Bispectral index versus COMFORT score to determine the level of sedation in paediatric intensive care unit patients: a prospective study

Andreas E Triltsch, Grit Nestmann, Helmut Orawa, Maryam Moshirzadeh, Michael Sander, Joachim Grosse, Arka Genähr, Wolfgang Konertz, Claudia D Spies, Andreas E Triltsch, Grit Nestmann, Helmut Orawa, Maryam Moshirzadeh, Michael Sander, Joachim Grosse, Arka Genähr, Wolfgang Konertz, Claudia D Spies

Abstract

Introduction: Most clinicians give sedatives and analgesics according to their professional experience and the patient's estimated need for sedation. However, this approach is prone to error. Inadequate monitoring of sedation and analgesia may contribute to adverse outcomes and complications. With this in mind, data obtained continuously using nonstimulating methods such as bispectral index (BIS) may have benefits in comparison with clinical monitoring of sedation. The aim of this prospective observational trial was to evaluate the use of electroencephalographic (EEG) BIS for monitoring sedation in paediatric intensive care unit (PICU) patients.

Methods: Forty paediatric patients (<18 years) were sedated for mechanical ventilation in a cardiac surgical and general PICU. In each paediatric patient BIS and COMFORT score were obtained. The study protocol did not influence ongoing PICU therapy. BIS and corresponding COMFORT score were collected three times for each patient. Measurements with the best starting EEG impedances were analyzed further. Deep sedation was defined as a COMFORT score between 8 and 16, and light sedation as a score between 17 and 26. Biometric and physiological data, and Pediatric Risk of Mortality III scores were also recorded.

Results: There was a good correlation (Spearman's rho 0.651; P = 0.001) between BIS and COMFORT score in the presence of deep sedation and low starting impedance. Receiver operating characteristic (ROC) analysis revealed best discrimination between deep and light sedation at a BIS level of 83.

Conclusion: In the presence of deep sedation, BIS correlated satisfactorily with COMFORT score results if low EEG impedances were guaranteed.

Figures

Figure 1
Figure 1
Study design. BIS, bispectral index; PICU, paediatric intensive care unit.
Figure 2
Figure 2
Correlation of bispectral index (BIS) and COMFORT score at different levels of sedation.
Figure 3
Figure 3
Receiver operating characteristic (ROC) analysis: cut-off point between light and deep sedation. BIS, bispectral index.
Figure 4
Figure 4
Correlation of bispectral index (BIS) and COMFORT score in patients younger and older than 6 months.

References

    1. Tobias JD. Tolerance, withdrawal, and physical dependency after long-term sedation and analgesia of children in pediatric intensive care unit. Crit Care Med. 2000;28:2122–2132. doi: 10.1097/00003246-200006000-00079.
    1. Selbst SM. Adverse sedation events in pediatrics: a critical incident analysis of contributing factors. Pediatrics. 2000;105:864–865. doi: 10.1542/peds.105.4.864.
    1. Ambuel B, Hamlett KW, Marx CM, Blumer JL. Assessing distress in pediatric intensive care environments: the COMFORT scale. J Pediatr Psychol. 1992;17:95–109.
    1. Marx CM, Smith PG, Lowrie LH, Hamlett KW, Ambuel B, Yamashita TS, Blumer JL. Optimal sedation of mechanically ventilated pediatric critical care patients. Crit Care Med. 1994;22:163–170.
    1. Burns AM, Shelly MP, Park GR. The use of sedative agents in critically ill patients. Drugs. 1992;43:507–515.
    1. Durbin CG., Jr Sedation in the critically ill patient. New Horiz. 1994;2:64–74.
    1. Kollef MH, Levy NT, Ahrens TS, Schaiff R, Prentice D, Sherman G. The use of continuous i.v. sedation is associated with prolongation of mechanical ventilation. Chest. 1998;114:541–548.
    1. Martin LD, Bratton SL, Quint P, Mayock DE. Prospective documentation of sedative, analgesic, and neuromuscular blocking agent use in infants and children in the intensive care unit: a multicenter perspective. Pediatr Crit Care Med. 2001;2:205–210. doi: 10.1097/00130478-200107000-00003.
    1. Sigl JC, Chamoun NG. An introduction to bispectral analysis for the electroencephalogram. J Clin Monit. 1994;10:392–404.
    1. Glass PS, Bloom M, Kearse L, Rosow C, Sebal P, Manberg P. Bispectral analysis measures sedation and memory effects of propofol, midazolam, isoflurane, and alfentanil in healthy volunteers. Anesthesiology. 1997;86:836–847. doi: 10.1097/00000542-199704000-00014.
    1. Rampil IJ. A primer for EEG signal processing in anesthesia. Anesthesiology. 1998;89:980–1002. doi: 10.1097/00000542-199810000-00023.
    1. Liu J, Singh H, White PF. Electroencephalogram bispectral analysis predicts the depth of midazolam-induced sedation. Anesthesiology. 1996;84:64–69. doi: 10.1097/00000542-199601000-00007.
    1. Liu J, Singh H, White PF. Electroencephalographic bispectral analysis correlates with intraoperative recall and depth of propofol-induced sedation. Anesth Analg. 1997;84:185–189. doi: 10.1097/00000539-199701000-00033.
    1. Doi M, Gajraj RJ, Mantzaridis H, Kenny GNC. Relationship between calculated blood concentrations of propofol and electrophysiological variables during emergence from anaesthesia: comparison of bispectral index, spectral edge frequency, median frequency and auditory evoked potentials. Br J Anaesth. 1997;78:180–184.
    1. De Deyne C, Struys M, Decruyenaere J, Creupelandt J, Hoste E, Colardyn F. Use of continuous bispectral EEG monitoring to assess depth of sedation in ICU patients. Intensive Care Med. 1998;24:1294–1298. doi: 10.1007/s001340050765.
    1. Simmons LE, Riker RR, Prato BS, Fraser GL. Assessing sedation during intensive care unit mechanical ventilation with the bispectral index and the Sedation–Agitation Scale. Crit Care Med. 1999;27:1499–1504. doi: 10.1097/00003246-199908000-00016.
    1. Shapiro BA. Bispectral index: better information for sedation in the intensive care unit? Crit Care Med. 1999;27:1663–1664. doi: 10.1097/00003246-199908000-00056.
    1. Triltsch AE, Welte M, von Homeyer P, Grosse J, Genahr A, Moshirzadeh M, Sidiropoulos A, Konertz W, Kox WJ, Spies CD. Bispectral index-guided sedation with dexmedetomidine in intensive care: a prospective, randomized, double blind, placebo-controlled phase II study. Crit Care Med. 2002;30:1007–1014. doi: 10.1097/00003246-200205000-00009.
    1. Iselin-Chaves IA, Flaishon R, Sebel PS, Howell S, Gan TJ, Sigl J, Ginsberg B, Glass PS. The effect of the interaction of propofol and alfentanil on recall, loss of consciousness, and the bispectral index. Anesth Analg. 1998;87:949–955. doi: 10.1097/00000539-199810000-00038.
    1. Werry C, Neulinger A, Eckert O, Lehmkuhl P, Pichlmayr I. [Age-related correlation between EEG parameters and depth of anesthesia under propofol. Effect of fentanyl] Anaesthesist. 1996;45:722–730. doi: 10.1007/s001010050304.
    1. Denman W, Swanson EL, Rosow D, Ezbicki K, Connors PD, Rosow CE. Pediatric evaluation of the bispectral index (BIS) monitor and correlation of BIS with end-tidal sevoflurane concentration in infants and children. Anesth Analg. 2000;90:872–877. doi: 10.1097/00000539-200004000-00018.
    1. Laussen PC, McGowan FX, Sullivan LJ, Murphy JA. Bispectral index monitoring in children during mild hypothermic cardiopulmonary bypass [abstract] Anesthesiology. 1998;89:A925. doi: 10.1097/00000542-199809160-00029.
    1. Johansen JW. Continuous intraoperative bispectral index monitoring and perioperative outcome in children [abstract] Anesth Analg. 1998;86:S406. doi: 10.1097/00000539-199802001-00404.
    1. McDermott NB, VanSickle T, Motas D, Friesen RH. Validation of bispectral index monitor during conscious sedation and deep sedation in children. Anesth Analg. 2003;97:39–43. doi: 10.1213/01.ANE.0000067402.02136.A2.
    1. Berkenbosch JW, Fichter CR, Tobias JT. The correlation of the bispectral index monitor with clinical sedation scores during mechanical ventilation in the pediatric intensive care unit. Anesth Analg. 2002;94:506–511. doi: 10.1097/00000539-200203000-00006.
    1. Crain N, Slonim A, Pollack MM. Assessing sedation in the pediatric intensive care unit by using BIS and the COMFORT scale. Pediatr Crit Care Med. 2002;3:11–14. doi: 10.1097/00130478-200201000-00003.
    1. Aneja R, Heard AM, Fletcher JE, Heard CM. Sedation monitoring of children by the Bispectral Index in the pediatric intensive care unit. Pediatr Crit Care Med. 2003;4:60–64. doi: 10.1097/00130478-200301000-00012.
    1. Courtman SP, Wardurgh A, Petros AJ. Comparison of the bispectral index monitor with the Comfort score in assessing level of sedation in critically ill children. Intensive Care Med. 2003;29:2239–2246. doi: 10.1007/s00134-003-1997-3.
    1. Electrode Position Nomenclature Committee American Electroencephalographic Society guidelines for standard electrode position nomenclature. J Clin Neurophysiol. 1991;8:200–202.
    1. Schmid RG. Clinical Electroencephalography in Infancy and Adolescence [in German] Berlin: Springer; 1995. The normal development of the EEG from neonates to adults in subjects with open eyes; pp. 55–79.
    1. Pollack MM, Patel KM, Ruttiman UE. PRISM III: an updated Pediatric Risk of Mortality score. Crit Care Med. 1996;24:743–752. doi: 10.1097/00003246-199605000-00004.
    1. De Jonghe B, Cook D, Appere-De-Vecchi C, Guyatt G, Meade M, Outin H. Using and understanding sedation scoring systems: a systematic review. Intensive Care Med. 2000;26:275–285. doi: 10.1007/s001340051150.
    1. Nasraway SA, Jr, Wu EC, Kelleher RM, Yasuda CM, Donally AM. How reliable is the bispectral index in critically ill patients? A prospective, comparative, single-blinded observer study. Crit Care Med. 2002;30:1483–1487. doi: 10.1097/00003246-200207000-00014.
    1. Bruhn J, Bouillon TW, Shafer SL. Electromyographic activity falsely elevates the bispectral index. Anesthesiology. 2000;92:1485–1487. doi: 10.1097/00000542-200005000-00042.
    1. Davidson AJ, McCann ME, Devavaram P, Auble SA, Sullivan LJ, Gillis JM, Laussen PC. The differences in bispectral index between infants and children during emergence from anesthesia after circumcision surgery. Anesth Analg. 2001;93:326–330. doi: 10.1097/00000539-200108000-00017.
    1. Schulte-Tamburen AM, Scheier J, Briegel J, Schwender D, Peter K. Comparison of five sedation scoring systems by means of auditory evoked potentials. Intensive Care Med. 1999;25:377–382. doi: 10.1007/s001340050861.
    1. Ibrahim AE, Taraday JK, Kharasch ED. Bispectral index monitoring during sedation with sevoflurane, midazolam and propoful. Anesthesiology. 2001;95:1151–1159. doi: 10.1097/00000542-200111000-00019.
    1. Frenzel D, Greim CA, Sommer C, Bauerle K, Roewer N. Is the bispectral index appropriate for monitoring the sedation level of mechanically ventilated surgical ICU patients? Intensive Care Med. 2002;28:178–183. doi: 10.1007/s00134-001-1183-4.

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