The ability of bispectral index to detect intra‐operative wakefulness during isoflurane/air anaesthesia,compared with the isolated forearm technique

Clinical signs are unreliable for guiding anaesthetic administration and it is suggested that using the bispectral index can improve anaesthetic delivery. In the current study, isoflurane administration was guided to a bispectral index range of 55–60. Intra‐operative responsiveness, as assessed by the isolated forearm technique, was compared with whether the bispectral index predicted/identified a patient's appropriate hand movements in response to commands. Thirty‐four women underwent major gynaecological surgery with isoflurane/air and atracurium. Eleven women responded on 32 occasions with appropriate hand movements to commands given during surgery, of which the bispectral index detected 17 (sensitivity 53%). The bispectral index suggested consciousness 660 times in the absence of any movement responses (specificity 69%). The positive predictive value of the bispectral index was 3%. The median (IQR range]) bispectral index value associated with an intra‐operative response was significantly lower than that associated with eye opening after surgery: 60 (50–68 36–83]) vs 77 (75–84 59–90]), respectively (p = 2.25 × 10^?8). Conversely, end‐tidal isoflurane concentration was significantly higher at intra‐operative response than at eye opening: 0.3 (0.3–0.4 0.2–0.9]) vs 0.2 (0.1–0.2 0.1–0.3]), respectively (p = 7.36 × 10^?8). For patients who responded more than once during surgery, the bispectral index value associated with a response was not constant. No patient had recall for surgery or the taped commands, and only one could remember dreaming (a good dream). Titrating isoflurane to target a bispectral index range of 55–60 may result in an unacceptable number of patients who are conscious during surgery (albeit without recall).