title: Bispectral index for improving anaesthetic delivery and postoperative recovery.
abstract: BACKGROUND
  The use of clinical signs may not be reliable in measuring the hypnotic component of anaesthesia. The use of bispectral index (BIS) to guide the dose of anaesthetic may have certain advantages over clinical signs. This is the second update of a review originally published in 2007.
  
  
  OBJECTIVE
  The primary objective of this review focused on whether the incorporation of BIS into the standard practice for management of anaesthesia can reduce the risk of intraoperative awareness, consumption of anaesthetic agents, recovery time and total cost of anaesthesia in surgical patients undergoing general anaesthesia.
  
  
  METHODS
  In this updated version, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 1), MEDLINE (1990 to 31 January 2013), EMBASE (1990 to 31 January 2013) and reference lists of articles. Previously, we searched to May 2009.
  
  
  METHODS
  We included randomized controlled trials comparing BIS with standard practice criteria for titration of anaesthetic agents.
  
  
  METHODS
  Two authors independently assessed trial quality, extracted data and analysed the data. We contacted study authors for further details.
  
  
  RESULTS
  We included 36 trials. In studies using clinical signs as standard practice, the results demonstrated a significant effect of the BIS-guided anaesthesia in reducing the risk of intraoperative awareness among surgical patients at high risk for awareness (7761 participants; odds ratio (OR) 0.24, 95% confidence interval (CI) 0.12 to 0.48). This effect was not demonstrated in studies using end tidal anaesthetic gas (ETAG) monitoring as standard practice (26,530 participants; OR 1.13, 95% CI 0.56 to 2.26). BIS-guided anaesthesia reduced the requirement for propofol by 1.32 mg/kg/hr (672 participants; 95% CI -1.91 to -0.73) and for volatile anaesthetics (desflurane, sevoflurane, isoflurane) by 0.65 minimal alveolar concentration equivalents (MAC) (95% CI -1.01 to -0.28) in 985 participants. Irrespective of the anaesthetics used, BIS reduced the following recovery times: time for eye opening (2557 participants; by 1.93 min, 95% CI -2.70 to -1.16), response to verbal command (777 participants; by 2.73 min, 95% CI -3.92 to -1.54), time to extubation (1501 participants; by 2.62 min, 95% CI -3.46 to -1.78), and time to orientation (373 participants; by 3.06 min, 95% CI -3.63 to -2.50). BIS shortened the duration of postanaesthesia care unit stay by 6.75 min (1953 participants; 95% CI -11.20 to -2.31) but did not significantly reduce the time to home readiness (329 participants; -7.01 min, 95% CI -30.11 to 16.09).
  
  
  CONCLUSIONS
  BIS-guided anaesthesia can reduce the risk of intraoperative awareness in surgical patients at high risk for awareness in comparison to using clinical signs as a guide for anaesthetic depth. BIS-guided anaesthesia and ETAG-guided anaesthesia may be equivalent in protection against intraoperative awareness but the evidence for this is inconclusive. In addition, anaesthesia guided by BIS kept within the recommended range improves anaesthetic delivery and postoperative recovery from relatively deep anaesthesia.
authors.affiliation: Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand, 50200.
authors.forename: Yodying
authors.initials: Y
authors.lastname: Punjasawadwong
authors.forename: Aram
authors.initials: A
authors.lastname: Phongchiewboon
authors.forename: Nutchanart
authors.initials: N
authors.lastname: Bunchungmongkol
mesh_terms: D000758:Anesthesia / Q000379:methods*; D000762:Anesthesia Recovery Period; D000776:Anesthesiology / Q000379:methods / Q000458:organization & administration; D000777:Anesthetics / Q000008:administration & dosage*; D004569:Electroencephalography; D006801:Humans; D058926:Intraoperative Awareness / Q000517:prevention & control*; D016343:Monitoring, Intraoperative / Q000379:methods*; D016032:Randomized Controlled Trials as Topic
chemical_list: D000777:Anesthetics