NOT ANESTHETISED
SUMMARY The fear of not being completely asleep during surgery becomes a reality for a significant number of patients. Degree of awareness varies considerably, as does severity of after-effects. Intensive treatment can be effective, but the patient must first be believed, and the doctor recognise the problem. As a cause of medical malpractice action, incomplete anesthesia has characteristic problems.
How frequent?
The fear of not being completely asleep during surgery becomes a reality for a significant number of patients.
Awareness during general anesthesia is common and one in two preoperative patients will, if asked, acknowledge fear of being inadvertently awake during the operation¹.
Depending on the type of surgery involved, 2^1a-15 or more patients out of every 1000 who are given a general anesthetic suffer awareness².
Symptoms
Degree of awareness varies considerably, as does severity of after-effects.
Patients afterwards talk of having been able to hear, of feeling paralysed, anxious, panicked and helpless³, particularly when neuromuscular blocking agents (muscle relaxants) have been administered⁴.
Up to 70% of those experiencing awareness during general anesthesia will subsequently have intrusive memories during sleeping or waking³. A minority will develop full-blown Post-Traumatic Stress Disorder, including irritability, recurrent nightmares, anxiety, and preoccupation with death³, ⁵.

Practice Point

Residual Symptoms
1. Sleep disturbances
2. Flashbacks
3. Anxiety
4. Post Traumatic Stress Disorder

Therapy
Intensive treatment can be effective, but the patient must first be believed, and the doctor recognise the problem.
Only a third of aware patients told their anesthetist afterwards³, and most victims felt that doctors they approached lacked understanding and training to treat the injuries⁶. However, intensive therapy can relieve symptoms within 3 weeks⁴.
Malpractice problems
As a cause of medical malpractice action, incomplete anesthesia has characteristic problems.

Practice Point

Characteristics of Anesthetic Awareness:
1. Small anesthetic doses
2. Nitrous oxide
3. Intravenous anesthetic
4. Muscle relaxants
5. No volatile anesthetics

Despite these characteristics, no general anesthesia techniques can ensure that awareness will not occur⁷.
Proving awareness during general anesthesia is often problematic.
Experienced anesthetic specialists reviewing the anesthetic records are unable to distinguish reliably between awareness cases and effective general anesthetics³.

Practice Point

Medicolegal Difficulties
1. Not entirely preventable.
2. Routine monitoring insensitive
3. Anesthetic records unrevealing
4. Low quantum of damages

Standard anesthetic monitoring cannot detect awareness during general anesthesia. Traditionally-taught variation inblood pressure, pulse-rate, sweating and tear production are crude and inadequate indicators of anesthetic awareness⁷.
Routinely measuring brain activity might detect some, but nearly a thousand patients would have to be monitored to prevent one case of awareness⁴.
Finally, with the possible exception of Post Traumatic Stress Disorder resistant to treatment, the quantum of damages is usually fairly low⁸.