Original Article
Effect of neuromuscular blockade on the bispectral index in critically ill patients
Efecto del bloqueo neuromuscular sobre la monitorización biespectral en los niños críticamente enfermos
Eva Sanaviaa, Mirian Garcíab,c,d,
, Jimena del Castillob,c,d, Rafael Gonzálezb,c,d, Jesús López-Herceb,c,d, Santiago Mencíab,c,d
Corresponding author
a Servicio de Pediatría, Hospital Infanta Leonor, Madrid, Spain
b Unidad de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Madrid, Spain
c Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
d Instituto de Investigación Sanitaria Gregorio Marañón, Red de Salud Materno Infantil y del Desarrollo (RedSAMID), Madrid, Spain
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"<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Servicio de Pediatría, Hospital Infanta Leonor, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Instituto de Investigación Sanitaria Gregorio Marañón, Red de Salud Materno Infantil y del Desarrollo (RedSAMID), Madrid, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Efecto del bloqueo neuromuscular sobre la monitorización biespectral en los niños críticamente enfermos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1780 "Ancho" => 3008 "Tamanyo" => 377894 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0045" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Haemodynamic parameters.</p> <p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">CVP, central venous pressure; HR, heart rate; MAP, mean arterial pressure; NMB, Neuromuscular blocker.</p> <p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">There were no significant changes in haemodynamic parameters during the administration or after discontinuation of the NMB.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The bispectral index (BIS) estimates the level of brain activity through a mathematical analysis of the frequencies of waves in electroencephalography (EEG) signals and it also obtains information from electromyography (EMG) data.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The BIS index was first introduced in 1992 by Aspect Medical Systems. The main component of the BIS monitor is the bispectral analysis, which evaluates the phase relations from a single channel EEG signal measured from the patient’s forehead. The BIS index is a dimensionless number from 0 to 100. Firstly, the EEG signal is digitized and pre-processed. BIS includes two types of burst suppression (BS) detection: the burst-suppression ratio (BSR) and the QUAZI-Suppression. The pre-processed data is used to calculate the β-ratio parameter (a ratio of empirically measured frequency bands, 30–47<span class="elsevierStyleHsp" style=""></span>Hz and 11–20<span class="elsevierStyleHsp" style=""></span>Hz). Simultaneously, the second parameter, synch-fast-slow, is calculated from bispectral analysis. Finally, all parameters are then fed to the weighting algorithm, which produces the BIS index.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Electromyographic data corresponds to the 30−50<span class="elsevierStyleHsp" style=""></span>Hz range, which can overlap with BIS.</p><p id="par0015" class="elsevierStylePara elsevierViewall">BIS was initially used for the objective assessment of sedation depth in patients undergoing general anaesthesia, but it has subsequently proved to be useful in monitoring the level of sedation in patients admitted to the ICU,<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–4</span></a> especially those under deep sedation.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> International guidelines recommend its use for monitoring patients treated with muscle relaxants in who it is not possible to use clinical scores.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Neuromuscular blockade (NMB) decreases electromyographic activity. Some authors have suggested that the administration of these drugs may also decrease BIS values and overestimate the degree of patient´s sedation.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Several studies, most of them conducted in adult patients, have analysed the impact of NMB on BIS, with contradictory results.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9–14</span></a> Many have found that neuromuscular blocking agents (NMBAs) decrease the EMG component of BIS, thus reducing the value of the latter.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,10,14</span></a> However, some authors attribute the impact of NMB on BIS to a coincidental deeper level of sedation in those cases.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,12</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Our hypothesis was that NMB does not alter the ability of BIS to monitor consciousness in sedated children in paediatric intensive care units (PICUs).</p><p id="par0030" class="elsevierStylePara elsevierViewall">The aim of our study was to analyse the impact of the use or discontinuation of NMB on BIS values in critically ill children.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Patients and methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">We conducted a prospective observational study in a tertiary referral hospital in Madrid, Spain, between 2011 and 2012. We included all patients aged 1 month to 16 years admitted to PICU during the period under study that were monitored with BIS and required infusion of NMBAs. We excluded patients with a duration of NMB of less than 6<span class="elsevierStyleHsp" style=""></span>h and those with seizures or encephalopathy that could affect BIS values. The study was approved by the local ethics committee.</p><p id="par0040" class="elsevierStylePara elsevierViewall">We collected data on demographic (age, sex) and clinical characteristics (reason for admission, underlying disease), haemodynamic parameters (blood pressure, heart rate, central venous pressure and urine output), inotropic therapy, mechanical ventilation and reason for using NMB. Sedatives and analgesic drugs were administered per the PICU protocol, which adheres to the guidelines of the Sociedad Española de Cuidados Intensivos Pediátricos (Spanish Society of Paediatric Intensive Care). The protocol includes the rotation of different sedative and analgesic drugs with the aim of minimising withdrawal symptoms on discontinuation of opioids and benzodiazepines. We recorded the administered sedatives and analgesics and their dosage. The NMBA used in every case was vecuronium, always given at a rate of 0.1<span class="elsevierStyleHsp" style=""></span>mg kg/h.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Bispectral index monitoring was performed with a BIS XP Aspect Medical Systems® monitor and paediatric BIS sensors. Bispectral index values were recorded continuously, as were values of electromyographic (EMG) parameters, the signal quality index (SQI), the total power (TP) and the spectral edge frequency (SEF). We measured and recorded BIS parameters, the blood pressure (BP) and the heart rate (HR) 30<span class="elsevierStyleHsp" style=""></span>min before initiation of NMB and 6, 12 and 24<span class="elsevierStyleHsp" style=""></span>h thereafter. We also measured and documented the same variables were also before discontinuing BNM, and 6, 12 and 24<span class="elsevierStyleHsp" style=""></span>h after discontinuation. At the same time, we monitored the level of pain and of sedation using internationally validated scales such as the COMFORT behaviour scale and the pain ladder, and adjusted the infusion of sedatives and analgesics based on the resulting scores.</p><p id="par0050" class="elsevierStylePara elsevierViewall">We defined moderate sedation as a BIS value of 40–60 and deep sedation as a BIS value of less than 40.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> We discarded BIS values when the signal quality index was less than 60% or the impedance level was greater than 10<span class="elsevierStyleHsp" style=""></span>kΩ.</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Statistical analysis</span><p id="par0055" class="elsevierStylePara elsevierViewall">We analysed the data using the software SPSS Statistics version 19. We used the Fisher exact test to compare frequencies and the Mann-Whitney <span class="elsevierStyleItalic">U</span> test to compare quantitative variables. Also, we used the Wilcoxon test to compare BIS, EMG, SQI, BP and HR values before and after NMB. We analysed the correlation between nonparametric variables by means of the Spearman rank correlation coefficient. We defined statistical significance as a <span class="elsevierStyleItalic">p-</span>value of less than 0.05.</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0060" class="elsevierStylePara elsevierViewall">The analysis included 35 patients with a mean age of 30 months (range, 2–288 months), 52.9% male. The primary diagnosis in 85% of cases was postoperative care after cardiac surgery, followed by head injury (9%) and bronchiolitis (6%). The most frequent reasons for use of NMB administration were haemodynamic instability (low cardiac output, ECMO, junctional ectopic tachycardia; 49%), improvement of patient-ventilator synchrony (23%), pulmonary hypertension (14%) and increased intracranial pressure (6%).</p><p id="par0065" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> presents the BIS, EMG and SQI values. The SQI was above 80% at all times. Before administration of NMBAs, patients were under moderate-to-deep sedation (mean BIS, 46.3<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>14.9). The mean EMG value before starting the NMB infusion was 34.9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>9.4.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">We did not observe significant changes on BIS values with the administration of vecuronium infusion (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). However, we found a small but significant increase in BIS values 6<span class="elsevierStyleHsp" style=""></span>h (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.001) and 12<span class="elsevierStyleHsp" style=""></span>h after discontinuing the NMBA (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.015).</p><p id="par0075" class="elsevierStylePara elsevierViewall">We observed a decrease in electromyogram (EMG) values at 6<span class="elsevierStyleHsp" style=""></span>h (34.9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>9.4 vs 31.2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>7; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.008) and 12<span class="elsevierStyleHsp" style=""></span>h after initiation of NMB (34.9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>9.4 vs 28.6<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>4.8; <span class="elsevierStyleItalic">P</span> = .006). There was a small significant increase in BIS on discontinuation of NMB (from 42.7<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>11 to 48.4<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>14.5; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.001), as well as 6 and 12<span class="elsevierStyleHsp" style=""></span>h after discontinuation (51.3<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>16.6; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.015). Furthermore, EMG values increased significantly after discontinuation of NMB at 6<span class="elsevierStyleHsp" style=""></span>h (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.08) and 12<span class="elsevierStyleHsp" style=""></span>h (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.012). We did not find any other statistically significant changes in BIS parameters.</p><p id="par0080" class="elsevierStylePara elsevierViewall">We did not find a significant correlation between BIS and EMG values before and after NMB. We also found no significant changes in haemodynamic parameters during the infusion or after discontinuation of NMB (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">There were no differences in the sedatives and analgesics used during these periods or their doses, save for the dose of fentanyl, which was significantly reduced after discontinuation of NMB (at 6<span class="elsevierStyleHsp" style=""></span>h, 2.2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.6 vs 1.9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.6; <span class="elsevierStyleItalic">P</span> = .011 and at 12<span class="elsevierStyleHsp" style=""></span>h, 2.2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.6 vs 1.7<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.6; <span class="elsevierStyleItalic">P</span> = .01) (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0090" class="elsevierStylePara elsevierViewall">Our study shows that the administration of NMBAs in children does not alter BIS significantly, so the latter is a useful method for monitoring sedation in patients under NMB.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Bruhn observed that, after administering NMB to a volunteer, electromyographic activity could distort BIS measurements,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> and other research groups have since confirmed these findings.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,13–16</span></a> However, other studies, most of them conducted in adults,<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8–16,18–20</span></a> have not found significant changes in those measurements.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,12,17,18</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Weber et al. compared the effect on BIS values of a dose of muscle relaxant versus placebo after anaesthetic induction in 40 children that were undergoing surgery. They found no differences between the treatment and the placebo groups.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">We conducted our study in critically ill children. Rather than analysing the effect on BIS values of a single dose of NMBA, we studied the effect of continuous infusion of NMB and its discontinuation. Our results showed no relevant changes in BIS values with administration of NMB, although we did find a small but significant increase in BIS values after discontinuation of vecuronium. However, although there was a statistically significant change in BIS values, they remained within the 40-to-60 range (moderate sedation).</p><p id="par0110" class="elsevierStylePara elsevierViewall">Previous studies that showed that BIS was affected by NMBAs were mostly performed in patients under moderate sedation or in conscious volunteers.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> However, studies conducted in patients under deep sedation have not found significant changes in BIS values.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">This could explain the discrepancies between the findings of different studies, as EMG activity probably affects BIS values in conscious patients. When NMB is used, EMG activity decreases and causes a secondary drop in BIS values.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> In contrast, our patients were already under moderate or deep sedation with low EMG activity before the initiation of NMB. This probably explains why the infusion of the NMBA was associated with a decrease in EMG values and NMB discontinuation with minor increase in EMG values, which did not have a significant effect on the BIS.</p><p id="par0120" class="elsevierStylePara elsevierViewall">In agreement with the findings of other authors,<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,10,12,14</span></a> we observed statically significant changes on BIS and EMG values 6 and 12<span class="elsevierStyleHsp" style=""></span>h after discontinuing the NMB infusion. These changes may be explained in part by muscular contraction, but they are so small that we think they do not have any clinical significance in the assessment of the level of sedation.</p><p id="par0125" class="elsevierStylePara elsevierViewall">In addition, we found no correlation between BIS values and haemodynamic parameters (blood pressure and heart rate), which was consistent with previous studies.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> A probable explanation is that these parameters are influenced by many different factors, and not only the degree of sedation or relaxation of the patient.</p><p id="par0130" class="elsevierStylePara elsevierViewall">There are several limitations to our study. The sample size was relatively small, which could reduce the statistical validity of comparisons. In addition, all of the participants were under deep sedation because, for ethical reasons, we do not use muscle relaxation in patients with mild sedation. Furthermore, our study did not measure the degree of muscle relaxation.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,10,14</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusion</span><p id="par0135" class="elsevierStylePara elsevierViewall">Continuous infusion of NMB produces small changes on BIS values in critically ill children under moderate-to-deep sedation that are not clinically relevant, and therefore it does not compromise BIS monitoring of the level of consciousness in critically ill children.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1520865" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1379120" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1520866" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1379121" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Patients and methods" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Statistical analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0020" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0030" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "xack534155" "titulo" => "Acknowledgements" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-03-13" "fechaAceptado" => "2019-07-16" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1379120" "palabras" => array:4 [ 0 => "Consciousness monitors" 1 => "Child" 2 => "Muscle relaxation" 3 => "Neuromuscular blockade" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1379121" "palabras" => array:4 [ 0 => "Monitorización de la conciencia" 1 => "Niño" 2 => "Relajantes musculares" 3 => "Bloqueo neuromuscular" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">It has been suggested that neuromuscular blockade (NMB) affects the capacity of bispectral index (BIS) monitoring to measure consciousness in sedated children. Our aim was to analyse the impact of NMB on BIS values in critically ill children.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">We conducted a prospective observational study of children monitored with a BIS system that received a continuous infusion of vecuronium. We analysed data on clinical, diagnostic and haemodynamic variables, sedatives, analgesics, muscle relaxants, and BIS parameters. We compared BIS parameters before the use of a muscle relaxant, during its administration, before its discontinuation and for the 24<span class="elsevierStyleHsp" style=""></span>h following the end of the infusion.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">The analysis included 35 patients (median age, 30 months). The most common diagnosis was heart disease (85%). The most frequent indication for initiation of NMB was low cardiac output (45%), followed by adaptation to mechanical ventilation (20%). Neuromuscular blockade did not produce a significant change in BIS values. We found a decrease was observed in electromyography (EMG) values at 6<span class="elsevierStyleHsp" style=""></span>h (34.9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>9.4 vs 31.2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>7; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.008) and 12<span class="elsevierStyleHsp" style=""></span>h after initiation of NMB (34.9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>9.4 vs 28.6<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>4.8; <span class="elsevierStyleItalic">P</span> =.006). We observed a small significant increase in BIS after discontinuation of NMB (from 42.7<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>11 to 48.4<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>14.5, <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.001), and 6 and 12<span class="elsevierStyleHsp" style=""></span>h later (51.3<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>16.6; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.015). There were no differences in the doses of sedatives or analgesics except for fentanyl, of which the dose was lowered after discontinuation of vecuronium.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Continuous NMB produces small changes on BIS values that are not clinically significant and therefore does not interfere with BIS consciousness monitoring in critically ill children.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Estudios previos sugieren que el bloqueo neuromuscular (BNM) altera la monitorización del índice bispectral (BIS) en los niños sedados. El objetivo fue analizar la repercusión del uso y suspensión del BNM en la monitorización BIS en niños críticamente enfermos.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional prospectivo. Se incluyeron los niños que recibían perfusiones intravenosas de vecuronio con monitorización BIS. Se analizaron variables clínicas, diagnósticas, hemodinámicas, sedoanalgesia y relajantes musculares y parámetros del BIS. Se compararon los valores del BIS antes del uso de relajantes neuromusculares (RNM), durante su administración, antes de su retirada y durante las 24<span class="elsevierStyleHsp" style=""></span>h siguientes a su suspensión.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Treinta y cinco pacientes (edad mediana 30 meses). El diagnóstico más frecuente fue cardiopatía (85%). Las indicaciones más frecuentes para iniciar RNM fueron bajo gasto cardiaco (45%) y adaptación a ventilación mecánica (20%). El BNM no produjo cambios significativos en los valores del BIS. Se observó una disminución de los valores del electromiograma a las 6<span class="elsevierStyleHsp" style=""></span>h (34.9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>9.4 vs 31.2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>7; p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.008) y a las 12<span class="elsevierStyleHsp" style=""></span>h del inicio de la perfusión de vecuronio (34.9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>9.4 vs 28.6<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>4.8; p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.006). Tras retirar el vecuronio hubo un ligero aumento significativo del BIS (de 42.7<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>11 a 48.4<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>14.5, p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.001), así como en las siguientes 6 y 12<span class="elsevierStyleHsp" style=""></span>h (51.3<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>16.6; p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.015). No hubo diferencias en las dosis de sedantes o analgésicos, excepto del fentanilo, que fue disminuido tras retirar el vecuronio.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusión</span><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">El BNM continuo produce pequeños cambios en los valores del BIS sin relevanciaclínica, y no altera la monitorización del nivel de conciencia del BIS en los niños críticamenteenfermos.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Sanavia E, et al. Efecto del bloqueo neuromuscular sobre la monitorización biespectral en los niños críticamente enfermos. An Pediatr (Barc). 2020;93:251–256.</p>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1545 "Ancho" => 2508 "Tamanyo" => 287061 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0040" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Evolution of BIS, EMG and SQI values.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">BIS, bispectral index; EMG, electromyography; SQI, signal quality index; NMB, neuromuscular blocker *: statistically significant.</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">BIS values: Comparison between BIS values at different time points: prior to NMB infusion and after 6<span class="elsevierStyleHsp" style=""></span>h of infusion (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.141); before NMB and at 12<span class="elsevierStyleHsp" style=""></span>h of infusion (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.344); before NMB and at 24<span class="elsevierStyleHsp" style=""></span>h of infusion (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.42); discontinuation of NMB and 6<span class="elsevierStyleHsp" style=""></span>h later (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.001); discontinuation of NMB and 12<span class="elsevierStyleHsp" style=""></span>h later (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.015).</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">EMG values: Comparison between EMG values at different time points: before NMB and at 6<span class="elsevierStyleHsp" style=""></span>h of infusion (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.008); before NMB and at 12<span class="elsevierStyleHsp" style=""></span>h of infusion (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.006); discontinuation of NMB and 6<span class="elsevierStyleHsp" style=""></span>h later (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.08); discontinuation of NMB withdrawal and 12<span class="elsevierStyleHsp" style=""></span>h later: (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.012).</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1780 "Ancho" => 3008 "Tamanyo" => 377894 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0045" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Haemodynamic parameters.</p> <p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">CVP, central venous pressure; HR, heart rate; MAP, mean arterial pressure; NMB, Neuromuscular blocker.</p> <p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">There were no significant changes in haemodynamic parameters during the administration or after discontinuation of the NMB.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1755 "Ancho" => 2925 "Tamanyo" => 294511 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0050" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Changes in sedatives and analgesics.</p> <p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">NMB, Neuromuscular blocker.</p> <p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">There were no differences in the doses of sedatives or analgesics, except for the dose of fentanyl, which was significantly reduced after discontinuation of the NMB infusion (at 6<span class="elsevierStyleHsp" style=""></span>h, 2.2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.6 vs 1.9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.6 [<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.011]; at 12<span class="elsevierStyleHsp" style=""></span>h, 2.2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.6 vs 1.7<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.6 [<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.01]).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:22 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Monitoring the depth of anaesthesia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "B. 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Sagy" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.128.1.303" "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2005" "volumen" => "128" "paginaInicial" => "303" "paginaFinal" => "307" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16002950" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack534155" "titulo" => "Acknowledgements" "texto" => "<p id="par0140" class="elsevierStylePara elsevierViewall">We thank our colleagues at the PICU of the Hospital Gregorio Marañón, who volunteered to participate in our study and contributed expertise and insights that were very helpful in the research project.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/23412879/0000009300000004/v2_202106040604/S2341287920300077/v2_202106040604/en/main.assets" "Apartado" => array:4 [ "identificador" => "26005" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Original Articles" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23412879/0000009300000004/v2_202106040604/S2341287920300077/v2_202106040604/en/main.pdf?idApp=UINPBA00005H&text.app=https://analesdepediatria.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341287920300077?idApp=UINPBA00005H" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 3 | 9 |
| 2024 October | 65 | 37 | 102 |
| 2024 September | 47 | 37 | 84 |
| 2024 August | 47 | 59 | 106 |
| 2024 July | 40 | 31 | 71 |
| 2024 June | 44 | 24 | 68 |
| 2024 May | 40 | 30 | 70 |
| 2024 April | 31 | 40 | 71 |
| 2024 March | 29 | 26 | 55 |
| 2024 February | 20 | 31 | 51 |
| 2024 January | 31 | 27 | 58 |
| 2023 December | 23 | 35 | 58 |
| 2023 November | 40 | 52 | 92 |
| 2023 October | 22 | 47 | 69 |
| 2023 September | 23 | 30 | 53 |
| 2023 August | 23 | 26 | 49 |
| 2023 July | 28 | 30 | 58 |
| 2023 June | 20 | 27 | 47 |
| 2023 May | 28 | 20 | 48 |
| 2023 April | 20 | 16 | 36 |
| 2023 March | 47 | 28 | 75 |
| 2023 February | 39 | 23 | 62 |
| 2023 January | 29 | 24 | 53 |
| 2022 December | 65 | 29 | 94 |
| 2022 November | 56 | 41 | 97 |
| 2022 October | 69 | 47 | 116 |
| 2022 September | 45 | 22 | 67 |
| 2022 August | 53 | 44 | 97 |
| 2022 July | 42 | 36 | 78 |
| 2022 June | 31 | 35 | 66 |
| 2022 May | 57 | 41 | 98 |
| 2022 April | 31 | 30 | 61 |
| 2022 March | 53 | 51 | 104 |
| 2022 February | 43 | 40 | 83 |
| 2022 January | 66 | 40 | 106 |
| 2021 December | 50 | 57 | 107 |
| 2021 November | 72 | 58 | 130 |
| 2021 October | 104 | 103 | 207 |
| 2021 September | 73 | 52 | 125 |
| 2021 August | 50 | 46 | 96 |
| 2021 July | 23 | 38 | 61 |
| 2021 June | 43 | 47 | 90 |
| 2021 May | 44 | 54 | 98 |
| 2021 April | 134 | 122 | 256 |
| 2021 March | 60 | 26 | 86 |
| 2021 February | 43 | 28 | 71 |
| 2021 January | 58 | 27 | 85 |
| 2020 December | 56 | 17 | 73 |
| 2020 November | 69 | 31 | 100 |
| 2020 October | 73 | 15 | 88 |
| 2020 September | 60 | 16 | 76 |
| 2020 August | 53 | 17 | 70 |
| 2020 July | 39 | 19 | 58 |
| 2020 June | 39 | 8 | 47 |
| 2020 May | 45 | 15 | 60 |
| 2020 April | 34 | 13 | 47 |
| 2020 March | 45 | 19 | 64 |
| 2020 February | 46 | 20 | 66 |
| 2020 January | 7 | 2 | 9 |
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