Ana Castro Lecture Series in Biomedical Signal and Image Processing MIM2013

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1 Ana Castro Lecture Series in Biomedical Signal and Image Processing MIM2013 Instituto de Telecomunicações Faculdade de Ciências da Universidade do Porto Porto, 16th March 2013

2 pain can be defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage International Association for the Study of Pain

3 Hypnosis Electroencephalogram Analgesia Heart Rate Blood Pressure Tears Sweat Muscle Paralysis Movement Electromiogram General Anaesthesia

4 Awareness and Pain

5 Michael Jackson Trial Monitor and Titrate

6 Environmental stimulus (light, sound, temperature, etc.) Perception of type and intensity of environmental stimulus Feedback control Accessory structures Central nervous system Sensory receptor Train of nerve impulses over specific nerve pathway

7 Experimental Methods of Pain Induction Cutaneous Muscular Visceral Electrical Thermal Mechanical Chemical Ischemia Exercise Electrical Mechanical Chemical Electrical Thermal Mechanical Chemical

Visual analogue scale: No Pain Very Severe Pain Numerical rating

Moderate Pain Severe Pain Very Severe Pain R. Melzack and W. S. Torgerson.

8 Visual analogue scale: No Pain Very Severe Pain Numerical rating scale: 100mm Verbal scale: No Pain Light Pain Moderate Pain Severe Pain Very Severe Pain R. Melzack and W. S. Torgerson. On the language of pain. Anesthesiology, 34(1): 50-59, F. Varoli and V. Pedrazzi. Adapted version of the McGill pain questionnaire to brazilian portuguese. Brazilian Dental Journal, 17(4): , 2006.

9 Remifentanil C. F. Minto, T. W. Schnider, T. G. Short, K. M. Gregg, A. Gentilini, and S. L.Shafer. Response surface model for anesthetic drug interactions. Anesthesiology, 92(6): , 2000.

10 Cardiovascular, EMG and EEG Derived Indexes Evoked Responses Objective Nociception Measurement Facial Electromyography Pupil Diameter Skin Conductance

13 Interpatient Variability + Intrapatient Variability Design adequate clinical protocol Inclusion criteria Data to collect Submit to the institution s Ethics Committee Written informed consent

14 Passive nociception assessment Active nociception assessment Interpatient Variability + Intrapatient Variability

15 Study Groups Remifentanil Effect-Site Concentration 2.0ng/ml Remifentanil Effect-Site Concentration 3.0ng/ml Remifentanil Effect-Site Concentration 4.0ng/ml Phase I Phase II Response to precise noxious stimuli: laringoscopy/intubation; tetanic stimulus; incision. Response of physiological variables to different combinations of stimulus intensity and drug doses: Remifentanil ascending/descending steps.

of the Anesthesiology, Emergency and Intensive Care Department President of the Administration Council Submission for appreciation

16 Clinical Protocol Design Main Researcher and Responsible Researcher Authorizations: Dir. of the Anesthesiology Service Dir. of the Operating Room Dir. of the Anesthesiology, Emergency and Intensive Care Department President of the Administration Council Submission for appreciation by the Research Coordination Office (Department of Education, Training and Research - DEFI) Authorization: DEFI Director Submission for appreciation by the Ethics Committe (CES) Authorization: CES President Research Study Start Data Collection

17 A B C D A BIS Monitor; B Orchestra pumps C Datex monitor; D Ruglopp II Waves

21 Hypnotic h (known) Analgesic a (known) Stimulus s (estimated) Patient System f(h, a, s) Outer Interferences Triggered Nociception/ Anti-Nociception Responses f

22 A total of 35 stimuli have been evaluated Target: Sociedade Portuguesa de Anestesia (SPA) and Anaesthesiologists from Centro Hospitalar do Porto Rasch Model G. Rasch. Probabilistic Models for Some Intelligence and Attainment Tests. Danish Institute for Educational Research, Copenhagen, Expanded edition, Chicago: Mesa Press, J. M. Linacre. Many-facet Rasch measurement. Mesa Press, Chicago, 2nd edition, 1994.

25 Study physiological responses to precise noxious stimuli Phase I HR, SBP, PPGA, ANSSI, BIS, EMG and EMG SD Analyze maintenance phase of general anaesthesia, and the impact of different anaesthetic drugs combinations Phase II Steady-State Detection Physiological Modelling

26 Abnormalities Detection Wavelet Transform Steady-Sate Index S. Mallat and S. Zhong. Characterization of signals from multiscale edges. Pattern Analysis and Machine Intelligence, IEEE Transactions on Signal Processing, 14(7): , T. Jiang, B. Chen, X. He, and P. Stuart. Application of steady-state detection method based on wavelet transform. Computers and Chemical Engineering, 27 (4): , 2003.

27 Input Steady-State β In Hypnotic Propofol Ce System PATIENT Analgesic Remifentanil Ce Output Variables Output Steady-State β Out

28 Outputs

Third order neurons project from the thalamus to the primary sensor cortex where the conscious perception of pain occurs. C. Thornton and R. M.

31 The nociceptive signal is transmitted over small diameter A-δ and C-fibers in the dorsal horn, via the dorsal root ganglion. Second order neurons relay the signal to the thalamus via the spinothalamic tract. Third order neurons project from the thalamus to the primary sensor cortex where the conscious perception of pain occurs. C. Thornton and R. M. Sharpe. Evoked responses in anaesthesia. British Journal of Anaesthesia, 81(5):771781, A. Kumar, A. Bhattacharya, and N. Makhija. Evoked potential monitoring in anaesthesia and analgesia. Anaesthesia, 55(3):225241, 2000.

32 Cortical Site Cervical Site

33 Sensitive (ST), Motor (MT) and Painful Threshold (PT) C A D B A Nicolet Viasys; B Medial stimulus electrodes C Datex monitor; D BIS sensor

34 ST Sensitive Threshold MT Motor Threshold PT Painful Threshold

35 Baseline Normalization

36 * * Maximum Effect Pharmacodynamic Model

38 Monitoring: HR BP PPGA Analgesia Analgesic General Anaesthesia Muscle Relaxant Paralysis Hypnosis Hypnotic Monitoring: EMG Movement Monitoring: EEG EP

39 Hypnosis Control Validated consciousness monitors Pharmacodynamic models Fast acting/excreted hypnotic drug R. K. Ellerkmann, M. Soehle, T. M. Alves, V. M. Liermann, I. Wenningmann, H. Roepcke, S. Kreuer, A. Hoeft, and J. Bruhn. Spectral entropy and bispectral index as measures of the electroencephalographic eects of propofol. Anesthesia and Analgesia, 102(5): , 2006.

40 Drug Dose Cp Ce PK Model PD Model Ce to Effect Noc/ANoc Balance k e0 Parameter Estimation (estimated deviations) Model Structure Ce Effect Parameters Estimation (estimated deviations) Noc/ANoc Index

42 Why is nociception monitoring important? Patient wellbeing Unable to communicate patients Post-operative persistent/chronic pain Long-term effects of anesthetics Titrate the anesthesia triad Automatic control of anesthesia 42

44 Hospital de Santo António, Centro Hospitalar do Porto Serviço de Anestesiologia Serviço de Bloco Operatório Departamento de Anestesiologia, Emergência e Cuidados Intensivos Departamento de Ensino Formação e Investigação Conselho de Administração Neurinbloc Luis Filipe Silva e Helena Silva Markku Paloheimo, ANSSI developer Aspect Medical Systems, CVI developers, Gabriele Sennholz Medstorm, Stress Detector developers, and Speculum Faculdade de Engenharia da Universidade do Porto Fundação para a Ciência e a Tecnologia Instituto de Telecomunicações

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