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Prevention of Intraoperative Awareness in a High-Risk Surgical Population LOGO Background Conscious awareness: the ability to remember and explicitly recall events that transpire during surgery 1846 William Morton’s Nowadays Amnesia underdosing of the anesthetic consciousness monitor administer more anesthesia general anesthesia Prevention of Intraoperative Awareness in a High-Risk Surgical Population From the Departments of Anesthesiology and Mathematics (N.L.), Washington University School of Medicine, St.Louis The Department of Anesthesiology, University of Manitoba, Winnipeg, Canada The Department of Anesthesiology, University of Chicago, Chicago The Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI End-tidal anesthetic-agent concentration BIS ？ ETAC Figure. Screening, Randomization, and Follow-up Figure. Screening, Randomization, and Follow-up www.themegaller Method <40 or >60 alarm BIS group no ETAC alarms Estimate of intraoperative awareness within 72 hours after surgery at 30 days after extubation <0.7 or >1.3 MAC alarm ETAC group conceal the BIS number Result √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ The Michigan Awareness Classification Instrument Result Result and conclusion BIS group ETAC group  7 of 2861 patients (0.24%)  2 of 2852 patients (0.07%) 19 of 2861 patients (0.66%)  8 of 2852 patients (0.28%) The superiority of the BIS protocol was not established; contrary to expectations, fewer patients in the ETAC group than in the BIS group experienced awareness. Discussion Depth-of-anesthesia monitors are controversial They perform poorly under some conditions Data on their ability to prevent awareness are conflicting Awareness occurred in 0.47% of the patients in optimal management 41% of the cases of awareness occurred when the ETAC or BIS values were in the target ranges intraoperative awareness was not entirely preventable with either monitoring method Discussion Without an unmonitored control group ETAC is not feasible when only intravenous medications ETAC Puts the focus on the dose that is administered, not on the response of the brain A poor proxy for cognitive function particularly among seniors Conclusion  Monitors are meant to supplement, not supplant, clinical decision making. It is unreasonable to expect any such monitor to unfailingly detect conscious awareness www.themegaller Thank You ! LOGO