Bispectral Index Guided Bispectral Index Guided Anesthetic Practice Anesthetic Practice in Cardiac Surgeryin Cardiac Surgery

Dr. Mohamed Essam, MDDr. Mohamed Essam, MDAssistant Professor, Anesthesia DepartmentAssistant Professor, Anesthesia Department

Ain Shams UniversityAin Shams University

Bispectral IndexBispectral IndexBISBIS

Processed EEG and Computer algorithm Processed EEG and Computer algorithm Assigns a numerical value based on the Assigns a numerical value based on the

probability of consciousnessprobability of consciousness

BISBIS

BISBIS Approved by the FDA on Oct.1996

Estimated Sensitivity 97.3 % Specificity 94.4 % Accuracy achieved with: - SQI 100% - EMG 0% - SR 0

Balanced General Balanced General AnesthesiaAnesthesia

HYPNOSISHYPNOSIS

ANALGESIAANALGESIA RELAXATIONRELAXATION

BISBIS

FACTS IN OPCABFACTS IN OPCAB

Anaesthetic ProspectiveAnaesthetic Prospective

HaemodynamicsHaemodynamics

Narcotics Vs. HypnoticsNarcotics Vs. Hypnotics

Surgical ProspectiveSurgical Prospective

Heart DislocationHeart Dislocation

Hazards of VasopressorsHazards of Vasopressors

Fast TrackingFast Tracking Term aims at reducing Cost & Stay of Surgical

Patients

Peri-operative process involving rapid progress from preoperative preparation through surgery and discharge from the hospital.

Early Extubation may be a component of this

process. However, early extubation and ‘fast track’ are not synonymous.

Anesthetic TechniqueAnesthetic Technique

Total Intravenous Technique :Total Intravenous Technique : Steady Plasma LevelSteady Plasma Level Decreased Total Dose RequirementsDecreased Total Dose Requirements Avoidance of Bolus effectsAvoidance of Bolus effects . Hypnotics . Hypnotics Hemodynamic Instability Hemodynamic Instability . Opioids . Opioids Rigidity Rigidity Rapid RecoveryRapid Recovery Eliminate incidence of AwarnessEliminate incidence of Awarness Saving of Inhalational Agents for IPC effectsSaving of Inhalational Agents for IPC effects

Anesthetic TechniqueAnesthetic Technique

Agents : Induction Maintenance Midazolam 0.05 – 0.1 mg / Kg 1.5 ug / Kg / min0.05 – 0.1 mg / Kg 1.5 ug / Kg / min Sufentanil 1 – 1.5 ug / Kg 0.2 ug / Kg / hr1 – 1.5 ug / Kg 0.2 ug / Kg / hr Rocuronium 0.9 mg / Kg 0.5 mg / Kg / hr0.9 mg / Kg 0.5 mg / Kg / hr

MethodologyRecorded Parameters Hemodynamics

BIS Reading

Data PointsT0= Baseline post-induction

T1= Skin incision

T2= Sternotomy

T3= 60 minutes post-induction

T4= 90 minutes post-induction

T5= With chest closure

Total IV Anaesthetic RequirementsTotal IV Anaesthetic Requirements Inhalational Sevoflurane SupplemetationInhalational Sevoflurane Supplemetation Total Phenylepherine DosageTotal Phenylepherine Dosage Inotropic Support Inotropic Support Awareness ( Questionnaire )Awareness ( Questionnaire ) Postoperative Data ( Fast Tracking )Postoperative Data ( Fast Tracking )

48

49

50

51

52

53

54

55

BIS Reading

Range

0 1 2 3 4 5

Data Points

BIS Assessment

• Male patient , 72 yrs.Male patient , 72 yrs.

• Wt. 62 Kg , Ht. 165 cmWt. 62 Kg , Ht. 165 cm

• ASA IVASA IV

• Medical history:Medical history: .HTN , DM.HTN , DM

..CAD CAD EFEF 30 % , old inf. MI 30 % , old inf. MI

PCIPCI LAD 90 % , RCA 100% , OM 90% LAD 90 % , RCA 100% , OM 90%

. Limited Pulmonary Reserve . Limited Pulmonary Reserve

.Old .Old CVA CVA (Frontal with small organized SDH) (Frontal with small organized SDH)

..Bilateral Carotid diseaseBilateral Carotid disease

Rt. 100% Occlusion , Lt. 90% StenosisRt. 100% Occlusion , Lt. 90% Stenosis

.Mild both Hepatic & Renal impairment.Mild both Hepatic & Renal impairment

CNS MonitoringCNS Monitoring

I. Functional Monitoring:I. Functional Monitoring: - Awake patient- Awake patient - EEG- EEG - SSEP’s- SSEP’s

II. Oxygen Supply & Perfusion:II. Oxygen Supply & Perfusion: - Stump Pressure- Stump Pressure - TCD - TCD

- SjVO- SjVO22

- RSO- RSO22

Surgical procedureSurgical procedure

CEA:CEA: - Exposure of CCA till the bifurcation- Exposure of CCA till the bifurcation

- Determining the severity of - Determining the severity of Cerebral IschemiaCerebral Ischemia

. Clamping of CCA. Clamping of CCA

. Measuring Stump Pressure. Measuring Stump Pressure

. BIS Tracing. BIS Tracing

- Shunt application- Shunt application

CABG:CABG: - Off pump Revascularisation of LAD- Off pump Revascularisation of LAD

- Initiation of CPB for Complete Revascularisation- Initiation of CPB for Complete Revascularisation

Detection of Cerebral IschemiaDetection of Cerebral IschemiaDuring CEADuring CEA

CONCLUSIONCONCLUSION

BIS Guided Anaesthetic PracticeBIS Guided Anaesthetic Practice ↓↓ Anaesthetic RequirementsAnaesthetic Requirements Hemodynamic stabilityHemodynamic stability Lower rate of Conversion to Conventional CABGLower rate of Conversion to Conventional CABG ↓↓ Vasopressor TherapyVasopressor Therapy NO Recorded AwarenessNO Recorded Awareness Fast Tracking AccomplishedFast Tracking Accomplished Cerebral IschemiaCerebral Ischemia