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Sleigh J. Unresponsiveness unconsciousness. Anesthesiology 2012;
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33. Tunstall ME, Lowitt IM. Clinical curio:
sleep phobia after awareness during
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34. Bricker S. The Anaesthesia Science
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35. Myles PS. Prevention of awareness
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36. Byers GF, Muir JG. Detecting wakefulness in anaesthetised children. Canadian Journal of Anesthesia 1997; 44:
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Week: Awareness under anaesthesia.
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Russell IF. The Narcotrend depth of
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isolated forearm technique. British
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Russell IF. The ability of bispectral
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anaesthesia, as compared with Isolated Forearm Technique. Anaesthesia
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doi:10.1111/anae.12265

Editorial
The place of the isolated forearm technique in modern
anaesthesia: yet to be defined
I agree with Dr Russell [1] that the
isolated forearm technique (IFT) has
come in for a lot of misinformed,
unfair, and irrational criticism. The
IFT is simple in concept, does not
require complex and expensive
equipment, and has been around for
more than 30 years. We must therefore ask the obvious question: Why
isnt the IFT routinely used to eliminate awareness associated with
general anaesthesia? We might also

consider the subsidiary question:

Why do anaesthetists seem to prefer
to use EEG-based methods of estimating unconsciousness? Are we just
a lazy and conservative profession?
Our practice is moulded by a wide
variety of inuences, but I would
suggest that the false perceptions
associated with the IFT that have
been so strongly enumerated by
Russell are only a small part of the
reason for the lack of widespread

2013 The Association of Anaesthetists of Great Britain and Ireland

uptake of the IFT. In my view the

main reasons are that: (i) the conduct of the IFT requires signicantly
extra effort that is potentially dangerously distracting; and (ii) there
does not exist a good epidemiological evidence base showing that use
of the IFT results in a greater number of happier patients (or at least, a
lower incidence of postoperative
recall). I am not making a claim in
favour of routine EEG monitoring to

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Anaesthesia 2013, 68, 677681

prevent intra-operative recall. In

their present form, all EEG-derived
anaesthesia-based monitors (ABM)
have been shown to be quite poor at
tracking the conscious state of the
patient [2], but they probably have
some role as a belt-and-braces check
for total intravenous anaesthetic
techniques, and in high-risk patients
who cannot tolerate > 0.7 MAC of
volatile anaesthetic drug. In my personal clinical practice, when I am
faced with the rare patient who has
suffered a previous instance of intraoperative awareness or who has an
excessive fear of this complication
I tell him/her that I plan to use both
a brain-wave monitor and the IFT to
conrm that he/she is unconscious
while under anaesthesia. This
practice is based on common sense
rather than epidemiological data, but
is easily comprehended by patients,
and provides some comfort for
them.

Performing the IFT is a

significant distraction and
may be dangerous
All practising anaesthetists know
that the operating theatre is full of
stimuli that compete for their attention, and they work in an environment in which their capacity for
multitasking is often stretched [3].
In moments of crisis, it is crucial
that our limited attention capacity is
focused on the most relevant lifethreatening issues; however, awareness is more likely at just these times
of crisis. Even when using an automated electronic voice command,
the IFT, in its present form, is a signicant added perceptual and motor
load on the single-handed anaesthetist (Table 1). Positive IFT responses
682

Editorial

will commonly occur around the

time of tracheal intubation [4]
especially when the intubation is
particularly prolonged and difcult.
At these times, the primary focus of
attention should be on securing the
airway and achieving adequate ventilation and cardiovascular stability
not in checking whether accidental
deation of the IFT cuff has caused
paralysis of the hand muscles, etc.
Similarly, when the anaesthetic concentration has to be reduced because
of cardiovascular compromise from
life-threatening haemorrhage, we
should properly be concentrating on

restoration of blood volume and

clotting.

Does it work?
The other main reason for the
poor uptake of the IFT is the lack
of relevant convincing studies. At
least 20 papers have been published on the IFT technique, and
these do indeed show an encouraging and consistent proof of principle. These papers report the
responses of between 12 and 184
patients (mostly n 2040), under a
variety of different general anaesthetic techniques. Often, these

Table 1 The processes required to check for possible intra-operative awareness when using: (a) the IFT; (b) an EEG monitor; and (c) an end-tidal volatile anaesthetic gas (ETAA) monitor.

(a) using the IFT:

1) Set up the extra cuff, neuromuscular junction monitor,  electronic patient
auditory command system. (N.B. there are no automatic auditory alarms).
2) Evaluate the times and doses of when the neuromuscular blocker was given
and their relationship to how long the cuff has been inflated or deflated.
3) Check adequate cuff inflation (50 mmHg above systolic blood pressure).
4) Check lack of paralysis in the hand using the neuromuscular monitor.
5) Give the patient a specific named command to move his/her hand.
6) See if any movement occurs in relationship to the command.
7) If a movement has occurred, manually check the patients cognition status
with further commands.
8) Adjust the anaesthetic drug delivery accordingly.
9) Remember to deflate/re-inflate cuff if long operation.
(b) using an EEG monitor:
1) Place electrodes.
2) Set the alarms.
3) Glance at the raw EEG waveform to confirm the reliability of the BIS number.
4) Adjust the anaesthetic drug delivery accordingly.
(c) using the ETAA monitor:
1) Set the alarms.
2) Glance at the vaporiser and anaesthetic monitor to check the gas waveform.
3) Adjust the anaesthetic drug delivery accordingly.

2013 The Association of Anaesthetists of Great Britain and Ireland

Editorial

patients receive little or no volatile

general anaesthetic drug [5] and
are only studied around the time
of tracheal intubation. There are
few studies that investigate the usefulness of the IFT in large numbers
of patients, over the whole course
of surgery, and who are receiving a
modern volatile-based heavy anaesthetic technique [6]. In this
instance, the incidence of IFT
responsiveness seems to be very
low, but rare events are often a
manifestation of unusual, and
unexpected, causative processes. To
minimise intra-operative patient
recall, the three options available to
the anaesthetist are: (i) the IFT; (ii)
some form of ABM (usually the bispectral index (BIS)) and; (iii)
maintenance of end-tidal volatile
anaesthetic
concentrations
> 0.7 MAC. From the results of
several large-scale epidemiological
studies, it would seem that either
maintaining the end-tidal volatile
anaesthetic concentrations > 0.7
MAC, or keeping the BIS < 60, will
be associated with a low (but not
zero) incidence of intra-operative
explicit recall [7]. Like all the ABM
systems except for the BIS, there is
no accurate estimate of the incidence
of intra-operative recall with the use
of the IFT. To obtain reliable epidemiological estimates of this incidence (< 1:500) would require a
study of many thousands of patients

Anaesthesia 2013, 68, 677683

in whom the IFT was used and acted

upon. The incidence of recall when
using an IFT is likely to be very low,
because higher concentrations of
anaesthetic drug are needed to block
responsiveness than those required
to block memory [8]. However, this
remains a speculative assumption
until a large study is done. There
may be numerous (known and
unknown) possible reasons why the
IFT might fail to detect responsiveness quickly enough for the anaesthetist to increase the anaesthetic to
prevent recall entirely. For example,
the anaesthetic drugs can occasionally induce a catatonic locked-in
state in the partially anaesthetised,
but conscious, patient [5], or various
unpredictable rare technical failures
could occur (e.g. cuff failure, unexpectedly prolonged clearance of neuromuscular blocking drugs, limb
ischemia, etc). We just wont know
the incidence of these potential rare
problems, until a large prospective
trial is done.

Conclusions
At present we have no clear idea
of either the actual benets of
the widespread use of the IFT,
or its risks when applied in
modern day-to-day anaesthetic
practice. The IFT deserves to be
evaluated in appropriately designed, public-good funded, large
scale studies.

Competing interests
No external funding and no competing interests declared.
J. Sleigh
Professor of Anaesthesia
Waikato Clinical School University
of Auckland
Hamilton, New Zealand
Email:
jamie.sleigh@waikatodhb.health.nz

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