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LETTER TO THE EDITOR

Informed Awareness: Is It Ethical?

Department of Anaesthesia, sanjib{at}cmcvellore.ac.in(Das) Department of Neurological Sciences, Christian Medical College and Hospital, Vellore, Tamilnadu, India(Babu)

To the Editor:

We would like to commend Professor White for bringing up the ethical issue in his Letter to the Editor (1). For unknown reasons the Bispectral Index (BIS) monitor (Aspect Medical Systems, Newton, MA) is used more commonly than other monitors to prevent intraoperative awareness as a depth of anesthesia monitor. It is almost now confirmed that BIS declines during administration of neuromuscular blocking agents (2,3), so there is definitely a possibility of awareness in totally or partially paralyzed patients if improperly anesthetized. There have been number of neurosurgical studies, particularly with reference to motor evoked potential monitoring (4,5), where BIS has been used to monitor awareness or depth of anesthesia. In those cases even with the authors precautions to prevent awareness it cannot be excluded completely because of compromised drug usage or technique requirements. On the other hand there are some neurosurgical procedures that are routinely performed under conscious sedation (e.g., awake craniotomy). Those patients give consent to be aware during the surgical procedure, as it is required during the surgical interventions to identify/monitor areas involving language or speech (6). We feel that in such cases intraoperative awareness is a necessity and acceptable in absence of any other noxious stimulus such as pain. In such cases the team involved in care of the patients should be made aware of the seriousness of the situation and take necessary steps to prevent any unwanted activities like making unnecessary sounds or irrelevant talk. If the patient gives informed consent for the readiness of being aware during such procedures then will it be ethically accepted? Or, do we have to develop new ethical guidelines and regulating process for at least for these special situations. Where do we stand ethically in these conditions?

References

1. White PF. Awake and paralyzed: was it really necessary? Anesth Analg 2005;101:297.[Free Full Text]
2. Seubert CN, Mahla ME. Bispectral index decline caused by neuromuscular blockade. Anesth Analg 2004;98:871.[Free Full Text]
3. Messner M, Beese U, Romstock J, et al. The bispectral index declines during neuromuscular block in fully awake persons. Anesth Analg 2003;97:488–91.[Abstract/Free Full Text]
4. Scheufler KM, Reinacher PC, Blumrich W, et al. The modifying effects of stimulation pattern and propofol plasma concentration on motor-evoked potentials. Anesth Analg 2005;100:440–7.[Abstract/Free Full Text]
5. van Dongen EP, ter Beek HT, Schepens MA, et al. Within patient variability of lower extremity muscle responses to transcranial electrical stimulation with pulse trains in aortic surgery. Clin Neurophysiol 1999;110:1144–8.[Medline]
6. Sarang A, Dinsmore J. Anaesthesia for awake craniotomy: evolution of a technique that facilitates awake neurological testing. Br J Anaesth 2003;90:161–5.[Abstract/Free Full Text]

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