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Emma Verastegui - One of the best experts on this subject based on the ideXlab platform.
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Bispectral Index Monitoring in cancer patients undergoing palliative sedation a preliminary report
Supportive Care in Cancer, 2017Co-Authors: Edith Monrealcarrillo, Silvia Allendeperez, David Hui, Maria Fernanda Garciasalamanca, Eduardo Bruera, Emma VerasteguiAbstract:Introduction Continuous palliative sedation (PS) is currently titrated based on clinical observation; however, it is often unclear if patients are still aware of their suffering. The aim of this prospective study is to characterize the level of consciousness in patients undergoing PS using Bispectral Index (BIS) Monitoring.
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Bispectral Index Monitoring in cancer patients undergoing palliative sedation a preliminary report
Supportive Care in Cancer, 2017Co-Authors: Edith Monrealcarrillo, Silvia Allendeperez, David Hui, Maria Fernanda Garciasalamanca, Eduardo Bruera, Emma VerasteguiAbstract:Continuous palliative sedation (PS) is currently titrated based on clinical observation; however, it is often unclear if patients are still aware of their suffering. The aim of this prospective study is to characterize the level of consciousness in patients undergoing PS using Bispectral Index (BIS) Monitoring. We enrolled consecutive patients with refractory symptoms requiring PS. We documented the level of sedation using Ramsay Sedation Scale (RSS) and BIS at 0, 2, 4, 6, 12, and 24 h during the first day of PS and examined their degree of association. Intravenous midazolam or propofol was titrated according to the sedation level. Twenty patients on PS were recruited and had BIS continuous Monitoring. Delirium was the most frequent reason for PS (n = 15, 75%). The median time of sedation was 24.5 h (interquartile range 6–46). The average time to achieve the desired sedation level was 6 h, and dose titration was required in 80% of the cases. At baseline, 14 (70%) patients were considered to be awake according to RSS (i.e., 1–3) and 19 (95%) were awake according to BIS (i.e., >60%). This proportion decreased to 31 and 56% at 4 h, 27% and 53 at 6 h, and 22 and 33% at 24 h. RS and BIS had moderate correlation (rho = −0.58 to −0.65); however, a small proportion of patients were found to be awake by BIS (i.e., ≥60%) despite clinical observation (i.e., RSS 4–6) indicating otherwise. The BIS is a noninvasive, bedside, real-time continuous Monitoring method that may facilitate the objective assessment of level of consciousness and dose titration in patients undergoing PS.
Paul S Myles - One of the best experts on this subject based on the ideXlab platform.
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the effect of Bispectral Index Monitoring on long term survival in the b aware trial
Anesthesia & Analgesia, 2010Co-Authors: Kate Leslie, Paul S Myles, Andrew Forbes, Mathew T V ChanAbstract:BACKGROUND:When anesthesia is titrated using Bispectral Index (BIS) Monitoring, patients generally receive lower doses of hypnotic drugs. Intraoperative hypotension and organ toxicity might be avoided if lower doses of anesthetics are administered, but whether this translates into a reduction in ser
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prediction of neurological outcome using Bispectral Index Monitoring in patients with severe ischemic hypoxic brain injury undergoing emergency surgery
Anesthesiology, 2009Co-Authors: Paul S Myles, D Daly, A Silvers, Sesto CairoAbstract:Background: Predicting outcome from ischemic-hypoxic brain injury can be difficult in patients rushed to the operating room for time-critical emergency surgery. The authors chose to evaluate the prognostic ability of Bispectral Index (BIS) in this setting. Methods: Twenty-five critically ill, unconscious patients with ischemic-hypoxic brain injury undergoing emergency surgery were prospecttvely studied. Clinical evaluation, laboratory investigations, BIS, and burst suppression ratio were recorded before and during surgery. Neurologic outcome of the patients was measured according to the Glasgow outcome scale at 30 days after injury, with poor neurologic outcome defined as severe disability or death. Results: The incidence of poor neurologic outcome was 68%. Neither clinical judgment (P = 0.40) nor pupillary responses (P = 0.21) were predictive of neurologic outcome after surgery. An abnormal BIS trace was strongly associated with poor neurologic outcome, positive likelihood ratio 6.6 (95% CI 1.7-36.4; exact test P = 0.002). Some BIS values were significantly different when comparing patients with and without poor outcome: c-statistics for the average BIS and maximal electroencephalographic burst-suppression were 0.80 (95% CI 0.62-0.98; P = 0.017) and 0.84 (95% CI 0.68-0.99; P = 0.007), respectively. A normal BIS (P < 0.0005) but not clinical judgment (P = 0.16) could identify a group of patients more likely to survive with a good neurologic outcome. Conclusions: BIS, when compared with clinical judgment and routine laboratory tests, provides useful information that may identify patients with a good chance of recovery after ischemic-hypoxic brain injury requiring emergency surgery.
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Bispectral Index Monitoring in ischemic hypoxic brain injury
The journal of extra-corporeal technology, 2009Co-Authors: Paul S MylesAbstract:Hypercoagulability has been reported after off-pump coronary artery bypass grafting (OPCAB) compared with patients undergoing standard coronary artery bypass grafting (CABG) with cardiopulmonary bypass. The aim of this study was to evaluate the changes in platelet reactivity in response to cardiac surgery, both OPCAB and CABG. Platelet reactivity was monitored pre- and postoperatively (days 1 and 4) in elective OPCAB (n = 29) and CABG (n = 24) patients using the maximal amplitude (MA) parameter obtained with thrombelastography. Platelet reactivity was also examined at 1 month in 30 of the 53 patients. Twenty-three percent of the patients (12/53) had a preoperative MA value above normal reference value (MA > 69 mm). By postoperative day 4, 88% of the patients presented with an MA > 69 mm, and significant increases in MA were shown in both groups (p < .0001). Of the 30 patients examined at 1 month after surgery, 75% of the patients with high preoperative MA (6/8) remained at this level. In contrast, only 4.5% of patients with normal preoperative MA (1/22) presented with high MA at day 30. MA has previously been shown to correlate with the incidence of thrombotic and ischemic complications and this study identified 23% of patients needing coronary bypass surgery to be at high risk for recurrent ischemic events at 1 month after surgery, based on the MA. These results suggest that a more aggressive antithrombotic treatment might be warranted for patients undergoing coronary artery bypass grafting, both OPCAB and CABG, presenting with a high MA pre- and postsurgery.
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Bispectral Index Monitoring to prevent awareness during anaesthesia the b aware randomised controlled trial
The Lancet, 2004Co-Authors: Paul S Myles, Kate Leslie, Andrew Forbes, John J Mcneil, Mathew T V ChanAbstract:Summary Background Awareness is an uncommon complication of anaesthesia, affecting 0·1–0·2% of all surgical patients. Bispectral Index (BIS) Monitoring measures the depth of anaesthesia and facilitates anaesthetic titration. In this trial we determined whether BIS-guided anaesthesia reduced the incidence of awareness during surgery in adults. Methods We did a prospective, randomised, double-blind, multicentre trial. Adult patients at high risk of awareness were randomly allocated to BIS-guided anaesthesia or routine care. Patients were assessed by a blinded observer for awareness at 2–6 h, 24–36 h, and 30 days after surgery. An independent committee, blinded to group identity, assessed every report of awareness. The primary outcome measure was confirmed awareness under anaesthesia at any time. Findings Of 2463 eligible and consenting patients, 1225 were assigned to the BIS group and 1238 to the routine care group. There were two reports of awareness in the BIS-guided group and 11 reports in the routine care group (p=0·22). BIS-guided anaesthesia reduced the risk of awareness by 82% (95% CI 17–98%). Interpretation BIS-guided anaesthesia reduces the risk of awareness in at-risk adult surgical patients undergoing relaxant general anaesthesia. With a cost of routine BIS Monitoring at US$16 per use in Australia and a number needed to treat of 138, the cost of preventing one case of awareness in high-risk patients is about $2200.
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case 8 2000 intraoperative Bispectral Index Monitoring and early extubation after cardiac surgery in patients with a history of awareness under anesthesia
Journal of Cardiothoracic and Vascular Anesthesia, 2000Co-Authors: Susan Kelly, Carl E. Rosow, Paul S Myles, D Bain, James RamsayAbstract:A 68-year-old, 84-kg man with unstable angina presented for coronary artery bypass graft surgery. Cardiac catheterization showed triple-vessel disease and good left ventricular function. Past history included an episode of awareness during a previous general anesthetic for orthopedic surgery several years earlier, in which the patient had vivid recollections of severe pain and of overhearing staff conversations. In anticipation of an uneventful intraoperative course and in accordance with usual practice, the use of short-acting anesthetic agents was planned to allow early extubation and discharge from the intensive care unit (ICU). The patient was premedicated with oral lorazepam, 2 mg, and intramuscular papaveratum, 20 mg; and scopolamine, 0.4 mg. In the operating room, intravenous midazolam was titrated (total dose 8 mg) to provide sedation during insertion of intravascular catheters (intravenous, arterial, and pulmonary artery catheters). Bispectral Index (BIS) Monitoring (Aspect Medical Systems, MA) was used to measure depth of anesthesia and to guide anesthetic drug titration. BIS electrodes were placed on the patient’s forehead according to the manufacturer’s instructions. The BIS reading was 94 immediately before induction. The patient was induced with propofol, administered by a target-controlled infusion device to a target concentration of 3.0 g/mL, and remifentanil, which was started at an initial rate of 1.5 g/kg/min. Once the eyelash reflex was lost and the BIS had decreased to 40, pancuronium, 8 mg, was administered, and the patient’s trachea was intubated. Anesthesia was maintained at a BIS value of 35 to 40 by titrating the propofol target concentration between 2.6 and 3.0 g/mL (infusion rate approximately 60 to 100 g/kg/ min), whereas remifentanil was maintained at 0.5 g/kg/ min. Nitroglycerin was administered at 20 g/min. The patient had a stable hemodynamic profile before cardiopulmonary bypass (CPB) with a systolic blood pressure between 120 and 90 mmHg and heart rate between 50 and 65 beats/min. Once CPB was established and the BIS decreased into the low 30s, the propofol target concentration was decreased to 2.0 g/mL. Four vessels were grafted with a cross-clamp time of 42 minutes and a total CPB time of 71 minutes. On rewarming, the BIS increased from 33 to 38, and the propofol target concentration was increased to 3.0 g/mL. CPB was terminated uneventfully with no inotropic support. Once the sternum was closed, the patient received intravenous ketorolac, 10 mg, and a morphine infusion was started at 5 mg/h after an initial 5-mg bolus. At the completion of surgery, neuromuscular blockade was reversed, a forced air warming device was applied, propofol was stopped, and the remifentanil infusion was reduced to 0.1 g/kg/min. Over the next 10 minutes, the BIS increased into the 90s, and the patient resumed spontaneous ventilation, although still unresponsive. The remifentanil infusion was then stopped. After a further 20 minutes, the patient awoke, his trachea was extubated, and he was transferred to the ICU. Flumazenil, 500 g, was administered in the ICU because the patient remained excessively drowsy. He spent an uneventful night in the ICU and was transferred to the ward the next morning. On direct questioning on the day after surgery, the patient’s last memory of the procedure was of being transferred into the operating room. His next recollection was his time in the ICU, and he had no recall during surgery. He made an uneventful recovery and was extremely satisfied with his anesthesia care.
Edith Monrealcarrillo - One of the best experts on this subject based on the ideXlab platform.
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Bispectral Index Monitoring in cancer patients undergoing palliative sedation a preliminary report
Supportive Care in Cancer, 2017Co-Authors: Edith Monrealcarrillo, Silvia Allendeperez, David Hui, Maria Fernanda Garciasalamanca, Eduardo Bruera, Emma VerasteguiAbstract:Introduction Continuous palliative sedation (PS) is currently titrated based on clinical observation; however, it is often unclear if patients are still aware of their suffering. The aim of this prospective study is to characterize the level of consciousness in patients undergoing PS using Bispectral Index (BIS) Monitoring.
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Bispectral Index Monitoring in cancer patients undergoing palliative sedation a preliminary report
Supportive Care in Cancer, 2017Co-Authors: Edith Monrealcarrillo, Silvia Allendeperez, David Hui, Maria Fernanda Garciasalamanca, Eduardo Bruera, Emma VerasteguiAbstract:Continuous palliative sedation (PS) is currently titrated based on clinical observation; however, it is often unclear if patients are still aware of their suffering. The aim of this prospective study is to characterize the level of consciousness in patients undergoing PS using Bispectral Index (BIS) Monitoring. We enrolled consecutive patients with refractory symptoms requiring PS. We documented the level of sedation using Ramsay Sedation Scale (RSS) and BIS at 0, 2, 4, 6, 12, and 24 h during the first day of PS and examined their degree of association. Intravenous midazolam or propofol was titrated according to the sedation level. Twenty patients on PS were recruited and had BIS continuous Monitoring. Delirium was the most frequent reason for PS (n = 15, 75%). The median time of sedation was 24.5 h (interquartile range 6–46). The average time to achieve the desired sedation level was 6 h, and dose titration was required in 80% of the cases. At baseline, 14 (70%) patients were considered to be awake according to RSS (i.e., 1–3) and 19 (95%) were awake according to BIS (i.e., >60%). This proportion decreased to 31 and 56% at 4 h, 27% and 53 at 6 h, and 22 and 33% at 24 h. RS and BIS had moderate correlation (rho = −0.58 to −0.65); however, a small proportion of patients were found to be awake by BIS (i.e., ≥60%) despite clinical observation (i.e., RSS 4–6) indicating otherwise. The BIS is a noninvasive, bedside, real-time continuous Monitoring method that may facilitate the objective assessment of level of consciousness and dose titration in patients undergoing PS.
Richard R Riker - One of the best experts on this subject based on the ideXlab platform.
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feasibility of Bispectral Index Monitoring to guide early post resuscitation cardiac arrest triage
Resuscitation, 2014Co-Authors: David B Seder, Gilles L Fraser, John Dziodzio, Kahsi A Smith, Paige Hickey, Brittany Bolduc, Philip Stone, Teresa May, Barbara Mccrum, Richard R RikerAbstract:Abstract Introduction Triage after resuscitation from cardiac arrest is hindered by reliable early estimation of brain injury. We evaluated the performance of a triage model based on early Bispectral Index (BIS) findings and cardiac risk classes. Methods Retrospective evaluation of serial patients resuscitated from cardiac arrest, unable to follow commands, and undergoing hypothermia. Patients were assigned to a cardiac risk group: STEMI, VT/VF shock, VT/VF no shock, or PEA/asystole, and to a neurological dysfunction group, based on the BIS score following first neuromuscular blockade (BISi), and classified as BISi > 20, BISi 10–20, or BISi Results BISi in 171 patients was measured at 267(±177) min after resuscitation and 35(±1.7)°C. BISi 20 12% neurological and 36% overall mortality. 33 patients presented with STEMI, 15 VT/VF-shock, 41 VT/VF-no shock, and 80 PEA/asystole. Among BISi > 20 patients, 75% with STEMI underwent urgent cardiac catheterization (cath) and 94% had good outcome. When BISi > 20 with VT/VF and shock, urgent cath was infrequent (33%), and 4 deaths (44%) were uniformly of circulatory etiology. Of 56 VT/VF patients without STEMI, 24 were BISi > 20 but did not undergo urgent cath – 5(20.8%) of these had circulatory-etiology death. Circulatory-etiology death also occurred in 26.5% BIS > 20 patients with PEA/asystole. When BISi Conclusions Neurocardiac triage based on very early processed EEG (BIS) is feasible, and may identify patients appropriate for individualized post-resuscitation care. This and other triage models warrant further study.
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Bispectral Index Monitoring in the intensive care unit provides more signal than noise.
Pharmacotherapy, 2005Co-Authors: Gilles L Fraser, Richard R RikerAbstract:The Bispectral Index (BIS) is processed electroencephalographic technology used in concert with clinical evaluations to objectively evaluate a patient's level of consciousness and probability of recall. Although the BIS has been extensively studied in the operating room setting, differences in patient populations, goals of treatment, and the environments themselves necessitate the development of BIS data specific to the intensive care unit. Data have evolved over the last several years, but for many reasons, the results and conclusions have varied. Yet within the data are important consistencies that help define the usefulness of BIS in patients who cannot be evaluated with subjective assessment tools such as the Sedation-Agitation Scale or the Richmond Agitation-Sedation Scale. Some of these patients cannot be evaluated with such tools because they lack motor responsiveness due to therapeutic paralysis or because they are receiving deep sedation. Bispectral Index scores that are higher than expected in clinically sedated patients can often be traced to electromyographic activity or to the possibility of inadequate sedation and analgesia. The BIS must not be regarded as the sole indicator of level of consciousness, but should be used as part of an integrated approach to the evaluation of carefully selected patients with critical illness.
Robert A. Cherry - One of the best experts on this subject based on the ideXlab platform.
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Bispectral Index Monitoring IN THE MANAGEMENT OF SEDATION IN AN INTENSIVE CARE UNIT PATIENT WITH LOCKED-IN SYNDROME Cases of Note
2016Co-Authors: A. Quraishi, Ralee A. Blosser, Robert A. CherryAbstract:Abstract Locked-in syndrome is an extremely rare neurological state caused by injury of the ventral pons. The syndrome is characterized by quadriplegia and anarthria with concomitant preservation of cortical function. When a reversible underlying pathological abnormality is identified and managed aggressively, meaningful recovery is possible. Because patients retain consciousness through-out their illness, a dependable method for titrating sedation may improve their quality of life. The case presented suggests that Bispectral Index Monitoring may be a cost-effective and reliable method for managing sedation in patients with locked-in syndrome. (American Journal of Critical Care. 2011;20:491,487-490) L ocked-in syndrome is a rare neurological state characterized by quadriplegia and anarthria.1 The syndrome is caused by lesions in the ventral pons (Figure), and higher cognitive function usuall
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Bispectral Index Monitoring in the Management of Sedation in an Intensive Care Unit Patient With Locked-in Syndrome
American Journal of Critical Care, 2011Co-Authors: Sadeq A. Quraishi, Sandralee A. Blosser, Robert A. CherryAbstract:Locked-in syndrome is an extremely rare neurological state caused by injury of the ventral pons. The syndrome is characterized by quadriplegia and anarthria with concomitant preservation of cortical function. When a reversible underlying pathological abnormality is identified and managed aggressively, meaningful recovery is possible. Because patients retain consciousness throughout their illness, a dependable method for titrating sedation may improve their quality of life. The case presented suggests that Bispectral Index Monitoring may be a cost-effective and reliable method for managing sedation in patients with locked-in syndrome.