consciousness monitoring by wael nasri
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Wael nasri
Product&therapy spiclest Wael Nasri 1
BIS monitoring provides additional information for the
anesthesia provider by directly measuring the effects of anesthesia on your patient.
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Overview of the TechnologyDemonstrated BenefitsClinical Applications & Special Considerations
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Key points to remember “Remember Red”
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BIS BackgroundTraditional Measures for Anesthesia Titration
BIS Range Guidelines
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10+ years development cycleFirst to market a direct measure of
anesthetic effectStatistically derived from EEGLinear across EEG statesCorrelated with hypnotic endpointsPatient / drug independent
Rampil, I, Anesthesiology, Oct. 1998. Wael Nasri 6
Designed for the anesthesia providerEase of Sensor Application Processing Speed + Data presentation
Measures the effects of anesthetics in the brainEndpoint: hypnosis / consciousnessPatient & drug* independentNo calibration or baseline
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Hemodynamic ResponsesEnd Tidal Agent MonitoringExpectations of Standard Dosages
Healthy Middle Aged MalesVariance in Metabolic & Clearance of DrugsEffects of Combined Drugs
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Balance of Anesthesia
Analgesia Muscle Relaxation
Consciousness / HypnosisBIS
Train of FourAutonomic & Somatic Responses Wael Nasri 9
BIS
100
70
60
40
0
HYPNOTIC STATE
AWAKE / LIGHT TO MODERATE SEDATION
LIGHT HYPNOTIC STATE
Low Probability of Explicit Recall <70
MODERATE HYPNOTIC STATE
Low Probability of Consciousness <60
DEEP HYPNOTIC STATEEEG SUPPRESSIONWael Nasri 10
Less drug utilization Faster wake-up and extubation More alert and oriented patients in
PACUEarlier discharge from PACU Facilitates PACU Phase I bypassReduced PONVMonitor for risk of awareness
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A Propofol
B Propofol
C Sevoflurane
D Desflurane
E Isoflurane
F Isoflurane
G Isoflurane
H Isoflurane
I Propofol
Reduction in Amount of AnestheticUsed in BIS Monitored Group
Ineffective: Recall Inadequate Anesthesia
Excessive: Cardiovascular Effects Prolonged Emergence Recovery Increased Drug Use $
AWAKE
FLAT LINE EEG
Optimal DepthOptimal Depthof Unconsciousnessof Unconsciousness
BIS
IN
DE
X
Awake
Light/Moderate Sedation
Deep Sedation
General Anesthesia
Deep Hypnotic State
Flat Line EEG
70
60
40
0
100
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50
60
70
80
PRE BIS POST BIS
•Length of PACU StayLength of PACU Stay
BIS Patients Discharged 16% Faster
•N=2659N=2659 •N=2505N=2505
0
2
4
6
8
Prior to BIS Use BIS Use
PO
NV
% 6.2%
2.8%
PONV reduced>50% when BIS wasused in ambulatoryanesthesia
Intraoperative patient assessmentPatient-based titration of anesthetic agents
Reduces anesthetic drug utilization Improves specificity of drug selection
Perioperative ImprovementsFaster, more consistent emergence / extubationHigher-quality recovery / more alert patients
Effective monitor for the risk of awareness
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BIS Applicable CasesSpecial Considerations
Sensor PlacementArtifactsPatient Movement
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General Surgery Cardiac Surgery Out Patient Surgery MAC with Sedation
Special Procedures ICU Patients
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Adoption Profile (“Learning Curve”)20-30 cases: Concept, Confidence, Clinical ToolReflect, not Direct, Anesthesia Care
The BIS Monitor doesn’t improve the anesthetic course / recovery doesn’t “prevent” awareness
The BIS Monitor Provides new information / perspective
Interpretation, Assessment Anesthesia Plan Agents, Doses, Timing
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Sensor acquisition Signal Quality EMG / Artifacts Patient Movement Analgesic Vs. Hypnotic State
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Most critical component of system!
Dual-position versatility
right or left application
Peel-place- and-press convenience
Designed to fit any adult patient
Single point monitor connection
Apply sensor on forehead at angle Circle #1: Centered, 2 inches above
nose Circle #4: Above/Adjacent to eyebrow Circle #3: Either temple between corner
of eye and hairline
Press edges of sensor Circle all 4 elements
Press each circle for 5 seconds Use fingertip Press firmly
2 Inches
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Indicates quality of EEG signalDisplayed from 0 - 100%% of good data throughout prior 60
secondsAveraged information
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What are they?signals generated from sources other than the
patient’s EEGexamples: bovie or noise from unshielded
equipmentBIS usually filters these out
examples: eye blinks, eye movement
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Arises from muscle activityMore prominent as patient lightens from
anesthesiaEMG may bias the BIS to a higher value
Could be artifact or real - indicates need for troubleshooting
Increasing analgesic and/or hypnotic can reduce EMG
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Patient Movement Analgesic Vs. Hypnotic State
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BRAINConsciousnessMemory Function
SPINAL CORDReflex MovementAnalgesia
Eger, et al. Anesth Analg 1997;84:915-8
Dose-Response
Drug-Drug Interactions
Patient-Surgery-Response
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BIS is not an anesthetic depth measureInformation about your patient to help in
your clinical decision-making processUse in conjunction with traditional
monitoringReliance on the BIS alone for
intraoperative anesthetic management is not recommended
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More PatientsMore BISMore Confidence
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