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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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Pandit J, Andrade J, Bogod D, Hitchman J, Jonker W, Lucas N, Mackay J, Nimmo A, O'Connor K, O'Sullivan E, Paul R, Palmer JM, Plaat F, Radcliffe J, Sury M, Torevell H, Wang M, Cook T. 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: protocol, methods, and analysis of data † ‡. Br J Anaesth 2014; 113:540-8. [DOI: 10.1093/bja/aeu312] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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10
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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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11
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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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12
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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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