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Background: Renewed interest in regional anaesthesia during the recent COVID-19 pandemic has inspired application of neuraxial anaesthesia for previously unconventional indications, such as awake abdominal surgeries. These patients needed little sedation, since studies demonstrate that neuraxial anaesthesia causes sedation as measured by the bispectral index (BIS). In contrast, no published study has investigated the possible sedative effects of non-neuraxial regional anaesthesia. This pilot randomised controlled trial (RCT) was designed as a template for, and to test the feasibility of, performing a definitive RCT to establish if non-neuraxial regional anaesthesia has any sedative effect. Method(s): Forty participants presenting for forearm surgery were randomly allocated to two treatment groups (supraclavicular block and control). Their level of sedation was monitored with BIS prior to surgery for 60 minutes. Specific feasibility outcomes were planned and data were collected according to CONSORT 2010 recommendations. Result(s): Out of 48 patients screened, 41 (85.42%) were invited to participate. Forty patients (97.56%) consented and 100% of these completed the study. In four participants (10%), BIS electrodes needed replacement, while inadequate contact was shown in three participants (7.50%). Data collection and form completion were deemed "easy" and block success rate was 100%. Differences in mean BIS between groups were < 5 and a difference of 10% between groups in incidence of BIS < 80 (85% block group, 75% control group) was shown. Conclusion(s): We propose that progression to formal RCT is feasible only with specific modifications to the study design. The decrease in BIS value from baseline should be measured per patient and a clinically significant decrease should be estimated;emergency patients should be excluded;the sample size should be 500 patients;and multiple trial sites should be used. Further consideration should be given to whether such a trial would provide clinically useful information, and would justify the risks, patient discomfort and the considerable financial cost.Copyright © 2023, Medpharm Publications. All rights reserved.
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Background: Patients undergoing an interventional radiology procedure report some degree of anxiety. Therefore, procedure-related anxiety needs to be managed. The aim of our study was to investigate patient satisfaction with monitored anesthesia care (MAC) for uterine artery embolization (UAE)-related procedural anxiety in symptomatic uterine fibroids or adenomyosis. Method(s): Between May 2021 and June 2022, 36 patients with symptomatic fibroids or adenomyosis underwent UAE with MAC. Follow-up evaluations consisted of clinical symptoms, degree of satisfaction with MAC in UAE, and complications. Result(s): MAC in UAE was successfully performed in all patients. UAE significantly reduced patients' complaints such as bleeding and pain: the scores for bleeding and pain were significantly reduced after 3 months of UAE compared with those before UAE, indicating the effectiveness of UAE. The mean score of satisfaction with MAC in UAE was 4.3 points, meaning that 94.4% of women were satisfied or very satisfied. No major complications were observed. Conclusion(s): MAC in UAE for symptomatic uterine fibroids or adenomyosis can be emotionally effective and safe for patients who are anxious about the procedure.Copyright © 2023 The Author(s).
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Introduction: The bispectral index monitors the unawareness component of balanced anaesthesia and gives us the depth of Anesthesia.It reflects the response of the brain to a variety of hypnotic and inhaled anaesthesia agents. The aim of this study was to see the effect of different MAC values of isoflurane on the bispectral index and hemodynamic variations at different MAC values. Material(s) and Method(s): This prospective study was conducted on 20 patients at tertiary care center for 6 months. After induction of Anesthesia, following parameters were recorded: noninvasive blood pressure measurement, heart rate, oxygen saturation, ETCo2 and BIS values. The BIS was continuously monitored and when the MAC values of isoflurane were 0.5, 0.7, 1, 1.2 and 1.5 corresponding BIS values and all the other haemodynamic parameters were noted. Result(s): In 11 patients out of 20 patients satisfactory BIS of 40-60 was achieved at MAC 0.5. In 16 out of 20 patients satisfactory BIS 40-60 was achieved at 0.7 MAC. In all the 20 patients satisfactory BIS was achieved at 1 MAC.In 2 out of 20 patients we couldn't proceed beyond 1.0 MAC because of the fall in MAP to <65mm of Hg. In 4 out of 20 patients we couldn't proceed beyond 1.2MAC because of the fall in MAP to <65mm of Hg. Conclusion(s): Isoflurane produced satisfactory BIS of 40-60 in 16 patients at 0.7 MAC and in all the 20 patients at 1 MAC.Use of BIS in our study helped in better titration of Isoflurane according to patient's individual needs thereby we avoided light plane of anaesthesia or deep hypnosis and the adverse effects associated with it. Copyright © 2022 Wolters Kluwer Medknow Publications. All rights reserved.
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Background: Sedation in coronavirus disease 2019 (COVID-19) patients has been identified as a major challenge. We aimed to investigate whether the use of a multiparameter electroencephalogram (EEG) protocol to guide sedation in COVID-19 patients would increase the 30-day mechanical ventilation-free days (VFD). Methods: We conducted a double-blind randomized clinical trial. We included patients with severe pneumonia due to COVID-19 who required mechanical ventilation (MV) and deep sedation. We randomized to the control (n = 25) or multiparameter group (n = 25). Sedation in the intervention group was administered following the standard institutional protocols together with a flow chart designed to reduce the propofol administration dose if the EEG suppression rate was over 2% or the spectral edge frequency 95 (SEF95) was below 10 Hz. We performed an intention-to-treat analysis to evaluate our primary outcome (30-day VFD). Results: There was no difference in VFD at day 30 (median: 11 [IQR 0-20] days in the control group vs. 0 [IQR 0-21] days in the BIS multiparameter group, p = 0.87). Among secondary outcomes, we documented a 17% reduction in the total adjusted propofol administered during the first 5 days of the protocol [median: 2.3 (IQR 1.9-2.8) mg/k/h in the control group vs. 1.9(IQR 1.5-2.2) mg/k/h in the MP group, p = 0.005]. This was accompanied by a higher average BIS value in the intervention group throughout the treatment period. Conclusion: A sedation protocol guided by multivariate EEG-derived parameters did not increase the 30-day VFD. However, the intervention led to a reduction in total propofol administration.
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BACKGROUND: Clinical assessments of depth of sedation are insufficient for patients undergoing neuromuscular blockade during treatment of acute respiratory distress syndrome (ARDS). This quality initiative was aimed to augment objective assessment and improve sedation during therapeutic paralysis using the bispectral index (BIS). METHODS: This quality improvement intervention provided education and subsequent implementation of a BIS monitoring and sedation/analgesia bundle in a large, urban, safety-net intensive care unit. After the intervention, a retrospective review of the first 70 admissions with ARDS assessed use and documented sedation changes in response to BIS. RESULTS: Therapeutic neuromuscular blockade was initiated for 58 of 70 patients (82.8%) with ARDS, of whom 43 (74%) had BIS monitoring and 29.3% had bundled BIS sedation-titration orders. Explicit documentation of sedation titration in response to BIS values occurred in 27 (62.8%) of those with BIS recordings. CONCLUSIONS: BIS sedation/analgesia bundled order sets are underused, but education and access to BIS monitoring led to high use of monitoring alone and subsequent sedation changes.
Subject(s)
Anesthesia , Neuromuscular Blockade , Respiratory Distress Syndrome , Conscious Sedation , Humans , Hypnotics and Sedatives/therapeutic use , Intensive Care Units , Monitoring, Physiologic , Pain , Paralysis , Respiratory Distress Syndrome/diagnosis , Respiratory Distress Syndrome/drug therapyABSTRACT
Background: Recent renewed interest in regional anaesthesia during the COVID-19 pandemic has inspired the application of neuraxial anaesthesia for previously unconventional indications, such as awake abdominal surgeries. These patients needed little sedation, since studies demonstrate that neuraxial anaesthesia causes sedation as measured by Bispectral Index (BIS). In contrast, no studies have investigated the possible sedative effects of non-neuraxial regional anaesthesia. Aim: This pilot randomised controlled trial (RCT) was designed as a template for, and to test the feasibility of performing a definitive RCT to establish if non-neuraxial regional anaesthesia has any sedative effect. Methods: Forty patients presenting for forearm surgery were randomly allocated to two treatment arms (supraclavicular block and control). Their level of sedation was quantitatively monitored before surgery for 60 minutes. Specific feasibility outcomes were planned and data collected according to CONSORT 2010 recommendations. Results: Out of 48 patients screened, 41 (85.42%) were invited to participate, 40 (97.56%) consented and 100% completed the study. Four (10.00%) BIS electrodes needed replacement, inadequate contact was shown in three patients (7.50%), data collection and form completion were deemed “easy”, and block success rate was 100%. Differences in mean BIS between groups were < 5, and a difference of 10% between groups in the incidence of BIS < 80 (85% block group, 75% control group) was shown. Conclusion: We propose that progression to formal RCT is feasible with modifications. Decrease in BIS value from baseline should be measured per patient, and clinically significant decrease should be estimated (we suggest a decrease of 10 or more), exclusion of emergency patients (starved for longer, more anxious, may affect BIS), the sample size should be 500 patients and multi-site involvement implemented.
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INTRODUCTION: During the COVID-19 pandemic, continuous infusion neuromuscular blocking agents (NMBA) were frequently utilized. International guidelines for NMBA use in critically ill patients recommend patients achieve deep sedation using a continuous sedative and analgesic prior to and during neuromuscular blockade, and documentation is essential to confirm adequate sedation. The aim of this evaluation was to assess the use of sedation and analgesia in paralyzed patients. METHODS: A retrospective multi-center study was performed on fifty adult patients randomly selected from five hospitals across the health system based on the proportion of patients on NMBA at each delivery network. Patients were included if they received a continuous infusion NMBA between March 24 and May 8, 2020. The primary outcome was documentation of adequate sedation and analgesia prior to NMBA initiation, defined as a Richmond Agitation- Sedation Scale (RASS) -4 to -5 while receiving both sedative and analgesic infusions. Secondary outcomes included RASS documentation within 2 hours prior to and bispectral index (BIS) 2 hours after NMBA initiation, and incidence of medication orders updated with appropriate sedation goal. RESULTS: We identified 21 (42%) patients with documentation of adequate sedation and analgesia prior to NMBA initiation. Adequate sedation was documented in 22 (44%) patients, with 24 (48%) not at goal, 3 (6%) not documented, and 1 (2%) without a continuous sedative order. Adequate analgesia was documented in 39 (78%) patients, with 8 (16%) having as-needed intravenous (IV) push opiates orders and 3 (6%) without analgesia orders. Medication orders were updated with appropriate sedation goal in 2 (4%) patients. Documentation of sedation was completed within 2 hours of NMBA initiation in 25 (50%) patients and in 18 (36%) 2 hours after initiation. CONCLUSIONS: Electronic health records should be optimized to facilitate ordering appropriate sedation and analgesia with appropriate titration parameters, and to ensure that an appropriate level of sedation is documented prior to NMBA initiation. Adequate documentation may have been limited due to BIS monitor availability and medication orders with outdated titration parameters.
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OBJECTIVE: This study aims to identify the correlation between bispectral index (BIS) value and modified Glasgow Coma Scale (MGCS) score in dogs with altered level of consciousness (ALOC). DESIGN: This prospective, observational, clinical study was conducted from February 2016 to March 2017, and follow-up was conducted until the death of dogs or their discharge from the hospital. SETTING: This study was performed at the Small Animal Teaching Hospital. ANIMALS: A total of 31 client-owned dogs (males, 20; females, 11) with ALOC and MGCS score <18 with no restrictions for age, breed, sex, and body weight were included. Dogs that received neuromuscular blocking agents before MGCS score evaluation were excluded. INTERVENTIONS: BIS values were measured using the Covidien BIS Loc 2 Channel OEM module and a pediatric 4 sensor with a bifrontal application pattern. MEASUREMENTS AND MAIN RESULTS: Minimal databases of initial neurological assessment, blood profiles, and chest and skull radiographs were developed. In addition, MGCS scores and BIS values were recorded. The mean BIS values for mild, moderate, and severe brain injuries were 89.14 ± 6.52, 77.21 ± 9.82, and 50.58 ± 27.04, respectively. Correlation analysis revealed a significantly positive relationship between BIS values and MGCS scores (r = 0.75; P < 0.001). CONCLUSIONS: The significant correlation observed between MGCS scores and BIS values in dogs with ALOC demonstrated the usefulness of BIS as an alternative to MGCS for monitoring consciousness in patients with ALOC caused by traumatic brain injury, encephalitis, etc.
Subject(s)
Dog Diseases/diagnosis , Glasgow Coma Scale/veterinary , Monitoring, Physiologic/veterinary , Unconsciousness/veterinary , Animals , Dogs , Female , Male , Prospective Studies , Unconsciousness/diagnosisABSTRACT
The purpose of this study was to assess Analgesia/Nociception Index (ANI) and bispectral index (BIS) variations in supine and prone position during closed-tracheal suction in intensive care unit (ICU) patients with severe COVID-19 pneumonia requiring myorelaxation and prone positioning. We retrospectively reviewed the data of 15 patients hospitalized in ICU for severe COVID-19 pneumonia requiring sedation, myorelaxation and prone positioning. The BIS, instant ANI (ANIi), mean ANI (ANIm), heart rate (HR), systolic blood pressure (SBP) and SpO2 were retrieved in supine and prone position 1 min before tracheal suction then every minute from the beginning of tracheal suction during 4 min and compared using ANOVA for repeated measures (p < 0.05 considered as statistically significant). Both ANIm and ANIi decreased significantly during tracheal suction with no difference between positions, whereas BIS showed no significant variation within time and between groups. The median [Q1-Q3] ANIm value decreased from 87 [68-98] to 79 [63-09] in supine position and from 79 [63-95] to 78 [66-98] in prone position 2 min after the beginning of tracheal suction. The median [Q1-Q3] ANIi value decreased earlier 1 min after the beginning of tracheal suction from 84 [69-98] to 73 [60-90] in supine position and from 84 [60-99] to 71 [51-88] in prone position. Both HR, SBP and SpO2 varied modestly but significantly during tracheal suction with no difference between positions. Monitoring ANI, but not BIS, may be of interest to detect noxious stimuli such as tracheal suction in ICU myorelaxed patients with severe COVID-19 pneumonia requiring prone positioning.