Anesthesia Awareness: When the Mind Is Not Suppressed

Chapter
Part of the Contemporary Clinical Neuroscience book series (CCNE)

Abstract

In approximately 1–2 general anesthetics/1000, adequate hypnosis and amnesia are not achieved, leading to intraoperative awareness and subsequent explicit recall. “Anesthesia awareness,” as it is sometimes called, is one of the most feared complications of surgery by both patients and physicians alike. A significant proportion of these patients develops long-term psychological sequelae, including posttraumatic stress disorder. In this chapter I discuss the incidence, risk factors, prevention, and postoperative consequences of anesthesia awareness.

Keywords

Awareness during general anesthesia, awareness with explicit recall, intraoperative awareness, anesthesia awareness, anesthetic depth, depth of anesthesia monitor 

Notes

Conflicts

The author has no conflicts of interest to declare. Funding for the author’s research on awareness comes from the Foundation for Anesthesia Education & Research and the American Society of Anesthesiologists.

References

  1. Alkire, M. T., A. G. Hudetz, and G. Tononi. 2008. Consciousness and anesthesia. Science 322(5903):876–880.CrossRefPubMedGoogle Scholar
  2. Avidan, M. S., L. Zhang, B. A. Burnside, K. J. Finkel, A. C. Searleman, J. A. Selvidge, L. Saager, M. S. Turner, S. Rao, M. Bottros, C. Hantler, E. Jacobsohn, and A. S. Evers. 2008. Anesthesia awareness and the bispectral index. New Engl J Med 358(11):1097–1108.CrossRefPubMedGoogle Scholar
  3. Bigelow, HJ. 1846. Insensibility during surgical operations produced by inhalation. Boston Med Surg J 35:309–317.Google Scholar
  4. Bowdle, T. A. 2006. Depth of anesthesia monitoring. Anesthesiol Clin 24(4):793–822.CrossRefPubMedGoogle Scholar
  5. Brice, D. D., R. R. Hetherington, and J. E. Utting. 1970. A simple study of awareness and dreaming during anaesthesia. Br J Anaesth 42(6):535–542.CrossRefPubMedGoogle Scholar
  6. Bruhn, J., P. S. Myles, R. Sneyd, and M. M. R. F. Struys. 2006. Depth of anaesthesia monitoring: what’s available, what’s validated and what’s next? Br J Anaesth 97(1):85–94.CrossRefPubMedGoogle Scholar
  7. Campagna, J. A., K. W. Miller, and S. A. Forman. 2003. Mechanisms of actions of inhaled anesthetics. New Engl J Med 348(21):2110–2124.CrossRefPubMedGoogle Scholar
  8. Cheng, V. Y., L. J. Martin, E. M. Elliott, J. H. Kim, H. T. J. Mount, F. A. Taverna, J. C. Roder, J. F. Macdonald, A. Bhambri, N. Collinson, K. A. Wafford, and B. A. Orser. 2006. Alpha5GABAA receptors mediate the amnestic but not sedative-hypnotic effects of the general anesthetic etomidate. J Neurosci 26(14):3713–3720.Google Scholar
  9. Dahaba, A. A. 2005. Different conditions that could result in the bispectral index indicating an incorrect hypnotic state. Anesth Analg 101(3):765–773.CrossRefPubMedGoogle Scholar
  10. Davidson, A. J., G. H. Huang, C. Czarnecki, M. A. Gibson, S. A. Stewart, K. Jamsen, and R. Stargatt. 2005. Awareness during anesthesia in children: a prospective cohort study. Anesth Analg 100(3):653–661.CrossRefPubMedGoogle Scholar
  11. Davidson, A. J., S. J. Sheppard, A. L. Engwerda, A. Wong, L. Phelan, C. M. Ironfield, and R. Stargatt. 2008. Detecting awareness in children by using an auditory intervention. Anesthesiology 109(4):619–624.CrossRefPubMedGoogle Scholar
  12. Eger, E. I., II, L. J. Saidman, and B. Brandstater. 1965. Minimum alveolar anesthetic concentration: a standard of anesthetic potency. Anesthesiology 26(6):756–763.CrossRefPubMedGoogle Scholar
  13. Ekman, A., M. L. Lindholm, C. Lennmarken, and R. Sandin. 2004. Reduction in the incidence of awareness using BIS monitoring. Acta Anaesthesiol Scand 48(1):20–26.CrossRefPubMedGoogle Scholar
  14. Errando, C. L., J. C. Sigl, M. Robles, E. Calabuig, J. García, F. Arocas, R. Higueras, E. Del Rosario, D. López, C. M. Peiró, J. L. Soriano, S. Chaves, F. Gil, and R. García-Aguado. 2008. Awareness with recall during general anaesthesia: a prospective observational evaluation of 4001 patients. Br J Anaesth 101(2):178–185.CrossRefPubMedGoogle Scholar
  15. Fitzgerald, B. M., and J. Elder. 2008. Will a 1-page informational handout decrease patients’ most common fears of anesthesia and surgery? J Surg Educ 65(5):359–363.CrossRefPubMedGoogle Scholar
  16. Gibbs, F. A., L. E. Gibbs, and W. G. Lennox. 1937. Effect on the electroencephalogram of certain drugs which influence nervous activity. Arch Intern Med 60:154–166.Google Scholar
  17. Grace, R. F. 2003. The effect of variable-dose diazepam on dreaming and emergence phenomena in 400 cases of ketamine-fentanyl anaesthesia. Anaesthesia 58(9):904–910.CrossRefPubMedGoogle Scholar
  18. Guedel, A. 1937. Inhalation anaesthesia: a fundamental guide. New York, NY: Macmillan.Google Scholar
  19. Healy, B. 2008. Under anesthesia, yet aware. US News World Rep 144(9):68.PubMedGoogle Scholar
  20. Hutchinson, R. 1961. Awareness during surgery. A study of its incidence. Br J Anaesth 33:463–469.CrossRefPubMedGoogle Scholar
  21. JCAHO. 2004. Preventing and managing the impact of anesthesia awareness. Joint Comm Persp 24(12):10–11.Google Scholar
  22. Kent, C. D., and K. B. Domino. 2007. Awareness: practice, standards, and the law. Best Pract Res Clin Anaesthesiol 21(3):369–383.CrossRefPubMedGoogle Scholar
  23. Kerssens, C., J. Klein, and B. Bonke. 2003. Awareness: monitoring versus remembering what happened. Anesthesiology 99(3):570–575.CrossRefPubMedGoogle Scholar
  24. Lee, U., G. A. Mashour, S. Kim, G.J. Noh, and B.M. Choi. 2009. Propofol Induction Reduces the capacity for neural information integration: implications for the mechanism of consciousness and general anesthesia. Conscious Cogn 18(1):56–64.Google Scholar
  25. Leslie, K., and H. Skrzypek. 2007. Dreaming during anaesthesia in adult patients. Best Pract Res Clin Anaesthesiol 21(3):403–414.CrossRefPubMedGoogle Scholar
  26. Leslie, K., P. S. Myles, A. Forbes, M. T. V. Chan, S. K. Swallow, and T. G. Short. 2005. Dreaming during anaesthesia in patients at high risk of awareness. Anaesthesia 60(3):239–244.CrossRefPubMedGoogle Scholar
  27. Leslie, K., H. Skrzypek, M. J. Paech, I. Kurowski, and T. Whybrow. 2007. Dreaming during anesthesia and anesthetic depth in elective surgery patients: a prospective cohort study. Anesthesiology 106(1):33–42.CrossRefPubMedGoogle Scholar
  28. Liem, E. B., C.-M. Lin, M.-I. Suleman, A. G. Doufas, R. G. Gregg, J. M. Veauthier, G. Loyd, and D. I. Sessler. 2004. Anesthetic requirement is increased in redheads. Anesthesiology 101(2):279–283.CrossRefPubMedGoogle Scholar
  29. Lu, J., L. E. Nelson, N. Franks, M. Maze, N. L. Chamberlin, and C. B. Saper. 2008. Role of endogenous sleep-wake and analgesic systems in anesthesia. J Comp Neurol 508(4):648–662.CrossRefPubMedGoogle Scholar
  30. Mashour, G. A. 2004. Consciousness unbound: toward a paradigm of general anesthesia. Anesthesiology 100(2):428–433.CrossRefPubMedGoogle Scholar
  31. Mashour, G. A. 2006. Monitoring consciousness: EEG-based measures of anesthetic depth. Semin Anesthesia Perioper Med Pain 25:205–210.Mashour, G. A., 2009. Post-traumatic stress disorder after intraoperative awareness and high-risk surgery. Anesth Analg, In press.CrossRefGoogle Scholar
  32. Mashour, G. A., and E. LaRock. 2008. Inverse zombies, anesthesia awareness, and the hard problem of unconsciousness. Conscious Cogn 17(4):1163–1168.CrossRefGoogle Scholar
  33. Mashour, G. A., Y. Jiang, and J. Osterman. 2006. Perioperative treatment of patients with a history of intraoperative awareness and post-traumatic stress disorder. Anesthesiology 104(4):893–894.CrossRefPubMedGoogle Scholar
  34. Mashour, G. A., L. Y. J. Wang, R. K. Esaki, and N. N. Naughton. 2008. Operating room desensitization as a novel treatment for post-traumatic stress disorder after intraoperative awareness. Anesthesiology 109(5):927–929.CrossRefPubMedGoogle Scholar
  35. Mashour, G. A., L. Y. J. Wang, C. R. Turner, A. Shanks, J. Vandervest, and K. K. Tremper. 2009. A retrospective study of intraoperative awareness with methodological implications. Anesth Analg 108(2):521–526.CrossRefPubMedGoogle Scholar
  36. Moerman, N., B. Bonke, and J. Oosting. 1993. Awareness and recall during general anesthesia. Facts and feelings. Anesthesiology 79(3):454–464.CrossRefPubMedGoogle Scholar
  37. Myles, P. S., K. Leslie, J. McNeil, A. Forbes, and M. T. Chan. 2004. Bispectral index monitoring to prevent awareness during anaesthesia: the B-Aware randomised controlled trial. Lancet 363(9423):1757–1763.CrossRefPubMedGoogle Scholar
  38. Myles, P. S., K. Leslie, and A. Forbes. 2008. Anesthesia awareness and the bispectral index. New Engl J Med 359(4):428–429.PubMedGoogle Scholar
  39. Paech, M. J., K. L. Scott, O. Clavisi, S. Chua, and N. McDonnell. 2008. A prospective study of awareness and recall associated with general anaesthesia for caesarean section. Intl J Obstetric Anesth 17(4):298–303.CrossRefGoogle Scholar
  40. Pollard, R. J., J. P. Coyle, R. L. Gilbert, and J. E. Beck. 2007. Intraoperative awareness in a regional medical system: a review of 3 years’ data. Anesthesiology 106(2):269–274.CrossRefPubMedGoogle Scholar
  41. Rampil, I. J. 1998. A primer for EEG signal processing in anesthesia. Anesthesiology 89(4):980–1002.CrossRefPubMedGoogle Scholar
  42. Sakai, T., H. Singh, W. D. Mi, T. Kudo, and A. Matsuki. 1999. The effect of ketamine on clinical endpoints of hypnosis and EEG variables during propofol infusion. Acta Anaesthesiol Scand 43(2):212–216.CrossRefPubMedGoogle Scholar
  43. Samuelsson, P., L. Brudin, and R. H. Sandin. 2007. Late psychological symptoms after awareness among consecutively included surgical patients. Anesthesiology 106 (1):26–32.CrossRefPubMedGoogle Scholar
  44. Samuelsson, P., L. Brudin, and R. H. Sandin. 2008a. BIS does not predict dreams reported after anaesthesia. Acta Anaesthesiol Scand 52(6):810–814.CrossRefPubMedGoogle Scholar
  45. Samuelsson, P., L. Brudin, and R. H. Sandin. 2008b. Intraoperative dreams reported after general anaesthesia are not early interpretations of delayed awareness. Acta Anaesthesiol Scand 52(6):805–809.CrossRefPubMedGoogle Scholar
  46. Sandin, R. H., G. Enlund, P. Samuelsson, and C. Lennmarken. 2000. Awareness during anaesthesia: a prospective case study. Lancet 355(9205):707–711.CrossRefPubMedGoogle Scholar
  47. Scheller, B., G. Schneider, M. Daunderer, E. F. Kochs, and B. Zwissler. 2005. High-frequency components of auditory evoked potentials are detected in responsive but not in unconscious patients. Anesthesiology 103(5):944–950.CrossRefPubMedGoogle Scholar
  48. Schneider, G., R. Hollweck, M. Ningler, G. Stockmanns, and E. F. Kochs. 2005. Detection of consciousness by electroencephalogram and auditory evoked potentials. Anesthesiology 103(5):934–943.CrossRefPubMedGoogle Scholar
  49. Sebel, P. S., T. Andrew Bowdle, M. M. Ghoneim, I. J. Rampil, R. E. Padilla, T. J. Gan, and K. B. Domino. 2004. The incidence of awareness during anesthesia: a multicenter United States study. Anesth Analg 99(3):833–839.CrossRefPubMedGoogle Scholar
  50. Sebel, P. S., T. Andrew Bowdle, I. J. Rampil, R. E. Padilla, T. J. Gan, M. M. Ghoneim, and K. B. Domino. 2007. Don’t ask, don’t tell. Anesthesiology 107(4):672.CrossRefPubMedGoogle Scholar
  51. Shafer, A., P. F. White, J. Schüttler, and M. H. Rosenthal. 1983. Use of a fentanyl infusion in the intensive care unit: tolerance to its anesthetic effects? Anesthesiology 59(3):245–248.PubMedGoogle Scholar
  52. Snow, J.D. 1847. On the inhalation of the vapour of ether in surgical operations. London: John Churchill.Google Scholar
  53. Strickland, R. A., and J. F. Butterworth. 2007. Sexual dreaming during anesthesia: early case histories (1849–1888) of the phenomenon. Anesthesiology 106(6):1232–1236.CrossRefPubMedGoogle Scholar
  54. Tammisto, T, and S. Takki. 1973. Nitrous oxide-oxygen-relaxant anaesthesia in alcoholics: a retrospective study. Acta Anaesthesiol Scand Supplementum 53:68–75.Google Scholar
  55. Tammisto, T., and I. Tigerstedt. 1977. The need for fentanyl supplementation of N2O-O2 relaxant anaesthesia in chronic alcoholics. Acta Anaesthesiol Scand 21(3):216–221.CrossRefPubMedGoogle Scholar
  56. Tononi, G. 2004. An information integration theory of consciousness. BMC Neurosci 5(1):42.CrossRefPubMedGoogle Scholar
  57. Toscano, A., C. Pancaro, and V. A. Peduto. 2007. Scopolamine prevents dreams during general anesthesia. Anesthesiology 106(5):952–955.CrossRefPubMedGoogle Scholar
  58. Voss, L., and J. Sleigh. 2007. Monitoring consciousness: the current status of EEG-based depth of anaesthesia monitors. Best Pract Res Clin Anaesthesiol 21(3):313–325.CrossRefPubMedGoogle Scholar
  59. Winterbottom, E. H. 1950. Insufficient anaesthesia. Br Med J 1(4647):247.CrossRefPubMedGoogle Scholar
  60. Xing, Y., J. M. Sonner, E. I. Eger, M. Cascio, and D. I. Sessler. 2004. Mice with a melanocortin 1 receptor mutation have a slightly greater minimum alveolar concentration than control mice. Anesthesiology 101(2):544–546.CrossRefPubMedGoogle Scholar
  61. Yamamura, T., M. Fukuda, H. Takeya, Y. Goto, and K. Furukawa. 1981. Fast oscillatory EEG activity induced by analgesic concentrations of nitrous oxide in man. Anesth Analg 60(5):283–288.CrossRefPubMedGoogle Scholar

Copyright information

© Humana Press, a part of Springer Science+Business Media, LLC 2009

Authors and Affiliations

  1. 1.Departments of Anesthesiology and NeurosurgeryUniversity of Michigan Medical SchoolAnn ArborUSA

Personalised recommendations