Title: Retrospective analysis of reported cases of intraoperative awareness in a large multi-hospital health system

Background: Awareness with recall under general anesthesia remains a rare but important issue that warrants further study. Methods: We present a series of seven cases of awareness that were identified from provider-reported adverse event data from the electronic anesthesia records of 647,000 general anesthetics. Results: The low number of identified cases suggests an under-reporting bias. Nonetheless, some important themes emerge from this small series that can serve as important reminders to anesthesia providers to ensure delivery of an adequate anesthetic for each patient. Commonalities between a majority of our identified anesthetic awareness cases include: obesity, use of total intravenous anesthesia, use of neuromuscular blockade, and either a lack of processed electroencephalogram (EEG) monitoring or documented high depth of consciousness index values. An interesting phenomenon was observed in one case, where adequately-dosed anesthesia was delivered without technical issue, processed EEG monitoring was employed, and the index value suggested an adequate depth of consciousness throughout the case. Conclusions: Provider-reported adverse event data in the immediate post-operative period is likely insensitive for detecting cases of intraoperative awareness. Themes identified in this series of cases of awareness under general anesthesia provide important reminders for anesthesia providers for maintain vigilance in monitoring depth and dose of anesthesia, particularly with total intravenous anesthesia.