Down But Not Out
Doctors disagree how best to keep patients from awakening during surgery
The mere mention of waking up during surgery makes anyone who is squeamish want to quickly change the subject. A few anesthesiologists still insist that they've never seen it and it doesn't happen. Most, however, acknowledge that sometimes surgery patients do regain consciousness because their anesthetic medication has fallen too low. Some victims of anesthesia awareness, as this is called, overhear the snappy repartee of the surgical team. Some register a tugging or other physical sensations but without pain. And some feel the agony of every incision, every step of the operation, every stitch. Surgery patients given drugs that immobilize them, as is typical, cannot communicate even with a grunt or a waving finger that they are no longer unconscious. And so the operation proceeds.
That, says Jodie Stanley, a grandmother from Rainbow City, Ala., is what happened to her. Unconscious as she went into hand surgery in January 2004, she suddenly sensed "something cold" on her hand and arm. A nurse herself, Stanley knew she was being painted with an antiseptic solution. "Oh, my gosh," she recalls thinking. "They're getting ready to do surgery on me, and I'm awake." Unable to move, she felt her palm being cut. "I can't expect anybody to understand the pain," says Stanley, age 68. A second incision was made and an instrument was inserted, and after that she remembers nothing. "I must have passed out," she says.
Anesthesiologists have wrestled with the problem for years. Some aggrieved patients argue that most of the risk would be eliminated if anesthesiologists used bispectral index (BIS) monitoring, a brain-wave technology developed by Aspect Medical Systems of Newton, Mass., and approved by the Food and Drug Administration in 1996. But last month, after a year of study, a task force of the American Society of Anesthesiologists issued a draft report concluding that BIS and related techniques are still unproven and the ASA should not recommend them, even for patients at a heightened risk of awareness. The task force could make changes before ASA delegates vote the report up or down at the group's annual meeting in October.
Using a BIS monitor is uncomplicated. Its signature is a brightly displayed number between 0 and 100, representing the patient's relative degree of consciousness according to brain waves picked up by sensors in a disposable forehead strip. Most of the evidence for BIS monitors comes from two large, recent studies, which found that when the number was kept between 40 and 60, as the company recommends, the rate of anesthesia awareness was reduced by 77 percent to 82 percent.
Rebuttal. But many anesthesiologists are unconvinced. They believe their current tools--such as checking levels of exhaled carbon dioxide and anesthetic drugs, monitoring blood pressure and heart rate, and watching for signs of movement--usually are sufficient. They note that both of the recent studies received funds from Aspect Medical. And they cite another study, also funded by the company, which found that a higher percentage of patients with BIS monitors had anesthesia awareness than unmonitored patients did. The purpose of that study, however, was to mount the largest study to date to gauge the frequency of awareness, not to evaluate BIS monitors.
Some anesthesiologists also complain that electrical disturbances, or artifacts, scramble BIS readings. The surgeon's electrocautery, which burns its way through tissue with an intense electrical current, is one cause. "Some people find that the monitors give them useful information despite the presence of artifacts that throw off the readings," says ASA President Eugene Sinclair, chief of the anesthesia service at Orthopedic Hospital of Wisconsin in Milwaukee, which is in the process of acquiring BIS monitors. "Others find that the presence of the artifacts is a distraction, and these people do not find the monitors helpful."
In a "President's Update" mailing to members when the draft report was released, Sinclair advised keeping an open mind on BIS monitors even if the evidence for their use falls short of conclusive. He and other anesthesiologists in the public eye, he wrote, often are asked: Why not use the technology? "That is a hard question to answer," he wrote. "It is a question each clinician should consider."
Devastating though anesthesia awareness can be, it is unlikely to happen to a particular patient. It does not occur, according to many studies, in 99.8 to 99.9 percent of procedures that involve general anesthesia. But with more than 20 million such operations performed annually in the United States, a 0.1 percent to 0.2 percent incidence generates 20,000 to 40,000 awareness episodes a year--roughly 50 to 100 a day. And patients who need to receive a relatively light dose of anesthetic because of open-heart surgery, severe injuries, organ failure, or certain other reasons face a higher risk of awareness.
Moreover, the studies have looked only at adults. Awareness in children hadn't been seriously considered until earlier this year, when an Australian study in the journal Anesthesia & Analgesia suggested that it might happen four to eight times as frequently as it does in adults. "I don't know if this is or isn't a problem, but as people in this profession, we need to ask whether this is real," says Peter Davis, author of an accompanying editorial and anesthesiologist-in-chief at Children's Hospital of Pittsburgh. One possible factor, noted the study's authors, is that children need higher concentrations of anesthetic drugs than adults do and may receive insufficient anesthetic more often.
Alert. Last October, hospitals got a stern warning on anesthesia awareness from the Joint Commission on Accreditation of Healthcare Organizations, their main credentialing body. In a "sentinel event alert," JCAHO called the problem under-recognized and undertreated and suggested that brain-function monitors--which according to Aspect Medical are used in about 40 percent of all U.S. operating rooms--may help prevent it in patients who are at especially high risk.
The group also cited studies showing emotional distress after such an event. When Stanley woke up in the recovery room and related her experience to the anesthesiologist, "he told me I must have been dreaming," she says. "And I said, no, I felt it, and he said, well, it must have been a reaction to the medications. Then he said I'm sorry, and he walked out."
The exchange was fairly predictable. Most surgery patients who experience awareness don't tell the anesthesiologist or any other doctor, and if they do, they rarely are taken seriously, says Boston University psychiatrist Janet Osterman, probably the leading investigator of the psychological wreckage an awareness episode can inflict. Even family and friends may be kept in the dark. Months or years later, the event can burst into the open as anger, crying jags, withdrawal, and other behavior similar to that displayed by some combat veterans and rape victims--a sign of post-traumatic stress disorder, says Osterman.
"I do not sleep flat, because that was the position I was in during surgery," says Carol Weihrer of Reston, Va., who woke up while her diseased eye was being removed in January 1998. "I sleep in a reclining chair. I have nightmares. I wake up with scratches and bruises. I tear my hair." A former flutist and office administrator, Weihrer, 53, responded by creating the Anesthesia Awareness Campaign (box).
"The question about BIS monitoring is, are you better off with it or are you better off without it?" says Donald Mathews, an anesthesiologist at St. Vincent's Hospital Manhattan who has used the device on all his general anesthesia patients for about five years. His answer: "I'm totally convinced that the information you get improves the way you take care of people."
Staying Blissfully Unaware
Patients worried about consciousness during surgery can ask whether a BIS monitor is available and about the possible use of an amnesiac drug. In addition, these resources have useful information:
American Society of Anesthesiologists. The ASA's draft report on BIS monitoring is available for comment (asahq.org).
Joint Commission on Accreditation of Healthcare Organizations. Click on "patient safety" to read the "sentinel event alert" (jcaho.org).
Anesthesia Awareness Campaign. News, brochures, and a MedAlert-type bracelet for those who have gone through an episode (anesthesia awareness.com).
Association for the Advancement of Behavior Therapy. Locate experts in post-traumatic stress syndrome (aabt.org).
This story appears in the August 8, 2005 print edition of U.S. News & World Report.