Following discharge after an uneventful surgical procedure, a patient contacted the hospital reporting an episode of accidental awareness during general anaesthesia. The anaesthetist and the ODP identified that the vaporiser although turned on, was empty. An episode of tachycardia had alerted the anaesthetic team and the error was identified and rectified perioperatively.

Commentary

There is not a lot of detail in this case report around what happened when the problem was identified perioperatively, and whether the duty of candour was fulfilled at the time of the incident, ensuring that the patient was informed and supported appropriately. However this case serves as a useful reminder of the recommendations in the National Audit Project 5: Accidental Awareness under General Anaesthesia (AAGA), which are distilled in the NAP 5 handbook,^1,2 the implementation pack accompanying these two documents includes a framework for managing patients reporting AAGA.³ This case also highlights the importance of conducting a structured postoperative review, for example using the BRICE questionnaire, to identify any awareness events.

This case demonstrates the importance of checking that vaporisers are fitted correctly, filled, and leak-free at the start of every case, and using volatile agent monitoring systems to ensure adequate end-tidal concentration of volatile agent in accordance with Association of Anaesthetists Safety Guidelines.^{4, 5}

References

1. Royal College of Anaesthetists and the Association of Anaesthetists. NAP 5: Accidental Awareness during General Anaesthesia in the UK and Ireland, 2014
2. Royal College of Anaesthetists and the Association of Anaesthetists. The NAP 5 Handbook: Concise practice guidance on the prevention and management of accidental awareness during general anaesthesia, 2019
3. Royal College of Anaesthetists and the Association of Anaesthetists of Great Britain and Ireland. NAP5 Anaesthesia Awareness Support Pack, 2014
4. Association of Anaesthetists of Great Britain and Ireland. Checking Anaesthetic Equipment 2012. Anaes 2012; 67: 660-8.
5. Klein AA, Meek T, Allcock E, Mincher N, et al. (2021). Recommendations for standards of monitoring during anaesthesia and recovery 2021 (Guideline from the Association of Anaesthetists). Anaes 2021; 76(9): 1212-23