Evaluating the role of Smartpilot® view assisted target-controlled infusion anesthesia during intracranial mass surgery: A comparative retrospective study with bispectral index-guided standard anesthesia

Abstract

Background/Aim: Neuroanesthesia necessitates the control of both systemic and cerebral hemodynamics, the prevention of intracranial pressure increase, knowledge of anesthetics’ cerebral effects, and early neurological recovery. The titration of anesthetics becomes crucial to optimize the appropriate level of anesthesia required for surgery while reducing postoperative neurological consequences. Smartpilot® View (SPV) is a new decision support system that uses pharmacologic models to optimize anesthetic depth and improve patient outcomes. The goal of this study was to compare the effectiveness of SPV with standard BIS-guided anesthesia administration in terms of intraoperative hemodynamic stabilization, anesthetic consumption, and postoperative recovery times during intracranial mass surgery. Methods: Following ethics committee approval, the records of the patients who underwent elective supratentorial craniotomy between November 15, 2017 and March 15, 2018 were reviewed retrospectively. The demographics of the patients, anesthesia and surgery times, eye opening and extubation times, time to reach an Aldrete score of 9 and anesthetic consumptions were compared between those who were monitored with SPV in addition to BIS (SPV Group) and those who were monitored with solely BIS for standard anesthetic follow-up (BIS Group). Results: A total of 139 subjects were analyzed (SPV (n=71), BIS (n=68)). Hemodynamic responses to induction and intubation were more pronounced in the BIS group (P<0.05). Time until eye opening and extubation were 3.6 (2.4) versus 6.06 (1.63) minutes and 5.76 (1.3) versus 9.16 (1.0) minutes in the SPV and BIS groups (P<0.001). In the SPV Group, it took much less time to achieve an Aldrete score of 9 or above (P<0.001). Total consumed amount of both propofol and remifentanil were significantly lower in the SPV group (P<0.001). Conclusion: Use of SPV compared to BIS-guided routine anesthesia follow-up improved titration and consumption of anesthetic drugs, thereby facilitating the early recovery process in patients who underwent intracranial mass surgery.

Keywords

• Intravenous anesthetics
• Propofol
• Remifentanil
• Anesthesia recovery period
• Bispectral index
• Neurosurgery

References

1. 1. Bilotta F, Guerra C, Rosa G. Update on anesthesia for craniotomy. Curr Opin Anaesthesiol. 2013 Oct;26(5):517-22. doi: 10.1097/01.aco.0000432513.92822.c2. PMID: 23995058.
2. 2. van den Berg JP, Vereecke HE, Proost JH, Eleveld DJ, Wietasch JK, Absalom AR, et al. Pharmacokinetic and pharmacodynamic interactions in anaesthesia. A review of current knowledge and how it can be used to optimize anaesthetic drug administration. Br J Anaesth. 2017 Jan;118(1):44-57. doi: 10.1093/bja/aew312.
3. 3. Lewis SR, Pritchard MW, Fawcett LJ, Punjasawadwong Y. Bispectral index for improving intraoperative awareness and early postoperative recovery in adults. Cochrane Database Syst Rev. 2019;9:CD003843. doi: 10.1002/14651858.CD003843.pub4.
4. 4. Chiang MH, Wu SC, Hsu SW, Chin JC. Bispectral Index and non-Bispectral Index anesthetic protocols on postoperative recovery outcomes. Minerva Anestesiol. 2018;84:216-28. doi: 10.23736/S0375-9393.17.12033-X.
5. 5. Struys MM, Vereecke H, Moerman A, Jensen EW, Verhaeghen D, De Neve N, et al. Ability of the bispectral index, autoregressive modelling with exogenous input-derived auditory evoked potentials, and predicted propofol concentrations to measure patient responsiveness during anesthesia with propofol and remifentanil. Anesthesiology 2003; Oct;99(4):802-12. doi: 10.1097/00000542-200310000-00010. PMID: 14508310.
6. 6. Gruenewald M, Harju J, Preckel B, Molnár Z, Yli-Hankala A, Rosskopf F, et al.; AoA Study Group. Comparison of adequacy of anaesthesia monitoring with standard clinical practice monitoring during routine general anaesthesia: An international, multicentre, single-blinded randomised controlled trial. Eur J Anaesthesiol. 2021 Jan;38(1):73-81. doi: 10.1097/EJA.0000000000001357.
7. 7. Kennedy RR. Application of pharmacokinetics and pharmacodynamics and signal analysis to drug administration in anaesthesia. In: Gambus PL, Hendrickx JFA, editors. Personalized anaesthesia. Targeting physiological systems for optimal effect. Cambridge: Cambridge University Press; 2019. p. 82-102.
8. 8. Cirillo V, Zito Marinosci G, De Robertis E, Iacono C, Romano GM, Desantis O, et al. Navigator® and SmartPilot® View are helpful in guiding anesthesia and reducing anesthetic drug dosing. Minerva Anestesiol. 2015 Nov;81(11):1163-9.

9. 9. Velik-Salchner C. Computed advisory systems in daily practice for predicting concentrations and effects of combined anesthetics: a new field in anesthesia? Minerva Anestesiol. 2015;81:1151-2.
10. 10. Leblanc D, Conté M, Masson G, Richard F, Jeanneteau A, Bouhours G, et al. SmartPilot® view-guided anaesthesia improves postoperative outcomes in hip fracture surgery: a randomized blinded controlled study. Br J Anaesth. 2017 Nov 1;119(5):1022-9. doi: 10.1093/bja/aex317.
11. 11. Gruenbaum SE, Meng L, Bilotta F. Recent trends in the anesthetic management of craniotomy for supratentorial tumor resection. Curr Opin Anaesthesiol. 2016 Oct;29(5):552-7. doi: 10.1097/ACO.0000000000000365.
12. 12. Xing Y, Lin N, Han R, Bebawy JF, Peng Y, Li J, et al. Sevoflurane versus PRopofol combined with Remifentanil anesthesia Impact on postoperative Neurologic function in supratentorial Gliomas (SPRING): protocol for a randomized controlled trial. BMC Anesthesiol. 2020 May 19;20(1):117. doi: 10.1186/s12871-020-01035-5.
13. 13. Ayrian E, Kaye AD, Varner CL, Guerra C, Vadivelu N, Urman RD, et al. Effects of Anesthetic Management on Early Postoperative Recovery, Hemodynamics and Pain After Supratentorial Craniotomy. J Clin Med Res. 2015 Oct;7(10):731-41. doi: 10.14740/jocmr2256w.
14. 14. Prabhakar H, Singh GP, Mahajan C, Kapoor I, Kalaivani M, Anand V. Intravenous versus inhalational techniques for rapid emergence from anaesthesia in patients undergoing brain tumour surgery. Cochrane Database Syst Rev. 2016 Sep 9;9(9):CD010467. doi: 10.1002/14651858.CD010467.pub2.
15. 15. Flexman AM, Meng L, Gelb AW. Outcomes in neuroanesthesia: What matters most? Can J Anaesth. 2016 Feb;63(2):205-11. doi: 10.1007/s12630-015-0522-9.
16. 16. Huang YH, Wu ZF, Lee MS, Lou YS, Wu KL, Cheng KI, et al. Propofol-based total intravenous anesthesia is associated with better survival than desflurane anesthesia in glioblastoma surgery. PLoS One. 2021 Aug 5;16(8):e0255627. doi: 10.1371/journal.pone.0255627.
17. 17. Strus MMRF, Sahinovic M, Lichtenbelt BJ, Vereecke HEM, Absalom AR. Optimizing intravenous drug administration by applying pharmacokinetic/pharmacodynamic concepts. Br J Anaesth. 2011;107:38-47.
18. 18. Mertens MJ, Olofsen E, Engbers FHM, Burm AGL, Bovill JG, Vuyk J. Propofol reduces perioperative remifentanil requirements in a synergistic manner: Response surface modeling of perioperative remifentanilpropofol interactions. Anesthesiology. 2003;99(2):347-59.
19. 19. Bouillon TW, Bruhn J, Radulescu L, Andresen C, Shafer TJ, Cohane C, et al. Pharmacodynamic interaction between propofol and remifentanil regarding hypnosis, tolerance of laryngoscopy, bispectral index, and electroencephalographic approximate entropy. Anesthesiology. 2004;100(6):1353-72.
20. 20. Luginbühl M, Schumacher PM, Vuilleumier P, Vereecke H, Heyse B, Bouillon TW, et al. Noxious stimulation response index: a novel anesthetic state index based on hypnotic-opioid interaction. Anesthesiology. 2010 Apr;112(4):872-80. doi: 10.1097/ALN.0b013e3181d40368.
21. 21. Hannivoort LN, Vereecke HE, Proost JH, Heyse BE, Eleveld DJ, Bouillon TW, et al. Probability to tolerate laryngoscopy and noxious stimulation response index as general indicators of the anaesthetic potency of sevoflurane, propofol, and remifentanil. Br J Anaesth. 2016 May;116(5):624-31. doi: 10.1093/bja/aew060.
22. 22. Mai S, Ami S, Takayuki K. Complementary Use of Effect Site-Target Controlled Infusion and SmartPilot View for Anesthetic Management in Semi-awake Craniotomy Near BIS 85. J Neurosurg Anesthesiol. 2018 Jan;30(1):78-9. doi: 10.1097/ANA.0000000000000388.
23. 23. Hagihira S, Okitsu K, Kawaguchi M. Unusually low bispectral index values during emergence from anesthesia. Anesth Analg. 2004;98:1036-8.
24. 24. Dahaba A. Different conditions that could results in the bispectral index indicating an incorrect hypnotic state. Anesth Analg. 2005;101:765-73.
25. 25. Morimoto Y, Shiramoto H, Yoshimura M. The usefulness of Smart Pilot View for fast recovery from desflurane general anesthesia. J Anesth. 2021 Apr;35(2):239-45. doi: 10.1007/s00540-021-02905-z.