Literature Survey on the Dependence of Demography on Depth of Anaesthesia

L. Disney Meitei, Project Asst. DoA, JNIMS

In this paper, I will make a short summary of information collected from a few publicly available studies, that I have
come across when I was tasked to do this survey as part of the project. Links to the studies which are available for open
access will be in each section. Doctors have been using General anaesthetics in medicine for more than a century without
a clear understanding of the underlying physiological mechanisms that regulate the transition from a wake state to an
anaesthetic-induced unconsciousness and from general anaesthesia to consciousness/wake state. Recent advances in the
field of neurobiology and the introduction of EEG based Depth of Anaesthesia monitors have made important
contributions towards the understanding of fundamental changes in brain activity brought about by general anaesthetics.
It has been known from the studies that differences in sensitivity to anaesthetic drugs exist among different ethnic
groups. Unfortunately these studies are a more than a decade old and no further studies showing demographic co-relation
and depth of anaesthesia monitoring could not be found.

Summary 1: Comparison of Propofol Consumption and Recovery Time in Caucasians from Italy, with Chinese,
Malays and Indians from Malaysia (Anaesth Intensive Care 2004; 32: 250-255)
O. ORTOLANI, A. CONTI, Y. K. CHAN, M. Y. SIE, G. S. Y. ONG https://journals.sagepub.com/doi/pdf/10.1177/0310057X0403200215

Dr O.Ortolani and his team has shown important differences have been found in propofol consumption between Indians,
Chinese and Malays in Malaysia and Caucasians in Italy. Patients undergoing total intravenous anaesthesia with
propofol and fentanyl were evaluated for propofol consumption and recovery time. The Bispectral Index (BIS) was used
to maintain the same anaesthesia depth in all patients. The BIS value, the response to verbal stimuli and eye-opening
time were used to assess recovery. In the study, Dr. Ortolani and his team made the following observation:

After propofol discontinuation, the BIS values returned to baseline in Time to eye-opening was
1. 11±4.2 min for Caucasians 1. 11.63±4.2 min in Caucasians
2. 12.5±5.1 min for Chinese 2. 13.23±4.9 min in Chinese
3. 15.9±6.3 min for Malays and 3. 16.97±5.2 min in Malays and
4. 22.1±8.1 for Indians. 4. 22.3±6.6 min in Indians.
Conclusion:The propofol consumption was significantly lower in Indians compared to the other three groups (P<0.01).
The recovery of Indians was much slower compared to Chinese, Malays and Caucasians. The recovery time of Malays
is significantly slower compared to Chinese and Caucasians. Differences in propofol consumption and recovery time
were not significant between Chinese and Caucasians, but the ratio recovery time/propofol consumption was
significantly lower in Caucasians compared to all the other groups. The results suggested pharmacokinetic or
pharmacodynamic differences do occur among different ethnic groups in relation to propofol (and possibly fentanyl).
Caution is also advised in applying their results to apparently similar ethnic groups living elsewhere. A
computerized propofol infusion scheme derived in one population should not be assumed to have the same effect if used
in a different ethnic group.
Summary 2: Ethnic differences in propofol and fentanyl response: a comparison among Caucasians, Kenyan Africans
and Brazilians
O Ortolani 1, A Conti, Z W Ngumi, L Texeira, P Olang, I Amani, V C Medrado

https://journals.lww.com/ejanaesthesiology/Fulltext/2004/04000/Ethnic_differences_in_propofol_and_fentanyl.11.aspx

Background and objective: Differences in sensitivity to anaesthetic drugs may exist among human races. Allelic
variants for drug metabolizing isoenzymes and other pharmacokinetic/pharmacodynamic differences may account for a
variable response to anaesthetic drugs. This study was designed to investigate comparatively the anaesthetic
requirements and the recovery trends of three different ethnic groups: Caucasians, African blacks and Brazilians.

Methods: The anaesthetic depth and recovery of groups of 45 patients undergoing total intravenous anaesthesia with
propofol and fentanyl were compared. The bispectral index and clinical parameters were used to assess the depth of
anaesthesia. The bispectral index, the response to verbal stimuli and the eye-opening time were used to assess recovery.
Results: After stopping propofol, the bispectral index values of Caucasians returned to the baseline in about 10.8 +/- 4
min, that of Kenyan African blacks in 18 +/- 7 min and that of Brazilians in a highly variable time ranging from 5 to 25
min, (14.9 +/- 9.9). The time from discontinuation of propofol and fentanyl infusion to eye opening was 18.8 +/- 7.1
min in African blacks (P < 0.01) and 13.5 +/- 8.8 min in Brazilians (P > 0.05) vs. 11.6 +/- 4.5 min in Caucasians. Time
to respond to verbal commands was 16.8 +/- 8 min in African blacks (P < 0.01) and 12.8 +/- 8.1 min in Brazilians (P >
0.05) vs. 9.9 +/- 4.5 min in Caucasians.

Conclusions: The recovery of Kenyan African blacks from anaesthesia with propofol and fentanyl is much slower, in
comparison with Caucasians. The recovery time of Brazilians is much more variable, in comparison with Caucasians.
Summary 3: Propofol consumption and recovery times after Bispectral index or cerebral state index guidance of
anaesthesia
E. Delfino, L. I. Cortinez, C. V. Fierro and H. R. Munoz https://pubmed.ncbi.nlm.nih.gov/19502288/

Background: The team compared the propofol requirements and recovery times when either the Bispectral index (BIS)
monitor or the cerebral state monitor (CSM) is used to guide propofol anaesthesia.

Methods: Forty patients undergoing laparoscopic

cholecystectomy were studied. All patients were
monitored with both monitors and were randomly
allocated into two groups according to the
monitor used to titrate propofol administration.
Propofol was administered to maintain BIS or
CSM within 40 and 60. Propofol consumption
and clinical markers of recovery were assessed
after surgery.
 Results: In the CSM group, the values of
cerebral state index (CSI) and BIS were 47 (5)
and 38 (6), respectively (P=0.00054). In the BIS
group, the values of CSI and BIS were 47 (5) and
45 (2), respectively (P=0.15). In the BIS group,
the total amount of propofol used was lower [109
(20) microg kg(-1) min(-1)] than in the CSM
group [130 (27) microg kg(-1) min(-1)]
(P=0.018). The time to eye opening was lower in
the BIS [7.2 (3.5) min] than in the CSM group
[10.7 (6.6)] (P=0.038). There were no
differences in fentanyl consumption, or in other clinical markers of recovery.

Conclusions: Compared with BIS, propofol anaesthesia guided with CSI resulted in 20% higher propofol doses. This,
however, does not lead to clinically relevant differences in recovery times.

References:
1. Propofol consumption and recovery times after bispectral index or cerebral state index guidance of anaesthesia
A E Delfino 1, L I Cortinez, C V Fierro, H R Muñoz BJA 2009 Jun 5
2. Ethnic differences in propofol and fentanyl response: a comparison among Caucasians, Kenyan Africans and Brazilians
O Ortolani 1, A Conti, Z W Ngumi, L Texeira, P Olang, I Amani, V C Medrado Eur J Anaesthesiol 2004 Apr 21

3. Comparison of Propofol Consumption and Recovery Time in Caucasians from Italy, with Chinese, Malays and Indians
from Malaysia O. ORTOLANI, A. CONTI, Y. K. CHAN, M. Y. SIE, G. S. Y. ONG (Anaesthesia Intensive Care 2004; 32: 250-255)

4. Monitoring the Depth of Anaesthesia

Bojan Musizza and Samo Ribaric , Sensors 2010, 10, 10896-10935: www.mdpi.com/journal/sensors