Judith Jacobi, PharmD, FCCM, BCPS; Gilles L. Fraser, PharmD, FCCM; Douglas B. Coursin, MD; Richard R. Riker, MD; Dorrie Fontaine, RN, DNSc, FAAN; Eric T. Wittbrodt, PharmD; Donald B. Chalfin, MD, MS, FCCM; Michael F. Masica, MD, MPH; H. Scott Bjerke, MD; William M. Coplin, MD; David W. Crippen, MD, FCCM; Barry D. Fuchs, MD; Ruth M. Kelleher, RN; Paul E. Marik, MDBCh, FCCM; Stanley A. Nasraway, Jr, MD, FCCM; Michael J. Murray, MD, PhD, FCCM; William T. Peruzzi, MD, FCCM; Philip D. Lumb, MB, BS, FCCM. Developed through the Task Force of the American College of Critical Care Medicine (ACCM) of the Society of Critical Care Medicine (SCCM), in collaboration with the American Society of Health-System Pharmacists (ASHP), and in alliance with the American College of Chest Physicians; and approved by the Board of Regents of ACCM and the Council of SCCM and the ASHP Board of Directors

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Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult.

A Primer for EEG Signal Processing in Anesthesia

Background:The bispectral index (BIS), a value derived from the electroencephalograph (EEG), has been proposed as a measure of anesthetic effect. To establish its utility for this purpose, it is important to determine the relation among BIS, measured drug concentration, and increasing levels of seda

Bispectral Analysis Measures Sedation and Memory Effects of Propofol, Midazolam, Isoflurane, and Alfentanil in Healthy Volunteers

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(04)16300-9.pdf

Bispectral index monitoring to prevent awareness during anaesthesia: the B-Aware randomised controlled trial

Background:The bispectral index (BIS), a parameter derived from the electroencephalograph (EEG), has been shown to correlate with increasing sedation and loss of consciousness. This study determined whether addition of BIS monitoring to standard anesthetic practice results in improvements in the con

Bispectral Index Monitoring Allows Faster Emergence and Improved Recovery from Propofol, Alfentanil, and Nitrous Oxide Anesthesia

The bispectral (BIS) index and 95% spectral edge frequency (SEF) of the electroencephalograph (EEG) have been used to study the anesthetic and sedative effects of intravenously (i.v.) administered drugs. This prospective study was designed to evaluate the effectiveness of the BIS index and 95% SEF for assessing the level of propofol-induced sedation and amnesia during regional anesthesia. Ten consenting adult patients undergoing surgery with regional anesthesia were administered propofol in increments of 10-20 mg i.v., every 5-10 min until they became unresponsive to tactile stimulation (i.e., mild prodding or shaking). The BIS index and 95% SEF were continuously recorded from a bifrontal montage (Fp1-Cz and Fp2-Cz) using the Aspect B500 monitor. The depth of sedation was assessed clinically at 5- to 10-min intervals using the observer's assessment of alertness/sedation (OAA/S) scale, with 1 = no response to tactile stimulation to 5 = wide awake. Each patient was shown a picture of an animal (cat) prior to administration of an initial dose of propofol, 40 mg i.v.. Subsequently, patients were administered intermittent bolus doses of propofol, 10-20 mg i.v., and shown different pictures upon achieving OAA/S scores of 4, 3, and 2 during the onset of and recovery from propofol-induced sedation. Picture recall was tested upon arrival of the patient in the postanesthesia care unit (PACU). Of the two EEG variables studied, the BIS index exhibited a better correlation with the OAA/S scores during both the onset (Spearman's rho = 0.744) and recovery (Spearman's rho = 0.705) phases of propofol-induced sedation. With the increasing depth of sedation, there was a progressive decrease in the BIS index (OAA/S score of 5, BIS = 94.5 +/- 2.9; 4, 93.3 +/- 3.3; 3, 89 +/- 6.1; 2, 80.1 +/- 8.7; 1, 75.6 +/- 7.5; mean +/- SD). Conversely, there was a progressive increase in the BIS value during recovery from propofol sedation (OAA/S score of 1, BIS = 75.6 +/- 7.5; 2, 82.4 +/- 10.5; 3, 84.9 +/- 5.9; 4, 93.8 +/- 0.8). Although the changes in the 95% SEF values were less consistent during the onset phase, this EEG variable increased from 16.4 +/- 5.0 to 19.3 +/- 5.6 as the OAA/S score increased from 1 to 4 during the recovery phase. Patient recall of the intraoperative pictures decreased with increasing depth of sedation and decreasing BIS values (OAA/S:% BIS:% recall = 5:94.5 +/- 2.9:100%; 4:93.4 +/- 3:63%; 3:87.3 +/- 6.1:40%; 2:80.8 +/- 8.3:0%; 1:75.6 +/- 7.5:0%). The BIS index appears to be a useful variable for assessing the depth of propofol-induced sedation. Increasing depth of sedation was associated with a significant decrease in intraoperative picture recall.

Electroencephalographic bispectral index correlates with intraoperative recall and depth of propofol-induced sedation.

BackgroundThe electroencephalogram (EEG) has been used to study the effects of anesthetic and analgesic drugs on central nervous system function. A prospective study was designed to evaluate the accuracy of various EEG parameters for assessing midazolam-induced sedation during regional anesthesia.Me

Electroencephalogram bispectral analysis predicts the depth of midazolam-induced sedation.

Intrathecal fentanyl with small-dose dilute bupivacaine: better anesthesia without prolonging recovery.

The purpose of investigation was to study the effect of intrathecal fentanyl on the onset and duration of hyperbaric bupivacaine-induced spinal block in adult male patients. Fortythree patients undergoing lower extremity or genitourinary surgery were enrolled to receive either 13.5 mg hyperbaric bupivacaine 0.75% + 0.5 ml CSF it, (Group I) or 13.5 mg hyperbaric bupivacaine 0.75% + 25 μg fentanyl it, (Group II) according to a randomized assessor-blind protocol. The onset and duration of sensory block were assessed by pinching the skin with forceps in the midclavicular line bilaterally every two minutes for first twenty minutes and then every five to ten minutes. Similarly, the onset and duration of motor block were assessed and graded at the same time intervals using the criteria described by Bromage. The time required for two sensory segment regression and sensory regression to L1 dermatome was 74 ± 18 and 110 ± 33 min vs 93 ± 22 and 141 ± 37 min in Groups I and II, respectively (P < 0.05). Intrathecal fentanyl did not enhance the onset of sensory or motor block, or prolong the duration of bupivacaine-induced motor spinal block. Fewer patients demanded pain relief in the fentanyl-treated group than in the control group in the early postoperative period (19% vs 59%; P < 0.05). Episodes of hypotension were more frequent in the fentanyl-treated group than in the control group (43% vs 14%; P < 0.05). We conclude that fentanyl, 25 μg it, prolonged the duration of bupivacaine-induced sensory block (sensory regression to L1 dermatone) by 28% and reduced the analgesic requirement in the early postoperative period following bupivacaine spinal block.

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Harbhej Singh

Papers

Electroencephalographic bispectral index correlates with intraoperative recall and depth of propofol-induced sedation.

Electroencephalogram bispectral analysis predicts the depth of midazolam-induced sedation.

Intrathecal fentanyl with small-dose dilute bupivacaine: better anesthesia without prolonging recovery.

Intrathecal fentanyl prolongs sensory bupivacaine spinal block

Comparative effects of lidocaine, esmolol, and nitroglycerin in modifying the hemodynamic response to laryngoscopy and intubation