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Feasibility of Closed-Loop Titration of Propofol and Remifentanil Guided by the Spectral M-Entropy Monitor

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Feasibility of Closed-Loop Titration of Propofol and Remifentanil Guided by the Spectral M-Entropy Monitor PERIOPERATIVE MEDICINE Feasibility of Closed-loop Titration of Propofol and Remifentanil Guided by the Spectral M-Entropy Monitor Ngai Liu, M.D., Ph.D.,* Morgan Le Guen, M.D.,* Fatima Benabbes-Lambert, M.D.,† Thierry Chazot, M.D.,* Bernard Trillat, M.Sc.,‡ Daniel I. Sessler, M.D.,§ Marc Fischler, M.D.ʈ Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/116/2/286/256592/0000542-201202000-00013.pdf by guest on 30 September 2021 ABSTRACT What We Already Know about This Topic • The use of electroencephalography to guide anesthetic ad- Background: This randomized controlled trial describes ministration remains controversial automated coadministration of propofol and remifentanil, • M-Entropy analysis provides dual analyses with differential guided by M-Entropy analysis of the electroencephalogram. sensitivities to hypnosis and analgesia The authors tested the hypothesis that a novel dual-loop controller with an M-Entropy monitor increases time spent within predetermined target entropy ranges. What This Article Tells Us That Is New Methods: Patients scheduled for elective surgery were ran- • Intraoperative automated propofol-remifentanil anesthesia domly assigned in this single-blind study using a computer- guided by M-Entropy is clinically feasible and more precise generated list, to either dual-loop control using a proportio- than skilled manual control nal-integral-derivative controller or skilled manual control of propofol and remifentanil using target-controlled-infusion mary outcome was the global score, which included the percent- systems. In each group, propofol and remifentanil adminis- age of state entropy or response entropy in the range 40–60, the tration was titrated to a state entropy target of 50 and was median absolute performance error and wobble. Data are pre- subsequently targeted to values between 40 and 60. The pri- sented as medians [interquartile range]. * Associate Professor of Anesthesia, Service d’Anesthe´sie, Results: Thirty patients assigned to the dual-loop group and Hoˆpital Foch, Suresnes, France. † Assistant Professor of Anesthe- 31 assigned to the manual group completed the study. The sia, Service d’Anesthe´sie, Hoˆpital Foch. ‡ Informatics Engineer, dual-loop controller was able to provide induction and mainte- Service d’Informatique, Hoˆpital Foch. § Professor of Anesthesia, Department of Outcomes Research, Cleveland Clinic, Cleve- nance for all patients. The Global Score of State Entropy was land, Ohio. ʈ Professor and Chairman of Anesthesia, Service better maintained with dual-loop than manual control (25 [19– d’Anesthe´sie, Hoˆpital Foch. 53] vs. 44 [25–110], P ϭ 0.043), and state entropy was more Received from Service d’Anesthe´sie and Service d’Informatique, frequently maintained in the range of 40–60 (80 [60–85] vs. Hoˆpital Foch, Suresnes, France, and the Department of Outcomes 60 [35–82]%, P ϭ 0.046). Propofol (4.1 [2.9–4.9] vs. 4.5 Research, Cleveland Clinic, Cleveland, Ohio. Submitted for publi- Ϫ1 Ϫ1 cation May 18, 2011. Accepted for publication October 10, 2011. [3.4–6.3] mg · kg ·h ) and remifentanil (0.18 [0.13– Ϫ Ϫ Support was provided by the Service d’Anesthe´sie, Hoˆpital Foch 0.24] vs. 0.19 [0.15–0.26] ␮g·kg 1 · min 1) consumptions (Suresnes, France); Vaincre la Mucoviscidose (Paris, France); Alaris Medical (Hampshire, United Kingdom), who loaned the Asena GH and the incidence of somatic side effects were similar. infusion pumps to the study; and GE Healthcare (Helsinki, Finland), Conclusion: Intraoperative automated control of hypnosis who loaned the Entropy Module. N. Liu, T. Chazot and B. Trillat and analgesia guided by M-Entropy is clinically feasible and have a patent in France for the gain constants in the control algo- rithm (N°BFF08P669, Institut National de la Proprie´te´ Industrielle, more precise than skilled manual control. France). None of the other authors has a personal financial interest in this research. Presented in part as an oral presentation at the N 1950, Mayo et al. reported that electrocortical activity American Society of Anesthesiologists annual meeting, October 17, 2007, San Francisco, California. I could be used to automatically titrate ether administra- 1 Address correspondence to Dr. Fischler: Service d’Anesthe´sie, tion. Subsequently, various signals including the median Hoˆpital Foch, 40 rue Worth, 92150 Suresnes, France. m.fischler@ frequency of the electroencephalogram power spectrum2 and hopital-foch.org. Information on purchasing reprints may be found at www.anesthesiology.org or on the masthead page at the begin- ning of this issue. ANESTHESIOLOGY’s articles are made freely acces- ᭜ This article is accompanied by an Editorial View. Please see: sible to all readers, for personal use only, 6 months from the cover Crosby G, Culley DJ: Processed electroencephalogram and date of the issue. depth of anesthesia: Window to nowhere or into the brain? Copyright © 2012, the American Society of Anesthesiologists, Inc. Lippincott ANESTHESIOLOGY 2012; 116:235–7. Williams & Wilkins. Anesthesiology 2012; 116:286–95 Anesthesiology, V 116 • No 2 286 February 2012 PERIOPERATIVE MEDICINE auditory evoked potentials3 have been used to guide auto- Protocol mated administration of methohexital,2 propofol,3,4 or al- An intravenous cannula dedicated to propofol and remifen- fentanil.5 Currently, the Bispectral Index Monitor (BIS tanil infusion pumps was connected via a three-way Smart- Monitor, Aspect Medical Systems, Newton, MA) is the best- site௡ Needle-Free System (Alaris Medical Systems, San Di- studied electroencephalographic monitor for the single feed- ego, CA) with a priming volume of 0.3 ml to the pumps. back control of propofol6–19 or remifentanil.20 Routine monitoring included core temperature and neuro- M-Entropy analysis of the electroencephalogram (GE muscular function at the adductor pollicis. The Entropy elec- Healthcare, Helsinki, Finland) calculates two parameters. trode was positioned on the patient’s forehead and connected The first is state entropy (SE), a measure of the irregularity of to the M-Entropy Module (GE-Healthcare, Helsinki, Fin- land). Just before induction of general anesthesia, patients frontal electroencephalogram activity within the frequency Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/116/2/286/256592/0000542-201202000-00013.pdf by guest on 30 September 2021 range of 0.8–32 Hz. SE is a surrogate measure of hypnotic were randomly assigned to the dual-loop controller or to depth and can identify varying levels of sedation21 and pre- skilled manual control based on the M-Entropy Module. dict volunteers’ ability to recall auditory stimuli.22 The sec- The sequence of treatments was determined in blocks of 10 ond parameter, response entropy (RE), measures electroen- (five dual-loop and five manual group) using a random num- ber computer-generator in a 1:1 ratio. Assignments were kept cephalogram and facial muscle electromyogram activity with in sequentially numbered opaque envelopes until just before a frequency range of 0.8–47 Hz.23,24 The difference between surgery. Investigators had considerable clinical experience RE and SE represents frequencies within the band between 32 titrating intravenous anesthesia using the spectral entropy and 47 Hz, corresponding to facial muscle electromyogram ac- monitor and target-controlled infusion systems. tivity. During painful stimuli, an increase in RE above SE facial All patients received total intravenous anesthesia in target- muscle activation may thus indicate that analgesia is inade- 25 controlled Infusion mode using the population pharmacoki- quate because facial muscle activity is a surrogate measure of 27 28 26 netic sets of Schnider et al. for propofol and Minto et al. depth of antinociception. The fact that M-Entropy analysis for remifentanil to target the effect-site concentration. Infu- provides distinct indications of hypnotic and analgesic status sion Toolbox 95 version 4.11 software29 (Universite´ Libre de makes it a potential output for a previously developed dual Bruxelles, Brussels, Belgium) implemented in a personal 20 closed-loop proportional-integral-derivative controller. computer served as a platform for calculating effect-site con- Therefore, we used our dual-loop system to control ad- centrations of propofol and remifentanil; displaying effect- ministration of propofol and remifentanil using M-Entropy site concentration estimates in real time; providing a user SE and RE. We compared manual versus closed-loop control interface that permits entry of patients’ demographic data during general anesthesia induction and maintenance. Spe- (sex, age, weight, and height) and modifications to target cifically, we tested the hypothesis that the dual-loop control- concentrations; controlling the propofol and remifentanil ler with M-Entropy as output increases time spent within infusion pumps (Alaris Medical, Hampshire, United predetermined target SE and RE ranges. Kingdom); and recording calculated effect-site drug con- centrations, entropy, and hemodynamic data from an AS/5 GE-Healthcare S/5™ monitor at 5-s intervals. Materials and Methods In the manual group, clinicians chose propofol and remifentanil effect-site concentrations for induction accord- Our prospective, randomized, single-blind clinical trial was ing to their clinical judgment. During maintenance, anes- approved by the Ethics Committee of our university (Comite´ thetic agents were adjusted to maintain a SE value as close to Consultatif de Protection des Personnes dans la Recherche
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