Perioperative use of bispectral (BIS) monitor for a pressure ulcer patient with locked‐in syndrome (LIS)

Abstract

The bispectral (BIS) monitor uses brain electroencephalographic data to measure depth of sedation and pharmacological response during anesthetic procedures. In this case, the BIS monitor was used for another purpose, to demonstrate postoperatively to the nursing staff that a patient with history of locked-in syndrome (LIS), who underwent pressure ulcer debridement, had periods of wakefulness and apparent sensation, even with his eyes closed. Furthermore, as patients with LIS can feel pain, despite being unable to move, local block or general anesthesia should be provided for sharp surgical debridement and other painful procedures. This use of the BIS has shown that as a general rule, the staff should treat the patient as though he might be awake and sensate even if he does not open his eyes or move his limbs. Our goal was to continuously monitor pain level and communicate these findings to the entire wound team, ie anesthesiologists, surgeons, and nurses.

Anesthetic Considerations for Patients with Locked-In Syndrome Undergoing Endoscopic Procedures

“…The ability to assess whether a patient is feeling pain during a procedure is a concern for anesthesiologists, especially for a patient unable to communicate. In a case report of an LIS patient undergoing sacral ulcer debridement, the MAC anesthetic plan included use of a bispectral (BIS) monitor to assess the anesthetic state of the patient in the operating room (OR) and post-anesthesia care unit (PACU) [ 17 ]. In that report, the authors describe how targeting a BIS value of 40–60 during anesthesia allowed them to differentiate between an anesthetized vs an awake state, despite the patient’s eyes being closed.…”

“… Consider using a BIS monitor or other neurophysiological monitoring device for more painful procedures performed under an MAC anesthetic. This plan may require pre-procedure testing to determine the range of values that represent awake or asleep, regardless of eye opening [ 17 ]. If such methods are not readily available or if the situation requires an urgent surgery or procedure, then general endotracheal anesthesia may be a better choice over MAC to ensure control of pain or discomfort.…”

Locked-in syndrome revisited

“…189 Bispectral monitoring was used to assess postoperative analgesia in a LiS patient. 190 Brain computer interfaces (BCIs) and other technical support systems are also highly important in the care of LiS patients. 164 EEG is the most commonly used method in BCIs, and the control signals are either evoked, spontaneous or hybrid.…”