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Emergence from Propofol Anesthesia in a Nonagenarian at a Bispectral Index of 52

Kakinohana, Manabu MD, PhD; Nakamura, Seiya MD; Miyata, Yuji MD; Sugahara, Kazuhiro MD, PhD

doi: 10.1213/01.ANE.0000153528.66576.BE
Technology, Computing, and Simulation: Case Report

In this case report, we describe a nonagenarian patient who could respond completely to verbal commands at a Bispectral Index (BIS) value of 52 after epidural lidocaine and IV propofol anesthesia. Measured blood lidocaine and propofol concentrations were 0.69 μg/mL and 0.74 μg/mL, respectively. Intraoperative awareness even in the recommended BIS range of 40–60 remains possible.

IMPLICATIONS: In this case report, we describe a nonagenarian patient who could respond completely to verbal commands at a Bispectral Index (BIS) value of 52 after epidural lidocaine and IV propofol anesthesia. Intraoperative awareness can occur even in the recommended BIS range 40–60.

Department of Anesthesiology, Faculty of the Medicine, University of the Ryukyus, Okinawa, Japan

Accepted for publication December 1, 2004.

Address correspondence and reprint requests to Manabu Kakinohana, MD, PhD, Department of Anesthesiology, Faculty of Medcine, University of the Ryukyus, 207 UEHARA, Nishihara-cho, Okinawa, 903–0125, Japan. Address e-mail to

The bispectral index (BIS) is a dimensionless variable between 0 and 100 that correlates with the degree of sedation (1,2). Values <60 correlate with a small probability of consciousness (3). In general, a BIS between 40 and 60 is recommended for adequate depth of anesthesia, and, at values higher than 80, patients regain consciousness (4). We report a case in which the patient could respond completely to verbal commands at a BIS value of 52 after propofol anesthesia.

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Case Report

A 91-year-old, 55-kg male with hypertension and complete right bundle branch block presented to the operating room for right hemilateral colorectomy as a result of cancer of the ascending colon. He had no history of use of psychological drugs or alcohol abuse. His surgical history was negative. Electrocardiogram, peripheral oxygen saturation, and arterial blood pressure were continuously measured. A BIS sensor was fixed at the frontal positions as recommended (Aspect A-1050; Aspect Medical Systems, Newton, MA). The BIS value before the induction of anesthesia was 98. An epidural catheter was inserted at T9-10. A 1% lidocaine test dose (2 mL) containing 10 μg of epinephrine was given. Anesthesia was induced by IV fentanyl 100 μg and propofol 65 mg with neuromuscular block induced with vecuronium 6 mg. After endotracheal intubation, anesthesia was maintained with continuous infusion of propofol at 2 mg · kg−1 · h−1 to control BIS values between 40 and 60 (5). No additional muscle relaxants were given thereafter. During the surgical procedure, 6 mL of 1% lidocaine was injected via the epidural catheter or IV fentanyl was given according to changes in arterial blood pressure and heart rate. Intraoperative usage of epidural lidocaine and IV fentanyl was 180 mg and 300 μg, respectively. The surgical procedure (3.5 h) was performed uneventfully, and then propofol infusion was discontinued. Bupivacaine (0.25%) was infused at 3 mL/h for postoperative analgesia. Spontaneous breathing occurred without reversal of neuromuscular blockade. His arterial blood pressure and heart rate increased gradually. Although we decided not to assess the response to verbal stimuli until the BIS value increased to greater than 80, the BIS values remained between 40 and 60 even 2 hours after propofol infusion was discontinued. Despite BIS values of 52 at 2 hours and 15 minutes after propofol infusion was discontinued, the patient responded to the first verbal command from an anesthesiology resident. At that time, a blood sample was taken from the right femoral artery and retained for high-performance liquid chromatography analysis (MC Medical, Inc., Osaka, Japan). We confirmed that the patient had awakened and he was then tracheally extubated and transferred to the postanesthetic care unit in stable condition. In the postanesthetic care unit, BIS values remained between 50 and 60 with complete response to verbal commands. After the electrode was removed, a new electrode was replaced to exclude the possibility of electrode impairment. However, the new electrode showed BIS values between 50 and 60 for the next 15 minutes.

During postanesthesia interviews 24 hours and 72 hours after surgery the patient reported that he could recall our voices in the operating room and feel his trachea being intubated but, fortunately, not his abdomen being operated on. He described some of our conversations after the surgery as the nurses and anesthesiologists conducted the postoperative evaluation. High-performance liquid chromatography analysis revealed that the arterial blood propofol and lidocaine concentrations taken at BIS 52 were 0.74 and 0.69 μg/mL, respectively.

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In this case, the patient could completely respond to verbal commands at a BIS value of 52 and a blood propofol concentration of 0.74 μg/mL. Electromyographic activity as a source of interference for BIS monitoring (6) might have resulted in a false interpretation of the BIS value in this case. In general, however, electromyographic signals are considered to increase BIS values because of the overlap of electroencephalogram (0.5–30 Hz) and electromyographic (30–300 Hz) signals (5). Therefore, we do not believe that an artifact induced by electromyographic signals was associated with the low BIS value during emergence from propofol anesthesia.

The emergence from anesthesia at a BIS value of 52 might result from a feature of the electroencephalogram in geriatric patients. However, Kazama et al. (7) showed no effect of age on the propofol dose-BIS relationship. Renna et al. (8) however, demonstrated that some elderly patients with dementia (Alzheimer’s disease or vascular dementia) had low BIS values in the awake state. In addition, it was reported that senile dementia may be associated with lower BIS values during anesthesia (9), suggesting that senile dementia might alter the pharmacodynamic response to propofol. Because our patient had not been diagnosed with senile dementia and the preinduction BIS value was 98, it is possible that this patient was an outlier in the normal relationship between BIS and plasma propofol concentration. There have been some studies demonstrating that epidural anesthesia might change the pharmacodynamics of general anesthetics (sevoflurane, isoflurane, and propofol) (10–12) via inhibition of tonic afferent spinal signaling to the brain. Our patient did not complain of postoperative pain in the postanesthetic care unit, suggesting suppression of afferent spinal signaling to the brain. In this case, therefore, it is also likely that epidural analgesia might have modulated the pharmacodynamic changes to propofol.

Although a BIS value between 40 and 60 is recommended for adequate depth of anesthesia (4), Glass et al. (3) demonstrated that a BIS value of 51 corresponded to a 95% chance of the patient being unconscious; i.e., a 5% chance of consciousness. A large prospective study (13) showed that one patient among 1225 had an episode of intraoperative awareness in the BIS range of 55–59. The authors suggested that awareness can occur when BIS is at the upper limit of the recommended (40–60) range.

Prospective, randomized studies (14,15) demonstrated that anesthetic titration using BIS monitoring can result in significantly reduced average drug use and faster patient recovery from anesthesia. In using BIS monitoring for propofol titration, Glass et al. (3) recommended that anesthesiologists should maintain BIS values below 50 if awareness is to be avoided in most cases. Based on the clinical experience in this episode, we agree with this recommendation.

The BIS index can be useful in guiding dosing of anesthetic drugs. However, the present case indicates that BIS may not be predictive of depth of anesthesia in all patients.

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