BIS EVALUATION IN TCI

ANESTHESIA BY PROPOFOL

Nguyễn Văn Chinh, MD, PhDProf. Nguyễn Văn Chừng, MD, PhD

INTRODUCTION

New situation: Science Equipments and techniques Advances in medical technology…

New techniques:TCI: Target Controlled InfusionBIS: Bispectral Index

INTRODUCTION

TARGET CONTROLLED INFUSION

Time

Time

Plasma Concentration (Cp)

TCI

1968

1981

1997

Now

BET: Bolus Elimination Transfer

DipprifusorSchwilden

FRANCE

KrugerThiemer

Many Hospital

TCI HISTORY

TARGET CONTROLLED INFUSION

TARGET CONTROLLED INFUSION

Cp

(Ce)

Dose

TARGET CONTROLLED INFUSION

(Ce)

Drugs Fomula Population Data file

Midazolam Zomorodi Adult Weight, Age, height

Propofol Marsch

Schnider

Katarian

Adult, Children

26 – 81 years of age

3 – 11 years of age

Weight, Age

Weight, Age, height

WeightSufentanil Gepts

Minto

Adult

20 – 85 years of age

Weight

Weight, Age, height

TARGET CONTROLLED INFUSION

Target of Propofol (Diprivan)Loss of consciousness: Cp: 1,9 – 7,7 mcg/ml

Ce: 1,1 – 4,7 mcg/ml

Loss of pain response: Cp: 3 – 6,8 mcg/ml

Maintenance: Cp: 2,5 – 6,8 mcg/ml

Cp: 4 – 7 mcg/ml

Awareness: Ce: 1,1 – 1,3 mcg/ml

TARGET CONTROLLED INFUSION

BIS TECHNOLOGY

1987-1997

1998

2003

Now

FDA

FDAMonitorA 2000

BIS BIS TechnologyTechnology

Research

ManyHospital

BIS HISTORY

BIS TECHNOLOGY

0

20

40

60

80

100

BIS 50

BIS ValueChỉ số

BIS TrendBiểu đồ lưu

EEG WaveformĐiện não đồ dạng sóng

EMG (electromyogram)Điện cơ đồ

SQI (signal quality index)Chỉ số chất lượng tín hiệu

SR (suppression ratio)Tỉ lệ ngừng phát xung

SQI 90

SQI

EMG 40

EMG

SR 0

BIS Display Information

Incidence of Inappropriate SedationIncidence of Inappropriate Sedation

Over-sedation/ Quá liều

On Target/ Đủ liều

Under-sedation/ Chưa đủ liều

54%

15.4%

30.6%

Kaplan L and Bailey H. Critical Care. 2000; 4(1):S110.

Olson D et al. NTI Proceedings. 2003; CS82:196.

10%20%

70%

Kaplan L. and Bailey H. Kaplan L. and Bailey H. 20002000

Olson D. et al.Olson D. et al.20032003

EEG Response to Anesthetics EEG Response to Anesthetics

Donald R. Stanski and Steven L. Shafer, Miller’s Anesthesia, ed. Ronald D. Miller (Philadelphia: Elsevier Inc., 2005), p. 1253.

15

MANAGING HYPNOTIC LEVEL

AWAKE/AWAKE/T NHỈT NHỈ

FLAT LINE EEG/FLAT LINE EEG/EEG hi n th ph ngể ị ẳEEG hi n th ph ngể ị ẳ

High risk of awareness

Deep AnesthesiaLonger Recovery

100

70

60

0

Optimal Depth of

Unconsciousness

Đ sâu gây mê t i uộ ố ư 45

Sedation

BIS-Guided Agent

Titration/BIS hướng dẫn điều chỉnh thuốc mê

Assumes Adequate Analgesia in Technique

OBJECTIVES

This study is performed to evaluate a change of Bispectral Index (BIS) in target controlled infusion (TCI) anesthesia.

METHODS

Prospective study on 54 patients From July 2011 to July 2013. All of them have undergone general anesthesia.

Pulse, blood presure, resspiratory rate and health status of the patients were monitored right before and after anesthesia.

Close careful monitoring during and after the operation must be applied in order to detect and manage in time complications.

METHODS

Premedication: Midazolam 0,04mg/kg + Fentanyl 2-3mcg/kgInduction:

O2: 3-5 minutes

Propofol (Diprivan) TCI: Cp: 6 mcg/ mlRocuronium: 0,3-0,6 mg/kgPLMA or Intubation: Ce: 3,5 – 4mcg/ml.Maintenance:Cp: 2-3mcg/ ml after PLMA or Intubation. Ventilation, Fentanyl and Rocuronium.

RESULTS AND DISCUSSION

ÑAËC ÑIEÅM CHUNG

Features Mean

Age 47,21 ± 5,52

Weight (kg) 53,17 ± 8,63

Height (cm) 151,06 ± 12,13

N 54

ADD DISEASE

Features n (%)

Circulation 5 (9,25)

Respiration 2 (3,70)

Diabetes 4 (7,41)

Other Disease 3 (5,56)

RESULTS AND DISCUSSION

Loss of consciousness time:

Loss of consciousness at Cp: 1,42 ± 0,27 mcg/ml, BIS: 63,66 ± 5,53.

Cp (mcg/ml)

BIS Time (s)

This Research 1,42 ± 0,27 63,66 ± 5,53 82,14 ± 10,42

Macquaire, Absalom vaø Struys.

1,4 – 1,9 68,37 ± 8,22 90 - 110

RESULTS AND DISCUSSION

Induction:

TCI had lower induction doses

Induction doses of Kenny: Cp: 8 mcg/ml

Propofol (mg/kg)

BIS

This Research 1,47 ± 0,06 44,11 ± 2,63

Macquaire 1,41 ± 0,09 40 – 60

Struys 1,31 ± 0,11 40 – 60

RESULTS AND DISCUSSION

Maintenance:

Nghieân cöùu

Cp (mcg/ml) Giaù trò BIS

This Research 3 40 – 60

Irwin 3,82 45

Ngai Liu 3,8 40 – 60

Struys 5,4 40 – 60

RESULTS AND DISCUSSION

Maintenance: BIS monitoring values helped guide anesthetic dosing. Decreasing the risk of awareness and recognizing Lehman: smooth maintenance by TCIRussel and Struys: Less hemodynamic changes and

smooth maintenance by TCI.Bonnin: Easy titration during TCI anaesthesia.

RESULTS AND DISCUSSION

RESULTS AND DISCUSSION

Following awareness with recall, 33–69% of the patients suffer from late psychological symptoms, incl. Post Traumatic Stress Disorder (PTSD)

Samuelsson et al., Anesthesiology. 2007 Jan;106(1):26-32.

Hemodynamic changes in anesthesia:

Less hemodynamic changes in anesthesia.Kazama: more hemodynamic changes in elderly patients.Tackley: less hemodynamic changes in anesthesia.

RESULTS AND DISCUSSION

Awareness stage :This Research: short recovery times, decreasing the

risk of awareness and recall.

Leslie: haven’t recall during anaesthesia at Cp level loss of consciousness.

Sandin: about 0,16% recall during anaesthesia.

Vermon: Decreasing the risk of awareness and recall at BIS 40 – 60.

RESULTS AND DISCUSSION

Clinical judgment should always be used when interpreting BIS in conjunction with other available clinical signs.

Reliance on the BIS alone for intraoperative anesthetic management is not recommended.

BIS values should be interpreted cautiously in patients:

With known neurological disorders

Taking psychoactive medications

In children below the age of one

RESULTS AND DISCUSSION

CONCLUSIONS

Propofol target controlled infusion is safe and effective.

Quick loss of consciousness.

Lower induction doses, smooth inductions.

Less hemodynamic changes in anesthesia.

Short recovery times, improve patient recovery.

Reduce the risk of awareness with recall during anaesthesia.

Thanks!