AAGBI Core Topics 2013 Depth of Anaesthesia Monitoring

Transcription

1 AAGBI Core Topics 2013 Depth of Anaesthesia Monitoring Dr Matt Wiles Consultant in Neuroanaesthesia & Neurointensive Care Sheffield Teaching Hospitals NHS Foundation 1

2 Objectives Objectives Why do I need to know about Depth of Anaesthesia monitors and should I be using them? Not enough anaesthetic (NAP5) Too much anaesthetic Practical tips for using BIS 2

3 National Audit Project 5: Accidental Awareness under General Anaesthesia in the UK National Audit Project 5: Accidental Awareness under General Anaesthesia in the UK Study Year Country Number Incidence of Awareness Sebel 2004 US % 1 in 769 Sandin 2000 Sweden % 1 in 555 Errando 2008 Spain % 1 in 167 Mashour 2012 US % 1 in 1000 Myles 2004 US % 1 in 192 Avidan 2008 US % 1 in 1000 Pollard 2007 US % 1 in

4 Brice Questionnaire Brice et al. Br J Anaesth1970; 42: What was the last thing you remember before going to sleep? What is the first thing you remember on waking up? Can you remember anything in between? Did you dream during the procedure? What was the worst thing about your operation? Cardiac Opthalmology Craniotomy Abdominal Thoracic Ortho 4

5 Why is the UK different? Use of supraglottic airways & less NMB More doctor (consultant) delivered care Genetically pharmacologically different Methodological flaws Trainees excluded Reliance on self-reporting No formal Brice questionnaire Where do DOA monitors fit in? 5

6 NICE DG6 Depth of Anaesthesia Monitors December 2012 BIS Technology Rampil. Anesthesiology 1998; 89: Degree of burstsuppression 6

7 BIS Technology Rampil. Anesthesiology 1998; 89: Beta ratio log ratio of power in two empirical frequency bands BIS Technology Rampil. Anesthesiology 1998; 89: Bispectrum Relationship between two sinusoidal components of EEG at two primary frequencies 7

8 BIS EMG EEG SQI SR 8

9 BIS and the Probability of Memory BIS will not predict movement Sebel et al. Anesth Analg 1997; 84:

10 B-Aware Myles et al. Lancet 2004; 363: patients at high-risk of awareness 45% cardiac surgery 43% TIVA Brice at 6 h, 36 h & 30 days Awareness Routine care 11 (0.92%) vs BIS 2 cases (0.17%) BIS awareness with values of & NNT=138 Swedish Awareness Follow-up Trial Ekman et al. Acta Anaesth Scand 2004; 48: standard patients 23% benzodiazepines 5% TIVA Brice at 1-3 & 7-14 days Awareness Routine care 14 (0.18%) vs BIS 2 cases (0.04%) BIS awareness with values of > 60 for 4-10 min ET Agent 80% vs 99% 10

11 BAG-RECALL Avidan et al. NEJM 2011; 365: at high-risk of awareness 48% cardiac BIS target vs ET-Agent MAC (age/n 2 O adjusted) Brice at 3 & 30 days Awareness BIS 7 (0.24%) vs ET-Agent 2 (0.07%) Not awake but too asleep? Monk et al. Anesthesia & Analgesia 2005; 100:4-10 Independent predictors of mortality 1. Patient comorbidity 2. Cumulative deep hypnotic time (BIS <45) 3. Intraoperative hypotension 11

12 Not awake but too asleep? Kertai et al. Anesthesiology 2011; 114: Triple Low Sessler et al. Anesthesiology 2012; 116: MAP < 75 mmhg; BIS < 45; ET Volatile < 0.8 MAC 12

13 BIS & POCD Radtke et al. BJA 2013; 110: patients aged > 60 years BIS guided vs BIS Blinded Postoperative delirium assessed BIS 16.7% vs Control 21.4% Related to % time with BIS <20 (p=0.04) No correlation with POCD BIS accounts for outliers Gan et al. Anesthesiology 1997; 87: % vs5% 13

14 Patient Recovery with BIS Gan et al. Anesthesiology 1997; 87: % 45% 40% 35% 30% 25% 20% 23% 43% BIS-titrated patients (n=302) Extubate sooner (4 min) Shorter PACU stay (6 min) Are more oriented upon arrival to the PACU 15% 10% 5% 0% Standard Practice BIS Titrated BIS & Recovery Time 40% 35% 30% 32% 29% 35% 25% 20% 21% 15% 10% 5% 0% Sevo: 6 studies (n=585) Propofol: 7 studies (n=584) Iso: 3 studies (n=106) Des: 2 studies (n=110) Prop Sevo Des Iso Control recovery time min Actual OR time saving 2-3 min 14

15 Anaesthetic drug consumption & BIS Ellerkmann et al. Acta Anaesthesiol Scand 2006; 50: pts in 14 studies Mean BIS in the standard practice group was 43.6 Mean BIS in the BIStitrated group was point of BIS difference reduces hypnotic drug use by 2%. Just a random number generator? Awareness Possibly in high-risk patients Unclear if using volatile & ET Excess depth of anaesthesia Studies in progress Recovery times Not clinically significant Drug cost savings Not financially significant 15

16 TOF & PORC Capron F et al. Anesth Analg 2006;102: CVP & Fluid Management Marik et al. Chest 2008; 134: study meta-analysis (n=803) Correlation between CVP and: Blood volume 0.16 Responsiveness to fluid challenge 0.18 AUC ROC curve 0.56 (95% CI ) 16

17 ECG for Perioperative Ischaemia Martinez et al. Crit Care Med 2003; 31: CM 5 sensitivity for ischaemia 12% (95% CI 7-17%) Why have I become a BIS user? Lets me give a better neuroanaesthetic Faster awakening More orientation in PACU More cardiostabilty with TIVA Early warning device for problems Anaesthetic Surgical Patient NICE have suggested I should... 17

18 Practical Tips for BIS in Theatres Practice make Perfect 18

19 26/09/

20 Remember the Connector! BIS & Muscle Relaxants 20

21 26/09/2013 BIS & Artefact Sudden Increases in BIS 21

22 26/09/2013 Sudden Increases in BIS Sudden Increases in BIS 22

23 Sudden Falls in BIS Sudden Falls in BIS 23

24 Sudden Falls in BIS Sudden Falls in BIS 24

25 In Summary Depth of anaesthesia monitors generally help you give a Goldilocks anaesthetic for little extra cost The available evidence may make it hard to convince your CD that they are necessary They are difficult to use effectively if reserved for special occasions and/or patients References Sebel, P. S., Bowdle, T. A., Ghoneim, M. M., Rampil, I. J., Padilla, R. E., Gan, T. J., & Domino, K. B. (2004). The incidence of awareness during anesthesia: a multicenter United States study. Anesthesia& Analgesia, 99(3), Lubke, G. H., Kerssens, C., Phaf, H., & Sebel, P. S. (1999). Dependence of explicit and implicit memory on hypnotic state in trauma patients. Anesthesiology, 90(3), 670. Mychaskiw, G., Horowitz, M., Sachdev, V., & Heath, B. J. (2001). Explicit intraoperativerecall at a bispectralindex of 47. Anesthesia& Analgesia, 92(4), Sebel, P. S., Lang, E., Rampil, I. J., White, P. F., Cork, R., Jopling, M., & Manberg, P. (1997). A multicenter study of bispectral electroencephalogram analysis for monitoring anesthetic effect. Anesthesia& Analgesia, 84(4), Sleigh, J. W., Andrzejowski, J., Steyn-Ross, A., & Steyn-Ross, M. (1999). The bispectralindex: a measure of depth of sleep? Anesthesia& Analgesia, 88(3), Myles, P. S., Leslie, K., McNeil, J., Forbes, A., & Chan, M. T. V. (2004). Bispectralindex monitoring to prevent awareness during anaesthesia: the B-Aware randomised controlled trial. Lancet, 363(9423), Ekman, A., Lindholm, M. L., Lennmarken, C., & Sandin, R. (2004). Reduction in the incidence of awareness using BIS monitoring. Acta anaesthesiologica scandinavica, 48(1), Avidan, M. S., Jacobsohn, E., Glick, D., Burnside, B. A., Zhang, L., Villafranca, A., & Mashour, G. A. (2011). Prevention of intraoperative awareness in a high-risk surgical population. New England Journal of Medicine, 365(7), Schneider, G., Wagner, K., Reeker, W., Hänel, F., Werner, C., & Kochs, E. (2002). BispectralIndex (BIS) may not predict awareness reaction to intubation in surgical patients. Journal of Neurosurgical Anesthesiology, 14(1), Messner, M., Beese, U., Romstöck, J., Dinkel, M., & Tschaikowsky, K. (2003). The bispectralindex declines during neuromuscular block in fully awake persons. Anesthesia& Analgesia, 97(2), Monk, T. G., Saini, V., Weldon, B. C., & Sigl, J. C. (2005). Anesthetic management and one-year mortality after noncardiac surgery. Anesthesia& Analgesia, 100(1), Kertai, M. D., Palanca, B. J., Pal, N., Burnside, B. A., Zhang, L., Sadiq, F., & Avidan, M. S. (2011). Bispectralindex monitoring, duration of bispectralindex below 45, patient risk factors, and intermediate-term mortality after noncardiac surgery in the B-Unaware Trial. Anesthesiology, 114(3), 545. Brice, D. D., Hetherington, R. R., & Utting, J. E. (1970). A simple study of awareness and dreaming during anaesthesia.british Journal of Anaesthesia,42(6),

26 References Radtke, F. M., Franck, M., Lendner, J., Krüger, S., Wernecke, K. D., & Spies, C. D. (2013). Monitoring depth of anaesthesia in a randomized trial decreases the rate of postoperative delirium but not postoperative cognitive dysfunction.british journal of anaesthesia, 110(suppl 1), i98-i105. Gan, T. J., Glass, P. S., Windsor, A., Payne, F., Rosow, C., Sebel, P., & Manberg, P. (1997). Bispectral index monitoring allows faster emergence and improved recovery from propofol, alfentanil, and nitrous oxide anesthesia. Anesthesiology, 87(4), Reschreiter, H., Maiden, M., & Kapila, A. (2008). Sedation practice in the intensive care unit: a UK national survey. Crit Care, 12(6), R152. Deogaonkar, A., Gupta, R., DeGeorgia, M., Sabharwal, V., Gopakumaran, B., Schubert, A., & Provencio, J. J. (2004). Bispectral Index monitoring correlates with sedation scales in brain-injured patients. Critical care medicine, 32(12), Triltsch, A. E., Nestmann, G., Orawa, H., Moshirzadeh, M., Sander, M., Große, J., & Spies, C. D. (2005). Bispectral index versus COMFORT score to determine the level of sedation in paediatric intensive care unit patients: a prospective study. Crit Care, 9(1), R9-17. Vivien, B., Di Maria, S., Ouattara, A., Langeron, O., Coriat, P., & Riou, B. (2003). Overestimation of Bispectral Index in sedated intensive care unit patients revealed by administration of muscle relaxant. Anesthesiology, 99(1), Lu, C. H., Man, K. M., Ou-Yang, H. Y., Chan, S. M., Ho, S. T., Wong, C. S., & Liaw, W. J. (2008). Composite auditory evoked potential index versus bispectral index to estimate the level of sedation in paralyzed critically ill patients: a prospective observational study. Anesthesia & Analgesia, 107(4), Olson, D. M., Thoyre, S. M., Peterson, E. D., & Graffagnino, C. (2009). A randomized evaluation of bispectral indexaugmented sedation assessment in neurological patients. Neurocritical care, 11(1), LeBlanc, J. M., Dasta, J. F., & Kane-Gill, S. L. (2006). Role of the bispectral index in sedation monitoring in the ICU. The Annals of pharmacotherapy, 40(3), Kaplan, L. J., & Bailey, H. (2000). Bispectral index (BIS) monitoring of ICU patients on continuous infusion of sedatives and paralytics reduces sedative drug utilization and cost. Critical Care, 4, 1-1. Dunham, C. M., Ransom, K. J., McAuley, C. E., Gruber, B. S., Mangalat, D., & Flowers, L. L. (2006). Severe brain injury ICU outcomes are associated with Cranial-Arterial Pressure Index and noninvasive Bispectral Index and transcranial oxygen saturation: a prospective, preliminary study. Crit Care, 10(6), 159. Fàbregas, N., Gambús, P. L., Valero, R., Carrero, E. J., Salvador, L., Zavala, E., & Ferrer, E. (2004). Can bispectral index monitoring predict recovery of consciousness in patients with severe brain injury? Anesthesiology, 101(1), Seder, D. B., Fraser, G. L., Robbins, T., Libby, L., & Riker, R. R. (2010). The bispectral index and suppression ratio are very early predictors of neurological outcome during therapeutic hypothermia after cardiac arrest. Intensive care medicine, 36(2), References Tobias, J. D. (2008). Bispectral index monitoring documents burst suppression during pentobarbital coma. Journal of Intensive Care Medicine, 23(4), Musialowicz, T., Mervaala, E., Kälviäinen, R., Uusaro, A., Ruokonen, E., & Parviainen, I. (2010). Can BIS monitoring be used to assess the depth of propofol anesthesia in the treatment of refractory status epilepticus?. Epilepsia, 51(8), Rampil, I. J. (1998). A primer for EEG signal processing in anesthesia. Anesthesiology, 89(4), Mashour, G. A., Shanks, A., Tremper, K. K., Kheterpal, S., Turner, C. R., Ramachandran, S. K.,... & Avidan, M. S. (2012). Prevention of intraoperative awareness with explicit recall in an unselected surgical population: a randomized comparative effectiveness trial. Anesthesiology, 117(4), Sandin, R. H., Enlund, G., Samuelsson, P., & Lennmarken, C. (2000). Awareness during anaesthesia: a prospective case study. The Lancet,355(9205), Errando, C. L., Sigl, J. C., Robles, M., Calabuig, E., García, J., Arocas, F.,& García-Aguado, R. (2008). Awareness with recall during general anaesthesia: a prospective observational evaluation of 4001 patients.british journal of anaesthesia,101(2), Pollard, R. J., Coyle, J. P., Gilbert, R. L., & Beck, J. E. (2007). Intraoperative awareness in a regional medical system: a review of 3 years' data. Anesthesiology, 106(2), Ellerkmann, R. K., Kreuer, S., Wilhelm, W., Röpcke, H., Hoeft, A., & Bruhn, J. (2006). Reduction in anaesthetic drug consumption is correlated with mean titrated intra-operative Bispectral Index values.acta anaesthesiologica scandinavica, 50(10), Capron, F., Fortier, L. P., Racine, S., & Donati, F. (2006). Tactile fade detection with hand or wrist stimulation using train-offour, double-burst stimulation, 50-hertz tetanus, 100-hertz tetanus, and acceleromyography.anesthesia & Analgesia,102(5), Marik, P. E., Baram, M., & Vahid, B. (2008). Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. CHEST Journal, 134(1), Sessler, D. I., Sigl, J. C., Kelley, S. D., Chamoun, N. G., Manberg, P. J., Saager, L., & Greenwald, S. (2012). Hospital stayand mortality are increased in patients having a triple low of low blood pressure, low bispectral index, and low minimum alveolar concentration of volatile anesthesia. Anesthesiology, 116(6), Liu, S. S. (2004). Effects of Bispectral Index monitoring on ambulatory anesthesia: a meta-analysis of randomized controlled trials and a cost analysis. Anesthesiology, 101(2), Misis, M., Raxach, J., Molto, H. P., Vega, S. M., & Rico, P. S. (2008, June). Bispectral index monitoring for early detection of brain death. In Transplantation proceedings(vol. 40, No. 5, pp ). Elsevier. Dunham, C. M., Katradis, D. A., & Williams, M. D. (2009). The bispectral index, a useful adjunct for the timely diagnosis of brain death in the comatose trauma patient. The American Journal of Surgery, 198(6),