1. Intraoperative Recall
Allison Russell

2. Intraoperative Recall
Unintended complication, occurs during general anesthesia or MAC
Occurs most during maintenance of anesthesia rather than induction or emergence
1-2 adult patients per 1000 patients undergoing general anesthesia
1 in 100 patients in high-risk surgeries (cardiovascular, obstetrics, trauma)

3. Intraoperative Recall
Awake Movie Clip
alternate link
Harold, Joby (Director). (2007). Awake [Motion picture]. United States: MGM Distribution Company.

4. Risk Factors MAC 0.3-0.4 associated with awakening from anesthesia
Mistake or failure in anesthesia delivery
Anesthetic technique resulting in inadequate anesthesia
Underappreciated patient dosing requirements
Patient condition unsafe to administer sufficient anesthesia

5. MAC Minimum Alveolar Concentration
50% of patients will not respond to a painful stimulus
MAC-awake: 50% of persons will follow command to “open your eyes”.
MAC associated with awakening from anesthesia. ~1/3 MAC=loss of recall
MAC-BAR: exceeds requirements for ablation of skeletal muscle movement with surgical stimuli.
1.3 MAC of any volatile agents

6. MAC Requirements Decreased MAC: Increased MAC
Increasing age *Decreased age (infants)
Opioids/benzo use * Hyperthermia
Sedative-hypnotics * Hyperthyroidism
Alpha-2 agnoists * Cocaine
Hypothermia * MAOIs
Anemia * Chronic ETOH abuse
Nitrous Oxide * Hypernatremia
Acute ETOH intoxication

7. Repercussions PTSD associated with awareness during surgery
Increases patient’s apprehension to undergo further surgery
Sleep disturbance, nightmares, anxiety

8. BIS Monitor Bispectral Index Represents a numerical value (0-100)
Correlated with the patient’s current hypnotic state
100=awake
65-85=sedated
40-65=general anesthesia
<40=cortical suppression
BIS monitor approved in 1996 by FDA as potential tool to decrease intraoperative awareness

9. Michigan Awareness Control Study
One group: BIS monitoring during surgery, anesthesia providers alerted when BIS values reached greater than 60
Second group: anesthesia provider alerted when MAC reached 0.5

10. Michigan Awareness Control Study
BIS monitor revealed trend toward reducing incidence of awareness
No statistically significant difference in intraoperative awareness between 2 groups
Increased alerting of anesthesia providers to potential “light” anesthesia was associated with fewer awareness events

11. Prevention Check all equipment, drugs and dosages
Administer amnestic premedication
Avoid using muscle relaxants if possible
Administer at least MAC
Set alarm for low MAC

12. Treatment Brice Questionnaire
“What was the last thing you remember before going to sleep?”
“Did you dream during your procedure?”
Prompt referral to mental health professional
Explain what happened to patient
Keep record of incident in patient’s chart to guide further anesthesia
Report claim to hospital lawyer

13. Conclusion
BIS monitor can be used as adjunct to detecting possibility of awareness
Evaluate patient for risk factors
Ensure patient has sufficient anesthesia and remains deep
Proper post-op follow-up
Vigilance is best prevention!!!

14. References
American Association of Nurse Anesthetists (2012). Anesthesia awareness during general anesthesia. Retrieved from:
Avidan, M.S. & Mashour, G.A. (2013). Prevention of intraoperative awareness with explicit recall. Anesthesiology, 118 (2),
Butterworth IV J.F., Mackey D.C., Wasnick J.D. (2013). Chapter 8. Inhalation Anesthetics. In J.F. Butterworth IV, Mackey, J.D. Wasnick, D.C. (Eds), Morgan & Mikhail's Clinical Anesthesiology, 5e. Retrieved October 31, 2013 from
Butterworth IV J.F., Mackey D.C., Wasnick J.D. (2013). Chapter 54. Anesthetic Complications. In J.F. Butterworth IV, Mackey, D.C., Wasnick, J.D. (Eds), Morgan & Mikhail's Clinical Anesthesiology, 5e. Retrieved October 31, 2013 from
Ghoneim, M.M. (2000). Awareness during anesthesia. Anesthesiology, 92(2),
Mashour, G.A., Shanks, A., Tremper, K.K., Kheterpal, S., Turner, C.R., Ramachandran, S.K.,…Avidan, M.S. (2012). Prevention of intraoperative awareness with explicit recall in an unselected surgical population: a randomized comparative effectiveness trial. Anesthesiology, 117(4),
Naglehout, J.J., & Plaus, K.L. (2014). Nurse anesthesia. St. Louis, Missouri: Elsevier Sanders.
Harold, Joby (Director). (2007). Awake [Motion picture]. United States: MGM Distribution Company.

15. Questions