Skip to main content

Advertisement

SpringerLink
Log in

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

  • Original Research
  • Published:
Journal of Clinical Monitoring and Computing Aims and scope Submit manuscript

Abstract

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 \(\hbox {CO}_{2}\) were continuously recorded. ECG, PPG and BP were processed to extract beat-to-beat information, and \(\hbox {CO}_{2}\) 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 \((P<0.05)\). 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 %, \(P<0.05\)), 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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Monk TG, Saini V, Weldon BC, Sigl JC. Anesthetic management and one-year mortality after non-cardiac surgery. Anesth Analg. 2005;100(1):4–10.

    Article  PubMed  Google Scholar 

  2. Sessler DI, Sigl JC, Kelley SD, Chamoun NG, Manberg PJ, Saager L, Kurz A, Greenwald S. Hospital stay and mortality are increased in patients having a “triple low” of low blood pressure, low bispectral index, and low minimum alveolar concentration of volatile anesthesia. J Am Soc Anesthesiol. 2012;116(6):1195–203.

    Article  Google Scholar 

  3. Mashour GA. Neurophysiology and intraoperative nociception: new potentials? Anesthesiology. 2013;118(2):239.

    Article  PubMed  Google Scholar 

  4. Huiku M, Uutela K, van Gils M, Korhonen I, Kymlinen M, Merilinen P, Paloheimo M, Rantanen M, Takala P, Vierti-Oja H, Yli-Hankala A. Assessment of surgical stress during general anaesthesia. Br J Anaesth. 2007;98(4):447–55.

    Article  CAS  PubMed  Google Scholar 

  5. Paloheimo MPJ, Sahanne S, Uutela KH. Autonomic nervous system state: the effect of general anaesthesia and bilateral tonsillectomy after unilateral infiltration of lidocaine. Br J Anaesth. 2010;104(5):587–895.

    Article  CAS  PubMed  Google Scholar 

  6. Storm H. Skin conductance and the stress response from heel stick in preterm infants. Arch Dis Child Fetal Neonatal Ed. 2000;83:143–7.

    Article  Google Scholar 

  7. Barvais L, Engelman E, Eba JM, Coussaert E, Cantraine F, Kenny GN. Effect site concentrations of remifentanil and pupil response to noxious stimulation. Br J Anaesth. 2003;91(3):347–52.

    Article  CAS  PubMed  Google Scholar 

  8. Castro A, Amorim P, Nunes C, de Almeida F. Effect of propofol and remifentanil on a somatosensory evoked potential indicator of pain perception intensity in volunteers. J Clin Monit Comput. 2015;29(5):561–7. doi:10.1007/s10877-014-9632-0.

    Article  PubMed  Google Scholar 

  9. Greenwald SD, Rosow C. Bis and emg variability increase before somatic responses during surgery. Anesthesiology. 2006;105:1027.

    Google Scholar 

  10. Rehberg B, Ryll C, Hadzidiakos D, Dincklage FV, Baars JH. Variability comparison of the composite auditory evoked potential index and the bispectral index during propofol-fentanyl anesthesia. Technol Comput Simul. 2008;107(1):117–24.

    Google Scholar 

  11. Bennet HL, Patel L, Farida N, Beddell S, Bobbin M. Separation of the hypnotic component of anesthesia and facial emg responses to surgical stimulation. Anesthesiology. 2007;A730. http://www.asaabstracts.com/strands/asaabstracts/abstract.htm;jsessionid=A478F09D2699BD4D6172FD68AF622F61?year=2007&index=5&absnum=1737.

  12. Rantanen M, Yli-Hankala A, Gils MV, Yppril-Wolters H, Takala P, Huiku M, Kymlinen M, Seitsonen E, Korhonen I. Novel multiparameter approach for measurement of nociception at skin incision during general anaesthesia. Br J Anaesth. 2006;96(3):367–76.

    Article  CAS  PubMed  Google Scholar 

  13. Cividjian A, Martinez J, Precloux ECP, Beraud AM, Rochette Y, Cler M, Bourdon L, Escarment J, Quintin L. Beat-by-beat cardiovascular index to predict unexpected intraoperative movement in anaesthetized unparalyzed patients: a retrospective analysis. J Clin Monit Comput. 2007;21(2):91–101.

    Article  CAS  PubMed  Google Scholar 

  14. Schnider TW, Minto CF, Gambus PL, Andresen C, Goodale DB, Shafer SL, Youngs EJ. The influence of method of administration and covariates on the pharmacokinetics of propofol in adult volunteers. Anesthesiology. 1998;88:1170–82.

    Article  CAS  PubMed  Google Scholar 

  15. Minto CF, Schnider TW, Shafer SL. Pharmacokinetics and pharmacodynamics of remifentanil. II. Model application. Anesthesiology. 1997;86:24–33.

    Article  CAS  PubMed  Google Scholar 

  16. Seshagiri CV, Rosow CE, Greenwald S. Bis(r) variability in response to skin incision was greater opposite to the side of surgery. Anesthesiology. 2007; 807.

  17. Castro A, Amorim P, Nunes CS, Almeida FG. Development of a scale to assess noxious stimuli intensity during anesthesia and surgery using rasch analysis. J Neurosurg Anesthesiol. 2011;23(4):426–7.

    Google Scholar 

  18. Sörnmo L, Laguna P. Bioelectrical signal processing in cardiac and neurological applications. 1st ed. Amsterdam: Elsevier; 2005.

    Google Scholar 

  19. Cleveland WS, Devlin SJ. Locally weighted regression: an approach to regression analysis by local fitting. J Am Stat Assoc. 1988;83(403):596–610.

    Article  Google Scholar 

  20. Jiang T, Chen B, He X, Stuart P. Application of steady-state detection method based on wavelet transform. Comput Chem Eng. 2003;27(4):569–78.

    Article  CAS  Google Scholar 

  21. Szabó Z. Contour image data compression using spline wavelets. J Electr Eng. 2004;55(11–12):290–5.

    Google Scholar 

  22. Bahoura M, Hassani M, Hubin M. DSP implementation of wavelet transform for real time ECG wave forms detection and heart rate analysis. Comput Methods Progr Biomed. 1997;52(1):35–44.

    Article  CAS  Google Scholar 

  23. Mallat S, Zhong S. Characterization of signals from multiscale edges. IEEE Trans Pattern Anal Mach Intell. 1992;14(7):710–32.

    Article  Google Scholar 

  24. Zbinden AM, Petersen-Felix S, Thomson DA, Anaes FRC. Anesthetic depth defined using multiple noxious stimuli during isoflurane/oxygen anesthesia. II hemodynamic responses. Anesthesiology. 1994;80(2):261–7.

    Article  CAS  PubMed  Google Scholar 

  25. Zbinden AM, Peterson-Felix S, Thomson DA, Anaes FRC. Reduction by fentanyl of the cp50 values of propofol and hemodynamic responses to various noxious stimuli. Anesthesiology. 1997;87(2):213–27.

    Article  Google Scholar 

  26. Albertin A, Casati A, Federica L, Roberto V, Travaglini V, Bergonzi P, Torri G. The effect-site concentration of remifentanil blunting cardiovascular responses to tracheal intubation and skin incision during bispectral index-guided propofol anesthesia. Anesth Analg. 2005;101(1):125–30.

    Article  CAS  PubMed  Google Scholar 

  27. Jeanne M, Clément C, Jonckheere J, Tavernier Logier R B. Variations of the analgesia nociception index during general anaesthesia for laparoscopic abdominal surgery. J Clin Monit Comput. 2012;26(4):289–94. doi:10.1007/s10877-012-9354-0.

    Article  CAS  PubMed  Google Scholar 

  28. La Rovere MT, Pinna GD, Raczak G. Baroreflex sensitivity: Measurement and clinical implications. Ann Noninvasive Electrocardiol. 2008;13(2):191–207.

    Article  PubMed  Google Scholar 

  29. Karri S, Maheshwari A, Koch C, Duncan MXMA. Deeper level of anesthesia is associated with adverse neurological outcomes in cardiac surgical patients. Anesth Analg. 2009;108(SCA Supp):1–104.

    Google Scholar 

  30. Farag E, Chelune GJ, Schubert A, Mascha EJ. Deeper level of anesthesia is associated with adverse neurological outcomes in cardiac surgical patients. Anesth Analg. 2006;103(3):633–40.

    Article  PubMed  Google Scholar 

  31. Myles PS, Leslie K, McNeil J, Forbes A, Chan MT. Bispectral index monitoring to prevent awareness during anaesthesia: the b-aware randomised controlled trial. Lancet. 2004;363(9423):1757–63.

    Article  CAS  PubMed  Google Scholar 

  32. Ekman A, Lindholm ML, Lennmarken C, Sandin R. Reduction in the incidence of awareness using bis monitoring. Acta Anaesthesiol Scand. 2004;48(1):20–6.

    Article  CAS  PubMed  Google Scholar 

  33. Bouillon TW, Bruhn J, Radulescu L, Andresen C, Shafer TJ, Cohane C, Shafer SL. Pharmacodynamic interaction between propofol and remifentanil regarding hypnosis, tolerance of laryngoscopy, bispectral index, and electroencephalographic approximate entropy. Anesthesiology. 2004;100(6):1353–72.

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgments

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.

Author information

Authors and Affiliations

  1. Faculdade de Engenharia da Universidade do Porto, Rua Dr. Roberto Frias, sn, 4200-465, Porto, Portugal

    Ana Castro & Fernando Gomes de Almeida

  2. Centro de Investigação Clínica em Anestesiologia, Serviço de Anestesiologia, Hospital de Santo António, Centro Hospitalar do Porto, Largo Prof. Abel Salazar, 4099-001, Porto, Portugal

    Ana Castro, Fernando Gomes de Almeida & Pedro Amorim

  3. Departamento de Ciências e Tecnologia, Universidade Aberta, Delegação do Porto, Rua do Amial 752, 4200-055, Porto, Portugal

    Catarina S. Nunes

  4. LAETA/INEGI, Porto, Portugal

    Catarina S. Nunes

Authors
  1. Ana Castro
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Fernando Gomes de Almeida
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Pedro Amorim
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Catarina S. Nunes
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Ana Castro.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Castro, A., de Almeida, F.G., Amorim, P. et al. A novel multivariate STeady-state index during general ANesthesia (STAN). J Clin Monit Comput 31, 851–860 (2017). https://doi.org/10.1007/s10877-016-9905-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10877-016-9905-x

Keywords

Search

Navigation