The tree, the forest & standard of care

Kudos to Kent, Posner, Mashour, et. al. on their recent publication. (1) As unpleasant as the ’tree’ of anesthesia awareness can be, there are no known deaths reported from it. Awareness pales in comparison to the ‘forest’ of daily routine anesthesia over medication death, (2) the probable consequence of failing use a bispectral (BIS) index monitor as a real time device. Only this year has the maker changed the default setting on the free standing VISTA units to include the real time signal of the electromyogram (EMG) of the frontalis muscle. BIS data alone is 15-30 seconds behind real time and is not especially useful for drug titration. Titrating with BIS alone is akin to driving one’s car with rear view ‘mirror’ information only. Adding the real time signal of the EMG is more like looking through the ‘windshield’ to drive one’s car. Making BIS/EMG monitoring a standard of care is the primary goal of my non-profit, 501c3, Goldilocks Anesthesia Foundation. Only with universal BIS/EMG monitoring will we learn how much postoperative delirium is attributable to anesthesia over medication. (3,4)

Barry L. Friedberg, M.D.
President & founder, Goldilocks Anesthesia Foundation
P.O. Box 10336
Newport Beach, CA 92658
Tel. 011-949-233-8845
FAX 011-949-760-9444

Disclaimer: Neither I, nor my non-profit Goldilocks Anesthesia Foundation, receive financial support from brain monitor makers.


1. Kent CD, Posner KL, Mashour GA, et al.: Patient perspectives on intraoperative awareness with explicit recall: report from a North American anesthesia awareness registry. Br J Anaesth 2015; i114-i12.

2. Li G, Warner M, Lang BH, et al: Epidemiology of Anesthesia-related Mortality in the United States, 1999–2005. Anesthesiol 2009;110:759-65.

3. Radtke, F.M., Franck, M., Lendner, J. et al. Monitoring depth of anaesthesia in a randomized trial decreases the rate of postoperative delirium but not postoperative cognitive dysfunction. Br J Anaesth 2013; 110: 98–105.

4. Chan MT, Cheng BC, Lee TM: BIS-guided anesthesia decreases postoperative delirium and cognitive decline. J Neurosurg Anesthesiol 2013;25:33-42.