Abstract
Liver transplantation (LT) recipients are known to require less anesthetic agents. Providing minimally required anesthetics while avoiding awareness is especially important in LT recipients because it would help manage perioperative hemodynamic instability with less vasopressor and fast track recovery. This study aims to compare state entropy (SE) against bispectral index (BIS) during isoflurane anesthesia in LT. We adjusted anesthesia to BIS values 40 - 60, and compared it with concomitant SE values. BIS, SE values, and anesthetic requirements according to liver failure severity, etiology and LT stages were analyzed. For BIS-SE differences, SE value that is different from the concomitant BIS by more than 15 was defined as a significant disagreement. Mann Whitney, Kruskal Wallis test and a Poisson exact test were used for analysis. The BIS-SE pair sets of 2895 from 38 patients were analyzed. BIS, SE values and anesthetic requirements were significantly lower in MELD ≥ 20 (p < 0.001 in all) and in alcoholic etiology (p < 0.001 in all). For BIS-SE differences, 320 disagreement data pairs were seen at a rate of 1.33 times/hr (95% CI = [1.19, 1.48], p < 0.001). A significant disagreement was delineated in MELD score ≥ 20 (3.04 times/hr, CI = [2.64, 3.49], p < 0.001), alcoholic etiology (3.19 times/hr, [2.67, 3.78], p < 0.001) and postreperfusion stage (1.63 times/hr, [1.43, 1.85], p < 0.001). In these significant BIS-SE differences, 95.9% (307/320 disagreement data pairs) showed higher BIS than SE. In conclusion, in high MELD and alcoholic etiology, anesthetic requirements were significantly less, and BIS and SE showed great discrepancy with lower SE values. Therefore, when SE monitoring is used during LT, anesthesiologists may need to consider that in high MELD and alcoholic etiology, SE tends to show lower values than the concomitant BIS values that are within optimal anesthetic depth ranges.
Highlights
Defining a proper anesthetic depth in patients with end stage liver diseases (ESLD) is an important concern to anesthesiologists caring for recipients of liver transplantation (LT)
May 12, 2021 may need to consider that in high model for end-stage liver disease (MELD) and alcoholic etiology, state entropy (SE) tends to show lower values than the concomitant bispectral index (BIS) values that are within optimal anesthetic depth ranges
Seven of 45 patents were excluded because SQI data were not collected in the first three patients (#1, 2, 3), remifenanil was used intraoperatively in two patients (#28, 34), sevoflurane was used throughout the surgery in one patient (#37) and an entropy sensor posed error during monitoring in one patient (#44)
Summary
Defining a proper anesthetic depth in patients with end stage liver diseases (ESLD) is an important concern to anesthesiologists caring for recipients of liver transplantation (LT). These patients are known to show decreased sensitivity to pain and reduced requirement for anesthetics, partly because of increased endogenous opioid peptides and pathophysiology of ESLD [1] [2] [3] [4]. Providing minimally required anesthetics can prevent too profound anesthesia and help manage hemodynamic instability with a decreased need for vasopressors [5]. EntropyTM (GE Healthcare, Helsinki, Finland) is a commonly used frontal electroencephalogram
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