Can we guarantee no awareness?

[Planktonmd]

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A certain CRNA on this forum is claiming that he can "guarantee" no awareness to all his patients.
Let's hear some opinions on that.

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[huktonfonix]

Can I guarantee it? Of course not. Nothing in life is 100% (excluding death and taxes). I can assure my typical fairly healthy patient that the risk is very low and that there are many variables I am monitoring to prevent the possibility of awareness. Its like playing the lottery. Your chances of winning the lottery are much less than the chances of having awareness (whether you use the reported 1/1000 or Blades 1/14500), but it COULD happen. You should have some idea which patients fall into a higher risk group and explain the possibilities accordingly. Now the patients on that crap CNN special seemed to be fairly healthy undergoing what seemed like intermediate risk surgery which should place them at low risk for awareness. Unfortunately,without seeing the record or talking to the anesthesia provider it is impossible to know what happened.

 

[Trisomy13]

A certain CRNA on this forum is claiming that he can "guarantee" no awareness to all his patients.
Let's hear some opinions on that.

​

achieving asystole guarantees no awareness 🙄

 

[atrxnasd]

Awareness is only a problem if you use muscle relaxants. So if your patient is not paralysed if he becomes aware he'll hit you or the surgeon and make his displeasure known.

 

[BLADEMDA]

Awareness is only a problem if you use muscle relaxants. So if your patient is not paralysed if he becomes aware he'll hit you or the surgeon and make his displeasure known.

When he HITS you and REMEMBERS doing so that is awareness. Yes, a lesser degree than the horror stories on cable but awareness nonetheless.

I had a patient (alcoholic) wake-up when the dressings were being applied.
He was not paralyzed and in no pain. He remembered the E.T. tube and us talking at the end of the case. I explained that this was not "awareness" and sometimes people recall the last 5 minutes of operating room time. He did NOT believe me and was convinced we operated oh him AWAKE.

When the Surgeon told him the same story he began to change his mind.
He realized that I was telling the truth and he could not remember anything but the final few minutes in the operating room. I pride myself on FAST wake-up and quick turn-over but there is a down side (very rare) .

Blade

 

[rmh149]

A certain CRNA on this forum is claiming that he can "guarantee" no awareness to all his patients.
Let's hear some opinions on that.

​

So some of your patients wake up during surgery?

The day my patients experience awareness when I guaranteed them they wouldnt, then you can call BS. But I feel pretty damn comfortable with the 1 in 14500 chance. Especially when the procedure is not trauma, emergency OB, or cardiac. Since I do no trauma or cardiac the odds are even less.

 

[Planktonmd]

So some of your patients wake up during surgery?

The day my patients experience awareness when I guaranteed them they wouldnt, then you can call BS. But I feel pretty damn comfortable with the 1 in 14500 chance. Especially when the procedure is not trauma, emergency OB, or cardiac. Since I do no trauma or cardiac the odds are even less.

You still don't get it do you?
The point is: If something could happen you can't "Guarantee" it won't.
In medicine you don't guarantee anything, period.
Let me give you an example:
Let's say you have a curable disease, let's say Gonorrhea.
So, you go to the doctor, he gives you antibiotics, can he guarantee that you will be cured?
The answer is obviously: NO
Because although unlikely, you can still develop Gonococcal Arthritis or even Septicemia and die.
So the Doctor can be reassuring and comforting but he can not guarantee anything.
Think about it.

 

[VentdependenT]

Does your airplane pilot guarantee you nothing will go badly when you board? He can't. Its not entirely under his/her control.

 

[rmh149]

You still don't get it do you?
The point is: If something could happen you can't "Guarantee" it won't.
In medicine you don't guarantee anything, period.
Let me give you an example:
Let's say you have a curable disease, let's say Gonorrhea.
So, you go to the doctor, he gives you antibiotics, can he guarantee that you will be cured?
The answer is obviously: NO
Because although unlikely, you can still develop Gonococcal Arthritis or even Septicemia and die.
So the Doctor can be reassuring and comforting but he can not guarantee anything.
Think about it.

You are going to compare gonorrhea to awareness?

 

[BlackSails]

You cant tell the patient anything with certainty. You can do everything right, but perhaps you got a bad batch of drugs from the factory. Telling them that you can say for sure that they will not be aware is a lie.

 

[rmh149]

You still don't get it do you?
The point is: If something could happen you can't "Guarantee" it won't.
In medicine you don't guarantee anything, period.
Let me give you an example:
Let's say you have a curable disease, let's say Gonorrhea.
So, you go to the doctor, he gives you antibiotics, can he guarantee that you will be cured?
The answer is obviously: NO
Because although unlikely, you can still develop Gonococcal Arthritis or even Septicemia and die.
So the Doctor can be reassuring and comforting but he can not guarantee anything.
Think about it.

Plankton, do you agree with the statement made below? Do you think that awareness should be an "accepted rare complication"? Do you think that it "isnt 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.

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.

 

[Planktonmd]

Plankton, do you agree with the statement made below? Do you think that awareness should be an "accepted rare complication"? Do you think that it "isnt a big deal"?

I agree that awareness should be an accepted rare complication, because that's what it is.
I would not say it's not a big deal, because it is, and we need to do everything we can to prevent it, but we give NO guarantees.

 

[milrisome]

So some of your patients wake up during surgery?

The day my patients experience awareness when I guaranteed them they wouldnt, then you can call BS. But I feel pretty damn comfortable with the 1 in 14500 chance. Especially when the procedure is not trauma, emergency OB, or cardiac. Since I do no trauma or cardiac the odds are even less.

Haven't you been watching the news? The last guy who guaranteed something wound up in court! He won the case, but I guarantee you he doesn't have that sign up in his business anymore.😎

 

[rmh149]

Haven't you been watching the news? The last guy who guaranteed something wound up in court! He won the case, but I guarantee you he doesn't have that sign up in his business anymore.😎

Which case you are talking about?

So how long before the BIS or equivilant becomes standard of care. And if it is available (in every room), does it become the standard for that facility?

 

[bostonblaz]

i always belived that if i was in the one mac range of a gas with no paralytic i was damn shure that there was no way anyone could remeber it. i did a knee scope with an lma in the last year where the sevo was 2.2% soon after induction and the pt did not move and vitals did not change but when i got a page a week later and had to go to preop clinic to meet this guy he told me he remebered most everything, never had any pain, but remebered what we were talking about and was able to tell me verbatum, he was not mad or upset but wanted to ask me what he could do in the future to never have this happen again. so note to self there is never an absolute in this feild and most times it is vodo majic.blaz

 

[BLADEMDA]

i always belived that if i was in the one mac range of a gas with no paralytic i was damn shure that there was no way anyone could remeber it. i did a knee scope with an lma in the last year where the sevo was 2.2% soon after induction and the pt did not move and vitals did not change but when i got a page a week later and had to go to preop clinic to meet this guy he told me he remebered most everything, never had any pain, but remebered what we were talking about and was able to tell me verbatum, he was not mad or upset but wanted to ask me what he could do in the future to never have this happen again. so note to self there is never an absolute in this feild and most times it is vodo majic.blaz

At the start of the case you have to "overdrive" the vaporizer to get your ET vapor to at least 0.5 MAC or greater. The new machines are even more effecient and the ET gases are lower during the first few minutes than the older "inefficient" Narkomed 2B's. My point is that your ET vapor was unlikely 2.2% with SEVO. This does not mean that recall is impossible with ET vapor of whatever but I have never heard of a case. Well? What was your ET Sevo reading? If you don't have this on your machine/monitor get it.

Blade

 

[milrisome]

Which case you are talking about?

quote]

I mean the guy who "guaranteed" satisfaction at his dry cleaning business. he lost a guy's pants and got taken to court. You can read about it here:

http://abcnews.go.com/TheLaw/story?id=3119381

Basically, if you guarantee something and then the opposite happens, people are going to be disgruntled. But if you're straight with them and say that it's low risk but still possible, and then you have a bad outcome, at least you have given full diclosure.

 

[onyX]

hypothetical... in an average 56 yo person having something like a ex lap for about 2.5 hours

- you would probably want more information, but use your imagination and recall your own cases/experience and what you did-

for awareness purposes only, what is the lowest MAC you would run on any gas (plus an additive MAC of a medium dose of a narcotic and a medium dose of paralytic) and what is the highest BIS you would ever be comfortable running?

examples include:

MAC 1.2 and BIS of 40 or less
MAC 1.1 and BIS of 41-48
MAC 0.8 and BIS of 49-56
MAC 0.6 and BIS of 56-62
MAC 0.5 and BIS of 62-69

And would you ever run MAC and/or BIS higher/lower based on if your anesthesia records were entered in court and you had to defend your decision?

Just wanting to know some practices/thoughts out there... later😴

 

[Noyac]

You are going to compare gonorrhea to awareness?

Nobody is comparing the two in the way you are talking about. They are not even related for your information since you seem to think they are being compared. The statement is refering to a "guarantee" of an outcome. Don't be a **** stirrer. Discuss the topic intelligently or go back to your area.

 

[rmh149]

Nobody is comparing the two in the way you are talking about. They are not even related for your information since you seem to think they are being compared. The statement is refering to a "guarantee" of an outcome. Don't be a **** stirrer. Discuss the topic intelligently or go back to your area.

I know Noy. And yes, I know I am taking a risk at the Guarantee when I do...which I dont do for everyone. But sometimes I am willing. I just depends on the day and the patient. Obviously there is a chance...But if I run the anesthetic the way I usually do with a BIS, the likelihood is very very slim.

My point of that post to to address the importance of awareness. Someone stated it "isnt a big deal". I disagreed. And thankfully, so did Plankton. It truly surprises me that any anesthesiologists thinks that it isnt.

 

[Noyac]

I know Noy. And yes, I know I am taking a risk at the Guarantee when I do...which I dont do for everyone. But sometimes I am willing. I just depends on the day and the patient. Obviously there is a chance...But if I run the anesthetic the way I usually do with a BIS, the likelihood is very very slim.

My point of that post to to address the importance of awareness. Someone stated it "isnt a big deal". I disagreed. And thankfully, so did Plankton. It truly surprises me that any anesthesiologists thinks that it isnt.

Do you use the BIS for every case?

The only cases I really use it in are the elderly that I want to run much less than 1 MAC on, occasional traumas, and spines under TIVA. Its another expense put on our system that isn't necessary all the time IMHO.

 

[BLADEMDA]

Do you use the BIS for every case?

The only cases I really use it in are the elderly that I want to run much less than 1 MAC on, occasional traumas, and spines under TIVA. Its another expense put on our system that isn't necessary all the time IMHO.

I agree with NOY. I use BIS on about 5% of my cases. I use BIS on every Heart and on SICK cases. This allows me to titrate the vapor to about 0.5MAC or less for the old folks. Thus, I need less pressors and the old people rarely remember anything anyway with trace vapor.

My rule of thumb for most cases without BIS is 0.5 MAC VAPOR minimum (this means VAPOR MAC only so narcotics, benzo, etc. don't count) on the exhaled vapor reading.
I have never had a case of awareness with that reading and neither has anyone in my practice. Again, you need to overdrive the vaporizer at the start of the case especially with the brand new anesthesia machines.

Blade

 

[VentdependenT]

Is mac awake .5 MAC?

Is mac awake 0.25 MAC?

I feel that if you run someone at a 1/2 mac your pretty much covered for amnesia. Plus there is always the 1mg or 2 of versed I give up front.

 

[BLADEMDA]

Is mac awake .5 MAC?

Is mac awake 0.25 MAC?

I feel that if you run someone at a 1/2 mac your pretty much covered for amnesia. Plus there is always the 1mg or 2 of versed I give up front.

Venty,

I am giving you YEARS of clinical experience when I state 0.5 MAC of vapor for amnesia. I wouldn't count on 0.25 MAC on your young, healthy, xanax alcoholic female patient for amnesia. Howver, on your 80 year old with mild dementia 0.25 MAC is MORE than sufficient. If your goal is MINIMAL vapor you should use BIS and other agents like midazolam, low dose ketamine, low dose propofol etc.

Remember, the 0.5 MAC VAPOR Rule refers to REAL EXHALED vapor reading and not the dial amount on the canister. At the start of the case get used to looking at the exhaled number and don't wait too long for 0.5 MAC on your young, healthy patients.

Blade

 

[rmh149]

Do you use the BIS for every case?

The only cases I really use it in are the elderly that I want to run much less than 1 MAC on, occasional traumas, and spines under TIVA. Its another expense put on our system that isn't necessary all the time IMHO.

I agree with you. I dont use it on every case. I cater each anesthetic to the individual patient.

 

[onyX]

"""Howver, on your 80 year old with mild dementia 0.25 MAC is MORE than sufficient. If your goal is MINIMAL vapor you should use BIS and other agents like midazolam, low dose ketamine, low dose propofol etc.""""

Blade... and others...

what's the highest BIS you would tolerate in a person to run the lowest vapor?

 

[Noyac]

Blade... and others...

what's the highest BIS you would tolerate in a person to run the lowest vapor?

Generally, 60's.

I would tolerate higher if I was having difficulty keeping them alive.

I've said this b/4 but it was some time back. I did an extraction of retained products in the OR after a delivery with some versed and ketamine a while back. The pt was not intubated (don't critisize its not the topic right now) but was sedated to the point of unresponsive. I slapped a BIS on her and it read 94. After the procedure she did not remember a thing. The BIS never dipped below 90. Ketamine will do this.

 

[BLADEMDA]

Generally, 60's.

I would tolerate higher if I was having difficulty keeping them alive.

I've said this b/4 but it was some time back. I did an extraction of retained products in the OR after a delivery with some versed and ketamine a while back. The pt was not intubated (don't critisize its not the topic right now) but was sedated to the point of unresponsive. I slapped a BIS on her and it read 94. After the procedure she did not remember a thing. The BIS never dipped below 90. Ketamine will do this.

I agree with NOY-60's (mid 60's for an 80 year old).

Blade

 

[Beck928]

Do you use the BIS for every case?

The only cases I really use it in are the elderly that I want to run much less than 1 MAC on, occasional traumas, and spines under TIVA. Its another expense put on our system that isn't necessary all the time IMHO.

In my institution BIS is a four-letter word

 

[flgasman]

I don't think anyone can guarantee no awareness. I would contend that awareness is not the worst thing that can happen so long as the patient is not in pain. obviously we dont want awareness but its going to happen especially during CABG at some point if you have a long career. Again as long as the patient is adequately anesthetized (with regard to pain)then there are many worse things that can happen.

 

[jwk]

If you start thinking of MAC as an ED50, maybe you won't be so hot to use that as a guide. What else do we do, what drugs do we use, where an ED50 is an acceptable success rate?

 

[Idiopathic]

Lotsa ball-swinging around here, and plenty of anecdotal evidence.

also, who thinks you cant get awareness if no NMB is on board? thats ridiculous. you may not have a problem with movement, but wait until you get that phone call a week later from the guy who heard everything (but maybe didnt move because they felt no pain, etc.).

BTW, the BIS costs $16 and the B-AWARE study quantified cost to prevent one legitimate case of awareness at $2200. (admittedly thats in australia) Id take that any day of the week and twice on Sundays. Also, an 04 report had it at a cost of $5.55 per patient when you factor in decreased drug usage and potential efficiency.

Im still on the fence somewhat about the BIS, but it has been shown to decrease incidence of awareness and it has been shown to improve efficiency.

 

[jwk]

Lotsa ball-swinging around here, and plenty of anecdotal evidence.

also, who thinks you cant get awareness if no NMB is on board? thats ridiculous. you may not have a problem with movement, but wait until you get that phone call a week later from the guy who heard everything (but maybe didnt move because they felt no pain, etc.).

BTW, the BIS costs $16 and the B-AWARE study quantified cost to prevent one legitimate case of awareness at $2200. (admittedly thats in australia) Id take that any day of the week and twice on Sundays. Also, an 04 report had it at a cost of $5.55 per patient when you factor in decreased drug usage and potential efficiency.

Im still on the fence somewhat about the BIS, but it has been shown to decrease incidence of awareness and it has been shown to improve efficiency.

BIS has not been proven to do anything - it's a device in search of an indication.

OK- at $16 each to prevent one "one legitimate case of awareness at $2200" ? That's one case of awareness for every 138 cases. GIMME A BREAK!

You must be reading Aspect's literature. Common sense and the realities of actual practice has to come in somewhere. Just like Sebel's "landmark" study - the incidence of awareness is 1:1000. BS!!!! A total crock!

 

[Idiopathic]

BIS has not been proven to do anything - it's a device in search of an indication.

OK- at $16 each to prevent one "one legitimate case of awareness at $2200" ? That's one case of awareness for every 138 cases. GIMME A BREAK!

You must be reading Aspect's literature. Common sense and the realities of actual practice has to come in somewhere. Just like Sebel's "landmark" study - the incidence of awareness is 1:1000. BS!!!! A total crock!

You are probably right. Ive gotten a little caught up in the literature working on a research project, I should have clarified those dollar figures for patients at high risk for awareness under anesthesia, as opposed to the general population.

Its definitely a dicey subject, but I also think processed EEG monitoring can have a place in anesthesia, especially high risk cases. You really think 1:1000 is that ridiculous a number? In just a few months Ive seen anesthetic machines fail, incorrect drug administration and high risk cases that could all realistically lead to awareness.

I dont have any allegiance to the BIS, but it would be nice to have a reliable EEG monitor for those cases when you may need to deepen your anesthetic.