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Neurocritical Care

, 11:20 | Cite as

A Randomized Evaluation of Bispectral Index-Augmented Sedation Assessment in Neurological Patients

  • DaiWai M. OlsonEmail author
  • Suzanne M. Thoyre
  • Eric D. Peterson
  • Carmelo Graffagnino
Original Article

Abstract

Objective

To assess whether monitoring sedation status using bispectral index (BIS) as an adjunct to clinical evaluation was associated with a reduction in the total amount of sedative drug used in a 12 h period.

Design

Prospective randomized controlled clinical trial.

Setting

Tertiary care neurocritical care unit.

Patients

Sixty-seven mechanically ventilated adult patients receiving continuous intravenous sedation with propofol.

Interventions

Sedation monitoring using clinical assessment with the Ramsay scale (Ramsay-alone group) or clinical assessment plus BIS monitoring (BIS-augmentation group). Subjects were randomized to Ramsay-alone (n = 35), or BIS-augmentation (n = 32). Nurses adjusted the dose of propofol to a Ramsay of 4, or a Ramsay of 4 and BIS between 60 and 70.

Measurements and Main Results

Patients in the BIS-augmentation group received significantly less propofol by volume (93.5 ml vs. 157.8 ml, respectively; P < .015), and had lower infusion rates (14.6 vs. 27.9 mcg/kg/min; P = .003). There is a lower risk of propofol infusion exceeding manufacturer’s recommended dosing guides in the BIS-augmentation group versus the Ramsay-alone group (0 vs. 23%, P = .0052). The BIS-augmentation group woke up much quicker than those in the Ramsay-alone group (1.2 vs. 7.5 min; P < .0001).

Conclusions

BIS-augmented sedation monitoring resulted in a marked reduction in the total dose of sedative used to achieve the same level of clinical sedation resulting in shortened time to wake up without any measurable adverse effects. Physiologic sedation assessment tools may provide a useful means of improving the care of sedated critically ill patients.

Keywords

Sedation assessment Nursing care Critical care Neurofunction monitoring Neurocritical care 

Notes

Acknowledgment

This research is supported by NIH T32 NR07091 Interventions to Prevent and Manage Chronic Illness and Aspect Medical Systems, Inc.

References

  1. 1.
    Jacobi J, Fraser GL, Coursin DB, et al. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med. 2002;30(1):119–41.PubMedCrossRefGoogle Scholar
  2. 2.
    Arbour RB. Using the Bispectral Index to assess arousal response in a patient with neuromuscular blockade. Am J Crit Care. 2000;9(6):383–7.PubMedGoogle Scholar
  3. 3.
    Carrasco G. Instruments for monitoring intensive care unit sedation. Crit Care. 2000;4(4):217–25. doi: 10.1186/cc697.PubMedCrossRefGoogle Scholar
  4. 4.
    Kollef MH, Levy NT, Ahrens TS, Schaiff R, Prentice D, Sherman G. The use of continuous I.V. sedation is associated with prolongation of mechanical ventilation. Chest. 1998;114(2):541–8. doi: 10.1378/chest.114.2.541.PubMedCrossRefGoogle Scholar
  5. 5.
    Weinert CR, Chlan L, Gross C. Sedating critically ill patients: Factors affecting nurses’ delivery of sedative therapy. Am J Crit Care. 2001;10(3):156–65. quiz 166–157.PubMedGoogle Scholar
  6. 6.
    Flaishon R, Windsor A, Sigl J, Sebel PS. Recovery of consciousness after thiopental or propofol. Bispectral index and isolated forearm technique. Anesthesiology. 1997;86(3):613–9. doi: 10.1097/00000542-199703000-00013.PubMedCrossRefGoogle Scholar
  7. 7.
    Mion LC, Minnick AF, Leipzig RM, Catrambone CD, Johnson ME. Patient-initiated device removal in intensive care units: a national prevalence study. Crit Care Med. 2007;35(12):2714–20.PubMedCrossRefGoogle Scholar
  8. 8.
    Tung A, Lynch JP, Roizen MF. Use of the bis monitor to detect onset of naturally occurring sleep. J Clin Monit Comput. 2002;17(1):37–42.PubMedCrossRefGoogle Scholar
  9. 9.
    Boulain T. Unplanned extubations in the adult intensive care unit: a prospective multicenter study. Association des Reanimateurs du Centre-Ouest. Am J Respir Crit Care Med. 1998;157(4 Pt 1):1131–7.PubMedGoogle Scholar
  10. 10.
    Grap MJ, Glass C, Lindamood MO. Factors related to unplanned extubation of endotracheal tubes. Crit Care Nurse. 1995;15(2):57–65.PubMedGoogle Scholar
  11. 11.
    Kaushal R, Bates DW, Franz C, Soukup JR, Rothschild JM. Costs of adverse events in intensive care units. Crit Care Med. 2007;35(11):2479–83.PubMedCrossRefGoogle Scholar
  12. 12.
    Olson D, Lynn M, Thoyre SM, Graffagnino C. The limited reliability of the Ramsay scale. Neurocrit Care. 2007;7(3):227–31. doi: 10.1007/s12028-007-0069-x.PubMedCrossRefGoogle Scholar
  13. 13.
    Tallgren M, Pettila V, Hynninen M. Quality assessment of sedation in intensive care. Acta Anaesthesiol Scand. 2006;50(8):942–6. doi: 10.1111/j.1399-6576.2006.01094.x.PubMedCrossRefGoogle Scholar
  14. 14.
    Chisholm CJ, Zurica J, Mironov D, Sciacca RR, Ornstein E, Heyer EJ. Comparison of electrophysiologic monitors with clinical assessment of level of sedation. Mayo Clin Proc. 2006;81(1):46–52.PubMedCrossRefGoogle Scholar
  15. 15.
    Watson BD, Kane-Gill SL. Sedation assessment in critically ill adults: 2001–2004 update. Ann Pharmacother. 2004;38(11):1898–906. doi: 10.1345/aph.1E167.PubMedCrossRefGoogle Scholar
  16. 16.
    Olson DM, Graffagnino C, King K, Lynch JR. Toward solving the sedation-assessment conundrum: bispectral index monitoring and sedation interruption. Crit Care Nurs Clin North Am. 2005;17(3):257–67. doi: 10.1016/j.ccell.2005.04.008.PubMedCrossRefGoogle Scholar
  17. 17.
    Abbott/American Association of Critical-Care Nurses; Saint Thomas Health System Sedation Expert Panel Members. Consensus conference on sedation assessment. A collaborative venture by Abbott Laboratories, American Association of Critical-Care Nurses, and Saint Thomas Health System. Crit Care Nurse 2004;24(2):33–41.Google Scholar
  18. 18.
    Ramsay MA, Savege TM, Simpson BR, Goodwin R. Controlled sedation with alphaxalone-alphadolone. BMJ. 1974;2(920):656–9.PubMedCrossRefGoogle Scholar
  19. 19.
    Glass PS, Bloom M, Kearse L, Rosow C, Sebel P, Manberg P. Bispectral analysis measures sedation and memory effects of propofol, midazolam, isoflurane, and alfentanil in healthy volunteers. Anesthesiology. 1997;86(4):836–47.PubMedCrossRefGoogle Scholar
  20. 20.
    Gan TJ, Glass PS, Windsor A, et al. Bispectral index monitoring allows faster emergence and improved recovery from propofol, alfentanil, and nitrous oxide anesthesia. BIS Utility Study Group. Anesthesiology. 1997;87(4):808–15. doi: 10.1097/00000542-199710000-00014.PubMedCrossRefGoogle Scholar
  21. 21.
    Song D, Joshi GP, White PF. Titration of volatile anesthetics using bispectral index facilitates recovery after ambulatory anesthesia. Anesthesiology. 1997;87(4):842–8. doi: 10.1097/00000542-199710000-00018.PubMedCrossRefGoogle Scholar
  22. 22.
    Johansen JW. Update on bispectral index monitoring. Best Pract Res Clin Anaesthesiol. 2006;20(1):81–99. doi: 10.1016/j.bpa.2005.08.004.PubMedCrossRefGoogle Scholar
  23. 23.
    Leblanc JM, Dasta JF, Kane-Gill SL. Role of the bispectral index in sedation monitoring in the ICU. Ann Pharmacother. 2006;40(3):490–500. doi: 10.1345/aph.1E491.PubMedCrossRefGoogle Scholar
  24. 24.
    Olson DM, Thoyre SM, Auyong DB. Perspectives on sedation assessment in critical care. AACN Adv Crit Care. 2007;18(4):380–95.PubMedGoogle Scholar
  25. 25.
    Cody RP, Smith JK. Applied statistics and the SAS programming language. 5th ed. Upper Saddle River, NJ: Pearson Prentice Hall; 2006.Google Scholar
  26. 26.
    Ahlen K, Buckley C, Pulsford AH. AstraZeneca’s response to the review by Wysowski and Pollock regarding deaths reported in association with propofol use. Anesthesiology. 2007;107(1):175. doi: 10.1097/01.anes.0000268507.33332.a3. author reply 176.PubMedCrossRefGoogle Scholar
  27. 27.
    Nicholson T, Patel J, Sleigh JW. Sleep patterns in intensive care unit patients: a study using the bispectral index. Crit Care Resusc. 2001;3(2):86–91.PubMedGoogle Scholar
  28. 28.
    Devlin JW, Nasraway SA Jr. Reversing oversedation in the intensive care unit: the role of pharmacists in energizing guideline efforts and overcoming protocol fatigue. Crit Care Med. 2008;36(2):626–8.PubMedCrossRefGoogle Scholar
  29. 29.
    Avidan MS, Zhang L, Burnside BA, et al. Anesthesia awareness and the bispectral index. N Engl J Med. 2008;358(11):1097–108. doi: 10.1056/NEJMoa0707361.PubMedCrossRefGoogle Scholar
  30. 30.
    Lindholm ML, Brudin L, Sandin RH. Bispectral index monitoring: appreciated but does not affect drug dosing and hypnotic levels. Acta Anaesthesiol Scand. 2008;52(1):88–94.PubMedGoogle Scholar
  31. 31.
    Weinert CR, Calvin AD. Epidemiology of sedation and sedation adequacy for mechanically ventilated patients in a medical and surgical intensive care unit. Crit Care Med. 2007;35(2):393–401. doi: 10.1097/01.CCM.0000254339.18639.1D.PubMedCrossRefGoogle Scholar
  32. 32.
    Rodrigues GR Jr, do Amaral JL. Influence of sedation on morbidity and mortality in the intensive care unit. Sao Paulo Med J. 2004;122(1):8–11. doi: 10.1590/S1516-31802004000100003.CrossRefGoogle Scholar
  33. 33.
    Anis AH, Wang XH, Leon H, Hall R. Economic evaluation of propofol for sedation of patients admitted to intensive care units. Anesthesiology. 2002;96(1):196–201. doi: 10.1097/00000542-200201000-00034.PubMedCrossRefGoogle Scholar
  34. 34.
    Ostermann ME, Keenan SP, Seiferling RA, Sibbald WJ. Sedation in the intensive care unit: a systematic review. JAMA. 2000;283(11):1451–9. doi: 10.1001/jama.283.11.1451.PubMedCrossRefGoogle Scholar
  35. 35.
    Kost M. Manual of conscious sedation. Philadelphia: W.B. Saunders; 1998.Google Scholar
  36. 36.
    Deogaonkar A, Gupta R, Degeorgia M, et al. Bispectral Index monitoring correlates with sedation scales in brain-injured patients. Crit Care Med. 2004;32(12):2403–6. doi: 10.1097/01.CCM.0000147442.14921.A5.PubMedCrossRefGoogle Scholar
  37. 37.
    Haberthur C, Lehmann F, Ritz R. Assessment of depth of midazolam sedation using objective parameters. Intensive Care Med. 1996;22(12):1385–90. doi: 10.1007/BF01709555.PubMedCrossRefGoogle Scholar
  38. 38.
    Schulte-Tamburen AM, Scheier J, Briegel J, Schwender D, Peter K. Comparison of five sedation scoring systems by means of auditory evoked potentials. Intensive Care Med. 1999;25(4):377–82. doi: 10.1007/s001340050861.PubMedCrossRefGoogle Scholar
  39. 39.
    Sessler CN, Gosnell MS, Grap MJ, et al. The Richmond agitation-sedation scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med. 2002;166(10):1338–44.PubMedCrossRefGoogle Scholar

Copyright information

© Humana Press Inc. 2009

Authors and Affiliations

  • DaiWai M. Olson
    • 1
    Email author
  • Suzanne M. Thoyre
    • 2
  • Eric D. Peterson
    • 3
  • Carmelo Graffagnino
    • 4
  1. 1.Department of Medicine-NeurologyDuke University Medical CenterDurhamUSA
  2. 2.School of NursingUniversity of North Carolina at Chapel HillChapel HillUSA
  3. 3.Division of Cardiology, Duke Clinical Research InstituteDuke University Medical CenterDurhamUSA
  4. 4.Division of Neurology, Neuroscience Intensive Care UnitDuke University Medical CenterDurhamUSA

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