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Sarraf E. The drug titration paradox: a control engineering perspective. Curr Opin Anaesthesiol 2024; 37:362-370. [PMID: 38841991 DOI: 10.1097/aco.0000000000001396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
PURPOSE OF REVIEW The drug titration paradox describes that, from a population standpoint, drug doses appear to have a negative correlation with its clinical effect. This paradox is a relatively modern discovery in anesthetic pharmacology derived from large clinical data sets. This review will interpret the paradox using a control engineering perspective. RECENT FINDINGS Drug titration is a challenging endeavor, and the medication delivery systems used in everyday clinical practice, including infusion pumps and vaporizers, typically do not allow for rapid or robust titration of medication being delivered. In addition, clinicians may be reluctant to deviate from a predetermined plan or may be content to manage patients within fixed goal boundaries. SUMMARY This drug titration paradox describes the constraints of how the average clinician will dose a patient with an unknown clinical response. While our understanding of the paradox is still in its infancy, it remains unclear how alternative dosing schemes, such as through automation, may exceed the boundaries of the paradox and potentially affect its conclusions.
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Affiliation(s)
- Elie Sarraf
- Penn State College of Medicine, Hershey, Pennsylvania, USA
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2
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S S, Dhingra U, Sindwani G, Yadav A, Arora V, Tempe DK. Determining the Target Concentration of Propofol for Sedation in Patients Undergoing Endoscopic Retrograde Cholangiopancreatography: A Target-Controlled Infusion Approach. Cureus 2024; 16:e62936. [PMID: 39050328 PMCID: PMC11265966 DOI: 10.7759/cureus.62936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/22/2024] [Indexed: 07/27/2024] Open
Abstract
Introduction Endoscopic retrograde cholangiopancreatography (ERCP) is vital for diagnosing and treating biliary and pancreatic diseases, necessitating deep sedation typically achieved through total intravenous anesthesia. Propofol, with its favorable pharmacokinetic profile, is the preferred sedative, but conventional administration methods of mg/kg boluses or infusion rates pose challenges. Target-controlled infusion (TCI) systems offer a solution that ensures precise dose delivery of propofol. Despite its widespread use, the literature lacks specific guidance on the target plasma concentration (Cp) of propofol for sedation in patients undergoing ERCP. Methods A prospective interventional study was conducted at the Institute of Liver and Biliary Sciences, Delhi, India to determine the target Cp of propofol for sedation during ERCP. The study enrolled 86 American Society of Anesthesiologists (ASA) grade I and II patients aged 18-70 years. The primary objective was to establish the optimal propofol concentration for sedation as guided by a bispectral index (BIS) value of 60-70. Secondary outcomes included induction time, recovery time, total propofol consumption, and the occurrence of adverse events (if any). The Marsh pharmacokinetic model guided the TCI pump, adjusting Cp until the target sedation was achieved. Results The mean Cp of propofol to maintain the BIS value 60-70 was 2.21 ± 0.42 µg/ml. Age-wise analysis revealed variations, emphasizing the need for individualized dosing. Induction time was 4.21 ± 0.68 minutes; recovery times were seven minutes (median, IQR: 5-10 minutes) for BIS >80 and seven minutes (median, IQR: 5-10 minutes) for achieving a Modified Observer's Assessment of Alertness/Sedation score of ≥5. The mean propofol consumption was 6.24 mg/kg/hr. Side effects were minimal, with 1.16% experiencing transient hypoxia and hypotension. Conclusion The study establishes a mean target propofol concentration of 2.21 ± 0.42 µg/ml for sedation in ASA I and II patients undergoing ERCP.
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Affiliation(s)
- Surbhi S
- Anesthesiology, Institute of Liver and Biliary Sciences, Delhi, IND
| | - Udit Dhingra
- Anesthesiology, Institute of Liver and Biliary Sciences, Delhi, IND
| | - Gaurav Sindwani
- Anesthesiology, Institute of Liver and Biliary Sciences, Delhi, IND
| | - Anil Yadav
- Anesthesiology, Institute of Liver and Biliary Sciences, Delhi, IND
| | - Vinod Arora
- Hepatology, Institute of Liver and Biliary Sciences, Delhi, IND
| | - Deepak K Tempe
- Anesthesiology, Institute of Liver and Biliary Sciences, Delhi, IND
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Vellinga R, Introna M, van Amsterdam K, Zhou XYT, De Smet T, Weber Jensen E, Struys MMRF, van den Berg JP. Implementation of a Bayesian based advisory tool for target-controlled infusion of propofol using qCON as control variable. J Clin Monit Comput 2024; 38:519-529. [PMID: 38112878 DOI: 10.1007/s10877-023-01106-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 11/09/2023] [Indexed: 12/21/2023]
Abstract
This single blinded randomized controlled trial aims to assess whether the application of a Bayesian-adjusted CePROP (effect-site of propofol) advisory tool leads towards a more stringent control of the cerebral drug effect during anaesthesia, using qCON as control variable. 100 patients scheduled for elective surgery were included and randomized into a control or intervention group (1:1 ratio). In the intervention group the advisory screen was made available to the clinician, whereas it was blinded in the control group. The settings of the target-controlled infusion pumps could be adjusted at any time by the clinician. Cerebral drug effect was quantified using processed EEG (CONOX monitor, Fresenius Kabi, Bad Homburg, Germany). The time of qCON between the desired range (35-55) during anaesthesia maintenance was defined as our primary end point. Induction parameters and recovery times were considered secondary end points and coefficient of variance of qCON and CePROP was calculated in order to survey the extent of control towards the mean of the population. The desired range of qCON between 35 and 55 was maintained in 84% vs. 90% (p = 0.15) of the case time in the control versus intervention group, respectively. Secondary endpoints showed similar results in both groups. The coefficient of variation for CePROP was higher in the intervention group. The application of the Bayesian-based CePROP advisory system in this trial did not result in a different time of qCON between 35 and 55 (84 [21] vs. 90 [18] percent of the case time). Significant differences between groups were hard to establish, most likely due to a very high performance level in the control group. More extensive control efforts were found in the intervention group. We believe that this advisory tool could be a useful educational tool for novices to titrate propofol effect-site concentrations.
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Affiliation(s)
- Remco Vellinga
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Michele Introna
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- NeuroAnesthesia and NeuroIntensive Care, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria, 11, 20133, Milan, Italy
| | - Kai van Amsterdam
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - X Y Tommy Zhou
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Erik Weber Jensen
- Centre for Biomedical Research (CREB), UPC-Barcelonatech, Barcelona, Spain
| | - Michel M R F Struys
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Basic and Applied Medical Sciences, Ghent University, Ghent, Belgium
| | - Johannes P van den Berg
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
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Kawata M, Yonezawa A, Mineharu Y, Itohara K, Mizota T, Matsui Y, Kikuchi T, Yamao Y, Hattori EY, Hamada M, Hira D, Furukawa K, Miyamoto S, Terada T, Matsubara K, Arakawa Y. Development of extended pharmacokinetic models for propofol based on measured blood and brain concentrations. Sci Rep 2024; 14:6326. [PMID: 38491119 PMCID: PMC10943190 DOI: 10.1038/s41598-024-56863-z] [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: 12/06/2023] [Accepted: 03/12/2024] [Indexed: 03/18/2024] Open
Abstract
Propofol's pharmacokinetics have been extensively studied using human blood samples and applied to target-controlled infusion systems; however, information on its concentration in the brain remains scarce. Therefore, this study aimed to simultaneously measure propofol plasma and brain concentrations in patients who underwent awake craniotomy and establish new pharmacokinetic model. Fifty-seven patients with brain tumors or brain lesions who underwent awake craniotomy were sequentially assigned to model-building and validating groups. Plasma and brain (lobectomy or uncapping margins) samples were collected at five time-points. The concentration of propofol was measured using high-performance liquid chromatography. Population pharmacokinetic analysis was conducted through a nonlinear mixed-effects modeling program using a first-order conditional estimation method with interactions. Propofol's brain concentrations were higher than its plasma concentrations. The measured brain concentrations were higher than the effect site concentrations using the previous models. Extended models were constructed based on measured concentrations by incorporating the brain/plasma partition coefficient (Kp value). Extended models showed good predictive accuracy for brain concentrations in the validating group. The Kp value functioned as a factor explaining retention in the brain. Our new pharmacokinetic models and Kp value can predict propofol's brain and plasma concentrations, contributing to safer and more stable anesthesia.
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Affiliation(s)
- Masayoshi Kawata
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Atsushi Yonezawa
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan.
- Graduate School of Pharmaceutical Sciences, Kyoto University, 46-29 Yoshida Shimo-Adachi-cho, Sakyo-ku, Kyoto, 606-8501, Japan.
| | - Yohei Mineharu
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
- Department of Artificial Intelligence in Healthcare and Medicine, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Kotaro Itohara
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Toshiyuki Mizota
- Department of Anesthesia, Kyoto University Hospital, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Yoshihiro Matsui
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
- Graduate School of Pharmaceutical Sciences, Kyoto University, 46-29 Yoshida Shimo-Adachi-cho, Sakyo-ku, Kyoto, 606-8501, Japan
| | - Takayuki Kikuchi
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Yukihiro Yamao
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Etsuko Yamamoto Hattori
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Miho Hamada
- Department of Anesthesia, Kyoto University Hospital, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Daiki Hira
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Keiko Furukawa
- Cancer Center, Kyoto University Hospital, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Susumu Miyamoto
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Tomohiro Terada
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Kazuo Matsubara
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Yoshiki Arakawa
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
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Ryalino C, Sahinovic MM, Drost G, Absalom AR. Intraoperative monitoring of the central and peripheral nervous systems: a narrative review. Br J Anaesth 2024; 132:285-299. [PMID: 38114354 DOI: 10.1016/j.bja.2023.11.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 11/03/2023] [Accepted: 11/03/2023] [Indexed: 12/21/2023] Open
Abstract
The central and peripheral nervous systems are the primary target organs during anaesthesia. At the time of the inception of the British Journal of Anaesthesia, monitoring of the central nervous system comprised clinical observation, which provided only limited information. During the 100 yr since then, and particularly in the past few decades, significant progress has been made, providing anaesthetists with tools to obtain real-time assessments of cerebral neurophysiology during surgical procedures. In this narrative review article, we discuss the rationale and uses of electroencephalography, evoked potentials, near-infrared spectroscopy, and transcranial Doppler ultrasonography for intraoperative monitoring of the central and peripheral nervous systems.
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Affiliation(s)
- Christopher Ryalino
- Department of Anaesthesiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Marko M Sahinovic
- Department of Anaesthesiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Gea Drost
- Department of Neurology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands; Department of Neurosurgery, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Anthony R Absalom
- Department of Anaesthesiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands.
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Hemmerling TM, Jeffries SD. Robotic Anesthesia: A Vision for 2050. Anesth Analg 2024; 138:239-251. [PMID: 38215704 DOI: 10.1213/ane.0000000000006835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2024]
Abstract
The last 2 decades have brought important developments in anesthetic technology, including robotic anesthesia. Anesthesiologists titrate the administration of pharmacological agents to the patients' physiology and the needs of surgery, using a variety of sophisticated equipment (we use the term "pilots of the human biosphere"). In anesthesia, increased safety seems coupled with increased technology and innovation. This article gives an overview of the technological developments over the past decades, both in terms of pharmacological and mechanical robots, which have laid the groundwork for robotic anesthesia: target-controlled drug infusion systems, closed-loop administration of anesthesia and sedation, mechanical robots for intubation, and the latest development in the world of communication with the arrival of artificial intelligence (AI)-derived chatbots are presented.
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Affiliation(s)
- Thomas M Hemmerling
- From the Department of Experimental Surgery, McGill University Health Center, Montreal, Quebec, Canada
- Department of Anesthesia, McGill University, Montreal, Quebec, Canada
| | - Sean D Jeffries
- From the Department of Experimental Surgery, McGill University Health Center, Montreal, Quebec, Canada
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Rössler J, Cywinski JB, Argalious M, Ruetzler K, Khanna S. Anesthetic management in patients having catheter-based thrombectomy for acute pulmonary embolism: A narrative review. J Clin Anesth 2024; 92:111281. [PMID: 37813080 DOI: 10.1016/j.jclinane.2023.111281] [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: 07/25/2023] [Revised: 08/25/2023] [Accepted: 09/30/2023] [Indexed: 10/11/2023]
Abstract
Pulmonary embolism is the third leading cause of cardiovascular death. Novel percutaneous catheter-based thrombectomy techniques are rapidly becoming popular in high-risk pulmonary embolism - especially in the presence of contraindications to thrombolysis. The interventional nature of these procedures and the risk of sudden cardiorespiratory compromise requires the presence of an anesthesiologist. Facilitating catheter-based thrombectomy can be challenging since qualifying patients are often critically ill. The purpose of this narrative review is to provide guidance to anesthesiologists for the assessment and management of patients having catheter-based thrombectomy for acute pulmonary embolism. First, available techniques for catheter-based thrombectomy are reviewed. Then, we discuss definitions and application of common risk stratification tools for pulmonary embolism, and how to assess patients prior to the procedure. An adjudication of risks and benefits of anesthetic strategies for catheter-based thrombectomy follows. Specifically, we give guidance and rationale for use monitored anesthesia care and general anesthesia for these procedures. For both, we review strategies for assessing and mitigating hemodynamic perturbations and right ventricular dysfunction, ranging from basic monitoring to advanced inodilator therapy. Finally, considerations for management of right ventricular failure with mechanical circulatory support are discussed.
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Affiliation(s)
- Julian Rössler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jacek B Cywinski
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA; Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Maged Argalious
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kurt Ruetzler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA; Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Sandeep Khanna
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA; Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Cardiothoracic and Vascular Anesthesia, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
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8
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Lee SH, Yoon H, Park J, Choi JM, Kim KM, Lee EK, Noh GJ, Moon JY, Cho BM. External validation of a pharmacokinetic model for target-controlled infusion of cefazolin as a prophylactic antibiotic. Br J Clin Pharmacol 2024; 90:582-587. [PMID: 37897050 DOI: 10.1111/bcp.15943] [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: 08/13/2023] [Revised: 10/18/2023] [Accepted: 10/19/2023] [Indexed: 10/29/2023] Open
Abstract
AIMS This study aimed to evaluate the predictive performance of previously constructed cefazolin pharmacokinetic models and determine whether cefazolin administration via the target-controlled infusion (TCI) method may be possible in clinical practice. METHODS Twenty-five gastrectomy patients receiving cefazolin as a prophylactic antibiotic were enrolled. Two grams of cefazolin was dissolved in 50 mL of normal saline to give a concentration of 40 mg mL-1 . Before skin incision, cefazolin was administered using a TCI syringe pump, and its administration continued until the end of surgery. The target total plasma concentration was set to 100 μg mL-1 . Total and unbound plasma concentrations of cefazolin were measured in three arterial blood samples collected at 30, 60 and 120 min after the start of cefazolin administration. The predictive performance of the TCI system was evaluated using four measures: inaccuracy, divergence, bias and wobble. RESULTS Total (n = 75) and unbound (n = 75) plasma concentration measurements from 25 patients were included in the analysis. The pooled median (95% confidence interval) biases and inaccuracies were 6.3 (4.0-8.5) and 10.5 (8.6-12.4) for the total concentration model and -10.3 (-16.8 to -3.7) and 22.4 (18.2-26.7) for the unbound concentration model, respectively. All unbound concentrations were above 10 μg mL-1 . CONCLUSION Administration of cefazolin by the TCI method showed a clinically acceptable performance. Applying the TCI method by setting the total concentration as the target concentration rather than the unbound concentration is effective in maintaining a constant target concentration of cefazolin.
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Affiliation(s)
- Sou Hyun Lee
- Department of Anesthesiology and Pain Medicine, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, South Korea
| | - Hyeongseo Yoon
- University of Ulsan College of Medicine, Seoul, South Korea
| | - Junik Park
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jae Moon Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Kyung Mi Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Eun-Kyung Lee
- Department of Statistics, Ewha Womans University, Seoul, South Korea
| | - Gyu-Jeong Noh
- Departments of Anesthesiology and Pain Medicine and Clinical Pharmacology and Therapeutics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Ju-Yeon Moon
- Department of Pharmaceutical Analysis, International Scientific Standards, Inc, Chucheon-si, South Korea
| | - Byung-Moon Cho
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Montana MC, McLeland M, Fisher M, Juriga L, Ercole PM, Kharasch ED. Opioid sensitivity in treated and untreated obstructive sleep apnoea: a prospective cohort study. Br J Anaesth 2024; 132:145-153. [PMID: 37945413 PMCID: PMC10797511 DOI: 10.1016/j.bja.2023.09.032] [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: 04/24/2023] [Revised: 09/25/2023] [Accepted: 09/26/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Opioid administration to patients with obstructive sleep apnoea (OSA) is controversial because they are believed to be more sensitive to opioids. However, objective data on opioid effects in OSA are lacking. We tested the hypothesis that subjects with untreated OSA have increased sensitivity to opioids compared with subjects without OSA, or with OSA treated with continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BIPAP). METHODS This was a single-centre, prospective cohort study in subjects without OSA (n=20), with untreated OSA (n=33), or with treated OSA (n=21). OSA diagnosis was verified using type III (in-home) polysomnography. Subjects received a stepped-dose remifentanil infusion (target effect-site concentrations of 0.5, 1, 2, 3, 4 ng ml-1). Primary outcome was miosis (pupil area fractional change), the most sensitive opioid effect. Secondary outcomes were ventilatory rate, end-expired CO2, sedation, and thermal analgesia. RESULTS There were no differences in miosis between untreated OSA subjects (mean=0.51, 95% confidence interval [CI] 0.41-0.61) and subjects without OSA (mean=0.49, 95% CI 0.36-0.62) (mean difference=0.02, 95% CI -0.18 to 0.22); between treated OSA subjects (mean=0.56, 95% CI 0.43-0.68) and subjects without OSA (difference=0.07, 95% CI -0.16 to 0.29); or between untreated OSA and treated OSA (difference=-0.05, 95% CI -0.25 to 0.16). There were no significant differences between subjects without OSA, untreated OSA, and treated OSA in ventilatory rate, end-expired CO2, sedation, or thermal analgesia responses to remifentanil. There was no relationship between OSA severity and magnitude of opioid effects. CONCLUSIONS Neither obstructive sleep apnoea nor obstructive sleep apnoea treatment affected sensitivity to the miotic, sedative, analgesic, or respiratory depressant effects of the opioid remifentanil in awake adults. These results challenge conventional notions of opioid effects in obstructive sleep apnoea. CLINICAL TRIAL REGISTRATION NCT02898792 (clinicaltrials.gov).
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Affiliation(s)
- Michael C Montana
- Department of Anesthesiology, Washington University in St. Louis, School of Medicine, St. Louis, MO, USA.
| | - Michael McLeland
- Sleep Laboratory, Saint Louis Children's Hospital, St. Louis, MO, USA
| | - Marilee Fisher
- Department of Anesthesiology, Washington University in St. Louis, School of Medicine, St. Louis, MO, USA; Pediatric Intensive Care Unit, Saint Louis Children's Hospital, St. Louis, MO, USA
| | - Lindsay Juriga
- Department of Anesthesiology, Washington University in St. Louis, School of Medicine, St. Louis, MO, USA; University of Missouri School of Medicine, Columbia, MO, USA
| | | | - Evan D Kharasch
- Department of Anesthesiology, Washington University in St. Louis, School of Medicine, St. Louis, MO, USA; Department of Anesthesiology, Duke University School of Medicine, Durham, NC, USA
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10
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Cuiabano IS, de Miranda Garbin P, Módolo NSP, do Nascimento P. Safety and efficacy of target-controlled infusion versus intermittent bolus administration of propofol for sedation in colonoscopy: a randomized controlled trial. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2023; 73:751-757. [PMID: 35803368 PMCID: PMC10625152 DOI: 10.1016/j.bjane.2022.06.003] [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: 06/28/2021] [Revised: 06/13/2022] [Accepted: 06/15/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Our objective was to compare the safety and efficacy of Target-Controlled Infusion (TCI) versus intermittent bolus of propofol for colonoscopy sedation. METHODS We conducted a randomized (1:1), single-blind, parallel-group superiority trial with fifty ASA I or II patients, both sexes, aged 18 to 65 years, Body Mass Index ≤ 30 kg.m-2, undergoing colonoscopy, allocated to receive propofol by TCI (effect-site, 2 μg.mL-1 plus 0.5 μg.mL-1 until unconsciousness and as necessary for agitation) or intermittent bolus (1 mg.kg-1 plus 0.5 mg.kg-1 every 5 minutes or as above). The primary safety outcome was the need for airway maneuvers and the primary efficacy outcome was the need for interventions to adjust the level of sedation. Secondary outcomes included incidence of agitation, propofol dose, and time to recovery. RESULTS The median (IQR) number of airway maneuvers and interventions needed to adjust sedation was 0 (0‒0) vs. 0 (0‒0) (p = 0.239) and 1 (0‒1) vs. 3 (1‒4) (p < 0.001) in the TCI and control groups, respectively. Agitation was more common in the intermittent bolus group ‒ 2 (0‒2) vs. 1 (0‒1), p < 0.001. The mean ± SD time to recovery was 4.9 ± 1.4 minutes in the TCI group vs. 2.3 ± 1.6 minutes in the control group (p < 0.001). The total propofol dose was higher in the TCI group (234 ± 46 µg.kg-1.min-1 vs. 195 ± 44 µg.kg-1.min-1 (p = 0.040)). CONCLUSIONS During colonoscopy, TCI is as safe as intermittent bolus of propofol while reducing the incidence of agitation and the need for dose adjustments. However, intermittent bolus administration was associated with lower total propofol dose and earlier recovery.
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Affiliation(s)
| | - Priscila de Miranda Garbin
- Hospital de Câncer de Mato Grosso (Hcan-MT), Cuiabá, MT, Brazil; Hospital Nossa Senhora do Perpétuo Socorro, Gaspar, SC, Brazil
| | - Norma Sueli Pinheiro Módolo
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu, Departamento de Especialidades Cirúrgicas e Anestesiologia, São Paulo, SP, Brazil
| | - Paulo do Nascimento
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu, Departamento de Especialidades Cirúrgicas e Anestesiologia, São Paulo, SP, Brazil
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11
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Anderson KJ, Absalom AR. Propofol/remifentanil patient-controlled sedation: caveat emptor! Can J Anaesth 2023; 70:1719-1725. [PMID: 37853278 DOI: 10.1007/s12630-023-02592-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 06/27/2023] [Accepted: 06/28/2023] [Indexed: 10/20/2023] Open
Affiliation(s)
- Keith J Anderson
- Department of Anesthesiology, Perioperative and Pain Medicine, Foothills Medical Centre, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
| | - Anthony R Absalom
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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12
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Johnson KB, Egan TD. In Total Intravenous Anesthesia We Trust: Building Confidence in Total Intravenous Anesthesia Techniques. Anesth Analg 2023; 137:559-564. [PMID: 37590800 DOI: 10.1213/ane.0000000000006622] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2023]
Affiliation(s)
- Ken B Johnson
- From the Department of Anesthesiology, University of Utah, Salt Lake City, Utah
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13
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Coetzee E, Absalom AR. Pharmacokinetic and Pharmacodynamic Changes in the Elderly: Impact on Anesthetics. Anesthesiol Clin 2023; 41:549-565. [PMID: 37516494 DOI: 10.1016/j.anclin.2023.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2023]
Abstract
Anesthesiologists are increasingly required to care for frail elderly patients. A detailed knowledge of the influence of age on the pharmacokinetics and dynamics of the anesthetic drugs is essential for optimal safety and care. For most of the anesthetic drugs, the elderly need lower doses to achieve the same plasma concentrations, and at any given plasma and effect-site concentration, they will have more profound clinical effects than younger patients. Caution is required, with close monitoring of clinical effects and active titration of dose administration to achieve the desired level of effect, ideally following the "start low, go slow" principle.
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Affiliation(s)
- Ettienne Coetzee
- Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, D23, Observatory, Cape Town 7925, Republic of South Africa
| | - Anthony Ray Absalom
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Post Box 30.001, Groningen 9700 RB, the Netherlands.
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14
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Malagutti N, McGinness G, Nithyanandam DA. Real-Time Personalised Pharmacokinetic-Pharmacodynamic Modelling in Propofol Anesthesia through Bayesian Inference. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2023; 2023:1-6. [PMID: 38082840 DOI: 10.1109/embc40787.2023.10339991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Pharmacological models describe a patient's response to the administration of a medicinal drug based on parameters derived from population studies. However, considerable inter-patient variability exists, such that population models may underperform when used to predict the actual response of a specific individual. In applications which demand predictive accuracy-such as target-controlled infusion of anesthetic agents-modeling uncertainty may reduce system dependability and introduce clinical risk. Our work investigates the use of Bayesian inference, implemented through a particle filter algorithm, to refine a prior model of propofol pharmacokinetics-pharmacodynamics and estimate patient-specific parameters in real-time. We report here on an observational clinical study conducted on 40 adults undergoing general anesthesia, where we evaluated the performance of Bayesian inference-personalized models in forecasting forward trends of depth of anesthesia (Bispectral Index) measurements and compared it with that of a traditional population-based pharmacological model. Our results show a significant reduction in prediction error metrics for the patient-specific models. Our study demonstrates the viability and practical implementability of Bayesian inference as a tool for real-time intra-operative estimation of personalized pharmacological models in anesthesia applications.
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15
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Ren D, Zhou B, Li J, Guo S, Guo B. Control of the injection velocity of embolic agents in embolization treatment. Biomed Eng Online 2023; 22:58. [PMID: 37316898 DOI: 10.1186/s12938-023-01126-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 06/08/2023] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Embolization is a common treatment method for tumor-targeting, anti-organ hyper-function, and hemostasis. However, the injection of embolic agents largely depends on the experiences of doctors, and doctors need to work in an X-ray environment that hurts their health. Even for a well-trained doctor, complications such as ectopic embolism caused by excessive embolic agents are always inevitable. RESULTS This paper established a flow control curve model for embolic injection based on local arterial pressure. The end-vessel network was simplified as a porous media. The hemodynamic changes at different injection velocities and embolization degrees were simulated and analyzed. Sponge, a typical porous medium, was used to simulate the blocking and accumulation of embolic agents by capillary networks in the in vitro experimental platform. CONCLUSIONS The simulation and experimental results show that the local arterial pressure is closely related to the critical injection velocity of the embolic agent reflux at a certain degree of embolization. The feasibility of this method for an automatic embolic injection system is discussed. It is concluded that the model of the flow control curve of embolic injection can effectively reduce the risk of ectopic embolism and shorten the time of embolic injection. The clinical application of this model is of great value in reducing radiation exposure and improving the success rate of interventional embolization.
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Affiliation(s)
- Dongcheng Ren
- Academy for Engineering and Technology, Fudan University, 220 Handan Rd., Shanghai, China
- Shanghai Engineering Research Center of AI & Robotics, 539 Handan Rd., Shanghai, 200433, China
- Engineering Research Center of AI & Robotics, Ministry of Education, 539 Handan Rd., Shanghai, China
| | - Bo Zhou
- Department of Interventional Radiology, Fudan University Zhongshan Hospital, 180 Fenglin Rd., Shanghai, China
- National Clinical Research Center for Interventional Medicine, 180 Fenglin Rd., Shanghai, China
| | - Jiasheng Li
- Academy for Engineering and Technology, Fudan University, 220 Handan Rd., Shanghai, China
- Shanghai Engineering Research Center of AI & Robotics, 539 Handan Rd., Shanghai, 200433, China
- Engineering Research Center of AI & Robotics, Ministry of Education, 539 Handan Rd., Shanghai, China
| | - Shijie Guo
- Academy for Engineering and Technology, Fudan University, 220 Handan Rd., Shanghai, China.
- Shanghai Engineering Research Center of AI & Robotics, 539 Handan Rd., Shanghai, 200433, China.
- Engineering Research Center of AI & Robotics, Ministry of Education, 539 Handan Rd., Shanghai, China.
| | - Baolei Guo
- Department of Vascular Surgery, Fudan University Zhongshan Hospital, 180 Fenglin Rd., Shanghai, 200032, China.
- National Clinical Research Center for Interventional Medicine, 180 Fenglin Rd., Shanghai, China.
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16
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Davoud SC, Kovacheva VP. On the Horizon: Specific Applications of Automation and Artificial Intelligence in Anesthesiology. CURRENT ANESTHESIOLOGY REPORTS 2023; 13:31-40. [PMID: 38106626 PMCID: PMC10722862 DOI: 10.1007/s40140-023-00558-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2023] [Indexed: 04/08/2023]
Abstract
Purpose of Review The purpose of this review is to summarize the current research and critically examine artificial intelligence (AI) technologies and their applicability to the daily practice of anesthesiologists. Recent Findings Novel AI tools are developed using data from electronic health records, imaging, waveforms, clinical notes, and wearables. These tools can accurately predict the perioperative risk for adverse outcomes, the need for blood transfusion, and the risk of difficult intubation. Intraoperatively, AI models can assist with technical skill augmentation, patient monitoring, and management. Postoperatively, AI technology can aid in preventing complications and discharge planning. While further prospective validation is needed, these early applications demonstrate promise in every area of perioperative care. Summary The practice of anesthesiology is at a precipice fueled by technological innovation. The clinical AI implementation would enable personalized and safer patient care by offering actionable insights from the wealth of perioperative data.
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Affiliation(s)
- Sherwin C. Davoud
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St., L1, Boston, MA, USA
| | - Vesela P. Kovacheva
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St., L1, Boston, MA, USA
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Nourmohammadi A, Swift JR, de Pesters A, Guay CS, Adamo MA, Dalfino JC, Ritaccio AL, Schalk G, Brunner P. Passive functional mapping of receptive language cortex during general anesthesia using electrocorticography. Clin Neurophysiol 2023; 147:31-44. [PMID: 36634533 PMCID: PMC10267852 DOI: 10.1016/j.clinph.2022.11.021] [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: 04/18/2022] [Revised: 09/30/2022] [Accepted: 11/10/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To investigate the feasibility of passive functional mapping in the receptive language cortex during general anesthesia using electrocorticographic (ECoG) signals. METHODS We used subdurally placed ECoG grids to record cortical responses to speech stimuli during awake and anesthesia conditions. We identified the cortical areas with significant responses to the stimuli using the spectro-temporal consistency of the brain signal in the broadband gamma (BBG) frequency band (70-170 Hz). RESULTS We found that ECoG BBG responses during general anesthesia effectively identify cortical regions associated with receptive language function. Our analyses demonstrated that the ability to identify receptive language cortex varies across different states and depths of anesthesia. We confirmed these results by comparing them to receptive language areas identified during the awake condition. Quantification of these results demonstrated an average sensitivity and specificity of passive language mapping during general anesthesia to be 49±7.7% and 100%, respectively. CONCLUSION Our results demonstrate that mapping receptive language cortex in patients during general anesthesia is feasible. SIGNIFICANCE Our proposed protocol could greatly expand the population of patients that can benefit from passive language mapping techniques, and could eliminate the risks associated with electrocortical stimulation during an awake craniotomy.
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Affiliation(s)
- Amin Nourmohammadi
- National Center for Adaptive Neurotechnologies, Washington University School of Medicine, St. Louis, MO, USA; Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO, USA; Department of Biomedical Sciences, State University of New York at Albany, Albany, NY, USA.
| | - James R Swift
- National Center for Adaptive Neurotechnologies, Washington University School of Medicine, St. Louis, MO, USA; Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO, USA; Department of Biomedical Sciences, State University of New York at Albany, Albany, NY, USA.
| | - Adriana de Pesters
- National Center for Adaptive Neurotechnologies, Washington University School of Medicine, St. Louis, MO, USA; Department of Biomedical Sciences, State University of New York at Albany, Albany, NY, USA.
| | - Christian S Guay
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA.
| | - Matthew A Adamo
- Department of Neurosurgery, Albany Medical College, Albany, NY, USA.
| | - John C Dalfino
- Department of Neurosurgery, Albany Medical College, Albany, NY, USA.
| | - Anthony L Ritaccio
- Department of Neurology, Albany Medical College, Albany, NY, USA; Department of Neurology, Mayo Clinic, Jacksonville, FL, USA.
| | - Gerwin Schalk
- National Center for Adaptive Neurotechnologies, Washington University School of Medicine, St. Louis, MO, USA; Department of Biomedical Sciences, State University of New York at Albany, Albany, NY, USA; Chen Frontier Lab for Applied Neurotechnology, Tianqiao and Chrissy Chen Institute, Shanghai, P.R. China.
| | - Peter Brunner
- National Center for Adaptive Neurotechnologies, Washington University School of Medicine, St. Louis, MO, USA; Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO, USA; Department of Biomedical Sciences, State University of New York at Albany, Albany, NY, USA; Department of Neurology, Albany Medical College, Albany, NY, USA.
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18
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Karer G, Škrjanc I. Improved Individualized Patient-Oriented Depth-of-Hypnosis Measurement Based on Bispectral Index. SENSORS (BASEL, SWITZERLAND) 2022; 23:293. [PMID: 36616891 PMCID: PMC9824030 DOI: 10.3390/s23010293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/21/2022] [Accepted: 12/22/2022] [Indexed: 06/17/2023]
Abstract
Total intravenous anesthesia is an anesthesiologic technique where all substances are injected intravenously. The main task of the anesthesiologist is to assess the depth of anesthesia, or, more specifically, the depth of hypnosis (DoH), and accordingly adjust the dose of intravenous anesthetic agents. However, it is not possible to directly measure the anesthetic agent concentrations or the DoH, so the anesthesiologist must rely on various vital signs and EEG-based measurements, such as the bispectral (BIS) index. The ability to better measure DoH is directly applicable in clinical practice-it improves the anesthesiologist's assessment of the patient state regarding anesthetic agent concentrations and, consequently, the effects, as well as provides the basis for closed-loop control algorithms. This article introduces a novel structure for modeling DoH, which employs a residual dynamic model. The improved model can take into account the patient's individual sensitivity to the anesthetic agent, which is not the case when using the available population-data-based models. The improved model was tested using real clinical data. The results show that the predictions of the BIS-index trajectory were improved considerably. The proposed model thus seems to provide a good basis for a more patient-oriented individualized assessment of DoH, which should lead to better administration methods that will relieve the anesthesiologist's workload and will benefit the patient by providing improved safety, individualized treatment, and, thus, alleviation of possible adverse effects during and after surgery.
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19
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Population pharmacokinetic and pharmacodynamic model of propofol externally validated in Korean elderly subjects. J Pharmacokinet Pharmacodyn 2022; 50:97-109. [PMID: 36522561 DOI: 10.1007/s10928-022-09836-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 12/01/2022] [Indexed: 12/23/2022]
Abstract
The Eleveld propofol pharmacokinetic (PK) model, which was developed based on a broad range of populations, showed greater bias (- 27%) in elderly subjects in a previous validation study conducted by Vellinga and colleagues. We aimed to develop and externally validate a new PK-pharmacodynamic (PK-PD) model of propofol for elderly subjects. A population PK-PD model was constructed using propofol plasma concentrations and bispectral index (BIS) values that were obtained from 31 subjects aged 65 years older in previously published phase I studies. The predictive performance of the newly-developed PK-PD model (Choi model) was assessed in a separate Korean elderly population and compared with that of the Eleveld model. A three-compartment mammillary model using an allometric expression and a sigmoid Emax model well-described the time courses of propofol concentrations and BIS values. The V1, V2, V3, Cl, Q1, Q2, E0, Emax, Ce50, γ, and ke0 of a 60-kg subject were 8.36, 58.0, 650 L, 1.26, 0.917, 0.669 L/min, 92.1, 18.7, 2.21 μg/mL, 2.89, and 0.138 /min, respectively. In the Choi model and Eleveld model, pooled biases (95% CI) of the propofol concentration were 7.78 ( 3.09-12.49) and 16.70 (9.46-23.93) and pooled inaccuracies were 22.84 (18.87-26.81) and 24.85 (18.07-31.63), respectively. The Choi PK model was less biased than the Eleveld PK model in Korean elderly subjects (age range: 65.0-79.0 yr; weight range: 45.0-75.3 kg). Our results suggest that the Choi PK model, particularly, is applicable to target-controlled infusion in non-obese Korean elderly subjects.
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Remifentanil pharmacodynamics during conscious sedation using algometry: a more clinically relevant pharmacodynamical model. Br J Anaesth 2022; 129:868-878. [DOI: 10.1016/j.bja.2022.08.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 07/16/2022] [Accepted: 08/10/2022] [Indexed: 11/18/2022] Open
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Khorsand S, Karamchandani K, Joshi GP. Sedation-analgesia techniques for nonoperating room anesthesia: an update. Curr Opin Anaesthesiol 2022; 35:450-456. [PMID: 35283459 DOI: 10.1097/aco.0000000000001123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW There has been a substantial increase in nonoperating room anesthesia procedures over the years along with an increase in the complexity and severity of cases. These procedures pose unique challenges for anesthesia providers requiring meticulous planning and attention to detail. Advancements in the delivery of sedation and analgesia in this setting will help anesthesia providers navigate these challenges and improve patient safety and outcomes. RECENT FINDINGS There has been a renewed interest in the development of newer sedative and analgesic drugs and delivery systems that can safely provide anesthesia care in challenging situations and circumstances. SUMMARY Delivery of anesthesia care in nonoperating room locations is associated with significant challenges. The advent of sedative and analgesic drugs that can be safely used in situations where monitoring capabilities are limited in conjunction with delivery systems, that can incorporate unique patient characteristics and ensure the safe delivery of these drugs, has the potential to improve patient safety and outcomes. Further research is needed in these areas to develop newer drugs and delivery systems.
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Affiliation(s)
- Sarah Khorsand
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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22
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Fujisawa T, Takuma S, Nitta Y. High initial target blood concentration in target‐controlled infusion: A randomized controlled trial. Clin Exp Dent Res 2022; 8:1117-1123. [PMID: 35869682 PMCID: PMC9562568 DOI: 10.1002/cre2.632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 06/26/2022] [Accepted: 06/28/2022] [Indexed: 11/28/2022] Open
Abstract
Objective Our previously modified propofol intravenous sedation (IVS) method using a target‐controlled infusion (TCI) pump with initial target blood concentration (TBC) set at 2.2 μg/ml enables the prediction of the personal optimal intraoperative TBC during induction with a minimal gap. This study aimed to verify whether this method can be useful in case of higher initial TBCs to reduce induction time. Methods Forty‐five patients scheduled to undergo oral surgery under IVS with propofol were randomly divided into three groups (group 1, TCI started with TBC set at 2.2 μg/ml; group 2, TBC was set at 2.6 μg/ml; group 3, TBC was set at 3.0 μg/ml). Immediately after reading the calculated brain concentration when the target sedation was achieved (value A), the initial TBC was manually reset to value A. We manually controlled the intraoperative TBC to maintain moderate sedation, according to the clinical signs and bispectral index values. Of the regulated TBC values, the value farthest from value A was defined as value B. The maximum discrepancy between values B and A and the induction time were compared among the three groups. Results The maximum discrepancy (mean ± standard deviation [SD]) was significantly larger in group 3 (1.0 ± 1.3 μg/ml, p = .005) and group 2 (0.8 ± 0.2 μg/ml p = .008) than in group 1 (0.5 ± 0.3 μg/ml). The induction time (mean ± SD) was significantly shorter in group 3 (124 ± 126 min, p = .004) and group 2 (135 ± 33 min, p = .006) than in group 1 (245 ± 1913 min). With the initial TBC set at 2.6 μg/ml, the maximum discrepancy was large at 0.8 μg/ml, but with a small SD (0.2 μg/ml). Conclusion Considering this discrepancy, this method with an initial TBC set at 2.6 μg/ml may be acceptable for clinical use for moderate sedation (UMIN 000017197).
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Affiliation(s)
- Toshiaki Fujisawa
- Department of Dental Anesthesiology, Faculty of Dental Medicine and Graduate School of Dental Medicine Hokkaido University Sapporo Japan
| | - Shigeru Takuma
- Department of Dental Anesthesiology, Faculty of Dental Medicine and Graduate School of Dental Medicine Hokkaido University Sapporo Japan
| | - Yukie Nitta
- Department of Dental Anesthesiology, Faculty of Dental Medicine and Graduate School of Dental Medicine Hokkaido University Sapporo Japan
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Kang HU, Kim KM, Choi JM, Lee EK, Choi BM, Noh GJ, Lee SH. Predictive performance of pharmacokinetic models for target concentration-controlled infusion of cefoxitin as a prophylactic antibiotic in patients with colorectal surgery. Clin Exp Pharmacol Physiol 2022; 49:1126-1135. [PMID: 35748860 PMCID: PMC9543581 DOI: 10.1111/1440-1681.13695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 06/20/2022] [Accepted: 06/21/2022] [Indexed: 11/29/2022]
Abstract
We aimed to evaluate the predictive performance of previously constructed free (Cfree) and total (Ctotal) cefoxitin pharmacokinetic models and the possibility of administering cefoxitin via the target‐controlled infusion (TCI) method in clinical practice. Two external validation studies (N = 31 for Cfree model, N = 30 for Ctotal model) were conducted sequentially. Cefoxitin (2 g) was dissolved in 50 mL of normal saline to give a concentration of 40 mg mL−1. Before skin incision, cefoxitin was infused with a TCI syringe pump. Target concentrations of free concentration and total concentration were set to 25 and 80 μg mL−1, respectively, which were administered throughout the surgery. Three arterial blood samples were collected to measure the total and free plasma concentrations of cefoxitin at 30, 60 and 120 min, after the start of cefoxitin administration. The predictive performance was evaluated using four parameters: inaccuracy, divergence, bias and wobble. The pooled median (95% confidence interval) biases and inaccuracies were − 45.9 (−47.3 to −44.5) and 45.9 (44.5 to 47.3) for Cfree model (Choi_F model), and − 16.6 (−18.4 to −14.8) and 18.5 (16.7 to 20.2) for Ctotal model (Choi_Told model), respectively. The predictive performance of the newly constructed model (Choi_Tnew model), developed by adding the total concentration data measured in the external validation, was better than that of the Choi_Told model. Models constructed with total concentration data were suitable for clinical use. Administering cefoxitin using the TCI method in patients maintained the free concentration above the minimal inhibitory concentration (MIC) breakpoints of the major pathogens causing surgical site infection throughout the operation period.
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Affiliation(s)
- Hyun-Uk Kang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Kyung Mi Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jae Moon Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Eun-Kyung Lee
- Department of Statistics, Ewha Womans University, Seoul, South Korea
| | - Byung-Moon Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Gyu-Jeong Noh
- Departments of Anesthesiology and Pain Medicine, Clinical Pharmacology and Therapeutics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Seok Hwan Lee
- Division of Physical Metrology, Korea Research Institute of Standards and Science, Daejeon, South Korea
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Schiavo M, Padula F, Latronico N, Paltenghi M, Visioli A. A modified PID-based control scheme for depth-of-hypnosis control: Design and experimental results. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2022; 219:106763. [PMID: 35349908 DOI: 10.1016/j.cmpb.2022.106763] [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: 12/06/2021] [Revised: 03/05/2022] [Accepted: 03/17/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND AND OBJECTIVE Many methodologies have been proposed for the control of total intravenous anesthesia in general surgery, as this yields a reduced stress for the anesthesiologist and an increased safety for the patient. The objective of this work is to design a PID-based control system for the regulation of the depth of hypnosis by propofol and remifentanil coadministration that takes into account the clinical practice. METHODS With respect to a standard PID control system, additional functionalities have been implemented in order to consider specific requirements related to the clinical practice. In particular, suitable boluses are determined and used in the induction phase and a nonzero baseline infusion is used in the maintenance phase when the predicted effect-site concentration drops below a safety threshold. RESULTS The modified controller has been experimentally assessed on a group of 10 patients receiving general anesthesia for elective plastic surgery. The control system has been able to induce and maintain adequate anesthesia without any manual intervention from the anesthesiologist. CONCLUSIONS Results confirm the effectiveness of the overall design approach and, in particular, highlight that the new version of the control system, with respect to a standard PID controller, provides significant advantages from a clinical standpoint.
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Affiliation(s)
- Michele Schiavo
- Dipartimento di Ingegneria dell'Informazione, University of Brescia, Brescia, Italy.
| | - Fabrizio Padula
- Curtin Centre for Optimisation and Decision Science, Curtin University, Perth, Australia.
| | - Nicola Latronico
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy; Department of Anesthesiology, Critical Care and Emergency Spedali Civili di Brescia, Brescia, Italy.
| | - Massimiliano Paltenghi
- Department of Anesthesiology, Critical Care and Emergency Spedali Civili di Brescia, Brescia, Italy.
| | - Antonio Visioli
- Dipartimento di Ingegneria Meccanica e Industriale University of Brescia, Brescia, Italy.
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Vandemoortele O, Hannivoort LN, Vanhoorebeeck F, Struys MMRF, Vereecke HEM. General Purpose Pharmacokinetic-Pharmacodynamic Models for Target-Controlled Infusion of Anaesthetic Drugs: A Narrative Review. J Clin Med 2022; 11:jcm11092487. [PMID: 35566617 PMCID: PMC9101974 DOI: 10.3390/jcm11092487] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/22/2022] [Accepted: 04/25/2022] [Indexed: 12/10/2022] Open
Abstract
Target controlled infusion (TCI) is a clinically-available and widely-used computer-controlled method of drug administration, adjusting the drug titration towards user selected plasma- or effect-site concentrations, calculated according to pharmacokinetic-pharmacodynamic (PKPD) models. Although this technology is clinically available for several anaesthetic drugs, the contemporary commercialised PKPD models suffer from multiple limitations. First, PKPD models for anaesthetic drugs are developed using deliberately selected patient populations, often excluding the more challenging populations, such as children, obese or elderly patients, of whom the body composition or elimination mechanisms may be structurally different compared to the lean adult patient population. Separate PKPD models have been developed for some of these subcategories, but the availability of multiple PKPD models for a single drug increases the risk for invalid model selection by the user. Second, some models are restricted to the prediction of plasma-concentration without enabling effect-site controlled TCI or they identify the effect-site equilibration rate constant using methods other than PKPD modelling. Advances in computing and the emergence of globally collected databases has allowed the development of new “general purpose” PKPD models. These take on the challenging task of identifying the relationships between patient covariates (age, weight, sex, etc) and the volumes and clearances of multi-compartmental pharmacokinetic models applicable across broad populations from neonates to the elderly, from the underweight to the obese. These models address the issues of allometric scaling of body weight and size, body composition, sex differences, changes with advanced age, and for young children, changes with maturation and growth. General purpose models for propofol, remifentanil and dexmedetomidine have appeared and these greatly reduce the risk of invalid model selection. In this narrative review, we discuss the development, characteristics and validation of several described general purpose PKPD models for anaesthetic drugs.
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Affiliation(s)
| | - Laura N. Hannivoort
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands; (L.N.H.); (M.M.R.F.S.)
| | | | - Michel M. R. F. Struys
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands; (L.N.H.); (M.M.R.F.S.)
- Department of Basic and Applied Medicine, Ghent University, 9000 Gent, Belgium
| | - Hugo E. M. Vereecke
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands; (L.N.H.); (M.M.R.F.S.)
- Department of Anaesthesia and Reanimation, AZ Sint-Jan Brugge-Oostende AV, 8000 Brugge, Belgium
- Correspondence:
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Kim KM, Jung J, Lee JM, Yang HS, Bang J, Lee E, Choi B, Noh G. The expected advantage of administering prophylactic antibiotics using target‐ concentration controlled infusion: Development of a new pharmacokinetic model of cefazolin. Clin Exp Pharmacol Physiol 2022; 49:731-739. [DOI: 10.1111/1440-1681.13648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 03/29/2022] [Accepted: 04/07/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Kyung Mi Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center University of Ulsan College of Medicine Seoul South Korea
| | - Jiwon Jung
- Department of Infectious Diseases, Asan Medical Center University of Ulsan College of Medicine Seoul South Korea
| | - Jong Min Lee
- Department of Anesthesiology and Pain Medicine Daejeon Eulji University Hospital Eulji University School of Medicine Daejeon Korea
| | - Hong Seuk Yang
- Department of Anesthesiology and Pain Medicine Daejeon Eulji University Hospital Eulji University School of Medicine Daejeon Korea
| | - Ji‐Yeon Bang
- 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 South Korea
| | - Byung‐Moon Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center University of Ulsan College of Medicine Seoul South Korea
| | - Gyu‐Jeong Noh
- Departments of Anesthesiology and Pain Medicine, Clinical Pharmacology and Therapeutics, Asan Medical Center University of Ulsan College of Medicine Seoul South Korea
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Zheng Z, Xue F, Wang H, He Y, Zhang L, Ma W, Zhang C, Guan Y, Ye F, Wen Y, Li X, Huang M, Huang W, Wang Z, Li J. A single nucleotide polymorphism-based formula to predict the risk of propofol TCI concentration being over 4 µg mL -1 at the time of loss of consciousness. THE PHARMACOGENOMICS JOURNAL 2022; 22:109-116. [PMID: 35064216 DOI: 10.1038/s41397-021-00263-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 11/27/2021] [Accepted: 11/30/2021] [Indexed: 11/09/2022]
Abstract
We aim to develop a formula based on single nucleotide polymorphisms (SNPs) to predict whether the propofol target-controlled infusion (TCI) concentration would be over 4 μg mL-1 at the time of loss of consciousness (LOC). We recruited 184 patients undergoing thyroid or breast surgeries with propofol anaesthesia. A total of 48 SNPs of CYP2B6, CYP2C9, UGT1A9, HNF4A, ABCB1, ABCC4, ABCG2, GABRA2, GABRA4, GABRB1, GABRB3, GABRG2, GABBR2, GAD1, SLC1A3, BDNF, and NRXN1, previously associated with propofol metabolic and pharmacology pathway, were genotyped. The formula was developed in the training cohort using the least absolute shrinkage and selection operator logistic regression model, and then validated in the testing cohort. The SNPs, GABBR2 rs1167768, GABBR2 rs1571927, NRXN1 rs601010, BDNF rs2049046, GABRA4 rs1512135, UGT1A9 rs11692021, GABBR2 rs2808536, HNF4A rs1884613, GABRB3 rs2017247, and CYP2B6 rs3181842 were selected to construct the SNP-based formula, which was used to calculate the risk score for over 4 μg mL-1 TCI concentration of propofol at the time of LOC. Patients in the high-risk group were more likely to require a propofol concentration higher than 4 μg mL-1 and presented a longer LOC latency. The SNP-based formula may significantly improve the safety and effectiveness of propofol-induced anaesthesia.
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Affiliation(s)
- Zhuoling Zheng
- Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, Guangdong, China.,Guangdong Provincial Key Laboratory of New Drug Design and Evaluation, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, Guangdong, China.,Department of Pharmacy, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Faling Xue
- Department of Anaesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Haini Wang
- Department of Pharmacy, Shenzhen Second People's Hospital, Shenzhen, Guangdong, China
| | - Yongqi He
- Department of Pharmacy, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Lingyi Zhang
- Department of Anaesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Wudi Ma
- Department of Anaesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Caibin Zhang
- Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, Guangdong, China.,Guangdong Provincial Key Laboratory of New Drug Design and Evaluation, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Yanping Guan
- Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, Guangdong, China.,Guangdong Provincial Key Laboratory of New Drug Design and Evaluation, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Fang Ye
- Department of Anaesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Yongzi Wen
- Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, Guangdong, China.,Guangdong Provincial Key Laboratory of New Drug Design and Evaluation, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Xiaoyan Li
- Department of Pharmacy, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Min Huang
- Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, Guangdong, China.,Guangdong Provincial Key Laboratory of New Drug Design and Evaluation, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Wenqi Huang
- Department of Anaesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Zhongxing Wang
- Department of Anaesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China.
| | - Jiali Li
- Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, Guangdong, China. .,Guangdong Provincial Key Laboratory of New Drug Design and Evaluation, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, Guangdong, China.
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Lee CZ, Poon CCM. An Update of Neuroanesthesia for Intraoperative Brain Mapping Craniotomy. Neurosurgery 2022; 90:1-6. [PMID: 33647962 DOI: 10.1093/neuros/nyab022] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 12/13/2020] [Indexed: 01/06/2023] Open
Abstract
The perioperative multidisciplinary team approach has probably been best exemplified by the care of awake craniotomy patients. Advancement in anesthesia and meticulous perioperative care has supported the safety and complexity of the surgical and mapping efforts in glioma resection. The discussions in this review will emphasize on anesthetic and perioperative management strategies to prevent complications and minimize their effects if they occur, including current practice guidelines in anesthesia, updates on the applications of anesthetic medications, and emerging devices. Planning the anesthetic and perioperative management is based on understanding the pharmacology of the medications, the goals of different stages of the surgery and mapping, and anticipating potential problems.
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Affiliation(s)
- Chanhung Z Lee
- Department of Anesthesia and Perioperative Care, University of California , San Francisco, San Francisco, California, USA
| | - Clara C M Poon
- Department of Anaesthesiology, Queen Mary Hospital, University of Hong Kong , Hong Kong
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Servatius H, Küffer T, Baldinger SH, Asatryan B, Seiler J, Tanner H, Novak J, Lam A, Noti F, Haeberlin A, Madaffari A, Sweda R, Mühl A, Branca M, Dütschler S, Erdoes G, Stüber F, Theiler L, Reichlin T, Roten L. Dexmedetomidine versus Propofol for Operator-Directed Nurse-Administered Procedural Sedation during Catheter Ablation of Atrial Fibrillation: a Randomized Controlled Study. Heart Rhythm 2021; 19:691-700. [PMID: 34971816 DOI: 10.1016/j.hrthm.2021.12.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 12/02/2021] [Accepted: 12/23/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Operator-directed nurse-administered (ODNA) sedation with propofol is the preferred sedation technique for catheter ablation of atrial fibrillation (AF) in many centers. OBJECTIVE We aimed to investigate whether Dexmedetomidine, an α2-adrenergic receptor agonist, is superior to propofol. METHODS We randomized 160 consecutive patients undergoing first AF ablation to ODNA sedation by dexmedetomidine (DEX group) versus propofol (PRO group), according to a standardized protocol. Patients were unaware of treatment allocation. The primary endpoint was a composite of inefficient sedation, termination/change of sedation protocol or procedure abortion, hypercapnia (transcutaneous CO2 >55 mmHg), hypoxemia (SpO2 <90%) or intubation, prolonged hypotension (systolic blood pressure <80 mmHg), and sustained bradycardia necessitating cardiac pacing. Secondary endpoints were the components of the primary endpoint and patient satisfaction with procedural sedation, as assessed by a standardized questionnaire the day following ablation. RESULTS The primary endpoint occurred in 15 DEX group and 25 PRO group patients (19% vs. 31%; p=0.068). Hypercapnia was significantly more frequent in PRO group patients (29% vs. 10%; p=0.003). There was no significant difference among the other components of the primary endpoint, no procedure was aborted. Patient satisfaction was significantly better in PRO group patients (visual analog scale 0-100; median 100 in PRO group vs. median 93 in DEX group; p<0.001). CONCLUSION Efficacy of ODNA sedation with dexmedetomidine was not different to propofol. Hypercapnia occurs less frequent with dexmedetomidine, but patient satisfaction is better with propofol sedation. In selected patients, dexmedetomidine may be used as an alternative to propofol for ODNA sedation during AF ablation. (ClinicalTrials.gov number NCT03844841).
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Affiliation(s)
- Helge Servatius
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas Küffer
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Samuel H Baldinger
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Babken Asatryan
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jens Seiler
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Hildegard Tanner
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jan Novak
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anna Lam
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Fabian Noti
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas Haeberlin
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Antonio Madaffari
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Romy Sweda
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Aline Mühl
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Sophie Dütschler
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Gabor Erdoes
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Frank Stüber
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Lorenz Theiler
- Department of Anaesthesiology, Kantonsspital Aarau, Aarau, Switzerland
| | - Tobias Reichlin
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Laurent Roten
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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Bang JY, Kang HI, Lee HJ, Chong YP, Hong SK, Lee EK, Choi BM, Noh GJ. Development of a new pharmacokinetic model for target-concentration controlled infusion of vancomycin in critically ill patients. Clin Exp Pharmacol Physiol 2021; 49:202-211. [PMID: 34596258 DOI: 10.1111/1440-1681.13597] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 09/15/2021] [Accepted: 09/27/2021] [Indexed: 11/28/2022]
Abstract
The aim of this prospective study was to construct a new pharmacokinetic model of vancomycin for target-concentration controlled infusion (TCI). As the first loading dose, 25 mg/kg of vancomycin was administered during 60-90 min. Arterial blood samples were obtained at pre-set intervals to measure the serum concentrations of vancomycin. Population pharmacokinetic analysis was performed using the NONMEM software (ICON Development Solutions). In total, 197 serum concentration measurements from 22 patients were used to characterise the pharmacokinetics of vancomycin. A three-compartment mammillary model best described the pharmacokinetics of vancomycin in critically ill patients. The ideal body weight was a significant covariate for the central and slow peripheral volume of distribution. The weight and age converted to categorical variables at a cut-off of 65 years were a significant covariate for the clearance. Based on the results of stochastic simulation, the TCI method maintained the therapeutic concentration range for the longest duration. In addition, assuming that vancomycin was administered by the TCI method for 7 days, the dose was reduced by about 15% compared with the standard administration methods. The daily area under the curve values were maintained between 500 mg·h/L and 600 mg·h/L. TCI has the potential to become a new infusion method for patient-tailored dosing in critically ill patients. To administer vancomycin via TCI in clinical practice, the newly constructed pharmacokinetic model should undergo proper external validation.
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Affiliation(s)
- Ji-Yeon Bang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyun Il Kang
- University of Ulsan College of Medicine, Seoul, Korea
| | - Hak-Jae Lee
- Division of Acute Care Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong Pil Chong
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Suk-Kyung Hong
- Division of Acute Care Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun-Kyung Lee
- Department of Statistics, Ewha Womans University, Seoul, Korea
| | - Byung-Moon Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gyu-Jeong Noh
- Departments of Anesthesiology and Pain Medicine, Clinical Pharmacology and Therapeutics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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The relationship between the effect-site concentration of propofol and sedation scale in children: a pharmacodynamic modeling study. BMC Anesthesiol 2021; 21:222. [PMID: 34503455 PMCID: PMC8427954 DOI: 10.1186/s12871-021-01446-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 08/28/2021] [Indexed: 11/10/2022] Open
Abstract
Background Continuous infusion of propofol has been used to achieve sedation in children. However, the relationship between the effect-site concentration (Ce) of propofol and sedation scale has not been previously examined. The objective of this study was to investigate the relationship between the Ce of propofol and the University of Michigan Sedation Scale (UMSS) score in children with population pharmacodynamic modeling. Methods A total of 30 patients (aged 3 to 6 years) who underwent surgery under general anesthesia with propofol and remifentanil lasting more than 1 h were enrolled in this study. Sedation levels were evaluated using the UMSS score every 20 s by a 1 μg/mL stepwise increase in the Ce of propofol during the induction of anesthesia. The pharmacodynamic relationship between the Ce of propofol and UMSS score was analyzed by logistic regression with nonlinear mixed-effect modeling. Results The estimated Ce50 (95% confidence interval) of propofol to yield UMSS scores equal to or greater than n were 1.84 (1.54–2.14), 2.64 (2.20–3.08), 3.98 (3.66–4.30), and 4.78 (4.53–5.03) μg/mL for n = 1, 2, 3, and 4, respectively. The slope steepness for the relationship of the Ce versus sedative response to propofol (95% confidence interval) was 5.76 (4.00–7.52). Conclusions We quantified the pharmacodynamic relationship between the Ce of propofol and UMSS score, and this finding may be helpful to predict the sedation score at the target Ce of propofol in children. Trial registration http://www.clinicaltrials.gov (No.: NCT03195686, Date of registration: 22/06/2017).
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Wingert T, Lee C, Cannesson M. Machine Learning, Deep Learning, and Closed Loop Devices-Anesthesia Delivery. Anesthesiol Clin 2021; 39:565-581. [PMID: 34392886 PMCID: PMC9847584 DOI: 10.1016/j.anclin.2021.03.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
With the tremendous volume of data captured during surgeries and procedures, critical care, and pain management, the field of anesthesiology is uniquely suited for the application of machine learning, neural networks, and closed loop technologies. In the past several years, this area has expanded immensely in both interest and clinical applications. This article provides an overview of the basic tenets of machine learning, neural networks, and closed loop devices, with emphasis on the clinical applications of these technologies.
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Affiliation(s)
- Theodora Wingert
- University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA, USA,Department of Anesthesiology and Perioperative Medicine, Ronald Reagan UCLA Medical Center, 757 Westwood Plaza, Suite 3325, Los Angeles, CA 90095-7403, USA,Corresponding author. Department of Anesthesiology and Perioperative Medicine, Ronald Reagan UCLA Medical Center, 757 Westwood Plaza, Suite 3325, Los Angeles, CA 90095-7403.
| | - Christine Lee
- Edwards Lifesciences, Irvine, CA, USA,Critical Care R&D, 1 Edwards Way, Irvine, CA 92614, USA
| | - Maxime Cannesson
- University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA, USA,Department of Anesthesiology and Perioperative Medicine, Ronald Reagan UCLA Medical Center, 757 Westwood Plaza, Suite 3325, Los Angeles, CA 90095-7403, USA
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Kim KM, Kim SH, Yun HY, Jung J, Bang JY, Lee EK, Choi BM, Noh GJ. Development of a new pharmacokinetic model for target-concentration controlled infusion of cefoxitin as a prophylactic antibiotic in colorectal surgical patients. Br J Clin Pharmacol 2021; 87:4648-4657. [PMID: 33929765 DOI: 10.1111/bcp.14883] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 04/08/2021] [Accepted: 04/23/2021] [Indexed: 11/29/2022] Open
Abstract
AIMS There are several limitations to the existing method of administering cefoxitin as a prophylactic antibiotic, and the limitations may be overcome by applying the target-concentration controlled infusion (TCI) method. Population pharmacokinetic parameters are required to administer cefoxitin by the TCI method. The aim of this study was to construct a new pharmacokinetic model of cefoxitin for the TCI method in colorectal surgical patients. METHODS In patients undergoing colorectal surgery, 2 g of cefoxitin was dissolved in 50 mL of saline and administered for 10 minutes prior to skin incision. Arterial blood samples were obtained at preset intervals to measure the total and free plasma concentrations of cefoxitin. Population pharmacokinetic analysis was performed using NONMEM software (ICON Development Solutions, Dublin, Ireland). Additionally, stochastic simulation was used to indirectly evaluate the effectiveness of the two administration methods (standard method vs TCI). RESULTS In total, 297 plasma concentration measurements from 31 patients were used to characterize the pharmacokinetics of cefoxitin. A three-compartment mammillary model described the pharmacokinetics of cefoxitin. Body weight and creatinine clearance were significant covariates for clearance. The stochastic simulation showed that when compared with the standard method, the TCI method has a significantly higher fraction of time that the free concentration of cefoxitin is maintained above the minimum inhibitory concentration (P < .001). CONCLUSIONS TCI has the potential to become a new infusion method for patient-tailored dosing in surgical patients. To administer cefoxitin via TCI in clinical practice, the newly constructed pharmacokinetic model should undergo proper external validation.
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Affiliation(s)
- Kyung Mi Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sung-Hoon Kim
- University of Ulsan College of Medicine, Seoul, South Korea
| | - Ho-Yong Yun
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jiwon Jung
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Ji-Yeon Bang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Eun-Kyung Lee
- Department of Statistics, Ewha Womans University, Seoul, South Korea
| | - Byung-Moon Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Gyu-Jeong Noh
- Departments of Anesthesiology and Pain Medicine, Clinical Pharmacology and Therapeutics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Coetzee E, Absalom A. Stability of BIS with Schnider or modified Marsh effect-site targeted infusions : as you like it, or much ado about nothing? SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2021. [DOI: 10.36303/sajaa.2021.27.2.2617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Chen W, Chen S, Huang Y. Induction and maintenance of procedural sedation in adults: focus on remimazolam injection. Expert Rev Clin Pharmacol 2021; 14:411-426. [PMID: 33686920 DOI: 10.1080/17512433.2021.1901575] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction: Procedural sedation (PS) is a humane way to help patients get through painful medical procedures by the administration of sedative drugs combined with analgesics. However, each of the currently used medications has certain shortcomings, urging the search for a new drug. Remimazolam, a novel benzodiazepine, is an ultra-short-acting hypnotic agent invented out of the 'soft drug' development.Areas covered: This presented review provides an overview of the drugs used in clinical practice for the induction and maintenance of procedural sedation in adults, focusing on the newly investigated benzodiazepine remimazolam. Literature search was conducted using the MEDLINE and ClinicalTrial.gov databases from January 2007 to December 2020.Expert opinion: Based on the reported clinical trials so far, remimazolam has demonstrated its effectiveness and safety with promising properties including rapid onset, short duration of action, predictable and consistent recovery profile, metabolism almost unaffected by liver or renal function, with non or minimal cardiorespiratory depression, and availability with a reversal drug. With marketing approval received recently, remimazolam is expected to have a place in the practice for procedural sedation in the near future if its efficacy and safety are further confirmed by more clinical trials and post-market analyses.
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Affiliation(s)
- Weiyun Chen
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, China
| | - Shaohui Chen
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, China
| | - Yuguang Huang
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, China
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Weber J, Mißbach C, Schmidt J, Wenzel C, Schumann S, Philip JH, Wirth S. Prediction of expiratory desflurane and sevoflurane concentrations in lung-healthy patients utilizing cardiac output and alveolar ventilation matched pharmacokinetic models: A comparative observational study. Medicine (Baltimore) 2021; 100:e23570. [PMID: 33578509 PMCID: PMC7886476 DOI: 10.1097/md.0000000000023570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 11/04/2020] [Indexed: 01/05/2023] Open
Abstract
The Gas Man simulation software provides an opportunity to teach, understand and examine the pharmacokinetics of volatile anesthetics. The primary aim of this study was to investigate the accuracy of a cardiac output and alveolar ventilation matched Gas Man model and to compare its predictive performance with the standard pharmacokinetic model using patient data.Therefore, patient data from volatile anesthesia were successively compared to simulated administration of desflurane and sevoflurane for the standard and a parameter-matched simulation model with modified alveolar ventilation and cardiac output. We calculated the root-mean-square deviation (RMSD) between measured and calculated induction, maintenance and elimination and the expiratory decrement times during emergence and recovery for the standard and the parameter-matched model.During induction, RMSDs for the standard Gas Man simulation model were higher than for the parameter-matched Gas Man simulation model [induction (desflurane), standard: 1.8 (0.4) % Atm, parameter-matched: 0.9 (0.5) % Atm., P = .001; induction (sevoflurane), standard: 1.2 (0.9) % Atm, parameter-matched: 0.4 (0.4) % Atm, P = .029]. During elimination, RMSDs for the standard Gas Man simulation model were higher than for the parameter-matched Gas Man simulation model [elimination (desflurane), standard: 0.7 (0.6) % Atm, parameter-matched: 0.2 (0.2) % Atm, P = .001; elimination (sevoflurane), standard: 0.7 (0.5) % Atm, parameter-matched: 0.2 (0.2) % Atm, P = .008]. The RMSDs during the maintenance of anesthesia and the expiratory decrement times during emergence and recovery showed no significant differences between the patient and simulated data for both simulation models.Gas Man simulation software predicts expiratory concentrations of desflurane and sevoflurane in humans with good accuracy, especially when compared to models for intravenous anesthetics. Enhancing the standard model by ventilation and hemodynamic input variables increases the predictive performance of the simulation model. In most patients and clinical scenarios, the predictive performance of the standard Gas Man simulation model will be high enough to estimate pharmacokinetics of desflurane and sevoflurane with appropriate accuracy.
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Affiliation(s)
- Jonas Weber
- Department of Anesthesiology and Critical Care, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Claudia Mißbach
- Department of Anesthesiology and Critical Care, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Johannes Schmidt
- Department of Anesthesiology and Critical Care, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christin Wenzel
- Department of Anesthesiology and Critical Care, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Stefan Schumann
- Department of Anesthesiology and Critical Care, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - James H. Philip
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Steffen Wirth
- Department of Anesthesiology and Critical Care, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Miyabe-Nishiwaki T, Kaneko A, Yamanaka A, Maeda N, Suzuki J, Tomonaga M, Matsuzawa T, Muta K, Nishimura R, Yajima I, Eleveld DJ, Absalom AR, Masui K. Propofol infusions using a human target controlled infusion (TCI) pump in chimpanzees (Pan troglodytes). Sci Rep 2021; 11:1214. [PMID: 33441704 PMCID: PMC7806914 DOI: 10.1038/s41598-020-79914-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 12/15/2020] [Indexed: 11/09/2022] Open
Abstract
Chimpanzees are genetically and physiologically similar to humans. Several pharmacokinetic models of propofol are available and target controlled infusion (TCI) of propofol is established in humans, but not in chimpanzees. The purpose of this study was to investigate if human pharmacokinetic models can accurately predict propofol plasma concentration (Cp) in chimpanzees and if it is feasible to perform TCI in chimpanzees. Ten chimpanzees were anaesthetized for regular veterinary examinations. Propofol was used as an induction or maintenance agent. Blood samples were collected from a catheter in a cephalic vein at 3–7 time points between 1 and 100 min following the propofol bolus and/or infusion in five chimpanzees, or TCI in six chimpanzees. Cp was measured using high-performance liquid chromatography. The Marsh, Schnider and Eleveld human pharmacokinetic models were used to predict Cp for each case and we examined the predictive performances of these models using the Varvel criteria Median PE and Median APE. Median PE and Median APE for Marsh, Schnider and Eleveld models were within or close to the acceptable range. A human TCI pump was successfully maintained propofol Cp during general anesthesia in six chimpanzees. Human propofol pharmacokinetic models and TCI pumps can be applied in chimpanzees.
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Affiliation(s)
| | - A Kaneko
- Primate Research Institute, Kyoto University, Inuyama, Aichi, Japan
| | - A Yamanaka
- Primate Research Institute, Kyoto University, Inuyama, Aichi, Japan
| | - N Maeda
- Primate Research Institute, Kyoto University, Inuyama, Aichi, Japan
| | - J Suzuki
- Primate Research Institute, Kyoto University, Inuyama, Aichi, Japan
| | - M Tomonaga
- Primate Research Institute, Kyoto University, Inuyama, Aichi, Japan
| | | | - K Muta
- Laboratory of Veterinary Surgery, Graduate School of Agricultural and Life Sciences, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - R Nishimura
- Laboratory of Veterinary Surgery, Graduate School of Agricultural and Life Sciences, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - I Yajima
- Department of Pharmacy, National Defense Medical College Hospital, Tokorozawa, Saitama, Japan
| | - D J Eleveld
- University Medical Center Groningen, Groningen, Netherlands
| | - A R Absalom
- University Medical Center Groningen, Groningen, Netherlands
| | - K Masui
- Department of Anesthesiology, Showa University School of Medicine, Shinagawa-ku, Tokyo, Japan.
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Prospective clinical validation of the Eleveld propofol pharmacokinetic-pharmacodynamic model in general anaesthesia. Br J Anaesth 2020; 126:386-394. [PMID: 33317804 DOI: 10.1016/j.bja.2020.10.027] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 09/28/2020] [Accepted: 10/19/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Target-controlled infusion (TCI) systems incorporating pharmacokinetic (PK) or PK-pharmacodynamic (PK-PD) models can be used to facilitate drug administration. Existing models were developed using data from select populations, the use of which is, strictly speaking, limited to these populations. Recently a propofol PK-PD model was developed for a broad population range. The aim of the study was to prospectively validate this model in children, adults, older subjects, and obese adults undergoing general anaesthesia. METHODS The 25 subjects included in each of four groups were stratified by age and weight. Subjects received propofol through TCI with the Eleveld model, titrated to a bispectral index (BIS) of 40-60. Arterial blood samples were collected at 5, 10, 20, 30, 40, and 60 min after the start of propofol infusion, and every 30 min thereafter, to a maximum of 10 samples. BIS was recorded continuously. Predictive performance was assessed using the Varvel criteria. RESULTS For PK, the Eleveld model showed a bias < ±20% in children, adults, and obese adults, but a greater bias (-27%) in older subjects. Precision was <30% in all groups. For PD, the bias and wobble were <5 BIS units and the precision was close to 10 BIS units in all groups. Anaesthetists were able to achieve intraoperative BIS values of 40-60 using effect-site target concentrations about 85-140% of the age-adjusted Ce50. CONCLUSIONS The Eleveld propofol PK-PD model showed predictive precision <30% for arterial plasma concentrations and BIS predictions with a low (population) bias when used in TCI in clinical anaesthesia practice.
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Absalom AR, Rigby‐Jones AE, Rushton AR, Robert Sneyd J. De-mystifying the "Mixifusor". Paediatr Anaesth 2020; 30:1292-1298. [PMID: 33051933 PMCID: PMC7756545 DOI: 10.1111/pan.14039] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 10/04/2020] [Indexed: 12/21/2022]
Abstract
Total intravenous anesthesia (TIVA) using a mixture of propofol and remifentanil in the same syringe has become an accepted technique in Pediatric Anesthesia. A survey by a group of respected UK anesthetists demonstrated a low incidence of serious complications, related to the pharmacology and dose of the drugs. However, a current guideline for the safe use of TIVA recommends against this practice. Pharmaceutical concerns include the physical stability of the emulsion when remifentanil is mixed with propofol; changes in drug concentration over time; nonuniform mixing of propofol and remifentanil; the risk of bacterial contamination; and the potential for drug administration errors. Propofol and remifentanil have markedly different pharmacokinetic profiles. When remifentanil is mixed with propofol and delivered as a target-controlled infusion (TCI) of propofol, remifentanil delivery is not target-controlled but passively follows the variable infusion rates calculated by the syringe driver to deliver predicted plasma or effect-site concentrations of propofol. The pharmacokinetic consequences can be illustrated using pharmacokinetic modeling similar to that used in TCI pumps. The clinical consequences reflect the dose-dependent pharmacodynamics of remifentanil. Increasing the target propofol concentration produces a rapid increase and peak in remifentanil concentration that risks apnea, bradycardia, and hypotension, especially with higher concentrations of remifentanil. The faster decline in remifentanil concentration with falling propofol concentrations risks inadequate narcosis and unwanted responses to surgical stimuli. Remifentanil delivery is inflexible and dosing cannot be adjusted to the clinical need and responses of individual patients. The medicolegal considerations are stark. In UK and EU Law, mixing propofol and remifentanil creates a new, unlicensed drug and the person mixing takes on the responsibilities of manufacturer. If a patient receiving anesthesia in the form of a mixed propofol-remifentanil infusion suffered a critical incident or actual harm, the clinician's practice may come under scrutiny and criticism, potentially involving a legal challenge and the Medical Regulator.
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Affiliation(s)
- Anthony R. Absalom
- University Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - Ann E. Rigby‐Jones
- Faculty of Health: MedicineDentistry and Human SciencesUniversity of PlymouthPlymouthUK
| | | | - J. Robert Sneyd
- Faculty of Health: MedicineDentistry and Human SciencesUniversity of PlymouthPlymouthUK
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Barends CRM, Driesens MK, van Amsterdam K, Struys MMRF, Absalom AR. Moderate-to-Deep Sedation Using Target-Controlled Infusions of Propofol and Remifentanil: Adverse Events and Risk Factors: A Retrospective Cohort Study of 2937 Procedures. Anesth Analg 2020; 131:1173-1183. [PMID: 32925338 DOI: 10.1213/ane.0000000000004593] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND In the University Medical Center Groningen in Groningen, the Netherlands, moderate-to-deep sedation is provided by nursing staff trained and supervised by the anesthesia department using protocol-based target-controlled infusions (TCIs) of propofol and remifentanil. The aim of this retrospective cohort study was to investigate the incidence of events with potential adverse health consequences within this service model and the risk factors for the occurrence of these events. METHODS We retrospectively interrogated a database containing the computerized anesthetic records of 2937 procedures where moderate-to-deep sedation was provided using TCI administration of propofol and remifentanil between May 2014 and October 2017. The primary outcome measures were the incidence of sedation-related events with potential adverse health consequences and risk factors for the occurrence of such events. The events under investigation were unplanned intensive care unit (ICU) admission, need for cardiopulmonary resuscitation (CPR), death on the day of the procedure due to sedation-related events, cardiovascular events (arrhythmias, hypertension, and hypotension), pulmonary events (aspiration, desaturation, unplanned tracheal intubation), anaphylactic or allergic reactions, and the termination of the procedure due to sedation-related events. Cardiovascular and pulmonary events were classified as severe, significant, or moderate. Events were identified by using computer algorithms to search the computerized records from all included procedures. RESULTS Data from 2937 procedures were analyzed. No patients suffered catastrophic events (death, need for CPR, or unplanned ICU admission). Thirty-two severe sedation-related events occurred in 32 procedures. Severe desaturation (0.6%; 95% confidence interval [CI], 0.4-0.9) and severe hypertension (0.2%; 95% CI, 0.04-0.37) were the most common severe events. Significant hypotension (8.8%; 95% CI, 7.73-9.77) and significant desaturation (1.6%; 95% CI, 1.12-2.02) were found to be the most common events with potential adverse health consequences. No patient suffered lasting health consequences. Average mean and maximum targeted effect-site concentrations (Cet) for propofol were 2.6 ± 0.83 and 3.3 ± 1.09 µg·mL, respectively, and for remifentanil 0.84 ± 0.18 and 0.99 ± 0.22 ng·mL, respectively. Maximum Cets of propofol were lower among patients with higher body mass index (BMI) and were higher among patients of younger age. Higher BMI was a risk factor for desaturation. Increased age and lower BMI were risk factors for hypotension. Longer procedure time was a risk factor for both desaturation and hypotension. CONCLUSIONS Moderate-to-deep sedation by propofol and remifentanil TCI has a low incidence of catastrophic and severe events.
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Affiliation(s)
- Clemens R M Barends
- From the Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Mendy K Driesens
- From the Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Kai van Amsterdam
- From the Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Michel M R F Struys
- From the Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Department of Anesthesia and Peri-operative Medicine, Ghent University, Ghent, Belgium
| | - Anthony R Absalom
- From the Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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Sahinovic MM, van den Berg JP, Colin PJ, Gambus PL, Jensen EW, Agustí M, Ferreiro T, Struys MMRF. Influence of an "Electroencephalogram-Based" Monitor Choice on the Delay Between the Predicted Propofol Effect-Site Concentration and the Measured Drug Effect. Anesth Analg 2020; 131:1184-1192. [PMID: 32925339 DOI: 10.1213/ane.0000000000004672] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Clinicians can optimize propofol titration by using 2 sources of pharmacodynamic (PD) information: the predicted effect-site concentration for propofol (Ceprop) and the electroencephalographically (EEG) measured drug effect. Relation between these sources should be time independent, that is, perfectly synchronized. In reality, various issues corrupt time independency, leading to asynchrony or, in other words, hysteresis. This asynchrony can lead to conflicting information, making effective drug dosing challenging. In this study, we tried to quantify and minimize the hysteresis between the Ceprop (calculated using the Schnider model for propofol) and EEG measured drug effect, using nonlinear mixed-effects modeling (NONMEM). Further, we measured the influence of EEG-based monitor choice, namely Bispectral index (BIS) versus qCON index (qCON) monitor, on propofol PD hysteresis. METHODS We analyzed the PD data from 165 patients undergoing propofol-remifentanil anesthesia for outpatient surgery. Drugs were administered using target-controlled infusion (TCI) pumps. Pumps were programmed with Schnider model for propofol and Minto model for remifentanil. We constructed 2 PD models (direct models) relating the Schnider Ceprop to the measured BIS and qCON monitor values. We quantified the models' misspecification due to hysteresis, on an individual level, using the root mean squared errors (RMSEs). Subsequently, we optimized the PD models' predictions by adding a lag term to both models (lag-time PD models) and quantified the optimization using the RMSE. RESULTS There is a counterclockwise hysteresis between Ceprop and BIS/qCON values. Not accounting for this hysteresis results in a direct PD model with an effect-site concentration which produces 50% of the maximal drug effect (Ce50) of 6.24 and 8.62 µg/mL and RMSE (median and interquartile range [IQR]) of 9.38 (7.92-11.23) and 8.41(7.04-10.2) for BIS and qCON, respectively. Adding a modeled lag factor of 49 seconds to the BIS model and 53 seconds to the qCON model improved both models' prediction, resulting in similar Ce50 (3.66 and 3.62 µg/mL for BIS and qCON) and lower RMSE (median (IQR) of 7.87 (6.49-9.90) and 6.56 (5.28-8.57) for BIS and qCON. CONCLUSIONS There is a significant "Ceprop versus EEG measured drug effect" hysteresis. Not accounting for it leads to conflicting PD information and false high Ce50 for propofol in both monitors. Adding a lag term improved the PD model performance, improved the "pump-monitor" synchrony, and made the estimates of Ce50 for propofol more realistic and less monitor dependent.
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Affiliation(s)
- Marko M Sahinovic
- From the Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Johannes P van den Berg
- From the Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Pieter J Colin
- From the Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Pedro L Gambus
- Anesthesiology Department, SPEC-M Research Group, Hospital Clinic de Barcelona, Barcelona, Spain
- Department of Anesthesia and Perioperative Care, University of California San Francisco (UCSF), San Francisco, California
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Neuroscience Department, NeuroImmunology Research Group, Barcelona, Spain
| | - Erik W Jensen
- Department ESAII, Center for Biomedical Engineering Research, UPC BarcelonaTech, Barcelona, Spain
| | - Mercé Agustí
- Anesthesiology Department, SPEC-M Research Group, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Teresa Ferreiro
- Anesthesiology Department, SPEC-M Research Group, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Michel M R F Struys
- From the Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Department of Fundamental and Applied Medical Sciences, Faculty of Medicine and Health Sciences, Ghent University, Gent, Belgium
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Moving from dose to concentration: as easy as TCI! Br J Anaesth 2020; 125:847-849. [PMID: 32950247 DOI: 10.1016/j.bja.2020.08.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/03/2020] [Accepted: 08/23/2020] [Indexed: 11/21/2022] Open
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43
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Zhang Y, Wang Y, Yan F, Song D, Wang H, Wang Q, Huang L. Influence of pre-anesthesia dynamic frontal-parietal communication on individual susceptibility to propofol. Clin Neurophysiol 2020; 131:2566-2577. [PMID: 32927212 DOI: 10.1016/j.clinph.2020.07.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 06/16/2020] [Accepted: 07/09/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVE We investigated whether pre-anesthesia dynamic frontal-parietal functional connectivity was correlated with the observed interindividual differences in propofol susceptibility. METHODS Three resting-state EEG datasets were used in the study (N = 29, N = 21 and N = 20). We estimated the pre-anesthesia strength and fluctuations of frontal-parietal functional connectivity by using sliding-window analysis. Propofol served as the sole anesthetic drug, and it was administered by using a target-controlled infusion system. Individual susceptibility to propofol was assessed by the induction time, from infusion onset until a bispectral index value of 60 was reached, for subjects in dataset-1 and dataset-2, and susceptibility was assessed by behavioral data for subjects in the external dataset. RESULTS We observed in the three datasets that subjects with high susceptibility to propofol had lower pre-anesthesia strength and lower fluctuation of frontal-parietal functional connectivity than the low-susceptibility group at alpha band. Moreover, the induction time was significantly correlated with the estimated pre-anesthesia frontal-parietal functional connectivity measures. We also validated the robustness of these findings by using different window lengths in sliding-window analysis. CONCLUSIONS Subjects with weaker pre-anesthesia dynamic frontal-parietal communication are more likely to be anesthetized. SIGNIFICANCE These observations suggest that the titration procedure for propofol should consider the pre-anesthesia brain functional state.
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Affiliation(s)
- Yun Zhang
- School of Life Science and Technology, Xidian University, Xi'an, China
| | - Yubo Wang
- School of Life Science and Technology, Xidian University, Xi'an, China
| | - Fei Yan
- Department of Anesthesiology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Dawei Song
- Department of Anesthesiology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Haidong Wang
- School of Life Science and Technology, Xidian University, Xi'an, China
| | - Qiang Wang
- Department of Anesthesiology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.
| | - Liyu Huang
- School of Life Science and Technology, Xidian University, Xi'an, China.
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Eleveld DJ, Colin P, Absalom AR, Struys MMRF. Target-controlled-infusion models for remifentanil dosing consistent with approved recommendations. Br J Anaesth 2020; 125:483-491. [PMID: 32654750 DOI: 10.1016/j.bja.2020.05.051] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 04/29/2020] [Accepted: 05/13/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Target-controlled infusion (TCI) systems use pharmacokinetic (PK) models to predict the drug infusion rates necessary to achieve a desired target plasma or effect-site concentration. As new PK models are developed and implemented in TCI systems, there can be uncertainty as to which target concentrations are appropriate. Existing dose recommendations can serve as a point of reference to identify target concentrations suitable for clinical applications. METHODS Simulations of remifentanil TCI were performed using three PK models (Minto, Eleveld, and Kim). We sought to identify models and target concentrations for remifentanil administration in children, adult, older people, and severely obese individuals, consistent with the remifentanil product label. In a typical adult this is an induction dose of 0.5-1 μg kg-1 and starting maintenance infusion rate of 0.25 μg kg-1 min-1. RESULTS For the Minto, Eleveld, and Kim remifentanil models, a plasma target concentration of ∼ 4 ng ml-1 achieves drug administration consistent with product label recommended initial doses for all groups with minor exceptions. With effect-site targeting in older individuals, a target concentration of ∼2 ng ml-1 is required for induction and ∼4 ng ml-1 for starting maintenance to achieve drug dosages close to product label recommendations. CONCLUSIONS We identified remifentanil TCI target concentrations that resulted in drug administration similar to product label dosing recommendations. This approach did not necessarily identify target concentrations that achieve desired clinical effect, only those that are consistent with the product label recommended doses. We estimate that plasma target concentrations of 3.1-5.3 ng ml-1 are suitable for initial dosing.
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Affiliation(s)
- Douglas J Eleveld
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
| | - Pieter Colin
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands; Department of Bioanalysis, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Anthony R Absalom
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Michel M R F Struys
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands; Department of Basic and Applied Medical Sciences, Ghent University, Ghent, Belgium
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Aldana E, Álvarez López-Herrero N, Benito H, Colomina MJ, Fernández-Candil J, García-Orellana M, Guzmán B, Ingelmo I, Iturri F, Martín Huerta B, León A, Pérez-Lorensu PJ, Valencia L, Valverde JL. Consensus document for multimodal intraoperatory neurophisiological monitoring in neurosurgical procedures. Basic fundamentals. ACTA ACUST UNITED AC 2020; 68:82-98. [PMID: 32624233 DOI: 10.1016/j.redar.2020.02.010] [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: 01/24/2020] [Revised: 02/04/2020] [Accepted: 02/18/2020] [Indexed: 01/27/2023]
Abstract
The present work aims to establish a guide to action, agreed by anaesthesiologists and neurophysiologists alike, to perform effective intraoperative neurophysiological monitoring for procedures presenting a risk of functional neurological injury, and neurosurgical procedures. The first section discusses the main techniques currently used for intraoperative neurophysiological monitoring. The second exposes the anaesthetic and non-anaesthetic factors that are likely to affect the electrical records of the nervous system structures. This section is followed by an analysis detailing the adverse effects associated with the most common techniques and their use. Finally, the last section describes a series of guidelines to be followed upon the various intraoperative clinical events.
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Affiliation(s)
- E Aldana
- Anestesiología y Reanimación, Hospital Vithas Xanit Internacional, Benalmádena, Málaga, España
| | - N Álvarez López-Herrero
- Neurofisiología, Servicio de Neurocirugía, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - H Benito
- Anestesiología y Reanimación, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
| | - M J Colomina
- Anestesiología y Reanimación, Hospital Universitari Bellvitge, L'Hospitalet de Llobregat, Universitat de Barcelona, Barcelona, España
| | | | - M García-Orellana
- Anestesiología y Reanimación, Hospital Clínic de Barcelona, Barcelona, España
| | - B Guzmán
- Neurofisiología clínica, Hospital Clínico Universitario Lozano de Blesa, Zaragoza, España
| | - I Ingelmo
- Anestesiología y Reanimación, Hospital Universitario Ramón y Cajal, Madrid, España
| | - F Iturri
- Anestesiología y Reanimación, Hospital Universitario de Cruces, Baracaldo, Vizcaya, España
| | - B Martín Huerta
- Anestesiología y Reanimación, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - A León
- Neurofisiología, Servicio de Neurología, Parc de Salut Mar, Barcelona, España
| | - P J Pérez-Lorensu
- Neurofisiología Clínica, Unidad de Monitorización Neurofisiológica Intraoperatoria, Hospital Universitario de Canarias, Tenerife, España
| | - L Valencia
- Anestesiología y Reanimación, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, España
| | - J L Valverde
- Anestesiología y Reanimación, Hospital Vithas Xanit Internacional, Benalmádena, Málaga, España
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47
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Van Hese L, Theys T, Absalom A, Rex S, Cuypers E. Comparison of predicted and real propofol and remifentanil concentrations in plasma and brain tissue during target‐controlled infusion: a prospective observational study. Anaesthesia 2020; 75:1626-1634. [DOI: 10.1111/anae.15125] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2020] [Indexed: 12/14/2022]
Affiliation(s)
- L. Van Hese
- Department of Anaesthesiology University Hospitals Leuven KU Leuven 3000 Leuven Belgium
- Maastricht MultiModal Molecular Imaging (M4I) institute Division of Imaging Mass Spectrometry Maastricht University Maastricht The Netherlands
| | - T. Theys
- Neurosurgery Department University Hospitals Leuven Laboratory for Experimental Neurosurgery and Neuroanatomy Department of Neurosciences KU Leuven 3000 Leuven Belgium
| | - A.R. Absalom
- Neurosurgery Department University Hospitals Leuven Laboratory for Experimental Neurosurgery and Neuroanatomy Department of Neurosciences KU Leuven 3000 Leuven Belgium
| | - S. Rex
- Department of Anaesthesiology University Medical Center Groningen University of Groningen The Netherlands
| | - E. Cuypers
- Toxicology and Pharmacology Department KU Leuven 3000 Leuven Belgium
- Maastricht MultiModal Molecular Imaging (M4I) institute Division of Imaging Mass Spectrometry Maastricht University Maastricht The Netherlands
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van den Berg JP, Absalom AR, Venema AM, Kalmar AF, Van Amsterdam K, Hannivoort LN, Proost JH, Meier S, Scheeren TWL, Struys MMRF, Vereecke HEM. Comparison of haemodynamic- and electroencephalographic-monitored effects evoked by four combinations of effect-site concentrations of propofol and remifentanil, yielding a predicted tolerance to laryngoscopy of 90. J Clin Monit Comput 2020; 35:815-825. [PMID: 32488680 PMCID: PMC8286956 DOI: 10.1007/s10877-020-00540-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 05/26/2020] [Indexed: 11/05/2022]
Abstract
This prospective study evaluates haemodynamic and electroencephalographic effects observed when administering four combinations of effect-site concentrations of propofol (CePROP) and remifentanil (CeREMI), all yielding a single predicted probability of tolerance of laryngoscopy of 90% (PTOL = 90%) according to the Bouillon interaction model. We aimed to identify combinations of CePROP and CeREMI along a single isobole of PTOL that result in favourable hypnotic and haemodynamic conditions. This knowledge could be of advantage in the development of drug advisory monitoring technology. 80 patients (18–90 years of age, ASA I–III) were randomized into four groups and titrated towards CePROP (Schnider model, ug⋅ml−1) and CeREMI (Minto model, ng⋅ml−1) of respectively 8.6 and 1, 5.9 and 2, 3.6 and 4 and 2.0 and 8. After eleven minutes of equilibration, baseline measurements of haemodynamic endpoints and bispectral index were compared with three minutes of responsiveness measurements after laryngoscopy. Before laryngoscopy, bispectral index differed significantly (p < 0.0001) between groups in concordance with CePROP. Heart rate decreased with increasing CeREMI (p = 0.001). The haemodynamic and arousal responses evoked by laryngoscopy were not significantly different between groups, but CePROP = 3.6 μg⋅ml−1 and CeREMI = 4 ng⋅ml−1 evoked the lowest median value for ∆HR and ∆SAP after laryngoscopy. This study provides clinical insight on the haemodynamic and hypnotic consequences, when a model based predicted PTOL is used as a target for combined effect-site controlled target- controlled infusion of propofol and remifentanil. Heart rate and bispectral index were significantly different between groups despite a theoretical equipotency for PTOL, suggesting that each component of the anaesthetic state (immobility, analgesia, and hypnotic drug effect) should be considered as independent neurophysiological and pharmacological phenomena. However, claims of (in)accuracy of the predicted PTOL must be considered preliminary because larger numbers of observations are required for that goal.
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Affiliation(s)
- J P van den Berg
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.
| | - A R Absalom
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - A M Venema
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - A F Kalmar
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - K Van Amsterdam
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - L N Hannivoort
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - J H Proost
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - S Meier
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - T W L Scheeren
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - M M R F Struys
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.,Department of Basic and Applied Medical Sciences, Ghent University, Ghent, Belgium
| | - H E M Vereecke
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.,Department of Anaesthesia and Reanimation, AZ Sint-Jan Brugge-Oostende AV, Brugge, Belgium
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Abstract
The practice of anesthesiology is inextricably dependent upon technology. Anesthetics were first made possible, then increasingly safe, and now more scalable and efficient in part due to advances in monitoring and delivery technology. Herein, we discuss salient advances of the last three years in the technology of anesthesiology. Consumer technology and telemedicine have exploded onto the scene of outpatient medicine, and perioperative management is no exception. Preoperative evaluations have been done via teleconference, and copious consumer-generated health data is available. Regulators have acknowledged the vast potential found in the transfer of consumer technology to medical practice, but issues of privacy, data ownership/security, and validity remain. Inside the operating suite, monitoring has become less invasive, and clinical decision support systems are common. These technologies are susceptible to the “garbage in, garbage out” conundrum plaguing artificial intelligence, but they will improve as network latency decreases. Automation looms large in the future of anesthesiology as closed-loop anesthesia delivery systems are being tested in combination (moving toward a comprehensive system). Moving forward, consumer health companies will search for applications of their technology, and loosely regulated health markets will see earlier adoption of next-generation technology. Innovations coming to anesthesia will need to account for human factors as the anesthesia provider is increasingly considered a component of the patient care apparatus.
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Affiliation(s)
- Christian Seger
- Department of Anesthesiology and Perioperative Medicine,UCLA David Geffen School of Medicine, University of California, 757 Westwood Plaza, Los Angeles, CA, 90095, USA
| | - Maxime Cannesson
- Department of Anesthesiology and Perioperative Medicine,UCLA David Geffen School of Medicine, University of California, 757 Westwood Plaza, Los Angeles, CA, 90095, USA
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50
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Jabaley CS, Lynde GC, Caridi-Scheible ME, O'Reilly-Shah VN. The Human-Machine Interface in Anesthesiology: Corollaries and Lessons Learned From Aviation and Crewed Spaceflight. Anesth Analg 2020; 130:1255-1260. [PMID: 32287132 DOI: 10.1213/ane.0000000000004628] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Craig S Jabaley
- From the Department of Anesthesiology, Emory University, Atlanta, Georgia
| | | | | | - Vikas N O'Reilly-Shah
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, Washington.,Department of Anesthesiology & Pain Medicine, Seattle Children's Hospital, Seattle, Washington
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