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Unerwünschte Wachphänomene („Awareness“) während Allgemeinanästhesie

Evidenzbasierter Kenntnisstand, aktuelle Diskussionen und Strategien zu Prävention und Management

Undesired awareness phenomena during general anesthesia

Evidence-based state of knowledge, current discussions and strategies for prevention and management

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Zusammenfassung

Unerwünschte Wachzustände während einer Allgemeinanästhesie mit Erinnerung als Folge einer situativ bedingten nichtausreichenden Narkosetiefe wird als sog. Awareness bezeichnet. Inzidenzen und resultierende mögliche Folgeschäden im Sinne eines posttraumatischen Belastungssyndroms (PTBS) sind Gegenstand kontroverser Diskussionen über nunmehr Jahrzehnte.

Studienergebnisse zu Awareness, die nach evidenzbasierten Kriterien (Level 1) eine Prävalenz von 0,1–0,2 % (1–2:1000) betragen, wurden jüngst vom 5. Nationalen Audit Projekt (5th National Audit Project, NAP5) aus Großbritannien/Irland infrage gestellt. Hierzu wurden Patientenberichte bezüglich „Accidental Awareness during General Anaesthaesia“ (AAGA) über monatliche Abfragen öffentlicher Krankenhäuser in einer zentralen Datenbank von über 2,7 Mio. Anästhesien erhoben. Irreführend und unwahrscheinlich erscheinen die postulierten Häufigkeiten für Awareness, die um etwa den Faktor 20 geringer mit „nur“ 1:19.600 (0,005 %) angegeben werden. Mit aller Wahrscheinlichkeit wird NAP5 auf nationale und internationale Kontroversen stoßen, da nicht auszuschließen ist, dass angesichts fehlender strukturierter Interviews nur die „Spitze des Eisbergs“ erfasst und hierdurch die wahre Prävalenz des Problems unterschätzt sowie verharmlost wird. Umgekehrt ist angesichts der Daten aus NAP5 nicht sicher auszuschließen, dass die Erfassung von Awareness mithilfe bisheriger, prospektiver evidenzbasierter Kriterien die wirkliche Prävalenz überschätzt.

Bislang existiert keine offizielle Empfehlung der Deutschen Gesellschaft für Anästhesie und Intensivmedizin e. V. (DGAI) zu dieser Thematik. Der vorliegende Beitrag fasst daher das gegenwärtige Wissen zum Problem Awareness zusammen und legt in der klinischen Routine nutzbare Vermeidungsstrategien dar. Letztlich liegt es in der Verantwortung des einzelnen Anästhesisten, Risikofaktoren zu erkennen und – sofern keine Kontraindikationen vorliegen – die hier dargelegten evidenzbasierten präventiven Strategien einzusetzen, um Awareness und assoziierte Folgeschäden mit großer Wahrscheinlichkeit zu vermeiden.

Abstract

Patient awareness during general anesthesia and the later recall of what happened during surgery can be experienced by patients as horrifying events that leave lasting mental trauma in the form of posttraumatic stress syndrome (PTSS). Awareness is related to a temporary insufficient depth of anesthesia. This phenomenon has been discussed for more than 20 years. According to randomized controlled studies, in the absence of risk factors awareness phenomena occur in 1-2 per 1000 operations involving general anesthesia (0.1–0.2 %) and are classified as occasionally occurring critical events. An astonishing twist occurred elicited by the recent data from the 5th National Audit Project from Great Britain (NAP5) published in the British Journal of Anaesthesia and in Anaesthesia. The NAP5 evaluated patient reports of accidental awareness during general anesthesia (AAGA) in a multicenter manner in more than 2.7 million cases and indicated incidences of awareness of only 1:19,600, a frequency 20 times less than previously reported. These results gave rise to some controversy. It seems likely that, due to the absence of structured interviews, the NAP5 data only demonstrated the tip of the iceberg and may have vastly underestimated the real incidence of intraoperative awareness. The present overview summarizes the current knowledge about awareness. Furthermore, it addresses the question whether the awareness problem has been overestimated by evidence-based criteria or underestimated by the results of the NAP5. The responsibility for sufficient anesthesia in the clinical routine requires knowledge of awareness risks and potential sequelae. A formal recommendation from the German Society of Anesthesia and Intensive Care Medicine (DGAI) concerning awareness is not yet available; however, the recognition of evidence-based strategies in the management of anesthesia may minimize the occurrence of awareness and its sequelae.

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Authors and Affiliations

  1. Klinik für Anästhesiologie, operative Intensivmedizin, Schmerz- und Palliativmedizin, Marien Hospital Herne, Universitätsklinikum der Ruhr-Universität Bochum, Hölkeskampring 40, 44625, Herne, Deutschland

    P. Bischoff

  2. Praxisgemeinschaft Dupierry, Callesen, Rundshagen, Hamburg, Deutschland

    I. Rundshagen

  3. Klinik für Anästhesiologie, HELIOS Klinikum Wuppertal, Klinikum der Universität Witten/Herdecke, Wuppertal, Deutschland

    G. Schneider

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  1. P. Bischoff
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  2. I. Rundshagen
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  3. G. Schneider
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Correspondence to P. Bischoff.

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Interessenkonflikt

P. Bischoff, I. Rundshagen und G. Schneider geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.

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Bischoff, P., Rundshagen, I. & Schneider, G. Unerwünschte Wachphänomene („Awareness“) während Allgemeinanästhesie. Anaesthesist 64, 732–739 (2015). https://doi.org/10.1007/s00101-015-0095-6

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