Intensive Care Medicine

, 35:2096

Frequency and clinical impact of preserved bispectral index activity during deep sedation in mechanically ventilated ICU patients

  • Pierre Trouiller
  • Pascal Fangio
  • Catherine Paugam-Burtz
  • Corinne Appéré-de-Vecchi
  • Paul Merckx
  • Nicolas Louvet
  • Sebastian Pease
  • Hervé Outin
  • Jean Mantz
  • Bernard De Jonghe
Original

Abstract

Objective

Despite an overall correlation between the bispectral index of the EEG (BIS) and clinical sedation assessment, unexpectedly high BIS values can be observed at deep sedation levels. We assessed the frequency, interindividual variability and clinical impact of high BIS values during clinically deep sedation.

Design and setting

Prospective observational study in two university-affiliated intensive care units.

Patients

Sixty-two mechanically ventilated patients requiring intravenous sedation and analgesia for ≥24 h.

Measurements and main results

Paired measurements of BIS and sedation measured on the adaptation to intensive care environment (ATICE) score were obtained every 3 h until awakening. A paired measurement with BIS >60 at deep sedation (ATICE Awakeness ≤2) was defined as discordant. Patients were considered discordant if their individual ratio of number of discordant measurements to number of total measurements during deep sedation was above the median discordance ratio of the overall cohort. At least one discordant assessment was observed in 52 patients (83.9%). Median individual discordance ratio was 32% (14.3–50.0%). Time from awakening to first T-piece trial [16 h (4–34) vs. 46 h (9–109), p = 0.01] and to extubation [35 h (23–89) vs. 88 h (46–152 h), p = 0.05] were significantly shorter in discordant compared to concordant patients. BIS-ATICE discordance was independently associated with successful extubation within 48 h after awakening (OR 6.7, CI 95% 1.8–25.0, p = 0.005). The rate of ICU recall was not different in BIS-ATICE discordant and concordant patients.

Conclusions

In mechanically ventilated ICU patients, discordance between high BIS values and deep clinical sedation is frequently observed and may suggest faster weaning from the ventilator.

Keywords

Bispectral index Sedation Mechanical ventilation Weaning Post-ICU recall 

Supplementary material

134_2009_1636_MOESM1_ESM.doc (91 kb)
Supplementary material 1 (DOC 91 kb)

References

  1. 1.
    Payen JF, Chanques G, Mantz J, Hercule C, Auriant I, Leguillou JL, Binhas M, Genty C, Rolland C, Bosson JL (2007) Current practices in sedation and analgesia for mechanically ventilated critically ill patients: a prospective multicenter patient-based study. Anesthesiology 106:687–695CrossRefPubMedGoogle Scholar
  2. 2.
    De Jonghe B, Cook D, Appere-De-Vecchi C, Guyatt G, Meade M, Outin H (2000) Using and understanding sedation scoring systems: a systematic review. Intensive Care Med 26:275–285CrossRefPubMedGoogle Scholar
  3. 3.
    Ely EW, Truman B, Shintani A, Thomason JW, Wheeler AP, Gordon S, Francis J, Speroff T, Gautam S, Margolin R, Sessler CN, Dittus RS, Bernard GR (2003) Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond agitation–sedation scale (RASS). JAMA 289:2983–2991CrossRefPubMedGoogle Scholar
  4. 4.
    Riker RR, Picard JT, Fraser GL (1999) Prospective evaluation of the sedation–agitation scale for adult critically ill patients. Crit Care Med 27:1325–1329CrossRefPubMedGoogle Scholar
  5. 5.
    De Jonghe B, Cook D, Griffith L, Appere-de-Vecchi C, Guyatt G, Théron V, Vagnère A, Outin H (2003) Adaptation to the intensive care environment (ATICE): development and validation of a new sedation assessment instrument. Critical Care Med 31:2344–2354CrossRefGoogle Scholar
  6. 6.
    Payen JF, Bru O, Bosson JL, Lagrasta A, Novel E, Deschaux I, Lavagne P, Jacquot C (2001) Assessing pain in critically ill sedated patients by using a behavioral pain scale. Crit Care Med 29:2258–2263CrossRefPubMedGoogle Scholar
  7. 7.
    Simmons LE, Riker RR, Prato BS, Fraser GL (1999) Assessing sedation during intensive care unit mechanical ventilation with the bispectral index and the sedation–agitation scale. Crit Care Med 27:1499–1504CrossRefPubMedGoogle Scholar
  8. 8.
    Riker RR, Fraser GL, Simmons LE, Wilkins ML (2001) Validating the sedation–agitation scale with the bispectral index and visual analog scale in adult ICU patients after cardiac surgery. Intensive Care Med 27:853–858CrossRefPubMedGoogle Scholar
  9. 9.
    Ely EW, Truman B, Manzi DJ, Sigl JC, Shintani A, Bernard GR (2004) Consciousness monitoring in ventilated patients: bispectral EEG monitors arousal not delirium. Intensive Care Med 30:1537–1543CrossRefPubMedGoogle Scholar
  10. 10.
    Frenzel D, Greim CA, Sommer C, Bauerle K, Roewer N (2002) Is the bispectral index appropriate for monitoring the sedation level of mechanically ventilated surgical ICU patients? Intensive Care Med 28:178–183CrossRefPubMedGoogle Scholar
  11. 11.
    Nasraway SS Jr, Wu EC, Kelleher RM, Yasuda CM, Donnelly AM (2002) How reliable is the bispectral index in critically ill patients? A prospective, comparative, single-blinded observer study. Crit Care Med 30:1483–1487CrossRefGoogle Scholar
  12. 12.
    Courtman SP, Wardurgh A, Petros AJ (2003) Comparison of the bispectral index monitor with the comfort score in assessing level of sedation of critically ill children. Intensive Care Med 29:2239–2246CrossRefPubMedGoogle Scholar
  13. 13.
    Tonner PH, Paris A, Scholz J (2006) Monitoring consciousness in intensive care medicine. Best Pract Res Clin Anaesthesiol 20:191–200CrossRefPubMedGoogle Scholar
  14. 14.
    Vivien B, Di Maria S, Ouattara A, Langeron O, Coriat P, Riou B (2003) Overestimation of bispectral index in sedated intensive care unit patients revealed by administration of muscle relaxant. Anesthesiology 99:9–17CrossRefPubMedGoogle Scholar
  15. 15.
    De Jonghe B, Bastuji-Garin S, Fangio P, Lacherade JC, Jabot J, Appere-De-Vecchi C, Rocha N, Outin H (2005) Sedation algorithm in critically ill patients without acute brain injury. Crit Care Med 33:120–127CrossRefPubMedGoogle Scholar
  16. 16.
    (2007) 4ème conférence de consensus commune: sédation et analgésie en réanimation (nouveau-né exclus). http://www.srlf.org/Data/ModuleGestionDeContenu/application/714.pdf
  17. 17.
    Richard C, Beydon L, Cantagrel S, Cuvelier A, Fauroux B, Garo B (2001) Sevrage de la ventilation mécanique (à l’exclusion du nouveau-né et du réveil d’anesthésie). http://www.srlf.org/Data/ModuleGestionDeContenu/PagesGenerees/Bibliothèque%20-%20Référentiels/Référentiels/Recommandations/CC/139.asp
  18. 18.
    Kleyweg RP, van der Meche FG, Meulstee J (1988) Treatment of Guillain–Barre syndrome with high-dose gammaglobulin. Neurology 38:1639–1641PubMedGoogle Scholar
  19. 19.
    Dubois MJ, Bergeron N, Dumont M, Dial S, Skrobik Y (2001) Delirium in an intensive care unit: a study of risk factors. Intensive Care Med 27:1297–1304CrossRefPubMedGoogle Scholar
  20. 20.
    Devlin JW, Fong JJ, Schumaker G, O’Connor H, Ruthazer R, Garpestad E (2007) Use of a validated delirium assessment tool improves the ability of physicians to identify delirium in medical intensive care unit patients. Crit Care Med 35:2721–2724CrossRefPubMedGoogle Scholar
  21. 21.
    Rotondi AJ, Chelluri L, Sirio C, Mendelsohn A, Schulz R, Belle S, Im K, Donahoe M, Pinsky MR (2002) Patients’ recollections of stressful experiences while receiving prolonged mechanical ventilation in an intensive care unit. Crit Care Med 30:746–752CrossRefPubMedGoogle Scholar
  22. 22.
    Jones C, Griffiths RD, Humphris G, Skirrow PM (2001) Memory, delusions, and the development of acute posttraumatic stress disorder-related symptoms after intensive care. Crit Care Med 29:573–580CrossRefPubMedGoogle Scholar
  23. 23.
    Mondello E, Siliotti R, Noto G, Cuzzocrea E, Scollo G, Trimarchi G, Venuti FS (2002) Bispectral index in ICU: correlation with Ramsay Score on assessment of sedation level. J Clin Monit Comput 17:271–277CrossRefPubMedGoogle Scholar
  24. 24.
    LeBlanc JM, Dasta JF, Kane-Gill SL (2006) Role of the bispectral index in sedation monitoring in the ICU. Ann Pharmacother 40:490–500CrossRefPubMedGoogle Scholar
  25. 25.
    Brocas E, Dupont H, Paugam-Burtz C, Servin F, Mantz J, Desmonts JM (2002) Bispectral index variations during tracheal suction in mechanically ventilated critically ill patients: effect of an alfentanil bolus. Intensive Care Med 28:211–213CrossRefPubMedGoogle Scholar
  26. 26.
    Spies CD, Rommelspacher H (1999) Alcohol withdrawal in the surgical patient: prevention and treatment. Anesth Analg 88:946–954CrossRefPubMedGoogle Scholar
  27. 27.
    Struys MM, Vereecke H, Moerman A, Jensen EW, Verhaeghen D, De Neve N, Dumortier FJ, Mortier EP (2003) Ability of the bispectral index, autoregressive modelling with exogenous input-derived auditory evoked potentials, and predicted propofol concentrations to measure patient responsiveness during anesthesia with propofol and remifentanil. Anesthesiology 99:802–812CrossRefPubMedGoogle Scholar
  28. 28.
    Struys MM, De Smet T, Greenwald S, Absalom AR, Binge S, Mortier EP (2004) Performance evaluation of two published closed-loop control systems using bispectral index monitoring: a simulation study. Anesthesiology 100:640–647CrossRefPubMedGoogle Scholar
  29. 29.
    De Jonghe B, Bastuji-Garin S, Sharshar T, Outin H, Brochard L (2004) Does ICU-acquired paresis lengthen weaning from mechanical ventilation? Intensive Care Med 30:1117–1121CrossRefPubMedGoogle Scholar
  30. 30.
    van de Leur JP, van der Schans CP, Loef BG, Deelman BG, Geertzen JH, Zwaveling JH (2004) Discomfort and factual recollection in intensive care unit patients. Crit Care 8:R467–R473CrossRefPubMedGoogle Scholar
  31. 31.
    Rundshagen I, Schnabel K, Wegner C, am Esch S (2002) Incidence of recall, nightmares, and hallucinations during analgosedation in intensive care. Intensive Care Med 28:38–43CrossRefPubMedGoogle Scholar
  32. 32.
    Weinert CR, Sprenkle M (2008) Post-ICU consequences of patient wakefulness and sedative exposure during mechanical ventilation. Intensive Care Med 34:82–90CrossRefPubMedGoogle Scholar
  33. 33.
    Kress JP, Vinayak AG, Levitt J, Schweickert WD, Gehlbach BK, Zimmerman F, Pohlman AS, Hall JB (2007) Daily sedative interruption in mechanically ventilated patients at risk for coronary artery disease. Crit Care Med 35:365–371CrossRefPubMedGoogle Scholar
  34. 34.
    Brook AD, Ahrens TS, Schaiff R, Prentice D, Sherman G, Shannon W, Kollef MH (1999) Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation. Crit Care Med 27:2609–2615CrossRefPubMedGoogle Scholar
  35. 35.
    Brattebo G, Hofoss D, Flaatten H, Muri AK, Gjerde S, Plsek PE (2002) Effect of a scoring system and protocol for sedation on duration of patients’ need for ventilator support in a surgical intensive care unit. Br Med J 324:1386–1389CrossRefGoogle Scholar
  36. 36.
    Quenot JP, Ladoire S, Devoucoux F, Doise JM, Cailliod R, Cunin N, Aube H, Blettery B, Charles PE (2007) Effect of a nurse-implemented sedation protocol on the incidence of ventilator-associated pneumonia. Crit Care Med 35:2031–2036CrossRefPubMedGoogle Scholar
  37. 37.
    Le Gall JR, Lemeshow S, Saulnier F (1993) A new simplified acute physiologic score (SAPS II) based on a European/North American multicenter study. JAMA 270:2957–2963CrossRefPubMedGoogle Scholar

Copyright information

© Copyright jointly hold by Springer and ESICM 2009

Authors and Affiliations

  • Pierre Trouiller
    • 1
  • Pascal Fangio
    • 2
  • Catherine Paugam-Burtz
    • 1
  • Corinne Appéré-de-Vecchi
    • 2
  • Paul Merckx
    • 1
  • Nicolas Louvet
    • 1
  • Sebastian Pease
    • 1
  • Hervé Outin
    • 2
  • Jean Mantz
    • 1
  • Bernard De Jonghe
    • 2
  1. 1.Department of Anaesthesiology and Critical CareBeaujon University HospitalClichyFrance
  2. 2.Critical Care UnitPoissy HospitalPoissyFrance

Personalised recommendations