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Kawata M, Yonezawa A, Mineharu Y, Itohara K, Mizota T, Matsui Y, Kikuchi T, Yamao Y, Hattori EY, Hamada M, Hira D, Furukawa K, Miyamoto S, Terada T, Matsubara K, Arakawa Y. Development of extended pharmacokinetic models for propofol based on measured blood and brain concentrations. Sci Rep 2024; 14:6326. [PMID: 38491119 PMCID: PMC10943190 DOI: 10.1038/s41598-024-56863-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 03/12/2024] [Indexed: 03/18/2024] Open
Abstract
Propofol's pharmacokinetics have been extensively studied using human blood samples and applied to target-controlled infusion systems; however, information on its concentration in the brain remains scarce. Therefore, this study aimed to simultaneously measure propofol plasma and brain concentrations in patients who underwent awake craniotomy and establish new pharmacokinetic model. Fifty-seven patients with brain tumors or brain lesions who underwent awake craniotomy were sequentially assigned to model-building and validating groups. Plasma and brain (lobectomy or uncapping margins) samples were collected at five time-points. The concentration of propofol was measured using high-performance liquid chromatography. Population pharmacokinetic analysis was conducted through a nonlinear mixed-effects modeling program using a first-order conditional estimation method with interactions. Propofol's brain concentrations were higher than its plasma concentrations. The measured brain concentrations were higher than the effect site concentrations using the previous models. Extended models were constructed based on measured concentrations by incorporating the brain/plasma partition coefficient (Kp value). Extended models showed good predictive accuracy for brain concentrations in the validating group. The Kp value functioned as a factor explaining retention in the brain. Our new pharmacokinetic models and Kp value can predict propofol's brain and plasma concentrations, contributing to safer and more stable anesthesia.
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Affiliation(s)
- Masayoshi Kawata
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Atsushi Yonezawa
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan.
- Graduate School of Pharmaceutical Sciences, Kyoto University, 46-29 Yoshida Shimo-Adachi-cho, Sakyo-ku, Kyoto, 606-8501, Japan.
| | - Yohei Mineharu
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
- Department of Artificial Intelligence in Healthcare and Medicine, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Kotaro Itohara
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Toshiyuki Mizota
- Department of Anesthesia, Kyoto University Hospital, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Yoshihiro Matsui
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
- Graduate School of Pharmaceutical Sciences, Kyoto University, 46-29 Yoshida Shimo-Adachi-cho, Sakyo-ku, Kyoto, 606-8501, Japan
| | - Takayuki Kikuchi
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Yukihiro Yamao
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Etsuko Yamamoto Hattori
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Miho Hamada
- Department of Anesthesia, Kyoto University Hospital, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Daiki Hira
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Keiko Furukawa
- Cancer Center, Kyoto University Hospital, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Susumu Miyamoto
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Tomohiro Terada
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Kazuo Matsubara
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Yoshiki Arakawa
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
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Syeda S, Bansal S, Chakrabarti D, Bhadrinarayan V. The requirement of propofol for induction of anesthesia in patients with traumatic brain injury determined using bilateral bispectral index and target controlled infusion - An observational cohort study. J Anaesthesiol Clin Pharmacol 2023; 39:208-214. [PMID: 37564867 PMCID: PMC10410018 DOI: 10.4103/joacp.joacp_216_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 07/12/2021] [Accepted: 07/13/2021] [Indexed: 08/12/2023] Open
Abstract
Background and Aims Patients with traumatic brain injury (TBI) frequently require emergency surgery. There is a paucity of literature with regard to anesthetic requirements in these patients. The aim of the study was to compare the dose of propofol required for induction of anesthesia in patients with different grades of TBI. Material and Methods This prospective, observational study included patients with mild, moderate, and severe grades of TBI undergoing emergency surgery within 48 h of injury. Bispectral Index (BIS) values were recorded using a bilateral BIS sensor. Anesthesia was induced with a target controlled infusion (TCI) pump. Once BIS reached 40, plasma (Cp) and effect-site (Ce) concentration and total dose of propofol required were noted from the TCI pump. Results Of the 96 patients recruited, 27, 36, and 33 patients belonged to mild, moderate, and severe TBI (sTBI) groups, respectively. The Ce of propofol in mild, moderate, and sTBI groups was 6 ± 0.9, 5.82 ± 0.98, and 4.48 ± 1.5 μg/mL (P < 0.001), and the dose of propofol required was 1.9 ± 0.2, 1.8 ± 0.4, 1.41 ± 0.5 mg/kg, respectively (P < 0.001). Baseline BIS on the injured side was 80 ± 7.8, 71 ± 9.4, 55 ± 11.6, and on the uninjured side was 89 ± 5.5, 81 ± 8.4, and 65 ± 12 in mild, moderate, and sTBI groups, respectively. Conclusions The requirement of propofol was reduced in patients with sTBI. The dose of propofol required for induction of anesthesia as determined using Ce was significantly lower only between sTBI and mild TBI and not between patients with sTBI and moderate TBI or between mild and moderate head injury. BIS values were significantly different between the groups (highest in mild TBI and lowest in sTBI) and between normal and injured sides within each group.
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Affiliation(s)
- Seham Syeda
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
| | - Sonia Bansal
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
| | - Dhritiman Chakrabarti
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
| | - V. Bhadrinarayan
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
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Ren W, Chen J, Liu J, Fu Z, Yao Y, Chen X, Teng L. Feasibility of intelligent drug control in the maintenance phase of general anesthesia based on convolutional neural network. Heliyon 2022; 9:e12481. [PMID: 36691533 PMCID: PMC9860284 DOI: 10.1016/j.heliyon.2022.e12481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 04/22/2022] [Accepted: 12/12/2022] [Indexed: 12/27/2022] Open
Abstract
Background The growth and aging process of the human population has accelerated the increase in surgical procedures. Yet, the demand for increasing operations can be hardly met since the training of anesthesiologists is usually a long-term process. Closed-loop artificial intelligence (AI) model provides the possibility to solve intelligent decision-making for anesthesia auxiliary control and, as such, has allowed breakthroughs in closed-loop control of clinical practices in intensive care units (ICUs). However, applying an open-loop artificial intelligence algorithm to build up personalized medication for anesthesia still needs to be further explored. Currently, anesthesiologists have selected doses of intravenously pumped anesthetic drugs mainly based on the blood pressure and bispectral index (BIS), which can express the depth of anesthesia. Unfortunately, BIS cannot be monitored at some medical centers or operational procedures and only be regulated by blood pressure. As a result, here we aim to inaugurally explore the feasibility of a basic intelligent control system applied to drug delivery in the maintenance phase of general anesthesia, based on a convolutional neural network model with open-loop design, according to AI learning of existing anesthesia protocols. Methods A convolutional neural network, combined with both sliding window sampling method and residual learning module, was utilized to establish an "AI anesthesiologist" model for intraoperative dosing of personalized anesthetic drugs (propofol and remifentanil). The fitting degree and difference in pumping dose decision, between the AI anesthesiologist and the clinical anesthesiologist, for these personalized anesthetic drugs were examined during the maintenance phase of anesthesia. Results The medication level established by the "AI anesthesiologist" was comparable to that obtained by the clinical anesthesiologist during the maintenance phase of anesthesia. Conclusion The application of an open-loop decision-making plan by convolutional neural network showed that intelligent anesthesia control is consistent with the actual anesthesia control, thus providing possibility for further evolution and optimization of auxiliary intelligent control of depth of anesthesia.
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Affiliation(s)
- Wei Ren
- Chengdu Institute of Computer Application, Chinese Academy of Sciences, Chengdu, 610041, China,University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Jiao Chen
- Department of Anesthesiology, West China Hospital, Sichuan University & The Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, China,Corresponding author.
| | - Jin Liu
- Department of Anesthesiology, West China Hospital, Sichuan University & The Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, China
| | - Zhongliang Fu
- Chengdu Institute of Computer Application, Chinese Academy of Sciences, Chengdu, 610041, China
| | - Yu Yao
- Chengdu Institute of Computer Application, Chinese Academy of Sciences, Chengdu, 610041, China
| | - Xiaoqing Chen
- Chengdu Institute of Computer Application, Chinese Academy of Sciences, Chengdu, 610041, China,University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Long Teng
- Chengdu Institute of Computer Application, Chinese Academy of Sciences, Chengdu, 610041, China,University of Chinese Academy of Sciences, Beijing, 100049, China
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González C, Garcia-Hernando G, Jensen EW, Vallverdú-Ferrer M. Assessing rheoencephalography dynamics through analysis of the interactions among brain and cardiac networks during general anesthesia. FRONTIERS IN NETWORK PHYSIOLOGY 2022; 2:912733. [PMID: 36926077 PMCID: PMC10013012 DOI: 10.3389/fnetp.2022.912733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 07/08/2022] [Indexed: 11/13/2022]
Abstract
Cerebral blood flow (CBF) reflects the rate of delivery of arterial blood to the brain. Since no nutrients, oxygen or water can be stored in the cranial cavity due to space and pressure restrictions, a continuous perfusion of the brain is critical for survival. Anesthetic procedures are known to affect cerebral hemodynamics, but CBF is only monitored in critical patients due, among others, to the lack of a continuous and affordable bedside monitor for this purpose. A potential solution through bioelectrical impedance technology, also known as rheoencephalography (REG), is proposed, that could fill the existing gap for a low-cost and effective CBF monitoring tool. The underlying hypothesis is that REG signals carry information on CBF that might be recovered by means of the application of advanced signal processing techniques, allowing to track CBF alterations during anesthetic procedures. The analysis of REG signals was based on geometric features extracted from the time domain in the first place, since this is the standard processing strategy for this type of physiological data. Geometric features were tested to distinguish between different anesthetic depths, and they proved to be capable of tracking cerebral hemodynamic changes during anesthesia. Furthermore, an approach based on Poincaré plot features was proposed, where the reconstructed attractors form REG signals showed significant differences between different anesthetic states. This was a key finding, providing an alternative to standard processing of REG signals and supporting the hypothesis that REG signals do carry CBF information. Furthermore, the analysis of cerebral hemodynamics during anesthetic procedures was performed by means of studying causal relationships between global hemodynamics, cerebral hemodynamics and electroencephalogram (EEG) based-parameters. Interactions were detected during anesthetic drug infusion and patient positioning (Trendelenburg positioning and passive leg raise), providing evidence of the causal coupling between hemodynamics and brain activity. The provided alternative of REG signal processing confirmed the hypothesis that REG signals carry information on CBF. The simplicity of the technology, together with its low cost and easily interpretable outcomes, should provide a new opportunity for REG to reach standard clinical practice. Moreover, causal relationships among the hemodynamic physiological signals and brain activity were assessed, suggesting that the inclusion of REG information in depth of anesthesia monitors could be of valuable use to prevent unwanted CBF alterations during anesthetic procedures.
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Affiliation(s)
- Carmen González
- Biomedical Engineering Research Centre, CIBER of Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Universitat Politècnica de Catalunya, Barcelona, Spain.,Research and Development Department, Quantium Medical, Mataró, Spain
| | - Gabriel Garcia-Hernando
- Biomedical Engineering Research Centre, CIBER of Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Universitat Politècnica de Catalunya, Barcelona, Spain.,Research and Development Department, Quantium Medical, Mataró, Spain
| | - Erik W Jensen
- Research and Development Department, Quantium Medical, Mataró, Spain
| | - Montserrat Vallverdú-Ferrer
- Biomedical Engineering Research Centre, CIBER of Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Universitat Politècnica de Catalunya, Barcelona, Spain
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Shim J, Cho EA, Ryu KH, Lee SH, Kim JI, Kim D, Oh EJ, Ahn JH. Effects of prophylactic atropine on the time to tracheal intubation with the pre-administration of remifentanil. Acta Anaesthesiol Scand 2021; 65:335-342. [PMID: 33165918 DOI: 10.1111/aas.13739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 10/15/2020] [Accepted: 10/16/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Pre-administration of remifentanil in target-controlled propofol and remifentanil anaesthesia could prolong the time of onset of muscle relaxation owing to haemodynamic effects, thereby prolonging the time to tracheal intubation. Although the sympatholytic effects of remifentanil result in bradycardia and hypotension, these responses can be attenuated by the administration of atropine. Therefore, we investigated whether prophylactic administration of atropine could prevent the prolongation of the time to tracheal intubation. METHODS Sixty-four patients were included in this study. They were randomised into Group A (atropine 0.5 mg, n = 32) and Group S (saline 0.9%, n = 32), immediately before the pre-administration of remifentanil. The primary outcome was the time to tracheal intubation and the secondary outcomes were rocuronium onset time, time to loss of consciousness (LOC), time to reach a value of 60 on the bispectral index (BIS) and haemodynamic variables. RESULTS The median [Interquartile range] of the time to tracheal intubation was 240 [214, 288]s in Group S and 190 [176, 212]s in Group A(median difference: 50 s, 95% confidence interval: 27-80 s, P = .001). Rocuronium onset time was significantly decreased in Group A compared to that in Group S (129 [110, 156] vs 172 [154, 200], P = .001). The times to LOC and reach 60 on the BIS were not significantly different between the two groups. Cardiac output(CO) and heart rate were less decreased in Group A than in Group S (P = .02, P < .001, respectively). CONCLUSIONS Prophylactic administration of atropine could compensate for the reduction in CO in cases pre-administered with remifentanil in target-controlled propofol and remifentanil anaesthesia. This in turn prevented the prolongation of rocuronium onset time and reduced the time to tracheal intubation.
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Affiliation(s)
- Jae‐Geum Shim
- Department of Anesthesiology and Pain Medicine Kangbuk Samsung HospitalSungkyunkwan University School of Medicine Seoul Korea
| | - Eun A. Cho
- Department of Anesthesiology and Pain Medicine Kangbuk Samsung HospitalSungkyunkwan University School of Medicine Seoul Korea
| | - Kyoung Ho Ryu
- Department of Anesthesiology and Pain Medicine Kangbuk Samsung HospitalSungkyunkwan University School of Medicine Seoul Korea
| | - Sung Hyun Lee
- Department of Anesthesiology and Pain Medicine Kangbuk Samsung HospitalSungkyunkwan University School of Medicine Seoul Korea
| | - Jeong In Kim
- Department of Anesthesiology and Pain Medicine Kangbuk Samsung HospitalSungkyunkwan University School of Medicine Seoul Korea
| | - Doyeon Kim
- Department of Anesthesiology and Pain Medicine Samsung Medical Centre Sungkyunkwan University School of Medicine Seoul Korea
| | - Eun Jung Oh
- Department of Anesthesiology and Pain Medicine Samsung Medical Centre Sungkyunkwan University School of Medicine Seoul Korea
| | - Jin Hee Ahn
- Department of Anesthesiology and Pain Medicine Kangbuk Samsung HospitalSungkyunkwan University School of Medicine Seoul Korea
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Zech N, Seemann M, Luerding R, Doenitz C, Zeman F, Cananoglu H, Kees MG, Hansen E. Neurocognitive Impairment After Propofol With Relevance for Neurosurgical Patients and Awake Craniotomies-A Prospective Observational Study. Front Pharmacol 2021; 12:632887. [PMID: 33679415 PMCID: PMC7930827 DOI: 10.3389/fphar.2021.632887] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 01/13/2021] [Indexed: 11/19/2022] Open
Abstract
Background: Short-acting anesthetics are used for rapid recovery, especially for neurological testing during awake craniotomy. Extent and duration of neurocognitive impairment are ambiguous. Methods: Prospective evaluation of patients undergoing craniotomy for tumor resection during general anesthesia with propofol (N of craniotomies = 35). Lexical word fluency, digit span and trail making were tested preoperatively and up to 24 h after extubation. Results were stratified for age, tumor localization and hemisphere of surgery. Results in digit span test were compared to 21 patients during awake craniotomies. Results: Word fluency was reduced to 30, 33, 47, and 87% of preoperative values 10, 30, 60 min and 24 h after extubation, respectively. Digit span was decreased to 41, 47, 55, and 86%. Performances were still significantly impaired 24 h after extubation, especially in elderly. Results of digit span test were not worse in patients with left hemisphere surgery. Significance of difference to baseline remained, when patients with left or frontal lesions, i.e., brain areas essential for these tests, were excluded from analysis. Time for trail making was increased by 87% at 1 h after extubation, and recovered within 24 h. In 21 patients undergoing awake craniotomies without pharmacological sedation, digit span was unaffected during intraoperative testing. Conclusion: Selected aspects of higher cognitive functions are compromised for up to 24 h after propofol anesthesia for craniotomy. Propofol and the direct effects of surgical resection on brain networks may be two major factors contributing (possibly jointly) to the observed deficits. Neurocognitive testing was unimpaired in patients undergoing awake craniotomies without sedation.
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Affiliation(s)
- Nina Zech
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Milena Seemann
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Ralf Luerding
- Department of Neurology, University Hospital Regensburg, Regensburg, Germany
| | - Christian Doenitz
- Department of Neurosurgery, University Hospital Regensburg, Regensburg, Germany
| | - Florian Zeman
- Centre for Clinical Studies, University Hospital Regensburg, Regensburg, Germany
| | - Hamit Cananoglu
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Martin G Kees
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Ernil Hansen
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
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7
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Irwin MG, Chung CKE, Wong GTC. Measuring the effect‐site. Anaesthesia 2020; 75:1583-1586. [DOI: 10.1111/anae.15186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2020] [Indexed: 11/29/2022]
Affiliation(s)
- M. G. Irwin
- Department of Anaesthesiology University of Hong Kong Queen Mary Hospital Hong Kong
| | - C. K. E. Chung
- Department of Anaesthesiology University of Hong Kong Queen Mary Hospital Hong Kong
| | - G. T. C. Wong
- Department of Anaesthesiology University of Hong Kong Queen Mary Hospital Hong Kong
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8
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Van Hese L, Theys T, Absalom A, Rex S, Cuypers E. Comparison of predicted and real propofol and remifentanil concentrations in plasma and brain tissue during target‐controlled infusion: a prospective observational study. Anaesthesia 2020; 75:1626-1634. [DOI: 10.1111/anae.15125] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2020] [Indexed: 12/14/2022]
Affiliation(s)
- L. Van Hese
- Department of Anaesthesiology University Hospitals Leuven KU Leuven 3000 Leuven Belgium
- Maastricht MultiModal Molecular Imaging (M4I) institute Division of Imaging Mass Spectrometry Maastricht University Maastricht The Netherlands
| | - T. Theys
- Neurosurgery Department University Hospitals Leuven Laboratory for Experimental Neurosurgery and Neuroanatomy Department of Neurosciences KU Leuven 3000 Leuven Belgium
| | - A.R. Absalom
- Neurosurgery Department University Hospitals Leuven Laboratory for Experimental Neurosurgery and Neuroanatomy Department of Neurosciences KU Leuven 3000 Leuven Belgium
| | - S. Rex
- Department of Anaesthesiology University Medical Center Groningen University of Groningen The Netherlands
| | - E. Cuypers
- Toxicology and Pharmacology Department KU Leuven 3000 Leuven Belgium
- Maastricht MultiModal Molecular Imaging (M4I) institute Division of Imaging Mass Spectrometry Maastricht University Maastricht The Netherlands
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9
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van den Berg JP, Eleveld DJ, De Smet T, van den Heerik AVM, van Amsterdam K, Lichtenbelt BJ, Scheeren TWL, Absalom AR, Struys MMRF. Influence of Bayesian optimization on the performance of propofol target-controlled infusion. Br J Anaesth 2019; 119:918-927. [PMID: 29028925 DOI: 10.1093/bja/aex243] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/02/2017] [Indexed: 11/12/2022] Open
Abstract
Background Target controlled infusion (TCI) systems use population-based pharmacokinetic (PK) models that do not take into account inter-individual residual variation. This study compares the bias and inaccuracy of a population-based vs a personalized TCI propofol titration using Bayesian adaptation. Haemodynamic and hypnotic stability, and the prediction probability of alternative PK models, was studied. Methods A double-blinded, prospective randomized controlled trial of 120 subjects undergoing cardiac surgery was conducted. Blood samples were obtained at 10, 35, 50, 65, 75 and 120 min and analysed using a point-of-care propofol blood analyser. Bayesian adaptation of the PK model was applied at 60 min in the intervention group. Median (Absolute) Performance Error (Md(A)PE) was used to evaluate the difference between bias and inaccuracy of the models. Haemodynamic (mean arterial pressure [MAP], heart rate) and hypnotic (bispectral index [BIS]) stability was studied. The predictive performance of four alternative propofol PK models was studied. Results MdPE and MdAPE did not differ between groups during the pre-adjustment period (control group: 6.3% and 16%; intervention group: 5.4% and 18%). MdPE differed in the post-adjustment period (12% vs. -0.3%), but MdAPE did not (18% vs. 15%). No difference in heart rate, MAP or BIS was found. Compared with the other models, the Eleveld propofol PK model (patients) showed the best prediction performance. Conclusions When an accurate population-based PK model was used for propofol TCI, Bayesian adaption of the model improved bias but not precision. Clinical trial registration Dutch Trial Registry NTR4518.
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Affiliation(s)
- J P van den Berg
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - D J Eleveld
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | - A V M van den Heerik
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - K van Amsterdam
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - B J Lichtenbelt
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - T W L Scheeren
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - A R Absalom
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - M M R F Struys
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Department of Anaesthesia and Peri-Operative Medicine, Ghent University, Ghent, Belgium
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10
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Measuring the accuracy of propofol target-controlled infusion (TCI) before and after surgery with major blood loss. J Clin Monit Comput 2019; 34:97-103. [PMID: 30671895 DOI: 10.1007/s10877-019-00261-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 01/17/2019] [Indexed: 10/27/2022]
Abstract
Target-controlled infusion (TCI) is based on pharmacokinetic models designed to achieve a desired drug level in the blood. TCI's predictive accuracy of plasma propofol levels at the end of surgery with major blood loss has not been well established. This prospective observational study included adult patients (BMI 20-35 kg/m2) undergoing surgery with expected blood loss ≥ 1500 mL. The study was conducted with the Schnider TCI propofol model (Alaris PK Infusion Pump, CareFusion, Switzerland). Propofol levels were assessed in steady-state at the end of anaesthesia induction (Tinitial) and before the end of surgery (Tfinal). Predicted propofol levels (CTCI) were compared to measured levels (Cblood). Twenty-one patients were included. The median estimated blood loss was 1600 mL (IQR 1000-2300), and the median fluid balance at Tfinal was + 3200 mL (IQR 2320-4715). Heart rate, mean arterial blood pressure, and blood lactate did not differ significantly between Tinitial and Tfinal. The median bispectral index (0-100) was 50 (IQR 42-54) and 49 (IQR 42-56) at the two respective time points. At Tinitial, median CTCI was 2.2 µmol/L (IQR 2-2.45) and Cblood was 2.0 µmol/L (bias 0.3 µmol/L, limits of agreement - 1.1 to 1.3, p = 0.33). CTCI and Cblood at Tfinal were 2.0 µmol/L (IQR 1.6-2.2) and 1 µmol/L (IQR 0.8-1.4), respectively (bias 0.6 µmol/L, limits of agreement - 0.89 to 1.4, p < 0.0001). Propofol TCI allows clinically unproblematic conduct of general anaesthesia. In cases of major blood loss, the probability of propofol TCI overestimating plasma levels increases.Trial registration German Clinical Trials Register (DRKS; DRKS00009312).
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Abstract
Propofol is an intravenous hypnotic drug that is used for induction and maintenance of sedation and general anaesthesia. It exerts its effects through potentiation of the inhibitory neurotransmitter γ-aminobutyric acid (GABA) at the GABAA receptor, and has gained widespread use due to its favourable drug effect profile. The main adverse effects are disturbances in cardiopulmonary physiology. Due to its narrow therapeutic margin, propofol should only be administered by practitioners trained and experienced in providing general anaesthesia. Many pharmacokinetic (PK) and pharmacodynamic (PD) models for propofol exist. Some are used to inform drug dosing guidelines, and some are also implemented in so-called target-controlled infusion devices, to calculate the infusion rates required for user-defined target plasma or effect-site concentrations. Most of the models were designed for use in a specific and well-defined patient category. However, models applicable in a more general population have recently been developed and published. The most recent example is the general purpose propofol model developed by Eleveld and colleagues. Retrospective predictive performance evaluations show that this model performs as well as, or even better than, PK models developed for specific populations, such as adults, children or the obese; however, prospective evaluation of the model is still required. Propofol undergoes extensive PK and PD interactions with both other hypnotic drugs and opioids. PD interactions are the most clinically significant, and, with other hypnotics, tend to be additive, whereas interactions with opioids tend to be highly synergistic. Response surface modelling provides a tool to gain understanding and explore these complex interactions. Visual displays illustrating the effect of these interactions in real time can aid clinicians in optimal drug dosing while minimizing adverse effects. In this review, we provide an overview of the PK and PD of propofol in order to refresh readers' knowledge of its clinical applications, while discussing the main avenues of research where significant recent advances have been made.
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Affiliation(s)
- Marko M. Sahinovic
- Department of Anaesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
- University Medical Center Groningen, Hanzeplein 1, PO Box 30.001, 9700 RB Groningen, The Netherlands
| | - Michel M. R. F. Struys
- Department of Anaesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
- Department of Anaesthesia and Peri-Operative Medicine, Ghent University, Ghent, Belgium
| | - Anthony R. Absalom
- Department of Anaesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
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12
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Abstract
We provide a synopsis of innovative research, recurring themes, and novel experimental findings pertinent to the care of neurosurgical patients and critically ill patients with neurological diseases. We cover the following broad topics: general neurosurgery, spine surgery, stroke, traumatic brain injury, monitoring, and anesthetic neurotoxicity.
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13
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Increasing the utility of target-controlled infusions: one model to rule them all. Br J Anaesth 2018; 120:887-890. [DOI: 10.1016/j.bja.2018.02.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Accepted: 02/14/2018] [Indexed: 11/17/2022] Open
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14
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Cortegiani A, Pavan A, Azzeri F, Accurso G, Vitale F, Gregoretti C. Precision and Bias of Target‐Controlled Prolonged Propofol Infusion for General Anesthesia and Sedation in Neurosurgical Patients. J Clin Pharmacol 2018; 58:606-612. [DOI: 10.1002/jcph.1060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Accepted: 11/16/2017] [Indexed: 12/15/2022]
Affiliation(s)
- Andrea Cortegiani
- Department of Biopathology and Medical Biotechnologies (DIBIMED), Section of Anesthesia Analgesia Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo Palermo Italy
| | - Alessandra Pavan
- Anestesia e Rianimazione Ospedale Civico di Chivasso Asl TO4 Chivasso Italy
| | | | | | - Filippo Vitale
- Department of Biopathology and Medical Biotechnologies (DIBIMED), Section of Anesthesia Analgesia Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo Palermo Italy
| | - Cesare Gregoretti
- Department of Biopathology and Medical Biotechnologies (DIBIMED), Section of Anesthesia Analgesia Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo Palermo Italy
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