How to Prevent Anesthesia Awareness. Waking up during surgery. It sounds like something out of a horror movie, but anesthesia awareness is a natural, albeit rare, phenomenon. As an anesthesia provider, I know how unsettling it is for patients. That’s why preventing anesthesia awareness is a top priority for any anesthesiologist. If you’re worried about experiencing intraoperative awareness, this comprehensive guide covers you.

What Exactly is Anesthesia Awareness?

Let’s start with the basics. Anesthesia awareness, also known as intraoperative awareness or unintended intraoperative awareness, refers to waking up during a procedure performed under general anesthesia. Instead of being in a state of unconsciousness as intended, the patient regains awareness while surgery is underway.

It’s every patient’s worst nightmare; even though you’re under anesthesia, you suddenly find yourself cognizant mid-surgery, feeling the sterile coldness of the OR and pressure from surgical instruments. You may even feel pain.

Luckily, while disturbing, anesthesia awareness is scarce, occurring in just 1-2 out of every 1,000 patients who go under general anesthesia. With certain precautions taken by the anesthesia care team, patients can rest assured the odds of experiencing this phenomenon are extremely low.

Why Does Awareness Under Anesthesia Sometimes Occur?

So why does anesthesia awareness happen if the drugs are supposed to keep you knocked out? There are a few reasons why a patient might accidentally wake up during surgery:

• Inadequate dosing of anesthesia meds. If you’re not given enough anesthesia, or it’s stopped too soon, you could regain consciousness. This is one of the most common causes of awareness.
• Rapid metabolism of anesthesia. Some folks metabolize meds ultra-quickly, causing them to break down anesthesia before the surgery is complete. Redheads and women may be more susceptible.
• Drug interactions. Medications you’re already taking, like blood pressure drugs, anti-seizure meds, and more, can interfere with anesthesia meds.
• Low blood pressure. Hypotension under anesthesia can prevent adequate blood flow to the brain, reducing the effects of anesthesia.
• Human error. Unfortunately, mistakes in anesthesia delivery, miscommunication, and equipment issues can also be blamed.
• Tolerance. Patients who’ve undergone multiple surgeries and have had a lot of exposure to anesthetic gases can develop a tolerance and require higher doses.

How to Prevent Anesthesia Awareness

The good news is there are numerous precautions anesthesia professionals take to avoid anesthesia awareness, significantly reducing the likelihood it will occur. These preventative measures include:

• Thorough pre-op assessment – During the pre-operative checkup, the anesthesiologist will ask about factors that could make you more prone to awareness, like drug sensitivities, medications you take, genetic redhead status, and previous anesthesia experiences. This allows them to plan dosing accordingly.
• Adjusting anesthesia per patient factors – Your anesthesiologist customizes and titrates the medications to your needs based on the surgical procedure, medical history, drug interactions, and other variables.
• Multiple drugs for balanced anesthesia – Rather than just one medication, a “balanced technique” uses various medicines that work via different mechanisms for a more profound, stable loss of consciousness.
• Use of EEG monitoring – Electroencephalography (EEG) technology allows doctors to monitor brain wave activity and depth of anesthesia from moment to moment, so dosing can be adjusted as needed.
• Double-checking equipment – Anesthesiologists are meticulous in their preparations, from verifying gas tank levels to ensuring proper oxygenation and breathing tube placement to having backup IVs and emergency meds on hand.
• Continuous care – The anesthesia care team never leaves your side from the second you go under to the moment you wake up. This consistent monitoring safeguards against any brief lapses in the level of anesthesia.
• Following up after surgery – If awareness is suspected, your anesthesiologist will discuss your experience to pinpoint what factors could have led to the issue and prevent it from happening again.

Essential Steps You Can Take to Prevent Awareness

While the anesthesia team takes care of most of the work, there are a few important things you, as the patient, can do before surgery to reduce your personal risk:

Be honest about medications, drug use, and health history – Mention every prescription, supplement, recreational drug, and prior reaction to anesthesia to your care team. Don’t leave anything out! Even medical marijuana matters. Trying to hide something could come back to bite you in the form of awareness.

Stop smoking – Smokers may need larger doses of anesthesia, which makes awareness more likely. Consider quitting several weeks before surgery.

Avoid alcohol – Heavy drinking can lead to cross-tolerance with anesthetic agents. Lay off the booze for a few days pre-op.

Talk to your anesthesiologist – Discuss awareness concerns with your anesthesiologist before the procedure so extra precautions can be taken if you’re at higher risk.

Use reminders – Some patients wear bracelets during surgery, asking providers to ensure they’re fully under. You can also place reminders like “Please check that I’m fully asleep” on your body.

Consider awareness-reducing anesthesia – Certain newer inhaled anesthetics like Sevoflurane and Desflurane plus the IV drug Ketamine are associated with lower rates of awareness. Discuss options with your anesthesiologist.

Learn more: How to Prevent Cerebral Palsy During Pregnancy

Signs of Intraoperative Awareness

Hopefully, with sound prevention methods, anesthesia awareness never happens. But if you have recalled memories or sensations from your procedure, here are some signs that you may have experienced awareness:

• Explicit recall of events during surgery
• Nausea or pain during the procedure
• Hearing noises/conversations in the OR
• Feeling a breathing tube placed down the throat
• Sensations of poking or prodding
• Paralysis but the ability to hear or see
• Panic, anxiety, sense of doom
• Nightmares or flashbacks of surgery after the fact

Let your surgeon and anesthesiologist know ASAP if you have any of these memories or symptoms. Don’t chalk it up to “just a weird dream.” Providers need to know to pinpoint where the error occurred so it doesn’t happen again. Promptly reporting it can prevent awareness for future patients, too.

The Psychological Impact and Aftermath of Anesthesia Awareness

Why do we make such a concerted effort as anesthesiologists to avoid intraoperative awareness at all costs? Because it can seriously impact patients’ psychological well-being.

Becoming aware of mid-operation can lead to highly distressing emotional consequences, including:

• Post-traumatic stress disorder (PTSD)
• Sleep disturbances, insomnia
• Flashbacks of the traumatic event
• Anxiety, depression
• Problems with sexual intimacy
• Decreased quality of life
• Loss of trust in medical providers

Some patients quite literally have their lives turned upside down by crippling after-effects. Others report feeling violated and demoralized by the experience.

The excellent news is that psychological treatment and counseling are available, primarily cognitive behavioral therapy, to process trauma-related medical events. Support groups can also help patients struggling with emotional repercussions feel less isolated.

If anesthesia awareness happens, having compassionate providers who listen and acknowledge the gravity of the situation makes a significant impact, too. Don’t downplay or invalidate patient experiences – sensitivity and emotional care go a long way in helping them heal.

How to Prevent Anesthesia Awareness? Patients can rest assured that anesthesia awareness is exceptionally unlikely, thanks to vigilance by the anesthesia care team in direct monitoring, customized dosing, redundant backup equipment, and more.

You minimize risks by giving your medical history, following prep instructions, and voicing concerns before surgery. While no method is 100% foolproof, you’re in caring, capable hands with your anesthesiologist.

If rare case awareness occurs, prompt reporting means the cause can be found and fixed to optimize future patients’ well-being and peace of mind. We can work together to avoid this unsettling phenomenon with open communication and the patient-provider partnership.