Based on the results of long-term follow-up, intraoperative awareness does not necessarily affect psychosocial outcome in the form of psychiatric disorder or distress. [Image source: Thinkstock]
Based on the results of long-term follow-up, intraoperative awareness does not necessarily affect psychosocial outcome in the form of psychiatric disorder or distress. [Image source: Thinkstock]

Post-traumatic stress disorder (PTSD) is a severe mental health problem that may manifest itself soon after a traumatic event or not be evident until years afterwards.  A large percentage of individuals who have served in the Afghanistan and Iraq wars suffer from the disorder, as do veterans of earlier conflicts. PTSD is found in the general population as well, reflecting extreme life experiences.

Intraoperative awareness also has the potential to lead to PTSD.  Individuals who have PTSD may repeatedly relive the traumatic event, avoid anything that might trigger memories of the experience, and also have hyperarousal-related symptoms.  Dr. Tanja Laukkala, Field Medicine Services Unit, Centre for Military Medicine, Helsinki, Finland, and colleagues evaluated nine patients and nine matched control patients 13-19 years after the patients had experienced an anesthesia awareness event with explicit recall.  The results of their study are published in this month’s issue of Anesthesia & Analgesia in the article titled “Long-Term Psychosocial Outcomes after Intraoperative Awareness with Recall.”

The patients in this study were all adults when they experienced their anesthesia with recall (AWR), also called  intraoperative awareness. All previously participated in the authors’ studies evaluating intraoperative awareness and had definite explicit recall of a period of general anesthesia.  These patients had an operation scheduled in 1 tertiary level hospital and 2 secondary level hospitals in southern Finland between June 1992 and December 1998.  The time from the AWR event to the study interview was 13.0-19.7 years in the study group and 13.2-18.6 years in the control group. This is more than threefold longer than comparable studies.  Both groups of patients were evaluated using a general health questionnaire, a depression inventory, an alcohol use disorders identification test, a quality of life questionnaire, and for those with a potential traumatic event, also a trauma screening questionnaire.  A structured psychiatric interview was also conducted.

Psychosocial well-being was no different between patients in the group with AWR compared to patients in the control group.  At the time of the evaluation, no patient in either group had a diagnosis of PTSD.  Based on the structured psychiatric interview, one individual in the study group had a current major depressive disorder and another had a lifetime panic disorder with agoraphobia.  In the control group, one had a current major depressive disorder, one had a current other depressive disorder, and another had lifetime major depressive disorder.  No one in the study group described the awareness during anesthesia as a potentially traumatic event in the structured psychiatric SCID interview.

As Drs. George A. Mashour and Michael S. Avidan, Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, and Department of Anesthesiology, Washington University, St. Louis, Missouri, write in their accompanying editorial titled “Psychological Trajectories after Intraoperative Awareness with Explicit Recall,” “We hope that patients will not develop persistent PTSD after AWR, but we must prepare for the worst by increasing vigilance for AWR itself as well as postoperative PTSD and related symptomatology.  Both this hope and preparation hinge on (1) understanding the preoperative, intraoperative, and postoperative risk factors for PTSD (including AWR), (2) screening those at highest risk, and (3) initiating early referral and treatment to maximize the chances of a healthy psychological trajectory in the long run.”