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BIS EVALUATION IN TCI 
ANESTHESIA BY PROPOFOL 
Nguyễn Văn Chinh, MD, PhD 
Prof. Nguyễn Văn Chừng, MD, PhD
INTRODUCTION 
New situation: 
 Science 
 Equipments and techniques 
 Advances in medical technology… 
New techniques: 
TCI: Target Controlled Infusion 
BIS: Bispectral Index
INTRODUCTION
TARGET CONTROLLED INFUSION 
Time 
Time 
Plasma Concentration (Cp) 
TCI
TARGET CONTROLLED INFUSION 
1968 
1981 
1997 
Now 
Schwilden Dipprifusor 
BET: Bolus Elimination Transfer 
FRANCE 
Kruger 
Thiemer 
Many 
Hospital 
TCI HISTORY
TARGET CONTROLLED INFUSION 
Cp 
(Ce) 
Dose
TARGET CONTROLLED INFUSION 
(Ce)
TARGET CONTROLLED INFUSION 
Drugs Fomula Population Data file 
Midazolam Zomorodi Adult Weight, Age, height 
Propofol Marsch 
Schnider 
Katarian 
Adult, Children 
26 – 81 years of age 
3 – 11 years of age 
Weight, Age 
Weight, Age, height 
Weight 
Sufentanil Gepts 
Minto 
Adult 
20 – 85 years of 
age 
Weight 
Weight, Age, height
TARGET CONTROLLED INFUSION 
Target of Propofol (Diprivan) 
Loss of consciousness: Cp: 1,9 – 7,7 mcg/ml 
Ce: 1,1 – 4,7 mcg/ml 
Loss of pain response: Cp: 3 – 6,8 mcg/ml 
Maintenance: Cp: 2,5 – 6,8 mcg/ml 
Cp: 4 – 7 mcg/ml 
 Awareness: Ce: 1,1 – 1,3 mcg/ml
BIS TECHNOLOGY
1987- 
1997 
BIS TECHNOLOGY 
1998 
2003 
Now 
FDA 
FDA 
Monitor 
A 2000 
BBIISS 
TTeecchhnnoollooggyy 
Research 
Many 
Hospital 
BIS HISTORY
100 
80 
60 
40 
20 
0 
BIS 
50 
BIS Value 
Chỉ số 
BIS Trend 
Biểu đồ lưu 
EEG Waveform 
Điện não đồ dạng sóng 
EMG (electromyogram) 
Điện cơ đồ 
EMG 
EMG 40 
SQI (signal quality index) 
Chỉ số chất lượng tín hiệu 
SQI 
SQI 90 
SR (suppression ratio) 
Tỉ lệ ngừng phát xung 
SR 
0 
BIS Display Information
Incidence ooff IInnaapppprroopprriiaattee SSeeddaattiioonn 
Over-sedation/ Quá liều 
On Target/ Đủ liều 
Under-sedation/ Chưa đủ liều 
15.4% 
54% 
30.6% 
Kaplan L and Bailey H. Critical Care. 2000; 4(1):S110. 
Olson D et al. NTI Proceedings. 2003; CS82:196. 
10% 
20% 
70% 
KKaappllaann LL.. aanndd BBaaiilleeyy HH.. 
22000000 
OOllssoonn DD.. eett aall.. 
22000033
EEEEGG RReessppoonnssee ttoo AAnneesstthheettiiccss 
Donald R. Stanski and Steven L. Shafer, Miller’s Anesthesia, ed. Ronald D. Miller (Philadelphia: Elsevier Inc., 2005), p. 1253.
MANAGING HYPNOTIC LEVEL 
AAWWAAKKEE//TTỈỈNNHH 
High risk of 
awareness 
Optimal Depth of 
Unconsciousness 
Độ sâu gây mê tối ưu 45 
Deep Anesthesia 
Longer Recovery 
FFLLAATT LLIINNEE EEEEGG//EEEEGG hhiiểểnn tthhịị pphhẳẳnngg 
15 
100 
70 
60 
0 
noi tadeS 
BIS-Guided 
Agent 
Titration/BIS 
hướng dẫn điều 
chỉnh thuốc mê 
Assumes Adequate Analgesia in Technique
OBJECTIVES 
This study is performed to evaluate a change of 
Bispectral Index (BIS) in target controlled infusion 
(TCI) anesthesia.
METHODS 
Prospective study on 54 patients 
From July 2011 to July 2013. 
All of them have undergone general anesthesia. 
Pulse, blood presure, resspiratory rate and 
health status of the patients were monitored 
right before and after anesthesia. 
Close careful monitoring during and after the 
operation must be applied in order to detect and 
manage in time complications.
METHODS 
Premedication: Midazolam 0,04mg/kg + Fentanyl 2-3mcg/kg 
Induction: 
O2: 3-5 minutes 
Propofol (Diprivan) TCI: Cp: 6 mcg/ ml 
Rocuronium: 0,3-0,6 mg/kg 
PLMA or Intubation: Ce: 3,5 – 4mcg/ml. 
Maintenance: 
Cp: 2-3mcg/ ml after PLMA or Intubation. 
Ventilation, Fentanyl and Rocuronium.
RESULTS AND DISCUSSION 
ÑAËC ÑIEÅM CHUNG 
Features Mean 
Age 47,21 ± 5,52 
Weight (kg) 53,17 ± 8,63 
Height (cm) 151,06 ± 12,13 
N 54
RESULTS AND DISCUSSION 
ADD DISEASE 
Features n (%) 
Circulation 5 (9,25) 
Respiration 2 (3,70) 
Diabetes 4 (7,41) 
Other Disease 3 (5,56)
RESULTS AND DISCUSSION 
Loss of consciousness time: 
Cp 
(mcg/ml) 
BIS Time (s) 
This Research 1,42 ± 0,27 63,66 ± 5,53 82,14 ± 10,42 
Macquaire, 
Absalom vaø 
1,4 – 1,9 68,37 ± 8,22 90 - 110 
Struys. 
Loss of consciousness at Cp: 1,42 ± 0,27 mcg/ml, BIS: 
63,66 ± 5,53.
RESULTS AND DISCUSSION 
Induction: 
Propofol 
(mg/kg) 
TCI had lower induction doses 
Induction doses of Kenny: Cp: 8 mcg/ml 
BIS 
This Research 1,47 ± 0,06 44,11 ± 2,63 
Macquaire 1,41 ± 0,09 40 – 60 
Struys 1,31 ± 0,11 40 – 60
RESULTS AND DISCUSSION 
Maintenance: 
Nghieân 
cöùu 
Cp (mcg/ml) Giaù trò BIS 
This Research 3 40 – 60 
Irwin 3,82 45 
Ngai Liu 3,8 40 – 60 
Struys 5,4 40 – 60
RESULTS AND DISCUSSION 
Maintenance: 
BIS monitoring values helped guide anesthetic dosing. 
Decreasing the risk of awareness and recognizing 
Lehman: smooth maintenance by TCI 
Russel and Struys: Less hemodynamic changes and 
smooth maintenance by TCI. 
Bonnin: Easy titration during TCI anaesthesia.
RESULTS AND DISCUSSION 
Following awareness with recall, 33–69% of the 
patients suffer from late psychological symptoms, incl. 
Post Traumatic Stress Disorder (PTSD) 
Samuelsson et al., Anesthesiology. 2007 Jan;106(1):26-32.
RESULTS AND DISCUSSION 
Hemodynamic changes in anesthesia: 
Less hemodynamic changes in anesthesia. 
Kazama: more hemodynamic changes in elderly patients. 
Tackley: less hemodynamic changes in anesthesia.
RESULTS AND DISCUSSION 
Awareness stage : 
This Research: short recovery times, decreasing the 
risk of awareness and recall. 
Leslie: haven’t recall during anaesthesia at Cp level 
loss of consciousness. 
Sandin: about 0,16% recall during anaesthesia. 
Vermon: Decreasing the risk of awareness and recall 
at BIS 40 – 60.
RESULTS AND DISCUSSION 
Clinical judgment should always be used when interpreting BIS 
in conjunction with other available clinical signs. 
Reliance on the BIS alone for intraoperative anesthetic 
management is not recommended. 
BIS values should be interpreted cautiously in patients: 
With known neurological disorders 
Taking psychoactive medications 
In children below the age of one
CONCLUSIONS 
Propofol target controlled infusion is safe and effective. 
Quick loss of consciousness. 
Lower induction doses, smooth inductions. 
Less hemodynamic changes in anesthesia. 
Short recovery times, improve patient recovery. 
Reduce the risk of awareness with recall during anaesthesia.
Thanks!

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Nguyen van chinh ta

  • 1. BIS EVALUATION IN TCI ANESTHESIA BY PROPOFOL Nguyễn Văn Chinh, MD, PhD Prof. Nguyễn Văn Chừng, MD, PhD
  • 2. INTRODUCTION New situation:  Science  Equipments and techniques  Advances in medical technology… New techniques: TCI: Target Controlled Infusion BIS: Bispectral Index
  • 4. TARGET CONTROLLED INFUSION Time Time Plasma Concentration (Cp) TCI
  • 5. TARGET CONTROLLED INFUSION 1968 1981 1997 Now Schwilden Dipprifusor BET: Bolus Elimination Transfer FRANCE Kruger Thiemer Many Hospital TCI HISTORY
  • 8. TARGET CONTROLLED INFUSION Drugs Fomula Population Data file Midazolam Zomorodi Adult Weight, Age, height Propofol Marsch Schnider Katarian Adult, Children 26 – 81 years of age 3 – 11 years of age Weight, Age Weight, Age, height Weight Sufentanil Gepts Minto Adult 20 – 85 years of age Weight Weight, Age, height
  • 9. TARGET CONTROLLED INFUSION Target of Propofol (Diprivan) Loss of consciousness: Cp: 1,9 – 7,7 mcg/ml Ce: 1,1 – 4,7 mcg/ml Loss of pain response: Cp: 3 – 6,8 mcg/ml Maintenance: Cp: 2,5 – 6,8 mcg/ml Cp: 4 – 7 mcg/ml  Awareness: Ce: 1,1 – 1,3 mcg/ml
  • 11. 1987- 1997 BIS TECHNOLOGY 1998 2003 Now FDA FDA Monitor A 2000 BBIISS TTeecchhnnoollooggyy Research Many Hospital BIS HISTORY
  • 12. 100 80 60 40 20 0 BIS 50 BIS Value Chỉ số BIS Trend Biểu đồ lưu EEG Waveform Điện não đồ dạng sóng EMG (electromyogram) Điện cơ đồ EMG EMG 40 SQI (signal quality index) Chỉ số chất lượng tín hiệu SQI SQI 90 SR (suppression ratio) Tỉ lệ ngừng phát xung SR 0 BIS Display Information
  • 13. Incidence ooff IInnaapppprroopprriiaattee SSeeddaattiioonn Over-sedation/ Quá liều On Target/ Đủ liều Under-sedation/ Chưa đủ liều 15.4% 54% 30.6% Kaplan L and Bailey H. Critical Care. 2000; 4(1):S110. Olson D et al. NTI Proceedings. 2003; CS82:196. 10% 20% 70% KKaappllaann LL.. aanndd BBaaiilleeyy HH.. 22000000 OOllssoonn DD.. eett aall.. 22000033
  • 14. EEEEGG RReessppoonnssee ttoo AAnneesstthheettiiccss Donald R. Stanski and Steven L. Shafer, Miller’s Anesthesia, ed. Ronald D. Miller (Philadelphia: Elsevier Inc., 2005), p. 1253.
  • 15. MANAGING HYPNOTIC LEVEL AAWWAAKKEE//TTỈỈNNHH High risk of awareness Optimal Depth of Unconsciousness Độ sâu gây mê tối ưu 45 Deep Anesthesia Longer Recovery FFLLAATT LLIINNEE EEEEGG//EEEEGG hhiiểểnn tthhịị pphhẳẳnngg 15 100 70 60 0 noi tadeS BIS-Guided Agent Titration/BIS hướng dẫn điều chỉnh thuốc mê Assumes Adequate Analgesia in Technique
  • 16. OBJECTIVES This study is performed to evaluate a change of Bispectral Index (BIS) in target controlled infusion (TCI) anesthesia.
  • 17. METHODS Prospective study on 54 patients From July 2011 to July 2013. All of them have undergone general anesthesia. Pulse, blood presure, resspiratory rate and health status of the patients were monitored right before and after anesthesia. Close careful monitoring during and after the operation must be applied in order to detect and manage in time complications.
  • 18. METHODS Premedication: Midazolam 0,04mg/kg + Fentanyl 2-3mcg/kg Induction: O2: 3-5 minutes Propofol (Diprivan) TCI: Cp: 6 mcg/ ml Rocuronium: 0,3-0,6 mg/kg PLMA or Intubation: Ce: 3,5 – 4mcg/ml. Maintenance: Cp: 2-3mcg/ ml after PLMA or Intubation. Ventilation, Fentanyl and Rocuronium.
  • 19. RESULTS AND DISCUSSION ÑAËC ÑIEÅM CHUNG Features Mean Age 47,21 ± 5,52 Weight (kg) 53,17 ± 8,63 Height (cm) 151,06 ± 12,13 N 54
  • 20. RESULTS AND DISCUSSION ADD DISEASE Features n (%) Circulation 5 (9,25) Respiration 2 (3,70) Diabetes 4 (7,41) Other Disease 3 (5,56)
  • 21. RESULTS AND DISCUSSION Loss of consciousness time: Cp (mcg/ml) BIS Time (s) This Research 1,42 ± 0,27 63,66 ± 5,53 82,14 ± 10,42 Macquaire, Absalom vaø 1,4 – 1,9 68,37 ± 8,22 90 - 110 Struys. Loss of consciousness at Cp: 1,42 ± 0,27 mcg/ml, BIS: 63,66 ± 5,53.
  • 22. RESULTS AND DISCUSSION Induction: Propofol (mg/kg) TCI had lower induction doses Induction doses of Kenny: Cp: 8 mcg/ml BIS This Research 1,47 ± 0,06 44,11 ± 2,63 Macquaire 1,41 ± 0,09 40 – 60 Struys 1,31 ± 0,11 40 – 60
  • 23. RESULTS AND DISCUSSION Maintenance: Nghieân cöùu Cp (mcg/ml) Giaù trò BIS This Research 3 40 – 60 Irwin 3,82 45 Ngai Liu 3,8 40 – 60 Struys 5,4 40 – 60
  • 24. RESULTS AND DISCUSSION Maintenance: BIS monitoring values helped guide anesthetic dosing. Decreasing the risk of awareness and recognizing Lehman: smooth maintenance by TCI Russel and Struys: Less hemodynamic changes and smooth maintenance by TCI. Bonnin: Easy titration during TCI anaesthesia.
  • 25. RESULTS AND DISCUSSION Following awareness with recall, 33–69% of the patients suffer from late psychological symptoms, incl. Post Traumatic Stress Disorder (PTSD) Samuelsson et al., Anesthesiology. 2007 Jan;106(1):26-32.
  • 26. RESULTS AND DISCUSSION Hemodynamic changes in anesthesia: Less hemodynamic changes in anesthesia. Kazama: more hemodynamic changes in elderly patients. Tackley: less hemodynamic changes in anesthesia.
  • 27. RESULTS AND DISCUSSION Awareness stage : This Research: short recovery times, decreasing the risk of awareness and recall. Leslie: haven’t recall during anaesthesia at Cp level loss of consciousness. Sandin: about 0,16% recall during anaesthesia. Vermon: Decreasing the risk of awareness and recall at BIS 40 – 60.
  • 28. RESULTS AND DISCUSSION Clinical judgment should always be used when interpreting BIS in conjunction with other available clinical signs. Reliance on the BIS alone for intraoperative anesthetic management is not recommended. BIS values should be interpreted cautiously in patients: With known neurological disorders Taking psychoactive medications In children below the age of one
  • 29. CONCLUSIONS Propofol target controlled infusion is safe and effective. Quick loss of consciousness. Lower induction doses, smooth inductions. Less hemodynamic changes in anesthesia. Short recovery times, improve patient recovery. Reduce the risk of awareness with recall during anaesthesia.

Editor's Notes

  1. eâm
  2. eâm
  3. V1: khoang trung öông bao goàm HT vaø caùc cô quan ñöôïc töôùi maùu nhieàu nhö tim, naõo, gan, thaän V2,V3: khoang ngoaïi bieân töông öùng vôùi caùc cô quan ñöôïc töôùi maùu ít nhö moâ noäi taïng, cô baép (thaêng baèng nhanh) vaø moâ môõ (thaêng baèng chaäm)
  4. THIS SLIDE WILL AUTOMATICALLY BUILD In addition to the BIS Value, there’s other important information displayed that you may find useful in interpreting BIS during surgery. As I mentioned, the BIS technology is available as either a standalone monitor or integrated into your patient monitoring system, so although the display may vary somewhat in how the data appears on the screen, these are the BIS data that are available on all systems. Ngoài giá trị BIS thì có những thông tin khác hiển thị trên màn hình giúp bạn giải thích BIS tốt hơn trong lúc phẫu thuật. Như đã đề cập, hệ thống BIS có thể là một monitor độc lập hoặc được tích hợp trong hệ thống theo dõi bệnh nhân. Cho nên dù các thông số hiển thị có thay đổi phần nào theo các dữ liệu trên màn hình, thì đó là những dữ liệu của BIS. BIS value/Giá trị BIS: Displayed as a number between 0 and 100/Hiển thị dạng số từ 0 đến 100 Trend/Biểu đồ lưu: Displays BIS over time/Hiển thị BIS toàn thời gian EEG Display: shows real-time raw EEG/Hiển thị EEG mới nhất theo thực tế Electromyograph (EMG): May be shown as a bar graph or numerically. Indicates presence of muscle activity or other high-frequency artifacts (electrosurgical instruments, convective warming blanket, fluid warmer). Optimal when EMG is absent or minimal. Increased EMG may elevate the BIS value/Có thể hiển thị trên thanh biểu đồ hoặc dạng số. Cho thấy hoạt động của cơ hoặc yếu tố gây nhiễu của sóng cao tần khác (dụng cụ phẫu thuật điện, chăn giữ ấm, bộ làm ấm). Tối ưu nhất khi EMG không xuất hiện hoặc nhỏ nhất. EMG tăng có thể nâng cao giá trị BIS. Signal Quality Index (SQI): May be shown as a bar graph or numerically. Indicates quality of EEG signal over the last 63 seconds. Optimal when SQI bar is full or at 100/Có thể hiển thị trên thanh biểu đồ hoặc dạng số. Cho thấy chất lượng tín hiệu EEG trên 63 giây cuối cùng. Tối ưu nhất khi thanh SQI đầy hoặc ở 100. Suppression Ratio (SR) Value: Indicates the % of time in the last 63 seconds that the EEG signal is suppressed. Example: SR = 72 means EEG is isoelectric over 72% (45 seconds) of the last 63 seconds. May be helpful when monitoring and managing suppression level during deep anesthesia or deep sedation (i.e., drug-induced coma). Cho thấy % thời gian trên 63 giây cuối cùng khi EEG bị ngưng lại. Ví dụ SR=72 có nghĩa là EEG bị đẳng điện hơn 72% của 63 giây cuối cùng. Rất có ích khi theo dõi và quản lý mức độ dừng lại trong lúc gây mê sâu.
  5. Here you’ll see the results of two different studies conducted 3 years apart, and yet the results are strikingly similar. Ở đây bạn sẽ thấy được kết quả của 2 nghiên cứu khác nhau được thực hiện cách nhau 3 năm, tuy nhiên kết quả hầu như tương tự. How many of you would perceive that you’re on target with sedation more than 20% or 30% of the time? And yet, these published studies show that we may not be doing as well as we think. Có bao nhiêu người cảm nhận rằng họ đang được gây mê đủ liều với hơn 20% hay 30% thời gian? Và các nghiên cứu này cho thấy rằng chúng ta không thực hiện tốt như chúng ta nghĩ. Using traditional approaches to sedation assessment, you can see that the majority of patients are over-sedated as determined by BIS monitoring in both studies. Khi sử dụng những phương pháp truyền thống để đánh giá độ sâu gây mê, bạn có thể nhận thấy rằng phần lớn các bệnh nhân đều bị gây mê quá liều theo kết quả theo dõi của BIS trong cả 2 nghiên cứu. And, while fewer patients were under-sedated, keep in mind that the patient population in the Kaplan study were all receiving neuromuscular blocking agents -- and this group reported an 18% occurrence of recall of unpleasant experiences. Và trong khi một số ít bệnh nhân bị gây mê không đủ liều, hãy nhớ rằng tất cả các bệnh nhân theo nghiên cứu Kaplan đều được chích thuốc phong bế thần kinh cơ, nhóm bệnh nhân này được kết luận là có 18% bị ám ảnh vì thức giấc trong lúc gây mê.
  6. This graphic displays the numerical value of the BIS index, from 0 to 100 relative to clinical endpoints, and the underlying EEG signal. BIS values of 0 represent an isoelectric EEG, whereas values of 100 represent an awake central nervous system. After administration of a hypnotic drug, the BIS Index decreases from an awake value of 100 as the patient’s level of consciousness undergoes a series of transitions. At a BIS of 60 the probability of consciousness is low. Biểu đồ này hiển thị giá trị dạng số của chỉ số BIS từ 0 đến 100 theo các điểm cuối lâm sàng, và tín hiệu EEG cơ bản. Giá trị BIS bằng 0 có nghĩa là EEG phẳng điện, giá trị 100 nghĩa là hệ thống thần kinh trung tâm tỉnh táo. Sau khi quản lý lượng thuốc mê, chỉ số BIS giảm từ giá trị 100 khi mức độ hôn mê của bệnh nhân trải qua hàng loạt chuyển đổi. Ở giá trị 60, khả năng tỉnh rất thấp. Like all electrophysiologic measures, it’s important to correlate the individual clinical state to the BIS value in each patient to adjust for variability between patients. Giống như tất cả các biện pháp điện lý sinh học khác, bạn cần phối hợp tình trạng lâm sàng của mỗi người với giá trị BIS để điều chính cho phù hợp với từng bệnh nhân.
  7. We now turn to this functional graphic regarding the level of anesthetic effect, to address a very specific question: Chúng ta hãy xem biểu đồ chức năng thể hiện mức độ gây mê để trả lời 1 câu hỏi rất đặc biệt sau: “What are the benefits of using BIS to influence or guide the dosing of anesthetic agents?” “Lợi ích khi sử dụng BIS để tác động hoặc hướng dẫn sử dụng liều lượng gây mê?” It is important to emphasize that in the vast majority of the studies to date, a “balanced” anesthetic was administered in which supplemental analgesics agents (e.g. opioid narcotics, or appropriate local or regional anesthetic techniques) were administered. Cần nhấn mạnh rằng theo hầu hết các nghiên cứu cho đến hôm nay, người ta thường đánh một lượng thuốc mê “cân đối”, trong đó cũng thêm vào lượng thuốc gây mất cảm giác đau khác. In most of the studies, the “BIS Group” was directed to use the information from the BIS monitor to adjust anesthetic dosing to keep the BIS values in the range of 45-60. Theo hầu hết các nghiên cứu thì “BIS Group” được hướng dẫn sử dụng thông tin từ BIS monitor để điều chỉnh lượng thuốc mê nhằm giữ cho giá trị của BIS ở mức 45-60. In some studies, higher values were permitted during the very end of the operation, while in others, BIS values were allowed to stay in the range 45-60. Đối với vài nghiên cứu, được phép cho giá trị cao hơn lúc gần kết thúc phẫu thuật, trong khi vài nghiên cứu khác cho rằng giá trị BIS được phép giữ nguyên ở mức 45-60.
  8. Intraoperative awareness is a rare but serious problem, resulting in late psychological problems in a large proportion of patients. REF: Samuelsson P, Brudin L, Sandin RH. Late psychological symptoms after awareness among consecutively included surgical patients. Anesthesiology. 2007 Jan;106(1):26-32. Osterman JE, Hopper J, Heran WJ, Keane TM, van der Kolk BA: Awareness under anesthesia and the development of posttraumatic stress disorder. Gen Hosp Psychiatry 2001; 23:198–204 Moerman N, Bonke B, Oosting J: Awareness and recall during general anesthesia: Facts and feelings. ANESTHESIOLOGY 1993; 79:454–64 Domino KB, Posner KL, Caplan RA, Cheney FW: Awareness during anesthesia: A closed claims analysis. ANESTHESIOLOGY 1999; 90:1053–6 Schwender D, Kunze-Kronawitter H, Dietrich P, Klasing S, Forst H, Madler C: Conscious awareness during general anaesthesia: Patients’ perceptions, emotions, cognition and reactions. Br J Anaesth 1998; 80:133–9 Lennmarken C, Bildfors K, Enlund G, Samuelsson P, Sandin R: Victims of awareness. Acta Anaesthesiol Scand 2002; 46:229–31
  9. As I’ve mentioned several times, the addition of BIS data provides a rational framework for patient assessment and intervention, but BIS should not be used in isolation to guide patient management. Như đã nói nhiều lần, việc có thêm dữ liệu BIS sẽ đem lại một hình thức đánh giá bệnh nhân và sự can thiệp hợp lý nhưng không nên dùng BIS độc lập để hướng dẫn quản lý bệnh nhân. No single monitoring parameter, whether BIS or another vital sign, should be used alone or in isolation to determine patient care. Không có thông số theo dõi đơn lập nào, dù là BIS hay các tin hiệu sống khác, được sử dụng độc lập để quyết định tình trạng của bệnh nhân. BIS monitoring systems utilize a variety of signal analysis methods to detect and reduce extraneous artifacts that contaminate the EEG. Many of the significant improvements in the BIS system over the past decade have been in the area of artifact processing, such as with the BIS-XP system that’s substantially improved the performance and reliability with EMG especially in the presence of electrocautery artifacts. However, despite these improvements, artifact can potentially interfere with the BIS. In situations where artifact seems likely to have influenced the BIS value, all of the data provided by the BIS system, such as signal quality index and EMG parameters and the EEG display, may assist in your assessment. Hệ thống BIS sử dụng nhiều phương pháp phân tích tín hiệu khác nhau để phát hiện và giảm thiểu yếu tố gây nhiễu EEG. Hệ thống BIS đã được cải thiện nhiều lần trog thập kỷ qua, xử lý được yếu tố gây nhiễu chẳng hạn như hệ thống BIS-XP đã được cải thiện nhiều và đưa ra EMG rất đáng tin cậy, đặc biệt khi có mặt yếu tố gây nhiễu từ máy cắt đốt điện. Tuy nhiên, dù đã được cải thiện nhiều nhưng yếu tố gây nhiễu vẫn có thể can thiệp vào BIS. Khi yếu tố gây nhiễu này ảnh hưởng đến BIS thì tất cả các dữ liệu khác trong hệ thống BIS như chỉ số chất lượng tín hiệu và thông số EMG, và hiển thị EEG sẽ hỗ trợ bạn trong việc đánh giá. BIS monitoring has been proven to be a practical tool to assess the effects of anesthetics, however its role continues to be explored and defined. Due to limited experience, BIS values should be interpreted cautiously in patients with known neurological disorders (e.g., hepatic or renal encephalopathy) and in patients taking psychoactive medications. As I mentioned earlier, there is a growing number of studies that have explored the relationship between anesthetic dose and BIS values in children, but because validation of the BIS Index has been challenging because of the limitations in infants and children to respond to sedation scoring scales, BIS values should be interpreted with caution in children below the age of one. BIS đã được chứng minh là công cụ đánh giá thực tế các tác động của thuốc mê, tuy nhiên vai trò của nó vẫn còn tiếp tục được khai thác và định rõ. Theo kinh nghiệm đã có, gía trị BIS nên được hiểu một cách thận trọng đối với bệnh nhân bị rối loạn thần kinh và đang uống thuốc điều trị thần kinh. Như đã nói bên trên, càng ngày càng có nhiều nghiên cứu khám phá mối tương quan giữa liều lượng thuốc mê và giá trị BIS ở tre em, nhưng do hiệu quả của BIS đang được thử thách vì những hạn chế ở trẻ nhỏ và trẻ em nhằm đáp ứng tỉ lệ gây mê, giá trị BIS nên được hiểu một cách thận trọng ở trẻ dưới 1 tuổi.
  10. Obstetric Causes The incidence of neurological complications related to obstetric causes varied from 1 : 2,600 to 1 : 6,400.36,37 These neurological complications were associated with prolonged labor and forceps delivery. Changes in the obstetric practice of difficult deliveries might have decreased the incidence of major obstetric-related neurological complications.38 Peripheral nerves that might be involved, apart from regional anesthesia, are as follows: 1. A prolapsed intervertebral disk may happen because of the exertional efforts of labor. This may cause spinal root compression, the incidence of which has been documented to be 1 in 6,000 deliveries. 2. The lumbosacral trunk (L4, L5) may be compressed between the descending fetal head and the ala of the sacrum. It might be associated with the use of mid to high forceps. Clinical findings may include foot drop, hypoesthesia of the lateral aspect of the foot and calf, a slight weakness of hip adductors, and quadriceps weakness. 3. The femoral nerve (L2, L3, L4) can be injured in the lithotomy position because of hyperacute hip flexion as well as the use of retractors during cesarean section. There will be impaired knee extension due to quadriceps paralysis, an absence of the patellar reflex, and hypoesthesia of the anterior portion of the thigh and medial aspect of the calf. 4. The lateral femoral cutaneous nerve (L2, L3) can be injured by retractors during cesarean section or during incorrect lithotomy positioning. There will be transient numbness of the thigh at the anterolateral aspect. 5. The sciatic nerve (L4, L5 and S1, S2, S3) can be injured by incorrect lithotomy positioning along with knee extension and external hip rotation. There will be pain in the gluteal region that radiates to the foot and an inability to flex the leg.