BRAIN MONITORING Dr.

Yuddi Gumara, SpAn KMN

General Anaesthesia is not an all or
nothing phenomenon!
 Reported incidence of awareness varies
and is difficult to determine

• Swedish study: 0.06%

Incidence of • American academic centres: 0.13%
Awareness
• Overall incidence: ~0.2%
• Conscious awareness with pain: 1 in
20,000 – 40,000 anaesthetics
Incidence of Awareness

• Cardiac surgery: 1 – 1.5%

• Trauma surgery: 11 – 43%

• Cesarian section: 0.4%

Causes

• Lack of complete understanding of

kinetics & dynamics of drugs

• Induction of anaesthesia:
• Coughing
• difficult intubation
Causes / Associations

Patient factors:
• Limited cardiac reserve (ASA IV & V)
• On going blood loss / hypotension
• Patients on beta blockers, Calcium channel blockers
• Drug / alcohol abusers / addicts
• Patients on regular opiates /sedative medications
Associations

• Opioid based anaesthesia / Neuroleptanaesthesia

• Regional anaesthesia & ‘Light’ GA

• Muscle relaxants

• Disconnection / empty vaporiser

• Caesarian section, Trauma, Cardiac bypass

 Stages of Awareness

Stage 1: Conscious awareness with explicit memory

Stage 2: Conscious awareness without explicit memory

Stage 3: Subconscious awareness with implicit memory

Stage 4: No awareness
Awareness with explicit memory

• Nearly always associated with neuromuscular

blocking drug use

• May or may not be associated with pain

• ‘State of awful helplessness’

• Patients can go on to develop severe unexplained

psychiatric disorder
Awareness without explicit memory

• Tunstall: 9/12 pts showed arm movements during

procedure (IFT) 4/9 appropriately – none recalled

• Russell: 61% were able to move arm to command

(given thio/dtc/nitous/oxygen) – none recalled

• Changes in BP, pulse, sweating & tears were

shown to be poor indicators of awareness
Awareness without explicit memory

• 80% of patients induced with Midazolam &

fentanyl and 70% induced with Midazolam &
Alfentanil showed hand movement

• While breathing low doses of Isoflurane (<0.4% ET)

subjects were able to comprehend and respond to
words
 Detection of Awareness

• Clinical signs
• Clinical experience
• IFT
• Lower oesophageal contractility
• Frontalis EMG
• Respiratory sinus arrhythmia
• EEG
• Raw EEG
• Processed EEG
• BiS
• AEP
The Bispectral IndexTM (BiS)
Aspect Medical Systems
The Bispectral IndexTM (BiS)
Aspect Medical Systems
The Bispectral IndexTM (BiS)
Bispectral index (BIS)
• Bispectral index (BIS) is one of several technologies used
to monitor depth of anesthesia.
• BIS monitors are used to determine depth of anesthesia.
Titrating anesthetic agents to a specific bispectral index during
general anesthesia in adults (and children over 1 year old) allows
the anesthetist to adjust the amount of anesthetic agent to the needs
of the patient, possibly resulting in a more rapid emergence from
anesthesia.
• Use of the BIS monitor could reduce the incidence of intraoperative
awareness during anaesthesia.[1] The exact details of the algorithm
used to create the BIS index have not been disclosed by the company
that developed it.
Bispectral index (BIS)
•BIS™ monitoring uses processed EEG signals
to measure sedation depth based on level of
consciousness (LOC) signals
• allows anesthesia providers to titrate
anesthesia to achieve a desired level of
consciousness (LOC).
Measurement
• The monitor calculates the data received by the two to four sensors
and displays this information as a numeric value from 0 to 100 with a
10- to 30-second delay. Each numerical range correlates to a degree
of sedation:
• 100 to 90-awake and responding appropriately to verbal stimulation
• 80 to 70-responsive to loud commands or mild shaking
• 70 to 60-intense tactile stimulation is needed for a response
• 60 to 40-unresponsive to verbal stimulus; general anesthesia obtained with
a low chance for explicit recall
• less than 40-deep hypnotic state; possible protective responses still intact
• less than 20-burst suppression (EEG pattern characterized by cycles of high-
voltage electrical movement alternating with cycles of no activity in the
brain); respiratory drive is limited, but possible protective responses still
intact
• 0-totally suppressed EEG (flat line)
Preventing Awareness
Preventing Awareness
Dealing with patients who have a history of
Awareness during Anaesthesia

• Take patient seriously

• Investigate previous anaesthetic technique &
circumstances
• Comorbidity / medications
• Reassure
• Sedative premed
• Intraop ET agent monitoring / BiS
• Postop visit
• Good Periop records
Intraoperative awareness

• Current evidence-based practice research reveals that intraoperative

awareness occurs in 1 to 2 patients per 1,000 receiving general
anesthesia. This awareness can result in the patient feeling severe
pain and experiencing long-term issues such as posttraumatic stress
disorder. Intraoperative awareness is considered a sentinel event by
The Joint Commission. BIS monitoring can prevent this occurrence by
adding another clinical test to determine the depth of anesthesia.
• Symptoms of intraoperative awareness include:
• * responding to verbal commands
• * eyelash reflex still functioning
• * 20% elevation in heart rate or BP from previous baseline
• * muscle tensing or movement
• * pupillary response.
• Awake, a 2007 film about anaesthetic
awareness

• Anaesthesia, an award-winning horror

film about anaesthesia awareness

• Return, a Korean thriller movie about

anaesthesia awareness

• In an episode of Nip/Tuck a woman

experiences anaesthesia awareness while
having surgery to repair scarring on her
face.

• Wide Awake, a Korean horror/thriller

movie was mainly about the outcomes
mentally after anaesthesia awareness.
Consequences of unintended awareness
during Anaesthesia

• Fear of Anaesthesia
• Post Traumatic Stress disorder
• Flashbacks, Anxiety, sustained emotional effects
• Anger / litigation
• Paranoia / loss of confidence / financial loss -
Anaesthesiologist
 "Awareness with
analgesia is regrettable;
awareness with pain is
unforgivable"

Thank you!