A Day to Remember
In this moving account, Dr Antje Friedwagner, Consultant Anaesthetist at UCLH, describes her harrowing experience of accidental awareness under anaesthesia during the birth of her first child by caesarean section.
Flashback to 9 years ago. I was pregnant with my first child and was also about to finish my training as an anaesthetist. Having worked many shifts on labour wards, I had carefully chosen the hospital where I wanted to give birth: a big university hospital with neonatal doctors on site and, of course, experienced colleagues for obstetrics and anaesthesiology. I had had an easy pregnancy and was expecting a healthy child. My biggest risk factor was probably being an anaesthetist or doctor myself!
I went into labour, had an epidural sited after some hours, but labour didn’t progress as planned. So, although I know there is no such thing as an ideal birth plan, I found myself exactly where I had not planned to be: on the way to theatre for a category 3 caesarean section.
By this time I was still relatively relaxed because I knew that my epidural could be topped up and used for the caesarean section. But after the full dose of local anaesthetic had been injected, I could still feel the urinary catheter being inserted. And when all the drapes were in place, the obstetric surgeons tested the quality of the block and I could feel the skin incision very clearly.
A quick decision was made that the top-up had failed and that I would need a general anaesthetic. My husband was escorted out of theatre and someone was holding an oxygen mask in front of my face. It was only because I am an anaesthetist myself that I knew what was going on: no one explained what had happened or that they were doing a general anaesthetic.
The thought of being anesthetised really worried me as I knew very well about the added risks for me and my baby due to the general (GA). Caught up in my thoughts and concentrating on my own pre-oxygenation, I suddenly heard the anaesthetists voice: “Laryngoscope please!“
I thought this must have been a mistake and instantly wanted to speak up, telling them that I was wide awake. This was when I realised, that I had not only lost the ability to speak or raise my arm, I could also no longer breathe. I was apparently completely paralysed.
I was so busy, figuring out what was happening to me that I didn’t even think about what was to come next: they started the operation. At that point, I felt the most excruciating pain.
Once again, I tried to make the doctors aware of my situation, but I only managed to move my legs slightly. Being in lithotomy position, this was noticed immediately by one of the surgeons and he informed the rest of the team. But the anaesthetist seemed to be confident, that everything was absolutely fine and replied that there were no concerns from his side regarding the depth of anesthesia.
Thankfully, my surging heart rate and blood pressure made him realize that that I wasn’t properly asleep. So then he finally decided to supplement the anaesthetic with some propofol. While he injected the white drug, he saw that the medication was not running into my veins, but was instead tracked back, all the way up the giving set. All the other drugs they had used for induction (Thiopental and Suxamethonium) had been clear formulations and the apparent glitch in the iv line had not been noticed so far. They decided to use a higher dose of anaesthetic gas, and so I finally drifted off to sleep shortly after.
I still remember the events of that day so clearly:
- Being intubated: the laryngoscope touched my upper front teeth but I do not recall this procedure being painful.
- The lack of oxygen and not being able to breathe by myself - until the airway was secured and the ventilator was connected.
- The discussions of the doctors during my awareness and whether I was properly asleep.
- The swearing of the anaesthetist when he realised that something had obviously gone very wrong.
- And of course, the unbearable pain that was inflicted during the operation.
When I woke up, the responsible consultant anaesthetist immediately and anxiously came to talk to me and shortly after, I confirmed his fear: that I could, in fact, remember everything. But, to his credit, he did the most important thing for me in that situation:
Firstly, he accepted what I described as my genuine experience and never doubted any part or detail of my story. Secondly, he also instantly apologised for what had happened.
I met him several times- as an inpatient and even after my discharge - and he was always very helpful and open in the process of understanding and investigating how the incident had happened. His whole attitude and the fact that he was profoundly and honestly sorry helped me tremendously during the following weeks. Being an anaesthetist myself, I was still convinced that understanding the circumstances and how the awareness could have happened would be the key to overcoming my trauma.
However, a few weeks later, I was still very tearful, I had flashbacks of the induction and I had also started having nightmares about people suffocating me. I was apparently showing all signs of PTSD. It was then that I decided to start trauma therapy. This really was pivotal to my recovery and only a few weeks later, I felt much better and more in control of my emotions.
A recent publication about accidental awareness during general anaesthesia (AAGA) is looking into the data obtained during NAP 5. The NAP5 Handbook summarises the findings and aims to provide practical recommendations to doctors and organizations in order to reduce the risk of accidental awareness. Reading the report, I learned that my case, unfortunately, seems to be more common than one would hope. One of the findings was that women undergoing a LSCS under general anaesthesia have statistically 13 times the risk for AAGA compared to the general surgical population. Furthermore, rapid sequence inductions are a stand-alone risk factor for awareness (6-fold compared to non-RSI inductions). Out of 300 reported cases of accidental awareness, one third occurred during RSI and in almost all of these cases, Thiopental was used as an induction agent. It seems that not only the circumstances, but also the choices of drugs are an important risk factor.
So what is my learning from this patient experience: what have I changed in my day-to-day practise as an anaesthetist? Firstly, I have definitely recognized awareness as a serious complication that may impact my patient´s life and cause severe trauma. Making sure you know which patients are at special risk for AAGA and what circumstances are more likely to cause this complication might help to reduce prevalence. If you are suspecting a difficult airway, make sure you have enough induction drugs prepared to deal with prolonged airway management. If I had experienced being awake together with having a difficult airway, I don’t think I could have ever gone back to working in that environment. However, thankfully, I was very easy to intubate - almost a grade 0 intubation as I jokingly say.
In my case, the error was caused by a missing one-way-valve and an anaesthetist who injected the induction drugs using the little button on top of the cannula. All the drugs he injected were backtracked up the giving set and I ended up having the Suxamethionium before the Thiopental. Therefore, I will always routinely check my giving sets and and use solely 3-way-taps to administer drugs: making sure they are going into the right direction. This is particularly important in an environment like a labour ward, where cannulas might have been sited many hours ago by someone else. Lastly, I also advocate replacing the whole giving set into one which you are familiar with once the patients enters the operating theatre.
Whilst these are all measures to hopefully prevent cases of accidental awareness, there is one even more important thing that should be done if things go wrong and you suspect that it might have happened: talk to your patient.
And I don’t mean just following up after the surgery, making sure affected patients receive all the necessary support they need, depending on the severity of the trauma. I am also talking about the actual moment in theatre, when accidental awareness is suspected. Gently talk to your patient and reassure them, that you are aware of the situation and are dealing with it. Had I had this, there is no doubt the intense vulnerability, fearfulness and helplessness would have been mitigated and perhaps resulted in a less traumatic experience.
Antje with her children
In the next step, Dr Nuala Lucas, Consultant Obstetric Anaesthetist at Northwick Park, goes on to examine all the factors that make anaesthesia and airway management on the labour word uniquely challenging.