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Aspect: What was your first experience with the BIS monitor?
ML: Our medical director, Philip S. Gibbs, MD, FCCM, staff anesthesiologist, introduced us to BIS. Aspect: What was it about this patient that led him to suspect that BIS might have some value? ML: The patient was receiving a non-physiologic form of mechanical ventilation and we were having trouble sedating him. Dr.Gibbs thought that if we could get a more accurate assessment of where we were with the patient?s level of sedation,we?d be better able to ventilate the patient. We didn?t realize then that our use of BIS would blossom to where it is now. At the time, we were just looking at the benefits for this one patient. Aspect: When did you realize BIS was going to be useful with other patients in the ICU? CF: Once we started using BIS with other sedated and paralyzed patients, we quickly realized that BIS could help us improve our clinical judgment as we guided them through sedation.We found that clinical observation alone was often inaccurate. It made sense for us to develop a clinical protocol that utilized BIS technology on paralyzed sedated patients because we could not objectively assess their level of consciousness or their risk for experiencing recall. When we realized how BIS helped us in this situation, its usage spread like wildfire. Aspect: Why do you think that BIS use spread so quickly at your hospital? ML: Before we began using BIS,we had to rely on subjective assessment scales alone.We might have had a gut feeling that our patient was awake, or see tears roll down the patient?s face and wonder if he or she was conscious, but we never had an objective way to make this determination.We lived with the unpleasant realization that there were probably patients who were not sufficiently sedated. Patient recall is a huge concern among critical care nurses. Our worst fear is to have a patient who is paralyzed and conscious. By objectively measuring depth of consciousness, BIS provided us with the comfort of knowing that our patients were sedated appropriately.
CF: Our nurses have been strong advocates of the technology from the beginning. It?s easy to understand and it provides objective data that the nurses can take to the physician team to help advocate for their patients. Aspect: Has BIS made the traditional assessment scales that you?ve used in the past obsolete? ML: No, it hasn?t. BIS is another piece of technology that ? in conjunction with other pieces of information, like clinical assessment and sedation assessment scales ? helps us make sound clinical judgments. Without the data BIS provides, we?d be making decisions with incomplete information. If we can combine that one piece of objective data with good clinical and subjective data, then we?re delivering the best care possible. Aspect: Do you now use BIS on all patients receiving sedation? ML: BIS is standard for patients that are mechanically ventilated, are receiving sedation with a neuromuscular blocking agent, that require bedside procedures, or are undergoing druginduced coma management.We also use BIS to manage sedation for challenging patient populations, such as obese patients, patients with neurological diseases, and patients with substance abuse problems. Even our most novice nurses now know how to utilize the BIS monitor. Aspect: Can you explain how BIS helps guide sedation for bariatric patients? CF: The drugs we use usually come with a weight-based calculation that correlates weight and dosage, but those general recommendations do not necessarily reflect the optimal therapeutic dosage for an individual patient. The issue of storage of sedative drugs in the adipose tissue and re-absorption can be challenging in the obese population. ML: Nurses often rely on past experience to make clinical decisions. If you don?t have a lot of experience sedating bariatric patients, your sedation decision-making may be based on the average patient you?ve cared for. When you apply those same techniques or principles to bariatric patients, you may miss the mark by a wide margin. For example, we recently had a patient who was receiving what looked like a very heavy dose of sedation, but the patient still didn?t seem to be adequately sedated. BIS confirmed that despite what appeared to be an enormous amount of sedative, the patient was under-sedated. CF: There is a great deal of variability in the way patient populations respond to a given amount of a drug. BIS provides objective data to help us determine appropriate sedation to meet each patient?s needs. Before BIS,we may not have even known that the patient was not appropriately sedated. Aspect: How have you used BIS in patients with neuro-degenerative disease? ML: We first learned of the value of BIS in these cases with a patient who suffered from Lou Gehrig?s disease. It would be easy to assume that because the patient wasn?t moving, he was well-sedated. However, this patient was not pharmacologically paralyzed; his disease process was much more advanced than initially assessed. When we placed a BIS sensor on him, we realized that he was more awake than he should have been. CF: We made the mistake of assuming that because this patient was not moving, the amount of sedative medication we were giving was appropriate.Without BIS we couldn?t be sure whether paralysis was the result of the disease or the drug. The challenge is that we don?t always know how advanced the disease is. BIS gives us greater confidence in treating such patients. Aspect: You also mentioned substance abuse patients. Why is sedation management so difficult in these patients? CF: The alcoholic or drug-addicted patient often gives the false presentation that they?re appropriately sedated. These patients metabolize drugs differently, and they tend to have a higher tolerance for the drugs we administer. They often require multiple pharmacologics to find the appropriate mix of drugs to keep them comfortable and safe. Substance abuse patients may also experience wide fluctuations between somnolence ? or deep sedation ? and delirium and anxiety. BIS technology has really helped us manage this situation. Before the patient reaches the delirium/anxiety stage,we?re given the ?early warning,? so-to-speak. BIS tells us when they?re starting to lighten and that we need to get the appropriate sedative drugs and people in the room to keep the patient safe. Aspect: In what other circumstances has BIS proven especially useful? ML: We use BIS in end-of-life scenarios because morally and ethically we want to make certain that we are providing comfort for the patient and the family. Specifically, we want an objective measure of the patient?s level of consciousness to minimize anxiety for the family and the risk of awareness for the patient during withdrawal of support. Aspect: Do you talk about BIS with families of end-of-life patients? CF: We offer BIS technology to all of our patients and families who are facing the end-of life scenario.This enables us to ensure that the patient gets the best possible sedation without expediting the death process. We?ve found that families greatly appreciate BIS technology because it gives them a sense of understanding and control in a situation where they are feeling overwhelmed and out of control. We teach them what the BIS monitor is, what BIS values mean and how it provides us with added assurance that their loved one will not experience awareness. In the past, families watched the heart rate monitor. Now, they watch the BIS monitor. ML: I?ve personally witnessed the tremendous value of BIS in an end-of-life experience for a family that was intensely concerned about their loved one being awake and aware. It was a much different scenario than what it would have been like if we had not been able to offer BIS. CF: For example, sometimes, as people die, they experience rudimentary reflexes, such as the palm grasp reflex. Well, it?s only a reflex until it?s your mother. I?ve had several families over the course of years say, ?She?s squeezing my hand. She?s awake in there, I know it.? BIS technology has been invaluable in helping families cope with the dying process in that we are able to assure the family that their loved one is not suffering or aware during the process. Aspect: Any final thoughts? CF: Sedation is both an art and a science. It takes both to appropriately sedate these patients. ML: BIS places the final piece ? objective assessment ? into our sedation care best practice. This is all about having the ability to make good clinical judgments. We need both subjective observation and objective data to make these sound judgments. |
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