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Aihara S, Hagihira S, Uno R, Kamibayashi T. Effect of remifentanil on three effect-site concentrations of propofol and their relationship during electroencephalography at loss of response, at maximum alpha power, and at onset of burst suppression: a prospective randomized trial. J Anesth 2024; 38:371-376. [PMID: 38376589 DOI: 10.1007/s00540-024-03318-4] [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: 12/19/2023] [Accepted: 02/04/2024] [Indexed: 02/21/2024]
Abstract
PURPOSE The effect-site concentration (Ce) at loss of response (Ce-LOR) to propofol closely correlates both with Ce as electroencephalographic alpha power becomes highest (Ce-alpha) and with Ce at onset of burst suppression (BS) (Ce-OBS), when no opioids are administered. Co-administration of opioids dose-dependently decreases Ce-LOR. We investigated the influence of remifentanil on the relationship between these three Ces. METHODS After receiving approval from our local ethical committee, with written informed consent, we enrolled 90 participants (ASA-PS I or II) who were scheduled for elective surgery. Participants were randomly assigned to three groups: constant remifentanil Ce 0 ng/ml (Remi_0); 1 ng/mL (Remi_1); and 2 ng/mL (Remi_2). We recorded both raw EEG and EEG-derived parameters on a computer. After reaching remifentanil equilibrium, we administered propofol using a target-controlled infusion pump such that propofol Ce increased to about 0.3 μg/mL/min. After determining Ce-LOR, we administered 0.6 mg/kg of rocuronium and started mask ventilation. The study protocol ended after observation of BS. RESULTS Three participants were excluded. Ce-LOR in each group (Remi_0, Remi_1, Remi_2) was 2.00 ± 0.58 μg/mL, 1.43 ± 0.49 μg/mL, and 1.37 ± 0.42 μg/mL. Ce-alpha was 2.91 ± 0.63 μg/mL, 2.30 ± 0.41 μg/mL, and 2.12 ± 0.39 μg/mL. Ce-OBS was 3.80 ± 0.69 μg/mL, 3.25 ± 0.68 μg/mL, and 2.90 ± 0.57 μg/mL. In three other instances, Ce was decreased by remifentanil. Generalized linear model analysis revealed that remifentanil had no influence on the relationship between the three Ces. CONCLUSION During propofol anesthesia, even low concentrations of remifentanil shifted concentration-related electroencephalographic changes.
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Affiliation(s)
- Satoshi Aihara
- Department of Anesthesiology, Kansai Medical University, 2-5-1 Shin-Machi, Hirakata, Osaka, 573-1191, Japan
| | - Satoshi Hagihira
- Department of Anesthesiology, Kansai Medical University, 2-5-1 Shin-Machi, Hirakata, Osaka, 573-1191, Japan.
| | - Rieko Uno
- Department of Anesthesiology, Kansai Medical University Medical Center, 10-15 Fumizono-Cho, Moriguchi, Osaka, 570-8507, Japan
| | - Takahiko Kamibayashi
- Department of Anesthesiology, Kansai Medical University, 2-5-1 Shin-Machi, Hirakata, Osaka, 573-1191, Japan
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The Use of Middle Latency Auditory Evoked Potentials (MLAEP) as Methodology for Evaluating Sedation Level in Propofol-Drug Induced Sleep Endoscopy (DISE) Procedure. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18042070. [PMID: 33672569 PMCID: PMC7924024 DOI: 10.3390/ijerph18042070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 02/04/2021] [Accepted: 02/12/2021] [Indexed: 11/17/2022]
Abstract
To analyze the middle latency auditory evoked potential index (MLAEPi), compared to the standard bispectral index (BIS), as a method for evaluating the sedation level in drug-induced sleep endoscopy (DISE). In this controlled clinical study on a sample of 99 obstructive sleep apnea (OSA) or snoring patients, we compared the MLAEPi with the BIS after propofol infusion during the standard DISE technique in order to define the MLAEPi values within the observational window of the procedure. The DISE procedure was divided into eight steps, and we collected both MLAEPi and BIS data values from the same patient in every step. The MLAEPi showed a faster response than the BIS after propofol infusion during DISE. Therefore, the clinical use of the MLAEPi in evaluating the sedation level seems to be a good alternative to the current technological standards.
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Supp GG, Higgen FL, Hipp JF, Engel AK, Siegel M. Mid-Latency Auditory Evoked Potentials Differentially Predict Sedation and Drug Level Under Opioid and Hypnotic Agents. Front Pharmacol 2018; 9:1427. [PMID: 30564126 PMCID: PMC6288227 DOI: 10.3389/fphar.2018.01427] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 11/19/2018] [Indexed: 11/13/2022] Open
Abstract
Background: Auditory-evoked brain potentials (AEPs) are widely used to assess depth of the sedative component of general anesthesia. Depth of sedation as induced by hypnotic drugs (e.g., propofol) is characterized by a gradual decline of mid-latency cortical AEPs (10–50 ms). Using the decline of mid-latency AEPs as a reliable index for sedation requires its robustness against confounding pharmaceutical influences, e.g., analgesic opioids such as remifentanil. Critically, in this context the following two questions remained unresolved so far: First, it is unclear whether opioids directly affect mid-latency AEPs. Second, high doses of opioids decrease arousal, but it is unknown whether opioid-induced sedation is reflected by the diminution of mid-latency AEPs. We hypothesized that opioids affect mid-latency AEPs and that these effects rely on different mechanisms compared to hypnotic agents. Methods: To address both questions, we performed a series of experiments under the participation of healthy human volunteers. We measured AEPs and quantified participants’ sedation state by a standardized rating scale during stepwise increase of different pharmaceutical agents (remifentanil, propofol or placebo). Results: Our results revealed a decline of mid-latency AEPs during remifentanil medication. This decrease was predicted by drug dose, rather than sedation level. In contrast, attenuation of the mid-latency AEPs during propofol was predicted by sedation level and was not related to hypnotic drug dose. We did not find any drug-induced changes of brainstem AEPs (1–10 ms). Conclusion: As remifentanil reduced mid-latency AEPs without inducing strong sedation levels, a decrease of this evoked brain component does not constitute an unequivocal index for the depth of sedation. These results challenge the use of mid-latency AEPs as a reliable marker of depth of the sedative component of anesthesia if hypnotic drugs are combined with opioids.
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Affiliation(s)
- Gernot G Supp
- Department of Neurophysiology and Pathophysiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Focko L Higgen
- Department of Neurophysiology and Pathophysiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Joerg F Hipp
- Centre for Integrative Neuroscience - MEG Center, University of Tübingen, Tübingen, Germany
| | - Andreas K Engel
- Department of Neurophysiology and Pathophysiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Markus Siegel
- Centre for Integrative Neuroscience - MEG Center, University of Tübingen, Tübingen, Germany
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Hagihira S. Brain Mechanisms during Course of Anesthesia: What We Know from EEG Changes during Induction and Recovery. Front Syst Neurosci 2017; 11:39. [PMID: 28611602 PMCID: PMC5447006 DOI: 10.3389/fnsys.2017.00039] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 05/11/2017] [Indexed: 12/11/2022] Open
Affiliation(s)
- Satoshi Hagihira
- Department of Anesthesiology, Kansai Medical UniversityOsaka, Japan.,Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of MedicineOsaka, Japan
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Kang H, Mohamed HMH, Takashina M, Mori T, Fujino Y, Hagihira S. Individual indicators of appropriate hypnotic level during propofol anesthesia: highest alpha power and effect-site concentrations of propofol at loss of response. J Anesth 2017; 31:502-509. [PMID: 28197775 DOI: 10.1007/s00540-017-2319-1] [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] [Received: 11/15/2016] [Accepted: 02/01/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Electroencephalogram (EEG) waveforms vary widely among individuals, this decreases the usefulness of BIS™ monitors for assessing the effects of propofol. Practically, anesthesia is only seen as too deep when evidence of burst-suppression is seen. We designed an experiment to help towards better assessment of individual anesthetic needs. First, to mark the Ce (effect-site concentration) of propofol at loss of response to calling name and gently shaking shoulders (LOR), we defined Ce-LOR. To mark the transient power increase in the alpha range (9-14 Hz), common to all patients, when propofol concentration gradually increases, we defined Ce-alpha as the highest recorded alpha power for Ce. We also defined Ce-OBS as the Ce of propofol at initial observation of burst-suppression. Then we tried to predict Ce-LOR and Ce-alpha from Ce-OBS, vice versa, and considered the significance of these parameters. METHODS We enrolled 26 female patients (age 33-65) who were undergoing scheduled mastectomy. During anesthesia, we recorded all raw EEG packets as well as EEG-derived parameters on a computer from BIS-XP™ monitor. Propofol was infused using a TCI pump. Target concentration was adjusted so that Ce of propofol was gradually increased. RESULTS We obtained the following regression equation; Ce-alpha or Ce-OBS = Ce-LOR × 0.87 + 1.06 + dummy × 0.83 (for Ce-alpha dummy = 0, and for Ce-OBS = 1; adjusted r = 0.90, p < 2.2e-16) by ANCOVA. At Ce-alpha, BIS was 50.2 ± 7.7. CONCLUSION Ce-alpha and Ce-OBS could be estimated from Ce-LOR. Based on Ce-LOR it is possible to manage the hypnotic level of individual patients.
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Affiliation(s)
- Hongling Kang
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita City, 565-0871, Osaka, Japan
| | | | - Masaki Takashina
- Surgical Center, Osaka University Hospital, 2-15 Yamadaoka, Suita City, 565-0871, Osaka, Japan
| | - Takahiko Mori
- Department of Anesthesilogy, Surgical Center, Osaka General Medical Center, 3-1-56 Bandai-higashi, Sumiyoshi-ku, Osaka, 558-8558, Japan
| | - Yuji Fujino
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita City, 565-0871, Osaka, Japan
| | - Satoshi Hagihira
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita City, 565-0871, Osaka, Japan. .,Department of Anesthesilogy, Surgical Center, Osaka General Medical Center, 3-1-56 Bandai-higashi, Sumiyoshi-ku, Osaka, 558-8558, Japan.
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Tsurukiri J, Nagata K, Hoshiai A, Oomura T, Jimbo H, Ikeda Y. Middle latency auditory-evoked potential index monitoring of cerebral function to predict functional outcome after emergency craniotomy in patients with brain damage. Scand J Trauma Resusc Emerg Med 2015; 23:80. [PMID: 26481109 PMCID: PMC4612431 DOI: 10.1186/s13049-015-0161-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 10/02/2015] [Indexed: 04/24/2023] Open
Abstract
Background At present, no satisfactory reports on the monitoring of cerebral function to predict functional outcomes after brain damage such as traumatic brain injury (TBI) and stroke. The middle latency auditory-evoked potential index (MLAEPi) monitor (aepEX plus®, Audiomex, UK) is a mobile MLAEP monitor measuring the degree of consciousness that is represented by numerical values. Hence, we hypothesized that MLAEPi predicts neurological outcome after emergency craniotomy among patients with disturbance of consciousness (DOC), which was caused by brain damage. Methods The afore-mentioned patients who underwent emergency craniotomy within 12 h of brain damage and were subsequently monitored using MLAEPi were enrolled in this study. DOC was defined as an initial Glasgow Coma Scale score < 8. MLAEPi was measured for 14 days after craniotomy. Neurological outcome was evaluated before discharge using a cerebral performance category (CPC) score and classified into three groups: favorable outcome group for a CPC score of 1 or 2, unfavorable outcome group for a score of 3 or 4, and brain dead (BD) group for a score of 5. Results Thirty-two patients were included in this study (17 with TBIs and 15 with acute stroke). Regarding outcome, 10 patients had a favorable outcome, 15 had an unfavorable outcome, and 7 were pronounced BD. MLAEPi was observed to be significantly higher on day 5 than that observed immediately after craniotomy in cases of favorable or unfavorable outcome (63 ± 3.5 vs. 36 ± 2.5 in favorable outcome; 63 ± 3.5 vs. 34 ± 1.8 in unfavorable outcome). MLAEPi was significantly lower in BD patients than in those with a favorable or unfavorable outcome on day 3 (24 ± 4.2 in BD vs. 52 ± 5.2 and 45 ± 2.7 in favorable and unfavorable outcome, respectively) and after day 4. MLAEPi was significantly higher in patients with a favorable outcome than in those with a favorable or unfavorable outcome after day 6 (68 ± 2.3 in favorable outcome vs. 48 ± 2.3 in unfavorable outcome). Conclusion We believe that MLAEPi satisfactorily denotes cerebral function and predicts outcomes after emergency craniotomy in patients with DOC, which was caused by acute brain damage.
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Affiliation(s)
- Junya Tsurukiri
- Emergency and Critical Care Medicine, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji, Tokyo, 193-0998, Japan.
| | - Katsuhiro Nagata
- Emergency and Critical Care Medicine, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji, Tokyo, 193-0998, Japan
| | - Akira Hoshiai
- Emergency and Critical Care Medicine, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji, Tokyo, 193-0998, Japan
| | - Taishi Oomura
- Emergency and Critical Care Medicine, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji, Tokyo, 193-0998, Japan
| | - Hiroyuki Jimbo
- Neurosurgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji, Tokyo, 193-0998, Japan
| | - Yukio Ikeda
- Neurosurgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji, Tokyo, 193-0998, Japan
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Cheung YM, Scoones GP, Stolker RJ, Weber F. Evaluation of the auditory evoked potentials derived aepEX(™) as a measure of hypnotic depth in pediatric patients receiving sevoflurane-remifentanil anesthesia. Paediatr Anaesth 2014; 24:760-5. [PMID: 24815810 DOI: 10.1111/pan.12434] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/13/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND The aepEX is a measure of depth of hypnosis (DoH), derived from processed mid-latency auditory evoked potentials. OBJECTIVES To evaluate the aepEX as a measure of DoH in children receiving sevoflurane-remifentanil anesthesia. METHODS aepEX and bispectral index (BIS) were recorded simultaneously in 75 children, (1-3, 3-6, and 6-18 years), receiving sevoflurane at endtidal concentrations (ETsevo ) between 1.5 and 0.5 MAC. The ETsevo at which the aepEX and BIS had a value of 50 (EC50aep EX and EC50BIS ) was calculated by nonlinear regression analysis. The accuracy of aepEX and BIS to predict the DoH was assessed by prediction probability (Pk ) and receiver operating characteristics (ROC) analysis. RESULTS Seventy-four children were included for analysis. The EC50aep EX (2.68%) and EC50BIS (2.10%) were comparable; the same accounts for the EC50aep EX of the different age groups and the EC50aep EX and EC50BIS of corresponding age groups. The EC50BIS in children aged 1-3 years was lower than in the older age groups (P < 0.05). Pk values of the aepEX (0.32, CI 95% 0.08-0.56) and BIS (0.47, CI 95% 0.19-0.75) were comparable. The area under the ROC curve was 0.72 (CI 95%: 0.62-0.82) and 0.67 (CI95%: 0.56-0.77) for the aepEX and BIS, respectively (P = 0.54). Optimal cutoff values were >60 (aepEX) and >68 (BIS), with corresponding specificities 91%, CI 95%: 80-97% (aepEX) and 66%, CI 95%: 52-77% (BIS). CONCLUSIONS In this study with children receiving sevoflurane anesthesia, the aepEX outperformed the BIS in distinguishing unconsciousness from consciousness. Both indices performed equally bad in differentiating different levels of DoH.
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Affiliation(s)
- Yuen M Cheung
- Department of Anesthesiology, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, the Netherlands
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Anestesia total intravenosa en un sistema de lazo cerrado: reporte del primer caso en Colombia. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2013. [DOI: 10.1016/j.rca.2013.05.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Cheung YM, Scoones GP, Hoeks SE, Stolker RJ, Weber F. Evaluation of the aepEX™ monitor of hypnotic depth in pediatric patients receiving propofol-remifentanil anesthesia. Paediatr Anaesth 2013; 23:891-7. [PMID: 23910045 DOI: 10.1111/pan.12235] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/28/2013] [Indexed: 01/05/2023]
Abstract
BACKGROUND The aepEX Plus monitor (aepEX) utilizes a mid-latency auditory evoked potential-derived index of depth of hypnosis (DoH). OBJECTIVE This observational study evaluates the performance of the aepEX as a DoH monitor for pediatric patients receiving propofol-remifentanil anesthesia. METHODS aepEX and BIS values were recorded simultaneously during surgery in three groups of 25 children (aged 1-3, 3-6 and 6-16 years). Propofol was administered by target-controlled infusion. The University of Michigan Sedation Scale (UMSS) was used to clinically assess the DoH during emergence. Prediction probability (P(k)) and receiver operating characteristics (ROC) analyses were performed to assess the accuracy of both DoH monitors. Nonlinear regression analysis was used to describe the dose-response relationships for the aepEX, the BIS, and propofol plasma concentrations (Cp). RESULTS The P(k) for the aepEX and BIS was 0.36 and 0.21, respectively (P = 0.010). ROC analysis showed an area under the curve of 0.77 and 0.88 for the aepEX and BIS, respectively (P = 0.644). At half-maximal effect (EC(50)), C(p) of 3.13 μg·ml(-1) and 3.06 μg·ml(-1) were observed for the aepEX and BIS, respectively. The r(2) for the aepEX and BIS was 0.53 and 0.82, respectively. CONCLUSION The aepEX performs comparable to the BIS in differentiating between consciousness and unconsciousness, while performing inferior to the BIS in terms of distinguishing different levels of sedation and does not correlate well with the C(p) in children receiving propofol-remifentanil anesthesia.
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Affiliation(s)
- Yuen M Cheung
- Department of Anesthesiology, Erasmus University Medical Center, Sophia Children's Hospital, Rotterdam, the Netherlands.
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Gómez Oquendo FJ, Casas Arroyave FD, Fernández JM, Guarín Grisales Á. Total intravenous anesthesia in a closed loop system: Report of the first case in Colombia. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2013. [DOI: 10.1016/j.rcae.2013.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Tsurukiri J, Nagata K, Okita T, Oomura T. Middle latency auditory-evoked potential index for predicting the degree of consciousness of comatose patients in EDs. Am J Emerg Med 2013; 31:1556-9. [PMID: 24060332 DOI: 10.1016/j.ajem.2013.06.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Revised: 06/14/2013] [Accepted: 06/18/2013] [Indexed: 10/26/2022] Open
Abstract
INTRODUCTION Digitized assessment of the degree of consciousness is a universal challenge in emergency departments (EDs) and intensive care units (ICUs). The middle latency auditory-evoked potential index (MLAEPi) monitor aepEX plus (Audiomex, Glasgow, Scotland, UK) is the first mobile middle latency auditory-evoked potential monitor. We speculated that the initial MLAEPi determined on arrival at EDs could indicate cerebral function and predict the degree of consciousness of comatose patients. METHODS We used MLAEPi-related data from 50 comatose patients with disturbance of consciousness (DOC), 50 patients with cardiopulmonary arrest (CPA), and 50 healthy volunteers (control). Comatose patients were defined as those with an initial Glasgow Coma Scale score of 8 or less. The CPA group consisted of patients who arrived at EDs without restoration of spontaneous circulation. Among the patients with DOC who underwent sedation at EDs, the change in the MLAEPi was evaluated between arrival at the ED and ICU admission. RESULTS The initial MLAEPi was significantly lower in the DOC group than in the control group but significantly higher in the DOC group than in the CPA group. Among the comatose patients, the receiver operating characteristic curve for the initial MLAEPi showed an area under the curve of 0.93 (P < .01) for the DOC group. Thirty patients with DOC underwent sedation at EDs, and the initial MLAEPi was significantly higher than those at other periods during emergency care. CONCLUSION The MLAEPi (simple numerical value) may be used to evaluate the degree of consciousness in comatose patients while performing emergency care in EDs.
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Affiliation(s)
- Junya Tsurukiri
- Department of Emergency and Critical Care Medicine, Tokyo Medical University Hospital, Tokyo, Japan.
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Total intravenous anesthesia in a closed loop system: Report of the first case in Colombia☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2013. [DOI: 10.1097/01819236-201341040-00014] [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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REBOSO JA, MÉNDEZ JA, REBOSO HJ, LEÓN AM. Design and implementation of a closed-loop control system for infusion of propofol guided by bispectral index (BIS). Acta Anaesthesiol Scand 2012; 56:1032-41. [PMID: 22834710 DOI: 10.1111/j.1399-6576.2012.02738.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND This study describes the design of a hypnosis closed-loop control system with propofol. The controller used a proportional-integral (PI) algorithm with the bispectral index (BIS) as the feedback signal. Our hypothesis was that a PI closed-loop control could be applied in clinical practice safely keeping the BIS within a pre-determined target range. METHODS The adjustment of the PI parameters was based on simulation. The procedure had three steps: obtaining a patient model using data from 12 patients, designing and adjusting the controller in simulation, and fine tuning the PI parameters in a pilot study (10 patients). The resulting controller was tested in 24 American Society of Anesthesiology (ASA) I-II patients. The controller directly decides the infusion rate of propofol, and no model is necessary in its online operation. The BIS target was set to 50. Remifentanil was used for analgesia. RESULTS We evaluated the efficiency and safety of the automatic feedback system. It worked properly in all the patients. The median performance error was -1.62, and the median absolute performance error was 11.03. Average propofol-normalized consumption was 5.3 ± 1.8 mg/kg/h. Mean percentage of BIS in the range 40-60 was 83%. Mean time to open eyes was 8 ± 4 min. Time to extubation was 9 ± 5 min. Hemodynamic adverse event or intraoperative awareness were not recorded. CONCLUSIONS The closed-loop system was able to maintain the BIS within an acceptable range of levels. The control of a propofol infusion guided by the BIS is feasible without hemodynamic instability in ASA I/II patients.
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Affiliation(s)
- J. A. REBOSO
- Department of Anesthesiology and Reanimation; Hospital Universitario de Canarias; La Laguna; Spain
| | - J. A. MÉNDEZ
- Department of Systems Engineering and Automation and Computer Architecture and Technology; University of La Laguna; La Laguna; Spain
| | - H. J. REBOSO
- Department of Systems Engineering and Automation and Computer Architecture and Technology; University of La Laguna; La Laguna; Spain
| | - A. M. LEÓN
- Department of Anesthesiology and Reanimation; Hospital Universitario de Canarias; La Laguna; Spain
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Haenggi M, Ypparila-Wolters H, Buerki S, Schlauri R, Korhonen I, Takala J, Jakob SM. Auditory event-related potentials, bispectral index, and entropy for the discrimination of different levels of sedation in intensive care unit patients. Anesth Analg 2009; 109:807-16. [PMID: 19690250 DOI: 10.1213/ane.0b013e3181acc85d] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Sedation protocols, including the use of sedation scales and regular sedation stops, help to reduce the length of mechanical ventilation and intensive care unit stay. Because clinical assessment of depth of sedation is labor-intensive, performed only intermittently, and interferes with sedation and sleep, processed electrophysiological signals from the brain have gained interest as surrogates. We hypothesized that auditory event-related potentials (ERPs), Bispectral Index (BIS), and Entropy can discriminate among clinically relevant sedation levels. METHODS We studied 10 patients after elective thoracic or abdominal surgery with general anesthesia. Electroencephalogram, BIS, state entropy (SE), response entropy (RE), and ERPs were recorded immediately after surgery in the intensive care unit at Richmond Agitation-Sedation Scale (RASS) scores of -5 (very deep sedation), -4 (deep sedation), -3 to -1 (moderate sedation), and 0 (awake) during decreasing target-controlled sedation with propofol and remifentanil. Reference measurements for baseline levels were performed before or several days after the operation. RESULTS At baseline, RASS -5, RASS -4, RASS -3 to -1, and RASS 0, BIS was 94 [4] (median, IQR), 47 [15], 68 [9], 75 [10], and 88 [6]; SE was 87 [3], 46 [10], 60 [22], 74 [21], and 87 [5]; and RE was 97 [4], 48 [9], 71 [25], 81 [18], and 96 [3], respectively (all P < 0.05, Friedman Test). Both BIS and Entropy had high variabilities. When ERP N100 amplitudes were considered alone, ERPs did not differ significantly among sedation levels. Nevertheless, discriminant ERP analysis including two parameters of principal component analysis revealed a prediction probability PK value of 0.89 for differentiating deep sedation, moderate sedation, and awake state. The corresponding PK for RE, SE, and BIS was 0.88, 0.89, and 0.85, respectively. CONCLUSIONS Neither ERPs nor BIS or Entropy can replace clinical sedation assessment with standard scoring systems. Discrimination among very deep, deep to moderate, and no sedation after general anesthesia can be provided by ERPs and processed electroencephalograms, with similar P(K)s. The high inter- and intraindividual variability of Entropy and BIS precludes defining a target range of values to predict the sedation level in critically ill patients using these parameters. The variability of ERPs is unknown.
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Affiliation(s)
- Matthias Haenggi
- Department of Intensive Care Medicine, Bern University Hospital and University of Bern, Bern, Switzerland
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[Target-controlled infusion (TCI) - a concept with a future?: state-of-the-art, treatment recommendations and a look into the future]. Anaesthesist 2008; 57:223-30. [PMID: 18322665 DOI: 10.1007/s00101-008-1329-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Over the last 10 years the technique of target-controlled infusion (TCI) has substantially influenced the development and practice of intravenous anaesthesia. It opened the possibility of many new and exciting applications of perioperative anaesthetic care. More recent and current developments, such as open TCI (target-controlled infusion) and the availability of generic anaesthetic agents combined with modern infusion pumps, means that TCI can become a standard procedure in anaesthesia and is no longer just a research tool for specialists and enthusiasts. This review explains the fundamentals and applications of intravenous drug delivery by TCI and gives practice guidelines to successfully implement the technique into clinical practice. The aim is to provide a comprehensive reference based on clinically proven evidence.
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Han JI, Lee H. Adequate Combination of Target Effect-site Concentration of Propofol and Remifentanil for Tracheal Intubation. Korean J Anesthesiol 2008. [DOI: 10.4097/kjae.2008.54.1.37] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Jong In Han
- Department of Anesthesiology and Pain Medicine, School of Medicine, Ewha Womans University, Seoul, Korea
| | - Heeseung Lee
- Department of Anesthesiology and Pain Medicine, School of Medicine, Ewha Womans University, Seoul, Korea
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Current World Literature. Curr Opin Anaesthesiol 2007; 20:388-94. [PMID: 17620851 DOI: 10.1097/aco.0b013e3282c3a878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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