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Unintended Intraoperative Awareness

Patient consciousness during surgery, with explicit recall after. Highest-risk groups: cardiac surgery, OB GA, trauma, NMBA paralysis with light anesthetic.

Recognition

  • •Intraoperative: tachycardia, hypertension, lacrimation, sweating with NMBA-blocked patient
  • •Postoperatively: patient reports pain, voices, sensation during surgery (Brice questionnaire)
  • •BIS > 60 in maintenance = increased risk; BIS < 40 + age-MAC > 0.7 protective

Steps

  1. 1
    Acknowledge + apologize without blame
    Empathic listening; do NOT minimize or argue.
  2. 2
    Document — what they remember, when, distress level
  3. 3
    Refer to mental health — PTSD risk > 50% if untreated
  4. 4
    Anesthesia QI/peer review of the case
    Most common cause: low-dose maintenance during NMBA.
  5. 5
    Disclosure to risk management + patient safety
  6. 6
    Future anesthetic plan: depth monitor, written record, consultation note

Drugs + doses

DrugDoseNote
Anxiolysis if revisiting ORMidazolam 2 mg IV pre-op

Pitfalls

  • !Don't argue with the patient. Acceptance reduces PTSD severity.
  • !BIS is not foolproof; use end-tidal MAC + clinical signs together.
  • !OB GA: avoid prolonged thiopental wash-out before delivery if MAC < 0.7.

Sources

  • AANA Position Statement: Awareness
  • ASA Practice Advisory 2006/2024
  • B-Aware Trial

Anatomy reference

Sourced reference images. 4 matches for "brain cortex consciousness".

Arteries_beneath_brain_Gray_closer-ar
Wikimedia · Public domain
Arteries_beneath_brain_Gray_closer
Wikimedia · Public domain
Arteries_beneath_brain
Wikimedia · Public domain
Autoradiography_of_a_brain_slice_from_an_embryonal_rat_-_PMID19190758_PLoS_0004371
Wikimedia · CC BY 2.5
Browse the full image library →
Education only — not a substitute for facility protocols, MOC certification, or clinical judgment. Always follow your institutional crisis algorithm and confirm doses against current package inserts.