Skip to main content

Advertisement

SpringerLink
Log in

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

  • Original Article
  • Published:
Neurocritical Care Aims and scope Submit manuscript

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  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.

    Article  PubMed  Google Scholar 

  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.

    PubMed  CAS  Google Scholar 

  3. Carrasco G. Instruments for monitoring intensive care unit sedation. Crit Care. 2000;4(4):217–25. doi:10.1186/cc697.

    Article  PubMed  CAS  Google Scholar 

  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.

    Article  PubMed  CAS  Google Scholar 

  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.

    PubMed  CAS  Google Scholar 

  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.

    Article  PubMed  CAS  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    PubMed  CAS  Google Scholar 

  10. Grap MJ, Glass C, Lindamood MO. Factors related to unplanned extubation of endotracheal tubes. Crit Care Nurse. 1995;15(2):57–65.

    PubMed  CAS  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  CAS  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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. Ramsay MA, Savege TM, Simpson BR, Goodwin R. Controlled sedation with alphaxalone-alphadolone. BMJ. 1974;2(920):656–9.

    Article  PubMed  CAS  Google Scholar 

  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.

    Article  PubMed  CAS  Google Scholar 

  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.

    Article  PubMed  CAS  Google Scholar 

  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.

    Article  PubMed  CAS  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  24. Olson DM, Thoyre SM, Auyong DB. Perspectives on sedation assessment in critical care. AACN Adv Crit Care. 2007;18(4):380–95.

    PubMed  Google Scholar 

  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. 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.

    Article  PubMed  Google Scholar 

  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.

    PubMed  CAS  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  CAS  Google Scholar 

  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.

    PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  CAS  Google Scholar 

  35. Kost M. Manual of conscious sedation. Philadelphia: W.B. Saunders; 1998.

    Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  CAS  Google Scholar 

  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.

    Article  PubMed  CAS  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

Download references

Acknowledgment

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

Author information

Authors and Affiliations

  1. Department of Medicine-Neurology, Duke University Medical Center, Durham, NC, 27710, USA

    DaiWai M. Olson

  2. School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27516, USA

    Suzanne M. Thoyre

  3. Division of Cardiology, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, 27710, USA

    Eric D. Peterson

  4. Division of Neurology, Neuroscience Intensive Care Unit, Duke University Medical Center, Durham, NC, 27710, USA

    Carmelo Graffagnino

Authors
  1. DaiWai M. Olson
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Suzanne M. Thoyre
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Eric D. Peterson
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Carmelo Graffagnino
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to DaiWai M. Olson.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Olson, D.M., Thoyre, S.M., Peterson, E.D. et al. A Randomized Evaluation of Bispectral Index-Augmented Sedation Assessment in Neurological Patients. Neurocrit Care 11, 20–27 (2009). https://doi.org/10.1007/s12028-008-9184-6

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12028-008-9184-6

Keywords

Search

Navigation