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Drugs - Real World Outcomes

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Open Access 01-06-2016 | Original Research Article

Inadequate Sedation During Therapeutic Paralysis: Use of Bispectral Index in Critically Ill Patients

Authors: Chelsea L. Tasaka, Jeremiah J. Duby, Komal Pandya, Machelle D. Wilson, Kimberly A. Hardin

Published in: Drugs - Real World Outcomes | Issue 2/2016

Abstract

Background

Patients receiving therapeutic paralysis may experience inadequate sedation due to intrinsic limitations of behavioral sedation assessment. Bispectral index (BIS™) provides an objective measure of sedation; however, the role of BIS™ is not well defined in intensive care unit (ICU) patients on neuromuscular blocking agents (NMBA).

Objective

The aim of this study was to delineate the relationship between BIS™ and level of sedation for critically ill patients during therapeutic paralysis.

Methods

This was a retrospective observational study conducted in ICU patients receiving continuous infusion NMBA and BIS™ monitoring. The primary endpoint was the correlation of BIS™ <60 during therapeutic paralysis with a Richmond Agitation Sedation Score (RASS) of −4 to −5 (i.e., deep or unarousable sedation) at the time of emergence from therapeutic paralysis.

Results

Thirty-one patients were included in the analysis. Three of these patients (9.6 %) were inadequately sedated upon emergence from paralysis; that is, restless or agitated (RASS +1 to +2). We did not observe a correlation between BIS™ and RASS upon emergence from paralysis (r = 0.27, p = 0.14). The sensitivity of BIS™ <60 in predicting deep sedation (RASS −5 to −4) was 100 % (95 % confidence interval [CI] 0–100) with a positive predictive value of 35.7 %. The sensitivity and positive predictive value of BIS™ <60 in predicting light sedation or deeper (RASS −5 to −2) was 92.9 % (95 %CI 83.3–100) and 92.9 %, respectively.

Conclusion

These results suggest that 1 in 10 critically ill patients receiving therapeutic paralysis may be inadequately sedated. BIS™ monitoring may serve as a useful adjunctive measure of sedation in critically ill patients receiving therapeutic paralysis.

Murray MJ, Cowen J, DeBlock H, et al. Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient. Crit Care Med. 2002;30(1):142–56.CrossRefPubMed

Papazian L, Fore JM, Gacouin A, et al. Neuromuscular blockers in early acute respiratory distress syndrome. NEJM. 2010;363(12):1107–16.CrossRefPubMed

Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41:263–306.CrossRefPubMed

Wagner BKJ, Zavotsky KE, Sweeney JB, Palmeri BA, Hammond JS. Patient recall of therapeutic paralysis in a surgical critical care unit. Pharmacotherapy. 1998;18(2):358–63.PubMed

Hardin KA, Seyal M, Stewart T, Bonekat HW. Sleep in critically ill chemically paralyzed patients requiring mechanical ventilation. Chest. 2006;129(6):1468–77.CrossRefPubMed

Avidan MS, Zhang L, Burnside BA, et al. Anesthesia Awareness and the Bispectral Index. N Engl J Med. 2008;358(11):1097–108.CrossRefPubMed

Avidan MS, Jacobsohn E, Glick D, et al. Prevention of intraoperative awareness in a high-risk surgical population. N Engl J Med. 2011;365(7):591–600.CrossRefPubMed

Schuller PJ, Newell S, Strickland PA, Barry JJ. Response of bispectral index to neuromuscular block in awake volunteers. Br J Anaesth. 2015;115(Suppl 1):i95–103.CrossRefPubMed

Simmons LE, Richard RR, Prato BS, Fraser G. Assessing sedation during intensive care unit mechanical ventilation with the Bispectral Index and the Sedation-Agitation Scale. Crit Care Med. 1999;27(8):1499–504.CrossRefPubMed

10.

Riker RR, Fraser GL, Simmons LE, Wilkins ML. Validating the sedation-agitation scale with the bispectral index and visual analog scale in adult ICU patients after cardiac surgery. Intensive Care Med. 2001;27:853–8.CrossRefPubMed

11.

Frenzel D, Greim Clemens A, Sommer C, Bauerle K, Roewer N. Is the bispectral index appropriate for monitoring the sedation level of mechanically ventilated surgical ICU patients? Intensive Care Med. 2002;28:178–83.CrossRefPubMed

12.

Chisholm CJ, Zurica J, Mironov D, Sciacca RR, Ornstein E, Heyer EJ. Comparison of electrophysiologic monitors with clinical assessment of level of sedation. Mayo Clin Proc. 2006;81(1):46–52.CrossRefPubMedPubMedCentral

13.

Haenggi M, Ypparila-Wolters H, Bieri C, Steiner C, Takala J, Korhonen I, Jakob SM. Entropy and bispectral index for assessment of sedation, analgesia and the effects of unpleasant stimuli in critically ill patients: an observational study. Crit Care. 2008;12(5):R119.CrossRefPubMedPubMedCentral

14.

Arbour R, Waterhouse J, Seckel MA, Bucher L. Correleation between the Sedation-Agitation Scale and the Bispectral Index in ventilated patients in the intensive care unit. Heart Lung. 2009;38:336–45.CrossRefPubMed

15.

Trouiller P, Fangio P, Paugam-Burtz C, et al. Frequency and clinical impact of preserved bispectral index activity during deep sedation in mechanically ventilated ICU patients. Intensive Care Med. 2009;35:2096–104.CrossRefPubMed

16.

Karamchandani K, Rewari V, Trikha A, Batra RK. Bispectral index correlates well with Richmond agitation sedation scale in mechanically ventilated critically ill patients. J Anesth. 2010;24:394–8.CrossRefPubMed

17.

Yaman F, Ozcan N, Ozcan A, Kaymak C, Basar H. Assessment of correlation between bispectral index and four common sedation scales in mechanically ventilated patients in ICU. Eur Rev Med Pharmacol Sci. 2012;16:660–6.PubMed

18.

Kelley SD. Monitoring consciousness using the Bispectral Index™ during anesthesia. 2nd ed. Boulder: Covidien; 2010.

19.

Sessler CN, Gosnell MS, Grap MJ, Brophy GM, O’Neal PV, Keane KA, Tesoro EP, Elswick RK. The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med. 2002;166(10):1338–44.CrossRefPubMed

20.

Vincent JL, de Mendonça A, Cantraine F, Moreno R, Takala J, Suter PM, Sprung CL, Colardyn F, Blecher S. Use of the SOFA score to assess the incidence of organ dysfunction/failure in intensive care units: results of a multicenter, prospective study. Crit Care Med. 1998;26(11):1793–800.CrossRefPubMed

21.

Glass PS, Bloom M, Kearse L, Rosow C, Sebel P, Manberg P. Bispectral analysis measures sedation and memory effects of propofol, midazolam, isoflurane, and alfentanil in healthy volunteers. Anesthesiology. 1997;86:836–47.CrossRefPubMed

22.

Rosow C, Manberg PJ. Bispectral index monitoring. Anesthiol Clin N America. 2001;19(4):947–66.CrossRef

23.

Rampil IJ. A primer for EEG signal processing in anesthesia. Anesthesiology. 1998;89:980–1002.CrossRefPubMed

24.

Pollmächer T, Schreiber W, Gudewill S, Vedder H, Fassbender K, Wiedemann K, Trachsel L, Galanos C, Holsboer F. Influence of endotoxin on nocturnal sleep in humans. Am J Physiol. 1993;264:R1077–83.PubMed

25.

Duarte LTD, Saraiva RA. When the bispectral index can give false results. Rev Bras Anestesiol. 2009;59(1):99–109.CrossRefPubMed

26.

Lysakowski C, Dumont L, Pellegrini M, Clergue F, Tassonyi E. Effects of fentanyl, alfentanil, remifentanil and sulfentail on loss of consciousness and bispectral index during propofol induction of anaesthesia. Br J Anaesth. 2001;86(4):523–7.CrossRefPubMed

27.

Koitabashi T, Johansen JW, Sebel PS. Remifentanil dose/electroencephalogram bispectral response during combined propofol/regional anesthesia. Anesth Analg. 2002;94(6):150–3.

28.

Struys MM, Vereecke H, Moerman A, Jensen EW, Verhaeghen D, De Neve N, Dumortier FJ, Mortier EP. Ability of the bispectral index, autoregressive modeling with exogenous input-derived auditory evoked potentials, and predicted propofol concentrations to measure patient responsiveness during anesthesia during anesthesia with propofol and remifentanil. Anesthesiology. 2003;99(4):802–12.CrossRefPubMed

29.

Gelb AW, Leslie K, Stanski DR, Shafer SL. Monitoring of the depth of anesthesia. Chapter 39, Miller’s anesthesia, 7th ed. Philadelphia: Churchill Livingstone: 2010. p. 1229–65.

30.

Rudis MI, Guslits BG, Zarowitz BJ. Technical and interpretive problems of peripheral nerve stimulation in monitoring neuromuscular blockade in the intensive care unit. Ann Pharmacother. 1996;30:165–72.PubMed

31.

Avidan MS, Jacobsohn E, Glick D, Burnside BA, Zhang L, Villafranca A, Karl L, Kamal S, Torres B, O’Connor M, Evers AS, Gradwohl S, Lin N, Palanca BJ, Mashour GA, BAG-RECALL Research Group. Prevention of intraoperative awareness in a high-risk surgical population. N Engl J Med. 2011;365(7):591–600.CrossRefPubMed

Title: Inadequate Sedation During Therapeutic Paralysis: Use of Bispectral Index in Critically Ill Patients
Authors: Chelsea L. Tasaka
Jeremiah J. Duby
Komal Pandya
Machelle D. Wilson
Kimberly A. Hardin
Publication date: 01-06-2016
Publisher: Springer International Publishing
Published in: Drugs - Real World Outcomes / Issue 2/2016
Print ISSN: 2199-1154
Electronic ISSN: 2198-9788
DOI: https://doi.org/10.1007/s40801-016-0076-3

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Inadequate Sedation During Therapeutic Paralysis: Use of Bispectral Index in Critically Ill Patients

Abstract

Background

Objective

Methods

Results

Conclusion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Objective

Methods

Results

Conclusion

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