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Laferrière-Langlois P, Morisson L, Jeffries S, Duclos C, Espitalier F, Richebé P. Depth of Anesthesia and Nociception Monitoring: Current State and Vision For 2050. Anesth Analg 2024; 138:295-307. [PMID: 38215709 DOI: 10.1213/ane.0000000000006860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2024]
Abstract
Anesthesia objectives have evolved into combining hypnosis, amnesia, analgesia, paralysis, and suppression of the sympathetic autonomic nervous system. Technological improvements have led to new monitoring strategies, aimed at translating a qualitative physiological state into quantitative metrics, but the optimal strategies for depth of anesthesia (DoA) and analgesia monitoring continue to stimulate debate. Historically, DoA monitoring used patient's movement as a surrogate of awareness. Pharmacokinetic models and metrics, including minimum alveolar concentration for inhaled anesthetics and target-controlled infusion models for intravenous anesthesia, provided further insights to clinicians, but electroencephalography and its derivatives (processed EEG; pEEG) offer the potential for personalization of anesthesia care. Current studies appear to affirm that pEEG monitoring decreases the quantity of anesthetics administered, diminishes postanesthesia care unit duration, and may reduce the occurrence of postoperative delirium (notwithstanding the difficulties of defining this condition). Major trials are underway to further elucidate the impact on postoperative cognitive dysfunction. In this manuscript, we discuss the Bispectral (BIS) index, Narcotrend monitor, Patient State Index, entropy-based monitoring, and Neurosense monitor, as well as middle latency evoked auditory potential, before exploring how these technologies could evolve in the upcoming years. In contrast to developments in pEEG monitors, nociception monitors remain by comparison underdeveloped and underutilized. Just as with anesthetic agents, excessive analgesia can lead to harmful side effects, whereas inadequate analgesia is associated with increased stress response, poorer hemodynamic conditions and coagulation, metabolic, and immune system dysregulation. Broadly, 3 distinct monitoring strategies have emerged: motor reflex, central nervous system, and autonomic nervous system monitoring. Generally, nociceptive monitors outperform basic clinical vital sign monitoring in reducing perioperative opioid use. This manuscript describes pupillometry, surgical pleth index, analgesia nociception index, and nociception level index, and suggest how future developments could impact their use. The final section of this review explores the profound implications of future monitoring technologies on anesthesiology practice and envisages 3 transformative scenarios: helping in creation of an optimal analgesic drug, the advent of bidirectional neuron-microelectronic interfaces, and the synergistic combination of hypnosis and virtual reality.
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Affiliation(s)
- Pascal Laferrière-Langlois
- From the Maisonneuve-Rosemont Research Center, CIUSSS de l'Est de L'Ile de Montréal, Montreal, Quebec, Canada
- Department of Anesthesiology and Pain Medicine, Montreal University, Montreal, Quebec, Canada
| | - Louis Morisson
- Department of Anesthesiology and Pain Medicine, Montreal University, Montreal, Quebec, Canada
| | - Sean Jeffries
- Department of Experimental Surgery, McGill University, Montreal, Quebec, Canada
| | - Catherine Duclos
- Department of Anesthesiology and Pain Medicine, Montreal University, Montreal, Quebec, Canada
| | - Fabien Espitalier
- Department of Anesthesia and Intensive Care, University Hospitals of Tours, Tours, France
| | - Philippe Richebé
- From the Maisonneuve-Rosemont Research Center, CIUSSS de l'Est de L'Ile de Montréal, Montreal, Quebec, Canada
- Department of Anesthesiology and Pain Medicine, Montreal University, Montreal, Quebec, Canada
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Jafarian AA, Khatibi A, Mesbah Kiaei M, Alebouyeh MR, Alimian M, Habibi A, Amniati S. Comparison of Effects of Stress and Midazolam on Retrograde and Anterograde Amnesia in Patients Undergoing General Anesthesia. Anesth Pain Med 2023; 13:e134300. [PMID: 37404263 PMCID: PMC10317029 DOI: 10.5812/aapm-134300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 01/23/2023] [Accepted: 01/24/2023] [Indexed: 07/20/2023] Open
Abstract
Background The identification of different factors affecting anesthesia and physiological changes during anesthesia can be effective in improving the quality of anesthesia. Midazolam is a benzodiazepine that has been used for many years for sedation under anesthesia. Stress is also an important factor affecting memory and other physiological changes, such as blood pressure and heart rate. Objectives his study aimed to investigate the effects of stress on retrograde and anterograde amnesia among patients undergoing general anesthesia. Methods This multi-center, parallel, stratified, randomized controlled trial was performed on patients undergoing non-emergency abdominal laparotomy. The patients were divided into high- and low-stress groups according to the Amsterdam Preoperative Anxiety and Information Scale. Then, both groups were randomly divided into three subgroups receiving 0, 0.02, or 0.04 mg/kg of midazolam. Recall cards were shown to patients at 4 minutes, 2 minutes, and immediately before injection to determine retrograde amnesia and at 2 minutes, 4 minutes, and 6 minutes after injection to determine anterograde amnesia. Hemodynamic changes were recorded during intubation. The chi-square and multiple regression tests were used to analyze the data. Results Midazolam injection was associated with the development of anterograde amnesia in all groups (P < 0.05); however, it had no effect on the development of retrograde amnesia (P < 0.05). Midazolam could decrease the systolic and diastolic blood pressure and heart rate during intubation (P < 0.05). Stress also caused retrograde amnesia in patients (P < 0.05); nevertheless, it had no effect on anterograde amnesia (P > 0.05). Stress and midazolam injection could not affect the oxygen levels during intubation. Conclusions The results showed that midazolam injection could induce anterograde amnesia, hypotension, and heart rate; nonetheless, it had no effect on retrograde amnesia. Stress was associated with retrograde amnesia and increased heart rate; however, it was not associated with anterograde amnesia.
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Affiliation(s)
- Ali Akbar Jafarian
- Department of Anesthesiology and Pain Medicine, Motahari Medical Center, Iran University of Medical Sciences, Tehran, Iran
| | - Ali Khatibi
- Firouzgar General Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Mehrdad Mesbah Kiaei
- Department of Anesthesiology and Pain Medicine, Rasoul-Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Mahmood-Reza Alebouyeh
- Department of Anesthesiology and Pain Medicine, Rasoul-Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Mahzad Alimian
- Pain Research Center, Department of Anesthesiology and Pain Medicine, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Azadeh Habibi
- Pain Research Center, Department of Anesthesiology and Pain Medicine, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Saied Amniati
- Pain Research Center, Department of Anesthesiology and Pain Medicine, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
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Hudson AE. Presumption of insensibility during general anaesthesia. Br J Anaesth 2023; 130:e209-e212. [PMID: 36344330 DOI: 10.1016/j.bja.2022.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 09/05/2022] [Accepted: 09/17/2022] [Indexed: 11/06/2022] Open
Abstract
Whilst the general presumption of the public is that general anaesthesia prevents awareness of any sensory stimuli, Lennertz and colleagues have shown in this issue of the British Journal of Anaesthesia that 11% of young adults were able to respond to auditory commands when neuromuscular blocking drugs were prevented from reaching one arm using the isolated forearm technique. This occurred with anaesthetic regimens that followed usual clinical practice in each of the 10 countries that enrolled patients, and it was significantly more common in women than in men. This high incidence demands attention. Further characterisation of the experience of these patients is essential to our understanding of the state of general anaesthesia.
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Affiliation(s)
- Andrew E Hudson
- Department of Anesthesiology, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA; Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, Los Angeles, CA, USA.
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Bektaş M, Çakan T, Kırdemir P, Engin M, Başar H. Detection method of intraoperative awareness: a randomized comparative study. Turk J Med Sci 2022; 52:1997-2003. [PMID: 36945981 PMCID: PMC10390120 DOI: 10.55730/1300-0144.5548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 09/12/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND : The incidence of intraoperative awareness varies in a wide range in the literature. The reasons for these different results include the questioning method used and the questioning time. The goal of this study is to compare the effectiveness of different questioning methods and times used in intraoperative awareness research for detecting the incidence. METHODS We recruited patients between the ages of 18-70 years, with normal cognitive functions and able to speak after general anesthesia to the study. The patients were randomly divided into two groups. In Group 1 we applied the modified Brice questionnaire in the first 2 h and 24 h after surgery for investigating intraoperative awareness. In Group 2, 24 h after surgery, we asked about anesthesia satisfaction and patients' complaints, if any. RESULTS There was no statistically significant difference between the groups in terms of age (p = 0.514).The proportion of women was significantly higher (p = 0.002), the duration of anesthesia was shorter, and the rate of narcotic analgesic use was higher in Group 2 (p < 0.001). The assessment in the first 2 h showed the frequency of awareness was statistically higher in Group 1 than in Group 2 (p = 0.016). In the postoperative 24-h assessment, we found no significant difference in the incidence of intraoperative awareness between the groups (p < 0.05). In Group 1, there was no statistically significant difference in terms of incidence of awareness according to evaluation time (p = 250). DISCUSSION The incidence of intraoperative awareness in Group 1 was significantly higher than in Group 2 in the evaluation conducted in the first 2 h. There was no significant difference in the determination of intraoperative awareness between questioning times in group 1.
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Affiliation(s)
- Meltem Bektaş
- Department of Anesthesiology and Reanimation, Ankara Training and Research Hospital, Ankara, Turkey
| | - Türkay Çakan
- Department of Anesthesiology and Reanimation, Ankara Training and Research Hospital, Ankara, Turkey
| | - Pinar Kırdemir
- Department of Anesthesiology and Reanimation, Etlik Zübeyde Hanım Women's Health Training and Research Hospital, Ankara, Turkey
| | - Melis Engin
- Department of Anesthesiology and Reanimation, Ankara Training and Research Hospital, Ankara, Turkey
| | - Hülya Başar
- Department of Anesthesiology and Reanimation, Ankara Training and Research Hospital, Ankara, Turkey
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George BM, Pandit JJ. General anaesthetics as 'awakening agents'? Re-appraising the evidence for suggested 'pressure reversal' of anaesthesia. Clin Exp Pharmacol Physiol 2021; 48:1454-1468. [PMID: 34309890 DOI: 10.1111/1440-1681.13554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 07/06/2021] [Accepted: 07/19/2021] [Indexed: 11/30/2022]
Abstract
Increasing ambient pressure has been suggested to reverse general anaesthesia and provides support for the 'lipid theory'. Anaesthetic dissolution into cell membranes is said to cause their expansion to a critical volume. This triggers a sequence of events as basis of a unitary theory of anaesthestic mechanism. Pressure is argued to restore membrane volume to below critical level, reversing this process. We wished to review the original literature to assess internal consistency within and across papers, and to consider if alternative interpretations were possible. A literature search yielded 31 relevant 'pressure reversal' papers for narrative review, and 8 papers that allowed us to re-plot original data more consistently as 'dose-response' curves for the anaesthetics examined. Original studies were heterogenous for end-points, pressure ranges, species, and agents. Pressure effects were inconsistent, with narcosis at certain pressures and excitation at others, influenced by carrier gas (e.g., nitrogen vs helium). Pressure reversal (a right- or downward-shift on the re-plotted dose-response curves) was evident, but only in some species and at certain pressures and anaesthetic concentrations. However, even more striking was a novel 'awakening' effect of anaesthetics: i.e., anaesthetics reversed the narcotic effect of pressure, but this was limited to certain pressures at generally low anaesthetic concentrations. Contrary to the established view, 'pressure reversal' is not a universal phenomenon. The awakening effect of anaesthetics - described here for the first time - has equal evidence to support it, within the same literature, and is something that cannot be fully explained. Pressure cannot meaningfully be used to gain insight into anaesthetic mechanisms because of its heterogenous, non-specific and unpredictable effects on biological systems.
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Affiliation(s)
- Ben M George
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Jaideep J Pandit
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Trust, Oxford, UK.,University of Oxford, Oxford, UK
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Takla A, Savulescu J, Wilkinson DJC, Pandit JJ. General anaesthesia does not inevitably result in apnoea or require ventilatory support. Anaesthesia 2021; 76:1543. [PMID: 34251682 DOI: 10.1111/anae.15539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2021] [Indexed: 11/27/2022]
Affiliation(s)
- A Takla
- University of Oxford, Oxford, UK
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7
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Odor PM, Bampoe S, Lucas DN, Moonesinghe SR, Andrade J, Pandit JJ. Incidence of accidental awareness during general anaesthesia in obstetrics: a multicentre, prospective cohort study. Anaesthesia 2021; 76:759-776. [PMID: 33434945 DOI: 10.1111/anae.15385] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2020] [Indexed: 12/11/2022]
Abstract
General anaesthesia for obstetric surgery has distinct characteristics that may contribute towards a higher risk of accidental awareness during general anaesthesia. The primary aim of this study was to investigate the incidence, experience and psychological implications of unintended conscious awareness during general anaesthesia in obstetric patients. From May 2017 to August 2018, 3115 consenting patients receiving general anaesthesia for obstetric surgery in 72 hospitals in England were recruited to the study. Patients received three repetitions of standardised questioning over 30 days, with responses indicating memories during general anaesthesia that were verified using interviews and record interrogation. A total of 12 patients had certain/probable or possible awareness, an incidence of 1 in 256 (95%CI 149-500) for all obstetric surgery. The incidence was 1 in 212 (95%CI 122-417) for caesarean section surgery. Distressing experiences were reported by seven (58.3%) patients, paralysis by five (41.7%) and paralysis with pain by two (16.7%). Accidental awareness occurred during induction and emergence in nine (75%) of the patients who reported awareness. Factors associated with accidental awareness during general anaesthesia were: high BMI (25-30 kg.m-2 ); low BMI (<18.5 kg.m-2 ); out-of-hours surgery; and use of ketamine or thiopental for induction. Standardised psychological impact scores at 30 days were significantly higher in awareness patients (median (IQR [range]) 15 (2.7-52.0 [2-56]) than in patients without awareness 3 (1-9 [0-64]), p = 0.010. Four patients had a provisional diagnosis of post-traumatic stress disorder. We conclude that direct postoperative questioning reveals high rates of accidental awareness during general anaesthesia for obstetric surgery, which has implications for anaesthetic practice, consent and follow-up.
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Affiliation(s)
- P M Odor
- Centre for Anaesthesia and Peri-operative Medicine, University College London Hospital, London, UK
| | - S Bampoe
- Centre for Anaesthesia and Peri-operative Medicine, University College London Hospital, London, UK
| | - D N Lucas
- Department of Anaesthesia, Northwick Park Hospital, London, UK
| | - S R Moonesinghe
- Centre for Peri-operative Medicine, Research Department for Targeted Intervention, University College London, London, UK
| | - J Andrade
- School of Psychology, University of Plymouth, Plymouth, UK
| | - J J Pandit
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Trust, Oxford, UK.,University of Oxford, Oxford, UK
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8
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Pandit JJ, Odor PM. Author's reply: the 5th National Audit Project Handbook and the realities of the dynamic phases of (dys)anaesthesia and
EEG
limitations. Anaesthesia 2019; 74:1333-1334. [DOI: 10.1111/anae.14801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- J. J. Pandit
- Oxford University Hospitals NHS Foundation Trust OxfordUK
| | - P. M. Odor
- University College London Hospital London UK
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9
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Abstract
Accidental awareness during general anaesthesia may cause many intraoperative discomforts and bring further moderate to severe long-term symptoms including flashbacks, nightmares, hyperarousal or post-traumatic stress disorder. The incidence of awareness varied from 0.017% to 4% among studies. The relatively reliable incidence of intraoperative awareness with postoperative recall is 0.02%. The reason causing awareness was unclear. Insufficient anaesthetic dosing was thought as the principal cause. Even awareness was not comprehensively understood, some endeavors have been raised to prevent or reduce it, including i) Reducing the insufficient anaesthetic dosing induced by negligence; ii) Providing close clinical observation and clinical parameters from the monitor such as bispectral index or electroencephalogram, as well as isolated forearm technique and passive brain-computer interface may bring some effects sometimes. Because current studies still have some flaws, further trials with new detecting approach, superior methodology and underlying aetiology are needed to unfasten the possible factors causing awareness.
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Affiliation(s)
- Lu Chang
- Department of Anesthesiology, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine.,Department of Anesthesiology, Guangdong Second Provincial General Hospital
| | - Quehua Luo
- Department of Anesthesiology, Guangdong Second Provincial General Hospital.,The Second School of Clinical Medicine, Southern Medical University
| | - Yunfei Chai
- Department of Anesthesiology, Cardiovascular Institute of Guangdong Province, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences
| | - Haihua Shu
- Department of Anesthesiology, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine.,Department of Anesthesiology, Guangdong Second Provincial General Hospital
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Sinmyee S, Pandit VJ, Pascual JM, Dahan A, Heidegger T, Kreienbühl G, Lubarsky DA, Pandit JJ. Legal and ethical implications of defining an optimum means of achieving unconsciousness in assisted dying. Anaesthesia 2019; 74:630-637. [PMID: 30786320 DOI: 10.1111/anae.14532] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2018] [Indexed: 01/15/2023]
Abstract
A decision by a society to sanction assisted dying in any form should logically go hand-in-hand with defining the acceptable method(s). Assisted dying is legal in several countries and we have reviewed the methods commonly used, contrasting these with an analysis of capital punishment in the USA. We expected that, since a common humane aim is to achieve unconsciousness at the point of death, which then occurs rapidly without pain or distress, there might be a single technique being used. However, the considerable heterogeneity in methods suggests that an optimum method of achieving unconsciousness remains undefined. In voluntary assisted dying (in some US states and European countries), the common method to induce unconsciousness appears to be self-administered barbiturate ingestion, with death resulting slowly from asphyxia due to cardiorespiratory depression. Physician-administered injections (a combination of general anaesthetic and neuromuscular blockade) are an option in Dutch guidelines. Hypoxic methods involving helium rebreathing have also been reported. The method of capital punishment (USA) resembles the Dutch injection technique, but specific drugs, doses and monitoring employed vary. However, for all these forms of assisted dying, there appears to be a relatively high incidence of vomiting (up to 10%), prolongation of death (up to 7 days), and re-awakening from coma (up to 4%), constituting failure of unconsciousness. This raises a concern that some deaths may be inhumane, and we have used lessons from the most recent studies of accidental awareness during anaesthesia to describe an optimal means that could better achieve unconsciousness. We found that the very act of defining an 'optimum' itself has important implications for ethics and the law.
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Affiliation(s)
- S Sinmyee
- Department of Anaesthesia, Northwick Park Hospital, London North West Healthcare NHS Trust, London, UK
| | - V J Pandit
- University of Kent, UK.,l'Aix-Marseille Université, Marseille, France
| | - J M Pascual
- Department of Neurology and Neurotherapeutics, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - A Dahan
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - T Heidegger
- Department of Anaesthesia, Intensive Care and Resuscitation Spitalregion Rheintal Werdenberg Sarganserland, Grabs, Switzerland.,University of Bern, Bern, Switzerland
| | - G Kreienbühl
- Kantonsspital St. Gallen and Former Head of Research Ethics Committee, Kanton St Gallen, Switzerland
| | - D A Lubarsky
- Human Health Sciences and Chief Executive Officer, University of California, UC Davis Health, USA
| | - J J Pandit
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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11
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Tasbihgou SR, Vogels MF, Absalom AR. Accidental awareness during general anaesthesia - a narrative review. Anaesthesia 2018; 73:112-122. [PMID: 29210043 DOI: 10.1111/anae.14124] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2017] [Indexed: 11/30/2022]
Abstract
Unintended accidental awareness during general anaesthesia represents failure of successful anaesthesia, and so has been the subject of numerous studies during the past decades. As return to consciousness is both difficult to describe and identify, the reported incidence rates vary widely. Similarly, a wide range of techniques have been employed to identify cases of accidental awareness. Studies which have used the isolated forearm technique to identify responsiveness to command during intended anaesthesia have shown remarkably high incidences of awareness. For example, the ConsCIOUS-1 study showed an incidence of responsiveness around the time of laryngoscopy of 1:25. On the other hand, the 5th Royal College of Anaesthetists National Audit Project, which reported the largest ever cohort of patients who had experienced accidental awareness, used a system to identify patients who spontaneously self-reported accidental awareness. In this latter study, the incidence of accidental awareness was 1:19,600. In the recently published SNAP-1 observational study, in which structured postoperative interviews were performed, the incidence was 1:800. In almost all reported cases of intra-operative responsiveness, there was no subsequent explicit recall of intra-operative events. To date, there is no evidence that this occurrence has any psychological consequences. Among patients who experience accidental awareness and can later remember details of their experience, the consequences are better known. In particular, when awareness occurs in a patient who has been given neuromuscular blocking agents, it may result in serious sequelae such as symptoms of post-traumatic stress disorder and a permanent aversion to surgery and anaesthesia, and is feared by patients and anaesthetists. In this article, the published literature on the incidence, consequences and management of accidental awareness under general anaesthesia with subsequent recall will be reviewed.
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Affiliation(s)
- S R Tasbihgou
- Department of Anesthesiology, University Medical Centre Groningen, University of Groningen, the Netherlands
| | - M F Vogels
- Department of Anesthesiology, University Medical Centre Groningen, University of Groningen, the Netherlands
| | - A R Absalom
- Department of Anesthesiology, University Medical Centre Groningen, University of Groningen, the Netherlands
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13
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The Isolated Forearm Paradox: Why Never a Response to Command in the Completely Unparalyzed? Anesthesiology 2017; 127:722-723. [PMID: 28926451 DOI: 10.1097/aln.0000000000001799] [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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Hajat Z, Ahmad N, Andrzejowski J. The role and limitations of EEG-based depth of anaesthesia monitoring in theatres and intensive care. Anaesthesia 2017; 72 Suppl 1:38-47. [DOI: 10.1111/anae.13739] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2016] [Indexed: 12/14/2022]
Affiliation(s)
- Z. Hajat
- Sheffield Teaching Hospitals NHS Trust; Sheffield UK
| | - N. Ahmad
- Sheffield Teaching Hospitals NHS Trust; Sheffield UK
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15
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Pandit JJ. The isolated forearm technique in non-paralysed patients - a reply. Anaesthesia 2016; 71:344-5. [DOI: 10.1111/anae.13381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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16
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Blokland Y, Farquhar J, Lerou J, Mourisse J, Scheffer GJ, Geffen GJV, Spyrou L, Bruhn J. Decoding motor responses from the EEG during altered states of consciousness induced by propofol. J Neural Eng 2016; 13:026014. [PMID: 26859192 DOI: 10.1088/1741-2560/13/2/026014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Patients undergoing general anesthesia may awaken and become aware of the surgical procedure. Due to neuromuscular blocking agents, patients could be conscious yet unable to move. Using brain-computer interface (BCI) technology, it may be possible to detect movement attempts from the EEG. However, it is unknown how an anesthetic influences the brain response to motor tasks. APPROACH We tested the offline classification performance of a movement-based BCI in 12 healthy subjects at two effect-site concentrations of propofol. For each subject a second classifier was trained on the subject's data obtained before sedation, then tested on the data obtained during sedation ('transfer classification'). MAIN RESULTS At concentration 0.5 μg ml(-1), despite an overall propofol EEG effect, the mean single trial classification accuracy was 85% (95% CI 81%-89%), and 83% (79%-88%) for the transfer classification. At 1.0 μg ml(-1), the accuracies were 81% (76%-86%), and 72% (66%-79%), respectively. At the highest propofol concentration for four subjects, unlike the remaining subjects, the movement-related brain response had been largely diminished, and the transfer classification accuracy was not significantly above chance. These subjects showed a slower and more erratic task response, indicating an altered state of consciousness distinct from that of the other subjects. SIGNIFICANCE The results show the potential of using a BCI to detect intra-operative awareness and justify further development of this paradigm. At the same time, the relationship between motor responses and consciousness and its clinical relevance for intraoperative awareness requires further investigation.
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Affiliation(s)
- Yvonne Blokland
- Radboud University Medical Centre, Department of Anaesthesiology, Pain and Palliative Medicine, PO Box 9101, 6500 HB Nijmegen, The Netherlands. Radboud University Nijmegen, Donders Institute for Brain, Cognition and Behaviour, Montessorilaan 3, 6525 HR Nijmegen, The Netherlands
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Pandit JJ. An observational study of the 'isolated forearm technique' in unparalysed, spontaneously breathing patients. Anaesthesia 2015; 70:1369-74. [PMID: 26443293 DOI: 10.1111/anae.13242] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2015] [Indexed: 11/27/2022]
Abstract
The isolated forearm technique enables a patient, otherwise paralysed by neuromuscular blockade, to communicate by movement if wakeful during surgery. The positive response rate to verbal command is high (~32%). The 5th National Audit Project recommended that this monitoring technique should become more widely taught and considered, so this study was designed to assess its utility as a standard of care in unparalysed patients. A positive response rate as high as in the paralysed would justify local adoption. Therefore, 100 consecutive patients undergoing urology surgery were given verbal commands to move at two-minute intervals from induction of anaesthesia (fentanyl and propofol) to full emergence and extubation of the supraglottic airway. Anaesthesia was maintained with isoflurane in oxygen/nitrous oxide. Although 24 patients moved during surgery (and therefore needed additional anaesthetic), none moved to verbal command. Even at extubation, when patients moved to expel the airway, there was no response to command until after wakening. These results suggest that in contrast to its use in paralysed patients, the isolated forearm technique does not yield useful information about the patient's state of wakefulness in the unparalysed. Another interpretation is that unparalysed patients are less prone to wakefulness than the paralysed.
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Affiliation(s)
- J J Pandit
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Trust, Oxford, UK
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Cook T, Pandit J. Pitfalls of comparing incidences of awareness from NAP5 and from Brice studies. Br J Anaesth 2015; 115:471-2. [DOI: 10.1093/bja/aev273] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
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Pandit J, Cook T. Appropriate dosing of lipid-soluble anaesthetics in obese patients: NAP5 recommendations. Br J Anaesth 2015; 115:141-2. [DOI: 10.1093/bja/aev176] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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20
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The 9th International Symposium on Memory and Awareness in Anesthesia (MAA9). Br J Anaesth 2015. [DOI: 10.1093/bja/aev204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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21
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Pandit J, Russell I, Wang M. Interpretations of responses using the isolated forearm technique in general anaesthesia: a debate. Br J Anaesth 2015; 115 Suppl 1:i32-i45. [DOI: 10.1093/bja/aev106] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
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22
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Pandit JJ, Cook TM, Wang M, Andrade J. NAP5 and isolated forearm technique: reply. Br J Anaesth 2015; 115:139-40. [PMID: 26089461 DOI: 10.1093/bja/aev196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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23
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Mashour GA, Avidan MS. Intraoperative awareness: controversies and non-controversies. Br J Anaesth 2015; 115 Suppl 1:i20-i26. [PMID: 25735710 DOI: 10.1093/bja/aev034] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2014] [Indexed: 01/17/2023] Open
Abstract
Intraoperative awareness, with or without recall, continues to be a topic of clinical significance and neurobiological interest. In this article, we review evidence pertaining to the incidence, sequelae, and prevention of intraoperative awareness. We also assess which aspects of the complication are well understood (i.e. non-controversial) and which require further research for clarification (i.e. controversial).
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Affiliation(s)
- G A Mashour
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - M S Avidan
- Washington University School of Medicine, St Louis, MO, USA
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24
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Veselis RA. Memory formation during anaesthesia: plausibility of a neurophysiological basis. Br J Anaesth 2015; 115 Suppl 1:i13-i19. [PMID: 25735711 DOI: 10.1093/bja/aev035] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
As opposed to conscious, personally relevant (explicit) memories that we can recall at will, implicit (unconscious) memories are prototypical of 'hidden' memory; memories that exist, but that we do not know we possess. Nevertheless, our behaviour can be affected by these memories; in fact, these memories allow us to function in an ever-changing world. It is still unclear from behavioural studies whether similar memories can be formed during anaesthesia. Thus, a relevant question is whether implicit memory formation is a realistic possibility during anaesthesia, considering the underlying neurophysiology. A different conceptualization of memory taxonomy is presented, the serial parallel independent model of Tulving, which focuses on dynamic information processing with interactions among different memory systems rather than static classification of different types of memories. The neurophysiological basis for subliminal information processing is considered in the context of brain function as embodied in network interactions. Function of sensory cortices and thalamic activity during anaesthesia are reviewed. The role of sensory and perisensory cortices, in particular the auditory cortex, in support of memory function is discussed. Although improbable, with the current knowledge of neurophysiology one cannot rule out the possibility of memory formation during anaesthesia.
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Affiliation(s)
- R A Veselis
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY, USA Department of Anesthesiology, Weill Cornell Medical College, 1300 York Avenue, New York, NY, USA
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25
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Absalom AR, Green D. NAP5: the tip of the iceberg, or all we need to know? Br J Anaesth 2014; 113:527-30. [PMID: 25236893 DOI: 10.1093/bja/aeu349] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- A R Absalom
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30 001, 9700 RB Groningen, The Netherlands
| | - D Green
- Department of Anaesthesia, Kings College Hospital London, UK
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27
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Pandit JJ, Andrade J, Bogod DG, Hitchman JM, Jonker WR, Lucas N, Mackay JH, Nimmo AF, O'Connor K, O'Sullivan EP, Paul RG, Palmer JHM, Plaat F, Radcliffe JJ, Sury MRJ, Torevell HE, Wang M, Hainsworth J, Cook TM. The 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: summary of main findings and risk factors. Anaesthesia 2014; 69:1089-101. [PMID: 25204236 DOI: 10.1111/anae.12826] [Citation(s) in RCA: 112] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2014] [Indexed: 12/17/2022]
Abstract
We present the main findings of the 5th National Audit Project on accidental awareness during general anaesthesia. Incidences were estimated using reports of accidental awareness as the numerator, and a parallel national anaesthetic activity survey to provide denominator data. The incidence of certain/probable and possible accidental awareness cases was ~1:19 600 anaesthetics (95% CI 1:16 700-23 450). However, there was considerable variation across subtypes of techniques or subspecialties. The incidence with neuromuscular blockade was ~1:8200 (1:7030-9700), and without it was ~1:135 900 (1:78 600-299 000). The cases of accidental awareness during general anaesthesia reported to 5th National Audit Project were overwhelmingly cases of unintended awareness during neuromuscular blockade. The incidence of accidental awareness during caesarean section was ~1:670 (1:380-1300). Two thirds (82, 66%) of cases of accidental awareness experiences arose in the dynamic phases of anaesthesia, namely induction of and emergence from anaesthesia. During induction of anaesthesia, contributory factors included: use of thiopental; rapid sequence induction; obesity; difficult airway management; neuromuscular blockade; and interruptions of anaesthetic delivery during movement from anaesthetic room to theatre. During emergence from anaesthesia, residual paralysis was perceived by patients as accidental awareness, and commonly related to a failure to ensure full return of motor capacity. One third (43, 33%) of accidental awareness events arose during the maintenance phase of anaesthesia, most due to problems at induction or towards the end of anaesthesia. Factors increasing the risk of accidental awareness included: female sex; age (younger adults, but not children); obesity; anaesthetist seniority (junior trainees); previous awareness; out-of-hours operating; emergencies; type of surgery (obstetric, cardiac, thoracic); and use of neuromuscular blockade. The following factors were not risk factors for accidental awareness: ASA physical status; race; and use or omission of nitrous oxide. We recommend that an anaesthetic checklist, to be an integral part of the World Health Organization Safer Surgery checklist, is introduced as an aid to preventing accidental awareness. This paper is a shortened version describing the main findings from 5th National Audit Project - the full report can be found at http://www.nationalauditprojects.org.uk/NAP5_home#pt.
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Affiliation(s)
- J J Pandit
- Nuffield Department of Anaesthesia, Oxford University Hospitals NHS Trust, Oxford, UK
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28
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Pandit JJ, Andrade J, Bogod DG, Hitchman JM, Jonker WR, Lucas N, Mackay JH, Nimmo AF, O'Connor K, O'Sullivan EP, Paul RG, Palmer JHMG, Plaat F, Radcliffe JJ, Sury MRJ, Torevell HE, Wang M, Hainsworth J, Cook TM. 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: summary of main findings and risk factors. Br J Anaesth 2014; 113:549-59. [PMID: 25204697 DOI: 10.1093/bja/aeu313] [Citation(s) in RCA: 259] [Impact Index Per Article: 25.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
We present the main findings of the 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia (AAGA). Incidences were estimated using reports of accidental awareness as the numerator, and a parallel national anaesthetic activity survey to provide denominator data. The incidence of certain/probable and possible accidental awareness cases was ~1:19,600 anaesthetics (95% confidence interval 1:16,700-23,450). However, there was considerable variation across subtypes of techniques or subspecialities. The incidence with neuromuscular block (NMB) was ~1:8200 (1:7030-9700), and without, it was ~1:135,900 (1:78,600-299,000). The cases of AAGA reported to NAP5 were overwhelmingly cases of unintended awareness during NMB. The incidence of accidental awareness during Caesarean section was ~1:670 (1:380-1300). Two-thirds (82, 66%) of cases of accidental awareness experiences arose in the dynamic phases of anaesthesia, namely induction of and emergence from anaesthesia. During induction of anaesthesia, contributory factors included: use of thiopental, rapid sequence induction, obesity, difficult airway management, NMB, and interruptions of anaesthetic delivery during movement from anaesthetic room to theatre. During emergence from anaesthesia, residual paralysis was perceived by patients as accidental awareness, and commonly related to a failure to ensure full return of motor capacity. One-third (43, 33%) of accidental awareness events arose during the maintenance phase of anaesthesia, mostly due to problems at induction or towards the end of anaesthesia. Factors increasing the risk of accidental awareness included: female sex, age (younger adults, but not children), obesity, anaesthetist seniority (junior trainees), previous awareness, out-of-hours operating, emergencies, type of surgery (obstetric, cardiac, thoracic), and use of NMB. The following factors were not risk factors for accidental awareness: ASA physical status, race, and use or omission of nitrous oxide. We recommend that an anaesthetic checklist, to be an integral part of the World Health Organization Safer Surgery checklist, is introduced as an aid to preventing accidental awareness. This paper is a shortened version describing the main findings from NAP5--the full report can be found at http://www.nationalauditprojects.org.uk/NAP5_home.
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Affiliation(s)
- J J Pandit
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Trust, Oxford, UK
| | - J Andrade
- Department of Psychology, School of Psychology and Cognition Institute, Plymouth University, Plymouth, UK
| | - D G Bogod
- Department of Anaesthesia, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - J M Hitchman
- Member Royal College of Anaesthetists' Lay Committee, London, UK
| | - W R Jonker
- Department of Anaesthesia, Intensive Care and Pain Medicine, Sligo Regional Hospital, Sligo, Ireland
| | - N Lucas
- Department of Anaesthesia, Northwick Park Hospital, Harrow, Middlesex, UK
| | - J H Mackay
- Department of Anaesthesia, Papworth Hospital, Cambridge, UK
| | - A F Nimmo
- Department of Anaesthesia, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - K O'Connor
- Bristol School of Anaesthesia, Bristol, UK
| | - E P O'Sullivan
- Department of Anaesthesia, St James Hospital, James Street, Dublin, Ireland
| | - R G Paul
- Adult Intensive Care Unit, Royal Brompton Hospital, London, UK
| | - J H M G Palmer
- Department of Anaesthesia, Salford Royal Hospital, Salford, UK
| | - F Plaat
- Department of Anaesthesia, Imperial College NHS Trust, London, UK
| | - J J Radcliffe
- Department of Neuroanaesthesia, National Hospital for Neurology and Neurosurgery, Queen Square, UK
| | - M R J Sury
- Department of Anaesthesia, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - H E Torevell
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - M Wang
- University of Leicester, Leicester, UK
| | - J Hainsworth
- Leicestershire Partnership NHS Trust, Leicester, UK
| | - T M Cook
- Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK
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29
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Cook TM, Andrade J, Bogod DG, Hitchman JM, Jonker WR, Lucas N, Mackay JH, Nimmo AF, O'Connor K, O'Sullivan EP, Paul RG, Palmer JHM, Plaat F, Radcliffe JJ, Sury MRJ, Torevell HE, Wang M, Hainsworth J, Pandit JJ. The 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: patient experiences, human factors, sedation, consent and medicolegal issues. Anaesthesia 2014; 69:1102-16. [DOI: 10.1111/anae.12827] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2014] [Indexed: 11/30/2022]
Affiliation(s)
- T. M. Cook
- Department of Anaesthesia and Intensive Care Medicine; Royal United Hospital; Bath UK
| | - J. Andrade
- Department of Psychology; School of Psychology and Cognition Institute; Plymouth University; Plymouth UK
| | - D. G. Bogod
- Nottingham University Hospitals NHS Trust; Nottingham UK
| | | | - W. R. Jonker
- Department of Anaesthesia, Intensive Care and Pain Medicine; Sligo Regional Hospital; Sligo Ireland
| | - N. Lucas
- Northwick Park Hospital; Harrow Middlesex UK
| | | | - A. F. Nimmo
- Department of Anaesthesia; Royal Infirmary of Edinburgh; Edinburgh UK
| | | | | | - R. G. Paul
- Adult Intensive Care Unit; Royal Brompton Hospital; London UK
| | | | - F. Plaat
- Department of Anaesthesia; Imperial College NHS Trust; London UK
| | - J. J. Radcliffe
- Department of Neuroanaesthesia; National Hospital for Neurology and Neurosurgery; University College Hospitals London Trust; London UK
| | - M. R. J. Sury
- Department of Anaesthesia; Great Ormond Street Hospital NHS Foundation Trust; London UK
| | - H. E. Torevell
- Bradford Teaching Hospitals NHS Foundation Trust; Bradford UK
| | - M. Wang
- Department of Clinical Psychology; University of Leicester; Leicester UK
| | | | - J. J. Pandit
- Nuffield Department of Anaesthesia; Oxford University Hospitals NHS Trust; Oxford UK
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30
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Cook TM, Andrade J, Bogod DG, Hitchman JM, Jonker WR, Lucas N, Mackay JH, Nimmo AF, O'Connor K, O'Sullivan EP, Paul RG, Palmer JHMG, Plaat F, Radcliffe JJ, Sury MRJ, Torevell HE, Wang M, Hainsworth J, Pandit JJ. 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: patient experiences, human factors, sedation, consent, and medicolegal issues. Br J Anaesth 2014; 113:560-74. [PMID: 25204696 DOI: 10.1093/bja/aeu314] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The 5th National Audit Project (NAP5) of the Royal College of Anaesthetists and the Association of Anaesthetists of Great Britain and Ireland into accidental awareness during general anaesthesia (AAGA) yielded data related to psychological aspects from the patient, and the anaesthetist, perspectives; patients' experiences ranged from isolated auditory or tactile sensations to complete awareness. A striking finding was that 75% of experiences were for <5 min, yet 51% of patients [95% confidence interval (CI) 43-60%] experienced distress and 41% (95% CI 33-50%) suffered longer term adverse effect. Distress and longer term harm occurred across the full range of experiences but were particularly likely when the patient experienced paralysis (with or without pain). The patient's interpretation of what is happening at the time of the awareness seemed central to later impact; explanation and reassurance during suspected AAGA or at the time of report seemed beneficial. Quality of care before the event was judged good in 26%, poor in 39%, and mixed in 31%. Three-quarters of cases of AAGA (75%) were judged preventable. In 12%, AAGA care was judged good and the episode not preventable. The contributory and human factors in the genesis of the majority of cases of AAGA included medication, patient, and education/training. The findings have implications for national guidance, institutional organization, and individual practice. The incidence of 'accidental awareness' during sedation (~1:15,000) was similar to that during general anaesthesia (~1:19,000). The project raises significant issues about information giving and consent for both sedation and anaesthesia. We propose a novel approach to describing sedation from the patient's perspective which could be used in communication and consent. Eight (6%) of the patients had resorted to legal action (12, 11%, to formal complaint) at the time of reporting. NAP5 methodology provides a standardized template that might usefully inform the investigation of claims or serious incidents related to AAGA.
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Affiliation(s)
- T M Cook
- Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK
| | - J Andrade
- School of Psychology and Cognition Institute, Plymouth University, Plymouth, UK
| | - D G Bogod
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - J M Hitchman
- Member Royal College of Anaesthetists' Lay Committee, London, UK
| | - W R Jonker
- Department of Anaesthesia, Intensive Care and Pain Medicine, Sligo Regional Hospital, Sligo, Ireland
| | - N Lucas
- Northwick Park Hospital, Harrow, Middlesex, UK
| | | | - A F Nimmo
- Department of Anaesthesia, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - K O'Connor
- Bristol School of Anaesthesia, Bristol, UK
| | | | - R G Paul
- Adult Intensive Care Unit, Royal Brompton Hospital, London, UK
| | | | - F Plaat
- Imperial College NHS Trust, London, UK
| | - J J Radcliffe
- Department of Neuroanaesthesia, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - M R J Sury
- Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - H E Torevell
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - M Wang
- University of Leicester, Leicester, UK
| | - J Hainsworth
- Leicestershire Partnership NHS Trust, Leicester, UK
| | - J J Pandit
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Trust, Oxford, UK
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