'AWAKE' the movie highlights the need for 'Goldilocks' anesthesia

Corona del Mar, CA Tuesday, November 27, 2007

‘Awake’ the movie is a psychological thriller that tells the story of a man who suffers "anesthetic awareness" and finds himself awake and aware, but paralyzed, during heart surgery.

It has been 30 years since Robin Cook’s ‘Coma’ captured and terrified the American public’s imagination. ‘Coma’ is the gripping story of patients who check into a hospital for "minor" surgery-and never wake up again.’

“Five years after the book and movie, I still had patients extremely reluctant to have surgery in Room 8, the site of Coma’s (fictional) dastardly deeds,” says Dr. Friedberg.

In 1977, the anesthesia profession was 7 years away from technology that would have obviated the premise of Coma; i.e. inflicting the lack of oxygen to produce the vegetative state in patients so they could be harvested for organ transplants.

That monitor, the pulse oximeter, was introduced in 1984. Pulse oximetry was only recognized by the American Society of Anesthesiologists (ASA) as a ‘standard of care’ nearly a decade later.

“Primarily serving as a political organization, the ASA sometimes lags behind reasonable clinical practice. After all, why wouldn’t you want to know instantaneously if your patient had adequate oxygen in their blood?” queries Friedberg.

In 2007, ‘Awake’ the movie may, again, needlessly terrify the American public. This time the technology that would have obviated the premise of the movie has been available since 1996, when the FDA approved its use. “Again,” asks Friedberg, “why wouldn’t you want to know how asleep your patient is?”

No technology is perfect, even level of consciousness monitors. The prototype is the bispectral (BIS) index monitor. Published scientific study (2004) showed it was 82% less likely for patients to remain awake when their anesthesiologist believed they were asleep.

Why, then, have considerable numbers of anesthesia providers been reluctant to adopt BIS monitoring?

"Because measuring the brain's response to anesthetics challenges the deeply held belief system that heart rate and blood pressure are reliable guides to depth of anesthesia," opines Dr. Friedberg (N.B. Heart rate and blood pressure are unreliable guides.)

In the well-known fairy tale, Goldilocks finds the three bears’ porridge not too hot, not too cold, but just right. ‘Goldilocks’ anesthesia alludes to minimally invasive anesthesia(MIA)® wherein patients are neither over-anesthetized nor under-anesthetized.

BIS has a scale of 0-100. Awake is BIS 98-100. Recall rarely occurs at BIS below 75. MIA falls between BIS 60-75. General anesthesia (the sleep portion) falls between BIS 45-60. Overdosed is BIS less than 45.

Anesthesia below 45 is remarkably commonplace.

The consequences of overdosing may be just as sinister as under-dosing.

It is not uncommon for relatives of elderly patients to observe that, in layman's terms, they are 'not quite the same' after their anesthesia as they were before surgery. This phenomenon is formally known as postoperative cognitive dysfunction (POCD).

"Many believe POCD may also be a function of anesthetic overdose," states Friedberg.

“Given its history with pulse oximetry, the public should rely of the ASA to insist that BIS monitoring be a standard of care,” asserts Friedberg, a long time, non-ASA member.

“The greatest good that may come from ‘Awake’ the movie is the groundswell of public opinion demanding routine BIS monitoring for general anesthesia,” states Friedberg who routinely monitors his patients with BIS and believes it should be a ‘standard of care.’

Disclaimer: Dr. Friedberg is not employed by Aspect Medical Systems, makers of the BIS monitor. He is not a stockholder or a paid consultant. The opinions expressed herein are his professional opinion based on 10 years experience with BIS monitoring.

More information can be found at www.cosmeticsurgeryanesthesia.com, a patient-oriented, non-commercial web site.

Source: Cosmetic Surgery Anesthesia