BIS monitoring and sedation titration

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Specializes in New Critical care NP, Critical care, Med-surg, LTC.

Hello, our unit recently rolled out BIS monitoring for paralyzed patients. We already use train-of-four for monitoring paralysis. However, the education we were provided on the floor was pretty much how to plug it in and hook it up. We have no parameters on how to use the data for optimizing patient sedation. Do your sedation medications have parameters for titrating to BIS? Do your providers give the sedation orders? Would you titrate up an infusion, or just give a PRN if your BIS numbers go up? I would love any insight so I can bring it back to my unit- our education position isn't filled at this time so there's no one who looked for EBP before this was instituted as a nursing intervention.  In my practice to this point, once we put someone on a paralytic, we don't reduce sedation. We will titrate sedation up if the patient has vent dyssynchrony or hypertension/tachycardia with interventions.  Thank you!

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Specializes in Burn, ICU.

Our target BIS is usually 40-60, where 100 is fully awake and 0 is completely unresponsive. You need to monitor signal quality as well as the score (our EMR has a place to chart both).  

I would titrate my sedation infusion to keep the resting patient on the target range. If PRNs are needed for turns or proning I'd ask for that order as well, but I'd prefer the patient to be sufficiently sedated all the time, not waking up and then being knocked back down with a PRN.  (I don't have EBP to cite for this, though.)

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Specializes in New Critical care NP, Critical care, Med-surg, LTC.

Thank you. Do your sedatives have parameters for titration based on BIS built into the MAR? Our problem is for example we have fentanyl infusions that titrate to CPOT and precedex/propofol/versed infusions to titrate to RASS. Those instructions are in the MAR for titration on those drugs. So as our orders are written now, we have nothing to titrate to BIS. We did find a spot in the EMR to titrate the BIS number and the signal quality. 

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Specializes in Burn, ICU.

Mmm, I think they don't.  I know our paralytics have titration instructions based on the TOF...but our default for the sedatives is RASS and I don't think we get it changed when we paralyze someone.  We just know, I guess. (Yeah, that's not a great answer!)

We use EPIC and I would think that the ordering provider could select from different types of parameters when ordering the gtt but I'm not certain whether this is built into our med profiles or not. I'll try to check next time I'm at work.

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Specializes in New Critical care NP, Critical care, Med-surg, LTC.

Thanks again for the answer. I agree that many times we titrate to "we just know", just trying to make sure we're legally covered with our orders. 

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Specializes in Nurse Anesthesiology.

Having a patient paralyzed and awake is not only wrong but basically malpractice in my eyes.  BIS is used as a trend to determine the patient's state of consciousness.  Like someone said anything over 60 and you worry about recall or being "too awake."  You can think of a BIS of < 20-30 as having a patient in burst suppression and very deep.  If you have a patient who is paralyzed and the BIS is slowly trending up close to 60 or higher then you need to deepen them with either increasing your propofol gtt, giving additional PRN versed/ativan, or increasing the versed gtt.  

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Specializes in New Critical care NP, Critical care, Med-surg, LTC.
On 3/4/2021 at 7:54 PM, PaSSiNGaS said:

Having a patient paralyzed and awake is not only wrong but basically malpractice in my eyes.

I agree 100%, that's why I'm wondering about the order sets to ensure that while we're doing what's right for the patient as a human being, keeping them appropriately sedated,  we're also doing what's within our scope of practice with orders. NONE of our medications currently have any parameters for BIS, so we're basically administering without an order if we give a PRN or titrate a med in our current system. We have RASS and CPOT scoring, but nothing for BIS. 

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Specializes in Nurse Anesthesiology.

If the order for a RASS is -4 then that should be equivalent to keep the BIS 40-60 and be in a good range for titration of the sedation.

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Specializes in New Critical care NP, Critical care, Med-surg, LTC.
15 hours ago, PaSSiNGaS said:

If the order for a RASS is -4 then that should be equivalent to keep the BIS 40-60 and be in a good range for titration of the sedation.

We are going to need a good education rollout for this new intervention and monitoring. Our titration for things like propofol and precedex is to keep intubated patients to RASS -2, for paralyzed patients there is no change in orders. Thank you for bringing that up. 

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Our BIS orders are for 40-60 with a paralyzed patient.  Our RASS is ordered at a -5 on all paralyzed patients.  I titrate to the BIS but I’m not sure our sedation orders state it.  I change out my BIS monitor once a shift regardless to ensure I am getting the best reading.  We use TOF as well but that’s only to titrate the paralytic not the sedation.    
 

I want my paralyzed patients sedated as much as possible so I keep my BIS number around 40-45.

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Specializes in Burn, ICU.

Finally got a chance to look...our default orders are for a RASS score (filled in by the provider).  They could choose to remove these instructions and replace them with instructions for a BIS score, but I don't think I've ever seen them do so!  So, OP, you're not alone! 

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Specializes in New Critical care NP, Critical care, Med-surg, LTC.
4 hours ago, marienm, RN, CCRN said:

They could choose to remove these instructions and replace them with instructions for a BIS score, but I don't think I've ever seen them do so! 

Thank you so much for looking into it! I guess it's good we're not alone, but not really comforting that we don't have solid orders backing us up. 

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