Awake During Anesthesia

©G.M. Woerlee, 2005–2024

Many people have heard stories of people who awoke during an operation performed under general anesthesia. Some of these are horrific tales of people who awaken during surgery to find themselves unable to move or speak, yet fully conscious, and fully able to feel the dreadful pain of the operation they are undergoing.

These are spectacularly horrible experiences. But not all experiences of consciousness during general anesthesia are nightmares such as this. This type of anesthetic awareness is the most spectacular, but there are actually several different types of awareness during general anesthesia:

Awake, aware, unable to move, unable to speak, feels the pain of surgery.
Awake, aware, able to move, unable to speak, feels the pain of surgery.
Awake, aware, unable to move, unable to speak, but feels no pain of surgery.
Awake, aware, able to move, unable to speak, but feels no pain of surgery.
Awake, aware, feels no pain but undergoes an out-of-body experience, or near-death experience.

How can these very different types of experiences during general anesthesia be explained?

Modern general anesthesia

To understand the phenomenon of consciousness, or awareness during general anesthesia, it is first necessary to understand the types of drugs used during general anesthesia. Modern general anesthesia uses three separate categories of drugs to provide the triad of general anesthesia.

Sleep-inducing drugs. Separate drugs are used to keep people asleep and remove all memory of events occurring during the operation. Lower concentrations of these drugs in the blood also suppress breathing to some degree, and in larger concentrations they cause breathing to stop altogether.
Muscle paralyzing drugs. Muscle paralyzing drugs are administered to paralyze all the muscles of the body. This is necessary because the pain of surgery causes the muscles surrounding the areas being operated to go into spasm, or the person to move and thrash about, making many forms of surgery on bones and inside the abdomen impossible. Muscle paralyzing drugs are all similar to curare, the deadly arrow poison of the Amazonian Indians. All muscles are paralyzed, so a paralyzed person cannot move, cannot speak, and cannot breathe. This latter is the reason people receiving these drugs are attached to a machine called a “respirator” or “ventilator” — these machines take over the function of breathing. These muscle paralyzing drugs do not cause paralysis of heart muscles - otherwise everyone would die while under general anesthesia. These muscle paralyzing drugs do not cause paralysis of the bladder or bowel muscles, which is why people under general anesthesia are not incontinent of urine or feces. And these muscle paralyzing drugs do only that — they only paralyze the muscles of the body, and do not affect the functioning of the brain, which is why a person can be paralyzed by these drugs but fully awake.
Powerful painkilling drugs. Powerful, usually synthetic morphine-like drugs, are administered to during general anesthesia remove the pain of operations. These drugs administered at higher doses may cause the muscles of the body to become stiff, always cause people to feel calm and indifferent, but not to lose consciousness, and in higher doses, they also cause people to forget to breathe.

Awareness during general anesthesia

Yet, even though unconscious due to general anesthesia with this standard combination of these three categories of drugs, people are still able to feel touch, to feel movements, to see light, to hear, and to smell. Yet they remember none of these things upon awakening, because of the effects of anesthetic drugs upon memory. Anesthesiologists always monitor many different body functions during anesthesia to determine whether the patients under their care are in good condition, are asleep, adequately paralyzed, or receive adequate amounts of painkilling drugs. Extra doses of these drugs are administered when required to provide extra muscle relaxation, painkilling, or to deepen the level of unconsciousness. Unfortunately, about 1-2 people per 1000 people undergoing general anesthesia experience various degrees of awareness or actual full consciousness under general anesthesia (see articles in Wikipedia on Awareness).

Not all experiences of awareness during anesthesia are distressing, painful or horrific. In fact there are several different experiences of awareness during anesthesia that are determined by the effects of the drug combinations used in modern general anesthesia. These different drug combinations explain all the horrific experiences, the partially conscious experiences, the fully conscious experiences, as well as the sometimes even wondrous conscious experiences of people under general anesthesia.

The person was awake, able to move, but felt no pain. These people have adequate concentrations of painkilling drugs in their body, but insufficient muscle paralyzing or sleep-inducing drugs in their bodies.
The person was awake, unable to move, but felt no pain. These people have adequate concentrations of painkilling and muscle paralyzing drugs in their bodies, but are awake because of insufficient concentrations of sleep-inducing drugs.
The person was awake, able to move, and felt the pain of the operation. These people have inadequate concentrations of all three groups of drugs in their bodies.
The person was awake, felt the pain of the operation, but was unable to move, speak, or do anything. This is due to inadequate concentrations of sleep-inducing and painkilling drugs, but where the person is still paralyzed by the muscle paralyzing drug. It is a terrible situation - like the torments of hell visited upon the living. This is a disaster, a situation which all anesthesiologists dread having happen with their patients. Usually this situation is immediately recognized and appropriately dealt with, but some people react so minimally to the pain of their operations that the situation is not recognized. These people then suffer the torments of the damned. Profoundly upsetting to anesthesiologists, and for the patients themselves - horrible, horrible.

The brain function of a person who awakens while supposedly under general anesthesia is abnormal, and this, combined with the effects of the other anesthetic drugs can also induce many strange and seemingly paranormal experiences such as out-of-body experiences, near-death experiences. So how do anesthesiologists asceratin whether a person is conscious or unconscious during general anesthesia?

Monitoring of awareness during anesthesia

The mainstays of monitoring and detecting awareness during general anesthesia still remain suspicion, the bodily reactions of the person, and supplementation of these things with diverse monitors. What do I mean by suspicion and the reaction of the person’s body?

Not everyone reacts exactly the same to standard dosages of anesthetic drugs. So some people may tell of awareness during previous general anesthetics, even though previous anesthetic records from that person reveal that the dosages of the drugs used, and the anesthetic technique was more than adequate to ensure unconsciousness. That person has a higher than normal chance of awareness during a subsequent anesthetic.
Sometimes a person is so critically ill, that lower dosages of general anesthetic drugs must be used, or the effect of even normal doses of these drugs will cause even more severe problems with the functioning of that person’s body. Such a person has a higher than normal chance or being aware during an operation, and all good anesthesiologists are aware of this risk and act accordingly.
Anesthesiologists always carefully check for signs of possible awareness. However, these signs are also the same as those of inadequate general anesthesia, so the anesthesiologist must always make a careful assessment of what the cause is likely to be from suspicion, assessment of the situation, and experience. These signs of possible awareness are: widened pupils, perspiration, rapid pulse, elevation of blood pressure.

Nowadays in modern countries, suspicion, experience, and reactions of the person’s body to surgery are often supplemented with electronic monitors purporting to accurately measure the level of consciousness, or depth of anesthesia. Unfortunately, none of these highly advanced electronic devices are 100% accurate, which is why some people are conscious during general anesthesia, even though the brain function monitor or EEG (electroencephalogram) indicates they were unconscious at the time. This is why professional associations of anesthesiologists in nearly all countries, (including the USA), while acknowledging the utility of these measures of consciousness, always recommend they not be relied upon 100%, and that anesthesiologists must also use experience and common sense to gauge the level of consciousness. The wondrous story of the musician, Pam Reynolds, is the best known account of a person who was conscious during general anesthesia, even though the brain monitoring indicated she was unconscious (click here to read an extensive analysis of the fascinating Pam Reynolds awareness experience).

Final remarks

A person who says they were conscious during an operation performed under general anesthesia is not hysterical or insane. They may very well have been conscious. Careful study of each story, together with an analysis of the anesthetic chart and the surgical procedure, often reveals the time period during which the period of consciousness occurred. The same considerations also apply to people reporting undergoing an apparently paranormal experience while seemingly unconscious during general anesthesia. All such experiences provide wonderful illustrations of the ways the functioning of the bodies of different individuals interact with the effects of surgery and anesthetic drugs. These are sometimes humbling events for the anesthesiologist, but are always to be taken seriously as learning moments for the true professional.


	PANSURAS^® is a computer program designed to facilitate improvement of perioperative anesthesia and surgical management quality within hospitals!

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