AORN JOURNAL
NOVEMBER 1992, VOL 5b, NO 5
President’s Message Who’s listening to whom?
I
oxide or other drugs because a laser was used n Kilgore. Tex. on March 15, 1979. the near the trachea. Postoperatively, the patient Newss-Hei.ald reported that an unconscious had posttraumatic stress symptoms (eg, not motorist was taken from his wrecked car and carried to a nearby gas station. As the victim being able to sleep through the night, being started to regain consciousness, he opened his awakened with the distinct reliving of the bumeyes and began to struggle violently. The resing pain of the laser as it cut through tissues). During surgery, she was unable to move or to cuers finally subdued him and took him to the let anyone know of this a w a ~ e n e s s . ~ hospital. In another example, a patient experienced Later, rescuers asked him why he struggled being paralyzed but awake throughout the surso vehemently. The patient said rescuers had carried him to the nearby Shell gasoline service gical procedure. S h e said she struggled to station, and someone was standing in front of scream, but she was so drugged that she could not open her eyes. She recounted the conversathe “S” when he opened his eyes.‘ tion during her surgery about the nurse’s friend Patient a w a r e n e s s a n d perception have who had just received breast implants. The surreceived increased attention as care has become gical team commented about the patient’s “nice more focused on patient responses and needs. body shape even after she had two children.” When I attended a session on this topic at the T h e y went on to say that “more husbands American Association of Nurse Anesthetists would want their wives to have children if they (AANA) conference in Denver last August. I all looked like this afterward.” The patient still was amazed to hear and read about patients remains in therapy for this traumatic experiwho appeared to be asleep during surgery but ence. She has constant nightmares and recall of who were able to recount verbatim conversathe pain of the hernia excision and tions among surgical team memrepair and the inappropriate conbers. In fact, 1 % of patients who versation that occurred during the have procedures performed under p r o c e d u r e . S h e currently is general anesthesia have some recall attempting to form a national supof the intraoperative course, with port group for patients who have rates b e t w e e n 1.5% a n d 4% in had similar shocking episode^.^ cesarean section deliveries to as T h i s patient w a s present at t h e high as 1 1% in trauma cases.? AANA conference to candidly disFor example, during a laser toncuss her experiences. s i l l e c t o m y , a p a t i e n t reported Awareness is the memory of explicit recall of being paralyzed events that have occurred during but conscious. The patient received general anesthesia in which the a propofol infusion without nitrous Kay A. Ball XLJ
AORN JOLRNAL
patient is able to recall the events postoperatively. This awareness can present in two different ways in memory. Explicit memory refers to intraoperative learning that is accompanied by postoperative recall. Implicit memory refers to learning that occurs without recall. The results of explicit or implicit memory can be termed as negative sequelae. Negative behavioral adaptations can be seen after surgery that were not present preoperatively. This type of behavior includes sleeplessness. restlessness, generalized anxiety or irritability, hallucinations, repetitive nightmares, nervousness, or other posttraumatic stress disorders.’ Anesthesiologists and nurse anesthetists need an “awareness monitor” to determine how conscious or aware the patient is during the surgical experience. Research has shown that drug levels, blood pressure. or heart rate are not sufficient markers of the patient‘s level of consciousness or adequacy of anesthesia. Some researchers have concluded that intraoperative monitoring for the possibility of awareness may be done with the isolated forearm technique, the electroencephalogram (EEG), galvanic skin response (GSR), and lower esophageal contractility measurements.h There are many disagreements, however, about the reliability of these tests. The isolated forearm method involves placing a blood pressure cuff around the a r m without an I V line.’ A f t e r t h e p a t i e n t i s induced and intubated, but before a long-acting muscle relaxant is administered, the cuff is inflated, and a taped message is given to the patient via headphones. The patient is regularly requested to move the nonparalyzed arm so the anesthesiologist o r nurse anesthetist can determine if the anesthesia level should be deepened. The tourniquet is deflated after 30 minuter to avoid pressure-induced nerve block injury. but it can be reinflated if more muscle relaxant is needed. This technique really detects wakefulness, which is not always related to recall. An EEG is expensive to perform, and it is difficult to interpret anesthesia depth with this technique. It can detect large anesthesia varia826
NOVEMBER 1992, VOL 56, NO 5
tions but is not adequate for detecting small changes. Facial movement or grimaces also are used to detect anesthesia levels. Galvanic skin response can be used to detect anesthesia lightening by measuring a change in the skin surface.8 The amount of perspiration determines the electrical conductance of the skin. Some researchers are trying to correlate skin conductance to the level of anesthesia, but results are inconclusive. Lower esophageal contractions are controlled by the esophageal motility center in the brain stem.9As anesthesia paralyzes the skeletal muscles of the upper esophagus, the smooth muscles of the lower esophagus remain active. As the concentration of anesthetic agents is increased, the rate and amplitude of the lower esophageal contractions are reduced. There are still questions about the test’s reliability. Awareness under anesthesia is not always associated with negative results, however. Studies are being conducted to show the positive effects of awareness during anesthesia by exploring learning while under anesthesia. Research studies have proven that a patient can be given intraoperative information that can be remembered after surgery. Learning can occur, and it can have an effect on thought processes, feelings, and actions without any explicit recall of the intraoperative surgical experience. For example, a study has shown significant postoperative therapeutic benefits of giving positively phrased instructions, and patients were discharged earlier with less use of patient-controlled analgesia. ’(’ What role does the perioperative nurse have in this controversial dilemma? Preoperatively, patients should b e informed of the risk of awareness during anesthesia. An informed consent should include an open and honest discussion with the patient about the possibility, even though unlikely, of this risk. The patient also should be assured that if awareness during anesthesia is recognized, every effort will be made to manage and control it appropriately. Premedication could include an amnesic agent, but the nurse should remember that as external stimuli increases, so does recall.
AORN JOURNAL
NOVEMBER 1992,VOL 56, NO 5
Intraoperatively, nurses should understand that awareness is more likely with 0 obstetric anesthesia, 0 trauma patients, patients who are chronic users of alcohol, tranquilizers, sedatives, or narcotics, 0 obese patients who may have an altered drug response because of excessive weight or due to intubation difficulties that can result in delay between induction and the time of administration of maintenance agents, 0 patients who have high metabolic rates, and pediatric patients.” The use of regional anesthesia agents without sedation will avoid the risk of awareness during anesthesia, but no absolutely reliable method to detect unconsciousness has been perfected. Many of the reported awareness experiences have occurred during apparently adequate anesthesia. Surgical team members should provide an auditory environment that is positive and constructive. The anesthetized patient should be treated with the respect and consideration he or she would be given if awake. Headphones could be used to offer positive suggestions, soothing or soft music, or simply to block the external auditory canals. Surgical team members must realize that negative and hostile stimuli during anesthesia are often the types of memories recalled. Operating room conversations and behavior should be appropriate, professional, and positive. The anesthesia department should check anesthesia equipment regularly for proper functioning. During anesthesia, the anesthesiologist or nurse anesthetist must observe the patient for signs of awareness and signs of light anesthesia. When detected, the patient’s face can be stroked lightly while verbal reassurance is given. More anesthetic agents then may be administered to deepen the anesthesia. Postoperatively, nurses should be cognizant of the negative sequelae that could be exhibited by the patient. Discrete conversations in the
postanesthesia room also are suggested as the patient could translate these sounds to the operating room experience. The patients may be reluctant to speak about explicit memory incidences or may have problems coping with implicit memories of the surgical experience. Nurses should question the patient postoperatively for possible intraoperative awareness. Nurses should allow the patient to vent any feelings. An understanding and supportive attitude that does not demean or invalidate the patient’s experiences is extremely helpful. If the patient voices an awareness during anesthesia, then a referral to a psychologist or social worker may be necessary to help lessen the negative sequelae. As perioperative nurses, we are the patients’ advocates. Listen to what is being said by the surgical team during a procedure. Remember, your patient may be listening, too. KAYA. BALL,RN, MSA, CNOR PRESIDENT Notes
1. P Harvey, Jr, ed, Paul Harvey’s For What It’s Worth (New York City: Bantam Books, 1992) 45. 2. M P Dosch, “Strategies for preventing, detecting, and treating awareness,” Anesthesia Today 3 no l(1991) 13-15. 3. H L Bennett, “Awareness and learning in anesthesia,” Anesthesia Today 3 no 1 (1 99 1) 5. 4. J Gerhorsam, “Surgical chitchat traumatic,” The Denver Post 29 June 1992,2E. 5. Bennett, “Awareness and learning in anesthesia,’’ 12; M M Ghoneim, R I Block, “Learning and c on sc iou s ne s s during gene r a1 ane s t he s i a, Anesthesiology 76 (February 1992) 279-280. 6. J Hess, “The auditory pathway and the testing for the formation of intraoperative memories,” Anesthesia Today 3 no 1 (1991) 10-11 . 7. Ibid. 8. Ibid. 9. Ibid. 10. Bennett, “Awareness and learning in anesthe”
sia,’’4-5. 11. Ibid, 13.
NOVEMBER 1992, VOL 5b, NO 5
President’s Message Who’s listening to whom?
I
oxide or other drugs because a laser was used n Kilgore. Tex. on March 15, 1979. the near the trachea. Postoperatively, the patient Newss-Hei.ald reported that an unconscious had posttraumatic stress symptoms (eg, not motorist was taken from his wrecked car and carried to a nearby gas station. As the victim being able to sleep through the night, being started to regain consciousness, he opened his awakened with the distinct reliving of the bumeyes and began to struggle violently. The resing pain of the laser as it cut through tissues). During surgery, she was unable to move or to cuers finally subdued him and took him to the let anyone know of this a w a ~ e n e s s . ~ hospital. In another example, a patient experienced Later, rescuers asked him why he struggled being paralyzed but awake throughout the surso vehemently. The patient said rescuers had carried him to the nearby Shell gasoline service gical procedure. S h e said she struggled to station, and someone was standing in front of scream, but she was so drugged that she could not open her eyes. She recounted the conversathe “S” when he opened his eyes.‘ tion during her surgery about the nurse’s friend Patient a w a r e n e s s a n d perception have who had just received breast implants. The surreceived increased attention as care has become gical team commented about the patient’s “nice more focused on patient responses and needs. body shape even after she had two children.” When I attended a session on this topic at the T h e y went on to say that “more husbands American Association of Nurse Anesthetists would want their wives to have children if they (AANA) conference in Denver last August. I all looked like this afterward.” The patient still was amazed to hear and read about patients remains in therapy for this traumatic experiwho appeared to be asleep during surgery but ence. She has constant nightmares and recall of who were able to recount verbatim conversathe pain of the hernia excision and tions among surgical team memrepair and the inappropriate conbers. In fact, 1 % of patients who versation that occurred during the have procedures performed under p r o c e d u r e . S h e currently is general anesthesia have some recall attempting to form a national supof the intraoperative course, with port group for patients who have rates b e t w e e n 1.5% a n d 4% in had similar shocking episode^.^ cesarean section deliveries to as T h i s patient w a s present at t h e high as 1 1% in trauma cases.? AANA conference to candidly disFor example, during a laser toncuss her experiences. s i l l e c t o m y , a p a t i e n t reported Awareness is the memory of explicit recall of being paralyzed events that have occurred during but conscious. The patient received general anesthesia in which the a propofol infusion without nitrous Kay A. Ball XLJ
AORN JOLRNAL
patient is able to recall the events postoperatively. This awareness can present in two different ways in memory. Explicit memory refers to intraoperative learning that is accompanied by postoperative recall. Implicit memory refers to learning that occurs without recall. The results of explicit or implicit memory can be termed as negative sequelae. Negative behavioral adaptations can be seen after surgery that were not present preoperatively. This type of behavior includes sleeplessness. restlessness, generalized anxiety or irritability, hallucinations, repetitive nightmares, nervousness, or other posttraumatic stress disorders.’ Anesthesiologists and nurse anesthetists need an “awareness monitor” to determine how conscious or aware the patient is during the surgical experience. Research has shown that drug levels, blood pressure. or heart rate are not sufficient markers of the patient‘s level of consciousness or adequacy of anesthesia. Some researchers have concluded that intraoperative monitoring for the possibility of awareness may be done with the isolated forearm technique, the electroencephalogram (EEG), galvanic skin response (GSR), and lower esophageal contractility measurements.h There are many disagreements, however, about the reliability of these tests. The isolated forearm method involves placing a blood pressure cuff around the a r m without an I V line.’ A f t e r t h e p a t i e n t i s induced and intubated, but before a long-acting muscle relaxant is administered, the cuff is inflated, and a taped message is given to the patient via headphones. The patient is regularly requested to move the nonparalyzed arm so the anesthesiologist o r nurse anesthetist can determine if the anesthesia level should be deepened. The tourniquet is deflated after 30 minuter to avoid pressure-induced nerve block injury. but it can be reinflated if more muscle relaxant is needed. This technique really detects wakefulness, which is not always related to recall. An EEG is expensive to perform, and it is difficult to interpret anesthesia depth with this technique. It can detect large anesthesia varia826
NOVEMBER 1992, VOL 56, NO 5
tions but is not adequate for detecting small changes. Facial movement or grimaces also are used to detect anesthesia levels. Galvanic skin response can be used to detect anesthesia lightening by measuring a change in the skin surface.8 The amount of perspiration determines the electrical conductance of the skin. Some researchers are trying to correlate skin conductance to the level of anesthesia, but results are inconclusive. Lower esophageal contractions are controlled by the esophageal motility center in the brain stem.9As anesthesia paralyzes the skeletal muscles of the upper esophagus, the smooth muscles of the lower esophagus remain active. As the concentration of anesthetic agents is increased, the rate and amplitude of the lower esophageal contractions are reduced. There are still questions about the test’s reliability. Awareness under anesthesia is not always associated with negative results, however. Studies are being conducted to show the positive effects of awareness during anesthesia by exploring learning while under anesthesia. Research studies have proven that a patient can be given intraoperative information that can be remembered after surgery. Learning can occur, and it can have an effect on thought processes, feelings, and actions without any explicit recall of the intraoperative surgical experience. For example, a study has shown significant postoperative therapeutic benefits of giving positively phrased instructions, and patients were discharged earlier with less use of patient-controlled analgesia. ’(’ What role does the perioperative nurse have in this controversial dilemma? Preoperatively, patients should b e informed of the risk of awareness during anesthesia. An informed consent should include an open and honest discussion with the patient about the possibility, even though unlikely, of this risk. The patient also should be assured that if awareness during anesthesia is recognized, every effort will be made to manage and control it appropriately. Premedication could include an amnesic agent, but the nurse should remember that as external stimuli increases, so does recall.
AORN JOURNAL
NOVEMBER 1992,VOL 56, NO 5
Intraoperatively, nurses should understand that awareness is more likely with 0 obstetric anesthesia, 0 trauma patients, patients who are chronic users of alcohol, tranquilizers, sedatives, or narcotics, 0 obese patients who may have an altered drug response because of excessive weight or due to intubation difficulties that can result in delay between induction and the time of administration of maintenance agents, 0 patients who have high metabolic rates, and pediatric patients.” The use of regional anesthesia agents without sedation will avoid the risk of awareness during anesthesia, but no absolutely reliable method to detect unconsciousness has been perfected. Many of the reported awareness experiences have occurred during apparently adequate anesthesia. Surgical team members should provide an auditory environment that is positive and constructive. The anesthetized patient should be treated with the respect and consideration he or she would be given if awake. Headphones could be used to offer positive suggestions, soothing or soft music, or simply to block the external auditory canals. Surgical team members must realize that negative and hostile stimuli during anesthesia are often the types of memories recalled. Operating room conversations and behavior should be appropriate, professional, and positive. The anesthesia department should check anesthesia equipment regularly for proper functioning. During anesthesia, the anesthesiologist or nurse anesthetist must observe the patient for signs of awareness and signs of light anesthesia. When detected, the patient’s face can be stroked lightly while verbal reassurance is given. More anesthetic agents then may be administered to deepen the anesthesia. Postoperatively, nurses should be cognizant of the negative sequelae that could be exhibited by the patient. Discrete conversations in the
postanesthesia room also are suggested as the patient could translate these sounds to the operating room experience. The patients may be reluctant to speak about explicit memory incidences or may have problems coping with implicit memories of the surgical experience. Nurses should question the patient postoperatively for possible intraoperative awareness. Nurses should allow the patient to vent any feelings. An understanding and supportive attitude that does not demean or invalidate the patient’s experiences is extremely helpful. If the patient voices an awareness during anesthesia, then a referral to a psychologist or social worker may be necessary to help lessen the negative sequelae. As perioperative nurses, we are the patients’ advocates. Listen to what is being said by the surgical team during a procedure. Remember, your patient may be listening, too. KAYA. BALL,RN, MSA, CNOR PRESIDENT Notes
1. P Harvey, Jr, ed, Paul Harvey’s For What It’s Worth (New York City: Bantam Books, 1992) 45. 2. M P Dosch, “Strategies for preventing, detecting, and treating awareness,” Anesthesia Today 3 no l(1991) 13-15. 3. H L Bennett, “Awareness and learning in anesthesia,” Anesthesia Today 3 no 1 (1 99 1) 5. 4. J Gerhorsam, “Surgical chitchat traumatic,” The Denver Post 29 June 1992,2E. 5. Bennett, “Awareness and learning in anesthesia,’’ 12; M M Ghoneim, R I Block, “Learning and c on sc iou s ne s s during gene r a1 ane s t he s i a, Anesthesiology 76 (February 1992) 279-280. 6. J Hess, “The auditory pathway and the testing for the formation of intraoperative memories,” Anesthesia Today 3 no 1 (1991) 10-11 . 7. Ibid. 8. Ibid. 9. Ibid. 10. Bennett, “Awareness and learning in anesthe”
sia,’’4-5. 11. Ibid, 13.
