OR Awareness

Question 1

The biggest fears intraoperatively:

Answer 1

Awareness

Question 2

Explicit Memory =

Answer 2

Conscious

Question 3

Implicit Memory =

Answer 3

Unconscious

Question 4

Conscious recollection of previous is what type of memory

Answer 4

explicit

Question 5

Memory equivalent to remembering is

Answer 5

Experience(s)

Question 6

Awareness during anesthesia describes

Answer 6

conscious recall (explicit memory ) of Intraop events

Question 7

Patients can respond to commands and lack conscious recall in what form of memory?

Answer 7

Implicit

Question 8

Questions to evaluate awareness:

Brice Questionnaire

Answer 8

1. )What was the last thing you remember bf going to sleep?
   2) What is the first thing you remember after your operation?
   3) Can you remember anything in b/w?
   4) Can you remember if you had any DREAMS during the procedure?
   5) What was the worst thing about your procedure?

Question 9

Incidence of awareness US & Sweden:

Answer 9

12,000 patients (sweden)
0.18% (18/10,000) had awareness under GA w/NMBD

.10% (10/10,000) had no NMB
0.13% (13/10,000) overall incidence

Question 10

Awareness most likely in:

Answer 10

-Co-exisiting morbidities
-OB
Cardiac procedures (EMERGENT/light sedation)
-Patients with INCREASED anesthesia requirements
-anesthetic delivery problems (machine, meds, circuit)
-When volatile anesthetics aren’t used

Question 11

Why would you have light anesthesia?

Answer 11

hemodynamic intolerance
OB or Cardiac surgeries
Reduced anesthetic doses for safety of hypovolemic or limited cardiac reserves

Question 12

Patients Requiring increased Anesthesia:

Answer 12

ASA 3-5 (in major surgery)
Abuse of ETOH or Drugs
Genetics (redheads)

Question 13

MAC Dose known to prevent conscious recall is:

Answer 13

MAC >= 0.7

Question 14

What might mask Awareness?

Answer 14

NMBD

Question 15

Most Patients often recall:

Answer 15

Lights, sounds, feelings of helplessness, fear, anxiety

-pain is less common; may occur w/NMBD use

Question 16

Psychological Sequelae is:

Answer 16

• flashbacks, ANXIETY, nervousness, loneliness, nightmares, fear and panic attacks.
• 1/3 patients who experience awareness manifest this
• an acute emotional reaction to the experience significantly predicted the development of late psychological sequela.

Question 17

Interventions for Psychological Sequelae

Answer 17

early psychotherapy may reduce acute and long term

-explain or validate the awareness effect presence and duration of psychological consequences.

Question 18

can patients report awareness?

Answer 18

yes - registry exists

Question 19

Preop Evaluation to reduce awareness complications (box 47.1)

Answer 19

*Identify Risk Factors:
*Interview Patient:
-listen to pt fears. answer questions.
Obtain informed consent:
-talk to pt about the anesthesia procedure
-let them know what to expect –> MAC case vs
Regional w/sedation, vs. GA
-let them know they’ll get pain & antiemetics; more if
they need when awake.

Question 20

Use of BIS (bispectral index system)?

Answer 20

Used to aid anesthesia administration and reduce awareness

• Not Gold Standard
• clinical trials: if one more pt had reported awareness, they would not be statistically significant. (Hawthorne effect)

Question 21

Hawthorne Effect

Answer 21

the alteration of behavior by the subjects of a study due to their awareness of being observed.

Question 22

Prevention of Awareness:

Answer 22

• Premed w/Benzo (VERSED)
• Adequate doses of induction drugs
• avoidance paralysis if possible
• MAC at least 0.7

Question 23

Out of how many injuries from negligent care result in malpractice claims (and fewer when standard of care was delivered)?

Answer 23

1 out of 25

Question 24

Approx how many claims per year are made for awareness?

Answer 24

10 per year

Question 25

Factors that influence Awareness Lawsuits:

Answer 25

- poor communication - unmet expectations - financial pressures on the pt * poor relationship with their physician/provider

Question 26

Brain Function monitoring

Answer 26

- Assess depth of anesthesia (EEG activity) - BIS - frontal eeg activities into an index of hypnotic level - 100 (awake) to 0.

Question 27

BIS Range recommended to reduce consciousness during GA?

Answer 27

40-60

Question 28

Compared to routine care, BIS is shown to reduce awareness in use of:

Answer 28

TIVA (total IV anesthesia)

Question 29

Does BIS or End Tidal gas monitoring decrease awareness?

Answer 29

end tidal anesthetic gas monitoring

Question 30

Preinduction Phase of Anesthesia: | to prevent awareness complications (box 47.1)

Answer 30

- Use checklist for machine/equip check - verify function of IV and infusion equip - Consider preop benzo

Question 31

Intraop Monitoring: | [ to prevent awareness complications (box 47.1)]

Answer 31

- multiple modalities to monitor depth of anesthesia - clinical (purposeful or reflex movement) - conventional monitoring (bp, hr, end tidal analyzer) - brain function monitoring

Question 32

Intraop and postop managment: | to prevent awareness complications (box 47.1)

Answer 32

- benzo may be needed if pt unexpectedly becomes conscious - speak w/pt postop - interview pt to determine pt experience (Brice questionnaire) - offer pt psychological counseling

Question 33

The anesthetic depth required to block implicit memory is GREATER THAN, OR LESS THAN that required to block explicit memory?

Answer 33

Greater than

Question 34

awareness is considered what form of memory?

Answer 34

explicit

Question 35

What types of patients tend to have awareness more frequently?

Answer 35

patients w/ co existing morbidities tend to have more frequent incidence of awareness

Question 36

tell me the three major causes of awareness

Answer 36

light anesthesia increased patient anesthesia requirements anesthetic delivery problems

Question 37

examples of when light anesthesia may be necessary:

Answer 37

due to hemodynamic intolerance of anesthetic drugs OB or caridac surgeries reduced anesthetic doses may be necessary for optimal physiology and safety in hypovolemic patients or those w/limited cardiac reserve.

Question 38

Name examples of when patients may have greater anesthesia requirements:

Answer 38

- ASA 3-5 undergoing major surgery - abuse of ETOH, opioids, amphetamines and cocaine - Genetics

Question 39

Who else is also more likely to experience awareness?

Answer 39

Children (p. 813)

Question 40

Intraoperative awareness is more likely to happen during...

Answer 40

induction of anesthesia with N20 and IV administered anesthetics.

Question 41

Awareness is less likely to occur ....

Answer 41

when volatile anesthetics are used. | MAC 0.7 or greater

Question 42

what prevents us from seeing early signs of inadequate anesthesia?

Answer 42

NMB | -miss patient movement

Question 43

A MAC of 0.7 or more prevents ______ _____.

Answer 43

Conscious recall

Question 44

A MAC of 0.7 or more prevents conscious recall in anesthetized patients similar to that achieved by:

Answer 44

a brain function monitor of anesthetic depth.

Question 45

What early sign of awareness is unavailable when NMB 's are used?

Answer 45

patient movement

Question 46

what is important in the pathogenesis of awareness during anesthesia?

Answer 46

anesthetic technique

Question 47

intraoperative awareness can occur in the absence of

Answer 47

tachycardia or htn