Emergence Simulator v2

Demographics

Age (yr)

Weight (kg)

Height (cm)

Sex

ASA

BMI

Surgery type

Core temp (°C)

EtCO₂ (mmHg)

Smoker PONV history Obese BMI>35 Elderly >70 Pediatric <16

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

Induction time (T₀)

Expected end of surgery

Case duration

— min

Time elapsed

— min

Volatile Agent

Agent

Entry mode

Maintenance 1.00 × MAC

Fresh gas flow (L/min)

Duration (min)

Start (min from T₀)

Stop (min from T₀)

Pending

N₂O (%)

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

Induction dose (mg/kg)

Time given (min ago)

Given at (min from T₀)

Stop / last bolus (min)

Pending

Additional boluses (mg)

Induction bolus (mg/kg)

Infusion rate (mg/kg/h)

Duration (min)

TCI model

Target (Cp or Ce — mcg/mL)

Target concentration (mcg/mL)

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

Dose (mg/kg)

Time given (min ago)

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

Ketamine type

Dose (mg/kg)

Time given (min ago)

Plasma Ce

— ng/mL

Bolus (mg/kg)

Infusion (mg/kg/h)

Duration (min)

📍 Ketamine redoses (affects emergence agitation + PACU time)

Hijazi Y. Anesthesiology 2003 · Olofsen E. Br J Anaesth 2012 · Geisslinger 1995

🩸 Remifentanil

Rate (mcg/kg/min)

Duration (min)

Infusion start (min)

Infusion stop (min)

Pending

Current rate (mcg/kg/min)

TCI model

Ce target (ng/mL)

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

PK model

Induction bolus (mcg)

Time given (min ago)

Additional boluses (mcg total)

Bolus (mcg)

Infusion (mcg/kg/h)

Duration (min)

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

PK model

Induction (mcg/kg)

Time given (min ago)

Additional boluses (mcg total)

Bolus (mcg)

Infusion rate (mcg/h)

Duration (min)

Bolus (mcg/kg)

Infusion (mcg/kg/h)

Duration (min)

Target Ce (ng/mL) — Gepts model

Ce target 0.3 ng/mL

Duration (min)

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

Dose (mg)

Time given (min ago)

Route

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

PK model

Loading dose (mcg/kg over 10 min)

Maintenance (mcg/kg/h)

Duration (min)

Bolus (mcg/kg)

Time given (min ago)

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

Bolus (mg/kg)

Infusion (mg/kg/h)

Duration (min)

📍 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)

Bolus (mg/kg)

Infusion (mg/kg/h)

Duration (min)

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

Magnesium (g IV over 20 min)

Dexamethasone (mg)

Paracetamol IV (g)

Ketorolac / NSAID (mg)

Clonidine (mcg/kg)

Combined opioid sparing

— %

Albrecht 2013 (Mg) · Apfel 2004 (Dexa) · McNicol 2011 (Paracetamol) · Ong 2010 (NSAIDs)

Neuraxial Blocks

Epidural Active

Spinal Active

Peripheral Nerve Blocks

Block type

LA agent

Volume (mL)

Dexamethasone adjunct (mg)

Expected duration (h)

Block performed at (min from T₀; negative = pre-op)

LA onset time (min)

Block duration (h)

Block Effects on Emergence

Pain reduction

—

Opioid sparing

— %

Block duration

— h

Fredrickson 2010 · Paul 2010 · Petersen 2010 · Forero 2016 · Davies 2006

NMB Agent

Agent

Last dose (min ago)

Top-ups given

Est. TOFR

1.00

Reversal agent

Reversal given (min ago)

Wait time

—

Top-up doses (each resets TOFR clock)

📍 NMB top-up doses

TOF Status

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

BIS 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.

Actual emergence time (min)

Actual BIS intraoperative (mean)

Actual pain score at emergence (0–10)

Actual PACU time (min)

Agitation at emergence?

PONV in PACU?

Block effective? (if regional used)

Clinical notes

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