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What do people expect of general anaesthesia?

2017; Elsevier BV; Volume: 118; Issue: 4 Linguagem: Inglês

10.1093/bja/aex040

1471-6771

Paul Rowley, Christina Boncyk, Amy Gaskell, Anthony Absalom, Vincent Bonhomme, Mark Coburn, Aeyal Raz, Jamie Sleigh, Robert D. Sanders,

Anesthesia and Neurotoxicity Research

It is universally acknowledged that the public expect general anaesthesia to be an unconscious state.1Sanders RD Tononi G Laureys S Sleigh JW. Unresponsiveness ≠ Unconsciousness.Anesthesiology. 2012; 116: 946-959Crossref PubMed Scopus (279) Google Scholar, 2Sanders RD Absalom A Sleigh JW Cons CG. V. ′For now we see through a glass, darkly′: the anaesthesia syndrome.Br J Anaesth. 2014; 112: 790-793Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar, 3Russell IF Sanders RD. Monitoring consciousness under anaesthesia: the 21st century isolated forearm technique.Br J Anaesth. 2016; 116: 738-740Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar, 4Sanders RD Raz A Banks MI Boly M Tononi G. Is consciousness fragile?.Br J Anaesth. 2016; 116: 1-3Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar While apparently self-evident, knowing whether different conscious states under anaesthesia are acceptable is important for clarification of the research agenda in anaesthesia, that is appropriately focused on patient-centred outcomes. Furthermore understanding patient expectations may be a key way to improve patient satisfaction with anaesthesia. The great success of anaesthesia is validated through low rates of explicit recall of intraoperative events, however it remains unclear whether the public think amnesia of intraoperative events is a sufficient endpoint for anaesthesia. It is unclear whether dreaming ("disconnected consciousness from the environment") or connected consciousness ("consciousness of external stimuli") are acceptable outcomes under general anaesthesia. These questions are made more pertinent by our recent report that 4.6% of patients undergoing intubation under general anaesthesia respond on the isolated forearm technique, implying they have connected consciousness,5Sanders RD Gaskell A Raz A et al.Incidence of connected consciousness after tracheal intubation: a prospective, international, multicenter cohort study of the isolated forearm technique.Anesthesiology. 2017; 126: 214-222Crossref PubMed Scopus (68) Google Scholar with 1.9% reporting connected consciousness with pain. To provide some initial insight into public opinion on this, we conducted a survey posted on our website (https://conscious.anaesthesia.wisc.edu/), social media (Twitter, Reddit, and Facebook) and distributed electronically. We explored the public's views of states such as disconnected consciousness or dreaming during anaesthesia and intraoperative consciousness with and without amnesia. After IRB approval (2016-0633), a web-based survey service (Qualtrics), was used to create a distributable version of the survey (https://uwmadison.co1.qualtrics.com/SE/?SID=SV_0jmj1H6ghjzQhQF). Progress was monitored but the content of responses was not inspected until reaching 500 responses, assuming that this pilot dataset would be sufficiently valid, reliable and reasonably generalizable as an indication of public opinion. Other methods of gauging public opinion including interviews and focus groups have not been conducted at this time. Survey responses to questions regarding the acceptability of various intraoperative states of consciousness and fear of intra- and postoperative events were filtered, based on whether subjects reported having undergone surgery under general anaesthesia or not. χ2 tests were run between groups of interest (gender, number of surgical operations, and history of intraoperative awareness) and between whole subgroup responses, to determine if and to what extent having surgery significantly affected expectations and fears of surgery under general anaesthesia. "Word Clouds" were generated using visualization tools in Qualtrics with default settings applied. A total of 509 responses were recorded between 11 July 2016 and 6 October 2016 (denominator unknown). Of the 439 who answered all questions, the median age (in those who reported their age) was 33 (SD 15) yr, with a range of 18-79 yr. For those reporting gender, 198 (40%) were male, 289 (59%) were female, and three (0.6%) chose not to specify. Respondents took a median of 169 sec (< 3 min) to complete the 12 question multiple choice survey. Most (57%) had undergone one (29%) or no surgeries (28%) under general anaesthesia. When asked to evaluate the importance of meeting their anaesthetist before surgery, 62% of respondents strongly agreed it was important to meet their anaesthetist before surgery, 26% agreed somewhat, and 12% did not agree. Most respondents (82%) believe they have a good understanding of the role of their anaesthetist in their surgical procedure, and 81% believe their anaesthetist is responsible for awareness and/or recall under general anaesthesia, using the words "responsible", "anaesthetist", and "patient" in their comments (Supplementary Fig. 1a). The remaining 19% of individuals who did not believe their anaesthetist to be responsible for awareness and/or recall under general anaesthesia used the terms "anaesthetist", "different", and "react" most often in their comments, suggesting that they considered differences in patient responses to have a more dominant effect (Supplementary Fig. 1b). Our primary objective when designing the study was to ascertain whether patients expect general anaesthesia to be an unconscious state. In answer to the question "would you expect to be unconscious under general anaesthesia?", 96% of respondents reported they would expect to be unconscious under general anaesthesia. About half (52%) would consider it acceptable to be conscious of surgery provided they were not in pain, while only 2% reported it would be acceptable if they were to be conscious of surgery and in pain (Table 1); 43% would consider it acceptable to be conscious of surgery and unable to recall it afterward, and 36% would consider it acceptable to be conscious during surgery and able to recall it afterward. Those who believed it acceptable to be conscious of surgery and able to recall it afterward, most often used the terms "pain", "surgery", and "depend" in their free text comments (Supplementary Fig. 1c.). Respondents who left comments in response to a scenario in which they would be conscious of surgery and unable to recall it held similar concerns, using the terms "pain", "conscious", and "traumatize" in their free text responses (Supplementary Appendix). Most (83%) would consider it acceptable to be dreaming during surgery and unaware of the surgical procedure.Table 1Gauging acceptability of intraoperative states of consciousness. The survey read as follows: We are interested in assessing different states of consciousness under anaesthesia. By conscious, we mean the ability to experience something so "conscious of surgery" means you are "experiencing the surgery". Please indicate how acceptable you consider the following states to be during general anaesthesia. Please comment further if desired." n = 439 respondentsAcceptable (%)Unacceptable (%)Unsure (%)1a. If you were to be conscious of surgery, but not in pain228 (52)115 (26)96 (22)1b. If you were to be conscious of surgery, and in pain8 (2)419 (95)12 (3)2a. If you were to be conscious of surgery, and could not recall it afterward191 (44)137 (31)111 (25)2b. If you were to be conscious during surgery, and could recall it afterward160 (36)195 (44)84 (19)3. If you were dreaming, but unaware of your surgical procedure366 (83)23 (5)50 (11) Open table in a new tab Subjects who reported experiencing intraoperative awareness (17/439) were relatively over-represented in our sample, suggesting selection bias.1Sanders RD Tononi G Laureys S Sleigh JW. Unresponsiveness ≠ Unconsciousness.Anesthesiology. 2012; 116: 946-959Crossref PubMed Scopus (279) Google Scholar6Mashour GA Avidan MS. Intraoperative awareness: controversies and non-controversies.Br J Anaesth. 2015; 115: i20-i26Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar Based on the comments made by these respondents, the disproportionately high incidence of recall reported herein likely reflects intraoperative experiences of individuals who were sedated rather than fully anaesthetized. However, these individuals were more likely to find dreaming unacceptable compared with the majority who did not report intraoperative awareness (422/439), P = 0.002. The 41% of subjects who had experienced intraoperative awareness were very fearful of being aware during surgery, compared with 17% of subjects who had not experienced intraoperative awareness, however (P = 0.096). Women were significantly more likely than men to consider an intraoperative state of consciousness with pain unacceptable, 98% vs 92% respectively (P = 0.0110). No other parameter varied by gender (data not shown). When asked to rate fearfulness of intraoperative awareness (as defined as seeing, feeling, or hearing during surgery), the greatest proportion of respondents (46%) reported they were somewhat fearful of this occurring (Supplementary Table 1). Comparable proportions of respondents were either very fearful, neutral, or not at all fearful of intraoperative awareness (18%, 19%, 17%, respectively). Most respondents indicated they were either very fearful (37%), or somewhat fearful (39%) of feeling pain during surgery. Most respondents expressed they were either very fearful (39%), or somewhat fearful (26%) of suffering permanent cognitive deficits after anaesthesia; however 20% were not at all fearful of this occurring, while 15% were neutral on the issue. Similarly, most respondents were either very fearful (32%) or somewhat fearful (31%) of not waking up after surgery; however, 24% were not at all fearful of waking after surgery. Responses of men and women did not differ significantly for any of the questions assessing fear of hypothetical intra- and postoperative events. When asked "if you were to be conscious of surgery, and in pain" respondents who had undergone surgery (320) reported finding that situation "unacceptable" more commonly than those with no history of previous surgery under anaesthesia (120), 97% vs 92% (P = 0.039) (Supplementary Table 2). Of 19 respondents who left comments in response to the question "if you were to be conscious during surgery, and not able to recall it", eight of 19 mentioned pain as being an important consideration. When asked "if you were to be conscious during surgery, and could recall it afterward", respondents who had undergone surgery more frequently considered this unacceptable compared with those who had not had surgery, 47% vs 37% (P = 0.04) (Supplementary Table 2), with six of 13 comments in response to this question mentioning pain as being an important to their response (Appendix 2). Respondents who had not undergone surgery were significantly more fearful (45% "very fearful") of not waking up after surgery, compared with those who had previously undergone surgery (27% "very fearful") (P = 0.0009) (Supplementary Table 3). Subjects were asked to indicate fear of feeling pain during surgery; those who've had surgery were significantly less fearful of feeling pain during surgery (32% "very fearful") compared with those who've not had surgery (50% very fearful) (P = 0.004) (Supplementary Table 3). Those who have had surgery were significantly less fearful of permanent cognitive deficits after anaesthesia (34% "very fearful") compared with those who've not had surgery (53% "very fearful") (P = 0.0015). This sample of 509 responses – with selection bias as evidenced by relative over-representation of anaesthesia awareness – cannot be considered a complete or representative survey. Nonetheless these data overwhelmingly suggest that the public expect general anaesthesia to be a state of unconsciousness. We believe that these observations support the clinical importance of identifying and preventing intraoperative consciousness. Indeed our data suggest that approximately one third of people believe that amnesia of intraoperative events is insufficient, with one quarter unsure. While amnesia is a useful effect of anaesthetic administration,7Eger 2nd, EI Sonner JM. Anaesthesia defined (gentlemen, this is no humbug).Best Pract Res Clin Anaesthesiol. 2006; 20: 23-29Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar8Perouansky M Pearce RA. How we recall (or don't): the hippocampal memory machine and anesthetic amnesia.Can J Anaesth. 2011; 58: 157-166Crossref PubMed Scopus (23) Google Scholar amnesia by itself, appears to be an insufficient goal for anaesthesia. We have previously argued that disconnected consciousness – where one is conscious during the anaesthesia but unaware of externally triggered sensory stimuli such as surgery (e.g. dreaming) – is an acceptable anaesthetic state, and 83% agreed with this proposition (though this was significantly lower in patients with previous self-reported anaesthesia awareness). Hence, while disconnection was regarded as superior to amnesia by the public, it remained inferior to being unconscious. Importantly only 2% of respondents considered it acceptable to be conscious and in pain, underscoring analgesia as a key component of anaesthesia. Fear of intraoperative awareness (painful or not), not waking after surgery, and permanent cognitive deficits from anaesthesia were reported by 60% of survey respondents. Experience of previous surgery reduced fear of outcomes, such as not waking after surgery or permanent cognitive deficits. Previous surgical experience also increased the perceived unacceptability of pain and/or amnesic consciousness during surgery. These observations are important when considering approaching patients and their concerns. Future larger studies should address these concepts more thoroughly in a wide range of ages, who may or may not feel vulnerable to different outcomes. We stress that our pilot survey suffers from selection bias such that generalizability of these findings remains unclear. Nonetheless these data suggest that prevention of intraoperative awareness, either through inducing unconsciousness or through sensory disconnection, should remain an important focus of the anaesthesia research agenda. Likewise prevention of intraoperative pain was rated as important. To address the limitations of our survey a much larger sample is required. Hence we intend to leave the study active on the ConsCIOUS website to accrue a greater number of responses. None declared. This study was supported by the Department of Anesthesiology at the University of Wisconsin, Madison, Wisconsin, USA.