








































Anesthesia eJournal
Volume 2 Issue 2 2014

AEJ

Educated Hand Publishing LLC 
“The Science Behind the Art”  

 Anesthesia eJournal - Online
ISSN 2333-2611

Background:
Achieving adequate anesthetic depth during an ECT procedure without suppressing the therapeutic seizure is 
challenging and increases the risk of patient awareness during the procedure.
Aim:
To assess provider satisfaction with, and identify potential barriers to the use of BIS monitoring during ECT as a means 
to determine the feasibility of adopting BIS monitoring in the clinical ECT setting. 
Setting:
The pilot project was conducted in a 274-bed general medical and tertiary care facility located on the mid-Atlantic coast 
that provides services to more than 200,000 patients and administers over 200 ECT treatments annually.
Participants:
Psychiatry staff and nurse anesthetists caring for patients undergoing ECT.
Methods:
A convenience sample of 11 patients scheduled for 25 ECT treatments received BIS monitoring. Provider (n= 12) 
satisfaction was anonymously assessed using an 8-question survey.
Results:
While 7 of the 12 providers rated their overall satisfaction with using the BIS monitor during ECT as Very good only 2 
providers affirmatively answered the BIS monitor added value to their decision-making process. 
Two anesthetized patients, who responded purposefully to verbal commands despite BIS values in the deep hypnotic 
range indicating sufficient anesthetic depth, were considered at risk for awareness under anesthesia. 
Conclusions:
Provider acceptance of the introduction of BIS monitoring to assess anesthetic depth during ECT was lukewarm at best. 
While the concept appears sound, one must question if the technology and tools are sufficiently developed to warrant 
its routine use in the described setting. Given the response of the two patients with BIS values indicating sufficient 
anesthetic depth, these observations merit further studies to replicate our findings in the psychiatric population and 
further explore the potential value of BIS monitoring during ECT. 
Key Words:
Electroconvulsive therapy; ECT; Consciousness Monitors; Bispectral Index Monitor; Intraoperative Awareness; 
Anesthesia Awareness; Awareness During Anesthesia

Abstract

Improving Anesthetic Depth Assessment During Electroconvulsive Therapy With 
Bispectral Index Monitoring: A Pilot Quality Improvement Project

J. Frank Titch, DNP, CRNA
Tracey Holsinger, MD
Charles Vacchiano, PhD, CRNA
Jane Blood-Siegfried, DNSc, CPNP
Affiliation:
From the Department of Psychiatry, Durham VA Medical Center, Durham, NC and the Duke University School of Nursing, Durham, NC.

Author Correspondence:
J. Frank Titch, DNP, CRNA, Duke University School of Nursing, DUMC 3322, 307 Trent Dr., Durham, NC 27710 
(frank.titch@duke.edu); 919.684.5772
Funding disclosure:
Departmental and institutional resources provided the principle financial support for this project. None of the authors 
have a conflict of interest to report.

mailto:frank.titch@duke.edu


Anesthesia eJournal                         www.anesthesiaejournal.com
Volume 2 Issue 2 2014 

INTRODUCTION
Background Knowledge

Electroconvulsive therapy (ECT), a recognized treatment 
for certain neuropsychiatric disorders, is performed after the 
administration of a short-acting intravenous hypnotic followed 
by the administration of a short-acting muscle paralytic that 
attenuates motor seizure activity.1 The intravenous anesthetic 
depresses therapeutic seizure activity in a dose-dependent 
manner.2 Given the challenge of achieving adequate anesthetic 
depth without suppressing the therapeutic seizure, the patient 
is at increased risk for awareness while paralyzed before the 
electrical stimulus.3 A search of the literature identified 3 case 
reports of awareness and recall during ECT therapy.4-6

Problem
Multiple sources cite light anesthesia, or an imbalance 

between anesthesia delivery and need, as the most common 
cause of awareness under anesthesia.7-9 Reported long-term 
psychological sequelae after awareness under anesthesia include 
anxiety, depression, nightmares, post-traumatic stress disorder 
(PTSD), and flashbacks.10,11 Previous studies have shown the 
bispectral index (BIS) monitor to be a reliable anesthesia depth 
monitor that lowers the incidence of awareness.12 The device is an 
electroencephalogram-derived monitor that provides real-time, 
continuous measurement of hypnosis, optimizing anesthetic drug 
delivery and avoiding extremes of drug dosages.13,14 However, use 
of BIS monitoring to prevent awareness under anesthesia during 
ECT, the actual incidence of awareness during ECT, and the 
process of implementing BIS monitoring in the clinical setting 
during ECT are not well reported in the psychiatric literature.
Intended Improvement

Current practice standards do not require BIS monitoring 
during ECT; therefore, we designed this pilot project to assess the 
feasibility of using the BIS during ECT in an active day-to-day 
clinical setting and evaluate its impact on provider satisfaction. 
Specifically, we report on the practical feasibility of developing 
full-scale implementation, pilot findings related to provider 
satisfaction, and potential barriers that may influence its use. 
Prospective barriers to the implementation of standardized BIS 
monitoring for ECT may be associated with many factors, such 
as the integrity of BIS values, provider satisfaction, increased 
treatment times, and cost of supplies. Consequently, the purpose 
of this pilot project was to implement a practice change using 
the BIS monitor to assess anesthetic depth during ECT to 
improve quality and safety and evaluate its effectiveness. The goal 
of BIS is to minimize the risk of awareness with recall that may 
lead to PTSD in this psychologically vulnerable population. In 
particular, we wanted to determine whether it was feasible to use 
the BIS during ECT and whether anesthesia providers would 
find it useful in day-to-day practice. To most accurately replicate 
implementation of such a change into an active practice, we 
chose a pilot project, selected a convenience sample, and did not 
standardize the anesthetic protocol. We report the complexities 
associated with implementing such a protocol during the 
administration of ECT.

METHODS
Ethical Concerns

The facility’s institutional review board approved both the 
pilot project’s implementation and subsequent survey analysis. 
Both the chair of the psychiatry department and the attending 
psychiatrist provided organizational consent. We reported only 
de-identified data.
Setting

The project was conducted in a 274-bed general medical and 
tertiary care facility on the mid-Atlantic coast that provides 
services to more than 200,000 patients living in a 26-county 
area. The facility treats more than 46,000 patients who make 
more than 339,000 outpatient visits annually. Psychiatric care 
is provided in both inpatient and outpatient settings and, at the 
time of the project, the psychiatry service administered slightly 
more than 200 ECT treatments yearly.
Intervention

We undertook a pilot project to assess the feasibility of using 
BIS monitoring during ECT. A convenience sample of 11 
patients scheduled for 25 ECT treatments as a routine healthcare 
service event received BIS monitoring over 53 calendar days. 
Patients were not randomly assigned to a study arm, and all 
patients received bilateral temporal index or maintenance 
ECT treatments using the spECTrum 5000Q® (Mecta Corp., 
Lake Oswego, OR). Standard procedural monitors, including a 
noninvasive blood pressure cuff, 5-lead electrocardiogram, pulse 
oximetry, and capnography, were employed during the ECT 
procedure. Per the manufacturer’s protocol, the BIS monitor was 
applied to the patient’s forehead when the patient entered the 
treatment area, and the device recorded values throughout the 
procedure.  

The BIS electroencephalogram signal was acquired using a 
4-electrode disposable sensor (BISTM Quatro Sensor; Covidien, 
Boulder, CO) applied to the patient’s forehead as recommended 
by the manufacturer. The signal was then analyzed and recorded 
using the BIS VISTATM monitoring system (software revision 
1.13.2.5; Covidien) with the latency period set at 15 seconds. 
On connecting the sensor to the monitoring system, the 
manufacturer’s proprietary Sensory Integrity Check software 
tests the impedance of each electrode and does not begin 
normal processing of the BIS value until the impedance test is 
successfully completed. 

We did not standardize anesthetic techniques for this pilot 
project. During the preoxygenation period, patients may or 
may not have received intravenous caffeine, labetalol, or opioid 
medications. General anesthesia was induced intravenously 
with either methohexital or etomidate after the administration 
of 100% oxygen by mask. On loss of responsiveness to verbal 
commands and eyelash reflex, we inflated a blood pressure 
cuff on the right lower leg, isolating circulation to the foot 
before succinylcholine administration. After the induction of 
hypnosis and paralysis, patients were asked to move the toes 
of their right foot. If there was no response, BIS values were 
noted and an electrical stimulus was delivered via bitemporal 
electrodes. We determined response to verbal command and 



motor seizure duration using the unparalyzed isolated right foot, 
while the duration of the induced seizure was recorded using 
single bifrontal electroencephalogram leads monitored through 
the spECTrum 5000Q. We provided controlled ventilation 
throughout the procedure with 100% oxygen until the resumption 
of spontaneous breathing. We removed all monitors, and patients 
were transported to the postanesthesia care unit for additional 
monitoring.
Evaluation

Following the sampled 25 ECT treatments, we anonymously 
assessed provider satisfaction with use of the BIS monitor during 
ECT using an 8-question, check-box paper survey. Participating 
psychiatry and nurse anesthesia providers (n=12) received the 
survey in an opaque envelope with instructions for completion. 
We developed the survey instrument using questions from 
previous surveys provided by the BIS manufacturer, and the 
survey’s content validity was peer-reviewed by 5 nurse anesthetists 
and 1 research nurse not linked with the project. In addition, we 
tracked procedure times for each treatment. 
Analysis

We performed statistical analyses using the SPSS Statistics 
software for Windows (version 19; IBM Inc., Somers, NY) 
and descriptive statistics to synthesize and describe the survey 
analysis. We analyzed survey responses by question type and 
evaluated the provider’s comfort level using the BIS monitor, 
satisfaction using it for ECT, and the added value of using BIS 
monitoring in the ECT setting. To assess provider comfort and 
satisfaction, we used a 5-point Likert scale with the response 
alternatives of Poor, Below Average, Average, Very Good, or 
Excellent. Responses of Very Good or Excellent were considered 
affirmative answers, and a response of Average was considered 
neutral. We assessed the added value of BIS monitoring during 
ECT using a 5-point Likert scale of Never, Rarely, Occasionally, 
Frequently, and Always, with Frequently and Always considered 
affirmative answers and Occasionally considered a neutral answer.

RESULTS
Outcomes

After 25 ECT treatments for 11 patients, all providers (n=12) 
directly involved with patient care during the pilot project 
completed the survey. All respondents denied having previously 
used the BIS monitor during ECT. However, 10 respondents 
reported routinely using the BIS to monitor depth of anesthesia 
during general anesthesia. Eleven providers reported personally 
using BIS technology for more than 3 years in the surgical 
setting; 9 of those respondents reported more than 5 years of 
experience. Three rated their level of comfort with using the BIS 
as Very Good, while 6 rated their comfort level as Excellent. 
Eleven providers rated their overall satisfaction with using the 
BIS monitor during ECT as Average (4) or Very good (7). No 
one rated his or her satisfaction as Excellent. Ten providers 
responded that the BIS monitor added value to their decision-
making process either Occasionally (8) or Frequently (2) during 
ECT. No respondents said they felt the BIS monitor Always 
added value during ECT. 

Procedure Time
Of the 25 procedures tracked, the mean procedure time was 

26±6 minutes, ranging from 15 minutes to 39 minutes. Numerous 
factors such as difficult intravenous access, individual provider, 
or total number of supporting psychiatry nurses confounded 
accounting for any additional procedure time resulting from 
inclusion of the BIS monitor during ECT.

DISCUSSION
Summary

Although most providers were comfortable using BIS 
technology, the survey results from this pilot project demonstrate 
that the overall reaction to assessing anesthetic depth with the 
BIS monitor during ECT was lukewarm at best. While 7 of the 
12 providers rated their overall satisfaction with using the BIS 
monitor during ECT as Very good, only 2 providers reported that 
the BIS monitor added value to their decision-making process. 

Much to our surprise, we also discovered that the BIS monitor 
alone did not allow consistent and accurate assessment of 
the patient’s anesthetic depth before delivery of the electrical 
stimulus. Two anesthetized patients who responded purposefully 
to verbal commands despite BIS values in the deep hypnotic 
range (40-60), indicating sufficient anesthetic depth, were 
considered at risk for awareness under anesthesia and received 
additional intravenous anesthetic (Table 1). However, no patients 
reported postseizure recall of events regardless of the prestimulus 
BIS score.

Table 1 – Pre-Stimulus Purposeful Responses to Verbal 
Commands

Interpretations
Initially, we were unsure how to integrate the BIS into everyday 

practice and did not wish to spend excessive time incorporating 
the device, which affected our ability to acquire a good signal 
quality in all cases. We were attempting to replicate true clinical 
practice and determine if the device would be useful. Due to 
limited available forehead space in patients receiving bilateral 
temporal ECT, the sensor was difficult to properly place. The 
monitor would not begin normal processing of the BIS value 
until it successfully completed its impedance test; therefore, it 
failed to record any data during 2 treatments. In addition, we were 
unable to record baseline BIS values, considered critical before 
the administration of anesthesia, for 6 of the 25 treatments. The 
device, in our view, required too much effort to troubleshoot, 
and we did not wish to excessively prolong the procedure. 
However, we began prewarming the BIS sensor array and applied 
a very small amount of ECT electrode gel to each 4-electrode 
disposable BIS sensor before patient application. Following 
initiation of this change at treatment 11, we consistently gathered 
BIS data for the duration of the project. 

Anesthesia eJournal                         www.anesthesiaejournal.com
Volume 2 Issue 2 2014 

Treatment Pre-Stimulus BIS EMG SQI
4 42 48 90
10 40 29 98

Note. EMG=electromyography; SQI=signal quality index



Anesthesia eJournal                         www.anesthesiaejournal.com
Volume 2 Issue 2 2014 

Limitations
While the results of our pilot project are important, they must 

be viewed through the lens of their limitations. The financial 
implications must be considered and include extended procedure 
times and the equipment expense. Unfortunately, too many 
additional variables confounded our ability to accurately assess 
any extension of procedure times. For the purposes of this project, 
BIS monitoring devices were readily available in the facility, but 
this may not always be the case and may represent an additional 

expense. Each BISTM Quatro Sensor cost our institution $25.20, 
resulting in an additional $630 for the 18 (72%) treatments 
supplying usable data. In addition, Spiegel and colleagues (2006) 
have proposed that the BIS could prove useful in the early 
diagnosis of certain neurological diseases such as Alzheimer’s.15 
Such findings suggest that BIS values are altered in patients 
with certain psychiatric conditions and the threshold indicating 
hypnosis in patients requiring ECT may differ from that of the 
rest of the population. 

Conclusions
The ECT setting would appear to offer an ideal application for the introduction of BIS monitoring. Yet, except for 

reports of using BIS monitoring for targeted anesthetic dosage administration, reports of its use in the psychiatric literature 
during ECT are limited.13,16,17 Achieving adequate anesthetic depth during the ECT procedure without suppressing the 
therapeutic seizure is challenging and increases the risk of patient awareness.3 Indeed, case reports describing instances of 
patient awareness during ECT exist in the literature.4-6 Past studies have also shown that using the BIS monitor reduces 
the incidence of awareness under anesthesia in at-risk patients.18,19 While the concept appears sound in its foundation, one 
must question if the technology and tools are sufficiently developed to warrant its routine use in the ECT setting. Based on 
our experiences, we would not recommend implementation. Could exclusive reliance on the device mask an insufficiently 
anesthetized patient? Given the intra-anesthetic purposeful response of two patients despite BIS values in the deep hypnotic 
range (40-60), indicating sufficient anesthetic depth, further studies are needed to replicate our findings in the psychiatric 
population and explore the potential value of BIS monitoring during ECT.



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Anesthesia eJournal                         www.anesthesiaejournal.com
Volume 2 Issue 2 2014 


