It Knows When You're Awake

The leading device that measures brain waves to detect whether a patient is adequately anesthetized is easy to use, costs about $9,000 and has been shown to reduce the risk of waking up in surgery by about 80 percent.

Although BIS monitors have been installed in the operating rooms of 34 percent of the nation's hospitals -- and 78 percent of teaching hospitals -- they are used in only about 10 percent of operations, according to manufacturer Aspect Medical Systems of Newton, Mass.

Locally Georgetown University Hospital and Washington Hospital Center own BIS monitors. Officials say they are used sporadically, at the discretion of individual anesthesiologists. Inova Fairfax Hospital officials say the BIS monitor and another brain wave device have been installed in operating rooms, where they are being tested.

The monitor calculates the depth of sedation from 0 to 100, using data from an electrode attached to a patient's forehead. A reading of zero signifies no brain activity, while 100 is wide awake; the recommended range for general anesthesia is between 40 and 60.

Anesthesiologist Mohamed M. Ghoneim, an expert on anesthesia awareness who is a professor at the University of Iowa, said he uses a BIS monitor in all his cases. In Ghoneim's view, apathy is the reason many anesthesiologists and nurse anesthetists do not use the devices.

Others attribute the resistance to a feud between Aspect and leaders of the American Society of Anesthesiologists (ASA) over the company's past marketing practices.

"Aspect angered a lot of people by very aggressively marketing this device," said one medical expert who requested anonymity, saying he didn't want to further inflame the situation. "Doctors felt coerced . . . So basically it's a battle between two intransigent groups -- with patients in the middle."

The enmity dates back to 2000, when the Wall Street Journal published a story quoting an Iowa anesthesiologist who said he had been warned by an Aspect sales representative that he risked a malpractice suit if he failed to use the device. Since then, ASA and Aspect officials have traded barbed letters about the issue of intraoperative awareness and monitoring, several of which the ASA has posted on its Web site.

"I object to the implication that we're trying to scare patients, [because] we haven't done that," said Paul Manberg, vice president of clinical and regulatory affairs at Aspect. "It's not a value to us to alienate the professional society."

ASA president Roger W. Litwiller said he rarely uses a BIS monitor because of uncertainties about its accuracy. Instead, he said, he monitors vital signs for changes that might indicate consciousness.

"A significant number of anesthesiologists are not ready to buy that technology," Litwiller said. "If you get a high reading, do you treat the machine or the patient?"

Robert A. Wise, vice president of regulatory affairs for the Joint Commission on the Accreditation of Healthcare Organizations, said he is puzzled by Litwiller's objection. "There are a lot of things that aren't 100 percent reliable," he said. "No blood test is. If the number [on the monitor] is in a certain range, you look closer."

Aspect's Manberg agreed. "We say in all our literature you don't use the BIS monitor in isolation," he said.

Tom McKibban, immediate past president of the American Association of Nurse Anesthetists, said he uses the device routinely.

Even though false readings sometimes occur, McKibban said, he has found he uses less anesthesia and believes the machine provides an additional safeguard for patients.

"If I have a vaporizer failure I don't catch," said McKibban, referring to the machine that delivers anesthetic gas, "the monitor does."

-- Sandra G. Boodman