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Kim MC, Fricchione GL, Akeju O. Accidental awareness under general anaesthesia: Incidence, risk factors, and psychological management. BJA Educ 2021; 21:154-161. [PMID: 33777414 DOI: 10.1016/j.bjae.2020.12.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2020] [Indexed: 12/20/2022] Open
Affiliation(s)
- M C Kim
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - G L Fricchione
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Benson-Henry Institute for Mind Body Medicine and the McCance Center for Brain Health, Harvard Medical School, Boston, MA, USA
| | - O Akeju
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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2
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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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3
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Blokland Y, Spyrou L, Lerou J, Mourisse J, Jan Scheffer G, Geffen GJV, Farquhar J, Bruhn J. Detection of attempted movement from the EEG during neuromuscular block: proof of principle study in awake volunteers. Sci Rep 2015; 5:12815. [PMID: 26248679 PMCID: PMC4528221 DOI: 10.1038/srep12815] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Accepted: 07/02/2015] [Indexed: 11/18/2022] Open
Abstract
Brain-Computer Interfaces (BCIs) have the potential to detect intraoperative awareness during general anaesthesia. Traditionally, BCI research is aimed at establishing or improving communication and control for patients with permanent paralysis. Patients experiencing intraoperative awareness also lack the means to communicate after administration of a neuromuscular blocker, but may attempt to move. This study evaluates the principle of detecting attempted movements from the electroencephalogram (EEG) during local temporary neuromuscular blockade. EEG was obtained from four healthy volunteers making 3-second hand movements, both before and after local administration of rocuronium in one isolated forearm. Using offline classification analysis we investigated whether the attempted movements the participants made during paralysis could be distinguished from the periods when they did not move or attempt to move. Attempted movement trials were correctly identified in 81 (68-94)% (mean (95% CI)) and 84 (74-93)% of the cases using 30 and 9 EEG channels, respectively. Similar accuracies were obtained when training the classifier on the participants' actual movements. These results provide proof of the principle that a BCI can detect movement attempts during neuromuscular blockade. Based on this, in the future a BCI may serve as a communication channel between a patient under general anaesthesia and the anaesthesiologist.
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Affiliation(s)
- Yvonne Blokland
- Radboud University Medical Centre, Department of Anaesthesiology, Pain and Palliative Medicine, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
- Radboud University Nijmegen, Donders Institute for Brain, Cognition and Behaviour, Montessorilaan 3, 6525 HR Nijmegen, The Netherlands
| | - Loukianos Spyrou
- Radboud University Medical Centre, Department of Anaesthesiology, Pain and Palliative Medicine, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
- Radboud University Nijmegen, Donders Institute for Brain, Cognition and Behaviour, Montessorilaan 3, 6525 HR Nijmegen, The Netherlands
| | - Jos Lerou
- Radboud University Medical Centre, Department of Anaesthesiology, Pain and Palliative Medicine, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Jo Mourisse
- Radboud University Medical Centre, Department of Anaesthesiology, Pain and Palliative Medicine, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Gert Jan Scheffer
- Radboud University Medical Centre, Department of Anaesthesiology, Pain and Palliative Medicine, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Geert-Jan van Geffen
- Radboud University Medical Centre, Department of Anaesthesiology, Pain and Palliative Medicine, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Jason Farquhar
- Radboud University Nijmegen, Donders Institute for Brain, Cognition and Behaviour, Montessorilaan 3, 6525 HR Nijmegen, The Netherlands
| | - Jörgen Bruhn
- Radboud University Medical Centre, Department of Anaesthesiology, Pain and Palliative Medicine, P.O. 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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Andrzejowski JC, Wiles MD. Was NAP5 ‘NICE’ enough; where next for depth of anaesthesia monitors? Anaesthesia 2015; 70:514-8. [DOI: 10.1111/anae.13045] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
| | - M. D. Wiles
- Sheffield Teaching Hospitals NHS Foundation Trust; Sheffield UK
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5
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Lucas DN, Yentis SM. Unsettled weather and the end for thiopental? Obstetric general anaesthesia after the NAP5 and MBRRACE-UK reports. Anaesthesia 2015; 70:375-9. [DOI: 10.1111/anae.13034] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- D. N. Lucas
- Northwick Park Hospital; Harrow Middlesex UK
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6
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Smith D, Goddard NG. Awareness in cardiothoracic anaesthetic practice - where now after NAP5? Anaesthesia 2014; 70:130-4. [DOI: 10.1111/anae.12952] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- D. Smith
- University Hospital Southampton NHS Foundation Trust; Southampton UK
| | - N. G. Goddard
- University Hospital Southampton NHS Foundation Trust; Southampton UK
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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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8
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Avidan MS, Sleigh JW. Beware the Boojum: the NAP5 audit of accidental awareness during intended general anaesthesia. Anaesthesia 2014; 69:1065-8. [PMID: 25204232 DOI: 10.1111/anae.12828] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- M S Avidan
- Department of Anesthesiology and Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
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9
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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, Cook TM. The 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: protocol, methods and analysis of data. Anaesthesia 2014; 69:1078-88. [DOI: 10.1111/anae.12811] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2014] [Indexed: 01/22/2023]
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
| | | | - 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
| | | | | | - 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; Queen Square UK
| | - M. R. J. Sury
- Department of Anaesthesia; Great Ormond Street Hospital; London UK
| | - H. E. Torevell
- Bradford Teaching Hospitals NHS Foundation Trust; Bradford UK
| | - M. Wang
- Department of Clinical Psychology; University of Leicester; Leicester UK
| | - T. M. Cook
- Department of Anaesthesia and Intensive Care Medicine; Royal United Hospital; Bath UK
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10
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Jonker WR, Hanumanthiah D, O'Sullivan EP, Cook TM, Pandit JJ. A national survey (NAP5-Ireland baseline) to estimate an annual incidence of accidental awareness during general anaesthesia in Ireland. Anaesthesia 2014; 69:969-76. [DOI: 10.1111/anae.12776] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2014] [Indexed: 12/01/2022]
Affiliation(s)
- W. R. Jonker
- Department of Anaesthesia and Intensive Care Medicine; Sligo Regional Hospital; Sligo Ireland
| | - D. Hanumanthiah
- Department of Anaesthesia and Intensive Care Medicine; Galway University Hospital; Galway Ireland
| | - E. P. O'Sullivan
- Department of Anaesthesia and Intensive Care Medicine; St James's Hospital; Dublin Ireland
| | - T. M. Cook
- Department of Anaesthesia and Intensive Care Medicine; Royal United Hospital; Bath UK
| | - J. J. Pandit
- Nuffield Department of Anaesthetics; Oxford University Hospitals; Oxford UK
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11
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Pandit JJ. Monitoring (un)consciousness: the implications of a new definition of ‘anaesthesia’. Anaesthesia 2014; 69:801-7. [DOI: 10.1111/anae.12668] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- J. J. Pandit
- Nuffield Department of Anaesthetics Oxford University Hospitals Oxford UK
- St John's College Oxford UK
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12
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Escallier KE, Nadelson MR, Zhou D, Avidan MS. Monitoring the brain: processed electroencephalogram and peri‐operative outcomes. Anaesthesia 2014; 69:899-910. [DOI: 10.1111/anae.12711] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2014] [Indexed: 11/29/2022]
Affiliation(s)
- K. E. Escallier
- Washington University School of Medicine Saint Louis Missouri USA
| | - M. R. Nadelson
- Washington University School of Medicine Saint Louis Missouri USA
| | - D. Zhou
- Washington University School of Medicine Saint Louis Missouri USA
| | - M. S. Avidan
- Washington University School of Medicine Saint Louis Missouri USA
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13
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Affiliation(s)
| | - M. Wang
- University of Leicester; Leicester UK
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14
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Pandit JJ. Isolated forearm - or isolated brain? Interpreting responses during anaesthesia - or 'dysanaesthesia'. Anaesthesia 2013; 68:995-1000. [PMID: 24047288 DOI: 10.1111/anae.12361] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- J J Pandit
- Nuffield Department of Anaesthetics, John Radcliffe Hospital, Oxford, UK.
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15
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Affiliation(s)
- M G Irwin
- University of Hong Kong, Hong Kong, China.
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16
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Smith D, Andrzejowski J, Smith A. Certainty and uncertainty: NICE guidance on 'depth of anaesthesia' monitoring. Anaesthesia 2013; 68:1000-5. [PMID: 23924038 DOI: 10.1111/anae.12385] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- D Smith
- Department of Anaesthesia, Southampton, General Hospital, Southampton, UK.
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Mahajan RP, Yentis SM. Editorial note. Anaesthesia 2013; 68:333-4. [DOI: 10.1111/anae.12216] [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]
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