Intra-operative awareness in children and post ... - Wiley Online Library

Anaesthesia, 2008, 63, pages 474–481 doi:10.1111/j.1365-2044.2007.05412.x .....................................................................................................................................................................................................................

Intra-operative awareness in children and post-traumatic stress disorder* U. Lopez,1 W. Habre,2 M. Van der Linden3 and I. A. Iselin-Chaves4 1 Psychologist, Division of Anaesthesiology, Pharmacology and Intensive Care, University Hospital of Geneva, 2 Senior Consultant, Paediatric Anaesthesia Unit, University Hospital of Geneva, 3 Professor of Psychology, Cognitive Psychopathology and Neuropsychology Unit, University of Geneva, and 4 Senior Registrar, Division of Anaesthesiology, University Hospital of Geneva, Geneva, Switzerland Summary

Adults who experience intra-operative awareness can develop disturbing long-lasting after-effects, such as daytime anxiety, sleep disturbances, nightmares, flashbacks and, in the worst case, a posttraumatic stress disorder (PTSD). It is unknown whether intra-operative awareness has a similar psychological impact in children. We designed the present study in order to evaluate the incidence of psychological symptoms in children who had either confirmed or possible intra-operative awareness. Attempts were made to locate 11 children who had been identified in a previous study, approximately 1 year following their experience. A PTSD questionnaire was administered to the children and their parents in order to detect any long-term or short-term psychological symptoms (the 1-month postoperative data were evaluated retrospectively). Factors believed to be associated with PTSD, such as intra-operative perceptions, the children’s temperament and cognitive strategies, and the parents’ coping strategies, were also analysed. Seven children were successfully located and interviewed and no short or long-term psychological symptoms were identified. None of them offered negative appraisals of the traumatic event and none had displayed dysfunctional behaviour or cognitive strategies. Thus, none of them had developed a PTSD syndrome. In contrast with what has been reported in adults, these children claimed not to have experienced major pain, terror or helplessness during their surgery. Despite the small sample size, the results of the present study suggest that children suffer less psychological sequelae than adults following intra-operative awareness. This may be due to the fact that the children reported less frightening intra-operative sensations as compared with the adults, and had less understanding of the anaesthesia procedure, and this may have influenced their appraisal of their awareness and protected them from the full impact of this potentially traumatic experience. . ......................................................................................................

Correspondence to: Ursula Lopez E-mail: [email protected] *Preliminary data were presented at the European Society of Anaesthesiology in June 2006. Accepted: 13 October 2007

In adults, many studies have highlighted the psychological sequelae that may result from intra-operative awareness [1–5]. The symptoms that have been described include nightmares, daytime anxiety and flashbacks [1–5]; and in the worst cases, patients may develop a posttraumatic stress disorder (PTSD) [4, 5]. PTSD is characterised by three long-lasting symptom complexes: (1) re-experiencing the traumatic event, (2) the avoidance of situations associated with the traumatic event (for example, hospital 474

and doctors) and (3) physiological hyperarousal, such as irritability and hypervigilance [6]. PTSD has been identified in more than half of the adult victims of intraoperative awareness even 17 years after the event [5]. Even if patients do not complain immediately after experiencing intra-operative awareness, psychological sequelae may be detected and may persist for years following the adverse event [4]. Intra-operative experiences such as helplessness, the inability to communicate, 2008 The Authors Journal compilation 2008 The Association of Anaesthetists of Great Britain and Ireland

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Anaesthesia, 2008, 63, pages 474–481 U. Lopez et al. PTSD after awareness in children . ....................................................................................................................................................................................................................

terror, pain and paralysis have been commonly reported by the patients [4, 5] and peri-operative dissociative experiences were identified as predictors of the development of chronic PTSD [5]. It has become clear that children can also experience intra-operative awareness, and the incidence of this complication has been reported to be higher than that among adults [7, 8]. It is also well recognised that children exposed to traumatic events can develop a PTSD [9]. Various personal factors are known to contribute to the development and ⁄ or maintenance of PTSD symptoms in the paediatric population, such as a negative appraisal of the traumatic event and its sequelae, and the adoption of dysfunctional behaviour and cognitive strategies (such as avoidance and rumination) designed to counter a perceived current threat [10]. Certain temperamental traits (emotionality and shyness) also appear to be related to psychiatric disorders, such as anxiety and depression [11, 12]. Finally, other findings have highlighted the importance of contextual factors in a child’s recovery from trauma, for instance an inadequate parental reaction (e.g. avoidance), which may influence the child’s capacity to cope [9]. Since the incidence of awareness is higher in children than in adults [7, 8], and symptoms of PTSD can interfere with normal childhood development, including the capacity to learn and the acquisition of socially appropriate behaviour [13], it appears mandatory to investigate the potential long-term negative after-effects of awareness in the paediatric population. To the best of our knowledge, these after-effects of awareness have not been properly investigated to date. Davidson et al., who first demonstrated interest in this topic, did not observe any difference in behavioural disturbances in the 30 days after the procedure between children with or without awareness [8]. Nevertheless, no data are available on the potential long-term psychological sequelae following intra-operative awareness in children. Accordingly, we designed the current study to evaluate the psychological sequelae and their severity in 11 children who had been previously identified in a study of intra-operative awareness. Additionally, we had the aims of establishing whether these children met the formal criteria for PTSD according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) [6], and of evaluating factors associated with PTSD symptoms. Materials and methods

In a recent study, by means of two specific interviews, conducted within 36 h and at 1 month after surgery under general anaesthesia, we detected five cases of confirmed intra-operative awareness and six cases of 2008 The Authors Journal compilation 2008 The Association of Anaesthetists of Great Britain and Ireland

possible intra-operative awareness [7]. The interviews were first recorded and transcribed and the potential cases of awareness were subsequently analysed by an independent endpoint adjudication committee of three experienced anaesthesiologists, who classified each case as ‘awareness’, ‘possible awareness’ or ‘not awareness’. Confirmed awareness was defined as a unanimous coding of ‘awareness’, or two adjudicators coding as ‘awareness’ and the third as ‘possible awareness’. Possible awareness was defined as one or more codings of the report as ‘awareness’ or ‘possible awareness’ [14]. Following approval by our University Hospital Ethics Committee, we attempted to locate these 11 children approximately one year after surgery. PTSD questionnaire PTSD is a psychiatric disorder generally diagnosed by means of DSM-IV. To meet the DSM-IV criteria, a child must have been exposed to an ‘extreme’ stressor (condition A), and his ⁄ her response to that stressful event must include a specific number of symptoms from each of three broad categories: at least one re-experiencing symptom (category B), three avoidance ⁄ numbing symptom (category C), and two hyperarousal symptoms (category D) [6]. A number of English instruments are available for the assessment of this disorder in children. A French– Canadian questionnaire designed to assess the PTSD in children [Child Post-Traumatic Stress-Reaction Index (CPTS-RI)] was recently validated (M. Be´riault, V. Lafrance, L. Turgeon, unpublished data). However, this questionnaire has certain limitations, such as the failure to include all of the symptoms listed in DSM-IV, the repeated assessment of some symptoms, the absence of an evaluation of the frequency ⁄ severity of the symptoms, and the use of Canadian expressions, some of which are not easy to understand. Accordingly, we designed a new questionnaire, based on the French–Canadian version of CPTS-RI, but taking into account the above comments. This instrument consisted of 16 items, assessing all the symptoms listed in the DSM-IV, and aiming to diagnose PTSD according to the criteria of DSM-IV. The item in DSM-IV ‘amnesia for an important aspect of the trauma’ (C3) was deleted since hypnotics have an amnesia effect. In order to evaluate the frequency ⁄ severity of each symptom, we introduced a five-point Likert scale, with scores ranging from 0 (never) to 4 (frequently ⁄ five times a week). Finally, as the DSM-IV criteria of PTSD are mainly adult-focused, we added nine items often found in traumatised children, but not mentioned in DSM-IV [15]. Thus, this instrument had the aims of: (1) the diagnosis of PTSD according to the DSM-IV criteria; (2) an 475

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U. Lopez et al. PTSD after awareness in children Anaesthesia, 2008, 63, pages 474–481 . ....................................................................................................................................................................................................................

evaluation of the severity of ‘child-specific’ posttraumatic stress symptoms (16 items) at long-term (1 year after surgery) and at short-term (the 1 month postoperative data were evaluated retrospectively); (3) and an evaluation of the severity of the ‘other post-traumatic symptoms’ (9 items) at long- and short-term. A score was obtained for the long- and short-term ‘child-specific’ post-traumatic stress symptoms by summing the score of each item and dividing the result by 16. A score was also calculated for the ‘other post-traumatic symptoms’ at long- and at short-term by summing the score of each item and dividing the result by 9. Intra-operative experience All interviews were recorded and subsequently transcribed. Cognitive factors Ehlers et al. identified three factors that determine the development and maintenance of PTSD in children: (1) trauma memory deficits: the memory of the traumatic event is poorly elaborated, which leads (together with strong priming and conditioning for associated cues) to easy triggering of re-experiencing symptoms when matching cues are present; (2) appraisals: the child makes negative appraisals of the traumatic event and ⁄ or its sequelae, leading to a sense of current threat; (3) maintaining behaviour and cognitive strategies: the negative appraisals encourage children to engage in dysfunctional behaviour and cognitive strategies designed to counter the perceived current threat, but maintain the problem, such as thought suppression, avoidance, rumination and persistent dissociation [10]. The first factor was obvious in a context of general anaesthesia, given that hypnotics have an amnesic effect and prevent the development of an elaborated memory of the intra-operative events. The second factor was evaluated from three aspects: (a) a negative interpretation of intrusive memories, (b) alienation from other people, and (c) appraisals relating to unfairness. Each dimension was assessed as in Ehlers et al. by one item, which was adapted for the context of general anaesthesia and translated into French (see Ehlers et al. for the details [10]). The third factor was also composed of three aspects, each assessed via one or two items: (a) rumination (scored as the mean of two items), (b) thought suppression (assessed via one item), and (c) persistent dissociation (assessed via one item). Each item involved in the two last cognitive factors was rated on a four-point Likert scale ranging from 0 (no) to 3 (yes, often). Two scores were obtained, one for each factor, by summing the items referring to the factor and dividing the result by three. 476

The children’s temperament To assess the children’s temperament, we used the Emotionality, Activity and Sociability Questionnaire (EAS, developed by Buss and Plomin [16], and translated into French by Gasman et al. [17]), which is a valid and reliable instrument and has been used extensively at all ages throughout childhood and adolescence [12, 16, 17]. Four aspects can be evaluated with this instrument: emotionality, activity, sociability and shyness. Emotionality refers to a great intensity of emotional reactions and to a negative quality of emotional style; activity refers to the tendency to be agitated; sociability refers to the preference for being with others rather than being alone; and shyness refers to the tendency to escape from novel or unfamiliar social interactions. This instrument is composed of 20 items, five items for each of the four aspects. Each item is rated on a five-point Likert scale ranging from 1 (not typical) to 5 (very typical). A mean score for each aspect is obtained by summing the scores of the five items referring to the dimension and dividing the result by five. These scores indicate the degree to which the child has the given temperamental feature. The parents’ coping strategy The Individual Coping Questionnaire (INCOPE-2) was used to evaluate the parents’ coping strategy [18]. The normality of this French instrument has been validated on 211 control subjects and mentioned in various studies [19]. However, it has not yet been validated on other coping questionnaires. INCOPE-2 is composed of 23 items, which measure two main strategies: functional (positive) and dysfunctional (negative) individual coping. The functional coping involves the following strategies: positive re-evaluation; positive palliation; positive autoverbalisation; sports and physical activities; seeking social support; active influence on the situation and humour. For dysfunctional coping, the following strategies were included: comparison with another person; negative palliation; reproach of oneself, of another person or of the partner; rumination and expression of negative emotions. Each item is rated on a five-point Likert scale, ranging from 1 (never) to 5 (most of the time). Two scores were obtained, one for each factor, by summing the items referring to the factor and dividing the result by the number of items referring to the strategy. These scores indicated to what degree parents have that coping strategy. Following approval from our Institutional Ethics Committee, and approximately 1 year after surgery we attempted to locate the 11 children who had earlier proved to exhibit definite or possible awareness. It was 2008 The Authors Journal compilation 2008 The Association of Anaesthetists of Great Britain and Ireland

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planned that all children would be interviewed by the main author (UL), preferably in the hospital with one of the parents. If the parents were unable to visit the hospital, the interview was conducted by phone. Verbal consent was obtained from all parents and children by telephone when they were located and written consent was obtained when they agreed to attend our clinic. The duration of the interview did not exceed 1 h. All the interviews were recorded on tape. The PTSD questionnaire was first addressed in order to detect the long-term psychological symptoms, and then the early symptoms retrospectively. After the PTSD questionnaire, the two cognitive factors were evaluated, and the parents were then asked to complete the Incope-2 and EAS questionnaires. When the interview was conducted by phone, these two last instruments were delivered by post. Results

In view of the small sample size, statistical analysis was not appropriate and this report is therefore purely descriptive. Intra-operative experience and psychological consequences Despite repeated attempts to locate all 11 children, one child could not be traced even with a close search via the phone company. We were unable to interview three other children because their parents declined to participate in the study. The parents of these children were, however willing to give some information about their situation. Two claimed family problems as the reason for non-participation. Divorce had occurred in one child’s family and the loss of a parent’s job in another. The third family was unwilling to give the reason for refusal. The parents of these children stated over the telephone that no modification had been noted in their children’s behaviour. Seven children (three with confirmed and four with possible awareness), aged between 8 and 16 years were interviewed between 8 and 15 months following the event. Table 1 summarises the demographic data, the intra-operative experience, and the type of interview (by phone or at the hospital). Table 2 lists the intra-operative sensations, emotions and cognition. In general, the children could still recall the intraoperative sensations reported approximately 1 year previously. However, none of them presented psychological symptoms at 1 month or at 1 year; accordingly, none of them had developed a PTSD syndrome. Despite recalling the intra-operative events, the children did not feel the need to talk or think about them. Furthermore, none expressed a negative feeling or was upset about the episode. All the children regarded the fact that they had experienced perceptions during their surgery as ‘normal’. 2008 The Authors Journal compilation 2008 The Association of Anaesthetists of Great Britain and Ireland

Their only real concern was the success and the consequences of the operation (for instance, some of them were afraid that they would be obliged to interrupt active sport or to have to undergo another operation if the first was unsuccessful). Negative intra-operative sensations were infrequent: only one child had felt pain and had had a decorporation experience (case 5). Another child had felt paralysed but did not seem to be worried by that feeling (case 1). Four children had experienced an unpleasant tactile sensation (cases 2–5), and three of them had felt immediate anxiety (cases 3–5). However, none of the children reported helplessness, terror, feeling unsafe or an inability to communicate. Cognitive strategies, children’s temperament and parents’ coping strategy In respect of the items developed by Ehlers et al., none of the children made negative appraisals of the traumatic event and none engaged in dysfunctional behaviour or cognitive strategies. The five questionnaires correctly completed by the parents evaluating the children’s temperament and the parents’ coping strategy (cases 5 and 6 did not return the questionnaires sent by mail), led to the identification of two children with higher scores for the aspects on emotionality (case 3) or shyness (case 4). Only one parent presented a dysfunctional coping strategy (case 3). Table 3 summarises the scores of the four aspects of the temperament (emotionality, activity, sociability and shyness) and the two coping strategies of the parents (functional and dysfunctional strategy). Discussion

This study has demonstrated that children who have experienced intra-operative awareness can still recall intra-operative events approximately 1 year following anaesthesia but none seem to make a negative appraisal of the traumatic event, to engage in dysfunctional behaviour or cognitive strategies, or to present short- and ⁄ or longterm psychological symptoms. Accordingly, none of the children participating in this study developed a PTSD syndrome. As far as we are aware, this is the first report of a long-term follow-up after intra-operative awareness in children. We interviewed seven children from among the 11 previously identified in our institution [7]. Most of the adult studies that have focused on this topic were unable to call back a higher number of patients [4]. Davidson et al. did not observe any differences in immediate behaviour (assessed by the Vernon questionnaire at 30 days postoperatively) between the children who experienced awareness and those who did not [8]. 477

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Table 1 Details of demographic data, surgery and intra-operative experience for children who experienced awareness. Demography

Patient

Sex

Current Age (years)

1

F

12.1

Orthopaedic surgery

2

M

10.1

Facial surgery

3

M

8.4

Plastic surgery

4

M

14.11

Orthopaedic surgery

5

M

16.10

Orthopaedic surgery

6

M

15.8

Orthopaedic surgery

7

M

7.9

Orthopaedic surgery

Surgery

Intra-operative experience recalled after the operation

Diagnose of Awareness*

PTSD interview (months)

Type of interview (phone/hospital)

Felt something like ‘a tube in her mouth’ which ‘‘tickled’’, but felt no pain. This tube ‘went as far as the little wall but not in her throat’ (laryngeal mask airway). Felt as if she was a ‘stone’, tried to ‘close her mouth’, but was unable to. Heard a ‘little noise of metal’ and ‘felt a little bit scared’, but was able reassure herself by telling herself that she was at the dentist. Saw ‘a big, round and yellow light above her head’. Felt that he ‘was opened up under his right eye and that they cut something’. Felt no pain, but an unpleasant sensation of ‘smarting’. Was not anxious. Felt ‘vibrations and tingles’ in his left leg. Also felt heat and discomfort. Tried to move his leg. Was a little anxious. Felt something which ‘came into his throat’. It ‘rasped on his throat, and it stayed a moment at the end of his throat’. Felt discomfort and was anxious. Heard ‘a man who asked for tools’ and the noise of ‘machines moving. Saw ‘a yellow light’. Felt something like a ‘duvet on the lower part of his legs’, and ‘a pressure on both legs from the knee to the foot’. Felt ‘three intravenous injections in his right arm’ (which was confirmed by the anaesthesia chart). It was ‘a little bit painful’, it ‘burnt’. Felt ‘worried’ and ‘anxious’ during the operation and was afraid of feeling pain. Tried to move, but could not. Had the impression that his ‘spirit left his body and was above him’. Heard music (which was confirmed by the surgeon) and the doctor’s voice. Saw three big lamps above him. Felt as ‘if someone was moving him on the operating table and putting him on his left side’ (his position was changed after the induction of anaesthesia to a left lateral position). Felt an injection on his hip (it was probably the puncture in the L4–L5 intervertebral space). Felt as if his arm was moving and jiggling. Felt no pain and was not worried.

Confirmed

15

Phone

Confirmed

8

Hospital

Confirmed

10

Hospital

Possible

12

Phone

Possible

10

Phone

Possible

9

Phone

Possible

10

Hospital

*Confirmed awareness is defined as a unanimous coding of ‘awareness’ or two adjudicators coding as ‘awareness’ and the third as ‘possible awareness’. Possible awareness is defined as one or more adjudicators coding of the report as ‘awareness’ or ‘possible awareness’.

It is interesting to consider the four children we initially identified who could not be interviewed since avoidance is a symptom of PTSD. Despite our requests, the parents of these three of these children stated that the non-participation was due to family problems and that, to their belief, no modification had been in their children’s behaviour subsequently to their intra-operative awareness. We cannot exclude the possibility that these four children had developed psychological symp478

toms because of their intra-operative awareness, and it is possible that the parents minimised the consequences of the intra-operative awareness on their child by highlighting the impact of their family problems on the child’s behaviour. Such an impact was identified by Kain et al., who were unable to differentiate between the long-term postoperative behavioural disorders related to anaesthesia and those related to family problems [20]. 2008 The Authors Journal compilation 2008 The Association of Anaesthetists of Great Britain and Ireland

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Table 2 Details of the intra-operative sensations, emotions and cognition. Motor function Mental reaction

Perception

Other phenomena

Unpleasant tactile Felt Tried to paralysed Pain move Patient Auditory Visual Tactile sensation

Immediate Immediate Negative Positive understanding anxiety thoughts thoughts Decorporation

1 2 3 4 5 6 7

Yes Yes No Yes Yes No No

Yes No No No Yes Yes No

Yes No No No Yes Yes No

Yes Yes Yes Yes Yes Yes Yes

No Yes Yes Yes Yes No No

Yes No No No No No No

Table 3 Scores of the children’s

temperament and the parents’ coping strategy.

No No No No Yes No No

Yes No Yes No Yes No No

Yes No Yes Yes Yes No No


Children’s temperament

Yes No No No No No No


Parent’s Coping strategy

Patient

Emotionality

Activity

Sociability

Shyness

Functional

Dysfunctional

1 2 3 4 7

3.2 3.4 4.6 2.4 2.2

3.2 4.2 4.4 3 4.8

3.6 3.4 4.5 2.8 4.2

1.8 3.4 2.4 4.2 1.6

2.8 3.1 2.4 2.7 3

2.4 2 2.8 1.6 2.11

In view of the lack of studies on long-lasting aftereffects of awareness in the paediatric population, the results of the present study can be compared only with findings reported on adults. Children appear to have fewer psychological sequelae than adults following intraoperative awareness. The higher incidence of PTSD observed in adults may be due to two main factors: the more negative and frightening intra-operative experience, and their prior knowledge concerning the anaesthesia procedure. The reason why the intra-operative experience may be perceived differently in children is that the intensity of the reported sensations, such as discomfort and anxiety, is low and does not generate panic or helplessness as observed in adults. Moreover, none of the children who experienced intra-operative awareness reported a negative and frightening intra-operative experience such as major pain, terror, feeling unsafe, or an inability to communicate [4, 5]. Although one child (case 5) described an intra-operative decorporation experience, which may increase the risk of PTSD, we did not identify any psychological sequelae in that child. Prior knowledge of the anaesthesia procedure may also influence the incidence of PTSD since it is very wellknown that such an understanding influences a subject’s appraisal of the events [21]. It is clear that adults have a broader knowledge base than children concerning the causes and outcomes of emotion elicited by events [22]. One implication of age-related changes in knowledge is that uncommon events may not be appraised as traumatic 2008 The Authors Journal compilation 2008 The Association of Anaesthetists of Great Britain and Ireland

[9]. As an example, Handford et al. demonstrated that children under eight were not affected by the Three Mile Island nuclear incident, possibly because they did not understand the dangerous consequences of that event [23]. Since the mean age of the children in our study was around 10 years, it is hardly likely that these children had a broad knowledge on such a specific domain as the anaesthesia procedure. In fact, all of the children interviewed in the present study considered it ‘normal’ to have some perceptions during surgery even though they did not experience severe pain. They were more concerned about the success and the consequences of their operation than about the anaesthesia procedure itself. It is probable therefore, that children’s concept of anaesthesia is greatly different from that of adults, who obviously consider intra-operative sensations abnormal, even if no anxiety or pain is associated with them. It is also probable that children’s concerns and expectancy towards anaesthesia and the medical staff are different from those of adults. It is plausible that the lack of knowledge and understanding may have influenced the children’s appraisal of their intra-operative awareness, and may have protected them from the impact of this potentially traumatic experience. The two interviews conducted to detect intra-operative awareness may have helped to prevent the development of PTSD, the child thereby elaborating a more complete and coherent representation of the intraoperative events, with a reduced risk of re-experiencing 479

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symptoms when matching cues are present. The empathy enhanced by the interviewing process and the follow-up could also have helped to make the child feel safe and to reduce any psychological consequences of the intraoperative awareness. Parents may have helped their children to cope with their awareness experience, since most of the parents interviewed in the present study were found to have a functional coping strategy known to have a positive impact on children [9]. Although two children proved to have high scores on emotionality and shyness, which are temperamental traits related to psychiatric disorders [11, 12], we were unable to demonstrate clearly the presence of PTSD in these children and neither of these children developed any other psychological sequelae from their awareness experience. This may be explained in part by the multifactorial aetiology of PTSD, and by the interaction between the pre-, peri- and post-traumatic factors [24]. Hence, the presence of high scores on emotionality and shyness may not be sufficient for PTSD to develop. In conclusion, this is the first study in the paediatric population that demonstrates the absence of psychological sequelae following intra-operative awareness, a situation different to that reported in adults. This finding may be attributed to the fact that the children reported less frightening intra-operative sensations and had less understanding of anaesthesia, which may have protected them from the impact of this event. However, in view of the small number of children in the present study, these results should be considered with caution. It is essential to carry out a large-scale follow-up in order to check on these findings. Finally, it is important that compassion is shown to children who have experienced awareness, and that time is taken to reassure both them and their parents, with the suggestion of psychological support if necessary. References 1 Schwender D, Kunze-Kronawitter H, Dietrich P, Klasing S, Forst H, Madler C. Conscious awareness during general anaesthesia: patients’ perceptions, emotions, cognition and reactions. British Journal of Anaesthesia 1998; 80: 133–9. 2 Ranta SO-V, Laurila R, Saario J, Ali-Mlekkila¨ T, Hynynen M. Awareness with recall during general anesthesia: incidence and risk factors. Anesthesia and Analgesia 1998; 86: 1084–9. 3 Moerman N, Bonke B, Oosting J. Awareness and recall during general anesthesia. Facts and feelings. Anesthesiology 1993; 79: 454–64. 4 Lennmarken C, Bildfors K, Enlund G, Samuelsson P, Sandin R. Victims of awareness. Acta Anaesthesiologica Scandinavia 2002; 46: 229–31.

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