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Anesthesiology:
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Perioperative Treatment of Patients with a History of Intraoperative Awareness and Post–Traumatic Stress Disorder

Mashour, George A. M.D., Ph.D.*; Jiang, Yandong M.D., Ph.D.; Osterman, Janet M.D.

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To the Editor:—

It has been estimated that approximately 25,000 patients each year in the United States alone may experience undesired intraoperative awareness with explicit recall.1 A significant proportion of these individuals may subsequently develop post–traumatic stress disorder (PTSD), characterized by reexperiencing the trauma (e.g., in nightmares or flashbacks), hyperarousal states (e.g., hypervigilance, insomnia, irritability), and avoidance of cues related to the initial trauma.2 Although there has been significant attention on the prevention of intraoperative awareness through the use of electroencephalographic measures of anesthetic depth,3 there has been little discussion of the treatment of patients with a history of awareness returning for surgical care and anesthesia. Here, we discuss the perioperative management of a patient who developed PTSD after awareness under general anesthesia during a tubal ligation and who returned for a further gynecologic procedure.
After the original surgery during which she was aware under general anesthesia, the patient was overly alert and unable to sleep in the recovery room, reporting severe leg and back pain. After discharge, she remained hypervigilant and experienced episodes of severe panic when seeing the color blue. Several days after the surgery, she recalled that she had been awake during her surgery and began having flashbacks of abdominal and pelvic pain. Her surgeon subsequently confirmed her recall of intraoperative events and discussions. She developed signs of PTSD, including increasing periods of irritability and worsening insomnia, as well as frequent nightmares, flashbacks, and intrusive thoughts related to the surgery. Signs of depression such as anorexia, weight loss, impaired concentration, and frequent crying spells were also present. Psychological and physiologic reactivity to reminders occurred (especially to seeing people in the community or on television wearing blue scrubs), followed by avoidance of all such cues. She did not return to her original surgeon, declined further gynecologic care, and developed a distrust of anesthesiologists.
Years later, the patient returned to our institution for anterior and posterior colporrhaphies, suburethral sling, cystoscopy, and gynecologic examination under anesthesia. The circumstances of her past surgery were identified in the preoperative evaluation clinic, leading to the question: What is the optimal perioperative anesthetic plan for a patient with a history of awareness and PTSD? The strategy of general anesthesia would create severe anxiety in such a patient, for fear of reexperiencing the trauma of intraoperative awareness. Furthermore, careful examination of the anesthetic record from the initial surgery gave no clear indication of why the general anesthetic did not effectively suppress awareness. The use of neuraxial anesthesia was another strategy considered, but would also allow the patient to experience the cues of her past trauma such as surgeons, anesthesiologists, and other healthcare providers in scrub suits. Furthermore, the use of ancillary sedation during regional anesthesia could potentially be subjectively experienced by the patient as insufficient anesthesia. There were also concerns of converting neuraxial to general anesthesia intraoperatively in the event of failed regional anesthesia or psychological events such as flashbacks.
The patient was interviewed in the preoperative evaluation clinic by an anesthesiologist who would not be her anesthesia provider, and three options were offered to her after a discussion: (1) not to proceed with the surgery; (2) have the surgery performed under general anesthesia with maximal efforts to prevent awareness; or (3) maintain total awareness by using a purely regional anesthetic. It was her preference that the final decision would be made on the day of the surgery after discussion with the anesthesiologist who would actually administer her anesthesia.
On the day of the surgery, the patient’s chart was reviewed by an anesthesiologist with specific interests in awareness under general anesthesia, and the patient was interviewed again in the preoperative holding area. The patient was extremely anxious and concerned about reexperiencing the trauma of intraoperative awareness and the anesthesiologist carefully discussed multiple anesthetic plans with her. Considering her extreme anxiety regarding general anesthesia, it was our suggestion and also her preference to have regional anesthesia to keep her fully awake during the surgery. She also agreed to general anesthesia if the regional anesthesia failed or if she had traumatic flashbacks or dissociation from reality. Spinal anesthesia with mild anxiolysis was then planned.
The goals were (1) to have the surgery performed under spinal anesthesia with a dense motor and sensory block that would last for the duration of the surgery; (2) to attenuate her anxiety but keep her alert enough to maintain an interactive relation with the anesthesiologist to prevent flashbacks; (3) to convert to general anesthesia in the event that she had distressing flashbacks or experienced pain; (4) to use a Bispectral Index monitor if general anesthesia was used, with target levels in the range of 30–40; and (5) to avoid long-acting neuromuscular blockade during induction in the event of general anesthesia.
The patient was given 2 mg intravenous midazolam in divided doses, and spinal anesthesia was initiated by intrathecal injection of 18.75 mg hyperbaric bupivacaine and 20 μg fentanyl in the sitting position with a 25-gauge Whitacre needle. After assuming the lithotomy position, her anesthesia level was confirmed by pinprick to a T10 level bilaterally. The surgery was performed uneventfully, and the patient was kept fully awake and engaged during the entire surgical period. Conversations with the patient on diverse topics unrelated to surgery and anesthesia were initiated by the anesthesiologist and maintained throughout the procedure. The goal was to keep the patient engaged in the present moment and prevent dissociation or flashbacks related to PTSD. This is often referred to in psychotherapy as a “grounding technique.” The patient experienced no flashbacks or pain and was discharged home within 48 h, with positive feelings about the experience.
Patients returning for surgery with a history of awareness and PTSD will likely have a distrust of anesthesiologists and severe anxiety about reexperiencing the trauma of surgery. Although anesthetic plans must vary with the given procedure, we found that initiating a thoughtful preoperative discussion with the patient about such plans helped facilitate a rapport and a sense of control for the patient. With the use of neuraxial blockade, we found it beneficial to use minimal sedation to keep the patient engaged in the present moment, to avoid altered states of consciousness that could potentially allow traumatic memories to emerge, and to actively provide the patient with intraoperative “grounding.” A history of awareness and PTSD presents challenges to both the patient and the anesthesiologist when further surgery is required. Further consideration of its clinical management is warranted.
George A. Mashour, M.D., Ph.D.,*
Yandong Jiang, M.D., Ph.D.,
Janet Osterman, M.D.
*Massachusetts General Hospital, Boston, Massachusetts. gmashour@partners.org
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References

1. Sebel PS, Bowdle TA, Ghoneim MM, Rampil IJ, Padilla RE, Gan TJ, Domino KB: The incidence of awareness during anesthesia: A multicenter United States study. Anesth Analg 2004; 99:833–9

2. Osterman JE, Hopper J, Heran WJ, Keane TM, van der Kolk BA: Awareness under anesthesia and the development of posttraumatic stress disorder. Gen Hosp Psychiatry 2001; 23:198–204

3. Myles PS, Leslie K, McNeil J, Forbes A, Chan MT: Bispectral index monitoring to prevent awareness during anaesthesia: The B-Aware randomised controlled trial. Lancet 2004; 363:1757–63

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