Going under Should your surgeon talk to you?

Awareness under anaesthesia (AUA) is the medical term for what happens when a patient is able to recall what happened while they were meant to be fully anaesthetised.

Thankfully, AUA is rare, affecting as few as one individual in every 1,000.

Petra Bischoff and Ingrid Rundshagen, a psychotherapist and anaesthetist working in Freiburg and Hamburg, reviewed cases of AUA over a 10-year period.

Those most at risk were individuals with reduced cardiovascular reserves, those undergoing caesarean section – because anaesthesia is introduced more cautiously than with other conditions, and so sometimes may be too “light” – and children, because the anaesthetic is redistributed more rapidly than it is in adults.

Professors Jaideep Pandit at Oxford and Tim Cook at Bath reviewed all reports of AUA in five countries over a year. Some 51 per cent described it as “distressing” and 41 per cent suffered longer-term flashbacks, sleep disturbance and emotional numbness or hyperarousal.

With AUA, there is a risk of developing Posttraumatic Stress Disorder and, if symptoms aren’t addressed promptly, it may become chronic. The best treatment is either Eye Movement Desensitisation and Reprocessing (EMDR), or cognitive behaviour therapy, both of which help patients learn to recall the trauma without experiencing the accompanying negative emotions.

But might awareness under anaesthesia ever be used therapeutically? The sense most likely to remain intact during surgery is hearing – and some researchers have questioned whether our ability to hear under anaesthesia is ever totally repressed.

Carlton Evans and PH Richardson randomly assigned 39 patients to either a “suggestion” or “control” group before surgery. Those in the “suggestion” group heard positive therapeutic statements through earphones, whereas “controls” were played a blank tape. Afterwards, participants in the “suggestion” group spent significantly less time in hospital, and were rated by nurses as having made a better-than-expected recovery.

Although this involved a small sample, it backs up the clinical findings of two American surgeons, David Cheek and LS Wolfe, who between them offered positive suggestions under anaesthesia to more than 1,500 patients and recorded some substantial benefits.

Bischoff and Rundshagen, however, emphasise the importance of word choice, in particular avoiding negative words, even in a positive context. For example, rather than, “You won’t feel pain”, it’s better to say: “This patient should make an excellent recovery.”

In conclusion, the attitude conveyed by the operating team during surgery may help make a positive difference to the outcome.