Case report:

“Accidental awareness under general anaesthesia. The patient had explicit recall after IV line for total intravenous anaesthesia became disconnected during surgery. The line disconnection was noticed by the consultant anaesthetist after a rise in the BIS number despite increasing the propofol and remifentanil infusions.  This was a rare but recognisable complication of TIVA, there was no obvious malpractice present.”

Commentary:

Accidental awareness with TIVA is commonly due to failure to deliver the drugs through i.v. cannulae.  Previous guidance suggested that the i.v. cannula should be visible at all times but current guidance from the Association [1] acknowledges that this is not always possible. The same guidance recommends the use of Luer-lock connectors; it is not clear if that was the case here. The cannula site should be inspected immediately if the patient’s response to the infused drugs appears less than would be expected, as happened in this case. The Association also has guidance in its NAP5 Handbook on how to proceed when awareness is suspected or confirmed, including detailed guidance for follow-up.

References:

[1] Safe Practice of Total Intravenous Anaesthesia TIVA, Association of Anaesthetists, 2018.

[2] The NAP 5 Handbook: Concise Practice Guidance on the Prevention and Management of Accidental Awareness During General Anaesthesia. Association of Anaesthetists, 2019.