5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: Patient experiences, human factors, sedation, consent, and medicolegal issues

British Journal of Anaesthesia

Volumn 113, Issue 4, 2014, Pages 560-574

  Cook, T M ^a   Andrade, J ^b   Bogod, D G ^c   Hitchman, J M ^d   Jonker, W R ^e   Lucas, N ^f   Mackay, J H ^g   Nimmo, A F ^h   O Connor, K ⁱ   O Sullivan, E P ^j   Paul, R G ^k   Palmer, J H M G ^l   Plaat, F F ^m   Radcliffe, J J ⁿ   Sury, M R J ^o   Torevell, H E ^p   Wang, M ^q   Hainsworth, J ^r   Pandit, J J ^s   Armstrong, James ^t   Bird, Jonathan ^u   Eddy, Alison ^v   Harrop Griffiths, William ^w   Love, Nicholas ^w   Mahajan, Ravi ^x   Mallick, Abhiram ^w   Barker, Ian ^y   Kirkpatrick, Anahita ^z   Molodynski, Jayne ^aa   Poonnusamy, Karthikeyen ^ab   Moonesinghe, Ramani ^ac   Weatherill, David ^ad   Smith, David ^ae   Grocott, Mike ^ac   Humphrey, Maddy ^af   Drake, Sharon ^ad   Casserly, Mary ^ad   Rangasami, Jairaj ^ag   more..

^a ROYAL UNITED HOSPITAL   (United Kingdom)

^b UNIVERSITY OF PLYMOUTH   (United Kingdom)

^c NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST   (United Kingdom)

^d ROYAL COLLEGE OF ANAESTHETISTS   (United Kingdom)

^e SLIGO UNIVERSITY HOSPITAL   (Ireland)

^f NORTHWICK PARK HOSPITAL   (United Kingdom)

^g PAPWORTH HOSPITAL   (United Kingdom)

^h ROYAL INFIRMARY OF EDINBURGH   (United Kingdom)

ⁱ Bristol School of Anaesthesia   (United Kingdom)

^j ST JAMES S HOSPITAL   (Ireland)

^k ROYAL BROMPTON HOSPITAL   (United Kingdom)

^l HOPE HOSPITAL   (United Kingdom)

^m IMPERIAL COLLEGE HEALTHCARE NHS TRUST   (United Kingdom)

ⁿ NATIONAL HOSPITAL FOR NEUROLOGY AND NEUROSURGERY   (United Kingdom)

^o GREAT ORMOND STREET HOSPITAL   (United Kingdom)

^p BRADFORD TEACHING HOSPITALS NHS FOUNDATION TRUST   (United Kingdom)

^q UNIVERSITY OF LEICESTER   (United Kingdom)

^r LEICESTERSHIRE PARTNERSHIP NHS TRUST   (United Kingdom)

^s OXFORD UNIVERSITY HOSPITALS NHS FOUNDATION TRUST   (United Kingdom)

^t Medical Defence Union   (United Kingdom)

^u ROYAL COLLEGE OF PSYCHIATRISTS   (United Kingdom)

^v Irwin Mitchell Solicitors   (United Kingdom)

^w AAGBI   (United Kingdom)

^x Safe Anaesthesia Liaison Group   (United Kingdom)

^y Association of Peadiatric Anaesthetists   (United Kingdom)

^z Medical and Dental Defence Union of Scotland   (United Kingdom)

^aa Medical Protection Society   (United Kingdom)

^ab GUY'S AND ST THOMAS' NHS FOUNDATION TRUST   (United Kingdom)

^ac HUMAN SCIENCES RESEARCH COUNCIL   (South Africa)

^ad Patient Liaison Group   (United Kingdom)

^ae UNIVERSITY HOSPITAL SOUTHAMPTON NHS FOUNDATION TRUST   (United Kingdom)

^af NAP5 Administrator   (United Kingdom)

^ag WEXHAM PARK HOSPITAL   (United Kingdom)

more..

Author keywords

Awareness; Consent; Patient experience; Sedation

Indexed keywords

ANESTHESIST; ARTICLE; AUDITORY SYSTEM; AWARENESS; CLINICAL AUDIT; DISTRESS SYNDROME; EDUCATION; GENERAL ANESTHESIA; HUMAN; INFORMED CONSENT; INTRAOPERATIVE AWARENESS; MEDICOLEGAL ASPECT; MEMORY; PAIN; PARALYSIS; PERSONAL EXPERIENCE; POSTTRAUMATIC STRESS DISORDER; PRIORITY JOURNAL; PSYCHOLOGICAL ASPECT; REASSURANCE; SEDATION; SENSATION; TOUCH; TRAINING; ANESTHESIOLOGY; CONSCIOUS SEDATION; CONSENT; DRUG EFFECT; EQUIPMENT; HEALTH CARE QUALITY; HEALTH CARE SURVEY; INTERPERSONAL COMMUNICATION; IRELAND; LEGAL ASPECT; MEDICAL ERROR; PATIENT EXPERIENCE; PHYSICIAN; QUESTIONNAIRE; UNITED KINGDOM;

AWARENESS; CONSENT; PATIENT EXPERIENCE; SEDATION;

ANESTHESIA, GENERAL; ANESTHESIOLOGY; COMMUNICATION; CONSCIOUS SEDATION; GREAT BRITAIN; HEALTH CARE SURVEYS; HUMANS; INFORMED CONSENT; INTRAOPERATIVE AWARENESS; IRELAND; MEDICAL ERRORS; MEMORY; PHYSICIANS; QUALITY OF HEALTH CARE; QUESTIONNAIRES; STRESS DISORDERS, POST-TRAUMATIC;

EID: 84908632075     PISSN: 00070912     EISSN: 14716771     Source Type: Journal    
DOI: 10.1093/bja/aeu314     Document Type: Article

References (50)

1. Pandit JJ,Andrade J,BogodDG, et al. 5thNationalAudit Project (NAP5) on accidental awareness during general anaesthesia: protocol, methods, and analysis of data. Br J Anaesth 2014; 113: 540-8
2. Pandit JJ, Andrade J, Bogod DG, et al. 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: summary of main findings and risk factors. Br J Anaesth 2014; 113: 549-59
3. Aean A, Møller K. Through and beyond anaesthesia awareness. Br Med J 2010; 341: 830-1
4. MoermanN, Bonke B,Oosting J.Awareness and recall during general anesthesia. Facts and feelings. Anesthesiology 1993; 79: 454-64
5. Sebel PS, Bowdle TA,GhoneimMM,et al. The incidence ofawareness during anesthesia: a multicenter United States study. Anesth Analg 2004; 99: 833-9
6. 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: 527-35
7. Samuelsson P, Brudin L, Sandin RH. Late psychological symptoms after awareness among consecutively included surgical patients. Anesthesiology 2007; 106: 26-32
8. Schwender D, Kunze-Kronawitter H, Dietrich P, Klasing S, Forst H, Madler C. Conscious awareness during general anaesthesia: patients' perceptions, emotions, cognition and reactions. Br J Anaesth 1998; 80: 133-9
9. SandinRH, Enlund G,SamuelssonP, LennmarkenC.Awarenessduring anaesthesia: a prospective case study. Lancet 2000; 355: 707-11
10. Andrade J. Learning during anaesthesia: a review. Br J Psychol 1995; 86: 479-506
11. Russell IF, Wang M. Absence of memory for intra-operative information during surgery with total intravenous anaesthesia. Br J Anaesth 2001; 86: 196-202
12. Brice DD, Hetherington RR, Utting JE. A simple study of awareness and dreaming during anaesthesia. Br J Anaesth 1970; 42: 535-42
13. Avidan MS, Jacobsohn E, Glick D, et al. BAG-RECALL Research Group. Prevention of intraoperative awareness in a high-risk surgical population. N Engl J Med 2011; 365: 591-600
14. Sara SJ. Retrieval and reconsolidation: toward a neurobiology of remembering. Learn Mem 2000; 7: 73-84
15. Brewin CR. The nature and significance of memory disturbance inposttraumaticstressdisorder.AnnRev ClinPsychol 2011;7:203-27
16. Andrade J, Deeprose C. Unconscious memory formation during anaesthesia. Best Pract Res Clin Anaesthesiol 2007; 21: 385-401
17. Loftus E. The reality of repressed memories. Am Psychol 1993; 48: 518-37
18. Wade KA, Garry M, Read JD, Lindsay DS. A picture is worth a thousand lies: using false photographs to create false childhood memories. Psychon Bull Rev 2002; 9: 597-603
19. Wheeler MA. Improvement in recall over time without repeated testing: spontaneous recovery revisited. J Exp Psychol Learn Mem Cogn 1995; 21: 173-84
20. Kelley MR, Nairne JS. Remembering the forgotten? Reminiscence, hypermnesia and memory for order. Q J Exp Psychol A 2003; 56: 577-99
21. Odinot G, Memon A, La Rooy D, Millen A. Are two interviews better than one? Eyewitness memory across repeated cognitive interviews. PLoS One 2013; 8: e76305
22. Patihis L, Ho LY, Tingen IW, Lilienfeld SO, Loftus EF. Are the 'Memory Wars' over? A scientist-practitioner gap in beliefs about repressed memory. Psychol Sci 2014; 25: 519-30
23. National Collaborating Centre for Mental Health. Post-Traumatic Stress Disorder: The Management of PTSD in Adults and Children in Primary and Secondary Care. London: Gaskell and the British Psychological Society, 2005
24. Aceto P, Perilli V, Lai C, et al. Update on post-traumatic stress syndrome after anesthesia. Eur Rev Med Pharmacol Sci 2013; 17: 1730-7
25. Leslie K, Chan MT, Myles PS, Forbes A, McCulloch TJ. Posttraumatic stress disorder in aware patients from the B-Aware trial. Anesth Analg 2010; 110: 823-8
26. Jones C,Wang M. The psychological sequelae of awareness during anaesthesia. Br J Anaesth 2004; 93: 482-3
27. Mashour GA, Esaki RK, Tremper KK, Glick DB, O'Connor M,Avidan MS. A novel classification instrument for intraoperative awareness events. Anesth Analg 2010; 110: 813-5
28. Wang M, Messina AG, Russell IF. The topography of awareness: a classification of intra-operative cognitive states. Anaesthesia 2012; 67: 1197-201
29. Pandit JJ, Cook TM, Jonker WR, O'Sullivan E. A national survey of anaesthetists (NAP5 Baseline) to estimate an annual incidence of accidental awareness during general anaesthesia in the UK. Br J Anaesth 2013; 110: 501-9
30. Jonker WR, Hanumanthiah D, O'Sullivan EP, Cook TM, Pandit JJ. A national survey (NAP5-Ireland baseline) to estimate an annual incidence of accidental awareness during general anaesthesia in Ireland. Anaesthesia 2014, doi: 10.1111/anae.12776 (epub ahead of print)
31. Topulos GP, Lansing RW, Banzett RB. The experience of complete neuromuscular blockade in awake humans. J Clin Anesth 1993; 5: 369-74
32. Mashour GA. Consciousness unbound: toward a paradigm of general anesthesia. Anesthesiology 2004; 100: 428-33
33. Sanders RD, Tononi G, Laureys S, Sleigh JW. Unresponsiveness = unconsciousness. Anesthesiology 2012; 116: 946-59
34. Pandit JJ. Isolated forearm-or isolated brain? Interpreting responses during anaesthesia-or 'dysanaesthesia'. Anaesthesia 2013; 68: 995-1000
35. Pandit JJ. 'Acceptably aware' during general anaesthesia: 'dysanaesthesia'-the uncoupling of perception from sensory inputs. Conscious Cogn 2014; 27C: 194-212
36. Mashour GA. Dreaming during anesthesia and sedation. Anesth Analg 2011; 112: 1008-10
37. Kent CD, Mashour GA, Metzger NA, Posner KL, Domino KB. Psychological impact of unexpected explicit recall of events occurring during surgery performed under sedation, regional anaesthesia, and general anaesthesia: data from the Anesthesia Awareness Registry. Br J Anaesth 2013; 110: 381-7
38. The Academy of Medical Royal Colleges. Safe Sedation Practice for Healthcare Procedures: Standards and Guidance. London: AoMRC, 2013
39. Chatman N, Sutherland JR, van der Zwan R, Abraham N. A survey of patient understanding and expectations of sedation/anaesthesia for colonoscopy. Anaesth Intensive Care 2013; 41: 369-73
40. Subramanian S, Liangpunsakul S, Rex DK. Preprocedure patient values regarding sedation for colonoscopy. J Clin Gastroenterol 2005; 39: 516-9
41. Esaki RK, Mashour GA. Levels of consciousness during regional anesthesia and monitored anesthesia care: patient expectations and experiences. Anesth Analg 2009; 108: 1560-3
42. Sury MRJ, Palmer JHMG, Cook TM, Pandit JJ. The state of UK anaesthesia: a survey of National Health Service Activity in 2013. Br J Anaesth 2014; 113: 575-84
43. Reason J. Human error: models and management. Br Med J 2000; 320: 768-70
44. Flin R, Fioratou E, Frerk C, Trotter C, Cook TM. Human factors in the development of complications of airway management: preliminary evaluation of an interview tool. Anaesthesia 2013; 68: 817-25
45. Gordon R, Mearns K, Flin R. Designing and evaluating a human factors investigation tool (HFIT) for accident analysis. Saf Sci 2005; 43: 147-71
46. Jothiraj H, Howland-Harris J, Evley R, Moppett IK. Distractions and the anaesthetist: a qualitative study of context and direction of distraction. Br J Anaesth 2013; 111: 477-82
47. White SM. Consent for anaesthesia. J Med Ethics 2004; 30: 286-90
48. Association of Anaesthetists of Great Britain and Ireland. Consent for Anaesthesia, Revised Edn. London: AAGBI, 2006
49. Mihai R, Scott S, Cook TM. Litigation related to inadequate anaesthesia: an analysis of claims against the NHS in England 1997-2005. Anaesthesia 2009; 64: 829-35
50. Liang BA, Kroll DA. Ulnar neuropathy following surgery: does res ipsa loquitur apply? J Clin Anesth 2000; 12: 234-7