Anaesthetists be'ware ... and alarmed
Sydney, Australia
E-mail: jamesrnielsen{at}gmail.com
Editor—Congratulations to Errando and colleagues1 on their excellent work surveying the problem of awareness under anaesthesia. Their finding of so high an incidence (1%) in a cohort from which some high-risk patients had been excluded is sobering, especially given the exclusion of cases in which a neuromuscular blocker had been administered in error before induction.
One particular strength of the survey is their definition of awareness based on the patient's view. It is too glib to dismiss patient reports as being confused or simply wrong—disproving the patient's account is a Pyrrhic victory when they remain certain of being aware ‘under’ your anaesthetic!
Finally, the fact that nearly 75% of ‘aware patients’ had not discussed the issue with the responsible anaesthetist highlights our own susceptibility not to be aware of the scope of the problem.
Valencia, Spain
E-mail: c.l.errando{at}carloserrando.com
Editor—Thank you for your comments. Although our ‘crude’ incidence of awareness with recall (AWR) during general anaesthesia is definitely high (1%), we prefer to take into account the ‘real’ incidence of 0.6% in elective procedures.1 Owing to space constraints, our discussion needed to be considerably shortened, so could not be more extensively discussed. However, the 1% figure is not so different from that of other published work as the definition of AWR can significantly modify the true incidence. As in other aspects of anaesthetic procedures, the patient perception should prevail. An important lesson learned from our work, as Dr Nielsen notes, is that we lose important information and feedback from our patients. The availability of a recovery room offers a possibility to pick up some of these cases, but this is not always possible. Another important question is whether patients should be informed about AWR at the preoperative visit. If this is done, maybe this would be the time when we should remind the patient or their relatives that if AWR occurs, they should inform their anaesthetist after the procedure. In this way, the preoperative interview could have the preventive action on the psychological after-effects.
Reference
1 Errando CL, Sigl JC, Robles M, et al. Awareness with recall during general anaesthesia: a prospective observational evaluation of 4001 patients. Br J Anaesth (2008) 101:178–85.
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