Awareness With Recall

[jcrewdson]

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I'm interested in learning about Awareness With Recall from the perspective of those of you who spend time in the OR and may have witnessed this phenomenon. All replies strictly confidential, if you wish.
John Crewdson
Project on Government Oversight
Washington, DC

 

[btbam]

 

[Idiopathic]

Well PoGO is certainly a thing...not sure about John Crewdson, however, unless its the Pulitzer-Prize winning journalist, in which case I would expect his prose to flow a little more naturally.

Regardless, Ive never seen it. Its incredibly rare, and the risk factors are well-established and published.

 

[drccw]

it's rare...
try a google search...

or try the ASA closed claims

http://www.ncbi.nlm.nih.gov/pubmed/10201677

 

[PMPMD]

Just don't watch the movie Awake, it's an hour and a half of your life you'll never get back. No amount of Jessica Alba as eye candy could save that.

 

[Gern Blansten]

Project on Government Oversight? I think we have way too much government oversight. Do we really need a "project?"

 

[countingdays]

Project on Government Oversight? I think we have way too much government oversight. Do we really need a "project?"

Hear, hear!

 

[jcrewdson]

Good morning. I had to chuckle at some of your replies. Yes, there's only one John Crewdson, now working for the Project on Government Oversight. POGO is a non-profit, non-partisan government watchdog whose investigations into waste, fraud and other corruption have saved taxpayers many millions of dollars over the last three decades. I'm guessing most of you don't have a problem with that. Check out our Web site for details. Meanwhile, I've come across some journal articles, including one from the BMJ published in 2010, which conclude that AWR occurs in some form about 100 times a day. Is that a small number or a large one? Either way, I would like to talk with any of you who have ever seen this happen, or know someone who's observed it.
All best,
John

 

[Mman]

Good morning. I had to chuckle at some of your replies. Yes, there's only one John Crewdson, now working for the Project on Government Oversight. POGO is a non-profit, non-partisan government watchdog whose investigations into waste, fraud and other corruption have saved taxpayers many millions of dollars over the last three decades. I'm guessing most of you don't have a problem with that. Check out our Web site for details. Meanwhile, I've come across some journal articles, including one from the BMJ published in 2010, which conclude that AWR occurs in some form about 100 times a day. Is that a small number or a large one? Either way, I would like to talk with any of you who have ever seen this happen, or know someone who's observed it.
All best,
John

It is very rare. It can happen. Risk is probably somewhere in the neighborhood of 1/10,000 to 1/50,000 general anesthetics. Of all the patients I've heard describe intraoperative awareness, at least 98% involved a sedation case where they were not supposed to be unconscious but they misunderstood what they were supposed to go through.

It is probably almost impossible to find an anesthesiologist that has "seen this happen" because at the time it is happening they are almost assuredly unaware that it is happening (pun intended). It's after the fact that a patient can recount some experience when it comes to light. We've had one documented case of intraop awareness in the last 5 years that happened during an emergency CABG and it involved a perfusionist not providing any isoflurane on pump, which the anesthesiologist was not informed of.

 

[RussianJoo]

Dr. Mashour from University of Michigan is doing research on this topic. In a lecture he gave during this years Michigan Society of Anesthesiologists annual meeting he stated that awareness occurs on average about 1-2cases/1,000.

Awareness depends on the type of surgery and type of anesthesia provided.

 

[pgg]

Good morning. I had to chuckle at some of your replies. Yes, there's only one John Crewdson, now working for the Project on Government Oversight. POGO is a non-profit, non-partisan government watchdog whose investigations into waste, fraud and other corruption have saved taxpayers many millions of dollars over the last three decades. I'm guessing most of you don't have a problem with that. Check out our Web site for details. Meanwhile, I've come across some journal articles, including one from the BMJ published in 2010, which conclude that AWR occurs in some form about 100 times a day. Is that a small number or a large one? Either way, I would like to talk with any of you who have ever seen this happen, or know someone who's observed it.
All best,
John

When the media reports on this issue, it's typically with a very loose or sloppy definition of "awareness" ... and always with an eye for sensationalization at the expense of actual facts and real data, which aren't really that exciting, interesting, or scary. So I hope you'll excuse our collective skepticism. 🙂

99% of the time when patients tell me they were "awake" during a past surgery, it turns out to have been a procedure under sedation, where the intent was never general anesthesia in the first place. Eg, colonoscopies. Or they remember waking up in the OR with the endotracheal tube still in ... when the surgery was over and the anesthesiologist was deliberately waking them up before removing the tube.

The other important thing to realize is that even when awareness to some degree DOES occur, it's not automatically a horribly tragic life-scarring traumatic experience. The kind of awareness that people freak out about - wide awake, paralyzed, undergoing something excruciatingly painful - is a far cry from "remembering voices" during a period the patient expected to be asleep. But it's all tallied up as "awareness" ... And some people do dream under anesthesia, and remember that. Sometimes patients don't dream about being on a beach in Hawaii.

 

[BLADEMDA]

Here is the study: Anesthesiology 106(2) 269-274 Feb 2007

Take a look at recall in this study


Here is another one:

http://www.nejm.org/doi/full/10.1056/NEJMoa1100403?query=featured_home

 

[sevoflurane]

A patient may interpret "awareness under anesthesia" if at the end of the case they remember having to breathe through an ETT. This is not awareness. It is emergence from anesthesia and it happens everyday. The problem is, patients don't know the difference.

I personally know of one person who had true awareness. It happened back in the late 80's at an academic institution. It was presumably due to a vaporizer malfunction.

That being said, there are certain OR cases whrere you want to keep the patient very "light". During these difficult cases not running a "light" anesthetic can lead to further cardio-respiratory insults that may contribute to intra-operative death. These cases are the ones that have the highest likelyhood of awareness.

Trauma cases, Cardiothoracic cases, OB/GYN cases round up the top three.

 

[RT2MD]

Well PoGO is certainly a thing...not sure about John Crewdson, however, unless its the Pulitzer-Prize winning journalist, in which case I would expect his prose to flow a little more naturally.

Regardless, Ive never seen it. Its incredibly rare, and the risk factors are well-established and published.

Good morning. I had to chuckle at some of your replies. Yes, there's only one John Crewdson, now working for the Project on Government Oversight. POGO is a non-profit, non-partisan government watchdog whose investigations into waste, fraud and other corruption have saved taxpayers many millions of dollars over the last three decades. I'm guessing most of you don't have a problem with that. Check out our Web site for details. Meanwhile, I've come across some journal articles, including one from the BMJ published in 2010, which conclude that AWR occurs in some form about 100 times a day. Is that a small number or a large one? Either way, I would like to talk with any of you who have ever seen this happen, or know someone who's observed it.
All best,
John

😆😆😆

 

[WholeLottaGame7]

When the media reports on this issue, it's typically with a very loose or sloppy definition of "awareness" ... and always with an eye for sensationalization at the expense of actual facts and real data, which aren't really that exciting, interesting, or scary. So I hope you'll excuse our collective skepticism. 🙂

99% of the time when patients tell me they were "awake" during a past surgery, it turns out to have been a procedure under sedation, where the intent was never general anesthesia in the first place. Eg, colonoscopies. Or they remember waking up in the OR with the endotracheal tube still in ... when the surgery was over and the anesthesiologist was deliberately waking them up before removing the tube.

The other important thing to realize is that even when awareness to some degree DOES occur, it's not automatically a horribly tragic life-scarring traumatic experience. The kind of awareness that people freak out about - wide awake, paralyzed, undergoing something excruciatingly painful - is a far cry from "remembering voices" during a period the patient expected to be asleep. But it's all tallied up as "awareness" ... And some people do dream under anesthesia, and remember that. Sometimes patients don't dream about being on a beach in Hawaii.

I've had maybe 5-10 pts tell me in my one year of pre-op questioning that they had awareness under anesthesia. Every time I've been able to either verify that during that surgery they did not have a general anesthetic, or if not at our institution, it was a procedure that almost certainly was not a general anesthetic. Or it's like the guy who thought he wasn't supposed to remember actually being in the OR and having the mask put over his face. Sorry sir, that's normal.

I'm certainly not saying it doesn't happen, but I will definitely say that it's much less than the general public thinks it happens.

 

[Gern Blansten]

 

[ASA6]

This is even a common misconception among physicians. A neurologist friend of mine was bashing her anesthesiologist, because she "woke up" in the middle of her surgery and he didnt notice until she yelled. I was, of course, interested in how she "yelled" with an ETT in place. Turns out, this was a sedation case. I explained to her the difference 🙂

 

[Bertelman]

This is even a common misconception among physicians. A neurologist friend of mine was bashing her anesthesiologist, because she "woke up" in the middle of her surgery and he didnt notice until she yelled. I was, of course, interested in how she "yelled" with an ETT in place. Turns out, this was a sedation case. I explained to her the difference 🙂

I think some of our colleagues also do a poor job of setting expectations for these cases. When you tell the patient "You will drift off to sleep" or "You won't remember a thing" for a sedation case, expect to disappoint. I tell all these patients they will be sedated, but they may feel pain, and they may have memories of the OR. I then tell them why this must be, ie why this is a sedation case.

If someone had established this with your neurologist friend, I suspect she wouldn't have been so upset.

 

[periopdoc]

I'm interested in learning about Awareness With Recall from the perspective of those of you who spend time in the OR and may have witnessed this phenomenon. All replies strictly confidential, if you wish.
John Crewdson
Project on Government Oversight
Washington, DC

Good morning. I had to chuckle at some of your replies. Yes, there's only one John Crewdson, now working for the Project on Government Oversight. POGO is a non-profit, non-partisan government watchdog whose investigations into waste, fraud and other corruption have saved taxpayers many millions of dollars over the last three decades. I'm guessing most of you don't have a problem with that. Check out our Web site for details. Meanwhile, I've come across some journal articles, including one from the BMJ published in 2010, which conclude that AWR occurs in some form about 100 times a day. Is that a small number or a large one? Either way, I would like to talk with any of you who have ever seen this happen, or know someone who's observed it.
All best,
John

Forgive our skepticism, but we have had a long history of individuals misrepresenting themselves and their motives on this forum when visiting in search of medical and legal advice. So, John Crewdson from POGO, since you have come here representing yourself in somewhat of an official capacity, what interest does POGO have in this issue? I fail to see the connection between POGO and intra-operative awareness.

I am not sure which article you are referring to that listed an incidence of 100 events per day (the only 2010 BMJ awareness article that I know of is a dramatic recollection of the patient's and physician's perspectives of an episode of intra-operative awareness) so it is hard to comment on what the prevalence might be (and prevalence is the real number you want). The number 100 per day in isolation is neither large nor small it just is. To answer the question is it large or small, you need a denominator to give you a prevalence. Obviously 100 episodes of awareness out of 200 cases would be a huge prevalence and a huge problem. 100 episodes out of 1 million (cue Dr. Evil stage left) cases would be less of a problem.

Is it 100 cases per day in The UK only, cases in the US, or cases world-wide? Further, is it is for all cases or only high risk cases?

For the sake of argument, we will assume the number 100 is true and it applies to all types of cases, performed in the US only. There are some 20-30 million anesthetics in the US per year which would give a prevalence of 0.122% - 0.18%. However, that number is both artificially high and low depending on the population you are looking at. The bulk of the risk will be taken by high-risk cases (cardio-pulmonary bypass, c-sections etc) so for them the risk would be higher than stated above. For non-high-risk patients the risk would be significantly lower.

However, if the number 100 is only for cases in the UK, then the risk is significantly higher. So you see, we need more detail to answer the question is 100 large or small.

Remember that was a mental exercise and the numbers stated are not indicative of reality until we have more information on your 100 cases.

Returning to reality, good studies peg the prevalence of intra-operative awareness at 0.1-0.2% in high-risk populations. For an example, see below. Keep in mind that the risk for non-high-risk populations is significantly lower.

http://xa.yimg.com/kq/groups/1099152/1264647715/name/awareness%2Bprevention%2B2011.pdf

- pod

 

[periopdoc]

I think some of our colleagues also do a poor job of setting expectations for these cases. When you tell the patient "You will drift off to sleep" or "You won't remember a thing" for a sedation case, expect to disappoint. I tell all these patients they will be sedated, but they may feel pain, and they may have memories of the OR. I then tell them why this must be, ie why this is a sedation case.

If someone had established this with your neurologist friend, I suspect she wouldn't have been so upset.

Agreed. Personally I tell the patients their choice is to be asleep (GA) or awake with some medicine to help you get through it that will likely cause you to drift off for periods of time during the case (sedation).

- pod

 

[RT2MD]

I think some of our colleagues also do a poor job of setting expectations for these cases. When you tell the patient "You will drift off to sleep" or "You won't remember a thing" for a sedation case, expect to disappoint. I tell all these patients they will be sedated, but they may feel pain, and they may have memories of the OR. I then tell them why this must be, ie why this is a sedation case.

If someone had established this with your neurologist friend, I suspect she wouldn't have been so upset.

I would also agree with you, although my statement is based purely on past personal experiences. I've had 3 procedures over the last 8 years involving conscious sedation... it has been very interesting to me how the sedation is explained. I've gotten anything from "You'll be put to sleep and won't remember any of it" to "You will be awake, but we will make you sleepy and make you as comfortable as possible". These were all done with a versed/fentanyl combo. I do have memories of all 3 of them, incidentally. I would not say that I experienced anesthesia awareness, though!

 

[dhb]

I do have memories of all 3 of them, incidentally.

You should sue

 

[RT2MD]

You should sue

 

[RussianJoo]

I tell all my sedation patients that there's a good chance that they might wake up a little, I tell them that if that happens I'll be right there watching them, I'll let them know that everything is going well and give them more medicine so they can go back to sleep. I justify this by telling them that the medicine I use causes people to stop breathing if I give too much and since each person is different I start off low also if they do wake up they won't feel any pain. No one wants to stop breathing so they agree with me that I should start off low. Obese pt's with OSA especially get this talk...

I used to tell people about the ET tube too, but then an attending told me that I am probably freaking some pt's out and that since they won't remember anyway just tell them that they'll be completely asleep.