Should brain function monitoring be standard during general anesthesia?(PRO & CON)

YES

Anesthesia has become an incredibly safe specialty as we in the anesthesia community have successfully overcome many complex patient safety issues. We are now in a position to take on the rare but serious issue of intraoperative awareness.

Repeated large-scale surveys in Europe, Australia, and the United States have shown that awareness during surgery occurs in about 1-2/1,000 general anesthesia patients and in as many as 1 in 100 open-heart and trauma patients. It is uncommon, but it does occur.

Standard high-quality anesthesia care can minimize the risk, but additional new technologies, such as bispectral index monitoring, can measure the depth of anesthesia and assist in appropriate anesthesia titration. No new technology is perfect, and some of these brain function monitors have been reported to malfunction in some circumstances, but over the last 5-10 years, the technology has improved by leaps and bounds.

I was involved in a recent prospective, randomized, double-blind, multicenter trial of bispectral index monitoring and found that the technology reduced the risk of awareness in at-risk adult surgical patients undergoing relaxant general anesthesia by 82% (Lancet 2004;363:1757-63). This is high-level evidence that is also supported by many nonrandomized studies.

Some critics charge that brain function monitoring is simplistic, that the monitors are inaccurate, and the anesthesiologist can do a better job on his or her own. These are valid concerns; however, brain function monitoring is a tool that, overall, offers a highly effective solution to a real and frightening safety issue for patients.

Use of brain monitoring in anesthesia varies markedly around the world, with some institutions embracing it and others rejecting it entirely. I believe the best patient care calls for a consistent approach and brain function monitoring should be included as a standard of care during general anesthesia, especially for those at risk of awareness: patients undergoing open heart surgery or who have poor heart function, trauma patients, women who require general anesthesia for a cesarean section, patients on some long-term drug therapies, and patients who have had a previous experience of awareness during surgery.