bis & train of four in the icu, - seton · clinical judgement critical...
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BIS & TRAIN OF FOUR IN THE ICU,
ADAM LIPP, MD CAPITOL ANESTHESIOLOGY ASSOCIATION AUSTIN, TEXAS
A CLINICAL REVIEW
NO DISCLOSURES
TWO DISTINCT CLINICAL MONITORS -USED INDEPENDENTLY -CAN BE COMBINED
BIS & TRAIN OF FOUR IN THE ICU
BIS MONITORING
BISPECTRAL INDEX, BIS, COVIDIEN
▸ Cerebral function monitor
▸ Intraoperative awareness (under anesthesia)
▸ Also useful when sedatives administered
▸ ICU: minimize over/undersedation, potentially lowering costs
Kaplan L ,Bailey H. Bispectral Index (BIS) monitoring of ICU patients on continuous infusions of sedatives and paralytics reduces sedative drug utilization. Crit Care. 2000;4(suppl 1):S110.
Simmons LE, Riker RR, PratoBS, FraserGL. Assessing sedation during intensive care unit mechanical ventilation with the Bispectral Index and the Sedation-Agitation Scale. Crit Care Med. 1999;27(8):1499-1504.
▸ processed EEG/EMG, proprietary algorithm
▸ 0-100 scale, 80 for sedation
▸ Not standard of care, "treating the BIS"
▸ Drugs, conditions, interventions can falsely impact values
TRAIN OF FOUR MONITORING
NEUROMUSCULAR BLOCKADE MEASUREMENT
TRAIN OF FOUR, RATIO
▸ Modality of neuromuscular monitoring
▸ Degree of neuromuscular blockade
▸ Useful when NMBDs given (limited movement, shivering)
▸ Pitfalls: crude measurement, clinical judgement critical etherpedia.wikispaces.com
Strange C, Vaughan L, Franklin C, Johnson J. "Comparison of Train-of-Four and Best Clinical Assessment during Continuous Paralysis", American Journal of Respiratory and Critical Care Medicine, Vol. 156, No. 5 (1997), pp. 1556-1561.
Strange C, Vaughan L, Franklin C, Johnson J. "Comparison of Train-of-Four and Best Clinical Assessment during Continuous Paralysis", American Journal of Respiratory and Critical Care Medicine, Vol. 156, No. 5 (1997), pp. 1556-1561.
TRAIN OF FOUR, RATIO
▸ Modality of neuromuscular monitoring
▸ Degree of neuromuscular blockade
▸ Useful when NMBDs given (limited movement, shivering)
▸ Pitfalls: crude measurement, clinical judgement critical
CASE SCENARIO
58 YR OLD MALE S/P TRAUMATIC PARTIAL LIMB AMPUTATION -Alcohol abuse -Severe coronary artery disease -Dilated cardiomyopathy, poor ejection fraction
▸ Microvascular re-anastomosis: no postop movement
▸ Ventilated: acute respiratory failure due to ARDS (transfusion related)
▸ Minimal sedative due to CAD, CM
CONSIDER COMBINATION OF BIS AND TRAIN OF FOUR
▸ When concerned about traumatic recall during neuromuscular blockade
▸ Use clinical judgement above all else