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Anesthesia Awareness in General Surgery

Texas Wesleyan University GPNA
by

mandy karimi

on 18 March 2015

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Transcript of Anesthesia Awareness in General Surgery

Anesthesia Awareness
with Recall

Consciousness with recollection of intraoperative surgical events
How often does it occur
Potentially 20,000 to 40,000 cases of anesthesia awareness every year
Should it be used for high-risk patients?
What is the Bispectral Index Monitor
Innovative non-invasive monitor
Sensors attached to the forehead
Analyzes EEG waves
Numerical value from 0-100
Measurement of depth of anesthesia

High-Risk Surgeries
Major trauma surgery
11-43% incidence
Cardiac surgery
1.1-1.5% incidence
Caesarian sections or other obstetrical surgeries
0.4% incidence
High-Risk Patients
Previous history of anesthesia awareness
Five times more likely to experience it again
Heavy alcoholics and chronic drug users
Increased anesthetic requirements
Difficult or prolonged intubations
Administration of light sedation
Patients with hemodynamic instability
Pregnant patients
Excessive use of muscle relaxants
Total intravenous anesthesia (TIVA)
Preoperative Recommendations
A thorough preoperative evaluation
Identify history of intraoperative awareness or any other complications with anesthesia in the past
AANA first standard of practice
Consider including the risk of anesthesia awareness
in the informed consent of high-risk patients
Thoroughly inspect all anesthesia equipment
Especially the machine, vaporizer, and infusion pumps
Label all medications and read the labels prior to
administering to prevent errors
Premedicate with amnestic agents if no
contraindications
Benzodiazepines
Versed, Valium, Ativan

Intraoperative Recommendations
Repeated intubation attempts may require additional doses of
sedatives
Limit use of paralytics
Lowest dose necessary to achieve desired effects

Maintain sedation with volatile anesthetics if possible
MAC of >0.8 is recommended if primary anesthetic
Use bispectral index (BIS) monitors for high-risk patients or TIVA
Maintaining BIS between the values of 40-60 is optimal
Hx of PONV may have better outcomes with TIVA that is monitored with BIS
Don't limit the anesthestic plan to one drug
Administer a combination of drug classes with different MOA
:
Sedatives, analgesics, inhalation gases, amnestic agents, etc...
Be vigilant throughout the intraoperative period
Always!!!

OBJECTIVES
Identify high-risk patients
Learn mitigation strategies
Preoperative interventions
Intraoperative interventions
Postoperative interventions
Why is it a problem?
Anesthesia-induced unconsciousness
Difficult to monitor
Clinical signs may not be reliable
Patients may remember everything!
Traumatic experience
Post-traumatic Stress Disorder
January 2, 2015
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Anesthesia Awareness
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Postoperative Recommendations
Always do post-op patient rounds
Assess if awareness occurred with a structured interview
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Methods
Databases:
PubMed, Cochrane, EBSCO, CINAHL,
Academic Search Complete
169 articles resulted
Excluded:
Non-English, editorials, not pertinent to general surgery, older than 5 years
Background information:
Classic article from JCAHO
16 journal articles:
meta-analysis, systematic reviews, review articles, cohort study, and a classic article
Reported cases of unintended anesthesia awareness occurred:

It is suggested to evaluate for anesthesia awareness during 3 different time intervals if there is a high suspicion of it occurring
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If Anesthesia Awareness is Reported
Post-Traumatic Stress Disorder
Detailed documentation
Offer emotional support and validation
May help to reduce patient's anxiety
Check on patient often during their inpatient stay
Address concerns and requests
Determine possible causes that may have led to awareness
Discuss the importance of reporting it to anesthesia providers prior to any future surgeries
Provide resources and referrals for psychological counseling
Occurrences of PTSD ranged from 33-71% depending on the severity
Psychiatric complications were more severe and often progressed to PTSD if awareness occurred without adequate pain control
5 Facts to know about
ANESTHESIA AWARENESS
1)
Anesthesia awareness is more likely to occur in certain high-risk surgeries


5 Facts to know about
ANESTHESIA AWARENESS

2)
Traumatic experience for patients and it can affect them for years after their surgery
Identify the patients at higher risk
Take every measure to prevent it from happening

5 Facts to know about
ANESTHESIA AWARENESS

3)
Good preoperative assessment and practical intraoperative strategies to minimize risk

5 Facts to know about
ANESTHESIA AWARENESS

5) VIGILANCE is most important
Table III.
Strategies to prevent anesthesia awareness
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5 Facts to know about
ANESTHESIA AWARENESS

4) Monitoring of depth of anesthesia should rely on multiple modalities
Conventional monitoring + additional assessment tools:
Bispectral Index Monitor
End Tidal Anesthetic Gas Monitor
Narcotrend
E-Entropy
Evoked Potentials

Table II.
Potential causes of anesthesia awareness
Major and minor patient risk factors
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Harold J.
Awake
. The Weinstein Company; 2007
QUESTIONS?
Intraoperative Monitoring: BIS Index
Evidence-based Decision Chart
Patient awareness is typically assessed by physiological signs:
Changes in heart rate
Increase in blood pressure
Sweating
Tear production
Spontaneous movement

Experts have suggested that these clinical signs alone may not be reliable
Diminished by use of beta-blockers and muscle relaxers

5,6
Anesthesia Awareness
0.1-0.2% of 21 million receiving general anesthesia
A patient reports after a CABG
: "Heard noises and voices during surgery, and the pain of people trying to tear my chest apart"
Another patient reports after AAA repair
: "Heard people shouting during surgery, associated with abdominal cramps and pain, like squeezing his gut... Unable to move and terrified"
1) Evaluate mental health before and after surgery
2) Intervene early to help the patient cope with the mental distress
Reduce psychological problems from occurring
2 Joint Commission on Accreditation of Healthcare Organizations.

Preventing, and managing the impact of, anesthesia awareness.
Sentinel event alert.
2004(32):1-3.
3 Leslie K, Chan MT, Myles PS, Forbes A, McCulloch TJ. Posttraumatic stress disorder in aware patients from the B-aware trial.
Anesth Analg
. 2010;110(3):823-828. doi:
10.1213/ANE.0b013e3181b8b6ca.
4 Chung HS. Awareness and recall during general anesthesia.
Korean Journal of Anesthesiology.
2014;66(5):339-345.

5 Punjasawadwong Y, Phongchiewboon A, Bunchungmongkol N. Bispectral index for improving anaesthetic delivery and postoperative recovery.
Cochrane Database Syst Rev.
2014;6:CD003843.
doi: 10.1002/14651858.CD003843.pub3.
6 Shepherd J, Jones J, Frampton G, Bryant J, Baxter L, Cooper K. Clinical effectiveness and cost-effectiveness of depth of anaesthesia monitoring (E-Entropy, Bispectral Index and Narcotrend): a
systematic review and economic evaluation.
Health Technol Assess.
2013;17(34). doi: 10.3310/hta17340.

3
3
7 Szostakiewicz KM, Tomaszewski D, Rybicki Z, Rychlik A. Intraoperative awareness during general anaesthesia: Results of the observational survey.
Anaesthesiol Intensive Ther.

2014;46(1):23-28. doi: 10.5603/AIT.2014.0005.
3 Leslie K, Chan MT, Myles PS, Forbes A, McCulloch TJ. Posttraumatic stress disorder in aware patients from the B-aware trial.
Anesth Analg.
2010;110(3):823-828. doi: 10.1213/
ANE.0b013e3181b8b6ca.

7
8 Fox News. 19-year-old girl wakes up during brain surgery, asks doctors 'how's it going?' [Web page]. http://www.foxnews.com/health/2015/01/03/1-year-old-girl-wakes-up-during-brain-surgery-asks-doctors-hows-it-going/. Accessed January 3, 2015.

2 Joint Commission on Accreditation of Healthcare Organizations.

Preventing, and managing the impact of, anesthesia awareness.
Sentinel event alert.
2004(32):1-3.
10 Nunes RR, Porto VC, Miranda VT, de Andrade NQ, Carneiro LMM. Risk factor for intraoperative awareness.
Brazilian Journal of Anesthesiology.
2012;62(3):365-374. doi:
http://dx.doi.org/10.1016/S0034-7094(12)70137-X.

10
13 Beobatcher. Anesthesia the rude awakening [Image].
http://translate.google.com/translate?hl=en&sl=de&u=http://www.beobachter.ch/leben-gesundheit/medizin-krankheit/artikel/narkose_das-boese-erwachen/&prev=search/. Accessed January 15, 2015.

12 Ziętkiewicz M, Nestorowicz A. Intraoperative awareness—recommendations of the committee on quality and safety in
anaesthesia, polish society of anaesthesiology and intensive therapy.
Anaesthesiology intensive therapy
. 2012;44(2):57-62.

12 Ziętkiewicz M, Nestorowicz A. Intraoperative awareness—recommendations of the committee on quality and safety in anaesthesia, polish society of anaesthesiology and intensive therapy.

Anaesthesiology intensive therapy
. 2012;44(2):57-62.
4 Chung HS. Awareness and recall during general anesthesia.
Korean Journal of Anesthesiology
. 2014;66(5):339-345.

14 Arnesano C. Intraoperative detection of awareness [Image]. http://bme240.eng.uci.edu/students/09s/arnesanc/bispectral_anslysis.html/. Accessed January 3, 2015.

15 Nadelson MR, Willingham MD, Avidan MS. Bispectral index monitoring and perioperative outcomes: does it make a difference?
Review Course Lectures
. 2013:19.
16 Rule E, Reddy S. Awareness under general anaesthesia.
Br J Hosp Med (Lond).
2014;75(10):573-577. http://search.ebscohost.com/login.aspx?direct=true&db=mnh&AN=25291610&site=ehost-live. doi: 10.12968/hmed.2014.75.10.573.

11 Radovanovic D, Radovanovic Z. Awareness during general anaesthesia--implications of explicit intraoperative recall.
Eur Rev Med Pharmacol Sci
. 2011;15(9):1085-1089.

3 Leslie K, Chan MT, Myles PS, Forbes A, McCulloch TJ. Posttraumatic stress disorder in aware patients from the B-aware trial.
Anesth Analg
. 2010;110(3):823-828. doi: 10.1213/ANE.0b013e3181b8b6ca.
4 Chung HS. Awareness and recall during general anesthesia.
Korean Journal of Anesthesiology
. 2014;66(5):339-345.

11 Radovanovic D, Radovanovic Z. Awareness during general anaesthesia--implications of explicit intraoperative recall.
Eur Rev Med Pharmacol Sci
. 2011;15(9):1085-1089.
11
11
11
2 Joint Commission on Accreditation of Healthcare Organizations.

Preventing, and managing the impact of
anesthesia awareness.
Sentinel event alert.
2004(32):1-3.
11 Radovanovic D, Radovanovic Z. Awareness during general anaesthesia--implications of explicit intraoperative recall.
Eur Rev Med Pharmacol Sci.
2011;15(9):1085-1089.
17 American Association of Nurse Anesthetists. Crnas: we’ll be watching. [Video].
http://www.aana.com/forpatients/Pages/CRNA-YouTube-Resources.aspx/. Accessed January 25, 2015.

5
Table I.
11
11
11 Radovanovic D, Radovanovic Z. Awareness during general anaesthesia--implications of explicit intraoperative recall.
Eur Rev Med Pharmacol Sci.
2011;15(9):1085-1089.
Supported by:
AANA, ASA, and JCAHO
5,6
5,6
Symptoms: Flashbacks, sleep disturbances, depression, personality changes, and severe anxiety for several years
3
Trauma surgery
Cardiac surgery
Ob/Gyn surgeries
5 Punjasawadwong Y, Phongchiewboon A, Bunchungmongkol N. Bispectral index for improving anaesthetic delivery and postoperative recovery.
Cochrane Database Syst Rev.
2014;6:CD003843. doi: 10.1002/14651858.CD003843.pub3.
15
15
15
15
15
11
3,4
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