Anesthesia awareness: here is what you need to know about it

Every year more than 21 million people across the world undergo routine surgery and receive general anesthesia. Normally, during the operation, the patient sleep without feeling pain. However, also every year about 30,000 patients suddenly regain consciousness on the operating table. The complex condition in which the patient regains consciousness after the administration of anesthesia during a major surgical procedure is known as anesthesia awareness or intraoperative awareness. Normally, anesthesia contains several different groups of drugs. None of them provide the necessary conditions for an operation individually. The occurrence of this condition is 0.1-0.2%.

Generally, anesthesia contains three main components:
Anesthetic: Induce the loss of sensation reversibly in the body for a specific period.
Relaxant: Paralyze the muscles of the patient, allowing the surgeon to work easily without interference.
Analgesic: Used for relief from pain during the operation.

These drugs entirely block the channel of painful nerve impulses during the operation and anesthesiologist advises a single unique cocktail for each patient. The doctor’s tasks are to completely put the patient in sleep, relax their muscles, and to deliver the analgesic effect. At the same time, the mixture should not lead to malfunctioning of the cardiovascular, nervous, or other systems of the body.

To calculate the optimal dose of anesthesia is tough. It is dependent on the particular characteristics of each patient’s body, their lifestyle, the habits of the patient, and much more. The complications are compounded by the fact that the mechanism of action of anesthetics is not completely understood and also, each person’s body responds to the medicine in its distinct way. So quite obviously, inaccuracy in the dosage is possible. If the mixture doesn’t contain the accurate amount of components or the patient’s body produces a surprising response for the patient, the operation can turn into a nightmare.

When inappropriate anesthesia is administered, events develop according to several different scenarios.

1. In one scenario, after wakening the patient can hear, see, and sometimes can even move but not feel any pain. In this case, while the use of pain-blocking medication, the anesthetist is undershot on the amount of anesthetic and relaxant. However, doctors are likely to quickly notice and early awakening of the patient in such cases and add in the necessary components to the anesthesia. After this, a person usually doesn’t have the strong memories of the experience that they could lead to mental disorders or depression.
2. Another scenario is having woken up, the patient neither feels pain nor his/her own body. So the dose of relaxant and pain killer for them is sufficient but the amount of anesthetic is too low. It might even happen the surgeon doesn’t notice the awaking of the patient until the end of the operation. But since there is no pain, the patient will not suffer serious psychological trauma. He/she just listen to the doctor’s conversation or look at their faces. Sometimes after awakening, the patient can feel pain and can move, so in such a cocktail there is not enough of any of the components of the anesthesia. This condition though is quickly recognized by doctors and they instantly add more anesthesia.
3. The worst of all scenarios is the condition if a patient wakes up. He/she can feel pain, but because of the paralysis, the patient cannot report it. In this case, the dose of relaxant is sufficient but the other components of anesthesia are not. This can cause tremendous suffering to the patient, and after the operation, the patient will most likely struggle for an extended period. The patient will suffer from such things as general stress, mental disorders, insomnia, and nightmares.

Stories related to anesthesia awareness

1. Carol Weiher experienced this condition during an eye removal surgery. In 1998, Carol Weiher had her eye removal surgery and she woke up hearing disco music. She heard the next thing was “Cut deeper, pull harder”. The entire surgery lasted five-and-a-half hours. When she awoke, she started screaming. The people who suffered from anesthesia awareness, Weiher is one of them. Even though a patient doesn’t remember anything about the surgery that concerns with general anesthesia normally, almost one or two persons in every 1,000 may wake up during general anesthesia.
2. June Carson underwent a cardiac failure in a surgical operation. During the operation, she was senseless. Just after the doctor incised with the scalpel to open her belly, she silently cried due to agony. The dosage of anesthesia was miscalculated by anesthetists and June was not able to move or make a sound. She was feeling every second of torture during her operation. After 15 minutes of the surgery, her heart stopped working. Luckily, with an injection of adrenaline, June’s heart started to beat again. She woke after the 2 hours in ICU and remembered her every nightmarish second.
3. It’s not surprising that most often the patient cannot forgive the doctors for such glaring mistakes. In the UK, a patient required leg surgery, in which drilling and cutting of leg were involved. He was conscious during the operation due to the poor effect of anesthesia. By shaking his toes, he tried to alert the surgeon. A nurse in the operation room observed this scene and informed to the surgeon with this situation. The surgeon said it was “just reflexes” and began the operation anyway. From the unbelievable pain and mental trauma, the patient became extremely ill and soon stopped breathing. However, physicians immediately connected him to an artificial respirator preventing him from expiring. After the operation, the victim filed a lawsuit and it was compensated with 15000 pounds.

Prognosis and outcomes of the anesthesia awareness

1. Patients who experience full awareness with explicit recall may have suffered enormous trauma. Some patients experience post-traumatic stress disorder (PTSD), leading to long-lasting after-effects such as nightmares, night terrors, flashbacks, insomnia, and in some cases even suicide.
2. In 2002 a study from Sweden attempted to follow up 18 patients for roughly 2 years after having been previously diagnosed with awareness under anesthesia. Four of the nine interrogated patients were still severely disabled due to psychiatric/psychological after-effects. All of these patients had suffered anxiety during the period of awareness, but only one had stated for feeling pain. Three patients were found with mild psychotic disorders; however, they could survive with these problems in their everyday life. Two of the patients refused to have any long-term consequences from their anesthesia awareness incident.

Society and culture about anesthesia awareness

• American activist “Carol Weihrer” has experienced anesthesia awareness in 1998.
• In 2007, a film “Awake” was made about anesthesia awareness.
• Return (2007), a Korean film.
• “Heartless (2014)” a Bollywood movie, filmed a person who suffered from anesthesia awareness during heart transplant surgery.
• In the USA, a horror and top-rated movie “Anesthesia” was filmed about anesthesia awareness in 2015.

Having learned all the horrors about anesthesia awareness, one could, of course, refuse to have the operation but this shouldn’t be done especially when there are strong indications of the need for surgical intervention.

It should be remembered that the probability of wakening under the scalpel is negligible (0.1-0.2%) of all operations and approximately 80% of all such cases, the patients don’t remember anything. Also, anesthesia awareness is most often only for a very short time and occurs just before the surgery begins or immediately after its onset.

In these modern times, there are new technologies that allow doctors to more accurately determine the patient’s condition during surgery, but it is also possible that soon such inventions will be of no use. Neurosurgeons from Germany have even been able to operate on parts of the brain of fully conscious patients. It is possible to dispense with general anesthesia and also local anesthesia on the skull of the patients.

Physicians more and more often are managing to carry out complex operations without anesthesia and without the patient feeling any pain or discomfort. During the operation, the doctor can simply ask the patient to speak, count, recognize faces and photos, or even to just lift a finger. Interestingly often such actions are necessary to identify the area that should not be touched during the operation. This new method has become indispensable in the case of contraindication of general anesthesia. The percentage of operation done without anesthesia is still quite small, but with the development of new technologies, their number can undoubtedly grow — and someday people wouldn’t have to suffer the long waking up and recovery period after anesthesia and depression falling anesthesia awareness and then we will achieve our dream. Even with the most serious of the operations, we will go to a surgeon only for a short time or a couple of hours.

How to avoid anesthesia awareness

• The threat of awareness can be decreased by keeping away from paralytics unless necessary.
• Vigilant inspection of drugs, quantities, and apparatus.
• Better observance, and careful monitoring during the incident.
• The Isolated Forearm Technique (IFT) can be used to observe consciousness. This technique involves applying a tourniquet to the patient’s upper arm before the administration of muscle relaxants so that the forearm can still be moved consciously. The technique is considered a reference standard by which other means of assessing consciousness can be assessed.

About the writer: Zeshan Zakir is a research scholar at Bahauddin Zakariya University, Multan-Pakistan