1. Bispectral Index Guided Anesthetic Practice in Cardiac Surgery Dr. Mohamed Essam, MD Assistant Professor, Anesthesia Department Ain Shams University

2. Bispectral Index BIS Processed EEG and Computer algorithm Assigns a numerical value based on the probability of consciousness

3. BIS

4. BIS  Approved by the FDA on Oct.1996  Estimated Sensitivity 97.3 % Specificity 94.4 %  Accuracy achieved with: - SQI 100% - EMG 0% - SR 0

5. Balanced General Anesthesia Balanced General Anesthesia HYPNOSIS ANALGESIA RELAXATION BIS

6. FACTS IN OPCAB Anaesthetic Prospective Haemodynamics Narcotics Vs. Hypnotics Narcotics Vs. Hypnotics Surgical Prospective Heart Dislocation Hazards of Vasopressors Hazards of Vasopressors

7. Fast Tracking  Term aims at reducing Cost & Stay of Surgical Patients  Peri-operative process involving rapid progress from preoperative preparation through surgery and discharge from the hospital.  Early Extubation may be a component of this process. However, early extubation and ‘fast track’ are not synonymous.

8. Anesthetic Technique Total Intravenous Technique :  Steady Plasma Level  Decreased Total Dose Requirements  Avoidance of Bolus effects. Hypnotics  Hemodynamic Instability. Hypnotics  Hemodynamic Instability. Opioids  Rigidity. Opioids  Rigidity  Rapid Recovery  Eliminate incidence of Awarness  Saving of Inhalational Agents for IPC effects

9. Anesthetic Technique Agents : Induction Maintenance 0.05 – 0.1 mg / Kg 1.5 ug / Kg / min Midazolam 0.05 – 0.1 mg / Kg 1.5 ug / Kg / min 1 – 1.5 ug / Kg 0.2 ug / Kg / hr Sufentanil 1 – 1.5 ug / Kg 0.2 ug / Kg / hr 0.9 mg / Kg 0.5 mg / Kg / hr Rocuronium 0.9 mg / Kg 0.5 mg / Kg / hr

14. Methodology Recorded Parameters  Hemodynamics  BIS Reading Data Points T0= Baseline post-induction T1= Skin incision T2= Sternotomy T3= 60 minutes post-induction T4= 90 minutes post-induction T5= With chest closure Total IV Anaesthetic Requirements  Total IV Anaesthetic Requirements  Inhalational Sevoflurane Supplemetation  Total Phenylepherine Dosage  Inotropic Support  Awareness ( Questionnaire )  Postoperative Data ( Fast Tracking )

17. Male patient, 72 yrs.Male patient, 72 yrs. Wt. 62 Kg, Ht. 165 cmWt. 62 Kg, Ht. 165 cm ASA IVASA IV Medical history:.HTN, DMMedical history:.HTN, DM.CAD EF 30 %, old inf. MI.CAD EF 30 %, old inf. MI PCI  LAD 90 %, RCA 100%, OM 90% PCI  LAD 90 %, RCA 100%, OM 90%. Limited Pulmonary Reserve. Limited Pulmonary Reserve.Old CVA (Frontal with small organized SDH).Old CVA (Frontal with small organized SDH).Bilateral Carotid disease.Bilateral Carotid disease Rt. 100% Occlusion, Lt. 90% Stenosis Rt. 100% Occlusion, Lt. 90% Stenosis.Mild both Hepatic & Renal impairment.Mild both Hepatic & Renal impairment

18. CNS Monitoring I. Functional Monitoring: - Awake patient - Awake patient - EEG - EEG - SSEP’s - SSEP’s II. Oxygen Supply & Perfusion: - Stump Pressure - Stump Pressure - TCD - TCD - SjVO 2 - SjVO 2 - RSO 2 - RSO 2

19. Surgical procedure CEA: - Exposure of CCA till the bifurcation - Exposure of CCA till the bifurcation - Determining the severity of Cerebral Ischemia - Determining the severity of Cerebral Ischemia. Clamping of CCA. Clamping of CCA. Measuring Stump Pressure. Measuring Stump Pressure. BIS Tracing. BIS Tracing - Shunt application - Shunt applicationCABG: - Off pump Revascularisation of LAD - Off pump Revascularisation of LAD - Initiation of CPB for Complete Revascularisation - Initiation of CPB for Complete Revascularisation

20. Detection of Cerebral Ischemia During CEA

23. CONCLUSION BIS Guided Anaesthetic Practice  ↓ Anaesthetic Requirements  Hemodynamic stability  Lower rate of Conversion to Conventional CABG  ↓ Vasopressor Therapy  NO Recorded Awareness  Fast Tracking Accomplished  Cerebral Ischemia