Best practice & research. Clinical anaesthesiology
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Dreaming during anaesthesia is defined as any recalled experience (excluding awareness) that occurred between induction of anaesthesia and the first moment of consciousness upon emergence. Dreaming is a commonly-reported side-effect of anaesthesia. The incidence is higher in patients who are interviewed immediately after anaesthesia (approximately 22%) than in those who are interviewed later (approximately 6%). ⋯ Most dreaming however, occurs in younger, fitter patients, who have high home dream recall, who receive propofol-based anaesthesia and who emerge rapidly from anaesthesia. Their dreams are usually short and pleasant, are related to work, family and recreation, are not related to inadequate anaesthesia and probably occur during recovery. Dreaming is a common, fascinating, usually pleasant and harmless phenomenon.
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Inadequate anaesthesia may lead to awareness. A properly trained anaesthetist, administering anaesthesia according to their knowledge of pharmacology and patient and surgical characteristics, assisted by clinical signs and monitoring, can minimize this risk. Relying upon volatile-based anaesthesia delivered at a concentration of at least 0.5 MAC may be effective, but this precludes the use of total intravenous anaesthesia techniques and in any case may lead to unwanted hypotension. ⋯ The development of electroencephalographic monitors of anaesthetic depth provides an opportunity to prevent awareness. Two large scale studies, one of which was a randomized trial, have identified a 5-fold reduction in risk of awareness when depth of anaesthesia using bispectral index monitoring was used. The incidence of awareness can be further reduced with currently available techniques used more widely.
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Best Pract Res Clin Anaesthesiol · Sep 2007
Monitoring consciousness: the current status of EEG-based depth of anaesthesia monitors.
Direct and indirect inhibitory effects of anaesthetic agents on cortical activity are reflected in the electroencephalogram (EEG) as: (i) a shift from low-amplitude, high-frequency EEG, to high-amplitude, low-frequency activity (indicative of cortical depowering) and; (ii) the appearance of spindles and K-complexes (indicative of thalamocortical hyperpolarisation and sensory blockade). Existing EEG monitors use cortical activity as a proxy measure for consciousness. ⋯ Also the literature reveals many instances where the EEG pattern is dissociated from conscious state (e.g. an awake-looking EEG, but an unresponsive patient; or a slow-wave EEG in an awake patient). Fortunately, a slow-wave EEG (even in the presence of a responsive patient) usually indicates profound amnesia for explicit memory.
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Increased attention in recent years in both the academic literature and general media on awareness during general anaesthesia has raised the spectre of an increase in the liability burden of anaesthesia awareness. Liability will be different around the world, largely influenced by factors such as the presence of no-fault compensation systems for medical complications in some countries and the characteristics of the common law tort systems in others, such as the United States. A review of the largest single source for liability data, the American Society of Anesthesiologists' Closed Claims database, found the proportion of anaesthesia malpractice claims and claim payment amounts for awareness did not increase during the 1990s. However, due to the time lag to settlement of claims, this data predates recent attention to awareness and electroencephalographic monitoring, factors that may increase liability for awareness in the future.
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Best Pract Res Clin Anaesthesiol · Sep 2007
Awareness, dreaming and unconscious memory formation during anaesthesia in children.
Recent studies have reported an incidence of awareness in children of around 1%, while older studies reported incidences varying from 0% to 5%. Measuring awareness in children requires techniques specifically adapted to a child's cognitive development and variations in incidence may be partly explained by the measures used. The causes and consequences of awareness in children remain poorly defined, though a consistent finding is that many children do not seem distressed by their memories. ⋯ Compared to explicit memory, implicit memory is more robust in young children; however there is no evidence yet for implicit memory formation during anaesthesia in children. Children less than 3 years of age do not form explicit memory, although toddlers, infants and even neonates have signs of consciousness and implicit memory formation. In these very young children the relevance of awareness remains largely unknown.