Influence of an "Electroencephalogram-Based" Monitor Choice on the Delay Between the Predicted Propofol Effect-Site Concentration and the Measured Drug Effect

Implementation of a Bayesian based advisory tool for target-controlled infusion of propofol using qCON as control variable

This single blinded randomized controlled trial aims to assess whether the application of a Bayesian-adjusted CePROP (effect-site of propofol) advisory tool leads towards a more stringent control of the cerebral drug effect during anaesthesia, using qCON as control variable. 100 patients scheduled for elective surgery were included and randomized into a control or intervention group (1:1 ratio). In the intervention group the advisory screen was made available to the clinician, whereas it was blinded in the control group. The settings of the target-controlled infusion pumps could be adjusted at any time by the clinician. Cerebral drug effect was quantified using processed EEG (CONOX monitor, Fresenius Kabi, Bad Homburg, Germany). The time of qCON between the desired range (35-55) during anaesthesia maintenance was defined as our primary end point. Induction parameters and recovery times were considered secondary end points and coefficient of variance of qCON and CePROP was calculated in order to survey the extent of control towards the mean of the population. The desired range of qCON between 35 and 55 was maintained in 84% vs. 90% (p = 0.15) of the case time in the control versus intervention group, respectively. Secondary endpoints showed similar results in both groups. The coefficient of variation for CePROP was higher in the intervention group. The application of the Bayesian-based CePROP advisory system in this trial did not result in a different time of qCON between 35 and 55 (84 [21] vs. 90 [18] percent of the case time). Significant differences between groups were hard to establish, most likely due to a very high performance level in the control group. More extensive control efforts were found in the intervention group. We believe that this advisory tool could be a useful educational tool for novices to titrate propofol effect-site concentrations.

Influence of release rate, dose and co-administration on pharmacokinetics, pharmacodynamics and PK-PD relationship of tanshinone IIA and tanshinol

The present study aims to investigate the influence of release rate, dose and co-administration on pharmacokinetics (PK) and pharmacodynamics (PD) of tanshinone IIA (TA) and tanshinol (TS), and reveal the changes in their PK-PD relationships. Sustained and immediate release pellets of TS and TA were prepared respectively, and oral administrated to angina model rabbits according to the experimental design. The administration dose of TS was 50, 35 or 20 mg/kg and that of TA was 30 mg/kg. Then, plasma concentrations of TS and TA were measured to evaluate the pharmacokinetics. Pharmacodynamic biomarkers including cardiac troponin (cTn-I), creatine kinase (CK-MB), superoxide dismutase (SOD) and nitric oxide (NO) were measured to evaluated the effects of cardioprotection, amelioration of oxidative stress and vasorelaxation of TS and TA. Parameters such as maximum plasma concentration (C_max), maximum effect (E_max), time to C_max or E_max (TC_max or TE_max), areas under the plasma concentration or effect curves (AUC_0-∞ or AUEC) and pharmacodynamic efficiency (EFF) were calculated based on non-compartmental analysis. Beside, PK-PD relationship/hysteresis was evaluated. The TE_max was less sensitive than TC_max to changes in release rate. The E_max, AUEC and EFF showed increasing trend as the decrease of release rate even that the AUC_0-∞ showed no significant difference. In addition, slow drug release decreased the magnitude of hysteresis of TS and TA. The sensitivities of E_max and AUEC of four biomarkers to changes in dose were varied and relatively lower than those of C_max and AUC_0-∞. The EFF decreased and the magnitude of hysteresis increased for high dose. The C_max and AUC_0-∞ of TS and TA showed little difference after co-administration. The E_max and AUEC of four biomarkers increased for immediate release pellets (P < 0.05 or P < 0.01) and generally decreased for sustained release pellets (P < 0.05 or P < 0.01) after co-administration. In addition, the magnitudes of hysteresis of four biomarkers decreased for immediate release pellets and generally increased for sustained release pellets after co-administration. In summary, the dissociated and unstable PK-PD relationship should be considered during optimization of dosage forms and regimens to make sure the rationality, safety and efficacy. These findings could also provide some valuable information for the development and clinical therapy of other drugs.

The influence of depth of anesthesia and blood pressure on muscle recorded motor evoked potentials in spinal surgery. A prospective observational study protocol

For high-risk spinal surgeries, intraoperative neurophysiological monitoring (IONM) is used to detect and prevent intraoperative neurological injury. The motor tracts are monitored by recording and analyzing muscle transcranial electrical stimulation motor evoked potentials (mTc-MEPs). A mTc-MEP amplitude decrease of 50–80% is the most common warning criterion for possible neurological injury. However, these warning criteria often result in false positive warnings. False positives may be caused by inadequate depth of anesthesia and blood pressure on mTc-MEP amplitudes. The aim of this paper is to validate the study protocol in which the goal is to investigate the effects of depth of anesthesia (part 1) and blood pressure (part 2) on mTc-MEPs. Per part, 25 patients will be included. In order to investigate the effects of depth of anesthesia, a processed electroencephalogram (pEEG) monitor will be used. At pEEG values of 30, 40 and 50, mTc-MEP measurements will be performed. To examine the effect of blood pressure on mTc-MEPs the mean arterial pressure will be elevated from 60 to 100 mmHg during which mTc-MEP measurements will be performed. We hypothesize that by understanding the effects of depth of anesthesia and blood pressure on mTc-MEPs, the mTc-MEP monitoring can be interpreted more reliably. This may contribute to fewer false positive warnings. By performing this study after induction and prior to incision, this protocol provides a unique opportunity to study the effects of depths of anesthesia and blood pressure on mTc-MEPs alone with as little confounders as possible.

Trial registration number NL7772.

Do epoch lengths of hypnotic depth indicators affect estimated of blood-brain equilibration rate constants of propofol?

This study aimed to investigate the effect of epoch length of hypnotic depth indicators on the blood-brain equilibration rate constant (k_e0) estimates of propofol. Propofol was administered by zero-order infusion (1.5, 3.0, 6, and 12 mg·kg^-1·h^-1) for one hour in 63 healthy volunteers. The k_e0 of propofol was estimated using an effect-compartment model linking pharmacokinetics and pharmacodynamics, in which response variables were electroencephalographic approximate entropy (ApEn) or bispectral index (BIS) (n = 32 each for propofol infusion rates of 6 and 12 mg·kg^-1·h^-1). Epoch lengths of ApEn were 2, 10, 30, and 60 seconds (s). The correlations between plasma propofol concentrations (Cp) and BIS and ApEn 2, 10, 30, and 60 s were determined, as was the Ce associated with 50% probability of unconsciousness (Ce_50,LOC). The pharmacokinetics of propofol were well described by a three-compartment model. The correlation coefficient between Cp and ApEn 2, 10, 30, and 60 s were -0.64, -0.54, -0.39, and -0.26, respectively, whereas correlation coefficient between Cp and BIS was -0.74. The blood-brain equilibration half-life based on the k_e0 estimates for ApEn at 2, 10, 30, 60 s and BIS were 4.31, 3.96, 5.78. 6.54, 5.09 min, respectively, whereas the Ce_50,LOC for ApEn at 2, 10, 30, 60 s and BIS were 1.55, 1.47, 1.28, 1.04, and 1.55 μg·ml^-1, respectively. Since k_e0, which determines the onset of drug action, varies according to the epoch length, it is necessary to consider the epoch length together when estimating k_e0.