I Became "Awake" During Procedure Under General Anaesthesia

[wpcoe]

A few hours ago (late Tues afternoon) I had a minor procedure at a major hospital in Bangkok: I forget the technical name, but a biopsy sample was taken from my lung via a tube sent through my trachea. In prep for the procedure, a numbing fluid was sprayed at the rear of my throat and up each nostril. I recall nothing further until some time during the procedure I regained consciousness. I was in pain, couldn't breathe, was aware somewhat what was happening. I tried to tell them to stop, but I couldn't talk. Then I remember nothing until my bed had been wheeled from the OR.

Much later I realized I had no visual memory, just pain, sound & panic. I also don't recall trying to stop them with my hands.

I'm still at the hospital -- overnight for observation. In fact, this is my first forum post from my iPhone.

Should I say/do anything about the incident, or is this just one of those "Mai pen rai" things.

Another odd thing: my hospital gown in soaked in blood around the collar. Is that significant?

[Tywais]

Anesthesia awareness is the term for this and happens to 1 to 2 patients per 1000. US reports 100 per day anesthesia failures occur in the US. USA Today. Redorbit video

It wouldn't hurt to bring it to the Doctor's attention in the small likelihood they will evaluate their anesthesiology program.

There was a movie made on this subject called 'Awake' but is considered an over dramatization of the syndrome - as is the norm for movies.

[wpcoe]

Thanks for the facts and figures. One hundred occurrences daily in the USA seems like way too many. It's QUITE frightening to be alert and aware, especially when unable to communicate. My procedure was fairly minor, and my "pain" relatively would be more like "discomfort" compared to someone undergoing, say, lung removal or open heart surgery.

[FBN]

Some people metabilises anaesthetic drugs more effectively than others due to various factors; if you consume alcohol regularly or take other medications that have the same effect, your liver enzymes are "primed" to deal with these substances more effectively and thus requires higher doses. Newer anaesthetic drug such as Popofol, midazolam etc, induces some short term memory loss as well and are usually used for short surgical procedures and will probably not prevent these "awakenings" but will leave the patient with no memory of the event.

[Sheryl]

The procedure you had is called a bronchoscopy and I don't think it was done under general anesthesia (in fact almost certainly not). Rather it would have been done under IV sedation, same as is used for things like colonoscopy, with medication given for pain and also sedation (likely popofel or midazolam as FBN mentioned). Under such medication people are not fully unconscious, more like a really deep sleep (so-called "twilight sleep").

At some point in the proceedings your level of sedation or analgesia lightened. Since you mention pain, my guess is that latter was the key problem and that the pain in turn roused you. They detected this (must have, since you did not remain at that lighter level) and increased dosage. One of the ways they would have known, even if you were not in any way moving, is that your heart rate would have shot upwards.

Still, a good idea to tell the doctor that you recall this event. Thais for some reason are extremely sensitive to all types of sedation and analgesia with the result that dosages conventionally used here are often lower than in the West (even when adapted for body weight/mass). (Just look at how readily they all doze off seated upright on inter-provincial bus trips! ).

It is not a SE Asian thing; Cambodians require western-strength dosages of pain-killer sand sedatives....and like Westerners often are not optimally served by the dosages of pain medication and sedatives they get in Thai hospitals.

[wpcoe]

Thanks for the further explanations.

Before the procedure, I *thought* that the doctor had mentioned "local anaesthesia" and I'd have *sworn* the legal forms I signed before the procedure had the check box for "local anaesthesia" checked. It was my assumption that since I recalled nothing shortly after the nasal/throat sprays until after being wheeled out of the OR, that it was "general anaesthesia." My bad. I wasn't aware of options other than "local" and "general."

If I were to be totally "knocked out" for the duration, it seemed odd that the doctor would spray a numbing fluid in my nostrils and throat.

I checked out of the hospital this morning before my doctor came on duty (I had to check out of my hotel), so only had a telephone consultation with him today. He didn't seem too concerned about my "awakening" episode, but I felt better having told him. He made a cryptic comment reminding me that he had told me (and I had forgotten) that I would need to be conscious at times to assist in the procedure. I assume he meant like when I was sedated (with Valium) for radial keratotomy where on command, I had to look up, down, to the side, etc. The ideas FBN and Sheryl introduce do make me wonder if I was actually semi-conscious, per my doctor's comment about needing at times to assist in the procedure, but short-term memory was to have been wiped out (or never stored?) However, how to reconcile that with the momentary episode where I suddenly had lucid awareness that I recalled later? <shrug>

None of it totally makes sense to me now, but overall my concerns have now been addressed here that this was not a religious experience <g>.

I also had wondered about the idea in Sheryl's last two paragraphs. Routinely, Thai doctors NEVER give me adequate dosage for pain relief. I had half-wondered if it were tied in with some Thai Buddhist concept of suffering .

[Familyonthemove]

I had the same procedure a few years ago prior to lung surgery, and just as metioned by Sheryl I was sedated but not fully under. Before the procedure the Doc explained that I would be able to hear the procedure and follow instructions. I could hear them telling me to relax, move my head back etc and I could vaguely feel something being stuffed up my nose, then felt a painful nip in my chest when they took the tissue sample.

Then I didn't remember anything more until waking up in bed later, but I had some chest and nose pain for a few days. I think the blood will be from the instruments that they used for the sample?

When they did the actual lung surgery it was totally different .... I felt nothing at all and remembered nothing.

[Sheryl]

Yes, the blood is probably fro mthe biopsy and nothing to worry about.

Wpcoe, the meds used for sedation have the known effect of interfering with memory of the event, and this effect varies greatly and unpredicatably among individuals. You will have been aware of more than you can now recall, sort of drifting in and out and most of the time feeling quite detached from your body and in no pain.

Then pain broke through, understabndably accompanied by fear; may have been due to an inadequate level of analgesia, may have been due to something done at that particulalr point in the procedure (e.g. taking the biopsy sample)., or a combination of the two both. It is possible that the pain break through also coincided with or followed a point at which they had intentionally lightened your level of sedation because they needed to give you some instruction to follow. Or it could have been at the smae level of sedation but the pain string enolugh to shake you out it so to speak.

Your complaint about inadequate pain relief is very common among foreign patients. It has nothing to do with Buddhist concepts of suffering...these ludicrously low dosages actually work on Thais. As I said, Thais on the whole are amazingly easy to sedate. I know, I've seen it.. seen patients absolutely knocked out by dosages that would have you or I not only wide awake but stuill seriously hurting.

Reminds me of when I had Lasik (laser surgery on my eye). I knew that it would be done under local and that they needed me awake and able to follow commands, but of course I was concerned about the natural fear associated with lying awake having one's eye lasered. They told me I would be given "something to relax" me. Luckily I knew enough about prevalent Thai medical practices by then to expect such a low dosage as to be completely useless, and I was right: 2 mg of valium orally. Anticipating this, I has self medicated with 10 mg just before arrival (NOTE: I am not recommending this to anyone else!). SO my actual dosage was 12mg and that was just fine, I was relaxed enough but wide awake. As soon as the procedure was done I was taken to another spot to "sleep" until what was assumed to be 2 mg of Valium wore off. As I wasn't feeling in the least bit sleepy, just eager to get out of there, I declined and got right up. The staff were horrifed and raced over sure that I would be reeling on my feet (from 2 mg of valium!); they were astounded by the fact that I was able to walk straight and seemed so unaffected by this "powerful" sedation. I saw no point in telling them that my true dose had been 6 times this and that most Westerners would likewise, under the circumstances, have been well able to walk out under their own steam. Meanwhile, all around me, Thai patients were snoring, deeply asleep in the recovery area, from the effects of just 2 mg Valium.

Of course, once I got back to my hotel, with the adrenaline surge of the procedure and being in the clinic past, I did go off to sleep but even then I was a hell of lot less sedated than the Thai patients on 1./6 the dose had been. It's just the way it is. I suspect differing neurochemistry. .

In other words, very low doses, for whatever reason, do usually work on Thai patients. Add to that stereotypes about foreigners abusing drugs, and the natural difficulty for a doctor in assessing the likelihood of this is a patient from a different culture, and the result is that when foreigners complain that the painkillers aren't working, they are often not believed.

As I mentioned, it's not just Westerners. I knew a Cambodian man who was in hospital here with terminal cancer of the stomach. The doctor and nurses gave what they genuinely believed to be a more than adequate level of powerful opiate painkillers; the poor man was in agony. (By western standards, the dosages he was on were absurdly low).

[wpcoe]

I found it interesting, too, that I didn't even recall the "wake up" episode until I was already back in my hospital room. I think I'll think twice before dating a anaesthesiologist!

What a great resource this forum ... and several of its members in particular ... are!

Thanks again to everybody who helped calm me down and reassure me.

[bina]

wierd... my husband (thai)just came back from dental surgery and throughout the entire procedure it seemed at times as if he were indeed asleep (he onlyreceived the usual full amounts of injected pain killers); but unlike israeli patients who are very active in expressing their pain and/or panic/or discomfort either verbally or phsically (raising a hand, grunting or whatever), the two surgeons asked me several times if he is in pain, and then he would nod yes.. the only way i knew was that he suddenly would move his feet/curl his toes as most of us do when feeling sudden pain/discomfort. the rest of the time, if i hadnt checked his abdomen/chest movement(a habit i have from anesthesiating small animals w/o monitor equpment), i would have thought that he was either dead or passed out as his hands were relaxed, eyes shut, and he never moved even to scratch his nose.

here they tend to underdose because they know that the patients will always 'add' more; more is better so i suffered horrible teeth pain a few weeks ago also because they never gave more then 400 mg nurofen (advil) three times a day when i was in excruciaating pain: the doses i got from the nurofen sites in the states were much higher for starters (initial pain)...

with that in mind, have adex (nurofen) 400 gel caps for hubby, so will give two for the night, then go to regular listed dose... and hope that he mostly sleeps like most thais do when in pain or annoyed or tired, or bored...

bina

but good to know if ever he would need treatments

[BlueSmurf]

Had some teeth out in hospital under a general anasthetic which included muscle relaxant..Gave me the wrong amounts.Too much muscle relaxant and not enough anasthetic.Result heart ztopped.Hands on resusitation which left my whole chest black and painful but I lived.I was paralised but awake and was being used as a guinie pig for teaching students.My eyrs eere open I could seeand hear but vould only growl..One nurse asked the doctor if I could heR them and he daid no.He proceeded to lift my head by putti g his fingers under and behind my ears.AGONY!!! He explained that this was to insure I did not swallow my tounge.

[smokie36]

Had some teeth out in hospital under a general anasthetic which included muscle relaxant..Gave me the wrong amounts.Too much muscle relaxant and not enough anasthetic.Result heart ztopped.Hands on resusitation which left my whole chest black and painful but I lived.I was paralised but awake and was being used as a guinie pig for teaching students.My eyrs eere open I could seeand hear but vould only growl..One nurse asked the doctor if I could heR them and he daid no.He proceeded to lift my head by putti g his fingers under and behind my ears.AGONY!!! He explained that this was to insure I did not swallow my tounge.

I can imagine a jaw thrush like this would be agony. Given your heart rate must have been ridiculous diring this not to mention your blood pressure the doc concerned must have been asleep himself! met one or two in my time....

Really given we can now measure the level of anaesthetic going in and out there's little excuse for this kind of thing.

I do recall a patient on cardiopulmonary bypass who was being given a narcotic drug via a syringe pump....well I was sitting there for ten minutes before I noticed the pump although flashing green lights and saying it was running hadn't moved in that time. Sure enough the patient started moving....frightening stuff but was quickly rectified. The patient had no recollection of this however.

[rafish]

Happened to me in America under anesthesia during a tumor removal from my neck. I woke up choking and flipping around like a fish out of water. I pulled the breathing tube out to stop choking and blood was flying all over the operating room. Fortunately they got me under again but it was a harrowing experience. I started the surgery at 6 pm and finished at 12 pm. They under estimated the dosage required for me which as I understand it varies on weight and physical condition. I suppose I could have been seriously damaged by this but I simply passed it off and fortunately I am walking and moving about like normal for the past 23 years.

I had a local anestesia once to remove a calcified saliva gland and I litterly died on the table. Panic went through the doctors and they revived me. Heart stopped and flat lined for a few minutes. No explanation offered. I suppose I react to different chemistry unlike expectations of doctors.

[wpcoe]

Wow. I suppose "misery loves company," but some of these episodes make me feel lucky. At least I have no recall of flat-lining!

I guess maybe I'm lucky I was "paralyzed" (or at least don't recall even raising my hands, which I think I would have done instinctively, if able to) so that I didn't rip the breathing tube out. Actually, I wonder which tube I would have gone for -- the bronchoscope or the breathing tube? Ripping out the bronchoscope could be perilous, no?

I wonder if these episodes of perhaps having too light of anaesthesia parallels not giving farang patients enough pain relief? i.e. If farang seem to require more pain relief as Sheryl & I discussed, I wonder if we also may require slightly higher levels of anaesthesia?

[smokie36]

Wow. I suppose "misery loves company," but some of these episodes make me feel lucky. At least I have no recall of flat-lining!

I guess maybe I'm lucky I was "paralyzed" (or at least don't recall even raising my hands, which I think I would have done instinctively, if able to) so that I didn't rip the breathing tube out. Actually, I wonder which tube I would have gone for -- the bronchoscope or the breathing tube? Ripping out the bronchoscope could be perilous, no?

I wonder if these episodes of perhaps having too light of anaesthesia parallels not giving farang patients enough pain relief? i.e. If farang seem to require more pain relief as Sheryl & I discussed, I wonder if we also may require slightly higher levels of anaesthesia?

To be clear OP there are 3 ways to carry out this procedure.

1. Using an endotracheal tube passed into the trachea. This would require a muscle relaxant to be used and usually anaesthesia is maintained using an inhalational drug.

2. Under sedation with you still breathing. No tube is inserted in the trachea....usually oxygen is given via nasal specs. This is administered intermittently or via a pump intravenously. No muscle relaxant is used.

3. A rigid bronchoscope can be inserted into the trachea with oxygen delivered using jet ventilation. Muscle relaxation is used and anaesthesia maintained intravenously using a pump. Usually this would be done by an ENT surgeon.

My guess is you had number 2.

[wpcoe]

Based on the several days of soreness in the back of my mouth and throat, I assumed I had something down my throat via my mouth. He had squirted ... twice ... the numbing agent through my mouth, and from the rear of my tongue everything was numbed.

I also assumed I had something down my nose. After spraying the numbing agent in my right nostril (and it burned like hell!), he said to brace myself as he was next going to spray my left nostril just in case the right nostril wasn't usable for some reason.

Interesting now to see how I made assumptions on what happened.

For number 2, are you saying both that the bronchoscope and oxygen would both have been delivered via the nose?

For the momentary period of lucidity that I can recall during the procedure, I clearly felt the sensation of not being able to breathe. That, more than the pain, was the cause of my panic. I felt something was down my throat preventing me from breathing, but can't recall clearly enough to know if it were via my nose or via my mouth (or both?)

FYI, I think the reason the numbing agent caused so much pain in my right nostril is from a surgery to correct a deviated septum a few years ago. The numbing agent did not burn at all in my left nostril.

[smokie36]

Based on the several days of soreness in the back of my mouth and throat, I assumed I had something down my throat via my mouth. He had squirted ... twice ... the numbing agent through my mouth, and from the rear of my tongue everything was numbed.

I also assumed I had something down my nose. After spraying the numbing agent in my right nostril (and it burned like hell!), he said to brace myself as he was next going to spray my left nostril just in case the right nostril wasn't usable for some reason.

Interesting now to see how I made assumptions on what happened.

For number 2, are you saying both that the bronchoscope and oxygen would both have been delivered via the nose?

For the momentary period of lucidity that I can recall during the procedure, I clearly felt the sensation of not being able to breathe. That, more than the pain, was the cause of my panic. I felt something was down my throat preventing me from breathing, but can't recall clearly enough to know if it were via my nose or via my mouth (or both?)

FYI, I think the reason the numbing agent caused so much pain in my right nostril is from a surgery to correct a deviated septum a few years ago. The numbing agent did not burn at all in my left nostril.

Passing the bronchoscope through the nose is an easier route into the trachea and less traumatic for the patient. Obviously I'm only giving an educated guess but its likely you were given some oxygen while the procedure was carried out either via the mouth or more likely the other nostril. Its possible the small oxygen tube which normally has a foam covering is what caused the pain in the other nostril.

Not surprised by your reaction but you must have been breathing or you wouldn't be posting here!

If you're interested to find out more just type "flexible bronchoscopy" into a youtube search.

Edited July 25, 2011 by smokie36