1. Strategies to eliminate Accidental Awareness under GA in children
Mike Sury
APA Linkman meeting
Birmingham 2016

2. The incidence of AAGA in adults
= % 15% get PTSD
Avidan et al. 2008
Avidan et al. 2011
Myles et al. 2004
Sandin et al. 2000
Sebel et al. 2004
Wennervirta et al. 2002

3. AAGA in children Authors Incidence Number Age range
Davidson et al. 2008
0.2%
1 of 500
5-12y
Blusse Van Oud-Alblas HJ et al. 2008
0.6%
6 of 928
3-16y
Davidson et al. 2005
0.8%
7 of 864
Malviya et al. 2009
14 of 1784
3-15y
Lopez and Habre 2009
1.2%
5 of 410
6-16y
Davidson et al 2011
0.74%
33 out of 4486
(95% binomial CI 0.49–1.00%)

4. 2.8m GA cases per year

6. Incidence: depends on circumstances
NAP5
The 5th National Audit Project
■ ■ ■ ■ ■

9. Categories of NAP5 reports
Of 311 reports
141 were class A or B
A = certain
B = probable
C = sedation
D = ICU
E = unassessable
F = unlikely
G = other
SO = statement only

10. BIG messages
2/3 preventable!
7% no obvious cause

12. Common/Important situations
Induction
Emergence
TIVA
Cardiovascular collapse
Drug swops
Sedation

13. Induction 50% of reports Causative/contributory factors were:
thiopental,
obesity,
rapid sequence induction (RSI),
prolonged airway management

16. Induction

19. Emergence
18%
almost all experienced distressing residual paralysis from unmonitored blockade

22. NAP5 The 5th National Audit Project
TIVA
Transfers to ICU/Radiology
poor & non-standard techniques
? monitoring
NAP5 The 5th National Audit Project

24. EEG changes during propofol anesthesia in children. (Personal data)
 EEG changes during propofol anesthesia in children. (Personal data). In children receiving IV propofol (bolus of 6 mg/kg during 6 min), the EEG trace shows slow oscillations up to the occurrence of burst suppression periods. The corresponding spectrum shows a shift of the F50 and SEF to the left (slow frequencies). During recovery, when the child opens his eyes, the EEG trace and the corresponding spectrum are close to those recorded at baseline.
© This slide is made available for non-commercial use only. Please note that permission may be required for re-use of images in which the copyright is owned by a third party.
Pediatric Anesthesia Volume 22, Issue 6, pages , 17 MAY 2012 DOI: /j x 24

26. Cardiovascular instability
Do not turn anaesthesia off
Except…………

27. Accidental paralysis from drug error
accounted for 10% of reports and caused identical effects.
“Such cases abounded with latent and organisational factors”
NAP5 The 5th National Audit Project

28. Reports from patients not intended to be asleep
Nearly 20% of all A&B reports
Long term effects were as severe as after AAGA
Contributory factors were communication and consent.
NAP5 The 5th National Audit Project

29. NAP5 The 5th National Audit Project

30. Preventing the psychological consequences of AAGA
Before
“if you waken you might not be able to move ………. this is reversible, I will look after you …..”
During
Reassure the patient if you think they are awake

31. Managing AAGA: suggested pathway
NAP5
The 5th National Audit Project
■ ■ ■ ■ ■

32. Incidence of reports of AAGA
Adults: %
(or 1 in 17670)
Children: 0.001%
(or 1 in 99800)
If incidence is 0.74%
there should be 3700 cases

34. NAP5 The 5th National Audit Project
NAP5 Executive Summary
The largest study of AAGA
of reports
141 reports
Wide range of experiences/sensations
50% reported distress linked to paralysis
Prevention & mitigation
NAP5 The 5th National Audit Project

36. Sedation
Anaesthesia
Margin of safety

37. Anaesthesia
(probably)
Anaesthesia
(definitely)
Sedation

38. Anaesthesia
(probably)
Anaesthesia
(definitely)
Sedation
DANGER

39. Anaesthesia
(probably)
Anaesthesia
(definitely)
Sedation
DANGER

40. Anaesthesia Anaesthesia (probably) (definitely) DANGER Sedation
Level of Consciousness
Depth of Anaesthesia