Your patients’ worst nightmare, and yours: Awareness despite anesthesia
Device allows 17% to 19% faster discharge, providers say
This summer, a jury awarded a Virginia woman $150,000 after she woke up during surgery and had to endure the 45-minute procedure while paralyzed but able to feel all the sensations of having her ovaries removed. The anesthesiologist acknowledged that, unbeknownst to him, the anesthetic being administered to the patient ran out during the procedure.
And earlier this year, People magazine featured a story on Jeanette Tracy, who woke up during a hernia repair. Tracy since has formed a group called Awareness with Anesthesia Research Education, a one-woman help line based in her home in Alexandria, VA.
Patients who have experienced sensations during surgery say it is a horrific experience. Clinicians have given it the term "patient awareness." And same-day surgery managers, those who recognize the legal and public relations implications, label it a disaster.
While providers might be tempted to overmedicate patients in order to avoid any potential problem of awareness, same-day surgery programs also face pressures to discharge patients more quickly. So how do you deal with this dilemma? A new monitor — the first of its type — is now available to measure the effects of anesthesia on consciousness. The Bispectral Index or BIS (pronounced "biz") monitor caused a stir at the October meeting of the American Society of Anesthesiologists, where 35 abstracts and multiple presentations highlighted the device. BIS is manufactured by Aspect Medical Systems in Natick, MA. (See contact information, p. 151.)
The BIS works in this way: A sensor is attached to the patient’s forehead, and a monitor provides a reading between zero and 100.
"Essentially, it’s an EEG machine that monitors brain waves," says Maureen Witte, CRNA, staff nurse anesthetist at Presbyterian Hospital in Philadelphia. "At 100, you’re completely awake, and at zero, you have total EEG suppression," Witte says.
Providers are instructed to keep patients around the 40 level, which should be an indi cation they’re asleep and unaware, she says. "Maybe we can avoid some lawsuits related to awareness if we keep our patients asleep enough."
Using the BIS monitor prevents providers from overdosing hypnotics or analgesics, she maintains, and other providers concur.
The BIS monitor allows about 30% less anesthetic to be administered, says Nand Varyani, MD, medical director of The Surgery Centers, based in Middleburg Heights, OH.
Surgery programs that use the BIS monitor tell Same-Day Surgery their patients are being discharged 17% to 19% faster. And some of those patients are able to bypass phase I recovery.
"Anesthesiologists need to know that if they want to be efficient, this is useful for reducing anesthesia cost: one, by saving anesthetics, and two, by quicker discharge time," Varyani explains.
At The Surgery Centers, about 35% of patients are bypassing phase I recovery, compared with 22% of patients who bypassed phase I before the BIS monitor was used. (For additional information on bypassing phase I recovery, see SDS, January 1998, p. 5.)
44% of patients skip phase I
At Massachusetts General Hospital in Boston, patients are being discharged 17% quicker since the BIS monitor was added, and 44% of patients are bypassing phase I, compared with 23% of patients before the BIS monitor, says James Mayfield, MD, associate director of the same-day care unit.
"I don’t consider it an awareness monitor. [Patient awareness] is so rare, we hardly we see it," Mayfield says. " I consider it an efficiency monitor."
He can titrate medication to meet specific needs of patients, Mayfield says. "Patients wake up quicker and more satisfied and get out of the hospital quicker," he says. "Patients like that. We’ve been calling patients after they’re bypassed the next day, and we’ve had very positive response. We haven’t had anyone have to revert to phase I PACU [postanesthesia care unit]."
Is there a downside to using the BIS monitor? "Just the cost," Varyani reports, which is $9,000 for each monitor and $15 for each disposable sensor.
While the efficiency benefits of the BIS monitor may get managers’ attention, it’s the problems with patient awareness they’re most anxious to avoid. Each year in the United States, an estimated 40,000 to 200,000 patients experience some degree of intraoperative awareness.1,2
Awareness is more likely with:
• patients who are chronic users of alcohol, tranquilizers, sedatives, or narcotics;
• obese patients who may have an altered drug response because of excessive weight or due to intubation difficulties that can result in delay between induction and the time of administration of maintenance agents;
• patients who have high metabolic rates;
• pediatric patients;
• obstetric patients;
• trauma patients.3
While patient awareness has always existed, recent publicity of cases has captured providers’ attention, Witte says. She is serving on the American Association of Nurse Anesthetists’ Council for Public Interest in Anesthesia. This group is educating providers and patients about the possibility of awareness during anesthesia.
Also serving on the board is Kay Ball, RN, MSA, CNOR, FAAN, perioperative consultant/ educator with K and D Medical in Lewis Center, OH, and part-time consultant with Steris Corp. in Mentor, OH. "We’re trying not to scare people but make them aware this possibly could happen," Ball says.
Some tips to follow
To avoid problems with patient awareness, Ball and Witte suggest the following tips:
• Before surgery, tell patients about the risk of awareness. As part of the informed consent procedure, tell them that if awareness occurs, the staff will work to manage and control the problem appropriately, Ball says.
• Check the level of the inhalation agent you’re using in the vaporizer to make sure it’s adequate, Witte suggests. "If you have a multi-gas monitor, that will usually tell you the percentage of the agent that the patient is getting."
• Use Versad and similar medication that offer an amnesia-like effect, Witte says. "Using it as a premedication may help you to avoid awareness."
• In the operating room, maintain a level of quiet that’s respectful and conscious of the fact that patients might be able to hear you, Witte advises. In other words, keep it professional.
• If awareness is detected, stroke the patient’s face lightly and offer reassurance, Ball suggests. At that point, more anesthetic agents can be administered.
• If you suspect a patient experienced awareness, educate the patient, Ball suggests. Such patients might have difficulty trying to remember what they experienced, she says. Reassure them that it’s OK to ask questions. Consider referring them to an anesthesia provider, as well as a psychologist or social worker, she advises.
References
1. McLeskey CH, Aitkenhead AR. Prevention of awareness. American Society of Anesthesiologists Newsletter 1994; 58:16-21.
2. Liu WHD et al. Incidence of awareness with recall during general anaethesia. Anaesthesia 1991; 46:435-437.
3. Bennett HL. Awareness and learning in anesthesia. Anesthesia Today 1991; 3:13.
Sources
For more information on the BIS monitor, contact:
• Aspect Medical Systems, 2 Vision Drive, Natick, MA 01760. Telephone: (508) 653-0603. Fax: (508) 653-6788. World Wide Web: www.aspectms.com.
For more information on patient awareness and the BIS monitor, contact:
• Kay Ball, RN, MSA, CNOR, 6743 S. Old State Road, Lewis Center, OH 43035-9227. Telephone: (800) 989-7575 Ext. 21407. Fax: (740) 548-6894. E-mail: [email protected].
• James Mayfield, MD, Department of Anesthesia and Critical Care, Massachusetts General Hospital, Fruit St., Boston, MA 02114. Telephone: (617) 726-8590. Fax: (617) 724-0305. E-mail: Mayfield@etherdome. mgh.harvard.edu.
• Nand Varyani, MD, Medical Director, The Surgery Centers, 19250 Bagley Road, Middleburg Heights, OH 44130. Telephone: (440) 826-3240. Fax: (440) 826-3250.
• Maureen Witte, CRNA, 334 Penn Road, Wynnewood, PA 19096. Telephone: (610) 896-5358. Fax: (610) 896-3728.
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