Frequency of awareness

gaspassah · Jan 19, 2005

b blockers will blunt the sympathetic response that usually indicates pain or light anesthesia,

emergent c section, the patient is brought into the OR and the md stands there as the pt is prepped and anesthesia is getting ready to put the pt to sleep, as soon as there is verified tube placement the md cuts, they usually stand there with then knife waiting for the tube to go in. just the lack of anesthesia depth at the begining can lead to recall.

trauma, sometimes the pt is so unstable their hemodynamic system cannot handle even the lightest anesthesia and some practioners will or can only use something like scopalamine as an anesthetic agent.

i'm not aware of any policy where i am currently training.

i havent used the bis yet, but some ppl like it some dont.

d

jwk · Jan 19, 2005

b blockers will blunt the sympathetic response that usually indicates pain or light anesthesia,
emergent c section, the patient is brought into the OR and the md stands there as the pt is prepped and anesthesia is getting ready to put the pt to sleep, as soon as there is verified tube placement the md cuts, they usually stand there with then knife waiting for the tube to go in. just the lack of anesthesia depth at the begining can lead to recall.
trauma, sometimes the pt is so unstable their hemodynamic system cannot handle even the lightest anesthesia and some practioners will or can only use something like scopalamine as an anesthetic agent.
i'm not aware of any policy where i am currently training.
i havent used the bis yet, but some ppl like it some dont.
d

If you're not aware of the policy, you will be shortly. JCAHO, in it's infinite wisdom, sent out a "sentinel alert" a few months ago regarding the "crisis" in awareness in anesthesia. No such crisis truly exists, outside of a few highly publicized cases that the media and a couple of equipment manufacturers just love. Many cases of "awareness" occur in patients receiving regional anesthetics or monitored anesthesia care (MAC) with sedation. Others occur in patients who are awakening from anesthesia at the completion of their procedure and are still disoriented as the dressings are being applied. There are a few emergency C-Sections and trauma cases where this can be a problem, although it is explainable in light of the risks involved. There are VERY VERY VERY FEW cases of true awareness under anesthesia, and while traumatic for a patient, don't warrant the millions upon millions of healthcare dollars that will be spent on this "Problem".

JCAHO is REQUIRING all hospitals and anesthesia departments to develop a policy and protocol to deal with the potential problem of awareness in anesthesia. One can't help but wonder where certain equipment manufacturer's are spending their promotional budgets.

lifeLONGstudent · Jan 19, 2005

jwk - I agree with you. I think this issue is receiveing an incredible amount of attention (considering it happens 0.1% of cases). That is why I was wondering how many of you have had personal experience with patients who claimed that they experienced "awareness". .. or it could even be that someone that you practice with had a case where the patient experienced awareness.

jwk · Jan 19, 2005

jwk - I agree with you. I think this issue is receiveing an incredible amount of attention (considering it happens 0.1% of cases). That is why I was wondering how many of you have had personal experience with patients who claimed that they experienced "awareness". .. or it could even be that someone that you practice with had a case where the patient experienced awareness.

It doesn't even happen that often. At 38,000 procedures a year at my hospital, that means I should see 38 cases a year, or about 3-4 a month. It simply doesn't happen.

A letter to the editor in an anesthesiologist publication basically said what a lot of us believe - if Dr. X (big proponent of BIS) has 0.1-0.2% of his patients having awareness under anesthesia, perhaps he should learn a new technique.

Pete495 · Jan 20, 2005

Hey JCAHO's just doing its job, just like all the other petty things they pick on when they come to your hospital. It's not entirely recent, but our hospital is just now making everyone sign off their prn insulin doses to patients who need sub-q insulin coverage. So in other words, as a seasoned critical care nurse, I can hang a dopamine drip by myself, but I can't give four units of insulin with out having somebody check to make sure I did it right. I know others have screwed up with insulin, but can't there be some leniency for those who know what the hell they are doing? Also irritating is JCAHO's inclusion of innappropriate abbreviations. I can write NITRO, but not NTG. Another instance is patient FALLS. Every admitted person in our hospital now gets fall teaching, no matter who they are, which is of course the nurses job also. yeah, i'll make sure I do my fall teaching before I check my insulin dosage with another nurse, and defintely before I hang that dopamine drip.

Many hospitals have gone away from certification by JCAHO due to the high cost of maintaining the certification. I wish my hospital would do this as well due to all the crap that they have come up with. Others will disagree, and I admit they have certainly refined the health care system, don't get me wrong, but lately it seems they've been an obstruction to health care rather than a protector.

jwk · Jan 20, 2005

It's a shame that JCAHO has, IMHO, become an organization that exists simply to keep existing. I fully realize there need to be standards in all professions, but JCAHO has gone so far overboard in so many areas as to render itself a joke. It's amazing how clean our hospital is when JCAHO shows up - floors are shiny, no equipment in the halls (see all those storage trailers in the back parking lot?), everyone on their best behavior, etc.

The new standards about awareness in anesthesia are a classic example. Millions of healthcare dollars that could be be better spent on true patient care end up going to unnecessary technology, unnecessary personnel, and a whole subset of the healthcare industry consisting of "consultants" and "mock surveyors", who, of course, cost even more money.

BigDave · Jan 20, 2005

It's amazing how the Discovery Channel show (obviously playing into the hand of Aspect Medical) immediately preceded the JCAHO alert.

I had obvious awareness (can remember exact words) during a surgery...it was no big deal. I'm not going to try to sue someone over it...but that is the way our country goes isn't?

jwk · Jan 20, 2005

It's amazing how the Discovery Channel show (obviously playing into the hand of Aspect Medical) immediately preceded the JCAHO alert.
I had obvious awareness (can remember exact words) during a surgery...it was no big deal. I'm not going to try to sue someone over it...but that is the way our country goes isn't?

Actually that particular show has been broadcast numerous times.

gaspassah · Jan 20, 2005

if you listen carefully the next time it is on, you will hear the author state that the reason she had recall was because her vaporizer was empty, this was mentioned while she was discussing her own case. empty vaporizer? duh recall.

now my question is

for those of you out their practicing or in school, do you treat initial increases in bp and hr as pain or light anesthesia then begin evaluating other causes? the reason i ask is.

did her practitioner thinking the vaper was empty give more narcs and not seeing a significant improvement start with beta blockers?

i usually will use beta blockers only when getting to the time tourniquet pain starts or insuflation is increasing svr too much. after i have tried to determine that the changes are not due to pain.

d

yoga crna · Jan 20, 2005

In nearly 45 years of practice I have never had a patient complain of awareness while under general anesthesia. I think it is becoming an issue for two reasons, the press is interested in medical errors and it makes for good TV and the most important reason is because the companies that make the BIS monitors are saying that if their monitors were used, the patients would not have had recall. As the saying goes, "follow the money". I don't use a BIS monitor and hope they don't become required by some agency with limited knowledge or being wined and dined by the corporation that sells BIS monitors.

If you watch your patient carefully, constantly monitor everything, including the anesthesia vaporizer, you will find it to be a very rare problem and not worth the money for a questionable monitor.

Some of you may not agree, but I ask that you keep an open mind.

Yoga

So

jwk · Jan 20, 2005

In nearly 45 years of practice I have never had a patient complain of awareness while under general anesthesia. I think it is becoming an issue for two reasons, the press is interested in medical errors and it makes for good TV and the most important reason is because the companies that make the BIS monitors are saying that if their monitors were used, the patients would not have had recall. As the saying goes, "follow the money". I don't use a BIS monitor and hope they don't become required by some agency with limited knowledge or being wined and dined by the corporation that sells BIS monitors.
If you watch your patient carefully, constantly monitor everything, including the anesthesia vaporizer, you will find it to be a very rare problem and not worth the money for a questionable monitor.
Some of you may not agree, but I ask that you keep an open mind.
Yoga
So

I agree with you 100%.

Will there still be awareness? Sure. Trauma cases and those pesky little stat C-Sections where the baby and/or mom are crashing. Virtually every other case of awareness, including the few highly publicized ones, are due either to negligence (empty vaporizer - certainly preventable with proper vigilance) or diversion of drugs from the patient to the anesthesia provider (could still be unfortunate but uncorrectable problem).