Professional Documents
Culture Documents
Gabriel M. Gurman
679
Few of our anesthesiology peers know that Freud was the physician who
published the first analytical and scientific research on cocaine and was the
first investigator to predict its use as local anesthetic.
But Sigmund Freud became worldwide known because the discovery of
the existence of an unconscious mind referred sometimes in the popular
literature as subconscious, an entire dynamic world of thoughts, fears and
behavior that exists in every person below the surface of his conscious
mind.
There is no normal access to this part of our mind, but it reveals itself in a
flamboyant charade in our dreams. For many years this was considered the
only window to this unique inner life. The entire process of psychoanalysis is
the exploration of conscious desires and fears.
Anesthesia and the unconscious mind
Anesthesia provides a unique interplay between the conscious and unconscious mind. In a daily clinical practice the anesthesiologist is happy to believe that the anesthetic produces a total lost of sensation and consciousness.
Do we have, however, reasons to challenge this concept?
We have no real measure of this behavior in the brain, but we assume
that the anesthetic agents produce a shift from consciousness to oblivion,
bypassing the unconscious mind.
To wake from an anesthetic oblivious of all the events that have taken
place during the operative procedure without any memory or awareness
of discomfort, is the natural expectation of all anesthesiologists. This is the
expected magic of the chemicals.
Ben Gurion University of the Negev and Mayney Hayeshuah Medical Center, Israel
gurman@bgu.ac.il
Timioara 2010
680
But does really the patient wake up from anesthesia without any storage
of information produced during surgery ?
Regarding memory, there are two possibilities that can occur during general anesthesia. The first is true awareness or explicit memory which means
complete recall of the events occurring during anesthesia. Depending on
the patients inner strengths, past history and general resourcefulness, the
implications of accidental awareness during general anesthesia can be far
reaching.
The patient may present himself for psychiatric care months later with all
the stigmata of a major depressive illness, such as, massive irritability, insomnia, nightmares, bubbling anxiety, an overwhelming sense of impending
doom and a preoccupation with death, all signs of the well known posttraumatic stress syndrome (PTSS).
The implicit memory during general anesthesia
But traumatic events that are held in the unconscious area have a far more
profound and often inexplicable effects on the patients psyche. This is the area
of major concern for the anesthesiologist: the world of implicit memory.
Implicit memory is defined as changes in performance or behavior that
are produced by prior experiences or tests and do not require a conscious,
intentional recollection of these events.
During clinically adequate anesthesia the brain is capable of receiving
auditory stimuli and processing them at a fairly complex level.
Hearing is the first senses to develop, starting at 28 weeks of intra uterine
age. We hear during sleep and during coma.
The research on implicit memory during anesthesia is not new. In the
mid 20th century researches on perception, therapeutic suggestions and a
response to crisis during general anesthesia were published in the medical
literature. More recently, together with Gidron and others, we have studied
the ability of the patients to recall words or association of words given repetitively during anesthesia, proving that many patients could adequately
recall them when anesthesia was conducted based on clinical signs only, but
this phenomenon is reduced when a cortical electrical activity monitor was
used for monitoring the adequacy of general anesthesia.
What are the implications of the implicit memory? Surgery itself is stressogenic.
Sleep disturbance and occasional depression are well known phenomenon
after surgery. In this setting, untoward events and the devastating power of
the words spoken during surgery can dramatically change the patients life,
but no one has any proof that this hypothesis is true.
Recomandri i Protocoale n Anestezie, Terapie Intensiv i Medicin de Urgen
681
682
Timioara 2010