Temporal linear mode complexity as a surrogate measure of the effect of remifentanil on the central nervous system in healthy volunteers.

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT: • Remifentanil, an intravenous ultra short-acting opioid, depresses central nervous system activity with an increase in the delta band power, and causes beta activation after discontinuation, resulting in a rebound of the processed electroencephalographic parameters, including 95% spectral edge frequency, the canonical univariate parameter and electroencephalographic approximate entropy. • A sigmoid Emax model, in which the highest predicted values of processed electroencephalographic parameters are restricted to the baseline value, cannot describe a rebound of these parameters. • Electroencephalographic approximate entropy correlated well with the remifentanil blood concentration and demonstrated high baseline stability. WHAT THIS STUDY ADDS: • A combined effect and tolerance model effectively characterized the time course of the remifentanil effect on the central nervous system, including the rebound which occurred during recovery from the remifentanil effect. • Temporal linear mode complexity was comparable with approximate entropy as a univariate electroencephalographic descriptor of the effect of remifentanil on the central nervous system. AIMS Previously, electroencephalographic approximate entropy (ApEn) effectively described both depression of central nervous system (CNS) activity and rebound during and after remifentanil infusion. ApEn is heavily dependent on the record length. Linear mode complexity, which is algorithmatically independent of the record length, was investigated to characterize the effect of remifentanil on the CNS using the combined effect and tolerance, feedback and sigmoid E(max) models. METHODS The remifentanil blood concentrations and electroencephalographic data obtained in our previous study were used. With the recording of the electroencephalogram, remifentanil was infused at a rate of 1, 2, 3, 4, 5, 6, 7 or 8 µg kg(-1) min(-1) for 15-20 min. The areas below (AUC(effect) ) or above (AAC(rebound) ) the effect vs. time curve of temporal linear mode complexity (TLMC) and ApEn were calculated to quantitate the decrease of the CNS activity and rebound. The coefficients of variation (CV) of median baseline (E(0)), maximal (E(max)), and individual median E(0) minus E(max) values of TLMC were compared with those of ApEn. The concentration-TLMC relationship was characterized by population analysis using non-linear mixed effects modelling. RESULTS: Median AUC(effect) and AAC(rebound) were 1016 and 5.3 (TLMC), 787 and 4.5 (ApEn). The CVs of individual median E(0) minus E(max) were 35.6, 32.5% (TLMC, ApEn). The combined effect and tolerance model demonstrated the lowest Akaike information criteria value and the highest positive predictive value of rebound in tolerance. CONCLUSIONS: The combined effect and tolerance model effectively characterized the time course of TLMC as a surrogate measure of the effect of remifentanil on the CNS.

Comparison of uncalibrated arterial pressure waveform analysis with continuous thermodilution cardiac output measurements in patients undergoing elective off-pump coronary artery bypass surgery.

OBJECTIVE: Monitoring of cardiac output is required during anesthesia for off-pump coronary artery bypass (OPCAB) surgery. Recently, FloTrac, a new device for arterial pressure waveform analysis for cardiac output (APCO) monitoring without external calibration, was developed. The authors have compared APCO with STAT-mode continuous cardiac output (SCCO) in patients undergoing OPCAB surgery. DESIGN: A clinical study. SETTING: A university hospital (single institution). PARTICIPANTS: Thirty consecutive patients undergoing elective OPCAB surgery. INTERVENTIONS: Arterial pressure measurement with FloTrac, pulmonary arterial catheter insertion. MEASUREMENTS AND MAIN RESULTS: APCO and SCCO measurements were recorded after pulmonary artery catheter insertion (T1), after sternotomy (T2), after heart positioning for left anterior descending artery anastomosis (T3, T4), after heart positioning for obtuse marginal artery anastomosis (T5, T6), after heart positioning for posterior descending artery anastomosis (T7, T8), and after sternal closure (T9). APCO and SCCO were compared using the Bland-Altman method and the percentage error by Critchley's criteria. SCCO and APCO ranged from 2.1 to 6.9 L/min and 1.2 to 7.4 L/min, respectively, and showed low correlation (r = 0.29). The overall bias by the Bland-Altman method between SCCO and APCO was -0.23 L/min, with a precision of -1.4 to 0.9 L/min, and the overall limits of agreement were -2.5 to 2.0 L/min. The overall mean CO was 4.0 ± 0.95 L/min. The overall percentage error between SCCO and APCO measurements was 57%. CONCLUSIONS: Uncalibrated APCO values do not agree with thermodilution SCCO and significantly overestimated the SCCO in patients undergoing OPCAB surgery. Further evaluation is required to verify the clinical acceptance of FloTrac APCO in OPCAB surgery.

Warming of intravenous fluids prevents hypothermia during off-pump coronary artery bypass graft surgery.

OBJECTIVE: Even mild perioperative hypothermia (34 degrees -36 degrees C) can cause numerous adverse outcomes, including morbid cardiac events, coagulopathy with increased blood loss, and a decreased resistance to surgical wound infection. The purpose of this study was to evaluate the effect of fluid warming on preventing hypothermia during off-pump coronary artery bypass (OPCAB) surgery. DESIGN: A prospective randomized clinical study. SETTING: A tertiary care university hospital. PARTICIPANTS: Forty patients undergoing OPCAB procedures. INTERVENTIONS: Patients were randomized into control (n = 20) and Hotline (n = 20) groups. In the Hotline group, all intravenous fluids were warmed to 41 degrees C by using 2 Hotline (SIMS Inc, Rockland, MD) systems. All patients (control and Hotline groups) were managed with standardized institutional practice by using a combination of increased ambient operating room temperature (to 25 degrees C) and the use of a warmed water mattress (38 degrees C). MEASUREMENTS AND MAIN RESULTS: Temperatures were recorded every hour after the induction of anesthesia at the pulmonary artery, nasopharynx, rectum, and bladder. In the Hotline group, temperatures were maintained or increased. In the control group, temperatures gradually decreased. There were no significant differences between the 2 groups in hemodynamic parameters, serum catecholamine concentrations, duration of intensive care unit stay, or duration of ward stay. CONCLUSIONS: The results show that the warming of intravenous fluids by using the Hotline system prevents decreases in systemic temperatures during OPCAB surgery.

Pretreatment of rocuronium reduces the frequency and severity of etomidate-induced myoclonus.

STUDY OBJECTIVE: To investigate the effect of pretreatment with a low dose of rocuronium on the occurrence of etomidate-induced myoclonus. DESIGN: Prospective, randomized, double-blinded study. SETTING: Medical center in South Korea. PATIENTS: 110 ASA physical status I, II, and III patients scheduled for elective cardiac or pulmonary surgery with general anesthesia. INTERVENTIONS: All patients were randomized to pretreatment with a low dose of rocuronium (0.06 mg/kg; Group R) or placebo (saline; Group S), followed three minutes later by etomidate (0.3 mg/kg). MEASUREMENTS: Patients were monitored for myoclonic movements and pain on a scale of 0-3. Bispectral index (BIS) and electromyographic (EMG) activity were recorded continuously throughout the procedure. MAIN RESULTS: Frequency of myoclonus was significantly lower in Group R (25%) than in Group S (63%). In the latter group, there was no difference in the frequency of male (59%) and female (68%) patients experiencing myoclonus. In Group S, EMG activity and BIS were significantly increased in patients who experienced severe myoclonus, and BIS was well correlated with EMG activity. CONCLUSIONS: Pretreatment with a small dose of rocuronium before induction of anesthesia with etomidate significantly reduced the frequency of myoclonus.

The effects of inspiratory to expiratory ratio on ventilation and oxygenation during high frequency partial liquid ventilation in a rabbit model of acute lung injury.

BACKGROUND: We examined the effects of varying inspiratory to expiratory (I : E) ratio on gas exchange and hemodynamics during high frequency partial liquid ventilation (HFPLV), a combination of high frequency ventilation (HFV) and partial liquid ventilation (PLV), in a rabbit model of acute lung injury. METHODS: Twelve rabbits treated with repeated saline lavage were divided into two groups. In the HFPL group (n = 6), 6 ml/kg of perfluorodecaline was administered through the endotracheal tube. Rabbits in this group and in the HFJ group (n = 6) were treated with high frequency jet ventilation (HFJV) at I : E ratios of 1 : 1, 1 : 2, and 1 : 3 for 15 minutes, and arterial blood gas, mixed venous blood gas and hemodynamic parameters were measured. RESULTS: We observed no significant respiratory and hemodynamic differences between the two groups. At an I : E ratio of 1 : 1, the PaO2 was significantly higher, and the shunt rate and PaCO2 were significantly lower in both groups, compared with I : E ratios of 1 : 2 and 1 : 3. Cardiac output at the 1 : 3 I : E ratio was significantly higher than at 1 : 1. CONCLUSIONS: These findings indicate that, in this model, a 1 : 1 I : E ratio was superior for oxygenation and ventilation than I : E ratios of 1 : 2 or 1 : 3, while having no detrimental effects on hemodynamics.

The changes of skin temperature on hands and feet during and after T3 sympathicotomy for palmar hyperhidrosis.

Unilateral thoracic sympathectomy in patients with palmar hyperhidrosis causes a skin temperature drop in the contralateral hand. A cross-inhibitory effect by the post-ganglionic neurons innervating hands is postulated as a mechanism of contralateral vasoconstriction. The purpose of our study was to evaluate whether this cross-inhibitory effect also occurs in the feet. Twenty patients scheduled for thoracoscopic sympathicotomy due to palmar hyperhidosis were studied. Right T3 sympathicotomy was performed first, followed by left T3 sympathicotomy. The thenar skin temperatures of both hands and feet were continuously monitored using a thermometer and recorded before induction of anesthesia, during the operation, 4 hr after and 1 week later. Following right T3 sympathicotomy, the skin temperature of the ipsilateral hand gradually increased, however the skin temperature of the contralateral hand gradually decreased. Immediately after bilateral sympathicotomy, the skin temperature differences between hands and feet increased, but these differences decreased 1 week later. Our results show that cross-inhibitory control may exist in feet as well as in the contralateral hand. Thus, the release of cross-inhibitory control following T3 sympathicotomy results in vasoconstriction and decrease of skin temperature on the contralateral hand and feet. One week later, however, the temperature balance on hands and feet recovers.

Electroencephalographic approximate entropy changes in healthy volunteers during remifentanil infusion.

BACKGROUND: The aim of this study was to investigate the independent effect of remifentanil on the approximate entropy (ApEn) in frontoparietal montages. The authors investigated which montages were relevant to assess the remifentanil effect on the electroencephalogram. Spectral edge frequency and the canonical univariate parameter were used as comparators. METHODS: Twenty-eight healthy volunteers were enrolled. With recording of the electroencephalogram at the F3, F4, Cz, P3, and P4 montages, remifentanil was infused at the rate of 1-8 mug . kg . min for 15-20 min. The relation between remifentanil concentration and the electroencephalographic parameters were tested by Spearman correlation. Signal-to-noise ratio, artifact robustness, coefficient of variation of the median baseline and maximal electroencephalographic effects, and ratio of average maximal electroencephalographic effect to interindividual baseline variability were measured. The performance of ApEn as an index of remifentanil effect site concentrations was tested by prediction probability. RESULTS: Approximate entropy showed significant correlation (R = -0.6465, P < 0.0001) with remifentanil concentration. It provided comparable signal-to-noise ratio, artifact robustness, and ratio of average maximal electroencephalographic effect to interindividual baseline variability to 95% spectral edge frequency. The coefficients of variation of the median baseline and maximal electroencephalo graphic effects were smallest in ApEn. Parietal montages showed higher ratios of average maximal electroencephalographic effect to interindividual baseline variability for all electroencephalographic parameters and lower coefficients of variation of the baseline values for ApEn and 95% spectral edge frequency than frontal montages. The prediction probability of ApEn was 0.7730. CONCLUSIONS: Approximate entropy derived from a parietal montage is appropriate for the assessment of the remifentanil effect on the electroencephalogram.