BIS & TRAIN OF FOUR IN THE ICU,

ADAM LIPP, MD CAPITOL ANESTHESIOLOGY ASSOCIATION AUSTIN, TEXAS

A CLINICAL REVIEW

NO DISCLOSURES

TWO DISTINCT CLINICAL MONITORS -USED INDEPENDENTLY -CAN BE COMBINED

BIS & TRAIN OF FOUR IN THE ICU

BIS MONITORING

BISPECTRAL INDEX, BIS, COVIDIEN

▸ Cerebral function monitor

▸ Intraoperative awareness (under anesthesia)

▸ Also useful when sedatives administered

▸ ICU: minimize over/undersedation, potentially lowering costs

Kaplan L ,Bailey H. Bispectral Index (BIS) monitoring of ICU patients on continuous infusions of sedatives and paralytics reduces sedative drug utilization. Crit Care. 2000;4(suppl 1):S110.

Simmons LE, Riker RR, PratoBS, FraserGL. Assessing sedation during intensive care unit mechanical ventilation with the Bispectral Index and the Sedation-Agitation Scale. Crit Care Med. 1999;27(8):1499-1504.

▸ processed EEG/EMG, proprietary algorithm

▸ 0-100 scale, 80 for sedation

▸ Not standard of care, "treating the BIS"

▸ Drugs, conditions, interventions can falsely impact values

TRAIN OF FOUR MONITORING

NEUROMUSCULAR BLOCKADE MEASUREMENT

TRAIN OF FOUR, RATIO

▸ Modality of neuromuscular monitoring

▸ Degree of neuromuscular blockade

▸ Useful when NMBDs given (limited movement, shivering)

▸ Pitfalls: crude measurement, clinical judgement critical etherpedia.wikispaces.com

Strange C, Vaughan L, Franklin C, Johnson J. "Comparison of Train-of-Four and Best Clinical Assessment during Continuous Paralysis", American Journal of Respiratory and Critical Care Medicine, Vol. 156, No. 5 (1997), pp. 1556-1561.

Strange C, Vaughan L, Franklin C, Johnson J. "Comparison of Train-of-Four and Best Clinical Assessment during Continuous Paralysis", American Journal of Respiratory and Critical Care Medicine, Vol. 156, No. 5 (1997), pp. 1556-1561.

TRAIN OF FOUR, RATIO

▸ Modality of neuromuscular monitoring

▸ Degree of neuromuscular blockade

▸ Useful when NMBDs given (limited movement, shivering)

▸ Pitfalls: crude measurement, clinical judgement critical

CASE SCENARIO

58 YR OLD MALE S/P TRAUMATIC PARTIAL LIMB AMPUTATION -Alcohol abuse -Severe coronary artery disease -Dilated cardiomyopathy, poor ejection fraction

▸ Microvascular re-anastomosis: no postop movement

▸ Ventilated: acute respiratory failure due to ARDS (transfusion related)

▸ Minimal sedative due to CAD, CM

CONSIDER COMBINATION OF BIS AND TRAIN OF FOUR

▸ When concerned about traumatic recall during neuromuscular blockade

▸ Use clinical judgement above all else