I STUDI PUSTAKA I

Kesadaran Intraoperaf dalam Anestesi Umum dan Pembentukkan Post-traumac Stress Disorder
Intra-operave Awareness in General Anesthesia and the Development of Post-traumac Stress Disorder
Maria Blandina ABSTRACT Intra operave awareness can be dened as the unexpected and explicit recall by paents of intra operave events that occur during general anesthesia. It is a complicaon of surgical general anesthesia that is oen overlooked. Conscious awareness with explicit recall has been known to potenally result in severe long-term psychological sequelae such as PTSD. The incidence rate for intra operave awareness in general surgical populaon varied between 0.10% and 1.0% (with an excepon of 0.0068% incidence rate reported in one study). Larger percentages were esmated for paents undergoing cesarean secons and cardiac surgeries with incidence rates of 0.26% and 0.5%, respecvely. The majority of cases were discovered within days or weeks aer the operaon and auditory percepon was the most common complaint reported by paents in the studies. The incidence of PTSD following awareness was found inconclusive due to the limited number of studies invesgang psychological sequelae of intra operave awareness and conicng results between the studies performed. Awareness detecon should be included in clinical rounes with the aim of improving anesthec pracce and postoperave professional psychiatric assessment and follow-up should be established as standard pracce for those in need of further assistance aer experiencing intra operave awareness. Keywords: general anesthesia, sequelae, psychological; post-traumac stress disorder; awareness, intra operave; incidence. ABSTRAK Kewaspadaan intraoperaf (intra operave awareness) didenisikan sebagai kemampuan pasien untuk mengingat kembali secara eksplisit periswa-periswa yang berlangsung pada saat pasien dalam pengaruh anestesia umum. Hal ini merupakan komplikasi dari anestesia umum yang sering sekali terabaikan. Kewaspadaan yang disertai ingatan eksplisit akan periswa-periswa intraoperaf berpotensi mengakibatkan gejala psikologis berat jangka panjang seper Post-Traumac Stress Disorder (PTSD). Insiden kewaspadaan intraoperaf pada bedah umum bervariasi antara 0,1% dan 1,0% (dengan pengecualian angka insiden 0,0068% pada satu literatur). Persentase lebih besar didapatkan pada caesarean secon dan bedah jantung dengan angka insiden 0,26% dan 0,5%. Kebanyakan dari kasus ditemukan beberapa hari hingga beberapa minggu setelah operasi dan persepsi auditorik merupakan keluhan yang paling sering dilaporkan oleh pasien. Insiden PTSD setelah terjadinya kewaspadaan intraoperaf belum dapat disimpulkan dikarenakan terbatasnya jumlah studi yang menginvesgasi gejala psikologis setelah kewaspadaan intraoperaf dan angka-angka insiden yang bertentangan yang didapatkan dari studi-studi yang telah dilakukan. Deteksi kewaspadaan intraoperaf seharusnya diikutsertakan dalam runitas klinik dengan tujuan meningkatkan kualitas pelayanan anestesia, dan evaluasi psikiatrik pascaoperaf dan follow up seharusnya ditetapkan sebagai standar praktek anestesia bagi mereka yang membutuhkan penanganan lebih lanjut setelah mengalami kewaspadaan intraoperaf. Kata Kunci: anestesia, umum; sequelae, psikologis, posttraumac stress disorder; awareness, intra operaf; insidens. INTRODUCTION Intra operave awareness can be dened as the unexpected and explicit recall by paents of intra operave events that occur during general anesthesia.1 It has been recognized as a complicaon of general anesthesia since 1846 when William Morton successfully demonstrated the use of ether but overlooked the paents recollecon of the surgery.2,3 The types of intra operave awareness differ from one paent to another and can usually be characterized by the duraon of awareness, whether or not pain and/or anxiety are experienced, and whether or not the paent is able to explicitly recall of the event.4 The worst and most feared cases of intra operave awareness are those of awake paralysis where the paents are fully aware for a prolonged period of me, subjected to pain and anxiety,

Maria Blandina
Department of Anesthesia and Pain Management The Royal Melbourne Hospital

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Developement of Post-traumatic Stress Disorder Table 1. Studies evaluang incidence of awareness between 1990 and 2008 Study (CounDates Design Sample Populaon try) performed size
Sandin et al. (Sweden) Myles et al. (Australia) Wennervirta et al. (Finland) Errando et al. (Spain) 1997-1998 Prospecve cohort study Prospecve cohort study Prospecve crossseconal study 11,785 All paents > 15 yo who have had GA All paents receiving GA (excluding obstetrics and paediatrics) All paents > 15 yo undergoing surgery using general anesthesia All paents > 15 yo scheduled for elecve or urgent surgery requiring GA, excluding cardiac surgery and paents transferred to Crical Care Unit All cardiac surgery paents

Kesadaran Intraoperatif dalam Anestesi Umum dan Pembentukkan Post-traumatic Stress Disorder I Intraoperative Awareness in General Anesthesia and the

1993-1999 April 1998-June 1999

10,811 3,843

April 1995-April Prospecve obser1997 & Decem- vaonal study ber 1998-November 2001 January 1995-January 1996 June 2005 January 2007 April 2001 December 2002 Prospecve crossseconal study Prospecve observaonal study Prospecve, nonrandomized, cohort study Prospecve observaonal study

4,001

Ranta et al. (Finland) Paech et al. (Australia) Sebel et al. (USA)

929

1,095

All women > 18 yo undergoing Caesarean Secon under GA All paents > 18 yo receiving GA, normal mental status, able to provide informed consent. All paents > 18 yo who underwent GA

19,575

Pollard et al. (USA)

177,468

GA = General Anesthesia yo = years old

January 2002 December 2004

1. 2. 3. 4. 5.

Table 2. Modied Brice interview10 What is the last thing you remember before going to sleep? What is the rst thing you remember waking up? Do you remember anything between going to sleep and waking up? Did you dream during your procedure? What was the worst thing about your operaon?

and able to fully recall the experience aerwards. The majority of awareness cases, however, are brief and without experience of pain/anxiety.4 The causes of awareness are sll uncertain and the problem is thought to be mul factorial. However, there are a few plausible causes that may explain the occurrence of awareness. Firstly, central nervous system target receptors may have inherited variability in their expression and/or funcon, which may result in unpredictable paent-specic variability in dose requirements of anesthec drugs. The basis underlying this theory is yet to be elucidated, but

preclinical studies involving mice have uncovered a genec deciency in one type of receptor for the inhibitory neurotransmier g-aminobutyric acid (GABA) that presented resistance to the memory-blocking properes of etomidate. Secondly, low physiologic reserves (e.g. poor cardiac funcon, severe hypovolemia) may render the paents less capable of tolerang an amnesic level of anesthesia because it may catastrophically worsen their state of hypotension. Insucient anesthec drugs could then result in awareness. Thirdly, a pacemaker or drugs such as -blockers may conceal the physiologic characteriscs that normally indi-

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cate the need for a dose change. And lastly, equipment malfuncon or misuse may compromise drug delivery systems pung the paents at risk for awareness.1 Previous studies have shown that the incidence of awareness in general anesthesia is approximately 0.18% when neuromuscular blockers are used and 0.10% in the absence of such drugs.5,6 Assessing anesthec depth when muscle relaxants are used is parcularly dicult because of the absence of motor responses to smuli.4 Muscle paralysis is perhaps the reason for higher incidence of awareness in view of the fact that the paents are unable to signal the anesthests when they are aware. Conscious awareness with explicit recall have been known to result in paent dissasfacon on anesthec care, distress, and potenal long-term psychological symptoms.6,7 Although the numbers are not similar in all studies performed, approximately 56% of paents experiencing conscious awareness during general anesthesia have been found to develop PTSD as a complicaon.7 The characterisc symptoms of PTSD include depression, anxiety aacks, sleep disorders, and ashbacks and nightmares of the traumac experience. PTSD have also been known to be diagnosed in paents without explicit recall of the events but develop symptoms such as recurrent dreams about being buried alive which indicate that intra operave awareness may have occurred.4 In a sense, suerers of PTSD are incapable of leaving the event behind. In 1982, Turnstall and Lowit8 gave an account of a paent who developed sleep phobia aer experiencing conscious awareness with pain during general anesthesia for a caesarean secon. This paent experienced a sense of panic and a sinking feeling when lying on her back, had recurrent nightmares, diculty going to sleep, and felt unable to breathe when she nally fell asleep. This problem dramacally altered her life and personality in the years that followed. This review aims to assess the incidence of intra operave awareness in general anesthesia and the psychological impact and psychiatric sequelae that may develop aerwards, with the intenon of increasing our knowledge about intra operave awareness, awareness-induced PTSD, and ways of prevenng such an unfortunate event from occurring. This review begins by summarizing research on the incidence of intra operave awareness and invesgates psychological symptoms following intra operave awareness. Further discussion then focuses on monitoring awareness in general anesthesia, risk factors for awareness, and strategies for prevenng awareness and the development of PTSD in paents with conscious awareness and recall. METHODS The literature search was conducted using computerized databases including PUBMED, The Cochrane Library, and MEDLINE in order to idenfy the relevant arcles that have been published unl April 2009. Arcles were retrieved using the keywords: awareness AND general anesthesia, awareness AND general anesthesia AND posraumac stress disorder, and also intra-operave awareness AND psychological sequelae. The search was limited to studies that were published in English and

used human adult subjects. Publicaons on pediatric cases were excluded because awareness in children has not been reported to result in PTSD. This may be caused by the difference between a childs expectaons of surgery than an adults in which an adult would expect to be fully unconscious without any memory throughout the procedure. The reported incidence of hosle behavioral changes and sleep disturbances of children who suered intra operave awareness was found to be not signicantly dierent than those in children without awareness.9 A total of sixty-seven arcles were acquired by the search and only seven arcles met the inclusion criteria. Abstracts were read thoroughly before complete arcles were obtained and the references from the relevant publicaons were manually explored to ascertain further potenal arcles. In the end, eleven publicaons were reviewed, including one literature review. RESULTS All available literature on awareness in general anesthesia and PTSD were considered for inclusion in the review. Prospecve randomized controlled trials and metaanalyses were originally preferred for the review; however, given the absence of level I (NHMRC guidelines) and scarcity of level II (NHMRC guidelines) evidence, observaonal studies on awareness in general anesthesia, case series and cohort studies were also considered. Retrospecve reviews and expert opinion were not eliminated. Study Designs The majority of selected studies evaluated the incidence of awareness (Table 1) and only a few addressed psychological sequelae of intra operave awareness. These studies employ dierent strategies in discovering the incidence of awareness and PTSD. Sandin et al.5 invesgated the possibility of awareness or awake paralysis in 11,785 paents who had undergone general anesthesia. Interviews were performed by trained sta using the Brice modied interview (Table 2) and took place before the paent le the post-anesthesia care unit (PACU); 1-3 days aer; and 7-14 days aer the surgery. A similar method was also used by Sebel et al.10 in interviewing 19,575 paents in the recovery room and follow-up interview up to two weeks following the surgery. Errando et al.11 also used a similar strategy (with the excepon of ulizing their own structured interview) when interviewing 4,001 paents in PACU immediately aer the surgery and follow-up interviews to conrm awareness episodes on the seventh and thireth day aer surgery. In another study conducted in Australia, Myles et al.12 calculated the incidence of awareness when evaluang paents sasfacon with anesthesia. Their interviews took place within 24 hours aer the surgery and the paents were asked whether they were sased, somewhat dissased, or dissased with the anesthec service they had received. The reasons for paents dissasfacon were further explored aerwards. Another study by Wennervita et al.13 aimed to assess the incidence of awareness and recall during general anesthesia in outpaent surgery and used inpaents

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Developement of Post-traumatic Stress Disorder

as controls. A total number of 1500 outpaents and 2343 inpaents were interviewed during their stay in the recovery room using a modied version of Brice interview method. Those found to have recollecons in the recovery room were reinterviewed by one of the researchers on the same day or the following day and later reinterviewed for the third me by phone within 12-24 months aer the operaon to evaluate the possibility of psychological sequelae that may follow (e.g. sleep disturbances, anxiety, depression, preoccupaon with death). Paech et al.14 also used modied Brice interview method in assessing 1095 cases of cesarean secon under general anesthesia for incidence of awareness and recall. Paents were interviewed at two occasions; the rst 2-6 hours postoperavely and the second at least 48 hours aer surgery (but before being discharged from the hospital). Brice modied interview was also used by Ranta et al.15 in evaluang paents conscious recollecons from cardiac surgery. Nine hundred and twenty nine paents were interviewed within postoperave days 1 to 18. Incidence of Awareness In 2000, Sandin et al.5 reported that aer interviewing 11,785 paents who had undergone general anesthesia, it was established that the rate of incidence of intra operave awareness was 0.18% in cases where neuromuscular blockers were used and 0.10% in the absence of those drugs. A similar incidence of awareness (0.11%) was also reported by Myles et al.6 on the same year when invesgating risk factors for paents dissasfacon aer anesthesia. Sebel et al.10 later conrmed that percentage with an overall incidence of 0.13% in 19,575 paents in a mulcenter study in the United States of America. This rate is equivalent to 1 to 2 cases of intra operave awareness in every 1000 paents who receive general anesthesia. However, Errando et al.11 reported an incidence rate as high as 1.0% among 4,001 interviewed paents or 0.8% if emergency paents were excluded, which is comparable to 8 to 10 cases in every 1000 paents receiving general anesthesia. An exceponally low incidence of intra operave awareness was reported by Pollard et al.16 in 2007. The authors reviewed the data collected over 3-year period through a major regional medical system in the United States. A dierent, somewhat modied version of Brice quesonnaire than previously used in other studies was ulized as a method for invesgang awareness in this study and six awareness cases out of the total of 177,468 paents was found. From this result, the authors then calculated a substanally lower incidence rate of 0.0068%, which is equivalent to 1 case per 14,560 paents. Risk Factors for awareness Types of surgery A slightly higher incidence of intra operave awareness than is normally reported in the general surgical populaon had been observed by Paech et al.14 amongst the obstetric populaon of women who underwent cesarean secon. The observed rate of 0.26% conrmed that pregnant women are at high-risk of awareness. Factors that

may account for higher risk of awareness in the obstetric populaon include physiological changes during pregnancy (e.g. an increased cardiac output), which accelerate the redistribuon of intravenous anesthec agents and reduce the establishment of an adequate paral pressure of volale anesthec agent, and lighter general anesthesia which is usually given for obstetric paents to avoid the depressant eects of volale agents on the newborn and on the uterine musculature aer delivery. 14, 17 Another group of paents with high-risk of awareness are those undergoing cardiac surgery. The main reason for the increased risk is that general anesthesia in cardiac surgery may rely only on opioids and benzodiazepines while volale agents may oen be avoided in paents who already have considerable preoperave myocardial morbidity and those who may develop complicaons (e.g. coagulaon problems) aer bypass surgery.17 A study by Ranta et al.15 invesgated the incidence of awareness with postoperave recall by surveying the experience of 929 cardiac surgery paents. They reported an incidence of 0.5% when only the paents with objecve recollecons were included which was sll a higher incidence compared to those in general surgical populaons. However, the authors claimed that the incidence rate was similar to those in non-cardiac surgery populaons. Hypovolemic trauma paents also have a signicantly increased risk of awareness even though they become more hypotensive with the administraon of anesthec drugs from which cerebral perfusion is expected to decrease and therefore, theorecally, should reduce awareness17. Postoperave recall, however, has been known to occur despite signicant hypotension during resuscitaon 17 . The incidence rate of awareness in trauma paents could not be obtained due to the lack of awareness studies assessing this group of paents. Paent variability A previous history of awareness and history of difcult intubaon, which could be discovered preoperavely, are both factors which signicantly increase the risk of awareness and may therefore inuence anesthec requirements. Less readily idenable and more complex factors, such as genecs, paent physiology, and drug interacons may also play a role in the variability of response to anesthecs. Chronic use of alcohol, opioids, sedaves, and the acute use of amphetamines may increase anesthec drugs doses required to produce and maintain anesthesia.17 Age and Gender Minimum alveolar concentraon (MAC) is the standard measurement used to determine the potency of inhaled anesthec drugs. MAC increases as age decreases and therefore larger inhaled concentraons of volale anesthecs are required in order to maintain the state of unconsciousness in young paents.18 An increase in anesthec requirements in young paents compared to elderly paents suggest that younger paents are more likely to suffer from awareness.17 In fact, a higher incidence of awareness among children has been reported in the literature. A

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prospecve study of awareness by Davidson et al.18 involving 864 children undergoing general anesthesia at the Royal Childrens Hospital in Melbourne, Australia, established an incidence rate of 0.8% which is equivalent to 8 awareness cases in every 1000 children. However, unlike adult cases of awareness, no signs of distress were observed in children who experienced awareness and the postoperave behavioral disturbances are comparable to those who did not experience awareness. Gender is also a risk factor for awareness. Women are found to be more likely to report intra operave awareness and they also recover from anesthesia more rapidly compared with men which suggests that women may be less sensive to the eects of anesthec agents.17 Incidence of PTSD following intra operave awareness Lennmarken et al.19 performed a follow-up study to invesgate the long-term mental eects of awareness by quesoning the 18 paents idened by Sandin et al.5 in the study published two years prior. Only nine out of 18 paents were available for evaluaon (six of them declined to parcipate) and four out of those nine paents were found to have severe psychiatric/psychological symptoms. All four paents could recall in detail their traumac events of awareness and the memories showed no propensity to diminish. They revealed common symptoms of PTSD such as re-experiencing events, feelings of fear and helplessness, ashbacks, panic aacks, anxiety, diculty concentrang, irritaon, insecurity, sleep disturbances and nightmares. All four of them armed that these symptoms had caused impairment in their social lives for the whole 2 years following the surgery. Samuelsson et al.7 reported 46 paents who had experienced awareness under general anesthesia earlier in their lives in a cohort of 2,681 paents. Thirty one of them denied any late psychological symptoms while the remaining 15 paents experienced nightmares, anxiety, and ashbacks. These symptoms faded within 2 months in 9 out of those 15 paents and persisted only in the form of nightmares and ashbacks for years in the other 4 paents. The remaining two paents developed severe mental problems and underwent psychiatric therapy. However, only one of the two paents was diagnosed with PTSD (while the other was diagnosed with schizophrenia) and whether or not it was caused by intra operave awareness was obscured by the fact that she had been exposed to extreme mental stress earlier in her life. An incidence rate of 56.3% for PTSD following awareness was accounted by Osterman et al.20 aer interviewing 16 subjects who were recruited from adversements in newspapers, iers in hospitals, self-referred following print and television news stories, or referred by an anesthesiologist. Subjects reported signicant postoperave distress during their awareness episode, with most common and intense experiences of feeling unsafe and helpless, abandoned by his/her doctors and nurses, feeling betrayed by his/her doctors and nurses, terror, and inability to communicate. Nine out of the sixteen subjects met the DSM-IV diagnosc criteria for PTSD with funconal impair-

ment years aer suering intra operave awareness. However, the study is weakened by potenal selecon bias. The more credible percentage was previously established by Schwender et al.21 aer interviewing two groups of paents with experience of awareness during general anesthesia (21 paents who answered to adversement and 24 paents who were referred by colleagues from three large hospitals involved in the study). Twentytwo of 45 paents (50%) were found to suer aer eects of their awareness episode (e.g. reluctance to undergo future anesthesia and operaons, suered anxiety during the day, and had nightmares at night) and three of them (6.6%) developed PTSD syndrome. Schwender et al. also discovered that, during the awareness episode, visual percepon was reported by nearly 50% of paents and an incidence of pain percepon of 25% with 17.8% of paents suering severe pain localized in the area where the pain smuli occured. All 45 paents reported auditory percepon during their episodes: 20 paents could recall the remarks made by the surgical team that were emoonally relevant to them (e.g. derogatory remarks) while the other 25 paents only recalled theatre conversaons and noises. Prevenon of intra operave awareness and PTSD The rst line of awareness prevenon starts with preoperave assessment. Paents at high risk of awareness should be idened in the pre-admission clinic and their management should be planned aerwards.2 Paents at risk of awareness include those having high-risk of awareness surgery (e.g. cardiac surgery and cesarean secon) or surgery associated with signicant blood loss, paents who are medicated with signicant doses of sedaves and analgesic drugs, and paents with previous history of awareness.2 This group of paents should be provided with informaon about awareness and assured that there would be eorts to prevent such an unfortunate event from happening.2 BIS Monitoring The bispectral index system (BIS) is an apparatus created to indirectly monitor hypnoc depth and anesthec drug concentraons in general anesthesia by processing electroencephalogram data through a proprietary algorithm, which is then displayed as a calculated dimensionless parameter between 0 and 100 (with 40 to 60 considered appropriate for general anesthesia).2, 12 BIS monitor was the rst device approved by the US Food and Drug Administraon for monitoring anaesthesic depth and it has the capability of reducing the incidence of awareness by alerng the anaesthests when the depth of anesthesia is inadequate. A randomized double-blind controlled trial by Myles et al.12 showed that BIS monitoring could reduce the incidence of awareness by 82% in at-risk adults undergoing relaxant general anesthesia. It also conrmed that awareness during BIS monitoring is less common than during roune care. However, Avidan et al.22 challenged this nding by proposing that BIS monitoring was not proven to be more benecial than a protocol based on end-dal anesthec gas (ETAG) concentraons for prevenng anesthesia aware-

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Kesadaran Intraoperatif dalam Anestesi Umum dan Pembentukkan Post-traumatic Stress Disorder I Intraoperative Awareness in General Anesthesia and the

Developement of Post-traumatic Stress Disorder

ness. However, the study was under-powered to draw any conclusions as there were only two cases of awareness in each group. Beta-Blockers Salomons et al.23 presented two cases of PTSD that persisted for years aer intra operave awareness in which the pain symptoms that they re-experienced were similar in locaon to the pain they had felt during their episodes of awareness. These two cases suggested that some smuli that were associated with the trauma may have triggered pain ashbacks and this could be further denoted as fear condioning that may have occurred around the me of trauma.23 Pitman et al.24 proposed that adrenaline release at the me of a psychologically traumac event could iniate an exaggerated emoonal memory and fear condioning which consequently manifest as PTSD symptoms. Given this theory, administraon of propanolol to block -adrenergic receptors immediately aer a traumac event could have a prophylacc eect. A double-blind, placebocontrolled pilot study24 proved that a course of propranolol which begun shortly aer an acute traumac event is effecve in reducing PTSD symptoms 1 month later. Further studies, however, are sll required to reassure this nding. DISCUSSION The word anesthesia originated from the Greek word anaisthsia which literally means loss of feeling or sensaon. 25 Indeed, the aim of anesthesia is to arcially induce the loss of physical sensaon, most especially pain, with or without loss of consciousness through the administraon of various anesthec drugs, gases, and any other anesthec agents. The fundamental role of an anaesthest in general anesthesia is therefore to keep a paent in a state of unconsciousness in conjuncon with complete loss of physical sensaon. Unfortunately, mulple factors may at mes fail anaesthests to achieve this idyllic goal and consequently result in awareness. This review found the incidence rate for intra operave awareness in general surgical populaon varied between 0.10% and 1.0% (with an excepon of 0.0068% incidence rate reported in one study 16 and equivalent to 1 to 10 awareness cases per 1000 paents. 5, 6, 10, 11 Larger percentages were esmated for paents undergoing cesarean secons and cardiac surgeries with incidence rates of 0.26% 14 and 0.5% 15, respecvely, which are comparable to 3 and 5 awareness cases per 1000 paents. The most common complaint reported by paents in these studies was auditory percepon, whether it was the voices of the surgeons conversing with other members of the surgical team or barely audible noises in the background. Other complaints include loss of motor funcon, feeling of imminent death, feeling helpless, anxiety, panic, and pain. Most awareness cases in the studies were detected using a modied Brice interview quesonnaire (Table 2) and enquired during the paents stay at the PACU and repeated at intervals of days and weeks aer the surgery. The majority of awareness cases were discovered within days or weeks aer the op-

eraon and not while the paents were in the PACU, which showed that paents recollecons of their awareness episode oen gradually emerged over me. The eects of residual anesthecs and the paents divided aenon in the early recovery period (which is usually more focused on common symptoms such as pain and nausea) are the main causes for delayed recollecons.17 Addionally, the trauma of conscious awareness may have dissociave effects on the paents mental state that leads to the division of memory of the event into sensory fragments and agonizing emoonal states, which consequently hinders these paents from fully recounng their experience. 17 The greatest concern surrounding intra operave awareness is the severe long-term psychological sequelae that may develop aerwards. The extent of psychological impact on paents following intra operave awareness varies individually. Some may only experience short-term psychological disturbances such as nightmares and diculty sleeping which are resolved within a few weeks, while others may develop debilitang long-term psychiatric disorder such as PTSD. Four studies that invesgated the psychological sequelae of awareness found incidences of PTSD in 22.2% 19, 56.3% 20 and 6.6% 21 of awareness cases. Limited number of studies and the potenals for selecon bias in the studies performed restrict the condence to draw any conclusions on the true incidence of PTSD following intra operave awareness. The development of PTSD in awareness may be due to inescapable stress situaon while paents are conscious of intra operave smuli. 26 Failure of escaping stressful event through normal ght or ight response results in passive coping mechanism or dissociaon. 26 Paents who suer from dissociaon would appear expressionless, silent, and indierent toward their surroundings. 20 They oen also appear calm and seemingly non-traumazed by the experience.20 Coping mechanism through parasympathec acvity would show reduced heart rate as a physical sign.20 A dissociave state around the me of trauma where the paents are incapable of narrang their experience as a result of fragmented memory is a signicant long-term predictor for the development of PTSD.27, 28 Van der Kolk & Fisler 27 explained that considerable narrowing of consciousness occur when people feel threatened. This narrowing of consciousness may advance toward loss of memory for parts or for the enre experience when an individual is traumazed, leaving him or her unable to give coherent account of the event. Some aspects of the trauma may invade consciousness when the person fails to organize the traumac memory into a narrave and results in terrifying percepons, obssessional preoccupaons, and somac reexperiences of the event.27 The three main characteriscs of PTSD are: 1). re-experience, 2). avoidance, and 3). hyperarousal.26 Reexperiencing usually happens in the form of nightmares and ashbacks in which they would re-experience paralysis, auditory percepon, sense of helplessness and anxiety, and somemes even feel the pain of surgical smuli.20 Re-experiencing is usually triggered by reminders that resemble their traumac situaon such as the state of light sleep or

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MARIA BLANDINA

the process of falling asleep, sounds of clinking silverware, or smell of alcohol.26 Re-experiencing and insomnia are the two most common complaints reported by postawareness paents in the studies. Postawareness paents have also been known to avoid cues and situaons that would confront them with their traumac memories such as hospitals, medical workers, television programs with hospital themes, and some even develop sleep phobias.8, 20 Avoiding these cues and situaon may oen prevent these paents from inquiring aercare and discussing their experience with medical personnel.26 Avoidance was perhaps the reason for paents refusal to parcipate in the two year follow-up study by Lennmarken et al19. For this same reason, paent recruitment through adversements to invesgate PTSD would be largely ineecve. Physiological hyperarousal symptoms in PTSD include easy startle, hypervigilance, and irritability.20 A paents understanding of their experience is crucial in prevenng psychological morbidity in postawareness paents.4 When awareness is suspected to have happened during a surgery, anaesthests or surgeons should clarify with the paent the reasons why awareness occurred and reassure that it is unlikely to happen again in the future.1 It should also be noted that, when awareness is suspected to be occurring during a procedure, speaking to the paents and telling them that the surgical team is aware that they are awake and that they are geng help would signicantly diminish the traumazing eect of the experience.20, 26 Validaon by medical personnel of the actuality of the traumatic experience has been reported to prevent the development of PTSD and even diminish or stop PTSD symptoms.4, 26 In conclusion, social support and acknowledgement are the most vital protecve factors against the development of PTSD in paents suering intra operave awareness.26 Further studies on intra operave awareness are necessary to establish more accurate prevalence, expand our comprehension on its psychological impact, improve detecon of awareness, and develop eectual treatment.26 Creang a registry for postawareness paents similar to the one established by The American Society of Anesthesiologists (www.AwareDB.org) would prove benecial to increase our knowledge of awareness from direct paent reports. This program would also be a useful way to educate paents by providing helpful informaon on awareness. Finally, educaon on intra operave awareness for surgical and anesthesia teams is necessary to further understand the issue as well as gaining knowledge of managing such an event. CONCLUSION It is crucial for surgical and anesthesia teams to acknowledge the reality of surgical experience and recognize the emoonal impact on paents. For a variety of reasons, paents rarely report awareness and their suerings oen le unrecognized. The propensity for avoidance rather than inquiring assistance in these paents makes it necessary to include awareness detecon in clinical rounes with the aim of improving anesthec pracce. Awareness assess-

ment should be an ongoing process that begins in the recovery room and connued through to follow-up visits with the surgeons. Awareness-induced PTSD should be considered for any paent with psychiatric complains following surgery and therefore connuous postoperave assessment is vital in discovering the maer. A thorough perioperave management of anesthesia is crucial in prevenng intra operave awareness and postoperave professional psychiatric assessment and follow-up should be established as standard pracce for those in need of further assistance aer experiencing intra operave awareness. KEY POINTS Intra operave awareness can be dened as the unexpected and explicit recall by paents of intra operave events that occur during general anesthesia. The causes of awareness are sll uncertain and the problem is thought to be mul factorial. The extent of psychological impact on paents following intra operave awareness varies individually; some may only experience short-term psychological disturbances, while others develop debilitang long-term psychiatric disorder such as PTSD. Re-experience, avoidance, and hyperarousal are the three main characteriscs of PTSD. Further studies on intra operave awareness that aim to establish more accurate prevalence, expand our comprehension on its psychological impact, improve detecon of awareness, and develop effectual treatment are indispensable. REFERENCES 1. Orser BA, Mazer CD, Baker AJ. Awareness during anesthesia. Canadian Medical Associaon Journal. 2008;178(2):185-8. 2. Myles PS. Prevenon of awareness during anesthesia. Best Pracce & Research Clinical Anaesthesiology. 2007;21(3):345-55. 3. Lennmarken C, Sydsjo G. Psychological consequences of awareness and their treatment. Best Pracce & Research Clinical Anaesthesiology. 2007;21(3):357-67. 4. Forman SA. Awareness during general anesthesia: concepts and controversies. Seminars in Anesthesia, Perioperave Medicine and Pain. 2006;25:211-8. 5. Sandin RH, Enlund G, Samuelsson P, Lennmarken C. Awareness during anesthesia: a prospecve case study. The Lancet. 2000;355:707-11. 6. Myles PS, Williams DL, Hendrata M, Anderson H, Weeks AM. Paent sasfacon aer anesthesia and surgery: results of a prospecve survey of 10,811 paents. British Journal of Anesthesia. 2000;84(1):6-10. 7. Samuelsson P, Brudin L, Sandin RH. Late Psychological Symptoms aer Awareness among Consecuvely Included Surgical Paents. Anesthesiology. 2007;106(2632). 8. Turnstall M, Lowit I. Clinical curio: sleep phobia af-

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Kesadaran Intraoperatif dalam Anestesi Umum dan Pembentukkan Post-traumatic Stress Disorder I Intraoperative Awareness in General Anesthesia and the

Developement of Post-traumatic Stress Disorder

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24. Pitman R, Sanders K, Zusman R, al. e. Pilot Study of Secondary Prevenon of Posraumac Stress Disorder with Propanolol. Biological Psychiatry. 2002;51:189-92. 25. ENCARTA. Encarta World English Diconary [North American Edion]. Bloomsbury Publishing Plc.; 2009 [updated 2009; cited 2009 May 19th]; Available from: hp://encarta.msn.com/diconary_1861585551/anesthesia.html. 26. Osterman JE, van der Kolk BA. Awareness During Anesthesia and Posraumac Stress Disorder. General Hospital Psychiatry. 1998;20:274-81. 27. Van der Kolk BA, Fisler R. Dissociaon and the Fragmentary Nature of Traumac Memories: Overview and Exploratory Study. Journal of Traumac Stress. 1995;8(4):505-25. 28. Davidson A. Consequences of Awareness. Australian and New Zealand College of Anaesthests; 2005 [updated 2005; cited 2009 May 20th]; Available from: http://www.anzca.edu.au/events/asm/asm2005/davidsona_awareness-1.htm.

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