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General anesthesia in the parturient. Int Anesthesiol Clin 2021; 59:78-89. [PMID: 34029247 DOI: 10.1097/aia.0000000000000327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bischoff P, Rundshagen I, Schneider G. [Undesired awareness phenomena during general anesthesia: Evidence-based state of knowledge, current discussions and strategies for prevention and management]. Anaesthesist 2016; 64:732-9. [PMID: 26411583 DOI: 10.1007/s00101-015-0095-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Patient awareness during general anesthesia and the later recall of what happened during surgery can be experienced by patients as horrifying events that leave lasting mental trauma in the form of posttraumatic stress syndrome (PTSS). Awareness is related to a temporary insufficient depth of anesthesia. This phenomenon has been discussed for more than 20 years. According to randomized controlled studies, in the absence of risk factors awareness phenomena occur in 1-2 per 1000 operations involving general anesthesia (0.1-0.2%) and are classified as occasionally occurring critical events. An astonishing twist occurred elicited by the recent data from the 5th National Audit Project from Great Britain (NAP5) published in the British Journal of Anaesthesia and in Anaesthesia. The NAP5 evaluated patient reports of accidental awareness during general anesthesia (AAGA) in a multicenter manner in more than 2.7 million cases and indicated incidences of awareness of only 1:19,600, a frequency 20 times less than previously reported. These results gave rise to some controversy. It seems likely that, due to the absence of structured interviews, the NAP5 data only demonstrated the tip of the iceberg and may have vastly underestimated the real incidence of intraoperative awareness. The present overview summarizes the current knowledge about awareness. Furthermore, it addresses the question whether the awareness problem has been overestimated by evidence-based criteria or underestimated by the results of the NAP5. The responsibility for sufficient anesthesia in the clinical routine requires knowledge of awareness risks and potential sequelae. A formal recommendation from the German Society of Anesthesia and Intensive Care Medicine (DGAI) concerning awareness is not yet available; however, the recognition of evidence-based strategies in the management of anesthesia may minimize the occurrence of awareness and its sequelae.
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Affiliation(s)
- P Bischoff
- Klinik für Anästhesiologie, operative Intensivmedizin, Schmerz- und Palliativmedizin, Marien Hospital Herne, Universitätsklinikum der Ruhr-Universität Bochum, Hölkeskampring 40, 44625, Herne, Deutschland.
| | - I Rundshagen
- Praxisgemeinschaft Dupierry, Callesen, Rundshagen, Hamburg, Deutschland
| | - G Schneider
- Klinik für Anästhesiologie, HELIOS Klinikum Wuppertal, Klinikum der Universität Witten/Herdecke, Wuppertal, Deutschland
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Laukkala T, Ranta S, Wennervirta J, Henriksson M, Suominen K, Hynynen M. Long-Term Psychosocial Outcomes after Intraoperative Awareness with Recall. Anesth Analg 2014; 119:86-92. [DOI: 10.1213/ane.0000000000000257] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Prendergast KM, Cullen-Drill M. Anesthesia Awareness-Induced Posttraumatic Stress Disorder. J Psychosoc Nurs Ment Health Serv 2012; 50:39-44. [DOI: 10.3928/02793695-20121003-03] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Accepted: 07/27/2012] [Indexed: 11/20/2022]
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Bruchas RR, Kent CD, Wilson HD, Domino KB. Anesthesia awareness: narrative review of psychological sequelae, treatment, and incidence. J Clin Psychol Med Settings 2012; 18:257-67. [PMID: 21512752 DOI: 10.1007/s10880-011-9233-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Awareness during general anesthesia occurs when patients recall events or sensations during their surgeries, although the patients should have been unconscious at the time. Anesthesiologists are cognizant of this phenomenon, but few discussions occur outside the discipline. This narrative review summarizes the patient recollections, psychological sequelae, treatment and follow-up of psychological consequences, as well as incidence and etiology of awareness during general anesthesia. Recalled memories include noises, conversations, images, mental processes, feelings of pain and/or paralysis. Psychological consequences include anxiety, flashbacks, and posttraumatic stress disorder diagnosis. Limited discussion for therapeutic treatment after an anesthesia awareness experience exists. The incidence of anesthesia awareness ranges from 0.1 to 0.2% (e.g., 1-2/1000 patients). Increased recognition of awareness during general anesthesia within the psychological/counseling community, with additional research focusing on optimal therapeutic treatment, will improve the care of these patients.
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Affiliation(s)
- Robin R Bruchas
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA, USA
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Intraoperative neurophysiological monitoring of the afferent pain pathway in cardiac surgery patients. Clin Neurophysiol 2011; 122:2093-9. [DOI: 10.1016/j.clinph.2011.03.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2010] [Revised: 02/23/2011] [Accepted: 03/24/2011] [Indexed: 11/20/2022]
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Kar N. Cognitive behavioral therapy for the treatment of post-traumatic stress disorder: a review. Neuropsychiatr Dis Treat 2011; 7:167-81. [PMID: 21552319 PMCID: PMC3083990 DOI: 10.2147/ndt.s10389] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2011] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Post-traumatic stress disorder (PTSD) is a psychiatric sequel to a stressful event or situation of an exceptionally threatening or catastrophic nature. Cognitive behavioral therapy (CBT) has been used in the management of PTSD for many years. This paper reviews the effectiveness of CBT for the treatment of PTSD following various types of trauma, its potential to prevent PTSD, methods used in CBT, and reflects on the mechanisms of action of CBT in PTSD. METHODS Electronic databases, including PubMed, were searched for articles on CBT and PTSD. Manual searches were conducted for cross-references in the relevant journal sites. RESULTS The current literature reveals robust evidence that CBT is a safe and effective intervention for both acute and chronic PTSD following a range of traumatic experiences in adults, children, and adolescents. However, nonresponse to CBT by PTSD can be as high as 50%, contributed to by various factors, including comorbidity and the nature of the study population. CBT has been validated and used across many cultures, and has been used successfully by community therapists following brief training in individual and group settings. There has been effective use of Internet-based CBT in PTSD. CBT has been found to have a preventive role in some studies, but evidence for definitive recommendations is inadequate. The effect of CBT has been mediated mostly by the change in maladaptive cognitive distortions associated with PTSD. Many studies also report physiological, functional neuroimaging, and electroencephalographic changes correlating with response to CBT. CONCLUSION There is scope for further research on implementation of CBT following major disasters, its preventive potential following various traumas, and the neuropsychological mechanisms of action.
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Affiliation(s)
- Nilamadhab Kar
- Department of Psychiatry, Wolverhampton City Primary Care Trust, Wolverhampton, UK
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Bischoff P, Rundshagen I. Awareness under general anesthesia. DEUTSCHES ARZTEBLATT INTERNATIONAL 2011; 108:1-7. [PMID: 21285993 PMCID: PMC3026393 DOI: 10.3238/arztebl.2011.0001] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2010] [Accepted: 06/24/2010] [Indexed: 11/27/2022]
Abstract
BACKGROUND Awareness while under general anesthesia, and the later recall of what happened during surgery, can be experienced by patients as horrific events that leave lasting mental trauma behind. Patients may have both auditory and tactile perception, potentially accompanied by feelings of helplessness, inability to move, pain, and panic ranging to an acute fear of death. For some patients, the experience of awareness under anesthesia has no sequelae; for others, however, it can lead to the development of post-traumatic stress disorder, consisting of complex psychopathological phenomena such as anxiety, insomnia, nightmares, irritability, and depression possibly leading to suicidality. METHODS The literature on the subject was selectively reviewed. RESULTS In the absence of risk factors awareness phenomena occur in one to two per 1000 operations under general anesthesia (0.1% to 0.2%) and are thus classed as an occasionally occurring critical event. In children, the risk of such phenomena occurring is 8 to 10 times higher. These phenomena are due to an inadequate depth of anesthesia with incomplete unconsciousness. They can be promoted by a number of risk factors that are either patient-related (ASA class III or above, medication abuse), surgery-related (Caesarean section, emergency procedures, surgery at night), or anesthesia-related (anesthesia without benzodiazepines, use of muscle relaxants). CONCLUSION Strategies for avoiding awareness phenomena under anesthesia include the training of staff to know about the problem and, specifically, the use of benzodiazepines, the avoidance of muscle relaxants if possible, and shielding the patient from excessive noise. EEG monitoring is effective but provides no guarantee against awareness. If awareness under anesthesia occurs despite these measures, the patient must be given expert, interdisciplinary treatment as soon after the event as possible in order to minimize its potential sequelae.
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Affiliation(s)
- Petra Bischoff
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Knappschaftskrankenhaus Bochum-Langendreer, Klinikum der Ruhr Universität Bochum, In der Schornau 23–25, 44892 Bochum, Germany
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A prospective study of bispectral index scoring in mentally retarded patients receiving general anesthesia. J Clin Anesth 2010; 22:432-6. [DOI: 10.1016/j.jclinane.2009.11.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2009] [Revised: 11/09/2009] [Accepted: 11/15/2009] [Indexed: 11/21/2022]
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Mashour GA, Esaki RK, Tremper KK, Glick DB, O'Connor M, Avidan MS. A novel classification instrument for intraoperative awareness events. Anesth Analg 2009; 110:813-5. [PMID: 19713251 DOI: 10.1213/ane.0b013e3181b6267d] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Intraoperative awareness with explicit recall occurs in approximately 1-2 cases per 1000. Given the rarity of the event, a better understanding of awareness and its sequelae will likely require the compilation of data from numerous studies. As such, a standard description and expression of awareness events would be of value. METHODS We developed a novel classification instrument for intraoperative awareness events: Class 0: no awareness; Class 1: isolated auditory perceptions; Class 2: tactile perceptions (e.g., surgical manipulation or endotracheal tube); Class 3: pain; Class 4: paralysis (e.g., feeling one cannot move, speak, or breathe); and Class 5: paralysis and pain. An additional designation of "D" for distress was also included for patient reports of fear, anxiety, suffocation, sense of doom, sense of impending death, or other explicit descriptions. We reviewed 15 studies of the incidence of awareness that provided specific information about awareness reports. Five anesthesiologists at three institutions who developed the categories independently classified the events. An additional 20 individuals (attending anesthesiologists, anesthesiology residents, nurse anesthetists, medical students, and ancillary staff) not involved in the development of the categories also independently classified the events. Fleiss's kappa statistic was used to evaluate inter-observer agreement. RESULTS One hundred fifty-one cases of intraoperative awareness in adults were identified as valid for analysis. The overall kappa value was 0.851 (0.847-0.856, 95% confidence interval) for the basic Classes 1-5. Including additional designations of emotional distress, the overall kappa value was 0.779 (0.776-0.783, 95% confidence interval). CONCLUSION We report a novel classification instrument for intraoperative awareness events that has excellent inter-observer agreement and that may facilitate the study of intraoperative awareness.
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Affiliation(s)
- George A Mashour
- Department of Anesthesiology, University of Michigan Medical School, 1H247 UH/SPC-5048, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5048, USA.
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Jensen EW, Jospin M, Gambus PL, Vallverdu M, Caminal P. Validation of the Index of Consciousness (IoC) during sedation/analgesia for ultrasonographic endoscopy. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2009; 2008:5552-5. [PMID: 19163975 DOI: 10.1109/iembs.2008.4650472] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The level of consciousness of patients undergoing surgery evolves continuously as the effect of the anesthetic agents is counteracted by the surgical stimuli. The monitors of depth of anesthesia, based on the analysis of the electroencephalogram (EEG), have been progressively introduced into the daily practice to provide additional information about the state of the patient. In this work, the Index of Consciousness (IoC), a recent index which uses the information from EEG spectrum and symbolic dynamics through a fuzzy inference system, is introduced. The bispectral index BIS, a well-established index, is used to validate the IoC. A good correlation is found between both indexes. Furthermore, IoC presents a significantly higher prediction probability Pk of the level of sedation than BIS, and can thus be considered as an interesting measure of the level of consciousness.
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Affiliation(s)
- Erik W Jensen
- Department of Automatic Control, Biomedical Engineering Research Center, Technical University of Catalonia (UPC), CIBER-BBN, 08028 Barcelona, Spain.
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Avidan MS, Mashour GA, Glick DB. Prevention of awareness during general anesthesia. F1000 MEDICINE REPORTS 2009; 1. [PMID: 20948688 PMCID: PMC2920697 DOI: 10.3410/m1-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Awareness during general anesthesia with subsequent explicit recall is a serious and frequently preventable problem that is gaining attention from clinicians and patients alike. Cost-effective interventions that increase vigilance should be implemented to decrease the likelihood of this complication.
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Affiliation(s)
- Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine, CampusBox 8054, 660 South Euclid Avenue, St Louis, MO 63110USA
| | - George A Mashour
- Department of Anesthesiology, University of Michigan1H247 UH, SPC 5048, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5048USA
| | - David B Glick
- Department of Anesthesia and Critical Care, University of ChicagoMC4028, 5841 South Maryland Avenue, Chicago, IL 60637USA
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Revuelta M, Paniagua P, Campos JM, Fernández JA, Martínez A, Jospin M, Litvan H. Validation of the index of consciousness during sevoflurane and remifentanil anaesthesia: a comparison with the bispectral index and the cerebral state index. Br J Anaesth 2008; 101:653-8. [PMID: 18723856 DOI: 10.1093/bja/aen245] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The purpose of this study was to validate a new level of consciousness monitor derived from the EEG, called the index of consciousness (IoC), by comparing it with the bispectral index (BIS) and the cerebral state index (CSI) during general anaesthesia for cardiac surgery using sevoflurane, remifentanil, and atracurium. METHODS After ethical committee approval and written patient consent, data from 35 patients [31 males, four females, age 55 (10) yr] were recorded during general anaesthesia for elective cardiac bypass surgery. All patients were induced with sevoflurane 8%, until the Observer's Assessment of Alertness and Sedation (OAAS) scale level 1 was reached, and then was set at a 1% end-tidal sevoflurane concentration. Subsequently, remifentanil and atracurium were administered, the trachea was intubated, and the procedure continued as usual. To assess accuracy, the prediction probability (Pk) was calculated both during induction and during maintenance. RESULTS The Pk values [mean (se)] for IoC, BIS, and CSI during induction were 0.90 (0.01), 0.90 (0.01), and 0.88 (0.01), respectively, whereas the corresponding Pk values during maintenance were 0.95 (0.01), 0.94 (0.01), and 0.60 (0.01). CONCLUSIONS The three indices performed equally well during the induction phase and were able to predict the level of consciousness of the patients satisfactorily. During maintenance, the IoC and the BIS showed good agreement with the clinical signs. The CSI was significantly influenced by the administration of atracurium; therefore, the agreement with the OAAS scale during the maintenance phase was significantly less for CSI than for IoC and BIS.
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Affiliation(s)
- M Revuelta
- Anaesthesia Research Group, Cardiac Anaesthesia and Postoperative Intensive Care Unit, Hospital Santa Creu i Sant Pau, Antonio Maria Claret 167, 08025 Barcelona, Spain.
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Affiliation(s)
- Kate Leslie
- Department of Pahrmacology, University of Melbourne, Melbourne, Australia.
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