Brit. J. Anaesth.

(1968), 40, 259

FACTORS CAUSING AWARENESS DURING SURGERY

BY
D. J. WATERS

SUMMARY
Factors which can lead to awareness during surgery are considered. They are divided
into those affecting induction and those affecting maintenance. Induction: The risk of a
patient recovering consciousness while still paralyzed is greater if an ultrashort-acting
intravenous anaesthetic is used. The time interval necessary before surgery may begin
is governed by the need to build up a sufficient concentration of inhalation agent to take
over from the waning effect of the intravenous agent Maintenance: Three sources of

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trouble are distinguished, each leading to the patient receiving an anaesthetic mixture
less potent than intended. (1) Ventilators may rniy air or oxygen with the anaesthetic
gas if they are not adjusted properly or if there are leaks. Ventilators are classified
according to their propensities for doing this. (2) Some anaesthetic machines have
pitfalls. (3) A circle system is shown to need time to acquire an adequate concentration
of anaesthetic. The importance of high flowrates is stressed both at the start of an
anaesthetic and also if the circuit should happen to be broken later on.

In recent years patients undergoing surgery have
benefited greatly from anaesthetic techniques
which allow major operations to be performed
under light general anaesthesia. Muscle relaxants
have made the biggest contribution to such tech-
niques but they have introduced the hazard that
a patient may be conscious but paralyzed (Hut-
chinson, 1961). Consequently every anaesthetist
must bear this hazard in mind and be meticulous
in his attention to detail so that the accident never
occurs. Trouble may arise during induction of
anaesthesia or during maintenance.
INDUCTION OF ANAESTHESIA
The intravenous agent.
When an intravenous agent is used before a
laparotomy it must ensure unconsciousness during
laryngoscopy and intubation and it must continue
to act until sufficient inhalation agent has been
introduced to take over. It does not matter if the
intravenous agent continues to act during the
laparotomy provided that it has worn off by the
end. It follows that intravenous agents with a very
short duration of action may not serve the pur-
pose; there may be a lucid interval.
Interval elapsing before surgery.
No rules can be given in terms of minutes. It
can only be stated that the effect of the intra-
venous injection diminishes in the course of time
and nothing can stop it. The effect of the inhala-
tion agent which follows increases over the course
of time but it can only do so if it is introduced
into the lungs. When the patient is paralyzed it is
required that ventilation be carried out vigorously
with this purpose in mind. It is not enough merely
to give an occasional squeeze to an oxygen-filled
bag.
The surgeon may be allowed to proceed when
the anaesthetist judges that enough inhalation
agent has been introduced to ensure unconscious-
ness. Occasionally it may be necessary to restrain
an obstetrician from beginning a Caesarean sec-
tion too early, especially if premedication has been
light, the dose of intravenous agent small and the
nitrous oxide unsupplemented.
MAINTENANCE OF ANAESTHESIA
Unconsciousness is frequently maintained by
means of a mixture of nitrous oxide and oxygen,
but there seems to have been a tendency recently
for anaesthetists to add small concentrations of
volatile agents (Mushin, Campbell and Shang Ng,
1967). Whatever is used it is incumbent upon the
anaesthetist to ensure that his patient is actually
receiving the intended mixture. The factors which
influence what the patient actually gets may be
260
considered under three heads: (i) the use of
mechanical ventilators, (ii) the peculiarities of
anaesthetic machines, and (iii) the elimination of
air from the apparatus and the lungs.
Ventilators.
Mechanical ventilators are convenient aids to the
anaesthetist but they introduce a risk that the
patient may not receive the same mixture as that
supplied from the anaesthetic machine. Air may
be drawn in through some aperture which exists
by accident or design. Such a risk is readily ap-
preciated when a negative pressure phase is used.
But a risk also exists if there is a discrepancy
between the manoeuvres which the ventilator is
set to perform and the amount of anaesthetic gas
made available to it. Such a discrepancy can only
arise if the ventilator is driven by some force
other than the anaesthetic gas. Air is thus only
likely to become mixed with ths anaesthetic gas
when the ventilator is not driven by the anaes-
thetic gas.
Dilution of anaesthetic mixture with air.
Incompatibility between fresh gas flow and
minute volume for which the ventilator is set.
Take as an example the East-Radcliffe ventilator,
a time-cycled pressure generator driven by an
electric motor. When the anaesthetist uses this
ventilator with soda-lime absorption he may be
accustomed to using a fresh gas flow of 3 l./min
and ventilating his patient's lungs at 9 l./min. But
if he changes over to the non-rebreathing circuit
of the ventilator he must increase the fresh gas
flow to 9 l./min. If he does not do so he may
imagine that all is well merely because the con-
certina bag is filling and emptying regularly and
the chest is moving in a corresponding fashion.
But if the machine is looked at more closely the
inspiratory relief valve will be seen to be acting
with each stroke of the concertina bag and 6 1.
of air are being drawn in every minute. If the
site of entry of air is occluded the bag dsvelops
"intercostal recession". The logical way of using
the machine as a non-rebreathing system is to
decide what minute volume th: patient should
receive, to supply this volume of fresh gas and
then to set the controls to match this figure,
BRITISH JOURNAL OF ANAESTHESIA
using reasonable tidal volumes and rates. If at a
later time the compliance of the chest increases
so that a larger volume of gas enters at each
breath, the fresh gas flow must be increased.
If the fresh gas flow is too small for the minute
volume which a ventilator is set to deliver, it is
useful if the ventilator shows it. Current versions
of the East-Raddiffe have a reservoir bag which
stores fresh gas and which flattens prematurely
when the fresh gas flow is too small. The Deans-
way and the Cape have such reservoir bags also.
Effects of a leak. Again consider the East-
Radcliffe ventilator. Suppose that the soda-lime
circuit is in use and the input of fresh gas is small
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compared with the minute volume ventilation.
During the inflating downstroke of the concertina
bag gas passes into the lungs and also out to tie
atmosphere through the leak. Because of the leak
the bag empties more than it would normally do.
When it comes to refill it can derive only a limited
amount of gas from the lungs and only a limited
amount from the fresh gas inflow. Yet the motor-
ized mechanism ensures that it rises to its full
extent. It therefore develops a subatmospheric
pressure and draws in air, so diluting the anaes-
thetic mixture.
The behaviour of the East-Radcliffe ventilater
described in the last two paragraphs may be con-
trasted with that of the Manley. The Manley is a
non-rebreatbing ventilator driven by tie anaes-
thetic gas; it is a minute volume divider. If the
fresh gas flow is small the concertina bag takes a
longer time to fill to tie volume required for
cycling and so tie number of breaths per minute
is reduced. The patient is ventilated at a minute
volume nominally equal to the fresh gas flow and
it is impossible to set e machine to do otter-
wise.
The Manley also behaves differently if there is
a leak. If the leak occurs while the bag is empty-
ing, some of the anaesthetic gas is lost to the
atmosphere and the lungs are under-inflated. If
the leak occurs when the bag is refilling the loss
of anaesthetic gas causes it to fill more slowly, bi
there is never any subatmospheric pressure to
draw in air.
The Manley and the East-Radcliffe have been
selected for mention merely because each is repre-
sentative of the group to which it belongs. An
other pair could equally well have been chosen
FACTORS CAUSING AWARENESS DURING SURGERY
Use of negative pressure phase. If negative
pressure is used during expiration and there is a
leak, air may be drawn into some part of the
ventilator. This is important if the air is subse-
quently included in the mixture used to inflate
the lungs.
Non-rebreathing ventilators discard the whole
of the patient's expiration, so it does not matter
if this part is mixed with air. But a danger still
exists if the site of entry of air is somewhere along
the inspiratory limb of the double pipe leading
from the ventilator to the patient. If this limb
becomes filled with air then air will enter the
lungs during the next inflation.
If the ventilator has a rebreathing circuit there
is a risk of air being included in the inflating mix-
ture no matter where the air was drawn in
originally. The commonest rebreathing arrange-
ment has a bag in a bottle and negative pressure
is achieved by (i) a weight acting at the bottom
of the free end of the concertina bag, for example
the Boyle Mark HI absorber driven by the
Cyclator, (ii) by a weight and a pulley acting at
the top free end of the concertina bag, for example
the Bennett B.A.4, or (iii) by a venturi bringing
about negative pressure in the chamber surround-
ing the concertina bag, for example the Air-
Shields Ventimeter. Any of these three variants is
susceptible to trouble from air entering through
a leak.
A leak during inspiration may be detected by
turning off the fresh gas inflow, obstructing the
flow into the patient and seeing if the bag empties
when positive pressure is applied. Likewise a leak
during expiration may be detected by turning off
the fresh gas inflow, obstructing the flow out of
die patient and seeing if the bag fills when nega-
tive pressure is applied. Recently Bookallil (1967)
reported an instance where a faulty inspiratory
relief valve on a Cape-Waine ventilator allowed
air to enter the apparatus during the expiratory
phase only.
Dilution of the anaesthetic mixture with
oxygen; the Cyclator.
The anaesthetist ignores the driving oxygen.
The Cyclator is so designed that the driving oxy-
gen passes through an injector which entrains
anaesthetic gas coming from the flowmeters in
261
such a way that 25 per cent of the issuing gas
consists of driving oxygen.
Trouble is likely to arise if the anaesdietist
changes from manual control of ventilation to
mechanical control of ventilation and forgets to
readjust the flowmeters. It is worth noting that
when the Cyclator is used to drive a bag-in-bottle
arrangement diere is no mixing of driving gas
with anaesthetic gas, so no dilution of anaesthetic
gas with oxygen can occur.
The anaesthetist allows the reservoir bag to be
drawn flat. The reservoir bag from which the
injector of the Cyclator draws its supply of anaes-
thetic gas will become empty if the anaesthetist
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has not matched the total gas flow with the
patient's minute volume. Either the tidal volume
is too big or the rate is too high or there is a
leak.
The manufacturers' stated ratio between the
volume of driving oxygen and the volume of
entrained anaesthetic gas in the issuing gas only
applies when anaesthetic gas is freely available.
After the bag has been drawn flat the ratio alters
to give a smaller proportion of anaesdietic gas in
the issuing mixtureor wording it differently, the
issuing gas has been diluted with oxygen. Once
the reservoir bag has become flat the flow of gas
from the ventilator as a whole is less and it takes
longer for the cycling pressure to be achieved. So
the anaesthetist should be able to tell from the
prolonged inspiratory time that all is not well,
even if he has overlooked the empty bag.
If by mistake a novice feeds anaesthetic gas
direct to the Cyclator without including a reser-
voir bag, the ventilator will behave during the
inflation phase as if the bag were flat all the time,
so there will be considerable dilution with
oxygen. In addition anaesthetic gas will be lost
through the spill valve during the expiratory
pause because there is nowhere for it to be
stored.
Readjustments are not made when the trigger
starts acting. All may be well when the patient is
apnoeic but when the earliest attempts at spon-
taneous breathing are made the respiratory rate
may be much more rapid than that formerly
determined by the ventilator. If a non-rebreathing
system is to be maintained the flowmeter set-
tings will need to be increased to provide more
fresh gas. If the adjustment is not made the bag
262
will became flat and dilution of the anaesthetic
mixture with oxygen will follow.
Anaesthetic Machines.
The oxygen bypass tap.
The bypass tap may be placed before or after
the flowmeter. If it is before, then the extra oxygen
is indicated by the position of the bobbin, but if
it is after, there is no such indication. It is possible
to administer a mixture containing more oxygen
than is intended if the tap is left partly turned
on, or if it is faulty.
Failure of nitrous oxide supply.
If nitrous oxide and oxygen comprise the whole
inhalation mixture, failure of the nitrous oxide
supply leads to a rapid recovery of consciousness.
If it is thought reasonable to fit devices to anaes-
thetic machines so that an alarm is sounded when
the supply of oxygen fails there might likewise be
a case for doing the same with nitrous oxide. If
alarms are thought to be inadvisable there is still
something to be said for fitting pressure gauges to
nitrous oxide cylinders.
The speed with which consciousness returns
when the nitrous oxide supply fails is influenced
by the circuit in use. With a non-rebreathing cir-
cuit each inspiration now consists of pure oxygen,
so consciousness returns rapidly. With a rebreath-
ing circuit each inspiration contains some nitrous
oxide from a previous expiration so consciousness
returns more slowly.
The machine does not supply any anaesthetic gas
to the ventilator.
Some versions of the Boyle apparatus have a
tap which directs the gas to the closed or the open
circuit. If the tap is in the wrong position no gas
is supplied to the ventilator. A ventilator operated
by the anaesthetic gas, for example the Manley or
the Howells, fails to operate, but one driven by
any other force will go on operating. If the venti-
lator which continues to operate has a non-
rebreathing circuit, air will be found to be getting
in somewhere. If it has a closed circuit all will
appear to be well until the patient has used up the
limited amount of oxygen in the circuit; he will
then become cyanosed.
BRITISH JOURNAL OF ANAESTHESIA
Elimination of Air.
Elimination of air at the beginning of an
anaesthetic.
The apparatus normally contains air at the
beginning of an anaesthetic. Most simple semi-
dosed systems contain only a small volume of air
and this is rapidly displaced by the flow of fresh
gas, but in a circle system this is not necessarily
so. Anaesthetic gas is fed into the circle system
at one place and gas is allowed to overflow at
another. Air is eliminated through the intentional
leak and the concentration of anaesthetic gas in
die system rises, but this takes time. Squeezing
the reservoir bag ensures good mixing, but the
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rise in concentration depends on the rate of inflow
of fresh gas.
If uptake of anaesthetic gas by the patient be
ignored and perfect mixing of gases is assumed it
may be shown theoretically that the concentration
of anaesthetic gas in the system rises exponentially
with time and that the time constant is given by
die fraction
Volume of system (lungs, tubing, bag, etc.)
Rate of inflow of fresh gas
From a knowledge of the properties of exponential
curves (Waters and Mapleson, 1964) it may be
said that after a lapse of time equal to three time-
constants the concentration in the system will
have reached 95 per cent of the maximum.
Experiments have been carried out to see
whether the concentration of gas within a circle
system does indeed rise in an exponential manner.
The apparatus used was a Boyle Mark III absorber
with a 4-lb. canister of soda-lime. The volume of
the apparatus was measured with its reservoir bag
empty by a gas dilution method and found to be
4.1 1. The system was full of air to begin with and
oxygen was used to simulate anaesthetic gas, the
flow rate being 4 l./min. The reservoir bag was
squeezed by hand, inflating a model lung of the
pattern described by Cohen (1966). The resting
volume of the "lung" was 2.1 1. and the initial
volume of the reservoir bag was 1.8 1. The total
volume of die system was dius 8 1. The bag was
emptied at each squeeze, excess gas being vented
to the atmosphere through the Heidbrink valve
near die "lung". Gas samples were taken from die
catheter mount leading to the 'lung" and dieir
 FACTORS CAUSING AWARENESS DURING SURGERY
oxygen content measured with an Astrup
apparatus.
The results depicted in figure 1 show that the
concentration of inflowing gas found in the in-
spired gas rises over the course of time in a
fashion resembling an exponential curve and a
logarithmic plot confirms this, but the time-
constant is only 1.4 minutes instead of the
expected 2 minutes. The lower curve in figure 1
shows how the concentration would have risen if
it had conformed to the theory which assumed
perfect mixing. Although the rise is more rapid
than expected it still takes more than 4 minutes
for the inspired gas to contain 95 per cent of the
inflowing gas.
7oANAESTHETIC GAS
IN INSPIRED GAS
8O
6Q
20
1 2 3 4 5 6
MINUTES
FIG. 1
Build-up of concentration of inflowing gas within a
circle system. The upper curve was obtained experi-
mentally; the lower curve was predicted theoretically.
For conditions, see text.
Small flows of fresh gas are often used with
circle systems because such flows are economical,
but when air has to be displaced from a system
big flows are needed. Eger (1960) has published
graphs showing how the rate of rise of concen-
tration of anaesthetic agent in a circle system is
influenced by the fresh gas flow. When the flow
was reduced by a factor of 10 the time needed to
reach 50 per cent of the maximum possible con-
centration was increased by a factor of 11.
Satisfactory mixing of gases calls for rhythmic
squeezing of the reservoir bag. If this is not
attended to, then air remains sequestered in the
lungs while the mixture lost through the expira-
263
tory valve consists of a high proportion of anaes-
thetic gas. At the beginning of an anaesthetic the
anaesthetist is often engaged with other tasks and
may neglect ventilation.
Elimination of air later on in an anaesthetic.
If it becomes necessary to disconnect the
apparatus from the patient during the administra-
tion of an anaesthetic, for example to perform
endotracheal suction, then one must consider the
possibility that air may gain access to the appara-
tus. With manually controlled ventilation this will
not happen to any great extent but with mechanic-
ally controlled ventilation it may be important.
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The circumstances are those already dealt with
mrW +"= heoHincr "Ventilators" (effects of a leak;
use of negative pressure phase), the disconnected
apparatus being regarded as constituting a very
large leak. Dilution with air can be avoided by
switching off the ventilator before disconnecting
the apparatus. If air has been allowed to enter it
should be flushed out by a large flow of fresh
anaesthetic gas; it is not sufficient merely to refill
the system with oxygen.
ACKNOWLEDGEMENTS
It is a pleasure to acknowledge the helpful advice and
criticism given me in the preparation of this paper by
Professor W. W. Mushin and Dr. W. W. Mapleson of
the Department of Anaesthetics, Welsh National School
of Medicine, Cardiff.
REFERENCES
BookaUil, M. J. (1967). Entrainment of air during
mechanical ventilation. Brit. J. Anaesth., 39, 184.
Cohen, A. D. (1966). An artificial lung. Anaesthesia,
21, 569.
Eger, E. I., n (1960). Factors affecting the rapidity of
alteration of nitrous oxide concentration in a
circle system. Anesthesiology, 21, 348.
Hutchinson, R. (1961). Awareness during surgery. Brit.
J. Anaesth., 33, 463.
Mushin, W. W., Campbell, H., and Shang Ng, W.
(1967). The pattern of anaesthesia in a general
hospital. Brit. J. Anaesth., 39, 323.
Waters, D. J., and Mapleson, W. W. (1964). Exponen-
tials and the anaesthetist. Anaesthesia, 19, 274.
FACTEURS CAUSANT LA CONSCIENCE
DURANT L'INTERVENTION CHIRURGICALE
SOMMAIRE
Les facteurs qui peuvent contribuer a rendre le malade
conscient durant une operation, sont pris en considera-
tion. Us sont partages d'une part en ceux qui affectent
Pinduction de l'anesthesie, et d'autre part ceux qui
affectent son maintien. Induction: le risque qu'un
264 BRITISH JOURNAL OF ANAESTHESIA

patitnt redevienne conscient, tout en itant encore
paralyse^ est plus grand lorsqu'un an;sthesique intra-
veineux d'action ultracourte a 6ti employ^. L'intervalle
requis avant que l'intervention puisse commencer, est
dittrmini par la necessity de faire exister une concen-
tration suffisante de l'anesthesique inhalatoire, pour
compenscr la disparition de l'effet de l'agent intra-
veineux. Maintien: on distingue trois sources de
difficultes, chacune en tant la cause que le patient
recoit un melange anesthesique moins puissant que
privu. (1) Les ventilateurs peuvent melanger de l'air
ou de l'oxygene au gaz anesthesiques, s'ils ne sont pas
bien rigles, ou s'il existe une fuite. (2) Dans certains
appareils d'anesthesie, il y a d:s pieges. (3) II est
connu qu'un systeme ferine n&essite un certain temps
avant d'atteindre une concentration anesthesique
adiquate. L'importance d'un flux elev est rappele',
aussi bien pour le dbut de l'anesthesie qu'en cas de
panne ulte'rieure dans le circuit.
zuriickkehren lassen konnen. Sic werden unterteilt in
solche, die die Einteitung, und solche, die die Erhalrung
der Narkose betreffen. Einleitung: Das Risiko, daO ein
Patient noch in gilahmtem Zustand zum Bewufitsein
zuriickkehn, ist grofler, wenn ein ultrakurz-wirkendes,
intravenos zu verabreichendes Narkotikum verwendet
wird. Das Zeitintervall, das bis zum Operationsbeginn
verg;h:n mull, wird von der Notwendigkeit beherrscht,
eine geniigend hohe Konzentration des Inhalations-
narkotikums aufzubauen, urn die nachlassende Wirkung
des intravenos verabreichten Narkotikums zu ersetzen.
Erhaltung: Drei Ursachen, die Sorgen bereiten konnen,
werden unterschieden, wobci jede davon ausgeht, daO
der Patient ein Narkosegemisch erhalt, das weniger als
biabsichtigt wirksam ist. (1) Die Mischung von Luft
oder Sauerstoff mit dem Gasnarkotikurn erfolgt mog-
lichirweise in nicht richtig geeichten oder undichten
Beatmungsgeraten. Beatmungsgerate werden ent-
sprcchend ihrer Eignung eingeteilt. (2) Einige Narkose-
gerate besitzen Senkraume, (die eine vollstandige

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FAKTOREN, DIE DEN PATIENTEN WAHREND
EINES OPERATIVEN EINGRIFFS ZUM
BEWUSSTSEIN ZUROCKKEHREN LASSEN
ZUSAMMENFASSUNG
Es werdsn Faktoren besprochen, die den Patienten
wahrend eines operativen Eingriffs zum Bewufitsein
Vermischung verhindern). (3) Es wird gezeigt, daO
ein Umlaufsystem Zeit bsnotigt, um fur eine aus-
reichende Konzentration des Narkotikums zu sorgen.
Die Wichtigkeit hoher Stromungsgeschwindigkeiten
sowohl zu Beginn der Narkose als auch spater nach
einer zufalligen Unterbrechung des Umkufs wird
hervorgehoben.

FOURTH WORLD CONGRESS OF ANAESTHESIOLOGISTS, LONDON

September 9-13,1968
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