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Bispectral analysis during procedural sedation in the pediatric emergency department
Carmen Gamble1, Jon Gamble, Rob Seal
1Department of Pediatrics, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.
Insights
Pediatric procedural sedation often leads to a general anesthetic state, as measured by the bispectral (BIS) index. Physicians frequently underestimate the depth of sedation achieved during these procedures.
Area of Science:
- Pediatric Emergency Medicine
- Anesthesiology
- Clinical Monitoring
Background:
- Procedural sedation in pediatric emergency departments aims to provide comfort and reduce patient movement.
- Accurate assessment of sedation depth is crucial for patient safety during procedures.
- The bispectral (BIS) index monitor offers an objective measure of brain activity related to sedation.
Purpose of the Study:
- To determine the maximum depth of sedation using the bispectral (BIS) index during procedural sedation in pediatric emergency patients.
- To compare objective BIS index monitoring with physician clinical assessments of sedation depth.
Main Methods:
- A prospective, blinded, observational study in a tertiary pediatric emergency department.
- 50 pediatric patients undergoing procedural sedation were enrolled.
- Bispectral (BIS) index monitoring was used alongside physician clinical assessments.
Main Results:
- The mean nadir BIS index was 43.1, significantly lower than the threshold for general anesthesia (<60).
- Approximately 80% of sedations were classified as achieving general anesthesia based on BIS index.
- Physicians frequently underestimated sedation depth, with low agreement between BIS index and clinical assessment.
Conclusions:
- Pediatric procedural sedation frequently results in a state of general anesthesia.
- Physicians involved in procedural sedation often underestimate the maximal depth of sedation in pediatric patients.
- Objective monitoring like the BIS index may be valuable for assessing sedation depth.
Objective:
Our primary objective was to determine the maximum depth of sedation achieved, as measured by the bispectral (BIS) index monitor, for pediatric patients undergoing procedural sedation in a pediatric emergency department.
Methods:
This prospective, blinded, observational study was conducted in a tertiary pediatric emergency department. Procedural sedation and analgesia were performed in the standard manner, with the addition of blinded BIS index monitoring. In addition, both the sedating physician and the procedural physician recorded their clinical impression of the maximum depth of sedation.
Results:
A convenience sample of 50 patients was enrolled. The median age was 9.2 years (range, 3-15 y). The mean nadir BIS index was 43.1 ± 17.4 (SD), with a 95% confidence interval from 37.8 to 48.4. This was significantly lower than the BIS index value that is considered to reflect general anesthesia (<60; P > 0.0001). Almost 80% of the analyzed patient sedations were classified as having achieved general anesthesia. When comparing the sedating physician and the procedural physician's clinical assessment of maximal depth of sedation with the nadir BIS index value, there was only slight agreement between the 2 groups (κ statistics, 0.19 and 0.057, respectively). Ninety-three percent of the sedating physicians and 88% of the procedural physicians underestimated the maximum depth of sedation of their patients.
Conclusions:
This study suggests that most pediatric procedural sedation patients spend at least a period in a general anesthetic state. During most procedural sedation, the physicians involved are likely underestimating the maximal depth of sedation for their patients.
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