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. 2016 May 28;3(2):201-208.
doi: 10.1007/s40801-016-0076-3. eCollection 2016 Jun.

Inadequate Sedation During Therapeutic Paralysis: Use of Bispectral Index in Critically Ill Patients

Chelsea L Tasaka  1 , Jeremiah J Duby  2 , Komal Pandya  3 , Machelle D Wilson  4 , Kimberly A Hardin  4
Affiliations

Inadequate Sedation During Therapeutic Paralysis: Use of Bispectral Index in Critically Ill Patients

Chelsea L Tasaka et al. Drugs Real World Outcomes. .

Abstract

Background: Patients receiving therapeutic paralysis may experience inadequate sedation due to intrinsic limitations of behavioral sedation assessment. Bispectral index (BIS™) provides an objective measure of sedation; however, the role of BIS™ is not well defined in intensive care unit (ICU) patients on neuromuscular blocking agents (NMBA).

Objective: The aim of this study was to delineate the relationship between BIS™ and level of sedation for critically ill patients during therapeutic paralysis.

Methods: This was a retrospective observational study conducted in ICU patients receiving continuous infusion NMBA and BIS™ monitoring. The primary endpoint was the correlation of BIS™ <60 during therapeutic paralysis with a Richmond Agitation Sedation Score (RASS) of -4 to -5 (i.e., deep or unarousable sedation) at the time of emergence from therapeutic paralysis.

Results: Thirty-one patients were included in the analysis. Three of these patients (9.6 %) were inadequately sedated upon emergence from paralysis; that is, restless or agitated (RASS +1 to +2). We did not observe a correlation between BIS™ and RASS upon emergence from paralysis (r = 0.27, p = 0.14). The sensitivity of BIS™ <60 in predicting deep sedation (RASS -5 to -4) was 100 % (95 % confidence interval [CI] 0-100) with a positive predictive value of 35.7 %. The sensitivity and positive predictive value of BIS™ <60 in predicting light sedation or deeper (RASS -5 to -2) was 92.9 % (95 %CI 83.3-100) and 92.9 %, respectively.

Conclusion: These results suggest that 1 in 10 critically ill patients receiving therapeutic paralysis may be inadequately sedated. BIS™ monitoring may serve as a useful adjunctive measure of sedation in critically ill patients receiving therapeutic paralysis.

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Conflict of interest statement

Compliance with Ethical Standards Ethical approvals Approval of this study was granted by the Institutional Review Board and the need for informed consent was waived (IRB ID# 534116). Conflict of interest Dr Tasaka, Dr Duby, Dr Pandya, Dr Wilson and Dr Hardin do not have any conflicts of interest to disclose. Funding The project described was supported in part by the National Center for Advancing Translational Sciences (NCATS), National Institutes of Health (NIH), through Grant #UL1 TR000002.

Figures

Fig. 1
Fig. 1
Study design timeline. This diagram represents the timeline for patients receiving NMBA in the ICU also showing the temporal relationship of key events and data points used in the study. BIS Bispectral index, ICU intensive care unit, NMBA neuromuscular blocking agent, RASS Richmond Agitation Sedation Scale
Fig. 2
Fig. 2
Richmond Agitation Sedation Scale (RASS) [19] and Bispectral Index (BIS) range [18]
Fig. 3
Fig. 3
Included and excluded patients. BIS Bispectral index, GCS Glasgow Coma Scale, ICP intracranial pressure, NMBA neuromuscular blocking agent, RASS Richmond Agitation Sedation Scale
Fig. 4
Fig. 4
BIS versus RASS scatter plot. Pearson correlation = 0.27 (p = 0.14)
See this image and copyright information in PMC

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