Entropy-guided sevoflurane administration during cardiopulmonary bypass surgery in the paediatric population

Abstract

Background

Maintaining optimal anesthetic depth during cardiopulmonary bypass (CPB) in pediatric patients is challenging due to altered physiology and unreliable conventional monitoring. Entropy, a processed electroencephalogram metric, offers a potential solution. This study aimed to evaluate the relationship between end oxygenator sevoflurane concentration and entropy values during pediatric CPB using fixed-dose versus entropy-guided sevoflurane administration.

Methodology

A prospective, randomized study was conducted on 62 pediatric patients undergoing congenital heart surgery with CPB. Patients were allocated into two groups: Group A received fixed-dose sevoflurane (1% v/v), and Group B received sevoflurane titrated to maintain entropy values between 40 and 60. Parameters such as end oxygenator sevoflurane concentration, entropy (Response and State entropy, RE and SE), and sevoflurane consumption were recorded intraoperatively. Postoperative hemodynamic data, length of stay, and complication rates were assessed.

Results

Entropy-guided patients showed significantly higher end oxygenator sevoflurane concentrations [1.64 (1.51–1.85)% versus 1.0%, p = .001] and sevoflurane consumption (1.26 ± 0.12 vs 0.645 ± 0.03 mL/min, p = .001). RE and SE values were significantly lower in the entropy group (p = .001), indicating better anesthetic depth control. A negative correlation was found between entropy and sevoflurane concentration (r = −0.6987, p = .02). Despite higher postoperative inotropic scores in the entropy group (p = .001), no significant differences were found in length of stay, mechanical ventilation duration, or morbidity and mortality rates between groups.

Conclusion

Entropy-guided sevoflurane administration during pediatric CPB provides improved anesthetic depth control at the cost of higher anesthetic and inotropic requirements. However, it does not adversely affect clinical outcomes, supporting its safety and potential utility in refining pediatric anesthesia practices.

Keywords

cardiopulmonary bypass congenital cardiac surgery entropy paediatric sevoflurane

Get full access to this article

View all access options for this article.

References

Barry

Chaney

London

. Anesthetic management during cardiopulmonary bypass: a systematic review. Anesth Analg 2015; 120(4): 749–769.

Nigro Neto

Landoni

Cassarà

, et al. Use of volatile anesthetics during cardiopulmonary bypass: a systematic review of adverse events. J Cardiothorac Vasc Anesth 2014; 28(1): 84–89.

McMullan

Alston

Tyrrell

. Volatile anaesthesia during cardiopulmonary bypass. Perfusion 2015; 30(1): 6–16.

Takamatsu

Ozaki

Kazama

. Entropy indices vs the bispectral index for estimating nociception during sevoflurane anaesthesia. Br J Anaesth 2006; 96: 620–626.

Wycherley

Bembridge

. Monitoring techniques; neuromuscular blockade and depth of anaesthesia. Intensive Care Med 2017; 18: 324–327.

Rogobete

Bedreag

Sandesc

. Entropy-guided depth of anesthesia in critically ill polytrauma patients. J Interdiscip Med 2017; 2: 10–11.

Cotae

Grintescu

. Entropy—the need of an ally for depth of anesthesia monitoring in emergency surgery. Cent Eur Ann Clin Res 2019; 1(1): 1–3.

Kennedy

Baker

. The effect of cardiac output changes on end-tidal volatile anaesthetic concentrations. Anaesth Intensive Care 2001; 29: 535–538.

Kumar

Ramamurthy

Tiwari

, et al. Fast-tracking with continuous thoracic epidural analgesia in paediatric congenital heart surgeries: an institutional experience. Indian J Thorac Cardiovasc Surg 2022; 38(5): 469–480.

10.

Xiong

Liu

Shu

, et al. Effects of sevoflurane inhalation during cardiopulmonary bypass on pediatric patients: a randomized controlled clinical trial. ASAIO J 2016; 62(1): 63–68.

11.

Kumar

Ghotra

Shukla

, et al. Optimising sevoflurane administration during paediatric cardiopulmonary bypass. J Anesthetic Anesthesiol 2023; 5(2): 140–148.

12.

Viertiö-Oja

Maja

Särkelä

, et al. Description of the entropy algorithm as applied in the datex-ohmeda S/5 entropy module. Acta Anaesthesiol Scand 2004; 48(2): 154–161.

13.

Klockars

Hiller

Ranta

, et al. Spectral entropy as a measure of hypnosis in children. Anesthesiology 2006; 104(4): 708–717.

14.

Vakkuri

Yli-Hankala

Sandin

, et al. Spectral entropy monitoring is associated with reduced propofol use and faster emergence in propofol-nitrous oxide–alfentanil anesthesia. Anesthesiology 2005; 103(2): 274–279.

15.

Liu

Chazot

Hamada

, et al. Closed-loop co-administration of propofol and remifentanil guided by the bispectral index: a randomized multicenter study. Anesth Analg 2016; 122(2): 288–295.

16.

Musizza

Ribaric

. Monitoring the depth of anaesthesia. Sensors 2010; 10(12): 10896–10935.

17.

Aimé

Verroust

Masson-Lefoll

, et al.

Does monitoring bispectral index or spectral entropy reduce sevoflurane use?

Anesth Analg 2006; 103(6): 1469–1477.

18.

Bautin

Siganevich

Malaya

, et al. Correlation of cardiac output and sevoflurane required to maintain anesthetic depth targeted with entropy index. Ann Card Anaesth 2014; 17: 4–7.

19.

Hudson

Hemmings

. Pharmacokinetics of inhaled anesthetics. In: Hemmings

Egan

(eds). Pharmacology and physiology for anesthesia. 2nd ed. Elsevier Inc., 2019, pp. 44–69.

20.

Nitzschke

Wilgusch

Kersten

, et al. Changes in sevoflurane plasma concentration with delivery through the oxygenator during on-pump cardiac surgery. Br J Anaesth 2013; 110: 957–965.

21.

Barry

Chaney

London

. Anesthetic management during cardiopulmonary bypass: a systematic review. Anesth Analg 2015; 120(4): 749–769.

22.

Wakasugi

Hirota

Doi

, et al. Estimation of volatile anesthetic concentrations during CPB: comparison between oxygenator outflow and end-tidal concentrations. J Cardiothorac Vasc Anesth 2009; 23(3): 348–353.

23.

Wollman

Scher

. Monitoring volatile anesthetic concentrations during CPB. Anesth Analg 2003; 96(3): 777–783.

24.

Sebel

Bowdle

Ghoneim

, et al. The incidence of awareness during anesthesia: a multicenter United States study. Anesth Analg 2004; 99(3): 833–839.

25.

Malviya

Voepel-Lewis

Tait

, et al. Depth of sedation in children undergoing CT scan: validity and reliability of the university of Michigan Sedation Scale (UMSS). Br J Anaesth 2006; 96(6): 725–730.

26.

Choi

Lim

Lee

, et al. Spectral entropy monitoring allowed lower sevoflurane concentration and faster recovery in children. Acta Anaesthesiol Scand 2010; 54(7): 859–862.

27.

Davidson

Huang

Rebmann

, et al. Performance of entropy and Bispectral Index as measures of anaesthesia effect in children of different ages. Br J Anaesth 2005; 95(5): 674–679.

28.

Nader

Khadra

, et al. Anesthetic myocardial protection with sevoflurane. J Cardiothorac Vasc Anesth 2004; 18(3): 269–274.

29.

Gaies

Gurney

Yen

, et al. Vasoactive-inotropic score as a predictor of morbidity and mortality in infants after cardiopulmonary bypass. Pediatr Crit Care Med 2010; 11(2): 234–238.

30.

Myles

Leslie

McNeil

, et al. Bispectral index monitoring to prevent awareness during anaesthesia: the B-Aware randomised controlled trial. Lancet 2004; 363(9423): 1757–1763.

31.

Avidan

Jacobsohn

Glick

, et al. Prevention of intraoperative awareness in a high-risk surgical population. N Engl J Med 2011; 365(7): 591–600.

32.

Davidson

Sun

. Clinical evidence for the neurotoxicity of anaesthesia in children. Br J Anaesth 2004; 113(Suppl 2): ii9–ii13.

33.

Hans

Dewandre

Brichant

, et al. Comparative effects of ketamine on bispectral index and spectral entropy of the electroencephalogram under sevoflurane anaesthesia. Br J Anaesth 2005; 94(3): 336–340.