Awareness with Recall Can Occur During General Anesthesia

Awareness with recall (AWR) while under general anesthesia is not a frequent event—a recent report noted that it occurs in 1 to 2 cases out of 1,000. With 21 million general anesthetics administered each year, 42,000 patients have some type of recall during their procedure.1

But the effects of AWR can be severe and long-lasting. One study suggests that patients who have experienced this type of event have a 70 percent chance of developing post-traumatic stress disorder that may last for years.2

Follow these tips to help prevent AWR:

  • Know the risk factors for awareness under anesthesia:
    • Anesthetic agents used in low concentrations for any reason.
    • Patient is excited before induction (however, AWR can occur covertly in any patient).
    • Total intravenous anesthesia techniques.
    • Abdominal delivery.
    • Trauma surgery.
    • Previous episodes of awareness under anesthesia.
  • Be proactive to prevent claims:
    • Discuss the potential for dreaming or AWR as part of the informed consent process.
    • Monitor and document end-tidal agent concentrations and patient response.
  • Take steps to decrease the risk of awareness under anesthesia:
    • Utilize an end-tidal monitor for volatile anesthetics with a low alarm limit set.
    • Utilize a processed EEG monitor to guide anesthesia management whenever possible, especially when using total intravenous anesthesia techniques and particularly for patients with a history of AWR.

If your patient experiences awareness under anesthesia, acknowledge and address the patient’s concerns and consider referring the patient to a psychiatrist or counselor who is knowledgeable about the various types of AWR.


1 Avidan MS, Mashour GA. Prevention of intraoperative awareness with explicit recall: making sense of the evidence. Anesthesiology. 2013 Feb;118(2):449-56.

2 Leslie K, Chan MT, Myles PS, Forbes A, McCulloch TJ. Posttraumatic stress disorder in aware patients from the B-aware trial. Anesthesia and Analg. 2010 Mar 1;110(3):823-8.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.



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