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

1

2

3

4

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.

*

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