Skip to main content
Download PDF

The bispectral index does not correlate with clinical signs of inhalational anesthesia during sevoflurane induction and arousal in children

L’index bispectral ne correspond pas aux signes cliniques de l’anesthésie par inhalation pendant l’induction au sévoflurane et le réveil chez les enfants

Canadian Journal of Anesthesia volume 51, pages 472–480 (2004)Cite this article

Abstract

Purpose

Validation of the bispectral index (BIS) in children requires correlating BIS with several levels of sedation, hypnosis and anesthesia. Our purpose was to compare BIS values with objective assessments of the level of hypnosis in children. We postulated that BIS predicted the level of anesthesia during induction and emergence in children.

Methods

In a prospective observational study, we evaluated the BIS monitor in 87 children (ages: 0.3 to 14 yr) ASA physical status I–II undergoing general surgery under sevoflurane and nitrous oxide. Clinical signs of inhalational anesthesia (CSA), the motor response to surgical incision and signs of arousal were used as indicators of the depth of anesthesia. CSA and BIS measurements were paired every minute during induction and emergence until arousal.

Results

CSA scores decreased during induction and increased during emergence (P < 0.001) and correlated with changes in sevoflurane concentrations (r = −0.46;P < 0.001). BIS was associated with changes in CSA scores during induction (r = 0.49;P < 0.01) and emergence (r = 0.62;P < 0.01), but the ranges of individual BIS values overlapped several levels of hypnosis. A BIS value greater than 50 had a positive predictive value of 25% for distinguishing between responders and non-responders to surgical incision. A BIS score equal or greater than 72 had a predictive value of 63% for discriminating between pre-arousal and arousal.

Conclusions

BIS correlates with several levels of hypnosis during inhalational induction and emergence in children, but individual BIS values show large inter-individual variability. The BIS monitor identified the physiological changes associated with arousal and distinguished the effects of preoperative sedation during emergence. The use of movement as an endpoint of hypnosis during surgical stimulation does not correlate with BIS values in children. The large inter-individual variability of BIS at different levels of anesthetic depth may limit the applicability of BIS to pediatric anesthesia.

Résumé

Objectif

La validation de l’index bispectral (BIS) chez les enfants exige la corrélation entre le BIS et quelques niveaux de sédation, d’hypnose et d’anesthésie. Nous voulions comparer les valeurs de BIS avec des évaluations objectives du niveau d’hypnose chez les enfants. Nous avons supposé que le BIS permettait de prédire la profondeur de l’anesthésie pendant l’induction et le retour à la conscience chez les enfants.

Méthode

Au cours d’une étude prospective par observation, nous avons évalué le moniteur de BIS chez 87 enfants de 0,3 à 14 ans, d’état physique ASA I–II, devant subir une intervention chirurgicale générale sous sévoflurane et protoxyde d’azote. Les signes cliniques de l’anesthésie par inhalation (SCA), la réponse motrice à l’incision chirurgicale et les signes d’éveil ont été les indicateurs de la profondeur de l’anesthésie. Les mesures des SCA et du BIS ont été pairées à chaque minute pendant l’induction et le retour à la conscience jusqu’au réveil.

Résultats

Les scores des SCA ont diminué pendant l’induction et augmenté pendant le retour à la conscience (P < 0,001) et correspondaient aux changements de concentrations de sévoflurane (r = −0,46 ; P < 0,001). Le BIS a été associé aux changements de scores des SCA pendant l’induction (r = 0,49 ; P < 0,01) et le retour à la conscience (r = 0,62 ; P < 0,01), mais l’étendue des valeurs individuelles de BIS recoupaient quelques niveaux d’hypnose. Une valeur de BIS plus grande que 50 présentait une valeur prédictive positive de 25 % pour la distinction entre les répondants ou non-répondants à l’incision chirurgicale. Un score de BIS égal à 72 ou plus élevé avait une valeur prédictive de 63 % pour la discrimination entre le préréveil et le réveil.

Conclusion

Le BIS correspond à quelques niveaux d’hypnose pendant l’induction par inhalation et le retour à la conscience chez les enfants, mais les valeurs individuelles de BIS montrent une grande variabilité interindividuelle. Le moniteur de BIS a enregistré les changements physiologiques associés au réveil et a distingué les effets de la sédation préopératoire pendant le retour à la conscience. Le mouvement utilisé comme paramètre de l’hypnose pendant la stimulation chirurgicale ne correspond pas aux valeurs de BIS chez les enfants. La grande variabilité interindividuelle du BIS à différents niveaux de profondeur d’anesthésie peut limiter l’applicabilité du BIS en anesthésie pédiatrique.

References

  1. Doi M, Gajraj RJ, Mantazridis H, Kenny GN. Relationship between calculated blood concentration of propofol and electrophysiological variables during emergence from anaesthesia: comparison of bispectral index, spectral edge frequency, median frequency and auditory evoked potential index. Br J Anaesth 1997; 78: 180–4.

    PubMed  CAS  Google Scholar 

  2. Rampil IJ. A primer for EEG signal processing in anesthesia. Anesthesiology 1998; 89: 980–1002.

    PubMed  Article  CAS  Google Scholar 

  3. Johansen JW, Sebel PS. Development and clinical application of electroencephalographic bispectrum monitoring. Anesthesiology 2000; 93: 1336–44.

    PubMed  Article  CAS  Google Scholar 

  4. Denman WT, Swanson EL, Rosow D, Ezbicki K, Connors PD, Rosow CE. Pediatric evaluation of the bispectral index (BIS) monitor and correlation of BIS with end-tidal sevoflurane concentration in infants and children. Anesth Analg 2000; 90: 872–7.

    PubMed  Article  CAS  Google Scholar 

  5. Davidson AJ, McCann ME, Devavaram P, et al. The differences in the bispectral index between infants and children during emergence from anesthesia after circumcision surgery. Anesth Analg 2001; 93: 326–30.

    PubMed  Article  CAS  Google Scholar 

  6. Bannister CF, Brosius KK, Sigl JC, Meyer BJ, Sebel PS. The effect of bispectral index monitoring on anesthetic use and recovery in children anesthetized with sevoflurane in nitrous oxide. Anesth Analg 2001; 92: 877–81.

    PubMed  Article  CAS  Google Scholar 

  7. Cullen DJ, Eger EI II, Stevens WC, et al. Clinical signs of anesthesia. Anesthesiology 1972; 36: 21–36.

    PubMed  Article  CAS  Google Scholar 

  8. Bimar J, Bellville JW. Arousal reactions during anesthesia in man. Anesthesiology 1977; 47: 449–54.

    PubMed  Article  CAS  Google Scholar 

  9. Epstein RH, Mendel HG, Guarnieri KM, Staudt SR, Lessin JB, Marr AT. Sevoflurane versus halothane for general anesthesia in pediatric patients: comparative study of vital signs, induction, and emergence. J Clin Anesth 1995; 7: 237–44.

    PubMed  Article  CAS  Google Scholar 

  10. Power C, Crowe C, Higgins P, Moriarty DC. Anaesthetic depth at induction. An evaluation using clinical eye signs and EEG polysomnography. Anaesthesia 1998; 53: 736–43.

    PubMed  Article  CAS  Google Scholar 

  11. Ibrahim AE, Taraday JK, Kharasch ED. Bispectral index monitoring during sedation with sevoflurane, midazolam, and propofol. Anesthesiology 2001; 85: 1151–9.

    Article  Google Scholar 

  12. Berkenbosch JW, Fichter CR, Tobias JD. The correlation of the bispectral index monitor with clinical sedation scores during mechanical ventilation in the pediatric intensive care unit. Anesth Analg 2002; 94: 506–11.

    PubMed  Article  Google Scholar 

  13. Nieuwenhuijs D, Coleman EL, Douglas NJ, Drummond GB, Dahan A. Bispectral index values and spectral edge frequency at different stages of physiologic sleep. Anesth Analg 2002; 94: 125–9.

    PubMed  Article  Google Scholar 

  14. Detsch O, Schneider G, Kochs E, Hapfelmeier G, Werner C. Increasing isoflurane concentration may cause paradoxical increases in the EEG bispectral index in surgical patients. Br J Anaesth 2000; 84: 33–7.

    PubMed  CAS  Google Scholar 

  15. Kellaway P. An orderly approach to visual analysis: characteristics of the normal EEG of adults and children.In: Daly DD, Pedley TA (Eds). Current Practice of Clinical Electroencephalography, 2nd ed. New York: Raven Press, Ltd.; 1990: 139–99.

    Google Scholar 

  16. de Weerd AW, van den Bossche RA. The development of sleep during the first months of life. Sleep Med Rev 2003; 7: 179–91.

    PubMed  Article  Google Scholar 

  17. Sebel PS, Lang E, Rampil IJ, et al. A multicenter study of bispectral electroencephalogram analysis for monitoring anesthetic effect. Anesth Analg 1997; 84: 891–9.

    PubMed  Article  CAS  Google Scholar 

  18. Katoh T, Suzuki A, Ikeda K. Electroencephalographic derivatives as a tool for predicting the depth of sedation and anesthesia induced by sevoflurane. Anesthesiology 1998; 88: 642–50.

    PubMed  Article  CAS  Google Scholar 

  19. Morley AP, Chung DC, Wong AS, Short TG. The sedative and electroencephalographic effects of regional anaesthesia. Anaesthesia 2000; 55: 864–9.

    PubMed  Article  CAS  Google Scholar 

  20. Pollock JE, Neal JM, Liu SS, Burkhead D, Polissar N. Sedation during spinal anesthesia. Anesthesiology 2000; 93: 728–34.

    PubMed  Article  CAS  Google Scholar 

  21. Komatsu H, Taie S, Endo S, et al. Electrical seizures during sevoflurane anesthesia in two pediatric patients with epilepsy. Anesthesiology 1994; 81: 1535–7.

    PubMed  Article  CAS  Google Scholar 

  22. Yli-Hankala A, Vakkuri A, Sarkela M, Lindgren L, Korttila K, Jantti V. Epileptiform electroencephalogram during mask induction of anesthesia with sevoflurane. Anesthesiology 1999; 91: 1596–603.

    PubMed  Article  CAS  Google Scholar 

  23. Kaisti KK, Jaaskelainen SK, Rinne JO, Metsahonkala L, Scheinin H. Epileptiform discharges during 2 MAC sevoflurane anesthesia in two healthy volunteers. Anesthesiology 1999; 91: 1952–5.

    PubMed  Article  CAS  Google Scholar 

  24. Degoute CS, Macabeo C, Dubreuil C, Duclaux R, Banssillon V. EEG bispectral index and hypnotic component of anaesthesia induced by sevoflurane: comparison between children and adults. Br J Anaesth 2001; 86: 209–12.

    PubMed  Article  CAS  Google Scholar 

  25. Crain N, Slonim A, Pollack MM. Assessing sedation in the pediatric intensive care unit by using BIS and the COMFORT scale. Pediatr Crit Care Med 2002; 3: 11–4.

    PubMed  Article  Google Scholar 

  26. Tayefeh F, Larson MD, Sessler DI, Eger EI II, Bowland T. Time-dependent changes in heart rate and pupil size during desflurane or sevoflurane anesthesia. Anesth Analg 1997; 85: 1362–6.

    PubMed  Article  CAS  Google Scholar 

  27. Nakatsuka I, Ochiai R, Takeda J. Changes in heart rate variability in sevoflurane and nitrous oxide anesthesia: effects of respiration and depth of anesthesia. J Clin Anesth 2002; 14: 196–200.

    PubMed  Article  CAS  Google Scholar 

Download references

Author information

Affiliations

  1. Department of Anesthesiology, Cardiac Division, Room H-341, University of Ottawa Heart Institute, 40 Ruskin Street, K1Y4W7, Ottawa, Ontario, Canada

    Rosendo A. Rodriguez

  2. Department of Anesthesiology, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada

    Leslie E. Hall, Scott Duggan & William M. Splinter

Authors
  1. Rosendo A. Rodriguez
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Leslie E. Hall
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Scott Duggan
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. William M. Splinter
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Rosendo A. Rodriguez.

Additional information

This work was supported through Departmental sources from the Department of Anesthesiology at the Children’s Hospital of Eastern Ontario. Space Labs Medical (Mississauga, Ontario) provided equipment and technical assistance.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Rodriguez, R.A., Hall, L.E., Duggan, S. et al. The bispectral index does not correlate with clinical signs of inhalational anesthesia during sevoflurane induction and arousal in children. Can J Anesth 51, 472–480 (2004). https://doi.org/10.1007/BF03018310

Download citation

  • Accepted:

  • Issue Date:

  • DOI: https://doi.org/10.1007/BF03018310

Keywords

  • Sevoflurane
  • Laryngeal Mask Airway
  • Bispectral Index
  • Inhalational Anesthesia
  • Sevoflurane Anesthesia