A novel multivariate STeady-state index during general ANesthesia (STAN)

The assessment of the adequacy of general anesthesia for surgery, namely the nociception/anti-nociception balance, has received wide attention from the scientific community. Monitoring systems based on the frontal EEG/EMG, or autonomic state reactions (e.g. heart rate and blood pressure) have been developed aiming to objectively assess this balance. In this study a new multivariate indicator of patients' steady-state during anesthesia (STAN) is proposed, based on wavelet analysis of signals linked to noxious activation. A clinical protocol was designed to analyze precise noxious stimuli (laryngoscopy/intubation, tetanic, and incision), under three different analgesic doses; patients were randomized to receive either remifentanil 2.0, 3.0 or 4.0 ng/ml. ECG, PPG, BP, BIS, EMG and [Formula: see text] were continuously recorded. ECG, PPG and BP were processed to extract beat-to-beat information, and [Formula: see text] curve used to estimate the respiration rate. A combined steady-state index based on wavelet analysis of these variables, was applied and compared between the three study groups and stimuli (Wilcoxon signed ranks, Kruskal-Wallis and Mann-Whitney tests). Following institutional approval and signing the informed consent thirty four patients were enrolled in this study (3 excluded due to signal loss during data collection). The BIS index of the EEG, frontal EMG, heart rate, BP, and PPG wave amplitude changed in response to different noxious stimuli. Laryngoscopy/intubation was the stimulus with the more pronounced response [Formula: see text]. These variables were used in the construction of the combined index STAN; STAN responded adequately to noxious stimuli, with a more pronounced response to laryngoscopy/intubation (18.5-43.1 %, [Formula: see text]), and the attenuation provided by the analgesic, detecting steady-state periods in the different physiological signals analyzed (approximately 50 % of the total study time). A new multivariate approach for the assessment of the patient steady-state during general anesthesia was developed. The proposed wavelet based multivariate index responds adequately to different noxious stimuli, and attenuation provided by the analgesic in a dose-dependent manner for each stimulus analyzed in this study.The first author was supported by a scholarship from the Portuguese Foundation for Science and Technology (FCT SFRH/BD/35879/2007). The authors would also like to acknowledge the support of UISPA—System Integration and Process Automation Unit—Part of the LAETA (Associated Laboratory of Energy, Transports and Aeronautics) a I&D Unit of the Foundation for Science and Technology (FCT), Portugal. FCT support under project PEst-OE/EME/LA0022/2013.info:eu-repo/semantics/publishedVersio

Real-time algorithm for changes detection in depth of anesthesia signals

This paper presents a real-time algorithm for changes detection in depth of anesthesia signals. A Page-Hinkley test (PHT) with a forgetting mechanism (PHT-FM) was developed. The samples are weighted according to their "age" so that more importance is given to recent samples. This enables the detection of the changes with less time delay than if no forgetting factor was used. The performance of the PHT-FM was evaluated in a two-fold approach. First, the algorithm was run offline in depth of anesthesia (DoA) signals previously collected during general anesthesia, allowing the adjustment of the forgetting mechanism. Second, the PHT-FM was embedded in a real-time software and its performance was validated online in the surgery room. This was performed by asking the clinician to classify in real-time the changes as true positives, false positives or false negatives. The results show that 69 % of the changes were classified as true positives, 26 % as false positives, and 5 % as false negatives. The true positives were also synchronized with changes in the hypnotic or analgesic rates made by the clinician. The contribution of this work has a high impact in the clinical practice since the PHT-FM alerts the clinician for changes in the anesthetic state of the patient, allowing a more prompt action. The results encourage the inclusion of the proposed PHT-FM in a real-time decision support system for routine use in the clinical practice. © 2012 Springer-Verlag

The breast feeding mother and xenon anaesthesia: four case reports. Breast feeding and xenon anaesthesia

<p>Abstract</p> <p>Background</p> <p>Four nursing mothers consented to anaesthesia for urgent surgery only on condition that their ability to breast feed would not be impaired.</p> <p>Methods</p> <p>Following induction of general anaesthesia with propofol and remifentanil, 65-69% xenon supplemented with remifentanil was used as an inhalational anaesthetic for maintenance.</p> <p>Results</p> <p>After finishing surgery the women could be extubated between 2:52 and 7:22 minutes. The women were fully alert just minutes after extubation and spent about 45 minutes in the recovery room before discharge to a regular ward. They resumed regular breast feeding some time later. The propofol concentration in the blood was measured after 0, 30, 90, and 300 minutes and in the milk after 90 and 300 minutes. Just 90 minutes after extubation, the concentration of propofol in the milk was limited (> 3 mg/l) so that pharmacological effects on the babies were excluded after oral intake. Also, no traces of xenon gas were found in the maternal milk at any time. After propofol induction and maintenance of anaesthesia with xenon in combination with a water-soluble short-acting drug like remifentanil, the concentration of propofol in maternal milk is low (> 3 mg/l 90 min after anesthesia) and harmless after oral intake.</p> <p>Conclusions</p> <p>These results, as well as the rapid elimination and absence of metabolism of xenon, are of great interest to nursing mothers. General anaesthesia with propofol for induction only, combined with remifentanil and xenon for maintenance, has not yet been described in breast feeding mothers.</p

Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries.

BACKGROUND: As global initiatives increase patient access to surgical treatments, there remains a need to understand the adverse effects of surgery and define appropriate levels of perioperative care. METHODS: We designed a prospective international 7-day cohort study of outcomes following elective adult inpatient surgery in 27 countries. The primary outcome was in-hospital complications. Secondary outcomes were death following a complication (failure to rescue) and death in hospital. Process measures were admission to critical care immediately after surgery or to treat a complication and duration of hospital stay. A single definition of critical care was used for all countries. RESULTS: A total of 474 hospitals in 19 high-, 7 middle- and 1 low-income country were included in the primary analysis. Data included 44 814 patients with a median hospital stay of 4 (range 2-7) days. A total of 7508 patients (16.8%) developed one or more postoperative complication and 207 died (0.5%). The overall mortality among patients who developed complications was 2.8%. Mortality following complications ranged from 2.4% for pulmonary embolism to 43.9% for cardiac arrest. A total of 4360 (9.7%) patients were admitted to a critical care unit as routine immediately after surgery, of whom 2198 (50.4%) developed a complication, with 105 (2.4%) deaths. A total of 1233 patients (16.4%) were admitted to a critical care unit to treat complications, with 119 (9.7%) deaths. Despite lower baseline risk, outcomes were similar in low- and middle-income compared with high-income countries. CONCLUSIONS: Poor patient outcomes are common after inpatient surgery. Global initiatives to increase access to surgical treatments should also address the need for safe perioperative care. STUDY REGISTRATION: ISRCTN5181700

Control of Anesthesia Based on Singularly Perturbed Model

International audienceThis chapter deals with the control of anesthesia taking into account the pos-itivity together with the upper limitation constraints of the variables and the target interval tolerated for the depth of anesthesia during a surgery. Due to the presence of multiple time scale dynamics in the anesthesia model, the system is re-expressed through a singularly perturbed system allowing to decouple the fast dynamics from the slow ones. Differently from general approaches for singularly perturbed systems , the control objective is then to control and accelerate the fast system without interest in modifying the slow dynamics. Thus, a structured state feedback control is proposed through quasi-LMI (linear matrix inequalities) conditions. The characterization of domains of stability and invariance for the system is provided. Associated convex optimization issues are then discussed. Finally, the theoretical conditions are evaluated on a simulated patient case

Comparison of train-of-four ratios measured with Datex-Ohmeda's M-NMT MechanoSensor (TM) and M-NMT ElectroSensor (TM)

Neuromuscular blockade is usually monitored using train-of-four (TOF) stimulation pattern. A TOF ratio of higher than 90 % is recommended to reduce the risk of adverse effects after anaesthesia. TOF ratio 90 % is used in clinical practice with all different neuromuscular monitors. Kinemyography (KMG) is one commercialized method to obtain numerical TOF values. We compared the KMG data obtained with Datex M-NMT MechanoSensor (TM) module, to the EMG data collected with Datex ElectroSensor (TM), during clinical anaesthesia. Ipsilateral comparisons of the sensors were performed in 20 female patients during clinical procedures in propofol-remifentanil anaesthesia. After initial bolus dose of rocuronium (0.6 mg/kg), the spontaneous recovery of TOF ratio and T1 % were monitored. KMG gave higher TOF values than EMG. The difference was significant at KMG TOF values of 40 % or higher. After anaesthetic induction, but before administration of rocuronium, both TOF sensor values drifted from the TOF value of 1.0, showing either significant spontaneous fade (T1 > T4) or tendency of reverse fade (T1 <T4). KMG overestimates the recovery from neuromuscular blockade when compared with EMG. KMG and EMG cannot be used interchangeably, and TOF ratio 90 % cannot be considered as adequate level of recovery with all monitoring devices.Peer reviewe