Emergence Simulator v3

Select operating mode:

Or enter T₀ manually:

Patient Demographics

Age (yr)

Weight (kg)

Height (cm)

Sex

ASA status

BMI (auto)

Surgery type

Induction time (T₀)

Smoker PONV/motion hx Obese BMI>35 Elderly >70 Pediatric <16

Premedications time from premed to induction reduces emergence

No premedications added.

Patient Metrics

LBM

— kg

Pain tier

—

Apfel

—/4

PONV risk

—%

Duration

— min

Elapsed

— min

Save / Discard

⚡ Ready — confirm patient to start case

MAC Reference (age-adjusted)

Sevoflurane MAC₄₀2.05%

Desflurane MAC₄₀6.0%

Isoflurane MAC₄₀1.17%

N₂O MAC₄₀104%

At age 45—

Mapleson WW. Br J Anaesth 1996;76:179

Enter all drugs given at induction. Each is referenced to T₀. Residual effect at emergence is calculated by pharmacokinetic superposition.

💉 Propofol — Induction Ce: —

Dose (mg/kg)

Given at (min from T₀)

PK model

Supplemental boluses

Schnider 1998 · Eleveld 2018 · Marsh 1991 · Cortínez 2010

💉 Etomidate Ce: —

Dose (mg/kg)

Given at (min from T₀)

t½ = 2–5h · Vd = 4.5 L/kg · ⚠ Adrenocortical suppression if dose >0.3 mg/kg

Van Hamme MJ. Anesthesiology 1978 · Forman SA. Anesthesiology 2011

💉 Ketamine — Induction / Analgesic Ce: —

Type

Induction dose (mg/kg)

Given at (min from T₀)

Hijazi Y. Anesthesiology 2003 · Olofsen E. Br J Anaesth 2012

💉 Thiopental Ce: —

Dose (mg/kg)

Given at (min from T₀)

t½ = 5–12h · Vd = 2.5 L/kg · ⚠ Prolonged emergence if high dose — PACU +30–60 min
Context-sensitive half-time increases markedly with duration

Stanski DR. Anesthesiology 1984 · Hung OR. Anesthesiology 1992

🩸 Induction Opioid Ce: —

Agent

Dose

Given at (min from T₀)

💊 Midazolam — Co-induction Ce: —

Dose (mg)

Given at (min from T₀)

ke₀ = 0.12 min⁻¹ · t½ = 2h · Ce50_sedation = 90 ng/mL

Flores-Pérez C. Pharmaceutics 2023

💪 NMB — Intubation dose

Not given

Agent

First dose given at (min from T₀)

Dose given (mg/kg)

Est. TOFR now

—

Induction Summary

Prop Ce now

—

Pred. BIS

—

Opioid Ce

—

TOFR

1.00

Intraoperative Vitals — update at each loop cycle

HR

bpm

SBP

mmHg

SpO₂

%

EtCO₂

mmHg

Temp

°C

Vital signs may indicate inadequate depth or analgesia — see maintenance alerts above

🔄 Intraoperative Prediction Loop

Loop fires sedation + analgesia adequacy checks. Popups appear if BIS predicted outside 40–60 or pain inadequate for surgery tier.

💨 Volatile Agent MAC: —

Agent

FGF (L/min)

Entry mode

Concentration (× MAC)

Start (min from T₀)

Stop / turned off (min)

N₂O (%)

MAC_eff

— %

F_total

— MAC

MAC-awake

— %

CSHT

— min

🩸 Remifentanil — Infusion Ce: —

Rate (mcg/kg/min)

Start (min)

Stop (min)

TCI model

Ce target (ng/mL)

Additional boluses

Css

— ng/mL

Ce at stop

— ng/mL

T to safe

— min

Drive

— %

Minto 1997 · Ce50_resp = 1.17 ng/mL · CSHT ≈ 3.5 min

🩸 Sufentanil — Maintenance Ce: —

PK model

Bolus (mcg/kg)

Given at (min from T₀)

Bolus total (mcg)

Given at (min from T₀)

Rate (mcg/h)

Start (min from T₀)

Stop (min from T₀)

Ce target (ng/mL) — Gepts model

TCI duration (min)

📍 Sufentanil redoses (superposition)

Bovill JG. Anesthesiology 1984 · Gepts E. Anesth Analg 1995 · ke₀ = 0.119 min⁻¹ · CSHT 30–60 min

🩸 Morphine Ce: —

Dose (mg)

Route

Given at (min from T₀)

Morphine redoses

t½ = 2–4h · Vd = 3.5 L/kg · Active metabolite M6G — caution in renal failure
Onset IV 5–10 min · Peak 20 min · PACU +25–30 min if Ce >20 ng/mL

Lotsch J. Clin Pharmacokinet 2005 · Osborne R. BMJ 1990

💉 Propofol — TIVA / Maintenance Ce: —

Rate (mg/kg/h)

Start (min)

Stop (min)

Model

Ce target (mcg/mL)

Ce (mcg/mL)

—

BIS pred.

—

CSHT

— min

🩸 Fentanyl — Maintenance Ce: —

PK model

Bolus dose (mcg)

Given at (min from T₀)

Rate (mcg/kg/h)

Start (min from T₀)

Stop (min from T₀)

Initial bolus (mcg)

Bolus given at (min)

Infusion rate (mcg/kg/h)

Infusion start (min)

📍 Additional fentanyl boluses (superposition)

Shafer SL. Anesthesiology 1990 · Stanski 1984 · Youngs & Shafer 1992 (CSHT)

💊 Dexmedetomidine Ce: —

Model

Loading (mcg/kg/10 min)

Maintenance (mcg/kg/h)

Duration (min)

⚠ Arousable sedation — BIS unreliable. MAC-sparing 30–40%. PACU +15–25 min if Ce >0.5 ng/mL at emergence.

Colin 2017 · Hannivoort 2015 · Bhana 2000

💊 Adjuvants Sparing: —

Lidocaine IV bolus (mg/kg)

Lidocaine infusion (mg/kg/h)

Ketamine sub-anaes (mg/kg)

Ketamine infusion (mg/kg/h)

Magnesium (g IV)

Dexamethasone (mg)

Paracetamol IV (g)

Ketorolac / NSAID (mg)

Kranke 2015 (Lido) · Bell 2006 (Ket) · Albrecht 2013 (Mg) · Apfel 2004 (Dexa) · McNicol 2011 (Para) · Ong 2010 (NSAIDs)

Drug Concentration Graph

Neuraxial Blocks

Epidural Active

Spinal Active

Peripheral Nerve Block

Block type

Performed at (min from T₀; neg=pre-op)

LA onset (min)

Expected duration (h)

Dexamethasone adjunct (mg)

Pain reduction

—

Opioid sparing

— %

Active at emerg.

—

Fredrickson 2010 · Petersen 2010 · Forero 2016 · Davies 2006

NMB Status & Reversal

Last top-up given (min ago)

Est. TOFR

—

Top-up doses (each resets TOFR clock)

Reversal agent

Reversal given (min ago)

Wait remaining

—

TOF Display

T1

T2

T3

T4

00.70.91.0

Extubation gate

—

Mg interaction

—

Agitation Risk Breakdown (Admin)

Sevoflurane+2

Age <50+1

Pain tier ≥3+1

Remi Ce >2 ng/mL (Joly 2005)+2

Ketamine Ce >200 ng/mL+2

Duration <30 min+1

ENT/tonsil/cataract+1

Block >60% sparing-1

0-2=LOW · 3-4=MODERATE · ≥5=HIGH · Lepouse 2006 · Yu 2010

Predicted time to emergence

—

min after volatile discontinuation

Pred. BIS

—

MAC at emerg.

—

Remi Ce at stop

— ng/mL

TOFR

—

Pain at emergence

—/10

Agitation risk

—

PACU discharge

— min

PONV risk

—%

PACU breakdown will appear after prediction.

Five-Gate Emergence Checklist

○

Gate 1 — Volatile washout

—

○

Gate 2 — Opioid respiratory drive

—

○

Gate 3 — NMB (TOFR ≥ 0.90)

—

○

Gate 4 — CO₂ / ventilatory drive

—

○

Gate 5 — N₂O / diffusion hypoxia

—

Not sent yet

Case ID: —

Enter Actual Outcomes — Case not started

Each field trains the Bayesian self-learning model. The more you fill, the faster accuracy improves for your patient population.

Actual emergence time (min)

Actual BIS (mean intraoperative)

Pain score at emergence (0–10)

Actual PACU time (min)

Agitation at emergence

PONV in PACU

Block effective? (if used)

Clinical notes

Model Performance

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Per-Variable Corrections

Case Management

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🏆 Leaderboard — EQI

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Prediction Error

Varvel JR et al. Anesthesiology 1992;76:67 · Bland JM & Altman DG. Lancet 1986