral protection after traumatic brain injuries. The authors hypothesized that a closed-loop anesthetic delivery system could automatically and precisely control the electroencephalogram state of burst suppression and efficiently maintain a medically induced coma. METHODS In six rats, the authors implemented a closed-loop anesthetic delivery system for propofol consisting of: a computer-controlled pump infusion, a two-compartment pharmacokinetics model defining propofol's electroencephalogram effects, the burst-suppression probability algorithm to compute in real time from the electroencephalogram the brain's burst-suppression state, an online parameter-estimation procedure and a proportional-integral controller. In the control experiment each rat was randomly assigned to one of the six burst-suppression probability target trajectories constructed by permuting the burst-suppression probability levels of 0.4, 0.65, and 0.9 with linear transitions between levels. RESULTS In each animal the controller maintained approximately 60 min of tight, real-time control of burst suppression by tracking each burst-suppression probability target level for 15 min and two between-level transitions for 5-10 min. The posterior probability that the closed-loop anesthetic delivery system was reliable across all levels was 0.94 (95% CI, 0.77-1.00; n = 18) and that the system was accurate across all levels was 1.00 (95% CI, 0.84-1.00; n = 18). CONCLUSION The findings of this study establish the feasibility of using a closed-loop anesthetic delivery systems to achieve in real time reliable and accurate control of burst suppression in rodents and suggest a paradigm to precisely control medically induced coma in patients.
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Affiliation(s)
- ShiNung Ching
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Department of Brain and Cognitive Science, Massachusetts Institute of Technology, Cambridge, Massachusetts
- Department of Anesthesia, Harvard Medical School, Boston, Massachusetts
- Research Fellow, Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts; Research Fellow, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts; Research Affiliate, Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Max Y. Liberman
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Research Assistant, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Jessica J. Chemali
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Research Assistant, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - M. Brandon Westover
- Department of Neurology, Massachusetts General Hospital & Harvard Medical School, Boston, Massachusetts
- Instructor, Department of Neurology, Harvard Medical School, Boston, Massachusetts; Assistant in Neurology, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jonathan Kenny
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Research Assistant, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Ken Solt
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Department of Anesthesia, Harvard Medical School, Boston, Massachusetts
- Assistant Professor, Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts; Assistant Anesthetist, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts; Research Affiliate, Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Patrick L. Purdon
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Department of Brain and Cognitive Science, Massachusetts Institute of Technology, Cambridge, Massachusetts
- Department of Anesthesia, Harvard Medical School, Boston, Massachusetts
- Instructor, Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts; Instructor, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts; Research Affiliate, Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Emery N. Brown
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Department of Brain and Cognitive Science, Massachusetts Institute of Technology, Cambridge, Massachusetts
- Department of Anesthesia, Harvard Medical School, Boston, Massachusetts
- Harvard-Massachusetts Institute of Technology Health Sciences and Technology Program, Massachusetts Institute of Technology, Cambridge, Massachusetts
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts
- Warren M. Zapol Professor of Anaesthesia, Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts; Anesthetist, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital Boston, Massachusetts; Professor of Computational Neuroscience, Professor of Health Sciences and Technology, Institute for Medical Engineering and Sciences, Department of Brain and Cognitive Sciences, Harvard-MIT Health Sciences and Technology Program, Massachusetts Institute of Technology, Cambridge, Massachusetts
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Liberman MY, Ching S, Chemali J, Brown EN. A closed-loop anesthetic delivery system for real-time control of burst suppression. J Neural Eng 2013; 10:046004. [PMID: 23744607 PMCID: PMC3746775 DOI: 10.1088/1741-2560/10/4/046004] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE There is growing interest in using closed-loop anesthetic delivery (CLAD) systems to automate control of brain states (sedation, unconsciousness and antinociception) in patients receiving anesthesia care. The accuracy and reliability of these systems can be improved by using as control signals electroencephalogram (EEG) markers for which the neurophysiological links to the anesthetic-induced brain states are well established. Burst suppression, in which bursts of electrical activity alternate with periods of quiescence or suppression, is a well-known, readily discernible EEG marker of profound brain inactivation and unconsciousness. This pattern is commonly maintained when anesthetics are administered to produce a medically-induced coma for cerebral protection in patients suffering from brain injuries or to arrest brain activity in patients having uncontrollable seizures. Although the coma may be required for several hours or days, drug infusion rates are managed inefficiently by manual adjustment. Our objective is to design a CLAD system for burst suppression control to automate management of medically-induced coma. APPROACH We establish a CLAD system to control burst suppression consisting of: a two-dimensional linear system model relating the anesthetic brain level to the EEG dynamics; a new control signal, the burst suppression probability (BSP) defining the instantaneous probability of suppression; the BSP filter, a state-space algorithm to estimate the BSP from EEG recordings; a proportional-integral controller; and a system identification procedure to estimate the model and controller parameters. MAIN RESULTS We demonstrate reliable performance of our system in simulation studies of burst suppression control using both propofol and etomidate in rodent experiments based on Vijn and Sneyd, and in human experiments based on the Schnider pharmacokinetic model for propofol. Using propofol, we further demonstrate that our control system reliably tracks changing target levels of burst suppression in simulated human subjects across different epidemiological profiles. SIGNIFICANCE Our results give new insights into CLAD system design and suggest a control-theory framework to automate second-to-second control of burst suppression for management of medically-induced coma.
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Affiliation(s)
- Max Y. Liberman
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - ShiNung Ching
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Department of Brain and Cognitive Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Jessica Chemali
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Emery N. Brown
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Department of Brain and Cognitive Science, Massachusetts Institute of Technology, Cambridge, MA, USA
- Institute for Medicine, Engineering, and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
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A technical description of a novel pharmacological anesthesia robot. J Clin Monit Comput 2013; 28:27-34. [DOI: 10.1007/s10877-013-9451-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Accepted: 03/02/2013] [Indexed: 10/26/2022]
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Fang M, Tao Y, Wang Y. An enriched simulation environment for evaluation of closed-loop anesthesia. J Clin Monit Comput 2013; 28:13-26. [PMID: 23748601 DOI: 10.1007/s10877-013-9483-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Accepted: 05/29/2013] [Indexed: 11/26/2022]
Abstract
To simulate and evaluate the administration of anesthetic agents in the clinical setting, many pharmacology models have been proposed and validated, which play important roles for in silico testing of closed-loop control methods. However, to the authors' best knowledge, there is no anesthesia simulator incorporating closed-loop feedback control of anesthetic agent administration freely available and accessible to the public. Consequently, many necessary but time consuming procedures, such as selecting models from the available literatures and establishing new simulator algorithms, will be repeated by different researchers who intend to explore a novel control algorithm for closed-loop anesthesia. To address this issue, an enriched anesthesia simulator was devised in our laboratory and made freely available to the anesthesia community. This simulator was built by using MATLAB(®) (The MathWorks, Natick, MA). The GUI technology embedded in MATLAB was chosen as the tool to develop a human-machine interface. This simulator includes four types of anesthetic models, and all have been wildly used in closed-loop anesthesia studies. For each type of model, 24 virtual patients were created with significant diversity. In addition, the platform also provides a model identification module and a control method library. For the model identification module, the least square method and particle swarm optimization were presented. In the control method library, a proportional-integral-derivative control and a model predictive control were provided. Both the model identification module and the control method library are extensive and readily accessible for users to add user-defined functions. This simulator could be a benchmark-testing platform for closed-loop control of anesthesia, which is of great value and has significant development potential. For convenience, this simulator is termed as Wang's Simulator, which can be downloaded from http://www.AutomMed.org .
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Affiliation(s)
- Mengqi Fang
- College of Information Science and Technology, Beijing University of Chemical Technology, Mail Box 4, 15# Beisanhuan East Road, Beijing, 100029, China
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Automated sedation outperforms manual administration of propofol and remifentanil in critically ill patients with deep sedation: a randomized phase II trial. Intensive Care Med 2012; 39:454-62. [PMID: 23223772 DOI: 10.1007/s00134-012-2762-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2012] [Accepted: 11/05/2012] [Indexed: 01/14/2023]
Abstract
PURPOSE To compare automated administration of propofol and remifentanil guided by the Bispectral index (BIS) versus manual administration of short-acting drugs in critical care patients requiring deep sedation. The primary outcome was the percentage of BIS values between 40 and 60 (BIS(40-60)). METHODS This randomized controlled phase II trial in the intensive care unit (ICU) was conducted in adults with multiorgan failure. Thirty-one patients were assigned to receive sedation with propofol or remifentanil either by an automated or a manual system, both targeting BIS(40-60). Performance and feasibility of an automated administration were assessed. RESULTS The study groups were well balanced in terms of demographic characteristics. Study duration averaged 18 [8-24] h in the automated group and 14 [9-21] h in the manual group (p = 0.81). Adequate sedation (BIS(40-60)) was significantly more frequent in the automated group 77 [59-82] % than in the manual group 36 [22-56] %, with p = 0.001. Propofol consumption was reduced by a factor of 2 in the automated group with a median change of infusion rates of 39 ± 9 times per hour. In contrast, there were only 2 ± 1 propofol and 1 ± 1 remifentanil dose changes per hour in the manual group compared to 40 ± 9 for remifentanil in the automated group (p < 0.001). Vasopressors were more often discontinued or reduced in the automated group than in the manual control group (36 [6-40] vs. 12 [4-20] modifications, p = 0.03). CONCLUSIONS Continuous titration of propofol and remifentanil sedation with an automatic controller maintains deep sedation better than manual control in severely ill patients. It is associated with reduced sedative and vasopressor use.
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Manecke GR. Algorithms: what computers do best. J Cardiothorac Vasc Anesth 2012; 26:759-61. [PMID: 22841524 DOI: 10.1053/j.jvca.2012.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2012] [Indexed: 11/11/2022]
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Chung JH, Cha SC, Hwang JH, Woo SC. Anesthetic experience in patient for single lung transplantation with previous contralateral pneumonectomy -A case report-. Korean J Anesthesiol 2012; 62:479-83. [PMID: 22679547 PMCID: PMC3366317 DOI: 10.4097/kjae.2012.62.5.479] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2011] [Revised: 05/13/2011] [Accepted: 05/19/2011] [Indexed: 11/11/2022] Open
Abstract
A 48-year-old woman with cystic fibrosis and a previous left pneumonectomy had surgery planned for single lung transplantation under general anesthesia. Due to progressive dyspnea and recurrent respiratory infection, she could not maintain her normal daily life without lung transplantation. The anesthetic management and surgical procedure was expected to be difficult because of the left mediastinal shift and an asymmetric thorax after the left pneumonectomy, but the single lung transplantation was successfully done under cardiopulmonary bypass.
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Affiliation(s)
- Ji-Hyun Chung
- Department of Anesthesiology and Pain Medicine, Eulji University Hospital, Daejeon, Korea
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Rinehart J, Liu N, Alexander B, Cannesson M. Review article: closed-loop systems in anesthesia: is there a potential for closed-loop fluid management and hemodynamic optimization? Anesth Analg 2011; 114:130-43. [PMID: 21965362 DOI: 10.1213/ane.0b013e318230e9e0] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Closed-loop (automated) controllers are encountered in all aspects of modern life in applications ranging from air-conditioning to spaceflight. Although these systems are virtually ubiquitous, they are infrequently used in anesthesiology because of the complexity of physiologic systems and the difficulty in obtaining reliable and valid feedback data from the patient. Despite these challenges, closed-loop systems are being increasingly studied and improved for medical use. Two recent developments have made fluid administration a candidate for closed-loop control. First, the further description and development of dynamic predictors of fluid responsiveness provides a strong parameter for use as a control variable to guide fluid administration. Second, rapid advances in noninvasive monitoring of cardiac output and other hemodynamic variables make goal-directed therapy applicable for a wide range of patients in a variety of clinical care settings. In this article, we review the history of closed-loop controllers in clinical care, discuss the current understanding and limitations of the dynamic predictors of fluid responsiveness, and examine how these variables might be incorporated into a closed-loop fluid administration system.
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Affiliation(s)
- Joseph Rinehart
- Department of Anesthesiology & Perioperative Care, University of California, Irvine, USA
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Liu N, Chazot T, Hamada S, Landais A, Boichut N, Dussaussoy C, Trillat B, Beydon L, Samain E, Sessler DI, Fischler M. Closed-loop coadministration of propofol and remifentanil guided by bispectral index: a randomized multicenter study. Anesth Analg 2011; 112:546-57. [PMID: 21233500 DOI: 10.1213/ane.0b013e318205680b] [Citation(s) in RCA: 122] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND We have developed a proportional-integral-derivative controller allowing the closed-loop coadministration of propofol and remifentanil, guided by a Bispectral Index (BIS) monitor, during induction and maintenance of general anesthesia. The controller was compared with manual target-controlled infusion. METHODS In a multicenter study, 196 surgical patients were randomly assigned to dual closed-loop or manual administration of propofol and remifentanil. Comparison between groups was evaluated by calculating a global score that characterized the overall performance of the controller including the percentage of adequate anesthesia, defined as BIS between 40 and 60, the median absolute performance error, and wobble. Secondary outcomes included occurrence of burst suppression ratio, time to tracheal extubation, and drug consumption. RESULTS Eighty-three patients assigned to dual-loop control and 84 patients assigned to manual control completed the study. The global score and the percentage of time with BIS between 40 and 60 were better in the dual-loop group (26 ± 11 vs 43 ± 40, P < 0.0001; 82% ± 12% vs 71% ± 19%, P < 0.0001). Overshoot (BIS <40), undershoot (BIS >60), and burst suppression ratio were all significantly less common in the dual-loop group. Modifications to the propofol and remifentanil infusions were more frequent, and adjustments smaller in the dual-loop group. Remifentanil consumption was greater (0.22 ± 0.07 vs 0.16 ± 0.07 μg · kg(-1) · min(-1); P < 0.0001) and the speed to tracheal extubation was shorter (10 ± 4 vs 11 ± 5 minutes; P = 0.02) in the dual-loop group. CONCLUSION The controller allows the automated delivery of propofol and remifentanil and maintains BIS values in predetermined boundaries during general anesthesia better than manual administration.
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Affiliation(s)
- Ngai Liu
- Service d'Anesthésie, Hôpital Foch, 40 rue Worth, 92150 Suresnes, France
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Bibian S, Dumont GA, Zikov T. Dynamic behavior of BIS, M-entropy and neuroSENSE brain function monitors. J Clin Monit Comput 2010; 25:81-7. [PMID: 21132561 DOI: 10.1007/s10877-010-9266-9] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2010] [Accepted: 11/15/2010] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The objective of this paper is to assess the suitability of brain function monitors for use in closed-loop anesthesia or sedation delivery. In such systems, monitors used as feedback sensors should preferably be Linear and Time Invariant (LTI) in order to limit sensor-induced uncertainty which can cause degraded performance. In this paper, we evaluate the suitability of the BIS A2000 (Aspect Medical Systems, MA), the M-Entropy Monitor (GE HealthCare), and the NeuroSENSE Monitor (NeuroWave Systems Inc, OH), by verifying whether their dynamic behavior conforms to the LTI hypothesis. METHODS We subjected each monitor to two different composite EEG signals containing step-wise changes in cortical activity. The first signal was used to identify Linear Time-Invariant (LTI) models that mathematically capture the dynamic behavior of each monitor. The identification of the model parameters was carried out using standard Recursive Least Squares (RLS) estimation. The second signal was used to assess the performance of the model, by comparing the output of the monitor to the simulated output predicted by the model. RESULTS While a LTI model was successfully derived for each monitor using the first signal, only the model derived for NeuroSENSE was capable to reliably predict the monitor output for the second input signals. This indicates that some algorithmic processes within the BIS A2000 and M-Entropy are non-linear and/or time variant. CONCLUSION While both BIS and M-Entropy monitors have been successfully used in closed-loop systems, we were unable to obtain a unique LTI model that could capture their dynamic behavior during step-wise changes in cortical activity. The uncertainty in their output during rapid changes in cortical activity impose limitations in the ability of the controller to compensate for rapid changes in patients' cortical state, and pose additional difficulties in being able to provide mathematically proof for the stability of the overall closed-loop system. Conversely, the NeuroSENSE dynamic behavior can be fully captured by a linear and time invariant transfer function, which makes it better suited for closed-loop applications.
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Affiliation(s)
- Stéphane Bibian
- Neurowave Systems Inc., 2490 Lee Blvd, Suite 300, Cleveland Heights, OH 44118, USA.
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Bi-spectral index guided closed-loop anaesthesia delivery system (CLADS™) in pheochromocytoma. J Clin Monit Comput 2009; 23:189-96. [DOI: 10.1007/s10877-009-9181-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2009] [Accepted: 05/23/2009] [Indexed: 10/20/2022]
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