Awareness: CNN Tonight

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Oh look at the promo:

Imagine waking up on the operating table with the surgeon still working on you. You can't move, you can't even cry out, but there's a device that could have prevented it. So why isn't it in every operating room? Tonight, 10 ET.
Click to expand...

Sounds like a BIS commercial.
 
All the more reason to have qualified physicians administering anesthesia, no?
 
One of the worst pieces of sensationalist journalism I've ever seen. I'll bet he didnt even read the studies or do any research on the topic. Completely irresponsible. Why doesnt he do a story on why everyone needs a full body CT?
 
Gents, forgive my limited experiences here, but I've always thought that HR was a pretty good indicator of patient "comfort" during surgery (aside from open heart etc.). Or is this not true??

I've seen how Parasympathetic antagonists were used to purposefully increase HR (or how certain lap procedures may stimulate the vagus), but are there also adrenergic blockers used in the OR to DECREASE HR/Inotropicity?? If so, I could see how HR would NOT be useful, or dependable as an "indicator".

Can anyone please shed some light on this?
 
cfdavid said:
Gents, forgive my limited experiences here, but I've always thought that HR was a pretty good indicator of patient "comfort" during surgery (aside from open heart etc.). Or is this not true??

I've seen how Parasympathetic antagonists were used to purposefully increase HR (or how certain lap procedures may stimulate the vagus), but are there also adrenergic blockers used in the OR to DECREASE HR/Inotropicity?? If so, I could see how HR would NOT be useful, or dependable as an "indicator".

Can anyone please shed some light on this?
Click to expand...
You are correct.
patients on Beta Blockers for example might not have tachycardia in response to pain or distress which limits the value of heart rate as a parameter, but heart rate is only one parameter in a whole clinical picture you are supposed to be monitoring when maintaining anesthesia:
You look at the patient, you look at the HR, BP, sweating, tearing, attempted movement or spontaneous breathing (if muscle relaxation is not complete), and you also look at the MAC of your anesthetics and make sure your end tidal inhaled agent or your IV infusion rate is where it should be based on your experience for this type of surgery and this type of patient.
You also limit your use of muscle relaxants to when they are actually indicated.
If you do these things correctly it's very unlikely that any of your patients will ever have recall.
You can also use brain activity monitoring devices including BIS as additional tools but you have to keep in mind that BIS was based on a secret algorithm that was never disclosed and that BIS technology was never shown to prevent awareness as these clowns are calamining on TV.
That show yesterday was another attempt to use drama to make the general public request BIS monitors, and this type of stuff works unfortunately.
The brief interview with Dr. Lema was very misleading and obviously heavily edited, They showed him to be defensive and not sure of his answers, he did not convey confidence to the public at all.
 
I agree that the Anderson Cooper segment was very sensationalistic. Very difficult to thoroughly cover awareness in 10 minutes or less. Unfortunately, we can expect many patients unfamiliar with anesthesia to greet us with concerns triggered by these segments. There have been several hour-long programs on the Discovery Health Channel within the last several years about anesthesia awareness. I believe the last one was entitled "When Anesthesia Fails." I think we can expect the issue of awareness to reach 20/20, 60 minutes, Today Show, Good Morning America, etc.

I watch these programs to see what my patients are watching, so that I can readily address any questions about awareness. I think it helps create rapport when you acknowledge that you watched a story on TV. (...rather than simply dismiss it at crap.)

If someone asked me today about last night's segment, I would reply as follows. I would acknowledge that awareness happens. I would agree with the figure that CNN stated (1-2 per 1000). I would also show concern that it happens, but would qualify this with the statemnent that awarenss often happens in emergent procedures in sick patients (stat C-section, trauma, cardiac, etc.) I would refuse to comment on the 3 patients CNN interviewed last night, as almost no information was provided on the cirmcumstances of their procedures/illnesses. I would then explain in lay terms my anesthetic plan and how I know that the patient is "asleep".

I think we also need to do a better job as anesthesiologists of explaining different types of anesthesia. There will be a growing need to differentiate true awareness under GA from light anesthesia. Many patients come into their day of surgery complaining that they "woke up during the last surgery." We need to do more than simply saying that we "give medicines through the IV so that you go to sleep." If a patient is having a carpal tunnel release under moderate sedation and local anesthesia, we need to be realistic about explaining our goals for that anesthetic. Most lay public do not know that their is a difference between (light-moderate) sedation for colonoscopy and general anesthesia for a Lap Chole.
 
Wow! Was that an Infomercial for BIS monitors or a report about awareness?
 
Masseter Spasm said:
I agree that the Anderson Cooper segment was very sensationalistic. Very difficult to thoroughly cover awareness in 10 minutes or less. Unfortunately, we can expect many patients unfamiliar with anesthesia to greet us with concerns triggered by these segments. There have been several hour-long programs on the Discovery Health Channel within the last several years about anesthesia awareness. I believe the last one was entitled "When Anesthesia Fails." I think we can expect the issue of awareness to reach 20/20, 60 minutes, Today Show, Good Morning America, etc.

I watch these programs to see what my patients are watching, so that I can readily address any questions about awareness. I think it helps create rapport when you acknowledge that you watched a story on TV. (...rather than simply dismiss it at crap.)

If someone asked me today about last night's segment, I would reply as follows. I would acknowledge that awareness happens. I would agree with the figure that CNN stated (1-2 per 1000). I would also show concern that it happens, but would qualify this with the statemnent that awarenss often happens in emergent procedures in sick patients (stat C-section, trauma, cardiac, etc.) I would refuse to comment on the 3 patients CNN interviewed last night, as almost no information was provided on the cirmcumstances of their procedures/illnesses. I would then explain in lay terms my anesthetic plan and how I know that the patient is "asleep".

I think we also need to do a better job as anesthesiologists of explaining different types of anesthesia. There will be a growing need to differentiate true awareness under GA from light anesthesia. Many patients come into their day of surgery complaining that they "woke up during the last surgery." We need to do more than simply saying that we "give medicines through the IV so that you go to sleep." If a patient is having a carpal tunnel release under moderate sedation and local anesthesia, we need to be realistic about explaining our goals for that anesthetic. Most lay public do not know that their is a difference between (light-moderate) sedation for colonoscopy and general anesthesia for a Lap Chole.
Click to expand...


I don't agree with those numbers: 1 out every 1000. NO WAY! A total fabrication by ASPECT. The real number is more like 1 out of 14,500!!
This agrees with my experience at a major medical center where Inhalational agents are used properly (at least 0.5 MAC or greater for GA during the case and End tidal gas verification of such MAC). My Group has performed about 200,000 general anesthetics (probably more) over the years. We have had two cases plus a possible third. One occured years ago on CPB when we had no ISO vaporizer on the perfusion machine. THe other had an EMPTY vaporizer that the provider failed to recognize and fill prior to starting the case. The third was RECALL and the data indicated at least 0.5 MAC. But, the woman had a history of a Psychiatric disorder and was on several psychotropic meds.

I tell patients that in experienced hands RECALL is a non issue for GENERAL ANESTHESIA. Sedation is another matter entirely (spinal, blocks, etc.).
Here is my reference plus hundreds of thousands of GA's:

Anesthesiology 2007 FEB;106 (2) 269-274

BIS is another tool to be used by us. NO more and No less. You MAY save vaporizer agent with BIS but the disposable head probe negates any real savings.

Blade
 
Please don't buy into the ASPECT propoganda of RECALL; Look at data from EXPERIENCED providers less biased in reporting the data.

Even if you don't agree with 1 out 14,500 cases (which I believe to be accurate) don't accept 1 out of 1000 as FACT. I can guarantee that statistic is not even close to private practice reality.

Blade
 
I think each society gets the media they deserve and we deserve this type of misleading irresponsible media.
This is a society that is moving backward, people are getting less educated every day, so don't expect the media to get better.
 
BLADEMDA said:
Even if you don't agree with 1 out 14,500 cases (which I believe to be accurate) don't accept 1 out of 1000 as FACT. I can guarantee that statistic is not even close to private practice reality.
Click to expand...

you're right again, blade. what we first need is a functional definition of awareness. having had anesthesia myself, i can tell you that i was "aware" in the PACU when i was still intubated. i can immediately recollect the portion of my emergence when i desperately wanted them to pull the tube. i also remember the feeling when i was extubated. the next thing i remember after that is waking-up in my hospital room.

this was an event that, if i were to inappropriately classify it, could constitute "awareness". i was not aware during the surgery. the last thing i remembered before that was being wheeled into the operating room and breathing from the mask prior to induction. but, some people may classify that as "awareness" - being aware that the tube was still in - in the PACU without a standard definition. i don't have any other recollections in the immediate peri-operative period, and i certainly didn't suffer PTSD from the occurrence.

it's about expectations. and, without an adequate definition and discussion with the patient, people have different expectations (and experiences) of what is unacceptable and stress inducing.
 
Thanks for the reference Blade (Anesthesiology 2007 FEB;106 (2) 269-274). This study reports the incidence of awareness as 1 per 14,560.

When I use 1-2 per 1000, I am merely referencing the historically published data. Even your reference acknowledges that the incidence classically reported to the literature is between 0.1-0.9%. (0.9%!!! I hope not. That is almost 1 per 100.) Much of this data must be old, collected in the era before LMA's, propofol, desflurane, midazolam, synthetic opiods, etc.

With our own specialty's increasing "awareness" of the issue, more studies like these should follow and the published data will reflect our own anecdotal experience.

The structured interview used by the study (modified Brice Interview) seems like it might be usefull:
What was the last thing you remember before surgery?
What is the first thing you remember once you woke up?
Did you have any dreams while you were asleep?
Were you put to sleep gently?
Did you have any problems going to sleep?
 
Masseter Spasm said:
The structured interview used by the study (modified Brice Interview) seems like it might be usefull:
What was the last thing you remember before surgery?
What is the first thing you remember once you woke up?
Did you have any dreams while you were asleep?
Were you put to sleep gently?
Did you have any problems going to sleep?
Click to expand...

this should be part of everyone's post-op check.
 
"Anderson Cooper 360, at 10 p.m. ET will be doing a special on anesthesia awareness. Just FYI. Should be interesting, at least."

A lawyer goes in for a C-Section with GETA. Remembers nothing. Her friend, who also had a C-Section, remembers everything; the cutting, the pulling, the tugging... First lady tells the second lady, "You can sue!!! We can both win vacation homes!!!" The second lady looks at her like she is crazy. "I had a spinal, you frickin ambulance chaser." How in the world did awareness ever become a big deal???

The point is bagillions of people undergoing surgery have recall. IT ISN'T A BIG DEAL!!!! Our field screws up in not pointing this out, as well as not implementing rare awareness as a rare normal side effect of prefectly good general anesthesia. People can't sue you for MH. It's an accepted rare complication. Awareness should be considered the same (though that doesn't free you from awareness due to YOUR fault, such as an empty vaporizer).

And if the patient wants to become a lifelong screwup because awareness supposedly ruined her life, have her speak to thousands of fully awared people that had regional anesthesia, and tell her to get a life.
 
fantastic said:
"Anderson Cooper 360, at 10 p.m. ET will be doing a special on anesthesia awareness. Just FYI. Should be interesting, at least."

A lawyer goes in for a C-Section with GETA. Remembers nothing. Her friend, who also had a C-Section, remembers everything; the cutting, the pulling, the tugging... First lady tells the second lady, "You can sue!!! We can both win vacation homes!!!" The second lady looks at her like she is crazy. "I had a spinal, you frickin ambulance chaser." How in the world did awareness ever become a big deal???

The point is bagillions of people undergoing surgery have recall. IT ISN'T A BIG DEAL!!!! Our field screws up in not pointing this out, as well as not implementing rare awareness as a rare normal side effect of prefectly good general anesthesia. People can't sue you for MH. It's an accepted rare complication. Awareness should be considered the same (though that doesn't free you from awareness due to YOUR fault, such as an empty vaporizer).

And if the patient wants to become a lifelong screwup because awareness supposedly ruined her life, have her speak to thousands of fully awared people that had regional anesthesia, and tell her to get a life.
Click to expand...

I have to disagree with you. I think awareness IS a big deal. The whole point of an anesthetic is that they are NOT aware of what is going on. I dont think I would consider awareness an ACCEPTED rare outcome. If I were about to be put to sleep by a anesthesiologist that admits the possibility of awareness as a possible accepted outcome, I would probably ask for another provider....because I want to be damn sure I wont experience anything during surgery. This obviously doesnt apply to MAC and regional.

When my patients ask me "will I wake up?" I tell them absolutely not...and if you do I will look for another Job because I am obviously not doing mine.

fantastic said:
Our field screws up in not pointing this out, as well as not implementing rare awareness as a rare normal side effect of prefectly good general anesthesia.
Click to expand...

How can it be a perfectly good general anesthetic if they were aware?
 
rmh149 said:
I have to disagree with you. I think awareness IS a big deal. The whole point of an anesthetic is that they are NOT aware of what is going on. I dont think I would consider awareness an ACCEPTED rare outcome. If I were about to be put to sleep by a anesthesiologist that admits the possibility of awareness as a possible accepted outcome, I would probably ask for another provider....because I want to be damn sure I wont experience anything during surgery. This obviously doesnt apply to MAC and regional.

When my patients ask me "will I wake up?" I tell them absolutely not...and if you do I will look for another Job because I am abviously not doing mine.



How can it be a perfectly good general anesthetic if they were aware?
Click to expand...

So,

Could you please enlighten us on how you make sure that 100 % of your patients will never have awareness?
You must know something that we don't!
Because so far no one in this field, other than you, has been able to make such a claim!
 
Planktonmd said:
So,

Could you please enlighten us on how you make sure that 100 % of your patients will never have awareness?
You must know something that we don't!
Because so far no one in this field, other than you, has been able to make such a claim!
Click to expand...

Whats wrong with guaranteeing to my patients that they will not wake up from their general anesthetic during surgery?

I guess you would you consider an anesthetic with awareness still a perfectly good anesthetic.
 
rmh149 said:
Whats wrong with guaranteeing to my patients that they will not wake up from their general anesthetic during surgery?

I guess you would you consider an anesthetic with awareness still a perfectly good anesthetic.
Click to expand...
You can guarantee whatever you want to lay people and they might even believe you, but here on this forum, when you say that none of your patients will ever have awareness, this means you are certain that you can do it.
How can you be the only one in the world with such certainty?
We still don't fully understand awareness so how can you say you can prevent it 100 %?
 
rmh149 your naivete is stunning. and embarrassing.

perhaps if you are the all-knowing, all-seeing eye, you can predict every nuance of your patient's physiology, and avoid awareness. assuming your omniscience includes what causes awareness in the first place.

or perhaps this is just another example of your dangerous arrogance. 😎
 
rmh is just playing the odds, as stated before by observing the patient and adjusting your anesthetic to thier responses awareness becomes very unlikley. Most cases of awareness are caused by anesthesia in trauma situations, "remembering" part of the induction. You sure do not tell a patient that they will have awareness, who would have surgery in that case? Does the surgeon state to his patient that they will die in surgery? No they state that it is a possibility but it will not happen with them, they reassure while laying out the facts.
Yes awarness is possible, no it is not likley if you do your job.
 
stanleykristian said:
rmh is just playing the odds, as stated before by observing the patient and adjusting your anesthetic to thier responses awareness becomes very unlikley. Most cases of awareness are caused by anesthesia in trauma situations, "remembering" part of the induction. You sure do not tell a patient that they will have awareness, who would have surgery in that case? Does the surgeon state to his patient that they will die in surgery? No they state that it is a possibility but it will not happen with them, they reassure while laying out the facts.
Yes awarness is possible, no it is not likley if you do your job.
Click to expand...


That's not what we are talking about, we are not saying that you tell the patient that he will have awareness, we are saying you don't say it will never happen !
There is nothing in medicine that is 100 % certain, and when you say it will never happen and it happens it's considered a breach of contract with the patient.
Go ahead, think about it, and come up with another meaningless argumentative statement now!
 
I wonder how long before the ASA is forced to add the BIS (or something similar) as a standard of care monitor d/t public pressure.

This show didnt help, and if that "awake" movie comes out it will only be worse for us.
 
stanleykristian said:
Most cases of awareness are caused by anesthesia in trauma situations, "remembering" part of the induction.
Click to expand...

no, they're not. most cases are caused by human error (forgetting to turn on the vaporizer, empty vaporizer, etc.). there are certain anesthetics that have a higher chance of awarenes, such as cardiac bypass, crash c-sections, trauma. but, they certainly aren't most cases. and, as i said before, "remembering" part of the induction or emergence does not constitute true "awareness".

stanleykristian said:
You sure do not tell a patient that they will have awareness, who would have surgery in that case?
Click to expand...

you don't tell them that they will have awareness, but you tell them it's a possibility during certain procedures.

stanleykristian said:
Does the surgeon state to his patient that they will die in surgery? No they state that it is a possibility but it will not happen with them, they reassure while laying out the facts.
Click to expand...

this statement proves how little you understand. surgeons routinely tell patients there is a chance that they may die during the surgery, and they then quantify the risks. this is part of "informed consent", and misrepresenting the facts or the situation is a violation of the patient-doctor relationship.

because you don't understand the subtle distinction, better stick to being a crna.

stanleykristian said:
Yes awarness is possible, no it is not likley if you do your job.
Click to expand...

which is it? you've managed to contradict yourself in this very post. either it's a result of human error (as you imply here), or there are certain anesthetics more prone to situations where awareness may occur. make up your mind.

there is more at play in this complex issue, as i stated before, than simplistically saying you just have to "do your job" and nothing will happen. true awareness is a rare event that most often has a traceable cause. what you actually do is explain this to the patient and have a discussion after the anesthetic, you vigilantly supervise your anesthetic during the case, you give appropriate medications, and if you, forbid the thought, realize that you forgot to turn the vaporizer on (or something similar) you post-treat the incident with a large dose of amnestic hoping you get some retrograde amnesia (for example, a big dose of midazolam).

and, you still can't guarantee that you will not have awareness 100% of the time. most patients will respond to the anesthetic the same way. some will not. and, in this case, even the BIS monitor can lead you astray.

(btw, i see you've been banned.)
 
rmh149 said:
I have to disagree with you. I think awareness IS a big deal. The whole point of an anesthetic is that they are NOT aware of what is going on. I dont think I would consider awareness an ACCEPTED rare outcome. If I were about to be put to sleep by a anesthesiologist that admits the possibility of awareness as a possible accepted outcome, I would probably ask for another provider....because I want to be damn sure I wont experience anything during surgery. This obviously doesnt apply to MAC and regional.

When my patients ask me "will I wake up?" I tell them absolutely not...and if you do I will look for another Job because I am obviously not doing mine.



How can it be a perfectly good general anesthetic if they were aware?
Click to expand...

please think b/4 posting.
 
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