Roy Esaki September 6 2012 PACU

Every year 20 million people are put under anesthesia. 1 in 500 stay awake the whole time
Claim from Awake

Survey of 130 patients assessing importance of postoperative outcomes:

20% of people reported recall without pain as the most important concern Overall relative weights:
Vomiting Gagging on ETT Pain Recall without pain Nausea Residual weakness 18 17.9 17.0 13.8 11.8 8.0

Macario, A&A; 1999

Clinical Background
Etiology Clinical Features Diagnosis

Brain Function Monitors

Treatment and Prevention Awareness without general anesthesia

Explicit recall of sensory perceptions during general anesthesia

Vs Awareness during MAC or Dreams (Correlate patient report with surgical events)

Inadequate Anesthetic Effect

Inadequate dose (TIVA) Resistance to anesthetic Machine malfunction

May result in:

Immediate emotional and physiological response Long-lasting Anxiety/PTSD Avoidance of future medical care or surgeries Lawsuits

Mashour, A&A, 2010

Generally accepted incidence 0.1-0.3%

Full range from .007-1% 2004 JCAHO Sentinel alert: 20,000-40,000 cases of awareness annually out of 21 million general anesthetics

1. Sandin, 2001 2. Sebel, 2004

High Risk Surgeries:

Cardiac Surgery

High Risk Situations: Difficult intubation Hypovolemia TIVA Paralysis

Trauma
(Emergent) Cesarean Section

Clinical Signs
Sympathetic activation Movement, Lacrimation, Sweating

Isolated Forearm
Inflate tourniquet prior to muscle relaxant (like ECT)

Brain Function Monitors

Processed EEG to quantify depth of sedation BIS, SEDLine, Narcotrend

Measure frontal cortex activity (+/-) EMG signal Analyze Frequency Proprietary and empirically derived formula outputs number indicating depth of anesthesia

BIS (Bi-spectral index) SEDLINE (Patient State Index) Keep value 40-60 for general anesthesia

BIS value
Unchanged by nitrous oxide Ketamine increases BIS value Lower BIS index in neurological impairment
Cerebral ischemia Dementia Hypoglycemia

Highly controversial
Industry-sponsored trials Direct-to-consumer advertising by device manufacturer

B-aware study (Myles, 2004)

2643 patients at high risk of awareness Routine (11/1418) ) vs BIS (2/1225) guided anesthesia 82% Reduction of awareness by BIS; NNT =138

B-unaware study (Avidan, 2008)

2000 high-risk patients End-tidal anesthetic gas-based protocol (2/974) vs BIS (2/967) No reduction in awareness

Ongoing Multi-center studies for average-risk patients

2006 ASA Task Force on Intraoperative Awareness

Brain function monitoring is not routinely indicated for patients undergoing general anesthesia, either to reduce the frequency of intraoperative awareness or to monitor depth of anesthesia There is insufficient evidence to justify a standard, guideline, or absolute requirement that (depth of anesthesia) devices be used to reduce the occurrence of intraoperative awareness in high-risk patients undergoing general anesthesia

2007 Cochrane Review:

Modest reduction in intraoperative primary anesthetic agent Faster recovery
Eye opening 2.4 minutes Verbal Command 2.3 minutes Extubation 3 minutes Decreased PACU stay by 6.8 minutes) No change in time to home readiness

Less post-operative nausea/vomiting Significantly reduced the incidence of intraoperative recall awareness in surgical patients with high risk of awareness (OR 0.20, 95% CI 0.05 to 0.79).

Listen, reassure, acknowledge

Document details of patient report Open-ended (vs leading) questions

Alert anesthesia team involved with case Offer medical and mental health follow-up Contact risk management (Anesthesia provider)

Novel Treatment
Psychotherapy + Gradual desensitization to OR
Mashour, Anesthesiology 2008

32 year old woman underwent a cesarean delivery. When interviewed about anesthetic problems postoperatively, she complained of hearing conversations, seeing bright lights, and feeling as though she were underwater. She was quite distressed by the recollections, as she felt as though she were dead

Patients report awareness

Occasionally with psychiatric consequences Patients report awareness to online awareness database, future anesthesia providers

Similar incidence of complaints of awareness in general (.023%) vs MAC or regional anesthesia ( .03%)

Mashour, A&A, 2009

117 patients undergoing regional anesthesia or MAC

Structured pre-operative and post-operative interviews

Examined role of expectations for level of consciousness

Nurse Esaki, A&A, 2009

Patients heavily sedated, or amnestic during previous MAC think they received general anesthesia may expect complete loss of consciousness for all future (MAC) cases

1-10 scale (completely asleep to completely awake)

Patients less awake than expected (15%)

Patients more awake than expected (8%)

Appropriate message for MAC case:

Dont worry youll be asleep for the whole procedure vs Well keep you comfortable and will give you medication for pain and anxiety
You may fall asleep or forget what happened, but that doesnt mean its general anesthesia Its like having a lot to drinksome people remember bits and pieces or dont remember all

The distinction between general and nongeneral anesthesia is often unclear from the patients perspective. might better educate patients regarding intraoperative levels of consciousness and postoperative recall.

The perioperative healthproviders Anesthesia care team

Esaki RK, Mashour Ga. Complaints Of Intraoperative Awareness After Regional Anesthesia And Sedation, In: Consciousness, Awareness, And Anesthesia, Mashour Ga Ed. Cambridge University Press. 2010 Esaki RK, Mashour GA. Level of Consciousness Monitoring, In: Handbook of Anesthesia Equipment, Sandberg W ed. Elsevier. 2011. Mashour GA, et al. A retrospective study of intraoperative awareness with methodological implications. Anesth Analg 2009;108:5216 Mashour, et al. A Novel Classification Instrument for Intraoperative Awareness Events. Anesth Anal 2010; 110: 813-815 Sebel PS, et al. The incidence of awareness during anesthesia: a multicenter United States study. Anesth Analg 2004;99:8339 Sandin RH, et al. Awareness during anaesthesia: a prospective case study. Lancet 2000; 355:70711 Pollard RJ, et al. Intraoperative awareness in a regional medical system: a review of 3 years data. Anesthesiology 2007;106:26974