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Brit. J. Anaesth.

(1968), 40, 259

FACTORS CAUSING AWARENESS DURING SURGERY


BY
D. J. WATERS

SUMMARY
Factors which can lead to awareness during surgery are considered. They are divided
into those affecting induction and those affecting maintenance. Induction: The risk of a
patient recovering consciousness while still paralyzed is greater if an ultrashort-acting
intravenous anaesthetic is used. The time interval necessary before surgery may begin
is governed by the need to build up a sufficient concentration of inhalation agent to take
over from the waning effect of the intravenous agent Maintenance: Three sources of

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trouble are distinguished, each leading to the patient receiving an anaesthetic mixture
less potent than intended. (1) Ventilators may rniy air or oxygen with the anaesthetic
gas if they are not adjusted properly or if there are leaks. Ventilators are classified
according to their propensities for doing this. (2) Some anaesthetic machines have
pitfalls. (3) A circle system is shown to need time to acquire an adequate concentration
of anaesthetic. The importance of high flowrates is stressed both at the start of an
anaesthetic and also if the circuit should happen to be broken later on.

In recent years patients undergoing surgery have venous injection diminishes in the course of time
benefited greatly from anaesthetic techniques and nothing can stop it. The effect of the inhala-
which allow major operations to be performed tion agent which follows increases over the course
under light general anaesthesia. Muscle relaxants of time but it can only do so if it is introduced
have made the biggest contribution to such tech- into the lungs. When the patient is paralyzed it is
niques but they have introduced the hazard that required that ventilation be carried out vigorously
a patient may be conscious but paralyzed (Hut- with this purpose in mind. It is not enough merely
chinson, 1961). Consequently every anaesthetist to give an occasional squeeze to an oxygen-filled
must bear this hazard in mind and be meticulous bag.
in his attention to detail so that the accident never The surgeon may be allowed to proceed when
occurs. Trouble may arise during induction of the anaesthetist judges that enough inhalation
anaesthesia or during maintenance. agent has been introduced to ensure unconscious-
ness. Occasionally it may be necessary to restrain
INDUCTION OF ANAESTHESIA an obstetrician from beginning a Caesarean sec-
The intravenous agent. tion too early, especially if premedication has been
When an intravenous agent is used before a light, the dose of intravenous agent small and the
laparotomy it must ensure unconsciousness during nitrous oxide unsupplemented.
laryngoscopy and intubation and it must continue
to act until sufficient inhalation agent has been MAINTENANCE OF ANAESTHESIA
introduced to take over. It does not matter if the
Unconsciousness is frequently maintained by
intravenous agent continues to act during the
means of a mixture of nitrous oxide and oxygen,
laparotomy provided that it has worn off by the
but there seems to have been a tendency recently
end. It follows that intravenous agents with a very
for anaesthetists to add small concentrations of
short duration of action may not serve the pur-
volatile agents (Mushin, Campbell and Shang Ng,
pose; there may be a lucid interval.
1967). Whatever is used it is incumbent upon the
Interval elapsing before surgery. anaesthetist to ensure that his patient is actually
No rules can be given in terms of minutes. It receiving the intended mixture. The factors which
can only be stated that the effect of the intra- influence what the patient actually gets may be
260 BRITISH JOURNAL OF ANAESTHESIA

considered under three heads: (i) the use of using reasonable tidal volumes and rates. If at a
mechanical ventilators, (ii) the peculiarities of later time the compliance of the chest increases
anaesthetic machines, and (iii) the elimination of so that a larger volume of gas enters at each
air from the apparatus and the lungs. breath, the fresh gas flow must be increased.
If the fresh gas flow is too small for the minute
volume which a ventilator is set to deliver, it is
Ventilators. useful if the ventilator shows it. Current versions
Mechanical ventilators are convenient aids to the of the East-Raddiffe have a reservoir bag which
anaesthetist but they introduce a risk that the stores fresh gas and which flattens prematurely
patient may not receive the same mixture as that when the fresh gas flow is too small. The Deans-
supplied from the anaesthetic machine. Air may way and the Cape have such reservoir bags also.
be drawn in through some aperture which exists Effects of a leak. Again consider the East-
by accident or design. Such a risk is readily ap- Radcliffe ventilator. Suppose that the soda-lime
preciated when a negative pressure phase is used. circuit is in use and the input of fresh gas is small

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But a risk also exists if there is a discrepancy compared with the minute volume ventilation.
between the manoeuvres which the ventilator is During the inflating downstroke of the concertina
set to perform and the amount of anaesthetic gas bag gas passes into the lungs and also out to tie
made available to it. Such a discrepancy can only atmosphere through the leak. Because of the leak
arise if the ventilator is driven by some force the bag empties more than it would normally do.
other than the anaesthetic gas. Air is thus only When it comes to refill it can derive only a limited
likely to become mixed with ths anaesthetic gas amount of gas from the lungs and only a limited
when the ventilator is not driven by the anaes- amount from the fresh gas inflow. Yet the motor-
thetic gas. ized mechanism ensures that it rises to its full
extent. It therefore develops a subatmospheric
pressure and draws in air, so diluting the anaes-
Dilution of anaesthetic mixture with air. thetic mixture.
Incompatibility between fresh gas flow and The behaviour of the East-Radcliffe ventilater
minute volume for which the ventilator is set. described in the last two paragraphs may be con-
Take as an example the East-Radcliffe ventilator, trasted with that of the Manley. The Manley is a
a time-cycled pressure generator driven by an non-rebreatbing ventilator driven by tie anaes-
electric motor. When the anaesthetist uses this thetic gas; it is a minute volume divider. If the
ventilator with soda-lime absorption he may be fresh gas flow is small the concertina bag takes a
accustomed to using a fresh gas flow of 3 l./min longer time to fill to tie volume required for
and ventilating his patient's lungs at 9 l./min. But cycling and so tie number of breaths per minute
if he changes over to the non-rebreathing circuit is reduced. The patient is ventilated at a minute
of the ventilator he must increase the fresh gas volume nominally equal to the fresh gas flow and
flow to 9 l./min. If he does not do so he may it is impossible to set e machine to do otter-
imagine that all is well merely because the con- wise.
certina bag is filling and emptying regularly and The Manley also behaves differently if there is
the chest is moving in a corresponding fashion. a leak. If the leak occurs while the bag is empty-
But if the machine is looked at more closely the ing, some of the anaesthetic gas is lost to the
inspiratory relief valve will be seen to be acting atmosphere and the lungs are under-inflated. If
with each stroke of the concertina bag and 6 1. the leak occurs when the bag is refilling the loss
of air are being drawn in every minute. If the of anaesthetic gas causes it to fill more slowly, bi
site of entry of air is occluded the bag dsvelops there is never any subatmospheric pressure to
"intercostal recession". The logical way of using draw in air.
the machine as a non-rebreathing system is to The Manley and the East-Radcliffe have been
decide what minute volume th: patient should selected for mention merely because each is repre-
receive, to supply this volume of fresh gas and sentative of the group to which it belongs. An
then to set the controls to match this figure, other pair could equally well have been chosen
FACTORS CAUSING AWARENESS DURING SURGERY 261

Use of negative pressure phase. If negative such a way that 25 per cent of the issuing gas
pressure is used during expiration and there is a consists of driving oxygen.
leak, air may be drawn into some part of the Trouble is likely to arise if the anaesdietist
ventilator. This is important if the air is subse- changes from manual control of ventilation to
quently included in the mixture used to inflate mechanical control of ventilation and forgets to
the lungs. readjust the flowmeters. It is worth noting that
Non-rebreathing ventilators discard the whole when the Cyclator is used to drive a bag-in-bottle
of the patient's expiration, so it does not matter arrangement diere is no mixing of driving gas
if this part is mixed with air. But a danger still with anaesthetic gas, so no dilution of anaesthetic
exists if the site of entry of air is somewhere along gas with oxygen can occur.
the inspiratory limb of the double pipe leading The anaesthetist allows the reservoir bag to be
from the ventilator to the patient. If this limb drawn flat. The reservoir bag from which the
becomes filled with air then air will enter the injector of the Cyclator draws its supply of anaes-
lungs during the next inflation. thetic gas will become empty if the anaesthetist

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If the ventilator has a rebreathing circuit there has not matched the total gas flow with the
is a risk of air being included in the inflating mix- patient's minute volume. Either the tidal volume
ture no matter where the air was drawn in is too big or the rate is too high or there is a
originally. The commonest rebreathing arrange- leak.
ment has a bag in a bottle and negative pressure The manufacturers' stated ratio between the
is achieved by (i) a weight acting at the bottom volume of driving oxygen and the volume of
of the free end of the concertina bag, for example entrained anaesthetic gas in the issuing gas only
the Boyle Mark HI absorber driven by the applies when anaesthetic gas is freely available.
Cyclator, (ii) by a weight and a pulley acting at After the bag has been drawn flat the ratio alters
the top free end of the concertina bag, for example to give a smaller proportion of anaesdietic gas in
the Bennett B.A.4, or (iii) by a venturi bringing the issuing mixtureor wording it differently, the
about negative pressure in the chamber surround- issuing gas has been diluted with oxygen. Once
ing the concertina bag, for example the Air- the reservoir bag has become flat the flow of gas
Shields Ventimeter. Any of these three variants is from the ventilator as a whole is less and it takes
susceptible to trouble from air entering through longer for the cycling pressure to be achieved. So
a leak. the anaesthetist should be able to tell from the
A leak during inspiration may be detected by prolonged inspiratory time that all is not well,
turning off the fresh gas inflow, obstructing the even if he has overlooked the empty bag.
flow into the patient and seeing if the bag empties If by mistake a novice feeds anaesthetic gas
when positive pressure is applied. Likewise a leak direct to the Cyclator without including a reser-
during expiration may be detected by turning off voir bag, the ventilator will behave during the
the fresh gas inflow, obstructing the flow out of inflation phase as if the bag were flat all the time,
die patient and seeing if the bag fills when nega- so there will be considerable dilution with
tive pressure is applied. Recently Bookallil (1967) oxygen. In addition anaesthetic gas will be lost
reported an instance where a faulty inspiratory through the spill valve during the expiratory
relief valve on a Cape-Waine ventilator allowed pause because there is nowhere for it to be
air to enter the apparatus during the expiratory stored.
phase only. Readjustments are not made when the trigger
starts acting. All may be well when the patient is
apnoeic but when the earliest attempts at spon-
Dilution of the anaesthetic mixture with taneous breathing are made the respiratory rate
oxygen; the Cyclator. may be much more rapid than that formerly
The anaesthetist ignores the driving oxygen. determined by the ventilator. If a non-rebreathing
The Cyclator is so designed that the driving oxy- system is to be maintained the flowmeter set-
gen passes through an injector which entrains tings will need to be increased to provide more
anaesthetic gas coming from the flowmeters in fresh gas. If the adjustment is not made the bag
262 BRITISH JOURNAL OF ANAESTHESIA

will became flat and dilution of the anaesthetic Elimination of Air.


mixture with oxygen will follow. Elimination of air at the beginning of an
anaesthetic.
Anaesthetic Machines. The apparatus normally contains air at the
beginning of an anaesthetic. Most simple semi-
The oxygen bypass tap.
dosed systems contain only a small volume of air
The bypass tap may be placed before or after and this is rapidly displaced by the flow of fresh
the flowmeter. If it is before, then the extra oxygen gas, but in a circle system this is not necessarily
is indicated by the position of the bobbin, but if so. Anaesthetic gas is fed into the circle system
it is after, there is no such indication. It is possible at one place and gas is allowed to overflow at
to administer a mixture containing more oxygen another. Air is eliminated through the intentional
than is intended if the tap is left partly turned leak and the concentration of anaesthetic gas in
on, or if it is faulty. die system rises, but this takes time. Squeezing
the reservoir bag ensures good mixing, but the

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Failure of nitrous oxide supply. rise in concentration depends on the rate of inflow
If nitrous oxide and oxygen comprise the whole of fresh gas.
inhalation mixture, failure of the nitrous oxide If uptake of anaesthetic gas by the patient be
supply leads to a rapid recovery of consciousness. ignored and perfect mixing of gases is assumed it
If it is thought reasonable to fit devices to anaes- may be shown theoretically that the concentration
thetic machines so that an alarm is sounded when of anaesthetic gas in the system rises exponentially
the supply of oxygen fails there might likewise be with time and that the time constant is given by
a case for doing the same with nitrous oxide. If die fraction
alarms are thought to be inadvisable there is still
Volume of system (lungs, tubing, bag, etc.)
something to be said for fitting pressure gauges to
nitrous oxide cylinders. Rate of inflow of fresh gas
The speed with which consciousness returns From a knowledge of the properties of exponential
when the nitrous oxide supply fails is influenced
curves (Waters and Mapleson, 1964) it may be
by the circuit in use. With a non-rebreathing cir-
said that after a lapse of time equal to three time-
cuit each inspiration now consists of pure oxygen,
constants the concentration in the system will
so consciousness returns rapidly. With a rebreath-
have reached 95 per cent of the maximum.
ing circuit each inspiration contains some nitrous
oxide from a previous expiration so consciousness Experiments have been carried out to see
returns more slowly. whether the concentration of gas within a circle
system does indeed rise in an exponential manner.
The apparatus used was a Boyle Mark III absorber
The machine does not supply any anaesthetic gas with a 4-lb. canister of soda-lime. The volume of
to the ventilator. the apparatus was measured with its reservoir bag
Some versions of the Boyle apparatus have a empty by a gas dilution method and found to be
tap which directs the gas to the closed or the open 4.1 1. The system was full of air to begin with and
circuit. If the tap is in the wrong position no gas oxygen was used to simulate anaesthetic gas, the
is supplied to the ventilator. A ventilator operated flow rate being 4 l./min. The reservoir bag was
by the anaesthetic gas, for example the Manley or squeezed by hand, inflating a model lung of the
the Howells, fails to operate, but one driven by pattern described by Cohen (1966). The resting
any other force will go on operating. If the venti- volume of the "lung" was 2.1 1. and the initial
lator which continues to operate has a non- volume of the reservoir bag was 1.8 1. The total
rebreathing circuit, air will be found to be getting volume of die system was dius 8 1. The bag was
in somewhere. If it has a closed circuit all will emptied at each squeeze, excess gas being vented
appear to be well until the patient has used up the to the atmosphere through the Heidbrink valve
limited amount of oxygen in the circuit; he will near die "lung". Gas samples were taken from die
then become cyanosed. catheter mount leading to the 'lung" and dieir
FACTORS CAUSING AWARENESS DURING SURGERY 263

oxygen content measured with an Astrup tory valve consists of a high proportion of anaes-
apparatus. thetic gas. At the beginning of an anaesthetic the
The results depicted in figure 1 show that the anaesthetist is often engaged with other tasks and
concentration of inflowing gas found in the in- may neglect ventilation.
spired gas rises over the course of time in a
fashion resembling an exponential curve and a Elimination of air later on in an anaesthetic.
logarithmic plot confirms this, but the time- If it becomes necessary to disconnect the
constant is only 1.4 minutes instead of the apparatus from the patient during the administra-
expected 2 minutes. The lower curve in figure 1 tion of an anaesthetic, for example to perform
shows how the concentration would have risen if endotracheal suction, then one must consider the
it had conformed to the theory which assumed possibility that air may gain access to the appara-
perfect mixing. Although the rise is more rapid tus. With manually controlled ventilation this will
than expected it still takes more than 4 minutes not happen to any great extent but with mechanic-
for the inspired gas to contain 95 per cent of the ally controlled ventilation it may be important.

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inflowing gas. The circumstances are those already dealt with
mrW +"= heoHincr "Ventilators" (effects of a leak;
use of negative pressure phase), the disconnected
7oANAESTHETIC GAS apparatus being regarded as constituting a very
IN INSPIRED GAS large leak. Dilution with air can be avoided by
8O switching off the ventilator before disconnecting
the apparatus. If air has been allowed to enter it
6Q should be flushed out by a large flow of fresh
anaesthetic gas; it is not sufficient merely to refill
the system with oxygen.

ACKNOWLEDGEMENTS
20
It is a pleasure to acknowledge the helpful advice and
criticism given me in the preparation of this paper by
Professor W. W. Mushin and Dr. W. W. Mapleson of
the Department of Anaesthetics, Welsh National School
1 2 3 4 5 6 of Medicine, Cardiff.
MINUTES

FIG. 1 REFERENCES
Build-up of concentration of inflowing gas within a BookaUil, M. J. (1967). Entrainment of air during
circle system. The upper curve was obtained experi- mechanical ventilation. Brit. J. Anaesth., 39, 184.
mentally; the lower curve was predicted theoretically. Cohen, A. D. (1966). An artificial lung. Anaesthesia,
For conditions, see text. 21, 569.
Eger, E. I., n (1960). Factors affecting the rapidity of
alteration of nitrous oxide concentration in a
Small flows of fresh gas are often used with circle system. Anesthesiology, 21, 348.
circle systems because such flows are economical, Hutchinson, R. (1961). Awareness during surgery. Brit.
J. Anaesth., 33, 463.
but when air has to be displaced from a system Mushin, W. W., Campbell, H., and Shang Ng, W.
big flows are needed. Eger (1960) has published (1967). The pattern of anaesthesia in a general
graphs showing how the rate of rise of concen- hospital. Brit. J. Anaesth., 39, 323.
Waters, D. J., and Mapleson, W. W. (1964). Exponen-
tration of anaesthetic agent in a circle system is tials and the anaesthetist. Anaesthesia, 19, 274.
influenced by the fresh gas flow. When the flow
was reduced by a factor of 10 the time needed to FACTEURS CAUSANT LA CONSCIENCE
reach 50 per cent of the maximum possible con- DURANT L'INTERVENTION CHIRURGICALE
centration was increased by a factor of 11. SOMMAIRE
Satisfactory mixing of gases calls for rhythmic Les facteurs qui peuvent contribuer a rendre le malade
squeezing of the reservoir bag. If this is not conscient durant une operation, sont pris en considera-
attended to, then air remains sequestered in the tion. Us sont partages d'une part en ceux qui affectent
Pinduction de l'anesthesie, et d'autre part ceux qui
lungs while the mixture lost through the expira- affectent son maintien. Induction: le risque qu'un
264 BRITISH JOURNAL OF ANAESTHESIA

patitnt redevienne conscient, tout en itant encore zuriickkehren lassen konnen. Sic werden unterteilt in
paralyse^ est plus grand lorsqu'un an;sthesique intra- solche, die die Einteitung, und solche, die die Erhalrung
veineux d'action ultracourte a 6ti employ^. L'intervalle der Narkose betreffen. Einleitung: Das Risiko, daO ein
requis avant que l'intervention puisse commencer, est Patient noch in gilahmtem Zustand zum Bewufitsein
dittrmini par la necessity de faire exister une concen- zuriickkehn, ist grofler, wenn ein ultrakurz-wirkendes,
tration suffisante de l'anesthesique inhalatoire, pour intravenos zu verabreichendes Narkotikum verwendet
compenscr la disparition de l'effet de l'agent intra- wird. Das Zeitintervall, das bis zum Operationsbeginn
veineux. Maintien: on distingue trois sources de verg;h:n mull, wird von der Notwendigkeit beherrscht,
difficultes, chacune en tant la cause que le patient eine geniigend hohe Konzentration des Inhalations-
recoit un melange anesthesique moins puissant que narkotikums aufzubauen, urn die nachlassende Wirkung
privu. (1) Les ventilateurs peuvent melanger de l'air des intravenos verabreichten Narkotikums zu ersetzen.
ou de l'oxygene au gaz anesthesiques, s'ils ne sont pas Erhaltung: Drei Ursachen, die Sorgen bereiten konnen,
bien rigles, ou s'il existe une fuite. (2) Dans certains werden unterschieden, wobci jede davon ausgeht, daO
appareils d'anesthesie, il y a d:s pieges. (3) II est der Patient ein Narkosegemisch erhalt, das weniger als
connu qu'un systeme ferine n&essite un certain temps biabsichtigt wirksam ist. (1) Die Mischung von Luft
avant d'atteindre une concentration anesthesique oder Sauerstoff mit dem Gasnarkotikurn erfolgt mog-
adiquate. L'importance d'un flux elev est rappele', lichirweise in nicht richtig geeichten oder undichten
aussi bien pour le dbut de l'anesthesie qu'en cas de Beatmungsgeraten. Beatmungsgerate werden ent-
panne ulte'rieure dans le circuit. sprcchend ihrer Eignung eingeteilt. (2) Einige Narkose-
gerate besitzen Senkraume, (die eine vollstandige

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FAKTOREN, DIE DEN PATIENTEN WAHREND Vermischung verhindern). (3) Es wird gezeigt, daO
EINES OPERATIVEN EINGRIFFS ZUM ein Umlaufsystem Zeit bsnotigt, um fur eine aus-
BEWUSSTSEIN ZUROCKKEHREN LASSEN reichende Konzentration des Narkotikums zu sorgen.
Die Wichtigkeit hoher Stromungsgeschwindigkeiten
ZUSAMMENFASSUNG sowohl zu Beginn der Narkose als auch spater nach
Es werdsn Faktoren besprochen, die den Patienten einer zufalligen Unterbrechung des Umkufs wird
wahrend eines operativen Eingriffs zum Bewufitsein hervorgehoben.

FOURTH WORLD CONGRESS OF ANAESTHESIOLOGISTS, LONDON


September 9-13,1968
REGISTRAR STEWARDS FOR SCIENTIFIC SESSIONS
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and Secretaries of Scientific Sessions from amongst the Senior Registrars and Registrars in the
United Kingdom.
Stewards will be admitted to the Congress free of charge on the day on which they are on
duty, but no guarantee can be given that they will be allocated to a particular Session. Those
who undertake one or two days' stewardship will be offered one additional day's admission free
of charge; those who undertake three day's stewardship will be offered two additional days free
of charge. A Senior Registrar or Registrar will thus be able to attend all the scientific sessions
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Daily travelling expenses will be paid only from an address in London or the Home Counties.
Volunteers for stewardship duty should write to:
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FOURTH WORLD CONGRESS OF ANAESTHESIOLOGISTS,
ROYAL MARSDEN HOSPITAL, FULHAM ROAD, LONDON, S.W.3
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