Full text is available at the source.
The Cochrane database of systematic reviews··
Comparing brain sedation monitoring and clinical checks in ventilated ICU adults and their effects on outcomes and resource use
Updated
Abstract
Only four studies with 256 participants met the inclusion criteria for examining BIS monitoring in mechanically ventilated ICU patients.
- No evidence was found of a difference in ICU length of stay between BIS and clinical assessment groups.
- The effect of BIS monitoring on the duration of mechanical ventilation was minimal, with little to no change observed.
- Reported adverse events related to sedation were uncertain due to very low-quality evidence.
- No clinically relevant adverse events, such as self-extubation, were reported in the studies reviewed.
- The overall quality of evidence regarding the benefits of BIS monitoring was very low, limiting the conclusions that can be drawn.
Simplified
BACKGROUND: Patients admitted to intensive care and on mechanical ventilation, are administered sedative and analgesic drugs to improve both their comfort and interaction with the ventilator. Optimizing sedation practice may reduce mortality, improve patient comfort and reduce cost. Current practice is to use scales or scores to assess depth of sedation based on clinical criteria such as consciousness, understanding and response to commands. However these are perceived as subjective assessment tools. Bispectral index (BIS) monitors, which are based on the processing of electroencephalographic signals, may overcome the restraints of the sedation scales and provide a more reliable and consistent guidance for the titration of sedation depth.The benefits of BIS monitoring of patients under general anaesthesia for surgical procedures have already been confirmed by another Cochrane review. By undertaking a well-conducted systematic review our aim was to find out if BIS monitoring improves outcomes in mechanically ventilated adult intensive care unit (ICU) patients.
OBJECTIVES: To assess the effects of BIS monitoring compared with clinical sedation assessment on ICU length of stay (LOS), duration of mechanical ventilation, any cause mortality, risk of ventilator-associated pneumonia (VAP), risk of adverse events (e.g. self-extubation, unplanned disconnection of indwelling catheters), hospital LOS, amount of sedative agents used, cost, longer-term functional outcomes and quality of life as reported by authors for mechanically ventilated adults in the ICU.
SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, CINAHL, ProQuest, OpenGrey and SciSearch up to May 2017 and checked references citation searching and contacted study authors to identify additional studies. We searched trial registries, which included clinicaltrials.gov and controlled-trials.com.
SELECTION CRITERIA: We included all randomized controlled trials comparing BIS versus clinical assessment (CA) for the management of sedation in mechanically ventilated critically ill adults.
DATA COLLECTION AND ANALYSIS: We used Cochrane's standard methodological procedures. We undertook analysis using Revman 5.3 software.
MAIN RESULTS: We identified 4245 possible studies from the initial search. Of those studies, four studies (256 participants) met the inclusion criteria. One more study is awaiting classification. Studies were, conducted in single-centre surgical and mixed medical-surgical ICUs. BIS monitor was used to assess the level of sedation in the intervention arm in all the studies. In the control arm, the sedation assessment tools for CA included the Sedation-Agitation Scale (SAS), Ramsay Sedation Scale (RSS) or subjective CA utilizing traditional clinical signs (heart rate, blood pressure, conscious level and pupillary size). Only one study was classified as low risk of bias, the other three studies were classified as high risk.There was no evidence of a difference in one study (N = 50) that measured ICU LOS (Median (Interquartile Range IQR) 8 (4 to 14) in the CA group; 12 (6 to 18) in the BIS group; low-quality evidence).There was little or no effect on the duration of mechanical ventilation (MD -0.02 days (95% CI -0.13 to 0.09; 2 studies; N = 155; I= 0%; low-quality evidence)). Adverse events were reported in one study (N = 105) and the effects on restlessness after suction, endotracheal tube resistance, pain tolerance during sedation or delirium after extubation were uncertain due to very low-quality evidence. Clinically relevant adverse events such as self-extubation were not reported in any study. Three studies reported the amount of sedative agents used. We could not measure combined difference in the amount of sedative agents used because of different sedation protocols and sedative agents used in the studies. GRADE quality of evidence was very low. No study reported other secondary outcomes of interest for the review. 2
AUTHORS' CONCLUSIONS: We found insufficient evidence about the effects of BIS monitoring for sedation in critically ill mechanically ventilated adults on clinical outcomes or resource utilization. The findings are uncertain due to the low- and very low-quality evidence derived from a limited number of studies.
Related papers
Nov '18
Sedation guided by protocols versus usual sedation in ventilated adults and children in intensive care
cited by 17 papers
systematic review
May '18
Melatonin's role in helping adults sleep in intensive care
cited by 21 papers
systematic review
Nov '18
Ways to prevent delirium in adults in intensive care
cited by 48 papers
systematic review
Dec '20
Oral care for seriously ill patients to help prevent pneumonia from ventilators
cited by 77 papers
systematic review
Jan '15
Using set sedation plans versus flexible sedation to shorten ventilator time in ICU patients
cited by 11 papers
systematic review
Jul '14
Daily sedation breaks compared to no breaks for critically ill adults on breathing machines
cited by 41 papers
systematic review
Nov '16
Oral care to help prevent lung infections in critically ill patients on ventilators
cited by 90 papers
systematic review
Aug '13
Oral care for critically ill patients to help prevent pneumonia from ventilators
cited by 55 papers
systematic review
Nov '22
Folic acid supplements and malaria risk and severity in people using antifolate malaria drugs in affected areas
cited by 29 papers
systematic review
Apr '15
Using alpha-2 agonists for long-term sedation in critically ill patients on mechanical ventilators
cited by 50 papers
systematic review