Total intravenous anesthesia in a closed loop system: Report of the first case in Colombia
Total intravenous anesthesia is a widely used technique that relies on the use of intravenous anesthetics, propofol being the most frequently used and studied. At present, there are pharmaceutical and pharmacokinetic tools that are used to generate mathematical models to ensure the safe and moderately effective use of this technique. However, the depth of anesthesia is determined purely on the clinical findings and this requires neurological monitoring such as the bi-spectral index (BIS) in order to correlate the data derived from the pharmacokinetic models used for the administration of the anesthetic with the determination of its desired clinical effect.
We designed an operating system for automated control of the propofol infusion that provides feedback on the basis of the data generated by the BIS monitor. The system is programmed to increase or decrease the propofol infusion within a specific BIS range and, consequently, in accordance with the needs of the individual patient.
We describe anesthetic management using this technique in a female patient taken to surgery for prosthetic mammary implantation under general anesthesia at the University Hospital. An intraoperative record was generated including the depth of anesthesia and its action on propofol concentration at the effective site using the automated administration and control system.
We concluded that the use of closed-loop total intravenous anesthesia under neurologic monitoring is the next step in the evolution of this technique. It is less reliant on the phar-macokinetic models available at present, and is better suited to adapt to the specific needs of individual patients and to the type of surgical intervention.
2. Decreto número 4725 del 2005, Capítulo III, Artículo 36: Dispositivos Médicos y Biomédicos de tecnología controlada tipo prototipo. Ministerio de la Protección Social de la República de Colombia.
3. Gan TJ, Glass PS, Windsor A, Payne F, Rosow C, Sebel P, et al., BIS Utility Study Group. Bispectral index monitoring allows faster emergence and improved recovery from propofol, alfentanil, and nitrous oxide anesthesia. Anesthesiology. 1997;87:808-15.
4. Reboso JA, Mendez JA, Reboso HJ. Design and implementation of a closed-loop control system for infusion of propofol guided by bispectral index (BIS). Acta Anaesthesiol Scand. 2012;56:1032-41.
5. Johansen JW. Update on bispectral index monitoring. Best Pract Res Clin Anaesthesiol. 2006;20:81-99.
6. Plourde G. BIS EEG monitoring: what it can and cannot do in regard to unintentional awareness. Can J Anaesth. 2002;49:1-4.
7. Roberts FL, Dixon J, Lewis GT, Tackley RM, Prys-Roberts C. Induction and maintenance of propofol anesthesia: a manual infusion schema. Anaesthesia. 1988;43:14-7.
8. Sigl JC, Chamoun NG. An introduction to bispectral analysis for the electroencephalogram. J Clin Monit. 1994;10:392-404.
9. Jastremski M, Jastremski C, Shepherd M. A model for technology assessment as applied toclosed loop infusion system: technology assessment taskforce of the Society of Critical Care Medicine. Crit Care Med. 1995;23:1745-55.
10. Hemmerling TM. Automated anesthesia. Curr Opin Anaesthesiol. 2009;22:757-63.
11. Struys MM, de Smet T, Versichelen LF. Comparison of closed-loop controlled administration of propofol using Bispectral Index as the controlled variable versus «standard practice» controlled administration. Anesthesiology. 2001;95:6-17.
12. Struys MM, de Smet T, Mortier EP. Closed-loop control of anaesthesia (drugs in anaesthesia). Curr Opin Anaesthesiol. 2002;15:421-5.
13. Schraag SJ, Flaschar J, Schleyer M. The contribution of remifentanil to middle latency auditory evoked potentials during induction of propofol anesthesia. Anesth Analg. 2006;103:902-7.
14. Absalom AR, Kenny GN. Closed-loop control of propofol anaesthesia using bispectral index: performance assessment in patients receiving computer-controlled propofol and manually controlled remifentanil infusions for minor surgery. BrJ Anaesth. 2003;90:737-41.
15. Locher S, Stadler KS, Boehlen T, Bouillon T, Leibundgut D, Schumacher PM, et al. A new closed loop control system for isoflurane using bispectral index out performs manual control. Anesthesiology. 2004;101:591-602.
16. Mendez JA, Torres S, Reboso JA. Adaptive computer control of anesthesia in humans. Comput Methods Biomech Biomed Engin. 2009;12:727-34.
17. Agarwal J, Puri GD, Mathew PJ. Comparison of closed loop vs. manual administration of propofol using the bispectral index in cardiac surgery. Acta Anaesthesiol Scand. 2009;53:390-7.
18. Liu N, le Guen M, Benabbes-Lambert F. Feasibility of closed-loop titration ofpropofol and remifentanil guided by the spectral M-entropymonitor. Anesthesiology. 2012;116:286-95.
19. Leslie K, Absalom A, Kenny GNC. Closed loop control of sedation for colonoscopy using the bispectral index. Anaesthesia. 2002;57:690-709.
20. Liu N, Chazot T, Genty A. Titration of propofol for anesthetic induction and maintenance guided by the bispectral index: closed-loop versus manual control: a prospective, randomized, multicenter study. Anesthesiology. 2006;104:686-95.
21. Morley A, Derrick J, Mainland P. Closed loop control of anaesthesia: an assessment of the bispectral index as the target of control. Anaesthesia. 2000;55:953-9.
22. Bennett C, Voss LJ, Barnard JP. Practical use of the raw electroencephalogram waveform during general anesthesia: the art and science. Anesth Analg. 2009;109:539-50.
23. Bouillon TW, Bruhn J, Radulescu L. Pharmacodynamic interaction between propofol and remifentanil regarding hypnosis, tolerance of laryngoscopy, bispectral index, and electroencephalographic approximate entropy. Anesthesiology. 2004;100:1353-72.
24. Tafur LA, Lema E. Anestesia total intravenosa: de la farmacéutica a la farmacocinética. Rev Colomb Anestesiol. 2010;38:215-23.
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