Dreaming during gastrointestinal endoscopy under propofol, ciprofol, or remimazolam anesthesia: study protocol for a parallel-design double-blind, single-center trial.

BACKGROUND: Dreaming sometimes occurs during sedation. It has been reported that factors such as different anesthetics, depth of anesthesia, age, sex, and preoperative psychological state may affect dreams. Ciprofol and remimazolam are novel choices for painless endoscopy. Herein, we aimed to investigate dreaming during gastrointestinal endoscopy under propofol, ciprofol, and remimazolam anesthesia respectively. METHODS: This is a prospective, parallel-design double-blind, single-center clinical trial. Three hundred and sixty subjects undergoing elective painless gastroscopy, colonoscopy, or gastroenteroscopy will be enrolled. Eligible subjects will undergo propofol-, ciprofol-, or remimazolam-induced anesthesia to finish the examination. Interviews about the modified Brice questionnaire will be conducted in the recovery room. Incidence of dreaming is set as the primary outcome. Secondary outcomes include type of dreams, improvement of sleep quality, evaluation of patients, incidence of insufficient anesthesia, and intraoperative awareness. Safety outcomes are the incidences of hypotension and hypoxia during examination and adverse events during recovery. DISCUSSION: This study may observe different incidences of dreaming and diverse types of dreams, which might lead to different evaluations to the anesthesia procedure. Based on the coming results, anesthesiologists can make a better medication plan for patients who are going to undergo painless diagnosis and treatment. TRIAL REGISTRATION: This trial was registered at the Chinese Clinical Trial Registry on May 18, 2023 (registration number ChiCTR2300071565).

Awareness Under Anesthesia.

You begin to hear distant rock music playing, people conversing about their weekend. Then the scalpel is requested-incision. Pain sends you reeling and you attempt to muster a scream. No one seems to hear you and you are unable to lift a finger. The scenario is so rare that numerous movies have been made about awareness under anesthesia. Awareness under anesthesia is a rare event, however, it is a complication that no one ever desires to occur. We will explore how frequent awareness is during surgery, what risk factors are involved, and what tools anesthesia providers utilize to ensure everyone undergoing surgery is adequately anesthetized.

Meta-analysis of the effect of entropy-assisted general anesthesia on the quality of postoperative recovery.

BACKGROUND: To evaluate the effect of the quality of postoperative anesthetic resuscitation in patients with entropy index monitoring assisted general anesthesia versus standard clinical practice. METHODS: The randomized controlled trials on the application of entropy index monitoring in general anesthesia were searched in PubMed, Web of Science, Embase, The Cochrane Library, CNKI, Wanfang, VIP, and other databases by computer. The data were collected from inception to January 2022. Two researchers independently screened the retrieved literature according to the inclusion and exclusion criteria and used Cochrane's risk-of-bias assessment criteria to evaluate the quality of the literature. The evaluation indicators included respiratory recovery time, extubation time, consciousness recovery time, emergence agitation, postoperative nausea and vomiting (PONV), and intraoperative awareness. The RevMan 5.4.1 software was used for the meta-analysis of the data. RESULTS: A total of 860 patients from 10 eligible randomized controlled trials were included in this study. The results showed that compared with the control group, the respiratory recovery time (MD = -3.37, 95% CI: -5.09 to -1.85, P < .0001), extubation time (MD = -4.57, 95% CI: -6.08 to -3.95, P < .00001), and consciousness recovery time (MD = -4.95, 95% CI: -7.21 to -2.70, P < .00001) in the entropy index group were significantly shortened. The incidence of emergence agitation in the entropy index group (RR = 0.23, 95% CI: 0.11-0.47, P < .0001) decreased significantly. The incidence of PONV (RR = 0.46, 95% CI: 0.27-0.79, P = .004) was significantly reduced. However, the incidence of intraoperative awareness (RR = 0.33, 95% CI: 0.04-3.16, P = .34) wasn't significantly different. CONCLUSION: The application of the entropy index can improve the recovery quality of patients under general anesthesia, not only shortening the postoperative recovery time but also reducing the occurrence of agitation and PONV. It does not affect the incidence of intraoperative awareness.

The use of processed electroencephalography (pEEG) in obstetric anaesthesia: a narrative review.

Accidental awareness under general anaesthesia (AAGA) remains a major complication of anaesthesia. The incidence of AAGA during obstetric anaesthesia is high relative to other specialities. The use of processed electroencephalography (pEEG) in the form of "depth of anaesthesia" monitoring has been shown to reduce the incidence of AAGA in the non-obstetric population. The evidence for using pEEG to prevent AAGA in the obstetric population is poor and requires further exploration. Furthermore, pregnancy and disease states affecting the central nervous system, such as pre-eclampsia, may alter the interpretation of pEEG waveforms although this has not been fully characterised. National guidelines exist for pEEG monitoring with total intravenous anaesthesia and for "high-risk" cases regardless of technique, including the obstetric population. However, none of the currently available guidelines relates specifically to obstetric anaesthesia. Using pEEG monitoring for obstetric anaesthesia may also provide additional benefits beyond a reduction in risk of AAGA. These potential benefits include reduced postoperative nausea and vomiting, reduced anaesthetic agent use, and a shorter post-anaesthetic recovery stay. In addition, pEEG acts as a surrogate marker of cerebral perfusion, and thus as an additional monitor for impending cardiovascular collapse, as seen in amniotic fluid embolism. The subtle physiological and pathological changes in EEG activity that may occur during pregnancy are an unexplored research area in the context of anaesthetic pEEG monitors. We believe that the direction of clinical practice is moving towards greater use of pEEG monitoring and individualisation of anaesthesia.

Effect of perioperative benzodiazepine use on intraoperative awareness and postoperative delirium: a systematic review and meta-analysis of randomised controlled trials and observational studies.

BACKGROUND: Benzodiazepine use is associated with delirium, and guidelines recommend avoiding them in older and critically ill patients. Their perioperative use remains common because of perceived benefits. METHODS: We searched CENTRAL, MEDLINE, CINAHL, PsycInfo, and Web of Science from inception to June 2021. Pairs of reviewers identified randomised controlled trials and prospective observational studies comparing perioperative use of benzodiazepines with other agents or placebo in patients undergoing surgery. Two reviewers independently abstracted data, which we combined using a random-effects model. Our primary outcomes were delirium, intraoperative awareness, and mortality. RESULTS: We included 34 randomised controlled trials (n=4354) and nine observational studies (n=3309). Observational studies were considered separately. Perioperative benzodiazepines did not increase the risk of delirium (n=1352; risk ratio [RR] 1.43; 95% confidence interval [CI]: 0.9-2.27; I2=72%; P=0.13; very low-quality evidence). Use of benzodiazepines instead of dexmedetomidine did, however, increase the risk of delirium (five studies; n=429; RR 1.83; 95% CI: 1.24-2.72; I2=13%; P=0.002). Perioperative benzodiazepine use decreased the risk of intraoperative awareness (n=2245; RR 0.26; 95% CI: 0.12-0.58; I2=35%; P=0.001; very low-quality evidence). When considering non-events, perioperative benzodiazepine use increased the probability of not having intraoperative awareness (RR 1.07; 95% CI: 1.01-1.13; I2=98%; P=0.03; very low-quality evidence). Mortality was reported by one randomised controlled trial (n=800; RR 0.90; 95% CI: 0.20-3.1; P=0.80; very low quality). CONCLUSIONS: In this systematic review and meta-analysis, perioperative benzodiazepine use did not increase postoperative delirium and decreased intraoperative awareness. Previously observed relationships of benzodiazepine use with delirium could be explained by comparisons with dexmedetomidine. SYSTEMATIC REVIEW PROTOCOL: PROSPERO CRD42019128144.

Perception and practices of depth of anesthesia monitoring and intraoperative awareness event rate among Jordanian anesthesiologists: a cross-sectional study.

BACKGROUND: Intraoperative awareness is the second most common complication of surgeries, and it negatively affects patients and healthcare professionals. Based on the limited previous studies, there is a wide variation in the incidence of intraoperative awareness and in the practices and attitudes toward depth of anesthesia (DoA) monitoring among healthcare systems and anesthesiologists. This study aimed to evaluate the Jordanian anesthesiologists' practice and attitudes toward DoA monitoring and estimate the event rate of intraoperative awareness among the participating anesthesiologists. METHODS: A descriptive cross-sectional survey of Jordanian anesthesiologists working in public, private, and university hospitals was utilized using a questionnaire developed based on previous studies. Practice and attitude in using DoA monitors were evaluated. Anesthesiologists were asked to best estimate the number of anesthesia procedures and frequency of intraoperative awareness events in the year before. Percentages and 95% Confidence Intervals (95%CI) were reported and compared between groups using chi-square tests. RESULTS: A total of 107 anesthesiologists responded and completed the survey. About one-third of the respondents (34.6%; 95% CI 26.1-44.2) had never used a DoA monitor and only 6.5% (95% CI 3.1-13.2) reported using it as a "daily practice". The use of a DoA monitor was associated with experience and type of health sector. However, 81.3% (95% CI 66.5-83.5) believed that currently available DoA monitors are effective for DoA monitoring and only 4.7% (95%CI 1.9-10.8) reported it as being "invalid". Most respondents reported that the main purpose of using a DoA monitor was to prevent awareness (86.0%; 95%CI 77.9-91.4), guide the delivery of anesthetics (63.6%; 95%CI 53.9-72.2), and reduce recovery time (57%; 95%CI 47.4-66.1). The event rate of intraoperative awareness was estimated at 0.4% among participating anesthesiologists. Most Jordanian hospitals lacked policy intending to prevent intraoperative awareness. CONCLUSIONS: Most anesthesiologists believed in the role of DoA monitors in preventing intraoperative awareness, however, their attitudes and knowledge are inadequate, and few use DoA monitors in routine practices. In Jordan, large efforts are needed to regulate the use of DoA monitoring and reduce the incidence of intraoperative awareness.

Spectral edge frequency during general anaesthesia: A narrative literature review.

Previous studies have attempted to determine the depth of anaesthesia with different anaesthetic agents using electroencephalogram (EEG) measurements with variable success. Measuring depth of anaesthesia is confounded by the complexity of the EEG and the fact that different agents create different pattens. A narrative review was undertaken to examine the available research evidence on the effect and reliability of spectral edge frequency (SEF) for assessing the depth of anaesthesia in adult patients under general anaesthesia. A systematic search of the PubMed®, Scopus®, CINAHL and Cochrane databases identified six randomized controlled trials and five observational studies. The findings of these studies suggest that SEF varies according to the anaesthetic drugs used. Remifentanil and age are two factors that can affect SEF, while other opioids and benzodiazepine (administered separately) seem to have no effect. No patients experienced intraoperative awareness. However, this does not indicate that SEF can provide full protection against it and the number of articles in which intraoperative awareness was studied was too small to afford any certainty. None of the studies demonstrated a reliable SEF interval associated with adequate general anaesthesia. SEF must be adapted to the anaesthetic drug used, the patient's age and state while under general anaesthesia.

Intraoperative hand strength as an indicator of consciousness during awake craniotomy: a prospective, observational study.

Awake craniotomy enables mapping and monitoring of brain functions. For successful procedures, rapid awakening and the precise evaluation of consciousness are required. A prospective, observational study conducted to test whether intraoperative hand strength could be a sensitive indicator of consciousness during the awake phase of awake craniotomy. Twenty-three patients who underwent awake craniotomy were included. Subtle changes of the level of consciousness were assessed by the Japan Coma Scale (JCS). The associations of hand strength on the unaffected side with the predicted plasma concentration (Cp) of propofol, the bispectral index (BIS), and the JCS were analyzed. Hand strength relative to the preoperative maximum hand strength on the unaffected side showed significant correlations with the Cp of propofol (ρ = - 0.219, p = 0.007), the BIS (ρ = 0.259, p = 0.002), and the JCS (τ = - 0.508, p = 0.001). Receiver operating characteristic curve analysis for discriminating JCS 0-1 and JCS ≥ 2 demonstrated that the area under the curve was 0.76 for hand strength, 0.78 for Cp of propofol, and 0.66 for BIS. With a cutoff value of 75% for hand strength, the sensitivity was 0.76, and the specificity was 0.67. These data demonstrated that hand strength is a useful indicator for assessing the intraoperative level of consciousness during awake craniotomy.

Detection method of intraoperative awareness: a randomized comparative study.

BACKGROUND: : The incidence of intraoperative awareness varies in a wide range in the literature. The reasons for these different results include the questioning method used and the questioning time. The goal of this study is to compare the effectiveness of different questioning methods and times used in intraoperative awareness research for detecting the incidence. METHODS: We recruited patients between the ages of 18-70 years, with normal cognitive functions and able to speak after general anesthesia to the study. The patients were randomly divided into two groups. In Group 1 we applied the modified Brice questionnaire in the first 2 h and 24 h after surgery for investigating intraoperative awareness. In Group 2, 24 h after surgery, we asked about anesthesia satisfaction and patients' complaints, if any. RESULTS: There was no statistically significant difference between the groups in terms of age (p = 0.514).The proportion of women was significantly higher (p = 0.002), the duration of anesthesia was shorter, and the rate of narcotic analgesic use was higher in Group 2 (p < 0.001). The assessment in the first 2 h showed the frequency of awareness was statistically higher in Group 1 than in Group 2 (p = 0.016). In the postoperative 24-h assessment, we found no significant difference in the incidence of intraoperative awareness between the groups (p < 0.05). In Group 1, there was no statistically significant difference in terms of incidence of awareness according to evaluation time (p = 250). DISCUSSION: The incidence of intraoperative awareness in Group 1 was significantly higher than in Group 2 in the evaluation conducted in the first 2 h. There was no significant difference in the determination of intraoperative awareness between questioning times in group 1.

A survey of current practices, attitudes and demands of anaesthesiologists regarding the depth of anaesthesia monitoring in China.

BACKGROUND: In this study, we aimed to analyse survey data to explore two different hypotheses; and for this purpose, we distributed an online survey to Chinese anaesthesiologists. The hypothetical questions in this survey include: (1) Chinese anaesthesiologists mainly use the depth of anaesthesia (DoA) monitors to prevent intraoperative awareness and (2) the accuracy of these monitors is the most crucial performance factor during the clinical daily practice of Chinese anaesthesiologists. METHODS: We collected and statistically analysed the response of a total of 12,750 anesthesiologists who were invited to participate in an anonymous online survey. The Chinese Society of Anaesthesiologists (CSA) trial group provided the email address of each anaesthesiologist, and the selection of respondents was random from the computerized system. RESULTS: The overall response rate was 32.0% (4037 respondents). Only 9.1% (95% confidence interval, 8.2-10.0%) of the respondents routinely used DoA monitors. Academic respondents (91.5, 90.3-92.7%) most frequently used DoA monitoring to prevent awareness, whereas nonacademic respondents (88.8, 87.4-90.2%) most frequently used DoA monitoring to guide the delivery of anaesthetic agents. In total, the number of respondents who did not use a DoA monitor and whose patients experienced awareness (61.7, 57.8-65.6%) was significantly greater than those who used one or several DoA monitors (51.5, 49.8-53.2%). Overall, the crucial performance factor during DoA monitoring was considered by 61.9% (60.4-63.4%) of the respondents to be accuracy. However, most respondents (95.7, 95.1-96.3%) demanded improvements in the accuracy of the monitors for DoA monitoring. In addition, broad application in patients of all ages (86.3, 85.2-87.4%), analgesia monitoring (80.4, 79.2-81.6%), and all types of anaesthetic agents (75.6, 74.3-76.9%) was reported. In total, 65.0% (63.6-66.5%) of the respondents believed that DoA monitors should be combined with EEG and vital sign monitoring, and 53.7% (52.1-55.2%) believed that advanced DoA monitors should include artificial intelligence. CONCLUSIONS: Academic anaesthesiologists primarily use DoA monitoring to prevent awareness, whereas nonacademic anaesthesiologists use DoA monitoring to guide the delivery of anaesthetics. Anaesthesiologists demand high-accuracy DoA monitors incorporating EEG signals, multiple vital signs, and antinociceptive indicators. DoA monitors with artificial intelligence may represent a new direction for future research on DoA monitoring.

Raw and processed electroencephalography in modern anesthesia practice: a brief primer on select clinical applications.

The evidence supporting the intraoperative use of processed electroencephalography (pEEG) monitoring to guide anesthetic delivery is growing rapidly. This article reviews the key features of electroencephalography (EEG) waveforms and their clinical implications in select patient populations and anesthetic techniques. The first patient topic reviewed is the vulnerable brain. This term has emerged as a description of patients who may exhibit increased sensitivity to anesthetics and/or may develop adverse neurocognitive effects following anesthesia. pEEG monitoring of patients who are known to have or are suspected of having vulnerable brains, with focused attention on the suppression ratio, alpha band power, and pEEG indices, may prove useful. Second, pEEG monitoring along with vigilant attention to anesthetic delivery may minimize the risk of intraoperative awareness when administering a total intravenous anesthesia in combination with a neuromuscular blockade. Third, we suggest that processed EEG monitoring may play a role in anesthetic and resuscitative management when adverse changes in blood pressure occur. Fourth, pEEG monitoring can be used to better identify anesthesia requirements and guide anesthetic titration in patients with known or suspected substance use.

Self-reported awareness during general anesthesia in pediatric patients: A study from Wake Up Safe.

BACKGROUND: Awareness under general anesthesia occurs rarely, but can result in emotional trauma. Although well-studied in adults, there is a paucity of data on unintentional awareness in children. AIMS: This case series examines instances of self-reported awareness registered with Wake Up Safe, a patient safety organization that maintains a database of adverse events in pediatric anesthesia. METHODS: Cases of self-reported intraoperative awareness submitted to Wake Up Safe from January 1, 2010 to May 31, 2020 were reviewed for circumstances, causative factors, and level of harm. RESULTS: Fourteen cases of self-reported intraoperative awareness out of 555 360 cases in patients aged 5-20 years were noted during the study period. Overall incidence of awareness was 2.52 (95% CI: 1.38-4.23) cases per 100 000 patients, or approximately 1:40 000. Self-reported intraoperative awareness was more frequently associated with cardiac and gastrointestinal endoscopic procedures. Incidence for cardiac procedures was 20.34 (95% CI: 8.18-41.90) cases per 100 000 patients. Incidence for gastrointestinal endoscopic procedures was 7.74 (95% CI: 1.60-22.62) cases per 100 000 patients. Most patients were assessed to have suffered harm. CONCLUSIONS: Self-reported intraoperative awareness is a rare complication in pediatric patients that has implications for harm. Compared to awareness cases elicited by a questionnaire method, cases of self-reported awareness during general anesthesia may represent those that have a greater impact. A preoperative discussion of intraoperative awareness should be considered for procedures that carry a higher likelihood of awareness in order to mitigate harm.

Optimizing Motor Intention Detection With Deep Learning: Towards Management of Intraoperative Awareness.

OBJECTIVE: This article shows the interest in deep learning techniques to detect motor imagery (MI) from raw electroencephalographic (EEG) signals when a functional electrical stimulation is added or not. Impacts of electrode montages and bandwidth are also reported. The perspective of this work is to improve the detection of intraoperative awareness during general anesthesia. METHODS: Various architectures of EEGNet were investigated to optimize MI detection. They have been compared to the state-of-the-art classifiers in Brain-Computer Interfaces (based on Riemannian geometry, linear discriminant analysis), and other deep learning architectures (deep convolution network, shallow convolutional network). EEG data were measured from 22 participants performing motor imagery with and without median nerve stimulation. RESULTS: The proposed architecture of EEGNet reaches the best classification accuracy (83.2%) and false-positive rate (FPR 19.0%) for a setup with only six electrodes over the motor cortex and frontal lobe and for an extended 4-38 Hz EEG frequency range while the subject is being stimulated via a median nerve. Configurations with a larger number of electrodes result in higher accuracy (94.5%) and FPR (6.1%) for 128 electrodes (and respectively 88.0% and 12.9% for 13 electrodes). CONCLUSION: The present work demonstrates that using an extended EEG frequency band and a modified EEGNet deep neural network increases the accuracy of MI detection when used with as few as 6 electrodes which include frontal channels. SIGNIFICANCE: The proposed method contributes to the development of Brain-Computer Interface systems based on MI detection from EEG.

Incidence of accidental awareness during general anaesthesia in obstetrics: a multicentre, prospective cohort study.

General anaesthesia for obstetric surgery has distinct characteristics that may contribute towards a higher risk of accidental awareness during general anaesthesia. The primary aim of this study was to investigate the incidence, experience and psychological implications of unintended conscious awareness during general anaesthesia in obstetric patients. From May 2017 to August 2018, 3115 consenting patients receiving general anaesthesia for obstetric surgery in 72 hospitals in England were recruited to the study. Patients received three repetitions of standardised questioning over 30 days, with responses indicating memories during general anaesthesia that were verified using interviews and record interrogation. A total of 12 patients had certain/probable or possible awareness, an incidence of 1 in 256 (95%CI 149-500) for all obstetric surgery. The incidence was 1 in 212 (95%CI 122-417) for caesarean section surgery. Distressing experiences were reported by seven (58.3%) patients, paralysis by five (41.7%) and paralysis with pain by two (16.7%). Accidental awareness occurred during induction and emergence in nine (75%) of the patients who reported awareness. Factors associated with accidental awareness during general anaesthesia were: high BMI (25-30 kg.m-2 ); low BMI (<18.5 kg.m-2 ); out-of-hours surgery; and use of ketamine or thiopental for induction. Standardised psychological impact scores at 30 days were significantly higher in awareness patients (median (IQR [range]) 15 (2.7-52.0 [2-56]) than in patients without awareness 3 (1-9 [0-64]), p = 0.010. Four patients had a provisional diagnosis of post-traumatic stress disorder. We conclude that direct postoperative questioning reveals high rates of accidental awareness during general anaesthesia for obstetric surgery, which has implications for anaesthetic practice, consent and follow-up.

Unintended intraoperative awareness: An analysis of Perioperative Anesthetic Adverse Events in Thailand (PAAd Thai).

BACKGROUND: Despite the improvement of anesthetic-related modalities, the incidence of unintended intraoperative awareness remains at around 0.005-0.038%. OBJECTIVE: We aimed to describe the intraoperative awareness incidents that occurred across Thailand between January to December, 2015. METHODS: Observational data was collected from 22 hospitals throughout Thailand. The awareness category was selected from incident reports according to the Perioperative Anesthetic Adverse Events in Thailand (PAAd Thai) study database and descriptive statistics were analyzed. The awareness characteristics and the related factors were recorded. RESULTS: A total of nine intraoperative awareness episodes from 2000 incidents were observed. The intraoperative awareness results were as follows: experience of pain (38.1%), perception of sound (33.3%), perception of intubation (9.5%) and feeling of paralysis (14.3%). The observed factors that affect intraoperative awareness were anesthesia-related (100%), patient-related (55.5%), surgery-related (22.2%) and systematic process-related (22.2%). The contributing factors were situational inexperience (77.8%) and inappropriate patient evaluation (44.4%). An awareness of anesthetic performer (100%) and experience (88.9%) were defined as incident-mitigating factors. The suggested corrective strategies were quality assurance activity (88.9%), improved supervision (44.4%) and equipment utilization (33.3%), respectively. CONCLUSION: Nine intraoperative awareness incidents were observed, however the causes were preventable. The anesthetic component seems to be the most influential to prevent these events.