Bispectral index as a predictor of unsalvageable traumatic brain injury

Deep Sedation in Traumatic Brain Injury Patients

Traumatic brain injury (TBI) is one of the leading causes of mortality and disability in adults. In cases of severe TBI, preventing secondary brain injury by managing intracranial hypertension during the acute phase is a critical treatment challenge. Among surgical and medical interventions to control intracranial pressure (ICP), deep sedation can provide comfort to patients and directly control ICP by regulating cerebral metabolism. However, insufficient sedation does not achieve the intended treatment goals, and excessive sedation can lead to fatal sedative-related complications. Therefore, it is important to continuously monitor and titrate sedatives by measuring the appropriate depth of sedation. In this review, we discuss the effectiveness of deep sedation, techniques to monitor the depth of sedation, and the clinical use of recommended sedatives, barbiturates, and propofol in TBI.

Correlation between bispectral index and prognosis of patients with acute cerebral infarction

INTRODUCTION

This study aimed to investigate the clinical value of bispectral index (BIS) monitoring in assessing the consciousness and prognosis of acute cerebral infarction (ACI) patients.

METHODS

In total, 64 patients who suffered from ACI with consciousness disturbance were enrolled in this study. Glasgow Coma Scale (GCS) was performed to evaluate the consciousness level of ACI patients, and BIS was used to monitor the depth of anesthesia and sedation. Then, patients were divided into good prognosis, poor prognosis and death groups according to modified Rankin score (mRS). Discrimination analysis of BIS values and GCS score for the prediction of prognosis was performed using the receiver operator characteristic (ROC) curve.

RESULTS

GCS score and BIS values showed statistically significant differences among the three groups. Spearman rank correlation analysis revealed a significant positive correlation between BIS values and GCS score, while BIS values was negatively related with mRS. The ROC curve of prognosis prediction showed strong prognostic power, with area under the curves (AUCs) between 0.830 and 0.917. Moreover, the AUC of BISmean score was higher than that of BISmax, BISmin and GCS, and BISmean of 74 was the best cut-off point for good prognosis.

CONCLUSION

BIS directly reflects the degree of consciousness disturbance in ACI patients, and thus accurately predicts the prognosis, indicating potential application values of BIS in clinical practice.

Evaluation of Prognosis of Coma Patients With Acute Brain Injury by Electroencephalogram Bispectral Index Monitoring

BACKGROUND

The high mortality rate of comatose patients with traumatic brain injury is a prominent public health issue that negatively impacts patients and their families. Objective, reliable tools are needed to guide treatment decisions and prioritize resources.

OBJECTIVE

This study aimed to evaluate the prognostic value of the bispectral index (BIS) in comatose patients with severe brain injury.

METHODS

This was a retrospective cohort study of 84 patients with severe brain injury and Glasgow Coma Scale (GCS) scores of 8 and less treated from January 2015 to June 2017. Sedatives were withheld at least 24 hr before BIS scoring. The BIS value, GCS scores, and Full Outline of UnResponsiveness (FOUR) were monitored hourly for 48 hr. Based on the Glasgow Outcome Scale (GOS) score, the patients were divided into poor (GOS score: 1-2) and good prognosis groups (GOS score: 3-5). The correlation between BIS and prognosis was analyzed by logistic regression, and the receiver operating characteristic curves were plotted.

RESULTS

The mean (SD) of the BIS value: 54.63 (11.76), p = .000; and GCS score: 5.76 (1.87), p = .000, were higher in the good prognosis group than in the poor prognosis group. Lower BIS values and GCS scores were correlated with poorer prognosis. Based on the area under the curve of receiver operating characteristic curves, the optimal diagnostic cutoff value of the BIS was 43.6, and the associated sensitivity and specificity were 85.4% and 74.4%, respectively.

CONCLUSION

Taken together, our study indicates that BIS had good predictive value on prognosis. These findings suggested that BIS could be used to evaluate the severity and prognosis of severe brain injury.

A Review of Bispectral Index Utility in Neurocritical Care Patients

Context: Bispectral Index (BIS) was introduced in 1960 to monitor the depth of anesthesia in the operating rooms. It has been recently used to monitor the sedation in the critically ill patients hospitalized in intensive care and neurocritical care units (NCCU). Evidence Acquisition: Patients in the NCCU, particularly those with prolonged mechanical ventilation require appropriate adjustments in the administration of sedative drugs. Similarly, those who require neuro protection with barbiturates need to be closely monitored in the depth of their coma. Results: BIS may be a useful tool in this situation, and it can also help shorten the duration of mechanical ventilation by determining the appropriate time to eliminate patients from mechanical ventilation. We conducted a literature search to evaluate the utility of BIS monitoring in the NCCU patients with subarachnoid hemorrhage, intracranial hemorrhage, coma, cerebral hypoxia, status epilepticus and traumatic brain injury. Conclusions: BIS monitoring may be a useful adjunct to take care of the patients. However, further studies with a larger population and better design are required to substantiate the role of BIS monitoring in the care of NCCU patients.

Sedatives in neurocritical care: an update on pharmacological agents and modes of sedation

PURPOSE OF REVIEW

In this article, the specific and general indications for sedatives in the neurocritical care unit are discussed, together with an overview on current insights in sedative protocols for these patients. In addition, physiological effects of sedative agents on the central nervous system are reviewed.

RECENT FINDINGS

In the general ICU population, a large body of evidence supports light protocolized sedation over indiscriminate deep sedation. Unfortunately, in patients with severe acute brain injury, the evidence from randomized controlled trials is scarce to nonexistent, and practice is supported by expert opinion, physiological studies and observational or small interventional trials. The different sedatives each have different beneficial effects and side-effects.

SUMMARY

Extrapolating the findings from studies in the general ICU population suggests to reserve deep continuous sedation in the neuro-ICU for specific indications. Although an improved understanding of cerebral physiological changes in patients with brain injury may be helpful to guide individualized sedation, we still lack the evidence base to make broad recommendations for specific patient groups.

Use of propofol for prevention of post-delivery nausea during cesarean section: a double-blind, randomized, placebo-controlled trial

PURPOSE

Nausea and vomiting are common, undesirable symptoms during cesarean section. We conducted this study to assess the antiemetic properties of propofol for the prevention and immediate treatment of post-delivery nausea and vomiting during cesarean section under combined spinal-epidural anesthesia.

METHODS

Eighty women undergoing elective cesarean delivery under combined spinal-epidural anesthesia were randomized to receive either propofol at a plasma concentration of 1000 ng/mL or normal saline immediately after clamping of the umbilical cord. The incidence of post-delivery nausea and vomiting, patients requiring rescue antiemetic, bispectral index, sedation score, and the incidence of hypotension were assessed intraoperatively. Satisfaction and neonatal behavioral neurological assessments were evaluated postoperatively.

RESULTS

The incidence of nausea was significantly lower in the propofol group compared to the placebo group (25% versus 60%, P < 0.001). The incidence of retching and vomiting showed no significant difference between the two groups. Propofol 20 mg as a rescue antiemetic was significantly effective in both the groups. Satisfaction level of patients and obstetricians in the propofol group was higher than in the placebo group. There was no statistical difference in the incidence of hypotension between the two groups both pre- and post-delivery. There was no difference in postoperative neonatal behavioral neurological assessment between groups.

CONCLUSION

Propofol at a plasma concentration of 1000 ng/mL significantly reduced the incidence of post-delivery nausea compared to placebo, but had no effect on reducing retching or vomiting episodes during cesarean section.