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Model-based control of neuromuscular block using mivacurium: design and clinical verification

Published online by Cambridge University Press:  04 April 2006

P. M. Schumacher ,
K. S. Stadler ,
R. Wirz ,
D. Leibundgut ,
C. A. Pfister  and
A. M. Zbinden
P. M. Schumacher
Affiliation:
University Hospital, Department of Anesthesiology, Bern
K. S. Stadler
Affiliation:
Swiss Federal Institute of Technology (ETH), Automatic Control Laboratory, Zurich
R. Wirz
Affiliation:
University Hospital, Department of Anesthesiology, Bern
D. Leibundgut
Affiliation:
University Hospital, Department of Anesthesiology, Bern
C. A. Pfister
Affiliation:
University Hospital, Department of Anesthesiology, Bern
A. M. Zbinden
Affiliation:
University Hospital, Department of Anesthesiology, Bern
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Summary

Background: Short-acting agents for neuromuscular block (NMB) require frequent dosing adjustments for individual patient's needs. In this study, we verified a new closed-loop controller for mivacurium dosing in clinical trials. Methods: Fifteen patients were studied. T1% measured with electromyography was used as input signal for the model-based controller. After induction of propofol/opiate anaesthesia, stabilization of baseline electromyography signal was awaited and a bolus of 0.3 mg kg−1 mivacurium was then administered to facilitate endotracheal intubation. Closed-loop infusion was started thereafter, targeting a neuromuscular block of 90%. Setpoint deviation, the number of manual interventions and surgeon's complaints were recorded. Drug use and its variability between and within patients were evaluated. Results: Median time of closed-loop control for the 11 patients included in the data processing was 135 [89–336] min (median [range]). Four patients had to be excluded because of sensor problems. Mean absolute deviation from setpoint was 1.8 ± 0.9 T1%. Neither manual interventions nor complaints from the surgeons were recorded. Mean necessary mivacurium infusion rate was 7.0 ± 2.2 μg kg−1 min−1. Intrapatient variability of mean infusion rates over 30-min interval showed high differences up to a factor of 1.8 between highest and lowest requirement in the same patient. Conclusions: Neuromuscular block can precisely be controlled with mivacurium using our model-based controller. The amount of mivacurium needed to maintain T1% at defined constant levels differed largely between and within patients. Closed-loop control seems therefore advantageous to automatically maintain neuromuscular block at constant levels.

Keywords

ANAESTHESIA GENERALNEUROMUSCULAR BLOCKADE, monitoring, automation, closed-loop controlNEUROMUSCULAR BLOCKING AGENTS, mivacuriumELECTROMYOGRAPHYCOMPUTER SIMULATION
Type
Original Article
Information
European Journal of Anaesthesiology , Volume 23 , Issue 8 , August 2006 , pp. 691 - 699
Copyright
© 2006 European Society of Anaesthesiology

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References

Eriksson LI, Sato M, Severinghaus JW. Effect of a vecuronium-induced partial neuromuscular block on hypoxic ventilatory response. Anesthesiology 1993; 78: 693–699.Google Scholar
Viby-Mogensen J. Postoperative residual curarization and evidence-based anaesthesia. Br J Anaesth 2000; 84: 301–303.Google Scholar
Olkkola KT, Schwilden H, Apffelstaedt C. Model-based adaptive closed-loop feedback control of atracurium-induced neuromuscular blockade. Acta Anaesthesiol Scand 1991; 35: 420–423.Google Scholar
Olkkola KT, Schwilden H. Adaptive closed-loop feedback control of vecuronium-induced neuromuscular relaxation. Eur J Anaesthesiol 1991; 8: 7–12.Google Scholar
Meretoja OA, Olkkola KT. Pharmacodynamics of mivacurium in children, using a computer-controlled infusion. Br J Anaesth 1993; 71: 232–237.Google Scholar
Geldner G, Schwarz U, Ruoff M et al. Development of a new closed-loop system for controlling mivacurium-induced neuromuscular blockade. Anaesthesist 1999; 48: 157–162. [German]Google Scholar
Kansanaho M, Olkkola KT. Performance assessment of an adaptive model-based feedback controller: comparison between atracurium, mivacurium, rocuronium and vecuronium. Int J Clin Monit Comput 1996; 13: 217–224.Google Scholar
Caldwell JE. New skeletal muscle relaxants. Int Anesthesiol Clin 1995; 33 (1): 39–60 (Review).Google Scholar
Viby-Mogensen J. Neuromuscular monitoring. In: Miller RD, ed. Anesthesia. Philadelphia: Churchill-Livingstone Inc, 2000: 1351–1366.
Viby-Mogensen J, Engbaek J, Eriksson LI et al. Good clinical research practice (GCRP) in pharmacodynamic studies of neuromuscular blocking agents. Acta Anaesthesiol Scand 1996; 40: 59–74.Google Scholar
Savarese JJ, Ali HH, Basta SJ et al. The clinical neuromuscular pharmacology of mivacurium chloride (BW B1090U). A short-acting nondepolarizing ester neuromuscular blocking drug. Anesthesiology 1988; 68: 723–732.Google Scholar
Stadler KS, Leibundgut D, Schumacher PM et al. Modelling and closed-loop control of skeletal muscle relaxation during general anaesthesia using mivacurium. European Control Conference ECC 2003.Google Scholar
Lien CA, Schmith VD, Embree PB, Belmont MR, Wargin WA, Savarese JJ. The pharmacokinetics and pharmacodynamics of the stereoisomers of mivacurium in patients receiving nitrous oxide/opioid/barbiturate anesthesia. Anesthesiology 1994; 80 (6): 1296–1302.Google Scholar
Cook DR, Freemann JA, Lai AA et al. Pharmacokinetics of mivacurium in normal patients and in those with hepatic or renal failure. BJA 1992; 69: 580–585.Google Scholar
Schumacher PM, Stadler KS, Zbinden AM. Performance assessment of feedback control systems for drug delivery in anesthesia. World Congress on Medical Physics and Biomedical Engineering, Sydney 2003.
Varvel JR, Donoho DL, Shafer SL. Measuring the predictive performance of computer-controlled infusion pumps. J Pharmacokinet Biopharm 1992; 20: 63–94.Google Scholar
Ostergaard D, Viby-Mogensen J, Pedersen NA, Holm H, Skovgaard LT. Pharmacokinetics and pharmacodynamics of mivacurium in young adult and elderly patients. Acta Anaesthesiol Scand 2002; 46 (6): 684–691.Google Scholar
Ali HH, Savarese JJ, Embree PB et al. Clinical pharmacology of mivacurium chloride (BW B1090U) infusion: comparison with vecuronium and atracurium. Br J Anaesth 1988; 61: 541–546.Google Scholar
De Mey JC, Fonck K, Mareels K, Rolly G. The influence of isoflurane on a continuous infusion of mivacurium. Anaesthesia 1995; 50: 947–949.Google Scholar
Powers DM, Brandom BW, Cook DR et al. Mivacurium infusion during nitrous oxide-isoflurane anesthesia: a comparison with nitrous oxide-opioid anesthesia. J Clin Anesth 1992; 4: 123–126.Google Scholar
Ezzine S, Donati F, Varin F. Mivacurium arteriovenous gradient during steady state infusion in anesthetized patients. Anesthesiology 2002; 97: 622–629.Google Scholar
Maddineni VR, Mirakhur RK, McCoy EP, Sharpe TD. Neuromuscular and haemodynamic effects of mivacurium in elderly and young adult patients. Br J Anaesth 1994; 73: 608–612.Google Scholar
Brandom BW, Woelfel SK, Cook DR, Weber S, Powers DM, Weakly JN. Comparison of mivacurium and suxamethonium administered by bolus and infusion. Br J Anaesth 1989; 62: 488–493.Google Scholar
Pellissier D, Bruder N, Mokart D et al. Continuous administration of mivacurium for short procedures. Delayed onset and recovery from neuromuscular blockade. Ann Fr Anesth Reanim 1995; 14: 467–471.Google Scholar
Viby-Mogensen J, Ostergaard D, Donati F et al. Pharmacokinetic studies of neuromuscular blocking agents: good clinical research practice (GCRP). Acta Anaesthesiol Scand 2000; 44: 1169–1190.Google Scholar
Arbous MS, Meursing AE, van Kleef JW et al. Impact of anesthesia management characteristics on severe morbidity and mortality. Anesthesiology 2005; 102 (2): 257–268; quiz 491–492.Google Scholar