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Case Report
Misleading elevation of the bispectral index (BIS) during return of neuromuscular activity
Pocknall Caroline1, Mihailovic Stevan2, Milan Zoka3
1ST6, Anaesthetic Department, King's College Hospital, London, UK.
2Consultant Anaesthetist, Specialist ofAnesthesiology, Reanimatology and intensive therapy, Opsta Bolnica Pancevo, Pancevo, Serbia.
3Consultant Anaesthetist, Honorary Senior Lecturer, Visiting Professor, King's College Hospital, London, UK.

Article ID: 100004A05PC2015

Address correspondence to:
Caroline Pocknall
King's College Hospital
Phone: +44 203 2999 000
Fax: + 44 203 299 3445

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How to cite this article
Pocknall C, Mihailovic S, Milan Z. Misleading elevation of the bispectral index (BIS) during return of neuromuscular activity. Edorium J Anesth 2015;1:16–18.

Introduction: The use of bispectral index (BIS) monitoring is now becoming standard practice for many anesthetists who feel it is a useful addition for measuring depth of anesthesia. We would like to highlight the limitations of interpreting BIS in the context of return of neuromuscular activity.
Case Report: A 67-year-old male undergoing general anesthesia for ablation of persistent atrial fibrillation with fentanyl and propofol TCI at effect site concentration 4 mg/ml; demonstrated a misleading elevation of the BIS value after return of neuromuscular activity evidenced by a cough reflex. After subsequent administration of a further dose of neuromuscular blocker, the BIS returned to its baseline value. The elevation of BIS towards a value consistent with a conscious state in our patient is confusing and is likely to be a reflection of alternative phenomenon such as the activation of the frontal electromyography (EMG) and interference with electroencephalographic (EEG) frequencies typical for wakefulness.
Conclusion: The routine use of BIS monitoring needs to be evaluated in the context of other clinical parameters and awareness of interference from EMG activity and other mechanisms.

Keywords: Bispectral Index monitoring, Anesthesia (General), Electromyography activity

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Author Contributions
Pocknall Caroline – Acquisition of data, Drafting the article, Final approval of the version to be published
Mihailovic Stevan – Analysis and interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published
Milan Zoka – Substantial contributions to conception and design, Revising it critically for important intellectual content, Final approval of the version to be published
Guarantor of submission
The corresponding author is the guarantor of submission.
Source of support
Conflict of interest
Authors declare no conflict of interest.
© 2015 Pocknall Caroline et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.

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