Editor’s Introduction: This series is based on a number of patient observations and personal inquiry by Dr. Chow between 2007 and 2009, Dr. Chow has filed a patent with the US Patent and Trade Office regarding the use and application of propofol-based sedation in the production of patient dreams and rapid eye movement or REM sleep. Certainly propofol has been in the news recently with the Conrad Murray trial in the death of Michael Jackson.
ASA: Statement Related to Media Inquiries Regarding Michael Jackson’s Death and the Trial of Dr. Conrad Murray
CNN: Some patients question propofol, doctor says
AP: Docs facing questions about 'Michael Jackson drug'
Newsweek: Doctors’ Crush on Jackson’s Drug
It is important to note that Dr. Chow’s scientific curiosity about the dream state induced in some instances by propofol is the underlying premise of this piece and the others that will follow in this series.
The Emotional World of Propofol Dreams, Part I: A Personal Perspective
As any practicing anesthesiologist can attest, the presence of patient-reported dreams, ranging from the mundane (driving a child to school) to the bizarre (being devoured by sexy vampires), is a common side effect seen in post-surgical patients receiving anesthesia. In the post-anesthesia recovery unit (PACU) we are particularly aware of these dreams. Anecdotal evidence suggests that most often, the presence of patient dreams involves a propofol infusion as part of their anesthetic.
Despite the often dramatic nature of dreams produced while under anesthesia, we treat them as a “throw-away” side effect, in comparison to the importance of surgical outcome, the stability of vital signs and symptoms of adequate pain control and post-operative nausea (PONV) concerns. Personally, I find the presence of patient-reported dreams a comforting sign of patient recovery. Frequently though, as I move from case to case, I miss the details of these often fascinating visual experiences described by my patients.
As a regional anesthesiologist in a San Jose practice, I have developed a clinical pattern of doing many surgical cases under a combined local/regional anesthesia block (neuroaxial or peripheral nerve blockade) for surgical anesthesia and in combination with hypnotic sedation for patient and surgeon comfort and patient amnesia. Often the choice of hypnotic sedation would be a propofol infusion titrated to patient movement and spontaneous ventilation during surgery. My patients often report fantastic sleep recovery (“Doc that was the best sleep I’ve ever had!”) and dreams. Most often I am told of work dreams (this being Silicon Valley, many patients' dreams involve the workplace), sports dreams, love affair dreams, reunion dreams, revenge dreams, psychedelic dreams, surfing dreams, sex dreams, and dreams conjuring every other emotion a human can generate! My patients experience these dreams with a timely titrated propofol infusion: a “throw-away” side effect, worth a couple of laughs with the patient and recovery room nurses, but clinically insignificant, right? My education tells me that we give short-acting anesthetics without long-term effects on the brain, but my experience tells me, perhaps, otherwise.
In 2007 I worked with “Jill,” a middle-aged female, on disability related to depression, who has post-traumatic stress disorder (PTSD). In my preoperative phone call to Jill, she informed me that she had a number of surgical procedures in the past, and that not only has she not had problems with anesthesia, but that she actually looks forward to the postoperative effects of anesthesia. Under “anesthesia sleep” she felt she had had wonderful dreams during previous surgeries (though she could not recall the dreams, specifically), followed by “normal” sleep for days afterwards.
By her own account, Jill had been sexually assaulted as a teenager and then been physically assaulted at gunpoint at work as an adult years later. Since then, she had been diagnosed and treated chronically for depression and PTSD, with antidepressants and psychotherapy. She suffered crippling insomnia during the night and agoraphobia during the day. By her own description, she lives a dark, stressful and fearful life, alone. However, after her procedures, Jill claimed that she became a “normal person,” with the symptoms of depression and agoraphobia fading for days afterwards, though eventually returning. “No promises,” I told her pre-operatively, “but we will see what happens afterwards.”
Jill’s surgery and anesthesia were routine and in recovery, she stated she “felt great” and talked about having a wonderful dream. She would later forget her own description of the dream (often patients become amnestic to their dreams within minutes of their becoming lucid in recovery), but I recounted the details to her. In her “propofol dream,” Jill described an open, green and flowery garden and a white house in the background, with a view that was sunny, open and calm. In the dream, Jill was a young child with her back turned as she stooped to garden, for hour and hours. As I talked to her postoperatively by phone, Jill recognized the location—the house and the garden were from her childhood. Today, fearing open spaces as a traumatized adult, Jill would never expose herself to such perceived danger in real life.
“If I was gardening for a whole day in my dream, how long was I under anesthesia?” she asked. “About 30 minutes of anesthesia,” I admitted, adding, “You didn’t get to dream as long as you thought.” This is a curious, common characteristic of these propofol dreams—the patient’s perception of time is severely distorted. As with previous anesthetics, Jill had normal sleep for days afterwards and was also able to go outdoors with renewed confidence. “What does the dream mean, and why do these changes occur?” she asked over the phone. “I’m not a psychiatrist, I’m an anesthesiologist,” I admitted to her, “but I’ll look into it and try to answer your questions”.
In this series of CSA Online First articles (based on my own observations and investigation), I will try to answer Jill’s questions and satisfy my own fascination with propofol dreams. I encourage other members to share their own experiences with patients and propofol dreams by commenting below.
Part 2: Of Motherly Love and the Syntax of Propofol Dreams
Part 3: Reconciling the “Nightmare” of Giant Hot Dogs and Surgical Awareness
Part 4: Déjà vu Memories
Dr. Harrison Chow (firstname.lastname@example.org) is a practicing anesthesiologist based out of Good Samaritan Hospital in San Jose California and is adjunct clinical faculty at the Department of Anesthesia, Stanford School of Medicine.