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ORIGINAL ARTICLE
Year : 2019  |  Volume : 22  |  Issue : 6  |  Page : 801-805

Comparison of bispectral index values and depth of sedation during deep sedation using sevoflurane anesthesia in healthy children versus children with cerebral palsy


Department of Pediatric Dentistry, Faculty of Dentistry, Gazi University, Ankara, Turkey

Date of Acceptance25-Feb-2019
Date of Web Publication12-Jun-2019

Correspondence Address:
Dr. G Kip
Department of Pediatric Dentistry, Faculty of Dentistry, Gazi University, 06510 Ankara
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_553_18

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   Abstract 


Background: Patients with cerebral palsy (CP) are at significant risk by means of periodontal disease and tooth decay. Pharmacological techniques that require intensive care such as sedation and general anesthesia are generally used for dental treatment of this patient group. Aim: The purpose of this retrospective study was to compare bispectral index (BIS) values and depth of sedation recorded during deep sedation protocols performed for healthy children and children with CP in the Department of Pediatric Dentistry, Faculty of Dentistry, Gazi University. Materials and Methods: The measurements of BIS and hemodynamic variables recorded during treatment of 26 healthy children and 26 children with CP between 3 and 10 years of age who were treated under sevoflurane and 50% N2O–50% O2 mixture deep sedation method were investigated retrospectively. Results: The mean BIS values in the CP group was statistically lower at all the time points when compared with the control group (P < 0.001). While there was no statistically significant difference between groups in terms of duration of treatment (P = 0.657), the median recovery time in the CP group was significantly longer than that recorded in the control group (P < 0.001). Significant correlation was found between modified Ramsay Sedation Scale (mRSS) scores and BIS levels at 5th, 10th, and 20th min in the control group (P < 0.001). Similar correlation was found in the CP group at 15th and 20th min. Conclusion: We concluded that it is necessary to consider the dosage and effect mechanisms of drugs used in children with CP to prevent overuse of anesthetics and emergence of anesthesia-related complications.

Keywords: Bispectral index, cerebral palsy, deep sedation, depth of anesthesia, sevoflurane


How to cite this article:
Onal P, Oztas N, Kip G. Comparison of bispectral index values and depth of sedation during deep sedation using sevoflurane anesthesia in healthy children versus children with cerebral palsy. Niger J Clin Pract 2019;22:801-5

How to cite this URL:
Onal P, Oztas N, Kip G. Comparison of bispectral index values and depth of sedation during deep sedation using sevoflurane anesthesia in healthy children versus children with cerebral palsy. Niger J Clin Pract [serial online] 2019 [cited 2019 Sep 15];22:801-5. Available from: http://www.njcponline.com/text.asp?2019/22/6/801/260041




   Introduction Top


Oral and dental health is a serious problem in children and young people with disabilities. In these patients, regular use of medication, immune system problems, nutritional disorders, gastroesophageal reflux, trauma, poor oral hygiene, periodontal problems, and missing teeth are more common than in healthy people. Cerebral palsy (CP) is one of these diseases.[1]

CP is a clinical syndrome characterized by movement and postural disturbances that occur in the motor centers of the brain resulting from various conditions occuring during the prenatal, natal, or postnatal period and is the most common chronic motor failure of childhood.[2],[3]

Pharmacological techniques that require intensive care such as sedation and general anesthesia are generally used for dental treatment performed in this patient group.[4] There is insufficient information about the pharmacodynamic effects of anesthetic drugs in this group of patients. Studies have reported that children with CP have different sensitivity to anesthetic agents when compared with healthy children.[5],[6],[7]

Bispectral index (BIS) monitoring is a useful and effective tool for measuring the depth of anesthesia in both adults and children. However, BIS values may differ between adults and children because of ongoing brain development and synapse formation until 5 years of age.[8] Also, different anesthetics may affect BIS values. As an example, Weber et al.[9] showed that remifentanil did not affect BIS values in children.

The purpose of this retrospective study is to evaluate the clinical efficacy (evaluated by comparing BIS and RSS scores) of the routinely used drug regimen during deep sedation protocols performed in the Department of Pediatric Dentistry, Faculty of Dentistry, Gazi University, using examination of medical records of both healthy children and children with CP.


   Materıals and Methods Top


Data used in the retrospective study were obtained by evaluating retrospectively the records of patients who underwent deep sedation treatment in the Department of Pediatric Dentistry of Gazi University between September 2015 and June 2017 using sevoflurane (at a concentration of 8% for induction and 5% for anesthesia maintenance) and 50% N2O–50% O2. A control group and a CP group were randomly created from medical records of patients treated in our clinic. The measurements of BIS and hemodynamic variables recorded during treatment of American Society of Anesthesiologists (ASA) I group 26 healthy children (control group) and ASA II–III group 26 noncommunicating children with CP (group CP) between 3 and 10 years old were compared. Exclusion criteria for the control group were presence of mental retadation and systemic disease (diabetes mellitus, rhemautological diseases) and/or usage of drugs (antiasthmatic drugs and antibiotics). Exclusion criteria for the CP group were presence of epilepsy and/or usage of anticonvulsant drugs.

Patient heart rates (HRs) were measured before the procedure and recorded as a baseline value and subsequently recorded every 5 min until the end of the treatment and recorded in the patient record and follow-up form. The depth of sedation was monitored by BIS monitoring (BIS® XP; Aspect, A-2000, USA) in accordance with the instructions of the manufacturer, and oxygen saturation was recorded every 5 min during the procedure and recorded in the patient record and follow-up form. The depth of sedation was evaluated every 5 min during the treatment using Modified Ramsay Sedation Scale (mRSS) [Table 1] and recorded in patient record and follow-up form. Modified Aldrete Score [Table 2] was used in the evaluation of the recovery. Patients were discharged when the score is ≥9 according to the Modified Aldrete Score, and the elapsed time was recorded in the patient follow-up form.
Table 1: Ramsay Sedation Scale

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Table 2: Modified Aldrete score

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Statistical analyses were performed with IBM SPSS 17.0 (IBM Corporation, Armonk, NY, USA). The significance of the difference between the control and CP groups in terms of mean values was assessed by Student's t-test, and the significance of the difference in terms of continuous numerical variables with normal distribution was examined by Mann–Whitney U-test. Categorical variables were assessed using Chi-square test. Spearman's rank correlation test was used to determine whether there was statistically significant correlation between continuous numerical variables. Wilk's Lambda test was used to investigate whether there was a statistically significant difference between the mean values for the measurements of HR and BIS between the control and CP groups. P value < 0.05 was considered statistically significant.


   Results Top


There were no differences between groups in gender and weight. The mean age of the CP group was statistically higher than the control group (P < 0.05) [Table 3].
Table 3: Demographics of study groups [mean±SD, n (%)]

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The mean pretreatment HR of the CP group was statistically significantly lower (P < 0.05) than that of the control group [Table 4]. There was no statistically significant difference obtained when control and CP groups were compared by means of the mean HR at all follow-up times (P > 0.05) [Table 5].
Table 4: Distribution of pretreatment heart rate of groups (mean±SD)

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Table 5: Heart rate levels according to the monitoring time (mean±SD)

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The mean BIS values in the CP group were statistically lower at all the time points when compared with the control group (P < 0.001) [Table 6]. There was no statistically significant correlation between BIS values and HR measurements at all time points in both the groups [Table 7].
Table 6: Mean BIS values recorded in groups [mean±SD, n (%)]

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Table 7: Correlation coefficients between the heart rate and BIS measurements in control and CP groups

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Within the control group, statistically significant correlation was found between mRSS scores and BIS levels at 5, 10, and 20 min (P < 0.001). Within the CP group, statistically significant correlation was found between mRSS scores and BIS levels at 15 and 20 min [Table 8].
Table 8: Correlation between mRSS scores and BIS measurements in control and CP groups

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While there was no statistically significant difference obtained between groups in terms of treatment duration (P = 0.657), the median duration of recovery period in the CP group was determined to be significantly longer than that of the control group (P < 0.001) [Table 9].
Table 9: Treatment duration and recovery period in groups [median (minimum-maximum)]

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   Discussion Top


BIS system is an electroencephalogram (EEG) monitor that measures the depth of anesthesia through a sensor placed on the patient's forehead.[10] Studies have shown that the administration of anesthetic agents under BIS monitoring provides more effective use of anesthetics and faster recovery from anesthesia.[11],[12]

Like other organ systems, the central nervous system has not yet matured functionally at birth, and most of the maturation is completed up to 5 years of age. Studies comparing the EEG values of adults and newborns indicate that the EEG of the newborn is different from that of the adults and that BIS monitoring is reliable in children over 2 years of age.[13],[14]

CP is the result of damage in the developing brain and encompasses several symptoms of heterogeneous etiology. Because there is a wide spectrum of neurologic deficits in children with CP, anesthetic properties and BIS values may differ in these situations. Hence, we included only noncommunicative and children with mental retardation in this study. Also, it is unknown whether the presence of seizures or the administration of various antiseizure medications affects BIS values.

Depending on the developments in recent years, the need for anesthesia has increased in the treatment of children with CP. However, there is not enough information on the pharmacodynamic effects of anesthetic drugs in this patient group. Many studies have shown that patients with CP have higher sensitivity to anesthetic agents that affect the central nervous system.[4],[6],[7] Frei et al.[6] compared the minimum alveolar concentration (MAC) values of halotane in normal children (Group 1) and children with CP or mental retardation either using medication (Group 2) or without any medication (Group 3) undergoing orthopedic surgery. They found lower MAC values in patients with CP/mental retardation. In addition, they found lower MAC values in patients taking anticonvulsant drugs when compared with patients without any medications.[6] In this study, we did not record and compare the MAC values of sevoflurane, and therefore we could not make any comparison between the MAC values of sevoflurane and halotane in similar patient groups. Lack of recording and comparing of MAC values can be assumed as a limitation for this study.

According to the results of this study, the mean BIS values in the CP group were statistically lower at all the time points when compared with those recorded in the control group. Similarly, Choudhry and Brenn[4] compared the BIS values at different sevoflurane concentrations between normal children and children with CP with mental retardation. They observed that the BIS values were lower than in normal children while awake and at different sevoflurane concentrations. In a similar study, Mello and Saraiva[7]compared the BIS values during general anesthesia with sevoflurane between normal children and children with spastic CP. They observed that the BIS values of children with CP were lower than in normal children at concentrations of 1.2% and 2.5% sevoflurane.

Costa et al.[5]evaluated the recovery of patients with CP compared with patients without central nervous system disease. They observed that the mean basal EEG-BIS value of CP patients was lower than in the control group, and after the anesthetics were discontinued, the mean EEG-BIS values of patients with CP returned more slowly to baseline values than in patients in the control group.

In this study, while there was no statistically significant difference obtained between groups in terms of duration of treatment, the median recovery time of the CP group was determined to be significantly longer than that of the control group. The results of our study are in parallel with the results of other studies conducted on similar patient groups. These results support the idea that a lower anesthetic may be required to prevent the altered functioning of cells in certain areas of the brain due to lesions or anomalies occurring at early stages of brain development and to reduce the loss of consciousness recorded by BIS.

In this study, which evaluates the difference in susceptibility of healthy children and children with CP to anesthetic agents used in sedation protocols in dentistry, it is necessary to consider the dosage and effect mechanisms of drugs used in children with CP patients. We believe that future studies on this topic will help ensure more effective usage of medications for patients with CP.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Kömerik N, Kırzıoǧlu Z, Efeoǧlu CG. Zihinsel engele sahip bireylerde aǧız saǧlıǧı. Atatürk Üniversitesi Diş Hekimliǧi Fakültesi Dergisi 2012;22:96-104.  Back to cited text no. 1
    
2.
Başarslan F, İnci M, Köksaldı Motor V, Yula E, Kaya S, ve Yılmaz C. Serebral Palsili Çocuklarda Kandida Kolonizasyonu. Düzce Tıp Fakültesi Dergisi 2014;16:16-9.  Back to cited text no. 2
    
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Kim EJ, Jo YY, Kil HK. Optimal sedative dose of propofol to start MRI in children with cerebral palsy. Korean J Anesthesiol 2011;61:216-9.  Back to cited text no. 3
    
4.
Choudhry DK, Brenn BR. Bispectral index monitoring: A comparison between normal children and children with quadriplegic cerebral palsy. Anesth Analg 2002;95:1582-5.  Back to cited text no. 4
    
5.
Costa VV, Saraiva RA, Domingues-Duarte LT. Regression of general anesthesia in patients with cerebral palsy: A comparative study using the bispectral index. Rev Bras Anestesiol 2006;56:431-42.  Back to cited text no. 5
    
6.
Frei FJ, Haemmerle MH, Brunner R. Minimum alveolar concentration for halothane in children with cerebral palsy and several mental retardation. Anaesthesia 1997;52:1056-60.  Back to cited text no. 6
    
7.
Mello SS, Saraiva RA. Electroneourophysiological changes in anesthesia with sevoflurane: Comparative study between healthy and cerebral palsy patients. Rev Bras Anestesiol 2003;53:150-9.  Back to cited text no. 7
    
8.
Zhang J-M, Wang F, Xin Z, Zi T-T, Lv H. Treatment of different-aged children under bispectral index monitoring with intravenous anesthesia with propofol and remifentanil. Eur Rev Med Pharmacol Sci 2015;19:64-6.  Back to cited text no. 8
    
9.
Weber F, Fussel U, Gruber M, Hobbhahn J. The use of remifentanil for intubation in paediatric patients during sevoflurane anesthesia guided by bispectral index (BIS) monitor. Anesthesia 2003;58:749-55.  Back to cited text no. 9
    
10.
Johansen JW, Sebel PS. Development and clinical application of electroencephalographic bispectrum monitoring. Anesthesiology 2000;93:1336-44.  Back to cited text no. 10
    
11.
Myles PS, Leslie K, McNeil J, Forbes A, Chan MTV. Bispectral index monitoring to prevent awareness during anaesthesia: The B-Aware randomised controlled trial. Lancet 2004;363:1757-63.  Back to cited text no. 11
    
12.
Sargın M, Uluer MS, Özmen S. The effects of bispectral index monitoring on hemodynamics and recovery profile in developmentally delayed pediatric patients undergoing dental surgery. Pediatr Anesth 2015;25:950-5.  Back to cited text no. 12
    
13.
Davidson AJ, McCann ME, Devavaram P, Auble SA, Sullivan LJ, Gillis JM, et al. The differences in the bispectral index between infants and children during emergence from anesthesia after circumcision surgery. Anesth Analg 2001;93:326-30.  Back to cited text no. 13
    
14.
Kim HS, Oh AY, Kim CS, Kim SD, Seo KS, Kim JH. Correlation of bispectral index with end-tidal sevoflurane concentration and age in infants and children. Br J Anaesth 2005;95:362-6.  Back to cited text no. 14
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]



 

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