High Incidence of Burst Suppression during Propofol Sedation for Outpatient Colonoscopy: Lessons Learned from Neuromonitoring

Jamie Bloom, David Wyler, Marc C Torjman, Tuan Trinh, Lucy Li, Amy Mehta, Evan Fitchett, David Kastenberg, Michael Mahla, Victor Romo, Jamie Bloom, David Wyler, Marc C Torjman, Tuan Trinh, Lucy Li, Amy Mehta, Evan Fitchett, David Kastenberg, Michael Mahla, Victor Romo

Abstract

Background: Although anesthesia providers may plan for moderate sedation, the depth of sedation is rarely quantified. Using processed electroencephalography (EEG) to assess the depth of sedation, this study investigates the incidence of general anesthesia with variable burst suppression in patients receiving propofol for outpatient colonoscopy. The lessons learned from neuromonitoring can then be used to guide institutional best sedation practice.

Methods: This was a prospective observational study of 119 outpatients undergoing colonoscopy at Thomas Jefferson University Hospital (TJUH). Propofol was administered by CRNAs under anesthesiologists' supervision. The Patient State Index (PSi™) generated by the Masimo SedLine® Brain Root Function monitor (Masimo Corp., Irvine, CA) was used to assess the depth of sedation. PSi data correlating to general anesthesia with variable burst suppression were confirmed by neuroelectrophysiologists' interpretation of unprocessed EEG.

Results: PSi values of <50 consistent with general anesthesia were attained in 118/119 (99.1%) patients. Of these patients, 33 (27.7%) attained PSi values <25 consistent with variable burst suppression. The 118 patients that reached PSi <50 spent a significantly greater percentage (53.1% vs. 42%) of their case at PSi levels <50 compared to PSi levels >50 (p=0.001). Mean total propofol dose was significantly correlated to patient PSi during periods of PSi <25 (R=0.406, p=0.021).

Conclusion: Although providers planned for moderate to deep sedation, processed EEG showed patients were under general anesthesia, often with burst suppression. Anesthesiologists and endoscopists may utilize processed EEG to recognize their institutional practice patterns of procedural sedation with propofol and improve upon it.

Conflict of interest statement

The authors declare no conflicts of interest.

Copyright © 2020 Jamie Bloom et al.

Figures

Figure 1
Figure 1
Four lead raw EEG from SedLine® displaying classic 1 : 10 burst to suppression ratio seen in neuroprotection with propofol in two separate patients from this study.
Figure 2
Figure 2
Patients' means ± SD PSi during BSpn (PSi p < 0.001) lower than their GA (PSi 25–50) for the case.
Figure 3
Figure 3
Mean ± SD percent of total case time spent with PSi 25–50 compared to percent of case time at PSi ≥50. The percent of time patients had PSi 25–50 was significantly higher than the percent of time PSi was >50.
Figure 4
Figure 4
The PSi measures are shown for the episodes of GA and BSpn versus total propofol dose. Propofol dose was not related to the patients' PSi during GA periods (R = 0.048, p=0.606); however, it was significantly correlated to the patients' PSi during BSpn (R = 0.406, p=0.021).

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