A novel classification instrument for intraoperative awareness events

Background: Intraoperative awareness with explicit recall occurs in approximately 1-2 cases per 1000. Given the rarity of the event, a better understanding of awareness and its sequelae will likely require the compilation of data from numerous studies. As such, a standard description and expression of awareness events would be of value. Methods: We developed a novel classification instrument for intraoperative awareness events: Class 0: no awareness; Class 1: isolated auditory perceptions; Class 2: tactile perceptions (e.g., surgical manipulation or endotracheal tube); Class 3: pain; Class 4: paralysis (e.g., feeling one cannot move, speak, or breathe); and Class 5: paralysis and pain. An additional designation of "D" for distress was also included for patient reports of fear, anxiety, suffocation, sense of doom, sense of impending death, or other explicit descriptions. We reviewed 15 studies of the incidence of awareness that provided specific information about awareness reports. Five anesthesiologists at three institutions who developed the categories independently classified the events. An additional 20 individuals (attending anesthesiologists, anesthesiology residents, nurse anesthetists, medical students, and ancillary staff) not involved in the development of the categories also independently classified the events. Fleiss's kappa statistic was used to evaluate inter-observer agreement. Results: One hundred fifty-one cases of intraoperative awareness in adults were identified as valid for analysis. The overall kappa value was 0.851 (0.847-0.856, 95% confidence interval) for the basic Classes 1-5. Including additional designations of emotional distress, the overall kappa value was 0.779 (0.776-0.783, 95% confidence interval). Conclusion: We report a novel classification instrument for intraoperative awareness events that has excellent inter-observer agreement and that may facilitate the study of intraoperative awareness.