title: Availability of anesthetic effect monitoring: utilization, intraoperative management and time to extubation in liver transplantation.
abstract: Titration of volatile anesthetics to anesthetic effect monitoring using the bispectral index (BIS) has been shown to decrease anesthetic requirements and facilitate recovery from anesthesia unrelated to liver transplantation (OLT). To determine whether availability of such monitoring influences its utilization pattern and affect anesthetic care and outcomes in OLT, we conducted a retrospective analysis in recipients with and without such monitoring. We evaluated annual BIS utilization over a period of 7 years, and compared 41 BIS-monitored patients to 42 controls. All received an isoflurane/air/oxygen and opioid-based anesthetic with planned postoperative ventilation. Data collection included age, body mass index (BMI), gender, Model for End-stage Liver Disease (MELD) score, and time to extubation (TtE). Mean preanhepatic, anhepatic, and postanhepatic end-tidal isoflurane concentrations were compared, as well as BIS values for each phase of OLT using the Kruskal-Wallis and Wilcoxon signed-rank tests, respectively. The use of anesthetic effect monitoring when available increased steadily from 15% of cases in the first year to almost 93% by year 7. There was no significant difference in age, gender, BMI, MELD, or TtE between groups. The BIS group received less inhalational anesthetic during each phase of OLT compared to the control group. However, this difference was statistically significant only during the anhepatic phase (P = .026), and was clinically not impressive. Within the BIS group, the mean BIS value was 38.74 ± 5.25 (mean ± standard deviation), and there was no difference for the BIS value between different transplant phases. Availability of anesthetic effect monitoring as an optional monitoring tool during OLT results in its increasing utilization by anesthesia care teams over time. However, unless integrated into an intraoperative algorithm and an early extubation protocol for fast tracking of OLT recipients, this utilization does not appear to provide a clinical benefit but instead drives cost.
authors.affiliation: Department of Anesthesiology, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts 02111, USA. rschumann@tuftsmedicalcenter.org
authors.forename: R
authors.initials: R
authors.lastname: Schumann
authors.forename: J
authors.initials: J
authors.lastname: Hudcova
authors.forename: I
authors.initials: I
authors.lastname: Bonney
authors.forename: M S
authors.initials: MS
authors.lastname: Cepeda
mesh_terms: D000328:Adult; D000777:Anesthetics / Q000008:administration & dosage*; D005260:Female; D006801:Humans; D007430:Intraoperative Care; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D008991:Monitoring, Physiologic
chemical_list: D000777:Anesthetics