February 2013 • Volume 116 • Number 2 www.anesthesia-analgesia.org 365 Copyright © 2013 International Anesthesia Research Society DOI: 10.1213/ANE.0b013e3182771d3b I ntraoperative awareness with explicit recall (AWR) is an outcome of interest in clinical practice, quality assur- ance initiatives, and clinical trials. Delayed reporting by patients may influence the accuracy and precision of initia- tives and clinical trials evaluating AWR. It may also pre- vent patients who experience psychological sequelae due to AWR from being identified and treated in a timely man- ner. Delayed reporting of AWR can be unintentional (due to delayed memory formation) 1 or volitional (purposeful non- disclosure). Volitionally delayed reporting occurs in clinical practice with patients who have not received routine postop- erative interviews. 2,3 However, combining structured inter- views with a preoperative explanation of AWR is assumed to ensure patient disclosure. Herein, we describe a volition- ally delayed reporting of AWR, after preoperative education and 2 negative structured postoperative interviews. The patient has provided consent to publish this report. The lack of (or delay in) disclosure draws attention to a limitation of research involving patient-reported outcomes. CASE DESCRIPTION A 75-year-old man with no psychiatric or neurologic history underwent on-pump 3-vessel coronary artery bypass graft- ing and aortic valve replacement. He had several suspected risk factors for AWR, including aortic stenosis, ASA physical status IV, cardiac ejection fraction of <40%, and pulmonary hypertension. He enrolled in the BAG-RECALL clinical trial 4 (NCT00682825; clinicaltrails.gov), which evaluated whether a Bispectral Index (BIS)-based protocol was superior to an end-tidal anesthetic concentration–based protocol in pre- venting AWR in high-risk patients. The patient underwent a consent process explaining the definition, possible mani- festations, and potential psychological sequelae of AWR. For anesthesia induction, the patient received propofol (0.9 mg/kg), rocuronium (70 mg), sufentanil (35 μg), and midazolam (1 mg). Key points during the surgery are identified in Figure 1. Chest incision (Fig. 1, arrow A) occurred 32 minutes after anesthesia induction (45 minutes after the start of data collection). Five minutes after chest incision, the BIS increased to 70 (Fig. 1, arrow B). In response, an additional 50 mg of propofol was administered. After this, the BIS value fluctuated between 47 and 68, until reaching a second peak of 71, which was treated with an increase in sevoflurane concentration (Fig. 1, arrow C). Tracheal extubation occurred 6 hours after skin closure. Clinical trial protocol 5 required 3 blinded follow-up interviews (modified Brice interviews at 24 hours and 1 month postoperatively, and a mortality/satisfaction follow- up at 1 year postoperatively). The patient did not report awareness at either Brice interview. However, during the 1-year follow-up, he spontaneously reported an intraopera- tive awareness event in response to the satisfaction query. A standardized follow-up interview for patients who reported awareness was then administered. 5 The patient reported a sequence of intraoperative recollections (Table 1). Volitional Delay of Self-Reported Outcomes: Insights from a Case of Intraoperative Awareness with Explicit Recall Alexander J. Villafranca, MSc,* Benjamin G. Arenson, BSc,* Michael S. Avidan, MBBCh, FCASA,† David Glick, MD, MBA,‡ George A. Mashour, MD, PhD,§ and Eric Jacobsohn, MB, ChB, FRCPC* From the *Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; †Department of Anesthesiology, Washington University, St. Louis, Missouri; ‡Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois; and §Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan. Accepted for publication, September 17, 2012. Supported by funds from the Winnipeg Regional Health Authority and University of Manitoba Department of Anesthesia and Perioperative Medicine (EJ). The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Eric Jacobsohn, MB, ChB, FRCPC, Department of Anesthesia and Perioperative Medicine, University of Manitoba, AE200 2nd Floor Harry Medovy House, 671 William Ave., R3E 0Z2. Address e-mail to ejacobsohn@exchange.hsc.mb.ca. Intraoperative awareness with explicit recall (AWR) is a self-reported outcome of interest in clinical practice, quality assurance initiatives, and clinical trials. Combining structured postop- erative interviews with a preoperative description of AWR is assumed to ensure prompt patient disclosure. We describe a volitionally delayed reporting of AWR because of the perceived unim- portance of nondistressing awareness experiences, despite preoperative education and 2 post- operative interviews. This delay had implications for a major randomized controlled trial on AWR. Volitionally delayed self-reported outcomes may affect statistical comparisons in clinical trials and quality assurance initiatives, and delay the treatment of subsequent sequelae in clinical practice. This limitation should be considered, even when using structured outcome assess- ment and preoperative education. (Anesth Analg 2013;116:365–7) Section Editor: Sorin J. Brull Anesthesia Patient Safety Foundation