[Depth of anesthesia, awareness and EEG]

Inapparent adverse intraoperative wakefulness is still a relevant problem in modern anaesthetic routine. It can be associated with serious negative effects on the postoperative recovery of the patients. Several different procedures have been developed to monitor and therefore avoid intraoperative situations of wakefulness during general anaesthesia. The most promising methods are the PRST-score, calculated from changes in the blood pressure, heart rate, sweating and tear production, the so-called isolated forearm technique, spontaneous EEG and its derived parameters such as spectral edge frequencies or BIS and finally mid-latency auditory evoked potentials. The observation of clinical autonomic signs, even including the calculation of the PRST-score does not seem to be valid enough to indicate or predict intraoperative wakefulness. The isolated forearm technique can be regarded as the most reliable tool to detect intraoperative wakefulness, but it can only be applied for a very limited period of time. The processed EEG with the median frequency, spectral edge frequency or bispectral index are important scientific tools to quantify central anaesthetic effects especially to develop pharmacodynamic-pharmacokinetic models of anaesthetic action. But they seem to be less suitable to indicate situations of intraoperative wakefulness or awareness. The mid-latency auditory evoked potentials are depressed dose-dependently by a series of anaesthetic agents, which correlate with the occurrence of situations of intraoperative wakefulness and awareness. There is a hierarchical correlation between certain values of the MLAEP and intraoperative wakefulness defined by purposeful movements, amnesic awareness with only implicit recall and conscious awareness with explicit recall. For some of the most commonly used anaesthetics reasonable threshold values of the MLAEP for the different states of consciousness have already been determined. Future studies in broad patient populations with all of the different routinely used anesthetics and procedures will have to finally identify the importance of the recording of mid-latency auditory evoked potentials as a routine method to assess the depth of anaesthesia.