This document discusses the problem of anesthesia awareness during surgery. It defines anesthesia awareness as a patient becoming conscious during a surgical procedure under general anesthesia and having recall of events. Risk factors for awareness include women, younger age, use of total intravenous anesthesia, long surgeries, previous awareness history, and natural red hair. Causes can include light anesthesia, increased anesthetic requirements, or anesthesiologist error. Prevention strategies include pre-operative evaluation, prophylactic benzodiazepines, monitoring anesthetic levels, and post-operative interviews. Methods to monitor consciousness during surgery include clinical signs, isolated forearm technique, brain monitoring like BIS, and measurements of muscle activity.

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