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Transcript of Intraoperative Recall Allison Russell. Intraoperative Recall Unintended complication, occurs during...
Intraoperative Recall
Allison Russell
Intraoperative Recall• Unintended complication, occurs during
general anesthesia or MAC• Occurs most during maintenance of
anesthesia rather than induction or emergence
• 1-2 adult patients per 1000 patients undergoing general anesthesia
• 1 in 100 patients in high-risk surgeries (cardiovascular, obstetrics, trauma)
Intraoperative Recall• Awake Movie Clip
alternate link
• Harold, Joby (Director). (2007). Awake [Motion picture]. United States: MGM Distribution Company.
Risk Factors• MAC 0.3-0.4 associated with awakening
from anesthesia• Mistake or failure in anesthesia delivery• Anesthetic technique resulting in
inadequate anesthesia• Underappreciated patient dosing
requirements• Patient condition unsafe to administer
sufficient anesthesia
MAC• Minimum Alveolar Concentration• 50% of patients will not respond to a painful
stimulus• MAC-awake: 50% of persons will follow command
to “open your eyes”.o 0.3-0.4 MAC associated with awakening from anesthesia. ~1/3
MAC=loss of recall
• MAC-BAR: exceeds requirements for ablation of skeletal muscle movement with surgical stimuli.o 1.3 MAC of any volatile agents
MAC Requirements• Decreased MAC: Increased MAC
o Increasing age *Decreased age (infants)
o Opioids/benzo use * Hyperthermiao Sedative-hypnotics * Hyperthyroidismo Alpha-2 agnoists * Cocaineo Hypothermia * MAOIso Anemia * Chronic ETOH
abuseo Nitrous Oxide * Hypernatremiao Acute ETOH intoxication
Repercussions• PTSD associated with awareness during
surgery• Increases patient’s apprehension to
undergo further surgery• Sleep disturbance, nightmares, anxiety
BIS Monitor• Bispectral Index• Represents a numerical value (0-100)• Correlated with the patient’s current hypnotic
state• 100=awake• 65-85=sedated• 40-65=general anesthesia• <40=cortical suppression• BIS monitor approved in 1996 by FDA as potential
tool to decrease intraoperative awareness
Michigan Awareness Control Study
• One group: BIS monitoring during surgery, anesthesia providers alerted when BIS values reached greater than 60
• Second group: anesthesia provider alerted when MAC reached 0.5
Michigan Awareness Control Study
• BIS monitor revealed trend toward reducing incidence of awareness
• No statistically significant difference in intraoperative awareness between 2 groups
• Increased alerting of anesthesia providers to potential “light” anesthesia was associated with fewer awareness events
Prevention• Check all equipment, drugs and dosages• Administer amnestic premedication• Avoid using muscle relaxants if possible• Administer at least 0.5-0.7 MAC• Set alarm for low MAC
Treatment• Brice Questionnaire
o “What was the last thing you remember before going to sleep?”
o “Did you dream during your procedure?”• Prompt referral to mental health
professional• Explain what happened to patient• Keep record of incident in patient’s chart
to guide further anesthesia• Report claim to hospital lawyer
Conclusion• BIS monitor can be used as adjunct to
detecting possibility of awareness• Evaluate patient for risk factors• Ensure patient has sufficient anesthesia
and remains deep• Proper post-op follow-up• Vigilance is best prevention!!!
References• American Association of Nurse Anesthetists (2012). Anesthesia awareness during general anesthesia. Retrieved from:
http://www.aana.com/resources2/professionalpractice/Pages/Con-Anesthesia-Awareness-during-General-Anesthesia.aspx
• Avidan, M.S. & Mashour, G.A. (2013). Prevention of intraoperative awareness with explicit recall. Anesthesiology, 118 (2), 449-456.
• Butterworth IV J.F., Mackey D.C., Wasnick J.D. (2013). Chapter 8. Inhalation Anesthetics. In J.F. Butterworth IV, Mackey, J.D. Wasnick, D.C.
(Eds), Morgan & Mikhail's Clinical Anesthesiology, 5e. Retrieved October 31, 2013 from
http://www.accessmedicine.com.proxy.kumc.edu:2048/content.aspx?
• Butterworth IV J.F., Mackey D.C., Wasnick J.D. (2013). Chapter 54. Anesthetic Complications. In J.F. Butterworth IV, Mackey, D.C., Wasnick,
J.D. (Eds), Morgan & Mikhail's Clinical Anesthesiology, 5e. Retrieved October 31, 2013 from
http://www.accessmedicine.com.proxy.kumc.edu:2048/content.aspx?aID=57239722.
•Ghoneim, M.M. (2000). Awareness during anesthesia. Anesthesiology, 92(2), 597-602.
• Mashour, G.A., Shanks, A., Tremper, K.K., Kheterpal, S., Turner, C.R., Ramachandran, S.K.,…Avidan, M.S. (2012). Prevention of intraoperative
awareness with explicit recall in an unselected surgical population: a randomized comparative effectiveness trial. Anesthesiology, 117(4), 717-725.
•Naglehout, J.J., & Plaus, K.L. (2014). Nurse anesthesia. St. Louis, Missouri: Elsevier Sanders.• Harold, Joby (Director). (2007). Awake [Motion picture]. United States: MGM Distribution Company.
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