The effect of cerebral monitoring on recovery after general anesthesia: a comparison of the auditory evoked potential and bispectral index devices with standard clinical practice.Anesth Analg. 2003 Dec; 97(6):1667-1674.A&A
The use of cerebral monitoring may improve the ability of anesthesiologists to titrate anesthetic drugs. However, there is controversy regarding the impact of the alleged anesthetic-sparing effects of cerebral monitoring on the recovery process and patient outcome. We designed this prospective double-blinded, sham-controlled study to evaluate the impact of intraoperative monitoring with the electroencephalogram bispectral index (BIS) or auditory evoked potential (AEP) device on the usage of desflurane and the time to discharge from the recovery room, as well as on patient satisfaction with their anesthetic experience and recovery. Ninety healthy patients undergoing laparoscopic general surgery procedures using a standardized anesthetic technique were randomly assigned to one of three monitoring groups: standard clinical practice (control), BIS-guided, or AEP-guided. Both the BIS and AEP monitors were connected to all patients before induction of general anesthesia. In the control group, the anesthesiologists were not permitted to observe the BIS or AEP index values during the intraoperative period. In the BIS-guided group, the volatile anesthetic was titrated to maintain a BIS value in the range of 45-55. In the AEP-guided group, the targeted AEP index range was 15-20. The BIS and AEP indices, as well as end-tidal desflurane concentration, were recorded at 3-5 min intervals. Recovery times to awakening, tracheal extubation, fast-track score >or=12, and postanesthesia care unit (PACU) discharge criteria were recorded at 1-10 min intervals. In addition, patient satisfaction with anesthesia and quality of recovery were evaluated on 100- and 18-point scales, respectively, at 24 h after surgery. The AEP- and BIS-guided groups were administered significantly smaller average end-tidal desflurane concentrations than the control group (3.8 +/- 0.9 and 3.9 +/- 0.6 versus 4.7 +/- 1.7, respectively) (P < 0.01). Although the emergence times to eye opening, tracheal extubation, and obeying commands were consistently shorter in the AEP and BIS groups (6 +/- 4 and 6 +/- 5 versus 8 +/- 8 min; 6 +/- 5 and 6 +/- 4 versus 11 +/- 10 min; and 8 +/- 4 and 7 +/- 4 versus 12 +/- 9 min, respectively), only the extubation times were significantly different from the control group (P < 0.05). More importantly, the length of the PACU stay was significantly shorter in both the AEP- and BIS-guided groups (79 +/- 43 and 80 +/- 47 versus 108 +/- 58 min, respectively) (P < 0.05). The patients' quality of recovery was also significantly higher in the two monitored groups (15 +/- 2 versus 13 +/- 3 in the control group, P < 0.05). We concluded that cerebral monitoring with either the BIS or AEP devices reduced the maintenance anesthetic (desflurane) requirement, resulting in a shorter length of stay in the PACU and improved quality of recovery after laparoscopic surgery. However, there were no significant outcome differences between the two cerebral monitored groups.
Compared with standard monitoring practices, use of an auditory evoked potential or bispectral index monitor to titrate the volatile anesthetic led to a significant reduction in the anesthetic requirement. The anesthetic-sparing effect of cerebral monitoring resulted in a shorter postanesthesia care unit stay and improved quality of recovery from the patient's perspective.