Bispectral Index Monitoring:Validity and Utility in Pediatric Dentistry

Reliable and safe provision of sedation and general anesthesia is dependent on continuous vigilance of patient’s sedation depth. Failure to do so may result in unintended oversedation or undersedation. It is a common practice to observe sedation depth by applying subjective sedation scales and in case of general anesthesia, practitioner is dependent on vital sign assessment. The Bispectral Index System (BIS) is a recently introduced objective, quantitative, easy to use, and free from observer bias, and clinically useful tool to assess sedation depth and it precludes the need to stimulate the patient to assess his sedation level. The present article is an attempt to orient the readers towards utility and validity of BIS for sedation and general anesthesia in pediatric dentistry. In this article, we attempt to make the readers understand the principle of BIS, its variation across sedation continuum, its validity across different age groups and for a variety of sedative drugs.

Bispectral Index Monitoring, BIS, General anesthesia, Pediatric Dentistry, Sedation.

1. Liu J, Singh H, White PF. Electroencephalogram bispectral analysis predicts the depth of midazolam-induced sedation. Anesthesiology 84:64–69, 1996.

2. Kearse LA Jr, Rosow C, Zaslavsky A, Connors P, Dershwitz M, Denman W. Bispectral analysis of the electroencephalogram predicts conscious processing of information during propofol sedation and hypnosis. Anesthesiology 88:25–34, 1998.

3. Katoh T, Suzuki A, Ikeda K. Electroencephalographic derivatives as a tool for predicting the depth of sedation and anesthesia induced by sevoflurane. Anesthesiology. 88:642–650, 1998.

4. Sigl JC, Chamoun NG. An introduction to bispectral analysis for the electroencephalogram. J Clin Monit 10:392-404, 1994.

5. BIS VISTA™ Monitoring System Operating Manual. Aspect Medical Systems, Inc. Norwood, USA. Available at www.aspectmedical.com

6. Sandler AN, Sparks SB. The Use of Bispectral Analysis in Patients Undergoing Intravenous Sedation for Third Molar Extractions. J Oral Moxillofac Surg 58:364-368, 2000.

7. Myles PS, Leslie K, McNeil J, et al. Bispectral index monitoring to prevent awareness during anaesthesia: the B-Aware randomised controlled trial. Lancet 363:1757– 63, 2004.

8. Johansen JW, Sebel PS. Development and clinical application of electroencephalographic bispectrum monitoring. Anesthesiology 93:1336–44, 2000.

9. Johansen JW, Sebel PS, Sigl JC. Clinical impact of hypnotictitration guidelines based on EEG bispectral index (BIS) monitoring during routine anesthetic care. J Clin Anesth 12: 433–43, 2000.

10. Messieha ZS, Ananda RC, HoffmanWE, Punwani IC, Koenig HM. Bispectral Index System (BIS) monitoring reduces time to discharge in children requiring intramuscular sedation and general anesthesia for outpatient dental rehabilitation. Pediatr Dent 26:256-260, 2004.

11. Messieha SZ, Ananda CR, Hoffman EW, Punwani CI, Koenig MH. Bispectral Index System (BIS) Monitoring Reduces Time to Extubation and Discharge in Children Requiring Oral Presedation and General Anesthesia for Outpatient Dental Rehabilitation. Pediatr Dent 27:500-504, 2005.

12. Kerssens C, Sebel SP. To BIS or not to BIS? Anesth Analg 102:380–2, 2006.

13. Eeg-Olofsson O. Longitudinal developmental course of electrical activity of brain. Brain Dev 2:33–44, 1980.

14. Malviya S, Voepel-Lewis T, Tait RA, Watcha FM, Sadhasivam S, Friesen RH. Effect of Age and Sedative Agent on the Accuracy of Bispectral Index in Detecting Depth of Sedation in Children. Pediatrics 120: e461- e470, 2007.

15. Berkenbosch JW, Fichter CR, Tobias JD. The correlation of the bispectral index monitor with clinical sedation scores during mechanical ventilation in the pediatric intensive care unit. Anesth Analg 94:506–511, 2002.

16. Powers KS, Nazarian EB, Tapyrik SA, et al. Bispectral index as a guide for titration of propofol during procedural sedation among children. Pediatrics 115:1666–1674, 2005.

17. Grindstaff RJ, Tobias JD. Applications of bispectral index monitoring in the pediatric intensive care unit. J Intensive Care Med 19:111–116, 2004.

18. Sleigh JW, Barnard JP. Entropy is blind to nitrous oxide: can we see why? Br J Anaesth 92:159–161, 2004.

19. Sakai T, Singh H, Mi WD, Kudo T, Matsuki A. The effect of ketamine on clinical endpoints of hypnosis and EEG variables during propofol infusion. Acta Anaesthesiol Scand 43: 212–216, 1999.

20. Hans P, Dewandre PY, Brichant JF, Bonhomme V. Comparative effects of ketamine on Bispectral Index and spectral entropy of the electroencephalogram under sevoflurane anaesthesia. Br J Anaesth 94:336–340, 2005.

21. Vereecke HE, Struys MM, Mortier EP. A comparison of bispectral index and ARX-derived auditory evoked potential index in measuring the clinical interaction between ketamine and propofol anaesthesia. Anaesthesia 58: 957–961, 2003.

22. Mi WD, Sakai T, Kudo T, Kudo M, Matsuki A. Performance of bispectral index and auditory evoked potential monitors in detecting loss of consciousness during anaesthetic induction with propofol with and without fentanyl. Eur J Anaesthesiol 21:807–811, 2004.

23. Vanluchene AL, Struys MM, Heyse BE, Mortier EP. Spectral entropy measurement of patient responsiveness during propofol and remifentanil: a comparison with the bispectral index. Br J Anaesth 93:645–654, 2004.

24. Kodaka M, Okamoto Y, Handa F, Kawasaki J, Miyao H. Relation between fentanyl dose and predicted EC50 of propofol for laryngeal mask insertion. Br J Anaesth 92:238–241, 2004.

25. Dahaba AA. Different conditions that could result in the bispectral index indicating an incorrect hypnotic state. Anesth Analg 101:765–773, 2005.

26. Pan YZ, Li DP, Chen SR, Pan HL. Activation of mu-opioid receptors excites a population of locus coeruleus-spinal neurons through presynaptic disinhibition. Brain Res 997: 67–78, 2004.

27. Malviya S, Voepel-Lewis T, Tait RA. A Comparison of Observational and Objective Measures to Differentiate Depth of Sedation in Children from Birth to 18 Years of Age. Anesth Analg 102: 389–94, 2006.

28. Overly LF, Wright OR, Connor AF, Jay DG, Linakis GJ. Bispectral Analysis During Deep Sedation of Pediatric Oral Surgery Patients. J Oral Maxillofac Surg 63:215-219, 2005.

29. Sadhasivam S, Ganesh A, Robinson A, Kaye R, Watcha FM. Validation of the Bispectral Index Monitor for Measuring the Depth of Sedation in Children. Anesth Analg 102:383–8, 2006.

30. Haberland MC, Baker S, Liu H. Bispectral Index Monitoring of Sedation Depth in Pediatric Dental Patients. Anesth Prog 58:66-72, 2011.

31. Jeleazcov C, Schmidt J, Schmidt B, Becke K, Albretch S. EEG variables as measures of arousal during propofol anaesthesia for general surgery in children: rational selection and age dependence. British J Anaes 99: 845–54, 2007.

32. Messieha ZS, Guirguis S, Hanna S. Bispectral index monitoring (BIS) as a guide for intubation without neuromuscular blockade in officebased pediatric general anesthesia: a retrospective evaluation. Anesth Prog 58:3-7, 2011.

33. Liu SS. Effects of Bispectral Index Monitoring on Ambulatory AnesthesiaA Meta-analysis of Randomized Controlled Trials and a Cost Analysis. Anesthesiology 101:311–5, 2004.