Unreported paediatric awareness during surgery

Reading the report on anaesthetic awareness with recall in children 1, 2 and noting that spontaneous reporting of accidental awareness by children is rare, prompted me to share my granddaughter FM's experience when she underwent strabismus surgery some seven years ago, at the age of 3 yr 9 months. This letter is written with the permission of FM's mother. FM's little sister (EM) trapped her thumb in a door, necessitating several hospital visits but, about three months after FM's surgery, it was decided that no surgery was required on the thumb. During a visit, while we adults were having a cup of tea and the girls were playing nearby with their teddy bears, FM's mother informed us that EM would not require surgery for her thumb. At this point FM piped up, “if EM doesn't have an operation, then she won't see the big round lights in the roof”! That comment caused our adult conversation to stop in its tracks! Her mother silently gestured that she knew nothing about this. I asked FM, “What kind of lights were they?” and she replied, “Big and bright and round.” While we sat there somewhat astounded and I was thinking how to ask more non-leading questions, FM laid her Teddy down on the settee and told him he was going to have an eye operation! She told Teddy that something was going to sting his hand and make him very cross but then he would go to sleep. From the perspective of accidental awareness without recall, things became quite fascinating after this. During the play, FM informed Teddy that a man would put a mask over his nose and mouth, and she demonstrated this to Teddy with cupped hands over her nose and mouth. FM continued, “A cloth is going to go over your eyes so you can't see”, at which point she laid a folded paper handkerchief over Teddy's face. FM's mother asked, “And what happens then”? FM replied, “Someone opens your eye and tries to pull it out, and then they put a bone in it to keep it open.” FM continued her play, explaining to Teddy that while they pulling his eye he would hear something that sounded like “loud breathing.” FM demonstrated by opening her mouth and breathing in an out quite loudly, and said “just like when grandma cleans her glasses”, and added, “And there will be a little mouse nibbling your finger”. FM's mother asked what happens next and was told, “At the end, they put your eye back in and take out the bone, so you can close your eye.” FM's mother then asked, “What happens now”? FM said, “They tickle you to wake you up”, and she demonstrated by putting the index finger of each hand just behind the lower part of both her ears. The recollection of FM's mother is that FM had EMLA cream on her hand and, in the anaesthetic room (which had strip lighting on the ceiling), she was holding FM so that FM's hand was behind her mother's back. FM's mother remembers FM saying “Oooow” and suddenly losing consciousness, at which point she laid FM on the trolley and left the anaesthetic room. Subsequently, I contacted the anaesthetist involved. He was mortified, but confirmed that there are only strip lights in the anaesthetic room, that FM had an intravenous induction with propofol, and was then received atracurium (0.5 mg kg−1), her trachea was intubated, and her lungs ventilated. The reason for the atracurium was because “the surgeon likes a very relaxed eye that can be pulled about with no muscle tension”. Maintenance of anaesthesia was isoflurane (about 1.3 MAC) in air/oxygen, with no other supplementary drugs. He also informed me that the recovery nurses ask children about their overall experience in theatre, but do not target questions specifically towards awareness/recall. It is difficult to believe that this story is simply a three-year old's imagination but it is easy for me to identify specific aspects of the procedure: a face mask before intubation; the theatre operating lights; surgical drapes over the head; pulling on the eye and insertion of a lid retractor; letting the eye go and removing the retractor at the end of surgery. Other easily identifiable aspects are the ventilator, a finger pulse oximeter probe, and finally a nurse in recovery stimulating her to wake her up. Some weeks later, and several times since, we have tried to steer the conversation/play towards her memory of the eye operation, but she has not shown the slightest interest and, when asked directly what she can remember about her operation, she says she can't remember anything. FM, now 10 years old, has no ill effects from her experience. It would appear that FM is younger than any previously reported case of accidental awareness, as children in various studies are only recruited if they are five years or older, and in NAP5 the youngest case was ~ five years old 1. Would FM's experience have been picked up by the methodology used in NAP5 3? This is debatable, as FM had never mentioned the experience to her mother and, in the general population, would depend on whether in a family, with no background in practical anaesthesia, a situation arose to trigger the play, the play content was understood by a parent/guardian and was subsequently reported. Although the Brice interview, or a modification, has been used in studies of accidental awareness in children as young as five years old, it is unknown if this technique would be suitable for under fives and, since many children do not report their awareness during the first interview, an extended follow-up over several weeks is suggested 4. Furthermore, there is considerable debate in paediatric psychology as to how best to elicit accurate recall of events from children (J. Andrade, personal communication). Some believe that using dolls / play material with a short story stem, saying to the child “Tell me what happens next” is the best option. Others feel that this encourages the child's imagination, thus risking ‘false memories’ and that the most accurate reports are elicited by free recall, with further probing based on what has been said already. In FM's case a mixture of these techniques occurred – spontaneous recall and spontaneous play along with further non-leading probing.

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