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Napoleone G, van Heusden K, Cooke E, West N, Görges M, Dumont GA, Ansermino JM, Merchant RN. The Effect of Low-Dose Intraoperative Ketamine on Closed-Loop-Controlled General Anesthesia: A Randomized Controlled Equivalence Trial. Anesth Analg 2021; 133:1215-1224. [PMID: 33560659 DOI: 10.1213/ane.0000000000005372] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Closed-loop control of propofol-remifentanil anesthesia using the processed electroencephalography depth-of-hypnosis index provided by the NeuroSENSE monitor (WAVCNS) has been previously described. The purpose of this placebo-controlled study was to evaluate the performance (percentage time within ±10 units of the setpoint during the maintenance of anesthesia) of a closed-loop propofol-remifentanil controller during induction and maintenance of anesthesia in the presence of a low dose of ketamine. METHODS Following ethical approval and informed consent, American Society of Anesthesiologist (ASA) physical status I-II patients aged 19-54 years, scheduled for elective orthopedic surgery requiring general anesthesia for >60 minutes duration, were enrolled in a double-blind randomized, placebo-controlled, 2-group equivalence trial. Immediately before induction of anesthesia, participants in the ketamine group received a 0.25 mg·kg-1 bolus of intravenous ketamine over 60 seconds followed by a continuous 5 µg·kg-1·min-1 infusion for up to 45 minutes. Participants in the control group received an equivalent volume of normal saline. After the initial study drug bolus, closed-loop induction of anesthesia was initiated; propofol and remifentanil remained under closed-loop control until the anesthetic was tapered and turned off at the anesthesiologist's discretion. An equivalence range of ±8.99% was assumed for comparing controller performance. RESULTS Sixty patients participated: 41 males, 54 ASA physical status I, with a median (interquartile range [IQR]) age of 29 [23, 38] years and weight of 82 [71, 93] kg. Complete data were available from 29 cases in the ketamine group and 27 in the control group. Percentage time within ±10 units of the WAVCNS setpoint was median [IQR] 86.6% [79.7, 90.2] in the ketamine group and 86.4% [76.5, 89.8] in the control group (median difference, 1.0%; 95% confidence interval [CI] -3.6 to 5.0). Mean propofol dose during maintenance of anesthesia for the ketamine group was higher than for the control group (median difference, 24.9 µg·kg-1·min-1; 95% CI, 6.5-43.1; P = .005). CONCLUSIONS Because the 95% CI of the difference in controller performance lies entirely within the a priori equivalence range, we infer that this analgesic dose of ketamine did not alter controller performance. Further study is required to confirm the finding that mean propofol dosing was higher in the ketamine group, and to investigate the implication that this dose of ketamine may have affected the WAVCNS.
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Affiliation(s)
- Gabby Napoleone
- From the Department of Anesthesiology, Pharmacology and Therapeutics
| | - Klaske van Heusden
- Department of Electrical and Computer Engineering, University of British Columbia (UBC), Vancouver, British Columbia, Canada.,Research Institute, BC Children's Hospital, Vancouver, British Columbia, Canada; and
| | - Erin Cooke
- From the Department of Anesthesiology, Pharmacology and Therapeutics.,Research Institute, BC Children's Hospital, Vancouver, British Columbia, Canada; and
| | - Nicholas West
- From the Department of Anesthesiology, Pharmacology and Therapeutics
| | - Matthias Görges
- From the Department of Anesthesiology, Pharmacology and Therapeutics.,Research Institute, BC Children's Hospital, Vancouver, British Columbia, Canada; and
| | - Guy A Dumont
- Department of Electrical and Computer Engineering, University of British Columbia (UBC), Vancouver, British Columbia, Canada.,Research Institute, BC Children's Hospital, Vancouver, British Columbia, Canada; and
| | - J Mark Ansermino
- From the Department of Anesthesiology, Pharmacology and Therapeutics.,Research Institute, BC Children's Hospital, Vancouver, British Columbia, Canada; and
| | - Richard N Merchant
- From the Department of Anesthesiology, Pharmacology and Therapeutics.,Department of Anesthesia, Royal Columbian Hospital, Fraser Health Authority, New Westminster, British Columbia, Canada
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Rüsch D, Arndt C, Eberhart L, Tappert S, Nageldick D, Wulf H. Bispectral index to guide induction of anesthesia: a randomized controlled study. BMC Anesthesiol 2018; 18:66. [PMID: 29902969 PMCID: PMC6003112 DOI: 10.1186/s12871-018-0522-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 05/22/2018] [Indexed: 02/07/2023] Open
Abstract
Background It is unknown to what extent hypotension frequently observed following administration of propofol for induction of general anesthesia is caused by overdosing propofol. Unlike clinical signs, electroencephalon-based cerebral monitoring allows to detect and quantify an overdose of hypnotics. Therefore, we tested whether the use of an electroencephalon-based cerebral monitoring will cause less hypotension following induction with propofol. Methods Subjects were randomly assigned to a bispectral index (BIS)-guided (target range 40–60) or to a weight-related (2 mg.kg− 1) manual administration of propofol for induction of general anesthesia. The primary endpoint was the incidence of hypotension following the administration of propofol. Secondary endpoints included the degree of hypotension and correlations between BIS and drop in mean arterial pressure (MAP). Incidences were analyzed with Fisher’s Exact-test. Results Of the 240 patients enrolled into this study, 235 predominantly non-geriatric (median 48 years, 25th – 75th percentile 35–61 years) patients without severe concomitant disease (88% American Society of Anesthesiology physical status 1–2) undergoing ear, nose and throat surgery, ophthalmic surgery, and dermatologic surgery were analyzed. Patients who were manually administered propofol guided by BIS (n = 120) compared to those who were given propofol by weight (n = 115) did not differ concerning the incidence of hypotension (44% vs. 45%; p = 0.87). Study groups were also similar regarding the maximal drop in MAP compared to baseline (33% vs. 30%) and the proportion of hypotensive events related to all measurements (17% vs. 19%). Final propofol induction doses in BIS group and NON-BIS group were similar (1.93 mg/kg vs. 2 mg/kg). There was no linear correlation between BIS and the drop in MAP at all times (r < 0.2 for all) except for a weak one at 6 min (r = 0.221). Conclusion Results of our study suggest that a BIS-guided compared to a weight-adjusted manual administration of propofol for induction of general anesthesia in non-geriatric patients will not lower the incidence and degree of arterial hypotension. Trial registration German Registry of Clinical Trials (DRKS00010544), retrospectively registered on August 4, 2016. Electronic supplementary material The online version of this article (10.1186/s12871-018-0522-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Dirk Rüsch
- Department of Anesthesia and Intensive Care, University Hospital Giessen-Marburg, Marburg Campus, Baldingerstraße, 35033, Marburg, Germany.
| | - Christian Arndt
- Department of Anesthesia and Intensive Care, University Hospital Giessen-Marburg, Marburg Campus, Baldingerstraße, 35033, Marburg, Germany
| | - Leopold Eberhart
- Department of Anesthesia and Intensive Care, University Hospital Giessen-Marburg, Marburg Campus, Baldingerstraße, 35033, Marburg, Germany
| | - Scarlett Tappert
- Department of Anesthesia and Intensive Care, University Hospital Giessen-Marburg, Marburg Campus, Baldingerstraße, 35033, Marburg, Germany
| | - Dennis Nageldick
- Department of Anesthesia and Intensive Care, University Hospital Giessen-Marburg, Marburg Campus, Baldingerstraße, 35033, Marburg, Germany
| | - Hinnerk Wulf
- Department of Anesthesia and Intensive Care, University Hospital Giessen-Marburg, Marburg Campus, Baldingerstraße, 35033, Marburg, Germany
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