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Choo YH, Seo Y, Oh HJ. Deep Sedation in Traumatic Brain Injury Patients. Korean J Neurotrauma 2023; 19:185-194. [PMID: 37431376 PMCID: PMC10329893 DOI: 10.13004/kjnt.2023.19.e19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/03/2023] [Accepted: 04/04/2023] [Indexed: 07/12/2023] Open
Abstract
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.
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Affiliation(s)
- Yoon-Hee Choo
- Department of Neurosurgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Youngbeom Seo
- Department of Neurosurgery, Yeungnam University Hospital, Yeungnam Universtiy College of Medicine, Daegu, Korea
| | - Hyuk-Jin Oh
- Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, College of Medicine, Soonchunhyang University, Cheonan, Korea
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Wiles MD, Braganza M, Edwards H, Krause E, Jackson J, Tait F. Management of traumatic brain injury in the non-neurosurgical intensive care unit: a narrative review of current evidence. Anaesthesia 2023; 78:510-520. [PMID: 36633447 DOI: 10.1111/anae.15898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2022] [Indexed: 01/13/2023]
Abstract
Each year, approximately 70 million people suffer traumatic brain injury, which has a significant physical, psychosocial and economic impact for patients and their families. It is recommended in the UK that all patients with traumatic brain injury and a Glasgow coma scale ≤ 8 should be transferred to a neurosurgical centre. However, many patients, especially those in whom neurosurgery is not required, are not treated in, nor transferred to, a neurosurgical centre. This review aims to provide clinicians who work in non-neurosurgical centres with a summary of contemporary studies relevant to the critical care management of patients with traumatic brain injury. A targeted literature review was undertaken that included guidelines, systematic reviews, meta-analyses, clinical trials and randomised controlled trials (published in English between 1 January 2017 and 1 July 2022). Studies involving key clinical management strategies published before this time, but which have not been updated or repeated, were also eligible for inclusion. Analysis of the topics identified during the review was then summarised. These included: fundamental critical care management approaches (including ventilation strategies, fluid management, seizure control and osmotherapy); use of processed electroencephalogram monitoring; non-invasive assessment of intracranial pressure; prognostication; and rehabilitation techniques. Through this process, we have formulated practical recommendations to guide clinical practice in non-specialist centres.
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Affiliation(s)
- M D Wiles
- Department of Critical Care, Major Trauma and Head Injuries, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield, UK.,University of Sheffield Medical School, Sheffield, UK
| | - M Braganza
- Department of Intensive Care, Chesterfield Royal Hospital NHS Foundation Trust, Chesterfield, UK
| | - H Edwards
- Department of Neurosciences, Major Trauma and Head Injuries, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - E Krause
- Neurology and Stroke, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, UK
| | - J Jackson
- Major Trauma and Head Injuries, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - F Tait
- Department of Anaesthesia, Northampton General Hospital NHS Trust, Northampton, UK
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Benedetti GM, Morgan LA, Sansevere AJ, Harrar DB, Guerriero RM, Wainwright MS, LaRovere KL, Kielian A, Ganesan SL, Press CA. The Spectrum of Quantitative EEG Utilization Across North America: A Cross-Sectional Survey. Pediatr Neurol 2023; 141:1-8. [PMID: 36731228 DOI: 10.1016/j.pediatrneurol.2022.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 11/16/2022] [Accepted: 12/30/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Continuous electroencephalography (cEEG) is commonly used for neuromonitoring in pediatric intensive care units (PICU); however, there are barriers to real-time interpretation of EEG data. Quantitative EEG (qEEG) transforms the EEG signal into time-compressed graphs, which can be displayed at the bedside. A survey was designed to understand current PICU qEEG use. METHODS An electronic survey was sent to the Pediatric Neurocritical Care Research Group and Pediatric Status Epilepticus Research Group, and intensivists in 16 Canadian PICUs. Questions addressed demographics, qEEG acquisition and storage, clinical use, and education. RESULTS Fifty respondents from 39 institutions completed the survey (response rate 53% [39 of 74 institutions]), 76% (37 of 50) from the United States and 24% (12 of 50) from Canada. Over half of the institutions (22 of 39 [56%]) utilize qEEG in their ICUs. qEEG use was associated with having a neurocritical care (NCC) service, ≥200 NCC consults/year, ≥1500 ICU admissions/year, and ≥4 ICU EEGs/day (P < 0.05 for all). Nearly all users (92% [24 of 26]) endorsed that qEEG enhanced care of children with acute neurological injury. Lack of training in qEEG was identified as a common barrier [85% (22 of 26)]. Reviewing and reporting of qEEG was not standard at most institutions. Training was required by 14% (three of 22) of institutions, and 32% (seven of 22) had established curricula. CONCLUSIONS ICU qEEG was used at more than half of the institutions surveyed, but review, reporting, and application of this tool remained highly variable. Although providers identify qEEG as a useful tool in patient management, further studies are needed to define clinically meaningful pediatric trends, standardize reporting, and enhance educate bedside providers.
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Affiliation(s)
- Giulia M Benedetti
- Division of Pediatric Neurology, Department of Neurology, University of Washington School of Medicine, Seattle, Washington
| | - Lindsey A Morgan
- Division of Pediatric Neurology, Department of Neurology, University of Washington School of Medicine, Seattle, Washington
| | - Arnold J Sansevere
- Department of Neurology, Children's National Hospital and Departments of Neurology and Pediatrics, George Washington University School of Medicine, Washington, District of Columbia
| | - Dana B Harrar
- Department of Neurology, Children's National Hospital and Departments of Neurology and Pediatrics, George Washington University School of Medicine, Washington, District of Columbia
| | - Réjean M Guerriero
- Division of Pediatric and Developmental Neurology, Department of Neurology, Washington University School of Medicine, St. Louis, Missouri
| | - Mark S Wainwright
- Division of Pediatric Neurology, Department of Neurology, University of Washington School of Medicine, Seattle, Washington
| | - Kerri L LaRovere
- Department of Neurology, Harvard Medical School and Boston Children's Hospital, Boston, Massachusetts
| | - Agnieszka Kielian
- Department of Neurology, Harvard Medical School and Boston Children's Hospital, Boston, Massachusetts
| | - Saptharishi Lalgudi Ganesan
- Paediatric Critical Care Medicine, Children's Hospital of Western Ontario, London Health Sciences Centre, London, Ontario, Canada; Department of Paediatrics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Craig A Press
- Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Marini CP, McNelis J, Petrone P. Multimodality Monitoring and Goal-Directed Therapy for the Treatment of Patients with Severe Traumatic Brain Injury: A Review for the General and Trauma Surgeon. Curr Probl Surg 2021; 59:101070. [DOI: 10.1016/j.cpsurg.2021.101070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 10/04/2021] [Indexed: 11/28/2022]
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Marini CP, McNelis J, Petrone P. In Brief. Curr Probl Surg 2021. [DOI: 10.1016/j.cpsurg.2021.101071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Processed EEG from depth of anaesthesia monitors and seizures: A scoping review. Seizure 2021; 91:198-206. [PMID: 34229228 DOI: 10.1016/j.seizure.2021.06.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 06/03/2021] [Accepted: 06/12/2021] [Indexed: 12/27/2022] Open
Abstract
PURPOSE Processed electroencephalogram (EEG) is used peri-operatively for monitoring depth of anaesthesia. Because these utilise EEG data, attempts have been made to investigate their use in diagnosing and monitoring seizures. This is important as formal EEG monitoring can be hard to obtain in many critical care environments. We undertook a scoping review of the evidence for using processed EEG (pEEG) from depth of anaesthesia monitors for this indication. METHODS Medline, Psych INFO, and Embase were searched for peer-reviewed journals until 20 March 2021. Data and conclusions taken from the study of pEEG in both critical care and peri-operative settings have been included in a qualitative synthesis about the current evidence for the use of pEEG in the detection and monitoring of seizures. RESULTS Searches yielded 8 observational studies, 1 randomised trial and 15 case reports in which the use of pEEG in critical care and peri-operative medicine was described. Most concerned the Bispectral Index (BIS) device. The majority of observational studies reported the use of BIS for optimisation of burst suppression in patients with refractory status-epilepticus (RSE), or in the comparison of pEEG data with conventional EEG during epileptic activity. Multiple case reports describe the application of pEEG in the presence of disorders of consciousness as a tool for detection of non-convulsive status-epilepticus, finding variable trends in the pEEG output. CONCLUSIONS Processed EEG may be helpful in monitoring pharmacologically induced burst suppression. Despite this, its use in the diagnosing or monitoring seizure activity is controversial and currently not evidenced, with numerous confounding variables that requires systematic assessment in future studies.
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Baldassano SN, Roberson SW, Balu R, Scheid B, Bernabei JM, Pathmanathan J, Oommen B, Leri D, Echauz J, Gelfand M, Bhalla PK, Hill CE, Christini A, Wagenaar JB, Litt B. IRIS: A Modular Platform for Continuous Monitoring and Caretaker Notification in the Intensive Care Unit. IEEE J Biomed Health Inform 2020; 24:2389-2397. [PMID: 31940568 PMCID: PMC7485608 DOI: 10.1109/jbhi.2020.2965858] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE New approaches are needed to interpret large amounts of physiologic data continuously recorded in the ICU. We developed and prospectively validated a versatile platform (IRIS) for real-time ICU physiologic monitoring, clinical decision making, and caretaker notification. METHODS IRIS was implemented in the neurointensive care unit to stream multimodal time series data, including EEG, intracranial pressure (ICP), and brain tissue oxygenation (PbtO2), from ICU monitors to an analysis server. IRIS was applied for 364 patients undergoing continuous EEG, 26 patients undergoing burst suppression monitoring, and four patients undergoing intracranial pressure and brain tissue oxygen monitoring. Custom algorithms were used to identify periods of elevated ICP, compute burst suppression ratios (BSRs), and detect faulty or disconnected EEG electrodes. Hospital staff were notified of clinically relevant events using our secure API to route alerts through a password-protected smartphone application. RESULTS Sustained increases in ICP and concordant decreases in PbtO2 were reliably detected using user-defined thresholds and alert throttling. BSR trends computed by the platform correlated highly with manual neurologist markings (r2 0.633-0.781; p < 0.0001). The platform identified EEG electrodes with poor signal quality with 95% positive predictive value, and reduced latency of technician response by 93%. CONCLUSION This study validates a flexible real-time platform for monitoring and interpreting ICU data and notifying caretakers of actionable results, with potential to reduce the manual burden of continuous monitoring services on care providers. SIGNIFICANCE This work represents an important step toward facilitating translational medical data analytics to improve patient care and reduce health care costs.
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Outin H, Gueye P, Alvarez V, Auvin S, Clair B, Convers P, Crespel A, Demeret S, Dupont S, Engels JC, Engrand N, Freund Y, Gelisse P, Girot M, Marcoux MO, Navarro V, Rossetti A, Santoli F, Sonneville R, Szurhaj W, Thomas P, Titomanlio L, Villega F, Lefort H, Peigne V. Recommandations Formalisées d’Experts SRLF/SFMU : Prise en charge des états de mal épileptiques en préhospitalier, en structure d’urgence et en réanimation dans les 48 premières heures (A l’exclusion du nouveau-né et du nourrisson). ANNALES FRANCAISES DE MEDECINE D URGENCE 2020. [DOI: 10.3166/afmu-2020-0232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
La Société de réanimation de langue française et la Société française de médecine d’urgence ont décidé d’élaborer de nouvelles recommandations sur la prise en charge de l’état mal épileptique (EME) avec l’ambition de répondre le plus possible aux nombreuses questions pratiques que soulèvent les EME : diagnostic, enquête étiologique, traitement non spécifique et spécifique. Vingt-cinq experts ont analysé la littérature scientifique et formulé des recommandations selon la méthodologie GRADE. Les experts se sont accordés sur 96 recommandations. Les recommandations avec le niveau de preuve le plus fort ne concernent que l’EME tonico-clonique généralisé (EMTCG) : l’usage des benzodiazépines en première ligne (clonazépam en intraveineux direct ou midazolam en intramusculaire) est recommandé, répété 5 min après la première injection (à l’exception du midazolam) en cas de persistance clinique. En cas de persistance 5 min après cette seconde injection, il est proposé d’administrer la seconde ligne thérapeutique : valproate de sodium, (fos-)phénytoïne, phénobarbital ou lévétiracétam. La persistance avérée de convulsions 30 min après le début de l’administration du traitement de deuxième ligne signe l’EMETCG réfractaire. Il est alors proposé de recourir à un coma thérapeutique au moyen d’un agent anesthésique intraveineux de type midazolam ou propofol. Des recommandations spécifiques à l’enfant et aux autres EME sont aussi énoncées.
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Riker RR, Craig A, Eubank L, May T, Seder DB. Validation of the suppression ratio from a simplified EEG montage during targeted temperature management after cardiac arrest. Resuscitation 2020; 153:1-5. [PMID: 32445782 DOI: 10.1016/j.resuscitation.2020.05.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 04/17/2020] [Accepted: 05/08/2020] [Indexed: 11/20/2022]
Abstract
AIM The Suppression Ratio (SR) estimates the percent of the electroencephalography (EEG) epoch with very low voltage, and is associated with neurological outcome after cardiac arrest. We aimed to compare the SR generated by two monitoring devices and determine the association between SR and patterns on amplitude integrated EEG (aEEG) and full conventional EEG (cEEG). METHODS Consecutive adult patients treated with TTM after cardiac arrest were enrolled. We compared the SR from the Medtronic Vista monitor (MSR) to the SR generated from the full montage cEEG with Persyst Magic-Marker software (PSR). A blinded neurologist, board certified in epilepsy, scored the 4-channel aEEG pattern and the cEEG background using standardized terminology. Values for SR were compared to aEEG and cEEG categories using Kruskal-Wallis ANOVA, and to each other using Altman-Bland methodology. RESULTS 23 adults treated with TTM had a mean core temperature of 33.8 °C at the time of SR and EEG background analysis. The MSR was 0% during continuous cEEG background, 23% when cEEG was discontinuous, and 64% during cEEG burst suppression (p = 0.01). The MSR was 0% during aEEG continuous patterns, 34% during aEEG burst suppression, and 46% during flat aEEG (p < 0.001). The MSR and PSR were highly correlated (0.88, p < 0.0001), with minimal bias (0.3%) and excellent 95% limits of agreement (-2.9 to 2.4%). CONCLUSION The Suppression Ratio from the Medtronic Vista monitor is highly correlated with the full montage SR from Persyst software. The MSR values are valid, changing with different aEEG patterns and cEEG background categories.
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Affiliation(s)
- Richard R Riker
- Tufts University School of Medicine, Department of Critical Care Medicine, Maine Medical Center, 22 Bramhall Street, Portland, ME 04102, USA
| | - Alexa Craig
- Tufts University School of Medicine, Neonatal and Pediatric Neurology, Maine Medical Partners Pediatric Neurology, 55 Spring St, Scarborough, ME 04074, USA
| | - Louis Eubank
- Department of Internal Medicine, University of Arizona College of Medicine, 1501 N Campbell Ave, Tucson, AZ 85724, USA
| | - Teresa May
- Tufts University School of Medicine, Department of Critical Care Medicine, Maine Medical Center, 22 Bramhall Street, Portland, ME 04102, USA
| | - David B Seder
- Tufts University School of Medicine, Department of Critical Care Medicine, Maine Medical Center, 22 Bramhall Street, Portland, ME 04102, USA
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Erratum to "Early Diagnosis of Nonconvulsive Status Epilepticus Recurrence with Raw EEG of a Bispectral Index Monitor". Case Rep Crit Care 2018; 2018:7147626. [PMID: 30643650 PMCID: PMC6311314 DOI: 10.1155/2018/7147626] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 10/11/2018] [Indexed: 12/03/2022] Open
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Muhlhofer WG, Zak R, Kamal T, Rizvi B, Sands LP, Yuan M, Zhang X, Leung JM. Burst-suppression ratio underestimates absolute duration of electroencephalogram suppression compared with visual analysis of intraoperative electroencephalogram. Br J Anaesth 2018; 118:755-761. [PMID: 28486575 DOI: 10.1093/bja/aex054] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2017] [Indexed: 12/21/2022] Open
Abstract
Background Machine-generated indices based on quantitative electroencephalography (EEG), such as the patient state index (PSI™) and burst-suppression ratio (BSR), are increasingly being used to monitor intraoperative depth of anaesthesia in the endeavour to improve postoperative neurological outcomes, such as postoperative delirium (POD). However, the accuracy of the BSR compared with direct visualization of the EEG trace with regard to the prediction of POD has not been evaluated previously. Methods Forty-one consecutive patients undergoing non-cardiac, non-intracranial surgery with general anaesthesia wore a SedLine ® monitor during surgery and were assessed after surgery for the presence of delirium with the Confusion Assessment Method. The intraoperative EEG was scanned for absolute minutes of EEG suppression and correlated with the incidence of POD. The BSR and PSI™ were compared between patients with and without POD. Results Visual analysis of the EEG by neurologists and the SedLine ® -generated BSR provided a significantly different distribution of estimated minutes of EEG suppression ( P =0.037). The Sedline ® system markedly underestimated the amount of EEG suppression. The number of minutes of suppression assessed by visual analysis of the EEG was significantly associated with POD ( P =0.039), whereas the minutes based on the BSR generated by SedLine ® were not associated with POD ( P =0.275). Conclusions Our findings suggest that SedLine ® (machine)-generated indices might underestimate the minutes of EEG suppression, thereby reducing the sensitivity for detecting patients at risk for POD. Thus, the monitoring of machine-generated BSR and PSI™ might benefit from the addition of a visual tracing of the EEG to achieve a more accurate and real-time guidance of anaesthesia depth monitoring and the ultimate goal, to reduce the risk of POD.
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Affiliation(s)
- W G Muhlhofer
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA.,Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - R Zak
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - T Kamal
- Department of Anaesthesia, University of California San Francisco, San Francisco, CA, USA
| | - B Rizvi
- Department of Anaesthesia, University of California San Francisco, San Francisco, CA, USA
| | | | - M Yuan
- Department of Biostatistics, Virginia Tech, Blacksburg, VA, USA
| | - X Zhang
- Department of Anaesthesia, University of California San Francisco, San Francisco, CA, USA
| | - J M Leung
- Department of Anaesthesia, University of California San Francisco, San Francisco, CA, USA
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Noninvasive Neuromonitoring: Current Utility in Subarachnoid Hemorrhage, Traumatic Brain Injury, and Stroke. Neurocrit Care 2018; 27:122-140. [PMID: 28004334 DOI: 10.1007/s12028-016-0361-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Noninvasive neuromonitoring is increasingly being used to monitor the course of primary brain injury and limit secondary brain damage of patients in the neurocritical care unit. Proposed advantages over invasive neuromonitoring methods include a lower risk of infection and bleeding, no need for surgical installation, mobility and portability of some devices, and safety. The question, however, is whether noninvasive neuromonitoring is practical and trustworthy enough already. We searched the recent literature and reviewed English-language studies on noninvasive neuromonitoring in subarachnoid hemorrhage, traumatic brain injury, and ischemic and hemorrhagic stroke between the years 2010 and 2015. We found 88 studies that were eligible for review including the methods transcranial ultrasound, electroencephalography, evoked potentials, near-infrared spectroscopy, bispectral index, and pupillometry. Noninvasive neuromonitoring cannot yet completely replace invasive methods in most situations, but has great potential being complementarily integrated into multimodality monitoring, for guiding management, and for limiting the use of invasive devices and in-hospital transports for imaging.
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Şerban CA, Barborică A, Roceanu AM, Mîndruță IR, Ciurea J, Zăgrean AM, Zăgrean L, Moldovan M. EEG Assessment of Consciousness Rebooting from Coma. THE PHYSICS OF THE MIND AND BRAIN DISORDERS 2017. [DOI: 10.1007/978-3-319-29674-6_16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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LeBlanc JM, Dasta JF, Kane-Gill SL. Role of the Bispectral Index in Sedation Monitoring in the ICU. Ann Pharmacother 2016; 40:490-500. [PMID: 16492796 DOI: 10.1345/aph.1e491] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Objective: To review and critique evidence for the use of the bispectral index (BIS) in intensive care unit (ICU) patients. Data Sources: A computer search of English-language articles in MEDLINE (1966–July 2005), International Pharmaceutical Abstracts (1971–July 2005), and Scientific Citation Index Expanded (1980–July 2005) was conducted. A manual search of abstracts was also performed using the key search terms BIS, sedation, and critical care. Study Selection and Data Extraction: Case series, letters, editorials, and clinical studies that evaluated BIS in ICU patients were considered for inclusion. Data Synthesis: Nineteen studies comparing the BIS with sedation scales were evaluated, revealing that the BIS trends lower with increasing sedation. The BIS appeared to correlate better when sedation scores were grouped rather than individual values. However, correlations between BIS and subjective scales were low in most studies (r2 0.21–0.93). Additionally, there was poor correlation between drug dosage and the BIS. Randomized, controlled trials demonstrating improved outcomes with BIS monitoring have not been reported. Conclusions: Interpreting literature on the usefulness of the BIS in the ICU is difficult for reasons that include heterogeneous populations, different methods of collecting BIS data, and use of different versions of BIS software and hardware. Outcomes data are lacking. The 2002 Society of Critical Care Medicine Sedation Guidelines recommendation that more data are needed before the BIS should be used routinely in the ICU remains unchanged. We recommend that further studies be conducted to determine the optimal method of obtaining BIS data and evaluate the impact of the BIS on relevant patient outcomes.
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Affiliation(s)
- Jaclyn M LeBlanc
- College of Pharmacy, The Ohio State University, Columbus, 43210, USA
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Papadelis C, Ashkezari SFS, Doshi C, Thome-Souza S, Pearl PL, Grant PE, Tasker RC, Loddenkemper T. Real-time multi-channel monitoring of burst-suppression using neural network technology during pediatric status epilepticus treatment. Clin Neurophysiol 2016; 127:2820-2831. [PMID: 27417058 DOI: 10.1016/j.clinph.2016.05.358] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Revised: 05/12/2016] [Accepted: 05/27/2016] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To develop a real-time monitoring system that has the potential to guide the titration of anesthetic agents in the treatment of pediatric status epilepticus (SE). METHODS We analyzed stored multichannel electroencephalographic (EEG) data collected from 12 pediatric patients with generalized SE. EEG recordings were initially segmented in 500ms time-windows. Features characterizing the power, frequency, and entropy of the signal were extracted from each segment. The segments were annotated as bursts (B), suppressions (S), or artifacts (A) by two electroencephalographers. The EEG features together with the annotations were inputted in a three-layer feed forward neural network (NN). The sensitivity and specificity of NNs with different architectures and training algorithms to classify segments into B, S, or A were estimated. RESULTS The maximum sensitivity (95.96% for B, 89.25% for S, and 75% for A) and specificity (89.36 for B, 96.26% for S, and 99.8% for A) was observed for the NN with 10 nodes in the hidden layer. By using this NN, we designed a real-time system that estimates the burst-suppression index (BSI). CONCLUSIONS Our system provides a reliable real-time estimate of multichannel BSI requiring minimal memory and computation time. SIGNIFICANCE The system has the potential to assist intensive care unit attendants in the continuous EEG monitoring.
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Affiliation(s)
- Christos Papadelis
- Center for Fetal-Neonatal Neuroimaging and Developmental Science, Boston Children's Hospital, Harvard Medical School, 1 Autumn St, Boston, MA 02215, USA; Division of Newborn Medicine, Department of Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Boston, MA 02115, USA.
| | - Seyedeh Fatemeh Salimi Ashkezari
- Center for Fetal-Neonatal Neuroimaging and Developmental Science, Boston Children's Hospital, Harvard Medical School, 1 Autumn St, Boston, MA 02215, USA; Division of Newborn Medicine, Department of Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Boston, MA 02115, USA
| | - Chiran Doshi
- Center for Fetal-Neonatal Neuroimaging and Developmental Science, Boston Children's Hospital, Harvard Medical School, 1 Autumn St, Boston, MA 02215, USA; Division of Newborn Medicine, Department of Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Boston, MA 02115, USA
| | - Sigride Thome-Souza
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Boston, MA 02115, USA
| | - Phillip L Pearl
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Boston, MA 02115, USA
| | - P Ellen Grant
- Center for Fetal-Neonatal Neuroimaging and Developmental Science, Boston Children's Hospital, Harvard Medical School, 1 Autumn St, Boston, MA 02215, USA; Division of Newborn Medicine, Department of Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Boston, MA 02115, USA; Department of Radiology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Boston, MA 02115, USA
| | - Robert C Tasker
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Boston, MA 02115, USA; Department of Anesthesia, Perioperative and Pain Medicine, Division of Critical Care Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Boston, MA 02115, USA
| | - Tobias Loddenkemper
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Boston, MA 02115, USA
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André-Obadia N, Parain D, Szurhaj W. Continuous EEG monitoring in adults in the intensive care unit (ICU). Neurophysiol Clin 2015; 45:39-46. [PMID: 25639999 DOI: 10.1016/j.neucli.2014.11.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 11/03/2014] [Indexed: 11/26/2022] Open
Abstract
Continuous EEG monitoring in the ICU is different from planned EEG due to the rather urgent nature of the indications, explaining the fact that recording is started in certain cases by the clinical team in charge of the patient's care. Close collaboration between neurophysiology teams and intensive care teams is essential. Continuous EEG monitoring can be facilitated by quantified analysis systems. This kind of analysis is based on certain signal characteristics, such as amplitude or frequency content, but raw EEG data should always be interpreted if possible, since artefacts can sometimes impair quantified EEG analysis. It is preferable to work within a tele-EEG network, so that the neurophysiologist has the possibility to give an interpretation on call. Continuous EEG monitoring is thus useful in the diagnosis of non-convulsive epileptic seizures or purely electrical discharges and in the monitoring of status epilepticus when consciousness disorders persist after initial treatment. A number of other indications are currently under evaluation.
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Affiliation(s)
- N André-Obadia
- Service de neurophysiologie et d'épileptologie, hôpital Neurologique P.-Wertheimer, hospices civils de Lyon, 59, boulevard Pinel, 69677 Bron cedex, France; Inserm U 1028, NeuroPain team, centre de recherche en neuroscience de Lyon (CRNL), université Lyon 1, 69677 Bron cedex, France.
| | - D Parain
- Service de neurophysiologie clinique, CHU Charles-Nicolle, 76031 Rouen cedex, France
| | - W Szurhaj
- Service de neurophysiologie clinique, hôpital Roger-Salengro, CHRU, 59037 Lille cedex, France; Faculté de médecine Henri-Warembourg, université Lille 2, 59045 Lille cedex, France
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[French guidelines on electroencephalogram]. Neurophysiol Clin 2014; 44:515-612. [PMID: 25435392 DOI: 10.1016/j.neucli.2014.10.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Accepted: 10/07/2014] [Indexed: 12/11/2022] Open
Abstract
Electroencephalography allows the functional analysis of electrical brain cortical activity and is the gold standard for analyzing electrophysiological processes involved in epilepsy but also in several other dysfunctions of the central nervous system. Morphological imaging yields complementary data, yet it cannot replace the essential functional analysis tool that is EEG. Furthermore, EEG has the great advantage of being non-invasive, easy to perform and allows control tests when follow-up is necessary, even at the patient's bedside. Faced with the advances in knowledge, techniques and indications, the Société de Neurophysiologie Clinique de Langue Française (SNCLF) and the Ligue Française Contre l'Épilepsie (LFCE) found it necessary to provide an update on EEG recommendations. This article will review the methodology applied to this work, refine the various topics detailed in the following chapters. It will go over the summary of recommendations for each of these chapters and underline proposals for writing an EEG report. Some questions could not be answered by the review of the literature; in those cases, an expert advice was given by the working and reading groups in addition to the guidelines.
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Mahmood S, Parchani A, El-Menyar A, Zarour A, Al-Thani H, Latifi R. Utility of bispectral index in the management of multiple trauma patients. Surg Neurol Int 2014; 5:141. [PMID: 25317356 PMCID: PMC4192905 DOI: 10.4103/2152-7806.141890] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2013] [Accepted: 07/02/2014] [Indexed: 11/23/2022] Open
Abstract
Background: Bispectral index (BIS) monitoring in multiple trauma patients has become a common practice in monitoring the sedation levels. We aimed to assess the utility of BIS in the trauma intensive care unit (ICU). Methods: A prospective observational study was conducted in the trauma ICU at Hamad General Hospital in Qatar between 2011 and 2012. Patients were divided in two groups: Group I (without BIS monitoring) and Group II (with BIS monitoring). The depth of sedation was clinically evaluated with Ramsey Sedation Scale, changes in vital signs and Glasgow Coma Scale (GCS) level. Use of sedatives, analgesics, and muscle relaxants were also recorded. Data were compared using Chi-square and Student t-tests. Results: A total of 110 mechanically ventilated trauma patients were enrolled with a mean age of 36 ± 14 years. The rate of head injury was greater in Group I when compared with Group II (94% vs. 81%, P = 0.04). In comparison to Group I, patients in Group II had lower GCS and higher mean Injury Severity Score (ISS) (6.3 ± 2.5 vs. 7.4 ± 2.7 and 25.5 ± 8.5 vs. 21.2 ± 4.7, respectively, P = 0.03). The used midazolam dose was less in Group II in comparison to Group I (5.2 ± 2.3 vs. 6.1 ± 2.1, P = 0.03). Also, fentanyl dose was less in Group II (152 ± 58 vs. 187 ± 59, P = 0.004). The rate of agitation, failure of extubation and tracheostomy in Group II were lower than those in Group I, P = 0.001. The length of stay for patients Group I was longer (14.6 ± 7.1 vs. 10.2 ± 5.9 days) in comparison to group II, P = 0.001. Conclusion: Management of multiple trauma patients in the trauma ICU with BIS monitoring was found to be associated with better outcomes. BIS monitoring is a guide for adjusting the dosage of sedative agents. It can also minimize agitation, failure of extubation, and length of stay in ICU.
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Affiliation(s)
- Saeed Mahmood
- Department of Surgery, Section of Trauma Surgery, Hamad General Hospital, Doha, Qatar
| | - Ashok Parchani
- Department of Surgery, Section of Trauma Surgery, Hamad General Hospital, Doha, Qatar
| | - Ayman El-Menyar
- Department of Clinical Research, Section of Trauma Surgery, Hamad General Hospital, Doha, Qatar ; Department of Clinical Medicine, Weill Cornell Medical School, Doha, Qatar
| | - Ahmad Zarour
- Department of Surgery, Section of Trauma Surgery, Hamad General Hospital, Doha, Qatar
| | - Hassan Al-Thani
- Department of Surgery, Section of Trauma Surgery, Hamad General Hospital, Doha, Qatar
| | - Rifat Latifi
- Department of Surgery, University of Arizona, Tucson, AZ, USA
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Westover MB, Shafi MM, Ching S, Chemali JJ, Purdon PL, Cash SS, Brown EN. Real-time segmentation of burst suppression patterns in critical care EEG monitoring. J Neurosci Methods 2013; 219:131-41. [PMID: 23891828 PMCID: PMC3939433 DOI: 10.1016/j.jneumeth.2013.07.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Revised: 06/08/2013] [Accepted: 07/04/2013] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Develop a real-time algorithm to automatically discriminate suppressions from non-suppressions (bursts) in electroencephalograms of critically ill adult patients. METHODS A real-time method for segmenting adult ICU EEG data into bursts and suppressions is presented based on thresholding local voltage variance. Results are validated against manual segmentations by two experienced human electroencephalographers. We compare inter-rater agreement between manual EEG segmentations by experts with inter-rater agreement between human vs automatic segmentations, and investigate the robustness of segmentation quality to variations in algorithm parameter settings. We further compare the results of using these segmentations as input for calculating the burst suppression probability (BSP), a continuous measure of depth-of-suppression. RESULTS Automated segmentation was comparable to manual segmentation, i.e. algorithm-vs-human agreement was comparable to human-vs-human agreement, as judged by comparing raw EEG segmentations or the derived BSP signals. Results were robust to modest variations in algorithm parameter settings. CONCLUSIONS Our automated method satisfactorily segments burst suppression data across a wide range adult ICU EEG patterns. Performance is comparable to or exceeds that of manual segmentation by human electroencephalographers. SIGNIFICANCE Automated segmentation of burst suppression EEG patterns is an essential component of quantitative brain activity monitoring in critically ill and anesthetized adults. The segmentations produced by our algorithm provide a basis for accurate tracking of suppression depth.
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Affiliation(s)
| | - Mouhsin M. Shafi
- Department of Neurology, Beth Israel Deaconess Medical Center, United States
| | - ShiNung Ching
- Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Boston, MA
| | - Jessica J. Chemali
- Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Boston, MA
- Department of Anaesthesia and Critical Care, Massachusetts General Hospital, Boston, MA
| | - Patrick L. Purdon
- Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Boston, MA
- Department of Anaesthesia and Critical Care, Massachusetts General Hospital, Boston, MA
| | - Sydney S. Cash
- Department of Neurology, Massachusetts General Hospital, Boston, MA
| | - Emery N. Brown
- Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Boston, MA
- Department of Anaesthesia and Critical Care, Massachusetts General Hospital, Boston, MA
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Abstract
Traumatic brain injury is a leading cause of childhood morbidity and mortality. The use of continuous EEG monitoring in the pediatric intensive care unit setting to aid in the management of acute traumatic brain injury is becoming more common, although practice does vary between institutions. This variability is a product of the relative paucity of data, particularly as it applies to prospective studies, in evaluating the use of continuous EEG after traumatic brain injury in the pediatric population. This review will summarize the current literature involving the utility of continuous EEG monitoring in children with acute traumatic brain injury, with focus on specific indications, impact on management, and prognostic value.
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Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 2013; 41:263-306. [PMID: 23269131 DOI: 10.1097/ccm.0b013e3182783b72] [Citation(s) in RCA: 2284] [Impact Index Per Article: 207.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To revise the "Clinical Practice Guidelines for the Sustained Use of Sedatives and Analgesics in the Critically Ill Adult" published in Critical Care Medicine in 2002. METHODS The American College of Critical Care Medicine assembled a 20-person, multidisciplinary, multi-institutional task force with expertise in guideline development, pain, agitation and sedation, delirium management, and associated outcomes in adult critically ill patients. The task force, divided into four subcommittees, collaborated over 6 yr in person, via teleconferences, and via electronic communication. Subcommittees were responsible for developing relevant clinical questions, using the Grading of Recommendations Assessment, Development and Evaluation method (http://www.gradeworkinggroup.org) to review, evaluate, and summarize the literature, and to develop clinical statements (descriptive) and recommendations (actionable). With the help of a professional librarian and Refworks database software, they developed a Web-based electronic database of over 19,000 references extracted from eight clinical search engines, related to pain and analgesia, agitation and sedation, delirium, and related clinical outcomes in adult ICU patients. The group also used psychometric analyses to evaluate and compare pain, agitation/sedation, and delirium assessment tools. All task force members were allowed to review the literature supporting each statement and recommendation and provided feedback to the subcommittees. Group consensus was achieved for all statements and recommendations using the nominal group technique and the modified Delphi method, with anonymous voting by all task force members using E-Survey (http://www.esurvey.com). All voting was completed in December 2010. Relevant studies published after this date and prior to publication of these guidelines were referenced in the text. The quality of evidence for each statement and recommendation was ranked as high (A), moderate (B), or low/very low (C). The strength of recommendations was ranked as strong (1) or weak (2), and either in favor of (+) or against (-) an intervention. A strong recommendation (either for or against) indicated that the intervention's desirable effects either clearly outweighed its undesirable effects (risks, burdens, and costs) or it did not. For all strong recommendations, the phrase "We recommend …" is used throughout. A weak recommendation, either for or against an intervention, indicated that the trade-off between desirable and undesirable effects was less clear. For all weak recommendations, the phrase "We suggest …" is used throughout. In the absence of sufficient evidence, or when group consensus could not be achieved, no recommendation (0) was made. Consensus based on expert opinion was not used as a substitute for a lack of evidence. A consistent method for addressing potential conflict of interest was followed if task force members were coauthors of related research. The development of this guideline was independent of any industry funding. CONCLUSION These guidelines provide a roadmap for developing integrated, evidence-based, and patient-centered protocols for preventing and treating pain, agitation, and delirium in critically ill patients.
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Cottenceau V, Masson F, Soulard A, Petit L, Guehl D, Cochard JF, Pinaquy C, Leger A, Sztark F. Asymmetry of Bispectral Index (BIS) in severe brain-injured patients treated by barbiturates with unilateral or diffuse brain injury. ACTA ACUST UNITED AC 2012. [PMID: 23182181 DOI: 10.1016/j.annfar.2012.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Bispectral index (BIS) may be used in traumatic brain-injured patients (TBI) with intractable intracranial hypertension to adjust barbiturate infusion but it is obtained through a unilateral frontal electrode. The objective of this study was to evaluate differences in BIS between hemispheres in two groups: unilateral frontal (UFI) and diffuse (DI) injured. PATIENTS AND METHODS Prospective monocenter observational study in 24 TBI treated with barbiturates: 13 UFI and 11 DI. Simultaneous BIS and EEG was recorded for 1h. Goal of monitoring was a left BIS between 5 and 15. Biases in BIS were considered as clinically relevant if greater than 5. Differences in biases were interpreted from both statistical (Mann-Whitney test) and clinical points of view. RESULTS Mean BIS in the two hemispheres remained in the same monitoring range. There were statistic and clinical differences in some values in the two groups of patients (15% of bias greater than I5I in UFI group and 10% in DI group). BIS monitoring allowed the adequate number of bursts/minutes to be predicted in 18 patients and did not detect an overdosage in 2. CONCLUSIONS While asymmetric BIS values in TBI patients occur whatever the kind of injury, they were not found to be clinically relevant in most of these heavily sedated patients. Asymmetrical BIS monitoring might be sufficient to monitor barbiturate infusion in TBI provided that the concordance between BIS and EEG is regularly checked.
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Affiliation(s)
- V Cottenceau
- Service de réanimation chirurgicale et traumatologique, SAR 1, hôpital Pellegrin, CHU de Bordeaux, place Amélie-Raba-Léon, Bordeaux, France.
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Bigham C, Bigham S, Jones C. Does the Bispectral Index Monitor have a Role in Intensive Care? J Intensive Care Soc 2012. [DOI: 10.1177/175114371201300410] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | - Sarah Bigham
- Registrar Intensive Care, St Mary's Hospital, Paddington
| | - Chris Jones
- Registrar, Anaesthesia, Royal Surrey County Hospital
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Abstract
There is a growing development of continuous EEG monitoring (cEEG) in the intensive care unit (ICU) management of neurological patients. Its main objective is the detection of epileptic seizures or status epilepticus because the sensitivity of standard short-duration EEG recording in the ICU is poor. The aim of monitoring is to allow rapid recognition and treatment of epileptic complications in order to decrease secondary insults to the brain and improve outcome. Several studies have demonstrated that a large proportion of patients has epileptic crisis after subarachnoid haemorrhage, stroke or brain trauma, without any clinical manifestation. The EEG feature has also demonstrated a prognosis value but its value for clinical management needs further studies. Another application of EEG in the ICU is monitoring depth of anaesthesia or barbiturate treatment. Due to artifacts contamination, this is possible only in deeply sedated of paralyzed patients. The impact or cEEG monitoring on clinical management and its indications have to be further defined.
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Thiopental-induced Burst Suppression Measured by the Bispectral Index is Extended During Propofol Administration Compared With Sevoflurane. J Neurosurg Anesthesiol 2012; 24:146-51. [DOI: 10.1097/ana.0b013e3182429829] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
BACKGROUND This study tested the hypothesis that the bispectral index (BIS) is reliable relative to clinical judgment for estimating sedation level during daily propofol spontaneous awakening trials (SATs) in trauma patients. METHODS This was a prospective observational trial with waiver of consent conducted in the intensive care unit of Level I trauma center in 94 mechanically ventilated trauma patients sedated with propofol alone or in combination with midazolam. BIS, Richmond Agitation Sedation Scale (RASS), electromyography, and heart rate variability, as a test of autonomic function, were measured for 45 minutes during daily SATs. Data were evaluated with analysis of variance, linear regression, and nonparametric tests. RESULTS The BIS wave form coincided almost exactly with propofol on/off. Steady-state BIS correlated with RASS (p < 0.0001) and with propofol dose (p < 0.0001), but the strengths of association were relatively low (all r(2) < 0.5). BIS wave form was not altered by age, heart rate, or heart rate variability and was similar with propofol alone or propofol plus midazolam, but the presence of brain injury or the use of paralytics shifted the curve downward (both p < 0.001). The overall test characteristics for BIS versus RASS without neuromuscular blockade were sensitivity: 90% versus 77% (p = 0.034); specificity: 90% versus 75% (p = 0.021); positive predictive value: 90% versus 76% (p = 0.021), and negative predictive value: 90% versus 76% (p = 0.021). CONCLUSIONS In the first trial in trauma patients and largest trial in any surgical population, the (1) BIS was reliable and has advantages over RASS of being continuous and objective, at least during a propofol SAT; (2) BIS interpretation remains somewhat subjective in patients receiving paralytic agents or with traumatic brain injury.
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Occurrence of and risk factors for electroencephalogram burst suppression during propofol–remifentanil anaesthesia. Br J Anaesth 2011; 107:749-56. [DOI: 10.1093/bja/aer235] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Musialowicz T, Mervaala E, Kälviäinen R, Uusaro A, Ruokonen E, Parviainen I. Can BIS monitoring be used to assess the depth of propofol anesthesia in the treatment of refractory status epilepticus? Epilepsia 2010; 51:1580-6. [DOI: 10.1111/j.1528-1167.2009.02514.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Hwang S, Lee SG, Park JI, Song GW, Ryu JH, Jung DH, Hwang GS, Jeong SM, Song JG, Hong SK, Lim YS, Kim KM. Continuous peritransplant assessment of consciousness using bispectral index monitoring for patients with fulminant hepatic failure undergoing urgent liver transplantation. Clin Transplant 2009; 24:91-7. [PMID: 19925461 DOI: 10.1111/j.1399-0012.2009.01148.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Rapid deterioration of consciousness is a critical situation for patients with fulminant hepatic failure (FHF). Bispectral (BIS) index was derived from electroencephalography parameters, primarily to monitor the depth of unconsciousness. AIM To assess the usability of peritransplant BIS monitoring in patients with FHF. METHODS A prospective study using peritransplant BIS monitoring was performed in 26 patients with FHF undergoing urgent liver transplantation (LT). RESULTS Pre-transplant Child-Pugh score was 12.2 +/- 1.0; model for end-stage liver disease score was 32.4 +/- 4.4; Glasgow coma score (GCS) was 9.9 +/- 1.3; and BIS index was 44.0 +/- 6.7. Pre-transplant sedation significantly decreased BIS index. After LT, all patients having endotracheal intubation recovered consciousness within one to three d and showed progressive increase in BIS index, which appeared slightly earlier and was more evident than the increase in derived GCS score. There was a significant correlation between BIS index and derived GCS scores (r(2) = 0.648). Timing of eye opening to voice was matched with BIS index of 66.3 +/- 10.4 and occurred 12.7 +/- 8.3 h after passing BIS index of 50. CONCLUSION These results suggest that BIS monitoring is a non-invasive, simple, easy-to-interpret method, which is useful in assessing peritransplant state of consciousness. BIS monitoring may therefore be a useful tool during peritransplant intensive care for patients with FHF showing hepatic encephalopathy.
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Affiliation(s)
- Shin Hwang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Al-Naimi KT, Mediratta NK, Pennefather SH. Hypothermic Cardiopulmonary Bypass in a Patient With Moyamoya Disease. J Cardiothorac Vasc Anesth 2009; 23:206-7. [DOI: 10.1053/j.jvca.2008.04.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2007] [Indexed: 11/11/2022]
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Cottenceau V, Petit L, Masson F, Guehl D, Asselineau J, Cochard JF, Pinaquy C, Leger A, Sztark F. The Use of Bispectral Index to Monitor Barbiturate Coma in Severely Brain-Injured Patients with Refractory Intracranial Hypertension. Anesth Analg 2008; 107:1676-82. [DOI: 10.1213/ane.0b013e318184e9ab] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
Sedative and analgesic treatment administered to critically ill patients need to be regularly assessed to ensure that predefinite goals are well achieved as the risk of complications of oversedation is minimized. In most of the cases, which are lightly sedation patients, the goal to reach is a calm, cooperative and painless patient, adapted to the ventilator. Recently, eight new bedside scoring systems to monitor sedation have been developed and mainly tested for reliability and validity. The choice of a sedation scale measuring level of consciousness, could be made between the Ramsay sedation scale, the Richmond Agitation Sedation scale (RASS) and the Adaptation to The Intensive Care Environment scale-ATICE. The Behavioral Pain Scale (BPS) is a behavioral pain scale. Two of them have been tested with strong evidence of their clinimetric properties: ATICE, RASS. The nurses'preference for a convenient tool could be defined by the level of reliability, the level of clarity, the variety of sedation and agitation states represented user friendliness and speed. In fine, the choice between a simple scale easy to use and a well-defined and complex scale has to be discussed and determined in each unit. Actually, randomized controlled studies are needed to assess the potential superiority of one scale compared with others scales, including evaluation of the reliability and the compliance to the scale. The usefulness of the BIS in ICU for patients lightly sedated is limited, mainly because of EMG artefact, when subjective scales are more appropriated in this situation. On the other hand, subjective scales are insensitive to detect oversedation in patients requiring deep sedation. The contribution of the BIS in deeply sedation patients, patients under neuromuscular blockade or barbiturates has to be proved. Pharmacoeconomics studies are lacking.
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Affiliation(s)
- M Thuong
- Service de réanimation médicale, centre hospitalier de Saint-Denis, 2, rue du Docteur-Delafontaine, 93205 Saint-Denis, France.
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Tobias JD. Bispectral Index Monitoring Documents Burst Suppression During Pentobarbital Coma. J Intensive Care Med 2008; 23:258-62. [DOI: 10.1177/0885066608318459] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
During pentobarbital coma, electroencephalographic monitoring is used to document burst suppression (3-5 episodes of electrical activity/min). The current study evaluates the association of the bispectral index number and suppression ratio with a burst suppression pattern on electroencephalograph. The records of 7 patients (aged 2.9-14 years) who received pentobarbital for elevated intracranial pressure were retrospectively reviewed. The bispectral index number was 7 ± 5, 14 ± 3, and 37 ± 12, whereas the suppression ratio was 93 ± 7%, 75 ± 6%, and 29 ± 18% when the electroencephalograph showed ≤ 2, 3-5, and ≥ 6 bursts/min, respectively. The sensitivity and specificity of a bispectral index value of 10 to 20 were 96% and 92%, respectively, whereas the sensitivity and specificity of a suppression ratio of 65% to 85% were 89% and 88%, respectively, in demonstrating the presence of 3 to 5 bursts/min. Bispectral index monitoring may be easier to perform and may require less technical expertise to interpret.
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Affiliation(s)
- Joseph D. Tobias
- Department of Anesthesiology and Department of Pediatrics, University of Missouri, Columbia, Missouri,
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35
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Sessler CN, Grap MJ, Ramsay MA. Evaluating and monitoring analgesia and sedation in the intensive care unit. Crit Care 2008; 12 Suppl 3:S2. [PMID: 18495053 PMCID: PMC2391268 DOI: 10.1186/cc6148] [Citation(s) in RCA: 135] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Management of analgesia and sedation in the intensive care unit requires evaluation and monitoring of key parameters in order to detect and quantify pain and agitation, and to quantify sedation. The routine use of subjective scales for pain, agitation, and sedation promotes more effective management, including patient-focused titration of medications to specific end-points. The need for frequent measurement reflects the dynamic nature of pain, agitation, and sedation, which change constantly in critically ill patients. Further, close monitoring promotes repeated evaluation of response to therapy, thus helping to avoid over-sedation and to eliminate pain and agitation. Pain assessment tools include self-report (often using a numeric pain scale) for communicative patients and pain scales that incorporate observed behaviors and physiologic measures for noncommunicative patients. Some of these tools have undergone validity testing but more work is needed. Sedation-agitation scales can be used to identify and quantify agitation, and to grade the depth of sedation. Some scales incorporate a step-wise assessment of response to increasingly noxious stimuli and a brief assessment of cognition to define levels of consciousness; these tools can often be quickly performed and easily recalled. Many of the sedation-agitation scales have been extensively tested for inter-rater reliability and validated against a variety of parameters. Objective measurement of indicators of consciousness and brain function, such as with processed electroencephalography signals, holds considerable promise, but has not achieved widespread implementation. Further clarification of the roles of these tools, particularly within the context of patient safety, is needed, as is further technology development to eliminate artifacts and investigation to demonstrate added value.
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Affiliation(s)
- Curtis N Sessler
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Virginia Commonwealth University Health System, Richmond, Virginia 23298, USA.
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Dunham CM, Ransom KJ, McAuley CE, Gruber BS, Mangalat D, Flowers LL. Severe brain injury ICU outcomes are associated with Cranial-Arterial Pressure Index and noninvasive Bispectral Index and transcranial oxygen saturation: a prospective, preliminary study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2007; 10:R159. [PMID: 17105656 PMCID: PMC1794465 DOI: 10.1186/cc5097] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/04/2006] [Revised: 10/19/2006] [Accepted: 11/14/2006] [Indexed: 12/02/2022]
Abstract
Introduction The purpose of this study was to determine if noninvasive transcranial oxygen saturation (StcO2) and Bispectral Index (BIS) correlate with severe traumatic brain injury intensive care unit (ICU) outcomes. Methods This is a prospective observational study. Values of intracranial pressure (ICP), mean arterial pressure (MAP), BIS, and StcO2 were recorded hourly for the first six, post-injury days in 18 patients with severe brain injury. Included in the analyses was the Cranial-Arterial Pressure (CAP) Index, which is ICP/(MAP - ICP). Results After 1,883 hours of data were analyzed, we found that StcO2 and BIS are associated with survival, good neurological outcome, ICP ≤20, cerebral perfusion pressure (CPP) ≥60, and CAP index ≤0.30 (p ≤ 0.001). Survival and good outcome are independently associated with BIS ≥60, StcO2 ≥70, and ICP ≤20 (p < 0.0001). BIS ≥60 or StcO2 ≥70 is associated with survival, good outcome, CPP ≥60, ICP ≤20, CAP index ≤0.30, and fewer ICP interventions (p < 0.0001). With BIS ≥60 or StcO2 ≥70, the rate of CPP ≥60 is 97.2% and the rate of ICP≤ 25 is 97.1%. An increased CAP index is associated with death, poor neurological outcome, and increased ICP interventions (p < 0.0001). With CAP index >0.25, MAP is not related to ICP (p = 0.16). Conclusion Numerous significant associations with ICU outcomes indicate that BIS and StcO2 are clinically relevant. The independent associations of BIS, StcO2, and ICP with outcomes suggest that noninvasive multi-modal monitoring may be beneficial. Future studies of patients with BIS ≥60 or StcO2 ≥70 will determine if select patients can be managed without ICP monitoring and whether marginal ICP can be observed. An increased CAP index is associated with poor outcome.
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Affiliation(s)
- C Michael Dunham
- Trauma/Critical Care Services, St Elizabeth Health Center, Youngstown, OH 44501, USA
| | - Kenneth J Ransom
- Trauma/Critical Care Services, St Elizabeth Health Center, Youngstown, OH 44501, USA
| | - Clyde E McAuley
- Trauma/Critical Care Services, St Elizabeth Health Center, Youngstown, OH 44501, USA
| | - Brian S Gruber
- Trauma/Critical Care Services, St Elizabeth Health Center, Youngstown, OH 44501, USA
| | - Dev Mangalat
- Trauma/Critical Care Services, St Elizabeth Health Center, Youngstown, OH 44501, USA
| | - Laurie L Flowers
- Trauma/Critical Care Services, St Elizabeth Health Center, Youngstown, OH 44501, USA
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Arbour R. Impact of bispectral index monitoring on sedation and outcomes in critically ill adults: a case series. Crit Care Nurs Clin North Am 2006; 18:227-41, xi. [PMID: 16728309 DOI: 10.1016/j.ccell.2006.02.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In situations in which clinical assessment of sedation level is compromised, such as deep sedation/analgesia with and without neuromuscular blockade (NMB), electroencephalogram-based monitoring may potentially assist in achieving balance between inadequate and excessive levels of sedation. To validate the bispectral index (BIS) for use in clinical practice, correlation and possible differences in outcome using clinical assessment versus clinical assessment augmented by electroencephalogram-based monitoring were determined. BIS monitoring was decisive in ICU care in 9 of 15 patients in this series. The most significant potential benefit was obtained in the subset of patients receiving NMB.
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Affiliation(s)
- Richard Arbour
- Albert Einstein Healthcare Network, 5501 Old York Road, Philadelphia, PA 19141-3211, USA.
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Bader MK, Arbour R, Palmer S. Refractory increased intracranial pressure in severe traumatic brain injury: barbiturate coma and bispectral index monitoring. ACTA ACUST UNITED AC 2006; 16:526-41. [PMID: 16269897 DOI: 10.1097/00044067-200510000-00009] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Patients with severe traumatic brain injury resulting in increased intracranial pressure refractory to first-tier interventions challenge the critical care team. After exhausting these initial interventions, critical care practitioners may utilize barbiturate-induced coma in an attempt to reduce the intracranial pressure. Titrating appropriate levels of barbiturate is imperative. Underdosing the drug may fail to control the intracranial pressure, whereas overdosing may lead to untoward effects such as hypotension and cardiac compromise. Monitoring for a therapeutic level of barbiturate coma includes targeting drug levels and using continuous electroencephalogram monitoring, considered the gold standard. New technology, the Bispectral Index monitor, utilizes electroencephalogram principles to monitor the level of sedation and hypnosis in the critical care environment. This technology is now being considered for targeting appropriate levels of barbiturate coma.
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Park TK, Han KR, Shin DW, Lee YJ, Kim C. Management of Complex Regional Pain Syndrome Type 1 with Barbiturate Coma Therapy -A case report-. Korean J Pain 2006. [DOI: 10.3344/kjp.2006.19.2.213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Tae Kyu Park
- Pain Clinic, Department of Anesthesiology and Pain Medicine, Ajou University Hospital, College of Medicine, Ajou University, Suwon, Korea
| | - Kyung Ream Han
- Pain Clinic, Department of Anesthesiology and Pain Medicine, Ajou University Hospital, College of Medicine, Ajou University, Suwon, Korea
| | - Dong Wook Shin
- Pain Clinic, Department of Anesthesiology and Pain Medicine, Ajou University Hospital, College of Medicine, Ajou University, Suwon, Korea
| | - Young Joo Lee
- Pain Clinic, Department of Anesthesiology and Pain Medicine, Ajou University Hospital, College of Medicine, Ajou University, Suwon, Korea
| | - Chan Kim
- Pain Clinic, Department of Anesthesiology and Pain Medicine, Ajou University Hospital, College of Medicine, Ajou University, Suwon, Korea
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Ramsay MA. Role of brain function monitoring in the critical care and perioperative settings. ACTA ACUST UNITED AC 2005. [DOI: 10.1053/j.sane.2005.10.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Alexander EW, Duane BB. Bispectral Index Monitoring in the Intensive Care Unit. Pharmacotherapy 2005; 25:1681-2; discussion 1682-3. [PMID: 16232031 DOI: 10.1592/phco.2005.25.11.1681] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Eric W Alexander
- Department of Pharmacy Services, Saint Louis University Hospital, St. Louis, Missouri 63110, USA.
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Tobias JD. Monitoring the depth of sedation in the pediatric ICU patient: where are we, or more importantly, where are our patients? Pediatr Crit Care Med 2005; 6:715-8. [PMID: 16276343 DOI: 10.1097/01.pcc.0000185478.29645.c4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Fraser GL, Riker RR. Bispectral Index Monitoring in the Intensive Care Unit Provides More Signal Than Noise. Pharmacotherapy 2005; 25:19S-27S. [PMID: 15899745 DOI: 10.1592/phco.2005.25.5_part_2.19s] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The bispectral index (BIS) is processed electroencephalographic technology used in concert with clinical evaluations to objectively evaluate a patient's level of consciousness and probability of recall. Although the BIS has been extensively studied in the operating room setting, differences in patient populations, goals of treatment, and the environments themselves necessitate the development of BIS data specific to the intensive care unit. Data have evolved over the last several years, but for many reasons, the results and conclusions have varied. Yet within the data are important consistencies that help define the usefulness of BIS in patients who cannot be evaluated with subjective assessment tools such as the Sedation-Agitation Scale or the Richmond Agitation-Sedation Scale. Some of these patients cannot be evaluated with such tools because they lack motor responsiveness due to therapeutic paralysis or because they are receiving deep sedation. Bispectral index scores that are higher than expected in clinically sedated patients can often be traced to electromyographic activity or to the possibility of inadequate sedation and analgesia. The BIS must not be regarded as the sole indicator of level of consciousness, but should be used as part of an integrated approach to the evaluation of carefully selected patients with critical illness.
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Affiliation(s)
- Gilles L Fraser
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Maine Medical Center, Portland, Maine 04102, USA
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Deogaonkar A, Gupta R, DeGeorgia M, Sabharwal V, Gopakumaran B, Schubert A, Provencio JJ. Bispectral Index monitoring correlates with sedation scales in brain-injured patients*. Crit Care Med 2004; 32:2403-6. [PMID: 15599143 DOI: 10.1097/01.ccm.0000147442.14921.a5] [Citation(s) in RCA: 113] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Monitoring critically ill, brain-injured patients with a decreased level of consciousness is challenging. Our goal is to determine in this population the correlation between the Bispectral Index (BIS) and three commonly used sedation agitation scales: the Richmond Agitation-Sedation Scale (RASS), the Sedation-Agitation Scale (SAS) and the Glasgow Coma Scale (GCS) scores. DESIGN Prospective, single-blinded observational study. SETTING Eight-bed neurology-neurosurgery intensive care unit at the Cleveland Clinic Foundation. PATIENTS Thirty critically ill patients admitted to the neurointensive care unit with primary brain injury and a decreased level of consciousness. MEASUREMENTS AND MAIN RESULTS Patients were prospectively evaluated for level of consciousness using the RASS, SAS, and GCS every hour and simultaneously were monitored continuously with a BIS monitor for 6 hrs. A Spearman's correlation coefficient was used to correlate the BIS scores with clinical scales. In 15 patients monitored with the newer BIS XP version, the BIS values correlated significantly with the RASS (R2 = .810; p < .0001), SAS (R2 = .725; p < .0001), and GCS (R2 = .655; p < .0001). In 15 patients monitored with the older BIS 2.1.1 software, the correlation was as follows: for RASS, R2 = .30 (p < .008), for SAS: R2 = .376 (p < .001), and for GCS: R2 = .274 (p < .015). This correlation was maintained in patients who received sedative medications. CONCLUSIONS A statistically significant correlation existed between BIS values and the RASS, SAS, and GCS scores in critically ill brain-injured patients, with and without sedation. The newer BIS XP software package may be a useful adjunctive tool in objective assessment of level of consciousness in brain-injured patients.
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Affiliation(s)
- Anupa Deogaonkar
- Department of Anesthesiology, The Cleveland Clinic Foundation, Cleveland, OH, USA
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Mantz J. Évaluation de la profondeur de la sédation en neuroréanimation : les scores cliniques, les méthodes électrophysiologiques et le BIS. ACTA ACUST UNITED AC 2004; 23:535-40. [PMID: 15158249 DOI: 10.1016/j.annfar.2004.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The primary goal of sedation is to achieve security and comfort of mechanically ventilated ICU patients. Delivery of pharmacologic agents must avoid over sedation, which increases morbidity by prolongation of the duration of mechanical ventilation. Similarly, under sedation may favour life-threatening events such as accidental extubation. Many clinical scales have been generated to regularly measure the level of sedation (consciousness and tolerance to the ICU environment). No electrophysiological monitor (BIS) has proved reliability for measuring the depth of sedation or analgesia yet. The presence of brain damage in ICU patients makes the level of sedation impossible to interpret. Glasgow coma scale, which is exclusively devoted to the consciousness domain, is the only recommendation that can be made in neurocritical care at the present time.
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Affiliation(s)
- J Mantz
- Service d'anesthésie-réanimation, faculté de médecine Xavier-Bichat, hôpital Xavier-Bichat, 46, rue Henri-Huchard, 75018 Paris, France.
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