I woke up during surgery, Have you?

[GatorRN]

I was responding to another thread the other day and made mention of the fact that I woke up DURING my last surgery. I got to wondering if this had ever happened to anybody else, so I thought I'd ask.

It happened to me last year. I had a vague memory of waking up and seeing the overhead operating room lights, and being in excruciating pain. I thought I had imagined it, until two different anesthesioligists (teaching hospital) came up to my room, on separate occasions, and asked me if I had any memory of waking up during my surgery. I was shocked to find out that it actually did happen. :uhoh21:

I later requested a copy of both my hospital records and my surgeons records for my own file, and amazingly enough, it wasn't mentioned anywhere in my records. I wooooonder why...Hmmmmm? Of course, my surgeon downplayed the whole incident at my follow up appt.

Has anybody else ever had this experience before? If so, what do you remember, and did your surgeon own up to it?

[mistersister]

Hello all.

This is my first post on allnurses though been reading for awhile. I've been an anaesthetic nurse (now in ICU for awhile) for several years (in Oz it's not the same as a CRNA, but we're like the scrub nurse is to the surgeon - and then some).

The incidence of awareness under anaesthetic is actually fairly high (something like 1 in 25000) but mostly (and admittedly not exclusively) limited to three types of surgery - trauma (loss of blood due to massive haemorrhage takes the drugs into third space loss and disrupts first pass metabolism, in addition to all the other metabolic disturbances), general anaesthetic cesaerean sections (gotta keep the doses light so you don't anaesthetise the baby as most drugs cross the placenta - usually ok from breast milk if surgery post delivery as long as first feed is expressed

post GA) and cardiac surgery (due to most of the surgery being run on something like a high dose larazepam (long acting benzodiazepine like a souped up midazolam) premed and fentanyl (synthetic opioid narcotic 1000 times stronger than morphine - not sure what its called in the US). Cardiac surgery is done this way because the other maintenance drugs we use (both inhalational and IV) are useless in the face of the cardioperfusion bypass machine - sort of ventilator/heart pump/metabolic dialysis machine.

Now the good news - the chances of have awareness in any other surgery is, nowadays, pretty low. We've got a new monitor that measures the pt's level of consciousness - something we just couldn't do until recently. We could infer by other parameters, but as has been pointed out - we're giving you drugs to cease (or sometimes just lower) respiration, lower heart rate and BP, so how much of that is actually lowering you're consciousness? There's the problem. We also based doses for inhalational agents on MAC, (mean alvoeolar concentration) which essentially is the concentration of the agent at the alveolus (also inferred) and based on the idea that 50% of patients had no reaction to surgical stimuli (in studies) therfore, at this dose the pt is probably asleep.

Strangely, one of the main drivers for the use of this monitor is to reduce the cost of drugs administered to pt's under anaesthesia. It was found that a goodly percentage of practitioners actually gave higher doses than they needed to - this increased drug costs, PACU time and ultimately length of stay.

'Course, any reason to institute widespread practice of this monitor is a good one, given its obvious benefits at reducing the incidence of this traumatic experience. The tip is it'll probably be compulsary in a few years, a bit like those pulse oximeters everyone said couldn't be trusted or wouldn't last.

Won't take up much more time because it's a big subject, and this is only an insight into some of the issues involved - how does it happen, should we admit it (yes we should), when is it negligence, etc.

Thanks for reading.

[kukukajoo, LPN]

Meistersister- Thank you for your very imformative response. Has the manufacturer of the consciousness monitor shared how they determine the levels? I am a first year student and was observing in the OR Friday and the CRNA was explaining that the manufacturer does not divulge just how this monitor works, just what the numbers are supposed to mean. She also stated that she has had pts sit bolt upright at 30 at times so it is not completely accurate.

Thanks again!

kukukajoo

[mistersister]

Hey there.

As I wrote in my post I'm not a CRNA either (we don't have them in Australia) so I envy you your career choice - it's the next step for me but I'd have to move overseas, so I've moved sideways instead.

My understanding of the BiS (stands for BiSpectral Index according to the manufacturer Aspect) monitor is that they took EEG recordings of a huge (76000 was one figure I've heard used) number of US marines undergoing surgery. They then analysed these with to find common elements or complexes in particular waves at certain points in the anaesthesia (there are textbooks that will still demonstrate the "planes" of anaesthesia - it used to be a recognised thing clinically, by now is more idealised as the drug the planes are based on was thiopentone (?or halothane) neither of which is used anymore. (You'll still find thiopentone in rare circumstances - propofol is the thing now).

Anyway, the planes deliniate certain characteristics of an anaesthetised pt. and as such if they could identify and design an algorithm to cheaply and easily sort out the mess of an EEG into a usuable graded number, well, that'd be worth something.

That's essentially the story, it does exactly that and since it Aspect put it on the market Datex Ohmeda have come up with a simpler and cheaper (no liscence fees for the algorithm) version that uses mathematics (chaos theory) to do the same thing (their's is called entropy).

Both use a four sensor arrangement to capture a simplified EEG and conduction of impulses along the facial nerve.

The end result is a number between 1 and 100, under 40 is unconscious, 100 is fully awake, and 0 is deceased, though I've seen a few 0's in my time that aren't, so reliability can still be an issue. Remember with all monitors, treat the patient, not the number.

Hope this helps

[lamazeteacher]

In 1974, during my breast lump biopsy (in those days, a frozen section of tissue was done quickly while the patient was anaesthetized. I'd told my surgeon before surgery and signed to go ahead with the modified radical mastectomy if cancer cells were seen).

However, I really couldn't conceive of having a mastectomy in that small community hospital where the biopsy was done, and remember my, and my surgeon's surprise when he exclaimed "It is!", while I was on the table. I felt no pain, however, or any emotional reaction like sadness.

When I awoke in the Recovery Room and felt the big bandage, I realized that it had happened. When I told my surgeon the above, he said, "You could hear that?" confirming my recall.

Of course, hearing is the sense that is lost last at death, and being anaesthetized is as close to that as you can come, and live. I saw the movie "The Doctor" after that, and recommended that it become required on all medical school curricula, as it outlines patients' need to have medical professionals use their knowledge of patients' awareness while unconscious, of what is said. Hopefully it curbed the crass telling of "dirty" jokes and nasty comments, thrown instruments, etc. that occurred in O.R.s when I worked there.

Lois Klein, R.N., P.H.N.

[AggieNurse99, BSN, RN]

As a first semester student, we recently had our perioperative lectures. Isn't one of the meds given in a general anesthetic mixture an amnesiac? Wouldn't this be important in cases as another poster suggested PTSD?

Myself, the GI doc who did both my colonoscopy forgot the amnesiac. It wasn't painful or anything, but kinda cool to watch! The EGD was another story, where's halcion when you want it! He kept saying, "No, don't cough."

[GatorRN]

siri - i wanted to thank you for the article/links that you posted. i finally had the chance to read through all of them. they were all great articles, i found them very informative.

mistersister - i wanted to thank you as well. the information you gave was also very informative. i appreciate you sharing your knowledge.

i am definately now more informed about what to discuss with my anesthesiologists for future surgeries that i may need. i had no idea that there was such a thing as the consciousness monitor. i have written out a list of questions that i gathered from the resources provided. i will certainly utilize it in the future to better inform myself preop, and hopefully calm the anxieties that i'm sure i'll have. you can learn something new here everyday, that's what i love about this site! :) thanks again

as i said before, i am amazed to find out just how many ppl have experienced this type of thing. it can be very traumatizing. some of you had experiences much worse than mine. i truly hope that you have been able to work through everything and will have no lasting effects. thanks for sharing your stories.

______________________________________

go gators!! :yelclap: sec champions!!

:w00t: national championship bowl bound!! :w00t:

[sirI, MSN, APRN, NP]

You are welcome, GatorRN

[analee23]

I work in the ER and do conscious sedations. I had a patient the other day that was a difficult fracture reduction. He woke up in the middle of the procedure, looked right at the ER attending and said "F*** YOU!" Then went right back out as I was pushing more meds right at that time. He had absolutely no memory of it, and kept asking if they had "fixed his arm" during recovery. Makes ya happy for the versed!!!

I remember briefly waking up at the end of my foot surgery, but it was when they were dressing my foot at the tail end, and then I don't remember anything for the rest of the day.... until waking up on the couch in my dad's office. Have had 3 surgeries since and never woken up, or remember anything until I'm back in my hospital room, don't remember recovery AT ALL!!

[louloubell1]

This thread is interesting, and to me the thing that makes it most interesting are the continued reports of "I woke up during surgery" despite several posts trying to explain some things from anesthesia providers.

Folks, if you "woke up" from your conscious sedation, if you "woke up" from your spinal or epidural or other regional block, if you "woke up" at the end of surgery as they were putting on the dressings, if you "woke up" hearing the anesthetist say to you "breathe, breathe," if you "woke up" from what you are wrongly assuming to be general anesthesia and actually "spoke" to your anesthetist quickly before "being back out", then you did not "wake up" inappropriately. I just am trying to help you all clear up some misconceptions here so that the people who have truly suffered awareness under anesthesia can have some suitable support and maybe other people can understand their post-traumatic feelings a bit better.

Conscious sedation is a realm of depressed consciousness sufficient to provide comfort while still the patient maintains the ability to respond. Sometimes people won't remember anything when they've had conscious sedation, but sometimes they will. That is ok. It is not expected that you will be unconscious for your procedure, hence the term conscious sedation. You may have heard conversations in the room, you may recall sounds & lights. If you recall something or "awakened" from a procedure you had done with conscious sedation, you did not suffer from awareness under general anesthesia.

Regional blockade, including spinals and epidurals, are not general anesthesia. Spinals are often done for many lower extremity and some abdominal surgeries. Sometimes, a patient who has had one of these forms of anesthesia is provided with some sedation as well during their procedure: Sedation, not general anesthesia (although regional blockade may indeed be combined with general anesthesia but not usually). Again, let me stress, sedation is not general anesthesia. If you awoke from your sedation, you did not suffer from awareness under general anesthesia. You may have heard conversations in the room, you may recall sounds & lights. You did not suffer awareness under anesthesia.

If you awoke and actually "talked" to your anesthesia provider before quickly being "put back out" you were likely receiving some sedation, not general anesthesia. General anesthesia involves the placement of an ETT or an LMA, or much less frequently, a very tight fitting mask. You won't be talking with any of those contraptions in your throat I can guarentee.

If you awakened hearing your anesthetist or anesthesiologist saying "breathe, breathe" you were likely being awakened at the end of the procedure. There comes a time when all general anesthetics must end, obviously, and we do indeed wake you up. And sometimes we wake you up fully with the ETT still in because we may deem it to be the safest (as opposed to extubating deep under anesthesia). Likewise, if you woke up and dressings were being applied, your procedure was over, and you were being awakened on purpose. You did not suffer awareness under general anesthesia.

Also, to answer a couple of other questions which have been posed: First, the BIS monitor is not utilized by every facility. BIS continues to be under study and its use is not standard of care. Mistersister posted that a BIS reading under 30 is unconscious, however, the true number range that correlates with general anesthesia is 40-60. The lower the number, the deeper the state of anesthesia. It is not desirable to run a patient too deep just as it is not desirable to run a patient too light, & I think you should know that some studies utilizing the BIS monitor to gauge depth of anesthesia have shown that anesthesia providers have a tendency to run their patients too deep, rather than too light. Many anesthesia professionals question the usefulness and accuracy of this tool, and so its use is not universal. Also, I must tell you that many anesthesia providers blame the makers of BIS for aggressive ad campaigning that has falsely led to people believing they have experienced awareness under anesthesia or believing that the incidence is astronomical. This thread is largely an example of that, of people who truly believe they had awareness under anesthesia, when they in fact were not receiving a general anesthetic.

Another question: Yes, drugs with amnestic properties are utilized often for general anesthesia. Versed is probably the most common. It is a benzodiazepine with can provide anterograde amnesia. However, not all patients experience amnesia with versed. In addition, versed is not appropriate for all patients. The other drugs utilized during general anesthesia also provide for amnesia and unawareness.

Another misconception that I have read so far on this thread involves pt movement under anesthesia. There are many, many procedures in which no muscle relaxation (paralysis) is necessary. Movement does not necessarily mean that a patient is not adequately anesthetized. The dose of inhalation agent necessary to prevent recall in a patient is about half that necessary to prevent movement to surgical stimulus, and the dose needed to prevent autonomic response (tachycardia, increased BP, etc) is even higher than that necessary to prevent movement. OR nurses who see a patient move under general anesthesia should be aware that it doesn't mean the patient is not unconscious.

Anyway, what this longwinded response amounts to is that people who have really suffered awareness under general anesthesia have endured a traumatic experience, and need support from professionals and others who have suffered similar events. Likewise, anesthesia providers maybe need to be doing more education with the public on what awareness under anesthesia really is, and what the different kinds of anesthesia are. There is obviously, even amongst this group of health care professionals, great misunderstanding of this.

Lou

[ewattsjt]

Thanks Lou,

Great post! Hopefully people will read your post and have a better understanding of anesthesia.

[crackerjack]

Working in the OR I've seen more than I care to of patients waking/moving on the table. For a patient to suddenly be moving and trying to come off the table, out of stirrups or whatever while the surgeon is trying to work and is nowhere near the beginning or end of the case (not like the patient wasn't fully under or in preparation for the end of a case that didnt' come quite as soon as anticipated) that's just a bit too light to be 'light' and it always happens with the same anesthetists. Over and over and over....soooo predictable. Let's just say I know who I would and wouldn't have for my anesthetist.

[ewattsjt]

That is one of the nice perks to working surgery! I know who I would choose too.