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1. AWARENESS
PROBLEMS
DURING
OPERATION
Dr Nisar Ahmed Arain
Assistant Professor
Anesthesia/Critical care/ER

2. -AWARENESS PROBLEMS WHAT HAPPENS IF WE ARE AWAKE
DURING GENERAL ANESTHESIA

3. -AWARENESS PROBLEMS
-INTRODUCTION
---Awareness in anesthesia during operation occurs, when a patient becomes conscious
during a surgical procedure performed under GA and subsequently has recall of these
events
=A-For Anesthesiologists, AAranks second only to death as a “Dreaded” complication
=Incidence:-o.1% to o.2%
-Cardiac surgery 1.1% to 1.5%
-Obstetric C/S (0.4%)
-Surgery in Trauma cases (11% to 43%)
=Significantly influence the cognitive and psychological functions of the patients
=Medicolegal issue

4. -AWARENESS PROBLEMS
-DEFINATION OF
AWARENESS

5. -AWARENESS PROBLEMS
WHO IS AT RISK FOR
-ANESTHESIA AWARENESS
--1-Women > Men
--2-Age < 60 years
--3-TIVA > Inhalational
--4-Long Duration of surgery
--5-Previous Awareness history
--6-People with natural Red Hair

6. -AWARENESS PROBLEMS
-CAUSES OF AWARENESS
A-LIGHT ANESTHESIA
a-Cardiac surgeries
b-C/S
c-Surgery in Trauma
d-ASA physical status 4 or 5
e-Premature discontinuation of
anesthetic agents

7. - AWARENESS PROBLEMS --WHO IS AT RISK FOR
-ANESTHESIA AWARENESS
B-INCREASED ANESTHETIC REQUIREMENTS
a-chronic use of Benzodiazepines or opioids
b-Alcoholics
c-Severly anxious patients
d-Difficult Intubation
e-Previous awareness experience
C-IMPROPER EQUIPMENT MAINTAINENCE
OR ANESTHESIOLOGISTS ERROR
a-Failure to fill vaporizers with inhalational agents
b-Judgement errors related to drug and volatile agents
c-Disconnections and Kinks in tubes from the ventilator

8. -AWARENESS PROBLEMS -WHO IS AT RISK FOR ANESTHESIA AWARENESS

9. -AWARENESS PROBLEMS
-PATIENTS PERCEPTION OF AWARENESS
--Recall immediately after surgery, Recovery room
or Several days later
MOST COMMON
a-Sounds and conversations – 89% to 100%
b-Sensation of Paralysis – 85%
c-Anxiety and Panic
d-Helplessness and powerlessness
e-Pain 39%
LEAST COMMON
a-Visual Perceptions
b-Intubation or tube
c-Feeling the operation without pain

10. -AWARENESS PROBLEMS
-AFTER EFFECTS
--1-Sleep disturbances
--2-Repititive nightmares
--3-Anxiety and panic attacks
--4-Depression
--5-Flash backs
--6-Avoidence of Medical care
--7-Suicide
--8-Post-Traumatic stress disorders(PTSD)

11. -AWARENESS PROBLEMS
-PREVENTION OF AWARENESS
--A- PRE-OPERATIVE EVALUATION
--1-History(proper and detailed)
--2-Thorough Physical examination
--3-Identifying patients risk factors for intra-operative
awareness
--4-Informing high risk patients regarding the possibility of
intra-operative awareness
--B- PRE-INDUCTION OF GENERAL ANESTHESIA
--5-Prophylactic administration of Benzodiazepines
--6-Checking the functioning of Anesthesia delivery system

12. -AWARENESS PROBLEMS
-PREVENTION OF AWARENESS
--C- INTRA-OPERATIVE INTERVENTIONS
--1-Cautionary use of the Neuromuscular Blocking agents
--2-Inhalant Anesthetics must be monitored with End-Tidal-Gas
analyzers and the minimum alveolar concentration (MAC)
of anesthetic agents should be maintained >0.8
--3-BIS value < 60
--D- POST-OPERATIVE INTERVENTIONS
--4-Post-operative interview to report awareness
a-What is the last thing you remember before surgery
b-What is first thing you remember after surgery
c-Do you remember anything during the procedure
d-Did you dream during the procedure
--5-Providing post-operative counseling or psychological support

13. -AWARENESS PROBLEMS
METHODS OF MONITORING
CONCIOUSNESS
DURING GENERAL ANESTHESIA
--A- CLINICAL SIGNS
--1-Sympathetic activity
-HR
-BP
-SWEATING
-PUPILARY DILATATION
*-LACRIMATION
-UNRELIABLE SIGNS ALSO

14. -AWARENESS PROBLEMS METHODS OF MONITORING
CONCIOUSNESS
DURING GENERAL ANESTHESIA
--B---ISOLATED FOREARM TECHNIQUE
--1-Tourniquet applied to the patient’s forearm before
the administration of muscle relaxants
--2-Moves fingers if aware
--3-Verbal command to confirm

15. -AWARENESS PROBLEMS METHODS OF MONITORING
CONCIOUSNESS
DURING GENERAL ANESTHESIA
--C---MONITORING OF BRAIN ELECTRICAL ACTIVITY
--1-BIS (bispectral index monitoring)
a-EEG derived multivariant scale
b-0 to 100 (For GA 40 to 60)
--2-AEP (Auditory evoked potential)
--3-Narcotrend

16. -AWARENESS PROBLEMS
METHODS OF MONITORING
CONCIOUSNESS
DURING GENERAL ANESTHESIA
--D- MEASUREMENTS OF LOWER ESOPHAGEAL
SPHINCTER CONTRACTIONS
--E- EEG OF FRONTALIS MUSCLE