Anestezi Uygulamalarında Kapalı Döngü Sistemleri
Özet
Anestezi uygulamalarında kapalı döngü (closed-loop) sistemleri konu alan bu makale, manuel kontrole alternatif olarak geliştirilen otomatik ilaç yönetim teknolojilerini incelemektedir. Geleneksel yöntemde anestezistler, hastanın yaşamsal bulgularını takip ederek ilaç dozlarını manuel olarak ayarlar; ancak bu durum yüksek iş yükü ve stres yaratarak hata riskini artırabilir. Kapalı döngü sistemleri ise "beyin" (algoritma), "etki" (hedef değişken) ve "aktüatör" (pompa) bileşenlerinden oluşarak, önceden belirlenen hedef değerleri korumak için ilaç infüzyonunu otomatik olarak düzenler. Bu sistemlerde hipnoz derinliği için Bispektral İndeks (BIS), kas gevşemesi için TOF ve analjezi için ANI veya SPI gibi parametreler geri bildirim aracı olarak kullanılır. McSleepy ve CLADS gibi cihazlar, hastalar arası değişkenliği minimize ederek daha kararlı bir anestezi düzeyi sağlar. Çalışmalar, bu teknolojilerin daha az ilaç tüketimi, daha iyi hemodinamik stabilite ve daha hızlı derlenme sağladığını göstermektedir. Henüz standart hastane rutinine tam entegre olmasa da, mühendislik ve tıp iş birliğiyle geliştirilen bu sistemler, perioperatif süreçte güvenliği artırıp anestezistin iş yükünü azaltma potansiyeline sahiptir.
This article on closed-loop systems in anesthesia examines automated drug management technologies developed as an alternative to manual control. Traditionally, anesthesiologists manually adjust drug doses by monitoring vital signs; however, this can increase workload and stress, leading to potential errors. Closed-loop systems consist of a "brain" (algorithm), an "effect" (target variable), and an "actuator" (pump), automatically regulating drug infusion to maintain predetermined target values. These systems use parameters such as the Bispectral Index (BIS) for hypnosis depth, TOF for muscle relaxation, and ANI or SPI for analgesia as feedback mechanisms. Devices like McSleepy and CLADS provide a more stable level of anesthesia by minimizing inter-patient variability. Studies indicate that these technologies result in lower drug consumption, better hemodynamic stability, and faster recovery. Although not yet fully integrated into standard hospital routines, these systems developed through medical-engineering collaboration have the potential to enhance safety and reduce the anesthesiologist's workload during the perioperative process.
Referanslar
Li H, Zuo M, Gelb AW, Zhang B, Zhao X, Yao D, et al. Chinese anesthesiologists have high burnout and low job satisfaction: a cross-sectional survey. Anesthesia & Analgesia. 2018;126(3):1004-12.
Simanski O, Schubert A, Kaehler R, Janda M, Bajorat J, Hofmockel R, et al., editors. Automatic drug delivery in anesthesia: From the beginning until now. 2007 Mediterranean Conference on Control & Automation; 2007: IEEE.
Xu T, Xia M, Jiang H. Advances in Medicine-Engineering Crossover in Automated Anesthesia. Journal of Shanghai Jiaotong University (Science). 2021:1-7.
Puri G, Kumar B, Aveek J. Closed-loop anaesthesia delivery system (CLADSTM) using bispectral index: a performance assessment study. Anaesthesia and intensive care. 2007;35(3):357-62.
Hemmerling T, Arbeid E, Wehbe M, Cyr S, Taddei R, Zaouter C. Evaluation of a novel closed-loop total intravenous anaesthesia drug delivery system: a randomized controlled trial. British journal of anaesthesia. 2013;110(6):1031-9.
Dussaussoy C, Peres M, Jaoul V, Liu N, Chazot T, Picquet J, et al. Automated titration of propofol and remifentanil decreases the anesthesiologist’s workload during vascular or thoracic surgery: a randomized prospective study. Journal of clinical monitoring and computing. 2014;28(1):35-40.
Agarwal J, Puri G, Mathew P. Comparison of closed loop vs. manual administration of propofol using the Bispectral index in cardiac surgery. Acta Anaesthesiologica Scandinavica. 2009;53(3):390-7.
Biswas I, Mathew PJ, Singh RS, Puri GD. Evaluation of closed‐loop anesthesia delivery for propofol anesthesia in pediatric cardiac surgery. Pediatric Anesthesia. 2013;23(12):1145-52.
De Smet T, Struys MM, Neckebroek MM, Van den Hauwe K, Bonte S, Mortier EP. The accuracy and clinical feasibility of a new bayesian-based closed-loop control system for propofol administration using the bispectral index as a controlled variable. Anesthesia & Analgesia. 2008;107(4):1200-10.
Hemmerling TM, Charabati S, Zaouter C, Minardi C, Mathieu PA. A randomized controlled trial demonstrates that a novel closed-loop propofol system performs better hypnosis control than manual administration. Canadian Journal of Anesthesia/Journal canadien d'anesthésie. 2010;57(8):725-35.
Hemmerling TM. Automated anesthesia. Current Opinion in Anesthesiology. 2009;22(6):757-63.
Kuck K, Johnson KB. The three laws of autonomous and closed-loop systems in anesthesia. LWW; 2017.
Liu N, Le Guen M, Benabbes-Lambert F, Chazot T, Trillat B, Sessler DI, et al. Feasibility of closed-loop titration of propofol and remifentanil guided by the spectral M-Entropy monitor. The Journal of the American Society of Anesthesiologists. 2012;116(2):286-95.
Liberman MY, Ching S, Chemali J, Brown EN. A closed-loop anesthetic delivery system for real-time control of burst suppression. Journal of neural engineering. 2013;10(4):046004.
Ching S, Liberman MY, Chemali JJ, Westover MB, Kenny JD, Solt K, et al. Real-time closed-loop control in a rodent model of medically induced coma using burst suppression. Anesthesiology. 2013;119(4):848-60.
Suppan P. FEED-BACK MONITORING IN ANAESTHESIA. IV THE INDIRECT MEASUREMENT OF ARTERIAL PRESSURE AND ITS USE FOR THE CONTROL OF HALOTHANE ADMINISTRATION. BJA: British Journal of Anaesthesia. 1977;49(2):141-50.
Biebuyck JF, O'Hara DA, Bogen DK, Noordergraaf A. The use of computers for controlling the delivery of anesthesia. The Journal of the American Society of Anesthesiologists. 1992;77(3):563-81.
Cannesson M, Rinehart J. Closed-loop systems and automation in the era of patients safety and perioperative medicine. Springer; 2014.
Struys MM, De Smet T, Versichelen LF, Van de Velde S, Van den Broecke R, Mortier EP. Comparison of closed-loop controlled administration of propofol using Bispectral Index as the controlled variable versus “standard practice” controlled administration. The Journal of the American Society of Anesthesiologists. 2001;95(1):6-17.
Liu N, Chazot T, Hamada S, Landais A, Boichut N, Dussaussoy C, et al. Closed-loop coadministration of propofol and remifentanil guided by bispectral index: a randomized multicenter study. Anesthesia & Analgesia. 2011;112(3):546-57.
Puri G. Closed Loop Anaesthesia Delivery System (CLADS)-Anaesthesia Robot.
Kong E, Nicolaou N, Vizcaychipi MP. Hemodynamic stability of closed-loop anesthesia systems: a systematic review. Minerva anestesiologica. 2019;86(1):76-87.
Gropper MA, Miller RD, Eriksson LI, Fleisher LA, Wiener-Kronish JP, Cohen NH, et al. Miller's Anesthesia, 2-Volume Set E-Book: Elsevier Health Sciences; 2019.
Liu N, Chazot T, Genty A, Landais A, Restoux A, McGee K, et al. Titration of propofol for anesthetic induction and maintenance guided by the bispectral index: closed-loop versus manual control: a prospective, randomized, multicenter study. The Journal of the American Society of Anesthesiologists. 2006;104(4):686-95.
Bibian S, Ries CR, Huzmezan M, Dumont GA, editors. Clinical anesthesia and control engineering: Terminology, concepts and issues. 2003 European Control Conference (ECC); 2003: IEEE.
West N, Dumont GA, van Heusden K, Petersen CL, Khosravi S, Soltesz K, et al. Robust closed‐loop control of induction and maintenance of propofol anesthesia in children. Pediatric Anesthesia. 2013;23(8):712-9.
Fuchs-Buder T, Meistelman C, editors. Monitoring of neuromuscular block and prevention of residual paralysis. Annales francaises d'anesthesie et de reanimation; 2009.
Debaene B, Beaussier M, Meistelman C, Donati F, Lienhart A. Monitoring the onset of neuromuscular block at the orbicularis oculi can predict good intubating conditions during atracurium-induced neuromuscular block. Anesthesia & Analgesia. 1995;80(2):360-3.
Meistelman C, editor Mivacurium and prolonged curarization. Annales francaises d'anesthesie et de reanimation; 1995.
Fuchs‐Buder T, Schreiber JU, Meistelman C. Monitoring neuromuscular block: an update. Anaesthesia. 2009;64:82-9.
Gruenewald M, Ilies C. Monitoring the nociception–anti-nociception balance. Best Practice & Research Clinical Anaesthesiology. 2013;27(2):235-47.
Wasiak J, Mahar P, McGuinness SK, Spinks A, Danilla S, Cleland H. Intravenous lidocaine for the treatment of background or procedural burn pain. Cochrane database of systematic reviews. 2012(6).
Mishriky B, Waldron N, Habib A. Impact of pregabalin on acute and persistent postoperative pain: a systematic review and meta-analysis. British journal of anaesthesia. 2015;114(1):10-31.
Weibel S, Jokinen J, Pace N, Schnabel A, Hollmann M, Hahnenkamp K, et al. Efficacy and safety of intravenous lidocaine for postoperative analgesia and recovery after surgery: a systematic review with trial sequential analysis. British journal of anaesthesia. 2016;116(6):770-83.
Management ASoATFoAP. Practice guidelines for acute pain management in the perioperative setting: an updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology. 2012;116(2):248-73.
Beaussier M, Sciard D, Sautet A. New modalities of pain treatment after outpatient orthopaedic surgery. Orthopaedics & Traumatology: Surgery & Research. 2016;102(1):S121-S4.
Rana MV, Desai R, Tran L, Davis DA. Perioperative pain control in the ambulatory setting. Current pain and headache reports. 2016;20(3):18.
Lundorf LJ, Nedergaard HK, Møller AM. Perioperative dexmedetomidine for acute pain after abdominal surgery in adults. Cochrane Database of Systematic Reviews. 2016(2).
Dunn LK, Durieux ME, Nemergut EC. Non-opioid analgesics: novel approaches to perioperative analgesia for major spine surgery. Best Practice & Research Clinical Anaesthesiology. 2016;30(1):79-89.
Le Gall L, David A, Carles P, Leuillet S, Chastel B, Fleureau C, et al. Benefits of intraoperative analgesia guided by the Analgesia Nociception Index (ANI) in bariatric surgery: an unmatched case-control study. Anaesthesia Critical Care & Pain Medicine. 2019;38(1):35-9.
Gruenewald M, Willms S, Broch O, Kott M, Steinfath M, Bein B. Sufentanil administration guided by surgical pleth index vs standard practice during sevoflurane anaesthesia: a randomized controlled pilot study. British journal of anaesthesia. 2014;112(5):898-905.
Rinehart J, Alexander B, Le Manach Y, Hofer CK, Tavernier B, Kain ZN, et al. Evaluation of a novel closed-loop fluid-administration system based on dynamic predictors of fluid responsiveness: an in silico simulation study. Critical Care. 2011;15(6):1-12.
Rinehart J, Le Manach Y, Douiri H, Lee C, Lilot M, Le K, et al., editors. First closed-loop goal directed fluid therapy during surgery: a pilot study. Annales francaises d'anesthesie et de reanimation; 2014: Elsevier.
Wysocki M, Jouvet P, Jaber S. Closed loop mechanical ventilation. Journal of clinical monitoring and computing. 2014;28(1):49-56.
Schwilden H, Schüttler J. The determination of an effective therapeutic infusion rate for intravenous anesthetics using feedback-controlled dosages. Der Anaesthesist. 1990;39(11):603-6.
Engbers F, Dahan A. Anomalies in target‐controlled infusion: an analysis after 20 years of clinical use. Anaesthesia. 2018;73(5):619-30.
Mahajan V, Samra T, Puri G. Anaesthetic depth control using closed loop anaesthesia delivery system vs. target controlled infusion in patients with moderate to severe left ventricular systolic dysfunction. Journal of clinical anesthesia. 2017;42:106-13.
Zaouter C, Hemmerling TM, Lanchon R, Valoti E, Remy A, Leuillet S, et al. The feasibility of a completely automated total IV anesthesia drug delivery system for cardiac surgery. Anesthesia & Analgesia. 2016;123(4):885-93.
Dumont GA. Closed-loop control of anesthesia-a review. IFAC Proceedings Volumes. 2012;45(18):373-8.
Ghita M, Ghita M, Copot D. An overview of computer-guided total intravenous anesthesia and monitoring devices—Drug infusion control strategies and analgesia assessment in clinical use and research. Automated Drug Delivery in Anesthesia. 2020:7-50.
Ionescu CM, De Keyser R, Torrico BC, De Smet T, Struys MM, Normey-Rico JE. Robust predictive control strategy applied for propofol dosing using BIS as a controlled variable during anesthesia. IEEE Transactions on biomedical engineering. 2008;55(9):2161-70.
Sawaguchi Y, Furutani E, Shirakami G, Araki M, Fukuda K. A model-predictive hypnosis control system under total intravenous anesthesia. IEEE transactions on biomedical engineering. 2008;55(3):874-87.
Haddad WM, Hayakawa T, Bailey JM. Adaptive control for nonlinear compartmental dynamical systems with applications to clinical pharmacology. Systems & Control Letters. 2006;55(1):62-70.
Mahfouf M, Nunes CS, Linkens DA, Peacock JE. Modelling and multivariable control in anaesthesia using neural-fuzzy paradigms: Part II. closed-loop control of simultaneous administration of propofol and remifentanil. Artificial Intelligence in Medicine. 2005;35(3):207-13.
Ralph M, Beck CL, Bloom M, editors. ℒ 1-adaptive methods for control of patient response to anesthesia. Proceedings of the 2011 American Control Conference; 2011: IEEE.
Liu N, Chazot T, Trillat B, Pirracchio R, Law-Koune J-D, Barvais L, et al. Feasibility of closed-loop titration of propofol guided by the Bispectral Index for general anaesthesia induction: a prospective randomized study. European journal of anaesthesiology. 2006;23(6):465-9.
Copot D. Automated Drug Delivery in Anesthesia: Academic Press; 2020.
