Awareness during emergence from anesthesia: Features and future research directions

A Retrospective Study of Intraoperative Awareness in Patients Undergoing Electroconvulsive Therapy at Dartmouth Hitchcock Medical Center Over a 3-Year Period

OBJECTIVE

At our academic institution, in a collaborative effort between the departments of anesthesiology, psychiatry, and nursing, we aimed to collect data about the incidence, nature, and predictive factors of intraoperative awareness in patients undergoing electroconvulsive therapy (ECT). Eligible patients were given modified Brice interviews, and the compliance rate of the interviews was analyzed and the effect of the educational initiatives put in place reviewed.

METHODS

Brice interviews were given to patients after ECT over a 3-year period, which included the education of staff. Data points were collected over this 3-year period via the electronic medical record for patients receiving ECT and those who were eligible to complete a Brice interview after procedure. Statistical analysis was conducted to meet our objectives.

RESULTS

The incidence of intraoperative awareness in our patients undergoing ECT was 4.7% (44 out of 936 interviews) and baseline characteristics were recorded. No predictors of intraoperative awareness were discovered. The nature of each positive interview was reviewed and put into categories, and anesthesia modification was reviewed for the positive interviews. Mental health after procedure was shown to be, by our measures, the same between patients with positive Brice interviews and patients with negative Brice interviews. The overall compliance rates of the modified Brice interview were analyzed, and to measure the impact of such initiatives, the compliance rates were compared before and after particular educational initiatives.

CONCLUSIONS

Our study underscores the importance of tracking intraoperative awareness in patients receiving ECT, using Brice interviews in this population, and executing quality initiatives in the departments involved.

The Effect of Anaesthesia Management with Different Fresh Gas Flows on Cognitive Functions of Geriatric Patients: A Randomized Double-blind Study

Objective

The present study aimed to compare the effects of two different fresh gas flows (FGFs) (0.5 L min^-1 and 2 L min^-1) applied during maintenance of anaesthesia on recovery from anaesthesia and early cognitive functions in geriatric patients.

Methods

In this prospective, randomised, double-blind study, sixty patients were divided into two groups according to the amount of FGF. Minimal-flow anaesthesia (0.5 L min^-1 FGF) was applied to group I and medium-flow anaesthesia (2 L min^-1 FGF) was applied to group II during maintenance of anaesthesia. Following the termination of inhalation anaesthesia, recovery times were recorded. The evaluation of cognitive functions was performed using the Addenbrooke's Cognitive Examination (ACE-R).

Results

There was no significant difference between the two groups in terms of demographic characteristics and recovery (P > 0.05). There was no significant difference between the two groups in terms of the preoperative day, the first postoperative day, and the third postoperative day; ACE-R scores (P > 0.05). In group II, on the third postoperative day ACE-R scores were found to be significantly lower than the preoperative ACE-R scores (P=0.04). In group II, third postoperative day ACE-R memory sub-scores (14.53 ± 3.34) were found to be significantly lower than preoperative ACE-R memory sub-scores (15.03 ± 3.57) (P=0.04).

Conclusion

In geriatric patients, minimal-flow anaesthesia was not superior to medium-flow anaesthesia in terms of recovery properties and cognitive functions. Keeping in mind that hypoxaemia and changes in anaesthesia levels may occur with the reduction of FGF, both minimal- and medium-flow anaesthesia can be applied with appropriate monitoring without adverse effects on recovery and cognitive functions.

Accidental Awareness Under General Anesthesia During Cesarean Section: An Observational Study

Background

A Caesarean section (CS) if performed under general anesthesia (GA) is a procedure with an increased risk of accidental awareness. This study aimed to examine the incidence of accidental awareness under GA in hospitals in the Republic of Srpska (Bosnia and Herzegovina) where GA for CS is performed in a significantly higher percentage compared to spinal anesthesia.

Methodology

In the period from 2016 to 2018, a multicenter, prospective, observational study was conducted in five medical centers in the Republic of Srpska (Bosnia and Herzegovina). The study included 1,161 patients who underwent CS. A total of 427 (36.7%) patients had elective and 734 (63.3%) had emergency CSs. The patients were surveyed postoperatively using the modified Brice questionnaire.

Results

Of the 1,161 patients included in the study, 12 (1.03%) reported memory in the period between induction and emergence of anesthesia. Five (0.43%) of them reported definite and seven (0.6%) possible and unlikely awareness. Significant psychological trauma due to pain was reported by two patients. Dreams during anesthesia were reported by 42 patients (3.61%) and five of them stated that the dreams were unpleasant.

Conclusions

Accidental awareness under GA during CS has a significant incidence in medical centers in the Republic of Srpska (Bosnia and Herzegovina). According to our findings, creating new protocols for GA when performing CS is necessary.

Intraoperative Awareness in Patients Undergoing Cardiac Surgery in an Academic Center in the North of Iran

Background

Coronary artery bypass grafting (CABG) has distinctive characteristics that may increase the risk of awareness during general anesthesia (AGA).

Objectives

This study was conducted to assess the incidence of AGA in cardiac surgery in an academic hospital in Guilan, Iran.

Methods

This descriptive cross-sectional study was performed in Dr. Heshmat Hospital in Rasht, Iran. Eligible patients candidates for CABG were enrolled in the survey in 2022. After surgery, when the patient was cooperative enough, a questionnaire including demographic data and specialized questions related to different stages of anesthesia was completed via face-to-face interviews. The data were analyzed using IBM SPSS Statistics 21 with chi-square, Fisher's exact, and t-test.

Results

The data from 322 patients were analyzed, of whom 14 (4.3%) experienced AGA. Among them, the "feeling of fear and anxiety" reported by 9 (39.1%) cases was the most common awareness state. "Dreaming during surgery and anesthesia" and "feeling unable to move during anesthesia,", each reported by 6 (26.1%) cases, were the other common types of awareness state. None of the demographic data had a significant association with the occurrence of AGA.

Conclusions

The incidence of AGA during CABG was almost acceptable according to the credible evidence.

Knowledge, Attitude and Practice during the COVID-19 Pandemic in South-East Gabon

COVID-19 is an emerging respiratory disease; it was declared a global pandemic by the World Health Organization. This survey aimed to describe the knowledge, attitudes, perception and practices of the Gabonese public towards COVID-19. This study was performed on 1016 participants. All participants filled in the questionnaire voluntarily, reporting demographic characteristics and answering questions assessing their level of knowledge, attitudes, perceptions and practice towards COVID-19. Among participants, there were 535 men and 476 women. The mean age of the participants was 33.2 ± 16.7 years old. Almost all participants (98.1%) said that they had heard about COVID-19 but only 2.8% knew the pathogenic agent responsible for COVID-19. More than 80% knew that the disease could be transmitted by greeting infected people (87.3%), kissing an infected person (90.0%), touching an infected doorknob (83.5%) and attending meetings (83.9%). The mean knowledge score was higher among younger than older participants, higher among participants living in urban areas than those living in rural areas and higher among participants with higher levels of education than those with lower levels of education. In general, respondents had good knowledge of COVID-19 and a positive attitude towards using protective measures; however, there were differences according to gender, age group, place of residence, professional group and level of education.

Bispectral Index Monitoring and Observer Rating Scale Correlate with Dreaming during Propofol Anesthesia for Gastrointestinal Endoscopies

Background and objectives: Dreaming is a commonly reported side effect of propofol anesthesia. Materials and Methods: We investigated the inci-dence and character of dreams in patients undergoing intravenous propofol anesthesia and cor-related it with an observer rating scale of facial expression on the seven-point scale from pain to smile. A total of 124 patients undergoing gastrointestinal endoscopy were recruited in the pro-spective observational study. Bispectral index (BIS), blood pressure (BP), and pulse were moni-tored. Upon emergence from anesthesia, the patient’s facial expression was rated numerically. Thereafter, patients were asked whether they had dreams and to rate their dreams as pleasant or unpleasant. The mean age of participants was 53; body mass index, 26.17; duration of procedure, 20 min; and average propofol dose, 265 mg. Results: Dreaming was reported by 43% of patients. Dreams were pleasant in all but one patient. There was a significant correlation of the observer’s rating of facial expression with dreaming (r = 0.260; p = 0.004). Dreamers had higher scores of observer rating of facial expression (1 (0–2) vs. 0.5 (0–1), p = 0.006). Conclusions: BIS values were lower in the dreamers vs. non-dreamers 2 min after the endoscopy started (48 (43–62) vs. 59 (45–71), p = 0.038). Both BIS and observer ratings correlate with dreaming in patients undergoing gastrointestinal endos-copy. Trial registration number: NCT04235894.

Identifying c-fos Expression as a Strategy to Investigate the Actions of General Anesthetics on the Central Nervous System

Although general anesthetics have been used in the clinic for more than 170 years, the ways in which they induce amnesia, unconsciousness, analgesia, and immobility remain elusive. Modulations of various neural nuclei and circuits are involved in the actions of general anesthetics. The expression of the immediate-early gene c-fos and its nuclear product, c-fos protein, can be induced by neuronal depolarization; therefore, c-fos staining is commonly used to identify the activated neurons during sleep and/or wakefulness, as well as in various physiological conditions in the central nervous system. Identifying c-fos expression is also a direct and convenient method to explore the effects of general anesthetics on the activity of neural nuclei and circuits. Using c-fos staining, general anesthetics have been found to interact with sleep- and wakefulness-promoting systems throughout the brain, which may explain their ability to induce unconsciousness and emergence from general anesthesia. This review summarizes the actions of general anesthetics on neural nuclei and circuits based on a c-fos expression.

Delayed Emergence from Anesthesia: What We Know and How We Act

The emergence from anesthesia is the stage of general anesthesia featuring the patient's progression from the unconsciousness status to wakefulness and restoration of consciousness. This complex process has precise neurobiology which differs from that of induction. Despite the medications commonly used in anesthesia allow recovery in a few minutes, a delay in waking up from anesthesia, called delayed emergence, may occur. This phenomenon is associated with delays in the operating room, and an overall increase in costs. Together with the emergence delirium, the phenomenon represents a manifestation of inadequate emergence. Nevertheless, in delayed emergence, the transition from unconsciousness to complete wakefulness usually occurs along a normal trajectory, although slowed down. On the other hand, this awakening trajectory could proceed abnormally, possibly culminating in the manifestation of emergence delirium. Clinically, delayed emergence often represents a challenge for clinicians who must make an accurate diagnosis of the underlying cause to quickly establish appropriate therapy. This paper aimed at presenting an update on the phenomenon, analyzing its causes. Diagnostic and therapeutic strategies are addressed. Finally, therapeutic perspectives on the "active awakening" are reported.

Break the Spasm with Succinylcholine, but Risk Intraoperative Awareness with Undiagnosed Pseudocholinesterase Deficiency

Succinylcholine is a commonly used medication in all aspects of anesthetic care, and there are a number of known side effects and complications associated with its use. However, when succinylcholine is used emergently, anesthesia providers must remain vigilant to undiagnosed conditions that pose additional risks to patients. We report the use of succinylcholine to treat acute, refractory laryngospasm after extubation leading to prolonged neuromuscular paralysis. There are unique challenges presented by this case including the risk of anesthesia awareness with recall due to the cognitive biases that prevent the clinical diagnosis of pseudocholinesterase deficiency.