AWARENESS

UNDER
ANAESTHESIA

MODERATOR : Dr Shreesh Mehrotra

PRESENTER: Dr Medha Bhardwaj
• General anaesthesia is a state of drug-induced, reversible
loss of consciousness. patient
 CONTENTS OF GENERAL
ANAESTHESIA
 Hypnosis ( unconsciousness)
 Analgesia (decreasing pain)
 Amnesia (preventing recall)
 Impairment of skeletal muscle (preventing
movement)
 Physiologic support (maintaining respiratory
and
 Cardiovascular function, fluid management,
electrolyte control, and thermoregulation )
STAGES OF ANAESTHESIA
HISTORY
 In 1845, Horace Wells
•N2O anesthesia
 Patient moved and cried out
 No recall of his operation
 In 1846, W.T.G. Morton

•Ether anesthesia
 Surgeons considered it a success
 Patient had been aware, no pain.
 From a pt’s perspective, Well’s anaesthetic may be
considered more successful than Morton’s.
INCIDENCE
A WORLD WIDE PROBLEM
 DEFINITIONS
Awareness
Postoperative recall of events occurring during general
anaesthesia

Amnesic wakefulness
Responsiveness during general anaesthesia without
postoperative recall

Dreaming
Any experience (excluding awareness) that patients are able
to recall postoperatively that they think occurred during
general anaesthesia and that they believe is dreaming
 Explicitmemory
Conscious recollection of previous
experiences (“awareness” is evidence of
explicit memory)

 Implicit
memory
Changes in performance or behaviour that are
produced by previous experiences but without any
conscious recollection of those experiences
(“unconscious memory formation” during general
anaesthesia)
 “Definite”awareness
Recall conversations or music that they hear in the
or during the period of awareness

 “Probable” awareness
Hearing voices or feeling discomfort
associated with intubation or surgery

 “Nearmiss” awareness
More vague and dream-like
Types of Memory
• Explicit memory may be recalled spontaneously, or may
be provoked by postoperative events or questioning.

• Implicit memory may not be consciously recalled, but may

affect behavior or performance at a later time

• General anaesthesia suppress cortical activity, and are thought

to disrupt the connectivity of cortical areas and subcortical–
cortical connections in a dose-dependent fashion.

• Some degree of information processing occurs in lighter planes

of anaesthesia even though patients appear to be adequately
anaesthetized.
 Bischoff P, Rundshagen I. Awareness under general anesthesia. Dtsch Arztebl Int. 2011;108(1-2):1–7.
doi:10.3238/arztebl.2011.0001
 ASA Closed Claims
Causes of Awareness in ASA Closed Claims
Risk Factors
o Anaesthesia related
 Reduced anaesthetic doses in presence of paralysis
 Rapid sequence induction
 total intravenous anaesthesia.
 Nitrous Opioid anaesthesia
 Pharmacological masking of signs of inadequate
depth of anaesthesia-
 Use of muscle relaxants
o Machine malfunction or misuse resulting in an
inadequate delivery of anaesthesia:
•Drug administration errors
•Mis-labeled drug syringes
•Empty vaporizers
•Leaky gas delivery circuits
•Dysfunctional or misused drug infusion pumps
•Intravenous lines that stopping running
 General anesthesia consists of the working together of
four different components (blockades)

Mental block (hypnosis, blocking of perception,

consciousness, and memory)
Sensory block (analgesia, blocking of pain perception)
Motor block (blocking of muscular tension and
stimulus-triggered motor responses)
Reflex block (blocking of autonomic nervous and
cardiovascular reactivity, prevention of blood pressure
spikes and/or cardiac arrhythmias).
 Bischoff P, Rundshagen I. Awareness under general anesthesia. Dtsch
Arztebl Int. 2011;108(1-2):1–7. doi:10.3238/arztebl.2011.0001
Sandhu K et al. Awareness during anaesthesia, Indian Journal of Anaesthesia
2009; 53 (2):148-157
Sandhu K et al. Awareness during anaesthesia, Indian Journal of Anaesthesia
2009; 53 (2):148-157
Sandhu K et al. Awareness during anaesthesia, Indian Journal of Anaesthesia
2009; 53 (2):148-157
Sandhu K et al. Awareness during anaesthesia, Indian Journal of Anaesthesia
2009; 53 (2):148-157
 Role of muscle relaxants
• Under general anesthesia, the patient's muscles may be
paralyzed in order to facilitate tracheal intubation,
surgical exposure or mechanical ventilation.
• It is incorrect to think that physiological signs such as
tachycardia, hypertension, mydriasis, sweating, and
lacrimation will continue to occur normally in response to
pain in the anesthetized state.
• If neuromuscular blocking drugs are used this causes
skeletal muscle paralysis and interferes with the
functioning of the autonomic nervous system. The
patient cannot signal their distress and they may not
exhibit the signs of awareness that would be expected to
be detectable by clinical vigilance.
CONSEQUENCES OF AWARENESS
o To the patient:
 Intraoperative:
 Most common
 • Sounds and conversation
 • Sensation of paralysis
 • Anxiety and panic
 • Helplessness and powerlessness
 • Pain
o Least common
 • Visual perceptions
 • Intubation or tube
 • Feelings operation without pain
o Postoperatively:

o Temporary effects:
• Sleep disturbances
• Nightmares
• Daytime anxiety

oSustained
Post traumatic stress disorder
POST TRAUMATIC STRESS DISORDER
•Most harmful consequence

• Depression, anxiety attacks, sleep

disorders,flashbacks to the experience, and
nightmares.
•Pt who have no explicit recall of intraop
events, but who develop symptoms
suggestive of intra operative awareness,
such as recurrent dreams about being buried
alive.
•A pt’s understanding of their experiences
can affect the psychological impact of
awareness.
 Pt may think their awareness is
impossible
 Leading them to become confused or
o Towards anaesthesiologist:
 Medicolegal implications
 2% of total claims
 ASA closed claim database
•1971 -2001 : 1% - 3% continue growing.
•Reported awards to pts for awareness with recall
 $1000 –$600, 000
MONITORING
oConventional monitoring systems
ECG,
blood pressure,
heart rate,
end tidal anaesthetic analyzer
capnography
Depth of Anaesthesia Monitoring
• Isolated Forearm Technique

o BRAIN ELECTRICAL ACTIVITY MONITORING

• EEG Derived Monitors:

 Bispectral Index
 The Narcotrend
 M-Entropy
 aepEX
• Patient state analyser
• SNAP index
 Isolated Forearm Technique
• There is acceptance amongst a majority of experts in the
field of awareness that the isolated forearm technique,
which measures responsiveness to command as a
surrogate for consciousness, is the ‘gold
standard’ against which other monitors
technique shouldbe

• validated.
However, 50% of patients who respond to
only
command with an isolated forearm can later recall doing
so.
Isolated Forearm Technique
 Bispectral Index
o BIS converts a single channel of frontal EEG
into an index of hypnotic level

o Targeting a range of BIS values 40-60 to

prevent awareness
NARCOTREND
NARCOTREND
• Narcotrend uses power spectral analysis and automated
pattern recognition algorithms to classify the EEG into
stages from A (awake) to F (general anaesthesia with
increasing burst suppression) and generate an index of
depth of anaesthesia.

• In comparison with bispectral index monitoring during

propofol-remifentanil-anaesthesia. The Narcotrend stages
D or E are assumed equivalent to BIS values between 64
and 40 indicating general anaesthesia.
 NARCOTREND
 Visual classification of the EEG patterns associated with
various stages of sleep.
 The original electronic algorithm classified the
frontal EEG according to:
 A (awake),
 B (sedated),
 C (light anaesthesia),
 D (general anaesthesia),
 E(general anaesthesia with deep hypnosis),
 F (general anaesthesia with increasing burst
suppression).
M-Entropy
 M-Entropy
• It analyses the amount of disorder in the EEG signal
(‘state’ entropy). During anaesthesia, the EEG signal
becomes more regular, resulting in decreased entropy.
• M-Entropy also measures the irregularity of the frontalis
electromyogram (FEMG), which diminishes as
anaesthesia deepens, providing an indication of
analgesic adequacy (‘response’ entropy).
• During anaesthesia, state entropy and response entropy
normally have the same value, but if response entropy
diverges by more than 10 points from the state entropy
value the ‘analgesic’ component of the anaesthetic may
be inadequate.
 aepEX
• This device generates loud clicks via earphones at 7 Hz
and records the EEG response.
• The responses are generated by synapses
evoked
during the passage of the signal from the
through the brainstem to the cortex, and arecochlea,
extracted from the EEG signal by digital averaging.
• All anaesthetics decrease the amplitude and increase
the latency of the early cortical (mid-latency) responses
following the auditory stimulus in a dose-dependent
manner.
aepEX
Patient State Analyser
 The patient state index (PSI) is derived from a four
channel electroencephalograph based on the
observation that there are reversible spatial changes
in power distribution of quantitative EEG at loss
and return of consciousness.

 The PSI has a range of 0-100 with decreasing values

indicating lower levels of consciousness and
sedation
SNAP index
 TheSNAP II calculates a “SNAP index” from a
single channel of EEG.

 Theindex calculation is based on a spectral analysis

of EEG activity in the 0-18 Hz and 80-420
frequency ranges and a burst suppression algorithm
Cerebral State Monitor
 This is a hand held device that analyses a single
channel EEG and presents a Cerebral State “Index”
scaled from 0-100

 It
also provides EEG suppression percentage and a
measure of electromyographic activity (75-85 Hz)
• All of these technologies may be affected by electrical
interference (e.g. surgical diathermy, pacemakers,
muscle artifact) and depressed cortical metabolism as a
result of ischaemia or hypothermia.
• All the monitors have a variable lag-time between a
state change and a displayed change in index values.
• Although this is unimportant in steady-state conditions,
it may be relevant where there is a sudden surge in
noxious stimulation and where analgesia may not be
adequate.
• The use of any depth of anaesthesia monitor should
always augment individual practitioner judgement, and
complement standard clinical methods of assessment.
 Recommendations for management of
post anaesthesia awareness

1) Providing a postoperative structured

interview and a questionnaire to the patient so as
to define the nature of the intraoperative
awareness episode, after it has been reported.
2) Offering postoperative counselling or
psychological support

Sandhu K et al. Awareness during anaesthesia, Indian Journal of Anaesthesia

2009; 53 (2):148-157
 Vigilance
• Preoperative assessment will identify relevant risk
factors.
• All apparatus should be checked before the start of
every list and if necessary between cases.
• Drug errors may be minimized by meticulous
preparation according to best practice.
• A depth of anaesthesia monitor should be
considered in the context of TIVA, when an
additional risk factor for awareness is present, or
both.
 Vigilance
• Supplementary doses of induction agent should
be given in the event of an unexpected difficult
intubation ( particularly for rapid sequence
intubation).
• Extra caution is required during certain types of
surgery, during transfer, and at the end of a
case in order to avoid premature lightening of
anaesthesia.
• Persistent tachycardia or hypertension require
investigation.
Ambulkar RP, Agarwal V, Ranganathan P, Divatia JV. Awareness during general anesthesia: An
Indian viewpoint. J Anaesthesiol Clin Pharmacol [serial online] 2016 [cited 2019 Apr 7];32:453-7
 When awareness has occurred
or is suspected
• Complaints of unintended awareness should always be
taken seriously, and should be followed up by a senior
anaesthetist.
• A full explanation and sympathy should be offered, and
counselling provided.
• Apology is not an admission of guilt, and may be all that
patients are looking for.
• If negative psychological symptoms are present and persist
for more than 4 weeks, referral to psychological services is
warranted in order to minimize long-term harm which may
be devastating for patients and their relatives.
THANK YOU