Patient awareness during a surgical procedure can be an alarming event for the person and troubling to the operating room staff. Although it does not happen very often, knowing that it does happen can be distressing to anyone anticipating an operation. Professor Jaideep Pandit, Consultant Anaesthetist & Fellow of St John’s College, Oxford, UK, feels that there can exist a third state of consciousness that is neither fully conscious nor unconscious, termed “dysanesthesia,” and that this presents a challenge for giving anesthesia safely. “Even in 2013, we are still struggling to define what consciousness actually is,” says Prof Pandit. “We can obviously see when someone is awake and responding, and when someone is asleep or unconscious, but our understanding of what changes us from one state to the other is still evolving.” I remember whispering to a patient that I had given anesthesia to that I was sorry if she was aware of anything that was happening, but it was necessary to do it this way because otherwise she might not ever wake up. It occurred during my surgical residency when I was assigned for an exciting six-month sojourn to the department of anesthesiology. I was on call and working that last night on my anesthesia rotation before leaving that service the next day to return to being on the other side of the drapes as the resident surgeon in the operating room. It started out as a pretty slow evening as I went through the hospital pre-oping patients for the next day’s surgical schedule; that is, until I was paged to come back stat to surgery. Quickly arriving at the scene with the other on-call resident, we were apprised of what was going on. It seemed there were two emergencies that were coming to the operating suites: a patient who had been in an automobile accident with an abdominal injury and a patient who had gastrointestinal bleeding that needed to be repaired. I can’t remember how it was determined, but as luck would have it, I got the automobile accident. I can clearly remember her arriving in the operating room-awake, drunk, and telling me with slurred speech, “I’m fine, why am I here?” With the help of the efficient OR staff, we prepared her for surgery and I administered the general anesthetic. I knew it had to be very light because her initial blood pressure readings were very low and a general anesthetic can lower pressure even further. As the chief surgical resident began the operation by opening her abdomen, the proverbial stuff hit the fan! Her blood pressure was quickly falling to a dangerous level, and the surgeon, using a small bucket, was scooping blood out of her belly as fast as he was able to so he could find the source of the bleeding. Because of the nature of the emergency, we already had plenty of blood ready to be transfused. In most cases, blood is given to a person as a slow drip — not in this case! I was in the middle at the head of the table doing the anesthesia, on my right was my attending anesthesiologist pumping the blood by drawing it into a large syringe in the IV line and forcing it into her as fast as he could, and on my left was another staff member doing the same thing with her other arm. No one said a word. We all did our jobs, and slowly her blood pressure stabilized as the surgeon was able to stop the bleeding, and then it began to rise to a safe level, and she made it. I visited my patient later that day when she was completely awake and sober and she did not mention anything about her memories of the surgery. Maybe she was just glad to be alive. I know I was glad she was! I later learned that the other emergency surgery patient with the GI bleed did not make it. Data from several studies reveal that if patients are directly asked following surgery if they recalled anything, about 1 in 500 will say that they did. Another report found that approximately 1 in 15,000 patients will spontaneously report awareness that they recall during their surgery. (Mom always said that if you can’t say something nice about someone, say nothing at all.) “The difference between the incidence of 1:500 and 1:15,000 suggests that even in the rare instances where patients are experiencing awareness, in most cases the sensation is a ‘neutral’ and not necessarily unpleasant one,” says Prof. Pandit. (Easy for him to say.) In addition, only 1 in 45000 patients undergoing surgery reported any pain or distress as part of the experience. (Not counting when they see the bill!) Prior experiments have been done in which patients were given a general anesthetic, and their whole body paralyzed except for one forearm, which allowed them to move their fingers in response to commands or to signify they are awake or in pain during surgery. (I know which finger I would be using to tell them.) None of the patients in these experiments ever moved their fingers to indicate that they were aware. “What we are possibly seeing is a third state of consciousness — dysanesthesia — in which the patient is certainly aware of events, but not concerned by this knowledge,” stressed Professor Pandit. Dr. Pandit is presently doing further research into the problem of dysanesthesia and how to monitor and recognize it early so it can be prevented. Source
