TECHNICAL COMMUNICATION

Correlation of Bispectral Index and Guedels Stages of

Ether Anesthesia
A. K. Bhargava, MD, R. Setlur, MD, and D. Sreevastava, MD, MNAMS
Department of Anesthesiology and Critical Care, Armed Forces Medical College, Pune, India
Bispectral index (BIS) analysis is a method of electroen-
cephalograph (EEG) analysis based on the interfre-
quency phase relationships of the EEG, designed to
quantify anesthetic hypnosis. The BIS was created after
concurrent collection of EEG and clinical data from a
large number of patients anesthetized with various
drugs over a prolonged period and then performing a
Fourier analysis followed by a bispectral calculation.
The clinical stages of anesthetic depth are very well
demonstrated in etherized patients. In this study, we
studied the BIS changes during various stages of ether
anesthesia and quantified the hypnotic depth during
the surgical stage of ether anesthesia. The values for BIS
under various stages and planes of ether anesthesia
were recorded in 21 patients listed for short surgical
procedures. During diethyl ether anesthesia, BIS ini-
tially increased and subsequently decreased. During
surgical anesthesia, a BIS value of 30 was observed.
(Anesth Analg 2004;98:1324)
T
he administration rate of general anesthetic
drugs is at present guided by clinical experience
and indirect indicators such as hemodynamic
variables. The application of electroencephalograph
(EEG) to assess the depth of anesthesia has been de-
veloping over the last decade (13). The bispectral
index (BIS) variable was created after concurrent col-
lection of EEG and clinical data from a large number
of patients undergoing general anesthesia over a pro-
longed period and then performing Fourier analysis
and subsequent bispectral calculations (46).
1
Using a
multivariate regression model represented as a single
number ranging from 100 for wide awake to 0 in the
absence of brain activity, variables for depth of hyp-
nosis were formulated based on results from a multi-
center study of the BIS involving the administration of
four frequently used anesthetic regimens (7).
Notwithstanding the disadvantages of ether, there
is no other anesthetic that defines the clinical stages
according to the depth of anesthesia. Moreover, it is
the only drug that has all the properties defined in the
triad of anesthesia for balanced anesthesia, i.e., hyp-
nosis, analgesia, and suppression of reflexes including
muscle relaxation. Thus, ether could be considered an
ideal volatile anesthetic in so far as these properties
are concerned.
Data for most IV and inhaled anesthetics exist, but
there are no data for ether because of its discontinu-
ance in the United States since 1982 (8). Ether is still in
use in the underdeveloped countries, and we felt it
would be worth doing BIS monitoring in patients
anesthetized in the classically established methods of
earlier times rather than concentrating on achieving
minimum alveolar anesthetic concentration (MAC)
values of an anesthetic for achieving sufficient anes-
thetic depth. The aim of this study was to determine
the BIS under various stages and planes of ether an-
esthesia. Particular interest was focused at the surgical
stage of ether anesthesia.
Methods
IRB approval and informed consent were obtained
before the study. Twenty-one adult female patients
aged 2030 yr old in ASA Grade I listed for short
gynecological procedures were the subjects of this
study. The operations performed were abdominal
tube ligations, dilation and curettage, cervical biop-
sies, and fractional curettage where no electrocautery
was envisaged. Premedication in all cases was glyco-
pyrrolate 0.2 mg IM and ondansetron 4 mg IV 30 min
before surgery.
1
Bloom MJ, Whitehurst S, Mandel M, et al. Bispectral index as an
EEG measure of the sedative effect of isoflurane. Anesthesiology
1995;7:A195.
Accepted for publication July 18, 2003.
Address correspondence and reprint requests to Col A.K. Bhar-
gava, MD, Department of Anesthesiology & Critical Care, Armed
Forces Medical College, Pune 411040, India. Address e-mail to
colakbamc@yahoo.com.
DOI: 10.1213/01.ANE.0000090740.32274.72
2003 by the International Anesthesia Research Society
132 Anesth Analg 2004;98:1324 0003-2999/03
The A-2000 BIS Monitor manufactured by Aspect
Medical Systems (Newton, MA) was used in this
study. In all cases, the BIS sensor was applied to the
forehead and connected to the BIS monitor via the
patient interface cable and digital signal converter
before the induction of anesthesia along with the stan-
dard monitors.
Apart from BIS, the other variables indicated on the
monitor are the electromyelogram (EMG) signal status
(1100), suppression ratio value (100 indicating com-
plete suppression), and signal quality index (SQI) as a
percentage. If the EMG status bar shows 50, then the
SQI ratio tends to decrease. A value of SQI more than
50% gives a more valid value of the BIS. The EMG and
SQI values are therefore necessarily recorded to vali-
date the BIS.
The ESAB anesthesia machine (similar to Boyles
Model F), or the Draw over EMO ether inhaler, was
used for the cases. Induction in all cases was accom-
plished by ether in gradual incremental doses and
thereafter maintained with approximately 45% ether.
The dosage of ether was guided purely by Guedels
classification (9) for the stages of ether anesthesia.
It was desired to keep the patient in the surgical
plane, i.e., Stage 3 plane 2, during maintenance. Clin-
ically, this stage was reached when respiration became
regular (thoraco-abdominal) with large tidal volume,
eye balls fixed with pupils moderately dilated, and
absence of corneal reflex. The moment there was a
tendency to go into plane 3 (abdomino-thoracic respi-
ration), the ether delivery was reduced.
Results and Observations
The demographic data of all patients were compara-
ble. The average time of surgery was 20 min. Figure 1
shows the changing pattern of BIS during various
stages of ether anesthesia. The mean BIS values for the
various stages are depicted. It shows that ether causes
both an increase and decrease of BIS. Of interest is the
pattern of recovery and emergence from ether anes-
thesia, which is the mirror image of the changes that
take place during the induction. The increase in BIS
value, soon after the initial decrease on induction with
a similar event occurring during emergence, is prob-
ably caused by excessive muscle activity during that
period as evidenced by increase in EMG activity.
Although the recovery was late in all patients, the
cardiovascular and respiratory stability was main-
tained. No retching or vomiting was noticed in any
patient.
Discussion
The BIS is supposed to be a derived variable from a
large data bank in the bifrontal EEG wave forms that
were analyzed off line in patients sedated with differ-
ent anesthetics (isoflurane, sevoflurane, propofol, and
midazolam). Although electrical signals are from the
main power supply, electrocardiogram and EMG in-
duce high-frequency signals and show a stimulation
pattern, the instrument, before interpretation of the
BIS largely eliminates them. However, artifacts may
still be present and showthat BIS is increased. BIS may
predict somatic and autonomic response to noxious
stimuli and movement by an absolute increase in BIS.
This has been evidence of inadequate intraoperative
analgesia. In all cases in this study, anesthesia was
induced and maintained with ether only. Nitrous ox-
ide, IV anesthetics, and analgesics were avoided in the
study so that the results were not vitiated. The dose
response curve of ether is different from other inhaled
anesthetics. During the induction with ether, after an
initial decrease of BIS to 75, there is again an increase
in the index. In most cases, it was more than 90. The
EMG activity during Stage 2 peak was nearly 100%,
and the SQI decreased to nearly zero. In fact, for a
period of 12 minutes, the BIS value was not dis-
played. Thus, for a short period during Stage 2, in-
valid BIS scores were being obtained. Clearly the ini-
tial decrease followed by an increase in BIS during the
induction corresponded to the analgesia and delirium
stage of Guedels classification of stages of ether an-
esthesia. During recovery, the mirror image effect of
BIS values is also peculiar to ether.
In a balanced anesthetic technique that uses multi-
ple drugs, the stages of anesthesia are concealed.
Moreover, the adequate levels of the triad of anesthe-
sia (hypnosis, analgesia, and abolition of reflex activ-
ity) may not be achieved, because we have no direct
variable to monitor them. In such circumstances, if one
considers the values of BIS obtained during ether an-
esthesia, we can at least assume that the correct level
of the hypnosis element is the value of BIS obtained
Figure 1. Bispectral index (BIS) values under various stages of ether
anesthesia (mean sd).
ANESTH ANALG TECHNICAL COMMUNICATION BHARGAVA ET AL. 133
2004;98:1324 BIS CHANGES DURING DIETHYL ETHER ANESTHESIA
during the surgical stage (Stage 3 plane 2) for perform-
ing surgery. Thus, an index of around 30 could be con-
sidered a guiding value in our anesthetic techniques.
In summary, by using ether as a sole anesthetic, we
have obtained an interesting correlation of BIS and the
classical stages of ether anesthesia that are usually
masked by modern induction techniques and contem-
porary measures for achieving anesthetic depth.
References
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Erratum
In the December 2003 issue, in the case report by Rosenblatt, The Use of the LMA-ProSeal in Airway
Resuscitation (Anesth Analg 2003;97:17735), the abstract was omitted. The publisher regrets the error.
The abstract is reproduced below:
Insufflation of the stomach with air can be a complication of face mask ventilation in the case of airway
obstruction. Although the laryngeal mask airway has proven value in airway resuscitation, it has two
major failings: a relatively low seal pressure and lack of access to the alimentary tract. A case is reported
in which failed intubation (by multiple techniques) and intermittent face mask ventilation resulted in
gastric distension, decreased airway compliance, and compromised gas exchange. The patient experi-
enced oxyhemoglobin saturation that did not improve despite laryngeal mask ventilation. The patient
was resuscitated with a LMA-ProSeal, which permitted ventilation with high airway pressures.
Return of oxyhemoglobin saturation occurred after decompression of the stomach with a gastric tube
inserted via the LMA-ProSeals gastric drain.
(Anesth Analg 2003;97:17735)
134 TECHNICAL COMMUNICATION BHARGAVA ET AL. ANESTH ANALG
BIS CHANGES DURING DIETHYL ETHER ANESTHESIA 2004;98:1324