Anesthesia Awareness for Perioperative Nurses
Submitted by Joan Boczany
I was in my 18th year of practicing perioperative nursing when I encounter my first case of anesthesia awareness. I had taken my post-operative patient to the Post Anesthesia Recovery Room (PACU), when I heard a disturbance from another patient. That patient wanted to talk to the person who referred to her obesity in negative terms during surgery.
According to this literature review, the purpose of general anesthesia is to induce unconsciousness in order that the patient that is unresponsive to pain sensation 1. Anesthesia awareness definition is an unexpected recall of events while under general anesthesia. The majority of the authors place the rate of anesthesia awareness to one patient out of every one thousand patients that experience some form of anesthesia awareness. The exact mechanism of the pharmacological action of anesthetic is not clearly understood 1, 3. However, neuroscience has given some answers. Anesthesia acts primarily on the neurotransmission pathways such as BABA_A , NMDA, NACH, dopamine , opioid, and iron gates receptors. In addition, it also relates to the cerebral blood flow and the glucose metabolism of the neuro cells 3.
The literature is consistent about what indicates high risk in a patient for experiencing an anesthesia awareness incident. Cardiac, thoracic, and trauma patient are at high risk. Patient long time use or abuse of benzodiazepines, alcohol, and recreational drugs are another high-risk population. In addition, anesthesia awareness may occur from mechanical malfunction of the anesthesia machine and devices, charge in patient status, and inappropriate administration of anesthesia drugs and gases 1,2,3,4.
Literature is consistent with preventive measures such as a thorough pre-operative interview and physical. Developing a plan of care design specifically to that patient is another measure to avoid this problem. There have also been several attempts to develop monitor to gage the depth of anesthesia. However, so far, literature does not indicate any significant reliability and the cost of the technology is not cost-effective. In addition, literature suggests post-operative measures to be taken should the patient experience anesthesia awareness, such as the Brice questions. It asks the questions :’what is the last thing you remember before surgery, the first thing you remember after surgery, did you dream while under anesthesia, do you remember anything about the surgery, and finally what is the worst thing about you surgery’. If the patient answers indicate anesthesia awareness the should be tested with the Brice questions daily while an inpatient, frequent physician visits, gather as much information, document all interactions and responses, and if necessary involve a psychiatrist 1,3,4.
In conclusion, there is not an easy solution for anesthesia awareness. It has been observed since the birth of modern anesthesia 1. The vigilance of the anesthesia provider, a complete and thorough history and physical, and the manner the other personnel conducts themselves in the room can determine the occurrence of anesthesia awareness. The most common type of this anesthesia complication is hearing conversations among the staff. As perioperative nurses, we are the advocates of our patients 1,2,3,4.
References1-Kotsovolis, G. & Komninos, G. (2009). Awareness during anesthesia: how can we be sure that the patient is sleeping indeed? Hippokratia, 13(2), 83-89. Rf
2-MacGregor, K. (2013). A wlking nightmare: how can we avoid accidental awareness during general anaesthesia? Journal of Perioperative Practices, 23(9), 185-190. Retrieved from h3-Orser, B., Mazer, D., & Baker, M. (2008). Awareness during anesthesia. Canadian Medical Association Journal, 178(2), 185-88.
4-Sigalovsky, N. (2003). Awareness under general anesthesia. American Association of Nurse Anesthetists, 71(5), 373-379.