One of my patients’ most common fears is “will I remember the surgery?” or "will I wake up?" referring to anesthesia awareness or intraoperative awareness.
Anesthesia is the most mysterious branch of medicine. We don’t really know how it works, and sometimes patients are able to break through the anesthesia and wakeup. Or at least remember things.
This can be serious and can cause trauma and PTSD, depression, and other serious health conditions. As rare as it is (under 1%) there’s things you can do to prevent waking up during surgery. Amazingly, some of the most powerful ways to minimize the risk involve all natural strategies. Meaning you don’t need more medications!
What happens to you with anesthesia awareness?
Anesthesia awareness takes on many forms. In fact, it can be hard to diagnose because patients can remember so many different things during surgery, like:
- Auditory perceptions (hearing things): “I heard people talking” or “I heard music”
- Paralysis (inability to move during the surgery): “I tried, I could not move”
- Helplessness
- Impending doom: “I felt agony, terror, shock”
- Panic, anxiety
- Feel things in/on their body: “I felt this going down my throat”
- Seeing things: “Saw people dressed in green”
- Dreams: “Had a dream… thought it was funny”
- Aware but without sensation: “No [feelings of] pain”
It can also take more than a week for the brain to consolidate the memory to figure out what happened. It may come in the form of noticing new anxiety, insomnia, nightmares, etc. This also makes it difficult to diagnose.
Awareness under anesthesia can be serious
Awareness of anesthesia can be the worst hospital experiences. It can be so distressing that some patients will never want surgery again.
Complications of anesthesia awareness
Intraoperative awareness can have serious mental and physical complications. Here are just a few:
- Sleep disturbances and nightmares
- Daytime anxiety
- Fear about future anesthesia
- Depression
- PTSD, hyperarousal
- Chronic fear
- Loneliness
These may just sound like mental health complications. Remember that all mental health conditions can seriously affect the body through the mind-body connection. That’s why I take these so seriously.
Who gets PTSD from intraoperative awareness?
Bad experiences can happen to many people, but not all people will develop complications from those experiences. Personal and environmental factors influence who will have complications from anesthesia awareness:
· Trust in your surgery team. Feeling like your life is in danger is a risk factor for intraoperative awareness becoming a serious complication.
· Environmental context of the awareness experience. A mother with awareness in her C-section who hears her newborn's cries and her partner’s voice is less likely to have the same complications as a patient who is paralyzed and in pain.
· Pre-existing conditions. We believe patients with pre-existing mental health conditions, like anxiety and depression, are more likely to suffer complications from anesthesia awareness.
· Perceived support after surgery.
Why do you get anesthesia awareness in surgery?
Your brain is like a balancing act under anesthesia. Your brain needs a specific anesthesia dose to cause amnesia. Amnesia means your brain isn’t forming new memories.
If your brain doesn’t get the dose it needs, you’re at risk of anesthesia awareness.
Therefore, anything that increases your anesthesia requirements can increase your risk of awareness. Also, anything that lowers your tolerance of anesthesia can also increase your risk of intraoperative awareness.
Low anesthesia tolerance means your heart can't handle as much anesthesia, so your body can't tolerate more.
What increases your anesthesia requirements?
Multiple factors increase your anesthesia requirements. Remember, the higher your requirements, the higher the likelihood of being underdosed. Being underdosed is a risk factor for intraoperative awareness.
- Pre-operative anxiety: your anxiety level before surgery can impact how much anesthesia you need to be asleep
- Pre-operative substance use: drugs like alcohol, marijuana, opioids, and amphetamines)
- Lower age, high body temperature: children need more anesthesia for their body weight than older adults
- Red hair: but anesthesia requirements depend on the specific medication
- Ehlers-Danlos syndrome: we don't really know yet
- Hypernatremia: high blood sodium concentration
- Obesity: likely because of relative underdosing
- Female sex: women may recover faster from anesthesia, hence increasing requirements, but controversial how much of a risk this really is
Interestingly, pregnancy and low body temperature decrease your anesthesia requirements.
What lowers your tolerance of anesthesia?
Anesthesia takes your nervous system offline. This blunts many of your body’s reflexes and takes a major toll on your heart and lungs.
Patients with heart and lung disease are less able to tolerate the effects of anesthesia. That means they may not be able to safely receive as much anesthesia. This can increase the risk of anesthesia awareness because they may be relatively underdosed.
If your heart and lungs can’t tolerate anesthesia, you may not receive enough to cause amnesia
This comes up in some key surgeries because your anesthesiologist needs to run the anesthesia “light” to protect your heart:
· Emergency trauma surgery. You may have lost lots of blood and are at risk of heart attacks and major cardiovascular problems. Your anesthesiologist may need to run the anesthesia lightly to keep you alive.
· Emergency cesarean sections. Similar to above, there can be major blood loss in emergency C-sections. We also want to limit the amount of anesthesia that reaches the fetus (but this is a secondary concern).
· Open heart surgery. Patients having open heart surgery already have serious cardiovascular disease. They may have had heart attacks or strokes. The heart may not be able to tolerate anesthesia fully, hence why they are under “light” anesthesia.
All three of these cases of patients receiving “light” anesthesia can raise the risk of intraoperative awareness.
How to Reduce Anesthesia Awareness and PTSD?
You can’t change your natural hair color, but there are lots of strategies to reducing your risk of intraoperative awareness. Based on the risk factors above:
- Bring headphones to modify your environment under surgery: if you experience awareness, you want to have the most peaceful and calming voices around you
- Optimize your mental health before surgery: the better controlled your depression, anxiety, and PTSD, the lest chance of consolidating experiences as trauma, should awareness occur
- Reducing substance use: especially marijuana
- Control anxiety before surgery there are many strategies, watch my YouTube videos for many examples!
- Maintaining normal body weight
- Treating sleep apnea with your CPAP machine: this can increase your anesthesia tolerance (especially for surgery with anesthesia sedation)
- Maintaining a healthy heart and lungs: this can increase your anesthesia tolerance for all surgeries
How to Treat PTSD from Anesthesia Awareness
Even with the best prevention, anesthesia awareness can still occur. Fortunately, there are many ways you can treat the complications, like PTSD, from intraoperative awareness, should it occur. We'll talk about that in an upcoming article.
Until then, remember that you have more power over your health, even against anesthesia awareness, then you've probably ever been told!
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