Improving Anesthetic Depth Assessment During Electroconvulsive Therapy with Bispectral Index Monitoring: A Pilot Quality Improvement Project
Abstract
Background: Achieving adequate anesthetic depth during an ECT procedure without suppressing the therapeutic seizure is challenging and increases the risk of patient awareness during the procedure.
Aim: To assess provider satisfaction with, and identify potential barriers to the use of BIS monitoring during ECT as a means to determine the feasibility of adopting BIS monitoring in the clinical ECT setting.
Setting: The pilot project was conducted in a 274-bed general medical and tertiary care facility located on the mid-Atlantic coast that provides services to more than 200,000 patients and administers over 200 ECT treatments annually.
Participants: Psychiatry staff and nurse anesthetists caring for patients undergoing ECT.
Methods: A convenience sample of 11 patients scheduled for 25 ECT treatments received BIS monitoring. Provider (n= 12) satisfaction was anonymously assessed using an 8-question survey.
Results: While 7 of the 12 providers rated their overall satisfaction with using the BIS monitor during ECT as Very good only 2 providers affirmatively answered the BIS monitor added value to their decision-making process.
Two anesthetized patients, who responded purposefully to verbal commands despite BIS values in the deep hypnotic range indicating sufficient anesthetic depth, were considered at risk for awareness under anesthesia.
Conclusions: Provider acceptance of the introduction of BIS monitoring to assess anesthetic depth during ECT was lukewarm at best. While the concept appears sound, one must question if the technology and tools are sufficiently developed to warrant its routine use in the described setting. Given the response of the two patients with BIS values indicating sufficient anesthetic depth, these observations merit further studies to replicate our findings in the psychiatric population and further explore the potential value of BIS monitoring during ECT.
References
2. Sartorius A, Muñoz-Canales E, Krumm B, et al. ECT anesthesia: the lighter the better? Pharmacopsychiatry. 2006;39(6):201–204. doi:10.1055/s-2006-950395.
3. Deiner S, Frost EA. Electroconvulsive therapy and anesthesia. Int Anesthesiol Clin. 2009;47(2):81–92. doi:10.1097/AIA.0b013e3181939b37.
4. Andrade C, Thirthalli J, Gangadhar BN. Unilateral nondominant electrode placement as a risk factor for recall of awareness under anesthesia during electroconvulsive therapy. J ECT. 2007;23(3):201–203. doi:10.1097/YCT.0b013e3180cab6a4.
5. Gajwani P, Muzina D, Gao K, Calabrese JR. Awareness under anesthesia during electroconvulsive therapy treatment. J ECT. 2006;22(2):158–159.
6. Litt L, Li D. Awareness without recall during anesthesia for electroconvulsive therapy. Anesthesiology. 2007;106(4):871–872. doi:10.1097/01.anes.0000264771.64168.63.
7. Ghoneim MM. Awareness during anesthesia. Anesthesiology. 2000;92(2):597–602.
8. Myles PS, Leslie K, McNeil J, Forbes A, Chan MT. Bispectral index monitoring to prevent awareness during anaesthesia: the B-Aware randomised controlled trial. Lancet. 2004;363(9423):1757–1763. doi:10.1016/S0140-6736(04)16300-9.
9. Pollard RJ, Coyle JP, Gilbert RL, Beck JE. Intraoperative awareness in a regional medical system: a review of 3 years' data. Anesthesiology. 2007;106(2):269–274.
10. Leslie K, Chan MT, Myles PS, Forbes A, McCulloch TJ. Posttraumatic stress disorder in aware patients from the B-aware trial. Anesth Analg. 2010;110(3):823–828. doi:10.1213/ANE.0b013e3181b8b6ca.
11. Samuelsson P, Brudin L, Sandin RH. Late psychological symptoms after awareness among consecutively included surgical patients. Anesthesiology. 2007;106(1):26–32.
12. Kotsovolis G, Komninos G. Awareness during anesthesia: how sure can we be that the patient is sleeping indeed? Hippokratia. 2009;13(2):83–89.
13. Hanss R, Bauer M, Bein B, et al. Bispectral index-controlled anaesthesia for electroconvulsive therapy. Eur J Anaesthesiol. 2006;23(3):202–207. doi:10.1017/S026502150500219X.
14. Johansen JW. Update on bispectral index monitoring. Best Pract Res Clin Anaesthesiol. 2006;20(1):81–99. doi:10.1016/j.bpa.2005.08.004.
15. Spiegel A, Tonner PH, Renna M. Altered states of consciousness: processed EEG in mental disease. Best Pract Research Clin Anaesthesiol. 2006;20(1):57–67.
16. Soehle M, Kayser S, Ellerkmann RK, Schlaepfer TE. Bilateral bispectral index monitoring during and after electroconvulsive therapy compared with magnetic seizure therapy for treatment-resistant depression. Br J Anaesth. 2014;112(4):695–702. doi:10.1093/bja/aet410.
17. Sartorius A, Krier A, Andres FJ, Bender HJ, Krumm B, Henn FA. Bispectral index monitoring for more effective electroconvulsive therapy? Br J Anaesth. 2006;96(6):806–807. doi:10.1093/bja/ael091.
18. Leslie K, Myles PS, Forbes A, Chan MT, Short TG, Swallow SK. Recovery from bispectral index-guided anaesthesia in a large randomized controlled trial of patients at high risk of awareness. Anaesth Intensive Care. 2005;33(4):443–451.
19. Punjasawadwong Y, Phongchiewboon A, Bunchungmongkol N. Bispectral index for improving anaesthetic delivery and postoperative recovery. Cochrane Database Syst Rev. 2014 Jun 17;6:CD003843. doi: 10.1002/14651858.CD003843.pub3.
Keywords
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Authors agree to the Creative Commons License listed below, which can be viewed by clicking the link below.
This work will be licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
