Patient Recall of Perioperative Events During Gynecologic Surgery

INTRODUCTION: Trauma-informed care recommends that physicians be mindful of how medical environments such as the operating room (OR) could trigger trauma response in patients. There is no published literature on the frequency with which patients recall common gynecologic perioperative events such as entering the OR, removal of their gown, leg positioning, or staff communication. OBJECTIVE: The objectives were to describe the frequency with which patients recall a predefined set of common perioperative events in the OR and to identify themes surrounding recall of these events. Additionally, we sought to describe associations between prior life experiences, perioperative recall, and postoperative satisfaction. METHODS: This prospective mixed-methods study enrolled participants undergoing minor or major gynecologic surgery with surgeons from two subspecialties at a large academic institution. Prior to surgery, participants completed a baseline demographics form, surgical fear questionnaire (SFQ) (Theunissen 2014), and traumatic life events checklist (LEC) (Weathers 2013). An OR team member completed a checklist of the occurrence of 22 common events in the OR during induction and emergence from anesthesia (Table 1). Anesthetic type and dosage were also collected. One week postoperatively, participants were surveyed about their recall of OR events (Table 2) and completed a surgical satisfaction questionnaire (Haff 2011) and a semi-structured qualitative interview regarding their perioperative recall. Paired t-tests are described for parametric data and Kruskal–Wallis tests for non-parametric data. Qualitative data were analyzed with MaxQDA. RESULTS: Thirty individuals completed all preoperative and postoperative surveys. Ten cases were done under monitored anesthesia care (MAC), 19 under planned general anesthesia (GA), and one was converted from MAC to GA. Participants had undergone a median (range) of 3 (0–9) prior surgeries. Mean (±SD) scores on the LEC were low (15 ± 11; max score 102), suggesting a low rate of lifetime trauma in our cohort. However, 7 participants (23%) had personally experienced sexual trauma. Higher LEC scores were weakly correlated with worse patient satisfaction with their postoperative pain control (rho=0.25, p<0.001). Of the 14 pre-induction events recorded by staff, patients remembered a median (range) of 3.5 (0–10) of these events. During emergence from anesthesia, staff recorded the presence of 8 events, of which patients remembered a median (range) of 1 (0–4) events. Anesthesia type was not associated with the number of induction (p=0.51) or emergence (p=0.76) events remembered by patients. In the qualitative portion, some patients described remembering entry into the OR, while others only recalled the preoperative room. No patients remembered waking in the OR during or after surgery, with all remembering waking up only in the postoperative room. Patients also described feelings of safety with the surgical team and comparison to prior surgeries (Figure 1). CONCLUSIONS: Patients undergoing routine gynecologic surgery under both MAC and general anesthetic protocols have minimal memory of any events in the operating room that could incite or trigger trauma. This does not obviate the need for trauma-informed care, but rather provides reassurance that necessary perioperative procedures are not recalled by our patients as traumatic.