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Anesthesia Awareness—What If I Am Awake During Surgery

Updated on November 4, 2016

TahoeDoc HealDove

Anesthesia Awareness - Awake Under Anesthesia

Fear of being awake under anesthesia, called anesthesia awareness or intraoperative awareness, causes a lot of anxiety for patients facing surgery.

Having anesthesia is scary for most people. As an anesthesiologist, I usually meet patients right before their surgeries. People facing surgery have many apprehensions and fears. More and more are concerned about anesthesia awareness.

I repeatedly hear that patients are often more apprehensive about the anesthesia than the surgery itself. And of all the fears that people have about the anesthetic side effects and anesthetic complications, the one I hear most often is, "I'm afraid of waking up during the surgery."

Anesthesia awareness has received a great deal of attention in the press over the last few years and even a full-length movie, called "Awake," capitalized on this fearful concept (I have reluctantly included the trailer here). But what is it really? Why and to whom does it occur? Keep reading to find out why it most likely won't happen to you.

"Awake" - Sensationalizing Anesthesia Awareness

What Is Anesthesia Awareness?

Anesthesia awareness, also called intraoperative awareness refers to a specific situation where a person is under general anesthesia for surgery and regains consciousness during the surgical procedure.

The definition of general anesthesia includes induction and maintenance of loss of consciousness. This means that you should not be able to wake up until the surgery is over. You do not respond to voice or painful stimuli.

For various reasons, some people do regain consciousness when they are under general anesthesia. For most people, this involves a very brief, hazy memory. Some people are aware of what is being said, but cannot move or indicate that they are awake. Still, there is usually no sensation of pain or awareness of the operation. The very rare, unfortunate few are awake, cannot move and do feel the surgery being done.

What Is NOT True Anesthesia Awareness?

There are many situations that are confused with anesthesia awareness.

Sedation anesthesia. I often have patients tell me they had anesthesia awareness during their colonoscopy or other procedure. These procedures are commonly done under intravenous sedation anesthesia. While the intravenous sedation drugs do cause sleepiness and often amnesia- you don't remember the procedure, they do not cause unconsciousness. It is not at all abnormal to be awake and remember these procedures. With the sedation, pain medications are either injected at the surgical site or given in the IV or both. You should still not be uncomfortable, even if you are awake, during surgeries or procedures under sedation.

Sedation plus spinal or epidural. Neither sedation or spinal/epidural anesthesia makes you unconscious during your operation. If you have spinal or epidural anesthesia to block the pain of surgery, you are usually also given sedation. The same is true for local anesthesia as well. In this case, it is not unusual or abnormal to have memories of being in the operating room. This is not anesthetic awareness.

Dreaming. Some people actually dream during their anesthetic, or more likely, when transitioning from unconsciousness back to wakefulness at the end of surgery. These dreams are often interpreted as actual wakefulness, but are not.

Waking at the end of surgery, but not able to move. When you return to consciousness, sometimes your brain is more awake than your body. You are waking up, but cannot move for a couple minutes. You can hear the anesthesiologist talking to you or feel the nurses putting bandages on your incisions, but cannot yet respond. The anesthesia wears off at different rates for different people. If your surgery is over, but you are still in the operating room and have memories of this, it is a normal variant of the emergence phase from anesthesia. Most people are conscious when they leave the operating room, post anesthesia, and many are talking and asking questions, but may not remember it later. If you do remember this phase, it's ok. The same is true for the beginning of your anesthetic, the anesthesia induction. Vague, hazy memories of being in the operating room are confusing and can be mistaken for being awake during the anesthetic.

Risk Factors for Intraoperative Awareness

Certain risk factors make anesthesia awareness more likely.

Type of surgery and type of anesthesia. Certain types of surgery are associated with higher incidences of anesthesia awareness. Surgeries where using lower concentrations and amounts of anesthetics is necessary to protect patients lead to more intraoperative awareness. Emergency cesarean sections, trauma surgeries, and open heart surgeries are the most likely cases to be associated with anesthesia awareness. Anesthesia challenges the body's physiology. Heart rates vary and blood pressures drop. When they cannot be adequately managed by giving more medication, the anesthetic must be "lightened" in order to NOT endanger the patients' lives.

There are certain brain and spinal cord surgeries that require that no anesthesia gas be used in order to not interfere with the nerve monitoring being used to prevent paralysis. The anesthetic called TIVA (total intra-venous anesthesia) also predisposes to higher rates of anesthesia awareness.

Type of patient. Patients who use illegal drugs such as cocaine and methamphetamine may be more likely to have intraoperative awareness. Not only do these drugs cause dangerous fluctuations in heart rate and blood pressure, they make the metabolism of anesthetic drugs much more unpredictable.

Some prescription medications. Certain prescription medications may also increase the risk. Anesthetics are adjusted throughout the surgery based on surgical stimulation level, type of anesthesia and the heart rate, breathing rate and blood pressure of the patient. Patients who take medications that block the normal increases in heart rate or blood pressure may have their signs of light anesthesia masked by the medication.

Statistics on Awareness Under Anesthesia

The American Society of Anesthesiologists estimates that some degree of anesthesia awareness occurs in about 1 in 1000 general anesthetics. It is believed that the majority of these cases are during the induction (beginning) of the anesthetic when the drugs haven't fully taken effect. Likewise, a great many cases are at the end of surgery, during anesthetic emergence, when the anesthetic is wearing off but isn't completely gone. These are not intraoperative awareness as the surgery is not occurring. Because the memories are fuzzy and confusing, patients often don't know that this wasn't during the surgery itself.

There are no exact statistics on true intraoperative awareness cases that occur during the surgery and cause distress and lasting trauma to the patient. It is, however, an area of active study and research.

Again, talk to your doctors and ask questions if you are remotely concerned that this has happened to you.

Prevention: What You Can Do to Prevent Intraoperative Awareness.

Talk to your anesthesia doctor and provide accurate information. This is your best defense against intraoperative awareness.

So, be honest with your doctor about:

Your fears. Usually, this will help calm you. While no absolute guarantees can ever be made, your doctor can help pinpoint whether or not you have higher risk than average for this complication and let you know how he or she will address the risk. Alcohol consumption. Chronic, excessive alcohol intake results in a higher need for anesthetic medications. Illegal drugs use. Your anesthesiologist needs to know this to figure out which and how much anesthesia it will take to get you to sleep and keep you there. They are not there to judge you, but cannot keep you safe if they don't have all relevant information. All of your prescriptions and supplements. Different medications affect the metabolism of anesthesia differently. And just because supplements are "natural" or "alternative" doesn't mean they don't have side-effects or don't interfere with anesthetic medicines. How the Anesthesiologist Monitors During Surgery

The anesthesiologist, using intraoperative monitoring, will be watching your heart rate, blood pressure, and breathing rate (if a ventilator doesn't need to be used). Increases in these seen on the intraop monitors indicates that the anesthesia is too "light." These parameters generally increase before any awareness occurs. The anesthesiologist is constantly adjusting the delivery of the anesthesia gas and giving other medication in the IV to keep the anesthesia level where it needs to be. The anesthesia is increased to ensure adequate depth of anesthesia if it's too light. Likewise, even though you are unconscious, your body will reflexively move to stimulation if the anesthetic depth needs to be increased. This also occurs before awareness.

The various brain monitors on the market have not been shown to reduce anesthesia awareness, despite what the makers of these expensive devices say. They do provide other useful information and may or may not be used if your hospital has them, at the discretion of the anesthesiologist.

BIS Monitor

A study published in the "New England Journal of Medicine" (August 18, 2011) has actually shown that relying on a BIS (brain) monitor can actually increase the incidence of intraoperative awareness vs. using measurement of the anesthetic concentration (the usual technique). This sounds counter-intuitive, but to me is not surprising. Here's why...

The BIS monitor (which I use for other information) gives a number that is indicates the level of consciousness. Other indicators include heart rate, blood pressure and breathing rate/pattern changes (if the patient is breathing on their own). In my experience (disclaimer-based on only my experience, not scientific study), the changes in vital signs happen first. Heart rate goes up before you see a change in the BIS number. That means that providers who rely only on the BIS number and ignore the changes in vital signs may be missing the chance to prevent awareness. The awareness may have already happened before the change in BIS number is seen. There is a lag between the event and the change in BIS.

Personally, I try to use all the data available to me and not rely on the BIS monitor for prevention of awareness. Vital signs to me are more reliable, happen earlier (before awareness can occur in most cases) and should not be ignored to focus on the BIS monitor. The BIS does provide other useful info, but is not as reliable as the manufacturer may claim to prevent awareness.

Treatment for Anesthesia Awareness

If you have had a case of genuine intraoperative awareness, let your doctor, surgeon, or anesthesiologist know right away. Many people do well with just an explanation of why it might have happened. Others suffer short-term or even long-term post-traumatic stress disorder. In those cases, an evaluation by a psychologist or psychiatrist and possible medications may be needed, usually on a short-term basis.

If you aren't sure if you had true anesthesia awareness, speak to your surgeon or contact the anesthesiologist. Most people who aren't sure have had one of the other experiences -- like sedation, dreaming, or waking at the end and being confused about the time -- and feel much better after having their questions answered.

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95 percent of the victims of violence are men. Because women are natural cowards who send men to handle things when they are dangerous.

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Scientists once gave dolphins LSD in attempt to communicate with them

Scientists once gave dolphins the hallucinogenic drug LSD, in an attempt to communicate with them.

Funded by NASA, the Communication Research Institute, informally known as The Dolphin House, investigated methods of talking to the creatures in the 1960s. They also used a range of techniques in an attempt to teach the animals English.

John Lilly, a neuroscientist who led the work, studied three dolphins in particular, one of which he chose to leave in an isolation tank with a human 24 hours a day for three months.

During the isolation period the dolphin, named Peter, began making sexual advances towards researcher, Margaret Howe Lovatt, who chose to relieve the animal's urges because it was proving to be disruptive to the training.

Ultimately, none of the dolphins were able to learn English.

But researchers found that they were 70 per cent more vocal after they were administered with LSD.

Dr Lilly wrote that “the important thing for us with the LSD in the dolphin is that what we see has no meaning in the verbal sphere."

He added: "We are out of what you might call the rational exchange of complex ideas because we haven't developed communication in that particular way as yet.”

When the funding for the experiment ran out in 1966, the dolphin that took part in the isolation experiment was moved to a facility in Miami where it effectively committed suicide.

Some argued this was because it could no longer cope without being in close contact with Ms Lovatt.

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Germany: the world's capital of penis enlargement

One in five surgeries takes place in Germany, according to data released by plastic surgeons. Find out what other aesthetic operations are popular worldwide

The Guardian

It seems that spam emails inviting men to try increasing the size of their member would be best targeted to addresses ending in .de.

According to the latest data release by the International Society of Aesthetic Plastic Surgery (ISAPS), there were 2,786 operations estimated to have taken place in Europe’s biggest country - which is more than in any other nation.

The organisation estimates that there were 15,414 of these operations performed worldwide so almost one in five of those seeking to add centimetres to their member were in Germany.

It is not a huge amount of men deciding to have an intimate nip and tuck in Germany - it’s roughly eight out of every 100,000 adult males usually resident in the country. However, only Venezuela, where four out of every 100,000 adult males have a penis enlargement operation, comes anywhere near close to the German rate.

It’s worth pointing out here that the figures are not broken down by the nationality of the patient so it’s not necessarily German men or people that live there going for the procedure.

The German Centre for Urology and Phalloplasty Surgery claims to have performed over 6,000 penis enlargements (be warned there are graphic pictures available on the site). They claim to be able to enhance the length of the member by 3-6cm and the girth by 2-3cm. The cost of the operation? €9,600 (including materials and ancillary costs).

The growing trend for penis enlargement was noticed back in 2011 by English language site The Local. They reported the president of the German Association of Aesthetic Plastic Surgery as saying that the surgery was now the seventh most popular type of aesthetic operation for men in the country.

The ISAPS data is not broken down by gender for each nation so the relative popularity of penile enlargement is not quite clear.

Breast augmentation the most popular surgery worldwide Taking a broader look at the data, there were more breast enhancement operations than any other surgical procedure worldwide last year. 18% of these took place in the United States.

The other procedures that are thought to have taken place over a million times were:

Liposuction (1.6m) - where fat is removed from the body Eyelid surgery (1.4m) - the removal of fat or skin from around the eye area Lipostructure/lipofilling (1m) - where parts of fat from the rest of the body are used to reshape the patients body (the count includes stem enhanced lipofilling) In total, there were an estimated 11.6m aesthetic surgical procedures that took place worldwide in 2013.

South American countries the most likely to have plastic surgery ISAPS collected the data using survey responses from 1,567 plastic surgeons. They were able to get counts for 96% of the total number of practitioners using national societies worldwide, which allowed them to project total worldwide numbers using these survey responses.

However, 1,567 is still a small sample size and they were only able to provide data breakdowns for the ten countries performing the most plastic surgery.

If you take the total number of procedures and adjust it by the country’s population in 2013 then Venezuela was the place where people were most likely to have had plastic surgery.

If you take a random sample of 1,000 Venezuelans, eight are likely to have had a surgical operation in 2013. Fellow South American countries Brazil and Colombia came second and third respectively for popularity per capita.

In terms of raw numbers, the most operations worldwide took place in this year’s World Cup host Brazil. The largest South American country had 1.5m operations in 2013, which is more than one in ten of all procedures worldwide.

However, when you factor in non-surgical operations such as botox then the US regains the top spot with almost 4m non-surgical and surgical procedures combined compared to 2.1m in runner up Brazil.

Update: 13.30pm The piece was rectified to make clear that it was not necessarily German men having the procedure but the operations took place in Germany.

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