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Anesth-aware - 225 Page 1 Awareness during General...

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Awareness during General Anesthesia Peter S. Sebel, M . B . B . S . , Ph.D., M . B . A . Atlanta, Georgia 225 Page 1 O BJECTIVES 1. Understand the incidence of awareness and factors leading to its occurrence. 2. Understand the concepts of memory function during anesthesia. C ASE P RESENTATION Introduction The state of general anesthesia implies a lack of consciousness, or awareness. Awareness can occur with or without conscious recollection of the event. Take, for example, patients who are intubated yet open their eyes to command at the end of surgery. In terms of responding to command, they are aware. Yet, frequently, they will not remember commands in the operating room, nor will they remember extubation. Thus, they are aware without recall. The challenge to anesthesiologists is to eliminate recall of unpleasant experiences during surgery. Incidence Recent prospective studies suggest that the incidence of awareness varies from 0.0015% (in 11,785 patients) 1 to 0.2% (in 1,000 patients) 2 . To put this in perspective, assuming 20,000,000 general anesthetics are performed in the United States each year, the number of patients suffering from awareness with recall will be between 30,000 and 40,000. It is noteworthy from the largest scale study 1 that the incidence approaches 0.2% in cases where neuromuscular blocking agents were used but is approximately half that in the absence of such drugs. Furthermore, although non-paralyzed patients recalled intraoperative events, none of them had anxiety during the wakefulness or had delayed psychiatric symptoms. In contrast, when neuromuscular blocking agents were used, 78% of aware patients had pain, anxiety or post-traumatic stress disorder (PTSD). Since patients will often not spontaneously report the occurrence of awareness with recall, the following set of questions has been proposed 2 as an instrument to assess the occurrence of awareness: What is the last thing you remembered before you went to sleep? What is the first thing you remembered when you woke up? Can you remember anything between these two periods? Did you dream during your operation? What was the worst thing about your operation? Legal Implications Cases of awareness represent between 1.9% (ASA Closed Claims Analysis) 3 to 12.2% (British data) 4 of claims against anesthesiologists. In the United States, the median payment for such cases is $18,000 3 , although recently, there have been several cases in which much larger claims
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225 Page 2 have been settled. The ASA Closed Claims Database 3 suggests that the majority of awareness claims occur in women younger than 60 years of age ASA physical class I-II undergoing elective surgery. It is noteworthy that what are generally considered to be the classic cues for light anesthesia were absent in most cases: hypertension occurring in 15% of recall cases and tachycardia occurring in 7%.
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