The document discusses bispectral index (BIS) monitoring, which uses EEG signals from the forehead to calculate a dimensionless index between 0-100 indicating a patient's level of consciousness under sedation or anesthesia. A BIS value between 40-60 indicates adequate anesthesia with no awareness. The monitor is useful but clinical judgment should also be used, as factors like muscle activity can interfere with BIS values. BIS monitoring is now used in critical care, endoscopy, and radiology to guide sedation levels outside the operating room.

2. Bispectral Index
(BIS Monitors)
By
Reda abu al majd ismail Mohamed
Lecturer of Anesthesia & ICU
Faculty of Medicine
Suez Canal University

3. Topics
 - awareness: definition- incidence- causes .
 - Short and long term effect of excessive anesthesia.
 - what BIS monitor and how it work.
 - calculation of BIS index.
 - Artifact and factors affecting.
 - uses outside OR.

4. AWARENESS
explicit memory from the anesthesia period during which the patient should have been
unconscious. (nightmares, anxiety and flashbacks)
In the United States, the incidence of intraoperative awareness is 0.1% to 0.2% of
patients undergoing general anesthesia.
In Europe the incidence of recall of intraoperative events and dreams during operation in
non-obstetric surgeries 0.2% and 0.9%, respectively.
Causes of Intraoperative Awareness:
Light anesthesia:
• Difficult intubation
• Premature discontinuation of anesthetic
• Myocardial depression
• Cesarean section

5. Machine malfunction or misuse of the technique:
• Failure to check equipment
• Vaporizers and circuit leaks
• Errors in intravenous infusion
• Accidental administration of muscle relaxants to patients who are awake
Increased anesthetic requirement :
• Individual variability in anesthetic requirements
• Chronic alcohol, opioid, or cocaine abuse

6. Short term effects from excessive anesthesia
• General anesthetics affect the circulation and cause hypotension by concentration-
dependent myocardial depression and effects on blood vessel tone.; postoperative
nausea and vomiting (PONV) ; delay recovery, and result in longer stay in the
postoperative care unit (PACU).
Long term morbidity and excessive anesthesia
• There is controversy whether anesthetics may have adverse long term effects on cognitive
function, in the very young as well as in the elderly.
•

8. BIS index
• Developed by Aspect Medical Systems (Newton, MA), the BIS system includes a sensor, a
patient interface cable, a digital signal converter, a BIS engine (microprocessor), and a
monitor.
• Wipe the forehead with alcohol and dry with gauze.
• Either side of the head can be used except in the case of stroke were you would use the
unaffected side.
• Electrode # 1 is placed in the centre of the forehead 1.5 inches above the bridge of the
nose
• Next electrode # 4 is placed directly above the eyebrow
• Place electrode #3 on the temple between the outer canthus of the eye and the hairline
• Now electrode #2 will be in the proper position to be secured.

9. Values for BIS Monitoring
General anaesthesia associated with no awareness
under anaesthesia occurs from BIS values of 40-60.
Deep Sedation occurs with BIS Values of 60-80
In special needs patients work around 80-90 for
sedation.

10. • The BIS monitor uses frontal EEG passively recorded via a strip containing 4 electrodes
applied to the patients' forehead.
• The EEG is composed of a number of sine waves of different frequencies put together.
• The EEG, which is an analogue signal, is digitized, artefact filtered and split into epochs.
The epochs, which are small periods of time 2 seconds. then transformed to a power
spectrum by the use of a fast Fourier analysis . The fast Fourier analysis splits the EEG
epochs into the different frequencies, and estimates the power in each frequency.
• This information is then used to analyze two of the four parameters which sums up to
give the BIS index. (the beta ratio and the sync fast slow)

11. • The EEG is also analyzed to detect periods of burst suppression shown as suppression ratio
(SR; the time of isoelectric EEG). A fourth analysis, QUASI, is used to detect background
noise to be able to correctly define the burst suppression periods.
• These four parameters are combined, by a proprietary algorithm, to give a dimensionless
number between 0-100 called the BIS index where 0 represents the isoelectric EEG and
95-100 the fully awake patient.
• Bis analysis quantifies the phase correlation between different frequencies in the EEG.

12. identifying and managing artifact
While studies have shown BIS monitoring is reliable in a wide variety of patients and
situations, in certain circumstances the BIS index may not accurately reflect a patient's level of
sedation.
The most frequent source of unreliable BIS readings is signal artifact from muscle activity,
typically from the patient's face or forehead muscles. This muscle activity, measured as EMG
in decibels, can be caused by pain, twitches, seizures, eye movement, or anything that results
in increased muscle tone or movement.
This activity can generate high-frequency signals that can contaminate the EEG and make the
BIS index unreliable.
For this reason, BIS monitors include an EMG bar graph. The higher the EMG, the greater the
muscle activity, and therefore the less reliable the BIS index.

13. Other sources of high-frequency activity that can lead to inaccurately high BIS values include
medical devices, such as warming blankets, circulatory assist systems, high-frequency
ventilators, suction devices, surgical instruments, and pacemakers and defibrillators. The
closer the device is to the BIS sensor or equipment, the more likely it is to generate artifact.
Ketamine causes an increase in high-frequency EEG activity; therefore, BIS values may
remain high when ketamine is administered, despite the onset of sedation.
Etomidate frequently produces skeletal muscle excitation, which can cause high-frequency
EMG activity and, hence, a high BIS reading.
Some clinicians have questioned the accuracy and reliability of the BIS index in patients with
abnormal brain structure or function—from stroke or encephalopathy.

14. BIS outside OR
• used to monitor patients during bedside procedures that require procedural sedation or
monitored anesthesia care.
• It has also been used to monitor the level of sedation in patients in neuromuscular
blockade or barbiturate coma.
• In some critical care units, BIS monitoring is also used as an adjunct to the neurological
exam. And in the perioperative setting, clinicians have used it to confirm brain activity
during critical events like cardiac arrest and resuscitation.

15. summery
The bispectral index (BIS) is a fairly recent technology used to measure the
effects of anesthetics and sedatives on the brain and consciousness
Uses a complex mathematical algorithm based upon descriptive EEG
parameters from the frontal cortex to suggest various levels of sedation
A sensor, placed on the patient’s forehead, sends raw EEG waveforms to the
monitor, where they are analyzed and a BIS index is calculated
This value ranges from 100 (completely awake) to 0 (isoelectric EEG)

16. summery
Originally used to monitor the effects of general anesthesia in the OR, BIS
monitoring is now used in a variety of settings where patients require
sedation, including critical care units, endoscopy suites, and radiology
departments.
While BIS monitoring is a valuable tool, you should not make clinical
decisions based solely on a BIS index. To make sure your patient's level of
sedation is safe and effective, use BIS monitoring in conjunction with your
clinical judgment and other methods of assessment, such as vital signs and
sedation scales.