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Spotlight is on awareness while under anesthesia
With National Public Radio, Oprah, and other media outlets covering patient awareness during anesthesia, many providers report an increasing number of questions about the issue from their patients.
Your surgeons and anesthetists should prepare for even more. This fall, a movie titled Awake will be released in which a man is awake but paralyzed during surgery. The movie is billed as doing for surgery what the movie Jaws did for swimming in the ocean, says Richard J. Pollard, MD, chief of neuro-anesthesia at Southeast Anesthesiology Consultants in Charlotte, NC. Pollard recently presented an audio conference titled Awake During Surgery: A Patient's and Surgeon's Nightmare, which was sponsored by AHC Media, publisher of Healthcare Risk Management. Pollard and his peers just published a study on awareness in Anesthesiology.1
Recent cases of awareness have received national attention:
"This is outcome that can have a horrible devastating effect on your patient," Pollard says. "Even having it happen one time is too many."
There's an increased willingness to report awareness, he says. "So we will quite possibly see more of these patients on the front pages and come to the point we will meet them in the courtroom," he says.
Pollard's views are backed by the American Society of Anesthesiologist closed claims database, which indicates an increased number of claims for awareness. In addition, 78% of those cases received payment, Pollard says. The size of damages is increasing, with the highest award at $850,000, he says.
When looking at ways to avoid awareness, keep in mind that muscle relaxants have no amnestic affect, sources says.
Michael Rieker, DNP, CRNA, director of the Nurse Anesthesia Program at Wake Forest University Baptist Medical Center in Winston-Salem, NC, says, "In cases where muscle relaxants are used heavily or patients are on beta-blockers or other antihypertensives, some signs of awareness may be masked by these medications."
Also keep in mind that benzodiazepines have a drip half-life of only 1½ hours, Pollard says. "If the case is two hours, three hours, or longer, and you have only a single dose of benzodiazepines on board, the protective affects of that agent may be gone," he warns. All six cases of awareness in his study used Versed, he reports.
If the anesthetist feels compelled to run a "light" anesthetic to speed wake-up or avoid nausea, or to discontinue the anesthetic early, these actions could contribute to awareness, sources say. Speeding patient extubation by five minutes may save 30-50 minutes if you are performing six to 10 cases per day. "However, the tragedy of patient awareness, not to mention the potential malpractice liability, vastly overshadows the benefit of saving this time," Rieker says. "Economics are important, but with awareness occurring in 100 patients every day in the United States, cutting corners in the anesthetic is not a tenable risk."
1. Pollard RJ, Coyle JP, Gilbert RL, et al. Intraoperative awareness in a regional medical system. Anesthesiology 2007; 106:269-274.