1
|
Coeckelenbergh S, Boelefahr S, Alexander B, Perrin L, Rinehart J, Joosten A, Barvais L. Closed-loop anesthesia: foundations and applications in contemporary perioperative medicine. J Clin Monit Comput 2024; 38:487-504. [PMID: 38184504 DOI: 10.1007/s10877-023-01111-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 11/21/2023] [Indexed: 01/08/2024]
Abstract
A closed-loop automatically controls a variable using the principle of feedback. Automation within anesthesia typically aims to improve the stability of a controlled variable and reduce workload associated with simple repetitive tasks. This approach attempts to limit errors due to distractions or fatigue while simultaneously increasing compliance to evidence based perioperative protocols. The ultimate goal is to use these advantages over manual care to improve patient outcome. For more than twenty years, clinical studies in anesthesia have demonstrated the superiority of closed-loop systems compared to manual control for stabilizing a single variable, reducing practitioner workload, and safely administering therapies. This research has focused on various closed-loops that coupled inputs and outputs such as the processed electroencephalogram with propofol, blood pressure with vasopressors, and dynamic predictors of fluid responsiveness with fluid therapy. Recently, multiple simultaneous independent closed-loop systems have been tested in practice and one study has demonstrated a clinical benefit on postoperative cognitive dysfunction. Despite their advantages, these tools still require that a well-trained practitioner maintains situation awareness, understands how closed-loop systems react to each variable, and is ready to retake control if the closed-loop systems fail. In the future, multiple input multiple output closed-loop systems will control anesthetic, fluid and vasopressor titration and may perhaps integrate other key systems, such as the anesthesia machine. Human supervision will nonetheless always be indispensable as situation awareness, communication, and prediction of events remain irreplaceable human factors.
Collapse
Affiliation(s)
- Sean Coeckelenbergh
- Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Saclay, Université Paris-Saclay, Hôpital Paul-Brousse, Assistance Publique Hôpitaux de Paris, Villejuif, France.
- Outcomes Research Consortium, Cleveland, OH, USA.
| | - Sebastian Boelefahr
- Department of Anesthesiology and Intensive Care, Klinikum Aschaffenburg-Alzenau, Frankfurt University and Wuerzburg University Affiliated Academic Training Hospital, Aschaffenburg, Germany
| | - Brenton Alexander
- Department of Anesthesiology & Perioperative Care, University of California San Diego, San Diego, CA, USA
| | - Laurent Perrin
- Department of Anaesthesia and Resuscitation, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Joseph Rinehart
- Outcomes Research Consortium, Cleveland, OH, USA
- Department of Anesthesiology & Perioperative Care, University of California Irvine, Irvine, CA, USA
| | - Alexandre Joosten
- Department of Anesthesiology & Perioperative Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Luc Barvais
- Department of Anaesthesia and Resuscitation, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| |
Collapse
|
2
|
Coeckelenbergh S, Sessler DI, Doria S, Patricio D, Jaubert L, Huybrechts I, Stefanidis C, Kapessidou P, Tuna T, Engelman E, Barvais L, Perrin L. Nociception level index-guided antinociception versus routine care during remifentanil-propofol anaesthesia for moderate-to-high risk cardiovascular surgery: A randomized trial. Eur J Anaesthesiol 2023; 40:790-793. [PMID: 37497778 DOI: 10.1097/eja.0000000000001892] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Affiliation(s)
- Sean Coeckelenbergh
- From the Department of Anaesthesia and Resuscitation, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium (SC, SD, DP, LJ, IH, TT, EE, LB, LP), Department of Anaesthesiology and Intensive Care, Paul Brousse Hospital - Hepatobiliary Centre, Assistance Publique - Hôpitaux de Paris, Université Paris-Saclay, Villejuif, France (SC), Outcomes Research Consortium, Cleveland, OH, United States (SC, DIS), Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, United States (DIS), Department of Cardiac Surgery, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium (CS), Department of Anaesthesiology, Saint Pierre University Hospital, Université Libre de Bruxelles, Brussels, Belgium (PK), EW Data Analysis, Brussels, Belgium (EE)
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
3
|
Joosten A, Chirnoaga D, Van der Linden P, Barvais L, Alexander B, Duranteau J, Vincent JL, Cannesson M, Rinehart J. Automated closed-loop versus manually controlled norepinephrine infusion in patients undergoing intermediate- to high-risk abdominal surgery: a randomised controlled trial. Br J Anaesth 2021; 126:210-218. [PMID: 33041014 PMCID: PMC8489152 DOI: 10.1016/j.bja.2020.08.051] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/07/2020] [Accepted: 08/05/2020] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Hypotension occurs frequently during surgery and may be associated with adverse complications. Vasopressor titration is frequently used to correct hypotension, but requires considerable time and attention, potentially reducing the time available for other clinical duties. To overcome this issue, we have developed a closed-loop vasopressor (CLV) controller to help correct hypotension more efficiently. The aim of this randomised controlled study was to evaluate whether the CLV controller was superior to traditional vasopressor management at minimising hypotension in patients undergoing abdominal surgery. METHODS Thirty patients scheduled for elective intermediate-to high-risk abdominal surgery were randomised into two groups. In the CLV group, hypotension was corrected automatically via the CLV controller system, which adjusted the rate of a norepinephrine infusion according to MAP values recorded using an advanced haemodynamic device. In the control group, management of hypotension consisted of standard, manual adjustment of the norepinephrine infusion. The primary outcome was the percentage of time that a patient was hypotensive, defined as MAP <90% of their baseline value, during surgery. RESULTS The percentage of time patients were hypotensive during surgery was 10 times less in the CVL group than in the control group (1.6 [0.9-2.3]% vs 15.4 [9.9-24.3]%; difference: 13 [95% confidence interval: 9-19]; P<0.0001). The CVL group also spent much less time with MAP <65 mm Hg (0.2 [0.0-0.4]% vs 4.5 [1.1-7.9]%; P<0.0001). CONCLUSIONS In patients undergoing intermediate- to high-risk surgery under general anaesthesia, computer-assisted adjustment of norepinephrine infusion significantly decreases the incidence of hypotension compared with manual control. CLINICAL TRIAL REGISTRATION NCT04089644.
Collapse
Affiliation(s)
- Alexandre Joosten
- Department of Anaesthesiology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium,Department of Anaesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Université Paris-Saclay, Hôpital De Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France,Corresponding author.
| | - Dragos Chirnoaga
- Department of Anaesthesiology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Philippe Van der Linden
- Department of Anaesthesiology, Brugmann Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Luc Barvais
- Department of Anaesthesiology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Brenton Alexander
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA
| | - Jacques Duranteau
- Department of Anaesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Université Paris-Saclay, Hôpital De Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Maxime Cannesson
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Joseph Rinehart
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Irvine, CA, USA
| |
Collapse
|
4
|
Rinehart J, Cannesson M, Weeraman S, Barvais L, Obbergh LV, Joosten A. Closed-Loop Control of Vasopressor Administration in Patients Undergoing Cardiac Revascularization Surgery. J Cardiothorac Vasc Anesth 2020; 34:3081-3085. [PMID: 32434724 DOI: 10.1053/j.jvca.2020.03.038] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 03/13/2020] [Accepted: 03/16/2020] [Indexed: 12/22/2022]
Affiliation(s)
- Joseph Rinehart
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Irvine, CA.
| | - Maxime Cannesson
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Sashini Weeraman
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Irvine, CA
| | - Luc Barvais
- Department of Anesthesiology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Luc Van Obbergh
- Department of Anesthesiology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Alexandre Joosten
- Department of Anesthesiology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium; Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Université Paris-Saclay, Hôpital De Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| |
Collapse
|
5
|
Joosten A, Rinehart J, Bardaji A, Van der Linden P, Jame V, Van Obbergh L, Alexander B, Cannesson M, Vacas S, Liu N, Slama H, Barvais L. Anesthetic Management Using Multiple Closed-loop Systems and Delayed Neurocognitive Recovery: A Randomized Controlled Trial. Anesthesiology 2020; 132:253-266. [PMID: 31939839 PMCID: PMC7517610 DOI: 10.1097/aln.0000000000003014] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Cognitive changes after anesthesia and surgery represent a significant public health concern. We tested the hypothesis that, in patients 60 yr or older scheduled for noncardiac surgery, automated management of anesthetic depth, cardiac blood flow, and protective lung ventilation using three independent controllers would outperform manual control of these variables. Additionally, as a result of the improved management, patients in the automated group would experience less postoperative neurocognitive impairment compared to patients having standard, manually adjusted anesthesia. METHODS In this single-center, patient-and-evaluator-blinded, two-arm, parallel, randomized controlled, superiority study, 90 patients having noncardiac surgery under general anesthesia were randomly assigned to one of two groups. In the control group, anesthesia management was performed manually while in the closed-loop group, the titration of anesthesia, analgesia, fluids, and ventilation was performed by three independent controllers. The primary outcome was a change in a cognition score (the 30-item Montreal Cognitive Assessment) from preoperative values to those measures 1 week postsurgery. Secondary outcomes included a battery of neurocognitive tests completed at both 1 week and 3 months postsurgery as well as 30-day postsurgical outcomes. RESULTS Forty-three controls and 44 closed-loop patients were assessed for the primary outcome. There was a difference in the cognition score compared to baseline in the control group versus the closed-loop group 1 week postsurgery (-1 [-2 to 0] vs. 0 [-1 to 1]; difference 1 [95% CI, 0 to 3], P = 0.033). Patients in the closed-loop group spent less time during surgery with a Bispectral Index less than 40, had less end-tidal hypocapnia, and had a lower fluid balance compared to the control group. CONCLUSIONS Automated anesthetic management using the combination of three controllers outperforms manual control and may have an impact on delayed neurocognitive recovery. However, given the study design, it is not possible to determine the relative contribution of each controller on the cognition score.
Collapse
Affiliation(s)
- Alexandre Joosten
- From the Department of Anesthesiology (A.J., A.B., V.J., L.V.O, L.B.) Department of Clinical and Cognitive Neuropsychology (H.S.) Erasme Hospital, and Department of Anesthesiology, Brugmann Hospital (P.V.d.L.), Université Libre de Bruxelles, Brussels, Belgium Department of Anesthesiology and Intensive Care, University of Paris-Saclay, Bicetre Hospital, Le Kremlin-Bicêtre, Paris, France (A.J.) Department of Anesthesiology and Perioperative Care, University of California, Irvine, Irvine, California (J.R.) Department of Anesthesiology, University of California, San Diego, San Diego, California (B.A.) Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California (M.C., S.V.) Department of Anesthesiology, Foch Hospital, Suresnes, Paris, France (N.L.) Outcome Research Consortium, Cleveland Clinic, Cleveland, Ohio (N.L.)
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
6
|
Brosseau C, Danger R, Durand M, Durand E, Foureau A, Lacoste P, Tissot A, Roux A, Reynaud-Gaubert M, Kessler R, Mussot S, Dromer C, Brugière O, Mornex JF, Guillemain R, Claustre J, Magnan A, Brouard S, Velly J, Rozé H, Blanchard E, Antoine M, Cappello M, Ruiz M, Sokolow Y, Vanden Eynden F, Van Nooten G, Barvais L, Berré J, Brimioulle S, De Backer D, Créteur J, Engelman E, Huybrechts I, Ickx B, Preiser T, Tuna T, Van Obberghe L, Vancutsem N, Vincent J, De Vuyst P, Etienne I, Féry F, Jacobs F, Knoop C, Vachiéry J, Van den Borne P, Wellemans I, Amand G, Collignon L, Giroux M, Angelescu D, Chavanon O, Hacini R, Martin C, Pirvu A, Porcu P, Albaladejo P, Allègre C, Bataillard A, Bedague D, Briot E, Casez‐Brasseur M, Colas D, Dessertaine G, Francony G, Hebrard A, Marino M, Protar D, Rehm D, Robin S, Rossi‐Blancher M, Augier C, Bedouch P, Boignard A, Bouvaist H, Briault A, Camara B, Chanoine S, Dubuc M, Quétant S, Maurizi J, Pavèse P, Pison C, Saint‐Raymond C, Wion N, Chérion C, Grima R, Jegaden O, Maury J, Tronc F, Flamens C, Paulus S, Philit F, Senechal A, Glérant J, Turquier S, Gamondes D, Chalabresse L, Thivolet‐Bejui F, Barnel C, Dubois C, Tiberghien A, Pimpec‐Barthes F, Bel A, Mordant P, Achouh P, Boussaud V, Méléard D, Bricourt M, Cholley B, Pezella V, Brioude G, D'Journo X, Doddoli C, Thomas P, Trousse D, Dizier S, Leone M, Papazian L, Bregeon F, Coltey B, Dufeu N, Dutau H, Garcia S, Gaubert J, Gomez C, Laroumagne S, Mouton G, Nieves A, Picard C, Rolain J, Sampol E, Secq V, Perigaud C, Roussel J, Senage T, Mugniot A, Danner I, Haloun A, Abbes S, Bry C, Blanc F, Lepoivre T, Botturi‐Cavaillès K, Loy J, Bernard M, Godard E, Royer P, Henrio K, Dartevelle P, Fabre D, Fadel E, Mercier O, Stephan F, Viard P, Cerrina J, Dorfmuller P, Feuillet S, Ghigna M, Hervén P, Le Roy Ladurie F, Le Pavec J, Thomas de Montpreville V, Lamrani L, Castier Y, Mordant P, Cerceau P, Augustin P, Jean‐Baptiste S, Boudinet S, Montravers P, Dauriat G, Jébrak G, Mal H, Marceau A, Métivier A, Thabut G, Lhuillier E, Dupin C, Bunel V, Falcoz P, Massard G, Santelmo N, Ajob G, Collange O, Helms O, Hentz J, Roche A, Bakouboula B, Degot T, Dory A, Hirschi S, Ohlmann‐Caillard S, Kessler L, Schuller A, Bennedif K, Vargas S, Bonnette P, Chapelier A, Puyo P, Sage E, Bresson J, Caille V, Cerf C, Devaquet J, Dumans‐Nizard V, Felten M, Fischler M, Si Larbi A, Leguen M, Ley L, Liu N, Trebbia G, De Miranda S, Douvry B, Gonin F, Grenet D, Hamid A, Neveu H, Parquin F, Picard C, Stern M, Bouillioud F, Cahen P, Colombat M, Dautricourt C, Delahousse M, D'Urso B, Gravisse J, Guth A, Hillaire S, Honderlick P, Lequintrec M, Longchampt E, Mellot F, Scherrer A, Temagoult L, Tricot L, Vasse M, Veyrie C, Zemoura L, Dahan M, Murris M, Benahoua H, Berjaud J, Le Borgne Krams A, Crognier L, Brouchet L, Mathe O, Didier A, Krueger T, Ris H, Gonzalez M, Aubert J, Nicod L, Marsland B, Berutto T, Rochat T, Soccal P, Jolliet P, Koutsokera A, Marcucci C, Manuel O, Bernasconi E, Chollet M, Gronchi F, Courbon C, Hillinger S, Inci I, Kestenholz P, Weder W, Schuepbach R, Zalunardo M, Benden C, Buergi U, Huber L, Isenring B, Schuurmans M, Gaspert A, Holzmann D, Müller N, Schmid C, Vrugt B, Rechsteiner T, Fritz A, Maier D, Deplanche K, Koubi D, Ernst F, Paprotka T, Schmitt M, Wahl B, Boissel J, Olivera‐Botello G, Trocmé C, Toussaint B, Bourgoin‐Voillard S, Séve M, Benmerad M, Siroux V, Slama R, Auffray C, Charron D, Lefaudeux D, Pellet J. Blood CD9 + B cell, a biomarker of bronchiolitis obliterans syndrome after lung transplantation. Am J Transplant 2019; 19:3162-3175. [PMID: 31305014 DOI: 10.1111/ajt.15532] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 06/12/2019] [Accepted: 07/07/2019] [Indexed: 01/25/2023]
Abstract
Bronchiolitis obliterans syndrome is the main limitation for long-term survival after lung transplantation. Some specific B cell populations are associated with long-term graft acceptance. We aimed to monitor the B cell profile during early development of bronchiolitis obliterans syndrome after lung transplantation. The B cell longitudinal profile was analyzed in peripheral blood mononuclear cells from patients with bronchiolitis obliterans syndrome and patients who remained stable over 3 years of follow-up. CD24hi CD38hi transitional B cells were increased in stable patients only, and reached a peak 24 months after transplantation, whereas they remained unchanged in patients who developed a bronchiolitis obliterans syndrome. These CD24hi CD38hi transitional B cells specifically secrete IL-10 and express CD9. Thus, patients with a total CD9+ B cell frequency below 6.6% displayed significantly higher incidence of bronchiolitis obliterans syndrome (AUC = 0.836, PPV = 0.75, NPV = 1). These data are the first to associate IL-10-secreting CD24hi CD38hi transitional B cells expressing CD9 with better allograft outcome in lung transplant recipients. CD9-expressing B cells appear as a contributor to a favorable environment essential for the maintenance of long-term stable graft function and as a new predictive biomarker of bronchiolitis obliterans syndrome-free survival.
Collapse
Affiliation(s)
- Carole Brosseau
- Centre de Recherche en Transplantation et Immunologie, UMR 1064, INSERM, Université de Nantes, Nantes, France.,Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France.,Institut du thorax, Inserm UMR 1087, CNRS, UMR 6291, Université de Nantes, Nantes, France.,Institut du thorax, CHU de Nantes, Nantes, France
| | - Richard Danger
- Centre de Recherche en Transplantation et Immunologie, UMR 1064, INSERM, Université de Nantes, Nantes, France.,Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France
| | - Maxim Durand
- Centre de Recherche en Transplantation et Immunologie, UMR 1064, INSERM, Université de Nantes, Nantes, France.,Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France.,Faculté de Médecine, Université de Nantes, Nantes, France
| | - Eugénie Durand
- Centre de Recherche en Transplantation et Immunologie, UMR 1064, INSERM, Université de Nantes, Nantes, France.,Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France
| | - Aurore Foureau
- Institut du thorax, Inserm UMR 1087, CNRS, UMR 6291, Université de Nantes, Nantes, France.,Institut du thorax, CHU de Nantes, Nantes, France
| | - Philippe Lacoste
- Institut du thorax, Inserm UMR 1087, CNRS, UMR 6291, Université de Nantes, Nantes, France.,Institut du thorax, CHU de Nantes, Nantes, France
| | - Adrien Tissot
- Centre de Recherche en Transplantation et Immunologie, UMR 1064, INSERM, Université de Nantes, Nantes, France.,Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France.,Institut du thorax, Inserm UMR 1087, CNRS, UMR 6291, Université de Nantes, Nantes, France.,Institut du thorax, CHU de Nantes, Nantes, France.,Faculté de Médecine, Université de Nantes, Nantes, France
| | - Antoine Roux
- Hôpital Foch, Suresnes, France.,Université Versailles Saint-Quentin-en-Yvelines, UPRES EA220, Versailles, France
| | | | | | - Sacha Mussot
- Centre Chirurgical Marie Lannelongue, Service de Chirurgie Thoracique, Vasculaire et Transplantation Cardiopulmonaire, Le Plessis Robinson, France
| | | | - Olivier Brugière
- Hôpital Bichat, Service de Pneumologie et Transplantation Pulmonaire, Paris, France
| | | | | | - Johanna Claustre
- Clinique Universitaire Pneumologie, Pôle Thorax et Vaisseaux, CHU Grenoble Alpes, Université Grenoble Alpes, Inserm U1055, Grenoble, France
| | - Antoine Magnan
- Institut du thorax, Inserm UMR 1087, CNRS, UMR 6291, Université de Nantes, Nantes, France.,Institut du thorax, CHU de Nantes, Nantes, France
| | - Sophie Brouard
- Centre de Recherche en Transplantation et Immunologie, UMR 1064, INSERM, Université de Nantes, Nantes, France.,Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France.,Centre d'Investigation Clinique (CIC) Biothérapie, CHU Nantes, Nantes, France
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
7
|
Joosten A, Jame V, Alexander B, Chazot T, Liu N, Cannesson M, Rinehart J, Barvais L. Feasibility of Fully Automated Hypnosis, Analgesia, and Fluid Management Using 2 Independent Closed-Loop Systems During Major Vascular Surgery: A Pilot Study. Anesth Analg 2019; 128:e88-e92. [PMID: 31094779 DOI: 10.1213/ane.0000000000003433] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Automated titration of intravenous anesthesia and analgesia using processed electroencephalography monitoring is no longer a novel concept. Closed-loop control of fluid administration to provide goal-directed fluid therapy has also been increasingly described. However, simultaneously combining 2 independent closed-loop systems together in patients undergoing major vascular surgery has not been previously detailed. The aim of this pilot study was to evaluate the clinical performance of fully automated hypnosis, analgesia, and fluid management using 2 independent closed-loop controllers in patients undergoing major vascular surgery before implementation within a larger study evaluating true patient outcomes.
Collapse
Affiliation(s)
- Alexandre Joosten
- From the Department of Anesthesiology, Cliniques Universitaires de Bruxelles Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Vincent Jame
- Department of Anesthesiology, Centre hospitalo-Universitaire Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Brenton Alexander
- Department of Anesthesiology, University of California San Diego, San Diego, California
| | - Thierry Chazot
- Department of Anesthesiology, Hopital Foch, Suresnes, France
| | - Ngai Liu
- Department of Anesthesiology, Hopital Foch, Suresnes, France
- Outcomes Research Consortium, Cleveland, Ohio
| | - Maxime Cannesson
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, Los Angeles, California
| | - Joseph Rinehart
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Orange, California
| | - Luc Barvais
- From the Department of Anesthesiology, Cliniques Universitaires de Bruxelles Erasme, Université Libre de Bruxelles, Brussels, Belgium
| |
Collapse
|
8
|
Joosten A, Boudart C, Vincent JL, Vanden Eynden F, Barvais L, Van Obbergh L, Rinehart J, Desebbe O. Ability of a New Smartphone Pulse Pressure Variation and Cardiac Output Application to Predict Fluid Responsiveness in Patients Undergoing Cardiac Surgery. Anesth Analg 2019; 128:1145-1151. [PMID: 31094781 DOI: 10.1213/ane.0000000000003652] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Pulse pressure variation (PPV) can be used to predict fluid responsiveness in anesthetized patients receiving controlled mechanical ventilation but usually requires dedicated advanced monitoring. Capstesia (Galenic App, Vitoria-Gasteiz, Spain) is a novel smartphone application that calculates PPV and cardiac output (CO) from a picture of the invasive arterial pressure waveform obtained from any monitor screen. The primary objective was to compare the ability of PPV obtained using the Capstesia (PPVCAP) and PPV obtained using a pulse contour analysis monitor (PPVPC) to predict fluid responsiveness. A secondary objective was to assess the agreement and the trending of CO values obtained with the Capstesia (COCAP) against those obtained with the transpulmonary bolus thermodilution method (COTD). METHODS We studied 57 mechanically ventilated patients (tidal volume 8 mL/kg, positive end-expiratory pressure 5 mm Hg, respiratory rate adjusted to keep end tidal carbon dioxide [32-36] mm Hg) undergoing elective coronary artery bypass grafting. COTD, COCAP, PPVCAP, and PPVPC were measured before and after infusion of 5 mL/kg of a colloid solution. Fluid responsiveness was defined as an increase in COTD of >10% from baseline. The ability of PPVCAP and PPVPC to predict fluid responsiveness was analyzed using the area under the receiver-operating characteristic curve (AUROC), the agreement between COCAP and COTD using a Bland-Altman analysis and the trending ability of COCAP compared to COTD after volume expansion using a 4-quadrant plot analysis. RESULTS Twenty-eight patients were studied before surgical incision and 29 after sternal closure. There was no significant difference in the ability of PPVCAP and PPVPC to predict fluid responsiveness (AUROC 0.74 [95% CI, 0.60-0.84] vs 0.68 [0.54-0.80]; P = .30). A PPVCAP >8.6% predicted fluid responsiveness with a sensitivity of 73% (95% CI, 0.54-0.92) and a specificity of 74% (95% CI, 0.55-0.90), whereas a PPVPC >9.5% predicted fluid responsiveness with a sensitivity of 62% (95% CI, 0.42-0.88) and a specificity of 74% (95% CI, 0.48-0.90). When measured before surgery, PPV predicted fluid responsiveness (AUROC PPVCAP = 0.818 [P = .0001]; PPVPC = 0.794 [P = .0007]) but not when measured after surgery (AUROC PPVCAP = 0.645 [P = .19]; PPVPC = 0.552 [P = .63]). A Bland-Altman analysis of COCAP and COTD showed a mean bias of 0.3 L/min (limits of agreement: -2.8 to 3.3 L/min) and a percentage error of 60%. The concordance rate, corresponding to the proportion of CO values that changed in the same direction with the 2 methods, was poor (71%, 95% CI, 66-77). CONCLUSIONS In patients undergoing cardiac surgery, PPVCAP and PPVPC both weakly predict fluid responsiveness. However, COCAP is not a good substitute for COTD and cannot be used to assess fluid responsiveness.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Joseph Rinehart
- Department of Anesthesiology & Perioperative Care, University of California, Irvine, Irvine, California
| | - Olivier Desebbe
- Departments of Anesthesiology and Intensive Care, Clinique de la Sauvegarde, Lyon, France
- Université Lyon 1, EA4169, SFR Lyon-Est Santé - INSERM US 7- CNRS UMS 3453, Lyon, France
| |
Collapse
|
9
|
Saxena S, Gonsette K, Terram W, Huybrechts I, Nahrwold DA, Cappello M, Barvais L, Engelman E. Gradual withdrawal of remifentanil delays initial post-operative analgesic demand after thyroid surgery; double-blinded, randomized controlled trial. BMC Anesthesiol 2019; 19:60. [PMID: 31027480 PMCID: PMC6485117 DOI: 10.1186/s12871-019-0731-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 04/05/2019] [Indexed: 12/04/2022] Open
Abstract
Background Mismanagement of remifentanil leads to severe side effects such as opioid-induced tolerance and hyperalgesia. Recently studies revealed an alternative withdrawal method to limit these side effects. A gradual withdrawal of remifentanil seems to be associated with less pain. The hypothesis of this double-blinded, randomized controlled trial was that a gradual withdrawal of remifentanil would be associated with less immediate post-operative pain compared to after an abrupt discontinuation of remifentanil in patients who underwent thyroid surgery. Methods This double-blinded, randomized controlled trial was conducted in a tertiary level hospital in Brussels (Belgium) from April until August 2017. 34 patients undergoing thyroid surgery were randomized and 29 patients completed the study. After randomization, patients undergoing thyroid surgery were allocated to two groups: one with an abrupt discontinuation of remifentanil after surgery and one with a gradual withdrawal of remifentanil after surgery. The primary outcome was the initial post-operative demand of analgesic medication. Results Gradual withdrawal of remifentanil was associated with a delayed initial post-operative demand of analgesic medication (P = 0.006). The first morphine bolus was given after 76.3 +/− 89.0 min in the group with a gradual withdrawal of remifentanil versus after 9.0 +/− 13.5 min in the group with an abrupt discontinuation of remifentanil. However, overall morphine consumption, numeric rating scale scores, Ramsay Sedation Scale scores, and quality of recovery scores (QoR-40) were similar in both groups (P > 0.05). Conclusion Though overall morphine consumption, numeric rating scale scores, Ramsay Sedation Scale scores, and quality of recovery scores (QoR-40) are not altered, a gradual withdrawal of remifentanil after thyroid surgery is safe and associated with a delayed initial post-operative demand of analgesic drugs. The withdrawal process does, however, require vigilance and training. Trial registration Clinicaltrials.gov NCT03110653 (PI: Luc Barvais; date of registration: 03/31/2017).
Collapse
Affiliation(s)
- Sarah Saxena
- Department of Anesthesia and Perioperative Care, CUB Erasme University Hospital, Université Libre de Bruxelles, 808, Route de Lennik, 1070, Brussels, Belgium. .,Department of Anesthesia and Perioperative Care, Zuckerberg San Francisco General Hospital & Trauma Center, University of California, San Francisco, USA.
| | - Kimberly Gonsette
- Department of Anesthesia and Perioperative Care, CUB Erasme University Hospital, Université Libre de Bruxelles, 808, Route de Lennik, 1070, Brussels, Belgium
| | - Willy Terram
- Department of Anesthesia and Perioperative Care, CUB Erasme University Hospital, Université Libre de Bruxelles, 808, Route de Lennik, 1070, Brussels, Belgium
| | - Isabelle Huybrechts
- Department of Anesthesia and Perioperative Care, CUB Erasme University Hospital, Université Libre de Bruxelles, 808, Route de Lennik, 1070, Brussels, Belgium
| | - Daniel A Nahrwold
- Department of Anesthesia and Perioperative Care, Zuckerberg San Francisco General Hospital & Trauma Center, University of California, San Francisco, USA.,Department of Anesthesiology, H. Lee Moffitt Cancer Center & Research Institute, University of South Florida, Tampa, USA
| | - Matteo Cappello
- Department of Cardiothoracic Surgery, CUB Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Luc Barvais
- Department of Anesthesia and Perioperative Care, CUB Erasme University Hospital, Université Libre de Bruxelles, 808, Route de Lennik, 1070, Brussels, Belgium
| | - Edgard Engelman
- Department of Anesthesia and Perioperative Care, CUB Erasme University Hospital, Université Libre de Bruxelles, 808, Route de Lennik, 1070, Brussels, Belgium
| |
Collapse
|
10
|
Defresne A, Harrison M, Clement F, Barvais L, Bonhomme V. Two different methods to assess sympathetic tone during general anesthesia lead to different findings. J Clin Monit Comput 2018; 33:463-469. [PMID: 29943169 DOI: 10.1007/s10877-018-0175-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 06/20/2018] [Indexed: 12/19/2022]
Abstract
Noxious stimulation influences the autonomic nervous system activity. Sympathetic tone monitoring is currently used to assess the adequacy of the balance between nociception and anti-nociception during general anesthesia. The Surgical Plethysmographic Index (SPI) and the EBMi software (Custos©) are commercial devices that use different algorithms to measure it. We aimed at determining whether those devices provide similar information during routine surgical procedures under general anesthesia. Data acquired during a previously published study in patients undergoing surgery under general anesthesia were retrospectively analyzed and passed through the EBMi software. The occurrence of EBMi alarms of increased sympathetic tone was compared to the occurrence of SPI values ≥ 60, a commonly recommended intraoperative SPI threshold. Trends in classical parameters of sympathetic tone during the 5 min preceding a SPI ≥ 60, namely blood pressure, heart rate, and plethysmographic pulse amplitude were assessed. SPI ≥ 60 episodes (n = 307) were more frequent than EBMi alerts (n = 240). Approximately 70% of EBMi alerts occurred during periods where the SPI was below 60. Among all episodes of SPI ≥ 60, absence of any EBMi alerts was much more frequent than the inverse. A majority, but not all SPI ≥ 60 episodes were consistently preceded by an increase in heart rate and/or a decrease in pulse amplitude. Blood pressure did not significantly change before SPI ≥ 60. Longer SPI ≥ 60 episodes were associated with lower anti-nociception anesthetic regimen. Different methods of sympathetic tone assessment during general anesthesia provide conflicting information. Prospective studies should be undertaken to clarify the clinical indications of both techniques.
Collapse
Affiliation(s)
- Aline Defresne
- GIGA - Consciousness, Anesthesia and Intensive Care Medicine Laboratory, University and CHU University Hospital of Liege, Liege, Belgium.,Department of Anaesthesia and Intensive Care Medicine, CHU University Hospital of Liege, Liege, Belgium.,University Department of Anaesthesia and Intensive Care Medicine, CHR Citadelle, Bd du 12eme de Ligne, 1, Liege, 4000, Belgium
| | - Michael Harrison
- Department of Surgery and Anaesthesia, University of Otago, Wellington, New Zealand
| | - François Clement
- Department of Anesthesiology, Erasme University Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Luc Barvais
- Department of Anesthesiology, Erasme University Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Vincent Bonhomme
- GIGA - Consciousness, Anesthesia and Intensive Care Medicine Laboratory, University and CHU University Hospital of Liege, Liege, Belgium. .,Department of Anaesthesia and Intensive Care Medicine, CHU University Hospital of Liege, Liege, Belgium. .,University Department of Anaesthesia and Intensive Care Medicine, CHR Citadelle, Bd du 12eme de Ligne, 1, Liege, 4000, Belgium.
| |
Collapse
|
11
|
Dache S, Van Rompaey N, Joosten A, Desebbe O, Saxena S, Eynden FV, Van Aelbrouck C, Huybrechts I, Obbergh LV, Barvais L. Comparison of the ability of esCCO and Volume View to measure trends in cardiac output in patients undergoing cardiac surgery. Anaesthesiol Intensive Ther 2018; 49:175-180. [PMID: 28803439 DOI: 10.5603/ait.2017.0043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Accepted: 05/22/2017] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Cardiac output (CO) is a physiological variable that should be monitored during cardiac surgery. The purpose of this study was to assess the trending ability of two CO monitors, esCCO (Nihon Kohden™, Tokyo, Japan) and Volume View (VV) (Edwards Lifesciences, Irvine, USA). METHODS A total of 19 patients were included in the study. Before cardiopulmonary bypass (CPB), CO was measured simultaneously using both esCCO and VV devices before and after three CO-modifying manoeuvres (passive leg raise [PLR], the end expiratory occlusion test [EEOT] and positive end expiratory pressure [PEEP] at 10 cm H₂O). Five CO values for esCCO and three for VV were averaged and compared during a one-minute period of time before and after each manoeuvre. RESULTS A total of 114 paired readings were collected. Median CO values were 4.3 L min⁻¹ (IQR: 3.8; 5.2) and 3.8 L min⁻¹ (IQR: 3.5; 4.5) for esCCO and VV, respectively. The precision error was 1.4% (95% CI:1.0-1.7) for esCCO and 2.2% (95% CI: 1.8-2.7) for VV. The bias between esCCO and VV values was normally distributed (P = 0.0596). Between esCCO and VV, the mean bias was +0.6 L min⁻¹ with a Limit of Agreement (LOA) of -1.8 L min⁻¹ and +3.0 L min⁻¹. The concordance rate was 43% (95% CI: 29-58) between esCCO and VV. CONCLUSION Both single and trended measurements of CO using esCCO and VV were not in agreement. This large discrepancy leads one to the conclusion that any outcome study conducted with one of these devices cannot be applied to the other.
Collapse
Affiliation(s)
| | | | | | | | - Sarah Saxena
- Department of Anaesthesiology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium.
| | | | | | | | | | | |
Collapse
|
12
|
Joosten A, Delaporte A, Ickx B, Touihri K, Stany I, Barvais L, Van Obbergh L, Loi P, Rinehart J, Cannesson M, Van der Linden P. Crystalloid versus Colloid for Intraoperative Goal-directed Fluid Therapy Using a Closed-loop System: A Randomized, Double-blinded, Controlled Trial in Major Abdominal Surgery. Anesthesiology 2017; 128:55-66. [PMID: 29068831 DOI: 10.1097/aln.0000000000001936] [Citation(s) in RCA: 96] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The type of fluid and volume regimen given intraoperatively both can impact patient outcome after major surgery. This two-arm, parallel, randomized controlled, double-blind, bi-center superiority study tested the hypothesis that when using closed-loop assisted goal-directed fluid therapy, balanced colloids are associated with fewer postoperative complications compared to balanced crystalloids in patients having major elective abdominal surgery. METHODS One hundred and sixty patients were enrolled in the protocol. All patients had maintenance-balanced crystalloid administration of 3 ml · kg · h. A closed-loop system delivered additional 100-ml fluid boluses (patients were randomized to receive either a balanced-crystalloid or colloid solution) according to a predefined goal-directed strategy, using a stroke volume and stroke volume variation monitor. All patients were included in the analysis. The primary outcome was the Post-Operative Morbidity Survey score, a nine-domain scale, at day 2 postsurgery. Secondary outcomes included all postoperative complications. RESULTS Patients randomized in the colloid group had a lower Post-Operative Morbidity Survey score (median [interquartile range] of 2 [1 to 3] vs. 3 [1 to 4], difference -1 [95% CI, -1 to 0]; P < 0.001) and a lower incidence of postoperative complications. Total volume of fluid administered intraoperatively and net fluid balance were significantly lower in the colloid group. CONCLUSIONS Under our study conditions, a colloid-based goal-directed fluid therapy was associated with fewer postoperative complications than a crystalloid one. This beneficial effect may be related to a lower intraoperative fluid balance when a balanced colloid was used. However, given the study design, the mechanism for the difference cannot be determined with certainty.
Collapse
Affiliation(s)
- Alexandre Joosten
- From the Department of Anesthesiology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium (A.J., B.I., K.T., L.B., L.V.O.); Department of Anesthesiology, Brugmann Hospital, Université Libre de Bruxelles, Brussels, Belgium (A.D., I.S., P.V.d.L.); Department of Abdominal Surgery, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium (P.L.); Department of Anesthesiology and Perioperative Medicine, University of California Irvine, Irvine, California (J.R.); and Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California (M.C.)
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
13
|
Joosten A, Desebbe O, Suehiro K, Murphy LL, Essiet M, Alexander B, Fischer MO, Barvais L, Van Obbergh L, Maucort-Boulch D, Cannesson M. Accuracy and precision of non-invasive cardiac output monitoring devices in perioperative medicine: a systematic review and meta-analysis † †This Article is accompanied by Editorial Aew442. Br J Anaesth 2017; 118:298-310. [DOI: 10.1093/bja/aew461] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
|
14
|
Joosten A, Delaporte A, Cannesson M, Rinehart J, Dewilde JP, Van Obbergh L, Barvais L. Fully Automated Anesthesia and Fluid Management Using Multiple Physiologic Closed-Loop Systems in a Patient Undergoing High-Risk Surgery. ACTA ACUST UNITED AC 2017; 7:260-265. [PMID: 27669030 DOI: 10.1213/xaa.0000000000000405] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Automated delivery of anesthesia guided by processed electroencephalogram monitoring using a closed-loop system is no longer a novel concept. However, combining multiple independent physiologic closed-loop systems together has never been documented before. The purpose of this case report was to evaluate the feasibility of automated anesthesia and fluid management based on a combination of physiological variables (bispectral index, stroke volume, and stroke volume variations) using 2 independent closed-loop systems.
Collapse
Affiliation(s)
- Alexandre Joosten
- From the *Department of Anesthesiology and Perioperative Care, CUB Erasme, Université Libre de Bruxelles, Brussels, Belgium; †Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, Los Angeles, California; ‡Department of Anesthesiology and Perioperative Care, University of California Irvine, Irvine, California; and §Department of Vascular Surgery, CUB Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | | | | | | | | | | | | |
Collapse
|
15
|
Bissot M, Henin PY, Aunac S, Colinet B, Barvais L, Simonet O, De Kock M. Preoperative frailty assessment: a review. Acta Anaesthesiol Belg 2016; 67:157-173. [PMID: 29873986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Elderly surgical population is growing faster than the rate of population ageing. The risk of postoperative complication is higher in this population, the type of complication and the risk indicators are different from younger patients. There is also a huge heterogeneity in the elderly population. The concept of frailty-emerges to explain these specific aspects and to risk stratify older patients. The present work intends to help the anaesthesiologist to take into account the concept of frailty at the preoperative visit. We reviewed, in the light of surgical context, the physiopathology of ageing, the definitions of frailty concept,the current existing strategies for peri-operational optimisation and the different frailty assessment tools. Our conclusions are that preoperative frailty assessment is essential in modern perioperative medicine practice and that the Edmonton Frail Scale stands out from other tools even though it cannot yet be considered as a gold standard.
Collapse
|
16
|
Boscolo M, Barvais L, Engelman E, Féry F. Perioperative management of hyperglycemia: the diabetologist's point of view. Acta Anaesthesiol Belg 2014; 65:167-174. [PMID: 25622382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
|
17
|
|
18
|
Barvais L, Lobo FA, Engbers FHM, Irwin MG, Schnider TW, Schraag S. Tips and tricks to optimize total intravenous anesthesia. Acta Anaesthesiol Belg 2013; 64:137-146. [PMID: 24605414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- L Barvais
- Department of Anesthesiology, Erasme Hospital, Université Libre Bruxelles, Belgium.
| | - F A Lobo
- Department of Anesthesiology, Hospital Geral de Santo António-Centro Hospitalar do Porto, Porto, Portugal
| | - F H M Engbers
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - M G Irwin
- Department of Anesthesiology, University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - T W Schnider
- Department of Anesthesiology, Kantonsspital St.Gallen, Switzerland
| | - S Schraag
- Department of Perioperative Medicine, Golden Jubilee National Hospital Clydebank, Scotland, UK
| |
Collapse
|
19
|
Barvais L, Sermeus L, Bonhomme V. Nursing aid specialized in anesthesia and resuscitation (NASAR): why should we promote the involvement of anesthesia helping nurses within the current and future Belgian anesthesia field? Acta Anaesthesiol Belg 2012; 63:1-2. [PMID: 22783704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
|
20
|
Lipszyc M, Winters E, Engelman E, Baurain M, Barvais L. Remifentanil patient-controlled analgesia effect-site target-controlled infusion compared with morphine patient-controlled analgesia for treatment of acute pain after uterine artery embolization. Br J Anaesth 2011; 106:724-31. [DOI: 10.1093/bja/aer041] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
|
21
|
Salengros JC, Hecquet F, Touihri K, Sekkat J, Barvais L, Engelman E. Low-dose intravenous ketamine and clonidine for poor postoperative opioid responsiveness: a double blind randomized study. Acta Anaesthesiol Belg 2011; 62:65-72. [PMID: 21919372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
In the immediate postoperative period, some patients present with pain that responds poorly to intravenous opioids. In a double-blind randomized study, we tested the hypothesis that administering small doses of intravenous ketamine (0.125 mg/kg) combined with clonidine (0.5 microg/kg) would enhance the speed of onset and the quality of an opioid analgesic regimen in patients who initially responded poorly to opioids. We enrolled 68 patients in the study, all physical status I to III according to the American Society of Anesthesiologists classification. If the patient's numerical rating scale (NRS) score remained > or = 5 after an initial intravenous injection of 10 mg piritramide (2-mg boluses every 5 minutes) in the post-anesthesia care unit, patients were randomized to either intravenous placebo (sodium chloride 0.9%) or active substances (ketamine 0.125 mg/kg plus clonidine 0.5 microg/kg). Fifteen minutes after administration of either placebo or active agents, patients with severe pain (NRS > 4) again received intravenous opioids until NRS < 4. The primary endpoint of the study was to reduce by 20 minutes the time necessary to achieve an NRS < 4. There was no statistically significant difference between the two groups regarding the time required for patients to achieve an NRS < 4. It was concluded that in the immediate postoperative period, the acute administration of small combined doses of intravenous ketamine (0.125 mg/kg) and clonidine (0.5 mirog/kg) does not reduce the onset of an opioid-based analgesia in patients with an initial poor response to intravenous opioids.
Collapse
Affiliation(s)
- J C Salengros
- Department of Anesthesiology, Cliniques Universitaires de Bruxelles, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium.
| | | | | | | | | | | |
Collapse
|
22
|
Abstract
BACKGROUND Penile nerve block (PNB) is a well-established technique used for circumcision; it requires the injection of local anesthetics close to the dorsal nerve of the penis. The goal of this study was to compare the efficacy of ultrasound-guided PNB versus the classical landmark-based technique (LBT) in children undergoing circumcision. METHODS Forty boys, aged 1-14 years old that were scheduled for circumcision were randomly assigned to ultrasound-guided and landmark-based groups. All patients were placed under standard anesthesia with sevoflurane. In each group, patients received the penile block with ropivacaine, 0.75 mg·kg(-1) per side, and 0.05 mg·kg(-1) at the penis base. Groups were compared for intraoperative failure rate of the block, anesthesia time, postoperative pain scale, time of first required dose of paracetamol, time to first micturition, and average duration of stay in the postanesthesia care unit. RESULTS The failure rate of dorsal PNB was not statistically different between groups (P = 0.5). Ultrasound guidance improved the efficacy of the PNB compared to the LBT in terms of postoperative pain scores on arrival in the PACU (P < 0.01) and after 30 min (P < 0.01). The ultrasound-guided technique also delayed the time to the first paracetamol dose administration (P < 0.0001), but the duration of the procedure, defined as the time between anesthesia induction and the end of surgery, was increased by 10 min in the US-guided group (P = 0.001). CONCLUSION Ultrasound-guided PNB improved the efficacy of the block compared with the LBT in terms of the postoperative pain during the first postoperative hour and the time to the first requirement for postoperative analgesia.
Collapse
Affiliation(s)
- David Faraoni
- Department of Anesthesia, CUB-Erasme Hospital, Brussels, Belgium.
| | | | | | | | | | | |
Collapse
|
23
|
Salengros JC, Huybrechts I, Ducart A, Faraoni D, Marsala C, Barvais L, Cappello M, Engelman E. Different Anesthetic Techniques Associated with Different Incidences of Chronic Post-thoracotomy Pain: Low-Dose Remifentanil Plus Presurgical Epidural Analgesia is Preferable to High-Dose Remifentanil with Postsurgical Epidural Analgesia. J Cardiothorac Vasc Anesth 2010; 24:608-16. [DOI: 10.1053/j.jvca.2009.10.006] [Citation(s) in RCA: 107] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2009] [Indexed: 11/11/2022]
|
24
|
Barvais L. Non-anesthesiologist administration of propofol? Acta Anaesthesiol Belg 2010; 61:181-182. [PMID: 21388075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
|
25
|
Pandin P, Haentjens L, Salengros JC, Quintin J, Barvais L. Combined Ultrasound and Nerve Stimulation-Guided Thoracic Epidural Catheter Placement for Analgesia Following Anterior Spine Fusion in Scoliosis. Pain Pract 2009; 9:230-4. [DOI: 10.1111/j.1533-2500.2009.00275.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
26
|
Bejjani G, Lequeux PY, Schmartz D, Engelman E, Barvais L. No Evidence of Memory Processing During Propofol-Remifentanil Target-Controlled Infusion Anesthesia With Bispectral Index Monitoring in Cardiac Surgery. J Cardiothorac Vasc Anesth 2009; 23:175-81. [DOI: 10.1053/j.jvca.2008.09.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2008] [Indexed: 11/11/2022]
|
27
|
Faraoni D, Salengros JC, Engelman E, Ickx B, Barvais L. Ketamine has no effect on bispectral index during stable propofol-remifentanil anaesthesia. Br J Anaesth 2009; 102:336-9. [PMID: 19189986 DOI: 10.1093/bja/aen403] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Ketamine 0.15-1 mg kg(-1) decreases postoperative morphine consumption, but 0.5 mg kg(-1) is associated with an increase in the bispectral index (BIS) values that can lead to an overdose of hypnotic agents. The purpose of our investigation was to study the effect of ketamine 0.2 mg kg(-1) administered over a 5 min period on the BIS during stable target-controlled infusion (TCI) propofol-remifentanil general anaesthesia. METHODS Thirty ASA I or II patients undergoing abdominal laparoscopic surgery were included in this double-blind, randomized study. Anaesthesia was induced and maintained with a TCI of propofol and remifentanil. After 5 min of steady-state anaesthesia (BIS at 40) without surgical stimulation, patients received either an infusion of ketamine 0.2 mg kg(-1) or normal saline. The test drug was infused over 5 min. Standard parameters and BIS values were recorded every minute until 15 min post-infusion. RESULTS The baseline mean (sd) value for the BIS was 37 (6.5) for the ketamine group and 39 (8.2) for the placebo group. The highest mean BIS value during the recording period was 41.5 (8.7) for the ketamine group and 40.1 (8.9) for the placebo group. BIS values were not statistically different between the groups (P=0.62); there was no significant change over time (P=0.65) with no group-time interaction (P=0.55). CONCLUSIONS Under stable propofol and remifentanil TCI anaesthesia, a slow bolus infusion of ketamine 0.2 mg kg(-1) administered over a 5 min period did not increase the BIS value over the next 15 min.
Collapse
Affiliation(s)
- D Faraoni
- CUB Erasmus Hospital, University Department of Anaesthesia-Reanimation, Route de Lennik, 808, Brussels, Belgium.
| | | | | | | | | |
Collapse
|
28
|
Koch M, De Backer D, Vincent J, Barvais L, Hennart D, Schmartz D. Effects of propofol on human microcirculation. Br J Anaesth 2008; 101:473-8. [DOI: 10.1093/bja/aen210] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
|
29
|
Sadis C, Teske G, Stokman G, Kubjak C, Claessen N, Moore F, Loi P, Diallo B, Barvais L, Goldman M, Florquin S, Le Moine A. Nicotine protects kidney from renal ischemia/reperfusion injury through the cholinergic anti-inflammatory pathway. PLoS One 2007; 2:e469. [PMID: 17520028 PMCID: PMC1867857 DOI: 10.1371/journal.pone.0000469] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2007] [Accepted: 04/29/2007] [Indexed: 11/19/2022] Open
Abstract
Kidney ischemia/reperfusion injury (I/R) is characterized by renal dysfunction and tubular damages resulting from an early activation of innate immunity. Recently, nicotine administration has been shown to be a powerful inhibitor of a variety of innate immune responses, including LPS-induced toxaemia. This cholinergic anti-inflammatory pathway acts via the α7 nicotinic acetylcholine receptor (α7nAChR). Herein, we tested the potential protective effect of nicotine administration in a mouse model of renal I/R injury induced by bilateral clamping of kidney arteries. Renal function, tubular damages and inflammatory response were compared between control animals and mice receiving nicotine at the time of ischemia. Nicotine pretreatment protected mice from renal dysfunction in a dose-dependent manner and through the α7nAChR, as attested by the absence of protection in α7nAChR-deficient mice. Additionally, nicotine significantly reduced tubular damages, prevented neutrophil infiltration and decreased productions of the CXC-chemokine KC, TNF-α and the proinflammatory high-mobility group box 1 protein. Reduced tubular damage in nicotine pre-treated mice was associated with a decrease in tubular cell apoptosis and proliferative response as attested by the reduction of caspase-3 and Ki67 positive cells, respectively. All together, these data highlight that nicotine exerts a protective anti-inflammatory effect during kidney I/R through the cholinergic α7nAChR pathway. In addition, this could provide an opportunity to overcome the effect of surgical cholinergic denervation during kidney transplantation.
Collapse
Affiliation(s)
- Claude Sadis
- Institute for Medical Immunology, Université Libre de Bruxelles, Gosselies, Belgium
- Department of Anesthesiology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Gwen Teske
- Department of Pathology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Geurt Stokman
- Department of Pathology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Carole Kubjak
- Institute for Medical Immunology, Université Libre de Bruxelles, Gosselies, Belgium
| | - Nike Claessen
- Department of Pathology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Fabrice Moore
- Institute for Medical Immunology, Université Libre de Bruxelles, Gosselies, Belgium
| | - Patrizia Loi
- Institute for Medical Immunology, Université Libre de Bruxelles, Gosselies, Belgium
| | | | - Luc Barvais
- Department of Anesthesiology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Michel Goldman
- Institute for Medical Immunology, Université Libre de Bruxelles, Gosselies, Belgium
| | - Sandrine Florquin
- Department of Pathology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Alain Le Moine
- Institute for Medical Immunology, Université Libre de Bruxelles, Gosselies, Belgium
- * To whom correspondence should be addressed. E-mail:
| |
Collapse
|
30
|
Schmartz D, Ferring M, Ducart A, Barvais L. Haemodynamics during remifentanil induction by high plasma or effect-site target controlled infusion. Acta Anaesthesiol Belg 2007; 58:15-8. [PMID: 17486919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
BACKGROUND During total intravenous anaesthesia, the target controlled infusion concentration of remifentanil can be achieved either in limiting maximum plasma concentration (Cp) to the effect site target concentration which corresponds to a plasma TCI technique (pTCI) or as fast as possible to achieve the effect-site target without limiting Cp (eTCI). The aim of this study was to compare the haemodynamic effects of remifentanil pTCI and eTCI during induction of anaesthesia in ASA III patients undergoing cardiac surgery. METHODS 28 ASA III patients, scheduled for cardiac surgery, were randomized in two groups: Group pTCI received remifentanil to achieve an effect-site target of 15 ng ml(-1) by limiting Cp to 15 ng ml(-1) and group eTCI received remifentanil to achieve an effect-site target of 15 ng ml(-1) without limiting remifentanil Cp. Before induction, all patients received 30 microg kg(-1) of midazolam intravenously and 2 ml kg(-1) of a gelatin solution. Heart rate, invasive arterial pressure and bispectral index were continuously measured. Differences from baseline values were compared between the two groups using a Mann-Whitney U test. Baseline population characteristics were compared using an analysis of variance. RESULTS There were no significant differences in haemodynamic parameters between the two groups. In the group pTCI final effect-site concentration was reached in 7.3 +/- 1.4 minutes and in the group eTCI in 2.2 +/- 0.2 minutes (p < 0.05). CONCLUSION In ASA III patients scheduled for elective cardiac surgery, remifentanil eTCI can be preferred to remifentanil pTCI for induction because of its shorter onset with the same haemodynamic stability.
Collapse
Affiliation(s)
- D Schmartz
- Erasme University Hospital, Dept of Anesthesiology, Brussels, Belgium.
| | | | | | | |
Collapse
|
31
|
Huybrechts I, Barvais L, Ducart A, Engelman E, Schmartz D, Koch M. Assessment of Thoracic Epidural Analgesia During General Anesthesia Using Pupillary Reflex Dilation: A Preliminary Study. J Cardiothorac Vasc Anesth 2006; 20:664-7. [DOI: 10.1053/j.jvca.2006.04.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2005] [Indexed: 11/11/2022]
|
32
|
Kapessidou Y, Habran C, Buonocore S, Flamand V, Barvais L, Goldman M, Braun MY. The replacement of graft endothelium by recipient-type cells conditions allograft rejection mediated by indirect pathway CD4+ T cells. Transplantation 2006; 82:582-91. [PMID: 16958183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
BACKGROUND Whereas the participation of alloreactive T cells sensitized by indirect allorecognition in graft rejection is well documented, the nature of recipient antigen presenting cells recognized by indirect pathway CD4+ T cells within the graft has yet to be identified. The purpose of this study was to determine the role played by graft endothelium replacement in the immune recognition of cardiac allografts rejected by indirect pathway CD4+ T cells. METHODS Transgenic RAG2-/- mice expressing I-Ab-restricted male antigen H-Y-specific TcR were studied for their capacity to reject H-2k male cardiac allografts. Chronic vascular rejection in this model was due to the indirect recognition of H-Y antigen shed from H-2k male allograft and presented by the recipient's own I-Ab APC to transgenic T cells. RESULTS Immunohistochemical analysis of rejected grafts revealed the presence of numerous microvascular endothelial cells (EC) that expressed recipient's I-Ab MHC class II molecules. This observation suggested that graft endothelium replacement by I-Ab-positive cells of recipient origin could stimulate the rejection of male H-2k graft by I-Ab-restricted H-Y-specific T cells. To investigate further this possibility, hearts from H-2b-into-H-2k irradiation bone marrow (BM) chimera were transplanted in transgenic recipients. A direct correlation was observed between the presence of I-Ab-positive EC within myocardial microvessels and the induction of acute rejection of chimeric H-2k male cardiac allografts transplanted in transgenic recipients. CONCLUSIONS We conclude that graft endothelium replacement by recipient-type cells is required for the rejection of cardiac allograft mediated by indirect pathway alloreactive CD4+ T cells.
Collapse
Affiliation(s)
- Yota Kapessidou
- Institute for Medical Immunology, Faculty of Medicine, Université Libre de Bruxelles, Brussels, Belgium
| | | | | | | | | | | | | |
Collapse
|
33
|
Liu N, Chazot T, Trillat B, Pirracchio R, Law-Koune JD, Barvais L, Fischler M. Feasibility of closed-loop titration of propofol guided by the Bispectral Index for general anaesthesia induction. Eur J Anaesthesiol 2006; 23:465-9. [PMID: 16672092 DOI: 10.1017/s0265021506000196] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2006] [Indexed: 11/06/2022]
Abstract
BACKGROUND This study was designed to evaluate the feasibility of propofol infusion by a closed-loop system for the titration of anaesthetic induction guided by Bispectral Index. METHODS Forty patients were prospectively and randomly allocated into two groups: the target control infusion (TCI) group, where propofol titration was performed manually guided by the Bispectral Index using a commercial pharmacokinetic model (Diprifusor device) and the closed-loop group where titration was performed using a proportional differential algorithm. For both groups, the objective was to achieve a Bispectral Index of 50. Remifentanil TCI was infused at a target of 2 ng mL-1 and was maintained constant throughout the study. Feasibility of automatic induction was evaluated with performance error and haemodynamic data. RESULTS Bispectral Index overshoot (-9 +/- 13% vs. -16 +/- 20%, P = 0.035) and mean duration of induction (381 +/- 106 s vs. 490 +/- 131 s, P = 0.004) were lower in the closed-loop group than in the TCI group. Haemodynamic data were similar between groups with a similar use of ephedrine bolus. CONCLUSION The system was able to allow induction clinically for all patients. Automated titration guided by Bispectral Index for propofol infusion was feasible without increase in haemodynamic adverse effects.
Collapse
Affiliation(s)
- N Liu
- Department of Anaesthesiology, Hôpital Foch, Suresnes, France
| | | | | | | | | | | | | |
Collapse
|
34
|
Liu N, Chazot T, Genty A, Landais A, Restoux A, McGee K, Laloë PA, Trillat B, Barvais L, Fischler M. Titration of propofol for anesthetic induction and maintenance guided by the bispectral index: closed-loop versus manual control: a prospective, randomized, multicenter study. Anesthesiology 2006; 104:686-95. [PMID: 16571963 DOI: 10.1097/00000542-200604000-00012] [Citation(s) in RCA: 127] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND This report describes a closed-loop titration of propofol target control infusion based on a proportional-differential algorithm guided by the Bispectral Index (BIS) allowing induction and maintenance of general anesthesia and compares this to manual propofol target control infusion. METHODS One hundred sixty-four patients scheduled to undergo elective minor or major surgery were prospectively randomized in a multicenter study into the closed-loop (n = 83) or manual target control infusion group (n = 81). The goal was to reach a BIS target of 50 during induction and to maintain it between 40 and 60 during maintenance. For both groups, remifentanil target control infusion was adjusted manually, and ventilation was without nitrous oxide. RESULTS Closed-loop control was able to provide anesthesia induction and maintenance for all patients. During induction, propofol consumption was lower in the closed-loop group (1.4 +/- 0.5 vs. 1.8 +/- 0.6 mg/kg; P < 0.0001), but the duration was longer (320 +/- 125 vs. 271 +/- 120 s; P < 0.0002). Adequate anesthesia maintenance, defined as the BIS in the range of 40-60, was significantly higher in the closed-loop group (89 +/- 9 vs. 70 +/- 21%; P < 0.0001), with a decrease of the occurrence of BIS less than 40 (8 +/- 8 vs. 26 +/- 22%; P < 0.0001). Time from discontinuation of propofol infusion to tracheal extubation was shorter in the closed-loop group (7 +/- 4 vs. 10 +/- 7 min; P < 0.017). Unwanted somatic events and hemodynamic instability were similar. CONCLUSION Automatic control of consciousness using the BIS is clinically feasible and outperforms manual control.
Collapse
Affiliation(s)
- Ngai Liu
- Department of Anesthesiology, Hôpital Foch, Suresnes, France
| | | | | | | | | | | | | | | | | | | |
Collapse
|
35
|
Kapessidou Y, Habran C, Buonocore S, Flamand V, Barvais L, Goldman M, Braun MY. The replacement of graft endothelium by recipient-type cells conditions allograft rejection mediated by indirect pathway CD4(+) T cells. Transplantation 2006; 81:726-35. [PMID: 16534475 DOI: 10.1097/01.tp.0000184444.93108.d1] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Whereas the participation of alloreactive T cells sensitized by indirect allorecognition in graft rejection is well documented, the nature of recipient antigen presenting cells recognized by indirect pathway CD4(+) T cells within the graft has yet to be identified. The purpose of this study was to determine the role played by graft endothelium replacement in the immune recognition of cardiac allografts rejected by indirect pathway CD4(+) T cells. METHODS Transgenic RAG2(-/-) mice expressing I-A(b)-restricted male antigen H-Y-specific TcR were studied for their capacity to reject H-2(k) male cardiac allografts. Chronic vascular rejection in this model was due to the indirect recognition of H-Y antigen shed from H-2(k) male allograft and presented by the recipient's own I-A(b) APC to transgenic T cells. RESULTS Immunohistochemical analysis of rejected grafts revealed the presence of numerous microvascular endothelial cells (EC) that expressed recipient's I-A MHC class II molecules. This observation suggested that graft endothelium replacement by I-A(b)-positive cells of recipient origin could stimulate the rejection of male H-2(k) graft by I-A(b)--restricted H-Y--specific T cells. To investigate further this possibility, hearts from H-2(b)--into--H-2(k) irradiation bone marrow (BM) chimera were transplanted in transgenic recipients. A direct correlation was observed between the presence of I-A(b)-positive EC within myocardial microvessels and the induction of acute rejection of chimeric H-2(k) male cardiac allografts transplanted in transgenic recipients. CONCLUSIONS We conclude that graft endothelium replacement by recipient-type cells is required for the rejection of cardiac allograft mediated by indirect pathway alloreactive CD4(+) T cells.
Collapse
Affiliation(s)
- Yota Kapessidou
- Institute for Medical Immunology, Faculty of Medicine, Université Libre de Bruxelles, Brussels, Belgium
| | | | | | | | | | | | | |
Collapse
|
36
|
Lequeux PY, Sosnowski M, Morrison S, Bejjani G, Cantraine F, Barvais L. The effect of analgesic state on implicit learning during propofol anesthesia in volunteers. Acta Anaesthesiol Belg 2006; 57:355-9. [PMID: 17236636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Noxious stimulation may enhance implicit learning during general anesthesia. It is unknown, however, whether analgesic state can influence this memory processing. Twenty healthy adult volunteers were enrolled our prospective, double-blinded, controlled experiments. Anesthesia was induced with a propofol target controlled infusion (TCI), titrated in step-wise increments to loss of consciousness. In phase A, a 10-word list was played to the subjects while a noxious stimulus was applied (hand immersion in cold water at 2-4 degrees C). In phase B, a remifentanil TCI infusion was added to the steady-state propofol TCI anesthesia, and titrated to loss of hand movement on cold water immersion. A second 10-word list was then played while maintaining the hand in cold water. Memory testing, 2 hours post-recovery revealed no evidence of explicit memory in any subject during either phase of the study. During phase A, the word stem completion test revealed implicit learning for played words. In contrast, no implicit memory was detected during phase B. This study indicates that analgesia with remifentanil TCI (titrated to loss of movement on noxious stimulation), prevented implicit memory processing during stable propofol anesthesia in healthy adult volunteers.
Collapse
Affiliation(s)
- P Y Lequeux
- Department of Anesthesiology, CHU Tivoli, La Louvière, Belgium.
| | | | | | | | | | | |
Collapse
|
37
|
Engelman E, Salengros JC, Paquot MC, Barvais L. The acute pain service (APS): How we should have done it. Acta Anaesthesiol Belg 2006; 57:233-8. [PMID: 17067133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Affiliation(s)
- E Engelman
- Department of Anesthesiology, Erasme Unversity Hospital, Free University of Brussels, Brussels, Belgium
| | | | | | | |
Collapse
|
38
|
Abstract
PURPOSES The aim of this prospective, randomized, double-blind study was to compare two doses of intranasal sufentanil for postoperative analgesia, titrated according to individual requirements based upon a numeric rating scale (NRS) from 0 to 10 for pain. METHODS Forty patients, American Society of Anesthesiologists physical status I-II, scheduled for herniorrhaphy or hemorrhoidectomy under general anesthesia, were included when postoperative NRS was > 3. Nurses used a nasal puff device delivering a constant volume. Patients were randomized into two groups: Group A patients received a dose of 0.025 microg x kg(-1) /puff, Group B patients a dose of 0.05 microg x kg(-1) /puff. Puffs were administered as often as needed to obtain NRS < or = 3, with an interval time of five minutes. Hemodynamic, respiratory measures and sedation were recorded every five minutes. RESULTS The probability of persistence of pain in Group B was consistently lower than in Group A. After 20 min, 20% of the patients had a NRS score > 3 in Group B, as opposed to 60% in Group A. At 60 min, no patient had a NRS > 3 in Group B, whereas there was a probability of 20% to record a NRS > 3 for Group A. Hemodynamic, respiratory parameters and sedation remained stable with no intergroup differences. CONCLUSIONS Nasal administration of 0.050 microg x kg(-1) /puff sufentanil allowed a NRS < 4 to be attained within one hour in all patients, with efficacy achieved after 20 min. These findings suggest that the intranasal route is an effective mode of sufentanil administration for immediate postoperative analgesia in adult patients.
Collapse
Affiliation(s)
- Nathalie Mathieu
- Department of Anesthesiology, Erasme Hospital, Free University of Brussels, University of Route de Lennik 808, B-1070 Brussels, Belgium.
| | | | | | | |
Collapse
|
39
|
Liu N, Chazot T, Huybrechts I, Law-Koune JD, Barvais L, Fischler M. The Influence of a Muscle Relaxant Bolus on Bispectral and Datex-Ohmeda Entropy Values During Propofol-Remifentanil Induced Loss of Consciousness. Anesth Analg 2005; 101:1713-1718. [PMID: 16301247 DOI: 10.1213/01.ane.0000184038.49429.8f] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Studies investigating the influence of muscle relaxants on the bispectral index have yielded contradictory results. In our prospective, randomized, double-blind experiments, patients received a fixed target concentration of remifentanil along with a target-controlled infusion of propofol, titrated until loss of consciousness. Two minutes after loss of consciousness, the study group received a bolus injection of atracurium, whereas the control group received a placebo. The following variables were recorded: bispectral index, spectral edge frequency, electromyographic activity, state entropy, and response entropy provided by the Datex-Ohmeda Entropy monitor. Similar values were obtained in both groups at loss of consciousness. Placebo administration induced a decrease in bispectral index (P < 0.002), spectral edge frequency (P < 0.05), electromyographic activity (P < 0.02), state entropy (P < 0.05), and response entropy (P < 0.01) compared with the values measured at loss of consciousness. Atracurium administration induced a decrease in bispectral index (P < 0.0001), spectral edge frequency (P < 0.01), electromyographic activity (P < 0.0001), state entropy (P < 0.0001), and response entropy (P < 0.0001) values. Decreases in bispectral index (P < 0.05), electromyographic activity (P < 0.0001), and response entropy (P < 0.01) were larger after atracurium than placebo injection. In lightly anesthetized patients, myorelaxant administration decreases bispectral index and response entropy, but not state entropy values.
Collapse
Affiliation(s)
- Ngai Liu
- *Department of Anesthesiology, Hôpital Foch, Suresnes, France; †Department of Anesthesiology, Hôpital Erasme, ULB, Brussels, Belgium
| | | | | | | | | | | |
Collapse
|
40
|
Lequeux PY, Velghe-Lenelle CE, Cantraine F, Sosnowski M, Barvais L. Absence of implicit and explicit memory during propofol/remifentanil anaesthesia. Eur J Anaesthesiol 2005; 22:333-6. [PMID: 15918379 DOI: 10.1017/s0265021505000566] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVE High doses of opioid associated with low doses of hypnotic is a popular anaesthetic technique since the use of remifentanil has become widespread. This type of anaesthesia could result in a higher incidence of implicit memory. METHODS Ten patients were anaesthetised with a target-controlled infusion of remifentanil (target concentration of 8 ng mL(-1)) combined with a target-controlled infusion of propofol with progressive stepwise increases until loss of consciousness was reached. A tape containing 20 words was then played to the patients. Bispectral index (BIS, Aspect Medical Systems, Newton, MA, USA) was continuously monitored during the whole study period. Implicit and explicit memories were tested between 2 and 4 h after recovery. RESULTS Loss of consciousness was obtained with a mean calculated propofol plasma concentration of 1.3 +/- 0.4 microg mL(-1). At this low hypnotic concentration no implicit or explicit memory was found in the three postoperative memory tests. Median (range) BIS value during word presentation was 93 (80-98). CONCLUSIONS In our group of young American Society of Anesthesiologists (ASA) I/II patients, no explicit or implicit memory was found when the calculated concentration of propofol combined with a high concentration of remifentanil was maintained at the level associated with loss of consciousness with high BIS values.
Collapse
Affiliation(s)
- P Y Lequeux
- Erasmus Hospital, Department of Anaesthesiology, ULB, Brussels, Belgium
| | | | | | | | | |
Collapse
|
41
|
Bastin R, Barvais L, Mélot C, Vincent JL, Berré J. Preliminary results of prolonged target controlled infusion of sufentanil adjusted to an effort pain score after cardiac surgery. Acta Anaesthesiol Belg 2005; 56:31-6. [PMID: 15822418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Repeated boluses of i.v. morphine are often used for analgesia after cardiac surgery, but this procedure frequently provides inadequate pain relief. Target controlled infusion (TCI) of opioid drugs has been proposed as an alternative. The objective of this study was to evaluate the effects of prolonged sufentanil TCI adjusted to an effort pain score on the postoperative course after cardiac surgery. Twenty-six patients scheduled for cardiac surgery were anaesthetised using TCI of propofol and sufentanil, followed by early extubation. In the postoperative period, patients were randomly allocated to receive either boluses of i.v. morphine (Bolus group), adapted to a pain score at rest, or sufentanil TCI with a low target concentration (0.08-0.1 ng/ml), adapted to a pain score during deep inspiration (TCI group). Postoperative pain was assessed using a Verbal Numerical Score (VNS) before and during three stimuli: extubation, lateral positioning and physiotherapy. In 15 patients, inspiratory capacity was evaluated by incentive spirometry (IS) on postoperative day 1. Three patients in each group were withdrawn because of delayed extubation. Clinical characteristics, mean time to extubation and PaCO2 were similar in both groups. Analgesia was adequate at rest in both groups as indicated by low pain scores. Pain intensity increased significantly during the three stimuli (p < 0.01). VNS were lower in the TCI than in the Bolus group (3.8 +/- 0.5 versus 4.8 +/- 0.5, p = 0.03). Nine of 10 patients in the TCI group but only 4 of 10 patients in the bolus group gave a VNS below 5 during the stimuli. IS performance was better preserved in the TCI than in the Bolus group (53 +/- 5% versus 35 +/- 5% of preoperative values, p < 0.05). These observations indicate that after cardiac surgery, postoperative pain management with prolonged TCI of sufentanil adapted to a pain score during deep inspiration can achieve better analgesia during routine bedside procedures and higher pulmonary volumes than on-demand boluses of morphine.
Collapse
Affiliation(s)
- R Bastin
- Department Intensive Care, Erasme University Hospital, Free University of Brussels, Belgium
| | | | | | | | | |
Collapse
|
42
|
Herregods L, Barvais L, Brichant JF, Camu F, De Hert S, De Kock M, Dubois P, Ewalenko P, Lamy M, Mortier E, Vandermeersch E, Vermeyen K, Wouters P. Position of SARB in regard to premedication. Acta Anaesthesiol Belg 2005; 56:389-94. [PMID: 16416955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
|
43
|
|
44
|
Barvais L, Engelman E, Eba JM, Coussaert E, Cantraine F, Kenny GN. Effect site concentrations of remifentanil and pupil response to noxious stimulation. Br J Anaesth 2003; 91:347-52. [PMID: 12925472 DOI: 10.1093/bja/aeg178] [Citation(s) in RCA: 101] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Opioid drugs block reflex pupillary dilatation in response to noxious stimulation. The relationship between the target effect site concentration (Ce(T)) of remifentanil and the pupil diameter and reactivity in response to a standard noxious stimulus were evaluated. METHODS Anaesthesia was induced with propofol TCI to obtain loss of consciousness (LOC) in 12 ASA I/II patients. Thereafter, remifentanil Ce(T) was titrated by increments of 1 up to 5 ng ml(-1). In the awake state, at LOC and at each plateau level of remifentanil Ce(T), arterial pressure, heart rate, and BIS (A2000) were recorded. Pupil size and dilatation after a 100 Hz tetanic stimulation (T100) were measured at LOC and at each plateau level of remifentanil Ce(T). RESULTS LOC was observed at a mean propofol Ce(T) of 3.53 (SD 0.43) microg ml(-1). Arterial pressure and heart rate decreased progressively from LOC to 5 ng ml(-1) remifentanil Ce(T) without any statistical difference between each incremental dose of remifentanil. Mean BIS values decreased from 96 (2) in the awake state, to 46 (12) at LOC (P<0.05) and then remained unchanged at all remifentanil Ce(T). Pupil dilatation in response to 100 Hz tetanic stimulation decreased progressively from 1.55 (0.72) to 0.01 (0.03) mm and was more sensitive than pupil diameter measured before and after 100 Hz tetanus. An inverse correlation between pupil dilatation in response to 100 Hz tetanus and an increase in remifentanil Ce(T) from 0 to 5 ng ml(-1) was found (R(2)=0.68). CONCLUSIONS During propofol TCI in healthy patients, the decrease in pupil response to a painful stimulus is a better measurement of the progressive increase of remifentanil Ce(T) up to 5 ng ml(-1) than haemodynamic or BIS measurements.
Collapse
Affiliation(s)
- L Barvais
- Department of Anaesthesia, Erasme Hospital, 808 route de Lennik, 1070 Anderlecht, Belgium.
| | | | | | | | | | | |
Collapse
|
45
|
Abstract
BACKGROUND Episodes of implicit memory have been described during propofol anaesthesia. It remains unclear whether implicit memory is caused by short periods of awareness or occurs in an unconscious subject. METHODS Sixty patients were randomized in an experimental group (EG), a control group (CG) and a reference group (RG). Loss of consciousness (LOC) was obtained by progressive stepwise increases of propofol using a target-controlled infusion device (Diprifusor, Alaris Medical Systems, San Diego, CA). A tape containing 20 words was played to the patients in the CG before the start of anaesthesia and to the patients in the EG at a constant calculated concentration of propofol associated with LOC. The tape was not played to the patients in the RG. Three memory tests were performed postoperatively. RESULTS Explicit and implicit memories were evidenced in the CG but not in the EG. CONCLUSION In our group of young ASA I/II patients, in the absence of any noxious stimulus, no implicit or explicit memory was found when the calculated concentration of propofol using a Diprifusor was maintained at the level associated with LOC.
Collapse
Affiliation(s)
- P Y Lequeux
- Department of Anaesthesia, Erasme Hospital, Anderlecht, Belgium
| | | | | | | |
Collapse
|
46
|
Abstract
The usefulness and safety of transesophageal echocardiography during cardiac surgery have been well described in the literature. However, rare complications of this procedure can occur and should be familiar to surgeons and anesthesiologists. A case of esophageal perforation by echoprobe during coronary artery bypass grafting treated successfully by endoscopic stenting is reported.
Collapse
Affiliation(s)
- Albert M Nana
- Department of Cardiac Surgery, Erasme Hospital, University of Brussels, Brussels, Belgium
| | | | | | | | | | | |
Collapse
|
47
|
Levarlet M, Barvais L, Baurain M, Dejonckeere M, Ducart A, Engelman E, Hennart D, Ickx B, Lipszyc M, Mathieu N, Pandin P, Schmartz D, Vandesteene A, Velghe-Lenelle CE, Verleije A. [The anesthesiology-recovery department]. Rev Med Brux 2003; 23 Suppl 2:23-6. [PMID: 12584904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/28/2023]
Abstract
The Department of Anesthesiology and Reanimation is organised in units with clinical activities, which include the pre-operative care of patients, anesthesiological care and immediate post-operative supervision. Two post-operative treatment rooms also form part of the department. The main fields of research of the various units result from collaborations with other departments of Hôpital Erasme, in particular with regard to the development of advanced techniques or fit within the confines of the speciality.
Collapse
|
48
|
Fattorutto M, Pradier O, Schmartz D, Ickx B, Barvais L. Does the platelet function analyser (PFA-100) predict blood loss after cardiopulmonary bypass? Br J Anaesth 2003; 90:692-3. [PMID: 12697601 DOI: 10.1093/bja/aeg110] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND This study was designed to determine if a new point-of-care test (PFA-100) platelet function analyser) that assesses platelet function predicts blood loss after cardiac surgery. METHODS and results. Blood samples from 70 patients were drawn before and after cardiopulmonary bypass (CPB) for PFA-100 measurements. The system consists of a cartridge in which a membrane and an aperture are coated with either collagen/adenosine-5'-diphosphate or collagen/epinephrine. The instrument determines the time required for full occlusion of the aperture (closure time). We observed a weak correlation between pre-CPB collagen/epinephrine closure time and second-hour mediastinal blood loss (r=0.34, P=0.01). The sensitivity and positive predictive value of the PFA-100 measurements were comparable to platelet count for predicting excessive bleeding after CPB (75 and 27% vs 100 and 25%, respectively). CONCLUSIONS The PFA-100 is a logical test for detecting patients who could have excessive bleeding after CPB. However, the PFA-100 was not able to separate patients at low risk of subsequent bleeding from those who had substantial bleeding.
Collapse
Affiliation(s)
- M Fattorutto
- Department of Anaesthesiology and Haematology, Hopital Erasme, 808 route de Lennik, B-1070 Brussels, Belgium.
| | | | | | | | | |
Collapse
|
49
|
Fattorutto M, Pradier O, Jansens JL, Ickx B, Barvais L. Plateletpheresis the day before cardiac surgery and the impairment of platelet function. Eur J Anaesthesiol 2003; 20:338-40. [PMID: 12703843 DOI: 10.1017/s0265021503250511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
|
50
|
Schmartz D, Tabardel Y, Preiser JC, Barvais L, d'Hollander A, Duchateau J, Vincent JL. Does aprotinin influence the inflammatory response to cardiopulmonary bypass in patients? J Thorac Cardiovasc Surg 2003; 125:184-90. [PMID: 12539003 DOI: 10.1067/mtc.2003.64] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Aprotinin has been shown to have anti-inflammatory properties, but its effects on the inflammatory reaction to cardiopulmonary bypass remain controversial. This prospective, randomized, double-blind study evaluated the influence of aprotinin on various blood markers of inflammation during and after cardiopulmonary bypass. METHODS Sixty male patients underwent coronary artery bypass grafting. The patients were randomized into 3 groups: a placebo group, a second group receiving 2,000,000 KIU of aprotinin followed by an infusion of 500,000 KIU/h and 2,000,000 KIU in the pump prime, and a third group receiving half this dosage. Measurements of tumor necrosis factor, interleukin 6, interleukin 8, interleukin 10, endotoxin, histamine, complement factors, prekallikrein, and prostaglandin D(2) were obtained at baseline, 30 minutes after study drug loading, 10 minutes after the beginning of cardiopulmonary bypass, before the end of bypass, 4 hours after bypass, and on the first and second postoperative days. RESULTS Aprotinin had no significant effect on any of these parameters. As expected, aprotinin reduced early blood loss in both treated groups. CONCLUSIONS These results indicate that aprotinin at doses currently used to reduce blood loss has no significant influence on the systemic inflammatory response during moderate hypothermic cardiopulmonary bypass in human subjects, as assessed by the mediators measured in this study.
Collapse
Affiliation(s)
- Denis Schmartz
- Department of Anesthesiology, Erasme University Hospital, Brussels, Belgium.
| | | | | | | | | | | | | |
Collapse
|