Intraop Awareness?

[twoliter]

http://www.foxnews.com/health/2015/...ing-brain-surgery-asks-doctors-hows-it-going/

Obviously this article is missing some (major) details. As in it doesn't mention how difficult it may be to verbalize question with an endotracheal tube in place. Thanks for the good publicity, media.

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[ZzzPlz]

Awake crani?

She's asking pertinent questions, sounds like everything went pretty well.

 

[deleted682700]

May be another publicity stunt by aspect technology.
Don't worry in my practice every one gets versed. Everyone gets the bis monitor and the reading is less than 50.
And I made sure the hospital administrator got desflurane vaporizer, so that the audible alarm goes off when the vaporizer is empty.
If the above are not there in a different setting, I document in the anesthesia chart that the hospital has not provided them and document end tidal sevo concentration.

 

[dhb]

May be another publicity stunt by aspect technology.
Don't worry in my practice every one gets versed. Everyone gets the bis monitor and the reading is less than 50.
And I made sure the hospital administrator got desflurane vaporizer, so that the audible alarm goes off when the vaporizer is empty.
If the above are not there in a different setting, I document in the anesthesia chart that the hospital has not provided them and document end tidal sevo concentration.

not sure if serious...

 

[IlDestriero]

I don't do any of those things. But Epic charts my Volatile for me and the machine has alarms for "low Mac". If I can't watch the numbers, it's time to hang it up.

 

[geogil]

May be another publicity stunt by aspect technology.
Don't worry in my practice every one gets versed. Everyone gets the bis monitor and the reading is less than 50.
And I made sure the hospital administrator got desflurane vaporizer, so that the audible alarm goes off when the vaporizer is empty.
If the above are not there in a different setting, I document in the anesthesia chart that the hospital has not provided them and document end tidal sevo concentration.

I hope this is tongue in cheek. You give every single patient versed? We have an EMR tickler that reminds us when the vaporizer is low, but seriously, if you can't keep an eye on that, what exactly are you monitoring?

 

[deleted682700]

I hope this is tongue in cheek. You give every single patient versed? We have an EMR tickler that reminds us when the vaporizer is low, but seriously, if you can't keep an eye on that, what exactly are you monitoring?

Very busy private practice where you move from room to room and do cases. Most of my patients except elderly get versed. Don't we have enough to worry about as anesthesiologists? BTW, when your patient reports awareness in the or it's your word against the patients. I don't take chances. The bis is monitored and recorded.

 

[risnwb]

Very busy private practice where you move from room to room and do cases. Most of my patients except elderly get versed. Don't we have enough to worry about as anesthesiologists? BTW, when your patient reports awareness in the or it's your word against the patients. I don't take chances. The bis is monitored and recorded.

Do you practice this defensively in all aspects of your anesthetics? It must be exhausting. The ridiculousness of this way of practicing should be evident in the fact that most posters actually thought you were being facetious.
I honestly believe none of the measures you take are actually decreasing anyone's risk of awareness anyway. Just wasting money (bis/des for every patient) and time (versed).

 

[jwk]

May be another publicity stunt by aspect technology.
Don't worry in my practice every one gets versed. Everyone gets the bis monitor and the reading is less than 50.
And I made sure the hospital administrator got desflurane vaporizer, so that the audible alarm goes off when the vaporizer is empty.
If the above are not there in a different setting, I document in the anesthesia chart that the hospital has not provided them and document end tidal sevo concentration.

You should try and keep up - Aspect sold out to Covidien several years ago.

 

[BobBarker]

And covidien sold to medtronic, right?

 

[pgg]

Very busy private practice where you move from room to room and do cases. Most of my patients except elderly get versed. Don't we have enough to worry about as anesthesiologists? BTW, when your patient reports awareness in the or it's your word against the patients. I don't take chances. The bis is monitored and recorded.

I could not possibly disagree more completely.


I'm a Bis disliker, but not a hater. It has its place, and I'll use it very rarely, for higher risk cases. I can even point to one occasion where it may have saved my ass and my patient some suffering. I was doing a c-spine case with MEPs/SSEPs and the surgeon and neuromonitoring flunkie insisted on no volatile. None at all. This was a place where I locum very occasionally so I didn't feel motivated to invest the time to argue with them, so I just went ahead with the pure propofol TIVA they asked for. I did slip a little ketamine in when they weren't looking. Some fentanyl, too. Anyway, I put the Bis on, set the propofol to a reasonable rate and saw a Bis in the upper 30s to low 40s and commenced trying to stay awake myself. A few hours into the case, the number started climbing out of the 50s. I bolused some propofol and it went back down, for a while, then started climbing again. Checked the IV line and found that the scrub tech had leaned up against the patient and partly unscrewed the stopcock so the propofol was going into the sheets. It seems my bolus had gone in fast enough that some had made past the leak into the patient, but the slow infusion was leaking out. Without the Bis I probably wouldn't have picked up on the leaking IV until the patient's HR/BP went up substantially, or she was light enough to start moving. By then she may have had genuine recall.

That said, this notion of giving Versed to everyone (as if you need it or can count on it) and using the Bis on everyone (as if you need it or can count on it) is bunk.

BTW, when your patient reports awareness in the or it's your word against the patients.

Well, that and your record of ~0.7+ MAC of exhaled volatile anesthetic, and your adherence to the standard of care, which absolutely doesn't include the Bis. Or Versed.

 

[deleted682700]

Do you practice this defensively in all aspects of your anesthetics? It must be exhausting. The ridiculousness of this way of practicing should be evident in the fact that most posters actually thought you were being facetious.
I honestly believe none of the measures you take are actually decreasing anyone's risk of awareness anyway. Just wasting money (bis/des for every patient) and time (versed).

Really? Otherwise you will be sold down the river by your lawyer.
If you don't practice and try to make more money for your hospital CEO at your risk that's your choice too. It's not wasting money. One of my attendings used to tell me that you treat everyone as the adversary and I used to wonder if he was cynical. But having done this for fifteen years, I totally concur with that attending.

 

[Noyac]

Inquisitiveanes, I must agree with everyone else here that your practice of giving everyone versed etc is a bit overkill. It reminds me of the crnas I used to supervise. They gave everyone versed and zofran. And I mean everyone. If they saw a pt for a pre-op consult I'm sure they would have still given versed and zofran.

Maybe your practice works for you but that is cookie cutter crna bullsh*t to me.

 

[Hoya11]

why is everyone hating on versed? I agree about BIS and rarely use it. But people are anxious before surgery, should they not get anxiolysis with 2 of versed? I give it to nearly everyone also, less or none in elderly. no? You certainly dont need it to ensure no awareness, but I do give it a lot and have had it myself and it is a good drug in combination with the other usuals.

 

[Arch Guillotti]

May be another publicity stunt by aspect technology.
Don't worry in my practice every one gets versed. Everyone gets the bis monitor and the reading is less than 50.
And I made sure the hospital administrator got desflurane vaporizer, so that the audible alarm goes off when the vaporizer is empty.
If the above are not there in a different setting, I document in the anesthesia chart that the hospital has not provided them and document end tidal sevo concentration.

I think the BIS is useful in only a very small amount of cases although others would disagree with me. The nurses love it.

If you can't pay attention to how full the vaporizer is and you need an alarm to tell you when it's empty, I think you have some problems.

True awareness is incredibly rare. I know second-hand of a few cases though and each one was due to a major screw-up that nothing you have described would have prevented.

 

[deleted682700]

Let's not get the crna discussion here. Whether they do cookie cutter medicine? Whether that is relevant? In fact I know some crnas who are better than anesthesiologists. It sure hurts us to acknowledge.

Probably ur patient population does not do meth, cocaine cannabis. One in 4 in my population have urine positive for multiple agents. They clearly tell me that they want to be asleep and give me history of feeling pain during surgery. Balanced anesthesia with multiple agents helps me to take care of my sicker patients with less cardiopulmonary reserve.

 

[deleted682700]

May be the guys who are riled up about Bis usage are the ones who feel threatened about their anesthesia judgement? I don't get anything from Bis company. However I do see advantage of using it to tailor my anesthetic to each individual.
When patients ask me about intraop awareness, I specifically tell them that I will use the bis monitor in addition to using all my anethetic skills.
It's not my ego. It's all about patient care.

 

[dhb]

"Very busy private practice" with one in four users? I don't envy you

 

[pgg]

I don't give most of my patients Versed because I find that after 3 minutes of even half-ass-efforted, confident, compassionate discussion with them and explanation of what's coming, most normal adults just aren't so anxious that they need to be medicated. Most are nervous about surgery, sure. But SO WHAT if they remember the gurney ride to the OR? That's not traumatic for a normal adult. They don't have separation anxiety from the person who drove them to the hospital.

For kids, I favor pre-meds well in advance of separation from their parents. Versed is great for them.

For sedation cases I use it most of the time. I just don't see the point for general anesthetics, most of the time.

Some adults are anxious and I give them Versed. It's a fine drug when there's an indication for it. I just don't think "surgery" is an absolute indication for Versed. For short cases, even 2 mg of it has a synergistic effect and wake ups are slower.

Every day I see people push 2 mg of midaz in the IV like robots as they leave the holding area. Maybe it hits before they reach the OR, maybe not. 5 minutes later they're under GA. They give it too late to be of real benefit, and they give it to patients who don't need it, and it makes me grind my teeth.


Have you ever added up the cost of putting a Bis monitor on every single patient? Those proprietary strips aren't cheap. The medium sized joint I work at now does about 10,000 general anesthetics per year, do the math.

 

[chfo]

Don't give versed. Quicker wakeups. Less dis-inhibition.

You think your 2mg of versed is going to make a difference 4 hours into a belly case? You have to re-dose it throughout the case if you expect decent amnesia just from versed.

Have fun redosing it throughout the case, and have one hard time waking them up.

 

[Spinach Dip]

We have an EMR tickler that reminds us when the vaporizer is low, but seriously, if you can't keep an eye on that, what exactly are you monitoring?

Sudoku?

 

[nap$ter]

I could not possibly disagree more completely.


I'm a Bis disliker, but not a hater. It has its place, and I'll use it very rarely, for higher risk cases. I can even point to one occasion where it may have saved my ass and my patient some suffering. I was doing a c-spine case with MEPs/SSEPs and the surgeon and neuromonitoring flunkie insisted on no volatile. None at all. This was a place where I locum very occasionally so I didn't feel motivated to invest the time to argue with them, so I just went ahead with the pure propofol TIVA they asked for. I did slip a little ketamine in when they weren't looking. Some fentanyl, too. Anyway, I put the Bis on, set the propofol to a reasonable rate and saw a Bis in the upper 30s to low 40s and commenced trying to stay awake myself. A few hours into the case, the number started climbing out of the 50s. I bolused some propofol and it went back down, for a while, then started climbing again. Checked the IV line and found that the scrub tech had leaned up against the patient and partly unscrewed the stopcock so the propofol was going into the sheets. It seems my bolus had gone in fast enough that some had made past the leak into the patient, but the slow infusion was leaking out. Without the Bis I probably wouldn't have picked up on the leaking IV until the patient's HR/BP went up substantially, or she was light enough to start moving. By then she may have had genuine recall.

That said, this notion of giving Versed to everyone (as if you need it or can count on it) and using the Bis on everyone (as if you need it or can count on it) is bunk.



Well, that and your record of ~0.7+ MAC of exhaled volatile anesthetic, and your adherence to the standard of care, which absolutely doesn't include the Bis. Or Versed.

i've met some scrub techs with some pretty talented groins, but never one that could unscrew a stopcock with intraop gyrations.

i would argue your scrub tech had nothing to do with your leak - your stopcock was loose and your bolus/pressure created a leak.

i would also argue that the BIS did nothing for you you can't do for yourself.

if your IV line leaked/came disconnected/IV infiltrates during a tiva - prior to recall, a few things would happen: the rate of dripping of your IV line would change, the neuromonitoring guy might tell you the pt looks light, she would start to breath, HR and/or BP would go up, she would move. there is more than enough time between all of this happening and actual recall occurring for you to turn on a little volatile and troubleshoot your tiva.

the BIS is not reliable - there is no evidence that it prevents recall.

ever talked to a cardioversion pt about their first memory after their jolt? it is amazing how long a little bolus of propofol makes one amnestic - even after breathing/moving/talking resumes.