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 Duke Study Demonstrates BIS Helps Maintain Adequate Sedation & Decrease Propofol Use Shona Patel, RN, BSN is an intensive care nurse in the NeuroCritical
Care Unit at Duke University
Aspect: What was the study?s most important conclusion? SP: The study confirmed our suspicion that without an objective measure of brain state, nurses in the ICU tend to over-sedate patients. Over-sedation is more common than undersedation because nurses want to ensure that patients are comfortable, pain-free, and recall-free. Using BIS on the twenty patients in the study, we were able to decrease propofol infusion rates in 14 of them while still maintaining adequate sedation.
Aspect: What prompted the team at Duke to undertake this study? SP: We suspected that over-sedation in patients on propofol was not uncommon based on slow wake-up times and difficulty in conducting accurate neurological exams which require a certain level of alertness in the patient.When your ability to conduct a neurological exam is compromised in this way you often send patients for CT scans to make sure there have not been adverse changes in the patients? neurological condition.We wanted to conduct this study to determine if using BIS to monitor patients sedated with propofol would enable us to see a decrease in over-sedation. BIS gave us an objective measure of brain state that allowed us to maintain optimal sedation with less drug in most patients. Aspect: Did you calculate the cost savings? SP: Yes. Propofol is the drug of choice in the neurocritical care unit because it?s fast-acting and wears off quickly so we can wake patients regularly for their neurological exams. Based on the average wholesale price of propofol we calculated a savings of $126 per day/per patient when the BIS monitor was used to monitor the brain for optimal sedation. Aspect: Cost savings are important, but what about the benefit to the patient? SP: Our primary purpose in doing this study was to see if nurses in our unit would alter patient care based on the BIS value they were getting.When it became clear that nurses were able to give less propofol and achieve optimal sedation we recognized we could also save money. Using BIS to help prevent over-sedation is important to the patient in the neurocritical care environment because we have to give them regular neurological assessments, sometimes every hour or two, to make sure their condition hasn?t changed. If we can?t wake the patient for these exams, we may have to send them for a costly CT scan just to ensure that their status hasn?t changed. It can be difficult to determine if a patient is unresponsive because he or she is over-sedated or because of a stroke or other neurological event. Obviously, we want sedation in every patient to be as close to optimal as possible, for their own comfort, for their own well-being and to avoid unnecessary, costly procedures that may be frightening or stressful for the family. Aspect: Did the results of your study surprise you? SP: We weren?t really surprised.We wanted to see how BIS might make a difference in our patient he or she operated on yesterday not following commands when they were able to do so the day before, or not opening their eyes,we go to CT scan to see if the patient has bled into the operative site or had a stroke. Often the results of the CT scan are the same as the day before, so we can conclude that we were probably over-sedating the patient. If we can put a BIS monitor on the patient and the BIS value is 40, for example, we can lower the propofol, add analgesia and the patient will be more comfortable, less agitated and their neurological exam will be more stable. They will be able to open their eyes and follow commands as they did post-operatively. In this regard the BIS monitor gives you a lot more confidence as you assess the patient?s sedative state. Aspect: How are you using BIS in your unit? SP: Typically, we use BIS on patients requiring sedation to manage situations such as agitation, ventilator dysynchrony and increased intracranial pressure. I also use the BIS monitor with my end-of-life patients who are typically receiving sedation and analgesia. I can use the BIS monitor, obtain a desired BIS value and tell the family with confidence that their loved one is comfortable and isn?t in pain. |
Medical Center in Durham, N.C. She was part of a five-member team
that recently concluded a study that demonstrated how BIS monitoring
can help clinicians maintain adequate sedation while decreasing
propofol use. The study will be presented at the NTI meeting in
San Antonio,Texas.
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