title: Feasibility of closed-loop titration of propofol and remifentanil guided by the bispectral monitor in pediatric and adolescent patients: a prospective randomized study.
abstract: BACKGROUND
  This study was designed to assess the feasibility of dual closed-loop titration of propofol and remifentanil guided solely by the Bispectral Index (BIS) monitor in pediatric and adolescent patients during anesthesia.
  
  
  METHODS
  Children undergoing elective surgery in this single-blind randomized study were allocated into the closed-loop (auto) or manual (manual) group. Primary outcome was the percentage of time with the BIS in the range 40 to 60 (BIS40-60). Secondary outcomes were the percentage of deep (BIS<40) anesthesia and drug consumption. Data are presented as median (interquartile range) or number (%).
  
  
  RESULTS
  Twenty-three patients (12 [10 to 14] yr) were assigned to the auto group and 19 (14 [7 to 14] yr) to the manual group. The closed-loop controller was able to provide induction and maintenance for all patients. The percentage of time with BIS40-60 was greater in the auto group (87% [75 to 96] vs. 72% [48 to 79]; P = 0.002), with a decrease in the percentage of BIS<40 (7% [2 to 17] vs. 21% [11 to 38]; P = 0.002). Propofol (2.4 [1.9 to 3.3] vs. 1.7 [1.2 to 2.8] mg/kg) and remifentanil (2.3 [2.0 to 3.0] vs. 2.5 [1.2 to 4.3] μg/kg) consumptions were similar in auto versus manual groups during induction, respectively. During maintenance, propofol consumption (8.2 [6.0 to 10.2] vs. 7.9 [7.2 to 9.1] mg kg h; P = 0.89) was similar between the two groups, but remifentanil consumption was greater in the auto group (0.39 [0.22 to 0.60] vs. 0.22 [0.17 to 0.32] μg kg min; P = 0.003). Perioperative adverse events and length of stay in the postanesthesia care unit were similar.
  
  
  CONCLUSIONS
  Intraoperative automated control of hypnosis and analgesia guided by the BIS is clinically feasible in pediatric and adolescent patients and outperformed skilled manual control.
authors.affiliation: From the Service d'Anesthésie Réanimation, Hôpital Universitaire Necker-Enfants Malades, Université Paris Descartes, Assistance Publique-Hôpitaux de Paris, Paris, France (G.A.O., F.B.L., P.G.); Service d'Anesthésie Réanimation, Hôpital Foch, Suresnes, France (T.C., M.F., N.L.); and the Outcomes Research Consortium, Cleveland Clinic, Cleveland, Ohio (N.L.).
authors.forename: Gilles A
authors.initials: GA
authors.lastname: Orliaguet
authors.forename: Fatema
authors.initials: F
authors.lastname: Benabbes Lambert
authors.forename: Thierry
authors.initials: T
authors.lastname: Chazot
authors.forename: Pauline
authors.initials: P
authors.lastname: Glasman
authors.forename: Marc
authors.initials: M
authors.lastname: Fischler
authors.forename: Ngai
authors.initials: N
authors.lastname: Liu
mesh_terms: D000293:Adolescent; D018686:Anesthetics, Intravenous / Q000008:administration & dosage*; D002648:Child; D056805:Consciousness Monitors; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D008297:Male; D016343:Monitoring, Intraoperative / Q000295:instrumentation / Q000379:methods*; D010880:Piperidines / Q000008:administration & dosage*; D015742:Propofol / Q000008:administration & dosage*; D011446:Prospective Studies; D000077208:Remifentanil; D016037:Single-Blind Method
chemical_list: D018686:Anesthetics, Intravenous; D010880:Piperidines; D000077208:Remifentanil; D015742:Propofol