Friday, March 10, 2006

Awareness followup

Sorry I haven't posted in a while, I've been busy at work. I got the following email from someone who came across this blog. I asked her if I could post it so others could share her experiences. Here it is edited (minimally) and posted with her permission.

Hi there,

I stumbled across your blog today and enjoyed reading your post about BIS monitors. I agree -- they DO NOT always work. I experienced awareness during anesthesia just last month, and my doctor was using the monitor.

I lost my baby during my pregnancy and needed a D&C. Unfortunately, my uterus was perforated during the D&C, and so the surgeon performed an emergency laparoscopy to repair the tear. I "woke up" feeling like I couldn't breathe, experiencing intense pain in my naval from the scope, and hearing parts of conversation in the OR around me. I was paralyzed, so I couldn't tell anyone what was happening. But I knew that if my belly was cut, something serious had gone wrong. I honestly thought that I was going to die. I eventually blacked out again for the remainder of the surgery, but have memories from pretty early after extubation (while still in the OR), and have much more recall of the recovery room than seems typical.

It had never occurred to me that something might go wrong with the anesthesia on top of everything else. (I figure that in the "Bizarro universe," my double has just won the lottery.) The only bright spot in this is that I ended up writing the anesthesiologist a letter describing what I experienced. He called me right away and said he was sorry, which was surprisingly helpful for me. He also said that when the perforation occurred, he'd had to quickly switch from using a mask to intubating me. From the details I described, he felt I woke up during that process. He said the BIS monitor lags real-time by at least a minute, and that while they are helpful, they obviously can't prevent all problems.

I do have a question for you: In future surgeries, how detailed does my description of what happend need to be to ensure I don't have awareness while under general anesthesia again? Any tips would be helpful.

My reply:

Sorry about your awful experience, and sorry about the loss of your child. From what I know, the experience you had was one that is typical of people that suffer recall. Generally an emergency happens and anesthetic techniques need to be changed in a hurry, or things are so tenuous, that the risk of recall is weighed against keeping a patient alive. Trauma situations and obstetric situations are classic. I'm glad you had a positive conversation about this with your anesthesiologist. Still must have been a traumatic experience.

As for future surgeries, I think the mention that you had awareness during a D&C converted to a general anesthetic for a laparoscopy, (Just the description you gave me) should be sufficient to avoid any problems. They will probably have you go through your experience so that they can be a better picture of what happened. Some may request a copy of the previous anesthesia record to see exactly what medications you received, but I'm guessing most won't.

I cannot of course promise that this won't ever happen again(you may be resistant to some of our medications) but I'm guessing the urgency of the situation was the main cause of your period of awareness.

Hopefully your future experiences will be more pleasant.

I hate to ask this, but would you mind terribly if I posted an edited redition of your experience on my blog, so that I can post the advice.

Good luck with everything. I'm happy to answer any other questions, sorry for my delay in reply.

Her response:

Hi again,

Thanks for the extra information. And yes, you can post my email(s) to your blog, in whatever edited version you want. I just request that you leave out my name.

The anesthesiologist for my surgery called me back again since I emailed you. He pulled my chart, and what he said matches up closely with what you surmised: Shortly after the lap began, my BP dropped. He administered ephedrine and lightened the anesthesia (propofol, I think he said?) to stabilize me. He believes this is when I initially became aware. He said that BIS readings remained in the 60s throughout the incident, which meant that I should have been out. I guess it just shows how hard it is to categorize levels of consciousness, even with a monitor. As a secondary
issue, he also wonders if I might metabolize Versed faster than normal, which would allow me to remember what happened.

It was a God-awful experience. I honestly thought I was dying, and you don't just immediately shrug off that sort of event afterwards. But, I don't really see how it could have been avoided. After doing some research and talking to both the surgeon and the anesthesiologist about what happened, I'm satisfied I got good care, despite my complications. So I am choosing to lump everything that happened to me -- the baby having trisomy 18 and dying, the uterine perf, and the anesthesia problems -- into the same category, which can be summed up as "sometimes you're lucky in life, and sometimes you are probability's bitch." I wish I'd been lucky.

Anyway, I'm hoping that this was a one-time bad event for me. For any planned surgeries, I'll follow your advice and explain my history as best I can.

Thanks again

This woman has had an awful experience, and has had the heart to share it with us. I think it illustrates that good communication between patients and physicians is of critical importance. It is especially important when "bad" things happen, though it should exist when things go well also.


Anonymous said...

Holy shit! That made my heart race. Glad she has been able to put it in a place she can deal with. wow!

Anonymous said...

When your doctor reviewed your anesthetic record, he probably did not mention that your heart rate and blood pressure were probably written down every 5 minutes and BIS values were probably written down every minutes. A lot of clinical changes can occur in 15 minutes and I am willing to bet that if the actual montor trend and values were reviewed, that your BIS values went significantly above 60. "Under 60" just happens to be what was written down at a 15 minute interval once values were back under control.

Anonymous said...

"...BIS values remained in the 60's.." In the 60's is not general anesthesia. Below 60 is the target.

manixter said...

Ok, the person who said that the BIS is only checked every 15 min and was probably over 60 can bite me. No matter what we write down, we're always looking at that stupid box. Unusual that it was hooked up at all if it was supposed to be a d&c (usually a sedation case).
In my rant about BIS I did forget to mention the 30 sec interval that has to be sampled, not to meniton that any interval (epoch) that is deemed "contaminated" (like from EMG artifact from intubation, or even rapid changes in the BIS) is dropped, so you get another 30 sec, not counting processing time...
Not to mention that recall is a slippy thing. You can have BIS in the 90's can full cooperation to command without recall. Don't make me come down there.

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