Intraoperative Awareness Linked to Posttraumatic Stress Disorder

Patients with confirmed episodes of consciousness during surgery have high rates of psychological problems including posttraumatic stress disorder (PTSD), even several years after the incident, reports a study in the March issue of Anesthesia & Analgesia, official journal of the International Anesthesia Research Society (IARS).

Another study finds that patients with very deep anesthesia shown on brainwave activity monitoring are at increased risk of heart attack, stroke and death. The studies add important new evidence for the debate over the use of brainwave monitoring to prevent intraoperative awareness while avoiding the side effects of excess anesthesia.

“Deep anesthesia is associated with an increase in side effects and slow recovery, so anesthesiologists try to keep patients just on the ‘asleep’ side of a grey zone that separates unconsciousness from consciousness,” Steven L. Shafer, MD of Columbia University, said in a press release. “There is scientific and clinical debate whether the anesthesiologist can trust these new devices enough to give the patient less drug, as opposed to simply pouring in enough anesthetic to be assured the patient is asleep.”

In the landmark “B-Aware” study, including nearly 2,500 patients, a technique called bispectral index (BIS) monitoring significantly reduced the risk of confirmed intraoperative awareness. There were two cases of awareness in patients undergoing BIS monitoring, compared to 11 of those operated on without monitoring.

One of the new studies evaluated the long-term consequences of intraoperative awareness. Five years after the episode, seven of the 13 “B-Aware” patients with intraoperative awareness were still alive, and underwent a battery of psychological tests. The results were disturbing, including a 71% rate of PTSD (compared to 12% of a group of closely matched control patients).

“Intraoperative awareness is obviously a terrible outcome, and clearly we need to do everything we can to prevent it,” Shafer said. “Should awareness occur despite our best efforts, we must engage the patient in a program of psychological rehabilitation to reduce these long-term consequences.”

A separate study of “B-Aware” patients evaluated the relationship between brainwave monitoring data and the long-term risks after surgery. Five years later, patients who had low levels of brainwave activity during their operation had a 40% increase in the risk of death. Patients who had deep anesthesia were also at twice the risk of heart attack and three times the risk of stroke.

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