Anaesthetic Awareness

Dr Alan Hope
Consultant Anaesthetist

Original events 1990

Preventing awareness (1-2 / 1000)

Recognise high risk groups
Clinical signs (hr,bp,sweating,pupils)
(resps,movement)
Isolated forearm
IV pharmacokinetic modelling
Monitors
ET Agent (MAC), (physical)
EEG:
stimulated (evoked potentials)
unstimulated.

Hans Berger, 1929

Elektrenkephalogramm
sleep, anaesthesia, & epilepsy

EEG information appeared to fall within

four frequency ranges which were
named:
Beta
Alpha
Theta
Delta

14-30hz <20microV
8-13
20-50
4-7
20-50
1-4
>50

Awake

Anaesthetised

But ...
N2O alpha + theta + beta
Hal low dose: beta + higher doses: delta +
Enf low dose: alpha + moderate doses: spikes
Iso EEG silence at 2 MAC (only volatile agent to do this)
Fentanyl delta +
Diazepam beta +
Hypotension theta -, delta
Hypocarbia delta +
Hypoxia mild: beta +, moderate: delta +
EEG often dissociated from clinically obvious level of
consciousness
Seed sown, however ...

1. Montage?

2. A display that anaesthetists could readily interpret

The Neurotrac
Print-output from an early EEG
depth of anaesthesia monitor.

CSA
DSA
SEF +/- adjustment for burst-suppression
BIS (Aspect Medical Systems)
a dimensionless integer value from 0 to 100
Other modern EEG monitors have followed this
convention.

Interference:
Frontalis EMG, movement, ECG (millivolt signal),
mains spikes, ocular and glosso-kinetic electrical
artifacts.

EEG slowing a shift to lower

frequencies.
Burst suppression increasing periods of
very low amplitude.
Isoelectric (total burst suppression).

BIS added bicoherence, and the algorithm

was fine-tuned with multivariate analysis
against a large clinical database.
Three large trials concluded that routine BIS
use was associated with an 80%
reduction in awareness.

Entropy rates the new kid on the block.

Chaos theory, and non-linear dynamics ...
... the underlying maths for most of these is
firmly in the province of the specialised
mathematician.
All correlate well with BIS without requiring
statistical tuning. They seamlessly cope
with burst suppression.
An EEG entropy depth-of-anaesthesia
monitor is now available (Datex-Ohmeda).

Entropy Rates Estimation

Hope & Rosipal
2001

Entropy Rates Estimation

Hope & Rosipal
2001
Coarse-grained Entropy
Estimation.
The transition between
moderate and light
TCI propofol
anaesthesia

So is everybody using these then? ...

2003, a study showed that the BIS
consistently fell to anaesthetic levels during neuromuscular block in awake
volunteers.
Hmmm ...
EMG interference unsurmountable?

Pollard et al, Intra-operative awareness in a

regional medical system, a review of 3 years
data. Anesthesiology 2007;106:269274

A large multi-centre study involving 87,361

patients between 2002-4. Brain monitors
were not used.
6 cases of awareness (124)
1:14,560 awareness,
1:42,000 outside the 3 recognised risk groups.

95% of awareness are due to human error,

faulty anaesthetic technique, or apparatus
failure. 2.5% no cause identified. 2.5%
spurious.

Anaesthetic machine checking

Litigation awareness
Routine monitoring and charting
Risky features designed out of equipment
ET Agent now essential in every volatile GA

Ariel Garten Quintist