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Anesthesia Awareness—What If I Am Awake During Surgery?

Updated on November 4, 2016

TahoeDoc HealDove

Anesthesia Awareness - Awake Under Anesthesia

Fear of being awake under anesthesia, called anesthesia awareness or intraoperative awareness, causes a lot of anxiety for patients facing surgery.

Having anesthesia is scary for most people. As an anesthesiologist, I usually meet patients right before their surgeries. People facing surgery have many apprehensions and fears. More and more are concerned about anesthesia awareness.

I repeatedly hear that patients are often more apprehensive about the anesthesia than the surgery itself. And of all the fears that people have about the anesthetic side effects and anesthetic complications, the one I hear most often is, "I'm afraid of waking up during the surgery."

Anesthesia awareness has received a great deal of attention in the press over the last few years and even a full-length movie, called "Awake," capitalized on this fearful concept (I have reluctantly included the trailer here). But what is it really? Why and to whom does it occur? Keep reading to find out why it most likely won't happen to you.

"Awake" - Sensationalizing Anesthesia Awareness

What Is Anesthesia Awareness?

Anesthesia awareness, also called intraoperative awareness refers to a specific situation where a person is under general anesthesia for surgery and regains consciousness during the surgical procedure.

The definition of general anesthesia includes induction and maintenance of loss of consciousness. This means that you should not be able to wake up until the surgery is over. You do not respond to voice or painful stimuli.

For various reasons, some people do regain consciousness when they are under general anesthesia. For most people, this involves a very brief, hazy memory. Some people are aware of what is being said, but cannot move or indicate that they are awake. Still, there is usually no sensation of pain or awareness of the operation. The very rare, unfortunate few are awake, cannot move and do feel the surgery being done.

What Is NOT True Anesthesia Awareness?

There are many situations that are confused with anesthesia awareness.

Sedation anesthesia. I often have patients tell me they had anesthesia awareness during their colonoscopy or other procedure. These procedures are commonly done under intravenous sedation anesthesia. While the intravenous sedation drugs do cause sleepiness and often amnesia- you don't remember the procedure, they do not cause unconsciousness. It is not at all abnormal to be awake and remember these procedures. With the sedation, pain medications are either injected at the surgical site or given in the IV or both. You should still not be uncomfortable, even if you are awake, during surgeries or procedures under sedation.

Sedation plus spinal or epidural. Neither sedation or spinal/epidural anesthesia makes you unconscious during your operation. If you have spinal or epidural anesthesia to block the pain of surgery, you are usually also given sedation. The same is true for local anesthesia as well. In this case, it is not unusual or abnormal to have memories of being in the operating room. This is not anesthetic awareness.

Dreaming. Some people actually dream during their anesthetic, or more likely, when transitioning from unconsciousness back to wakefulness at the end of surgery. These dreams are often interpreted as actual wakefulness, but are not.

Waking at the end of surgery, but not able to move. When you return to consciousness, sometimes your brain is more awake than your body. You are waking up, but cannot move for a couple minutes. You can hear the anesthesiologist talking to you or feel the nurses putting bandages on your incisions, but cannot yet respond. The anesthesia wears off at different rates for different people. If your surgery is over, but you are still in the operating room and have memories of this, it is a normal variant of the emergence phase from anesthesia. Most people are conscious when they leave the operating room, post anesthesia, and many are talking and asking questions, but may not remember it later. If you do remember this phase, it's ok. The same is true for the beginning of your anesthetic, the anesthesia induction. Vague, hazy memories of being in the operating room are confusing and can be mistaken for being awake during the anesthetic.

Risk Factors for Intraoperative Awareness

Certain risk factors make anesthesia awareness more likely.

Type of surgery and type of anesthesia. Certain types of surgery are associated with higher incidences of anesthesia awareness. Surgeries where using lower concentrations and amounts of anesthetics is necessary to protect patients lead to more intraoperative awareness. Emergency cesarean sections, trauma surgeries, and open heart surgeries are the most likely cases to be associated with anesthesia awareness. Anesthesia challenges the body's physiology. Heart rates vary and blood pressures drop. When they cannot be adequately managed by giving more medication, the anesthetic must be "lightened" in order to NOT endanger the patients' lives.

There are certain brain and spinal cord surgeries that require that no anesthesia gas be used in order to not interfere with the nerve monitoring being used to prevent paralysis. The anesthetic called TIVA (total intra-venous anesthesia) also predisposes to higher rates of anesthesia awareness.

Type of patient. Patients who use illegal drugs such as cocaine and methamphetamine may be more likely to have intraoperative awareness. Not only do these drugs cause dangerous fluctuations in heart rate and blood pressure, they make the metabolism of anesthetic drugs much more unpredictable.

Some prescription medications. Certain prescription medications may also increase the risk. Anesthetics are adjusted throughout the surgery based on surgical stimulation level, type of anesthesia and the heart rate, breathing rate and blood pressure of the patient. Patients who take medications that block the normal increases in heart rate or blood pressure may have their signs of light anesthesia masked by the medication.

Statistics on Awareness Under Anesthesia

The American Society of Anesthesiologists estimates that some degree of anesthesia awareness occurs in about 1 in 1000 general anesthetics. It is believed that the majority of these cases are during the induction (beginning) of the anesthetic when the drugs haven't fully taken effect. Likewise, a great many cases are at the end of surgery, during anesthetic emergence, when the anesthetic is wearing off but isn't completely gone. These are not intraoperative awareness as the surgery is not occurring. Because the memories are fuzzy and confusing, patients often don't know that this wasn't during the surgery itself.

There are no exact statistics on true intraoperative awareness cases that occur during the surgery and cause distress and lasting trauma to the patient. It is, however, an area of active study and research.

Again, talk to your doctors and ask questions if you are remotely concerned that this has happened to you.

Prevention: What You Can Do to Prevent Intraoperative Awareness.

Talk to your anesthesia doctor and provide accurate information. This is your best defense against intraoperative awareness.

So, be honest with your doctor about:

Your fears. Usually, this will help calm you. While no absolute guarantees can ever be made, your doctor can help pinpoint whether or not you have higher risk than average for this complication and let you know how he or she will address the risk. Alcohol consumption. Chronic, excessive alcohol intake results in a higher need for anesthetic medications. Illegal drugs use. Your anesthesiologist needs to know this to figure out which and how much anesthesia it will take to get you to sleep and keep you there. They are not there to judge you, but cannot keep you safe if they don't have all relevant information. All of your prescriptions and supplements. Different medications affect the metabolism of anesthesia differently. And just because supplements are "natural" or "alternative" doesn't mean they don't have side-effects or don't interfere with anesthetic medicines. How the Anesthesiologist Monitors During Surgery

The anesthesiologist, using intraoperative monitoring, will be watching your heart rate, blood pressure, and breathing rate (if a ventilator doesn't need to be used). Increases in these seen on the intraop monitors indicates that the anesthesia is too "light." These parameters generally increase before any awareness occurs. The anesthesiologist is constantly adjusting the delivery of the anesthesia gas and giving other medication in the IV to keep the anesthesia level where it needs to be. The anesthesia is increased to ensure adequate depth of anesthesia if it's too light. Likewise, even though you are unconscious, your body will reflexively move to stimulation if the anesthetic depth needs to be increased. This also occurs before awareness.

The various brain monitors on the market have not been shown to reduce anesthesia awareness, despite what the makers of these expensive devices say. They do provide other useful information and may or may not be used if your hospital has them, at the discretion of the anesthesiologist.

BIS Monitor

A study published in the "New England Journal of Medicine" (August 18, 2011) has actually shown that relying on a BIS (brain) monitor can actually increase the incidence of intraoperative awareness vs. using measurement of the anesthetic concentration (the usual technique). This sounds counter-intuitive, but to me is not surprising. Here's why...

The BIS monitor (which I use for other information) gives a number that is indicates the level of consciousness. Other indicators include heart rate, blood pressure and breathing rate/pattern changes (if the patient is breathing on their own). In my experience (disclaimer-based on only my experience, not scientific study), the changes in vital signs happen first. Heart rate goes up before you see a change in the BIS number. That means that providers who rely only on the BIS number and ignore the changes in vital signs may be missing the chance to prevent awareness. The awareness may have already happened before the change in BIS number is seen. There is a lag between the event and the change in BIS.

Personally, I try to use all the data available to me and not rely on the BIS monitor for prevention of awareness. Vital signs to me are more reliable, happen earlier (before awareness can occur in most cases) and should not be ignored to focus on the BIS monitor. The BIS does provide other useful info, but is not as reliable as the manufacturer may claim to prevent awareness.

Treatment for Anesthesia Awareness

If you have had a case of genuine intraoperative awareness, let your doctor, surgeon, or anesthesiologist know right away. Many people do well with just an explanation of why it might have happened. Others suffer short-term or even long-term post-traumatic stress disorder. In those cases, an evaluation by a psychologist or psychiatrist and possible medications may be needed, usually on a short-term basis.

If you aren't sure if you had true anesthesia awareness, speak to your surgeon or contact the anesthesiologist. Most people who aren't sure have had one of the other experiences -- like sedation, dreaming, or waking at the end and being confused about the time -- and feel much better after having their questions answered.

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Men risk their lives in wars so women can enjoy societies where they can pursue feminist goals, such as punishing men for sexist language.

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A Penis Enlargement Technique That Works—And Is Only Kind of Terrifying

Things are looking up for guys in the market for a penis enlargement. It appears some researchers from Korea University have found a method that is actually effective—and you don't even have to reply to some sketchy spam email to get it. The results of their research were recently published in the Journal of Sexual Medicine, and it turns out they used the same thing some ladies use for their faces, Restylane. After injecting Restylane into 50 men's penises, they found that there was average increase in circumference (or girth) of 4 cm. That increase still held 18 months later.

The procedure was definitely not without its drawbacks. It required them to use a "hefty" needle to inject an average of 20.5 cc of the Restylane, which is a little under an ounce, using "a back-and-forth technique" into the deep soft tissue layers of the penis. Ouch! But it didn't end there, "the product was then ‘homogenized with a roller.'" That sounds deeply unpleasant—though it's definitely better than surgery and certainly faster than using a penis extender.

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Im a Pedophile

Well I don't really know why im posting this, if this will help anyone or make people hate me.

Im a pedophile and before anyone jumps to conclusions as I think most people don't actually know what the word means. Pedophile doesnt mean your a child abuser (I know most will find that hard to believe), it is an adult who is sexually attracted to children. I would never hurt or abuse a child. Personally im attacted to boys aged 8 - 12y/o.

I know many of you have been abused by pedophiles so I don't know if you guys wanna ask me questions about pedophilla or about me, if it will come to terms about anything. If you think im a sick fuck, thats fine just say why you think I am don't just leave abusive post and ill answer back.

Hey creation, I don't really have it in me to hate anyone but I do hate child abusers or what I should really call active pedophiles. I believe you when you say you would never harm a child and I think that is a noble ideal given how you feel about youngsters, however I will urge you to seek help if you are not already and to warn you in all honesty that we've had pedophiles on the site before, mostly those justifying their actions and have been banned pretty quickly for doing so.

Just looking for support, I have been a member for years, but never really posted anything. I have been depressed since I was 13 and suicidal since I was 15... I am now 21, because I am a pedophile.

I think it's pretty brave to admit what you have but support will be pretty hard to find here and personally I don't feel a pedophile would benefit from peer to peer support that the site offers, the best way to get help for your depression is to get professional help for your condition, in that respect I will support you how I can, otherwise if you are unwilling to get professional help I doubt your presence would benefit anyone, least of all yourself.

I don't mean to sound harsh, am just being as honest as possible while setting boundaries that will allow you to continue to remain active on the website.

Thanks Robin. Well TBH I have stopped look for support. I could never tell someone this IRL not even a doctor. Because of this I have resorted to self medicating. I have brought lots of different anti-depressants of the net to try and help me. Unfortunatly they have not helped me the only thing I have noticed from them is the side effects. I was also quite stupid the first time I self medicated, as I took quite a hight dose before I went to work, thinking it would solve everything. Unfortunatly I ended up being sick at work, my body was shaking and I made myself ill for days. I don't think there is support for a pedophile.

All I can say is that in my own thoughts I see you on a sure downward spiral which will d in a child being abused. If you really do not want to step over the boundaries of your own conscience and remain a member of this site I urge you to get professional help before your mind like all human minds does what it does best and justifies doing what you ideally abhor to get what it wants.

Hello Creation,

I think you are very brave admitting that you're a pedophile.

Self medicating won't do you any good in the long term hun. A counsellor would probably be the ideal person to tell but I understand you feel you can't tell anyone. Have you tried getting support in any other form such as helplines? :hug:

Hi Daisychain,

I don't see how a counsellor would help. Because I am ONLY attacted to boys, If anyone thinks its just a sexual attractions then they are wrong. What I want is a loving relationship with a boy. I understand that will never happen and I will always be alone, and never experience love.

I don't see how talking to someone would help me, I mean if you could never be in a relationship with anyone your whole life how do you think that would make you feel.

I fail to see how professional help will not benefit you but asking for peer to peer support on a forum where many of the members have been abused by pedophiles in the past will.

I wasn't asking for peer to peer support from people who have been abused, that wasn't the intention of my post, sorry if you saw it that way. I was hoping that somehow I would be able to help people who have been abused.

I'd like to say something supportive to you, but my head is just kinda elsewhere at the moment. So think nice things and I'll try and remember to come back and be all understanding and stuff later.

It's my experience the only effect that will have on your mental health is to justify what you currently abhor.

Creation-Do you not think that you should try and get help? Do you want help?

You could end up really hurting someone. :(

You damn well better. You're getting some sympathy here because you claim to not be an active pedophile. But there's no such thing. You have the thoughts so unless you get help NOW you will eventually act on them. And end up ruining some innocent child's life.

I know what you're about to claim. That you would never do that. That's a lie. A lie you say to other people and to yourself. Look at what you just did. You immediately denied the first word of helpful advice. You don't even want to TRY to get help and get better. That makes you dangerous.

You were wondering if anyone would hate you for admitting what you admitted here? It's not trying to fight it or get help that makes you worthy of hate. GET HELP NOW. Don't become the evil person that it's likely you will if you don't do something about it.

Should I try to get help, well yes I guess so, I don't cause im too scared to ask for it.

Do I want help, I use to, but now I don't care anymore.

As I said I would never hurt a child. If your hetrosexual it doesn't mean you are gonna abuse someone of the opposite sex, same goes with being a pedophile, doesn't mean you will abuse a kid.

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