Intraoperative Wachheit

Zusammenfassung

Seit den Anfängen der klinischen Anästhesie wird über nicht vorhersehbare Episoden von intraoperativer Wachheit und postoperativer Erinnerung berichtet. Auch heute werden von Zeit zu Zeit Fallberichte über intraoperative Wachheit veröffentlicht. Diese dürften jedoch nur die Spitze des Eisbergs darstellen, denn die Mehrzahl der Patienten mit Erinnerung an intraoperative Wachheit erzählen ihrem Anästhesisten davon nichts. Nach neueren Studien liegt die Häufigkeit postoperativer Erinnerung an intraoperative Wachheitsphasen bei 0,1 - 0,2 % aller Allgemeinanästhesien. Die Häufigkeit ist höher bei kompletter neuromuskulärer Blockade. Das Risiko ist erhöht bei Patienten, die nur geringe Mengen Anästhetika erhalten, z. B. bei hämodynamischer Instabilität, Sectio caesarea vor Abnabelung oder herzchirurgischen Eingriffen. Intraoperative Wachheit zieht nicht zwingend explizite (bewusste) Erinnerung nach sich. Auch ohne das Vorliegen expliziter Erinnerung an intraoperative Wachheit kann implizite (unbewusste) Erinnerung Folgen für den Patienten haben, schlimmstenfalls zur Entstehung der posttraumatischen Belastungsstörung führen. Positive Folgen intraoperativer Wahrnehmung scheinen durch Einsatz intraoperativer positiver Suggestionen möglich, dies ist jedoch umstritten. Der Einsatz von Benzodiazepinen zur Blockade bewusster Erinnerung sollte kritisch überdacht werden. Wichtiger scheint es, auf komplette Blockade der neuromuskulären Übertragung wann immer möglich zu verzichten. Bei Vermutung intraoperativer Wachheit sollte der Anästhesist mit dem Patienten sprechen, ihm die momentane Situation erklären und beruhigend auf ihn einwirken, bis wieder ausreichende Narkosetiefe erreicht ist. Im Rahmen der postoperativen Visite sollte nach Erinnerung an Wachheitsphasen gefragt werden. Patienten, die über intraoperative Wachheit berichten, müssen ernst genommen werden. Eine Erklärung des Geschehens sowie der rasche Beginn psychologischer Betreuung verringern die Wahrscheinlichkeit schwerer Folgen.

Abstract

The first cases of general anesthesia were already cases with awareness. Until today, case reports of patients with awareness are published. These published cases are likely to be the top of the iceberg, as most patients with postoperative recall do not inform their anesthesiologist. Incidence of awareness with recall is between 0.1 and 0.2 %. In a large multicenter-study, incidence of recall was 0.1 % without, and 0.18 % with the use of muscle relaxants. The risk is increased with decreased doses of anesthetics, e.g. in patients with hemodynamic instability (trauma cases), patients undergoing cesarean section or cardiac surgery. Intraoperative awareness does not necessarily cause explicit (conscious) memory. Even in the absence of explicit memory, implicit (unconscious) memory can still have consequences for the patient. In the worst case, it can cause post-traumatic stress disorder. There is doubt whether patients may profit from positive suggestions given during intraoperative awareness. Recommendations to administer benzodiazepines to prevent explicit memory must be reconsidered. Complete neuromuscular block should be avoided whenever possible. If a patient is thought to be aware, he should be contacted , his situation should be explained and affirming comments should be given until consciousness is lost again. Postoperative visit should include questions about awareness and recall. The anesthetist should not disbelieve reported recall. Explanation of what had happened and referral to an experienced psychologist must be offered. Thus, the incidence of severe sequelae should decrease.

Schlüsselwörter

Allgemeinanästhesie - Wachheit - Erinnerung - Gedächtnis - posttraumatische Belastungsstörung

Key words

Anesthesia, general - wakefulness - awareness - memory - recall - recognition - stress disorders, post-traumatic

Literatur

• 1 On being aware. Br J Anaesth 1979 51: 711-712
• 2 Gilron I, Solomon P, Plourde G. Unintentional intraoperative awareness during sufentanil anaesthesia for cardiac surgery.  Can J Anaesth. 1996;  43 295-298
• 3 Tong D, Chung F. Recall after total intravenous anaesthesia due to an equipment misuse.  Can J Anaesth. 1997;  44 73-77
• 4 Moerman N, Bonke B, Oosting J. Awareness and recall during general anesthesia. Facts and feelings.  Anesthesiology. 1993;  79 454-464
• 5 Liu W H, Thorp T A, Graham S G, Aitkenhead A R. Incidence of awareness with recall during general anaesthesia.  Anaesthesia. 1991;  46 435-437
• 6 Ranta S O, Laurila R, Saario J, Ali-Melkkilä T, Hynynen M. Awareness with recall during general anesthesia: incidence and risk factors.  Anesth Analg. 1998;  86 1084-1089
• 7 Lyons G, Macdonald R. Awareness during caesarean section.  Anaesthesia. 1991;  46 62-64
• 8 Phillips A A, McLean R F, Devitt J H, Harrington E M. Recall of intraoperative events after general anaesthesia and cardiopulmonary bypass.  Can J Anaesth. 1993;  40 922-926
• 9 Bogetz M S, Katz J A. Recall of surgery for major trauma.  Anesthesiology. 1984;  61 6-9
• 10 Sandin R H, Enlund G, Samuelsson P, Lennmarken C. Awareness during anaesthesia: a prospective case study.  Lancet. 2000;  355 707-711
• 11 Rampil I J. Anesthetic potency is not altered after hypothermic spinal cord transection in rats.  Anesthesiology. 1994;  80 606-610
• 12 Antognini J F, Schwartz K. Exaggerated anesthetic requirements in the preferentially anesthetized brain.  Anesthesiology. 1993;  79 1244-1249
• 13 Tunstall M E. Detecting wakefulness during general anaesthesia for caesarean section.  BMJ. 1977;  1 1321
• 14 Tunstall M E. On being aware by request. A mother's unplanned request during the course of a Caesarean section under general anaesthesia.  Br J Anaesth. 1980;  52 1049-1051
• 15 Russell I F. Auditory perception under anaesthesia.  Anaesthesia. 1979;  34 211
• 16 Ghoneim M M. Awareness during anesthesia. Oxford: Butterworth-Heinemann 2001
• 17 Schacter D L, Chiu C Y, Ochsner K N. Implicit memory: a selective review.  Annu Rev Neurosci. 1993;  16 159-182
• 18 Bennett H L, Davis H S, Giannini J A. Non-verbal response to intraoperative conversation.  Br J Anaesth. 1985;  57 174-179
• 19 Schwender D, Kaiser A, Klasing S, Peter K, Poppel E. Midlatency auditory evoked potentials and explicit and implicit memory in patients undergoing cardiac surgery.  Anesthesiology. 1994;  80 493-501
• 20 Münte S, Münte T F, Mitzlaff B, Walz R, Leuwer M, Piepenbrock S. Postoperative reading speed does not indicate implicit memory in elderly cardiac patients after propofol and remifentanyl anaesthesia.  Acta Anaesthesiol Scand. 2001;  45 750-755
• 21 Jelicic M, Bonke B, Wolters G, Phaf R H. Implicit memory for words presented during anaesthesia.  European Journal of Cognitive Psychology. 1992;  4 71-80
• 22 Lubke G H, Kerssens C, Phaf H, Sebel P S. Dependence of explicit and implicit memory on hypnotic state in trauma patients.  Anesthesiology. 1999;  90 670-680
• 23 Andrade J, Englert L, Harper C, Edwards N D. Comparing the effects of stimulation and propofol infusion rate on implicit and explicit memory formation.  Br J Anaesth. 2001;  86 189-195
• 24 Goldmann L. Factors determining the probability of recollection of intraoperative events. Bonke B, Fitch W, Millar K Memory and Awareness in Anaesthesia. Amsterdam: Swets and Zeitlinger 1990: 45-49
• 25 Goldmann L, Shah M V, Hebden M W. Memory of cardiac anaesthesia. Psychological sequelae in cardiac patients of intra-operative suggestion and operating room conversation.  Anaesthesia. 1987;  42 596-603
• 26 Bennett H L. Memory for events during anesthesia does occur: A psychologist's viewpoint. Sebel PS, Bonke B, Winograd E Memory and Awareness in Anesthesia. Englewood Cliffs, NJ: Prentice-Hall Inc 1993: 459-466
• 27 Levinson B W. Quo vadis. Sebel PS, Bonke B, Winograd E Memory and Awareness in Anesthesia. Englewood Cliffs, NJ: Prentice-Hall Inc 1993: 498-500
• 28 Ghoneim M M, Block R I. Learning and memory during general anesthesia: an update.  Anesthesiology. 1997;  87 387-410
• 29 Brice D D, Hetherington R R, Utting J E. A simple study of awareness and dreaming during anaesthesia.  Br J Anaesth. 1970;  42 535-542
• 30 Nordström O, Engström A M, Persson S, Sandin R. Incidence of awareness in total i.v. anaesthesia based on propofol, alfentanil and neuromuscular blockade.  Acta Anaesthesiol Scand. 1997;  41 978-984
• 31 Jones J G, Konieczko K. Hearing and memory in anaesthetised patients.  BMJ. 1986;  292 1291-1293
• 32 Cobcroft M D, Forsdick C. Awareness under anaesthesia: the patients' point of view.  Anaesth Intensive Care. 1993;  21 837-843
• 33 Schwender D, Kunze-Kronawitter H, Dietrich P, Klasing S, Forst H, Madler C. Conscious awareness during general anaesthesia: patients' perceptions, emotions, cognition and reactions.  Br J Anaesth. 1998;  80 133-139
• 34 Meyer B C, Blacher R S. A traumatic neurotic reaction induced by succinylcholine chloride.  N Y State J Med. 1961;  61 1255-1261
• 35 Levinson B W. States of awareness during general anaesthesia. Preliminary communication.  Br J Anaesth. 1965;  37 544-546
• 36 Blacher R S. On awakening paralyzed during surgery - A syndrome of traumatic neurosis.  JAMA. 1975;  234 67-68
• 37 Lennmarken C, Bildfors K, Enlund G, Samuelsson P, Sandin R. Victims of awareness.  Acta Anaesthesiol Scand. 2002;  46 229-231
• 38 Wolfe L S, Millett J B. Control of post-operative pain by suggestion under general anesthesia.  Am J Clin Hypn. 1960;  3 109-112
• 39 Hutchins D D. The value of suggestions given under general anesthesia: A report and evaluation of 200 consecutive cases.  Am J Clin Hypn. 1961;  4 26-29
• 40 Evans C, Richardson P H. Improved recovery and reduced postoperative stay after therapeutic suggestions during general anaesthesia.  Lancet. 1988;  2 491-493
• 41 Liu W H, Standen P J, Aitkenhead A R. Therapeutic suggestions during general anaesthesia in patients undergoing hysterectomy.  Br J Anaesth. 1992;  68 277-281
• 42 Millar K. Efficacy of therapeutic suggestions presented during anaesthesia: re-analysis of conflicting results.  Br J Anaesth. 1993;  71 597-601
• 43 McLintock T T, Aitken H, Downie C F, Kenny G N. Postoperative analgesic requirements in patients exposed to positive intraoperative suggestions.  BMJ. 1990;  301 788-790
• 44 Boeke S, Bonke B, Bouwhuis-Hoogerwerf M L, Bovill J G, Zwaveling A. Effects of sounds presented during general anaesthesia on postoperative course.  Br J Anaesth. 1988;  60 697-702
• 45 Block R I, Ghoneim M M, Sum P ing, Ali M A. Human learning during general anaesthesia and surgery.  Br J Anaesth. 1991;  66 170-178
• 46 Block R I, Ghoneim M M, Sum Ping S T, Ali M A. Efficacy of therapeutic suggestions for improved postoperative recovery presented during general anesthesia.  Anesthesiology. 1991;  75 746-755
• 47 van der Laan W H, van Leeuwen B L, Sebel P S, Winograd E, Baumann P, Bonke B. Therapeutic suggestion has not effect on postoperative morphine requirements.  Anesth Analg. 1996;  82 148-152
• 48 Williams A R, Hind M, Sweeney B P, Fisher R. The incidence and severity of postoperative nausea and vomiting in patients exposed to positive intra-operative suggestions.  Anaesthesia. 1994;  49 340-342
• 49 Lebovits A H, Twersky R, McEwan B. Intraoperative therapeutic suggestions in day-case surgery: are there benefits for postoperative outcome?.  Br J Anaesth. 1999;  82 861-866
• 50 Bonke B, Schmitz P I, Verhage F, Zwaveling A. Clinical study of so-called unconscious perception during general anaesthesia.  Br J Anaesth. 1986;  58 957-964
• 51 Woo R, Seltzer J L, Marr A. The lack of response to suggestion under controlled surgical anesthesia.  Acta Anaesthesiol Scand. 1987;  31 567-571
• 52 Dawson P, van Hamel C, Wilkinson D, Warwick P, O'Connor M. Patient-controlled analgesia and intra-operative suggestion.  Anaesthesia. 2001;  56 65-69
• 53 Bonke B. Psychological consequences of so-called unconscious perception and awareness in anaesthesia. Bonke B, Fitch W, Millar K Memory and Awareness in Anaesthesia. Amsterdam: Swets and Zeitlinger 1990: 197-218
• 54 Bennett H L. Influencing the brain with information during general anaesthesia: A theory of ‘unconscious hearing’. Bonke B, Fitch W, Millar K Memory and Awareness in Anaesthesia. Amsterdam: Swets and Zeitlinger 1990: 50-56
• 55 Cheney F W. The American Society of Anesthesiologists Closed Claims Project: what have we learned, how has it affected practice, and how will it affect practice in the future?.  Anesthesiology. 1999;  91 552-556
• 56 Domino K B, Posner K L, Caplan R A, Cheney F W. Awareness during anesthesia: a closed claims analysis.  Anesthesiology. 1999;  90 1053-5061
• 57 Domino K B. Closed malpractice claims for awareness during anesthesia.  ASA Newsletter. 1996;  60 14-17
• 58 Ranta S, Ranta V, Aromaa U. The claims of compensation for awareness with recall during general anaesthesia in Finland.  Acta Anaesthesiol Scand. 1997;  41 356-359
• 59 Lehmann A, Thaler E, Boldt J. Ist es sinnvoll, die Narkosetiefe zu messen? - Ein Versuch der Marktübersicht über die kommerziell erhältlichen Geräte zur Messung der Narkosetiefe.  Anästhesiol Intensivmed Notfallmed Schmerzther. 2001;  36 683-692
• 60 Kochs E, Schneider G. Kann die Narkosetiefe gemessen werden?.  Anästhesiol Intensivmed Notfallmed Schmerzther. 2001;  36 661-663
• 61 Ghoneim M M. Awareness during anesthesia.  Anesthesiology. 2000;  92 597-602
• 62 Le Doux J. The emotional brain: The mysterious underpinnings of emotional life. New York: Touchstone 1996
• 63 Arkhipov VI. Memory dissociation: the approach to the study of retrieval processes.  Behav Brain Res. 1999;  106 39-46
• 64 Dixon N F. Unconscious perception and general anaesthesia.  Baillieres Clin Anaesthesiol. 1989;  3 267-289
• 65 Le Doux J E. Cognitive-emotional interactions in the brain.  Cognition and emotion. 1989;  3 267-289
• 66 Murphy S T, Zajonc R B. Affect, cognition, and awareness: affective priming with optimal and suboptimal stimulus exposures.  J Pers Soc Psychol. 1993;  64 723-739
• 67 Bennett H L. Memory for trauma surgery: Trauma victims talk back. Bonke B, Fitch W, Millar K Memory and Awareness in Anaesthesia. Amsterdam: Swets and Zeitlinger 1990: 237-243
• 68 Bennett H L. Treating psychological sequelae of awareness.  ASA Newsletter. 1994;  58 12-15
• 69 Payne J P. Awareness and its medicolegal implications.  Br J Anaesth. 1994;  73 38-45
• 70 Sebel P S. Awareness during general anesthesia.  Can J Anaesth. 1997;  44 R124-130