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ObjectivesObjectives
Describe the basic technology of Bispectral Index (BIS™) 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
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Sedation: Current IssuesSedation: Current Issues
Over-sedated
• increased drug costs• delayed weaning • increased ICU length of stay• increased testing
Under-sedated
• anxiety and agitation• awareness and recall• post-traumatic stress disorder• increased adverse events• increased use of paralytics
Without a means to objectively titrate
the level of sedation, patients may be:
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
Components of ComfortComponents of Comfort
AnalgesiaAnalgesia Muscle Muscle RelaxationRelaxation
Consciousness/SedationConsciousness/Sedation
COMFORTCOMFORT
Autonomic & Somatic Response + Pain Scales
Movement + Nerve Stimulator
Vital Signs + Sedation Scales + BIS Monitoring
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 patient’s response to sedation
Optimizes sedation assessment and titration
Numerical scale correlates to sedation endpoints
GE BIS Display / BIS SensorGE BIS Display / BIS Sensor
GE BIS Display
BIS Sensor
Philips BIS Display / BIS SensorPhilips BIS Display / BIS Sensor
BIS Sensor
Philips BIS Display
BIS TechnologyBIS Technology
BIS Monitor
BIS Modules
BIS Sensor
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
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.
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
Moderate/Deep Sedation During Moderate/Deep Sedation During Mechanical VentilationMechanical Ventilation
Challenges/Concerns
•Over-sedation • longer wake-up• increased MV time• increased drug costs• increased length of stay
• Under-sedation • anxiety, agitation• failure to effectively ventilate• unintended medical device removal
• NMBA use when adequate sedation cannot be achieved
• Inadequacy of sedation assessment tools
BIS Value
• Objective measure of level of sedation
• Improved drug titration
• May avoid use of NMBA with better controlled sedation
• Help reduce adverse events associated with over- and under-sedation
BIS in Deep SedationBIS in Deep Sedation
Jaspers et al. Intensive Care Medicine. 1999;25(Suppl 1):S67.
• Titration to maximal Ramsay Score of 6 (unarousable)• Blinded BIS monitoring
Results:• Ramsay Score remains the same, with significant decrease of BIS values over time. • 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
BIS
Val
ue
BIS
Val
ue BIS
Ram
say Sco
re*R
amsay S
core*
6868
4545
3131
66 66 66
23
4
56
* Mondello et al. Minerva Anestesiology. 2002;68(102):37-43.
Ramsay
BIS in Deep SedationBIS in Deep Sedation
Riker. AJRCCM 1999De Deyne. Int Care Med 1998
Unarousable
0
10
20
30
40
50
60
70
80
90
100B
isp
ectr
al I
nd
ex (
BIS
)
SAS 1 Ramsay 6
• Titration to unarousable state by subjective scale• Blinded BIS monitoring
Results: • Patients were unarousable at maximal sedation score. • All patients appeared similar clinically, but displayed wide variation in sedation level as measured objectively with BIS monitoring.
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:• Average Cost Savings: $185/patient/day• 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.
Neuromuscular BlockadeNeuromuscular Blockade
Challenges/Concerns
• Under-sedation / Awareness
• Over-sedation / Extended wake-up
• Inability to use traditional subjective sedation assessment tools
BIS Value
• Provides objective information where sedation scales can not be used
• More information to assure proper sedation dosage
• Monitors for the risk of awareness
• Provides reassurance to staff and family
BIS Reduces Sedative Cost &BIS Reduces Sedative Cost & Improves Patient Experience Improves 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: • Average sedative savings of $150 per patient• Unpleasant recall reduced from 18% to 4% (p<0.05)
BIS TitratedControl
Sed
ativ
e C
ost
/ p
atie
nt
($) 18% Decrease
$819
$669
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
20%
BIS TitratedControl
Pat
ien
t R
ecal
l:F
rig
hte
ned
/ P
ain
ful (
%) 78% Decrease
18%
4%
Drug Induced ComaDrug Induced Coma
Challenges/Concerns
• Traditional EEG monitoring is:
• complex• costly• difficult to interpret
• Ongoing assessment is critical to assure targeted suppression
BIS Value
• Simplified interpretation of patient response to treatment
• Improve drug titration with continuous, objective information
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
Bedside ProceduresBedside Procedures
Challenges/Concerns
• Patients are too sick or unstable to transport to OR
• Need to assure same standard of care for patients regardless of location
• Risks associated with over- and under-sedation
• Over-sedation / Delayed recovery• Under-sedation / Awareness
BIS Value
• Improves quality of care by optimizing sedation
• Allows same standard of care for surgical procedures
• Monitors for risk of awareness
• Cost savings potential
BIS: Procedural MonitoringBIS: Procedural Monitoring• Sedation drugs and doses administered at discretion of bronchoscopist• Bronchoscopists blinded to BIS values
Results:• Patients who recalled feeling “too awake” 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.
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.
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40
50
60
70
80
90
100
Base Start Low 1st Dx Mean Dx End
Time during Bronchoscopy
Bis
pec
tral
Ind
ex (
BIS
)
Too AwakeLess Recall95% Limits
*
= p<0.05
* *
*
Objective sedation assessment
Minimize consequencesof 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
For more information about clinical applications for BIS monitoring
in critical care,
please contact Aspect Medical Systems, Inc.
USA: 1 888 247 4633Outside 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.
©2004, Aspect Medical Systems, Inc.080-0386 1.00