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General anesthesia is defined as the condition of
pharmacogenic loss of consciousness which is
purposeful and easily reversible. In this condition patient
is unresponsive to painful surgical stimuli .
During anesthesia the depth of unconsciousness,
status of cardiovascular system and respiratory system
are closely monitored.
Awareness is defined as unintended perception of some
of stimuli in form of pain or hearing when a patient has not
had enough general anesthetic or analgesic to prevent
It can be a distressing or traumatic experience for the
patient and it occurs usually just prior to the anesthetic
completely taking effect or as the patient is emerging from
anesthesia. In very few instances, it may occur during the
surgery itself.
Awareness is a rare complication in general
anesthesia. The risk varies among countries,
depending on their anesthetic practices. In the
United States, the incidence of intraoperative
awareness is 0.1 per cent to 0.2 per cent of
patients undergoing general anesthesia. The
incidence of intra operative awareness depends
on the type of surgery. Trauma patients have the
highest incidence (11%-43%) followed by patients
undergoing cardiac surgery (1.14%) and patients
undergoing Cesarean section (0.9%).
The cause of awareness is usually
traceable to one of three factors:
Light anesthesia due to
Specific anesthetic techniques such as
the use of nitrous oxide, opioids, and
muscle relaxants
Difficult intubation
Premature discontinuation of anesthetic
Myocardial depression
Cesarean section
Machine malfunction or misuse of the
technique such as :
Failure to check equipment
Vaporizer and circuit leaks
Errors in intravenous infusion
Accidental administration of muscle
relaxants to patients who are awake
Increased anesthetic requirement for
the following reasons:
Individual variability in anesthetic
Chronic alcohol, opioid, or cocaine abuse
1. Conversations of the surgical staff
2. Various images and pictures
3. Dream-like events
4. Pain
5. Paralysis
6. Anxiety
7. Helplessness
8. Posttraumatic stress disorder:
I. nightmares, irritating dreams, sleep
II. irritating thoughts
III. excitability
IV. avoidance of medical care
The recalling of these experiences can start immediately
after surgery, in the recovery room, or several days later.
A. Subjective methods
1. Autonomic response
2. Patient Response to Surgical Stimulus (PSRT)
Scoring system
3. Isolated forearm technique
B. Objective methods
1. Spontaneous surface electromyogram (SEMG)
2. Lower oesophageal contractility (LOC)
3. Heart rate variability (HRV)
4. Electroencephalogram and derived indices
Compressed spectral array/ Spectral edge
frequency/ Median frequency
Bispectral index
Narcotrend index
Patient state index
Snap index
Cerebral state index
5. Evoked potentials
Somatosensory evoked potentials
Visual evoked potentials
Auditory evoked potentials
Auditory evoked potential index
A-Line autoregressive index
6 .Functional near infrared (fNIR) technology
1.Isolated forearm technique
Tunstall in 1977 was the first who tried to
estimate the anesthesia depth of his patients by
applying the isolated forearm technique. Before
the administration of the neuromuscular blocking
agents he was inflating a cuff at the patients hand
and was estimating the depth of anesthesia by the
movement of the hand after giving orders via
microphone and headphones24. The danger of
hand ischemia limited the time that this method
could be applied
2.Autonomic and harmonic response

The anesthetic drugs have actions like analgesia,

paralysis of the striated muscles, amnesia and blockade
of the autonomic and harmonic response to painful
stimuli. That is why the estimation of anesthesia depth
can be based on the changes of the patients cardiac and
respiratory rhythm, blood pressure, the production of
sweat and tears or the pupil size
3. Contractions of the lower esophageal sphincter.

Measurement of the contractions of the lower

esophageal sphincter with the use of a special
manometer has been applied in the past. Although the
response of the esophagus to stimuli is related to the
depth of anesthesia, it can not be considered a safe
method of intra operative anesthesia monitoring.
4 .Frontalis muscle contraction.
The electroencephalogram of the frontalis
muscle, which is the least sensitive to
neuromuscular blockers, is another available
but unreliable method.
5.Auditory evoked potentials
The monitor records the electrical activity
of the brain stem, and cortex after auditory
stimuli that are delivered to the patients with
the use of headphones. The signal is processed
mathematically and is finally shown on the
screen of the device as a number from 0 to
100. The lower the number on the screen, the
greater the depth of anesthesia is.
6. Narcotrend
Narcotrend records brain activity without the application
of any stimulus. This monitor analyses the signal of the
encephalogram and categorizes anesthesia depth in a
system of 6 letters. It also produces a number from 0 to
100 (Narcotrend index). The stages are:
= awake, 0-2= sedation, C0-2= light anesthesia,
D0-2= general anesthesia,
0-2= general anesthesia with deep hypnosis,
F0-1= general anesthesia with heavy depression of
reaction to painful stimuli.
7.Bispectral index scale

The only reliable anesthesia depth monitor is the BIS.

BIS works like the Narcotrend. It records the
electroencephalogram from 3 electrodes and after
processing it with mathematic algorithms it generates a
number from 0 to 100. When the BIS value is lower than
40, the patient is in deep anesthesia state, when the value
is over 80, the patient is under light sedation.

(Two thousand and two hundred dollars are required in order to prevent one case of
Bispectral Index Values

100 awake
65 - 85 sedation
45 - 65 general anesthesia
<40 burst suppression
0 no electrical activity
8. Infrared Gas Analyzers
Continuous measurement of concentration of volatile
agent by Infrared Gas Analyzers in anesthesia circuit
gives very good clue about the level of anesthesia
,because we know the MAC of each volatile agent.
MAC is that concentration which causes no response to
surgical stimulus in 50% of cases.
Minimum alveolar concentration of various volatile agents.

* Halothane 0.74 percent

* Enflurane 1.68 percent
* Isoflurane 1.15 percent
* Desflurane 6.3 percent
* Sevoflurane 2.0 percent
* Nitrous oxide 104 percent
9.Alternative technologies to quantify the depth of
anesthesia include, but are not limited to, the following :
SNAP EEG monitor system
Patient State Analyzer 4000 (PSA 4000)
Spectral Edge Frequency 95 (SEF 95)
Automated Responsiveness Test (ART)
Drexels anesthesia monitor uses functional near infrared
(fNIR) technology that directly measures hemodynamic
parameters of brain activity associated with the effects of
Specific measures can be used for prevention
and reduction of awareness during anesthesia.
Firstly, the preoperative evaluation of the patient
is very important. The presence of the risk factors
must be checked.
Although there is doubt whether the patients be
informed about the possibility of being awake
during the operation or whether this information
can cause anxiety, the American Society of
Anesthesiology recommends that patients in high
risk of awareness must be informed.
The checking of the anesthesia device and other devices
which will be used during administration of anesthesia
must always be done. The protocol of device checking
must be complete and signed.
In every case there must be an anesthetic plan designed
for every patient individually.
Extra care must be given for the dosage of the inhaled
and intravenous drugs .
It is better to avoid the use of neuromuscular blocking
agents when it is possible.
The use of benzodiazepines, which affect memory, does
not have any effect in preventing awareness but it helps
in reducing the chances of recall .
The use of b- blocker decreases the possibility of post-
traumatic stress disorder in the cases where awareness
1. Patient assurance
2. Gathering of as much information as possible
about the patients experience
3. Explanations for satisfaction of patient.
4. Frequent post-surgical visits
5. Detailed recording of all the actions
6. Referral to a psychiatrist
7. Inform all the persons concerned with patient
care ,like OT staff and OT nurse.
Explanations must be given to the patient who must be
exactly informed about what happened and why.
The anesthesiologist must be ready to answer every
question to the patient and to apologize after accepting
the responsibility.
Intraoperative awareness is an important problem for the
patient and the doctor. The patients have a very
unpleasant experience which can affect their mental
health for the rest of their life.
The complete and proper preoperative evaluation, the
checking of the anesthesia device and the postoperative
visits are very important for prevention of awareness and
assurance of patient if it occurs.
Joint Commission recommendations

Anesthesia awareness is under-recognized and under-treated in

health care organizations. The Joint Commission recommends that
health care organizations which perform procedures under general
anesthesia do the following to help prevent and manage anesthesia
Develop and implement an anesthesia awareness policy that
addresses the following:
Education of clinical staff about anesthesia awareness and how to manage
patients who have experienced awareness.
Identification of patients at proportionately higher risk for an awareness
experience, and discussion with such patients, before surgery, of the
potential for anesthesia awareness.
The effective application of available anesthesia monitoring techniques,
including the timely maintenance of anesthesia equipment.
Appropriate post-operative follow-up of all patients who have undergone
general anesthesia, including children.
The identification, management and, if appropriate, referral of patients who
have experienced awareness.
Assure access to necessary counseling or other support for patients
who are experiencing post-traumatic stress syndrome or other mental

The main mechanism of action is by interfering with the

neurotransmission systems and especially with ion gates
which regulate the secretion of stimulating and inhibiting
neurotransmitters like GAAA (Gama-Amino-Butyric-Acid)
receptors, NMDA(N-Methyl-D-Aspartate) receptors and
nicotinic receptors of the central nervous system (nACh).
Beside ion gates, anesthetic drugs also act on G protein
receptor (g protein coupled receptors or GPCRs) which
are related to the function of the receptors of
acetylcholine, nor epinephrine, dopamine, adenosine and
opioids. This action is responsible for the multiple adverse
reactions of these drugs.
During the last years, the action of anesthetic drugs on
newer types of potassium receptors (2p or background
potassium channels), which regulate the excitability of the
nerve cells by providing backup electrical currents, has
been discovered.
Consciousness is the state where someone can
evaluate and process the information he/she gets from
the environment. The available data indicate that there
are many central nervous system structures that
participate in this function like the brain stem, the
hypothalamus and parts of the cerebral cortex while the
reticular formation has an important role in the waking up
As far as memory is concerned, there are two categories,
the short term and the long term memory. According to
Bailey and Jones,
short term memory involves storage and processing of
information connected with learning, taking decisions and
recalling memories which are stored in long term memory.
The storage of information is done either phonetically (an
inner voice repeats the information) or visually (the
information is stored as a picture). The mode of storage is
regulated by a central processing system. The
hippocampus and the medial temporal lobe seem to play
the most important role in this procedure.
Long term memory includes facts which are stored
immediately in memory and are recalled after effort (a car
crash for example or somebodys name) and are called
explicit memory
Mainly by interfering with the thalamocortical neurons,
anesthesia causes loss of consciousness while other
mechanisms include decrease of brain hematosis and
glucose metabolism by the nervous cells.
procedures and skills that are gradually learned but are
recalled without conscious effort (learning how to drive,
writing) and affect behavior and habits and are called
implicit memory.
Long term memory is related to activity in various areas of
the central nervous system like the hippocampus,
amygdala, neostriatum, cerebellum and the cortex which
are connected via multiple neuronal circuits in order to
perform complicated brain functions.
Anesthetic drugs seem to affect these circuits and
deregulate the coding of the stimuli and their storage in
long term memory
The Snow was first to describe stages of anesthesia in
1847 which were later modified by Guedel in 1937.
Stages of Anesthesia Guedel (1937)
STAGE I = Analgesia
STAGE II = Loss of consciousness to rhythmical
STAGE III= Surgical Anesthesia
Plane 1 = cessation of eye movements
Plane 2 = respiratory paresis
Plane 3 = respiratory paralysis
Plane 4 = diaphragmatic paresis and
STAGE IV = Apnea
Jones described four stages of general
anesthesia in relation to memory and
1. Perception and explicit memory,
where the patient recalls intra operative facts and
feelings without necessarily feeling pain (if large doses of
opioids were administered to them) and having
psychological disorders,
2. Perception without explicit memory,
where the patient can follow instructions and perform
movements without being able to recall hearing them,
3. No perception and implicit memory
4. No perception and no memory.
There are some studies which indicate that even during
deep anesthesia, learning, processing of information and
storing it in long term memory is possible.
1. Insufficient drug administration
I. Cardiothoracic surgeries
II. Trauma
III. Emergency operations
IV. Cesarean section
V. ASA 4-5
2. Patients with different anesthetic requirements
I. Chronic use of benzodiazepines or opioids
II. Alcoholics
III. Severely anxious patients
IV. Difficult airway
V. Previous awareness experience
3. Anesthesia machine malfunction
I. Disorder
II. Incomplete check
4.Hemodynamically unstable patients
,due to hypotension, cardiac
arrhythmias or cardiac arrest.
Reducing the risk of anesthesia awareness
Both the ASA and the AANA provide guidelines for administering
and monitoring anesthesia. Specific recommendations for the
prevention of awareness are addressed in the February 2000 issue of
Anesthesiology.(4) These include:
Consider premedication with amnesic drugs, e.g., benzodiazepines or
scopolamine, particularly when light anesthesia is anticipated.
Administer more than a "sleep dose" of induction agents if they will be
followed immediately by tracheal intubation.
Avoid muscle paralysis unless absolutely necessary and, even then,
avoid total paralysis [by using only the amount clinically required].
Conduct periodic maintenance of the anesthesia machine and its
vaporizers, and meticulously check the machine and its ventilator
before administering anesthesia.
In addition, anesthesia practitioners should be alert to patients on
beta-blockers, calcium channel blockers and other drugs that can
mask physiologic responses to inadequate anesthesia
Managing the impact of anesthesia awareness

As noted above, anesthesia awareness cannot always be prevented.

Health care practitioners must therefore be prepared to acknowledge
and manage the occurrence of anesthesia awareness with
compassion and diligence. This management includes the following
suggestions for patients who report awareness (4):
Interview the patient after the procedure, taking a detailed account of
his or her experience and include it in the patient's chart.
Apologize to the patient if anesthesia awareness has occurred.
Assure the patient of the credibility of his or her account and
sympathize with the patient's suffering.
Explain what happened and its reasons, e.g., the necessity to
administer light anesthesia in the presence of significant
cardiovascular instability.
Offer the patient psychological or psychiatric support, including
referral of the patient to a psychiatrist or psychologist.
Notify the patient's surgeon, nurse and other key personnel about the
incident and the subsequent interview with the patient.
Surgical team members should also be educated about anesthesia
awareness and its management.