Influence of an 'Electroencephalogram-Based' Monitor Choice on the Delay Between the Predicted Propofol Effect-Site Concentration and the Measured Drug Effect
| Autor: | Johannes P van den Berg, Pedro L. Gambús, Mercè Agustí, Marko M. Sahinovic, Michel Struys, Teresa Ferreiro, Pieter Colin, Erik W. Jensen |
|---|---|
| Přispěvatelé: | Critical care, Anesthesiology, Peri-operative and Emergency medicine (CAPE) |
| Jazyk: | angličtina |
| Rok vydání: | 2020 |
| Předmět: |
Adult
Male Adolescent Intraoperative Neurophysiological Monitoring Mean squared error Remifentanil Young Adult 03 medical and health sciences Consciousness Monitors 0302 clinical medicine Predictive Value of Tests 030202 anesthesiology medicine Humans Prospective Studies Lead (electronics) Propofol Infusion Pumps Drug effect Aged Aged 80 and over Models Statistical business.industry Electroencephalography Middle Aged NONMEM Anesthesiology and Pain Medicine Pharmacodynamics Bispectral index Anesthesia Intravenous Female business Algorithms Anesthetics Intravenous 030217 neurology & neurosurgery Biomedical engineering medicine.drug |
| Zdroj: | Anesthesia and Analgesia, 131(4), 1184-1192. LIPPINCOTT WILLIAMS & WILKINS |
| ISSN: | 0003-2999 |
| Popis: | BACKGROUND: Clinicians can optimize propofol titration by using 2 sources of pharmacodynamic (PD) information: the predicted effect-site concentration for propofol (Ceprop) and the electroencephalographically (EEG) measured drug effect. Relation between these sources should be time independent, that is, perfectly synchronized. In reality, various issues corrupt time independency, leading to asynchrony or, in other words, hysteresis. This asynchrony can lead to conflicting information, making effective drug dosing challenging. In this study, we tried to quantify and minimize the hysteresis between the Ceprop (calculated using the Schnider model for propofol) and EEG measured drug effect, using nonlinear mixed-effects modeling (NONMEM). Further, we measured the influence of EEG-based monitor choice, namely Bispectral index (BIS) versus qCON index (qCON) monitor, on propofol PD hysteresis.METHODS: We analyzed the PD data from 165 patients undergoing propofol-remifentanil anesthesia for outpatient surgery. Drugs were administered using target-controlled infusion (TCI) pumps. Pumps were programmed with Schnider model for propofol and Minto model for remifentanil. We constructed 2 PD models (direct models) relating the Schnider Ceprop to the measured BIS and qCON monitor values. We quantified the models' misspecification due to hysteresis, on an individual level, using the root mean squared errors (RMSEs). Subsequently, we optimized the PD models' predictions by adding a lag term to both models (lag-time PD models) and quantified the optimization using the RMSE.RESULTS: There is a counterclockwise hysteresis between Ceprop and BIS/qCON values. Not accounting for this hysteresis results in a direct PD model with an effect-site concentration which produces 50% of the maximal drug effect (Ce50) of 6.24 and 8.62 µg/mL and RMSE (median and interquartile range [IQR]) of 9.38 (7.92-11.23) and 8.41(7.04-10.2) for BIS and qCON, respectively. Adding a modeled lag factor of 49 seconds to the BIS model and 53 seconds to the qCON model improved both models' prediction, resulting in similar Ce50 (3.66 and 3.62 µg/mL for BIS and qCON) and lower RMSE (median (IQR) of 7.87 (6.49-9.90) and 6.56 (5.28-8.57) for BIS and qCON.CONCLUSIONS: There is a significant "Ceprop versus EEG measured drug effect" hysteresis. Not accounting for it leads to conflicting PD information and false high Ce50 for propofol in both monitors. Adding a lag term improved the PD model performance, improved the "pump-monitor" synchrony, and made the estimates of Ce50 for propofol more realistic and less monitor dependent. |
| Databáze: | OpenAIRE |
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