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World J Clin Cases. Jan 26, 2020; 8(2): 245-254
Published online Jan 26, 2020. doi: 10.12998/wjcc.v8.i2.245
Awareness during emergence from anesthesia: Features and future research directions
Marco Cascella, Sabrina Bimonte, Nagoth Joseph Amruthraj
Marco Cascella, Sabrina Bimonte, Anesthesia Section, Department of Anesthesia and Pain Medicine, Istituto Nazionale Tumori-IRCCS-Fondazione Pascale, Napoli 80100, Italy
Nagoth Joseph Amruthraj, Department of Translational Medicine, University Vanvitelli, Naples 80100, Italy
Author contributions: Cascella M designed the work, performed acquisition of data and wrote the manuscript; Bimonte S performed analysis and interpretation of data; Amruthraj NJ made critical revisions related to important intellectual content of the manuscript and revised the text. All authors approved the final the version of the article to be published
Conflict-of-interest statement: The authors have no conflict of interest to declare.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Marco Cascella, MD, Academic Fellow, Professor, Anesthesia Section, Department of Anesthesia and Pain Medicine, Istituto Nazionale Tumori-IRCCS-Fondazione Pascale, Via M. Semmola, Napoli 80100, Italy. m.cascella@istitutotumori.na.it
Received: December 9, 2019
Peer-review started: November 9, 2019
First decision: December 4, 2019
Revised: December 17, 2019
Accepted: January 2, 2020
Article in press: January 2, 2020
Published online: January 26, 2020
Abstract

The anesthesia awareness with recall (AAWR) phenomenon represents a complication of general anesthesia consisting of memorization of intraoperative events reported by the patient immediately after the end of surgery or at a variable distance from it. Approximately 20% of AAWR cases occur during emergence from anesthesia. Clinically, these unexpected experiences are often associated with distress especially due to a sense of paralysis. Indeed, although AAWR at the emergence has multiple causes, in the majority of cases the complication develops when the anesthesia plan is too early lightened at the end of anesthesia and there is a lack of use, or misuse, of neuromuscular monitoring with improper management of the neuromuscular block. Because the distress caused by the sense of paralysis represents an important predictor for the development of severe psychological complications, the knowledge of the phenomenon, and the possible strategies for its prophylaxis are aspects of considerable importance. Nevertheless, a limited percentage of episodes of AAWR cannot be prevented. This paradox holds also during the emergence phase of anesthesia which represents a very complex neurophysiological process with many aspects yet to be clarified.

Keywords: Intraoperative awareness, Anesthesia awareness with recall, Explicit memory, Emergence from anesthesia, Neuromuscular monitoring, Butyrylcholinesterase deficiency

Core tip: Approximately 20% of all awareness with recall cases regard the end stage of anesthesia. Of note, emergency-related complications are associated with distress, especially due to paralysis. On these premises, it is of fundamental importance to recognize the mechanisms that lead to the complication and to implement appropriate preventive strategies.