1.

0 OVERVIEW:

BIS monitoring is an excellent monitor that assesses a processed EEG signal that reflects a patients level of consciousness during anesthesia. BIS may provide early warning of awareness during anesthesia, allows titration of anesthesia, may provide early warning of neurologic injury, and may indicate insufficient perfusion. It is quickly becoming the standard of care in many parts of the country. This monitor can be used in a variety of patients undergoing surgical procedures, but deciding which patients receive this monitor (like any other monitor such as arterial catheters, central venous catheters or Swan Ganz catheters) is a CLINICAL decision determined by the anesthesia provider on a case by case basis. (Corporate Name) will use this monitoring device to help provide excellent patient care on indicated patients and improve outcomes at an advantageous cost/benefit ratio. 2.0 Purpose: The purpose of this policy is to outline the desired clinical use of the BIS monitor in the operating room as well as in the critical care setting. These recommendations are in place to assist the anesthesia as well as critical care staff in the clinical application of this technology for provision of excellent care and improving outcomes through access to additional clinical information provided by the use of BIS monitoring. 3.0 Scope: This policy applies to all employees, contractors, temporaries, and other workers (Corporate Name), including all personnel affiliated with third parties. This policy applies to all BIS monitoring equipment that is owned or leased by (Corporate Name) 4.0 Policy: 4.1 Use in Anesthesia and Surgery 1. BIS monitoring should be used at the discretion of the anesthesia provider on all patients having general anesthesia and deep MAC sedation with or without regional or local anesthesia regardless of the duration of the anesthetic. It is preferable to initiate BIS monitoring prior to sedation administration in order to gain additional patient dose response information. The monitoring period should continue thru the conclusion of the patient's emergence from anesthesia 2. Special consideration should be given to BIS monitoring Sensors when the patient is in the prone position. If used, consider relieving any persistent points of pressure at least every 2 hours. For example turn the patients head from the midline to one side or another, etc. Evaluate all pressure points every two hours for any sign of irritation. 3. If the surgery is to involve the head and or neck, take care to position the sensor on the opposite side of the surgical procedure where possible. The sensor can be covered with an impervious drape to allow for sterile preparation of the surgical field. Please take care to assess any turban like head drape that it is not secured too tightly against the sensor or causing excessive pressure on the patient's forehead.

4. All BIS values will be recorded on the Anesthesia Flow sheet. This should be done every 5 minutes or as frequently as possible particularly during rapidly changing states of consciousness. The BIS monitor can be attached to an accessory printer if needed for hard copy download of the case trend. 4.2 Use in Critical Care (currently being reviewed by critical care committees) 1. BIS monitoring should be used on all patients who are receiving sedation and analgesia as well those who are also receiving Neuromuscular Blockade. 2. BIS monitoring should be used on all patients receiving sedation for the following: 1. Mechanical ventilation with ordered sedation level 3. 2. Management of Intracranial Hypertension with IV barbiturates or propofol 3. Patients who are receiving NMB 4. Patients who are receiving sedation management for ETOH withdrawal or significant delirium or agitation 5. Patients whose level of consciousness is altered with or without sedation as an adjunct to other neuromonitoring procedures and assessments 6. Patients who are receiving sedation and analgesics for end of life care 7. Patients who are on drug holiday, sedation termination for weaning purposes 8. Patients who are receiving additional sedation and analgesia during a bedside procedures 3. BIS monitoring is initiated by the nursing staff and does require a physicians order in order to so. Ideally BIS monitoring is introduced as early in the sedation process as possible. BIS sensors should be marked with date and time of initiated use and it is recommended that the sensor be changed every 24 hrs in order to allow for skin integrity assessment. It is not unexpected to see mild redness after sensor removal which is short-lived and self resolving. 4. BIS sensor placement should be done according to the following instructions for use: The sensor should be placed on clean dry skin, which can be prepped prior to placement with wet gauze or face cloth using saline, soap & water or alcohol swabs. The skin should be dried with a towel or gauze. Placement of the sensor should be done in accordance with the manufacturers prescribed sensor placement, known as montage. See sensor package for instructions. The edges of the sensor should be sealed first then the area between the circles to prevent gel migration out from under the sensor. After sealing all of the adhesive areas, gently press with a non-twisting or shearing motion of each of the 4 separate elements for 5 seconds ensuring close contact to the skin. Attach the Patient Interface Cable (PIC) to the BIS sensor tab until the sensor connection is recognized by the monitor. A picture of the sensor is revealed on the screen of the monitor when sensor and PIC are connected. An impedance test will automatically be initiated by the software. Each element will be tested for the amount of resistance being offered and a numerical impedance value will be displayed. Each number is qualified as to PASS, HIGH, NOISE. Do not continue to touch the sensor when the check is running or if you see the NOISE message, remove the cause and ask the patient to hold still. If you see a persistently HIGH value, go back to that specific element and again gently prep it by pressing downward toward the patient without shearing or twisting motion. The combined total impedance between sensor element # 1 and # 3 should be less than 15 Ohms in order to pass into monitoring. The lower the impedance values the better and less likely it is that electrical noise will interfere with the signal. The monitor will default into monitoring after impedances thresholds are met. The monitor will automatically change to the monitoring screen when this process is completed. Please observe this screen for a minute or so as the SQI, signal quality index builds up its EEG data collection store and BIS calculations begin. A BIS value will be displayed when a minimum threshold of 15% good data is reached. The number

will be hollowed out until it reaches 50% good data and then will become solid yellow. The BIS values displayed are valid data as BIS will not calculated a value on artifact data. The BIS values displayed are valid data as BIS will not calculated a value on artifact data. The SQI may not reach 100% in an awake patient. Asking the patient to close their eyes and relax will facilitate data collection. 5. BIS should be used to guide sedation drug titration to levels between 40-60. BIS values should be documented on the patients flow sheet every time VS are assessed and as needed during drug titration assessments. If BIS monitoring is being used in conjunction with a sedation score or scale, then BIS should be assessed and recorded prior to administration of the sedation assessment tool. BIS should be re-evaluated after the sedation assessment is completed. A delta BIS or BIS change of 10 points or more after stimulation can be an indication of the patient's analgesic state or the patient's state of comfort. Consider the patients analgesic state if BIS is or becomes very variable with stimulation of the patient. The patients state of neuromuscular paralysis should be assessed using a twitch monitor as a separate assessment from BIS monitoring. 6. Please contact technical support at Aspect Medical systems at 888-BIS-INDE(X), 888-247-4633 with any questions or concerns related to clinical application or equipment performance.