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Yuan I, Garcia-Marcinkiewicz AG, Zhang B, Ulrich AM, Georgostathi G, Missett RM, Lang SS, Bruton JL, Kurth CD. Electroencephalographic Indices for Clinical Endpoints during Propofol Anesthesia in Infants: An Early-phase Propofol Biomarker-finding Study. Anesthesiology 2024; 141:353-364. [PMID: 38718376 DOI: 10.1097/aln.0000000000005043] [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: 07/10/2024]
Abstract
BACKGROUND Unlike expired sevoflurane concentration, propofol lacks a biomarker for its brain effect site concentration, leading to dosing imprecision particularly in infants. Electroencephalography monitoring can serve as a biomarker for propofol effect site concentration, yet proprietary electroencephalography indices are not validated in infants. The authors evaluated spectral edge frequency (SEF95) as a propofol anesthesia biomarker in infants. It was hypothesized that the SEF95 targets will vary for different clinical stimuli and an inverse relationship existed between SEF95 and propofol plasma concentration. METHODS This prospective study enrolled infants (3 to 12 months) to determine the SEF95 ranges for three clinical endpoints of anesthesia (consciousness-pacifier placement, pain-electrical nerve stimulation, and intubation-laryngoscopy) and correlation between SEF95 and propofol plasma concentration at steady state. Dixon's up-down method was used to determine target SEF95 for each clinical endpoint. Centered isotonic regression determined the dose-response function of SEF95 where 50% and 90% of infants (ED50 and ED90) did not respond to the clinical endpoint. Linear mixed-effect model determined the association of propofol plasma concentration and SEF95. RESULTS Of 49 enrolled infants, 44 evaluable (90%) showed distinct SEF95 for endpoints: pacifier (ED50, 21.4 Hz; ED90, 19.3 Hz), electrical stimulation (ED50, 12.6 Hz; ED90, 10.4 Hz), and laryngoscopy (ED50, 8.5 Hz; ED90, 5.2 Hz). From propofol 0.5 to 6 μg/ml, a 1-Hz SEF95 increase was linearly correlated to a 0.24 (95% CI, 0.19 to 0.29; P < 0.001) μg/ml decrease in plasma propofol concentration (marginal R2 = 0.55). CONCLUSIONS SEF95 can be a biomarker for propofol anesthesia depth in infants, potentially improving dosing accuracy and utilization of propofol anesthesia in this population. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Ian Yuan
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Annery G Garcia-Marcinkiewicz
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Bingqing Zhang
- Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Allison M Ulrich
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Georgia Georgostathi
- Vagelos Intergrated Program in Energy Research, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Richard M Missett
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Shih-Shan Lang
- Department of Neurosurgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - James L Bruton
- Small Molecule and Metabolite Laboratory, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - C Dean Kurth
- Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Bruns N, Joist CA, Joist CM, Daniels A, Felderhoff-Müser U, Dohna-Schwake C, Tschiedel E. Correlation of Comfort Score and Narcotrend Index during Procedural Sedation with Midazolam and Propofol in Children. J Clin Med 2024; 13:1483. [PMID: 38592307 PMCID: PMC10932229 DOI: 10.3390/jcm13051483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 02/28/2024] [Accepted: 03/02/2024] [Indexed: 04/10/2024] Open
Abstract
Background/Objectives: Precise assessment of hypnotic depth in children during procedural sedation with preserved spontaneous breathing is challenging. The Narcotrendindex (NI) offers uninterrupted information by continuous electrocortical monitoring without the need to apply a stimulus with the risk of assessment-induced arousal. This study aimed to explore the correlation between NI and the Comfort Scale (CS) during procedural sedation with midazolam and propofol and to identify an NI target range for deep sedation. Methods: A prospective observational study was conducted on 176 children (6 months to 17.9 years) undergoing procedural sedation with midazolam premedication and continuous propofol infusion. Statistical analyses included Pearson correlation of NI and CS values, logistic regression, and receiver operating curves. Results: Median NI values varied with CS and age. The correlation coefficient between CS and NI was 0.50 and slightly higher in procedure-specific subgroup analyses. The optimal NI cut-off for deep sedation was between 50 and 60 depending on the analyzed subgroup and displayed high positive predictive values for sufficient sedation throughout. Conclusion: Our study found a moderate correlation between NI and CS, demonstrating reliable identification of adequately sedated patients.
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Affiliation(s)
- Nora Bruns
- Department of Pediatrics I, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany (E.T.)
- Center for Translational Neuro- and Behavioural Sciences (C-TNBS), University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany
| | - Carolina A. Joist
- Department of Pediatrics I, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany (E.T.)
- Center for Translational Neuro- and Behavioural Sciences (C-TNBS), University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany
| | - Constantin M. Joist
- Department of Pediatrics I, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany (E.T.)
- Center for Translational Neuro- and Behavioural Sciences (C-TNBS), University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany
| | - Anna Daniels
- Department of Pediatrics I, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany (E.T.)
- Center for Translational Neuro- and Behavioural Sciences (C-TNBS), University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany
| | - Ursula Felderhoff-Müser
- Department of Pediatrics I, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany (E.T.)
- Center for Translational Neuro- and Behavioural Sciences (C-TNBS), University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany
| | - Christian Dohna-Schwake
- Department of Pediatrics I, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany (E.T.)
- Center for Translational Neuro- and Behavioural Sciences (C-TNBS), University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany
| | - Eva Tschiedel
- Department of Pediatrics I, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany (E.T.)
- Center for Translational Neuro- and Behavioural Sciences (C-TNBS), University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany
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Puchner WF, Dünser MW, Paulus P, Neuner MP, Mayer CL, Pomberger IM, Hackl R, Meier JM. A comparative study on adequate anesthesia depth: clinical judgement and the Narcotrend® measurement. Can J Anaesth 2020; 67:664-673. [PMID: 32128723 PMCID: PMC7214482 DOI: 10.1007/s12630-020-01602-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 11/26/2019] [Accepted: 12/04/2019] [Indexed: 12/19/2022] Open
Abstract
Purpose To compare the clinical judgement of electroencephalogram (EEG)-naïve anesthesiologists with an EEG-based measurement of anesthetic depth (AD) using the Narcotrend® monitor. Methods In this prospective cohort study including 600 patients, AD during stable anesthesia was assessed by clinical judgement of the attending, EEG-blinded anesthesiologist (using a scale staging the AD as mid-adequate, adequate but fairly deep, or adequate but fairly light) and by simultaneously recorded Narcotrend measurements. Results In 42% of patients (n = 250), the anesthesiologist’s clinical judgement was in agreement with anesthetic levels as measured by the Narcotrend monitor. In 46% of patients (n = 274), the anesthesiologist’s judgement and the Narcotrend monitor differed by one AD level (minor discordance). Major discordance was observed in 76 (13%) measurements (judged deeper than measured, n = 29 [5%]; judged lighter than measured, n = 47 [8%]). In 7% of patients (n = 44), the Narcotrend index was outside the limits of adequate AD (too deep, n = 28 [5%]; too superficial, n = 16 [3%]). The overall level of agreement between the anesthesiologist’s judgement and the Narcotrend monitor was not statistically significant (Cohen’s kappa, −0.039; P = 0.17). Using a random forests algorithm, age, mean blood pressure, the American Society of Anesthesiologists classification, body mass index, and frailty were the variables with the highest relative feature importance to predict the level of agreement. Conclusion These results suggest that clinical judgement of AD during stable anesthesia was not in agreement with EEG-based assessment of anesthetic depth in 58% of cases. Nevertheless, this finding could be influenced by the lack of validated scales to clinically judge AD. Trial registration www.clinicaltrials.gov (NCT02766894); registered 10 May, 2016.
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Affiliation(s)
- Wolfgang F Puchner
- Department of Anesthesiology and Intensive Care, Kepler University Hospital and Johannes Kepler University, Krankenhausstraße 9, 4021, Linz, Austria.
| | - Martin W Dünser
- Department of Anesthesiology and Intensive Care, Kepler University Hospital and Johannes Kepler University, Krankenhausstraße 9, 4021, Linz, Austria
| | - Patrick Paulus
- Department of Anesthesiology and Intensive Care, Kepler University Hospital and Johannes Kepler University, Krankenhausstraße 9, 4021, Linz, Austria
| | - Markus P Neuner
- Department of Anesthesiology and Intensive Care, Kepler University Hospital and Johannes Kepler University, Krankenhausstraße 9, 4021, Linz, Austria
| | - Charlotte L Mayer
- Department of Anesthesiology and Intensive Care, Kepler University Hospital and Johannes Kepler University, Krankenhausstraße 9, 4021, Linz, Austria
| | - Irmgard M Pomberger
- Department of Anesthesiology and Intensive Care, Kepler University Hospital and Johannes Kepler University, Krankenhausstraße 9, 4021, Linz, Austria
| | - Ruth Hackl
- Department of Anesthesiology and Intensive Care, Kepler University Hospital and Johannes Kepler University, Krankenhausstraße 9, 4021, Linz, Austria
| | - Jens M Meier
- Department of Anesthesiology and Intensive Care, Kepler University Hospital and Johannes Kepler University, Krankenhausstraße 9, 4021, Linz, Austria
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Practicalities of Total Intravenous Anesthesia and Target-controlled Infusion in Children. Anesthesiology 2019; 131:164-185. [DOI: 10.1097/aln.0000000000002657] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Abstract
Propofol administered in conjunction with an opioid such as remifentanil is used to provide total intravenous anesthesia for children. Drugs can be given as infusion controlled manually by the physician or as automated target-controlled infusion that targets plasma or effect site. Smart pumps programmed with pharmacokinetic parameter estimates administer drugs to a preset plasma concentration. A linking rate constant parameter (keo) allows estimation of effect site concentration. There are two parameter sets, named after the first author describing them, that are commonly used in pediatric target-controlled infusion for propofol (Absalom and Kataria) and one for remifentanil (Minto). Propofol validation studies suggest that these parameter estimates are satisfactory for the majority of children. Recommended target concentrations for both propofol and remifentanil depend on the type of surgery, the degree of surgical stimulation, the use of local anesthetic blocks, and the ventilatory status of the patient. The use of processed electroencephalographic monitoring is helpful in pediatric total intravenous anesthesia and target-controlled infusion anesthesia, particularly in the presence of neuromuscular blockade.
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Guo Z, Pang L, Jia X, Wang X, Su X, Li P, Mi W, Hao J. Intraoperative target-controlled infusion anesthesia application using remifentanil hydrochloride with etomidate in patients with severe burn as monitored using Narcotrend. Burns 2014; 41:100-5. [PMID: 24931823 DOI: 10.1016/j.burns.2014.04.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2013] [Revised: 04/29/2014] [Accepted: 04/29/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE This study aims to evaluate the feasibility of intraoperative composite target-controlled infusion (TCI) anesthesia application using remifentanil hydrochloride with etomidate in patients with severe burns, as monitored by Narcotrend. METHODS A total of 40 patients with severe burns with eschar excisions and skin grafts were randomly and equally grouped into the etomidate (E) and the propofol groups (P). Anesthesia was induced and maintained by a remifentanil hydrochloride TCI combined with etomidate or propofol. The depth of anesthesia and other relevant indicators were recorded through intraoperative electroencephalogram monitoring using a Narcotrend monitor. RESULTS No statistically significant differences were observed between the drug withdrawal times, eye opening requirements, or orientation recoveries of the two groups (P>0.05). The cortisol and aldosterone levels in group E were significantly lower than those in group P 24h post operation (P<0.05). No significant differences between the number of operations, hospitalization duration, mean arterial pressure, heart rate, and postoperative adverse reaction incidence of the two groups were observed at each time point (P>0.05). CONCLUSION The application of a composite remifentanil hydrochloride combined with etomidate TCI is feasible for the early eschar excision in patients with severe burns.
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Affiliation(s)
- Zhenggang Guo
- Department of Anesthesiology, First Affiliated Hospital of General Hospital of PLA, Beijing 100048, China
| | - Liwei Pang
- Department of Anesthesiology, First Affiliated Hospital of General Hospital of PLA, Beijing 100048, China
| | - Xiaopeng Jia
- Department of Anesthesiology, First Affiliated Hospital of General Hospital of PLA, Beijing 100048, China
| | - Xiaoyan Wang
- Department of Anesthesiology, First Affiliated Hospital of General Hospital of PLA, Beijing 100048, China
| | - Xiaojun Su
- Department of Anesthesiology, First Affiliated Hospital of General Hospital of PLA, Beijing 100048, China
| | - Ping Li
- Department of Anesthesiology, First Affiliated Hospital of General Hospital of PLA, Beijing 100048, China
| | - Weidong Mi
- Anesthesia and Operation Center, Chinese PLA General Hospital, Beijing 100853, China.
| | - Jianhua Hao
- Department of Anesthesiology, First Affiliated Hospital of General Hospital of PLA, Beijing 100048, China.
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Al-Kadi MI, Reaz MBI, Ali MAM. Evolution of electroencephalogram signal analysis techniques during anesthesia. SENSORS 2013; 13:6605-35. [PMID: 23686141 PMCID: PMC3690072 DOI: 10.3390/s130506605] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Revised: 05/06/2013] [Accepted: 05/07/2013] [Indexed: 12/25/2022]
Abstract
Biosignal analysis is one of the most important topics that researchers have tried to develop during the last century to understand numerous human diseases. Electroencephalograms (EEGs) are one of the techniques which provides an electrical representation of biosignals that reflect changes in the activity of the human brain. Monitoring the levels of anesthesia is a very important subject, which has been proposed to avoid both patient awareness caused by inadequate dosage of anesthetic drugs and excessive use of anesthesia during surgery. This article reviews the bases of these techniques and their development within the last decades and provides a synopsis of the relevant methodologies and algorithms that are used to analyze EEG signals. In addition, it aims to present some of the physiological background of the EEG signal, developments in EEG signal processing, and the effective methods used to remove various types of noise. This review will hopefully increase efforts to develop methods that use EEG signals for determining and classifying the depth of anesthesia with a high data rate to produce a flexible and reliable detection device.
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Affiliation(s)
- Mahmoud I. Al-Kadi
- Department of Electrical, Electronic & Systems Engineering, Faculty of Engineering and Built Environment, Universiti Kebangsaan Malaysia, UKM Bangi Selangor 43600, Malaysia; E-Mails: (M.B.I.R.); (M.A.M.A.)
- Department of Biomedical Engineering, Al-Khwarizmi College of Engineering, Baghdad University, Baghdad 47146, Iraq
- Authors to whom correspondence should be addressed; E-Mail: ; Tel.: +60-1-7991-7098
| | - Mamun Bin Ibne Reaz
- Department of Electrical, Electronic & Systems Engineering, Faculty of Engineering and Built Environment, Universiti Kebangsaan Malaysia, UKM Bangi Selangor 43600, Malaysia; E-Mails: (M.B.I.R.); (M.A.M.A.)
| | - Mohd Alauddin Mohd Ali
- Department of Electrical, Electronic & Systems Engineering, Faculty of Engineering and Built Environment, Universiti Kebangsaan Malaysia, UKM Bangi Selangor 43600, Malaysia; E-Mails: (M.B.I.R.); (M.A.M.A.)
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Monitoring the depth of anaesthesia. SENSORS 2010; 10:10896-935. [PMID: 22163504 PMCID: PMC3231065 DOI: 10.3390/s101210896] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/01/2010] [Revised: 09/29/2010] [Accepted: 11/22/2010] [Indexed: 11/25/2022]
Abstract
One of the current challenges in medicine is monitoring the patients’ depth of general anaesthesia (DGA). Accurate assessment of the depth of anaesthesia contributes to tailoring drug administration to the individual patient, thus preventing awareness or excessive anaesthetic depth and improving patients’ outcomes. In the past decade, there has been a significant increase in the number of studies on the development, comparison and validation of commercial devices that estimate the DGA by analyzing electrical activity of the brain (i.e., evoked potentials or brain waves). In this paper we review the most frequently used sensors and mathematical methods for monitoring the DGA, their validation in clinical practice and discuss the central question of whether these approaches can, compared to other conventional methods, reduce the risk of patient awareness during surgical procedures.
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Are there still limitations for the use of target-controlled infusion in children? Curr Opin Anaesthesiol 2010; 23:356-62. [DOI: 10.1097/aco.0b013e32833938db] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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