The report of this investigation conducted at the University of Munich confirms some well-known facts about intraoperative awareness and expands our understanding of the high level of cognitive performance of patients who are aware. Dr. Schwender and colleagues recruited 45 patients through advertisements and referrals. A standardized questionnaire was administered 0.1 to 30 years after the awareness event. It contained six sections: personal data, detailed description in own words, sensory perceptions (including auditory, visual, tactile, paralysis and nociceptive), feelings and emotions, cognition and interpretations, and consequences.

The majority of the cases of awareness occurred during elective surgery, not just during obstetric, cardiac or emergency surgery where anesthetic techniques specific to these circumstances make awareness more likely. Consistent with other reports, all patients who recalled awareness were able to hear. They reported comments like "How can a man/woman be so fat?", "This woman is lost anyhow" and jokes at the patient's expense. All patients recognized their situation as a real event, half of them suffered from after effects of the episode and 25% recalled pain.

Almost all of the patients informed medical personnel and/or family members of their experience. Unfortunately one fourth of these reports were met with defensive responses ranging from disbelief to denial. Until we understand more about the molecular mechanisms of anesthesia or until we have a "consciousness monitor" we may not be able to reduce the incidence of awareness, even during general anesthesia for elective surgery, to zero. However, we should be able to improve the empathy and respect we show patients while they are anesthetized and when they report adverse events.

Auditory perceptions, hearing sounds or voices were mentioned by all patients (45 of 45); 33 of 45 patients understood and recalled conversations; 21 of 45 patients had visual perceptions; 12 of 21 recognized things or faces; 29 of 45 felt being touched; three patients had the sensation of moderate pain; and eight patients were in sever pain. Patients� feelings were mostly related to paralysis (27 of 45), helplessness (28 of 45), anxiety and fear (22 of 45); 18 were in severe panic. All patients (45 of 45) recognized the situation as a real event; 22 of 45 patients experienced unpleasant after effects; 11 suffered from anxiety and nightmares; and three developed post-traumatic stress disorder syndrome and required medical treatment. Twenty of 45 patients were especially attentive to emotionally relevant remarks on their own person, their disease and the course of their operation.