Is It Possible to Feel Surgical Procedure

jwk · Jul 12, 2004

The research doesn't support reliable retrograde amnesia with either agent.

Thanks for the literature review.

In my experience, there is a higher incidence of retrograde amnesia with Versed than there is Valium. We have far fewer complaints when Valium is used. As I said in my other post, I prefer not to use either one anyway - I'd rather use fentanyl. I save the Valium for those patients who aren't really hurting but just can't seem to get settled down.

Then there's always Ketamine - it's a great drug when you've gone through the fentanyl and valium and your patient still has poly-lordy syndrome (oh lordy, lordy, lordy). :)

cnyrn · Jul 12, 2004

I could feel the ob suturing me after the last c-section, could feel the yanking and tugging, not exactly pain but pressure and pulling (had a spinal) very disturbing.

Gotosleepy · Jul 12, 2004

it is normal to feel pressure and pulling w/ a spinal... your anesthesia provider should have warned/explained that to you prior to the c-section so as to not create high expectations.

mshultz · Jul 19, 2004

I am not a nurse, let alone a CRNA, but here is my experience with conscious sedation. I was admitted to the hospital on May 6, 2003 due to a hemorrhage from a duodenal ulcer. Prior to the EGD, the critical care nurse said that I would be sedated, and described the effect as "not caring what they do to me", which sounded rather appealing at the time. I was given a reduced dose due to my condition (I had lost about four units of blood). The EGD was surprisingly tolerable, with no discomfort or gagging. Immediately after the procedure, the gastroenterologist asked if I wanted pictures, and explained the results to me.

When I returned to the CCU, the nurse was surprised that I had pictures. About an hour later, I recalled her description of sedation, and thought to myself "That's odd, I don't recall any change of mood." After I was released, I hit the books, and read about Versed causing amnesia, but there were no gaps in my memory, either.

From what I have been reading, my tolerance for tubes down the throat may be greater than average. The gastroenterologist made a "happy face" when he said that he was going to remove the EG tube prior to the EGD. Although having an EG tube inserted or removed is unpleasant, I had no trouble with gagging either time. In fact, I had become completely used to it by the time it was removed. Also, I immediately choked and had to swallow when trying to gargle with the anesthetic throat spray, so my throat may not have been properly numbed, but I still had no problem with gagging during the EGD.

From my perspective, the fact that I was not sedated was wonderful. Since I was not gorked, I was able to answer "Yes" that I wanted pictures, and able to remember the discussion about the results. No further mention was made concering the EGD results, so if I had suffered amnesia, I would never have known what I had missed.

You can read about my colonoscopy experience in the Gastroenterology Forum, under the "recent colonoscopy experience" thread. The gastroenterologist found out about my awareness only because:

1. I decided to read about colonoscopies on the web.

2. I found a site that said it was possible to have a colonscopy without sedation. This site is now gone, and if the "recent colonoscopy experience" thread had appeared before my colonoscopy, I would have never made the attempt.

3. I got up the nerve to write to my gastroenterologist and ask for the same reduced amounts of drugs, so that I could watch.

When I gave up and asked for additional sedation, my memory continued for about a minute after the injection, so there was no retrograde amnesia. I wrote to the ED, the CCU, and the gastroenterologist in February 2004 to let them all know just how well I am doing (more than a complete recovery, and no loss of cognitive function, although I had been unconscious for about an hour at home the morning of the hemorrhage). I wonder what the gastroenterologist thinks about me telling him that I want to try again and watch the next colonoscopy?

I realize that my responses can be different. The agony that I was in during the colonoscopy does not bother me, but the amnesia after I asked for additional sedation bothers me a lot. I would rather be aware and paralyzed, than be given an amnesiac, if it came to that. This is my only experience with any sort of mind-altering drug, and I really do not like it. Nevertheless, I do have sympathy for those who are in pain, or have unpleasant memories.

jwk · Jul 19, 2004

I am not a nurse, let alone a CRNA, but here is my experience with conscious sedation. I was admitted to the hospital on May 6, 2003 due to a hemorrhage from a duodenal ulcer. Prior to the EGD, the critical care nurse said that I would be sedated, and described the effect as "not caring what they do to me", which sounded rather appealing at the time. I was given a reduced dose due to my condition (I had lost about four units of blood). The EGD was surprisingly tolerable, with no discomfort or gagging. Immediately after the procedure, the gastroenterologist asked if I wanted pictures, and explained the results to me.
When I returned to the CCU, the nurse was surprised that I had pictures. About an hour later, I recalled her description of sedation, and thought to myself "That's odd, I don't recall any change of mood." After I was released, I hit the books, and read about Versed causing amnesia, but there were no gaps in my memory, either.
From what I have been reading, my tolerance for tubes down the throat may be greater than average. The gastroenterologist made a "happy face" when he said that he was going to remove the EG tube prior to the EGD. Although having an EG tube inserted or removed is unpleasant, I had no trouble with gagging either time. In fact, I had become completely used to it by the time it was removed. Also, I immediately choked and had to swallow when trying to gargle with the anesthetic throat spray, so my throat may not have been properly numbed, but I still had no problem with gagging during the EGD.
From my perspective, the fact that I was not sedated was wonderful. Since I was not gorked, I was able to answer "Yes" that I wanted pictures, and able to remember the discussion about the results. No further mention was made concering the EGD results, so if I had suffered amnesia, I would never have known what I had missed.
You can read about my colonoscopy experience in the Gastroenterology Forum, under the "recent colonoscopy experience" thread. The gastroenterologist found out about my awareness only because:
1. I decided to read about colonoscopies on the web.
2. I found a site that said it was possible to have a colonscopy without sedation. This site is now gone, and if the "recent colonoscopy experience" thread had appeared before my colonoscopy, I would have never made the attempt.
3. I got up the nerve to write to my gastroenterologist and ask for the same reduced amounts of drugs, so that I could watch.
When I gave up and asked for additional sedation, my memory continued for about a minute after the injection, so there was no retrograde amnesia. I wrote to the ED, the CCU, and the gastroenterologist in February 2004 to let them all know just how well I am doing (more than a complete recovery, and no loss of cognitive function, although I had been unconscious for about an hour at home the morning of the hemorrhage). I wonder what the gastroenterologist thinks about me telling him that I want to try again and watch the next colonoscopy?
I realize that my responses can be different. The agony that I was in during the colonoscopy does not bother me, but the amnesia after I asked for additional sedation bothers me a lot. I would rather be aware and paralyzed, than be given an amnesiac, if it came to that. This is my only experience with any sort of mind-altering drug, and I really do not like it. Nevertheless, I do have sympathy for those who are in pain, or have unpleasant memories.

Having memories of procedures after having only sedation is an entirely different thing than awareness under general anesthesia. Awareness during sedation is not considered cause for concern - awareness during general anesthesia is a rare occurrence and is a major concern when it happens.

Sedation for procedures such as EGD or colonoscopy is done with a variety of drugs in a variety of ways, depending on whether the drugs are given by the nurses in the GI room or by an anesthesia provider. If you lost four units of blood, you probably were given a minimal amount of sedation due to your condition. A small dose of Versed may not have caused any amnesia, whereas a larger dose could have.

We often provide sedation for GI procedures, maybe 20% of the GI procedures at our hospital. Anesthesia provides their sedation if they really want to be well sedated. Those patients receive enough drugs that they will not have recall of their procedure. If patients want to try the procedure with minimal or no sedation, they can if their physician doesn't mind. It's their call. It is certainly possible and not really that uncommon to have EGD's or colonoscopies with minimal or no sedation. It really depends on the patient's tolerance.

mshultz · Aug 16, 2004

jwk:

Thanks for the reply. It has since occurred to me that a patient who chooses general anaesthesia, even when other options are available, really does not want to remember the procedure.

74 pages and $30 later, I have my hospital records. For the EGD, I was given 2mgs Versed and 50 mgs Demerol. For the colonoscopy, I was originally given 1 mg Versed and 50 mgs of Demerol. When I gave up, I was given an additonal 2 mgs of Versed and 25 mgs of Demerol. In looking at the records, I would guess that I regained short term memory about 30 minutes after the last injection of drugs.

While I was enduring the colonoscopy, I thought of asking what drugs they were using, and then requesting additional Demerol for pain control without more Versed. I did not have the nerve to make this request because I thought doctors might be reluctant to have you experience and remember a narcotic buzz (It's OK, you can laugh at me).

susanna · Aug 20, 2004

This may be a real stupid question but, Wouldn't maybe an EEg pick up consciousness on the part of the patient? Or is it too much to set up and monitor an eeg and all the other patient equipment at the same time?

PA-C in Texas · Aug 21, 2004

First off, I am NOT on the level of the CRNAs around here. Anesthesia providers really float my boat because what they do is very technical and at the same time an art in and of itself. I mean I can put someone down with etomidate for a tube, but the realm of anesthesia maintenace and inhalational anesthetics is really out of my league.

Having said that, I spent a year as a first assist in the OR for a CT surgery group. All I did was operate and follow up with patients in the hospital. Despite assisting on sometimes up to four cases per day, and through all the CABGs and saphenous veins I harvested, never once did I encounter a case of anesthesia awareness with any of those patients. From what I am hearing from my anesthesia colleagues, thoracic surgery cases (perhaps particularly those requiring extracorporeal perfusion) may be at slightly higher risk due to a different anesthetic technique. But I would be hard pressed to find anyone who has actually seen a case of anesthesia awareness. I am almost certain that the surgeons I worked with, most with 20+ years of experence, had never seen a case.

I think most cases can be explained by equipment malfunction (empty desflurane cannisters or some other -ane cannister) or just plain malpractice, ie. only administering more paralytics when a patient makes purposeful movement and not increasing the anesthetic dose. The really intriguing cases are the ones in which there is not a physiological response to the intense pain- no tachycardia, etc. I'll leave that discussion to those wiser than I. But if you follow the money it leads right back to the people who manufacture the BIS monitor.

On the conscious sedation note, I had an EGD a while back for a suspected dx of GERD/hiatal hernia. No meds other than Aciphex 20 mg po qd and no other hx. They gave me eight of midazolam and 125 mg of Demerol before it was all said and done, and I remember every damn minute of it. I remember my throat really hurting when they advanced the scope, but I also felt absolutely elated during the whole thing. I had the same cocktail when I had my wisdom teeth extracted several years ago and I was totally snowed. I didn't even remember going into the procedure room. It might have been the 25 mg of Phenergan they gave me. I really have no clue.

jwk · Aug 21, 2004

On the conscious sedation note, I had an EGD a while back for a suspected dx of GERD/hiatal hernia. No meds other than Aciphex 20 mg po qd and no other hx. They gave me eight of midazolam and 125 mg of Demerol before it was all said and done, and I remember every damn minute of it. I remember my throat really hurting when they advanced the scope, but I also felt absolutely elated during the whole thing. I had the same cocktail when I had my wisdom teeth extracted several years ago and I was totally snowed. I didn't even remember going into the procedure room. It might have been the 25 mg of Phenergan they gave me. I really have no clue.

Next time request MAC from your friendly neighborhood anesthetist. At most mine get a little versed, a little fentanyl, and some propofol. Very smooth, very short acting, no thrashing around.

Your experiences are a prime reason why so many anesthesia providers have a big problem with GI nurses and docs (or oral surgeons and others) thinking it's OK for them to start using propofol for procedures and not involving the anesthesia department. They don't even handle what they currently have very well, and they'll really get into trouble with propofol. I remember when versed was first released. All the GI docs that were used to giving 10-20 of valium were giving 10-20 of versed. No pulse ox back then. It made for lots of codes in the GI suite. And I know several oral surgeons who do their own anesthesia and then do the surgery. No anesthetist or doc present. Yikes!

loisane · Aug 21, 2004

This may be a real stupid question but, Wouldn't maybe an EEg pick up consciousness on the part of the patient? Or is it too much to set up and monitor an eeg and all the other patient equipment at the same time?

Susanna,

The EEG in many forms has been tried for a monitor of anesthetic depth. The EEG itself is very complex, and reading it is a specialized skill. There is a monitor that compresses the signal into a single number, but it has not been found to correlate very well with anesthetic depth.

The BIS and PAS monitors (that many have referred to in this discussion) are the most current attempt to apply EEG modality to the monitoring of anesthetic depth. How well it does this depends on who you talk to. The response from providers is still mixed. I think it is safe to say we still do not have a completely useful monitor of anesthetic depth and consciousness.

loisane crna

Gotosleepy · Aug 21, 2004

interesting note: we used to do and interpret our own EEGs for SSEPs/MEPs and carotids while doing those cases.... now the neuro depts have a political stranglehold...

the incidence of awareness used to be more common in cardiac cases during the 60s/70s/early 80s due to the high narcotic techniques... at the time they would give whopping doses of morphine with no inhalational agent and no benzos (as those two were felt to contribute to hemodynamic instability - propofol wasn't an option yet)... and in fact, on those old cardiac consent forms, the patient was made aware that there was a 15% chance at that institution of intra-operative awareness.... by the way, do you know how many times we had to start CPR after some of those monster doses of Morphine (in fact we would pretreat with 1gm of solumedrol to combat the "histamine" release of morphine to stabilize BP during induction.... crazy times)

Gompers, BSN, RN · Aug 21, 2004

Yep, I can believe it. I don't think it's always deliberate, but I think it happens. I know in adult/peds cases they give patients paralytics, analgesics, and sedatives. I work in NICU, and often they just give paralytics and analgesics. They figure giving enough Fentanyl will knock the baby out so they don't need Versed or anything. My problem is that unless you're giving Fentanyl every 15 minutes or as a drip, it isn't good enough! (It sucks, but it beats the days when they didn't give babies ANYTHING for pain, since they "didn't feel anything" people thought.)

But like I said, it's not always deliberate. Sometimes they unknowlingly underdose people who have a tolerance to medications already, or purposely hold back on the meds if the blood pressure is borderline. I remember a baby we sent for a bowel resection, and he came back the unit in complete shock despite sufficient fluid resuscitation. It took me 3 hours, maximum dopamine/dobutamine/epinephrine drips, several transfusions/boluses, and shock steroids to even get a blood pressure on this baby - and even then it was only 14/9. When I got the OR report, I noticed that the baby had gotten a 5mcg dose of Fentanyl - ONCE - during the whole 2 hour procedure!!! WHAT?!?! Plus this was a 1 kg baby who had been on a 4 mcg/kg/hr Fentanyl drip going INTO the procedure, and they turned off the drip when they started the surgery! Do the math - the poor kid was so traumatized he probably just tried to die.

During his next bowel resection 2 weeks later, I politely told the anesthesiologist to make sure he got tons of Fentanyl, that he was really tolerant to it, etc. Well, she did just that, and the kid sailed through surgery with no problems. Go figure.