1. Mike Sury APA Linkman Meeting 2014
NAP5 & AAGA
Mike Sury
APA Linkman Meeting 2014

4. AAGA is recall of an experience
Is it from
Direct questioning?
Spontaneous reporting?

5. The incidence of AAGA in adults
%, mainly related to paralysis 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

7. NAP5 Spontaneous reports A procedure managed by an anaesthetist
First reports only
A procedure managed by an anaesthetist
In and out of theatres
the patent complains

9. How many reports? Of 300 reports A = certain B = probable C = sedation
141 were class A or B
A = certain
B = probable
C = sedation
D = ICU
E = unassessable
F = unlikely
G = other
SO = statement only

10. Classification: experience
NAP5
The 5th National Audit Project
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11. NAP5 activity survey
Denominator
Important details
Who
What
Which
When

12. Intended Conscious level (LOC)GA
2,766,600
76.9%
Sedation (of any level)
308,800
8.6%
Awake
523,100
14.5%

13. Main procedure

15. Intended LOC

16. 2.8m GA cases per year
(overall incidence of AAGA reports = 1:20,000)

17. Incidence: depends on circumstances
NAP5
The 5th National Audit Project
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20. Vignettes: Unassessable or Statement Only

21. If 0.74% is the true rate of AAGA, there should be approximately 3,700 children per year in the UK with recall of events during general anaesthesia.
? Missing reports

22. NAP5 The 5th National Audit Project
NAP5 Executive Summary
The largest AAGA study ever undertaken
Of 300 reports
141 classified as “certain/probable” or “possible” AAGA
Wide range of experiences/sensations
50% reported distress linked to paralysis.
psychological sequelae pronounced and long lasting in 41%
NAP5 The 5th National Audit Project

23. Common/Important situations
Induction
Transfer
Emergence
Cardiovascular collapse
Syringe swops
TIVA

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

27. drug omission on transfer (‘Mind the gap’)

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

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

31. Accidental paralysis from drug error
10% of reports
identical effects.
“organisational factors”
NAP5 The 5th National Audit Project

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

34. Preventable?
2/3 were
Or were they?
7% had no obvious explanation

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

36. Managing AAGA: suggested pathway
NAP5
The 5th National Audit Project
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37. NAP5 The 5th National Audit Project
NAP5: Recommendations
N = 64
TIVA and EEG – both need training with pragmatic protocols
SOPs (Who checklist, what to say to patients, how to manage AAGA)
NAP5 The 5th National Audit Project