Module: Stages of Anesthesia and

Awareness
Slides (3-20)

Question: A score of “3” on the Modified

Observer Assessment of Alertness/ Sedation
Scale (MOAA/S) suggests that a patient
undergoing sedation will respond how?
ANESTHESIA PROCEDURES, METHODS, A. Lethargic response to his name spoken in
& TECHNIQUES II a normal tone
B. Responds only after name is called out
Jerrold Lerman, MD
loudly/repeatedly
Clinical Professor of Anesthesiology
C. Responds only after mild prodding or
John R. Oishei Children’s Hospital,
shaking
Jacobs School of Medicine and Biomedical
D. Responds only after painful trapezius
Sciences,
squeeze
Buffalo, NY
jerrold.lerman@gmail.com

Question Based Learning

Lecture Modules

• Stages of Anesthesia and Awareness

Notes:

Anesthesiology: Anesthesia Procedures, Methods, & Techniques II

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Jerrold Lerman © 2014-2018 ThePassMachine.com 877-225-8384 1
Distribution is a violation of copyright laws.
MOAA/S Scale

Source: Chernik DA, Gillings D, Laine H, et al: Validity and reliability of the Observer's Assessment of Alertness/Sedation Scale: Study with intravenous
midazolam. J Clin Psychopharmacol 1990; 10:244-251.

Question: The MAC of anesthesia required to prevent movement in 100% of patients is greatest for which
of the following noxious stimuli?
A. Laryngoscopy
B. Rib retraction
C. Abdominal incision and exploration
D. Electrical tetany

Source: Zbinden AM, et al. Anesthesiology 1994:80;253.

Notes:

Anesthesiology: Anesthesia Procedures, Methods, & Techniques II

This document is for exclusive use of: Lindsay Wetzel lindsay.wetzel@uhhospitals.org
Jerrold Lerman © 2014-2018 ThePassMachine.com 877-225-8384 2
Distribution is a violation of copyright laws.
Stages of Anesthesia/Awareness
• Awareness—postoperative recall of events
occurring during general anesthesia
• Amnesic wakefulness—responsiveness during
general anesthesia without postoperative recall
• Dreaming—any experience (excluding
awareness) that patients are able to recall
postoperatively that they think occurred during
general anesthesia and that they believe is
dreaming
• Explicit memory—conscious recollection of
previous experiences (“awareness” is evidence
of explicit memory)
• Implicit memory—changes in performance or
behavior that are produced by previous
experiences but without any conscious
recollection of those experiences (“unconscious
memory formation” during general anesthesia)
• What are the 4 questions that comprise the
Brice Questionnaire?
• Abouleish and Taylor modified the Brice
questionnaire to the form most commonly used
in subsequent studies
– What was the last thing you remembered
before going to sleep?
– What was the first thing you remembered on
waking?
– Do you remember anything between going to
sleep and waking?
– While you were sleeping during the
operation, did you dream?
• Patients should be questioned on more than
one occasion postoperatively to maximize the
likelihood of detecting all cases of awareness
• Clinicians should note that the modified Brice
questionnaire has been administered to tens of
thousands of patients in quality assurance
audits and research projects without reports of
undue distress to patients, thereby making it a
useful tool for their routine postoperative
rounds
• The utility of the BIS in preventing awareness
has been investigated in three large studies
Notes:
Anesthesiology: Anesthesia Procedures, Methods, & Techniques II
This document is for exclusive use of: Lindsay Wetzel lindsay.wetzel@uhhospitals.org
Jerrold Lerman © 2014-2018 ThePassMachine.com 877-225-8384
Distribution is a violation of copyright laws.
Stages of Anesthesia/Awareness cont’d
• Ekman and colleagues conducted a prospective
cohort study in Swedish patients undergoing
non-cardiac surgery under relaxant general
anesthesia with routine BIS monitoring
– Patients were interviewed three times with a
modified Brice questionnaire. The incidence
of awareness was significantly reduced in the
BIS-monitored group in comparison to a
historical control group without BIS
monitoring (0.04% versus 0.18%; P = .038)
• The utility of the BIS in preventing awareness
has been investigated in three large studies
• Myles and co-authors multi-center, randomized
controlled trial in 2463 patients at high risk of
awareness undergoing all types of surgery
under relaxant general anesthesia (the B-Aware
Trial)
– Patients were randomized to BIS-guided
anesthesia (BIS titrated to 40 to 60) or
routine care; were interviewed three times
with a modified Brice questionnaire
– The overall incidence of awareness was 0.5%.
There were two confirmed cases of
awareness in the BIS-guided group and 11
confirmed cases in the control group (odds
ratio, 0.18; 95% confidence interval, 0.02 to
0.84; P = .022). Awareness was not predicted
from clinical signs in any case
– The authors concluded that BIS monitoring is
warranted in patients at high risk for
awareness undergoing relaxant general
anesthesia
• Avidan and co-authors conducted a randomized
controlled trial in 1941 patients at higher
risk for awareness who were undergoing all
types of surgery under relaxant general
anesthesia (B-Unaware trial)
– Patients were randomized to receive BIS-
guided anesthesia (BIS titrated to 40 to 60) or
end-tidal anesthetic gas (ETAG)
concentrations of 0.7 to 1.3 MAC and were
interviewed three times with a modified
Brice questionnaire. The overall incidence of
awareness was 0.2%
– There were two cases of awareness in each
group (absolute difference, 0%; 95%
confidence interval, -0.56% to 0.57%)
3
Stages of Anesthesia/Awareness cont’d
Answer Key
– The authors concluded that their results did
not support routine BIS
Question: A score of “3” on the Modified
monitoring. Subsequently, it has been shown
Observer Assessment of Alertness/ Sedation
that the study was underpowered and ETAG
Scale (MOAA/S) suggests that a patient
concentrations in the 0.7 to 1.3 MAC range
undergoing sedation will respond how?
are likely to prevent awareness
A. Lethargic response to his name spoken in
– In fact, adequate power to detect a
a normal tone
difference between BIS
B. Responds only after name is called out
and ETAG would have required a group size
loudly/repeatedly
of more than
C. Responds only after mild prodding or
9000 patients
shaking
• On this basis, the ASA taskforce concluded that
D. Responds only after painful trapezius
“the decision to use a brain function monitor
squeeze
should be made on a case-by-case basis by the
individual practitioner for selected Question: The MAC of anesthesia required to
patients (e.g., light anesthesia)” prevent movement in 100% of patients is
greatest for which of the following noxious
Question: Dreaming during general anesthesia is
stimuli?
LEAST likely with which of the following
A. Laryngoscopy
maintenance techniques?
B. Rib retraction
A. Propofol infusion
C. Abdominal incision and exploration
B. Propofol and ketamine infusions
D. Electrical tetany
C. Isoflurane and ketamine infusion
D. Fentanyl, midazolam and ketamine Question: Dreaming during general anesthesia is
infusions LEAST likely with which of the following
maintenance techniques?
Stages of Anesthesia/Awareness
A. Propofol infusion
• Dreaming during anesthesia is a commonly
B. Propofol and ketamine infusions
reported and fascinating phenomenon that is
C. Isoflurane and ketamine infusion
poorly understood
D. Fentanyl, midazolam and ketamine
– Incidence varies with age and sex, the type of
infusions
anesthesia, and the timing of the
postoperative interview End of Lecture
• Dreaming is more common in younger
patients and after propofol-based, opioid-
based, or ketamine-based anesthesia
• If an interview is conducted at emergence from
anesthesia, about 25% of patients will report
dreaming. However, if the interview is delayed
until discharge from the postanesthesia care
unit, the incidence  to ~6%

Notes:

Anesthesiology: Anesthesia Procedures, Methods, & Techniques II

This document is for exclusive use of: Lindsay Wetzel lindsay.wetzel@uhhospitals.org
Jerrold Lerman © 2014-2018 ThePassMachine.com 877-225-8384 4
Distribution is a violation of copyright laws.