Abstract
We report the use of perioperative bispectral index (BIS) monitoring in a patient who underwent living donor liver transplantation (LDLT). Hepatic encephalopathy featuring extreme excitement developed in a 42-year-old male and was diagnosed as acute hepatitis. Sedation with continuous infusion of midazolam was necessary. BIS value gradually decreased and reached 0 17 h after commencement of continuous infusion of midazolam. Midazolam infusion was stopped but BIS value remained 0. Brain CT scan revealed an almost normal image. Multi-lead electroencephalogram was recorded revealing almost no electrical activity. Administration of flumazenil did not improve his consciousness and BIS value. Adequate spontaneous respiration was maintained and the possibility of brain death was excluded. LDLT was performed on the 5th ICU day. BIS value remained 0 throughout surgery. BIS value suddenly increased 2 h after surgery and reached 60 11 h after surgery. It became possible to communicate with the patient and his trachea was extubated on the 4th postoperative day. We believe that, with BIS, we were able to follow preoperative exacerbation of the “pathological” process of hepatic encephalopathy, and predict postoperative emergence from general anesthesia, suggesting normal graft function.
Similar content being viewed by others
References
Hassanein TI, Hilsabeck RC, Perry W. Introduction to the hepatic encephalopathy scoring algorithm (HESA). Dig Dis Sci. 2008;53:529–38.
Vivien B, Di Maria S, Ouattara A, Langeron O, Coriat P, Riou B. Overestimation of bispectral index in sedated intensive care unit patients revealed by administration of muscle relaxant. Anesthesiology. 2003;99:9–17.
Avidan MS, Zhang L, Burnside BA, Finkel KJ, Searleman AC, Selvidge JA, Saager L, Turner MS, Rao S, Bottros M, Hantler C, Jacobsohn E, Evers AS. Anesthesia awareness and the bispectral index. N Engl J Med. 2008;358:1097–108.
Dumans-Nizard V, Hamada S, Fischler M. Bispectral index during cardiopulmonary resuscitation: a poor indicator of recovery. Two very different cases. Anaesthesia. 2009;65:196–8.
Miyake W, Oda Y, Ikeda Y, Hagihira S, Iwaki H, Asada A. Electroencephalographic response following midazolam-induced general anesthesia: relationship to plasma and effect-site midazolam concentrations. J Anesth. 2010;24:386–93.
Khurana P, Agarwal A, Verma R, Gupta P. Comparison of midazolam and propofol for BIS-guided sedation during regional anaesthesia. Indian J Anaesth. 2009;53:662–6.
Sunzel M, Paalzow L, Berggren L, Eriksson I. Respiratory and cardiovascular effects in relation to plasma levels of midazolam and diazepam. Br J Clin Pharmacol. 1988;25:561–9.
Reves JG, Fragen RJ, Vinik HR, Greenblatt DJ. Midazolam: pharmacology and uses. Anesthesiology. 1988;62:310–24.
Dahaba AA, Worm HC, Zhu SM, Bao FP, Salah A, Zakaria S, Bornemann H, Stadlbauer V, Rehak PH, Metzler H, Stauber RE. Sensitivity and specificity of bispectral index for classification of overt hepatic encephalopathy: a multicentre, observer blinded, validation study. Gut. 2008;57:77–83.
Kobayashi S, Ochiai T, Hori S, Suzuki T, Shimizu T, Gunji Y, Shimada H, Kanazawa M, Ogawa A, Kohno Y, Hirasawa H, Oda S, Tanaka K. Complete recovery from fulminant hepatic failure with severe coma by living donor liver transplantation. Hepatogastroenterology. 2003;50:515–8.
Kobayashi T, Sato Y, Yamamoto S, Takeishi T, Oya H, Hideki N, Kokai H, Kurosaki I, Hatakeyama K. Auxiliary partial orthotopic living donor liver transplantation for fulminant hepatic failure with flat electroencephalogram: a case report. Transplant Proc. 2010;42:990–3.
Dahaba AA, Feng ZY, Zhu SM, Bornemann H, Rehak PH, Metzler H. The utility of using bispectral index monitoring as an early intraoperative indicator of initial poor graft function after orthotopic or split-graft liver transplantation. Gut. 2009;58:605–6.
Reeves RR, Struve FA, Burke RS. Quantitative EEG analysis before and after liver transplantation. Clin EEG Neurosci. 2006;37:34–40.
Kasuya Y, Govinda R, Rauch S, Mascha EJ, Sessler DI, Turan A. The correlation between bispectral index and observational sedation scale in volunteers with dexmedetomidine and propofol. Anesth Analg. 2009;109:1811–5.
Author information
Authors and Affiliations
Corresponding author
About this article
Cite this article
Okawa, H., Ono, T., Hashiba, E. et al. Use of bispectral index monitoring for a patient with hepatic encephalopathy requiring living donor liver transplantation: a case report. J Anesth 25, 117–119 (2011). https://doi.org/10.1007/s00540-010-1055-6
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00540-010-1055-6