Bispectral Index Monitoring in Healthy, Cirrhotic, and End-Stage Liver Disease Patients Undergoing Hepatic Operation
C.-H. WangC.-L. ChenK.-W. ChengC.-J. HuangK.-H. ChenC.-C. WangAllan M. ConcejeroYu ChengTsuey‐Yuan HuangKing‐Wah ChiuS.-H. WangC.-C. LinY.-W. LiuBruno Jawan
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Keywords:
Bispectral index
Liver disease
Univariate analysis
Liver function
Objective:The aim of this study was to compare the recovery of sevoflurane,isoflurane or propofol TCI anesthesia combined with epidural block on partial hepatectomy under the similar depth of anesthesia as guided by bispectral index (BIS) measurements in cirrhotic patients. We hypothesize that sevoflurane or propofol would yield better recovery than isoflurane.Methods:Forty-five patients with liver cirrhosis scheduled for right liver segmentectomy were assigned into three groups with 15 cases each. The patients in group S,I and P were given sevoflurane,isoflurane or propofol for the maintenance of anesthesia combined with epidural block with a similar BIS value of 50±5. Hemodynamic values,recovery profile and BIS value were recorded as well as adverse events. The consumption of the three anesthetics was also calculated. Results:The quality of recovery in the S group and the P group were better. The hemodynamic was stable during the operation.The three groups had the similar side effects. The cost for maintenance of anesthesia,exincluding wasted drugs,was highest in the P group and lowest in the I group.Conclusion:A trend towards a better recovery profile was obtained with propofol and sevoflurane during liver operation in cirrhotic patients. The maintenance of isoflurane sounds economic.
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Awareness and recall, though not common, are the major hazards of general anesthesia, especially in Cesarean section (C/S) because of the absence of benzodiazepine and opioids for a significant time during anesthesia. In this study, the Bispectral Index (BIS), end-tidal isoflurane, and hemodynamic parameters were examined to evaluate the depth of the routine general anesthetic technique in C/S.This study was carried out on 60 parturient patients undergoing elective C/S. A standardized anesthetic technique was applied: induction with Thiopental (4-5 mg/kg) and Succinylcholine (1.5-2 mg/kg) as well as maintenance with O2, N2O, and isoflurane. Electrocardiogram, heart rate, blood pressure, Spo2, end-tidal isoflurane concentration, BIS, and any clinical signs of inadequate depth of anesthesia such as movement, sweating, lacrimation, coughing, and jerking were continuously monitored and recorded at 16 fixed time points during anesthesia.A median BIS of less than 70 (range: 42-68) was obtained on all occasions during surgery; however, at each milestone, at least 20% of the patients had BIS values above 60. Hemodynamic parameters increased significantly in some patients, especially during laryngoscopy and intubation. No patient experienced recall or awareness.The currently used general anesthetic technique in our center appears inadequate in some milestones to reliably produce BIS values less than 60, which are associated with lower risk of awareness. Therefore, with respect to such desirable outcomes as good Apgar and clinical status in neonates, we would recommend the application of this method (if confirmed by further studies) through larger dosages of anesthetic agents.
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A 39-year-old man was diagnosed with hepatitis B virus-related cirrhosis, and because of hepatic exacerbations with icterus and ascites, he had been repeatedly hospitalized. He was treated with lamivudine. Several months later, his ascites disappeared and his liver function was improved from class C to A according to the Child-Pugh classification. Two years later, one small hepatocellular carcinoma was detected, and he underwent a successful hepatectomy. From this case, we consider lamivudine to be useful for improving hepatic function in decompensated liver cirrhosis type B and lamivudine might enable surgical resection of hepatocellular carcinoma.(Internal Medicine 42: 416-420, 2003)
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Background Hemodynamic changes and anesthetic awareness occurring during surgery under general anesthesia is a great concern for both surgeon and anesthesiologist. Maintenance of the adequate depth of anesthesia throughout the intraoperative period is important in maintaining hemodynamic stability, preventing intraoperative awareness, and avoiding postoperative recall. Aim This study aims to predict the anesthetic stability of propofol, dexmedetomidine, and isoflurane by measuring bispectral index (BIS) and hemodynamic indices. Materials and methods This is a prospective comparative study. Sixty patients of either sex, aged 18-60 years, with American Society of Anesthesiologist (ASA) physical status classification I and II, undergoing elective surgical procedures requiring general anesthesia were allocated into three groups of 20 each. Patients in each group were administered standard general anesthesia with routine hemodynamic monitoring along with BIS, and values were recorded at baseline and thereafter at every five-minute interval for the duration of surgery. Anesthesia was maintained in Group P using a bolus dose of propofol 1 milligram.kg-1 for 10 minutes followed by propofol infusion 50-75 microgram.kg-1.minute-1, Group D with a bolus dose of dexmedetomidine 1 microgram.kg-1 for 10 minutes followed by infusion 0.2-0.7 microgram.kg-1.hour-1, and Group I with isoflurane at 1 minimum alveolar concentration (MAC) for 10 minutes and then maintained between 0.5 MAC and 1.5 MAC until the duration of surgery. To maintain the surgical plane of anesthesia, the BIS score was monitored between 40 and 65. The quantitative variables were expressed as mean±SD and compared between groups using Student's unpaired t-test. Data analysis was done using SPSS Statistics for Windows version 20.0 (IBM Corp., Armonk, NY, USA). A p-value of <0.05 was considered statistically significant. Results During intergroup comparison among study drugs, the mean BIS values were statistically significant among the groups (p<0.05). Hemodynamic indices were significantly better maintained in the dexmedetomidine group as compared to the isoflurane and propofol groups throughout the intraoperative period (p<0.05). Conclusion Dexmedetomidine is better than propofol and isoflurane in maintaining the BIS score and hemodynamic parameters during the intraoperative period.
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Dexmedetomidine
Bolus (digestion)
Minimum alveolar concentration
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Modalities for titrating anesthetic drug-like bispectral index (BIS) and end-tidal anesthetic gas (ETAG) concentration in predicting early extubation had been studied with old anesthetic agents such as isoflurane.The aim of this study is to compare the effect of ETAG concentration versus BIS-guided protocol as directing tool on time to tracheal extubation for sevoflurane-based general anesthesia.This prospective, randomized, double-blind trial studied sixty patients with American Society of Anesthesiologists physical status classes I and II who received sevoflurane-based general anesthesia and were allocated to either BIS-guided anesthesia group (n = 30) or ETAG-guided anesthesia group (n = 30). Time to tracheal extubation was measured. BIS value was kept between 40 and 60 in BIS group, whereas minimum alveolar concentration value was kept between 0.7 and 1.3 in ETAG group. The two groups were compared using Student's t-test, and P < 0.05 was considered statistically significant. The statistical analysis was performed using the open source "R" programming language.Mean time to tracheal extubation was significantly shorter in BIS group (308.77 ± 20.48 s) as compared to ETAG group (377.90 ± 25.06 s) (P < 0.001). The sevoflurane concentration used was also significantly less in group BIS than group ETAG at multiple time intervals (P = 0.001).Prediction of extubation was significantly early with BIS monitoring as compared to ETAG monitoring in sevoflurane-based general anesthesia.
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ABSTRACT Background: Propofol and isoflurane have been used as anesthetic drug. Objective: For the purpose of this research, we compared total intravenous (IV) anesthesia (TIVA) with propofol and inhalational anesthesia of isoflurane on hhemodynamic parameters. Method: This study is a randomized clinical trial, carried out on patients aged 20–40 years; they were randomly divided into two groups. The anesthetics drug administered in both groups were similar. This study comprises of 92 patients undergoing LC. The patients were divided into two groups, forty-six (46) patients received inhaled anesthesia with isoflurane (Group I), and the other forty-six (46) in propofol group (Group P). Hemodynamic variables and depth of anesthesia at various distances were measured and recorded. Result: In this study, the difference in depth of anesthesia between the two groups over a period of time was statistically significant. Changes in hemodynamic parameters such as HR, SBP and DBP between the two groups was statistically significant over time. Bispectral index in the group receiving isoflurane was statistically lower than those in propofol-based anesthetic treated group ( p = 0.051). Conclusion: Propofol and isoflurane are appropriate agent used as a relaxant after general anesthesia for LC. Thus, propofol unlike isoflurane provide less hemodynamic changes, and presented a greater hemodynamic stability. This clinical trial was carried out in Iran at the center of clinical trial registered with a special registration code: IRCT2015092716516N2. Highlights
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Objective To assess the effect of intravenous anesthetics propofol and inhaled anesthetics isoflurane on auditory evoked potential index (AEPI) and the value of AEPI in the monitoring of anesthetic depth. Methods Thirty patients scheduled for elective surgery with no audition obstacle and non-neurotic were randomly divided into 2 groups and received propofol TCI 2 μg/mL (group I, n=15), or inhaled isoflurane P ET1.5% (group II, n=15), respectively. The induction of anesthesia with midazolam 0.08 mg/kg, propofol or isoflurane, fentanyl 5 μg/kg, vecuronium 0.15 mg/kg and then tracheal intubation were performed. The auditory evoked potential indexes (AEPI) were recorded during anesthesia period. Results The AEPI was decreased to less than 30 in group I and II. The time from induction to AEPI under 30 was (6.2±2.5)min(group I),(15.2±1.9)min (group II) respectively. During anesthesia, the incidence of AEPI instability were much more profound in group I (40%) than in group II (13%) (P0.01). Conclusion The propofol and isoflurane decrease the APEI to less than 30. The changes of AEPI were not accorded between the propofol and isoflurane during surgery. The AEPI monitoring is valuable in assessment of anesthetic depth during anesthesia with propofol or isoflurane.
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บทคดยอ Bispectral index (BIS)เปนวธทชวยวดความลกของการหลบโดยอาศยการวเคราะหและแปลผลจากคลนไฟฟาสมอง โดยคาBIS ระหวาง 40-60สามารถปองกนการเกดภาวะรสกตวขณะผาตด ระหวางการระงบความรสกแบบทวไปและยงชวยใหการปรบปรมาณยาขณะระงบความรสกเปนไปอยางเหมาะสม ลดผลขางเคยงทอาจเกดขน สงผลใหฟนตวจากยาดมสลบไดเรวและลดระยะเวลาการอยหองพกฟนวตถประสงคของการวจยครงนเพอศกษาปรมาณการใชกาซดมสลบ ระยะเวลาการฟนตวจากยาดมสลบและระยะเวลาสงเกตอาการทหองพกฟน รวมถงภาวะแทรกซอนหลงการระงบความรสกภายใน 24 ชวโมง เมอเฝาตดตามความลกของการหลบโดยใช BIS เปรยบเทยบกบการเฝาตดตามโดยใชสญญาณชพ ในผปวยทเขารบการระงบความรสกแบบทวไป ซงใชวธการศกษาโดยเกบขอมลในผปวยทมสขภาพแขงแรง (ASA classification I) อายตงแต 18 ถง 60 ป ซงมารบการผาตดและไดรบการระงบความรสกแบบทวไป ไมเรงดวน ณ ศนยการแพทยสมเดจพระเทพรตนราชสดา สยามบรมราชกมารฯ จำนวน 60 ราย โดยแบงผปวยเปน 2 กลม ดวยวธการสม กลมละ 30 คน กลมท 1 เฝาตดตามความลกของการหลบโดยใช BIS และกลมท 2 เฝาตดตามความลกของการหลบโดยใชสญญาณชพ ผปวยทงหมดใชเครองดมยาสลบระบบ autoflowผลจากการศกษาและวเคราะหขอมลพบวาปรมาณการใชoxygen ในกลมทตดตามดวยสญญาณชพนอยกวากลมทตดตามดวย BIS อยางมนยสำคญ ( p =0.026) สวนisofluraneและ N 2 O ไมมความแตกตางอยางมนยสำคญทางสถต นอกจากนยงไมพบความแตกตางกนของระยะเวลาการฟนตวจากยาดมสลบและระยะเวลาสงเกตอาการทหองพกฟน รวมถงภาวะแทรกซอนหลงการระงบความรสกภายใน 24 ชวโมงไมมผปวยรายใดเกดภาวะรสกตวขณะผาตดจากการศกษานสรปไดวาการตดตามความลกของการหลบดวย BIS ไมไดชวยลดปรมาณการใชกาซดมสลบลง เปรยบเทยบกบการเฝาตดตามโดยใชสญญาณชพ เมอใชเครองดมยาสลบระบบ autoflow Abstract Bispectral index (BIS) is a method for monitoring depth of anesthesia by using electroencephalogram(EEG) analysis. BIS value of 40-60 can reduce the incidence of awareness during general anesthesia. Another advantage of BIS is facilitating adjustment of anesthetic requirement in each patient which will lead to reduction of emergence time, recovery time and postanesthetic complications. The objectives of this studyare comparison of consumption of volatile anesthetic agents, emergence, andrecovery time including postanesthetic complications within 24 hours between the patients that are monitored by BIS and hemodynamics during general anesthesia. The method of data collection was in prospective randomized controlled trial of 60 healthy patients (ASA I), age between 18-60 years old under general anesthesia for elective surgery. The patients were randomly divided into 2 groups; group B (BIS group) was monitored by BIS and group H (hemodynamic group) monitored by hemodynamic responses. All patients were ventilated with autoflow mode of Draeger® Zeus anesthesia machine.The statisticalanalysis showed the oxygen consumption in hemodynamic group was lower than BIS group with statistical significance ( p =0.026). The result showed no differences in isoflurane and nitrous oxide consumption, emergence time, recovery time and postanesthetic complications between bothgroups. No intraoperative awareness was observed.This study concluded that monitoring depth of anesthesia by BIS did not reduce the consumption of volatile anesthetic agents comparedto hemodynamic monitoring.
Bispectral index
Cardiac index
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Background: Refl exes, muscle tonus, heart rate, respiratory frequency and blood pressure are parameters that can be used to evaluate the depth of anesthesia. Bispectral index (BIS) was developed with the objective of evaluating quantitatively the sedative and hypnotic effects of anesthetic drugs. It is widely used to assess central nervous system depression levels. The objective of this study was to compare changes in BIS and several vital parameters during general anesthesia achieved with either propofol or isofl urane, following premedication with dexmedetomidine. Materials, Methods & Results: Adult female New Zealand rabbits (Mean ± SD body weight 3.6 ± 0.4 kg) were procured from a commercial source certifi ed for medical experimentation. The animal number in each of the two study groups was four, for a total of eight. The animals were checked before the study to ascertain their good health. The animals, randomly allocated to either of two study groups, were given dexmedetomidine, 20 µg/kg i.v. Induction was realized by means of propofol, 8 mg/kg i.v. in the propofol group (n = 4), and by administration through a glove mask of isofl urane, 4%, in the isofl urane group (n = 4). Anesthesia maintenance was assured by propofol, 0.6 mg/kg/min or 2% isofl urane with oxygen, respectively. Both anesthetic applications were well tolerated by the rabbits. Before premedication (T0), at the time points of 1 (T1) and 5 min (T2) after dexmedetomidine injection, 1 min into anesthesia induction (T3), and 10 (T4), 30 (T5) and 60 min (T6) after start of maintenance, the following were recorded: BIS, systolic, diastolic and mean arterial blood pressure, heart rate and Anesthesia Score (AS). Blood gas analysis, serum sodium and potassium, blood glucose level, hemoglobin and hematocrit were measured at time points T0 and T6. MAP dropped signifi cantly lower in the propofol group at times T 2 , T 3 and T 4 (P < 0.05). Under BIS monitoring, BIS values were also found to be relatively lower in the propofol group at times T 1 , T 2 and T 4 , corresponding in this to AS. At T 4 , the BIS values were, respectively, 69.5 ± 6.24 and 68.25 ± 3.59 in the isofl urane and propofol groups (P < 0.05). In summary, premedication with dexmedetomidine did not, differently than with humans, assure deep sedation; BIS values, in parallel with our AS evaluation, reached levels of deep anesthesia in the maintenance stage both in the propofol and isofl urane groups. BGA results in arterial blood (pH, PaO 2 , PaCO 2 , BE, HCO 3 ) as well as hematocrit (Hct), Na + , K + , glucose, hemoglobin (Hb) were recorded and reported in Table 2. A signifi cant increase in pH was noted at T 6 (P < 0.05) in the propofol groups compared to animals given isofl urane (7.39 ± 0.01 vs 7.35 ± 0.003, respectively), all measurements remaining within the normal values. Discussion: Vital parameters showed parallelism with the values of both our AS and BIS in this study, in which we administered general anesthesia with either propofol or isofl urane to rabbits premedicated with dexmedetomidine. Publications on humans show that surgical anesthesia is realized at BIS values under 60; BIS fell in rabbits in parallel to MBP at 10, 30 and 60 min of anesthesia, and AS also showed that the depth of anesthesia was adequate. No surgery having been performed in this study, we think that the parameters noted in this paper should be investigated in future studies that include surgery.
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Premedication
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