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Background: Closed-loop control of anesthesia involves continual adjustment of drug infusion rates according to measured clinical effect. The NeuroSENSE monitor provides an electroencephalographic measure of depth of hypnosis (wavelet-based anesthetic value for central nervous system monitoring [WAVCNS]). It has previously been used as feedback for closed-loop control of propofol, in a system designed using robust control engineering principles, which implements features specifically designed to ensure patient safety. Closed-loop control of a second drug, remifentanil, may be added to improve WAVCNS stability in the presence of variable surgical stimulation. The objective of this study was to design and evaluate the feasibility of a closed-loop system for robust control of propofol and remifentanil infusions using WAVCNS feedback, with an infusion safety system based on the known pharmacological characteristics of these 2 drugs., Methods: With Health Canada authorization, research ethics board approval, and informed consent, American Society of Anesthesiologists I-III adults, requiring general anesthesia for elective surgery, were enrolled in a 2-phase study. In both phases, infusion of propofol was controlled in closed loop during induction and maintenance of anesthesia, using WAVCNS feedback, but bounded by upper- and lower-estimated effect-site concentration limits. In phase I, remifentanil was administered using an adjustable target-controlled infusion and a controller was designed based on the collected data. In phase II, remifentanil was automatically titrated to counteract rapid increases in WAVCNS., Results: Data were analyzed for 127 patients, of median (range) age 64 (22-86) years, undergoing surgical procedures lasting 105 (9-348) minutes, with 52 participating in phase I and 75 in phase II. The overall control performance indicator, global score, was a median (interquartile range) 18.3 (14.2-27.7) in phase I and 14.6 (11.6-20.7) in phase II (median difference, -3.25; 95% confidence interval, -6.35 to -0.52). The WAVCNS was within ±10 of the setpoint for 84.3% (76.6-90.6) of the maintenance of anesthesia in phase I and 88.2% (83.1-93.4) in phase II (median difference, 3.7; 95% confidence interval, 0.1-6.9). The lower propofol safety bound was activated during 30 of 52 (58%) cases in phase I and 51 of 75 (68%) cases in phase II., Conclusions: Adding closed-loop control of remifentanil improved overall controller performance. This controller design offers a robust method to optimize the control of 2 drugs using a single sensor. The infusion safety system is an important component of a robust automated anesthesia system, but further research is required to determine the optimal constraints for these safe conditions.

Background: Recent research and advances in the automation of anesthesia are driving the need to better understand electroencephalogram (EEG)-based anesthesia end points and to test the performance of anesthesia monitors. This effort is currently limited by the need to collect raw EEG data directly from patients., Methods: A procedural method to synthesize EEG signals was implemented in a mobile software application. The application is capable of sending the simulated signal to an anesthesia depth of hypnosis monitor. Systematic sweeps of the simulator generate functional monitor response profiles reminiscent of how network analyzers are used to test electronic components., Results: Three commercial anesthesia monitors (Entropy, NeuroSENSE, and BIS) were compared with this new technology, and significant response and feature variations between the monitor models were observed; this includes reproducible, nonmonotonic apparent multistate behavior and significant hysteresis at light levels of anesthesia., Conclusions: Anesthesia monitor response to a procedural simulator can reveal significant differences in internal signal processing algorithms. The ability to synthesize EEG signals at different anesthetic depths potentially provides a new method for systematically testing EEG-based monitors and automated anesthesia systems with all sensor hardware fully operational before human trials.