BIS guide for clinicians

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BIS Monitoring During Typical GA • Clinical trials demonstrate that adjustment of anesthetic dosing to maintain BIS values within a target range of 45 to 60 during maintenance results in improved perioperative recovery patterns as compared with 4, 25 standard anesthesia care. • BIS responses to stimulation may be markedly attenuated in a dosedependent fashion with opioid administration, e.g., fentanyl or remifentanil. 26 • BIS variability – the cyclic oscillation in BIS during surgery – may be useful to observe. Both short-term BIS variability and BIS-derived EMG activity have been useful in assessing the adequacy of analgesia in surgical patients. In volunteers, opioid analgesia 27, 28, 29, 30 reduced BIS variability. • Abrupt, unexpected changes in the BIS trend warrant additional assessment and clinical correlation. (See Tables 4 and 5.) • BIS trend will reflect the decreasing hypnotic effect when anesthetic agent delivery is reduced or stopped at the end of surgery. • BIS values during emergence are variable: - May increase gradually in response to a reduction in anesthetic dose (e.g., endtidal agent concentration). - May increase rapidly to values >60 prior to return of consciousness, particularly if EMG tone increases substantially. - Are typically lower immediately after emergence than at baseline, consistent with residual drug effect. • With adequate analgesia, a patient may remain unconscious and display BIS values
Integrating BIS Information During Anesthesia Care The integration of BIS monitoring with other traditional monitoring has created new paradigms for intraoperative 31, 32, 33 patient assessment and management. Table 2 outlines conceptual management strategies based on integration of clinical profile with BIS data for “balanced” anesthesia techniques utilizing hypnotic and analgesic components. Using the BIS value in combination with hemodynamic data and patient assessment can facilitate the rational selection of sedatives, analgesics and autonomic blockers. Although a BIS value of 40 to 60 is a typical target during the maintenance phase, the BIS value target range needs to be tailored to the anesthetic technique. For example, during balanced anesthesia including opioid administration to provide adequate analgesia, a target range of 45 to 60 may be very appropriate. However, for anesthesia management which utilizes little or no opioid or analgesic supplementation, increased dosing of the hypnotic agent – typically, a volatile anesthetic – to produce acceptable suppression of a noxious stimulation response (e.g., movement) will result in lower BIS values, commonly in the 25 to 35 range. Since there is no single anesthetic technique that is appropriate for every patient for every clinical situation, optimum use of BIS monitoring to guide anesthesia care will depend upon the clinical goals of the anesthesia professional. Based on this consideration and agent-specific BIS responses (discussed in greater detail earlier), it is 14
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Page 43 and 44: References 1. Sigl J, et al. J Clin
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