LAUSR

Learning Objectives: Currently, there is no standard method or validated tool for assessing sedation in patients receiving neuromuscular blocking agents (NMBA). Bispectral index (BIS) has been used to monitor sedation and mitigate risk of awareness in patients undergoing general anesthesia; however, the role of BIS is not clearly established in patients undergoing sustained paralysis in the intensive care unit (ICU). The purpose of this study was to determine the impact of BIS monitoring on analgesia and sedation in patients with acute respiratory distress syndrome (ARDS) on NMBA. Methods: This was a retrospective study of patients admitted to Detroit Receiving Hospital and Harper University Hospital from 1/1/2011 to 6/30/2017 and received a 24–48 hr continuous infusion of cisatracurium (CIS) for moderate to severe ARDS. The primary outcome was cumulative dose of sedatives (in lorazepamequivalents) and analgesics (in fentanyl-equivalents) over CIS infusion duration. Secondary outcomes included frequency of titrations, RASS after NMBA discontinuation, incidence of delirium, barotrauma and tracheostomy, ventilator-free days, ICU-free days, and hospital length of stay (LOS). Results: 20 patients met all inclusion criteria, 9 patients who received BIS monitoring and 11 patients who did not (non-BIS). The median cumulative dose of analgesia was 4.03mg (IQR 2.29–6.87) for BIS and 9.93mg (IQR 5.38–19.37) for non-BIS (P = 0.04). The median analgesia infusion rate was 1.50mcg/kg/hr (IQR 0.66–2.94) for BIS and 2.58mcg/kg/hr (IQR 2.16–6.66) for non-BIS (P=0.02). The BIS group received a greater number of titrations, median 3 dose changes (IQR 2.5–6) vs. 1 (IQR 1–2) for non-BIS (P <0.01). 43% of BIS patients had a RASS > -4 upon NMBA discontinuation vs. 20% of non-BIS patients (P = 0.40). There was no difference in incidence of delirium, barotrauma and tracheostomy, ventilator-free days, ICU-free days, or hospital LOS. Conclusions: BIS monitoring reduced the cumulative amount and median infusion rate of analgesia for ARDS patients. However, this reduction may be inappropriate as a greater proportion of BIS patients were inadequately sedated (RASS > -4) upon NMBA discontinuation. BIS monitoring also increased nursing workload with more frequent titrations without improving patient outcomes compared to standard management.