Review of unusual patient care experiences is a cornerstone of medical education. Each month, the AQI-AIRS Steering Committee abstracts a patient history submitted to the Anesthesia Incident Reporting System (AIRS) and authors a discussion of the safety and human factors challenges involved. Real-life case histories often include multiple clinical decisions, only some of which can be discussed in the space available. Absence of commentary should not be construed as agreement with the clinical decisions described. Feedback regarding this article can be sent by email to firstname.lastname@example.org. Report incidents or download the AIRS mobile app at www.aqiairs.org.
Case 2019-7: Aware Under Anesthesia: When the Gift of Oblivion Meets the Mystery of Consciousness
ERAS sleeve gastrectomy patient given gabapentin, acetaminophen and TAP block preoperatively. Medications administered for the TAP were midazolam 2mgs and bupivacaine 0.25 percent 20cc each side. Anesthesia was induced with Propofol 150mg, midazolam 2mg (total 4mg), ketamine 50mg, lidocaine 70mg and rocuronium 50mgs was administered after apnea, loss of eyelid reflex and absence of response to verbal command. Three weeks post surgery, the patient confided to her surgeon at clinic appointment that she was aware on induction of anesthesia. She remembers a person asking for the tube, she remembers her mouth being opened with the thumb and the tube being placed. She reported that the first week post surgery, she had difficulty sleeping and that she had nightmares. These improved during the second week post surgery. She declined any professional counseling or therapy.
49-year-old admitted with H1N1 pneumonia, developed respiratory failure. Rapid Response called, escalated to code blue, anesthesia team arrived and intubated with 150 propofol and 60 of rocuronium; verified tube placement and left. A week later, patient came to O.R. for small procedure and reported to the team that he had been awake and paralyzed for 45 minutes after his intubation. Every time he felt the paralysis waning, he would hear “oh, he’s awake” and then he would be re-paralyzed. Very traumatic for him as he is claustrophobic. Patient reports severe nightmares since the event.
Intraoperative awareness with explicit recall remains a very present danger for our patients despite much research on how to prevent this dreaded event.1,2 In many of the large observational studies, awareness occurred without any clear malfunction of equipment (vaporizer ran dry) or clear medical error (succinylcholine given prior to propofol), although these events have been frequent in the Closed Claims database. Both of this month’s cases were reported as “preventable” and readers would likely agree. Dosing of induction agents in morbidly obese patients remains controversial, with some suggesting that a dose based on ideal body weight is sufficient, others recommending total body weight. Using ideal body weight would have indicated a dose of approximately 130 mg of propofol, while dosing for total body weight would have been at least 200 mg, assuming a weight of 100 kg (although not noted, this was bariatric surgery). The reporter states, “a higher dose of induction agents would have prevented this complication.”
Our understanding of how and why awareness occurs despite an intention to provide unconsciousness has improved significantly in the past 15 years. Mashour and colleagues have presented a review of the neurobiology of anesthetic unconsciousness and awareness.3 In addition to the neurobiology of awareness, several studies have explicitly tested methods to prevent awareness. In two studies (BAG-RECALL1 and B UNAWARE4 ), the authors found that either maintenance with 0.7 MAC or targeting a BIS of 40-60 were equally effective in preventing recall. Prevention of awareness with recall on induction is not as well studied in the literature, and the intraoperative studies are not applicable for awareness during induction, as few clinicians mask ventilate until a 0.7 MAC is reached, especially in obese patients. In an observational study of 61 patients undergoing cesarean section under GA, an isolated forearm technique (IFT) was used to study consciousness at 16 points during the procedure. A tourniquet was applied to one arm prior to induction, and the patient was instructed to move their fingers if they could hear commands. Positive IFT responses were seen in 41 percent, 46 percent, and 23 percent of the parturients at laryngoscopy, intubation, and skin incision, respectively. BIS could not reliably differentiate between IFT responders and non-responders during these three stages.5 After skin incision, IFT was negative in 90 percent and a BIS of 40-63 was associated with a negative response. No parturient with a positive IFT had explicit recall of any events. In one other IFT study, patients were ventilated with inhalational gas prior to intubation; no patients had a positive response at or after intubation.6 In our first reported event, the author suggests that use of a BIS monitor (or other EEG monitoring) might have led to more appropriate dosing.
The second case represents a more disquieting sequence. Having given a neuromuscular blocker with an expected duration of 40-60 minutes of paralysis and an induction agent with only five minutes duration, the anesthesia team apparently was comfortable walking away. It is unclear if they communicated that the patient would be awake in five minutes, but that muscle relaxation would endure for at least 30 minutes. They appear to have assumed that the rest of the code team would simply know that further sedation would be needed. One factor likely contributing to this cavalier attitude is the anticipation that patients will be unconscious during an arrest. However, improvements in CPR techniques provide better brain perfusion, and up to 2 percent of patients have complete recall of all events during their resuscitation.7 This event, of course, was not a cardiac arrest, just developing respiratory failure, and the team should have anticipated complete awareness by the patient once the single dose of propofol had been eliminated.
In both cases, the patients eventually reported their awareness with recall to either anesthesia or surgery staff. From the data in the Washington Anesthesia Awareness Registry, 77 patients (59 general anesthesia, 27 sedation or regional anesthesia) were contacted about the psychological sequelae of unanticipated awareness. Of those cases, 78 percent of those with sedation/RA reported awareness and 94 percent of those with awareness under GA reported distress.8 In both groups, 40 percent of patients reported persistent psychological sequelae. Patients reported adverse impact on work (15 percent) and personal relationships (11 percent). PTSD was diagnosed in 15 percent.8 In the same registry, 75 percent of patients who reported awareness were dissatisfied with the response from the clinical team, citing no expression of sympathy. Only 10 percent received an apology, and only 15 percent received a referral for counseling.9
Awareness with recall under anesthesia represents a medical error, as none of us intend for patients to be paralyzed and aware. Certainly, some errors are more clear-cut than others. A failure to form a plan for sedation after paralysis or a syringe swap where succinylcholine is given prior to induction agent are obvious errors. At times, patients report awareness even when the dosing of the anesthetic agents seemed to be adequate at the time. However, if the plan was to have a patient unconscious, and the patient experienced awareness, then there was a failure to carry out the intended plan, which is the very definition of a medical error. If awareness is reported during sedation, our response is often to discount those reports, but if awareness is planned (MAC with or without RA), the anesthesiologist must make it explicitly clear that some awareness is anticipated. If the patient expects to be completely unaware during the procedure, and does have awareness, the psychological injury appears to be the same as those occurring under GA.9
Once the patient reports an episode of awareness under anesthesia, what should the practitioner do, and what does the patient want and need for recovery? Again, from the Awareness Registry, patients desire validation of their experience (37 percent), they want to have an explanation of why this occurred (28 percent) and they want further discussion or follow up. Often patients want to know what will be done to prevent this happening to another patient.9 The expressed desires of patients from the Awareness Registry echo those from more general cases of medical error. Ottonsen and colleagues interviewed 72 patients and family members at a minimum of five years after the event. Virtually all reported long-lasting impact, and can vividly recall the event, using words such as “terrifying” and “horrifying.” Many lost trust in health care. Much of this distrust had to do with how they were treated after the event. Patients reported feeling dismissed, refused access to their records, and being ignored or even lied to. In many cases, the hospitals refused to apologize or even acknowledge the event.10
Historically, the approach to medical error has been one of secrecy and concealment, with the prevailing view that an apology constitutes an admission of error that would result in higher malpractice penalties. Fortunately, over the past 20 years, there has been a growing acceptance of the concept of full disclosure, that patients deserve an apology for what happened to them, they deserve validation of the trauma they have experienced, they deserve to know as many of the details of why error occurred as possible, and very often, they want to be updated on any findings of an investigation, and what steps will be taken to ensure that such an error won’t happen to others.11 Perhaps more than anything, patients want empathy, they want a chance to describe in detail what the impact has been, they want us to recognize their suffering and distress, and they want (and deserve) compensation for any financial impact.10,12 This “full disclosure” approach should be undertaken even in situations where an unexpected adverse outcome occurred, even if we are not sure how it came about or whether a medical error occurred. In the case of awareness during a GA that may more clearly be an error, the presence of a bad outcome does not, in itself, stipulate that a medical error occurred. However, expression of empathy, and even an apology for the adverse outcome, is appropriate, given that things went poorly under our care. The initial disclosure and discussion should be undertaken with caution. At the first visit, only the facts should be given with the acknowledgement that further investigation will be required (many institutions now have professionals who can guide these discussions). All too often, in our own distress over an error, our “full disclosure” approach is to “hit and run,” briefly describe the error and leave (and never return). This is perceived by patients to be cold and uncaring, just when they most need our support. An earnest commitment is needed to both support the patient and family through what may be a difficult recovery, and to continue to stay in contact and provide updates as appropriate until the patient agrees no further updates are necessary.
These disclosures and continued contact can be very uncomfortable for us as providers, as we expect perfection from ourselves. However, we cannot compound one error with another – that of abandonment.