Intraoperative Recall Allison Russell Intraoperative Recall Unintended complication

Intraoperative Recall Allison Russell

Intraoperative Recall • Unintended complication, occurs during general anesthesia or MAC • Occurs most during maintenance of anesthesia rather than induction or emergence • 1 -2 adult patients per 1000 patients undergoing general anesthesia • 1 in 100 patients in high-risk surgeries (cardiovascular, obstetrics, trauma)

Intraoperative Recall • Awake Movie Clip alternate link • Harold, Joby (Director). (2007). Awake [Motion picture]. United States: MGM Distribution Company.

Risk Factors • MAC 0. 3 -0. 4 associated with awakening from anesthesia • Mistake or failure in anesthesia delivery • Anesthetic technique resulting in inadequate anesthesia • Underappreciated patient dosing requirements • Patient condition unsafe to administer sufficient anesthesia

MAC • Minimum Alveolar Concentration • 50% of patients will not respond to a painful stimulus • MAC-awake: 50% of persons will follow command to “open your eyes”. o 0. 3 -0. 4 MAC associated with awakening from anesthesia. ~1/3 MAC=loss of recall • MAC-BAR: exceeds requirements for ablation of skeletal muscle movement with surgical stimuli. o 1. 3 MAC of any volatile agents

MAC Requirements • Decreased MAC: o o o o Increasing age Opioids/benzo use Sedative-hypnotics Alpha-2 agnoists Hypothermia Anemia Nitrous Oxide Acute ETOH intoxication Increased MAC *Decreased age (infants) * Hyperthermia * Hyperthyroidism * Cocaine * MAOIs * Chronic ETOH abuse * Hypernatremia

Repercussions • PTSD associated with awareness during surgery • Increases patient’s apprehension to undergo further surgery • Sleep disturbance, nightmares, anxiety

BIS Monitor • • Bispectral Index Represents a numerical value (0 -100) Correlated with the patient’s current hypnotic state 100=awake 65 -85=sedated 40 -65=general anesthesia <40=cortical suppression BIS monitor approved in 1996 by FDA as potential tool to decrease intraoperative awareness

Michigan Awareness Control Study • One group: BIS monitoring during surgery, anesthesia providers alerted when BIS values reached greater than 60 • Second group: anesthesia provider alerted when MAC reached 0. 5

Michigan Awareness Control Study • BIS monitor revealed trend toward reducing incidence of awareness • No statistically significant difference in intraoperative awareness between 2 groups • Increased alerting of anesthesia providers to potential “light” anesthesia was associated with fewer awareness events

Prevention • • • Check all equipment, drugs and dosages Administer amnestic premedication Avoid using muscle relaxants if possible Administer at least 0. 5 -0. 7 MAC Set alarm for low MAC

Treatment • Brice Questionnaire o “What was the last thing you remember before going to sleep? ” o “Did you dream during your procedure? ” • Prompt referral to mental health professional • Explain what happened to patient • Keep record of incident in patient’s chart to guide further anesthesia • Report claim to hospital lawyer

Conclusion • BIS monitor can be used as adjunct to detecting possibility of awareness • Evaluate patient for risk factors • Ensure patient has sufficient anesthesia and remains deep • Proper post-op follow-up • Vigilance is best prevention!!!

References • American Association of Nurse Anesthetists (2012). Anesthesia awareness during general anesthesia. Retrieved from: http: //www. aana. com/resources 2/professionalpractice/Pages/Con-Anesthesia-Awareness-during-General-Anesthesia. aspx • Avidan, M. S. & Mashour, G. A. (2013). Prevention of intraoperative awareness with explicit recall. Anesthesiology, 118 (2), 449 -456. • Butterworth IV J. F. , Mackey D. C. , Wasnick J. D. (2013). Chapter 8. Inhalation Anesthetics. In J. F. Butterworth IV, Mackey, J. D. Wasnick, D. C. (Eds), Morgan & Mikhail's Clinical Anesthesiology, 5 e. Retrieved October 31, 2013 from http: //www. accessmedicine. com. proxy. kumc. edu: 2048/content. aspx? • Butterworth IV J. F. , Mackey D. C. , Wasnick J. D. (2013). Chapter 54. Anesthetic Complications. In J. F. Butterworth IV, Mackey, D. C. , Wasnick, J. D. (Eds), Morgan & Mikhail's Clinical Anesthesiology, 5 e. Retrieved October 31, 2013 from http: //www. accessmedicine. com. proxy. kumc. edu: 2048/content. aspx? a. ID=57239722. • • Ghoneim, M. M. (2000). Awareness during anesthesia. Anesthesiology, 92(2), 597 -602. Mashour, G. A. , Shanks, A. , Tremper, K. K. , Kheterpal, S. , Turner, C. R. , Ramachandran, S. K. , …Avidan, M. S. (2012). Prevention of intraoperative awareness with explicit recall in an unselected surgical population: a randomized comparative effectiveness trial. Anesthesiology, 117(4), 717 -725. • • Naglehout, J. J. , & Plaus, K. L. (2014). Nurse anesthesia. St. Louis, Missouri: Elsevier Sanders. Harold, Joby (Director). (2007). Awake [Motion picture]. United States: MGM Distribution Company.

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