Anesthesia awareness—the unexpected cognizance that occurs when anesthesia lightens during surgery—is the subject of a recent Sentinel Event Alert issued by the Joint Commission on Accreditation of Healthcare Organizations. Forty-eight percent of patients who experience awareness report auditory recollections, 48% report being unable to breathe, and 28% report pain—without being able to communicate this to the surgical team.

Although quite rare when viewed as a percentage of surgeries, unintended intraoperative awareness may affect as many as 20,000-40,000 patients annually and has been linked to posttraumatic stress disorder and other forms of mental distress. Patients most at risk are those who are hemodynamically unstable, necessitating careful titration of anesthesia (certain cardiac, obstetric, and trauma cases) as well as those who metabolize anesthetics more quickly than normal. "Our intent [in issuing the alert] is to help facilitate increased transparency in health care and promote the compassionate management of patients who do experience awareness," stated Dennis O'Leary, M.D., president of JCAHO.

Guidelines already in place from both the American Society of Anesthesiologists (ASA) and the American Association of Nurse Anesthetists (AANA) recommend reducing the risk of anesthesia awareness by premedication with amnesic drugs, particularly when light anesthesia is anticipated; giving more than a sleep dose of induction agents if they will be followed immediately by tracheal intubation; and limiting muscle paralysis to only what is absolutely clinically necessary. But as Julie Golembiewski, Pharm.D., clinical associate professor with the departments of pharmacy practice and anesthesiology at the University of Illinois at Chicago, told Drug Topics, "Not everyone is a candidate for a benzodiazepine."

While effective anesthesia monitoring would seem an ideal solution to prevent anesthesia awareness, appropriate techniques are still in their infancy. Roger Litwiller, M.D., president of ASA, explained, "There are at least three monitors available on the market. The problem is being able to accurately interpret the data they give you."

Thus, until monitors of consciousness are adequately tested and validated, other approaches must be used judiciously. Tom McKibban, CRNA, M.S., immediate past president of AANA, commented, "The JCAHO alert is a good starting point for developing a policy within the hospital to educate hospital personnel and physicians on what to look for." Identifying patients at risk is the No. 1 problem, followed by the proper treatment, he said. In addition, the alert cautioned practitioners to be conscious of patients on beta-blockers, calcium-channel blockers, and other drugs that can mask physiologic responses to inadequate anesthesia.

Given the short time many surgical patients are hospitalized, O'Leary also expects follow-up would be needed after discharge. "It is akin to postoperative follow-up for hospital-acquired infections postsurgically," he said. "We're extending the boundaries of potential hospital responsibility beyond the time of admission. That is controversial to be sure."

Golembiewski stated that she did not see a direct role for pharmacists in addressing the JCAHO alert. "I would really see a more peripheral role with protocols and quality improvement if someone chooses that as their quality assurance indicator."

Peter J. Koo, Pharm.D., associate clinical professor of pharmacy and pharmacist specialist in pain management, University of California, San Francisco, noted that in the cases of anesthesia awareness he has encountered, the issue is often drug interactions—perhaps recreational drug interactions—that cause the patient to metabolize the anesthesia more quickly than expected. "The key is we have to do better in presurgical medication evaluation, and that includes the anesthesia department. Because a lot of times in the presurgical clinic they just write down a drug, no frequency, regimen, or dose. That will have to change."