AWARENESS
DURING
ANESTHESIA
DOCTOR NASRULLAH KHAN
MBBS FCPS
CONSULTANT
ANESTHETIST
INTRODUCTION
ANESTHESIA
General anesthesia is defined as the
condition of pharmacogenic loss of
consciousness which is purposeful and
easily reversible. In this condition
patient is unresponsive to painful
surgical stimuli .
During anesthesia the depth of
unconsciousness, status of
cardiovascular system and respiratory
system are closely monitored.
AWARENESS
Awareness is defined as unintended
perception of some of stimuli in form of pain
or hearing when a patient has not had
enough general anesthetic or analgesic to
prevent consciousness.
It can be a distressing or traumatic
experience for the patient and it occurs
usually just prior to the anesthetic completely
taking effect or as the patient is emerging
from anesthesia. In very few instances, it may
occur during the surgery itself.
INCIDENCE
Awareness is a rare complication in general
anesthesia. The risk varies among countries,
depending on their anesthetic practices. In the
United States, the incidence of intraoperative
awareness is 0.1 per cent to 0.2 per cent of
patients undergoing general anesthesia. The
incidence of intra operative awareness depends
on the type of surgery. Trauma patients have
the highest incidence (11%-43%) followed by
patients undergoing cardiac surgery (1.14%)
and patients undergoing Cesarean section
(0.9%).
CAUSES
The cause of awareness is usually
traceable to one of three factors:
Light anesthesia due to
Specific
anesthetic techniques such as
the use of nitrous oxide, opioids, and
muscle relaxants
Difficult intubation
Premature discontinuation of anesthetic
Myocardial depression
Cesarean section
Machine malfunction or misuse of the
technique such as :
Failure
to check equipment
Vaporizer and circuit leaks
Errors in intravenous infusion
Accidental administration of muscle
relaxants to patients who are awake
Increased anesthetic requirement for
the following reasons:
Individual
variability in anesthetic
requirements
Chronic alcohol, opioid, or cocaine
abuse
EXPERIENCES RECALLED
BY PATIENTS
1. Conversations of the surgical staff
2. Various images and pictures
3. Dream-like events
4. Pain
5. Paralysis
6. Anxiety
7. Helplessness
8. Posttraumatic stress disorder:
I. nightmares, irritating dreams,
sleep
disorders
II. irritating thoughts
III. excitability
IV. avoidance of medical care
The recalling of these experiences can
start immediately after surgery, in the
recovery room, or several days later.
MONITORING DEPTH OF
ANESTHESIA
A. Subjective methods
1. Autonomic response
2. Patient Response to Surgical Stimulus
(PSRT) Scoring system
3. Isolated forearm technique
B. Objective methods
1. Spontaneous surface electromyogram
(SEMG)
2. Lower oesophageal contractility (LOC)
3. Heart rate variability (HRV)
4. Electroencephalogram and
derived indices
Compressed spectral array/
Spectral edge
frequency/ Median frequency
Bispectral index
Entropy
Narcotrend index
Patient state index
Snap index
Cerebral state index
5. Evoked potentials
Somatosensory evoked
potentials
Visual evoked potentials
Auditory evoked potentials
Auditory evoked potential
1.Isolated forearm technique
Tunstall in 1977 was the first who
tried to estimate the anesthesia depth
of his patients by applying the
isolated forearm technique. Before
the administration of the
neuromuscular blocking agents he
was inflating a cuff at the patients
hand and was estimating the depth of
anesthesia by the movement of the
hand after giving orders via
microphone and headphones24. The
danger of hand ischemia limited the
time that this method could be
2.Autonomic and harmonic response
The anesthetic drugs have actions like
analgesia, paralysis of the striated
muscles, amnesia and blockade of the
autonomic and harmonic response to
painful stimuli. That is why the
estimation of anesthesia depth can be
based on the changes of the patients
cardiac and respiratory rhythm, blood
pressure, the production of sweat and
tears or the pupil size
3. Contractions of the lower
esophageal sphincter.
Measurement of the contractions of
the lower esophageal sphincter with
the use of a special manometer has
been applied in the past. Although the
response of the esophagus to stimuli
is related to the depth of anesthesia, it
can not be considered a safe method
of intra operative anesthesia
monitoring.
4 .Frontalis muscle contraction.
The electroencephalogram of the
frontalis
muscle, which is the least sensitive
to
neuromuscular blockers, is
another available
but unreliable method.
5.Auditory evoked potentials
The monitor records the
electrical activity
of the brain stem, and cortex after
auditory
stimuli that are delivered to the
patients with
6. Narcotrend
Narcotrend records brain activity without
the application of any stimulus. This monitor
analyses the signal of the encephalogram
and categorizes anesthesia depth in a system
of 6 letters. It also produces a number from 0
to 100 (Narcotrend index). The stages are:
= awake, 0-2= sedation, C0-2= light
anesthesia, D0-2= general anesthesia,
0-2= general anesthesia with deep
hypnosis,
F0-1= general anesthesia with heavy
depression of reaction to painful stimuli.
.
7.Bispectral index scale
The only reliable anesthesia depth monitor
is the BIS. BIS works like the Narcotrend.
It records the electroencephalogram from 3
electrodes and after processing it with
mathematic algorithms it generates a
number from 0 to 100. When the BIS value
is lower than 40, the patient is in deep
anesthesia state, when the value is over 80,
the patient is under light sedation.
(Two thousand and two hundred dollars are required in order to prevent one case of
awareness).
Bispectral Index Values
100
65 - 85
45 - 65
anesthesia
<40
0
activity
awake
sedation
general
burst suppression
no electrical
8. Infrared Gas Analyzers
Continuous measurement of
concentration of volatile agent by
Infrared Gas Analyzers in anesthesia
circuit gives very good clue about the
level of anesthesia ,because we know
the MAC of each volatile agent.
MAC is that concentration which
causes no response to surgical stimulus
in 50% of cases.
Minimum alveolar concentration of
various volatile agents.
* Halothane
* Enflurane
* Isoflurane
* Desflurane
* Sevoflurane
* Nitrous oxide
0.74 percent
1.68 percent
1.15 percent
6.3 percent
2.0 percent
104 percent
9.Alternative technologies to quantify the
depth of anesthesia include, but are not
limited to, the following:
SNAP EEG monitor system
Patient State Analyzer 4000 (PSA 4000)
Spectral Edge Frequency 95 (SEF 95)
Automated Responsiveness Test (ART)
Drexels anesthesia monitor uses
functional near infrared (fNIR)
technology that directly measures
hemodynamic parameters of brain
activity associated with the effects of
anesthesia.
PREVENTION
POSTSURGICAL
MANAGEMENT
Specific measures can be used for prevention
and reduction of awareness during
anesthesia.
Firstly, the preoperative evaluation of the
patient is very important. The presence of the
risk factors must be checked.
Although there is doubt whether the patients
be informed about the possibility of being
awake during the operation or whether this
information can cause anxiety, the American
Society of Anesthesiology recommends that
patients in high risk of awareness must be
informed.
The checking of the anesthesia device
and other devices which will be used
during administration of anesthesia
must always be done. The protocol of
device checking must be complete and
signed.
In every case there must be an
anesthetic plan designed for every
patient individually.
Extra care must be given for the dosage
of the inhaled and intravenous drugs .
It is better to avoid the use of
neuromuscular blocking agents when it
is possible.
The use of benzodiazepines, which
affect memory, does not have any effect
in preventing awareness but it helps in
reducing the chances of recall .
The use of b- blocker decreases the
possibility of post-traumatic stress
disorder in the cases where awareness
occurs.
MEASURES AFTER A CASE
OF AWARENESS
1. Patient assurance
2. Gathering of as much information as
possible about the patients experience
3. Explanations for satisfaction of patient.
4. Frequent post-surgical visits
5. Detailed recording of all the actions
6. Referral to a psychiatrist
7. Inform all the persons concerned with
patient care ,like OT staff and OT nurse.
Explanations must be given to the
patient who must be exactly
informed about what happened and
why.
The anesthesiologist must be ready
to answer every question to the
patient and to apologize after
accepting the responsibility.
CONCLUSIONS
Intraoperative awareness is an important
problem for the patient and the doctor.
The patients have a very unpleasant
experience which can affect their mental
health for the rest of their life.
The complete and proper preoperative
evaluation, the checking of the anesthesia
device and the postoperative visits are
very important for prevention of
awareness and assurance of patient if it
occurs.
THANK
YOU
Joint Commission recommendations
Anesthesia awareness is under-recognized and under-treated in
health care organizations. The Joint Commission recommends
that health care organizations which perform procedures under
general anesthesia do the following to help prevent and manage
anesthesia awareness:
Develop and implement an anesthesia awareness policy that
addresses the following:
Education of clinical staff about anesthesia awareness and how to
manage patients who have experienced awareness.
Identification of patients at proportionately higher risk for an
awareness experience, and discussion with such patients, before
surgery, of the potential for anesthesia awareness.
The effective application of available anesthesia monitoring
techniques, including the timely maintenance of anesthesia
equipment.
Appropriate post-operative follow-up of all patients who have
undergone general anesthesia, including children.
The identification, management and, if appropriate, referral of
patients who have experienced awareness.
Assure access to necessary counseling or other support for
patients who are experiencing post-traumatic stress syndrome or
other mental distress.
MECHANISM OF ACTION
OF ANESTHETIC AGENTS.
The main mechanism of action is by
interfering with the neurotransmission
systems and especially with ion gates
which regulate the secretion of
stimulating and inhibiting
neurotransmitters like GAAA (GamaAmino-Butyric-Acid) receptors,
NMDA(N-Methyl-D-Aspartate)
receptors and nicotinic receptors of the
central nervous system (nACh).
Beside ion gates, anesthetic drugs also act
on G protein receptor (g protein coupled
receptors or GPCRs) which are related to
the function of the receptors of
acetylcholine, nor epinephrine, dopamine,
adenosine and opioids. This action is
responsible for the multiple adverse
reactions of these drugs.
During the last years, the action of
anesthetic drugs on newer types of
potassium receptors (2p or background
potassium channels), which regulate the
excitability of the nerve cells by providing
backup electrical currents, has been
discovered.
EFFECTS OF ANESTHETICS
ON VARIOUS PARTS OF
BRAIN.
Consciousness is the state where
someone can evaluate and process the
information he/she gets from the
environment. The available data indicate
that there are many central nervous
system structures that participate in this
function like the brain stem, the
hypothalamus and parts of the cerebral
cortex while the reticular formation has
an important role in the waking up
process.
As far as memory is concerned, there are two
categories, the short term and the long term
memory. According to Bailey and Jones,
short term memory involves storage and processing
of information connected with learning, taking
decisions and recalling memories which are stored
in long term memory. The storage of information is
done either phonetically (an inner voice repeats
the information) or visually (the information is stored
as a picture). The mode of storage is regulated by a
central processing system. The hippocampus and the
medial temporal lobe seem to play the most
important role in this procedure.
Long term memory includes facts which are stored
immediately in memory and are recalled after effort
(a car crash for example or somebodys name) and
are called explicit memory
Mainly by interfering with the
thalamocortical neurons, anesthesia
causes loss of consciousness while
other mechanisms include decrease of
brain hematosis and glucose
metabolism by the nervous cells.
procedures and skills that are
gradually learned but are recalled
without conscious effort (learning how
to drive, writing) and affect behavior
and habits and are called implicit
memory.
Long term memory is related to activity
in various areas of the central nervous
system like the hippocampus,
amygdala, neostriatum, cerebellum and
the cortex which are connected via
multiple neuronal circuits in order to
perform complicated brain functions.
Anesthetic drugs seem to affect these
circuits and deregulate the coding of
the stimuli and their storage in long
term memory
STAGES OF GENERAL
ANESTHESIA
The Snow was first to describe stages of anesthesia
in 1847 which were later modified by Guedel in
1937.
Stages of Anesthesia Guedel (1937)
STAGE I = Analgesia
STAGE II = Loss of consciousness to rhythmical
respiration
STAGE III= Surgical Anesthesia
Plane 1 = cessation of eye movements
Plane 2 = respiratory paresis
Plane 3 = respiratory paralysis
Plane 4 = diaphragmatic paresis and
paralysis
STAGE IV = Apnea
Jones described four stages of general
anesthesia in relation to memory and
consciousness
1. Perception and explicit memory,
where the patient recalls intra operative facts and
feelings without necessarily feeling pain (if large doses
of opioids were administered to them) and having
psychological disorders,
2. Perception without explicit memory ,
where the patient can follow instructions and perform
movements without being able to recall hearing them,
3. No perception and implicit memory
4. No perception and no memory.
There are some studies which indicate that even
during deep anesthesia, learning, processing of
information and storing it in long term memory is
possible.
RISK FACTORS OF
INTRAOP AWARENESS.
1. Insufficient drug administration
I. Cardiothoracic surgeries
II. Trauma
III. Emergency operations
IV. Cesarean section
V. ASA 4-5
2. Patients with different anesthetic requirements
I. Chronic use of benzodiazepines or opioids
II. Alcoholics
III. Severely anxious patients
IV. Difficult airway
V. Previous awareness experience
3. Anesthesia machine malfunction
I. Disorder
II. Incomplete check
4.Hemodynamically unstable
patients ,due to hypotension,
cardiac arrhythmias or cardiac
arrest.
Reducing the risk of anesthesia awareness
Both the ASA and the AANA provide guidelines for
administering and monitoring anesthesia. Specific
recommendations for the prevention of awareness are
addressed in the February 2000 issue of Anesthesiology.(4)
These include:
Consider premedication with amnesic drugs, e.g.,
benzodiazepines or scopolamine, particularly when light
anesthesia is anticipated.
Administer more than a "sleep dose" of induction agents if
they will be followed immediately by tracheal intubation.
Avoid muscle paralysis unless absolutely necessary and,
even then, avoid total paralysis [by using only the amount
clinically required].
Conduct periodic maintenance of the anesthesia machine
and its vaporizers, and meticulously check the machine
and its ventilator before administering anesthesia.
In addition, anesthesia practitioners should be alert to
patients on beta-blockers, calcium channel blockers and
other drugs that can mask physiologic responses to
inadequate anesthesia
Managing the impact of anesthesia awareness
As noted above, anesthesia awareness cannot always be
prevented. Health care practitioners must therefore be
prepared to acknowledge and manage the occurrence of
anesthesia awareness with compassion and diligence. This
management includes the following suggestions for patients
who report awareness (4):
Interview the patient after the procedure, taking a detailed
account of his or her experience and include it in the patient's
chart.
Apologize to the patient if anesthesia awareness has occurred.
Assure the patient of the credibility of his or her account and
sympathize with the patient's suffering.
Explain what happened and its reasons, e.g., the necessity to
administer light anesthesia in the presence of significant
cardiovascular instability.
Offer the patient psychological or psychiatric support, including
referral of the patient to a psychiatrist or psychologist.
Notify the patient's surgeon, nurse and other key personnel
about the incident and the subsequent interview with the
patient.
Surgical team members should also be educated about
anesthesia awareness and its management.
