Increased Risk of Intraoperative Awareness in Patients with a History of Awareness

Aranake, Amrita; Gradwohl, Stephen C.; Ben-Abdallah, Arbi; Lin, Nan; Shanks, Amy; Helsten, Daniel L.; Glick, David B.; Jacobsohn, Eric; Villafranca, Alexander; Evers, Alex S.; Avidan, Michael S.; Mashour, George A.

doi:10.1097/aln.0000000000000023

Cited by 52 publications

(23 citation statements)

References 27 publications

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“…Certain types of surgery (e.g. cardiac, obstetric), female sex [21,22], higher ASA physical status [21,23,24] and obesity [25][26][27] are all implicated. The notion of an intrinsic, possibly genetic, resistance to anaesthesia has also been raised, with up to 11% of patients with AAGA having a previous history [8,27] and an important minority of AAGA cases having no apparent cause [9,28].…”

Section: Introductionmentioning

confidence: 99%

The 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: summary of main findings and risk factors

et al. 2014

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SummaryWe present the main findings of the 5th National Audit Project on accidental awareness during general anaesthesia. Incidences were estimated using reports of accidental awareness as the numerator, and a parallel national anaesthetic activity survey to provide denominator data. The incidence of certain/probable and possible accidental awareness cases was ~1:19 600 anaesthetics (95% CI 1:16 700–23 450). However, there was considerable variation across subtypes of techniques or subspecialties. The incidence with neuromuscular blockade was ~1:8200 (1:7030–9700), and without it was ~1:135 900 (1:78 600–299 000). The cases of accidental awareness during general anaesthesia reported to 5th National Audit Project were overwhelmingly cases of unintended awareness during neuromuscular blockade. The incidence of accidental awareness during caesarean section was ~1:670 (1:380–1300). Two thirds (82, 66%) of cases of accidental awareness experiences arose in the dynamic phases of anaesthesia, namely induction of and emergence from anaesthesia. During induction of anaesthesia, contributory factors included: use of thiopental; rapid sequence induction; obesity; difficult airway management; neuromuscular blockade; and interruptions of anaesthetic delivery during movement from anaesthetic room to theatre. During emergence from anaesthesia, residual paralysis was perceived by patients as accidental awareness, and commonly related to a failure to ensure full return of motor capacity. One third (43, 33%) of accidental awareness events arose during the maintenance phase of anaesthesia, most due to problems at induction or towards the end of anaesthesia. Factors increasing the risk of accidental awareness included: female sex; age (younger adults, but not children); obesity; anaesthetist seniority (junior trainees); previous awareness; out‐of‐hours operating; emergencies; type of surgery (obstetric, cardiac, thoracic); and use of neuromuscular blockade. The following factors were not risk factors for accidental awareness: ASA physical status; race; and use or omission of nitrous oxide. We recommend that an anaesthetic checklist, to be an integral part of the World Health Organization Safer Surgery checklist, is introduced as an aid to preventing accidental awareness. This paper is a shortened version describing the main findings from 5th National Audit Project – the full report can be found at http://www.nationalauditprojects.org.uk/NAP5_home#pt.

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Section: Introductionmentioning

confidence: 99%

The 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: summary of main findings and risk factors

et al. 2014

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“…To move towards an individualised alerting approach, a multinomial logistic regression model must be developed that incorporates patient-specific risk factors (such as history of AWR) 35 along with anaesthetic concentrations and, if possible, neurophysiological indices. Furthermore, we used the median from a 5-min period and must acknowledge that the individual BIS or MAC values could have nonetheless fluctuated in a way that might not be detected with our methodology.…”

Section: Discussionmentioning

confidence: 99%

Alerting thresholds for the prevention of intraoperative awareness with explicit recall

Shanks

Avidan

Kheterpal³

et al. 2015

European Journal of Anaesthesiology

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BACKGROUND Intraoperative awareness with explicit recall is a potentially devastating complication of surgery that has been attributed to low anaesthetic concentrations in the vast majority of cases. Past studies have proposed the determination of an adequate dose for general anaesthetics that could be used to alert providers of potentially insufficient anaesthesia. However, there have been no systematic analyses of appropriate thresholds to develop population-based alerting algorithms for preventing intraoperative awareness. OBJECTIVE To identify a threshold for intraoperative alerting that could be applied for the prevention of awareness with explicit recall. DESIGN Secondary analysis of a randomised controlled trial (Michigan Awareness Control Study). SETTING Three hospitals at a tertiary care centre in the USA. PATIENTS Unselected patients presenting for surgery under general anaesthesia. INTERVENTIONS Alerts based on end-tidal anaesthetic concentration or Bispectral Index values. MAIN OUTCOME MEASURES Using case and outcomes data from the primary study, end-tidal anaesthetic concentration and Bispectral Index values were analysed using Youden’s index and c-statistics derived from a receiver operating characteristic curve to determine a specific alerting threshold for the prevention of awareness. RESULTS No single population-based threshold that maximises sensitivity and specificity could be identified for the prevention of intraoperative awareness, using either anaesthetic concentration or Bispectral Index values. The c-statistic for anaesthetic concentration was 0.431 ± 0.046, and 0.491 ± 0.056 for Bispectral Index values. CONCLUSIONS We could not derive a single population-based alerting threshold for the prevention of intraoperative awareness using either anaesthetic concentration or Bispectral Index values. These data indicate a need to move towards individualised alerting strategies in the prevention of intraoperative awareness.

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“…High-risk situations include cardiac surgery, trauma surgery, cesarean sections and emergency interventions [6,8]. Other risk factors are female gender, young age, high American Society of Anesthesiologists score (i.e., low physical status), previous experience of IA, history of addiction and chronic use of analgesics [6,8,9]. Conversely, short preoperative prescription of benzodiazepines reduces the incidence of IA [4].…”

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confidence: 96%

Psychiatric consequences of intraoperative awareness: short review and case series

Vulser

Airagnes

Lahlou‐Laforêt

et al. 2015

General Hospital Psychiatry

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Increased Risk of Intraoperative Awareness in Patients with a History of Awareness

Abstract: Surgical patients with a history of AWR are five times more likely to experience AWR than similar patients without a history of AWR. Further consideration should be given to modifying perioperative care and postoperative evaluation of patients with a history of AWR.

Cited by 52 publications

References 27 publications

The 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: summary of main findings and risk factors

The 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: summary of main findings and risk factors

Alerting thresholds for the prevention of intraoperative awareness with explicit recall

Psychiatric consequences of intraoperative awareness: short review and case series

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