Awake, Alert, and Aware During Surgery

You are wheeled into surgery and the anesthesiologist asks you to count backwards from 10, but then you get to zero and you think to yourself, "Wait, I am still awake." While this phenomenon is extremely rare, some patients remain keenly aware of what is going on while surgeons cut away.

It is unfathomable to think that someone would go under the knife without some form of anesthesia. Ever since the mid-1800s when an enterprising dentist discovered that inhaling ether gas would knock a patient out well enough to painlessly extract a tooth, anesthesia has been indispensible. However, as you can imagine, the methods of that time were both imprecise and dangerous: If the patient inhaled too little ether they would wake, and if they inhaled too much they died.

Today, general anesthesia techniques are so advanced that surgeons can confidently operate knowing that patients will not move about, feel pain or remember anything from the moment they start counting backwards, to the time they regain consciousness in the recovery room.

Every year, millions of people go under the knife – and under general anesthesia. They remain completely asleep during the procedure and have zero awareness of the event.

But not always.

Sometimes general anesthesia is administered and the surgery begins, but the patient isn't completely "under." Like something straight out of the "Twilight Zone," people hear conversations, feel the surgeon manipulating their bodies, even smell the cauterizing of flesh, but they are unable to let anyone know.

This rare phenomenon of being consciously alert but physically paralyzed is called unintentional intraoperative awareness or anesthesia awareness, and its effects can bring about a lifetime of mental anguish. Remembrances can intrude into every day life causing sleep loss, nightmares, anxiety, panic attacks and post-traumatic stress syndrome.

Going Under

There are 3 types of anesthesia: local, regional and general. While there may be some intentional awareness with regional or local anesthesia, the goal of general anesthesia is to not only keep patients still and pain-free, but also to keep them from being aware of what happens throughout the procedure and certainly from recalling it later on.

To achieve this, anesthesiologists use a combination of intravenous drugs and inhaled gases to block muscle activity, pain signals and memory of the event. The exact cocktail depends on how long the patient needs to be asleep, the type of procedure being performed and the overall condition of the patient including their physical attributes and health.

After the anesthesia is administered, electronic devices continually monitor and regulate breathing, oxygen, carbon dioxide, heart rate, body temperature and blood pressure. All the while, the anesthesiologist can make adjustments as needed.

An active brain however is particularly difficult to monitor. Doctors might suspect that consciousness isn't fully dampened when they see signs such as a elevated blood pressure or heart rate, or muscle movement. But certain drugs used to achieve anesthesia may mask these changes. Some hospitals use the bispectral index (BIS) brain-sensing monitor, similar to an electroencephalogram (EEG), to measure a patient's level of consciousness. But not all hospitals use this monitoring method and some doctors dispute their value in signaling or preventing anesthesia awareness.

Not Quite Under

For the 20 million patients wheeled into surgical suites across the US every year, general anesthesia will be given without incident. Still, 1 in 1000 patients will experience anesthesia awareness every year. Researchers have tried to figure out who is most likely to be at risk for the event, but few factors have emerged.

Risk factors for anesthesia awareness include:

  • Light anesthesia – As you might expect the most common reason for anesthesia awareness is inadequate anesthesia. Still, sometimes it is a necessary safety measure, particularly when operating on patients requiring cesarean sections, heart surgery and for certain operations performed on critically ill or trauma patients.
  • Personal history of awareness – Patients are more likely to experience anesthesia awareness if they have had it once before.
  • Machine malfunction or misuse – Can affect the amount of anesthesia delivered.
  • Human error – Administering the wrong dose or wrong drug.
  • Natural red hair – Redheads may be genetically programmed to need more anesthesia.
  • Family history – May point to genetic factors that influence metabolism of anesthetic agents.
  • Type of anesthesia – Some agents used to maintain anesthesia are short acting.

Staying Under

As always, patients play a roll in getting good care, so be a smart patient and choose your doctors wisely. But, beyond that, there are some activities that can help you stay asleep during surgery.

Meet your anesthesiologist. If you know in advance that you will be requiring surgery, make it a point to know and meet your anesthesiologist before the surgery takes place. He or she should be able to explain the type of anesthesia you will be receiving, and to discuss their policy for protecting patients from anesthesia awareness.

Report all remembrances you have during surgery to your surgeon and anesthesiologist even if they occur days or weeks later.


Tell all your doctors everything you are taking. This is the time to be honest about every over-the-counter remedy, prescription medication, recreational drug, herbal or dietary supplement you are taking, as well as alcohol consumption, because some will affect how much anesthesia needs to be given.


Find out your family's history with anesthesia. If there is a genetic propensity for anesthesia awareness, other family members (including children) may have experienced it. Their history can be a forewarning for the potential in you.

Resources and information about anesthesia awareness

American Society of Anesthesiologists Patient Education

Anesthesia Awareness Registry

Anesthesia Awareness Campaign

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