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Adequacy of Anaesthesia (Aoa) Clinical Brochure Adequacy of Anaesthesia (Aoa)

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Adequacy of Anaesthesia (Aoa) Clinical Brochure Adequacy of Anaesthesia (Aoa) GE Healthcare Adequacy of Anaesthesia (AoA) Clinical brochure Adequacy of Anaesthesia (AoA) AoA parameters provide continuous non-invasive measurement of: Adequacy of Anaesthesia (AoA) is a • Depth of anaesthesia with SPECTRAL ENTROPY™ concept made up of various parameters • Patient’s response to surgical stimuli and analgesic medications with SURGICAL PLETH INDEX (SPI)™ to help you assess patients’ individual • Muscle relaxation/recovery with NEUROMUSCULAR responses to the delivery of inhaled TRANSMISSION (NMT) and intravenous hypnotics, opioids, and The AoA split screen view incorporates values and trends obtained from the SPI, Entropy (State Entropy SE, Response Entropy RE and NMBAs during general anaesthesia. Burst Suppression Ratio BSR) and Neuromuscular Transmission (NMT) modules, providing a holistic view of the patient’s response to anaesthesia. When seconds counts in an intensive and multitasking enviroment, the BalanceView is guidance for prompt visualization of the patients’ responses to changes of anaesthesia conditions and may help save valuable time on responsiveness to analgesia/depth of anaesthesia optimization for each individual patient. The “white dot” that moves drastically away from the target zone may indicate inadequate hypnosis or analgesia level. Target Region Level of conciousness of Level Nociception-Antinociception Balance. Current data support SPI target range 20-50. Target at present reflects only the user preference. Spectral Entropy™ Control Entropy Entropy monitoring provides two indexes: parameters such as the EEG raw signal The GE Healthcare Entropy module, Figure 1 - Propofol consumption μg/kg/min • State Entropy (SE): Steady and robust which can help for in depth and more 120 E-ENTROPY, and accessories are -9% signal. The State Entropy value is always comprehensive analysis of state of brain. (p<0.001) 100 110 indicated for adult and pediatric less than or equal to Response Entropy. -14.7% (p<0.01) 100 patients older than 2 years within The estimation of the hypnotic effect of In adult patients, Response Entropy (RE) 80 95 and State Entropy (SE) may be used as an 81 a hospital for monitoring the state anaesthetic drugs on the brain during 60 of the brain by data acquisition general anaesthesia may be based on aid in monitoring the effects of certain anaesthetic agents, which may help the 40 of electroencephalograph (EEG) the State Entropy value. SE is not affected by sudden reactions to the facial muscles user titrate anaesthetic drugs (inhaled 20 and frontal electromyograph and intravenous hypnotics) according because it is based on the EEG signal. 0 (FEMG) signals during general • Response Entropy (RE): is sensitive to the to the individual needs of adult patients. Gruenewald 2007 Vakkuri 2005 anaesthesia. The spectral activation of facial muscles, (i.e., FEMG). Furthermore in adults, the use of Entropy Its response time is very fast; less than 2 parameters may be associated with a Figure 2 - Sevoflurane consumption mg/kg/hr entropies, Response Entropy 150 seconds. FEMG is especially active during reduction of anaesthetic use and faster (RE) and State Entropy (SE), are emergence from anaesthesia. Studies have the awake state but may also activate 120 140 -29% processed EEG and FEMG variables. during surgery. Facial muscles may also shown that such optimization leads to a (p<0.003) The Entropy measurement is to significant reduction in the consumption 90 give an early indication of emergence, 100 be used as an adjunct to other and this can be seen as a quick rise in RE. of anaesthetic agents (See Figures 1 60 physiological parameters. and 2) as well as fastened emergence. Additionally, Gruenewald et al. have seen 30 that propofol-remifentanil Entropy-guided anaesthesia may lead to a lower frequency 0 of hemodynamic unwanted events such Aimé 2006 as hypertension/hypotension, tachycardia and bradycardia. (See Figure 3) Figure 3 - Number of hemodynamic events 50 SE varies between 0 (deep anaesthesia) - 91 (awake) 41 RE varies from 0 (deep anaesthesia) to 100 (awake/ 40 moving) -42% 30 (p<0.01) 20 27 The recommended range for both RE and SE is from 40-60, therefore a decrease 10 of SE below 40 may indicate a too deep 1. M-Entropy guidance vs Standard Practice during propofol-remifentanil anaesthesia: a randomised controlled trial. Gruenewald et al. anaesthesia while an increase above 60 may Anaesthesia 2007 Dec; 62(12): 1224-9 0 Gruenewald 2007 indicate the need for adjusted titration. 2. Spectral Entropy Monitoring Is Associated with Reduced Propofol Use and Faster Emergence in Propofol–Nitrous Oxide–Alfentanil The Entropy measurement is to be used Anaesthesia Vakkuri A. et al. Anesthesiology 2005; 103:274–9. 3. Does Monitoring Bispectral Index or Spectral Entropy Reduce as an adjunct to other physiological Sevoflurane Use? Aimé et al. Anesth Analg 2006; 103:1469 –77. Surgical Pleth Index (SPI) The Surgical Pleth Index (SPI) By observing the SPI value and trend, Figure 1A - Remifentanil consumption μg/kg/hr clinicians can monitor real time adult 15 is indicated for monitoring the Control: patient’s responses to surgical stimuli and 12 hypnosis monitoring patient’s response to surgical -22.7% S PI: Combined SPI analgesic medications therefore saving 12,3 (p<0.05) & hypnosis monitoring stimuli and analgesic medications. valuable time for optimization analgesia 9 The SPI is indicated for unconscious delivery. 9,5 and fully anaesthetized adults 6 -25% The optimal SPI target has not been (p<0.006) over 18 years of age and is to 3 4,8 recommended yet as more studies need 3,6 be used as an adjunct to other to prove the clinically relevant range of 0 physiological parameters. SPI is a SPI measurements. However, in several Chen 2010 Bergmann 2012 physiologic parameter derived from studies, a range of [20; 50] has been Patient case screenshot: SPI rapid increase seemed to 1,2 hemodynamic information in the considered for guiding opioids titration . indicate real time patient’s response to surgical stimuli, while ECG variation was minimal and NIBP output was Figure 1B - Number of unwanted events during general 300 photoplethysmographic waveform SPI may represent the balance between reliant to manual activation anaesthesia nociception and antinociception and 250 obtained from a patient’s finger prediction probability when compared to Control group (n:40) as such, the variation from its baseline S PI group (n:40) using GE Healthcare SpO2 modules other common variables (HR, MAP, BIS) for 200 is another critical element to consider. indicating maximum stimulation during 150 and sensors. Gruenewald et al. 3 demonstrated that surgery. ΔSPI of 10 was found to be the threshold 100 for movement in patients receiving low 6 Bergmann et al. also demonstrated that 50 remifentanil dosage. It may be reasonable SPI-guided remifentanil titration additional SPI is calculated from the beat-to-beat Pulse Rate (PR) to assume that if SPI increases from 0 to the already given maximal sufentanil Hypertension Tachycardia Movements and the plethysmogram amplitude (PPGA) Hypotension Bradycardia Total baseline by 10 or more during surgical concentration, seemed to result in much stimulation an inadequate analgesia level lower rate of adverse hemodynamic events 1. Comparison of surgical stress index-guided analgesia with standard can be present. Further clinical validation during sternotomy and sternal spread. SPI clinical practice during routine general anaesthesia: a pilot study. is needed to validate these preliminary Chen X et al. Anesthesiology 2010; 112:1175–83. seemed to help finding the specific patient 2. Surgical stress index as a measure of nociception/antinociception findings. additional remifentanil dose without balance during general anaesthesia. Wennervirta et al. Acta Anaesthesiol Scand 2008; 52: 1038–45 substantial risk of hyperalgesia6. Chen et al. 4 compared SPI-guided 3. Influence of different remifentanil concentrations on the performance SPI varies between 100 (high reactivity) to 0 (no reactivity) of the surgical stress index to detect a standardized painful stimulus analgesia to standard clinical practice and during sevoflurane anaesthesia. Gruenewald et al. Br J Anaesth 2009 concluded that SPI-guided remifentanil 4. Comparison of Surgical Stress Index-guided Analgesia with Standard Clinical Practice during Routine General Anaesthesia. Chen X. et al. titration resulted in a significant reduction Anesthesiology 2010; 112:1175– 83. 5. Surgical pleth index-guided remifentanil administration reduces of opiods consumption and reduced remifentanil and propofol consumption and shortens recovery times incidence of unwanted events such as in outpatient anaesthesia. Bergmann I. and al. BJA Advance Access published December 5, 2012 hypertension, hypotension, tachycardia 6. Remifentanil added to sufentanil-sevoflurane Anaesthesia and movement during surgery (Figures 1A suppresses hemodynamic and metabolic stress responses to intense surgical stimuli more effectively than high-dose sufentanil- and 1B). Further, SPI showed the highest sevoflurane alone’ Bergmann et al, BMC Anesthesiology 2015 Neuromuscular Transmission (NMT) Electromyography (EMG) is the process of defined as an EMG or MMG TOF ratio of 1. Residual neuromuscular block: lessons unlearned. Part I: definitions, Quantitative NMT monitoring gives incidence, and adverse physiologic effects of residual neuromuscular a clear picture of the individual recording the specific electrical muscular <0.90, cannot be excluded immediately block. Murphy and Brull.
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