Sedation assessment in a mobile intensive care unit: a prospective pilot-study on the relation of clinical sedation scales and the bispectral index

Sevoflurane sedation in COVID-19 acute respiratory distress syndrome: an observational study with a propensity score matching model

Introduction

The management of severe COVID-19-induced acute respiratory distress syndrome (C-ARDS) often involves deep sedation. This study evaluated the efficacy of sevoflurane, a volatile anesthetic, as an alternative to traditional intravenous sedation in this patient population.

Methods

This single-center, retrospective cohort study enrolled 112 patients with C-ARDS requiring invasive mechanical ventilation. A propensity score matching model was utilized to pair 56 patients receiving sevoflurane sedation with 56 patients receiving intravenous sedation. The primary outcome was mortality, with secondary outcomes being changes in oxygenation (PaO2/FiO2 ratio), pulmonary compliance, and levels of D-Dimer, CRP, and creatinine.

Results

The use of sevoflurane was associated with a statistically significant reduction in mortality (OR 0.40, 95% CI 0.18-0.87, beta = -0.9, p = 0.02). In terms of secondary outcomes, an increase in the PaO2/FiO2 ratio and pulmonary static compliance was observed, although the results were not statistically significant. No significant differences were noted in the levels of D-Dimer, CRP, and creatinine between the two groups.

Conclusion

Our findings suggest an association between the use of sevoflurane and improved outcomes in C-ARDS patients requiring invasive mechanical ventilation. However, due to the single-center, retrospective design of the study, caution should be taken in interpreting these results, and further research is needed to corroborate these findings. The study offers promising insights into potential alternative sedation strategies in the management of severe C-ARDS.

Systematic review and meta‐analysis of the correlation between bispectral index ( BIS ) and clinical sedation scales: Toward defining the role of BIS in critically ill patients

INTRODUCTION

The bispectral index (BIS) is an attractive approach for monitoring level of consciousness in critically ill patients, particularly during paralysis, when commonly used sedation scales cannot be used.

OBJECTIVES

As a first step toward establishing the utility of BIS during paralysis, this review examines the strength of correlation between BIS and clinical sedation scales in a broad population of non-paralyzed, critically ill adults.

METHODS

We included studies evaluating the strength of correlation between concurrent assessments of BIS and Richmond Agitation Sedation Scale (RASS), Ramsay Sedation Scale (RSS), or Sedation Agitation Scale (SAS) in critically ill adult patients. Studies involving assessment of depth sedation periperative or procedural time periods, and those reporting BIS and sedation scale assessments conducted >5 min apart or while neuromuscular blocking agents (NMBA) were administered, were excluded. Data were abstracted on sedation scale, correlation coefficients, setting, patient characteristics, and BIS assessment characteristics that could impact the quality of the studies.

RESULTS

Twenty-four studies which enrolled 1235 patients met inclusion criteria. The correlation between BIS and RASS, RSS, and SAS overall was 0.68 (95% confidence interval, 0.61-0.74, Ƭ²  = 0.06 I²  = 71.26%). Subgroup analysis by sedation scale indicated that the correlation between BIS and RASS, RSS, and SAS were 0.66 (95% confidence interval 0.58-0.73, Ƭ²  = 0.01 I²  = 30.20%), 0.76 (95% confidence interval 0.69-0.82, Ƭ²  = 0.04 I²  = 67.15%), and 0.53 (95% confidence interval 0.42-0.63, Ƭ²  = 0.01 I²  = 26.59%), respectively. Factors associated with significant heterogeneity included comparator clinical sedation scale, neurologic injury, and the type of intensive care unit (ICU) population.

CONCLUSIONS

BIS demonstrated moderate to strong correlation with clinical sedation scales in adult ICU patients, providing preliminary evidence for the validity of BIS as a measure of sedation intensity when clinical scales cannot be used. Future studies should determine whether BIS monitoring is safe and effective in improving outcomes in patients receiving NMBA treatment.

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.

Guidelines for safe transfer of the brain-injured patient: trauma and stroke, 2019: Guidelines from the Association of Anaesthetists and the Neuro Anaesthesia and Critical Care Society

The location of care for many brain-injured patients has changed since 2012 following the development of major trauma centres. Advances in management of ischaemic stroke have led to the urgent transfer of many more patients. The basis of care has remained largely unchanged, however, with emphasis on maintaining adequate cerebral perfusion as the key to preventing secondary injury. Organisational aspects and training for transfers are highlighted, and we have included an expanded section on paediatric transfers. We have also provided a table with suggested blood pressure parameters for the common types of brain injury but acknowledge that there is little evidence for many of our recommendations. These guidelines remain a mix of evidence-based and consensus-based statements. We have received assistance from many organisations representing clinicians who care for these patients, and we believe our views represent the best of current thinking and opinion. We encourage departments to review their own practice using our suggestions for audit and quality improvement.

Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU

OBJECTIVE

To update and expand the 2013 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the ICU.

DESIGN

Thirty-two international experts, four methodologists, and four critical illness survivors met virtually at least monthly. All section groups gathered face-to-face at annual Society of Critical Care Medicine congresses; virtual connections included those unable to attend. A formal conflict of interest policy was developed a priori and enforced throughout the process. Teleconferences and electronic discussions among subgroups and whole panel were part of the guidelines' development. A general content review was completed face-to-face by all panel members in January 2017.

METHODS

Content experts, methodologists, and ICU survivors were represented in each of the five sections of the guidelines: Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption). Each section created Population, Intervention, Comparison, and Outcome, and nonactionable, descriptive questions based on perceived clinical relevance. The guideline group then voted their ranking, and patients prioritized their importance. For each Population, Intervention, Comparison, and Outcome question, sections searched the best available evidence, determined its quality, and formulated recommendations as "strong," "conditional," or "good" practice statements based on Grading of Recommendations Assessment, Development and Evaluation principles. In addition, evidence gaps and clinical caveats were explicitly identified.

RESULTS

The Pain, Agitation/Sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) panel issued 37 recommendations (three strong and 34 conditional), two good practice statements, and 32 ungraded, nonactionable statements. Three questions from the patient-centered prioritized question list remained without recommendation.

CONCLUSIONS

We found substantial agreement among a large, interdisciplinary cohort of international experts regarding evidence supporting recommendations, and the remaining literature gaps in the assessment, prevention, and treatment of Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) in critically ill adults. Highlighting this evidence and the research needs will improve Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) management and provide the foundation for improved outcomes and science in this vulnerable population.

Behavior of a dual closed-loop controller of propofol and remifentanil guided by the bispectral index for postoperative sedation of adult cardiac surgery patients: a preliminary open study

A dual-loop controller permits the automated titration of propofol and remifentanil during anesthesia; it has never been used in intensive care after cardiac surgery. The goal of this preliminary study was to determine the efficacy of this controller to provide postoperative sedation in 19 adult cardiac surgery patients with a Bispectral Index target of 50. Results are presented as numbers (percentages) or medians [25th-75th percentiles]. The sedation period lasted 139 min [89-205] during which the Richmond Agitation Sedation Scale was at - 5 and the Behavioral Pain Scale score at three points for all patients and observation times but one (82 out of 83 assessments). Sedation time in the range 40-60 for the Bispectral Index was 87% [57-95]; one patient had a period of electrical silence defined as Suppression Ratio at least > 10% for more than 60 s. The time between the end of infusions and tracheal extubation was 84 min [63-129]. The Richmond Agitation Sedation Scale was 0 [0-0], 0 [- 1 to 0], and 0 [0-0] respectively during the 3 h following extubation while the verbal numerical pain scores were 6 [4.5-7], 5 [4-6], and 2 [0-5]. Mean arterial pressure decreased during sedation requiring therapeutic interventions, mainly vascular filling in 15 (79%) patients. Automated sedation device was discontinued in two patients for hemodynamic instability. No patient had awareness of the postoperative sedation period. Dual closed-loop can provide postoperative sedation after cardiac surgery but the choice of the depth of sedation should take into account the risk of hypotension.

Feasibility of continuous sedation monitoring in critically ill intensive care unit patients using the NeuroSENSE WAVCNS index

Sedation in the intensive care unit (ICU) is challenging, as both over- and under-sedation are detrimental. Current methods of assessment, such as the Richmond Agitation Sedation Scale (RASS), are measured intermittently and rely on patients' behavioral response to stimulation, which may interrupt sleep/rest. A non-stimulating method for continuous sedation monitoring may be beneficial and allow more frequent assessment. Processed electroencephalography (EEG) monitors have not been routinely adopted in the ICU. The aim of this observational study was to assess the feasibility of using the NeuroSENSE™ monitor for EEG-based continuous sedation assessment. With ethical approval, ICU patients on continuous propofol sedation were recruited. Depth-of-hypnosis index (WAV_CNS) values were obtained from the NeuroSENSE. Bedside nurses, blinded to the NeuroSENSE, performed regular RASS assessments and maintained the sedation regimen as per standard of care. Participants were monitored throughout the duration of their propofol infusion, up to 24 h. Fifteen patients, with median [interquartile range] age of 57 [52-62.5] years were each monitored for a duration of 9.0 [5.7-20.1] h. Valid WAV_CNS values were obtained for 89% [66-99] of monitoring time and were widely distributed within and between individuals, with 6% [1-31] spent < 40 (very deep), and 3% [1-15] spent > 90 (awake). Significant EEG suppression was detected in 3/15 (20%) participants. Observed RASS matched RASS goals in 36/89 (40%) assessments. The WAV_CNS variability, and incidence of EEG suppression, highlight the limitations of using RASS as a standalone sedation measure, and suggests potential benefit of adjunct continuous brain monitoring.

Correlation of bispectral index and Richmond agitation sedation scale for evaluating sedation depth: a retrospective study

Background

This study aims to verify the correlation of bispectral index (BIS) and Richmond agitation sedation scale (RASS) for evaluating these and explore possibility of replacing RASS with BIS.

Methods

This retrospective cohort study consisted of 74 patients who were collected from the third Intensive Care Unit (ICU) ward of XXX Hospital between May 2012 and June 2015 in this retrospective study. Sedation levels were evaluated using the 10-grade RASS and were continuously monitored with a BIS monitor during the procedure every 5 minutes. BIS values and RASS scores were recorded.

Results

Patients were divided into dexmedetomidine (n=31) and midazolam (n=43) groups, and 342 paired data were collected. A statistically significant correlation existed between BIS values and RASS scores either in all patients undergoing flexible fiberoptic bronchoscopy (FFB) or in dexmedetomidine and midazolam groups at different time points. Correlation coefficient was higher in midazolam group compared with dexmedetomidine group at different time points (P<0.05).

Conclusions

A correlation was observed between BIS and RASS for evaluating depth of sedation in ICU patients undergoing FFB (P<0.05). Study results indicated that BIS monitoring is a meaningful tool, which can be applied as an adjunctive and alternative method to assess sedation, especially for high-risk patients who are prone to be under- or over-sedation.

Individual reactions to viewing preferred video representations of the natural environment: A comparison of mental and physical reactions

AIM

Globally, awareness of the vital link between health and the natural environment is growing. This pilot study, based on the idea of "forest bathing," or shinrin-yoku, the mindful use of all five senses to engage with nature in a natural environment, was initiated in order to determine whether stimulation by viewing an individual's preferred video of sea or forest had an effect on relaxation.

METHODS

The participants were 12 healthy men in their twenties and they were divided into two groups based on their preference for sea or forest scenery by using the Visual Analogue Scale. The participants watched 90 min DVDs of sea with natural sounds and forest with natural sounds while their heart rate variability and Bispectral Index System value were measured by using MemCalc/Tawara and a Bispectral Index System monitor.

RESULTS

The participants were divided into two groups of six based on their preference for sea or forest scenery and each indicator was compared between them. Significant differences in a decrease in heart rate, increase in high frequency, and sustained arousal level were observed while viewing the preferred video. These results indicated that the viewing individual's preferred video of sea or forest had a relaxation effect.

CONCLUSION

This study suggests that individual preferences should be taken into consideration for video relaxation therapy.

The validation and inter-rater reliability of the Serbian translation of the Richmond agitation and sedation scale in post anesthesia care unit patients

BACKGROUND

Targeted light sedation is recommended because it shortens the time of mechanical ventilation and the length of stay in an intensive care unit (ICU). However, there is no validated scale for sedation and agitation in ICU in the Serbian speaking area. The aim of the current study was to validate, verify the reliability and enable the application of the Richmond Agitation and Sedation Scale (RASS) in the Serbian speaking area.

METHODS

In this prospective cohort study, RASS was applied to 301 adult patients hospitalized in surgical ICUs by two different research team members. We tested RASS for inter-rater reliability by the correlation between them. The scale was validated by comparison to Glasgow Coma Scale (GCS) scores which was applied by the third investigator. Interrater agreement was measured using weighted kappa (k) and for correlation Spearman's test was used.

RESULTS

The inter-rater reliability of the scale was high (k ˃0.7). The degree of correlation between the RASS and the GCS during all five days of observation was high (˃0.7 for both investigators, the fifth day). In all the cases, Spearman's correlation coefficient was highly significant (p ˂0.01).

CONCLUSIONS

The Serbian translation of the RASS is a reliable and valid instrument for the assessment of the levels of sedation and agitation with patients in ICU. Hippokratia 2016, 20(1): 50-54.