Awareness Movie “Awake”

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jwk said:
Just curious - do you speak on behalf of Aspect and BIS - if so, where is your disclaimer?

And I'll happily go the rest of my career (27 years so far, at least 10-15 more to go) without using a BIS. The other monitors, while not "perfect" are much more reliable, dependable, predictable, reproducible, and USEFUL than BIS could ever hope to be. After 10 years (or more?) it's still a monitor in search of an indication that seeks to solve a problem that is largely not an issue in the hands of competent, unimpaired, and vigilant anesthesia providers.
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DISCLAIMER: I do not work for Aspect Medical Systems. I am neither a stockholder nor a paid consultant. My opinions are based on my 10 year experience with the monitor.

Another cranky old fart like myself.🙁
It took me nearly 2 full years to wean myself from the fantasy I was taught and practiced for 20 years; i.e. that trends in HR & BP have something relevant to say about pt. level of anesthesia. Total nonsense.

It is far more important to avoid routinely overdosing pts. for fear of underdoing them.

As I said in my previous post, the awareness issue had nothing to do with my interest in BIS. I was trying to find a way to do my technique with less propofol to placate the surgeons.

If you fear being replaced by a BIS hooked up to a closed loop computer, fear not. It isn't going to happen. Heard the same issue when the Dinamp was introduced 30 yrs ago.

If you would like to add some interest to your day😴, BIS with EMG as a secondary trace will do very nicely. In my paradigm, the clonidine keeps the EMG very low, so that spikes in EMG are reflective of pt. mvmt or change in level of consciousness

Frankly though, I really don't care what you do with your practice but your patients might.

Try a little tenderness for your pts. and yourself.

Have a nice day.🙂

aghast1
 
dhb said:
Did you read it yourself??? It offers no info on how to adjust the depth of anesthesia with ketamine it is just a description of your technique. What i'm saying (and you still haven't answered this) is that you say your doing a goldilocks anesthesia without knowing if you could be lighter on the propofol with ketamine on-board...😱😱😱

Dude,

Of course I read it. I wrote it.

You don't adjust the level of consciousness with ketamine.

That's the role of the propofol and the BIS monitor.

BIS <75 in the presence of an incremental propofol induction creates a reproducible, numerical basis upon which the initial (and subsequent if needed) dose(s) of ketamine can be given without hallucinations.

Speaking as a clinician, not a scientist (which I never claimed to be), I use the ketamine to block the painful, noxious stimuli from the local injections from reaching the cortex, thus creating reproducible pre-emptive anlgesia.

BIS does not affect ones ability to titrate propofol in the presence of a 50 mg dissociative dose of ketamine.

Take a deep breath and read it again.

😱 I have not had a single case of awareness so i wouldn't benefit from an 82% reduction 🙄 0.2% of case that's friggin nuts!

If you could spare your own mother an episode of awareness, would it be worth considering? On second thought, you might hate your mother.🙁

You probably have insufficient data to make 'no awareness in my practice' observation.

As I stated in previous posts, I was never attracted to BIS because of the awareness issue.

My pts. are never paralyzed and perfectly capable of moving or speaking.
Because of adequate local anesthesia, they rarely have a reason to do so.

My surgeons were crying the blues about the cost of the propofol (although they loved the outcomes). I was looking for a way to do my technique with more efficient use of the propofol.

It is far more important to stop the practice of routinely overdosing for fear of underdosing. Post-operative cognitive (POCD) dysfunction is a real phenomenon about which you are in a perfect position to do something.

Check out Monk & Sebel on this issue.👍

Smelling the roses along the way😀,

aghast1
Click to expand...
 
Aghast, careful on quoting Terri Monk's research. One study does not make it true, especially a retrospective one at that. Dr. Monk herself urges caution before translating her work to use on all cases. At least she did at the PGA 2 years ago. Taken at face value, her study showed that hypotension (greater than 20 %) and/or deep anesthesia ( BIS less than 45) independently increased DEATH rates in a dose related fashion. Very interesting, but I don't buy it. Not yet at least. And Why would the death rate increase include cancer? I may be wrong, but I'll need a few more studies before I take the plunge. I mean lets at least see a prospective study please. We don't all go around quoting Goldberg do we?

Your immediate discount of the cost of BIS monitoring is incorrect as well.

You work in a plastic surgeons office, using a lot of propofol, which years ago was quite expensive. The monitor most likely paid for itself in decreased drug costs. Generalizing it to all operations is another matter. If every operation used a BIS, the total cost I believe would be staggering.

Certain monitors advantages are clear, others are not. Pulse Ox, ECG, Capnography, and others don't need champions. That is why they are standard. And although I have members of my group who trained using open drop techniques, none of them want to do a case without pulse oximetry. If the BIS was so clearly effective, it wouldn't start arguments, agreed?

I am not saying that BIS doesn't have its place, namely in education, the section room, the open heart room, and apparently your room. Hell, I probably use it myself more than I should. But I don't want my residents requiring it as a crutch. Using the BIS has a cost and it may not be just the purchase price.

I must give you some credit, I re-examined my use of ketamine because of these posts. Previously, I used to think of ketamine as a drug to use primarily when a block failed. I associated it with failure, and therefore didn't use it as much as I could. I realize I was under utilizing it. Anytime you re-examine your practice it is a good thing. And as long as people do that as a result of this discussion, it's worth it.
 
numbmd said:
Aghast, careful on quoting Terri Monk's research. One study does not make it true, especially a retrospective one at that. Dr. Monk herself urges caution before translating her work to use on all cases. At least she did at the PGA 2 years ago. Taken at face value, her study showed that hypotension (greater than 20 %) and/or deep anesthesia ( BIS less than 45) independently increased DEATH rates in a dose related fashion. Very interesting, but I don't buy it. Not yet at least. And Why would the death rate increase include cancer? I may be wrong, but I'll need a few more studies before I take the plunge. I mean lets at least see a prospective study please. We don't all go around quoting Goldberg do we?

Your immediate discount of the cost of BIS monitoring is incorrect as well.

You work in a plastic surgeons office, using a lot of propofol, which years ago was quite expensive. The monitor most likely paid for itself in decreased drug costs. Generalizing it to all operations is another matter. If every operation used a BIS, the total cost I believe would be staggering.

Certain monitors advantages are clear, others are not. Pulse Ox, ECG, Capnography, and others don't need champions. That is why they are standard. And although I have members of my group who trained using open drop techniques, none of them want to do a case without pulse oximetry. If the BIS was so clearly effective, it wouldn't start arguments, agreed?

I am not saying that BIS doesn't have its place, namely in education, the section room, the open heart room, and apparently your room. Hell, I probably use it myself more than I should. But I don't want my residents requiring it as a crutch. Using the BIS has a cost and it may not be just the purchase price.

I must give you some credit, I re-examined my use of ketamine because of these posts. Previously, I used to think of ketamine as a drug to use primarily when a block failed. I associated it with failure, and therefore didn't use it as much as I could. I realize I was under utilizing it. Anytime you re-examine your practice it is a good thing. And as long as people do that as a result of this discussion, it's worth it.
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Actually, my screen name is aghast1👍

I also cited Peter Sebel's follow-up study confirming Terri's hypothesis that the increase in death rate might be related to an inflammatory response with XS anes. BIS <45.

"Your immediate discount of the cost of BIS monitoring is incorrect as well."

OK, so why didn't you state what you believe to be the correct cost? Cost is not the issue, cost:benefit is. Is we can keep from neither over- nor under-dosing our pts. (Goldilocks), then I believe the benefit outweighs the costs.

Remember, I don't work for Aspect, don't hold stock and am not a paid consultant. If another level of consciousness monitor publishes superiority to BIS, I will be there to check it out.

"You work in a plastic surgeons office, using a lot of propofol, which years ago was quite expensive. The monitor most likely paid for itself in decreased drug costs."

I paid, they saved.

"But I don't want my residents requiring it as a crutch."

You mean a 'crutch,' 'jefferson airplane,' or 'roach clip,' like something used to hold the leftover doobie?

Seriously, how can something that gives one info not obtainable by any other means be a crutch.

Do you still believe in 'reading the tea leaves?' or using trends in vital signs to assess level of consciousness? That's right up there with Santa Claus, the Ether Bunny, and the Tooth Fairy.:laugh:

"Certain monitors advantages are clear, others are not. Pulse Ox, ECG, Capnography, and others don't need champions. That is why they are standard."

SpO2 wasn't clear (as a standard of care) to the ASA (circa 1992) for nearly a decade after its introduction (1984!).

"I must give you some credit, I re-examined my use of ketamine because of these posts. Previously, I used to think of ketamine as a drug to use primarily when a block failed. I associated it with failure, and therefore didn't use it as much as I could. I realize I was under utilizing it. Anytime you re-examine your practice it is a good thing. And as long as people do that as a result of this discussion, it's worth it."

Thank you. My comments, while often mis-interpreted, are not about how right I am but how much better you could do for your pts., if you were willing to re-examine your belief systems.

No level I studies of dissociative technique is likely why Moiniche et al Anesthesiol 96:725, 2002 concluded there was no evidence for the phenomenon.

I have been making a living providing pre-emptive analgesia for a decade preceding this study and afterwards as well.

The bests thing about teaching others is how much you learn yourself! However, one cannot put tea into a full cup. Thank you for making room in your cup.

Regards,

aghast1
 
It has gotten some crappy reviews and officially rotten on rottentomatoes.

http://www.rottentomatoes.com/m/awake/

The New York Times review starts like this
"In the loopy medical thriller "Awake," Hayden Christensen plays Clayton Beresford Jr., a wealthy young man who suffers a condition called anesthesia awareness during a heart transplant. Conscious but immobile, he gives us a voice-over play-by-play of the proceedings, and if you are one of those who viewed his portrayal of Anakin Skywalker as the ne plus ultra of lifelessness, prepare to be proven wrong."

And ends with this
"The writer and director, Joby Harold, claims to have been inspired to write the film while suffering from a particularly painful kidney stone. Watching it may be for some a comparable experience."

I got all giggly...
 
http://abcnews.go.com/WN/story?id=3938302&page=1

Woman Wakes Up Mid-Surgery, Paralyzed and in Pain
20,000 to 40,000 Americans May Wake Up Mid-Surgery

JOHN MCKENZIE and SUSAN SCHWARTZ
Nov. 30, 2007

It is one horror that not even Hollywood can exaggerate.

You're supposed to be unconscious from the anesthetic, but suddenly your brain wakes up, so you hear and feel everything. But your body remains "paralyzed" -- unable to cry out for help or stop the pain to come.


When you have surgery, you assume you'll be unconscious and feel no pain. And that's usually the case. But 20,000 to 40,000 Americans each year aren't so lucky.

Click here for more information on when patient awareness happens and how you can reduce the risk of it happening to you.

Waking up during surgery is just what happened to Jeannette Magdelene.

"As soon as he put the scalpel into my flesh," she said, "It was as though someone took a blow torch and stuck it in the right side of my stomach."

But she was powerless to stop it.

"I couldn't speak to let someone know I was awake. I couldn't move anything. I was buried alive inside myself. Frozen from head to toe."

Joint Commission, the independent, nonprofit organization that accredits hospitals, calls it a "frightening phenomenon" that is "under recognized and under treated."

The cause of the problem often boils down to basic medical errors: Anesthesiologists using the wrong drugs, or inadequate doses of the right drugs.

One solution, according to Memorial Hermann Hospital in Houston, is to use brain monitors.

Dr. John Zerwas, who works at the Houston hospital, said, "The brain wave activity starts to get to a point where we see that awareness is a potential problem, and so we can deepen the anesthesia."

The machine, which sells for as little as $5,000, reassured Bill Hamm as he went into surgery this morning.

"It takes away the chance for human error in anesthesia," he said.

But the American Society of Anesthesiologists is not convinced and said there's just not enough data to prove the machines are the answer.
 
casualkid said:
http://abcnews.go.com/WN/story?id=3938302&page=1

Woman Wakes Up Mid-Surgery, Paralyzed and in Pain
20,000 to 40,000 Americans May Wake Up Mid-Surgery

JOHN MCKENZIE and SUSAN SCHWARTZ
Nov. 30, 2007

It is one horror that not even Hollywood can exaggerate.

You're supposed to be unconscious from the anesthetic, but suddenly your brain wakes up, so you hear and feel everything. But your body remains "paralyzed" -- unable to cry out for help or stop the pain to come.


When you have surgery, you assume you'll be unconscious and feel no pain. And that's usually the case. But 20,000 to 40,000 Americans each year aren't so lucky.

Click here for more information on when patient awareness happens and how you can reduce the risk of it happening to you.

Waking up during surgery is just what happened to Jeannette Magdelene.

"As soon as he put the scalpel into my flesh," she said, "It was as though someone took a blow torch and stuck it in the right side of my stomach."

But she was powerless to stop it.

"I couldn't speak to let someone know I was awake. I couldn't move anything. I was buried alive inside myself. Frozen from head to toe."

Joint Commission, the independent, nonprofit organization that accredits hospitals, calls it a "frightening phenomenon" that is "under recognized and under treated."

The cause of the problem often boils down to basic medical errors: Anesthesiologists using the wrong drugs, or inadequate doses of the right drugs.

One solution, according to Memorial Hermann Hospital in Houston, is to use brain monitors.

Dr. John Zerwas, who works at the Houston hospital, said, "The brain wave activity starts to get to a point where we see that awareness is a potential problem, and so we can deepen the anesthesia."

The machine, which sells for as little as $5,000, reassured Bill Hamm as he went into surgery this morning.

"It takes away the chance for human error in anesthesia," he said.

But the American Society of Anesthesiologists is not convinced and said there's just not enough data to prove the machines are the answer.
Click to expand...

"But the American Society of Anesthesiologists is not convinced and said there's just not enough data to prove the machines are the answer."

The ASA is primarily a political organization concerned mostly with member remuneration for services, which I loudly applaud.:hardy:

If the data from >3,000 scientific papers is not enough, there will never be enough for the ASA. Even the fact that Aspect spurred several commercial competitiors to be created in the level of consciousness field made no difference.

HR & BP trends are notoriously unreliable clues to depth of anesthesia or level of consciousness.

For me, I'll take the 82% reduction in anesthesia awareness every day of the week.😎

Of course, it was never an issue in 'my week.'

The bigger problem is routine over-dosing which may increase 1 yrs. mortality and increase POCD in sensitive pts.😱

SpO2 (1984) would have obviated the premise of 'Coma' (1977). Given it took ASA 8 yrs. to declare SpO2 a standard of care, we should not wait for their 'blessing' to do so in our practices. BIS has been around since 1996. That's 11 yrs for those w/o a pocket calculator.🙄

Disclaimer: I do not work for Aspect, have Aspect stock, or am a paid consultant for them. My opinion solely is based on my 10 yrs. experience with BIS.

FWIW, those looking for a less expensive BIS need only to ask for a 'refurbished salesman's demo unit.' Much less than the $5K cited above. Probably not much use for an institutional buyer.

"What a long, strange trip it's been." - Grateful Dead

Ciao,

aghast1
 
I forced myself to go see the movie last night.

Its not going to scare anyone....its that friggen bad. The OR scenes are COMPLETELY devoid of any realism. In fact, they are quite boring. There is some gore factor but thats about it.

The movie, otherwise, is awful.

Oh, btw, the anesthesiologist leaves the room for 90% of the case. He is also a drunk. Thanks MGM!
 
VentdependenT said:
I forced myself to go see the movie last night.

Its not going to scare anyone....its that friggen bad. The OR scenes are COMPLETELY devoid of any realism. In fact, they are quite boring. There is some gore factor but thats about it.

The movie, otherwise, is awful.

Oh, btw, the anesthesiologist leaves the room for 90% of the case. He is also a drunk. Thanks MGM!
Click to expand...

As a former resident with the Stanford cardiac transplant team, the technical deficiencies of the flick made it hard for me to concentrate/enjoy the story. I mean having an ungloved hand in the field, dropping facemasks mid-surgery, and access to the transplant room directly of a hospital corridor without any security. Ridiculous. Enjoyable story though.

"Its not going to scare anyone....its that friggen bad."

I respectfully disagree. I feel for anyone who sees the flick and then has to go in for surgery.

The best possible good to come from the flick is the 'awareness' of technology that, while not perfect, can reduce the incidence of awareness by 82% and an increased public demand for it to be used routinely, not on selected cases.

There may be some cases that pose a higher risk than others (cardiac and c/s), but patient differences in drug tolerance are not limited to 'selected' cases.

Interesting that no one answered my repeated challenge: If that one in 1-2,000 pts was you or your family, how would you feel about BAM (brain activity monitoring)?

BAM (brain activity monitoring) is Carol Weihrer's new acronym. I like it.

aghast1
 
Actually, your name should be picky1. I am glad you DID realize I was referring to you, Aghast.

Sebel is a paid consultant by Aspect. Therefore he is automatically discounted in my book. He may be right but once he starts taking money his research cannot be counted as objective. Sorry.

Crutch? Roach clip? Tea leaves? I have refrained from childish comments, please do the same.

I have previously admitted there are uses for EEG monitoring. However useful the BIS monitor is in your practice, it does not have a place in all anesthetics. I use the BIS frequently in my practice. I do NOT use it in all cases. Using it in all cases is irresponsible, and wasteful.

BIS is not as useful in extremes of age, nor in short cases. Put a 15 $ probe on a patient for a 15 minute case? I think not. Cost? Cost for the probe is approx. 15 dollars at my institution. Let's see, 15 x 25 million anesthetics a year? 375 million a year. I'd like to say it's OK if I don't have to pay it. But I actually do have to pay it, we all do. Benefit is the issue, but not at ridiculous cost.

You may not know, but there are certain things that must be taught (and learned) in medical school, residency, and also continuing education (if you choose to recert). They are called the six competencies. Part of the six competencies includes cost effective care. Really, its true.

After practicing for more than a few years, I have learned a few things. One is individualizing care to each patient. Even something as simple as supplemental oxygen is not for everyone. I am encouraging everyone to use their brain.

BIS is a good but imperfect monitor. I understand that at the ASA there was a slide with a BIS reading of 60 on a dead patient! (if anyone has it I would appreciate forwarding it to me) I find that it has many flaws and inconsistencies, and many times the info it tells me is too little too late. I have also had a patient breathing an end tidal of 12% Desflurane and a BIS of 98. Go figure.

In summary, I find that while using a BIS has its place, it is no substitute for an attentive anesthesiologist. I also find that sensationalist movies, and articles such as the one quoted above serve only their own purposes, and that is to sell either tickets or advertising. Certainly it is not patient education. I would hope that being in the profession you would take a balanced view. Let the outsiders be the only ones to fan the flames.

Pour a little out of your own cup.
 
1 in 2000 is an asinine number. If you really believe that number then it will be difficult to discuss this reasonably. That is not even close to a reproducible number. There are many levels of recollection. It is the completely awake and completely sensate patient that is the horrible case and that does not happen in 1 in 2000 anesthetics. If that was true there would be a real issue and not something that requires a movie to gain foothold.

My family member would get a board-certified, attentive anesthesiologist. I'll take my chances with that.

The BIS does not guarantee amnesia. ANESTHESIA is what gives amnesia. Let me ask you a different question. What if you had a patient that suddenly became tachycardic, hypertensive, and diaphoretic right after incision? What if the BIS read 60? Would you still do nothing? I hope not.
 
VentdependenT said:
http://www.anesthesia-analgesia.org/cgi/content/full/100/5/1363
Click to expand...

And therein lies the problem - a false sense of security. Besides this case report:

Bowls of jello have been reported to have a low BIS reading.

Then there's the study with what I affectionately call the three crazy German docs who gave each other rocuronium only and had BIS readings under 50.

There's a report out with a lovely picture of a patient with two BIS monitors being used simultaneously, one strip on each side of the head, one monitor reading low numbers, the other indicating the patient was awake.
 
aghast1 said:
BAM (brain activity monitoring) is Carol Weihrer's new acronym. I like it.
Click to expand...

Just what we need - Carol Weihrer making the rules.
 
aghast1 said:
BAM (brain activity monitoring) is Carol Weihrer's new acronym. I like it.
Click to expand...

Just what we need - Carol Weihrer making the rules. Has she trademarked that phrase yet?
 
jwk said:
But wait - what about Jessica Alba??
Click to expand...

There are several wet-tee shots to keep the dads and teenage males in the crowed excited for several minutes.

ANyhoots, there is no panacea: Ketamine is a potential neurotoxin. We have to balance that against its positives. More remains to be discovered on this topic but perphaps its best avoided in the geriatric population/post CVA folks. Who knows.

Maybe you'll chase your Ketamine with Erythropoietin to reverse or prevent cerebral injury?
http://www.springerlink.com/content/gfd855mglj6f4f07/
http://www.springerlink.com/content/m5x2bpyx7lm26pwb/


http://www.anesthesia-analgesia.org/cgi/content/full/101/2/524
Neurotoxin

http://www.nature.com/bjp/journal/v130/n7/abs/0703479a.html
N20 is on the way out anyways...

http://www.blackwell-synergy.com/doi/abs/10.1046/j.1460-9592.2002.00883.x
maybe its better given as a one time shot than over an extended period in susceptible individuals?
 
Trisomy13 said:
We got a reading of 42 on an OB nurse.
Click to expand...

actually i think one even can get a bis reading on a bowl of jello

must have been some of the lights on the list:laugh:

aspect states quite clearly that bis does not replace vital signs monitoring or clinical judgment - but it does provide one with information not obtainable from any other source👍

comments like this and other similar ones reveal nothing more than ignorance

bis is not a 'doc in the box' anymore than a Dinamap® was

never will be

bis will not make you a world class anesthesiologist any more than a stradavarius will make you a world class violinist:idea:

aghast1
 
emoticons are the new punctuation.

i might be ignorant, but i'm not a condescending d-bag.


with all due respect, naturally. 😀
 
jwk said:
Just what we need - Carol Weihrer making the rules. Has she trademarked that phrase yet?
Click to expand...

Your lack of compassion👎 for a person suffering from PTSD is unfortunate.

aghast1
 
Trisomy13 said:
emoticons are the new punctuation.

i might be ignorant, but i'm not a condescending d-bag.


with all due respect, naturally. 😀
Click to expand...

actually, i'd prefer 'snarky' d-bag, fewer letters for you to type:laugh:

aghast1
 
aghast1 said:
actually, i'd prefer 'snarky' d-bag, fewer letters for you to type:laugh:

aghast1
Click to expand...



i had more letters, but went conservative since d-bag is usually reserved for personal encounters in my book. 🙄

but you're doing a good job over the internet. 👍
 
jwk said:
Bowls of jello have been reported to have a low BIS reading.
Click to expand...

Yep, it's in Morgen & Mikhail.

I will occasionally give more anesthesia because of the BIS. I will very, very rarely give less anesthesia because of it.
 
Re: "Onscreen villain makes doctors wince" (Dec 11): Being an anesthesiologist as well as a film enthusiast, I felt compelled to go see "Awake." The anesthesiologist in me applauded the parts which were portrayed accurately, but my inner cinephile wished it were more terrifying.

Physicians who condemn the film forget that it is a work of fiction. The most effective horror films transform the seemingly mundane to sheer terror. Overall, I am thankful for the film - perhaps it will generate more publicity for my specialty, and the crucial role that we play in the operating room. Perhaps, it will lead to fewer patients presenting grudgingly to their preoperative evaluations only to ask, "So how long will this take?" or "Are you actually with me the whole time?"

C.M., M.D.
Martinez, CA
 
mtllady said:
Re:I am thankful for the film - perhaps it will generate more publicity for my specialty, and the crucial role that we play in the operating room. Perhaps, it will lead to fewer patients presenting grudgingly to their preoperative evaluations only to ask, "So how long will this take?" or "Are you actually with me the whole time?"

C.M., M.D.
Martinez, CA
Click to expand...
So, could you explain to us how is this movie going to make your patients have less questions and concerns before surgery?
Do you ever read the things that you post?
 
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