• NAP5
    Link:www.nationalauditprojects.org.uk/NAP5home
    • The latest published NAP study following on from NAP4
      • Aimed to establish the incidence of accidental awareness under general anaesthetic (AAGA)
      • All UK hospitals included, 1 year registry
      • Included all cases of awareness where the patient expected to be unconscious
    • What people reported
      • Usually short period of awareness <5 mins
      • 1/2 of cases caused distress, 1/2 more ‘neutral’ about experience.
      • 41% went on to have longstanding psychological morbidity
      • Early recognition and reassurance associated with better outcomes
    • Risk factors for awareness
      • Patient factors
        • Female, young adults, obesity, previous AAGA, difficult airway
      • Drug factors
        • Thiopentone, TIVA, NMBDs used
      • Subspecialty
        • Obstetric, cardiothoracic, neurosurgical
      • Organisational
        • Junior anaesthetist, out of hours, emergencies
    • Incidence of awareness
      • The overall incidence of awareness was 1:19,000
      • Much higher where NMBDs used (1:8,000) compared to when not used (1:136,000)
      • NMBDs used in 46% of anaesthetics but 97% of reports were in such cases
      • High risk specialties included cardiothoracics (1:8,600) & C-Section (1:670)
      • C-Section accounted for 0.8% of GAs but 10% of cases of awareness
    • Complaints occurred in 10-20% or cases, litigation in 5%.
    • Some key recommendations
      • A database of AAGA should be established
      • The relevant authorities should work to seek solutions to problems associated with similar drug packaging
      • Standards of TIVA ought to be set
      • The use of PNS should be seen as standard
      • Anaesthetists should be familiar with DOA monitors
      • Patients with difficult airway should be considered high risk for AAGA
      • Caution with RSI using thiopentone
      • Patient transfer is a high risk period for AAGA
      • It should be explained that sedation does not guarantee amnesia
      • A structured pathway should exist for patients who have suffered AAGA
    • Timing of awareness
      • 1/2 of cases at induction
        • Be wary of gaps in the delivery of anaesthetic agents. BEWARE THE GAP.
          • The gap
        • Consider the need for further induction agent in difficult airway cases
      • 1/3 of cases during maintenance
        • Pain recall more of an issue in this group
        • No obvious cause in 25% (?resistant to anaesthetic drugs)
        • TIVA more commonly implicated (but often without using TCI models.
      • 2/3 occurred at induction or emergence
        • Residual paralysis a common theme
        • Usually distressing
        • Newer volatiles agents may have been switched off too early
      • 20% of cases were related to sedation
        • Poor communication with regards to what to expect is the main reason
      • ITU
        • Commonly due to low dose propofol infusions
      • DOA monitors are rarely used
        • Should be considered for TIVA plus NMBD anaesthesia as they were particularly high risk
    • NAP5 App
      Link:itunes.apple.com/gb/app/inap5/id989805582?ls=1&mt=8