Assessment of surgical stress during general anaesthesia

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Assessment of surgical stress during general anaesthesia M. Huiku, K. Uutela, M. van Gils, I. Korhonen, M. Kymäläinen, P. Meriläinen, M. Paloheimo, M. Rantanen, P. Takala, H. Viertiö-Oja, A. Yli-Hankala British Journal of Anaesthesia Volume 98, Issue 4, Pages 447-455 (April 2007) DOI: 10.1093/bja/aem004 Copyright © 2007 British Journal of Anaesthesia Terms and Conditions

Fig 1 Search of the parameter model for surgical stress. (a) Correlation analysis of the candidate parameters with the predicted remifentanil effect-site concentration (open bars) and severity of stimulation (filled bars). The bars show the median (vertical line), the low and high quartiles (the box), and the minimum and maximum values without outliers (the line ends; open circles for outliers) of the correlation coefficients calculated for each patient. (b) Comparison of different models explaining the total, TSS. The graph shows the decrease in the unexplained variability as more parameters are added. PPGAnorm, normalized photoplethysmographic pulse amplitude; HBInorm, normalized heart beat interval; RRI S/V, sympatho-vagal ratio of the heart rate variability; RE, response entropy; NIBP SYS, systolic non-invasive blood pressure; PTT, pulse transit time. British Journal of Anaesthesia 2007 98, 447-455DOI: (10.1093/bja/aem004) Copyright © 2007 British Journal of Anaesthesia Terms and Conditions

Fig 2 SSI during general anaesthesia in all patients [mean (se)]. The effect-site target concentration of remifentanil (Ce) was cycled between 1, 3, and 5 ng ml−1 in the development set, and between 1 and 5 ng ml−1 in the validation set for each patient during surgery. Therefore, the SSI average data over the surgery at each remifentanil target level include data segments from each patient; the other SSI data include data only from a certain subgroup of patients. British Journal of Anaesthesia 2007 98, 447-455DOI: (10.1093/bja/aem004) Copyright © 2007 British Journal of Anaesthesia Terms and Conditions

Fig 3 SSI, the remifentanil concentration, raw PPGA, and heart rate during general anaesthesia. Time (hh:mm) is on the x-axis. Intubation at remifentanil 5 ng ml−1 was done at 12:07 and incision at remifentanil less than 1 ng ml−1 at 12:20. The propofol infusion was kept constant during the whole operation. HR, heart rate; PPGA, photoplethysmographic pulse amplitude; Remif. Ce, effect-site concentration of remifentanil; SSI, surgical stress index. British Journal of Anaesthesia 2007 98, 447-455DOI: (10.1093/bja/aem004) Copyright © 2007 British Journal of Anaesthesia Terms and Conditions

Fig 4 Normalization transformation. (a) Transformation function. The x-scale, referring to the input value of the parameter, either HBI or PPGA, is arbitrary. The upper plot represents the histogram of the input parameter values for the a priori (group) average data, the second plot shows the histogram of individual patient data, and the third plot depicts a combination of these two. The normalization transformation function, the cumulative distribution, is presented in the bottom plot. The input value is first mapped onto the transformation curve and from there to the percentage output, as shown by the arrows. (b) An example of the normalization. The transformation from the original raw PPGA to the normalized PPGA (PPGAnorm) and from the original HBI to the normalized HBI (HBInorm) are shown for one patient during general anaesthesia. The responses to electric tetanic stimuli (50 mA, 50 Hz, 30 s on the ulnar nerve) and skin incision are indicated by vertical lines. The predicted remifentanil and propofol effect-site concentrations are plotted in the bottom plot. British Journal of Anaesthesia 2007 98, 447-455DOI: (10.1093/bja/aem004) Copyright © 2007 British Journal of Anaesthesia Terms and Conditions