Yearly NYT news story re: awareness under anesthesia...

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Urzuz

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...with the added twist that they are focusing more on patients remaining aware during procedures involving "conscious sedation"

Awake on the Table
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Unfortunately the majority of claims of “awareness” are for patients that actually had MAC. I see it frequently, patients for MAC are told they will sleep through the procedure, could easily be misinterpreted. I always tell people they will be awake, or may intermittently wake up, etc.
 
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Always tell MAC pts they might be awake for parts of the procedure. Tell them it's for their safety and relates to their breathing... They don't mind then
 
complaints about awareness under sedation are a sign of poor communication.

my spiel goes

"we do this procedure under sedation rather than general anaesthesia - that way you are ready to go home faster, and have less side effects from the anaesthetic. you are likely to sleep through the procedure and the next thing you know you will be waking up in the recovery area, but it's not a full anaesthetic so you may remember hearing voices in the background or parts of the procedure.

you will look like you are sleeping, and at any stage if you look uncomfortable, I will just give you more sedation.

any questions?"
 
I didn't think the article was bad. Conscious sedation was distinguished from general anesthesia, and she got her information from the cited anesthesiologists. She also acknowledged that unpleasant recall from conscious sedation is very rare.
 
zizzer said:
I didn't think the article was bad. Conscious sedation was distinguished from general anesthesia, and she got her information from the cited anesthesiologists. She also acknowledged that unpleasant recall from conscious sedation is very rare.
Click to expand...

It's bad rep for our field, and for those who doesn't really understand anesthesia which is pretty much everyone not in our field. For those it can be misleading, and can easily be confused with the rare type of awareness people talk about. Some people may see it as a mistake of the anesthesiologist etc, without realizing that is what sedation is. The main focus of the article may be the distress part but that can easily be lost with the other aspects she talked about.

Basically like many others stated above, I always prepare my patients. It's all about setting expectations. I tell them it is normal to be awake for the procedure, but they may also fall asleep. If you feel uncomfortable let me know, i'll be there the whole time with you. I dont know why so many anesthesiologists do not do this. I see plenty of anesthesiologists telling patients you'll be asleep despite it being a MAC case. That's why i occasionally get those patients who report awareness under anesthesia when I ask them if they had any issues before, and I look back in the chart and its a MAC case.

And midazolam is not a reliable amnestic at all.
 
anbuitachi said:
It's bad rep for our field, and for those who doesn't really understand anesthesia which is pretty much everyone not in our field. For those it can be misleading, and can easily be confused with the rare type of awareness people talk about. Some people may see it as a mistake of the anesthesiologist etc, without realizing that is what sedation is. The main focus of the article may be the distress part but that can easily be lost with the other aspects she talked about.

Basically like many others stated above, I always prepare my patients. It's all about setting expectations. I tell them it is normal to be awake for the procedure, but they may also fall asleep. If you feel uncomfortable let me know, i'll be there the whole time with you. I dont know why so many anesthesiologists do not do this. I see plenty of anesthesiologists telling patients you'll be asleep despite it being a MAC case. That's why i occasionally get those patients who report awareness under anesthesia when I ask them if they had any issues before, and I look back in the chart and its a MAC case.

And midazolam is not a reliable amnestic at all.
Click to expand...
I find that a reliable amnestic is the pre-op interview... the patient reliably forgets everything as soon as I say it.
 
i think it's patients who simply don't understand the words coming out of our mouths. I always hear "doc i woke the **** up during my surgery!", and when i ask them about it, it was always a MAC case. Initially I thought it must have been the anesthesiologist not explaining that sedation carries the risk of being aware. However I hear it so much that it seems like 90% of providers in our field must not be explaining that MAC carries the risk of awareness. I don't think thats whats happening. I think most of us ARE explaining sedation correctly to them, I just think that they literally don't understand
 
T-burglar said:
i think it's patients who simply don't understand the words coming out of our mouths. I always hear "doc i woke the **** up during my surgery!", and when i ask them about it, it was always a MAC case. Initially I thought it must have been the anesthesiologist not explaining that sedation carries the risk of being aware. However I hear it so much that it seems like 90% of providers in our field must not be explaining that MAC carries the risk of awareness. I don't think thats whats happening. I think most of us ARE explaining sedation correctly to them, I just think that they literally don't understand
Click to expand...
IMHO, it's frequently not explained well. And due respect - if you're telling the patient that "MAC carries the risk of awareness", that doesn't help. "Awareness" is not a risk of sedation, certainly not in the way that aspiration, death, etc. are potential risks.
 
jwk said:
IMHO, it's frequently not explained well. And due respect - if you're telling the patient that "MAC carries the risk of awareness", that doesn't help. "Awareness" is not a risk of sedation, certainly not in the way that aspiration, death, etc. are potential risks.
Click to expand...

Some patient just don’t understand well.

When mix awareness, sleep, consciousness, PTSD.... I don’t know how much I can really explain without going to very theoretical or spiritual realm.

If they don’t remember, did it really happen to them?
 
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One of the comments on the article screenshotted below. Worth reading.
 

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nimbus said:
The comments are always good for laughs. There was another comment that said general anesthesia is fatal for infants.
Click to expand...

Wow, didn’t realize I’ve been dead ever since my pyloromyotomy. I must’ve been a real a**hole for those first 6 weeks because this is clearly purgatory.
 
In case you were wondering, SDN automatically changes “a**hole” to “dingus.”

Purgatory indeed.
 
Kate Johnson is a freelance medical journalist based in Montreal.

The article doesn't say for certain, but the author is "based" in Montreal. Perhaps her ordeal is just another example of the inferiority of socialized medicine. You mean they can't even do conscious sedation right? Wow. Oh, Canada.
 
Urzuz said:
...with the added twist that they are focusing more on patients remaining aware during procedures involving "conscious sedation"

Awake on the Table
Click to expand...

I believe the title should be changed to:

"[When You're Intentionally] Awake On The Table [Having Procedures Because You Are A Sick Person But You Are Not Psychologically Capable Of Coping With It And Want To Blame The Medical System]

Fixed it.
 
zizzer said:
I didn't think the article was bad. Conscious sedation was distinguished from general anesthesia, and she got her information from the cited anesthesiologists. She also acknowledged that unpleasant recall from conscious sedation is very rare.
Click to expand...

I always start and frame my Very Journalistic Articles with my sensationalized personal experiences.
 
About 1 in 22 patients may be aware under general anesthesia, they just don't remember it:
What happens when anaesthesia fails

"This suggests many more people might be conscious during surgery, but they simply can’t remember it afterwards.

To investigate this phenomenon, researchers are using what they call the isolated forearm technique. During the induction of the anaesthesia, the staff place a cuff around the patient’s upper arm that delays the passage of the neuromuscular agent through the arm. This means that, for a brief period, the patient is still able to move their hand. So, a member of staff could ask them to squeeze their hand in response to two questions: whether they were still aware, and, if so, whether they felt any pain.

In the largest study of this kind to date, Robert Sanders at the University of Wisconsin–Madison recently collaborated with colleagues at six hospitals in the US, Europe and New Zealand. Of the 260 patients studied, 4.6% responded to the experimenters’ first question, about awareness."
 
FFP said:
About 1 in 22 patients may be aware under general anesthesia, they just don't remember it:
What happens when anaesthesia fails

"This suggests many more people might be conscious during surgery, but they simply can’t remember it afterwards.

To investigate this phenomenon, researchers are using what they call the isolated forearm technique. During the induction of the anaesthesia, the staff place a cuff around the patient’s upper arm that delays the passage of the neuromuscular agent through the arm. This means that, for a brief period, the patient is still able to move their hand. So, a member of staff could ask them to squeeze their hand in response to two questions: whether they were still aware, and, if so, whether they felt any pain.

In the largest study of this kind to date, Robert Sanders at the University of Wisconsin–Madison recently collaborated with colleagues at six hospitals in the US, Europe and New Zealand. Of the 260 patients studied, 4.6% responded to the experimenters’ first question, about awareness."
Click to expand...

Anyone have the reference they’re referring to or is this unpublished?

Also, what do people think about awareness without recall? Is it harmful?

Hard to believe 1/22 patient will have awareness. Just think f all the cases cases we do withou paralytics, I don’t think 1/22 of them move.
 
I can 100% believe it. There is an old video with Dr. Joseph Artusio demonstrating the stages of ether anesthesia (unfortunately not available online), and the patient was following commands and answering questions (while not remembering anything afterwards). It was so mesmerizing I still remember it 10 years later (it was part of a grand rounds presentation).

Btw, 30 seconds on Google led to this: Incidence of Connected Consciousness after Tracheal Intubation:A Prospective, International, Multicenter Cohort Study of the Isolated Forearm Technique | Anesthesiology | ASA Publications

Awareness without conscious recall could lead to PTSD.
 
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Dogma dictates that cardiac (CPB) cases are among the highest in recall/awareness rates. This is repeated ad nauseam despite a conventional wisdom "fast track" trajectory in the last 20 or so years. Yet current "fast track" cardiac anesthetics are, for all practical purposes, indistinguishable from routine GA outside the CT suite.

Do folks do anything fundamentally different for their bypass cases than for anyone else?
 
I think the dogma of awareness during cardiac cases is relic of the days when the anesthetic consisted of 200cc’s fentanyl and little else.
 
drmwvr said:
Dogma dictates that cardiac (CPB) cases are among the highest in recall/awareness rates. This is repeated ad nauseam despite a conventional wisdom "fast track" trajectory in the last 20 or so years. Yet current "fast track" cardiac anesthetics are, for all practical purposes, indistinguishable from routine GA outside the CT suite.

Do folks do anything fundamentally different for their bypass cases than for anyone else?
Click to expand...

The CRNAs at my shop gave everyone (including decrepit 80yos) a shtton of versed pre pump and then immediately coming off. I made them stop doing that and instead, pay attention to the random number generator (BIS), pay attention to what the pefusionist has his iso vaporizer set to, and run a precedex drip throughout the entirety of the case.
 
vector2 said:
The CRNAs at my shop gave everyone (including decrepit 80yos) a shtton of versed pre pump and then immediately coming off. I made them stop doing that and instead, pay attention to the random number generator (BIS), pay attention to what the pefusionist has his iso vaporizer set to, and run a precedex drip throughout the entirety of the case.
Click to expand...

Love it. Random Number Generator! Haven't used it since residency except to hold up the drapes when I can't find a clamp
 
sethco said:
Love it. Random Number Generator! Haven't used it since residency except to hold up the drapes when I can't find a clamp
Click to expand...

It has its uses. Has saved me twice.

Once during a TIVA when positioning loosened the IV connector enough that the slow infusion went into the sheets.

Once during a heart when the perfusionist didn't turn on his isoflurane vaporizor. I usually don't use the Bis for hearts but that day my resident put it on.
 
dipriMAN said:
Anyone have the reference they’re referring to or is this unpublished?

Also, what do people think about awareness without recall? Is it harmful?

Hard to believe 1/22 patient will have awareness. Just think f all the cases cases we do withou paralytics, I don’t think 1/22 of them move.
Click to expand...

It's this study here:

Incidence of Connected Consciousness after Tracheal Intubation:A Prospective, International, Multicenter Cohort Study of the Isolated Forearm Technique | Anesthesiology | ASA Publications

Anesthesiology is free online. Whether this is awareness or not is debatable (they call it connected consciousness). Yes, 4.6% moved their arm to command, but only something like 2% followed a second, more complex command, and none had recall. It is thought-provoking, for sure, and maybe even disconcerting. Truth is, we have no idea what the drugs really do, what unconsciousness really is, with no real way to measure it, and yet we do it every single day. Amazing.
 
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