It's everybody's BIS™

A positive surgical outcome includes much more than remedying the problem requiring surgery.The patient experience, from initial anesthesia delivery through surgery and then recovery can be negatively impacted when not enough-or too much-anesthesia is used.

 

Recent, peer-reviewed evidence now suggests that brain function monitor guided anesthetic dosing may decrease the rate of postoperative delirium.

 

Brain function monitoring with Bispectral Index"' (BIS™) technology during surgical procedures gives you the ability to directly monitor the anesthetic effect on your patient's brain to optimize the anesthetic dosing.

 

This web page is intended as a resource to help you identify and reduce the risks of postoperative delirium in the elderly and patients at high risk.

 

Delirium: The problem and solution

In the clinical review "Anticipating and managing postoperative delirium and cognitive decline in adults",1 the authors conclude:

  • "Neurobehavioral problems are common after surgery" and include "emergence delirium, postoperative delirium, and postoperative cognitive decline".
  • Delirium is defined as having "reduced clarity, inability to focus, disorientation, memory loss, speech problems and other factors".
  • "Postoperative delirium is the most severe form of delirium". In fact, it is "...tantamount to acute brain failure and should be considered akin to other postoperative organ failures".

The clinical team may not recognize more than 50% of delirium cases.2


Risk factors for postoperative delirium

Earlier research concluded that "univariate factors associated with delirium include age, preexisting cognitive impairment, greater preoperative functional limitations and a history of prior delirium".3 However, in a more recent randomized controlled trial of 1155 patients, it was shown that "episodes of deep anesthesia (bispectral index score <20) were independently predictive for postoperative delirium".4
 

The type of operation and degree of operative stress is also a factor. For example, high-operative stress vascular procedures can carry a high risk of delirium in elderly patients - up to 36%.5

  1. Lepouse, C., Lautner, C., et al. Emergence delirium in adults in postanaesthesia care unitBritish Journal Anaesthesia. May 2, 2006;(96) 747-53
  2. de Lange, E., Verhaak, P.F., van der Meer, K. Prevalence, presentation and prognosis of delirium in older people in the population, at home and in long term care: a reviewInt J Geriatr Psychiatry. Feb 28, 2013.
  3. Selinger, S. Preventing Hospital Delirium. The New Old Age blog. New York Times Website. November 11,2011. Accessed March 6, 2015.
  4. Inouye, Sharon K. et al. Postoperative Delirium in Older Adults: Best Practice Statement from the American Geriatrics Society. lntraoperative Measures to Prevent DeliriumJ Am Coll Surg. 2014;220;2 ,136-148.e1.
  5. Leslie, D.L., Marcantonio, E.R., Zhang, Y., Leo-Summers, L., & Inouye, S.K. (2008). One-year health care costs associated with delirium in the elderly populationArchives of Internal Medicine. 168(1), 27-32.
  6. Whitlock, E.L., Torres, B.A., Lin, N., Helsten, D.L., Nadelson, M.R., & Mashour, G.A. (2014). Postoperative delirium in a substudy of cardiothorac ic surgical patients in the BAG-RECALL clinical trialAnesthesia & Analegesia. 118(4),809-817.
  7. Sieber, F.E., Zakriya, K.J., Gottschalk, A., Blute, M.R., Lee, H.B., Rosenberg, P.B., Mears S.C. Sedation depth during spinal anesthesia and the development of postoperative delirium in elderly patients undergoing hip fracture repairMayo Clin Proc. 2010 Jan;85(1):18-26.
  8. Inouye, S.K., Bogardus, S.T. Jr., Charpentier, P.A. et al. A multicomponent intervention to prevent delirium in hospitalized older patientsN Engl J Med. 1999;340:669-676. (ET)
  9. Marcantonio, E.R., Flacker, J.M., Wright, R.J. et al. Reducing delirium after hip fracture: A randomized trialJ Am Geriatr Soc. 2001;49:516-522.(ET)
  10. Rubin, F.H., Neal, K., Fenlon, K., Hassan, S., Inouye, S.K. Sustainability and scalability of the hospital elder life program at a community hospitalJ Am Geriatr Soc. Feb 2011;59(2):359-65.
  11. Chan, M.T., Cheng, B.C., Lee, T.M. et al. BIS-guided anesthesia decreases postoperative delirium and cognitive declineJ Neurosurg Anesthesiol. 2013; 25: 33-42.
  12. Radtke, F. M., Franck, M., Lendner, J., Kruger, S., Wernecke, K. D., & Spies, C. D. (2013). Monitoring depth of anaesthesia in a randomized trial decreases the rate of postoperative delirium but not postoperative cognitive dysfunctionBr J Anaesth. 2013; 110: i98-105.
  13. Kaplan, L.J., Bailey, H. Bispectral index (BIS) monitoring of ICU patients on continuous infusion of sedatives and paralytics reduces sedative drug utilization and costCrit Care Med. 2000;4(Suppl):S110.
  14. Gan, T.J., Glass, P. S., Windsor, A., Payne, F., Rosow, C., Sebel, P., & Manberg, P. (1997). Bispectral index monitoring allows faster emergence and improved recovery from propofol, alfentanil, and nitrous oxide anesthesiaAnesthesiology. 87(4), 808-815.
  15. Myles P.S., Leslie, K., McNeil, J., Forbes, A., Chan, M.T. Bispectral index monitoring to prevent awareness during anaesthesia: the B-Aware randomised controlled trialLancet. 2004;363(9423):1757-1763.
  16. White, P.F., Ma, H., Tang, J., Wender, R.H., Sloninsky, A., Kariger, R. Does the use of electroencephalographic bispectral index or auditory evoked potential index monitoring facilitate recovery after desflurane anesthesia in the ambulatory setting?Anesthesiology. 2004; 100(4):811-817.

 

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Evidence and Supporting Resources

Delirium: Prevalence

Ten percent of patients over 50 will experience some level of delirium postoperatively, and the incidence increases up to 60% for those over 65. In young adults, the occurrence of emergence delirium in the PACU ranges from 3 to 20%.1

In an article published in the International Journal of Geriatric Psychiatry, the authors conclude: "In long-term care, prevalence ranges between 1.4% and 70%, depending on diagnostic criteria and on the prevalence of dementia. Most studies agree that older people who previously experienced delirium have a higher risk of dementia and a higher mortality rate. Population and long-term care studies show the same tendency."2

Delirium: Risks to Healthcare Providers

In an era of increasing accountability and a focus on outcomes-based medicine, the risk to HCPs is high.According to Dr. Sharon K. lnnoye, a professor of medicine at Harvard Medical School and director of the Aging Brain Center at Hebrew Seniorlife in Boston, "Not only do patients have a 25-70% higher chance of dying during their hospital stay, but they are also at a 62% higher risk of mortality in the following year."3

The American Geriatrics Society now believes there is sufficient peer-reviewed published data on levels of anesthesia as an independent predictor of delirium in the postsurgical setting. Their Expert Panel on Postoperative Delirium in Older Adults consensus statement on intraoperative monitoring asserts that practitioners may use "processed electroencephalographic monitors of anesthetic depth during intravenous sedation or general anesthesia of older patients to reduce postoperative delirium."4

Delirium: Costs to Hospitals

Numerous studies have shown an increased risk of institutionalization, dementia and death in patients with postoperative delirium5 as well as increases in hospital length of stay by up to six days.6 Moreover, "total cost estimates attributable to delirium ranged from $16,303 to $64,421 per patient".5

According to a study in The Journal of American Geriatric Society, post-hospital treatment for delirium costs $143-$152 billion per year,5 which includes additional rehabilitation services, home healthcare and nursing home care.7

Delirium: How BIS™ monitoring can help mitigate risk

Postoperative delirium is preventable in up to 40% of such cases,6 with a proper screening program, the identification of risk factors and the implementation of evidence-based monitoring methods within the OR.

Brain function monitoring-guided anesthesia dosing may decrease the rate of postoperative delirium.6,7,11,12 Monitoring with Bispectral Index™ (BIS™') technology during surgical procedures gives anesthesia providers the ability to directly monitor the anesthetic effect on the patient's brain to optimize the anesthetic dosing for the individual.

Peer-reviewed literature has shown BIS-guided anesthetic titration may aid in a reduction in the incidence of delirium in elderly and other patient populations at increased risk.5

BIS monitoring has also been clinically shown to reduce primary anesthetic delivery (as much as 50%) and promote faster wake-up, recovery and discharge from the PACU.11,12,13,14 BIS also reduces the risk of awareness or ''wake-up" during surgery by up to 80%.14

BIS™ monitoring ensures a more positive experience for patients

Brain function monitoring with Bispectral lndex (BIS™) technology during surgical procedures gives anesthesiologists the ability to directly monitor the anesthetic effect on the patient's brain to optimize dosing,which can result in:

  • Improved safety: Helps the anesthesia professional optimize the anesthetic dosing for each patient
  • Reduced postoperative delirium: Research has now shown that monitoring brain function monitoring-guided anesthesia dosing may decrease the rate of postoperative delirium11,12
  • Reduced costs: Reduction in primary anesthetic delivery of up to 50%; fewer delirium episodes may reduce treatment costs6,13
  • Improved patient satisfaction: Faster wake-up, recovery and discharge from PACU; 80% less risk of patient awareness during surgery14,15,16

 

  1. Lepouse, C., Lautner, C., et al. Emergence delirium in adults in postanaesthesia care unitBritish Journal Anaesthesia. May 2, 2006;(96) 747-53
  2. de Lange, E., Verhaak, P.F., van der Meer, K. Prevalence, presentation and prognosis of delirium in older people in the population, at home and in long term care: a reviewInt J Geriatr Psychiatry. Feb 28, 2013.
  3. Selinger, S. Preventing Hospital Delirium. The New Old Age blog. New York Times Website. November 11,2011. Accessed March 6, 2015.
  4. Inouye, Sharon K. et al. Postoperative Delirium in Older Adults: Best Practice Statement from the American Geriatrics Society. lntraoperative Measures to Prevent DeliriumJ Am Coll Surg. 2014;220;2 ,136-148.e1.
  5. Leslie, D.L., Marcantonio, E.R., Zhang, Y., Leo-Summers, L., & Inouye, S.K. (2008). One-year health care costs associated with delirium in the elderly populationArchives of Internal Medicine. 168(1), 27-32.
  6. Whitlock, E.L., Torres, B.A., Lin, N., Helsten, D.L., Nadelson, M.R., & Mashour, G.A. (2014). Postoperative delirium in a substudy of cardiothorac ic surgical patients in the BAG-RECALL clinical trialAnesthesia & Analegesia. 118(4),809-817.
  7. Sieber, F.E., Zakriya, K.J., Gottschalk, A., Blute, M.R., Lee, H.B., Rosenberg, P.B., Mears S.C. Sedation depth during spinal anesthesia and the development of postoperative delirium in elderly patients undergoing hip fracture repairMayo Clin Proc. 2010 Jan;85(1):18-26.
  8. Inouye, S.K., Bogardus, S.T. Jr., Charpentier, P.A. et al. A multicomponent intervention to prevent delirium in hospitalized older patientsN Engl J Med. 1999;340:669-676. (ET)
  9. Marcantonio, E.R., Flacker, J.M., Wright, R.J. et al. Reducing delirium after hip fracture: A randomized trialJ Am Geriatr Soc. 2001;49:516-522.(ET)
  10. Rubin, F.H., Neal, K., Fenlon, K., Hassan, S., Inouye, S.K. Sustainability and scalability of the hospital elder life program at a community hospitalJ Am Geriatr Soc. Feb 2011;59(2):359-65.
  11. Chan, M.T., Cheng, B.C., Lee, T.M. et al. BIS-guided anesthesia decreases postoperative delirium and cognitive declineJ Neurosurg Anesthesiol. 2013; 25: 33-42
  12. Radtke, F. M., Franck, M., Lendner, J., Kruger, S., Wernecke, K. D., & Spies, C. D. (2013). Monitoring depth of anaesthesia in a randomized trial decreases the rate of postoperative delirium but not postoperative cognitive dysfunctionBr J Anaesth. 2013; 110: i98-105.
  13. Kaplan, L.J., Bailey, H. Bispectral index (BIS) monitoring of ICU patients on continuous infusion of sedatives and paralytics reduces sedative drug utilization and costCrit Care Med. 2000;4(Suppl):S110.
  14. Gan, T.J., Glass, P. S., Windsor, A., Payne, F., Rosow, C., Sebel, P., & Manberg, P. (1997). Bispectral index monitoring allows faster emergence and improved recovery from propofol, alfentanil, and nitrous oxide anesthesiaAnesthesiology. 87(4), 808-815.
  15. Myles P.S., Leslie, K., McNeil, J., Forbes, A., Chan, M.T. Bispectral index monitoring to prevent awareness during anaesthesia: the B-Aware randomised controlled trialLancet. 2004;363(9423):1757-1763.
  16. White, P.F., Ma, H., Tang, J., Wender, R.H., Sloninsky, A., Kariger, R. Does the use of electroencephalographic bispectral index or auditory evoked potential index monitoring facilitate recovery after desflurane anesthesia in the ambulatory setting?Anesthesiology. 2004; 100(4):811-817.

 

COVIDIEN, COVIDIEN with logo, Covidien logo and positive results for life are U.S. and internationally registered trademarks of Covidien AG. Other brands are trademarks of a Covidien company. ©2015 Covidien.