You are on page 1of 6

Brit. J. Anaesth.

(1968), 40, 259

FACTORS CAUSING AWARENESS DURING SURGERY
BY
D. J. WATERS

SUMMARY
Factors which can lead to awareness during surgery are considered. They are divided
into those affecting induction and those affecting maintenance. Induction: The risk of a
patient recovering consciousness while still paralyzed is greater if an ultrashort-acting
intravenous anaesthetic is used. The time interval necessary before surgery may begin
is governed by the need to build up a sufficient concentration of inhalation agent to take
over from the waning effect of the intravenous agent Maintenance: Three sources of

Downloaded from http://bja.oxfordjournals.org/ at :: on December 27, 2016
trouble are distinguished, each leading to the patient receiving an anaesthetic mixture
less potent than intended. (1) Ventilators may rniy air or oxygen with the anaesthetic
gas if they are not adjusted properly or if there are leaks. Ventilators are classified
according to their propensities for doing this. (2) Some anaesthetic machines have
pitfalls. (3) A circle system is shown to need time to acquire an adequate concentration
of anaesthetic. The importance of high flowrates is stressed both at the start of an
anaesthetic and also if the circuit should happen to be broken later on.

In recent years patients undergoing surgery have venous injection diminishes in the course of time
benefited greatly from anaesthetic techniques and nothing can stop it. The effect of the inhala-
which allow major operations to be performed tion agent which follows increases over the course
under light general anaesthesia. Muscle relaxants of time but it can only do so if it is introduced
have made the biggest contribution to such tech- into the lungs. When the patient is paralyzed it is
niques but they have introduced the hazard that required that ventilation be carried out vigorously
a patient may be conscious but paralyzed (Hut- with this purpose in mind. It is not enough merely
chinson, 1961). Consequently every anaesthetist to give an occasional squeeze to an oxygen-filled
must bear this hazard in mind and be meticulous bag.
in his attention to detail so that the accident never The surgeon may be allowed to proceed when
occurs. Trouble may arise during induction of the anaesthetist judges that enough inhalation
anaesthesia or during maintenance. agent has been introduced to ensure unconscious-
ness. Occasionally it may be necessary to restrain
INDUCTION OF ANAESTHESIA an obstetrician from beginning a Caesarean sec-
The intravenous agent. tion too early, especially if premedication has been
When an intravenous agent is used before a light, the dose of intravenous agent small and the
laparotomy it must ensure unconsciousness during nitrous oxide unsupplemented.
laryngoscopy and intubation and it must continue
to act until sufficient inhalation agent has been MAINTENANCE OF ANAESTHESIA
introduced to take over. It does not matter if the
Unconsciousness is frequently maintained by
intravenous agent continues to act during the
means of a mixture of nitrous oxide and oxygen,
laparotomy provided that it has worn off by the
but there seems to have been a tendency recently
end. It follows that intravenous agents with a very
for anaesthetists to add small concentrations of
short duration of action may not serve the pur-
volatile agents (Mushin, Campbell and Shang Ng,
pose; there may be a lucid interval.
1967). Whatever is used it is incumbent upon the
Interval elapsing before surgery. anaesthetist to ensure that his patient is actually
No rules can be given in terms of minutes. It receiving the intended mixture. The factors which
can only be stated that the effect of the intra- influence what the patient actually gets may be

bi site of entry of air is occluded the bag dsvelops there is never any subatmospheric pressure to "intercostal recession". The logical way of using draw in air.org/ at :: on December 27. If he does not do so he may it is impossible to set ± e machine to do otter- imagine that all is well merely because the con. Such a risk is readily ap./min. so diluting the anaes- Dilution of anaesthetic mixture with air. the fresh gas flow must be increased. If with each stroke of the concertina bag and 6 1. and (iii) the elimination of so that a larger volume of gas enters at each air from the apparatus and the lungs. between the manoeuvres which the ventilator is During the inflating downstroke of the concertina set to perform and the amount of anaesthetic gas bag gas passes into the lungs and also out to tie made available to it. wise. Air is thus only When it comes to refill it can derive only a limited likely to become mixed with ths anaesthetic gas amount of gas from the lungs and only a limited when the ventilator is not driven by the anaes./min. Such a discrepancy can only atmosphere through the leak. amount from the fresh gas inflow. the machine as a non-rebreathing system is to The Manley and the East-Radcliffe have been decide what minute volume th: patient should selected for mention merely because each is repre- receive. (ii) the peculiarities of later time the compliance of the chest increases anaesthetic machines. If the leak occurs while the bag is empty- But if the machine is looked at more closely the ing. The Manley is a a time-cycled pressure generator driven by an non-rebreatbing ventilator driven by tie anaes- electric motor. When the anaesthetist uses this thetic gas. circuit is in use and the input of fresh gas is small Downloaded from http://bja.260 BRITISH JOURNAL OF ANAESTHESIA considered under three heads: (i) the use of using reasonable tidal volumes and rates./min longer time to fill to tie volume required for and ventilating his patient's lungs at 9 l. Suppose that the soda-lime preciated when a negative pressure phase is used. Radcliffe ventilator. described in the last two paragraphs may be con- Take as an example the East-Radcliffe ventilator. other pair could equally well have been chosen . 2016 But a risk also exists if there is a discrepancy compared with the minute volume ventilation. But cycling and so tie number of breaths per minute if he changes over to the non-rebreathing circuit is reduced. If the ventilator with soda-lime absorption he may be fresh gas flow is small the concertina bag takes a accustomed to using a fresh gas flow of 3 l. The patient is ventilated at a minute of the ventilator he must increase the fresh gas volume nominally equal to the fresh gas flow and flow to 9 l. to supply this volume of fresh gas and sentative of the group to which it belongs. Current versions Mechanical ventilators are convenient aids to the of the East-Raddiffe have a reservoir bag which anaesthetist but they introduce a risk that the stores fresh gas and which flattens prematurely patient may not receive the same mixture as that when the fresh gas flow is too small. a leak. some of the anaesthetic gas is lost to the inspiratory relief valve will be seen to be acting atmosphere and the lungs are under-inflated.oxfordjournals. The Deans- supplied from the anaesthetic machine. Air may way and the Cape have such reservoir bags also. Again consider the East- by accident or design. If the of anaesthetic gas causes it to fill more slowly. Because of the leak arise if the ventilator is driven by some force the bag empties more than it would normally do. If the fresh gas flow is too small for the minute volume which a ventilator is set to deliver. other than the anaesthetic gas. ized mechanism ensures that it rises to its full extent. thetic mixture. An then to set the controls to match this figure. If at a mechanical ventilators. trasted with that of the Manley. useful if the ventilator shows it. It therefore develops a subatmospheric pressure and draws in air. Incompatibility between fresh gas flow and The behaviour of the East-Radcliffe ventilater minute volume for which the ventilator is set. it is a minute volume divider. breath. it is Ventilators. certina bag is filling and emptying regularly and The Manley also behaves differently if there is the chest is moving in a corresponding fashion. be drawn in through some aperture which exists Effects of a leak. the leak occurs when the bag is refilling the loss of air are being drawn in every minute. Yet the motor- thetic gas.

It is worth noting that Non-rebreathing ventilators discard the whole when the Cyclator is used to drive a bag-in-bottle of the patient's expiration. issuing gas has been diluted with oxygen. system is to be maintained the flowmeter set- gen passes through an injector which entrains tings will need to be increased to provide more anaesthetic gas coming from the flowmeters in fresh gas. changes from manual control of ventilation to quently included in the mixture used to inflate mechanical control of ventilation and forgets to the lungs. determined by the ventilator. the about negative pressure in the chamber surround. But a danger still with anaesthetic gas. So a leak. Recently Bookallil (1967) oxygen. the Cyclator. Cyclator. In addition anaesthetic gas will be lost reported an instance where a faulty inspiratory through the spill valve during the expiratory relief valve on a Cape-Waine ventilator allowed pause because there is nowhere for it to be air to enter the apparatus during the expiratory stored. for example to give a smaller proportion of anaesdietic gas in the Bennett B. The reservoir bag from which the becomes filled with air then air will enter the injector of the Cyclator draws its supply of anaes- lungs during the next inflation. If this limb drawn flat.FACTORS CAUSING AWARENESS DURING SURGERY 261 Use of negative pressure phase. for example the Air. turning off the fresh gas inflow.4. air may be drawn into some part of the Trouble is likely to arise if the anaesdietist ventilator. obstructing the even if he has overlooked the empty bag. leak. thetic gas will become empty if the anaesthetist Downloaded from http://bja. leak. for example entrained anaesthetic gas in the issuing gas only the Boyle Mark HI absorber driven by the applies when anaesthetic gas is freely available. Readjustments are not made when the trigger starts acting. die patient and seeing if the bag fills when nega. the reservoir bag has become flat the flow of gas Shields Ventimeter. obstructing the flow out of inflation phase as if the bag were flat all the time. If a non-rebreathing The Cyclator is so designed that the driving oxy. Likewise a leak direct to the Cyclator without including a reser- during expiration may be detected by turning off voir bag. Any of these three variants is from the ventilator as a whole is less and it takes susceptible to trouble from air entering through longer for the cycling pressure to be achieved.org/ at :: on December 27. The commonest rebreathing arrange. Once ing the concertina bag. ment has a bag in a bottle and negative pressure The manufacturers' stated ratio between the is achieved by (i) a weight acting at the bottom volume of driving oxygen and the volume of of the free end of the concertina bag.A. the inspiratory limb of the double pipe leading The anaesthetist allows the reservoir bag to be from the ventilator to the patient. the ventilator will behave during the the fresh gas inflow. patient's minute volume. so no dilution of anaesthetic exists if the site of entry of air is somewhere along gas with oxygen can occur. All may be well when the patient is apnoeic but when the earliest attempts at spon- Dilution of the anaesthetic mixture with taneous breathing are made the respiratory rate oxygen.oxfordjournals. This is important if the air is subse. may be much more rapid than that formerly The anaesthetist ignores the driving oxygen. readjust the flowmeters. flow into the patient and seeing if the bag empties If by mistake a novice feeds anaesthetic gas when positive pressure is applied. so there will be considerable dilution with tive pressure is applied. phase only. or (iii) by a venturi bringing the issuing mixture—or wording it differently. (ii) by a weight and a pulley acting at After the bag has been drawn flat the ratio alters the top free end of the concertina bag. 2016 If the ventilator has a rebreathing circuit there has not matched the total gas flow with the is a risk of air being included in the inflating mix. Either the tidal volume ture no matter where the air was drawn in is too big or the rate is too high or there is a originally. If negative such a way that 25 per cent of the issuing gas pressure is used during expiration and there is a consists of driving oxygen. If the adjustment is not made the bag . so it does not matter arrangement diere is no mixing of driving gas if this part is mixed with air. the anaesthetist should be able to tell from the A leak during inspiration may be detected by prolonged inspiratory time that all is not well.

catheter mount leading to the 'lung" and dieir . It is possible at one place and gas is allowed to overflow at to administer a mixture containing more oxygen another. whether the concentration of gas within a circle system does indeed rise in an exponential manner. Elimination of air at the beginning of an anaesthetic. The volume of to the ventilator. The resting any other force will go on operating. The system was full of air to begin with and circuit. If the venti.1 1./min. tubing. rise in concentration depends on the rate of inflow If nitrous oxide and oxygen comprise the whole of fresh gas. If die fraction alarms are thought to be inadvisable there is still Volume of system (lungs.org/ at :: on December 27.oxfordjournals. The total rebreathing circuit. If the tap is in the wrong position no gas oxygen was used to simulate anaesthetic gas. The apparatus normally contains air at the beginning of an anaesthetic. volume of the "lung" was 2. Air is eliminated through the intentional than is intended if the tap is left partly turned leak and the concentration of anaesthetic gas in on. excess gas being vented appear to be well until the patient has used up the to the atmosphere through the Heidbrink valve limited amount of oxygen in the circuit. If it has a closed circuit all will emptied at each squeeze. A ventilator operated flow rate being 4 l. and the initial lator which continues to operate has a non. may be shown theoretically that the concentration thetic machines so that an alarm is sounded when of anaesthetic gas in the system rises exponentially the supply of oxygen fails there might likewise be with time and that the time constant is given by a case for doing the same with nitrous oxide. failure of the nitrous oxide If uptake of anaesthetic gas by the patient be supply leads to a rapid recovery of consciousness. With a non-rebreathing cir- said that after a lapse of time equal to three time- cuit each inspiration now consists of pure oxygen. die system rises. 2016 Failure of nitrous oxide supply. mixture with oxygen will follow. but the Downloaded from http://bja. inflating a model lung of the the Howells. The apparatus used was a Boyle Mark III absorber The machine does not supply any anaesthetic gas with a 4-lb. Squeezing the reservoir bag ensures good mixing. the is supplied to the ventilator. volume of the reservoir bag was 1. then the extra oxygen gas. Anaesthetic Machines. for example the Manley or squeezed by hand. With a rebreath- have reached 95 per cent of the maximum.) something to be said for fitting pressure gauges to nitrous oxide cylinders. Most simple semi- The oxygen bypass tap. or if it is faulty. Gas samples were taken from die then become cyanosed. Rate of inflow of fresh gas The speed with which consciousness returns From a knowledge of the properties of exponential when the nitrous oxide supply fails is influenced curves (Waters and Mapleson.1 1. ignored and perfect mixing of gases is assumed it If it is thought reasonable to fit devices to anaes. inhalation mixture. fails to operate. he will near die "lung". but one driven by pattern described by Cohen (1966). 1964) it may be by the circuit in use. but this takes time.262 BRITISH JOURNAL OF ANAESTHESIA will became flat and dilution of the anaesthetic Elimination of Air. air will be found to be getting volume of die system was dius 8 1. dosed systems contain only a small volume of air The bypass tap may be placed before or after and this is rapidly displaced by the flow of fresh the flowmeter. canister of soda-lime. there is no such indication. bag. Anaesthetic gas is fed into the circle system it is after. If it is before. the apparatus was measured with its reservoir bag Some versions of the Boyle apparatus have a empty by a gas dilution method and found to be tap which directs the gas to the closed or the open 4. ing circuit each inspiration contains some nitrous oxide from a previous expiration so consciousness Experiments have been carried out to see returns more slowly.8 1. The bag was in somewhere. but if so. constants the concentration in the system will so consciousness returns rapidly. The reservoir bag was by the anaesthetic gas. etc. but in a circle system this is not necessarily is indicated by the position of the bobbin.

Brit. 1 REFERENCES Build-up of concentration of inflowing gas within a BookaUil. use of negative pressure phase).. MINUTES FIG. Awareness during surgery. mechanical ventilation. With manually controlled ventilation this will than expected it still takes more than 4 minutes not happen to any great extent but with mechanic- for the inspired gas to contain 95 per cent of the ally controlled ventilation it may be important. et d'autre part ceux qui lungs while the mixture lost through the expira. 463. 274. FACTORS CAUSING AWARENESS DURING SURGERY 263 oxygen content measured with an Astrup tory valve consists of a high proportion of anaes- apparatus. Factors affecting the rapidity of alteration of nitrous oxide concentration in a Small flows of fresh gas are often used with circle system. The circumstances are those already dealt with •mrW •+"=• heoHincr "Ventilators" (effects of a leak. For conditions. Anaesth. Anesthesiology. Mushin and Dr. W. Dilution with air can be avoided by 8O switching off the ventilator before disconnecting the apparatus. (1961). At the beginning of an anaesthetic the The results depicted in figure 1 show that the anaesthetist is often engaged with other tasks and concentration of inflowing gas found in the in. J. If air has been allowed to enter it 6Q should be flushed out by a large flow of fresh anaesthetic gas. Although the rise is more rapid tus. Induction: le risque qu'un . Anaesthesia. thetic gas. but when air has to be displaced from a system Mushin. and Mapleson. Mapleson of the Department of Anaesthetics.. 21. 19. 39. The pattern of anaesthesia in a general graphs showing how the rate of rise of concen. Downloaded from http://bja. 323. may neglect ventilation. J. Anaesthesia. the disconnected 7oANAESTHETIC GAS apparatus being regarded as constituting a very IN INSPIRED GAS large leak. Campbell. Cardiff. If this is not conscient durant une operation. 2016 inflowing gas. see text. Us sont partages d'une part en ceux qui affectent Pinduction de l'anesthesie. sont pris en considera- attended to.. Exponen- tration of anaesthetic agent in a circle system is tials and the anaesthetist. M. D. W. I. (1967). spired gas rises over the course of time in a fashion resembling an exponential curve and a Elimination of air later on in an anaesthetic. If it becomes necessary to disconnect the constant is only 1. ACKNOWLEDGEMENTS 20 It is a pleasure to acknowledge the helpful advice and criticism given me in the preparation of this paper by Professor W.. affectent son maintien. circle systems because such flows are economical. W. When the flow was reduced by a factor of 10 the time needed to FACTEURS CAUSANT LA CONSCIENCE reach 50 per cent of the maximum possible con. influenced by the fresh gas flow. mentally.. An artificial lung. 33. R. The lower curve in figure 1 tion of an anaesthetic. big flows are needed. 21. Cohen.. 569. J. DURANT L'INTERVENTION CHIRURGICALE centration was increased by a factor of 11. E. Anaesth. 348. then air remains sequestered in the tion. Eger (1960) has published (1967). Entrainment of air during circle system. W. but the time. (1964). (1966). W.oxfordjournals. J. then one must consider the it had conformed to the theory which assumed possibility that air may gain access to the appara- perfect mixing. Welsh National School 1 2 3 4 5 6 of Medicine. it is not sufficient merely to refill the system with oxygen. for example to perform shows how the concentration would have risen if endotracheal suction. the lower curve was predicted theoretically.. H. and Shang Ng. Eger. 184. Waters.org/ at :: on December 27. Hutchinson. Brit. hospital. 39. n (1960). J. Brit. W.4 minutes instead of the apparatus from the patient during the administra- expected 2 minutes. W. logarithmic plot confirms this. D. The upper curve was obtained experi. Anaesth. A. W. SOMMAIRE Satisfactory mixing of gases calls for rhythmic Les facteurs qui peuvent contribuer a rendre le malade squeezing of the reservoir bag.

If the numbrr of offers in response to this appeal is greater than the number of stewards required. FULHAM ROAD. wird. chacune en £tant la cause que le patient eine geniigend hohe Konzentration des Inhalations- recoit un melange anesthesique moins puissant que narkotikums aufzubauen. pour intravenos zu verabreichendes Narkotikum verwendet compenscr la disparition de l'effet de l'agent intra. (1) Les ventilateurs peuvent melanger de l'air des intravenos verabreichten Narkotikums zu ersetzen. il y a d:s pieges. DIE DEN PATIENTEN WAHREND Vermischung verhindern). leaving the actual name to be supplied nearer the time of the Congress. L'intervalle der Narkose betreffen. ou de l'oxygene au gaz anesthesiques. tout en itant encore zuriickkehren lassen konnen.h:n mull. Stewards will be admitted to the Congress free of charge on the day on which they are on duty. s'ils ne sont pas Erhaltung: Drei Ursachen. die Sorgen bereiten konnen. Maintien: on distingue trois sources de verg. difficultes.org/ at :: on December 27. those who undertake three day's stewardship will be offered two additional days free of charge.3 enclosing a letter of consent from the Head of the Department in which they work. die den Patienten einer zufalligen Unterbrechung des Umkufs wird wahrend eines operativen Eingriffs zum Bewufitsein hervorgehoben. Further details and an application form will then be supplied. die die Erhalrung veineux d'action ultracourte a 6ti employ^. Einleitung: Das Risiko. Das Zeitintervall. Die Wichtigkeit hoher Stromungsgeschwindigkeiten ZUSAMMENFASSUNG sowohl zu Beginn der Narkose als auch spater nach Es werdsn Faktoren besprochen. wobci jede davon ausgeht. das bis zum Operationsbeginn veineux. Beatmungsgerate werden ent- panne ulte'rieure dans le circuit. (3) Es wird gezeigt.sthesique intra. Heads of Departments may prefer to offer "a Registrar" or "a Senior Registrar" for steward- ship duty. und solche. bien rigles. S.oxfordjournals. Assistance of this kind will be most welcome.1968 REGISTRAR STEWARDS FOR SCIENTIFIC SESSIONS The Organizing Committee wish to recruit volunteer Stewards to serve as aides to the Chairmen and Secretaries of Scientific Sessions from amongst the Senior Registrars and Registrars in the United Kingdom. das weniger als connu qu'un systeme ferine n&essite un certain temps biabsichtigt wirksam ist. daO ein requis avant que l'intervention puisse commencer.W. wenn ein ultrakurz-wirkendes. (2) Dans certains werden unterschieden. A Senior Registrar or Registrar will thus be able to attend all the scientific sessions of the Congress free of charge (three days' stewardship and two extra days free of charge). but no guarantee can be given that they will be allocated to a particular Session. est Patient noch in gilahmtem Zustand zum Bewufitsein dittrmini par la necessity de faire exister une concen. wird von der Notwendigkeit beherrscht. zuriickkehn. (3) II est der Patient ein Narkosegemisch erhalt. (2) Einige Narkose- gerate besitzen Senkraume. the Organizing Committee reserve the right to select the team from amongst the volunteers. LONDON. die die Einteitung. Those who undertake one or two days' stewardship will be offered one additional day's admission free of charge. lichirweise in nicht richtig geeichten oder undichten aussi bien pour le d£but de l'anesthesie qu'en cas de Beatmungsgeraten. ROYAL MARSDEN HOSPITAL. Please write to the above address. tration suffisante de l'anesthesique inhalatoire. FOURTH WORLD CONGRESS OF ANAESTHESIOLOGISTS. solche. daO EINES OPERATIVEN EINGRIFFS ZUM ein Umlaufsystem Zeit bsnotigt.264 BRITISH JOURNAL OF ANAESTHESIA patitnt redevienne conscient. ou s'il existe une fuite. sprcchend ihrer Eignung eingeteilt. um fur eine aus- BEWUSSTSEIN ZUROCKKEHREN LASSEN reichende Konzentration des Narkotikums zu sorgen. L'importance d'un flux elev£ est rappele'. (die eine vollstandige Downloaded from http://bja. Sic werden unterteilt in paralyse^ est plus grand lorsqu'un an. FOURTH WORLD CONGRESS OF ANAESTHESIOLOGISTS. urn die nachlassende Wirkung privu. daO appareils d'anesthesie. (1) Die Mischung von Luft avant d'atteindre une concentration anesthesique oder Sauerstoff mit dem Gasnarkotikurn erfolgt mog- adiquate. LONDON September 9-13. 2016 FAKTOREN. . ist grofler. Volunteers for stewardship duty should write to: THE SECRETARY. Daily travelling expenses will be paid only from an address in London or the Home Counties.