Sedation BIS monitorage
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Sedation BIS monitorage
- 2. ObjectivesObjectives Describe the basic technology of Bispectral Index (BISā¢) monitoring State the key applications for BIS monitoring in the ICU Describe the impact of inappropriate sedation in the critical care setting Identify challenges with sedation assessment 1 2 3 4
- 3. Sedation: Current IssuesSedation: Current Issues Over-sedated ā¢ increased drug costs ā¢ delayed weaning ā¢ increased ICU length of stay ā¢ increased testing Under-sedated ā¢ anxiety and agitation ā¢ awareness and recall ā¢ post-traumatic stress disorder ā¢ increased adverse events ā¢ increased use of paralytics Without a means to objectively titrate the level of sedation, patients may be:
- 4. Incidence of Inappropriate SedationIncidence of Inappropriate Sedation Over-sedation On Target Under-sedation 54% 15.4% 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% Kaplan L. and Bailey H.Kaplan L. and Bailey H. 20002000 Olson D. et al.Olson D. et al. 20032003
- 5. Components of ComfortComponents of Comfort AnalgesiaAnalgesia MuscleMuscle RelaxationRelaxation Consciousness/SedationConsciousness/Sedation COMFORTCOMFORT Autonomic & Somatic Response + Pain Scales Movement + Nerve Stimulator Vital Signs + Sedation Scales + BIS Monitoring
- 6. Bispectral Index (BIS)Bispectral Index (BIS) A practical, processed EEG parameter that measures the direct effects of sedatives on the brain Frontal montage Provides objective information about an individual patientās response to sedation Optimizes sedation assessment and titration Numerical scale correlates to sedation endpoints
- 7. GE BIS Display / BIS SensorGE BIS Display / BIS Sensor GE BIS Display BIS Sensor
- 8. Philips BIS Display / BIS SensorPhilips BIS Display / BIS Sensor BIS Sensor Philips BIS Display
- 9. BIS TechnologyBIS Technology BIS Monitor BIS Modules BIS Sensor
- 10. Sensor ApplicationSensor Application Apply sensor on forehead at angle Circle #1: Centered, 2 inches above nose Circle #4: Directly above eyebrow Circle #3: On temple, between corner of eye and hairline Press around the edges of each circle to assure adhesion Press each circle for 5 seconds
- 11. BIS Range GuidelinesBIS Range Guidelines Titration of sedatives to BIS ranges should be dependent upon the individual goals for sedation that have been established for each patient. These goals and associated BIS ranges may vary over time, in the context of patient status and treatment plan.
- 12. Objective assessment of sedation during: BIS in the ICU: Key ApplicationsBIS in the ICU: Key Applications Mechanical Ventilation Neuromuscular Blockade Bedside Procedures Drug Induced Coma
- 13. Moderate/Deep Sedation DuringModerate/Deep Sedation During Mechanical VentilationMechanical Ventilation Challenges/Concerns ā¢Over-sedation ā¢ longer wake-up ā¢ increased MV time ā¢ increased drug costs ā¢ increased length of stay ā¢ Under-sedation ā¢ anxiety, agitation ā¢ failure to effectively ventilate ā¢ unintended medical device removal ā¢ NMBA use when adequate sedation cannot be achieved ā¢ Inadequacy of sedation assessment tools BIS Value ā¢ Objective measure of level of sedation ā¢ Improved drug titration ā¢ May avoid use of NMBA with better controlled sedation ā¢ Help reduce adverse events associated with over- and under-sedation
- 14. BIS in Deep SedationBIS in Deep Sedation Jaspers et al. Intensive Care Medicine. 1999;25(Suppl 1):S67. ā¢ Titration to maximal Ramsay Score of 6 (unarousable) ā¢ Blinded BIS monitoring Results: ā¢ Ramsay Score remains the same, with significant decrease of BIS values over time. ā¢ Data suggest possible accumulation of sedatives and inherent risks of over-sedation. 0 10 20 30 40 50 60 70 80 90 100 Day 1 Day 3 Day 5 BISValueBISValue BIS RamsayScore*RamsayScore* 6868 4545 3131 66 66 66 2 3 4 5 6 * Mondello et al. Minerva Anestesiology. 2002;68(102):37-43. Ramsay
- 15. BIS in Deep SedationBIS in Deep Sedation Riker. AJRCCM 1999 De Deyne. Int Care Med 1998 Unarousable 0 10 20 30 40 50 60 70 80 90 100 BispectralIndex(BIS) SAS 1 Ramsay 6 ā¢ Titration to unarousable state by subjective scale ā¢ Blinded BIS monitoring Results: ā¢ Patients were unarousable at maximal sedation score. ā¢ All patients appeared similar clinically, but displayed wide variation in sedation level as measured objectively with BIS monitoring.
- 16. BIS in the ICU:BIS in the ICU: Reduces Sedative CostReduces Sedative Cost Maintains Adequate SedationMaintains Adequate Sedation Neurocritical Care Unit at Duke University Hospital Compared cost of propofol pre-BIS monitoring vs. BIS-guided titration Results: ā¢ Average Cost Savings: $185/patient/day ā¢ All patients were considered adequately sedated Annual savings (2 patients/day): > $135,000 Olson D et al. Critical Care Nurse. 2003; 23(3):45-52.
- 17. Neuromuscular BlockadeNeuromuscular Blockade Challenges/Concerns ā¢ Under-sedation / Awareness ā¢ Over-sedation / Extended wake-up ā¢ Inability to use traditional subjective sedation assessment tools BIS Value ā¢ Provides objective information where sedation scales can not be used ā¢ More information to assure proper sedation dosage ā¢ Monitors for the risk of awareness ā¢ Provides reassurance to staff and family
- 18. BIS Reduces Sedative Cost &BIS Reduces Sedative Cost & Improves Patient ExperienceImproves Patient Experience $0 $100 $200 $300 $400 $500 $600 $700 $800 $900 Kaplan L and Bailey H. Critical Care. 2000; 4(1):S110. SICU patients (n=57): Infusions of sedatives & paralytics Control: Sedatives titrated to vital signs and comfort BIS: Sedatives titrated to BIS 70-80 (post-stimulation) BIS-Guided Titration Results: ā¢ Average sedative savings of $150 per patient ā¢ Unpleasant recall reduced from 18% to 4% (p<0.05) BIS TitratedControl SedativeCost/patient($) 18% Decrease $819 $669 0% 2% 4% 6% 8% 10% 12% 14% 16% 18% 20% BIS TitratedControl PatientRecall: Frightened/Painful(%) 78% Decrease 18% 4%
- 19. Drug Induced ComaDrug Induced Coma Challenges/Concerns ā¢ Traditional EEG monitoring is: ā¢ complex ā¢ costly ā¢ difficult to interpret ā¢ Ongoing assessment is critical to assure targeted suppression BIS Value ā¢ Simplified interpretation of patient response to treatment ā¢ Improve drug titration with continuous, objective information
- 20. Burst Suppression EEG PatternBurst Suppression EEG Pattern Riker RR et al. Pharmacotherapy. 2003; 23(9):1087-1093. -250 -200 -150 -100 -50 0 50 100 150 200 250 Pentobarbital Coma (15 sec)Pentobarbital Coma (15 sec) SAS 1 BIS 14 SR 67SAS 1 BIS 14 SR 67
- 21. Bedside ProceduresBedside Procedures Challenges/Concerns ā¢ Patients are too sick or unstable to transport to OR ā¢ Need to assure same standard of care for patients regardless of location ā¢ Risks associated with over- and under-sedation ā¢ Over-sedation / Delayed recovery ā¢ Under-sedation / Awareness BIS Value ā¢ Improves quality of care by optimizing sedation ā¢ Allows same standard of care for surgical procedures ā¢ Monitors for risk of awareness ā¢ Cost savings potential
- 22. BIS: Procedural MonitoringBIS: Procedural Monitoring ā¢ Sedation drugs and doses administered at discretion of bronchoscopist ā¢ Bronchoscopists blinded to BIS values Results: ā¢ Patients who recalled feeling ātoo awakeā were less sedated as measured by the BIS, despite receiving similar sedative doses. ā¢ Physicians performing bronchoscopy usually overestimate the adequacy of sedation compared to patients experiencing bronchoscopy. Riker RR, Vijay P, Prato BS. Patient Recall After Bronchoscopy Corresponds to EEG Monitoring (Bispectral Index) But Not Sedative Drug Doses. American Journal Respiratory Critical Care Medicine 1997; 155: A397. * 40 50 60 70 80 90 100 Base Start Low 1st Dx Mean Dx End Time during Bronchoscopy BispectralIndex(BIS) Too Awake Less Recall 95%Limits * = p<0.05 * * *
- 23. Objective sedation assessment Minimize consequences of over- and under-sedation Improve quality of sedation management Value of BIS in the ICUValue of BIS in the ICU Optimize clinical and economic outcomes
- 24. For more information about clinical applications for BIS monitoring in critical care, please contact Aspect Medical Systems, Inc. USA: 1 888 247 4633 Outside USA: +31 30 662 9140 www.aspectmedical.com Bispectral Index, the BIS logo and BIS are trademarks of Aspect Medical Systems, Inc. and are registered in the USA, EU and other countries. Ā©2004, Aspect Medical Systems, Inc. 080-0386 1.00
Editor's Notes
- At the end of this presentation you will be able to: Describe issues with inappropriate sedation in the ICU: the causes, the risks and the consequences of both over- and under-sedation. Ā Discuss the complex issues involved in monitoring or quantifying sedation in critically ill patients with traditional methods of sedation assessment, Answer the question āwhat is BISā - weāll review what basic principles of the technology, and Ā Identify sedation strategies to optimize sedation assessment and management. Ā
- The majority of patients will receive some form of sedation during their stay in an intensive care unit, and for many, this is a critical component of their care regime. However ICU patients are very complex and their needs for sedatives are unpredictable and complicated, and often highly variable. Sedation challenges in the ICU are well documented and recognized, and even more so in recent years. It is clear that the problems associated with sedation are indeed bipolar, branching into 2 extreme conditions of over sedation and under-sedation -- each with their important consequences. Over-sedation Can result in unnecessary costs of sedative drugs, which in some cases can range into hundreds of dollars per patient per day. When patients are over-sedated, they often experience delayed weaning from mechanical ventilation (MV), which can impose additional costs. Even more importantly, extended and unnecessary time on MV can lead to complications such as ventilator associated pneumonias and the need for tracheostomies. Extension of MV and other complications can result in increased length of stay (LOS) in the ICU and hospital. Additionally, when patients do not show signs of waking up when sedation is weaned or discontinued, many of them will be subjected to expensive and unnecessary diagnostic tests to rule out the incidence of a neurological event. Under-sedation Can result in patients who are anxious and agitated, and increase the risk of awareness and recall of unpleasant events, even in patients who are receiving neuromuscular blocking agents (NMBAs). These occurrences are far more common than they are in the OR setting. They may also result in long-term sequelae such as Post-Traumatic Stress Disorder (PTSD) In addition, patients who do not have adequate sedation may receive other classes of drugs, such as NMBAs.
- Here youāll see the results of two different studies conducted 3 years apart, and yet the results are strikingly similar. How many of you would perceive that youāre 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. 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. 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.
- Each practitioner may approach these components through a variety of different drug concentrations and practices. There are numerous means involved in providing comfort, and it is helpful to think of them in terms of three main components - hypnosis (lack of consciousness), analgesia (lack of autonomic and somatic responses), and areflexia or muscle relaxation (lack of involuntary movement). Ā Monitoring each of these components requires separate measurements. There are well accepted methods to monitor the latter two components (analgesia and muscle relaxation). Until recently, it has been challenging to accurately measure the first: the state of consciousness.
- After many years of development, the BIS monitor found itās first home in the anesthesia environment. The intent was to bring some level of objective monitoring to the science and art of administering anesthesia. There are clinicians who have given anesthesia for many, many years and have done a very good job at it, but the bottom line is that after all of the advances in technology, these clinicians have not had the ability to objectively determine how appropriately sedated the patient was from that anesthetic care. That may resonate well with many of you āyouāll probably agree that there are no objective means or sophisticated measures to assess sedation in the critical care setting. The Bispectral Index technology is evolving in its purpose now to extend the same benefits of providing an optimum level of objective assessment to the ICU and is moving beyond the OR like a lot of good technologies. There are many institutions that have thoughtfully integrated BIS into sedation practice. The Bispectral Index is a direct measure of the effects of anesthetics and sedatives on the brain. It is an integrated measure of cerebral electrical activity, derived from the EEG. The BIS is designed to correlate with hypnotic, or consciousness, endpoints. Itās important to emphasize that the BIS is not intended to tell you about movement. Movement is more related to analgesic adequacy than sedative adequacy. Early on in its development, it was thought that the BIS might be a good predictor of movement, but it was not so. So, the BIS is specifically going to tell you how awake or sedate the patient is. The BIS is a single number that is patient independent and it is drug independent. It requires no calibration for either the patient or the drugs that are being used. The BIS is statistically and empirically derived from the EEG. It is a combination of several signal-processing parameters including the Power Spectrum, bispectrum and time domain variables. Suffice it to say that over the years of development the analysis of very complex EEG patterns has been refined and translated into very simple forms of information that make it much easier for those of us that are not EEG experts to use. A detailed discussion of the technology underlying the BIS can be found in a review article by Dr. Ira Rampil in the October 1998 issue of Anesthesiology.
- USE THIS SLIDE FOR BIS WITH GE PATIENT MONITORING SYSTEMS (Hide the Philips and BIS A-2000 slides) Here is a picture of the BIS display on the GE Patient Monitoring System. The BIS System is comprised of a sensor and the BIS module. The sensor, placed on the patientās forehead, detects the electrical activity of the brain, or EEG. Ā The characteristic changes in the EEG are evaluated by the monitorās sophisticated algorithm, and an objective measure of the sedative drug effect is provided by the BIS value shown on the screen.
- USE THIS SLIDE FOR BIS WITH Philips PATIENT MONITORING SYSTEMS (Hide the GE and BIS A-2000 slides) Here is a picture of the BIS display on the Philips Patient Monitoring System. The BIS System is comprised of a sensor and the BIS module. The sensor, placed on the patientās forehead, detects the electrical activity of the brain, or EEG. Ā The characteristic changes in the EEG are evaluated by the monitorās sophisticated algorithm, and an objective measure of the sedative drug effect is provided by the BIS value shown on the screen.
- USE THIS SLIDE FOR BIS A-2000 OR FOR BIS WITH PATIENT MONITORING SYSTEMS OTHER THAN GE OR PHILIPS (Hide the Philips and GE slides) As you can see, the BIS technology is available as a stand-alone monitor or in modular format integrated into leading patient monitoring systems. To monitor a patient, you will need a monitor or a module and a sensor. The sensor, placed on the patientās forehead, detects the electrical activity of the brain, or EEG. Ā The characteristic changes in the EEG are evaluated by the monitorās sophisticated algorithm, and an objective measure of the sedative drug effect is displayed as the BIS value.
- The EEG information, from which the BIS value is derived, is obtained byplacing the Sensor on the patientās forehead It can be place on either side of the patientās forehead. It connects to the patient interface cable The Sensor: Is an electrode strip that is designed to pick up the typically very small, or low amplitude, EEG signal Is designed with adhesive to give good contact with patient skin Has self prepping electrodes, eliminating extensive skin preparation. Each of the electrodes contains a pre-filled conductive gel to allow for conduction of the EEG signal Has a 4th electrode placed over the eye which improves artifact/EMG resistance (usually secondary to patient muscle movement) for a more accurate and precise measure of sedation Reads the frontal montage ā single channel EEG Is Single-use, to be changed every 24 hours. The Extend Sensor has date/time area to record time of sensor application Is Latex-free
- BIS values range on a scale of 0 to 100, with the numbers correlated to level of sedation. As you can see the higher numbers are correlated with an increasingly awake state and the lower numbers are correlated with an increasingly flattened EEG waveform. For instance: awake patients will usually demonstrate BIS values in the mid-to- upper 90s moderate sedation may decrease the BIS to the 70s or 80s deeper sedation may drop the BIS into the 40 to 60 range, and in drug-induced coma, the BIS value may be in the teens and 20s. You may chose a range between 0 and 100 that will help you to meet specific treatment goals for your patient. The range you chose may change at different points during care to meet the specific sedation goal and patient situation at that time. Clinical judgment should always be used when interpreting the BIS in conjunction with other available clinical signs.
- There are 4 key applications that are common situations for sedative use in the ICU and for which BIS may be very helpful to you in assessing and managing the sedation needs of your patients. The next few slides will detail each of these applications.
- Patients who are receiving deep sedation for MV are excellent candidates for BIS monitoring. Aggressive sedation and analgesia is often the preferred alternative for the patient to reach the desired end-point with out resorting to chemical paralysis. We recognize that adequacy of sedation for MV is often critical to effectively manage the ventilation requirements of patients, particularly if they are receiving forms of ventilation that are non-physiologic. By administering too little sedative, thereās the potential risk of recall and/or an agitated patient that harms himself by pulling out tubes and drains. On the other side, too much drug can cause dips in blood pressure and prolong the need for mechanical ventilation. The value of BIS-guided titration of sedation: itās an objective measure may help to avoid use of NMB with better controlled sedation may help reduce adverse events associated with over- and under sedation Letās look more closely at sedation assessment for moderate to deep sedation and how the use of BIS technology may help in optimizing sedation management.
- In this study by Jaspers et al, sedation was titrated to a Ramsay Score of 6, which is unarousable. As you can see, even though the patients looked the same clinically to the nurses every day and the nurses felt that they were consistently maintaining a Ramsay of 6, the patientās brain states were changing over time. Patients were actually becoming more deeply sedated each day although their clinical presentation looked the same from day to day. As you can see, itās difficult to determine level of sedation once a patient is in a moderate to deep state. BIS can help you to achieve and maintain the therapeutic goal for each patient. NOTE: Correlation of BIS Values to Ramsay Scores was published by Mondello et al. Ramsay ScoreBIS Value 2 88 3 81 4 70 5 56 6 52
- This chart contains two studies that graphically illustrate the limitation of subjective scales and the benefit of objective BIS monitoring in more deeply sedated patients. The graph shows data points from two different studies. You will see BIS values on the Y axis and a scatter of data points. The blue points indicate individual patients in the Riker Study and the red are patients in the DeDeyne study. In each of these studies, patientsā sedation was titrated to an unarousable state using a sedation assessment scale (a sore of 1 on the SAS in the Riker study and a score of 6 on the Ramsay Scale in the DeDeyne study). The point of this slide is to show you that, while in each of the studies patientsā sedation was titrated to a subjective assessment score representative of an unarousable state, there is a wide variation in the objective values. So, even though these patients may look the same clinically, the actual effect of the sedatives on the brain was very different for individual patients. As you can see on the graph, some patients were at values for which the possibility for explicit recall was much higher, while others titrated to the same subjective scale were in the range of near isoelectric brain activity. By using BIS-guided sedation, you can determine the therapeutic goal range for each patient, and titrate the sedative to achieve your goal.
- This is a study that was conducted by the nurses at Duke University Hospital. (Article included in the packet) As you can see, by utilizing BIS-guided sedation instead of traditional sedation assessment, they were able to save $185 per patient per day in the cost of propofol, while maintaining adequate sedation. If 2 patients were monitored per day, this would account for more than $135,000 in savings per year.
- An important application for BIS use in the critical care setting is clearly going to be patients who are receiving neuromuscular blockade. The use of paralytics has been decreasing, and itās estimated that less than 5% of ICU patients are paralyzed in the US. Some ICUs will use paralytics more frequently and others not. Paralytics may be used in selective circumstances, such as for improvement of patient compliance with complex mechanical ventilation, and for short-term control of life-threatening agitation and combativeness. In many cases aggressive sedation and analgesia are sufficient for the patient to reach the desired end-point with out resorting to chemical paralysis. However, when paralytics are necessary, itās important to administer sedation and analgesia to the point of unconsciousness prior to instituting paralysis. And, itās important to remember that paralytics have no sedative or analgesic properties and that they only prevent movement. Because chemically paralyzed patients donāt have the ability to move, nor the ability to cue us into their state of sedative adequacy, sedation assessment scales are ineffective in this population to determine level of sedation. The value of BIS monitoring during NMBA use is to: Provide an objective means of titrating sedation when sedation scales are ineffective Provide assurance to both staff and the family that these patients are receiving enough sedation so that they arenāt awake or aware while paralyzed Reduce extended times to wake up after the cessation of the sedative agent (in an effort to avoid under-sedation, well-intended staff may inadvertently over-sedate patients).
- Study by Drs. Kaplan and Bailey at the Medical College of Pennsylvania. In the first 2 months of the study, sedation was titrated to vital sign changes and clinicians were blinded to the BIS values. During the last 2 months of the study, sedation was titrated to achieve a BIS range of 70-80. Ā Results: Patients who were BIS monitored required less sedative than initially predicted by the staff, and There was found to be a $150 average cost savings per patient for sedative drugs in the BIS Monitored group Perhaps more clinically important, 18% of patients in the group whose sedatives were titrated to vital signs recalled a frightening or painful experience during their period of continuous sedation and paralysis, which decreased to 4% in the BIS monitored group.
- Patients receiving drug-induced comas, like those that receive barbiturates to control increased intracranial pressure caused by brain injury, or patients with uncontrolled seizures, are often excellent candidates for this technology. These are patients for whom the goal is to suppress the metabolic rate of brain tissue, and in traditional forms of practice complex EEG technology is often employed to assure that it is accomplished. A publication from the Maine Medical Center describes how they utilized the BIS monitor to attain a burst suppression pattern of 3-5 bursts per minute. On the next slide Iāll show you the burst suppression EEG tracing and talk about how they used the Suppression Ratio to achieve this goal. Some critical care units, like the Maine Medical Center, use the BIS as a proxy for assessing how deeply sedated that brain state is1. The Suppression Ratio, along with the BIS value, is easy to interpret and can assist in making real-time assessment and titration adjustments to maintain the burst suppression pattern. 1Riker RR et al. Comparing the Bispectral Index and Suppression Ratio with Burst Suppression of the Electroencephalogram During Pentobarbital Infusions in Adult Intensive Care Patients. Pharmacotherapy. 2003; 23(9):1087-1093.
- This is the patientās real-time EEG wave-form that you would see in EEG window on the BIS Monitor screen. This patient is in a drug-induced coma, and this is a burst suppression pattern. As you can see, there is isoelectric activity, followed by a burst of electrical activity, and then another period of isoelectric activity. This patient is unarousable, as evidenced by a SAS of 1 and a BIS of 14. The suppression ratio, or percent of time over the last 63 seconds that there has been isoelectric activity, is 67, which means that there has been 42 seconds of flatline EEG in the last 63 seconds. In the study by Dr. Riker at Maine Medical Center, 62 patient days were monitored in 6 patients. The mean pentobarbital infusion rate was 124Ā±49 mg/hr and the mean pentobarbital serum concentration was 29.7Ā±13 mcg/ml. Mean BIS value corresponding to 3-5 bursts per minute was 15 (95% CI = 10-20) and the mean suppression ratio was 71 (95% CI = 61-80). Dr. Riker et al conclude that āthe BIS worked well as a bedside EEG monitor, providing a raw EEG signal as well as continuous processed EEG data such as the BIS and SR. to titrate barbiturate therapy. The continuous trend data and real time digital output for the BIS and SR quantify the degree of EEG suppression well and may prove helpful in facilitating titration of barbiturate infusions.ā 1Riker RR et al. Comparing the Bispectral Index and Suppression Ratio with Burst Suppression of the Electroencephalogram During Pentobarbital Infusions in Adult Intensive Care Patients. Pharmacotherapy. 2003; 23(9):1087-1093.
- What types of procedures do you see taking place at the bedside? Procedures that are more invasive, that might have traditionally been performed in the OR? Many units are caring for higher acuity patients, and find that moving them to another setting for a procedure is costly and may create risk for critically ill patients. Procedural sedation is an area in which clinicians are using sedation in the ICU, and very commonly patients are receiving deep levels of sedation, not unlike they would receive in the OR. The purpose for utilizing BIS is to help ensure that patients are receiving a therapeutic window of sedation where they are not over- sedated or under-sedated.
- This study included 29 patients undergoing transnasal fiberoscopic bronchoscopy (FOB) that required sedation. Mean duration of the procedure was 30 minutes. Sedation drugs and doses administered at the discretion of the bronchoscopist. Bronchoscopists were blinded to BIS values. Patients rated sedation and their willingness to repeat FOB. Most patients willing to repeat FOB received more sedation compared to less willing patients. Patients who recalled feeling too awake during FOB were less sedated as measured by the BIS despite receiving similar sedative doses. Physicians performing bronchoscopy usually overestimate the adequacy of sedation compared to patients experiencing bronchoscopy. This study supports the ability of BIS-guided sedation to assist in individually titrating sedation drugs for each patient to attain sedation goal.
- In summary, weāve discussed that: The majority of critically ill patients receive sedation at some point during their stay, and that inappropriate sedation is common. Under-sedation and over-sedation each contribute to consequences that can negatively impact both clinical and financial outcomes. Sedation Assessment Scales are subjective and may be unreliable in more deeply sedated patients and cannot be used when paralytics are administered. BIS is an easy-to-use, objective, direct measure of the effects of sedatives on the brain. It can help you to optimize sedation management individually for each patient. Good candidates for BIS monitoring are those that are paralyzed and/or more deeply sedated. The 4 key applications include patients who are: sedated while receiving neuromuscular blocking agents receiving moderate to deep sedation for mechanical ventilation maintained in burst suppression for drug-induced coma management are sedated for bedside procedures BIS monitoring can help to optimize both clinical and economic outcomes.