BIS guide for clinicians

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Table 5: BIS decrease/low value assessment. Clinical Management Responding to a Sudden BIS Decrease Assess for pharmacologic changes Assess the current level of surgical stimulation Consider decrease as possible response to administration of muscle relaxants Assess for other potential physiologic changes Assess for emergence from anesthesia Bolus administration of intravenous anesthetic, recent changes in inhalation anesthesia, administration of adjuvant agents (beta blockers, alpha 2 agonists) can all result in acute decreases in the BIS. The BIS may show a decrease in response to decreases in noxious stimulation. In some situations, the BIS will decrease in response to administration of neuromuscular blocking agent, especially if excessive EMG was present prior to giving it. Profound hypotension, hypothermia, hypoglycemia, or anoxia can produce decreases in the brain state activity. Paradoxical emergence patterns have been described with transient abrupt decreases in the BIS prior to awakening during inhalation anesthesia. The clinical significance of such changes remains unknown. 23
Clinical Impact of BIS Monitoring There is a large and growing body of scientific literature on BIS monitoring that can be reviewed by the practitioner to ascertain usage of BIS for a patient based on the type of anesthetic agent, dosage and individual patient parameters. To date, at least 25 prospective, randomized clinical investigations have measured the influence of BIS-guided anesthesia care compared with standard practice. In most of these studies, the primary anesthetic was adjusted to maintain BIS values in a “target zone,” typically either 40 to 60 or 45 to 60. The range of benefits that have been observed in at least one clinical trial with certain anesthetic agents include: • Reduction in primary anesthetic use 4 • Reduction in emergence and recovery time 4 • Improved patient satisfaction 36 • Decreased incidence of intraoperative awareness and recall 5, 6 The first two benefits above were shown in a study by Gan and co-workers that utilized propofol/alfentanil/nitrous oxide and found that 1) 13 to 23% less hypnotic drug was used; 2) 35 to 40% faster wake up was obtained; 3) 16% faster eligibility for PACU discharge was achieved; and 4) more patients were rated as “excellent-fully oriented” on admission to the PACU (43% vs 23%). 4 As noted, BIS monitoring is also being recognized as an effective intervention to decrease the incidence of intraoperative awareness – an issue that has taken on new importance in the last several years. 5, 6 Using BIS monitoring to reduce intraoperative awareness is discussed in detail in the following section. 24
Page 2 and 3: Monitoring Consciousness Using the
Page 4: Table of Contents Executive Overvie
Page 7 and 8: With progressive drug-induced sedat
Page 9 and 10: 4 Important Information About Using
Page 11 and 12: the correlation between all the fre
Page 13 and 14: It should be noted that the BIS ind
Page 15 and 16: halothane has been found to have hi
Page 17 and 18: Table 1: BIS monitoring during a ge
Page 19 and 20: Integrating BIS Information During
Page 21 and 22: Table 2: Anesthesia management stra
Page 23 and 24: Special Issues Impacting BIS Monito
Page 25 and 26: Table 3: Reported factors influenci
Page 27: Table 4: BIS increase/high value as
Page 31 and 32: Table 6: Potential risk factors for
Page 33 and 34: ASA Practice Advisory The “Practi
Page 35 and 36: AVOIDING AWARENESS ALGORITHM Preope
Page 37 and 38: BIS Monitoring and Awareness: Evide
Page 39 and 40: Intraoperative Awareness & Anesthes
Page 41 and 42: The ability of brain function monit
Page 43 and 44: References 1. Sigl J, et al. J Clin
Page 45 and 46: 45. Mychaskiw G, et al. Anesth Anal

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