Awareness During General Anesthesia: Current Trends and Practices

Michael Hoess
University of Pennsylvania
Introduction
Intraoperative awareness refers to the aility of an anestheti!ed patient to retain "e"ories
of sensory perceptions during the intraoperative period in which they were supposed to e fully
unconscious# The intention of this paper is to address current practice and research related to
intraoperative awareness# $hile technological and phar"acological advances have allowed
great advances in the ad"inistration and "anage"ent of anesthetic agents% the prevention of
intraoperative awareness re"ains rudi"entary#
Modern anesthetic techni&ues and surgery settings have "any factors that can contriute
to cases of intraoperative awareness# The use of endotracheal intuation% while necessary in
"ost cases for the safety of the patient% prevents the patient fro" vocali!ing disco"fort should
they e aware of it# Additionally% patients "ay e restrained% tied down% or otherwise secured#
$hile this secures the surgical field and patient% this also "eans they have no physical way of
co""unicating% should they eco"e aware# 'inally% "any procedures involve the use of
neuro"uscular loc(ers# This can lead to the trau"atic pheno"enon of )paraly!ed ut awa(e*
and also contriutes to the an+iety and inaility to co""unicate should a patient eco"e aware
during a procedure#
The process of deter"ining depth of anesthesia has changed significantly over the past
half,century# $ith the introduction of neuro"uscular loc(ing agents% anesthesia has gone fro"
eing used as an i""oili!er to eing used as an a"netic and hypnotic -'or"an% .//01#
However% these agents "a(e it hard to assess response to sti"uli in patients% which was a
pri"ary indicator of depth of anesthesia# Therefore% anesthesia providers use autono"ic signs
such as lood pressure and heart rate to gauge anesthesia# However% these signs can e affected
y a "yriad of other factors and are therefore not e+tre"ely reliale indicators of consciousness
-'or"an% .//01#
The co""only cited statistic is that awareness occurs in /#.2/#34 of anesthetic cases
-5itti 6 5itti% 7Chapter 30# Anesthetic Co"plications71 ut "any studies have found incidences
lower than this -8lusse van 9ud,Allas% et al#% .//:; Pollard et al#% .//<; 7Practice advisory for
intraoperative awareness%7 .//01# $hile it is pri"arily the responsiility of the anesthesia
provider to atte"pt to gauge the depth of anesthesia% the sutle signs of awareness should e
reported y any staff oserving the"# Awareness incidents "ay not e uncovered until long after
the operative period# =igalovs(y -.//>1 starts her review y discussing a case of awareness that
was discovered% ut not until two days after surgery# Therefore it is i"portant for all nurses% e
they involved in intraoperative care% post,anesthesia care% or any sort of post,surgical or
procedural care% to e aware of the i"pact and possiility of intraoperative awareness#
Incidents of intraoperative awareness can co"e at a huge cost to oth the health care
providers or syste" and to the patient# Patients e+periencing intraoperative awareness can suffer
fro" post,trau"atic stress disorder and suffer long,ter" disaility -7Practice advisory for
intraoperative awareness%7 .//01# These patients have undergone a frightening e+perience and
"ay have an aversion to future surgery that could e detri"ental to their long,ter" health# 9f
course% litigation often follows cases of awareness# Payouts fro" these clai"s were around
?@A%/// on average% ut ranged aove ?0//%/// -9BConnor et al#% .//@1# 9ther financial
considerations include the a"ount of lost productivity due to disaility% or other urdens to
society#
In addition to the financial costs of these incidents% it is possile that these incidents can
e detri"ental to the course of treat"ent for these patients# Plans of care "ay need to e
"odified to avoid procedures involving general anesthesia# Increased an+iety can also ha"per
patient recovery and progression# =ince so"e of the feelings that have een reported after such
an event include terror% pain% and etrayal -=igalovs(y% .//>1% it is unsurprising that these
patients "ay no longer trust health care providers to protect the" fro" har"#
8ac(ground and =ignificance
The literature in the area of intraoperative awareness falls into certain general categories#
=ince esti"ates of the incidence of intraoperative awareness vary greatly% a certain a"ount of the
literature has si"ply een atte"pts to esti"ate incidence and deter"ine ris( for intraoperative
awareness# Deter"ining the actual incidence of the pheno"enon and &uantifying the e+perience
has a huge i"pact on the other findings of related research# As a conse&uence of these
esti"ations% there have also een studies of the effectiveness of new "onitoring technologies and
interventions to i"prove outco"es# The interventions are of course% largely ased in identifying
at,ris( groups% ut also in techni&ues and procedures that help to reduce incidence of
intraoperative awareness# The new technologies afore"entioned are to "onitoring technologies
that atte"pt to &uantify )depth of anesthesia* or the a"ount of patient awareness# The studies
are not necessarily seeing how well these new technologies "easure the para"eters that they
have een designed to "easure% ut rather how well these para"eters correlate to predicting and
preventing awareness during anesthesia#
Incidence of Intraoperative Awareness
=ource Incidence Population Co""ents
5itti et al# /#.,/#34 5ot specified Te+too(% not original research
Pollard -.//<1 /#////0A4 overall
/#@.4 cardiac
A<%>0@ &ualified cases Cardiac incidence si"ilar to other esti"ates# Ci"ited
y only surveying . days post,operatively
@
#
Dlusee van 9ud,
Allas -.//:1
/#04 :.A pediatric cases 'ound awareness was not reported as stressful
e+perience# Did not "eet statistical significance#
Malviya -.//:1 /#///A4 @%<A3 &ualified pediatric
participants
'ound no signs of long ter" distress or psychological
se&ulae
=eel -.//31 /#@>4 @:%E<E &ualified cases 30 additional )possile* cases and @@A> cases of
)intraoperative drea"ing*
Ci"ited y only surveying @ wee( post,operatively
@
#
Mashour -.//:1 5o valid incidence
discovered
Fetrospective record search%
included cases of sedation with
higher than intended awareness
Ci"ited y data collection "ethods of retrospective
study# Ci"ited y data collected @ day post,
operatively
@
#
Gu -.//:1 /#3@4 @@%@/@ patients in .E centers in
China
Theori!ed to e higher due to use of local anesthesia in
low,ris( patients# Ci"ited y only surveying @ and 3
days post,operatively
@
#
Hrrando -.//A1 @4 >:.@ &ualified cases H+cluded post,operative patients recovered in ICU#
Incidence closer to other esti"ates when e+cluding
cardiac patients in sa"ple#
Ghonei" -.//<1 /#@,/#.4 general anesthesia
/#3E4 cardiac
@@,3>4 trau"a
<4 inter"ittent ID
anesthesia
Citerature review
1
Many studies of awareness have found "any cases are captured "ore than > days -8lusse van 9ud,Allas% et al%# .//:; Malviya% et al#%
.//:;1 to a wee( -Hrrando et al#% .//A1 post,operatively#
Determining Risk for Awareness
$hile ris(s for awareness are largely theoretical at this ti"e% a nu"er of the studies have
loo(ed ris( factors that "ight e involved in awareness# 8ecause of the low incidence of
awareness it "a(es it difficult to derive statistically "eaningful conclusions regarding ris(
factors# In addition% the way in which awareness is &uantified "a(es it difficult to "a(e any
"ore than correlational relationships# 5onetheless% these studies are the est evidence we have
to corroorate theoretical ideas of ris(#
=ource Fis( factors identified
)Practice advisory*
Anesthesiology
Practice Advisory Fesearch
Cardiac surgery
Trau"a surgery
Caesarian section
Feduced anesthetic doses
Fapid se&uence induction
=urvey of Anesthesiologists
=ustance ause
Drug tolerance
Poor general health as indicated y A=A status ID or D
Ghonei" -.//<1 Techni&ue related
5euro"uscular loc(ade
Cight anesthesia as re&uired y hypvole"ia% low cardiac reserve%
anticipated difficult intuation
Patient characteristics
Ioung age
9esity
'e"ale
Patient history
=ustance ause
Genetic resistance
Previous intraoperative awareness
=urgery related
9stetric surgery under general anesthesia
Cardiac surgery
Trau"a surgery
H+tensive surgery resulting in lood lossJfluid shift
Figid ronchoscopy or endoscopic surgery using Ket ventilation
Provider related
Insufficient (nowledge
Poor "achine "aintenance
5ot using "onitoring techni&ues
'or"an -.//01 5euro"uscular loc(ade secondary to inaility to identify level of
consciousness
Hrrando -.//A1 5o pre"edication
ID induction with nitrous o+ide "aintenance
Monitoring Techniques and Technologies
=everal studies have loo(ed at "onitoring techni&ues that are used to prevent awareness
and ensure ade&uate anesthesia in patients# Techni&ues have ranged fro" the conventional to
newer technology% including ispectral inde+ "onitoring -8I= "onitoring1# In general% the
research has shown that the "onitoring techni&ues widely in use today are not effective y
the"selves in preventing as "any cases of intraoperative awareness as possile#
=eel et al# -.//31 did find a few cases of awareness during anesthesia% where they
concluded that the awareness proaly was predictale y a high 8I= value -"eaning the
"onitors "ay have een effective in predicting the ris( of awareness1# The Practice Advisory
fro" Anesthesiology -.//01 cited evidence that while these "onitors appear to e helpful% their
nu"ers are not asolute correlates% and the nu"ers given y these "onitors typically correlate
with other physiological signs used y anesthesia providers to "onitor depth of anesthesia# They
found so"e other studies that showed no statistical difference etween use of 8I= "onitors and
control groups# Therefore% they found insufficient evidence to reco""end the usage of these
"onitors# Avidan et al# -.//A1 loo(ed at using Hnd Tidal Anesthesia Gas "onitoring -HTAG1
versus 8I= "onitoring% in a rando"i!ed controlled trial# They did not find any statistically
significant difference etween the groups where the anesthesia was guided y HTAG values
versus 8I= values# This is a follow up to Myles et al# -.//31 who did a doule,lind rando"i!ed
controlled trial that found a significant difference etween 8I= "onitored patients and the
control group receiving routine care# The reduction they found was A.4% as . patients of @%..E
in the 8I= "onitored group e+perienced awareness% as opposed to @@ of @%.>A of the routine care
control# These nu"ers do not "eet criteria for statistical significance# In addition% Ceslie et al#
-.//:1 followed up with @%:3< patients fro" the Myles et al# trial% fro" >/ days to 0#E years
postoperatively# Coo(ing at MI% stro(e% and death as predictors% Ceslie et al# found that patients
whose 8I= inde+ was never L3/ for "ore than ME "inutes during their surgery were at decreased
ris( for stro(e% MI% and death# This indicates ris( for )too deep* anesthesia% as the Myles et al#
trial was loo(ing to (eep a 8I= inde+ under 0/#
Interestingly% 9BConnor et al# -.//@1% efore the wor( of Myles% calculated the
populations in a study that would e re&uired to prove effectiveness of "onitor effectiveness#
They listed the "ini"u" study si!e to prove effectiveness of a 8I= "onitor given a certain
incidence of intraoperative awareness -as this is deatale in the general population and can vary
a"ong different surgical populations1# The authors suggested that the only li(ely practical way
to study effectiveness is in an )at ris(* population% which would re&uire a study of Kust over
.%/// patients to prove an effectiveness of :/4# They also showed that given the rare
occurrence of intraoperative awareness% it would e nearly i"possile and not cost effective to
prove the use of 8I= "onitoring effective in all patients#
Analysis
Trends in findings
The "aKority of research has de"onstrated that sic(er patients and those where the
procedure necessitates lighter than nor"al anesthetic doses are at a higher ris( of intraoperative
awareness# In addition% the research has ac(nowledged that lac( of education a"ong anesthesia
providers and lac( of careful preoperative chec(s of e&uip"ent pose a significant ris( of
intraoperative awareness# Fesearch in general indicates that the overall incidence of awareness
see"s to e trending downward -Ghonei"% .//<1 over ti"e#
8asically% research has een clear that light anesthesia -'or"an% .//01% inade&uate
pre"edication -Hrrando% .//A1% and other factors that (eep patients closer to a conscious state
have shown to e ris(y# These are often present in e"ergency% trau"a% cardiac% and ostetric
surgery# However% it see"s that (eeping a patient )too anestheti!ed* carries an increased ris( of
MI% stro(e% and death as well -Ceslie% .//:1#
Gaps in knowledge
Unfortunately% "ost research in this area is not definitive enough to truly say we have
answered "any &uestions# There is yet to e a definitive and consistent answer as to the actual
incidence of awareness# =ince awareness is such a rare event% estalishing statistical significance
in "easure"ents of its incidence ta(es a lot of effort and resources# The only way to increase
incidence in a study is to loo( specifically at high ris( groups% which "eans that "ost research%
especially on interventions% is targeted at already,identified high ris( groups# Therefore% the
research is &uite li"ited on interventions for low ris( groups% while so"e research has e+cluded
high ris( groups such as cardiac surgery# In addition% only Mashour et al# -.//:1 addressed
awareness in sedated patients% which is a new concept caused either y inade&uate sedation% or
y a disconnect etween patient and anesthesia provider e+pectations for level of awareness#
Pediatric anesthesia% while present in the research studies% was not addressed at length#
9ne study suggested that pediatric patients "ay e at a higher ris( for awareness -9ud,Allas% et
al# .//:1 ut was unale to statistically confir" this# 5o other research appears to confir" or
deny that pediatric patients are a high ris( for awareness# This re"ains a ris( category that has
gone relatively unaddressed in the ody of current literature# 9ud,Allas% et al# -.//:1 also
suggested that since awareness is a self,reported co"plication% reporting in pediatrics "ay e
especially unreliale and hard to study# This is co"pounded y the fact that "any large studies
e+clude pediatric patients fro" their populations% so it is possile that this population and
possile ris( factor will re"ain unaddressed in the near future#
Hven ris( factors for awareness can e deatale ecause of the low incidence and li"ited
study population# $hile Ghonei" -.//<1 hypothesi!ed e+tensively aout the possile reasons
ehind each ris( factor he listed% however there is no strong research to verify causality or even
the e+act "echanis"s that Ghonei" na"es# =ince it would e unethical to test these factors
prospectively -i#e# intentionally give too light a dose of anesthesia% allow a hypovole"ic patient
to go without fluid resuscitation1% "any ris( factors can never e tested through rando"i!ed
controlled trials#
Therefore% awareness is only "easurale retrospectively# Interventions cannot e tested
in )real ti"e* and it is hard to correlate specific clinical signs and intraoperative periods to vague
events of awareness# In studying 8I= "onitors and other interventions% the researchers "ay
struggle to definitely connect periods of awareness with 8I= inde+ nu"ers# Most studies are
forced then to loo( only at whether or not awareness occurred# This prevents% or at least "a(es
rare and difficult% research that correlates all physiological signs typically "onitored to 8I=
values during confir"ed awareness# =ince the evidence is conflicting with regards to the actual
enefits of 8I= "onitoring% there re"ains a need for e+tensive testing of 8I= "onitoring to
definitely answer whether it is indicated in the high,ris( population#
Advances of Research
The specific research around intraoperative awareness has not provided "any huge
rea(throughs in recent years# Gold standard "easures such as chec(ing for purposeful
"ove"ent and "onitoring heart rate% lood pressure% end,tidal anesthetic gases and other signs
re"ain unchanged -7Practice advisory for intraoperative awareness%7% .//01# The est advances
co"e in recognition of high,ris( procedures% techni&ues and patient characteristics# =tudies and
literature reviews have allowed identification of these ris(y procedures and techni&ues% allowing
anesthesia providers to e "ore cogni!ant of the ris(s associated with the"% should they e
necessary# =i"ilarly% identifying patient factors that "ay raise their ris( for awareness alerts
anesthesia practitioners to e particularly aware of possile co"plications#
In addition% while inconclusive% early research with 8I= "onitoring suggests there "ay e
added enefits to 8I= "onitoring in identified high,ris( patients# 9viously% "ore research is
necessary efore translating it to a road practice reco""endation% ut the early evidence is
enough for providers to consider it case,y,case as they see fit#
Discussion
The science studying intraoperative awareness is sparse at est# In uilding their practice
advisory% Anesthesiology -.//01 did an e+tensive literature search# They found only .
rando"i!ed controlled trials% which loo(ed at the effectiveness of rain "onitors# Most of the
literature discovered was either descriptive or correlational in nature# They also found that a
large outlet for incidences of awareness was individual case studies -proaly due to their
relative rarity% they are "ore li(ely to appear as single case studies1# Most of the research in this
area is not hypothesis,driven# Aside fro" new for"s of "onitoring% there are very few testale
interventions entering the practice of anesthesia with regards to intraoperative awareness#
8ecause the population e+periencing intraoperative awareness is such a s"all one% even large
scale studies struggle to prove statistical significance# 9f all the evidence discussed% only the
Myles et al# -.//31 was conducted in a rigorous "anner -doule,lind rando"i!ed clinical trial1%
and given the power analysis conducted y 9BConnor et al# -.//@1 even the Myles trial "ay not
have truly had a large enough study population to prove the efficacy that the e+peri"ental data
see"ed to show# In ter"s of true scientific rigor% the ody of evidence on intraoperative
awareness is poor at est# It lac(s statistically significant nu"ers% "ethodological rigor% and
leaves "any unresolved &uestions and issues in the field# That is not to say that this research
without value# The direction given in all of this wor( has i"pact on clinical practice% clinical
education% and further research#
The ris(s outlined in the research have strong practice i"plications for practitioners of
anesthesia and nurses involved in preoperative% intraoperative% and postoperative care# The first
step in preventing awareness is careful consideration of the patient# A co"plete and full "edical%
surgical% and social history is of great enefit# History of sustance ause% resistance to
anesthetic agents or history of intraoperative awareness are all part of a preoperative social
history that "ay e a nursing responsiility to otain% or "ay "ost li(ely co"e up in a nursing
assess"ent# In addition% nurses "ust e "indful of preoperative conditions such as hypovole"ia
or li"ited cardiac capaility# $or(ing cooperatively with the surgical and anesthesia tea"% the
preoperative nurse can "a(e sure to highlight these ite"s to the anesthesia tea"#
Intraoperatively% the research has shown oth types of surgery and anesthesia procedures
that increase the ris( of awareness# =ince the techni&ue of assessing for voluntary or refle+ive
"ove"ent is still a standard of practice% intraoperative nurses "ust e aware that "ove"ent in
the patient could potentially e a sign of awareness# The nurse "ust also e aware that a
neuro"uscular loc(ade "ay stop these "ove"ents ut does not li"it awareness in any way#
Cight anesthesia% which is also a ris( factor for awareness% "ay e used in co"ination with the
neuro"uscular loc(ade% greatly increasing the ris( of awareness# In these instances% all
providers should e aware of the ris(s and advocate for the safest yet deepest anesthesia viale in
the situation# Given that cardiac% trau"a% and ostetric surgery carry higher ris( of awareness%
nurses caring for these patients intraoperatively "ust e aware and advocate for patients
undergoing these types of surgeries# In addition% co"plications that increase ris( of awareness
intraoperatively% li(e high volu"e of fluid loss% should also e noted so that anesthesia providers
can adKust accordingly#
Post,operatively% the nurses "ust e aware of the possiility of awareness and the
co"plications that can ensue# Most of the literature used techni&ues to capture awareness in
"ore than the i""ediate post,operative period# Disclosure of awareness events can happen up
to days or wee(s post,operatively# Therefore% it is i"portant that any post,operative nurse (now
aout intraoperative awareness# The appropriate referrals need to e "ade% oth to "ental health
and to notify the anesthesia tea"% so they "ay also spea( to the patient# The nurse should also e
aware that intraoperative awareness could e a cause for sy"pto"s of an+iety and disturances
of sleep seen in post,operative patients#
Clinical utcomes
Ghonei" et al# -.//<1 hinted in his literature that a previous history of intraoperative
awareness was a ris( factor for further incidents of awareness# Patients who e+perience
intraoperative awareness have widely varying responses# Malviya et al# -.//:1 suggested that it
is possile that pediatric patients have less negative se&ulae resulting fro" intraoperative
awareness# However% "ost other literature suggests that patients "ay suffer an+iety% further
distress% slowed clinical progress% and post,trau"atic stress disorder ste""ing fro" the trau"a
of eing aware during surgery#
Conclusion
Fesearch has advanced the practice of anesthesia very far in the past few decades# Fates
of intraoperative awareness have een dropping with advances in technology and techni&ue#
However% as in all aspects of patient care% the science "ust strive for a perfect result# $hile
intraoperative awareness is% y all (nown research% a rare event% the ai"s of our research "ust e
to eli"inate it if possile# In addition% every clinical nurse that deals in any way with surgical
patient% efore or after their surgery% needs to e aware of the potential for intraoperative
awareness# $ith an eye oth to prevention and treat"ent% alert and educated nurses can play a
huge rule in preventing this co"plication of anesthesia#
$or(s Cited
Avidan% M#% Nhang% C#% 8urnside% 8#% 'in(el% O#% =earle"an% A#% =elvidge% P#% et al# -.//A1#
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@/:<#
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Q
#
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