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Bispectral Index Guided Bispectral Index Guided Anesthetic Practice Anesthetic Practice in Cardiac Surgeryin Cardiac Surgery
Dr. Mohamed Essam, MDDr. Mohamed Essam, MDAssistant Professor, Anesthesia DepartmentAssistant Professor, Anesthesia Department
Ain Shams UniversityAin Shams University
Bispectral IndexBispectral IndexBISBIS
Processed EEG and Computer algorithm Processed EEG and Computer algorithm Assigns a numerical value based on the Assigns a numerical value based on the
probability of consciousnessprobability of consciousness
BISBIS
BISBIS Approved by the FDA on Oct.1996
Estimated Sensitivity 97.3 % Specificity 94.4 % Accuracy achieved with: - SQI 100% - EMG 0% - SR 0
Balanced General Balanced General AnesthesiaAnesthesia
HYPNOSISHYPNOSIS
ANALGESIAANALGESIA RELAXATIONRELAXATION
BISBIS
FACTS IN OPCABFACTS IN OPCAB
Anaesthetic ProspectiveAnaesthetic Prospective
HaemodynamicsHaemodynamics
Narcotics Vs. HypnoticsNarcotics Vs. Hypnotics
Surgical ProspectiveSurgical Prospective
Heart DislocationHeart Dislocation
Hazards of VasopressorsHazards of Vasopressors
Fast TrackingFast Tracking Term aims at reducing Cost & Stay of Surgical
Patients
Peri-operative process involving rapid progress from preoperative preparation through surgery and discharge from the hospital.
Early Extubation may be a component of this
process. However, early extubation and ‘fast track’ are not synonymous.
Anesthetic TechniqueAnesthetic Technique
Total Intravenous Technique :Total Intravenous Technique : Steady Plasma LevelSteady Plasma Level Decreased Total Dose RequirementsDecreased Total Dose Requirements Avoidance of Bolus effectsAvoidance of Bolus effects . Hypnotics . Hypnotics Hemodynamic Instability Hemodynamic Instability . Opioids . Opioids Rigidity Rigidity Rapid RecoveryRapid Recovery Eliminate incidence of AwarnessEliminate incidence of Awarness Saving of Inhalational Agents for IPC effectsSaving of Inhalational Agents for IPC effects
Anesthetic TechniqueAnesthetic Technique
Agents : Induction Maintenance Midazolam 0.05 – 0.1 mg / Kg 1.5 ug / Kg / min0.05 – 0.1 mg / Kg 1.5 ug / Kg / min Sufentanil 1 – 1.5 ug / Kg 0.2 ug / Kg / hr1 – 1.5 ug / Kg 0.2 ug / Kg / hr Rocuronium 0.9 mg / Kg 0.5 mg / Kg / hr0.9 mg / Kg 0.5 mg / Kg / hr
MethodologyRecorded Parameters Hemodynamics
BIS Reading
Data PointsT0= Baseline post-induction
T1= Skin incision
T2= Sternotomy
T3= 60 minutes post-induction
T4= 90 minutes post-induction
T5= With chest closure
Total IV Anaesthetic RequirementsTotal IV Anaesthetic Requirements Inhalational Sevoflurane SupplemetationInhalational Sevoflurane Supplemetation Total Phenylepherine DosageTotal Phenylepherine Dosage Inotropic Support Inotropic Support Awareness ( Questionnaire )Awareness ( Questionnaire ) Postoperative Data ( Fast Tracking )Postoperative Data ( Fast Tracking )
48
49
50
51
52
53
54
55
BIS Reading
Range
0 1 2 3 4 5
Data Points
BIS Assessment
• Male patient , 72 yrs.Male patient , 72 yrs.
• Wt. 62 Kg , Ht. 165 cmWt. 62 Kg , Ht. 165 cm
• ASA IVASA IV
• Medical history:Medical history: .HTN , DM.HTN , DM
..CAD CAD EFEF 30 % , old inf. MI 30 % , old inf. MI
PCIPCI LAD 90 % , RCA 100% , OM 90% LAD 90 % , RCA 100% , OM 90%
. Limited Pulmonary Reserve . Limited Pulmonary Reserve
.Old .Old CVA CVA (Frontal with small organized SDH) (Frontal with small organized SDH)
..Bilateral Carotid diseaseBilateral Carotid disease
Rt. 100% Occlusion , Lt. 90% StenosisRt. 100% Occlusion , Lt. 90% Stenosis
.Mild both Hepatic & Renal impairment.Mild both Hepatic & Renal impairment
CNS MonitoringCNS Monitoring
I. Functional Monitoring:I. Functional Monitoring: - Awake patient- Awake patient - EEG- EEG - SSEP’s- SSEP’s
II. Oxygen Supply & Perfusion:II. Oxygen Supply & Perfusion: - Stump Pressure- Stump Pressure - TCD - TCD
- SjVO- SjVO22
- RSO- RSO22
Surgical procedureSurgical procedure
CEA:CEA: - Exposure of CCA till the bifurcation- Exposure of CCA till the bifurcation
- Determining the severity of - Determining the severity of Cerebral IschemiaCerebral Ischemia
. Clamping of CCA. Clamping of CCA
. Measuring Stump Pressure. Measuring Stump Pressure
. BIS Tracing. BIS Tracing
- Shunt application- Shunt application
CABG:CABG: - Off pump Revascularisation of LAD- Off pump Revascularisation of LAD
- Initiation of CPB for Complete Revascularisation- Initiation of CPB for Complete Revascularisation
Detection of Cerebral IschemiaDetection of Cerebral IschemiaDuring CEADuring CEA
CONCLUSIONCONCLUSION
BIS Guided Anaesthetic PracticeBIS Guided Anaesthetic Practice ↓↓ Anaesthetic RequirementsAnaesthetic Requirements Hemodynamic stabilityHemodynamic stability Lower rate of Conversion to Conventional CABGLower rate of Conversion to Conventional CABG ↓↓ Vasopressor TherapyVasopressor Therapy NO Recorded AwarenessNO Recorded Awareness Fast Tracking AccomplishedFast Tracking Accomplished Cerebral IschemiaCerebral Ischemia