⚡ Emergence v2
BIS —
MAC —
Pain —
Emerg —
6h 00m
Demographics
Premedications (time since given → reduces emergence)
Calculated Metrics
LBM
kg
BMI
Pain tier
Apfel
/4
PONV risk
%
Premed burden
Enter patient demographics and confirm.
Anesthesia Timing
Case duration
min
Time elapsed
min
Volatile Agent
Maintenance 1.00 × MAC
Pending
N₂O concentration 0%
MAC Calculations — All Models
MAC_age = MAC₄₀ × 10^[−0.00269×(age−40)] Mapleson 1996
MAC_temp = MAC_age × 10^[−0.00269×(37−T)] Lerou 2004
F_total = ET_vol/MAC_eff + ET_N₂O/MAC_N₂O Becker 2008
MAC-awake: sevo 0.34×, des 0.33×, iso 0.40× Torri 2004
MAC_eff
%
MAC-awake
%
F_total
MAC
CSHT
min
Alveolar Washout Curve
Mapleson 1996 · Eger 1974 · Nickalls & Mapleson 2003
N₂O Effects
MAC sparing
0 %
Diffusion hypoxia
None
PONV multiplier
×1.0
N₂O not selected.
Peyton 2011 · Tramèr 1996 · Becker 2008
💉 Propofol
Pending
Target Ce 3.0 mcg/mL
All models — Ce at current target (range shows inter-model variability)
Prop Ce
mcg/mL
Pred. BIS
Prop ke0
min⁻¹
CSHT prop
min
📍 Propofol supplemental boluses
Marsh 1991 · Schnider 1998 · Eleveld 2018 · Cortínez 2010 · Kern 2004 RSM
💉 Etomidate
Residual Ce
t½ = 2–5h · Vd = 4.5 L/kg · F = 1.0 IV · Adrenocortical suppression flag if dose >0.3 mg/kg
Forman SA. Anesthesiology 2011 · Van Hamme 1978
💉 Ketamine
Plasma Ce
ng/mL
📍 Ketamine redoses (affects emergence agitation + PACU time)
Hijazi Y. Anesthesiology 2003 · Olofsen E. Br J Anaesth 2012 · Geisslinger 1995
🩸 Remifentanil
Pending
Target 2.0 ng/mL
Minto vs Eleveld vs Kim — Ce estimates
Cl₁ (Minto)
Css
ng/mL
Ce stop
ng/mL
T safe
min
Drive
%
Ce Decay Curve
Minto 1997 · Eleveld 2017 · Kim 2017 · Ce50_resp = 1.17 ng/mL · CSHT = 3.5 min
🩸 Fentanyl
Ce (ng/mL)
CSHT
min
T to safe
Resp drive
%
📍 Fentanyl redoses / additional boluses
Shafer 1990 · Stanski 1984 · Ginsberg 1996 · Youngs & Shafer 1992 (CSHT)
🩸 Sufentanil
Ce target 0.3 ng/mL
Ce (ng/mL)
CSHT
min
T to safe
Resp drive
%
📍 Sufentanil redoses
Bovill 1984 · Gepts 1995 · Greeley 1987 · ke0 = 0.119 min⁻¹ · CSHT 30–60 min
🩸 Morphine
Ce plasma
ng/mL
M6G flag
Resp drive
%
📍 Morphine redoses
t½ = 2–4h · Vd = 3.5 L/kg · Active metabolite M6G accumulates in renal failure — flags when creatinine entered
Lotsch J. Clin Pharmacokinet 2005 · Osborne R. BMJ 1990
💊 Dexmedetomidine
Ce (ng/mL)
⚠ Dexmedetomidine = AROUSABLE sedation. BIS less predictive. Sympatholysis persists beyond sedation offset.
MAC-sparing: 30–40% (Bhana 2000). ke0 = 0.20 min⁻¹
Colin 2017 · Hannivoort 2015 · Weerink 2017 · Bhana N. Drugs 2000
💊 Lidocaine IV
📍 Lidocaine supplemental boluses
Opioid-sparing 20–30% · Pain score −1.5 · NNT=4 for opioid reduction
Toxicity threshold: plasma >5 mcg/mL
Kranke P. Cochrane 2015 · Vigneault L. Cochrane 2011
💊 Ketamine — Sub-anaesthetic (Opioid-sparing)
Opioid-sparing 30–40% · ⚠ Emergence agitation flag if Ce >200 ng/mL · Psychomimetic effects at >1 mg/kg
Jouguelet-Lacoste 2015 · Bell RF. Cochrane 2006
💊 Other Adjuvants
Combined opioid sparing
%
Albrecht 2013 (Mg) · Apfel 2004 (Dexa) · McNicol 2011 (Paracetamol) · Ong 2010 (NSAIDs)
Neuraxial Blocks
Epidural
Spinal
Peripheral Nerve Blocks
Block Effects on Emergence
Pain reduction
Opioid sparing
%
Block duration
h
Fredrickson 2010 · Paul 2010 · Petersen 2010 · Forero 2016 · Davies 2006
NMB Agent
Est. TOFR
1.00
Wait time
Top-up doses (each resets TOFR clock)
📍 NMB top-up doses
TOF Status
T1
T2
T3
T4
00.70.91.0
Extubation gate
Magnesium
No interaction
TOFR ≥ 0.90 = safe extubation (adductor pollicis)
Sugammadex 2mg/kg (T2): ~1.5 min to TOFR 0.9
Sugammadex 4mg/kg (T1): ~3 min
Neostigmine: unreliable if TOFR < 0.10
Murphy 2010 · Brull 2017
⚡ Ready — enter patient data then save case to database
Predicted time to emergence
min after volatile discontinuation
Pred. BIS
MAC_eff
%
Pain score
/10
PACU
min
Agitation
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
Model Comparison — All PK Models Running Simultaneously
All models run in parallel. Range shown = inter-model variability. Use attending judgment when models diverge >20%.
Intraoperative Loop Control
Combined Drug Graph — All Agents + Interactions + Premedications
Kern 2004 RSM · Heyse 2012 · Minto 2000 · Struys 2003 · Eleveld 2018
Not sent to API yet
Case ID: —
Enter Actual Outcomes — trains Bayesian model
Each field you fill updates the self-learning correction model for all future cases. The more fields you fill, the faster the model converges to your patient population.
Agitation Risk — Admin Score Breakdown
Sevoflurane+2 pts
Age <50 yr+1 pt
Pain tier ≥3+1 pt
Remifentanil Ce >2 ng/mL — acute hyperalgesia (Joly 2005)+2 pts
Ketamine Ce >200 ng/mL — psychomimetic (Hijazi 2003)+2 pts
Duration <30 min+1 pt
ENT / tonsillectomy / cataract (Lepouse 2006)+1 pt
Active regional block >60% sparing-1 pt
0-2=LOW | 3-4=MODERATE | ≥5=HIGH
Joly V. Anesthesiology 2005;102:1004 · Lepouse C. Br J Anaesth 2006;96:747 · Yu D. Anesth Analg 2010;111:1167
Bayesian Corrections (live model)
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Model Accuracy Over Time
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🏆 Leaderboard — Emergence Quality Index
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EQI = composite score based on prediction accuracy, pain control, agitation rate, PACU time. Rewards clinical judgment not just case volume.
Prediction vs Actual — All Cases
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Per-Variable Accuracy
Bayesian Model Drift
Bland-Altman — Emergence Time
Bland JM & Altman DG. Lancet 1986;1:307
Prediction Error Distribution
EQI Trend Over Time
Case Management — Delete individual cases
Click 'Load cases' to view.
MDPE = Median prediction error · MDAPE = Median absolute performance error · Varvel JR et al. Anesthesiology 1992;76:67 (TCI performance metrics)