Correlating the Depth of Sedation Between the Ramsay Sedation Scale and Bispectral Index Using Either Intravenous Midazolam or Intravenous Propofol in Elderly Patients Under Spinal Anaesthesia.

Abstract

Supplementation of spinal anaesthesia with sedatives or anxiolytics has emerged as a standard protocol to alleviate patients' anxiety and to produce amnesia during the surgical procedure. Thus, judicious use of sedation can make surgeries under spinal anaesthesia more comfortable and acceptable for the elderly patient, the surgeon, and the anaesthesiologist. However, over-sedation may jeopardise the safety of the patient. Appropriate sedation helps reduce physiological stress, which leads to a better result. Therefore, monitoring the depth of sedation becomes essential. The Ramsay sedation scale (RSS) and bispectral index (BIS) both are used widely to assess the depth of sedation. The primary objective of the study was to assess and correlate the depth of sedation between the BIS and RSS in elderly patients using midazolam and propofol under spinal anaesthesia. The secondary objectives were to observe any difference in the commencement of sedation between the two groups and to observe haemodynamic changes between the two groups. A total of 60 elderly patients undergoing urological procedures under spinal anaesthesia were randomly assigned to receive either midazolam (Group A, n=30) or propofol (Group B, n=30) for sedation. In Group A, patients were given an initial bolus of midazolam 0.03 mg/kg and a maintenance incremental bolus of 0.01 mg/kg up to a maximum of 2.5 mg in 10-minute intervals. Group B used propofol with an initial bolus dose of 0.5 mg/kg over two minutes and a maintenance bolus of 10-20 mg as required for the maintenance of sedation depth. Sedation was titrated to achieve a BIS score of 70-80 and an RSS score of 3-4. Heart rate, non-invasive systolic, diastolic, mean arterial blood pressure, oxygen saturation (SPO2), and the correlation coefficient between the BIS and RSS were measured at 0 (baseline), 5, 10, 20, 30, 40, 50, and 60 minutes of interval. The correlation coefficient between the BIS and RSS scores in Group A at various time intervals indicate a strong correlation coefficient of -0.76 at five minutes, -0.64 at 20 minutes, -0.78 at 30 minutes, -0.56 at 40 minutes, and -0.39 at 50 minutes. In Group B, the correlation coefficient between the BIS and RSS scores at various time intervals indicate a strong correlation coefficient of -0.75 at five minutes, -0.76 at 20 minutes,-0.64 at 30 minutes, -0.89 at 40 minutes, and -0.46 at 50 minutes of interval. We also observed that the BIS drops to a lower level in patients receiving propofol (Group B) with a significant difference depicting early onset of sedation with propofol. In Group B, HR and MAP were significantly less than those of Group A. There was no significant difference in terms of mean age, sex, and body weight in the patients of both groups. The BIS and RSS scores indicate a strong correlation with a magnitude of 70%-80%, but more in Group B (propofol) than Group A (midazolam). Therefore, the characteristics of each sedative drug can influence the level of sedation during spinal anaesthesia. Clinicians should use a combination of BIS values and other objective sedative methods to determine the degree of sedation, rather than relying exclusively on BIS values.