Introduction

Accidental awareness during general anesthesia (AAGA) is an uncommon but recognized adverse event that may involve explicit recall of intraoperative events, sensory perception, pain, or paralysis. AAGA can be profoundly distressing and has been associated with acute and long-term psychological reactions, including post-traumatic stress disorder (PTSD). This systematic review synthesizes available evidence on psychological outcomes following AAGA.

Methods

We searched Cochrane, PubMed, and Embase (2000–2025), identifying 88 records. After removal of 3 duplicates, 85 studies underwent title and abstract screening; 14 full texts were reviewed, and 8 studies met inclusion criteria. Eligible studies included patients of any age with confirmed AAGA and reported at least one psychological outcome. Data were synthesized qualitatively using narrative methods.

Results

The eight included studies consistently identified acute panic or psychological distress as a common response to AAGA, though prevalence varied. Reported PTSD rates among patients ranged from 0% to 56% across studies, with considerable variability related to differences in study design, patient populations, and timing of outcome assessment. In a retrospective case–control study, 56% of patients met PTSD criteria a mean of 17.9 years after awareness, compared with none of the non-aware controls (p<0.01). In a prospective obstetric cohort, 33% of awareness patients received a provisional PTSD diagnosis at 30 days of follow-up. Secondary analysis of a randomized trial demonstrated persistent PTSD symptomatology in 43% of awareness patients versus 16% of non-aware patients, with 14.3% meeting PTSD diagnostic criteria versus 7.6% at 2 years of follow-up. Awareness involving pain or paralysis was associated with greater prevalence of psychological harm, while early postoperative support appeared protective.

Conclusion

While many patients experiencing AAGA recover without lasting psychological sequelae, a clinically significant subset develop persistent trauma-related symptoms. Early identification, structured debriefing, and standardized follow-up may mitigate long-term psychological harm and should be integrated into perioperative care pathways.