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A Comparative Study Between Entropy and Clinical Response To Med. J. Cairo Univ., Vol. 87, No. 3, June: 2025-2031, 2019 www.medicaljournalofcairouniversity.net A Comparative Study between Entropy and Clinical Response to Determine the Requirement of Propofol for Induction of General Anesthesia in Geriatric Patients MAI A.K. NIDA, M.Sc.; WESAM F. MOUSA, M.D.; AHMED S. ELGEBALY, M.D. and HESHAM E. EL-ASHRY, M.D. The Department Anesthesiology and Surgical Intensive Care, Faculty of Medicine, Tanta University Abstract Key Words: Entropy – Clinical response – Requirement of propofol – Geriatric patients. Background: Anesthesia under dosage causes awareness, while over dosage results in drug complications. Endotracheal intubation must be after an adequate level of anesthesia. Introduction Propofol is an IV short-acting anesthetic which causes hypo- tension in a dose dependent effect. With entropy, SE level 40- ANESTHESIA under dosage causes awareness, 60 and RE-SE difference <10 are the target during anesthesia. while over dosage results in drug complications Geriatrics are different in EEG spectral patterns than young [1] patients and are more vulnerable to complications of endotra- . Endotracheal intubation must be after an ade- cheal intubation and propofol. quate level of anesthesia as light anesthesia leads to sympathetic stimulation, laryngospasm, bron- Aim of Study: The aim of this study was to compare chospasm, and traumatization of airway and over between the conventional clinical end-point of hypnosis and entropy on the dosage requirement of propofol and hemody- dosage of anesthetics with delay in intubation leads namic during propofol induction of general anesthesia in to bradycardia, arrhythmia, hypotension and at geriatric patients. last, respiratory and cardiovascular arrest [2] . Methods and Material: 60 patients, aged 60-80y, from Propofol is an IV short-acting anesthetic which both sexes, ASA I-II scheduled for an elective surgery required causes hypotension in a dose dependent effect [3] . general anesthesia and endotracheal intubation were included. Group-I (control group): Propofol 30mg every 1min till loss Over or under dosage may occur if fixed dose is of response to verbal commands and group-II (entropy group): given guided by loss of verbal response [1] . Propofol 30mg every 1min till response entropy 48±2. Patient's demographic data, the total dose of propofol used for induction, Entropy monitor is a combined EEG and EMG (HR, MAP and entropy parameters) at baseline (T1), after monitor which is used to monitor hypnosis and induction of anesthesia (T2), during (T3), 1min and 5min depth of anesthesia [4] . The State Entropy (SE) after tracheal intubation (T4, T5). reflects the effect of anesthetics on the cortex as Results: Total dose of propofol, HR & MAP readings it is the EEG dominant part whereas the Response revealed no significant difference between two groups. After Entropy (RE) comprises both EEG and frontal induction, both RE and SE dropped significantly in both EMG [5] , so it impends awakening of the patient. groups when compared to baseline. There was no difference in SE & RE between the two groups. RE varies from 0 to 100, whereas SE ranges be- tween 0 and 91. SE level 40-60 and RE-SE differ- Conclusion: During intubation, usual titration of propofol ence <10 are the target during anesthesia [6,7] . until loss of verbal response, with the dose given in our study, is as good as entropy monitoring in elderly patients. So, Geriatrics are different in EEG spectral patterns routine use for this may not be necessary and can be used in than young patients and also they are more vulner- other age groups, other anesthesia situations, medicolegal purposes and research. able to complications of endotracheal intubation and propofol [8,9] . The aim of this study was to compare between Correspondence to: Dr. Mai Abd El-Haleem Kamal Nida, The Department Anesthesiology and Surgical Intensive Care, the conventional clinical end-point of hypnosis Faculty of Medicine, Tanta University and entropy on the dosage requirement of propofol 2025 2026 Entropy Vs. Clinical Response to Determine Propophol Requirement and hemodynamic during propofol induction of Datex-Ohmeda EntropyTM Module. By applying general anesthesia in geriatric patients. the entropy sensor (self-adhesive entropy sensor consisting of three electrodes) on the patient's Methods and Material forehead (fronto-temporal region) according to the instructions provided on the sensor pouch after This prospective randomized blind study was skin preparation with disinfectant alcohol and slight carried out at Tanta University Hospitals for six rubbing. This sensor connected to the entropy months from October 2017 to March 2018. All monitor (M-Entropy Plug-in Module S/5; Datex- data of patients was confidential with secret codes Ohmeda, Finland). Baseline parameters were re- and private file for each patient. After approval corded. from ethical committee, a written informed consent obtained from all participants in this research. Each Before induction of anesthesia, 100% oxygen patient received an explanation to the purpose of for 2-3min was applied. The induction was done the study. µ with IV fentanyl (1 g/kg), followed 3min later by propofol as following: Group-I (control group): Sixty patients, aged 60-80y, from both sexes, IV propofol 30mg was given every 1 minute till ASA I-II scheduled for an elective surgery required loss of response to verbal commands. Group-II general anesthesia and endotracheal intubation (entropy group): IV propofol 30mg every 1 minute were included. till response entropy 48 ±2 as an end point of hyp- Exclusion criteria were: Patient refusal, patients nosis. Then cis-atracurium 0.15mg/kg was given with severe cardiac disease, liver diseases and then lungs were ventilated with bain circuit by renal dysfunction, patients with known hypersen- oxygen and isoflurane at 1 MAC for 3 minutes by sitivity to study drugs, anticipated difficult airway tightly fitted face mask, thereafter, tracheal intu- access, two unsuccessful attempts of tracheal intu- bation was performed with a cuffed endotracheal bation were considered secondary exclusion crite- tube of appropriate size. Tidal volume and respira- rion, history of alcohol or drug abuse and chronic tory rate were adjusted to maintain EtCO 2 between analgesic use, patients with history of any psychi- 32 to 35mmHg. Maintenance was by mixture of atric illness, stroke with residual neurologic deficits oxygen and isoflurane at 1MAC. or altered mentation, CNS disorders, Alzheimer disease, dementia, brain atrophy and other neuro- The following data were measured for each patient: Patient's demographic data (age, sex, logical disorders and patients under treatment with sedatives, anticonvulsants, opioids or any long- weight and body mass index), the total dose of propofol used for induction of anesthesia to attain term use of other drugs affecting the CNS. This study included 60 patients who were randomly the desired end points as loss of verbal response ± 2 (Group II) classified using sealed envelopes into two equal (Group I) or response entropy of 48 groups, each group contains 30 patients. were recorded (primary outcome), hemodynamics (HR & MAP) were recorded at baseline, induction, Pre-operative assessment was done by: History intubation, and at 1, 5 minutes after intubation and taking, clinical examination including airway eval- entropy parameters (RE and SE). The values of uation using Mallampati classification, routine entropy and hemodynamics were recorded at the laboratory investigations including complete blood following measurement time (T): Baseline value picture, coagulation profile (prothrombin time, before induction of anesthesia (T 1 ), after induction activity and INR), liver functions, renal functions, of anesthesia at end point of hypnosis as per group random blood sugar, cardiovascular assessment (T2), during tracheal intubation (T 3), 1 minute after and ECG. A pre-operative fasting period of 6 hours tracheal intubation (T 4) and 5 minutes after tracheal for solids and 2 hours for clear fluids. No premed- intubation (T 5). itation was given. Intraoperative hypotension was defined as a On arrival of the patient to OR, an IV line fall in MAP by >20% from baseline and was treated inserted and IV infusion of ringer lactated was with boluses of ephedrine 6mg every 3min as started. All patients connected to monitor displaying needed. Bradycardia was defined as HR <50 beats/ the following: Electrocardiogram (ECG), Heart min and was treated with atropine 0.01mg/kg in Rate (HR), peripheral oxygen saturation (SpO 2) both groups. After our study measurements com- using pulse oximetry, Non-Invasive Blood Pressure pleted, the study was discontinued. (NIBP) monitoring Mean Arterial blood Pressure (MAP), end tidal carbon dioxide (EtCO 2) by using The sample size was calculated according to capnogram, entropy parameters (SE & RE) by GE the results of a previous study [10] using epi-info Mai A.K. Nida, et al. 2027 software computer program created by center of but increased insignificantly at intubation Fig. (2). disease prevention and control, version 2002. It MAP significantly decreased after induction com- was calculated as 30 patients for each study group pared to the baseline in both groups Fig. (3). based on the following criteria: 95% confidence limit, 80%power of study, group I to Group II ratio There was no significant difference in the en- 1: 1 and 2 groups comparison (30 in each). tropy readings (RE & SE) at baseline, induction, intubation, 1min
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