Even without the experience of waking up during the operation, I believe most people can imagine the extreme fear of being unable to move, being awake but not expressing to the outside world in any way "he/she is awake".

Leviathan's note: Even if you don't have the experience of waking up during the operation, I believe most people can imagine the extreme fear of being unable to move, being awake but unable to express to the outside world in any way "he/she is awake". It's like a living zombie, or a patient with the weakest consciousness, all the channels that he/she can send a living message are invalid - this deep sense of despair and powerlessness must have been greater than the pain of the body at some point.

In a sense, this is obviously no longer a simple medical problem, but more like a philosophical question: in what way should we use to test and recognize the existence of others' awake consciousness?

text/David Robson

translation/Mid Black Man

proofreading/Holihuo

Original text/mosaicscience.com/story/anaesthesia-anesthesia-awake-awareness-surgery-operation-or-paralysed/

This article is based on the Creation Common Agreement (BY-NC). The article was published by Mid Black Man in Leviathan

only for the author's point of view and does not necessarily represent Leviathan's position. In 1983, Polish doctor Zbignev Religa looked at the patient's vital sign data tiredly after undergoing a 23-hour heart transplant. Source: Getty

Donna Penner once underwent an operation. More than ten years have passed. Some small things that cannot be small can instantly evoke her horrible memories of the operation.

For example, one day, she drove out with her daughter and asked her daughter to run errands, and she was waiting in the car. At this time, she found that she was locked in the car. It was just an awkward little surprise, but Donna suddenly fell into deep horror. She recalled: "I started screaming, waving my hands and crying, and at that moment I was trembling all over."

Even if I just put on inappropriate clothes, it would aggravate this anxiety. Donna is now 55 years old and lives in Altona, Manitoba, Canada. She says she "does not wear any tightened neck clothes, and when I wear them, I will feel like I'm going to suffocate to death" .

If Donna had not undergone that minor operation before her 45th birthday, she might not have left such "futures". She was an employee of the accounting department of a local trucking company. She had just finished her daughter's wedding and was suffering from menstrual hemorrhage and dysmenorrhea. Donna's family physician suggested that she undergo an Exploratory Surgery and find the cause of the disease.

This should have been a routine operation, but for some reason, general anesthesia failed to work properly. Donna should have entered a state of ignorance calmly, but just before the doctor slashed her lower abdomen, she woke up. However, under the action of anesthetic, her whole body was still paralyzed, so she could not send any help signal to the doctor.

The hopeless Donna could only lie on the operating table like she was frozen. She was forced to experience great pain as the surgeon cut her body open for exploration. "I thought at the time, 'I'm done, I'll die here today, and I'll die on this operating table. My family doesn't even know how I spent the last few hours before my death, because no one knows what I've experienced.'"

, this psychological trauma that cannot be escaped is still extremely destructive. Not only will it cause psychological collapse by subtle things, but it also makes Donna "have two or three nightmares every night." Donna had to resign after being injured and resigned and lost her financial independence. More than a decade passed, and she began to doubt that she would never truly escape the shadow of that day. "It was like a lifelong judgment."

For a long time, the Anaesthesia Awareness was shrouded in a layer of fog. Although there are few extreme cases like Donna, , there is some evidence today that 5% of patients in the population undergoing surgery are perceptual on the operating table - this number may be even higher.

Since anesthetics may also cause memory loss, most patients suffering from this pain cannot recall this experience - as for whether we should focus on such accidents that will not be remembered, this is not only a practical problem, but also a philosophical problem.

Given that general anesthesia is now widely used, it is becoming increasingly important to explore the conclusions of these problems. Peter Odor, director of archives at St. George's Hospital in London, said: "In the UK alone, 3 million people are undergoing general anesthesia every year. In other words, at this moment, somewhere in the world, it is very likely that a patient who undergoes surgery is actually awake."

In the past, humans have unexpectedly little understanding of the principles of anesthetics. But today, researchers are doing their best to study the nature of unconsciousness and the conditions for the failure of anesthetic drugs. Through these studies, scholars hope that the risk of unexpected arousal in anesthesia can be reduced in the future. Not only that, when we have a deeper understanding of the anesthetic state, humans may even use this semi-ansthetic and semi-awake state in the future - this will become a medical hypnosis technology.

Let us first make it clear: anesthesia is a medical miracle. As early as the era of Hippocrates, the father of medicine in ancient Greece, doctors and pharmacists were looking for ways to relieve medical pain. Although people at that time found a variety of sedatives, such as wine, opium, and even plants of the genus genus, their efficacy was not reliable and most patients were not immune to torture.

Until the 1840s, scientists discovered several gases that seemed to produce a calming effect. A dentist from Boston , William Morton, was very interested in anesthesia. He noticed one of these gases and conducted a public demonstration of anesthesia surgery at the Massachusetts General Hospital in 1846. This gas is " sulfate ether " (Sulphuric Ether. In this historical event, Morton used the gas ethyl ether , corresponding to the English name "Ether", and the general formula is "R-O-R'". The Sulphuric Ether in the original text is literally translated as "sulfate ether", which is the old name of ethyl ether, which was accidentally synthesized and named by Prussian botanist Vallius Kordus in 1540). After the anesthesia, although the patient could still express some incoherent ideas in ambiguous manner, he did report that he did not feel pain, but that his skin was "scratched by a hoe" and seemed to have only a slight touch.

News of this demonstration surgery quickly spread to the medical community and opened the curtain of modern anesthesia. Subsequently, more effective anesthetics such as chloroform were also constantly emerging, and the symbols of fear and pain that are unique to surgical scalpels seemed to have quickly become history.

"General anesthesia triggers a controlled unconscious state . This state is even deeper than the unconsciousness during sleep, and

is also more out of reality."

To this day, the treatment range of anesthesiologist is very wide, which can both analgesic and weaken consciousness. The anesthesiologist will choose the intensity of the agent based on the specific surgery and the specific needs of the patient.

Generally speaking, the purpose of an anesthesiologist is not to deprive consciousness, but to temporarily eliminate the perception of a certain part of the body. The so-called local anesthesia techniques include lumbar spinal anesthesia and epidural anesthesia. Both anesthesia methods are to inject drugs into the spinal canal of the spine of the spine to paralyze the perception of the lower body. Today's delivery surgery, bladder surgery, and hip replacement surgery are widely used in large quantities.

Source: Wikipedia

You can also choose to undergo sedative anesthesia - it can put the patient into a state of relaxation, drowsiness without completely eliminating consciousness.

In contrast, the goal of general anesthesia is to deprive consciousness. uses drugs to enter a state of unresponsive fainting, or trigger a controlled unconscious state, which is deeper than the unconsciousness during sleep and is more out of reality. No memory should be left behind in any experience during the period. Robert Sanders, an anesthesiologist at the University of Wisconsin-Madison, described general anesthesia as "apparently intended to completely erase a period of time from this person's experience."

Today we cannot fully understand how anesthetics eliminate perception, but it is generally believed that these agents can interfere with the normal function of neurotransmitters, a series of chemicals in the brain. These chemicals can activate or inhibit neuronal activity, especially information exchanges across different brain regions.

Take propofol as an example - it is a milky white liquid used for general anesthesia and is also used to make several types of sedatives - , anesthetic agent, seems to enhance the effect of γ-aminobutyric acid. As an inhibitor, γ-aminobutyric acid can itself reduce the activity of certain areas of the brain and stop information exchange in these areas. The brain regions where are inhibited include the frontal lobe and the parietal lobe, which cover a large area of ​​the brain from the front to the back.

Sanders' colleagues recently conducted a non-invasive brain stimulation experiment to demonstrate the process of stimulation of the above-mentioned drug stimulation. In the experiment, the brain waves that usually respond to this stimulation are significantly suppressed under the action of propofol.

Sanders said: "The anesthetic drugs are likely to interfere with signals in the ascending Spinal Pathway." If fails to receive these signals, consciousness will temporarily strike like a blank screen, unable to respond to any signals from the body, let alone process and respond to these signals.

upstream conduction pathway is also known as sensory conduction pathway. Sensory impulses pass through the peripheral nerves to the center, pass through the spinal cortex and brainstem, and finally reach the cerebral cortex. Source: Pinterest

Of course, in clinical surgery, medical personnel need to consider many complex situations. Anesthesiologists will choose one drug to cause coma and another drug to maintain the coma. In this process, they need to consider many factors - the patient's age, weight, whether they smoke, whether they are drug-the characteristics of the disease they suffer from - and finally determine the medication and dosage.

Muscle relaxants are also used in many surgeries, such as neuromuscular blockers (Neuromuscular Blockers). In the UK, nearly half of general anesthesia surgeries use this type of agent. This type of drug can temporarily cause physical paralysis, not only preventing surgery from being disturbed by spasms or nerve reflexes, but also does not need to increase the dose of anesthetic drugs to avoid the danger of excessive medication.

As for those surgeries that require insertion of catheters into the trachea, neuromuscular blockers can also be used to alleviate adverse reactions, which can not only ensure that oxygen or nebulized drugs pass through the trachea during the operation, but also prevent gastric acid from entering the lungs in reverse. However, once the paralysis agent suspends the function of the diaphragm and abdominal muscles, the patient must use a ventilator to assist in breathing.

Source: The Irish Times

The above complex situations make anesthesia both a science and an art. However, in most cases, the anesthesia is quite excellent. More than 170 years have passed since Morton performed a public demonstration operation. Millions of patients undergo general anesthesia every year and are successfully awakened after the operation. Many traumatic life-saving surgeries would not have been possible without the advancement of general anesthesia technology.

However, for any medical surgery, it is a complicated situation. Many people may be born with difficulty in being anesthesia, which means that drugs cannot reduce brain activity to the point where consciousness fades.

In addition, for certain clinical situations, such as serious injuries that cause major bleeding, the anesthesiologist may have to reduce the anesthetic dose for the sake of the patient's life safety.

is also extremely difficult to estimate the dosage and aging of different anesthetic drugs, because must ensure that the so-called induction dosage (the anesthetic drug that allows the patient to fall asleep) will not fail before the maintenance dosage (the anesthetic drug that keeps the patient unconscious) begins to work.

Sometimes, before the surgeon picks up the scalpel, the patient can lift his leg, or even say a few words to signal that the anesthesiologist's medication is not effective. But if the patient receives neuromuscular blockers, he cannot do this help-seeking behavior. So the ending for a small number of people can only be lying awake on the operating table during the entire operation or for a period of time, enduring the pain silently without asking for help.

Source: The New York Times

Donna and I made a long phone call. She sat at her home in Canada and told me about her misfortune.

She told me that although she had undergone a general anesthesia operation and there was no accident at that time, on the day of the accident, she felt very anxious during the preparations for the operation. At that time, she was pushed into the operating room, lying on the operating table, receiving her first anesthesia injection, and soon fell asleep, thinking in her mind: "The anesthesia has begun."

When she woke up, she could hear the nurse saying something around the operating table, she felt someone scrubbing her abdomen herself - she thought the operation was over, they were just doing cleaning. "At that time, I thought to myself, 'Look, you're just worried.'" But when she heard the surgeon ask the nurse to hand her a scalpel, she suddenly realized the status quo: the operation was not over at all, and it didn't even begin.

Immediately afterwards, she felt that when the doctor cut the first cut, the blade cut open her stomach, instantly causing a huge pain. She wanted to sit up, she wanted to yell—but her body was still paralyzed because the neuromuscular blockers were working. Donna told me: "I feel very, very helpless, I can't do anything. I can't move, I can't shout, I can't even open my eyes. I try to cry out and let the tears slide down my face, I think they will notice something strange. but I can't even shed tears. "

Finally, she focused all her attention and tried to move her feet. One of her feet made a very slight twist, and a nurse put her hand on her feet, and Donna breathed a sigh of relief. But just before Donna let her feet move again, the nurse had already moved her hand away. She kept working hard to ask the nurse to put her hands on her feet three times, but the results were the same. "When I found out that this was the only way to communicate with the outside world, and it didn't work at all, I was very frustrated."

This feeling of frustration was extremely huge. She said, "I felt like someone was sitting on me, holding me tightly, and I couldn't do anything, and there was no hope."

"I felt very, very helpless, I couldn't do anything.

I couldn't move, I couldn't shout, I couldn't even open my eyes."

Donna's pain should have stopped when the doctor finished the operation, but her pain came from more than just a knife wound. As the neuromuscular blockers gradually lost their efficacy, she began to lick the plastic trachea in her throat with her tongue. She thought, maybe this method can finally tell the medical staff: she is still awake.

However, the medical staff did not see anything unusual from this action, but instead made a wrong judgment and took out the insertion gas tube too early. However, at that time, the paralysis agent in Donna's body had not yet failed, and her lungs could not breathe independently. "So the situation was that I was lying on that operating table and he took away my lifeline. Once the source of oxygen was cut off, I couldn't breathe at all." Donna said that she felt that she would definitely die at the time.

From that moment on, Donna felt that the operating room was slowly moving away from her, and she experienced a feeling of "soul out of body". As a Christian, she said she felt that God was by her side at that time.It was not until the medical staff inserted the oxygen supply catheter into her again that she finally returned to the operating room, finally woke up, and finally cried.

Pain, fear, and absolute helplessness still lingers in Donna's heart to this day - these psychological trauma forced her to resign after she had to handle her injuries. This means that she has lost her ability to be financially independent, lost her self-confidence, and had to give up some of the dreams and hopes she and her husband have pursued for many years. "I sit at home and watch all those neighbors rush out of the house early in the morning, start cars and go to work, but I can't do it. It's all too difficult for me."

Source: Andrea Ucini at Anna Goodson Illustration for Mosaic

Today, medical organizations around the world try to record tragic cases like Donna, among which, the Anesthesia Awakening Archives at the University of Washington, Seattle conducted quite detailed analysis. The organization was founded in 2007 and has collected more than 340 reports today – most from North America – although the reports are confidential, some details are published in a paper, and these cases are very inspiring.

(www.sciencedirect.com/science/article/pii/S0007091217310176)

Almost all patients who experience this pain mention that they can still hear people talking after general anesthesia, or other noises (because patients usually have their eyes closed during surgery, visual experience is quite rare) .

Source: The Weinstein Company/youtube

One of the patients said, "I heard the surgeon playing music, and I kept thinking about why he chose to play this kind of music during surgery." Another patient said, "I heard a few people around me talking, and they seemed to be panicked. I heard them say they were going to lose me."

Maybe you have guessed that in these reports, more than 70% of cases involved enduring great pain during surgery. For example, one of the patients wrote: "I felt the tingling and burning sensation caused by the four incisions when they were cut open. It seemed like I had a sharp knife to cut my fingers first, and then the burning pain followed, which was unbearable."

Another patient's surgery required a big hole in the femur. The patient recalled: "There are two details in the operation that I remember very clearly. One of them, I first started with the first one. I heard the sound of the drill bit and felt the pain, and then felt the vibration caused by the drill bit spread throughout my hips. The second thing was the vibration of my legs when they pinned the rivets into my thighs one after another. And that kind of pain was beyond my imagination. How could such pain exist in the world…”

However, most of these patients think that the most painful thing is the paralysis effect brought by neuromuscular blockers. First, the first feeling this drug gives you is that you can't breathe - one of the patients said, "That kind of fear is something that humans can't bear."

Then, it will create a sense of helplessness. Another patient recalled: "My mind was filled with shouts, such as, 'Don't they know I was awake?!' Or, 'Give them a signal!'"

Source: The Weinstein Company/youtube

Because these patients didn't know why they were awake but couldn't move, this further aggravated their panic. Christopher Kent of the University of Washington, one of the authors of the paper, said: "There is no possibility for these patients to figure out what is going on." He also said that the result is that many patients begin to fear that this is the moment they were before they died. "This can be called the worst and most terrible anesthesia experience."

If you want to estimate the probability of anesthesia accidental awakening, the obtained numbers may also vary greatly depending on the statistical methods used. If you estimate based on the number of postoperative reports of patients, the probability of such accidents seems to be very low.

The fifth national review conducted by the UK and Ireland Anesthesiologists Association is one of the largest surveys in the field, and all public hospitals in the UK and Ireland must report all anesthesia accidents of the year. According to the results released by in 2014, among all patients who received anesthesia, the proportion of anesthesia accidental awakening was only 1 in every 19,000 people. If the accident caused by paralysis drugs is included, this rate will be even higher, and about 1 in every 8,000 people will suffer an accident, after all, paralysis drugs may prevent patients from sending a help signal to their doctors.

(academic.oup.com/bja/article/113/4/527/230769)

"There may be more people who are awake during the operation,

, but they forgot to suffer after the operation."

These seemingly not-high probability numbers are indeed reassuring. As the media reported in the year, the probability of patients waking up anesthesia accident during the operation, and they have not even died of anesthesia accident. The number of seems to confirm the speculation of many doctors, who believe that the risk of unexpected anaesthesia is far away from people.

However, these numbers are likely to underestimate the actual situation, and at St. George's Hospital in London explained to me the reason. First, this series of investigations relies on patients to report anesthesia accidents during surgery to the hospital on their own - but many people find it difficult to face such accidents on their own, or they are reluctant to remember them at all. They would rather leave such an experience behind.

In addition, it is necessary to consider the memory loss caused by anesthetic drugs . Oudor said, "Not only can anesthetic drugs interfere with people's memory ability, but the dose required to eliminate memory is also less than the dose required to eliminate consciousness. Therefore, memory is likely to be eliminated more easily during anesthesia than consciousness."

In other words, there may be more people who are awake during surgery, but they forgot to suffer after the operation.

In order to study this phenomenon, scholars have proposed a research method called " forearm isolation method " (Isolated Forearm Technique). Before anesthesia, medical staff tied a tourniquet to the patient's forearm to delay the time when the anesthetic drugs reach the forearm. That is, for a period of time, the patient can still make movements with his hands. This way, medical staff can ask patients if they are still conscious or if they are in pain by asking them to clench their fists or gesture.

forearm isolation method was used during surgery.

Source: Springer Link

Sanders of the University of Wisconsin-Madison recently cooperated with six hospitals from the United States, Europe and New Zealand to jointly initiate the largest research in this field. Among the 260 patients observed in the study, 12 patients responded to the investigator's first question, that is, 4.6% of patients remained conscious during the operation.

is hundreds of times higher than the figures released by the national review. Not only that, among the patients who remained conscious during these surgeries, four out of every 10 — 1.9% of all patients surveyed — gave a positive response when the researchers asked if they felt pain. The result of

makes people feel dilemma on the ethical level. In response, Sanders said: "Whenever I chat with an anesthesiologist in the training, I will talk about this philosophical issue - if the patient doesn't remember this experience, do we need to care about it? "

Sanders said that as for patients who had pain feedback in the forearm isolation experiment but could not recall the surgery after the operation, there is currently no evidence that these people subsequently developed post-traumatic stress disorder (PTSD) or other psychological disorders similar to Donna. Since does not have adverse consequences, people may think that it is indeed unfortunate to keep consciousness temporarily during surgery, but at the same time there is no need to sound the alarm for this.

However, Sanders' research made him very upset, and he launched a poll to solicit public opinions on the issue.Sanders said people's views vary widely. "Most think that just forgetting this painful experience is still not enough to make them feel at ease. On the contrary, some people think that as long as they don't remember it afterwards, it's not a problem. Although people who hold this view account for a relatively small number, the number of people is still amazing."

In this regard, Sanders believes, "Patients are looking forward to losing consciousness during surgery, and I am first of all, I want to understand the pharmacology of anesthetic drugs. In addition, I am also a clinician. I want to provide high-quality medical care and meet the expectations of patients. Therefore, it is my responsibility to figure out how to balance the reaction of the drug with the body, figure out the real probability of accidents, figure out what the real harm to patients, figure out whether the patients will be harmed, and figure out what we have to prevent these injuries."

Source: Andrea Ucini at Anna Goodson Illustration for Mosaic

No matter what, considering that most patients will not leave painful memories after general anesthesia surgery, then there is at least one danger, that is, reporting the unexpected anaesthesia awakening - such as this article - to cause patients to experience unnecessary anxiety before the operation.

In the worst case, such a sense of fear may even cause some people to refuse to undergo very necessary and necessary medical procedures. Of course, Sanders and other anesthesiologists emphasize that the risk of being able to clearly recall the surgical procedure after surgery is small, but if you are anxious about it, you should talk to the hospital’s medical staff about your concerns.

has long been fierce debate on whether this phenomenon should be spread to the public. The report from the University of Washington Archives Department shows that for some patients who have encountered accidents, their pain has been exponentially amplified because they have little awareness of anesthesia accident before the operation. They will think that the reason they keep their consciousness is because this is the moment before death. Perhaps, if they knew about such risks in advance before the operation, if an accident occurred, at least part of the pain caused by panic could be alleviated.

If people learn more about anesthesia accidental awakening, it may also allow medical staff to better help patients who have experienced this pain. Many patients who have experienced this pain, including Donna, feel that their experiences have been misunderstood by professional medical staff, or even ignored by them.

In this regard, a statistical study by the University of Washington Archives Department found that among those who remembered that they had experienced anesthesia accident, 675% of people were very dissatisfied with the responses of medical staff after the operation, and 51% said that neither surgeon nor anesthesiologist had sympathized with their painful experiences. Among this group, only 10% received a sorry response after the operation, and only 15% received psychological counseling or related help for trauma response after the operation.

"There is at least one danger, that is, report the accidental arousal of anesthesia - for example -

causes patients to experience unnecessary anxiety before the operation."

Donna said that in the hospital where she underwent the operation, many employees were confused by the trauma she received. When she woke up, she once tried to tell the nurse what she had experienced, but the nurses just stood quietly without reacting. Donna said, "I can never forget their expressions, as if they were frightened and they had no idea how to deal with this situation." Donna attributed this to the lack of training and education related to this phenomenon, and lacked understanding of this field.

After more than a few years, Donna has finally accumulated enough courage and strength. She is trying to correct this accident in her life. She will work with many Canadian universities to popularize the knowledge of anesthesia accident awakening and the best way to help patients. “I hope they are prepared because when an accident happens, you need to know how you should deal with those patients, and that’s a crucial step in the recovery process after surgery."

Source: Medium

Just like researchers are using the forearm isolation to understand the optimal operating procedures that trigger unconscious states, the ultimate goal of all efforts is to prevent such tragedies from happening again. Sanders believes that " may have some specific combinations of anesthetic agents that can just mix several anesthetic effects to better separate patients from the sensory world around them ."

If we can understand the anesthetic state more deeply, even has another possibility, which in turn uses the semi-awake and semi-coma state to get some feedback from patients during the operation to help further treatment. in some controlled clinical trials, Researchers have found that certain medical hypnosis methods can indeed affect patients' surgical experiences - since anesthetics are facing some problems nowadays, it may be a good time to practice new hypnosis methods.

In general anesthesia, although electrical signals throughout the brain seem to be severely hindered, has evidence that some brain areas, including the auditory cortex, still maintain a sensitive response, which may mean that after patients enter anesthesia, medical staff can encourage and even advise patients during the surgery to help them relieve postoperative pain.

Although the current study believes that this possibility is not high, Jenny Rosendal of the University Hospital of Jena, Germany Rosendahl and her colleagues are collecting all relevant favorable evidence. After a comprehensive analysis, they found that it would make sense to continue to communicate with patients after anesthesia. Although they currently find that this move will not have a surprising impact on the surgery, it has significantly improved the rate of nausea and vomiting after the surgery, and reduced the amount of morphine used to relieve pain after the surgery.

Of course, no one would recommend that doctors deliberately keep patients awake during the surgery, but perhaps one day in the future, more anesthesiologists will likely use some of the brain's abilities to obtain more information. As patients, the experiences we hear and see between half-wake and half-awake may improve the recovery process after the surgery, which is indeed exciting. Ideas.

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