Processing pain and the awareness of consciousness are functions of the highest part of the brain; i.e. above the eyebrows (cerebral cortex). Moderate to deep sedation is achieved with BIS between 60 and 75. General anesthesia is achieved with BIS between 40 to 60. Less than 40 is considered over medicated. With the number generated from a patient’s forehead neither too much, nor too little, only just the right (or Goldilocks) amount of anesthesia should be given during major surgery.
Since 2000, it has been known anesthesia given with the BIS reduces drug use by 30% (1). This finding has not been enthusiastically received by the companies that make anesthesia drugs; i.e. Big Pharma. Drug makers are 4 of the 8 major corporate sponsors listed at the bottom of the ASA’s website (www.asahq.org). Big Pharma financial support is totally opaque, not transparent, to the general public. In 2009, a major study showed that 14M of the 40M American patients anesthetized every year wake up with ‘brain fog’ or postoperative cognitive dysfunction (POCD). (2)
There is an obvious conflict of interest between the ASA’s organizational needs, patients, and Big Pharma’s financial support. Patients need to know why the best available technology to avoid too much medication is not routinely used for major surgery under anesthesia. Preferably before lying on the OR gurney, patients need to insist their anesthesiologist use a brain monitor. Brain monitoring as a standard of care may not eliminate all causes of ‘brain fog.’ However, not until all patients receive brain monitoring will the role of over medication without a brain monitor be eliminated. (3)
When the ASA members are asked if too much anesthesia is why ‘granny’ isn’t mentally the same after her surgery, the standard organization explanation is, “No, we just uncovered a previously undiagnosed, underlying condition.” Contrasted against 14M patients every year with postoperative ‘brain fog,’ the ASA ‘explanation’ flies in the face of common sense, says board-certified anesthesiologist, Dr. Barry Friedberg.
While most hospitals and surgery centers have the BIS brain monitor, too often, it is not used, mainly because patients do not know the potentially avoidable dangers of ‘going under’ for major surgery without a brain monitor. Helping patients advocate for the use of a brain monitor is the only goal of the nonprofit, 501c3, Goldilocks Anesthesia Foundation. Written by Dr. Friedberg, this patient information book, ‘Getting Over Going Under,’ is a free, no obligation download is available from the foundation web site (www.goldilocksfoundation.org).
Prospective patients and their families need to have this information (and share it with friends and social media contacts) to create a similar force for change that got fathers in delivery rooms… public knowledge and demand. On free-standing BIS units only, anesthesiologists also need to know to trend real time frontalis muscle electromyogram (EMG) secondary to the BIS to make the device extremely responsive and, therefore, useful to them as well.
Disclaimer: Neither Dr. Friedberg, nor the foundation, receive BIS maker financial support.
- Friedberg BL, Sigl JC: Clonidine premedication decreases propofol consumption during bispectral (BIS) index monitored propofol ketamine technique for office-based surgery. Dermatologic Surgery 2000;26:848-852.
- Li G, Warner M, Lang BH, et al: Epidemiology of Anesthesia-related Mortality in the United States, 1999–2005.Anesthesiology2009;110:759-65.
- 3. Friedberg BL: The tree, the forest and standard of care. British Journal of Anaesthesia Sep 28, 2015; 115:i114-i121.