Comparison of Bispectral Index (BIS) and Patient State Index (PSI) as objective measures of sedation and analgesia in critically ill/injured patients

Critically ill and injured patients require pain relief and sedation to reduce the body's stress response and to facilitate painful diagnostic and therapeutic procedures. Presently, the level of sedation and analgesia is guided by the use of clinical scores which can be unreliable. There is therefore, a need for an objective measure of sedation and analgesia. The Bispectral Index (BIS) and Patient State Index (PSI) were recently introduced into clinical practice as objective measures of the depth of analgesia and sedation. ^ Aim. To compare the different measures of sedation and analgesia (BIS and PSI) to the standard and commonly used modified Ramsay Score (MRS) and determine if the monitors can be used interchangeably. ^ Methods. MRS, BIS and PSI values were obtained in 50 postoperative cardiac surgery patients requiring analgesia and sedation from June to December 2004. The MRS, BIS and PSI values were assessed hourly for up to 6-h by a single observer. ^ The relationship between BIS and PSI values were explored using scatter plots and correlation between MRS, BIS and PSI was determined using Spearman's correlation coefficient. Intra-class correlation (ICC) was used to determine the inter-rater reliability of MRS, BIS and PSI. Kappa statistics was used to further evaluate the agreement between BIS and PSI at light, moderate and deep levels of sedation. ^ Results. There was a positive correlation between BIS and PSI values (Rho = 0.731, p<0.001). Intra-class correlation between BIS and PSI was 0.58, MRS and BIS 0.43 and MRS and PSI 0.27. Using Kappa statistics, agreement between MRS and BIS was 0.35 (95% CI: 0.27–0.43) and for MRS and PSI was 0.21 (95% CI: 0.15–0.28). The kappa statistic for BIS and PSI was 0.45 (95% CI: 0.37–0.52). Receiver operating characteristics (ROC) curves constructed to detect undersedation indicated an area under the curve (AUC) of 0.91 (95% CI = 0.87 to 0.94) for the BIS and 0.84 (95% CI = 0.79 to 0.88) for the PSI. For detection of oversedation, AUC for the BIS was 0.89 (95% CI = 0.84 to 0.92) and 0.80 (95% CI = 0.75 to 0.85) for the PSI. ^ Conclusions. There is a statistically significant positive correlation between the BIS and PSI but poor correlation and poor test agreement between the MRS and BIS as well as MRS and PSI. Both the BIS and PSI demonstrated a high level of prediction for undersedation and oversedation; however, the BIS and PSI can not be considered interchangeable monitors of sedation. ^

(Table 1) Summary of sampling points described and main petrographic, morphological and geochemical characteristics

Targeted sampling on the Dolgovskoy Mound (northern Shatsky Ridge) revealed the presence of spectacular laterally extensive and differently shaped authigenic carbonates. The sampling stations were selected based on sidescan sonar and profiler images that show patchy backscatter and irregular and discontinuous reflections in the near subsurface. The interpretation of acoustic data from the top part of the mound supports the seafloor observations and the sampling that revealed the presence of a complex subsurface plumbing system characterized by carbonates and gas. The crusts sampled consist of carbonate cemented layered hemipelagic sedimentary Unit 1 associated with several centimetres thick microbial mats. Three different carbonate morphologies were observed: (a) tabular slabs, (b) subsurface cavernous carbonates consisting of void chambers up to 20 cm**3 in size and (c) chimney and tubular conduits vertically oriented or forming a subhorizontal network in the subsurface. The methanogenic origin of the carbonates is established based on visual observations of fluids seepage structures, 13C depletion of the carbonates (d13C varying between -36.7 per mil and -27.4 per mil), and by thin carbonate layers present within the thick microbial mats. Laboratory experiments with a Hele-Shaw cell were conducted in order to simulate the gas seepage through contrasting grain size media present on the seafloor. Combined petrography, visual observations and sandbox simulations allowed a characterization of the dynamics and the structures of the plumbing system in the near subsurface. Based on sample observations and the experiments, three observed morphologies of authigenic carbonates are interpreted, respectively, as (a) Darcian porous flow through the finely laminated clayey/coccolith-rich layers, (b) gas accumulation chambers at sites where significant fluid escape was impeded by thicker clayey layers forming the laminated Unit1 and (c) focussed vertical fluid venting and subhorizontal migration of overpressured fluids released from (b). The Hele-Shaw cell experiments represent a promising tool for investigating shallow fluid flow pathways in marine systems.

Reconstructed glaciation limits in Eurasia (digitized from map Fig.1)

Based on field investigations in northern Russia and interpretation of offshore seismic data, we have made a preliminary reconstruction of the maximum ice-sheet extent in the Barents and Kara Sea region during the Early/Middle Weichselian and the Late Weichselian. Our investigations indicate that the Barents and Kara ice sheets attained their maximum Weichselian positions in northern Russia prior to 50 000 yr BP, whereas the northeastern flank of the Scandinavian Ice Sheet advanced to a maximum position shortly after 17000 calendar years ago. During the Late Weichselian (25 000-10000 yr BP), much of the Russian Arctic remained ice-free. According to our reconstruction, the extent of the ice sheets in the Barents and Kara Sea region during the Late Weichselian glacial maximum was less than half that of the maximum model which, up to now, has been widely used as a boundary condition for testing and refining General Circulation Models (GCMs). Preliminary numerical-modelling experiments predict Late Weichselian ice sheets which are larger than the ice extent implied for the Kara Sea region from dated geological evidence, suggesting very low precipitation.

Age determination of sediment cores off western Spitsbergen

The Late Weichselian glacial history of the continental shelf off western Spitsbergen is discussed, based on acoustic sub-bottom records and sediment cores. The outer part of Isfjorden and the inner shelf to the west of this fjord are characterized by a thin veneer (10-20 m) of glacigenic sediments and absence of ice-marginal features. Towards the outer shelf the sediment thickness increases significantly, and exceeds 500 m at the shelf edge. Possible moraine complexes were identified in this outer part. Sediment cores from the inner shelf sampled a firm diamicton, interpreted as till, beneath soft glaciomarine sediments. Radiocarbon dates on shells from the clay resting directly on the till, suggest an age of around 12,500 yrs B.P. for the base of the marine sequence. We argue that grounded ice covered the sites shortly before. In contrast to suggestions that the fjords and coast were partly ice free during the Late Weischselian, we conclude that the ice must have reached out onto the continental shelf.

Composite depth scale, tie points and magnetic susceptibilities of ODP Site 178-1098 sediments

Multiple holes were cored at Ocean Drilling Program Leg 178 Sites 1098 and 1099 in two subbasins of the Palmer Deep in order to recover complete and continuous records of sedimentation. By correlating measured properties of cores from different holes at a site, we have established a common depth scale, referred to as the meters composite depth scale (mcd), for all cores from Site 1098. For Site 1098, distinct similarities in the magnetic susceptibility records obtained from three holes provide tight constraints on between-hole correlation. Additional constraints come from lithologic features. Specific intervals from other data sets, particularly gamma-ray attenuation bulk density, magnetic intensity, and color reflectance, contain distinctive anomalies that correlate well when placed into the preferred composite depth scale, confirming that the scale is accurate. Coring in two holes at Site 1099 provides only a few meters of overlap. None of the data sets within this limited overlap region provide convincing correlations. Thus, the preferred composite depth scale for Site 1099 is the existing depth scale in meters below seafloor (mbsf).