bispectral index (BIS). However, none of these modalities have been found to be 100% effective in detecting awareness under anaesthesia.

Incidence of awareness in developed countries is found to be 0.1%–0.2%.^5,6 Although there are very few studies in the developing world, the incidence of intraoperative awareness is thought to be somewhat higher as compared to Western world.⁷ This may in part be due to increased patient load, limited patient knowledge and lack of trained hospital staff, reliance on older, cheaper but less effective drugs, and lack of proper equipment both for providing anaesthesia, as well as monitoring the patient. Problem can be even more complex and multifold in rural areas. However, even after a thorough review of literature, we could not find any study specifically estimating the problem of awareness under anaesthesia in rural areas. Therefore, we conducted this hospital based cross sectional study to assess the incidence of intraoperative awareness during general anaesthesia among patients in rural India and any factors associated with or influencing the same.

MATERIALS AND METHODS

This hospital based cross sectional study was performed in M.G.M. Medical College and Hospital, Jamshedpur. Patients undergoing elective surgical procedures in various specialties (Including general surgery, orthopedics, ear, nose and throat surgery, urosurgery, and plastic surgery) under general anaesthesia from October 1, 2016, to September 30, 2017, i.e., over a period of 1 year were considered for this study.

Inclusion Criteria

Patients aged 18 years or more, American Society of Anesthesiologist (ASA) Physical Status III or less, with normal neurological status.

Written informed consent was obtained from all patients in their own language before including them in this study.

The technique and drugs used for anaesthesia varied according to patient's preoperative condition, surgical procedure planned, and choice of anesthesiologist; however, all patients considered for this study underwent general anaesthesia with endotracheal intubation and positive pressure ventilation. Induction agent used was either thiopentone sodium or propofol given intravenously followed by muscle relaxant which was either vecuronium or atracurium. After intubation maintenance of anaesthesia was done using 50% oxygen, 50% nitrous oxide, and volatile anesthetic (Isoflurane or sevoflurane). During the procedure and throughout the postoperative period, vital signs (including heart rate, oxygen saturation, electrocardiography, and noninvasive blood pressure) of the patients were monitored. Concentration of volatile anesthetic was adjusted according to patient's vital signs, as well as clinical parameters such as pupillary response, sweating, and tearing. Instrumental monitoring of cerebral electrical activity and volatile anesthetic concentration was not carried out, as the same was not available in our institute. None of the patients included in this study underwent surgical procedure under mask ventilation or laryngeal mask airway insertion. Furthermore, total intravenous anaesthesia was not used in any patient. A consultant anesthesiologist (With sufficient experience of general anaesthesia) who was unaware about the patients being included in this study anesthetized all patients. Noise levels in Operation Theater were kept to a minimum, with only minor chat surgeons, anesthesiologist, and operation theater staff. After the completion of surgical procedure, anaesthesia was reversed, extubated, and shifted to postanaesthesia care unit (PACU) after adequate return of consciousness.

Approximately after 1 h of arrival in PACU, anesthesiologist (Not involved in administering anaesthesia) assessed intraoperative awareness. Anesthesiologist visited the patient and asked questions in his/her own language. First general information such as age, sex, ASA status, anaesthesia technique used, history of chronic drug intake or substance abuse, and any previous history of awareness was obtained. The second part of the questionnaire was a modified form of Brice questionnaire,⁸ used by similar studies designed to assess intraoperative awareness,^9,10 in the past-

• What is the last thing you remember before going to sleep?
• What is the first thing you remember after waking up?
• Do you remember anything between going to sleep and waking up?
• Did you dream during your procedure?
• What was the worst thing about your operation?

After the questionnaire was completed, it was analyzed, and patients were categorized into either having definite awareness, possible awareness, and no awareness. If the event recalled was confirmed by attending personnel present in Operation Theater, or investigators were convinced that memory was real, patients were categorized under definite awareness. If the patient was unable to recall any event definitely indicative of awareness, but memories could have been related to intraoperative events, he/she was categorized as possible awareness. No awareness was defined as a patient with no reported awareness or if the recalled events had a high probability of occurring in immediate pre- or post-operative period. This classification is similar to one used in various other studies assessing intraoperative awareness. Patients having intraoperative dreaming were categorized separately.

Patients having awareness or possible awareness were offered to follow up in anaesthesia outpatient department.

Statistical Analysis

Data were collected on a Microsoft Excel^® sheet and analyzed using Statistical Package for the Social Sciences^® version 23 (SPSS Inc., Chicago, IL, USA) for windows. Data were expressed as ratio, percentages and proportions. Fisher's extract test was used for comparison. P < 0.05 was considered statistically significant.

RESULTS

A total of 1068 adult patients underwent elective surgical procedures under general anaesthesia. Out of these, 37 patients were ASA Grade IV, so were excluded from the study, 121 patients refused to take part in the study. Of the remaining, 12 had to be shifted to Intensive Care Unit intubated and 2 were disoriented so were thus excluded from the study. There was no disruption of anaesthesia or circuit failure in any case. Hence, a total of 896 patients completed the questionnaire.

Of these 896 patients, 25.89% of patients were <30 years of age, 32.48% were between 30 and 44 years, 25.78% were between 45 and 59 years, and remaining 15.85% were 60 years and above. Nearly 32.59% of participants were males and the rest were females. As far as education level was concerned, 194 (21.65%) patients were illiterate, 258 (28.79%) patients studied up to primary standard, 189 (21.09%) patients till secondary level, 211 (23.55%) were graduates, and remaining 44 (4.91%) were postgraduates. Based on socioeconomic status, roughly half of the patients were poor (51.01%), 44.31% belonged to middle class, and 42 (4.61%) patients were rich. According to ASA grading, 62.95% of patients were ASA Grade I, 23.32% were ASA Grade II, and 13.73% were ASA Grade III. All the patients underwent elective surgical procedures under general anaesthesia with endotracheal intubation using muscle relaxants. A maximum number of patients participating in the present study underwent general surgical procedures (77.01%), followed by ear, nose, and throat surgery (11.38%), orthopedic surgery (5.13%), urosurgery (4.24%), and plastic surgery (2.23%). Among the patients undergoing general surgical procedures, 439 patients (65.72%) underwent laparoscopic cholecystectomy, 58 (8.68%) underwent laparoscopic hernioplasty, 14 (2.09%) laparoscopic appendectomy, 25 (3.74%) open cholecystectomy, 30 (4.49%) modified radical mastectomy, 16 (2.39%) laparotomy, and remaining 86 patients (12.87%) had various other elective surgical procedures.