Anesthesia Awareness During Surgery – A Rare But Potentially Horrifying Occurrence

The thought of being wide awake, unable to speak or move a muscle, while having major surgery performed is terrifying, more so because it has happened before an almost certainly will happen to someone again. The fact that its occurrence is less than 0.5% doesn’t help the psyche much, especially if you are a patient in the pre-op holding area contemplating their day ahead.

When given a general anesthesia a patient is administered a ‘cocktail’ of drugs most often including a mixture of: an induction agent such as propofol or sodium pentathol (the initial drug that puts you to sleep), an opiate such as fentanyl or sufentanyl, which provides analgesia (blunts the pain) as well as having a synergistic effect on the induction agent, a benzodiazepine, most commonly midazolam, which reduces anxiety and also has a synergistic effect on both the induction agent and the opiate, and finally a neuromuscular blocking agent such as succinycholine, vecuronium, rocuronium, and others. Once asleep, the patient is most often kept asleep by breathing a vaporized liquid anesthetic such as isoflurane or desflurane mixed with oxygen, room air and sometimes nitrous oxide. Total Intravenous Anesthesia is also a valid and effective technique where the patient is kept asleep using an infusion of IV drugs (propofol or sufentanyl for example). Most often, perhaps >95% of the time, general anesthesia is maintained by a mixture of an inhalation anesthetic and intermittent doses of an opiate (the Balanced Anesthesia Technique).

The neuromuscular blocking agent does not affect consciousness, but does completely paralyze the patient. The paralysis is the desired affect and the only reason these drugs are used. It facilitates the insertion of a breathing tube and control of the patient’s respiration (all of the previously mentioned anesthesia agents cause breathing to slow or cease at anesthetic doses).

Now that you know all about the anesthesia process, it is easy to immediately identify at least one obvious situation where a patient would be awake, unable to move or speak, while still being able to feel all the pain of surgery: the neuromuscular blocking agent is working, while the anesthetic is insufficient (has worn off and the current doses are inadequate to maintain the anesthetic state, whether due to an unusual patient tolerance or human or mechanical error such as an empty or malfunctioning inhalation anesthesia vaporizer). All general anesthesia patients have specific continuous, standard monitoring of physiologic systems such as blood pressure, heart rate, respiratory rate, expired carbon dioxide and blood oxygen saturation.

When anesthesia ‘lightens’ most patients will exhibit an increase in blood pressure and heart rate well before they become conscious and the anesthetic is adjusted appropriately. Expired inhalation anesthetic is also measured confirming adequate dosing. Also widely available but not as yet standard is the use of a Bispectral Index Monitoring (BIS) where sticky pads are applied to the forehead and attached to a monitor which applies a novel algorithmic analysis of the patients EEG and then produces a quantitative wave form which allows determination of level of consciousness. The theory is that the BIS will identify patients whose anesthetic is inadequate before they would wake up, thus preventing Anesthesia Awareness as well as refining the ‘art’ of anesthesia to a more exacting process.

Unfortunately some large patient studies have not shown that using BIS lowers the incidence of memory of events during anesthesia.

Certain subsets of patients are more prone to Anesthesia Awareness because of their current medical condition. Trauma patients and other patients with dangerously low blood pressures cannot tolerate usual doses of anesthesia, yet require emergency life saving surgery. Alternative IV drugs which have less effect on blood pressure such as ketamine and etomidate, can be employed as alternatives in some of these patients to produce unconsciousness without killing them…which a typical general anesthetic would do. Female patients requiring emergency c-section cannot be given usual doses of general anesthesia since the drugs readily cross into the blood stream of the fetus until the umbilical cord is clamped. A balance must always be struck between patient safety and anesthetic administered.

Anesthesia Awareness is relatively rare, but has tremendous lingering psychological effects of many who experience it. Severity depends on level and length of awareness combined with amount of pain and discomfort felt. “If anesthesia awareness does occur about 42% feel the pain of the operation, 94% experience panic/anxiety and 70% experience lasting psychological symptoms”. N. Moerman et al.,Anesthesiology;79:454-464, 1993 Anesthesia Awareness is not necessarily predictive of malpractice as it occurs absent avoidable error.

The 2007 movie “Awake” centered on a man who had Anesthesia Awareness during surgery when he heard a plot to murder him being hatched. Then award winning horror flick “Anesthesia”, whose entire plot was based on a woman experiencing Anesthesia Awareness during heart surgery, was made in 2006.

Anesthesia and Cerebral Palsy

Usually anesthesia is defined as the loss of sensitivity to pain.  In many cases, patients are given anesthesia while undergoing medical procedures that are painful.  This was there is little feeling if any at all.  As good as that sounds, there are cases where it does more harm than good.

There are many different kinds of anesthesia used for procedures; it depends on the patient and what type of procedure is being done.  Frequently known types of anesthesia are:

  • Local anesthesia
  • Regional anesthesia
  • Epidural/spinal anesthesia
  • General anesthesia

The epidural anesthesia is used during labor.  This anesthetic is injected close to the spinal cord in the nerves connected to it.  It blocks the pain from the whole area of the body, particularly the abdomen, hips and legs.

How Can Anesthesia Cause Cerebral Palsy?

Even though researchers and doctors do not know the exact cause of how anesthesia causes cerebral palsy, they know it happens.  They know the fetal heart rate drops too low; it cannot properly flow to the uterus to deliver oxygen to the body.

To repeat what was said above, the epidural anesthesia makes it difficult for the blood in the patient’s lower body to flow properly through the body.  The heart is unable to respond adequately to the changing needs of the body.  Consequently, if the anesthesia is not properly given, or if the doctor failed to monitor it, the infant could be born with cerebral palsy.

Many infants go through periods of slow heart rate when the mother is given epidural anesthesia.  Healthy infants are normally unaffected.  Infants can be harmed if there is a difficult childbirth such as a compromised position.

Cerebral Palsy Resulting from Anesthesia

An infant can develop cerebral palsy due to inefficient amount oxygen given because of the effects of anesthesia.  This is a condition that is not curable, it affects the muscles, the brain and motor functions.  The severity of the condition varies, but whatever degree of cerebral palsy someone has, it is life changing.  Treatments are given to those to help cope with the condition.

If you know someone who has cerebral palsy because of an error with the anesthesia, contact a medical attorney to learn more about your legal options.

Breast Reconstruction After Mastectomy, Lumpectomy Or Other Trauma

Techniques for reconstructing the breast after mastectomy, lumpectomy or other trauma are constantly improving. Advancements such as new tissue transfer methods, improved implants and better nipple reconstruction techniques contribute to much more natural-looking restorations than in the past. At this time, there are two basic ways of creating a new breast. One uses a breast implant in place of lost tissue, while the other transfers skin and fat from other areas on the patient’s body, such as the back, buttock or abdomen, for a breast that looks, feels and moves more naturally. Each technique offers its own set of benefits and disadvantages and can achieve very satisfactory results when used in the appropriate situation.

Expander and Implant Reconstruction
The simplest form of reconstruction uses a skin expander followed by an implant. This option can be started at the time of the mastectomy and involves the shortest hospital stay and recovery period. During the initial stage, temporary, adjustable-volume expanders are placed where the more permanent device will eventually be. The expander is filled with a small amount of saline (salt water) which is gradually increased over a period of several months to create space for the size needed.

The expansion is performed during office visits at one- to four-week intervals. Three to five expansions are generally performed, each session taking approximately five minutes. This expansion process can be performed during chemotherapy, while the implantation can be performed approximately a month after chemotherapy is complete.

The expander, which tends to sit somewhat high on the chest, is replaced by the implant in an outpatient procedure. Once in place, it is repositioned for optimal balance, and if needed, the other breast is lifted or augmented to better correspond with the reconstructed breast. This process is done under general anesthesia on an outpatient basis. Usually about two months later, the new nipple is constructed, using skin and fat taken from other areas of the body, such as that overlaying the device or from the other nipple.

Though implant reconstruction is typically the simplest procedure, requiring the shortest recovery period and hospital stay, it does have some draw backs when compared with other methods. For instance, these devices require maintenance, often needing replacement due to rupture, deflation or capsular contracture (a hardening of scar tissue surrounding the pocket). While some patients may go 15 years or longer without the need for replacement, others face replacement much more often. Saline or silicone, these devices also tend to feel and look less natural than restorations with a patient’s own tissue, but implant reconstructions do create less scarring on other parts of the body than other techniques.

Autologous Reconstruction (Using the Patient’s Own Tissue)
There are a variety of reconstructive techniques available using the patient’s own tissue to create a new breast. These techniques are more complex than implant-based restoration. They produce more scarring, require longer hospital stays and recovery periods, and can cause weakness at the donor site. They also tend to offer permanent, more natural results.

Several autologous techniques use skin and fat and possibly muscle from the patient’s abdomen, using redundant skin and fat from the area to create a new breast. These techniques include the traditional TRAM flap, the muscle-sparing free TRAM flap, and the DIEP perforator flap. Each of these procedures has its own benefits and disadvantages to be weighed before surgery.

The traditional TRAM flap technique uses fat and muscle taken from the abdominal wall. The tissue is tunneled to the chest area rather than transplanted. Though this technique uses more muscle than other autologous methods, the risk of total tissue loss is greatly reduced. There is, however a greater risk for partial tissue loss with this method, due to the inferior blood supply. The technique sometimes causes discomfort and bulging from the tunneling process as well. Because this method uses more abdominal muscle than others, greater weakening of the donor site often occurs.

An alternative to traditional TRAM flap restoration, the free TRAM flap method transplants the abdominal skin, fat and muscle to the chest, reattaching the blood vessels using microsurgical techniques. This method offers advantages such as a more robust blood supply, and the use of less abdominal muscle for potentially less weakening of the donor site. This method requires microsurgical expertise to perform, and though there a lessoned risk of partial flap loss, it does carry a risk of total flap loss due to its complexity.

The DIEP flap reconstruction method offers the benefit of sparing more visible abdominal muscle. Still there is some weakness and its degree of functional benefit has been a point of discussion. Involving more microsurgical complexity than the free TRAM flap method, this technique relies on a weaker blood supply and may not be as suitable for the creation of larger breasts or in cases involving radiation.

All abdominal autologous reconstructions require lengthier hospital stays than implant-based options, generally 5 to 7 days. They also involve lengthy abdominal scars as well as scarring around the navel, similar to tummy tuck scarring. Abdominal weakness also often occurs to some extent in the majority of these methods, sometimes resulting in bulges or hernias which need to be repaired. Though some women prefer the contour of implant restoration over autologous reconstruction, others see the look and feel of the latter option as more natural.

For those without enough redundant abdominal tissue, other options exist, including reconstruction using skin and fat from the buttock or back. Like other restoration methods, these have their own benefits and disadvantages to explore and discuss with your surgeon.

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