Movie Review

711494615
A REACTION PAPER ON
UNINTENDED
INTRA-OPERATIVE AWARENESS
Unintended Intra-operative Awareness or Anesthesia Awareness
-15875140970Anesthesia awareness happens when the medications provided to render the patient unconscious during general anesthesia are not effective but the agents used to paralyze the patient are.
This means that the patient is unable to move or speak, but is wide awake, hearing and feeling the entire procedure.
Awareness during a surgical procedure is a rare, but it remains a concern for many patients who are anticipating having surgery with general anesthesia.
If you are concerned about anesthesia awareness or have experienced it in the past, be sure to inform your anesthesia provider. Doctors can address your concerns and your specific situation to make sure your anesthesia is adequate for your surgery.
Risk Factors
Paralytics/muscle relaxant use
Light anesthesia
Improper equipment maintenance/anesthetist error
Patient physiology
Paralytics/muscle relaxant use
A common risk factor is the use of a medication that induces muscle paralysis. Under general anesthesia, the patient's muscles may be paralysed in order to facilitate tracheal intubation, surgical exposure, or mechanical ventilation. The paralytic agent does not cause unconsciousness or take away the patient's ability to feel pain.
A fully paralyzed patient is unable to move, speak, blink the eyes, or otherwise respond to the pain except through physiological signs such as increased heart rate (tachycardia), blood pressure (hypertension), dilation of the pupils (HYPERLINK " http://en.wikipedia.org/wiki/Mydriasis" o " Mydriasis" mydriasis), sweating (diaphoresis), and the formation of tears (HYPERLINK " http://en.wikipedia.org/wiki/Lacrimation" o " Lacrimation" lacrimation) in response to pain. This is because these paralytic drugs cause skeletal muscle paralysis but do not typically interfere with the functioning of the autonomic nervous system. Even though the patient cannot directly signal their distress, they may exhibit signs of awareness detectable by clinical vigilance.
Many types of surgery do not require the patient to be paralysed. A patient who is anesthetised but not paralysed can move in response to a painful stimulus if the analgesia is inadequate. This may serve as a warning sign that the anesthetic depth is inadequate. However, movement under general anesthesia does not necessarily correlate with awareness, nor does the absence of movement necessarily correlate with amnesia.
Light anesthesia
For certain operations, such as Caesarean section, or in hypovolemic patients or patients with minimal cardiac reserve, the anesthesia provider may aim to provide " light anesthesia." During such circumstances, consciousness and recall may occur because judgments of depth of anesthesia are not precise. The anesthesia provider must weigh the need to keep the patient safe and stable with the goal of preventing awareness. Sometimes, it is necessary to provide lighter anesthesia in order to preserve the life of the patient. 'Light' anesthesia means less drugs by the intravenous route or via inhalational means, leading to less cardiovascular depression but, unfortunately, causing 'awareness' in the anesthetized subject. A lighter dose may also be administered due to cost-cutting.
Improper equipment maintenance/anesthetist error
Human errors include inadequate drug dose, inadequate monitoring, and failure to refill the anesthetic machine's vaporisers with volatile anesthetic. Other causes of awareness include unfamiliarity with techniques used, e.g. intravenous anesthetic regimes, or inexperience. Poor anesthetic technique is a combination of any of the above, but also includes techniques which could be described as outside the boundaries of " normal" practice. The American Society of Anesthesiologists recently released a Practice Advisory outlining the steps that anesthesia professionals and hospitals should take to minimize these risks. Other societies have released their own versions of these guidelines, including the Australian and New Zealand College of Anaesthetists.
Machine malfunction or misuse may result in an inadequate delivery of anesthetic. Many Boyle's machines used in many hospitals have the oxygen regulator serving as a slave to the pressure in the nitrous oxide regulator, to enable the nitrous oxide cut off safety feature. If nitrous oxide delivery suffers due to a leak in its regulator or tubing, an 'inadequate' mixture can be delivered to the patient, causing awareness. Many World War II vintage Boyle 'F' models are still functional. Their emergency oxygen flush valves have a tendency to release oxygen into the breathing system, which when added to the mixture set by the anaesthesiologist, can lead to awareness. This may also be caused by an empty vaporizer (or nitrous oxide cylinder) or a malfunctioning intravenous pump or disconnection of its delivery tubing.
To reduce the likelihood of awareness, anesthetists must be adequately trained and supervised while still in training. Equipment which monitors depth of anesthesia, such as bispectral index monitoring, should not be used in isolation.
Patient physiology
Possible causes of awareness include drug tolerance, or a tolerance induced by the interaction of other drugs. Some patients may be more resistant to the effects of anesthetics than others. Younger age, obesity, tobacco smoking or long-term use of certain drugs (alcohol, opiates, or amphetamines) may increase the anesthetic dose needed to produce unconsciousness. There may be genetic variations that cause differences in how quickly patients clear anesthetics, and there may be differences in how the sexes react to anesthetics as well. Additionally, anesthetic requirement is increased in persons with naturally red hair. Anxiety prior to the surgery can increase the amount of anesthesia required to prevent recall
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Awareness and recall
There are two states of consciousness which may be present:
Awareness. When patients seem to be vigilant and cognizant responding to commands but with no postoperative recall or memory of the events.
Memorization and recall. When patients can recall events postoperatively but were not necessarily conscious enough for responding to commands.
The incidence of a state with both responses in diverse degrees is also possible.
The experience of anesthesia awareness
The most traumatic case of anesthesia awareness is full consciousness during surgery with pain and explicit recall of intraoperative events. In less severe cases, patients may have only poor recollection of conversations, events, pain, pressure or of difficulty in breathing.
The experiences of patients with anesthesia awareness vary widely, and patient responses and sequelae vary widely as well. This experience may be extremely traumatic for the patient or not at all.
Because the medical staff may not know if a person is unconscious or not, it has been suggested that the staff maintain the professional conduct that would be appropriate for a conscious patient.
Conscious Sedation and Monitored Anesthesia Care
There are various levels of consciousness. Wakefulness and general anesthesia are two extremes of the spectrum. Conscious sedation and monitored anesthesia care (MAC) refer to an awareness somewhere in the middle of the spectrum depending on the degree to which a patient is sedated. It is important to note that awareness/wakefulness is not necessarily correlated with pain or discomfort. The aim of conscious sedation or minimal anesthetic care is to provide a safe and comfortable anesthetic while maintaining the patient's ability to follow commands.
Under certain circumstances, a general anesthetic, whereby the patient is completely unconscious, may be unnecessary and/or undesirable. For instance, with a cesarean delivery, the goal is to provide comfort with neuroaxial anesthetic yet maintain consciousness so that the mother can participate in the birth of her child. Other circumstances may include, but are not limited to, procedures that are minimally invasive or purely diagnostic (and thus not uncomfortable). Sometimes, the patient's health may not tolerate the stress of general anesthesia. The decision to provide monitored anesthesia care versus general anesthesia can be complex involving careful consideration of individual circumstances.
Patients who undergo conscious sedation or monitored anesthesia care are never meant to be without recall. Whether or not a patient remembers the procedure depends on the type of medications uses, the dosages used, patient physiology, and other factors. Many patients undergoing monitored anesthesia care do not remember the experience.
Incidence
The incidence of anesthesia awareness is higher when muscle relaxants are used.
Several studies have indicated this is a rare phenomenon, with rates varying from 0.13% to as low as 0.0068%. The modified patient interview used in this retrospective study did not specifically ask the patient if he/she had experienced awareness during the surgery.
Prompt inspection of the anesthesia equipment and record is important and may help prevent future occurrences. It is also important that a case of suspected awareness be communicated to the patient's healthcare team, and that the event be scrutinised closely by senior anesthetic medical staff.
Outcomes
Patients who experience full awareness with explicit recall may have suffered an enormous trauma. Some patients experience posttraumatic stress disorder (PTSD), leading to long-lasting after-effects such as nightmares, night terrors, flashbacks, insomnia, and in some cases even suicide. There is evidence that early psychological counselling and support can reduce the amount of harm and chances of developing PTSD. The patient must be treated sympathetically and with compassion.
Awake is a truly bizarre film, a brave, high-concept conspiracy thriller that falls short of its ambitions under the weight of its accumulative flaws.
With laudable commitment to his story, first time writer/director Joby Harold has compromised nothing bringing this plot-heavy drama to the screen. Yet throughout, you wonder if the script might have benefited from a second opinion, tempering his fidelity to his vision and naivety presenting it. For this admittedly rather squeamish reviewer, Awake managed the curious feat of being, by turns, gripping and literally unwatchable. The intrigue of the plot and the voyeuristic horror of the intimate surgical procedures presented are initially grimly compelling. But the former is undermined by unnecessary daftness, while the latter becomes too gorily overwhelming. According to the opening captions as many as 30,000 of the 21million people put under anaesthesia every year in the US remain awake during operations which is a brilliant, terrifying hook. But while making us graphically empathise with them, to the extent of revulsion, the film overplays it as a plot device. Hayden Christensen is Clay Beresford, a 22-year-old Manhattan billionaire and the scion of a real estate dynasty established by his late father. Engaged to the beautiful Samantha (Jessica Alba), Clay keeps their relationship secret from his shrewish mother Lilith (Lena Olin), preferring to confide in his friend Dr Jack Harper (Terence Howard).
Jack is the surgeon who saved Clay’s life after a heart attack and it is to him that the young man entrusts the impending transplant operation he needs to save his life, despite his mother’s preference for a brusque, top-flight doctor (Arliss Howard) who has operated on presidents and suffers none of Jack’s debts or malpractice suits. Jack advises Clay to marry Sam, and despite disapproval from his mother, he does so in a hastily arranged ceremony. No sooner are they wed than a call comes through that a donor heart is available. The newlyweds rush to the hospital and Sam makes peace with her mother-in-law as Clay goes under Jack’s knife. To reveal more would include spoilers, save for noting the arrival of a last-minute replacement for one of Jack’s team, the apparently drunk Dr Larry Lupin (Christopher McDonald) and to acknowledge that Clay does indeed fail to succumb to the anaesthetic, remaining awake throughout the procedure as his chest is sliced open.
Christensen conveys the full horror of this waking nightmare, but to keep his star and film together, Harold has Clay’s soul floating off the operating table and roaming the hospital corridors like Patrick Swayze in Ghost, discovering more about those closest to him as he transmigrates.
The out-of-body exposition serves its narrative purpose, but Harold gets carried away and eventually the ridiculousness of scenes that should have been dismissed as Clay’s agitated fantasies ruin an otherwise disturbing, suspenseful thriller.
Synopsis: A rich man becomes aware during surgery, yet is paralyzed to the extent that he cannot communicate with the doctors about what is happening. While this is going on, the man’s wife is dealing with her own set of problems.
Review: Awake is a semi-engaging, yet mostly predictable, attempt at a psychological thriller, as there is not much psychology or thrills to be had. A review of this type of movie is always difficult, even though you will probably see most things coming, on the outside chance that you don’t, we don’t want to give too much away.
On the good side of things, was the performance of Lena Olin (TV’s Alias), as the mother of Hayden Christensen’s Clay Beresford, the man that goes under the knife for a heart transplant. Olin’s performance reminds you why season two of Alias was so great. She commands your attention when she is on screen. Also, Terrence Howard, as the transplant surgeon is great, in an understated performance. The guy is just good.
On the other side of things, pretty much anyone could have played Clay in as a convincing manor as found here, but since a lot of the acting is done via voiceover, someone better skilled at conveying emotion via narration might have been a better choice.
The movie’s runtime is quite short, but that is probably a good thing for the most part. If it had gone too much longer, Clay might have been the only one in the theater that was awake. Although, maybe a couple minutes longer would have been good. Then they could have given you a better wrap up, as opposed to the bookend shot it ends on, cause you kind of feel that it shouldn’t be over yet. You need more than a sentence of closure.
Overall, you should wait for the rental. The runtime and predictable-ness make it not worth even the matinee ticket price at your local theater.
" You can see a number that rises as the patient becomes more awake," Shankder explains. " The idea is that if there is any kind of suggestion that the number that we're reading is one where the patient may not have anesthesia on board, we will treat it."
New guidelines from a leading healthcare accreditor now urge all hospitals to take the necessary steps to address the problem.The new guidelines suggest that these types of monitors (or some other form of monitoring) be used under general anesthesia, Shander notes. " They also give you guidelines in how to approach a patient who has been diagnosed with awareness and to recognize that when you have a patient who has had awareness under anesthesia during surgery, that these patients are suffering from a post-traumatic stress disorder.'" I still have nightmares, night tremors," Weihrer says.She hopes the new guidelines will help others like her who experience the worst: " Every patient will now be asked if they have any recall. And those that respond 'yes' will be treated specially." ------
Anesthesia Awareness
Anesthesia awareness happens when the medications provided to render the patient unconscious during general anesthesia are not effective but the agents used to paralyze the patient are. This means that the patient is unable to move or speak, but is wide awake, hearing and feeling the entire procedure.
Awareness during a surgical procedure is a rare, but it remains a concern for many patients who are anticipating having surgery with general anesthesia.
If you are concerned about anesthesia awareness or have experienced it in the past, be sure to inform your anesthesia provider. Doctors can address your concerns and your specific situation to make sure your anesthesia is adequate for your surgery.
First, it is important to understand that, with the exception of general anesthesia, complete unconsciousness is usually not the goal of surgical anesthesia. In fact, one of the reasons for choosing another type of anesthesia is that the patient’s awareness can be helpful to the surgeon during the procedure, as well as providing some measure of protection to the patient.
With local or regional anesthetic, you remain totally conscious, although sometimes oral sedatives are given to help you relax and feel comfortable. With intravenous conscious sedation, although the patient is not technically “unconscious,” one of the goals is often to minimize or eliminate memory of a procedure. However, memory loss isn’t always complete. Having some memory, especially of the beginning or end of a procedure, is not all that unusual, and shouldn’t be of much concern.
When it comes to general anesthesia, awareness during surgery is rare. Usually, this phenomenon occurs when anesthesia dosage must be decreased due to complications such as significant blood loss, respiratory distress, or heart failure.
The good news is that even in those cases of awareness during anesthesia, the experience is almost never painful. If you do experience awareness during general anesthesia, be sure to speak up about it to your surgical team.
Here's what the term means: When a real-life patient receives anesthesia for surgery, it typically consists of two main ingredients. The first produces paralysis, allowing the machines (ventilators, for example) to work without the pesky patient fighting back. The second part of the cocktail makes the patient comatose so he or she doesn't have to feel or hear what's going on during the surgery. The problem is that, once in a while—at a rate that is subject to much debate—the paralysis part works just fine but the coma part, not so much. So a patient might have the nightmarish experience of being 100 percent paralyzed yet 100 percent awake. This is worse than your typical nightmare of being unable to scream when an evil-doer is chasing you down a dark alley, because this time the surgeon is holding a noisy buzz-saw an inch above your ribs.
Of course the Hollywood approach to adopting a cause (and a cause it is, complete with this Web site and victims' stories) is to concoct a sly plot device and then drop it. True to form, Awake starts with a grim recitation of alleged statistics scrolled out in Star Wars script—21 million Americans will receive anesthesia this year and 30,000 will have an anesthesia awareness experience. If true, that's pretty scary. Then we meet our hero, Clayton (Hayden Christensen), a young billionaire with a cute girlfriend (Jessica Alba) and a terminal cardiac condition. At the movie's opening, Clayton is submerged in a bathtub for a long time.
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Movie Review

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