Genel Anestezi Sırasında Farkındalık

Yıl 2024, Cilt: 6 Sayı: 1, 1 - 5, 01.03.2024

Gülseren Yılmaz Ziya Salihoğlu

https://doi.org/10.38175/phnx.1322627

Öz

Genel anestezinin uygulanma amacı ameliyat sırasında bilinç kaybı ve amnezi oluşturmak, yeterli analjezi ve kas gevşemesi sağlamaktır. Anestezi sırasında farkındalık, genel anestezi altında hastanın bilinçli olması veya cerrahi işlemi hatırlayabilmesi durumunu ifade eder. Bu durum, anestezinin yetersiz olduğunun bir göstergesi olabilir ve potansiyel psikolojik komplikasyonlara yol açabilir. Ayrıca, anestezistlere yönelik iddiaların yaklaşık %2’si anestezi sırasında farkındalık komplikasyonlarıyla ilgilidir. Farkındalığın insidansı nadirdir, ancak risk faktörleri hastaya ve teknik faktörlere bağlıdır. Entübasyon zorluğu, obezite, daha önce anestezi sırasında farkındalık yaşama öyküsü, ilaç toleransı gibi faktörler riski artırabilir. Ayrıca, teknik hatalar, anestezi makinelerinin yanlış kullanımı ve anestezik uygulama hataları da farkındalığa neden olabilir. Bazı cerrahi prosedürler ve total intravenöz anestezi tekniği de risk faktörleri arasındadır. Bu risk faktörlerinin farkında olmak, farkındalığı önlemek, tanımak ve yönetmek için önemlidir. Anestezi uygulamasında farkındalık halini önlemek için optimal bir strateji, hastaların bireysel hazırlığı ve dikkatli anestezi yönetiminin kombinasyonudur. Risk altındaki hastaların belirlenmesi, ilaçların dikkatli bir şekilde hazırlanması ve uygulanmasıyla birlikte, anestezi yönetimi için uygun stratejilerin kullanılmasıyla bu komplikasyon azaltılabilir. İlaçların kullanım miktarını, nöromuskuler blok düzeyini ve uyku derinliğini ölçen cihazların rutin kullanımı ameliyat sırasındaki farkındalığı azaltmaya yardımcı olacaktır. Bu yazıda anestezi sırasında farkındalık durumunun risk faktörleri, önlenmesi, tanınması ve yönetimi tartışılacaktır.

Anahtar Kelimeler

İntraoperatif farkındalık, Anestezi komplikasyonları, Genel anestezi, Monitorizasyon

Awareness During General Anesthesia

Öz

The aim of general anesthesia is to induce unconsciousness and amnesia during the surgery, and to provide adequate analgesia and muscle relaxation. Awareness during anesthesia refers to the state of the patient being conscious or able to remember the surgical procedure under general anesthesia. This may be an indication of insufficient anesthesia and may lead to potential psychological complications. Also, about 2% of claims against anesthesiologists have been related to the awareness complications during anesthesia. The incidence of awareness is rare, but the risk factors depend on the patient and technical factors. Factors such as difficulty in intubation, obesity, previous awareness during anesthesia, drug tolerance may increase the risk. In addition, technical errors, misuse of anesthesia machines and anesthetic administration errors may also cause awareness. Some surgical procedures and total intravenous anesthesia technique are also among the risk factors. Being aware of these risk factors is crucial for preventing, recognizing and managing awareness. An optimal strategy for avoiding awareness in anesthesia practice is a combination of individual patient preparation and careful anesthesia management. This complication can be reduced by identifying patients at risk, careful preparation and administration of drugs, and the use of appropriate strategies for anesthesia management. Routine use of devices that measure the amount of medication, neuromuscular block level and depth of sleep will help reduce awareness during surgery. In this article, the risk factors, prevention, recognition and management of awareness during anesthesia will be discussed.

Anahtar Kelimeler

intraoperative awareness, anesthesia complications, general anesthesia, monitoring

Kaynakça

• Tasbihgou SR, Vogels MF, Absalom AR. Accidental awareness during general anaesthesia - a narrative review. Anaesthesia. 2018;73(1):112-122. doi: 10.1111/anae.14124. PMID: 29210043.
• Lee AC, Redding AT, Tjia I, Rana MS, Heitmiller E. Self-reported awareness during general anesthesia in pediatric patients: A study from wake up safe. Paediatr Anaesth. 2021;31(6):676-685. doi: 10.1111/pan.14176.
• Cascella M, Bimonte S, Amruthraj NJ. Awareness during emergence from anesthesia: Features and future research directions. World J Clin Cases. 2020;8(2):245-254. doi: 10.12998/wjcc.v8.i2.245.
• Odor PM, Bampoe S, Lucas DN, Moonesinghe SR, Andrade J, Pandit JJ; Pan-London Peri-operative Audit and Research Network (PLAN), for the DREAMY Investigators Group. Incidence of accidental awareness during general anaesthesia in obstetrics: a multicentre, prospective cohort study. Anaesthesia. 2021;76(6):759-776. doi: 10.1111/anae.15385.
• Veselis RA. Memory formation during anaesthesia: plausibility of a neurophysiological basis. Br J Anaesth. 2015;115 Suppl 1(Suppl 1):i13-i19. doi: 10.1093/bja/aev035.
• Asok A, Leroy F, Rayman JB, Kandel ER. Molecular Mechanisms of the Memory Trace. Trends Neurosci. 2019;42(1):14-22. doi: 10.1016/j.tins.2018.10.005.
• Schulz CM, Burden A, Posner KL, Mincer SL, Steadman R, Wagner KJ, et al. Frequency and Type of Situational Awareness Errors Contributing to Death and Brain Damage: A Closed Claims Analysis. Anesthesiology. 2017;127(2):326-337. doi: 10.1097/ALN.0000000000001661.
• Mehta SP, Eisenkraft JB, Posner KL, Domino KB. Patient injuries from anesthesia gas delivery equipment: a closed claims update. Anesthesiology. 2013;119(4):788-95. doi: 10.1097/ALN.0b013e3182a10b5e. PMID: 23835591.
• Bischoff P, Rundshagen I, Schneider G. Unerwünschte Wachphänomene (“Awareness”) während Allgemeinanästhesie: Evidenzbasierter Kenntnisstand, aktuelle Diskussionen und Strategien zu Prävention und Management [Undesired awareness phenomena during general anesthesia: Evidence-based state of knowledge, current discussions and strategies for prevention and management]. Anaesthesist. 2015;64(10):732-9. German. doi: 10.1007/s00101-015-0095-6. PMID: 26411583.
• Pandit JJ, Andrade J, Bogod DG, Hitchman JM, Jonker WR, Lucas N, et al; Royal College of Anaesthetists; Association of Anaesthetists of Great Britain and Ireland. 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: summary of main findings and risk factors. Br J Anaesth. 2014;113(4):549-59. doi: 10.1093/bja/aeu313.
• Cascella M, Fusco R, Caliendo D, Granata V, Carbone D, Muzio MR, et al. Anesthetic dreaming, anesthesia awareness and patient satisfaction after deep sedation with propofol target controlled infusion: A prospective cohort study of patients undergoing day case breast surgery. Oncotarget. 2017;8(45):79248-79256. doi: 10.18632/oncotarget.17238.
• Bruchas RR, Kent CD, Wilson HD, Domino KB. Anesthesia awareness: narrative review of psychological sequelae, treatment, and incidence. J Clin Psychol Med Settings. 2011;18(3):257-67. doi: 10.1007/s10880-011-9233-8.
• Cyr S, Guo X, Marcil MJ, Dupont P, Jobidon L, Benrimoh D, et al. Posttraumatic stress disorder prevalence in medical populations: A systematic review and meta-analysis. Gen Hosp Psychiatry. 2021;69:81-93. doi: 10.1016/j.genhosppsych.2021.01.010. %
• El-Gabalawy R, Sommer JL, Pietrzak R, Edmondson D, Sareen J, Avidan MS, et al. Post-traumatic stress in the postoperative period: current status and future directions. Can J Anaesth. 2019;66(11):1385-1395. English. doi: 10.1007/s12630-019-01418-4.
• Vulser H, Airagnes G, Lahlou-Laforêt K, Galliot AM, Limosin F, Cholley B, et al. Psychiatric consequences of intraoperative awareness: short review and case series. Gen Hosp Psychiatry. 2015;37(1):94-5. doi: 10.1016/j.genhosppsych.2014.10.006.
• Ghoneim MM, Block RI, Haffarnan M, Mathews MJ. Awareness during anesthesia: risk factors, causes and sequelae: a review of reported cases in the literature. Anesth Analg. 2009;108(2):527-35. doi: 10.1213/ane.0b013e318193c634.
• Members of the Working Party; Nightingale CE, Margarson MP, Shearer E, Redman JW, Lucas DN, Cousins JM, et al.; Association of Anaesthetists of Great Britain; Ireland Society for Obesity and Bariatric Anaesthesia. Peri-operative management of the obese surgical patient 2015: Association of Anaesthetists of Great Britain and Ireland Society for Obesity and Bariatric Anaesthesia. Anaesthesia. 2015;70(7):859-76. doi: 10.1111/anae.13101.
• Aranake A, Gradwohl S, Ben-Abdallah A, Lin N, Shanks A, Helsten DL, et al. Increased risk of intraoperative awareness in patients with a history of awareness. Anesthesiology. 2013 Dec;119(6):1275-83. doi: 10.1097/ALN.0000000000000023.
• Sleigh JW, Leslie K, Davidson AJ, Amor DJ, Diakumis P, Lukic V, et al. Genetic Analysis of Patients Who Experienced Awareness with Recall while under General Anesthesia. Anesthesiology. 2019;131(5):974-982. doi: 10.1097/ALN.0000000000002877.
• Vadivelu N, Mitra S, Kaye AD, Urman RD. Perioperative analgesia and challenges in the drug-addicted and drug-dependent patient. Best Pract Res Clin Anaesthesiol. 2014;28(1):91-101. doi: 10.1016/j.bpa.2014.02.003.
• Pulley DD. Preoperative Evaluation of the Patient with Substance Use Disorder and Perioperative Considerations. Anesthesiol Clin. 2016;34(1):201-11. doi: 10.1016/j.anclin.2015.10.015.
• Nieminen TH, Hagelberg NM, Saari TI, Neuvonen M, Laine K, Neuvonen PJ, Olkkola KT. St John’s wort greatly reduces the concentrations of oral oxycodone. Eur J Pain. 2010 Sep;14(8):854-9. doi: 10.1016/j.ejpain.2009.12.007.
• Sury MR, Arumainathan R, Belhaj AM, MacG Palmer JH, Cook TM, Pandit JJ. The state of UK pediatric anesthesia: a survey of National Health Service activity. Paediatr Anaesth. 2015;25(11):1085-92. doi: 10.1111/pan.12753.
• Checketts MR, Alladi R, Ferguson K, Gemmell L, Handy JM, Klein AA, et al.; Association of Anaesthetists of Great Britain and Ireland. Recommendations for standards of monitoring during anaesthesia and recovery 2015: Association of Anaesthetists of Great Britain and Ireland. Anaesthesia. 2016;71(1):85-93. doi: 10.1111/anae.13316.
• Nimmo AF, Absalom AR, Bagshaw O, Biswas A, Cook TM, Costello A, et al. Guidelines for the safe practice of total intravenous anaesthesia (TIVA): Joint Guidelines from the Association of Anaesthetists and the Society for Intravenous Anaesthesia. Anaesthesia. 2019;74(2):211-224. doi: 10.1111/anae.14428.
• American Society of Anesthesiologists Task Force on Intraoperative Awareness. Practice advisory for intraoperative awareness and brain function monitoring: a report by the american society of anesthesiologists task force on intraoperative awareness. Anesthesiology. 2006;104(4):847-64. doi: 10.1097/00000542-200604000-00031.
• Kimball D, Kincaide RC, Ives C, Henderson S. Rapid Sequence Intubation from the Patient’s Perspective. West J Emerg Med. 2011;12(4):365-7. doi: 10.5811/westjem.2010.11.1922.
• Carley SD, Gwinnutt C, Butler J, Sammy I, Driscoll P. Rapid sequence induction in the emergency department: a strategy for failure. Emerg Med J. 2002 Mar;19(2):109-13. doi: 10.1136/emj.19.2.109.
• El-Orbany M, Connolly LA. Rapid sequence induction and intubation: current controversy. Anesth Analg. 2010;110(5):1318-25. doi: 10.1213/ANE.0b013e3181d5ae47.
• Zhang C, Xu L, Ma YQ, Sun YX, Li YH, Zhang L, et al. Bispectral index monitoring prevent awareness during total intravenous anesthesia: a prospective, randomized, double-blinded, multi-center controlled trial. Chin Med J (Engl). 2011;124(22):3664-9. P
• Schünemann H. Awareness - Aktuelle juristische Aspekte [Awareness - medico legal aspects]. Anasthesiol Intensivmed Notfallmed Schmerzther. 2013 Jan;48(1):58-62. German. doi: 10.1055/s-0032-1333081. Epub 2013 Jan 30. PMID: 23364827.
• Şeker İ, Şeker H, Boran E. Anestezik Ölçümleme, Değerlendirme ve Kayıtlamanın Strasbourg Delil Sistemi ile Yaşam Hakkı Bağlamında Değerlendirilmesi ve Delillerin Kabul Edilebilirliği Sorunu. Ankara Barosu Dergisi. 2014; 7(4): 155-269.
• Ekman A, Lindholm M.-L., Lennmarken C, Sandin R. Reduction in the incidence of awareness using BIS monitoring. Acta Anaesthesiologica Scandinavica, 2003;48(1): 20–26. doi:10.1111/j.1399-6576.2004.00260.x
• Akinci SB, Çelebioglu B. Bispektral Indeks Monitörizasyonu. J Turk Soc Intens Care 2006;4(2): 85-90.