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Dreaming during Anaesthesia Kate Leslie Royal Melbourne Hospital.

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Presentation on theme: "Dreaming during Anaesthesia Kate Leslie Royal Melbourne Hospital."— Presentation transcript:

1 Dreaming during Anaesthesia Kate Leslie Royal Melbourne Hospital

2 Scope of this Talk Importance of this topic Dreaming during sleep Hallucinations during anaesthesia Dreaming during anaesthesia

3 Contributors (in chronological order) … and all our research nurses and anaesthetists K LeslieP MylesA Forbes H Skrzpyek M ChanS Swallow T ShortM PaechI Kurowski T WhybrowM Stait R Bailey C Sleigh U Padmanabhan C Lim J Sleigh A Eer

4 “To sleep, perchance to dream: ay, there’s the rub, for in that sleep of death what dreams may come…” Definitions and Importance

5 Definitions Dreaming during sleep Any mental activity occurring during sleep Dreaming during anaesthesia Any mental activity occurring during anaesthesia or sedation that is not awareness Hallucination Perception in the absence of stimulus in an awake patient

6 Importance of Dreaming Common Usually pleasant and harmless Occasionally mistaken for awareness Occasionally a sign of near-miss awareness

7 Importance of Hallucinations Uncommon Usually unpleasant and may be harmful May have professional/legal consequences

8 Definitions and Importance Dreams and hallucinations are distinct phenomena with differing consequences Increased understanding of these phenomena is warranted

9 “Such another sleep, that I might dream of such another man!” Dreaming during Sleep

10 History of Dreaming Neurophysiologic correlates of dreaming occur in all mammals Dreaming has evolved and been retained during human evolution Dreaming has inspired healers, artists & religions

11 Dreaming entered scientific mainstream in early 1900s Interpretation of dreams was cornerstone of psychoanalysis Dreams conceal hidden meanings about the unconscious wishes of the patients that were able to escape when ego was weakened by sleep Dreams and Psychiatry Sigmund Freud

12 History of Dreaming Dreaming has evolved and been retained during human evolution Dreaming entered scientific mainstream in early 1900s with psychoanalysis Sleep scientists now dominate with electrophysiology and neurochemistry described Sigmund Freud

13 Dreams and Neuroscience Sleep scientists dominated in the 2 nd half of the 20 th C Freud’s theories debunked Sleep biology described Electrophysiology Neurochemistry Cause and purpose of dreaming hotly debated

14 Why Dream? Brain activation during sleep must be important All mammals have REM sleep More REM sleep in babies than adults Sleep deprivation reduces functioning But is dreaming important? Threat simulation Memory consolidation Neurotransmitter recovery Epiphenomenon of neurophysiology

15 The EEG of Sleep  ACh transmission;  NA & 5HT transmission during REM sleep

16 The EEG of Sleep Dream recall 85% in REM and 43% in non-REM Duration, bizarreness and complexity of dreaming greater during REM sleep than non-REM sleep Dreams of sleep onset and awakening are simple ruminations

17 Form of Dreams HallucinatoryDelusional Perceptually vivid EmotionalBizarre Poor memory Hyper-associative

18 Dreaming during Sleep A universal part of human experience Has distinctive form and content Occurs most commonly during REM sleep Causes and purposes of dreaming debated

19 “Dream as if you'll live forever. Live as if you'll die today." Dreaming During Anaesthesia

20 Incidence of Dreaming PatientsYearInterviewIncidence Women2003Emergence34% Unselected1992Emergence27% Unselected2004PACU6% High risk of awareness20042-4 h6% Lap Chole2003Day 12.5% TIVA1997Day 12.5% Ketamine2003PACU81%

21 Characteristics of Dreamers Younger Healthier More likely to be female Higher home dream recall Emerge more rapidly More likely to dream or more likely to RECALL dreaming?

22 Is dreaming caused by inadequate anaesthesia? Content relates to intra-operative events Dreaming patients receive lower doses Awareness patients often dream Emergency patients often dream Dreamers more likely to move Dreamers recover more rapidly Monitors sometimes indicate light anaesthesia BIS monitoring may reduce incidence of dreaming Causes of Dreaming

23 Early Reports of Dreaming “I dreamed about pain… my wife was paralyzed” “I dreamed I was at a fairground and someone was throwing darts at my stomach” “I dreamed I was at a party at a public house in which there was a generous supply of gin and the anaesthetist was the landlord!”

24 DreamersControlsp value Age52 (37-68)61 (46-71)0.001 Female55%36%<0.001 ASA 1-244%26%<0.001 ICU38%51%0.009 Dreamers more anxious and less satisfied with anaesthesia

25 TimeBISControlp value 2-4 h21 (2.7%)44 (5.7%)0.004 PredictorDreamNo Dreamp value BIS45 (40-50)44 (40-49)0.72 PACU stay55 (22-85)65 (40-99)0.02 Contradictory evidence about anaesthetic depth

26 Aims of GENIE-1 1.To determine whether dreaming is associated with light or inadequate anaesthesia 2.To assess the form and content of dreams reported after anaesthesia 3.To determine whether dreaming is associated with poorer quality of recovery or satisfaction with anaesthetic care

27 Patients aged 18-50 years and ASA I-III Elective surgery under relaxant GA BIS monitoring from induction to 1 st interview Interview on emergence and 2-4 h postoperatively Primary endpoint Median BIS values during maintenance of anaesthesia in dreamers and non-dreamers

28 Dreams recalled at 1 st and 2 nd interview not the same Dreams not usually spontaneously disclosed Emergence2-4 h All dreaming64 (22%)74 (25%) Dream narrative recalled47 (16%)53 (18%)

29 No DreamDreamp Age (years)35 ± 931 ± 80.0003 Male sex36%42%0.43 ASA I42%71%<0.0001 Dream every day17%28%0.02 Propofol TCI9%18%0.03 Regional anaesthesia5%14%0.01 Eye opening (min)14 (2-143)12 (2-41)0.04 No difference in quality of recovery or satisfaction with care

30 12345 Strangeness The Form of Dreams 12345 Emotional Content 12345 Memorability 12345 Visual Vividness 12345 Amount of Sound 12345 Emotional Intensity 12345 Meaningfulness 12345 Amount of movement

31 Content of Dreams Was playing with daughter and her dad was there… Took some friends out into the bay…the water was really rough… he caught a few fish… Dreamed that she was at work serving meals… people were chatting around her…

32 Dreams about Everyday Life Was playing with daughter and her dad was there… Took some friends out into the bay…the water was really rough… he caught a few fish… Dreamed about doing a bit of weeding…then remembers taking the turkey out of the fridge, cooking it, then wrapping it in foil and putting it back in the fridge...

33 Dreams about Talking Lots of people talking at a social event… can't remember the location but was listening…can't remember what was said… just lots of people standing around talking… Dreamed that she was at work serving meals… people were chatting around her…she was taking orders…

34 Unpleasant Dreams He shot some guys… His sister was shot… She was teaching a prep class and she was in pain and wanted her mum… ‘A tiger was chasing me. I was in a glass room and felt scared… Every glass door I went through, the tiger was there… It kept roaring and chasing me… I was running’

35 Weird Dreams An ALDI shopping centre in his knee, very bright, not many people in the aisles, quiet... In a cave….talking to her husband about how they weren't taking any photographs…They were in a magazine - a very bad magazine - and she was talking in Czech so 'they' couldn't understand her…

36 Near-miss Awareness? She was a fan-tailed orange goldfish, swimming around in a fish bowl… She remembered splashing around and the colour blue… For most of the operation, the surgical team had been discussing fishing trips…

37 Driving on a road… The road just swallowed her up… The doctor said she was OK but the car was wrecked… She couldn't move… she was trying to tell the driver to stop but he couldn't hear her … Near-miss Awareness?

38 p = 0.03

39 Multivariate Predictors PredictorOR (95% CI)p Age >35 years0.4 (0.2-0.8)0.01 Female0.3 (0.1-0.7)0.005 ASA 2-30.3 (0.1-0.5)0.0001 Dream every day3.2 (1.2-8.5)0.02 Propofol maintenance3.5 (1.4-8.5)0.005 Regional anaesthesia3.4 (1.1-10.7)0.03 Eyes open >14 min0.2 (0.1-0.6)0.003 Gender*Time to eyes open4.9 (1.3-18)0.02

40 Gender and Dreaming 20% of women dreamt regardless of time to eye opening 36% of men who opened their eyes <14 min dreamt 12% of men who opened their eyes >14 min dreamt

41 Dreaming is not related to anaesthetic depth during maintenance Most anaesthetic dreams are similar to the dreams of sleep Dreaming most likely occurs during recovery Occasional dreams reflect near-miss awareness

42 Dreaming Hypothesis Sleep During Recovery Inadequate Anaesthesia Types of Dreaming 

43 Near-miss Awareness Dreams Evidence of light anaesthesia during surgery Inclusion of anaesthetist’s voice in dream Adjudication committee  possible awareness Dreaming prevented by BIS monitoring in patients at high risk of awareness Auditory cortex remains responsive and memory formation possible during general anaesthesia Evidence

44 Recovery Dreams Preoperative characteristics of dreamers were similar to people with high home dream recall Dreamers often reported dreaming just before they woke up Dreams were short, simple and not very strange like dreams of sleep onset and non-REM sleep Dreams often contained movement and talking Depth of anaesthesia during maintenance similar in dreamers and non-dreamers Evidence

45 FeaturesSleepRecoveryNear-Miss Risk factorsDreaming Awareness NarrativeBizarreSimpleRelevant DurationLongShort MemorabilityLow High Light anaesthesia-NoYes EEGSleep?Awake The EEG and Dreaming

46 More dreaming with propofol than volatiles Different pharmacological action Faster emergence than older volatiles Selection bias in cohort studies Propofol and Dreaming

47 Aims of GENIE-II 1.To determine the incidence of dreaming with propofol and desflurane 2.To analyse EEG patterns in dreamers and non-dreamers 3.To analyse EEG patterns in propofol and desflurane patients

48 Patients aged 18-50 years and ASA I-III Elective surgery under relaxant GA Randomized to propofol or desflurane maintenance Raw EEG collected until interview on emergence Primary endpoint Incidence of dreaming on emergence in propofol and desflurane patients

49 DesfluranePropofol Age (years)36 ± 9 Female sex68% ASA I46%49% Dream every day20%18%

50 DesfluranePropofolp Anaesthetic dose5.8 (3.1-9.0)4.5 (2.5-8.0)- Fentanyl dose (  g) 100 (50-700)150 (50-700)0.03 Signs of light anaesthesia10%31%<0.0001 BIS during maintenance40 ± 638 ± 60.12 Eyes open – interview (min)8 (0-57)10 (0-100)0.04 BIS at interview92 (40-98)85 (69-98)<0.0001 Dreaming29%27%0.70 No difference in quality of recovery or satisfaction with care

51 No dreamDreamp Age (years)36 ± 935 ± 80.55 Female sex68% 0.80 ASA I47%49%0.44 Dream every day17%23%<0.0001 BIS during maintenance39 ± 638 ± 60.34 Eye opening (min)10 (0-49)9 (2-80)0.66 BIS at interview88 (40-98)91 (69-98)0.002 PACU discharge (min)73 (10-213)66 (12-185)0.09

52 Evidence of REM-like EEG in dreamers during recovery More cortical activation Fewer sleep spindles Higher frequency EEG What does this mean? More dreaming? Less amnesia for dreams?

53 Dreamers vs. Non-dreamers Change in spectral power in 20 min before interview Coloured surface = dreamers Mesh surface = non-dreamers 10-Hz spindle peak lost as patients approach interview Greater loss in dreamers than non- dreamers High-frequency power greater in dreamers than non-dreamers close to interview

54 More marked oscillatory peak in 8-16 Hz band at wound closure in propofol patients Sleep spindle-like activity Different mechanisms of action Propofol patients emerged at lower BIS than desflurane patients Relationship between BIS and arousal is drug-specific At wound closure

55 Dreaming during Anaesthesia Common and harmless Young healthy patients with high home dream recall Not related to anaesthetic depth Similar with propofol and desflurane Associated with REM-like EEG during recovery

56 “Too weird to live; too rare to die” Hallucinations during Anaesthesia

57 Definitions Hallucination Perception in the absence of a stimulus whilst awake Delusion Fixed belief that is either false, fanciful or derived from deception May result from dreams or hallucination or arise when circumstances suggest that certain events occurred whilst the patient was unconscious Disinhibition Lack of restraint manifested by disregard for social conventions, impulsivity and poor risk assessment

58 These unpleasant manifestations (lascivious dreams) were most frequent in the lower classes, addicted to the abuse of ardent spirits… It was very unbecoming to say (suggest) that most English ladies should have sexual dreams (like one French prostitute)…

59 He stared ahead unseeingly, crossed himself and shouted ‘rank and number’ She saw a praying women in the recovery room He attested that there was a flock of hens on the ward and the nurses had possums on their heads He made amorous advances towards the recovery nurse asserting she was his wife She spent half an hour shouting for her orthopaedic surgeon in an amorous manner Reports of Hallucinations

60 Prof AB Baker

61 Treatment of acute episodes Exclude cardiac, respiratory and neurologic causes Intravenous benzodiazpines to calm agitated patients Risk management Ensure that witnesses are present when patients are receiving or recovering from anaesthesia or sedation

62 Hallucinations during Anaesthesia Reported more commonly after propofol use May be confused with dreaming or disinhibited behaviour Ensure witnesses are present for patients recovering from anaesthesia or sedation

63 Conclusions Dreaming is a common, fascinating and harmless part of the anaesthetic experience Dreaming is unrelated to anaesthetic depth or choice of maintenance anaesthetic Dream recall is associated with REM-like EEG during recovery Hallucinations may be unpleasant and a risk to patients and staff

64 Thank You ‘Whatever you can do or dream you can, begin it. Boldness has genius, power and magic in it’

65 Stait

66 Eer

67 New Studies

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