Through and beyond anaesthesia awareness
BMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c3669 (Published 12 July 2010) Cite this as: BMJ 2010;341:c3669
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
The article by Aaen & Moller (1) is a salutary reminder that
awareness under anaesthesia remains a rare but ever-present risk, and that
muscle relaxants in particular must be treated with great respect. The
case also highlights the fact that, surprisingly, even severe cases of
awareness with pain may not be recalled until some time afterwards. The
authors are to be applauded for reporting this case, and for the way in
which they dealt with the situation afterwards.
Would the authors be able to give more details about the anaesthesia,
as the causes of the incident do not seem completely clear from the
article? It is mentioned that the cannula supplying the propofol infusion
became displaced, but it would be very helpful to know the exact drug
doses and timings involved, and in particular why the initial dose of
thiopentone had so little effect. In order to prevent similar cases
occurring in future, such details would be extremely helpful for all
anaesthetists to learn from.
1. Aaen A-M, Moller K. Through and beyond anaesthesia awareness.
BMJ 2010;341:830-1.
Competing interests: No competing interests
As a previous anaesthetist, and now retired GP, I was very moved to
read this account of a Danish patient's awareness during emergency
Caesarian section, and her recovery from the effects of the ordeal being
supported so well by the anaesthetist.
Both showed great courage, honesty and empathy in describing the
effect the incident had on both their lives, and how they worked through
it together.
I fear that this would never happen in the UK, as we now have such a
litiginous and defensive culture, and yet it seems to me that the best
possible outcome was reached in this way for all concerned.
I can only hope that the new generation of doctors might be allowed
to resolve similar issues by such a constructive route.
Competing interests: No competing interests
Preventing awareness
I read with interest the recent article on awareness which
highlighted the emotional consequences, both for patient and anaesthetist,
of this most feared of anaesthetic complications. I can relate to how Dr
Moller felt as the same thing happened to me as a trainee whilst giving
anaesthesia for a patient undergoing electro-convulsive therapy. I can
vividly remember the devastation I felt thinking I had caused suffering to
a patient by not doing my job properly. I had to answer to the head of the
department, the suggestion being that I hadn't mixed up the induction
agent (methohexitone) correctly and that I had in fact injected only
saline followed by a muscle relaxant. I was adamant I hadn't.
My case was similar in that my patient had an induction agent and
suxamethonium without opioids or volatile agent, underwent a stimulating
procedure and experienced terrifying awareness (unlike Dr Moller I did not
use a propofol infusion for maintenance of anaesthesia as the procedure
was extremely short). To this day I cannot understand why the induction
agent did not work, but I'm sure I gave it and not, as was implied,
saline. Dr Moller stresses the important psychological lessons learnt,
which I agree with, but I wonder if there isn't also a very practical one
these cases demonstrate: Anaesthesia for a stimulating procedure with only
an induction agent for initiation and maintenance of anaesthesia, combined
with a relaxant, but no opioids or volatile agent, carries a high risk of
awareness and should be avoided.
Competing interests: No competing interests