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Awareness with Recall During General Anesthesia Department of Anaesthesia and Intensive Care Medicine University of Helsinki, Finland Awareness with recall during general anesthesia Seppo Ranta Academic Dissertation To be publicly discussed by permission of the Medical Faculty of the University of Helsinki, in Auditorium 2, Biomedicum Helsinki, Haartmaninkatu 8, on September 21, 2002, at 12 o’clock noon Helsinki 2002 Supervised by: Docent Markku Hynynen, MD Department of Anaesthesia and Intensive Care Medicine, Helsinki University Central Hospital, Jorvi Hospital, Espoo, Finland Reviewed by: Professor Harry Scheinin, MD Turku PET Centre, Turku University Hospital Turku, Finland Docent Arvi Yli-Hankala, MD Department of Anaesthesia, Tampere University Hospital Tampere, Finland Official opponent: Professor Rolf Sandin, MD The Karolinska Institute, Stockholm, and Department for Anesthesia and Intensive Care, Länssjukhuset, Kalmar, Sweden ISBN 952-91-4981-6 (nid.) ISBN 952-10-0642-0 (PDF) Hakapaino Oy Helsinki 2002 http://ethesis.helsinki.fi/ Contents Abstract .............................................................................................. 7 List of original publications ................................................................ 9 Abbreviations.................................................................................... 10 1. Introduction ................................................................................. 11 2. Review of the literature................................................................. 12 2.1. Definitions............................................................................... 12 2.1.1. General anesthesia ..............................................................................12 2.1.2. Consciousness ....................................................................................12 2.1.3. Awareness ...........................................................................................12 2.1.4. Memory and Recall ............................................................................13 2.1.5. Awareness with recall during general anesthesia ..................................13 2.2. The nature of the experience of awareness during general anesthe- sia ................................................................................................... 14 2.3. Methods of detecting awareness during general anesthesia ........ 14 2.4. Incidence of awareness and recall during general anesthesia ...... 15 2.4.1. General surgery ..................................................................................15 2.4.2. Cardiac surgery ..................................................................................18 2.4.3. Other types of surgery ........................................................................18 2.5. Reasons for awareness with recall during general anesthesia ...... 22 2.5.1. General considerations .......................................................................22 2.5.2. Anesthetics .........................................................................................23 2.5.2.1. The concepts of minimum alveolar concentration and effective concentration . 23 2.5.2.2. Potent volatile anesthetic agents ........................................................................ 23 2.5.2.3. Intravenous anesthetics ..................................................................................... 24 2.5.2.4. Opioids ............................................................................................................. 24 2.5.2.5. Benzodiazepines ................................................................................................ 24 2.5.2.6. Nitrous oxide .................................................................................................... 25 2.5.2.7. Neuromuscular blocking agents ........................................................................ 25 2.6. Prevention of awareness with recall ........................................... 25 2.6.1. General recommendations ..................................................................25 2.6.2. Methods of monitoring consciousness during general anesthesia ........26 2.6.2.1. Clinical signs ..................................................................................................... 26 2.6.2.2. The isolated forearm technique ......................................................................... 26 2.6.2.3. Electroencephalography .................................................................................... 27 2.7. After-effects of awareness with recall during general anesthesia . 28 2.7.1. Mental after-effects.............................................................................28 2.7.2. Medico-legal after-effects ....................................................................29 3. Aims of the study.......................................................................... 30 4. Patients and methods.................................................................... 31 4.1. Patients .................................................................................... 31 4.2. Interviews and classification ..................................................... 33 4.3. Medications ............................................................................. 33 4.4. Artificial neural networks ......................................................... 34 4.5. Feedback information .............................................................. 36 4.6. Psychiatric interview and testing............................................... 37 4.7. Statistical methods ................................................................... 37 5. Results .......................................................................................... 38 5.1. The nature of the experience of awareness during general anesthe- sia ................................................................................................... 38 5.2. Incidence of awareness with recall during general surgery ......... 38 5.3. Incidence of awareness with recall during open heart surgery.... 38 5.4. Differences in anesthetic drug dosing between patients with and without awareness ........................................................................... 39 5.5. Conventional statistical methods and artificial neural networks in detecting awareness from monitored physiologic variables ............... 39 5.6. The possibility of reducing the incidence of awareness by giving feedback information to the anesthesiologists .................................. 40 5.7. Psychiatric consequences of awareness during anesthesia........... 41 5.8. Medico-legal consequences of awareness with recall in Finland . 42 6. Discussion .................................................................................... 46 6.1. Patients’ experiences during the episode of intra-anesthetic aware- ness ................................................................................................. 46 6.2. Methods used in the present studies ......................................... 46 6.2.1. Interviews ............................................................................. 46 6.2.2. Anesthetic records ................................................................. 47 6.3. Incidence of awareness with recall during general surgery ......... 47 6.4. Incidence of awareness with recall during cardiac surgery ......... 48 6.5. Differences in anesthetic drug dosing between patients with and without awareness ........................................................................... 49 6.6. Conventional statistical methods and artificial neural networks in detecting awareness from monitored physiologic parameters............ 49 6.7. The possibility of reducing the incidence of awareness by giving feedback information to the anesthesiologists .................................. 50 6.8. Psychiatric consequences of awareness during anesthesia........... 51 6.9. Medico-legal consequences of awareness with recall in Finland . 52 7. Conclusions .................................................................................. 53 8. Practical considerations ................................................................ 55 9. Future implications....................................................................... 57 Acknowledgements ........................................................................... 58 References ......................................................................................... 60 Appendix .......................................................................................... 65 Abstract Awareness with recall is a rare but serious com- In the present studies, the incidence of plication of general anesthesia with potentially undisputed intraoperative awareness was 0.2- very disabling psychiatric consequences. Pre- 0.4 % of all general anesthetics given for gen- requisites for the phenomenon of awareness eral surgery procedures, while the incidence and recall are (1) consciousness with the abil- was about 0.3 % during cardiac anesthesia. ity to receive and process sensory information, Both incidences are 6 to 7 fold higher if cases (2) storage of the processed information in of possible awareness and recall are included. memory, and (3) recollection of the stored Lower doses of primary anesthetic agents were information at some later time. given to patients with awareness and recall The present study examines incidence of when compared to controls (isoflurane 0.42 awareness with recall during general anesthe- Fi% vs.
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