I. PURPOSE: To establish a process for preventing and dealing with unintended intraoperative awareness during general anesthesia.
II. POLICY STATEMENT:
NIA
III. DEFINITION OF TERMS:
ASA- American Society of Anesthesia
IV. RESOURCES:
Department of Surgery and Anesthesia
V. POLICY AUTHORITY:
CNO
VI. RELATED (SUPPORTING) POLICIES:
VI I. APPLICABILITY (Place an X next to all that apply)
WHO: _x_ Employees
Volunteers
_x_ Physicians
Others -----
SITES:
x ALL SITES
(if not all check applicable sites) Brook Park Urgicare
Brunswick Medical Center Commerce Park
Jefferson Park Lifeworks
__ Neighborhood Care Center Oakview
Health Center Main Campus Off Campus Business Locations
Home Health Hospice
__ Strongsville Medical Center
Southwest General Medical Group Physicians Offices Other_ _ _ __
BACKGROUND:
Unintended intraoperative awareness occurs when a patient becomes cognizant of some or all events during surgery, or other procedure, performed under general anesthesia, and has direct recall of those events. This does not include times before the induction of anesthesia is complete, or during intended emergence.
The incidence of awareness during general anesthesia is reported to be greater inpatients for whom a smaller-than-usual dose of general anesthetic is necessary to decrease dangerous side effects (e.g., hemodynamic instability). Procedures identified as typically falling into this category are some cardiac, obstetric, and major trauma cases. Because unintended intraoperative awareness during general anesthesia is not always preventable, health care practitioners should be prepared to anticipate, acknowledge, and manage this occurrence with compassion and diligence.
Monitoring patients during general anesthesia to prevent intraoperative awareness can be challenging. Despite a variety of available monitoring methods, awareness is difficult to recognize while it is occurring. Typical indicators of physiologic and motor response, such as hypertension, tachycardia, or movement are often masked by the use of neuromuscular blocking agents to achieve necessary muscle relaxation during the procedure, as well as the concurrent administration of other drugs necessary to the patient's management, such as beta-blockers or calcium channel blockers .
VIII. IMPLEMENTATION PROCEDURES
A) Prevention
1) Equipment maintenance.
Periodic maintenance of the anesthesia machines and its vaporizers will be performed and documented by Biomedical Technician.
B) Preoperative identification
Certain procedures may entail a higher risk of unintended intraoperative awareness and some patients with certain characteristics may be at an increased risk for the occurrence of intraoperative awareness. These include:
1) Cardiac surgery patients
2) Acute trauma patients with hypovolemia
3) Cesarean section patients under general anesthesia
4) Patients undergoing emergency surgery
5) ASA Physical Status 4 and 5 patients
6) Patients with impaired cardiovascular status
7) Patients with unanticipated difficult intubation
8) Patients with a history of awareness
9) Patients with a history of heavy alcohol intake
10) Patients with a history of chronic use of benzodiazepines, opioids or both.
11) Patients requiring TIVA (total IV anesthesia) to facilitate spinal cord monitoring
Patients considered by the anesthesiologists to present significantly higher risk for an awareness experience should be informed of the potential for awareness in preoperative discussions with their anesthesiologists.
C) Reducing the risk of intraoperative awareness during general anesthesia
The appropriate anesthesia techniques and medications are determined by clinical judgment based on each patient's unique circumstances.
1) The anesthesia provider should consider pre-medication with benzodiazepine whenever deemed appropriate, especially patients at increased risk. Adjust benzodiazepine dosage to account for individual drug tolerance.
2) If intubation of . the trachea is difficult, consideration should be given to the administration of additional dosages of the induction or amnesic agent after an initial failed attempt.
3) Anesthesia practitioners should realize that certain medications (e.g. beta-blockers , calcium channel blockers, alpha-2 agonists) and neuromuscular blocking agents may mask the hemodynamic and physiologic responses to inadequate anesthesia.
4) Long acting neuromuscular blockers should only be utilized for surgical relaxation and not to prevent unintended patient movement.
5) The use of EEG monitoring (i.e., BIS monitor) may be beneficial in patients at higher risk undergoing elective surgery.
6) Consider the use of scopolamine in hemodynamically unstable patients who cannot tolerate the use of benzodiazepine and/or normal anesthetic dosages.
7) For cardiac surgery patients, consider supplementing high dose narcotic anesthetics with some form of amnestic agent that can be hemodynamically tolerated.
D) Education of clinical staff
1) This policy and the JCAHO Sentinel Event Alert regarding anesthesia awareness (Issue 32 - October 6, 2004) will be available to all employees. (The sentinel Alert is posted on SWGHC Intranet). The Department of Anesthesia will review the policy annually to reassess ways of reducing awareness including review of new technologies.
2) Patient Interviews
a) Inpatients will be interviewed by the Anesthesia Care Team during the follow up visit.
b) Outpatients will be interviewed by Nursing during follow up post op calls. Two questions will be asked:
1. What was the last thing you remember when you went to sleep?
2. What was the first thing you remember when you woke up? The following statements may be triggers:
"This was the worst hospital experience" or "I will never undergo surgery again". Nursing may ask the patient to explain. If Intraoperative Awareness is suspected, notify Anesthesia Coordinator via pager or Control desk at 8990.
E) Managing an Episode of Unintended Intraoperative Awareness During General Anesthesia :
When an anesthesiologist learns that a patient may have had unintended intraoperative awareness of surgical or procedural events during general anesthesia, the anesthesiologist should explore, document, and report the experience and provide for any necessary follow-up care. When other personnel learn that a patient may have experienced unintended intraoperative awareness during general anesthesia, the personnel should inform the anesthesiologist of record about the suspected occurrence.
PROCEDURE FOR AN EPISODE OF UNINTENDED INTRA OPERATIVE ANESTHESIA AWARENESS DURING GENERAL ANESTHESIA:
A) Anesthesia Responsibilities
1. The Anesthesiologist responsible for the patient's care, or a qualified designee, should interview the patient.
2. Document the details of the patient's experience.
3. If the Anesthesiologist or designee determines that unintended intraoperative awareness during general anesthesia occurred, the following steps may serve to mitigate serious patient sequelae:
• Assure the patient of the credibility of his or her account and sympathize with the patient's experience.
• Explain what happened and why, if a reason can be given (e.g., the necessity to administer light anesthesia in the presence of significant cardiovascular instability).
• Offer the patient support, including referral of the patient to a psychiatrist , psychologist, or the Hospital Counseling Services if appropriate.
• Document any referrals or treatment provided to the patient.
• Notify the patient's surgeon and nurse.
• Complete an occurrence report concerning the event for the purpose of quality management.
B) Nursing Responsibility
Notify anesthesia or designee of suspected anesthesia awareness based on known triggers.
APPROVED:
Marti Bauschka
Vice President and Chief Nursing Officer Southwest General Health Center
Thomas A. Selden President and CEO
Southwest Community Health System