HS 8096 Report: Awareness During Anesthesia and Challenges

This report delves into the critical issue of awareness during anesthesia, a distressing experience for patients. It explores the challenges faced in current practice, including the impact of conversations, paralysis, and surgical incisions on patient well-being. A comprehensive literature review examines five key articles, analyzing findings, strengths, limitations, and applications to contemporary practice. The report offers recommendations, such as the use of BIS monitoring and benzodiazepines, to mitigate the risk of awareness. It also references the ASPAN standards and discusses the limitations and implications of anesthesia. The conclusion emphasizes the importance of ongoing research and monitoring technologies to improve patient safety and outcomes in peri-operative care.

Running head: AWARENESS IN ANESTHESIA
Awareness in Anesthesia
Name of the student
Name of the university
Author’s name

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Table of Contents
Introduction......................................................................................................................................2
Discussion........................................................................................................................................3
Challenges........................................................................................................................................3
Literature review..............................................................................................................................4
Recommendations............................................................................................................................6
Clinical Practice Guidelines............................................................................................................7
Limitations and implications of anaesthesia............................................................................7
Conclusion.......................................................................................................................................7
References........................................................................................................................................9

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Introduction
Awareness during anaesthesia can be extremely distressing for a patient, mainly if the
unpleasant memories of the operation are remembered (Mashour, Orser & Avidan, 2011). For 1
to 2 out of 1000 cases, the occurrence of anaesthesia awareness is known to occur. Such
hazardous situation will also have significant medical effects (Mashour, Orser & Avidan, 2011).
Awareness of conversations during surgery also makes a patient stressed. Still, an awareness of
total paralysis or the discomfort of the surgical incision may forever change the existence of a
patient (Ghoneim & Weiskopf, 2000).
Due to these reasons, the following article will discuss the types of challenges faced
when the patient is aware of his surroundings during the anaesthesia procedure while a literature
review is conducted. This article will also provide recommendations or areas for improvement to
reduce the effects of awareness during anaesthesia procedure.

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Discussion
Anaesthesia refers to the process of delivering medicines, either through injection or
inhalation, to prevent pain or to generate deep unconsciousness allowing medical and operational
procedures without causing unfair discomfort or unpleasantness. Without being questioned
explicitly, many people cannot willingly disclose their observations. There are times when the
incidents might not be remembered immediately after anaesthesia service, though it might occur
after 1 or 2 weeks.
Challenges
The challenge for anaesthesia leaders of the 21st century is to bridge the wide gap in the
field of practice and education and at the same time, improve its security.
The future of anaesthesia in developing countries remains in the hands of residents of
individual states. The allocation of government funding for the purchase of surgical and
anaesthetic equipment/drugs should be individually audited (Bharati, Chowdhury, Gupta,
Schaller, Cappellani & Maguire, 2014).
Literature review
Article 1
Author and research topic - Hardman and Aitkenhead (2005) conducted a study on the
awareness during anaesthesia procedure exploring the frequency, consequences, reasons,
management and recommendations for the prevention of intraoperative awareness.

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Findings/Arguments - It was found that there were 7% people (which are around 1 in 14
patients) who were aware during the anaesthesia procedure when given with 60–70% nitrous
oxide as the sole anesthetic agent (Hardman & Aitkenhead, 2005). In contrast, it was estimated
that approximately 0.1–0.7% did not recall the feeling of pain when the patients were
consciously aware of the surroundings. It was observed that the majority of the risks of
awareness were related to the type of anesthetic provided primarily by the neuromuscular
blocking agent.
Strengths and Limitations –Researchers suggested that patients can be given benzodiazepines
with the premedication and also benzodiazepines can be given during induction.
A limitation of the study is that during the anesthetic procedure, patients suffer psychological
stress such as depression or anxiety. This makes them fear from future surgical processes,
especially those which involve anesthetic procedure.
Application of findings to current practice – As the researchers suggested, from next time
whenever a patient will receive surgical procedures, they can be given benzodiazepines with the
premedication and during induction.
Article 2
Author and research topic - Tasbihgou, Vogels and Absalom (2018) performed a literature
review with a subsequent recall of the occurrence, effects and strategic planning of the
unexpected awareness of general anaesthesia.
Findings/Arguments - The leading causes of accidental anaesthesia were overly light
anaesthesia and abuse or defects in the anaesthesia delivery system. The researchers found that a
dynamic equilibrium among the concentration of noxious stimulation and the pharmacodynamic

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sensitivity of the patient to the effect‐site levels of administered drugs represented the depth of
anaesthesia (Tasbihgou, Vogels & Absalom, 2018).
Strengths and Limitations – The strength of the paper is that it suggests a thorough
examination of the anesthetic procedures especially recommended for those patietns who will
have IV anaesthesia and neuromuscular blockade.
The limitation of the paper is that it failed to validate the available treatment for the
psychological sequelae of AAGA due to lack of evidence.
Application of findings to current practice – As the paper have discussed, to further prevent
the medical errors related to the syringe swaps from the all syringes should be labeled properly
and a thorough re-check should be done before use.
Article 3
Author and research topic – In another report by Leslie, Culwick, Reynolds, Hannam and
Merry (2017) did an analytical study on the incidents of awareness during general anaesthesia in
the first 4,000 cases which were reported to the webAIRS.
Findings/Arguments -The researchers observed that patients were at constant risk of awareness
due to various reasons like syringe swaps and also due to specific other new errors related to new
anaesthetic equipment, for example, electronic anaesthesia workstations (Leslie, Culwick,
Reynolds, Hannam & Merry, 2017).
Strengths and Limitations – The strength of this study is that it described several cases of
awareness-related incidents which have been gathered from the last ten years which have
occurred in Australian and New Zealand.

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One limitation of this study is that it could not provide an estimate of the incidence as patients
were not aware of what happened to them and that is why they do not discuss the awareness to
their anaesthetists postoperatively.
Application of findings to current practice – The following study did not provide any
recommendations or strategies to counter the errors described in the paper.
Article 4
Author and research topic – In the literature review by Smith (2017), a qualitative approach
was undertaken related to the ‘awareness under general anaesthesia (AAGA)’ during surgery
with explicit recall of events.
Findings/Arguments – In the paper the researcher found that perioperative event occurs around
0.03-0.3% of cases involving a general anaesthetic. Incidences of awareness have been seen to
occur in 1 person out of 600 people and also in 1 person out of 1000 people during a general
anaesthetic.
Strengths and Limitations – The strength of this study is that it described that by measuring
minimum alveoli concentration (MAC) will help in ensuring that a patient’s level of anaesthesia
is adequate. Though, the paper have also discussed the limitation of using the MAC, which is
that using MAC will enable the use of IV anaesthesia since there is no inhaled volatile agent to
assess and thus awareness is possible during anaesthesia.
Application of findings to current practice – The paper recommended that by staying attentive
will help in identifying the physiological signs of awareness and thus it will enable to act and
adjust the anaesthetic technique for each patient and thus will decrease the chance of AAGA.

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Article 5
Author and research topic – In another paper, the researcher Chung (2014) tried to introduce
intraoperative consciousness of general anaesthesia and addresses recognition processes and risk
factors, different forms of control, outcomes and intraoperative perception avoidance.
Findings/Arguments - According to the findings of the report auditory recalls (48 per cent),
difficulty in breathing (48 per cent) and painful sensations (28 per cent) have been described by
patients (Chung, 2014).
Strengths and Limitations – The limitation of this paper is that the paper failed to find any
reliable method to detect awareness during anaesthesia and stated that there is a lack in the
knowledge of consciousness.
The strength of this paper is that modern day technologies which are under development will
help in measuring brain activity rather than physiological responses of awareness during
anaesthesia.
Application of findings to current practice - The article concluded that numerous monitoring
instruments could be used to sensitize the anaesthesia to reduce the occurrence of this
complication, which is highly damaging.
Recommendations
 In the report of Ambulkar, Agarwal, Ranganathan and Divatia it is recommended that
patients at elevated danger of awareness during general anaesthesia should undertake BIS
monitoring in collaboration with relaxation exercises to reduce the occurrence of awareness
(Ambulkar, Agarwal, Ranganathan & Divatia, 2016).

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 While the numerous EEG monitors are not sufficient to diagnose and avoid awareness to the
extent of anaesthesia, the use of anaesthetic including the use of neuromuscular blocking
agents in patients receiving general anaesthesia should be strictly implemented (Chung,
2014).
 Benzodiazepines have been recommended as a premedical for prophylactic administration,
particularly if light-anaesthesia is expected (Checketts et al., 2016).
Clinical Practice Guidelines
ASPAN Standards 2019-2020 edition includes security and ethical principles in peri
anaesthesia practices, standards for peri anaesthesia practices, practice guidelines, position
statements, partner organisations resources, and interpretation statements that explain and
elucidate critical components. The legal obligations of ASPAN are to identify and enforce
minimum rules for nursing peri-anaesthesia (Mamaril, 2003).
Limitations and implications of anaesthesia
The side effects of anaesthesia are several such as confusion, dizziness, nausea, feeling
cold and many more. None of the side effects is particularly durable and tends to occur
immediately following anaesthesia. Also, non-adherence to ASPAN guidelines and inefficient
training to nurses can create errors during the anaesthesia procedure.
Conclusion
Intraoperative consciousness is characterized both by perception and by the clear
recollection of operative activities. The incidences vary with the patient population, the
methodologies used to study awareness and the time frame for the study in one to two out of

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every 1000 surgical cases. The memory may be broken down into implicit and explicit
(conscious) subsets, the latter regulated by medial temporal lobe systems. As scientific research
into the fundamental intraoperative neurobiology progresses, researchers will be better able to
understand and track the influence of anaesthesia on these neural processes. Such developments
hopefully lead one day to a successful solution to avoiding a dangerous and clinically damaging
occurrence in peri-operative care.

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References
Ambulkar, R. P., Agarwal, V., Ranganathan, P., & Divatia, J. V. (2016). Awareness during
general anesthesia: An Indian viewpoint. Journal of anaesthesiology, clinical
pharmacology, 32(4), 453.
Bharati, S. J., Chowdhury, T., Gupta, N., Schaller, B., Cappellani, R. B., & Maguire, D. (2014).
Anaesthesia in underdeveloped world: present scenario and future challenges. Nigerian
medical journal: journal of the Nigeria Medical Association, 55(1), 1.
Bischoff, P., & Rundshagen, I. (2011). Awareness under general anesthesia. Deutsches Ärzteblatt
International, 108(1-2), 1.
Checketts, M. R., Alladi, R., Ferguson, K., Gemmell, L., Handy, J. M., Klein, A. A., ... &
Rodney, G. E. (2016). Recommendations for standards of monitoring during anaesthesia
and recovery 2015: Association of Anaesthetists of Great Britain and
Ireland. Anaesthesia, 71(1), 85-93.
Chung, H. S. (2014). Awareness and recall during general anesthesia. Korean journal of
anesthesiology, 66(5), 339.
Ghoneim, M. M., & Weiskopf, R. B. (2000). Awareness during anesthesia. Butterworth-
Heinemann.
Hardman, J. G., & Aitkenhead, A. R. (2005). Awareness during anesthesia. Continuing
Education in Anesthesia, Critical Care & Pain, 5(6), 183-186.

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Leslie, K., Culwick, M. D., Reynolds, H., Hannam, J. A., & Merry, A. F. (2017). Awareness
during general anesthesia in the first 4,000 incidents reported to webAIRS. Anesthesia
and intensive care, 45(4), 441-447.
Mashour, G. A., Orser, B. A., & Avidan, M. S. (2011). Intraoperative AwarenessFrom
Neurobiology to Clinical Practice. Anesthesiology: The Journal of the American Society
of Anesthesiologists, 114(5), 1218-1233.
Smith, A. (2017). Literature review: Awareness of anaesthesia. Journal of perioperative
practice, 27(9), 191-196.
Tasbihgou, S. R., Vogels, M. F., & Absalom, A. R. (2018). Accidental awareness during general
anesthesia–a narrative review. Anesthesia, 73(1), 112-122.
Wang, M. (2001). The psychological consequences of explicit and implicit memories of events
during surgery. Awareness during anesthesia. Oxford: Butterworth-Heinemann, 145-54.
Mamaril, M. E. (2003). Standards of perianesthesia nursing practice: Advocating patient
safety. Journal of PeriAnesthesia Nursing, 18(3), 168-172.