title: Bispectral electroencephalographic analysis of patients undergoing procedural sedation in the emergency department.
abstract: OBJECTIVE
  To determine whether there is a correlation between the level of sedation achieved during procedural sedation (PS) in the emergency department as determined by bispectral electroencephalographic (EEG) analysis (BIS) and the rate of respiratory depression (RD), the patient's perception of pain, recall of the procedure, and satisfaction.
  
  
  METHODS
  This was a prospective observational study conducted in an urban county hospital of adult patients undergoing PS using propofol, methohexital, etomidate, and the combination of fentanyl and midazolam. Consenting patients were monitored by vital signs, pulse oximetry, nasal-sample end-tidal carbon dioxide (ETCO(2)), and BIS monitors during PS. Respiratory depression (RD) was defined as an oxygen saturation <90%, a change from baseline ETCO(2) of >10 mm Hg, or an absent ETCO(2) waveform at any time during the procedure. After the procedure, patients were asked to complete three 100-mm visual analog scales (VASs) concerning their perception of pain, recall of the procedure, and satisfaction with the procedure. Patients were divided into four groups based on the lowest BIS score recorded during the procedure, group 1, >85; group 2, 70-85; group 3, 60-69; group 4, <60. Rates of RD and VAS outcomes were compared between groups using chi-square statistics.
  
  
  RESULTS
  One hundred eight patients were enrolled in the study. No serious adverse events were noted. RD was seen in three of 14 (21.4%) of the patients in group 1, seven of 34 (20.6%) in group 2, 16 of 26 (61.5%) in group 3, and 18 of 34 (52.9%) in group 4. The rate of RD in patients in group 2 was not significantly different from that in group 1 (p = 0.46). The rate of RD in group 2 was significantly lower than that in groups 3 (p = 0.0003) and 4 (p = 0.006). For the VAS data, when group 1 was compared with the combined groups 2, 3, and 4, it had significantly higher rates of pain (p = 0.003) and recall (p = 0.001), and a dissatisfaction rate (p = 0.085) that approached significance. When groups 2, 3, and 4 were compared with chi-square test, there was not a significant difference in pain (p = 0.151), recall (p = 0.27), or satisfaction (p = 0.25).
  
  
  CONCLUSIONS
  Patients with a lowest recorded BIS score between 70 and 85 had the same VAS outcomes as more deeply sedated patients and the same rate of RD as less deeply sedated patients. This range of scores represented the optimally sedated patients in this study.
authors.affiliation: Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN 55415, USA. james.miner@co.hennepin.mn.us
authors.forename: James R
authors.initials: JR
authors.lastname: Miner
authors.forename: Michelle H
authors.initials: MH
authors.lastname: Biros
authors.forename: William
authors.initials: W
authors.lastname: Heegaard
authors.forename: David
authors.initials: D
authors.lastname: Plummer
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002245:Carbon Dioxide / Q000378:metabolism; D016292:Procedural Sedation / Q000009:adverse effects / Q000379:methods*; D004569:Electroencephalography / Q000379:methods*; D004632:Emergency Medical Services / Q000379:methods*; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D006993:Hypnotics and Sedatives / Q000627:therapeutic use; D008297:Male; D011939:Mental Recall / Q000187:drug effects; D008875:Middle Aged; D010092:Oximetry; D010146:Pain / Q000523:psychology; D010147:Pain Measurement; D017060:Patient Satisfaction; D011446:Prospective Studies; D012131:Respiratory Insufficiency / Q000139:chemically induced
chemical_list: D006993:Hypnotics and Sedatives; D002245:Carbon Dioxide