NAP5
The 5th National Audit Project
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NAP5 & AAGA
Mike Sury
APA Linkman Meeting 2014
NAP5
The 5th National Audit Project
AAGA is recall of an experience
• Is it from
– Direct questioning?
– Spontaneous reporting?
The incidence of AAGA in adults
0.1 - 0.2%,
mainly related to paralysis
15% get PTSD
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Avidan et al. 2008
Avidan et al. 2011
Myles et al. 2004
Sandin et al. 2000
Sebel et al. 2004
Wennervirta et al. 2002
NAP5
• Spontaneous reports
– First reports only
• A procedure managed by an anaesthetist
– In and out of theatres
– the patent complains
How many reports?
• Of 300 reports
– 141 were class A or B
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A = certain
B = probable
C = sedation
D = ICU
E = unassessable
F = unlikely
G = other
SO = statement only
Classification: experience
NAP5
The 5th National Audit Project
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NAP5 activity survey
• Denominator
• Important details
– Who
– What
– Which
– When
Intended Conscious level (LOC)
GA
2,766,600
76.9%
Sedation (of
any level)
308,800
8.6%
Awake
523,100
14.5%
Main procedure
Intended LOC
2.8m GA cases per year
(overall incidence of AAGA
reports = 1:20,000)
Incidence: depends on circumstances
NAP5
The 5th National Audit Project
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Vignettes:
Unassessable or Statement Only
? Missing reports
• If 0.74% is the true rate of AAGA, there should
be approximately 3,700 children per year in
the UK with recall of events during general
anaesthesia.
NAP5 Executive Summary
• The largest AAGA study ever undertaken
• Of 300 reports
– 141 classified as “certain/probable” or “possible” AAGA
• Wide range of experiences/sensations
• 50% reported distress linked to paralysis.
– psychological sequelae pronounced and long lasting in 41%
NAP5 The 5th National Audit Project
Common/Important situations
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Induction
Transfer
Emergence
Cardiovascular collapse
Syringe swops
TIVA
Induction
• 50% of reports
• Causative/contributory factors were:
– thiopental
– obesity,
– rapid sequence induction (RSI),
– prolonged airway management
• drug omission on transfer (‘Mind the gap’)
Emergence
• 18%
• almost all experienced distressing residual
paralysis from unmonitored blockade
Cardiovascular instability
• Do not turn anaesthesia off
• Except…………
Accidental paralysis from drug error
• 10% of reports
• identical effects.
• “organisational factors”
NAP5 The 5th National Audit Project
TIVA
• Transfers to ICU/Radiology
• poor & non-standard techniques
• ? monitoring
NAP5 The 5th National Audit Project
Preventable?
• 2/3 were
– Or were they?
• 7% had no obvious
explanation
Minimising the psychological
consequences of AAGA
• Before
– “if you waken you might not be able to move
………. this is reversible, I will look after you …..”
– Reconfirm intended conscious level
• During
– Reassure the patient if you think they are awake
Managing AAGA: suggested pathway
NAP5
The 5th National Audit Project
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NAP5: Recommendations
• N = 64
• TIVA and EEG – both need training with pragmatic
protocols
• SOPs (Who checklist, what to say to patients, how to
manage AAGA)
NAP5 The 5th National Audit Project