Preventing and Managing the impact of Awareness during

Preventing and Managing the impact of Awareness during Anaesthesia Dr. Subbiah Chelliah MBBS, DA (UK), FRCA (UK), DESA (Sweden) Consultant Anaesthesiologist, Kovai Medical Centre & Hospitals, Coimbatore

Awareness during Anaesthesia • Awareness: – – – Definition Brief history Incidence Causes Associations Stages • Prevention: – Detecting Awareness – Preventing Awareness • Consequences of intra-op awareness – – PTSD Public awareness Dealing with patients who complain of awareness during anaesthesia Medico legal aspects

Definition • Awareness is the conscious experiencing of an event at the time that it occurs. (Guerra 1986) • Recall denotes the retention of an event in memory after it has occurred. (Guerra 1986)

1895 • Horace Wells attempted to demonstrate N 2 O to physicians at MGH, Boston • Patient moved & cried out! • Surgeons considered the demonstration a failure • Patient had no recall of his operation

1896 • W. T. G. Morton demonstrated the use of Ether in the same venue • Patient did not move • Surgeons considered it a ground breaking success! • Morton’s patient Gilbert Abbot, reported that he had been aware during his surgery, while experiencing no pain

1943 • Muscle relaxants came into clinical use • Anaesthetists started giving lesser amount of anaesthetic agents

Levinson study (1965) • 10 pts undergoing dental extraction with ether; shortly after induction, the anaesthetist called to the surgeon ‘STOP THE OPERATION, I don’t like the patient’s color. His/her lips are turning too blue. I am going to give a little oxygen!’ • One month later, probed for assimilation of crisis by hypnosis • 4/10 patients were able to quote verbatin the words spoken by the anaesthetist; 4 more showed evidence of having registered the event, in the form of emotional distress

Levinson study • Obvious methodological flaws: no controls, non-randomisation, absence of double blind study, asking leading questions • Thirty years later, Levinson repeated this study but failed to replicate his original findings!

General Anaesthesia is not an all or nothing phenomenon!

Incidence of Awareness Reported incidence of awareness varies and is difficult to determine • Swedish study: 0. 06% • American academic centres: 0. 13% • Overall incidence: ~0. 2% • Conscious awareness with pain: 1 in 20, 000 – 40, 000 anaesthetics

Incidence of Awareness • Cardiac surgery: 1 – 1. 5% • Trauma surgery: 11 – 43% • Cesarian section: 0. 4%

Causes • Lack of complete understanding of kinetics & dynamics of drugs • Induction of anaesthesia: – Coughing – difficult intubation

Causes / Associations Patient factors: – Limited cardiac reserve (ASA IV & V) – On going blood loss / hypotension – Patients on beta blockers, Calcium channel blockers – Drug / alcohol abusers / addicts – Patients on regular opiates /sedative medications

Associations • Opioid based anaesthesia / Neuroleptanaesthesia • Regional anaesthesia & ‘Light’ GA • Muscle relaxants • Disconnection / empty vaporiser • Caesarian section, Trauma, Cardiac bypass

Stages of Awareness Stage 1: Conscious awareness with explicit memory Stage 2: Conscious awareness without explicit memory Stage 3: Subconscious awareness with implicit memory Stage 4: No awareness

Awareness with explicit memory • Nearly always associated with neuromuscular blocking drug use • May or may not be associated with pain • ‘State of awful helplessness’ • Patients can go on to develop severe unexplained psychiatric disorder

Awareness without explicit memory • Tunstall: 9/12 pts showed arm movements during procedure (IFT) 4/9 appropriately – none recalled • Russell: 61% were able to move arm to command (given thio/dtc/nitous/oxygen) – none recalled • Changes in BP, pulse, sweating & tears were shown to be poor indicators of awareness

Awareness without explicit memory • 80% of patients induced with Midazolam & fentanyl and 70% induced with Midazolam & Alfentanil showed hand movement • While breathing low doses of Isoflurane (<0. 4% ET) subjects were able to comprehend and respond to words

Subconscious awareness with implicit memory • Increasing anaesthetic concentration leads to reduction in working memory, then loss of conciousness and explicit memory, whereas implicit memory of intraop events may remain!! • Indirect tests of memory must be used to demonstrate evidence of implicit memory & learning

Subconscious awareness with implicit memory • Category generation, free association, stem completion tests are used • Conflicting study results • Positive suggestions intraop: stop smoking, faster recovery

Preventing Awareness • ‘High’ risk patients / situations • Detecting / Monitoring anaesthetic depth intraop • Drugs • Avoiding certain anaesthetic techniques • Patient information

Detection of Awareness • • Clinical signs Clinical experience IFT Lower oesophageal contractility Frontalis EMG Respiratory sinus arrhythmia EEG – Raw EEG – Processed EEG • Bi. S • AEP

PRST Score

Isolated Forearm Technique (IFT) • • First used by Tunstall Isolate forearm with BP cuff before giving NMB Patients asked to squeeze hand for ‘Yes’ Limitations: time; surgery on the hand • Even when patients responded, rarely did they have any memory of this after the operation

Monitoring Awareness… • • Clinical experience Lower oesophageal contractility Frontalis EMG Heart rate variability (Respiratory sinus arrhythmia)

EEG

Bi. S (Bi. Spectral index monitoring) • Complex EEG parameter under development by Aspect Medical systems since 1985 using clinical data from 1500 anaesthetic regimes and 500 hrs of EEG signals gathered under anaesthetics • Approved by the FDA in 1996 • Several hundred publications to date

Bi. S • Direct measure of the effects of anaesthetics on the brain • BIS monitoring allows anaesthesia providers to administer the appropriate amount of drug that each patient needs

The Bispectral Index. TM (Bi. S) Aspect Medical Systems

Auditory Evoked Potential

The early cortical AEP waves called Pa and Nb, which occurs between 20 and 80 ms reflects the activity in the temporal lobe/primary auditory cortex ( the site of sound registration) Changes in the latency of these waves ( in particular the Nb wave) are highly correlated with a transition from awake to loss of consciousness

Mid-latency AEP

AEP • Limitations: hearing impaired; head & neck surgery

Other processed EEG monitors • • Narcotrend Index Cerebral state index (CSI) Entropy Snap index

Preventing Awareness

Preventing Awareness

Dealing with patients who have a history of Awareness during Anaesthesia • Take patient seriously • Investigate previous anaesthetic technique & circumstances • Comorbidity / medications • Reassure • Sedative premed • Intraop ET agent monitoring / Bi. S • Postop visit • Good Periop records

Consequences of unintended awareness during Anaesthesia • Fear of Anaesthesia • Post Traumatic Stress disorder • Flashbacks, Anxiety, sustained emotional effects • Anger / litigation • Paranoia / loss of confidence / financial loss Anaesthesiologist

• Awake, a 2007 film about anaesthetic awareness • Anaesthesia, an award-winning horror film about anaesthesia awareness • Return, a Korean thriller movie about anaesthesia awareness • In an episode of Nip/Tuck a woman experiences anaesthesia awareness while having surgery to repair scarring on her face. • Wide Awake, a Korean horror/thriller movie was mainly about the outcomes mentally after anaesthesia awareness.

Patient associations / support groups

Dealing with patient who complaints of Awareness during Anaesthesia • Don’t trivialise the problem – take patient’s complaint seriously • Visit patient as soon as possible, along with a witness • Detailed history – modified Brice interview

Modified Brice Interview 1. What is the last thing you remember before surgery? 2. What is the first thing you remember after surgery? 3. Do you remember anything happening during surgery? 4. Did you have any dreams during surgery? 5. What is the worst thing about your surgery?

Dealing with patient who complaints of Awareness during Anaesthesia • Document patient’s exact memory • Attempt to confirm validity of account • Patient anaesthetic records / theatre circumstances • Try to determine cause • Reassure / offer explanation / document • Keep a copy of records • Offer psychological support • Notify medical defence / hospital admin / patient’s GP

Medico legal aspects (American closed claims database: 1971 - 2001) • Small fraction of patients initiate legal action • Most of them are women (>70%) • Cases of intraop awareness with explicit recall are difficult to defend • Awards to patients for awareness with recall range from $1000 $800, 000

"Awareness with analgesia is regrettable; awareness with pain is unforgivable" Thank you!