Hoya11

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I am an ms1 interested in anesthesiology, i saw a tv show about a few different people who claimed to be awake during surgery, feeling everything, and then permanantly messed up mentally from it.

what do anesthesiologists do to prevent this?
can some people just be non-responsive and there is no way to know until afterwards?
why not just overshoot a little on the medications?
why not do a local block AND a general block in case this happens?

these are the questions i had if anyone has any insight it would be appreciated
 

ameier14

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Hoya11 said:
I am an ms1 interested in anesthesiology, i saw a tv show about a few different people who claimed to be awake during surgery, feeling everything, and then permanantly messed up mentally from it.

what do anesthesiologists do to prevent this?
can some people just be non-responsive and there is no way to know until afterwards?
why not just overshoot a little on the medications?
why not do a local block AND a general block in case this happens?

these are the questions i had if anyone has any insight it would be appreciated

..."When Anesthesia Fails"... Discovery Channel right?
 

candycane

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okay, lets try to think for a second. You are paralyzed and aware of everything that is happening. Imagine for a few seconds what your vital signs would be doing, what your skin would look and feel like. Then try to imagine that this would go unnoticed by the anesthesiologist or the surgeon for that matter.

Yeah discover channel....BS
 

doc05

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candycane said:
okay, lets try to think for a second. You are paralyzed and aware of everything that is happening. Imagine for a few seconds what your vital signs would be doing, what your skin would look and feel like. Then try to imagine that this would go unnoticed by the anesthesiologist or the surgeon for that matter.

Yeah discover channel....BS
actually, if spend any time with an anesthesiologist, you learn that this phenomenon does occur -- rarely though. I'll leave it to an anesthesia expert to explain it. any takers?
 

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candycane said:
okay, lets try to think for a second. You are paralyzed and aware of everything that is happening. Imagine for a few seconds what your vital signs would be doing, what your skin would look and feel like. Then try to imagine that this would go unnoticed by the anesthesiologist or the surgeon for that matter.

Yeah discover channel....BS
Im not sure why it is unreasonable to think that you could be autonomically paralyzed as well. I could certainly foresee this happening, and I believe there is strong anecdotal evidence. Of course, I also believe that individuals who undergo procedures under conscious sedation form some sort of repressed memory of the event.
 

jwk

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Do a search for BIS and awareness in this forum. You'll find it's been debated numerous times.
 

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Interesting topic. Intraoperative awareness does occur, albeit rarely. By descriptions on TV, one may wonder how this can occur and why, but if you spend some time in the OR you'll begin to formulate at least some plausible explanations. Other times, even board certified anesthesiologists (like me) cannot explain.
The use of muscle relaxants are common in anesthesia. Not the flexeril muscle relaxant type, but drugs that act at the neuromuscular junction that essentially causes temporary paralysis. This is useful to intubate someone, to help the surgeon's exposure during an intra-abdominal operation like a bowel obstruction, etc. One would think that if a patient were paralyzed by the muscle-relaxants and they became "aware", it would be obvious by looking at the hemodynamic response. Turns out this isnt always the case. That is, an autonomic response does not always accompany intra-op awareness, nor is every increase in HR and BP a sign of awareness.
Some cases are easy to figure out the cause. Say you're in an open heart case, things go awry, and in order to save the patients life you have to "lighten" the anesthesia (even though there are steps you can take to minimize awareness risk). Or maybe the clinician forgets to do something, like turning on the "gas". Other cases like I said earlier are a mystery.

There are steps clinicians take to minimize the risk.

I personally like liberal use of short acting antegrade amnestics preoperatively (i.e. midazolam). Midazolam is a great drug which in my humble opinion has several purposes.
1) Great anxiolytic which makes the patient comfortable.
2) Since it affects memory in an antegrade fashion, safeguards against intra-op awareness (not a sure thing, but helpful)
3) Patient's response to a standard dose gives the anesthesiologist an idea where the patient falls on the dose response curve. In other words, did you administer 1 milligram and the patient is snoring? Did you give 8 milligrams and the patient is wide awake? SO, it acts as a guide to anesthetic requirement.

Anesthesia administration has alot of "steps" so it is important to be kinda neurotic, especially when you first start in the field, to make sure everything is covered: amnesia, analgesia, muscle relaxation, etc.

Some of the newer monitoring technology, like the BIS monitor, is steering us in the right direction, helping us monitor anesthetic depth. Unfortunately the BIS monitor has not (so far) been shown to prevent intraoperative awareness.
In summary, intraoperative awareness is a possibility, albeit remote. An astute clinician can take several steps to minimize the risk, although the risk can probably never be totally eliminated.

Hope this helps.
 

emt30119

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candycane said:
okay, lets try to think for a second. You are paralyzed and aware of everything that is happening. Imagine for a few seconds what your vital signs would be doing, what your skin would look and feel like. Then try to imagine that this would go unnoticed by the anesthesiologist or the surgeon for that matter.

Yeah discover channel....BS

Interesting that you would automatically call it BS simply because it is critical of physicians. Surely the discovery channel is wrong because physicians are never wrong and never make a mistake. Also what exactly would your skin look and feel like?
I have had patients post op who have had their sedation drugs wear off before the paralytic. Post op CABG patient, SBP shot up from 110's to 240's, high risk of blowing his fresh grafts. He was paralyzed and awake. Simple cure....Versed. without the amnesia affect of versed I have no doubt that he would have been able to remember being awake and unable to move.
 

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emt30119 said:
Interesting that you would automatically call it BS simply because it is critical of physicians. Surely the discovery channel is wrong because physicians are never wrong and never make a mistake. Also what exactly would your skin look and feel like?
I have had patients post op who have had their sedation drugs wear off before the paralytic. Post op CABG patient, SBP shot up from 110's to 240's, high risk of blowing his fresh grafts. He was paralyzed and awake. Simple cure....Versed. without the amnesia affect of versed I have no doubt that he would have been able to remember being awake and unable to move.

Glad the versed worked here. But how did you know this was not a pain crisis versus an awareness crisis?

Another issue calls on the loose definition of awareness. Some label it as any recall, including that portion of awakening with the tube still in, which really shouldn't be put in the withe cases of paralysis/no treatment of pain perception.

For those of you who love the BIS monitor, do you understand how it works? Really? How they arrived at the numbers? Do you understand why it uses QUAZI and BSR? What a bispectrum is? Artifact reduction? Make sure your love isn't blind; it is just a monitor, and has plenty of caveats.
 

jwk

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emt30119 said:
Interesting that you would automatically call it BS simply because it is critical of physicians. Surely the discovery channel is wrong because physicians are never wrong and never make a mistake. Also what exactly would your skin look and feel like?
I have had patients post op who have had their sedation drugs wear off before the paralytic. Post op CABG patient, SBP shot up from 110's to 240's, high risk of blowing his fresh grafts. He was paralyzed and awake. Simple cure....Versed. without the amnesia affect of versed I have no doubt that he would have been able to remember being awake and unable to move.
Awareness under anesthesia (rare) is entirely different than being on a vent with little sedation (common).

Unless you understand the problem (which apparently you don't), you shouldn't be quite so quick to be critical of those who do. Maybe you think the major medical breakthroughs and advances and critical problems with modern medical care are all reported via the Discovery Channel (and perhaps Reader's Digest). :laugh:
 

ameier14

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A little background for those of you who haven't seen the show on DC: This particular program, "When Anesthesia Fails" was created by a bunch of British docs who have studied intraoperative awareness. They also interview people who have actually claimed to have experienced awareness during surgery. They then go on to talk about new (at the time) innovations to help prevent awareness, specifically the BIS monitor. Its entertaining and meant to get people talking.

Here's the kicker: they put this show on during DC's "Extremely Rare and Unheard Of Medical Diseases and Conditions Week". One day there talking about fetus in fetu, the next day about anesthesia failing. I mean come on! Both are incredibly rare but the frenzied public, moms, premeds and med students eat this stuff up. It's simply provoked sensationalism to those inexperienced enough to not know better. The bottom line is that intraoperative awareness is rare, anesthesiologists simply need to be conscientious of it and the public needs to relax.
 

emt30119

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jwk said:
Awareness under anesthesia (rare) is entirely different than being on a vent with little sedation (common).

Unless you understand the problem (which apparently you don't), you shouldn't be quite so quick to be critical of those who do. Maybe you think the major medical breakthroughs and advances and critical problems with modern medical care are all reported via the Discovery Channel (and perhaps Reader's Digest). :laugh:
I am in no way defending discovery channel. What I am saying is that I believe that you can be paralyzed and aware. Paralytics do not decrease awareness. With intubation (or durring OR case) they give both paralytics and sedation, because paralytics do not sedate.
Why do I think he was paralyzed and aware and not "being on the vent with a little sedation". He was hemodynamically stable, without being messed with, then when he was lifted to place X-ray plate, he immediately became HTN. He was not overbreathing vent,(likely still paralyzed) he was not recieving any sedation since coming out of OR 20 mins before. We do not give sedatives in post op CABG in ICU in hopes of quick extubation.
So, I cannot say for sure, his was paralyzed and aware, but It seems to be the most likely case in my opinion
 

jwk

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emt30119 said:
I am in no way defending discovery channel. What I am saying is that I believe that you can be paralyzed and aware.
As I said before - common in the ICU, rare in the OR.
emt30119 said:
Paralytics do not decrease awareness.
No kidding?
emt30119 said:
With intubation (or durring OR case) they give both paralytics and sedation, because paralytics do not sedate.
Actually, we ANESTHETIZE patients in the OR - we don't just sedate them. There is a HUGE difference.