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Intraoperative Awareness With Recall: A Descriptive, Survey-Based, Cohort Study

Bombardieri, Anna Maria MD, PhD*; Mathur, Shagun MD; Soares, Andrea MD; Sharma, Anshuman MD, MBA*; Ben Abdallah, Arbi DES, PhD*; Wildes, Troy S. MD*; Avidan, Michael S. MBBCh*

doi: 10.1213/ANE.0000000000004358
Patient Safety: Original Clinical Research Report

BACKGROUND: Unintended intraoperative awareness with recall (AWR) is a potential complication of general anesthesia. Patients typically report recollections of (1) hearing sounds or conversations, (2) being unable to breathe or move, (3), feeling pain, and/or (4) experiencing emotional distress. The purpose of the current study was to identify and further characterize AWR experiences identified through postoperative surveys of a large unselected adult surgical cohort.

METHODS: This is a substudy of a prospective registry study, which surveys patients on their health and well-being after surgery. Responses to 4 questions focusing on AWR were analyzed. Patients who reported AWR with pain, paralysis, and/or distress were contacted by telephone to obtain more information about their AWR experience. The interview results for patients who received general anesthesia were sent to 3 anesthesiologists, who adjudicated the reported AWR episodes.

RESULTS: Of 48,151 surveys sent, 17,875 patient responses were received. Of these respondents, 622 reported a specific memory from the period between going to sleep and waking up from perceived general anesthesia and 282 of these reported related pain, paralysis, and/or distress. An attempt was made to contact these 282 patients, and 149 participated in a telephone survey. Among the 149 participants, 87 endorsed their prior report of AWR. However, only 22 of these patients had received general anesthesia, while 51 received only sedation and 14 received regional anesthesia. Three anesthesiologists independently adjudicated the survey results of the 22 general anesthesia cases and assigned 6 as definite AWR, 8 as possible AWR, and 8 as not AWR episodes. Of the 65 patients who confirmed their report of AWR after regional or sedation anesthesia, 37 (31 with sedation and 6 with regional anesthesia) had not expected to be conscious during surgery.

CONCLUSIONS: The complication of AWR continues to occur during intended general anesthesia. Many reports of AWR episodes occur in patients receiving sedation or regional anesthesia and relate to incorrect expectations regarding anesthetic techniques and conscious experiences, representing a potential target for intervention.

From the *Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri

Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan

Department of Medicine, Washington University School of Medicine, St Louis, Missouri.

Published ahead of print 24 June 2019.

Accepted for publication June 24, 2019.

Funding: The study was supported by departmental resources (to Systematic Assessment and Targeted Improvement of Services Following Yearlong Surgical Outcomes Surveys [SATISFY-SOS]) and a Barnes-Jewish Hospital Foundation (BJHF) grant 7937–77 from the Barnes-Jewish Hospital Foundation, St Louis, Missouri (to M.S.A.).

Conflicts of Interest: See Disclosures at the end of the article.

The study was presented, in part, at the annual meeting of the International Anesthesia Research Society, May 18, 2019, Montreal, Quebec, Canada.

Reprints will not be available from the authors.

Address correspondence to Anna Maria Bombardieri, MD, PhD, Department of Anesthesiology, Washington University School of Medicine in St Louis, 660 S Euclid Ave, Campus Box 8054, St Louis, MO 63110. Address e-mail to

Copyright © 2019 International Anesthesia Research Society
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