If a BIS is available in your room......

[CremeSickle]

Do you feel compelled to use it for legal reasons or otherwise?

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[Planktonmd]

Do you feel compelled to use it for legal reasons or otherwise?

The short answer is : Yes.

 

[The_Sensei]

Do you feel compelled to use it for legal reasons or otherwise?

Was forced to use it a time or two during residency. NEVER use it now.

 

[CremeSickle]

Reason im asking.

We got into a discussion with our attending about BIS. In anycase, noone believes they are what the company says they are but our attending felt that if anything happened in a room with a pt and a bis was available yet you didnt use it... youd be screwed.

What do others think about this?

 

[urgewrx]

I didn't feel compelled in my old hospital because only a few people used it.

In my new gig everybody uses it, so I use it too.

I love it when you place it and it does not work. Which is about 50% of the time. Then you place another strip and that one does not work either. What should I document in the chart? "Damn BIS did not work again?" Do patients get charged for it? Or the department pays? Anyone knows? Those things are $20 each. If I had a nickel for everyone that does not work! How about when you use 2 or 3 strips and none of them work, can you still charge the patient and not have a single BIS number documented in the chart?

I think it should be used like a PA catheter; only for select cases.
​

 

[Planktonmd]

Reason im asking.

We got into a discussion with our attending about BIS. In anycase, noone believes they are what the company says they are but our attending felt that if anything happened in a room with a pt and a bis was available yet you didnt use it... youd be screwed.

What do others think about this?

He is right.

 

[Planktonmd]

I didn't feel compelled in my old hospital because only a few people used it.​

In my new gig everybody uses it, so I use it too.​

I love it when you place it and it does not work. Which is about 50% of the time. Then you place another strip and that one does not work either. What should I document in the chart? "Damn BIS did not work again?" Do patients get charged for it? Or the department pays? Anyone knows? Those things are $20 each. If I had a nickel for everyone that does not work! How about when you use 2 or 3 strips and none of them work, can you still charge the patient and not have a single BIS number documented in the chart?​

I think it should be used like a PA catheter; only for select cases.​

If a patient claims awareness under anesthesia and decides to sue you, and if you have the BIS available but you elected not to use it, there will be 10 professors who will testify that what you did was negligent.
Now, before Jet and the others say it I am going to say it myself: " We don't practice for the lawyers", but I prefer fighting more meaningful battles.

 

[BLADEMDA]

Look,

I have BIS available in most of my rooms. I use it less than 5% of the time Why? First, there is no evidence that BIS is realiable/guarantees no recall.
Second, a large study by a BIG private practice GRoup in Charlotte, N.C. (Southeast Anesthesiology Associates) showed recall was like 0.1%. This Group is bigger than most academic departments and does more cases than just about anybody. Third, if you use Midazolam preoperatively and at least 1 MAC intraoperatively recall is about zero. Fourth, the only recall in my hospital the past twenty years was when the provider didn't fill the vaporizer (before we had Expired gases).

So, if you want to use the BIS go ahead. Particulary, on anxiuos young female patients BIS may be warranted. Now, some real world BIS negatives.
Elderly patients having their forehead skin removed after a 4 hour case (supine). A young female having significant skin damge after a 6 hour back case (prone). An elderly male NEEDING A SKIN GRAFT after an 8 hour back in the prone position.

PLEASE don't ever put a BIS on me in the prone position. Instead, narcotics and 1 MAC will be just fine.

Here is the study: Anesthesiology 106(2) 269-274 Feb 2007
The exact percentage was 0.068% in this study.

Blade

 

[Planktonmd]

Look,

I have BIS available in most of my rooms. I use it less than 5% of the time Why? First, there is no evidence that BIS is realiable/guarantees no recall.
Second, a large study by a BIG private practice GRoup in Charlotte, N.C. (Southeast Anesthesiology Associates) showed recall was like 0.2%. THis Group is bigger than most academic departments and does more cases than just about anybody. Third, if you use Midazolam preoperatively and at least 1 MAC intraoperatively recall is about zero. Fourth, the only recall in my hospital the past twenty years was when the provider didn't fill the vaporizer (before we had Expired gases).

So, if you want to use the BIS go ahead. Particulary, on anxiuos young female patients BIS may be warranted. Now, some real world BIS negatives.
Elderly patients having their forehead skin removed after a 4 hour case (supine). A young female having significant skin damge after a 6 hour back case (prone). An elderly male NEEDING A SKIN GRAFT after an 8 hour back in the prone position.

PLEASE don't ever put a BIS on me in the prone position. Instead, narcotics and 1 MAC will be just fine.

Blade

All these things you said are wonderful and I couldn't agree more about how useless BIS is.
On the other hand you have to admit that the lay public and the legal system see things differently, so if the contraption is available to you and you chose not to use it, they are going to hang you up to dry, and some very big names in anesthesia will testify against you.

 

[Arch Guillotti]

I don't normally use one but I did today. I ran the pt. at .2-.3 MAC the whole time.

 

[2ndyear]

I don't normally use one but I did today. I ran the pt. at .2-.3 MAC the whole time.

And that's the beauty of the BIS. Would you run 0.2-0.3 MAC with no BIS? I wouldn't. Less drugs = better outcomes? Who knows. But possibly. I don't use it on every case, but if I have someone who's 'fragile' I'll plug it in. This includes most every liver transplant, and a lot of emergencies.

 

[Mman]

Fourth, the only recall in my hospital the past twenty years was when the provider didn't fill the vaporizer (before we had Expired gases).

Blade

How do you know that there was only one case of recall in your hospital in the last 20 years? That study suggests it happens roughly 1/10,000 times. Does your hospital do more than 500 cases per year?

I ask because it has been documented that most cases of recall are not immediately evident post-operatively. Sometimes the patient does not recall the events for up to several days post op. Unless you are doing a 1 week postop check with every single patient, you cannot know the true number of incidents of awareness.

Then again, what percentage of incidents of awareness are even unpleasant? It is less than 100%.

 

[BLADEMDA]

How do you know that there was only one case of recall in your hospital in the last 20 years? That study suggests it happens roughly 1/10,000 times. Does your hospital do more than 500 cases per year?

I ask because it has been documented that most cases of recall are not immediately evident post-operatively. Sometimes the patient does not recall the events for up to several days post op. Unless you are doing a 1 week postop check with every single patient, you cannot know the true number of incidents of awareness.

Then again, what percentage of incidents of awareness are even unpleasant? It is less than 100%.

If the "awareness" is not unpleasant then does it matter? Second, if the patient doesn't complain does it matter? Third, isn't less than 0.1% a really low number and there is no evidence BIS Would change that number.

Blade

 

[BLADEMDA]

If you want to use BIS and make ASPECT rich then go ahead. There are two scenarios where I use BIS routinely:

1. An elederly patient ASA 3 or 4 undegoing a vascular stent (usually for severe PVD) under GA. I can cut my inhalational agents way back and still keep the BIS below 50. I find the amount of "pressors" are minimal on these patients when the inalational agents are low.

2. The Anxious female patient worried about being "awake" during surgery.
They have heard "stories" about being paralyzed and awake. I discuss BIS with them.

AS far as waking up faster for the average ASA 1-3 patient I don't believe that it is true. An experienced provider can easily predict the end of the case because we work with SAME Surgeons day in and day out. What BIS allows is less agent to be used. Our cost on SEVO is extremely low due to an exceptional contract. The disposable BIS forehead monitor costs more than the amount of agent saved per case.

I am not worried about the "lawyers" because 100,000 cases over the past 5 years with NO AWARENESS COMPLAINTS is sufficient evidence that BIS is not needed in the average case. However, if the situation is called for BIS is readily available. This is like CVP monitoring, Pulmonary Artery Catheters, U/S guidance and TEE. All available if needed per clinical judgement. Do you really need BIS on every case? The studies don't support that statement and neither does the ASA.

Blade

 

[BLADEMDA]

I don't normally use one but I did today. I ran the pt. at .2-.3 MAC the whole time.

Good for you. Perhaps, you can show less Neurocognitive dysfunction on the elderly using BIS compared to the control (no Bis). After all, less agent may help the elderly with mild dementia.

That said, there is no evidence that using less agent makes a clinical difference in our outcomes. If and when this happens the ASA would endorse BIS as a routine monitor like pulse oximetry, EKG, BP, etc.
Until then I will use it when clinically indicated like my other advanced tools.

Blade

 

[Arch Guillotti]

My patient was old and sick and hypotensive (4E) so I ran the bare minimum of volatile. I put the bis on about 30-45 minutes into the case after things started to settle out and I had a spare minute. I didn't think about it at the time as a reason to use the BIS, but he did have a hx of early dementia. I didn't really think he would have recall, I was really just curious to see what number it would spit out given the low dose of anesthetic he was receiving.

 

[jetproppilot]

If you want to use BIS and make ASPECT rich then go ahead. There are two scenarios where I use BIS routinely:

1. An elederly patient ASA 3 or 4 undegoing a vascular stent (usually for severe PVD) under GA. I can cut my inhalational agents way back and still keep the BIS below 50. I find the amount of "pressors" are minimal on these patients when the inalational agents are low.

2. The Anxious female patient worried about being "awake" during surgery.
They have heard "stories" about being paralyzed and awake. I discuss BIS with them.

AS far as waking up faster for the average ASA 1-3 patient I don't believe that it is true. An experienced provider can easily predict the end of the case because we work with SAME Surgeons day in and day out. What BIS allows is less agent to be used. Our cost on SEVO is extremely low due to an exceptional contract. The disposable BIS forehead monitor costs more than the amount of agent saved per case.

I am not worried about the "lawyers" because 100,000 cases over the past 5 years with NO AWARENESS COMPLAINTS is sufficient evidence that BIS is not needed in the average case. However, if the situation is called for BIS is readily available. This is like CVP monitoring, Pulmonary Artery Catheters, U/S guidance and TEE. All available if needed per clinical judgement. Do you really need BIS on every case? The studies don't support that statement and neither does the ASA.

Blade

Well said.

The BIS is another tool in your shed.

No more, no less.

Can be helpful.......mostly in CABGs to monitor anesthetic depth....loved the Bis while using Dex, which allowed opiods to be limited to <250 ug fentanyl for the entire case.

Throw out da awareness-reduction claims.

 

[BLADEMDA]

Well said.

The BIS is another tool in your shed.

No more, no less.

Can be helpful.......mostly in CABGs to monitor anesthetic depth....loved the Bis while using Dex, which allowed opiods to be limited to <250 ug fentanyl for the entire case.

Throw out da awareness-reduction claims.

Agree. BIS used on every Heart. A good tool for the ASA 4 patient.

Blade

 

[blackjack]

BIS is not a standard monitor but an elective monitoring device. I would not use it just to cover legalities if it was in my room.

 

[urgewrx]

I don't normally use one but I did today. I ran the pt. at .2-.3 MAC the whole time.

Let's say that pt had awareness eventhough the BIS was 20. Do you honestly think the BIS going to protect you when you get sued? Are you going to walk away unscratched after the pt has developed PTSD? I doubt it. The same way the BIS reads too high, it reads too low. I'm sure the lawyers won't have any qualms about pointing out its shortcommings. In fact there was a paper like 18 mo ago on A+A where 2 bis monitor where placed on the same pt. One read 40 and the other read 70. They had like 50pts and there was no correlation at all.

 

[Planktonmd]

Let's say that pt had awareness eventhough the BIS was 20. Do you honestly think the BIS going to protect you when you get sued? Are you going to walk away unscratched after the pt has developed PTSD? I doubt it. The same way the BIS reads too high, it reads too low. I'm sure the lawyers won't have any qualms about pointing out its shortcommings. In fact there was a paper like 18 mo ago on A+A where 2 bis monitor where placed on the same pt. One read 40 and the other read 70. They had like 50pts and there was no correlation at all.

There is 2 separate issues here:
1- Science: It strongly indicates that BIS monitors are at best a tool that can be sometimes of value.
2- The legal system: this system does not follow logic or science, it is made of lawyers who will try to show that you did not do all you could do to protect your patient from such a horrible thing as awareness, and that you are such a negligent heartless doctor, who makes too much money and deserves to be punished, and guess who is going to make the decision on your liability: a bunch of lay people who have been already terrified by the media and Aspect, and who also think that doctors are too rich and too evil.

It will be interesting to see the outcome of that case that was all over the news, where they are accusing the anesthesiologist of causing the patient to commit suicide because of awareness, I am sure this anesthesiologist is right now regretting not using the BIS and writing down that it was under 50 all the time (if he actually didn't do that).

 

[urgewrx]

It will be interesting to see the outcome of that case that was all over the news, where they are accusing the anesthesiologist of causing the patient to commit suicide because of awareness, I am sure this anesthesiologist is right now regretting not using the BIS and writing down that it was under 50 all the time (if he actually didn't do that).

I think he regrets no turninh ON the vaporizer more than anything.

 

[OldManDave]

Like everything else we do in medicine - appropriate pt + appropriate intervention maximizes your odds for a positive outcome...does NOT guarantee it. For a select group of pts, the BIS makes sense & I think Blade does a heck of a job laying out the groups I generally offer it to as well. But, there is a ton of evidence that does not support the claims of Aspect/BIS & there are so many detractors, I seriously doubt it will ever become "standard of care".

However, as I learned while going through my divorce many years ago, the legal system is NOT about seeking truth, justice or fairness. It is all about manipulation of fact, outright fantasy & rhetoric in order to secure a victory for their client - that applies to both sides of the fence. And, even though "trial by a jury of our peers" is a constitutional right, that is NOT what is provided for physicians.

Sadly, I fear that even if I laid out all of the damning evidence in front of a typical jury, their eyes would glaze over & I would get screwed...no kiss & no gratuitous reach around. I personally feel that the US should adopt a variation of the system employed in some of the European countries where all medical malpractice cases go before a judge & officers of the court who are specially trained in medical/legal issues. These sub-tribunals essentially decides whether the case has merit before allowing it to proceed. These same countrie also tend to have reasonable limitations on dollar amounts payable in legit cases.

Before you ask, no, I do not have a printed reference to point you towards. I learned of this approach by talking to several FMGs when I was in med school. If I correctly recall, these guys were from Romania, Hungary - in & around that region.

 

[VolatileAgent]

PLEASE don't ever put a BIS on me in the prone position. Instead, narcotics and 1 MAC will be just fine.

it's okay if your patient is prone in head pins. i do this sometimes for c-spine cases when running a tiva.

other than a few rare instances (like above), though, it basically sits on top of the machine gathering dust. generally, not a tool that changes what i'd normally do anyway (and therefore adds nothing but cost).

 

[Planktonmd]

Like everything else we do in medicine - appropriate pt + appropriate intervention maximizes your odds for a positive outcome...does NOT guarantee it. For a select group of pts, the BIS makes sense & I think Blade does a heck of a job laying out the groups I generally offer it to as well. But, there is a ton of evidence that does not support the claims of Aspect/BIS & there are so many detractors, I seriously doubt it will ever become "standard of care".

However, as I learned while going through my divorce many years ago, the legal system is NOT about seeking truth, justice or fairness. It is all about manipulation of fact, outright fantasy & rhetoric in order to secure a victory for their client - that applies to both sides of the fence. And, even though "trial by a jury of our peers" is a constitutional right, that is NOT what is provided for physicians.

Sadly, I fear that even if I laid out all of the damning evidence in front of a typical jury, their eyes would glaze over & I would get screwed...no kiss & no gratuitous reach around. I personally feel that the US should adopt a variation of the system employed in some of the European countries where all medical malpractice cases go before a judge & officers of the court who are specially trained in medical/legal issues. These sub-tribunals essentially decides whether the case has merit before allowing it to proceed. These same countrie also tend to have reasonable limitations on dollar amounts payable in legit cases.

Before you ask, no, I do not have a printed reference to point you towards. I learned of this approach by talking to several FMGs when I was in med school. If I correctly recall, these guys were from Romania, Hungary - in & around that region.

Man, your wisdom is beyond your level of training.
But unfortunately this radical change of the legal system is not going to happen as we all know, so I advocate trying to work with the current system and maybe avoid the cowboy attitude that some people have.