Pressure in busy surgery departments to shorten patient recovery time and reduce delays may be contributing to a relatively rare but frightening experience during surgery in which a patient wakes up from general anesthesia while still under the knife, the Joint Commission on Accreditation of Healthcare Organizations said last week.
The phenomenon, a consequence of insufficient levels of anesthesia drugs and the widespread use of immobilizing medications, "is underrecognized and undertreated in healthcare organizations," said JCAHO President Dennis O'Leary. An estimated 20,000 to 40,000 patients among 21 million given general anesthesia each year suffer through episodes in which they experience the sounds-and sometimes the pain-of their surgical procedure.
Compounding the potential for trauma is the pervasive use of immobilizing drugs called paralytics, which keep a body from moving during delicate surgical work but also prevent the slightest twitch of a finger or toe that could alert doctors to adjust the delivery of anesthesia levels, said Robert Wise, the JCAHO's vice president of standards. A patient waking up while in the grip of these strong muscle-relaxing agents is powerless to give any clue that he or she is awake, Wise said.
In a "sentinel event alert" to the problem, the accrediting agency said contributing factors include the "premature lightening of anesthesia at the end of procedures to facilitate (operating room) turnover."
Even with the best doctors using the best medical practices, the incidence of patient awareness during surgery "cannot be avoided in all cases," Wise said. It's a constant balancing act between manipulating safe levels of anesthesia, which can lower blood pressure among other effects, and ensuring adequate sedation, he said.
But "cutting corners" to keep doctors on schedule and recovery rooms from getting crowded must be avoided, Wise added.
"There is a lot of production pressure out there," said Michael Ramsay, chairman of the anesthesia department at Baylor University Medical Center, Dallas. Surgical departments are expensive to staff and manage, he said, and clinicians are under the gun to get patients through recovery as quickly as they can and still ensure safety.
That pressure doesn't lead to hurry-up measures at Baylor, Ramsay said, but he added, "I think there are institutions out there that just look at the bottom line."
Part of the routine for anesthesiologists or nurse anesthetists is to ease up on the dose of drugs used to keep the patient sedated as the procedure nears its end. Anesthesia specialists try to keep the time of complete sedation as short as possible for safety reasons and to make sure the patient is as recovered as possible from the anesthesia before leaving the operating room, said Roger Litwiller, president of the American Society of Anesthesiologists.
A patient can't be moved out of the recovery room until the anesthesia wears off, Wise said. And doctors administering the anesthesia have to be available until a cer- tain level of recovery has been reached, he added, preventing them from leaving for another appointment-at a different facility, for example.
Professionals who run the recovery room have a difficult task managing a busy department without overloading it, and they have only a certain number of nurses and beds, Wise said. If all patients were given the deepest anesthesia, the room would be crowded. Such pressures, he said, could contribute to the lightening of anesthesia at the end of procedures, which the JCAHO alerted against.
But although anesthesia specialists "walk a tightrope" between sedating and keep- ing safe dosages, they don't make decisions based on scheduling factors, said Clarence Thomas Jr., chief quality officer for St. Thomas Health Services, Nashville, and a career surgeon.
"In 30 years in the operating room, I've never witnessed that as being a factor," he said.