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Control of Experimental Perioperative Hypotension Using Phenylephrine Infusion Controlled by

Anesthesiologist versus Computerized Closed Loop Algorithm


Nicole R. Marques, Sean Funston, William Whitehead, Mindy Milosch, Muzna Khan, Upendar Kallu, Karolos Grigoriadis, George Kramer
University of Texas Medical Branch, Department of Anesthesiology
University of Houston, Department of Mechanical Engineering

INTRODUCTION

CLOSED LOOP SYSTEM - PACCS

REPRESENTATIVE STUDY

Perioperative episodes of hypotension increase the risk of


cardiovascular events and mortality.

MD vs.CL blood pressure control with phenylephrine infusion


MAP = MAP measured - MAP Target (mmHg)

Tight control of perioperative blood pressure (BP) using automated


closed loop (CL) control of pressor infusion is one approach to
mitigate these risks.
We developed a prototype automated critical care system (PACCS)
for decision support and closed loop delivery of fluid and drugs.
Objective: Test the performance of the closed loop pressor
algorithm and compare it to that of an expert anesthesiologist.

METHODS
The PACCS integrates:
vital sign monitor (Philips MP2)

Philips MP2

Body Guard Twin


IV Drug Pump

IV pump (Body Guard)


tablet PC (Panasonic H2) using Java-based software
Phenylephrine (PHP) infusion was controlled by a PI-AW algorithm
(proportional integral with anti-windup).

Panasonic Toughbook H2

5 anesthetized pigs subjected to hypotensive challenge induced by


a 1-hour fluctuating infusion of nitroprusside.

Fig 1: MAP measured - MAP target ( mmHg)


during a 1-hour study for 5 animals.
20

Treatment objective was to maintain mean arterial pressure (MAP)


with phenylephrine infusion to a MAP target.

RESULTS
MAP was maintained within 5 mmHg of MAP target as followed:
CL group: 90% of the time
MD group: 54% of the time (P = 0.08)
PHP infusion rate was adjusted 41 25 times during one hour
protocol.

mmHg

CONCLUSION

-10

75

-20

MD group
-30
20

10

20

30

40

50

MD

% time

A randomized cross-over design using PACCS versus a bedside


anesthesiologist focused on BP monitoring and adjusting infusion
rate.

100

10

60

The PACCS maintained MAP as well or better than a focused,


experienced anesthesiologist.

CL

Cruise control pressor therapy with caregiver override has the


potential to reduce perioperative BP variability, hypotension and
allow the anesthesiologist to focus in other key tasks.

50

10
mmHg

A set goal MAP of ~ 10 mmHg above baseline.

Fig 2: Percentage of time (%) that MAP


measured was within target

REFERENCES

25

-10
-20

CL group

-30
0

10

20

Minutes

30

40

50

60

-20

-15

-10
-5
0
5
10
15
MAP measured - MAP target (mmHg)

20

INTRODUCTION
Perioperative episodes of hypotension increase the risk of cardiovascular
events and mortality.
Tight control of perioperative blood pressure (BP) using automated closed
loop (CL) control of pressor infusion is one approach to mitigate these
risks.
We developed a prototype automated critical care system (PACCS) for
decision support and closed loop delivery of fluid and drugs.

Objective: Test the performance of the closed loop pressor algorithm and
compare it to that of an expert anesthesiologist.

METHODS

The PACCS integrates:


vital sign monitor (Philips MP2)
IV pump (Body Guard)
tablet PC (Panasonic H2) using Java-based software

Phenylephrine (PHP) infusion was controlled by a PI-AW algorithm (proportional


integral with anti-windup)
5 anesthetized pigs subjected to hypotensive challenge induced by a 1-hour
fluctuating infusion of nitroprusside.
Treatment objective was to maintain mean arterial pressure (MAP) with
phenylephrine infusion to a MAP target.
A set goal MAP of ~ 10 mmHg above baseline.
A randomized cross-over design using PACCS versus a
anesthesiologist focused on BP monitoring and adjusting infusion rate.

bedside

Philips MP2

Body Guard Twin


IV Drug Pump

Panasonic Toughbook H2

RESULT

MAP was maintained within 5 mmHg of MAP target as followed:


CL group: 90% of the time
MD group: 54% of the time (P = 0.08)
PHP infusion rate was adjusted 41 25 times during one hour protocol.

Fig 1: MAP measured - MAP target ( mmHg)


during a 1-hour study for 5 animals
20

mmHg

10
0
-10
-20
-30
20 0

10

20

10

20

30

40

50

60

mmHg

10
0
-10

-20
-30
0

Minutes

30

40

50

60

Fig 2: Percentage of time (%) that MAP measured was within target

100

75
% time

MD
50

CL

25

0
-20

-15

-10
-5
0
5
MAP measured - MAP target (mmHg)

10

15

20

REPRESENTATIVE STUDY
MD vs.CL blood pressure control with phenylephrine infusion

MAP = MAP measured - MAP Target (mmHg)

CONCLUSION

The PACCS maintained MAP as well or better than a focused, experienced


anesthesiologist.
Cruise control pressor therapy with caregiver override has the potential to
reduce perioperative BP variability, hypotension and allow the
anesthesiologist to focus in other key tasks.