Media and lawsuits put spotlight on awareness in outpatient surgery

With emphasis on cutting time and costs, how can you prevent it?

With National Public Radio, Oprah, and other media outlets covering patient awareness during anesthesia, many outpatient surgery providers report an increasing number of questions about the issue from their patients.

Prepare for even more. This fall, a movie titled Awake will be released in which a man is awake but paralyzed during surgery. The movie is billed as doing for surgery what the movie Jaws did for swimming in the ocean, says Richard J. Pollard, MD, chief of neuroanesthesia at Southeast Anesthesiology Consultants in Charlotte, NC. Pollard recently presented an audio conference titled Awake During Surgery: A Patient's and Surgeon's Nightmare, which was sponsored by AHC Media, publisher of Same-Day Surgery. Pollard and his peers just published a study on awareness in Anesthesiology.1

Recent cases of awareness have received national attention:

  • One laparoscopic cholecystectomy patient received a large settlement after she reported being aware during surgery and hearing the surgeon call her a "fat whale," according to Pollard.
  • In West Virginia, a Baptist minister had surgery to diagnose abdominal pain. The anesthesia providers gave him muscle relaxants but failed to give him general anesthesia until 16 minutes after the first cut. He was not told about the anesthesia incident, and he doubted his memories. After the procedure, he was unable to sleep, he was afraid of being left alone, and he complained of people trying to bury him alive. Two weeks after the surgery, he committed suicide. A lawsuit has been filed by the family.

"This is outcome that can have a horrible devastating effect on your patient," Pollard says. "Even having it happen one time is too many."

There's an increased willingness to report awareness, he says. "So we will quite possibly see more of these patients on the front pages and come to the point we will meet them in the courtroom," Pollard says.

His views are backed by the American Society of Anesthesiologist closed claims database, which indicates an increased number of claims for awareness. In addition, 78% of those cases received payment, Pollard says. The size of damages is increasing, with the highest award at $850,000, he says.

What causes awareness?

According to Pollard, the causes of awareness include:

  • The patient receives too light anesthesia. In Pollard's study, every patient who experienced intraoperative awareness had a low dose of the anesthetic agent, he says.1
  • Anesthesia machines malfunction or are misused. "If your machine is not working, if it's not being meticulously maintained, if you haven't been able to give enough drug to patients because of breaks or errors with your machinery, the patient is not going to get enough anesthesia and is not going to be asleep during surgery," Pollard says.
  • The patient has increased anesthetic requirements. Anesthetic requirements may be increased by factors such as whether they drink alcohol or take medications, Pollard says. To address this potential problem, ask the patient about medications, previous operations, and previous problems, he advises. A thorough evaluation before surgery is critical, Pollard says, "but that can bring us into conflict with people who want us to move fast."

Due to the need to reduce dosages of medications, other patients at risk for anesthesia awareness include cardiac surgery (2%-4% of patients at risk for awareness), obstetric surgery (0.4%-1% of patients at risk for awareness), and trauma surgery (11%-43% of patients at risk for awareness), Pollard says.

Other trends may be contributing to the problem of anesthesia awareness, including total IV anesthesia, Pollard says. "There's been a trend in anesthesia to move away from inhalational agents to keep patients asleep more to shorter acting, easy-to-give medications through the IV," he says. Unfortunately, some of these medications do not provide amnesia, Pollard says. Also, muscle relaxants can hide a patient's response to surgery, he says.

Being alert to causes of awareness

When looking at ways to avoid awareness, keep in mind that muscle relaxants have no amnestic affect, sources says.

Michael Rieker, DNP, CRNA, director of the Nurse Anesthesia Program at Wake Forest University Baptist Medical Center in Winston-Salem, NC, says, "In cases where muscle relaxants are used heavily or patients are on beta-blockers or other antihypertensives, some signs of awareness may be masked by these medications."

Also keep in mind that benzodiazepines have a drip half-life of only 1½ hours, Pollard says. "If the case is two hours, three hours, or longer, and you have only a single dose of benzodiazepines on board, the protective affects of that agent may be gone," he warns. All six cases of awareness in his study used midazolam, he reports.

Awareness may continue to be a problem as long as there is an emphasis on decreasing costs, sources say. This trend can lead to less anesthesia being administered, Pollard warns.

Outpatient surgery may be particularly at risk for awareness because of time issues, sources say. Rieker says, "Any time an anesthesia practitioner is rushed, there is the potential for them to miss an important piece of the patient's history." Most of the components of assessing awareness risk are fairly straightforward, such as history of legal or illegal drug use, or previous awareness under anesthesia, Rieker says. "If the anesthetist is rushed to the point of not determining such basic components of the preoperative assessment, awareness will not be the only complication plaguing the institution," he warns.

If the anesthetist feels compelled to run a "light" anesthetic to speed wake-up or avoid nausea, or to discontinue the anesthetic early, these actions could contribute to awareness, sources say. Speeding patient extubation by five minutes may save 30-50 minutes if you are performing six to 10 cases per day. "However, the tragedy of patient awareness, not to mention the potential malpractice liability, vastly overshadows the benefit of saving this time," Rieker says. "Economics are important, but with awareness occurring in 100 patients every day in the United States, cutting corners in the anesthetic is not a tenable risk."


  1. Pollard RJ, Coyle JP, Gilbert RL, et al. Intraoperative awareness in a regional medical system. Anesthesiology 2007; 106:269-274.


A CD copy of the audio conference "Awake During Surgery: A Patient's and A Surgeon's Nightmare" is available for $299 including slides, from AHC Media, the publisher of Same-Day Surgery. To order, call (800) 688-2421 and ask for priority code 11T07162. Or order online: