emember the movie "The Perfect Storm"? It was essentially a true story and a real meteorological oddity — there was Hurricane Grace in the Atlantic, energy coming across from the Great Lakes and a frontal system in the New England area. Over time the energy from these three storms combined out in the Atlantic to form one perfect storm.

In similar fashion, four factors have converged to produce a real conundrum for anesthesiology regarding intraoperative awareness and the role of brain function (consciousness) monitoring:

1. There are at least two patients whose episodes of painful intraoperative awareness affected them to the degree that they are now passionate advocates of eliminating this problem. Their experiences have received widespread attention by the news media.

2. In the last few years, several large clinical studies on intraoperative awareness have appeared, and the number of ASA abstracts and editorial discussions dealing with this issue has significantly increased.

3. There are companies that have developed electroencephalography-based monitors that promise to assist in preventing awareness. One monitor is already being marketed for this purpose, and all of them will likely generate profits for the manufacturers.

4. There are a number of anesthesiologists who have not embraced the technology and loudly question either the value of the monitors or the way they are marketed.

This problem gained a sense of urgency when the Joint Commission on Accreditation of Healthcare Organizations jumped into the fray in October with its Sentinel Event Alert.

Many on all sides wonder, “Why doesn’t ASA do something — like write a standard?”

One point needs to be stressed. Anesthesiologists are professionals. They do not require ASA or any other entity telling them how to practice. Anesthesiologists evaluate new knowledge (hopefully much of it presented to them by ASA or its journal) and decide whether or not to incorporate new developments into their practices. As an example, ASA has not told anesthesiologists to use perioperative beta blockade to minimize ischemia, but many anesthesiologists have already adopted it into their practices. Every day each of us individually does what we believe is best for our patients without the need for mandated standards.

Thus, not suprisingly, this unusual confluence of factors about awareness has, to date, produced much more heat than light. ASA decided that one way to help patients and anesthesiologists alike was to develop a practice parameter and appointed a task force to do just that. ASA has a well-established process in developing practice parameters; the first, on the difficult airway, was published in 1993, and 12 more have been published since. In addition to this practice parameter, four others are currently being written.

When the task force was appointed, some were unhappy with ASA’s decision to exclude those who had a conflict of interest on this subject. The argument was made that those with conflicts also were those with the most knowledge of the technology. ASA, however, used what it believes to be a routine policy among standard-setting bodies by excluding those with a conflict. There will be a special effort made to include the views of the excluded experts.

Part of the usual practice parameter process is to present a draft parameter to an open forum at one or more major anesthesiology meetings in order to allow feedback from the membership. Because of the controversy surrounding awareness monitoring, the task force decided to conduct an additional open forum at the beginning of the process to get a better sense of the environment. It was held at the ASA Annual Meeting, and each of the six companies producing monitors was invited to present.

Meanwhile, in response to member requests, the Committee on Quality Management and Departmental Administration has made available a sample department policy on intraoperative awareness. This document may be found on the “Members Only” section of the ASA Web site.

It was a real eye opener for me, not so much on the issue of awareness but rather for my personal realization of the lack of attention to brain monitoring. I heard a number of profound statements that morning, and I am sorry that I cannot attribute this wisdom to the proper authors.

It was pointed out that we readily accept a particular heart rate as optimum for a given patient but give little attention to a precise level of anesthetic depth. My personal and naive view of anesthetic depth has been that as long as the patient was not aware and/or in pain and was not dead, then everything was OK. The only time I usually pay scrupulous attention to anesthetic depth is when I am very concerned with hemodynamic parameters such as myocardial oxygen demand or contractility. We readily accept the premise that there is an optimum heart rate for an anesthetized patient and that additional comorbid conditions may narrow the acceptable heart rate range. Why is it so hard to accept that there will be an optimum depth of anesthesia?

Another thought-provoking question: if you were to personally suffer a nonlife-threatening perioperative complication, which would you rather have, a small stroke or a small myocardial infarction?

Our current level of sophistication of brain monitoring is analogous to the three lead “bullet” electrocardiography monitor I used 30 years ago. Compare that to S-T segment analysis, transesophageal echocardiography, thermodilution cardiac outputs and pulmonary artery pressures available today. Do we use these sophisticated cardiac monitors because we need to or because we can? When the only tool you have is a hammer, then the whole world is a nail. If we could monitor the brain with the same level of sophistication as the heart, would we? You bet!

Another part of the puzzle is the effect of anesthetic depth on long-term outcome. The Anesthesia Patient Safety Foundation (APSF) recently organized an expert panel on “The Long-Term Impact of Surgery and Anesthesia” that strongly suggested that the perioperative experience may have a much longer effect than previously appreciated and that depth of anesthesia may be one of the factors affecting outcome. The early data raises more questions than answers, but this is a profound question that demands an answer.

My opinion is that part of the future of anesthesiology is in more sophisticated monitoring of both the function of the brain as well as anesthetic effect. We may find that developments in monitoring the brain will take the science of anesthesiology to a different level. We have to do what is best for our patients based on science and not paint ourselves into a corner by opposing brain function monitoring because of external forces. Maybe we should stop worrying about how companies market their devices. Our focus ought to be on encouraging research on neurological monitoring, optimum anesthetic depth and long-term outcomes by anesthesiologist scientists and technology companies.

Orin F. Guidry, M.D., is Chair, Department of Anesthesiology, Ochsner Clinic and Ochsner Foundation Hospital, New Orleans, Louisiana.