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Lee S, Kang D, Song E, Yoo S, Jeong S. External validation of the modified Marsh and Schnider models for medium-chain triglyceride propofol in target-controlled infusion anesthesia. BMC Anesthesiol 2024; 24:70. [PMID: 38395779 PMCID: PMC10885499 DOI: 10.1186/s12871-024-02461-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 02/18/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Propofol formulated with medium- and long-chain triglycerides (MCT/LCT propofol) has rapidly replaced propofol formulated with long-chain triglycerides (LCT propofol). Despite this shift, the modified Marsh and Schnider pharmacokinetic models developed using LCT propofol are still widely used for target-controlled infusion (TCI) of propofol. This study aimed to validate the external applicability of these models by evaluating their predictive performance during TCI of MCT/LCT propofol in general anesthesia. METHODS Adult patients (n = 48) undergoing elective surgery received MCT/LCT propofol via a TCI system using either the modified Marsh or Schnider models. Blood samples were collected at various target propofol concentrations and at specific time points, including the loss of consciousness and the recovery of consciousness (13 samples per patient). The actual plasma concentration of propofol was determined using high-performance liquid chromatography. The predictive performance of each pharmacokinetic model was assessed by calculating four parameters: inaccuracy, bias, divergence, and wobble. RESULTS Both the modified Marsh and Schnider models demonstrated predictive performances within clinically acceptable ranges for MCT/LCT propofol. The inaccuracy values were 24.4% for the modified Marsh model and 26.9% for the Schnider model. Both models showed an overall positive bias, 16.4% for the modified Marsh model and 16.6% for the Schnider model. The predictive performance of MCT/LCT propofol was comparable to that of LCT propofol, suggesting formulation changes might exert only a minor impact on the reliability of the TCI system during general anesthesia. Additionally, both models exhibited higher bias and inaccuracy at target concentrations ranging from 3.5 ~ 5 ug/ml than at concentrations between 2 ~ 3 ug/ml. CONCLUSIONS The modified Marsh and Schnider models, initially developed for LCT propofol, remain clinically acceptable for TCI with MCT/LCT propofol. TRIAL REGISTRATION This study was registered at the Clinical Research Information Service of the Korean National Institute of Health ( https://cris.nih.go.kr ; registration number: KCT0002191; 06/01/2017).
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Affiliation(s)
- Seongheon Lee
- Department of Anesthesiology and Pain Medicine, Chonnam University Hospital, Gwangju, South Korea
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, 160, Baekseo-ro, Dong-gu, Gwangju, South Korea
| | - Dongho Kang
- Department of Anesthesiology and Pain Medicine, Chonnam University Hospital, Gwangju, South Korea
| | - Eunjin Song
- Department of Anesthesiology and Pain Medicine, Chonnam University Hospital, Gwangju, South Korea
| | - Sungah Yoo
- Department of Anesthesiology and Pain Medicine, Chonnam University Hospital, Gwangju, South Korea
| | - Seongwook Jeong
- Department of Anesthesiology and Pain Medicine, Chonnam University Hospital, Gwangju, South Korea.
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, 160, Baekseo-ro, Dong-gu, Gwangju, South Korea.
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Patterns of Hysteresis Between Induction and Emergence of Neuroanesthesia Are Present in Spinal and Intracranial Surgeries. J Neurosurg Anesthesiol 2020; 32:82-89. [PMID: 30371631 DOI: 10.1097/ana.0000000000000559] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Recovery of consciousness is usually seen as a passive process, with emergence from anesthesia depicted as the inverse process of induction resulting from the elimination of anesthetic drugs from their central nervous system sites of action. However, that need not be the case. Recently it has been argued that we might encounter hysteresis to changes in the state of consciousness, known as neural inertia. This phenomenon has been debated in neuroanesthesia, as manipulation of the brain might further influence recovery of consciousness. The present study is aimed at assessing hysteresis between induction and emergence under propofol-opioid neuroanesthesia in humans using estimated propofol concentrations in both spinal and intracranial surgeries. METHODS We identified the moments of loss (LOR) and recovery of responsiveness (ROR) in 21 craniotomies and 25 spinal surgeries. Propofol was given slowly until loss of responsiveness and stopped at the end of surgery. An opioid was present at induction and recovery. Propofol infused was recorded and plasma and effect-site concentrations were estimated using 2 pharmacokinetic models. Dose-response curves were generated. Estimated propofol plasma and effect-site concentrations were compared to assess hysteresis. RESULTS Estimated propofol concentrations at LOR and ROR showed hysteresis. Whether for spinal or intracranial surgeries, the EC50 of propofol at which half of the patients entered and exited the state of responsiveness was significantly different. CONCLUSIONS Hysteresis was observed between propofol concentrations at LOR and ROR, in both patients presenting for spinal and intracranial surgeries. Manipulation of the brain does not appear to change patterns of hysteresis, suggesting that neural inertia may occur in humans, in a way similar to that found in animal species. These findings justify performing a clinical study in patients using measured propofol concentrations to assess neural inertia.
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Yi JM, Doh I, Lee SH, Kim SY, Lee YH, Lee EK, Lee SH, Choi BM, Noh GJ. Predictive performance of a new pharmacokinetic model for propofol in underweight patients during target-controlled infusion. Acta Anaesthesiol Scand 2019; 63:448-454. [PMID: 30690713 DOI: 10.1111/aas.13335] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 01/02/2019] [Accepted: 01/07/2019] [Indexed: 01/24/2023]
Abstract
BACKGROUND In a previous study, the modified Marsh and Schnider models respectively showed negatively- and positively-biased predictions in underweight patients. To overcome this drawback, we developed a new pharmacokinetic propofol model-the Choi model-for use in underweight patients. In the present study, we evaluated the predictive performance of the Choi model. METHODS Twenty underweight patients undergoing elective surgery received propofol via TCI using the Choi model. The target effect-site concentrations (Ces) of propofol were 2.5, 3, 3.5, 4, 4.5, and 2 μg/mL. Arterial blood samples were obtained at least 10 minutes after achieving pseudo-steady-state. Predicted propofol concentrations with the modified Marsh, Schnider, and Eleveld pharmacokinetic models were obtained by simulation (Asan pump, version 2.1.3; Bionet Co. Ltd., Seoul, Korea). The predictive performance of each model was assessed by calculation of four parameters: inaccuracy, divergence, bias, and wobble. RESULTS A total of 119 plasma samples were used to determine the predictive performance of the Choi model. Our evaluation showed that the pooled median (95% CI) bias and inaccuracy were 4.0 (-4.2 to 12.2) and 23.9 (17.6-30.3), respectively. The pooled biases and inaccuracies of the modified Marsh, Schnider, and Eleveld models were clinically acceptable. However, the modified Marsh and Eleveld models consistently produced negatively biased predictions in underweight patients. In particular, the Schnider model showed greater inaccuracy at a target Ce ≥ 3 µg/mL. CONCLUSION The new propofol pharmacokinetic model (the Choi model) developed for underweight patient showed adequate performance for clinical use.
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Affiliation(s)
- Jung-Min Yi
- Department of Anesthesiology and Pain Medicine; Catholic Kwandong University International St. Mary's Hospital; Incheon Korea
| | - Il Doh
- Center for Medical Metrology; Korea Research Institute of Standards and Science (KRISS); Daejeon Korea
| | - Seok-Hwan Lee
- Center for Thermometry and Fluid Flow Metrology; Korea Research Institute of Standards and Science (KRISS); Daejeon Korea
| | - Soo-Young Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center; University of Ulsan College of Medicine; Seoul Korea
| | - Yong-Hun Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center; University of Ulsan College of Medicine; Seoul Korea
| | - Eun-Kyung Lee
- Department of Statistics; Ewha Womans University; Seoul Korea
| | - Soo-Han Lee
- New Drug Development Center; Osong Medical Innovation Foundation; Chungcheongbuk-do Korea
| | - Byung-Moon Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center; University of Ulsan College of Medicine; Seoul Korea
| | - Gyu-Jeong Noh
- Department of Anesthesiology and Pain Medicine, Asan Medical Center; University of Ulsan College of Medicine; Seoul Korea
- Department of Clinical Pharmacology and Therapeutics, Asan Medical Center; University of Ulsan College of Medicine; Seoul Korea
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Lee AKY, Kong AYH, Kong CF. Performance of TCI Propofol Using the Schnider Model for Cardiac Surgery on Cardiopulmonary Bypass-A Pilot Study. J Cardiothorac Vasc Anesth 2017; 32:723-730. [PMID: 29225156 DOI: 10.1053/j.jvca.2017.10.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Indexed: 11/11/2022]
Abstract
OBJECTIVE This pilot study aimed to evaluate the performance of target-controlled infusion (TCI) of propofol using the Schnider pharmacokinetic model in patients undergoing cardiac surgery requiring cardiopulmonary bypass. DESIGN This was a prospective pharmacokinetic study. SETTING A tertiary care hospital. PARTICIPANTS This study is comprised of 10 patients, aged between 46 and 81, who underwent elective cardiac surgery requiring the use of cardiopulmonary bypass. INTERVENTIONS Anesthetic technique was standardized. Hypnosis was maintained using TCI of propofol, titrated to achieve a bispectral index of 30 to 60. Calculated plasma propofol concentrations were recorded at 5 time points in total, before, during, and after cardiopulmonary bypass. Blood propofol concentration was measured at each of these time points. MEASUREMENTS AND MAIN RESULTS The prediction errors and absolute prediction errors were calculated for each sample. From these, the median prediction error (MDPE) and its absolute value (MDAPE) were derived. Agreement between predicted and measured propofol concentrations was assessed using a Bland-Altman plot. Mean prediction errors were also compared pre-, on, and post-bypass using the generalized linear latent and mixed model. The MDPE and MDAPE were both found to be 45%, indicating significant bias toward under-prediction in the Schnider pharmacokinetic model. This bias was increased at an average propofol concentration of 4.5 μg/mL and above. A significant decrease in mean prediction error was noted while on bypass (45.6%, 95% confidence intervals 9.2-82.1). CONCLUSIONS The performance of the Schnider pharmacokinetic model for TCI propofol was poor, with a tendency toward under-prediction of blood propofol concentration, especially at higher average concentrations of propofol. While mitigating the risk of awareness, the risk of other adverse effects like hypotension and cardiorespiratory depression is increased. Patients should therefore be adequately monitored, and predicted plasma propofol concentrations taken in context with other patient parameters. A lower target concentration of propofol is probably sufficient to maintain an adequate depth of anesthesia as measured by BIS.
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Affiliation(s)
| | | | - Chee Fai Kong
- Department of Anaesthesiology, Singapore General Hospital, Singapore
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de Valence T, Elia N, Czarnetzki C, Dumont L, Tramèr MR, Lysakowski C. Effect of sufentanil on bispectral index in the elderly. Anaesthesia 2017; 73:216-222. [PMID: 29098683 DOI: 10.1111/anae.14102] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2017] [Indexed: 11/29/2022]
Abstract
We examined the impact of adding sufentanil during anaesthesia induction with propofol on bispectral index values in elderly patients (≥ 65 years). Patients were randomly assigned to receive a target-controlled sufentanil infusion (effect-site concentration of 0.3 ng.ml-1 ) or matching placebo, followed by a target-controlled propofol induction (initial effect-site concentration of 0.5 μg.ml-1 ; step-wise increase of 0.5 μg.ml-1 ) until loss of consciousness defined as an Observer's Assessment of Alertness/Sedation score < 2. Seventy-one patients (sufentanil 35, placebo 36) completed the study. Mean (SD) age was 72.3 (5.8) years; 41% were women. At loss of consciousness, mean (SD) bispectral index value was 75.0 (8.6) with sufentanil and 70.0 (8.0) with placebo; mean difference -5.0 (95% confidence interval -8.9 to -1.1), p = 0.013. Post-hoc analyses suggest that the difference was significant in men only (mean difference -7.3 (-11.8 to -2.6), p = 0.003). Sufentanil co-induction with propofol results in higher bispectral index values at loss of consciousness in elderly patients.
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Affiliation(s)
- T de Valence
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology and Intensive Care Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - N Elia
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology and Intensive Care Medicine, Geneva University Hospitals, Geneva, Switzerland.,Institute of Global Health, Medical Faculty, University of Geneva, Geneva, Switzerland
| | - C Czarnetzki
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology and Intensive Care Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - L Dumont
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology and Intensive Care Medicine, Geneva University Hospitals, Geneva, Switzerland.,Medical Faculty, University of Geneva, Geneva, Switzerland
| | - M R Tramèr
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology and Intensive Care Medicine, Geneva University Hospitals, Geneva, Switzerland.,Medical Faculty, University of Geneva, Geneva, Switzerland
| | - C Lysakowski
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology and Intensive Care Medicine, Geneva University Hospitals, Geneva, Switzerland.,Medical Faculty, University of Geneva, Geneva, Switzerland
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Affiliation(s)
- F. Engbers
- Department of Anaesthesiology; Leiden University Medical Center; Leiden the Netherlands
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A Retrospective Observational Study of Anesthetic Induction Dosing Practices in Female Elderly Surgical Patients: Are We Overdosing Older Patients? Drugs Aging 2017; 33:737-746. [PMID: 27581549 DOI: 10.1007/s40266-016-0394-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND/OBJECTIVES Despite guidelines suggesting a 25-50 % reduction in induction doses of intravenous anesthetic agents in the elderly (≥65 years), we hypothesized that practitioners were not sufficiently correcting drug administration for age, contributing to an increased incidence of hypotension in older patients undergoing general anesthesia. STUDY DESIGN We conducted a retrospective, observational study in a tertiary-care academic hospital. The study included 768 female patients undergoing gynecologic surgeries who received propofol-based induction of general anesthesia. MAIN OUTCOME MEASURES Weight-adjusted anesthetic induction dosing, age-associated differences in dosing by ASA-PS (American Society of Anesthesiology-Physical Status), and hemodynamic outcomes between younger (18-64 years, n = 537) and older (≥65 years, n = 231) female patients were analyzed. RESULTS Older patients received lower doses of propofol and midazolam than younger patients (propofol: 2.037 ± 0.783 vs 2.322 ± 0.834 mg/kg, p < 0.001; midazolam: 0.013 ± 0.014 vs 0.023 ± 0.042 mg/kg, p < 0.001). However, practitioners still consistently exceeded the FDA recommended dose (1-1.5 mg/kg) of propofol for elderly patients. There was no significant difference in the doses of fentanyl administered between the two age groups (1.343 ± 0.744 vs 1.363 ± 0.763 μg/kg, p = 0.744), and doses of fentanyl in older patients exceeded the recommended dose (0.5-1.0 μg/kg). Corresponding to observed overdosing of induction agents, older patients experienced larger decreases in post-induction blood pressure and were more likely to receive vasopressor therapy. CONCLUSIONS Anesthetic induction doses of fentanyl and propofol were not sufficiently corrected in older patients in accordance with recommendations. Significantly greater frequency of post-induction hypotension occurred amongst older patients. Quality improvement efforts may lead to improved outcomes in this vulnerable population.
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Lee JW, Choi BM, Noh GJ. Predictive performance of target controlled infusion of propofol-MCT/LCT using the modified Marsh and Schnider models: a simulation study. Anesth Pain Med (Seoul) 2017. [DOI: 10.17085/apm.2017.12.2.117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Trefz P, Kamysek S, Fuchs P, Sukul P, Schubert JK, Miekisch W. Drug detection in breath: non-invasive assessment of illicit or pharmaceutical drugs. J Breath Res 2017; 11:024001. [DOI: 10.1088/1752-7163/aa61bf] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Davis CA, Seddighi R, Cox SK, Sun X, Egger CM, Doherty TJ. Effect of fentanyl on the induction dose and minimum infusion rate of propofol preventing movement in dogs. Vet Anaesth Analg 2017. [PMID: 28624496 DOI: 10.1016/j.vaa.2016.11.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To determine the effect of fentanyl on the induction dose of propofol and minimum infusion rate required to prevent movement in response to noxious stimulation (MIRNM) in dogs. STUDY DESIGN Crossover experimental design. ANIMALS Six healthy, adult intact male Beagle dogs, mean±standard deviation 12.6±0.4 kg. METHODS Dogs were administered 0.9% saline (treatment P), fentanyl (5 μg kg-1) (treatment PLDF) or fentanyl (10 μg kg-1) (treatment PHDF) intravenously over 5 minutes. Five minutes later, anesthesia was induced with propofol (2 mg kg-1, followed by 1 mg kg-1 every 15 seconds to achieve intubation) and maintained for 90 minutes by constant rate infusions (CRIs) of propofol alone or with fentanyl: P, propofol (0.5 mg kg-1 minute-1); PLDF, propofol (0.35 mg kg-1 minute-1) and fentanyl (0.1 μg kg-1 minute-1); PHDF, propofol (0.3 mg kg-1 minute-1) and fentanyl (0.2 μg kg-1 minute-1). Propofol CRI was increased or decreased based on the response to stimulation (50 V, 50 Hz, 10 mA), with 20 minutes between adjustments. Data were analyzed using a mixed-model anova and presented as mean±standard error. RESULTS ropofol induction doses were 6.16±0.31, 3.67±0.21 and 3.33±0.42 mg kg-1 for P, PLDF and PHDF, respectively. Doses for PLDF and PHDF were significantly decreased from P (p<0.05) but not different between treatments. Propofol MIRNM was 0.60±0.04, 0.29±0.02 and 0.22±0.02 mg kg-1 minute-1 for P, PLDF and PHDF, respectively. MIRNM in PLDF and PHDF was significantly decreased from P. MIRNM in PLDF and PHDF were not different, but their respective percent decreases of 51±3 and 63±2% differed (p=0.035). CONCLUSIONS AND CLINICAL RELEVANCE Fentanyl, at the doses studied, caused statistically significant and clinically important decreases in the propofol induction dose and MIRNM.
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Affiliation(s)
- Carrie A Davis
- Department of Small Animal Clinical Sciences, University of Tennessee, Knoxville, TN, USA.
| | - Reza Seddighi
- Department of Large Animal Clinical Sciences, University of Tennessee, Knoxville, TN, USA
| | - Sherry K Cox
- Department of Biological and Diagnostic Sciences, University of Tennessee, Knoxville, TN, USA
| | - Xiaocun Sun
- Office of Information and Technology, University of Tennessee, Knoxville, TN, USA
| | - Christine M Egger
- Department of Small Animal Clinical Sciences, University of Tennessee, Knoxville, TN, USA
| | - Thomas J Doherty
- Department of Large Animal Clinical Sciences, University of Tennessee, Knoxville, TN, USA
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Total Intravenous Anaesthesia (TIVA) for Ambulatory Surgery: An Update. CURRENT ANESTHESIOLOGY REPORTS 2016. [DOI: 10.1007/s40140-016-0179-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Reed RA, Seddighi MR, Odoi A, Cox SK, Egger CM, Doherty TJ. Effect of ketamine on the minimum infusion rate of propofol needed to prevent motor movement in dogs. Am J Vet Res 2016; 76:1022-30. [PMID: 26618726 DOI: 10.2460/ajvr.76.12.1022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine the minimum infusion rate (MIR) of propofol required to prevent movement in response to a noxious stimulus in dogs anesthetized with propofol alone or propofol in combination with a constant rate infusion (CRI) of ketamine. ANIMALS 6 male Beagles. PROCEDURES Dogs were anesthetized on 3 occasions, at weekly intervals, with propofol alone (loading dose, 6 mg/kg; initial CRI, 0.45 mg/kg/min), propofol (loading dose, 5 mg/kg; initial CRI, 0.35 mg/kg/min) and a low dose of ketamine (loading dose, 2 mg/kg; CRI, 0.025 mg/kg/min), or propofol (loading dose, 4 mg/kg; initial CRI, 0.3 mg/kg/min) and a high dose of ketamine (loading dose, 3 mg/kg; CRI, 0.05 mg/kg/min). After 60 minutes, the propofol MIR required to prevent movement in response to a noxious electrical stimulus was determined in duplicate. RESULTS Least squares mean ± SEM propofol MIRs required to prevent movement in response to the noxious stimulus were 0.76 ± 0.1 mg/kg/min, 0.60 ± 0.1 mg/kg/min, and 0.41 ± 0.1 mg/kg/min when dogs were anesthetized with propofol alone, propofol and low-dose ketamine, and propofol and high-dose ketamine, respectively. There were significant decreases in the propofol MIR required to prevent movement in response to the noxious stimulus when dogs were anesthetized with propofol and low-dose ketamine (27 ± 10%) or with propofol and high-dose ketamine (30 ± 10%). CONCLUSIONS AND CLINICAL RELEVANCE Ketamine, at the doses studied, significantly decreased the propofol MIR required to prevent movement in response to a noxious stimulus in dogs.
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Rosero EB. Characterizing depth of anesthesia during target-controlled infusions: Not an easy job. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2016. [DOI: 10.1016/j.rcae.2016.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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La caracterización de la profundidad de la anestesia durante las infusiones controladas a objetivo: no es un trabajo fácil. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2016. [DOI: 10.1016/j.rca.2016.05.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Comparison of propofol pharmacokinetic and pharmacodynamic models for awake craniotomy: A prospective observational study. Eur J Anaesthesiol 2016; 32:527-34. [PMID: 25774459 DOI: 10.1097/eja.0000000000000255] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Anaesthesia for awake craniotomy aims for an unconscious patient at the beginning and end of surgery but a rapidly awakening and responsive patient during the awake period. Therefore, an accurate pharmacokinetic/pharmacodynamic (PK/PD) model for propofol is required to tailor depth of anaesthesia. OBJECTIVE To compare the predictive performances of the Marsh and the Schnider PK/PD models during awake craniotomy. DESIGN A prospective observational study. SETTING Single university hospital from February 2009 to May 2010. PATIENTS Twelve patients undergoing elective awake craniotomy for resection of brain tumour or epileptogenic areas. INTERVENTION Arterial blood samples were drawn at intervals and the propofol plasma concentration was determined. MAIN OUTCOME MEASURES The prediction error, bias [median prediction error (MDPE)] and inaccuracy [median absolute prediction error (MDAPE)] of the Marsh and the Schnider models were calculated. The secondary endpoint was the prediction probability PK, by which changes in the propofol effect-site concentration (as derived from simultaneous PK/PD modelling) predicted changes in anaesthetic depth (measured by the bispectral index). RESULTS The Marsh model was associated with a significantly (P = 0.05) higher inaccuracy (MDAPE 28.9 ± 12.0%) than the Schnider model (MDAPE 21.5 ± 7.7%) and tended to reach a higher bias (MDPE Marsh -11.7 ± 14.3%, MDPE Schnider -5.4 ± 20.7%, P = 0.09). MDAPE was outside of accepted limits in six (Marsh model) and two (Schnider model) of 12 patients. The prediction probability was comparable between the Marsh (PK 0.798 ± 0.056) and the Schnider model (PK 0.787 ± 0.055), but after adjusting the models to each individual patient, the Schnider model achieved significantly higher prediction probabilities (PK 0.807 ± 0.056, P = 0.05). CONCLUSION When using the 'asleep-awake-asleep' anaesthetic technique during awake craniotomy, we advocate using the PK/PD model proposed by Schnider. Due to considerable interindividual variation, additional monitoring of anaesthetic depth is recommended. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT 01128465.
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Michel Foehn ER. Adult and pediatric anesthesia/sedation for gastrointestinal procedures outside of the operating room. Curr Opin Anaesthesiol 2016; 28:469-77. [PMID: 26087269 DOI: 10.1097/aco.0000000000000215] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW This review presents current trends of safe and efficient anesthesia and sedation for adults and children for gastrointestinal procedures outside of the operating room with a special focus on total intravenous anesthesia (TIVA), target-controlled infusion (TCI), intravenous or topical lidocaine, and the use of the video laryngoscope. RECENT FINDINGS The concepts of a well tolerated and adequate anesthesia or sedation for gastrointestinal procedures outside of the operating room have to meet the needs of the adult and pediatric patients and the special requests of the gastroenterologists. Anesthesia and sedation of adults for gastrointestinal procedures with TIVA or TCI and spontaneous breathing is well established. Many institutions perform anesthesia for pediatric patients undergoing gastrointestinal procedures with an inhalational agent, especially in young children and for short procedures. Unlike adults, in young children the airways frequently must be secured with a tracheal tube or laryngeal mask. Respiration may be spontaneous, assisted, or controlled. TIVA and TCI are increasingly chosen for older children and longer procedures. A local anesthetic administered intravenously or topically to the upper airways and the use of the video laryngoscope can facilitate the insertion of the endoscope. SUMMARY Both anesthesiologists and nonanesthesiologists have to achieve a consensus and develop quality-improvement strategies to provide safe and efficient anesthesia and sedation for gastrointestinal procedures outside of the operating room for pediatric and adult patients. Techniques using TIVA, TCI, intravenous or topical application of lidocaine, and the video laryngoscope may improve and facilitate gastrointestinal procedures for the patients, the anesthesiologists, and the gastroenterologists.
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Affiliation(s)
- Esther R Michel Foehn
- Department of Anesthesia, Critical Care and Pain Medicine, Bethanien Hospital, Zurich, Switzerland
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Characterizing depth of anesthesia during target-controlled infusions: Not an easy job☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2016. [DOI: 10.1097/01819236-201644030-00001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Glen JB, Engbers FHM. The influence of target concentration, equilibration rate constant (ke0) and pharmacokinetic model on the initial propofol dose delivered in effect-site target-controlled infusion. Anaesthesia 2015; 71:306-14. [DOI: 10.1111/anae.13345] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2015] [Indexed: 11/28/2022]
Affiliation(s)
- J. B. Glen
- Research Department; Glen Pharma; Cheshire UK
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