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CASE REPORT
Year : 2008  |  Volume : 52  |  Issue : 2  |  Page : 214-216 Table of Contents     

Bispectral Index Monitoring in Guillain Barre Syndrome with Dysautonomia


1 Ex- Senior Resident, Department of Neuroanaesthesiology, Neurosciences Centre, All India Institute of Medical Sciences (A.I.I.M.S.), New Delhi -110029, India
2 Senior Resident, Department of Neuroanaesthesiology, Neurosciences Centre, All India Institute of Medical Sciences (A.I.I.M.S.), New Delhi -110029, India
3 Assistant Professor, Department of Neuroanaesthesiology, Neurosciences Centre, All India Institute of Medical Sciences (A.I.I.M.S.), New Delhi -110029, India
4 Professor, Department of Neuroanaesthesiology, Neurosciences Centre, All India Institute of Medical Sciences (A.I.I.M.S.), New Delhi -110029, India

Date of Acceptance11-Mar-2008
Date of Web Publication19-Mar-2010

Correspondence Address:
Parmod K Bithal
Department of Neuroanaesthesiology, Neurosciences Centre, All India Institute of Medical Sciences, New Delhi -110029
India
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Source of Support: None, Conflict of Interest: None


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Bispectral index (BIS) is commonly used as an index of depth of anaesthesia and sedation. BIS can provide an additional benefit in detecting a critical neurological event, especially if the change of neurological status is caused by the critical illness itself. We encountered such an incident where the BIS value was decreased in a patient with Guillain Barre Syndrome, possibly due to cerebral hypoperfusion. The present report emphasises that BIS can be used not only as an indicator of cerebral ischaemia, but also as a tool to judge adequacy and efficacy of interventions targeted to restore the same.

Keywords: Bispectral index monitor; Dysautonomia; Cerebral hypoperfusion


How to cite this article:
Sharma D, Jain V, Rath GP, Bithal PK. Bispectral Index Monitoring in Guillain Barre Syndrome with Dysautonomia. Indian J Anaesth 2008;52:214-6

How to cite this URL:
Sharma D, Jain V, Rath GP, Bithal PK. Bispectral Index Monitoring in Guillain Barre Syndrome with Dysautonomia. Indian J Anaesth [serial online] 2008 [cited 2019 Dec 13];52:214-6. Available from: http://www.ijaweb.org/text.asp?2008/52/2/214/60627


   Introduction Top


The bispectral index (BIS) of the electroencepha­logram (EEG) is an empirical, statistically derived vari­able that provides information about the interaction of brain cortical and subcortical regions. [1] Since its intro­duction to the clinical armamentarium, BIS has gained popularity over years as an index of measure of depth of anaesthesia. It is expressed as a dimensionless num­ber between 0 and 100, with scores of 95 or greater typically indicating conscious state. [2] Recently, attempts have been made to extend the use of BIS to patients in the intensive care units (ICU), where sedative drugs are used frequently. [3] In this setting, BIS was shown to be correlated with the depth of sedation, and was pro­posed as a guide to prevent over-sedation in cases, where neurological assessment is a frequent requirement.


   Case report Top


A 36-yr-old male patient (weight 50 kg) of Guillain­Barre (GB) Syndrome was admitted in our ICU with complaint of progressive difficulty in breathing. In view of impending respiratory failure, his trachea was intu­bated and mechanical ventilation was initiated. Intrave­nous immunoglobulin (IVIg) 100gm/day was given for 5 days. Monitoring parameters included ECG, SpO 2 , non­invasive blood pressure (BP), central venous pressure (CVP), and urine output. A BIS sensor was attached on the forehead of the patient, connected to a BIS monitor. Intravenous infusion of midazolam and fentanyl was started and dose titrated to keep the BIS at 70-80. Two days after initiation of IVIg therapy the patient devel­oped fluctuations of BP and dysrrhythmias. An associa­tion of dysautonomia was confirmed with positive tests for autonomic function. As the patient developed se­vere and persistent hypotension, sedative medicants were withdrawn, and dopamine infusion was started to achieve a mean BP of 65-75 mmHg.

On day 4, while the patient was still on ventilatory and inotropic support, BIS was observed to be zero with suppression ratio (SR) of 100, and the EEG signal was a flat line. The patient was unresponsive and peripheral pulses were not palpable. Monitor showed absence of pulse oximetry tracing with sinus bradycardia (heart rate of 42 bpm). Cardiopulmonary resuscitation (CPR) was started, immediately. Atropine 0.6 mg followed by mephentermine 6 mg was administered, intravenously and patient was ventilated with 100% oxygen. Normal saline 500 ml was infused rapidly. Within a minute, ra­dial pulse could be palpated; heart rate increased to 120 bpm and blood pressure was 116/54 mm Hg. Simulta­neously, the BIS value increased to 58 and SR decreased to 10. Soon, the patient regained consciousness and started following verbal commands. Five minutes later, the patient was fully alert with BIS of 90. The monitor­ing trend revealed last BP of 96/58 mmHg, which was recorded 3 minutes before the event. It was observed that the infusion pump delivering dopamine has stopped delivering the drug, without an alarm. Dopamine infu­sion was restarted. Monitoring trends revealed progres­sive hypotension with bradycardia over last 10 minutes with progressive fall of BIS value over same time pe­riod.

Dopamine infusion was tapered off, over next two days, as the haemodynamic status improved. In view of prolonged intubation, tracheostomy was performed and he was weaned off ventilator over next 4 weeks. His muscle power gradually improved and he was discharged from the hospital after 6 weeks with intact neurological status and stable vital parameters.


   Discussion Top


GB Syndrome or acute inflammatory polyneuropa­thy is characterized by ascending and areflexic motor paralysis, respiratory failure, and autonomic dysfunction. [4] Autonomic failure (dysautonomia) may cause profound hypotension or hypertension, urinary retention, various dysrrhythmias, and ECG changes. Some episodes of hypotension are precipitated by suctioning or other pro­vocative vagal stimuli, but most seem to be spontane­ous. Vasodepressor response mediated by medullary and sympathetic mechanism may cause severe hypotension which may even lead to loss of consciousness due to cerebral hypoperfusion. [4] Probably, a similar type of epi­sode occurred in this patient. Hypotension in GB syn­drome may not always be due to autonomic failure. It may occur as a result of prolonged bed rest, dehydra­tion, positive pressure ventilation, and heavy sedation, or else because of sepsis and myocardial infarction. [4] As these causes were ruled out, we attribute the cause of sudden hypotension to malfunction of infusion pump of dopamine, in presence of an already existing dysauto­nomia.

Well known causes of low BIS value include deep anaesthesia, over-sedation, and hypothermia. In addi­tion, low BIS values attributable to hypoxia [5] , cerebral hypoperfusion [6] and intracranial catastrophe [7] have been reported in anaesthetized individuals. Our observation represents reversible global cerebral hypoperfusion in a conscious patient, detected by BIS monitoring.

The patient was not administered any sedative medication at the time of the event and was on inotropic support. The fall in BIS value was associated with flat EEG tracing with simultaneous loss of consciousness and circulatory collapse. The haemodynamic recovery was associated with return of consciousness and simul­taneous normalization of BIS value with normal EEG pattern. Hence, we believe, the cause of low BIS in this patient was cerebral hypoperfusion. Nevertheless, an invasive BP monitoring could have helped in early diag­nosis of this untoward event.

Cerebral autoregulation is a critical homeostatic mechanism that minimizes fluctuations in cerebral blood flow (CBF) with changes in cerebral perfusion pres­sure (CPP) and thus, protects the brain against ischaemic and hyperaemic insults. Though there is no information available regarding the status of cerebral autoregulation in patients with autonomic dysfunction, acute ischaemia with fall in blood pressure below the critical level of 50 mm Hg is expected to cause compromise of CBF. There are no clinical studies to indicate a definite relationship between BIS and CBF or CPP. However, it has been suggested that a BIS value below 30 is an indicator of EEG suppression. [8] Consequently, cerebral hypoperfusion leading to EEG suppression should result in low BIS values and restoration of adequate perfusion with con­sequent recovery of EEG activity should lead to 'nor­malization' of BIS values.

The present case indicates that BIS can be used as an indicator of cerebral ischaemia in conscious patients admitted into the intensive care unit. It may be helpful not only in early detection of impending neurological cata­strophic events, but also to judge the adequacy and effi­cacy of interventions targeted to restore the same.

 
   References Top

1.Shapiro BA. Bispectral index: Better information for sedation in the intensive care unit? Crit Care Med 1999; 27: 1663-1664.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]  
2.Flaishon R, Windsor A, Sigl J, et al. Recovery of conscious­ness after thiopental or propofol: Bispectral index and the isolated forearm technique Anesthesiology 1997; 86: 613-619.  Back to cited text no. 2      
3.Simmons LE, Riker RR, Prato BS, et al. Assessing sedation during intensive care unit mechanical ventilation with bispectral index and Sedation-Agitation Scale. Crit Care Med 1999; 27:1499-1504.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]  
4.Critical care of Guillain-Barre syndrome. Neurological and neurosurgical intensive care. Ropper AH, Gress DR, Diringer MN, Green DM, Mayer SA, Bleck TP (Eds). Lippincott Williams Wilkins: Philadelphia 2004: 278-298.  Back to cited text no. 4      
5.Hayashida M, Chinzei M, Komatsu K, Tamai H, Orji R, Hanaoka K, Murakami A. Detection of cerebral hypoperfusion with bispectral index during paediatric cardiac surgery. Br J Anaesth 2003; 90: 694-698.  Back to cited text no. 5      
6.Morimoto Y, Monden Y, Ohtake K, Sakabe T, Hagihira S. The detection of cerebral hypoperfusion with bispectral index monitoring during general anesthesia. Anesth Analg 2005; 100: 158-161.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]  
7.Jain V, Prabhakar H, Rath GP, Sharma D. Tension pneumocephalus following deep brain stimulation surgery with bispectral index moni­toring. Eur J Anaesthesiol 2007; 24: 203-204.  Back to cited text no. 7  [PUBMED]    
8.Prior PF. EEG monitoring and evoked potentials in brain is­chaemia. Br J Anaesth 1985; 57: 63-81.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]  




 

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