Monitoring Depth of Anaesthesia (original) (raw)
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Awareness during anaesthesia. . . .Its medicolegal threat. . . .How to tackle it?
IP innovative publication pvt. ltd, 2019
Awareness during anesthesia is an infrequent but a grievous complication with an estimated incidence of around 0.1% and 0.2% in western world. It is not only troublesome for the patient but can pose a serious medicolegal threat for anaesthesiologist as well. Preoperative assessment targeting patient’s characteristics and the type of surgery helps in stratifying the risk of awareness during surgery and provides a better chance at counseling the patients for the same. Preinduction phase of anaesthesia is an important phase which includes equipment check and function of monitors and preparation of an adequate plan of anaesthesia taking into consideration the risk of awareness. Errors in this phase leads to majority of cases of awareness. With the advent of advance monitoring techniques, the management of anaesthesia has become even more balanced and helps detect signs of awareness in early stage which can be curtailed immediately. Postoperative phase can be the most neglected part of anaesthesia in terms of assessment for any incidence of awareness. A detailed follow-up is always recommended even after discharge and if awareness is confirmed postoperatively, one must provide explanation to the patient about what has happened and must be offered both psychological and psychiatric support. In this letter we are going to briefly talk about factors associated with awareness and measures to avoid them taking into consideration the medicolegal aspect of the same.
Risk Factor for Intraoperative Awareness
Brazilian Journal of Anesthesiology, 2012
Background and objectives: The intraoperative awareness is an adverse event in the general anesthesia, and may occur in approximately 20,000 cases per year, which justifies the study of the risk factors for this event. The objective of this study was to review this subject in order to reduce the incidence of intraoperative awareness and psychological sequelae incurring from this incident, which may result in post-traumatic stress disorder with negative repercussions on the surgical patient social, psychic and functional development. Content: It was conducted a review of the intraoperative awareness assessing its different phases during general anesthesia such as dreaming, wakefulness, explicit and implicit memory, as well as the analysis, consequences and prevention of its main related factors. Conclusions: The reduction of awareness incidence during anesthesia is related to the anesthesiologist improved scientific and technical performance, involving issues such as monitoring, comprehension of the anesthesia activity components, hypnotic and analgesic drugs, neuromuscular blocking agents, autonomic and motor reflex control, in addition to the risk factors involved in this event.
BMC Anesthesiology
Background Awareness with recall under general anesthesia remains a rare but important issue that warrants further study. Methods We present a series of seven cases of awareness that were identified from provider-reported adverse event data from the electronic anesthesia records of 647,000 general anesthetics. Results The low number of identified cases suggests an under-reporting bias. Themes that emerge from this small series can serve as important reminders to anesthesia providers to ensure delivery of an adequate anesthetic for each patient. Commonalities between a majority of our identified anesthetic awareness cases include: obesity, use of total intravenous anesthesia, use of neuromuscular blockade, and either a lack of processed electroencephalogram (EEG) monitoring or documented high depth of consciousness index values. An interesting phenomenon was observed in one case, where adequately-dosed anesthesia was delivered without technical issue, processed EEG monitoring was emp...
Research Square (Research Square), 2019
Background: Awareness with recall under general anesthesia remains a rare but important issue that warrants further study. Methods: We present a series of seven cases of awareness that were identi ed from provider-reported adverse event data from the electronic anesthesia records of 647,000 general anesthetics. Results: The low number of identi ed cases suggests an under-reporting bias. Nonetheless, some important themes emerge from this small series that can serve as important reminders to anesthesia providers to ensure delivery of an adequate anesthetic for each patient. Commonalities between a majority of our identi ed anesthetic awareness cases include: obesity, use of total intravenous anesthesia, use of neuromuscular blockade, and either a lack of processed electroencephalogram (EEG) monitoring or documented high depth of consciousness index values. An interesting phenomenon was observed in one case, where adequately-dosed anesthesia was delivered without technical issue, processed EEG monitoring was employed, and the index value suggested an adequate depth of consciousness throughout the case. Conclusions: Provider-reported adverse event data in the immediate post-operative period is likely insensitive for detecting cases of intraoperative awareness. Themes identi ed in this series of cases of awareness under general anesthesia provide important reminders for anesthesia providers for maintain vigilance in monitoring depth and dose of anesthesia, particularly with total intravenous anesthesia.
British Journal of Anaesthesia, 2015
Background: Awareness during general anaesthesia is a source of concern for patients and anaesthetists, with potential for psychological and medicolegal sequelae. We used a registry to evaluate unintended awareness from the patient's perspective with an emphasis on their experiences and healthcare provider responses. Methods: English-speaking subjects self-reported explicit recall of events during anaesthesia to the Anesthesia Awareness Registry of the ASA, completed a survey, and submitted copies of medical records. Anaesthesia awareness was defined as explicit recall of events during induction or maintenance of general anaesthesia. Patient experiences, satisfaction, and desired practitioner responses to explicit recall were based on survey responses. Results: Most of the 68 respondents meeting inclusion criteria (75%) were dissatisfied with the manner in which their concerns were addressed by their healthcare providers, and many reported long-term harm. Half (51%) of respondents reported that neither the anaesthesia provider nor surgeon expressed concern about their experience. Few were offered an apology (10%) or referral for counseling (15%). Patient preferences for responses after an awareness episode included validation of their experience (37%), an explanation (28%), and discussion or follow-up to the episode (26%). Conclusions: Data from this registry confirm the serious impact of anaesthesia awareness for some patients, and suggest that patients need more systematic responses and follow-up by healthcare providers.
Research Square (Research Square), 2022
Background Intraoperative awareness is the second most common complication of surgeries, and it negatively affects patients and healthcare professionals. Based on the limited previous studies, there is a wide variation in the incidence intraoperative awareness and in the practices and attitudes of depth of anesthesia (DoA) monitoring among healthcare systems and anesthesiologists. This study aimed to evaluate the Jordanian anesthesiologists' practice and attitudes toward DoA monitoring and their estimation of the incidence of intraoperative awareness. Methods A descriptive cross-sectional survey of the Jordanian anesthesiologists working in public, private, and university hospitals was utilized using questionnaire developed based on previous studies. Practice and attitude in using DoA monitors were evaluated. Anesthesiologists were asked to best estimate the number of anesthesia procedures and frequency of intraoperative awareness events in the year before. Percentages and 95% Con dence Intervals (95%CI) were reported and compared between groups using chi-square tests. Results A total of 107 physicians participated and completed the survey. About one-third of the participant (34.6%; 95% CI 26.1-44.2) had never used a DoA monitor and only 6.5% (96% CI) reported using it as a "daily practice". The use of a DoA monitor was associated with experience and type of health sector. However, 81.3% (95% CI 66.5-83.5) believed that currently available DoA monitors are effective for DoA monitoring, and only 4.7% (95%CI 1.9-10.8) reported it as being "invalid". Most participants reported that the main purpose of using the DoA monitor was to prevent awareness (86.0%; 95%CI 77.9-91.4), guide the delivery of anesthetics (63.6%; 95%CI 53.9-72.2), and reduce recovery time (57%; 95%CI 47.4-66.1). The event rate of intraoperative awareness was estimated at 0.4% among participated anesthesiologists. Most of participants' hospitals lacked policy intended to prevent intraoperative awareness. Conclusions Most anesthesiologists believed in the role of DoA monitors in preventing intraoperative awareness, however, their attitudes and knowledge are inadequate, and few use DoA monitors in routine practices. In Jordan, large efforts are needed to regulate the use of DoA monitoring and reduce the incidence of intraoperative awareness.
Anaesthetic interventions for prevention of awareness during surgery
Cochrane Database of Systematic Reviews , 2016
Background General anaesthesia is usually associated with unconsciousness. ’Awareness’ is when patients have postoperative recall of events or experiences during surgery. ’Wakefulness’ is when patients become conscious during surgery, but have no postoperative recollection of the period of consciousness. Objectives To evaluate the efficacy of two types of anaesthetic interventions in reducing clinically significant awareness:- anaesthetic drug regimens; and- intraoperative anaesthetic depth monitors. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL, ISSUE 4 2016); PubMed from 1950 to April 2016;MEDLINE from 1950 to April 2016; and Embase from 1980 to April 2016. We contacted experts to identify additional studies. We performed a hand search of the citations in the review. We did not search trial registries. Selection criteria We included randomized controlled trials (RCTs) of either anaesthetic regimens or anaesthetic depth monitors. We excluded volunteerstudies,studiesofpatientspriortoskinincision,intensivecareunitstudies,andstudiesthatonlyrandomizeddifferentwordpresentationsfor memory tests (not anaesthetic interventions). Anaesthetic drug regimens included studies of induction or maintenance, or both. Anaesthetic depth monitors included the Bispectral Index monitor, M-Entropy, Narcotrend monitor, cerebral function monitor, cerebral state monitor, patient state index, and lower oesophageal contractility monitor. The use of anaesthetic depth monitors allows the titration of anaesthetic drugs to maintain unconsciousness. 1Anaesthetic interventions for prevention of awareness during surgery (Review)Copyright © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. Data collection and analysis At least two authors independently scanned abstracts, extracted data from the studies, and evaluated studies for risk of bias. We made attempts to contact all authors for additional clarification. We performed meta-analysis statistics in packages of the R language. Main results We included 160 studies with 54,109 enrolled participants; 53,713 participants started the studies and 50,034 completed the studies or data analysis (or both). We could not use 115 RCTs in meta-analytic comparisons because they had zero awareness events. We did not merge 27 of the remaining 45 studies because they had excessive clinical and methodological heterogeneity. We pooled the remaining 18 eligible RCTs in meta-analysis. There are 10 studies awaiting classification which we will process when we update the review. The meta-analyses included 18 trials with 36,034 participants. In the analysis of anaesthetic depth monitoring (either Bispectral Index or M-entropy) versus standard clinical and electronic monitoring, there were nine trials with 34,744 participants. The overall event rate was 0.5%. The effect favoured neither anaesthetic depth monitoring nor standard clinical and electronic monitoring, with little precision in the odds ratio (OR) estimate (OR 0.98, 95% confidence interval (CI) 0.59 to 1.62).In a five-study subset of Bispectral Index monitoring versus standard clinical and electronic monitoring, with 34,181 participants, 503participants gave awareness reports to a blinded, expert panel who adjudicated or judged the outcome for each patient after reviewing the questionnaires: no awareness, possible awareness, or definite awareness. Experts judged 351 patient awareness reports to have no awareness, 87tohavepossibleawareness, and65tohavedefiniteawareness. The effect size favoured neither Bispectral Index monitoring nor standard clinical and electronic monitoring, with little precision in the OR estimate for the combination of definite and possible awareness (OR 0.96, 95% CI 0.35 to 2.65). The effect size favoured Bispectral Index monitoring for definite awareness, but with little precision in the OR estimate (OR 0.60, 95% CI 0.13 to 2.75). We performed three smaller meta-analyses of anaesthetic drugs. There were nine studies with 1290 participants. Wakefulness was reduced by ketamine and etomidate compared to thiopental. Wakefulness was more frequent than awareness. Benzodiazepines reduces awareness compared to thiopental, ketamine, and placebo., Also, higher doses of inhaled anaesthetics versus lower doses reduced the risk of awareness. We graded the quality of the evidence as low or very low in the ’Summary of findings’ tables for the five comparisons. Most of the secondary outcomes in this review were not reported in the included RCTs. Authors’ conclusions Anaesthetic depth monitors may have similar effects to standard clinical and electrical monitoring on the risk of awareness during surgery. In older studies comparing anaesthetics in a smaller portion of the patient sample, wakefulness occurred more frequently than awareness. Use of etomidate and ketamine lowered the risk of wakefulness compared to thiopental. Benzodiazepines compared to thiopental and ketamine, or higher doses of inhaled anaesthetics versus lower doses reduced the risk of awareness
Increased Risk of Intraoperative Awareness in Patients with a History of Awareness
Anesthesiology, 2013
Background: Patients with a history of intraoperative awareness with explicit recall (AWR) are hypothesized to be at higher risk for AWR than the general surgical population. In this study, the authors assessed whether patients with a history of AWR (1) are actually at higher risk for AWR; (2) receive different anesthetic management; and (3) are relatively resistant to the hypnotic actions of volatile anesthetics. Methods: Patients with a history of AWR and matched controls from three randomized clinical trials investigating prevention of AWR were compared for relative risk of AWR. Anesthetic management was compared with the use of the Hotelling’s T2 statistic. A linear mixed model, including previously identified covariates, assessed the effects of a history of AWR on the relationship between end-tidal anesthetic concentration and bispectral index. Results: The incidence of AWR was 1.7% (4 of 241) in patients with a history of AWR and 0.3% (4 of 1,205) in control patients (relative...