Robust closed-loop control of induction and maintenance of propofol anesthesia in children
Article first published online: 13 MAY 2013
© 2013 John Wiley & Sons Ltd
Volume 23, Issue 8, pages 712–719, August 2013
How to Cite
West, N., Dumont, G. A., van Heusden, K., Petersen, C. L., Khosravi, S., Soltesz, K., Umedaly, A., Reimer, E., Ansermino, J. M. (2013), Robust closed-loop control of induction and maintenance of propofol anesthesia in children. Pediatric Anesthesia, 23: 712–719. doi: 10.1111/pan.12183
- Issue published online: 4 JUL 2013
- Article first published online: 13 MAY 2013
- Manuscript Accepted: 7 APR 2013
- intravenous/administration & dosage;
- drug delivery systems/methods;
- electroencephalography/drug effects;
- propofol/administration & dosage;
During closed-loop control, a drug infusion is continually adjusted according to a measure of clinical effect (e.g., an electroencephalographic depth of hypnosis (DoH) index). Inconsistency in population-derived pediatric pharmacokinetic/pharmacodynamic models and the large interpatient variability observed in children suggest a role for closed-loop control in optimizing the administration of intravenous anesthesia.
To clinically evaluate a robustly tuned system for closed-loop control of the induction and maintenance of propofol anesthesia in children undergoing gastrointestinal endoscopy.
One hundred and eight children, aged 6–17, ASA I-II, were enrolled. Prior to induction of anesthesia, NeuroSENSE™ sensors were applied to obtain the WAVCNS DoH index. An intravenous cannula was inserted and lidocaine (0.5 mg·kg−1) administered. Remifentanil was administered as a bolus (0.5 μg·kg−1), followed by continuous infusion (0.03 μg·kg−1·min−1). The propofol infusion was closed-loop controlled throughout induction and maintenance of anesthesia, using WAVCNS as feedback.
Anesthesia was closed-loop controlled in 102 cases. The system achieved and maintained an adequate DoH without manual adjustment in 87/102 (85%) cases. Induction of anesthesia (to WAVCNS ≤ 60) was completed in median 3.8 min (interquartile range (IQR) 3.1–5.0), culminating in a propofol effect-site concentration (Ce) of median 3.5 μg·ml−1 (IQR 2.7–4.5). During maintenance of anesthesia, WAVCNS was measured within 10 units of the target for median 89% (IQR 79–96) of the time. Spontaneous breathing required no manual intervention in 91/102 (89%) cases.
A robust closed-loop system can provide effective propofol administration during induction and maintenance of anesthesia in children. Wide variation in the calculated Ce highlights the limitation of open-loop regimes based on pharmacokinetic/pharmacodynamic models.