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TheInternetJournalofAnesthesiology

OriginalArticle

DelayedAwakeningFromAnaesthesia
S Saranagi

Citation

SSaranagi.DelayedAwakeningFromAnaesthesia.TheInternetJournalof
Anesthesiology.2008Volume19Number1.

Abstract

Ideally,oncompletionofsurgeryandanaesthesia,thepatientshouldbe
awakeoreasily
arousable,protectingtheairway,maintainingadequateventilationandwith
theirpain
undercontrol.Timetoemergefromanaesthesiaisvariable,anddependson
manyfactors
relatedtothepatient,thetypeofanaestheticgivenandthelengthofsurgery.
Unexpected
delayedemergenceaftertheuseofgeneralanaesthesiahasaplethoraof
causes.

EmergenceFromAnaesthesia
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Followinganinhalationalbasedanaesthetic,thespeedofemergenceis
directlyproportionaltoalveolarventilationandinverselyproportionaltothe
agent'sbloodsolubility.Asthedurationofanaesthesiaincreases,
emergencealsobecomesincreasinglydependentontotaltissueuptakeof
theanaesthetic,whichisafunctionoftheagent'ssolubility,theaverage
concentrationusedandthedurationofexposure.EmergencefromanIV
anaestheticisafunctionofitspharmacokinetics.RecoveryfrommostIV
agentsisdependentchieflyonredistributionratherthaneliminationhalflife.
Thischangesoncethetotaladministereddoseincreasesandthetissue
becomessaturated.Oncethisoccurs,theterminationofactionbecomes
increasinglydependentontheeliminationormetabolichalflife.Hence,
advancedage,renalorhepaticdiseasecanprolongemergence.Pre
operativemedicationscanalsoinfluencethespeedofemergence,
particularlyifitsdurationofactionoutlaststhedurationoftheprocedure.

CausesOfDelayedAwakening

Residualdrugeffectwhichmaybeduetooverdosage,undue
susceptibilityofthepatientordelayeddrugmetabolism.

Durationandthetypeofanaestheticgivenagentswithlowbloodgas
solubilityareeliminatedmorerapidly.

Potentiationbyotherdrugssedatives,anxiolyticsandtranquilizers
areknowntopotentiatethedepthofanaesthesia.

ProlongedNMblockadesecondarytooverdosageorincomplete
reversal,canmimicunconsciousnessbypreventingmotorresponse
tostimuli.Prolongedapnoeafollowingsuxamethoniumduetoan
abnormalorabsentplasmacholinesteraseenzymemayleadto
delayedemergence.

Metabolicandendocrinaldisordersdecreaseddrugmetabolismin
hypothyroidpatientsmayleadtoprolongedunconsciousness.
Similarlyseverehypo/hyperglycaemiaarecommoncausesofpost
operativecoma.

Acidbaseandelectrolyteimbalancehyperphosphataemiafollowing
administrationofsodiumphosphateforbowelpreparation,
hyponatraemiafollowingTURParecommoncausesofdelayed
emergence.

Hypothermiaseverehypothermiacanleadtoreducedlevelof
consciousness.Acoretemperatureoflessthan330C,itselfhasa
markedanaestheticeffectandwillpotentiatetheCNSdepressant
effectofanaestheticdrugsbyreducingtheMACvalueofinhalational
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effectofanaestheticdrugsbyreducingtheMACvalueofinhalational
agents.ItalsopotentiatesNMblockadeandlimitsdrugmetabolism.

Neurologicalcomplicationcerebralhypoxiaasaresultofany
intraoperativehypoxicinsultandintracerebraleventslike
haemorrhage,embolismorthrombosismayallleadtodelayed
awakening.AnotherrarecauseisFactitiousdisorderwhichis
definedbyDiagnosticandStatisticalManualofMentalDisordersas
theintentionalproductionofphysicalorpsychologicalsymptomsin
ordertoassumethesickrole.Thepatients'achieveatrancelikestate,
andhavetheabilitytoignorepain.Theyoftenhaveaperiodof
amnesia.Itisadiagnosisofexclusionthatshouldbeconsideredonly
afterothermedicalconditionshavebeenruledoutasacauseof
alteredconsciousness.

Assessment

Theevaluationofprolongedunconsciousnessafteranaesthesiarequiresan
organizedanalysis:

LevelofpreoperativeresponsivenessIsthereunrecognized
intoxicationwithdrugsoralcohol?Wasthereanypreexistingmental
dysfunction?

PreoperativeandintraoperativemedicationsThetimeandamount
ofallmedicationsgivenshouldbenotedandanyunusualintraop
eventshouldbereviewed.

StimulusFirmtactilestimulus,whichisoftenmoreeffectivethan
verbalStimulation,shouldbeusedtoelicitarousal.

VentilationTherateandcharacterofspontaneousventilationcan
indicatethedepthofanaesthesia.

AutonomictoneHeartrate,rhythmandsystemicbloodpressurecan
indicatethelevelofautonomictoneandtheadequacyofcerebral
perfusion.

PracticePoints

Plananaesthesiaaccordingto

Durationofsurgery

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TypeofsurgeryanabdominalsurgerywillneedadenserNM
blockadeascomparedtolimbsurgery.

CoexistingdiseasesHypothyroidism,MysthaeniaGravis,
hepaticorrenaldisease.

PeripheralnervestimulatorguidedNMblockade.

Bispectralindexmonitoringfordepthofanaesthesia4060is
recommendedforgeneralanaesthesia.

Maintainnormothermia,normocarbiaandavoidhypoxia.

Management

Immediatecare

Airwaymaintainaclearairwayandoxygenation.Reintubateif
indicated.

Breathingensureadequaterespiration.Ifindicated,ventilate
thepatientviaETT.

Circulationassessheartrate,BP,ECGandperipheral
perfusion.

Temperatureusebodywarmer.

Intensivemonitoringofallhaemodynamicparameters,EtCO2,SpO2,
CVP,intakeandoutputismandatory.

Reviewthehistory,investigationsandperioperativemanagement
includingtheanaesthesiachartandthetimingsofdrugadministration.

AssessforpersistingNMblockadeusinganervestimulatorand
repeatreversalifneeded.Incaseofsuccinylcholineapnoeaprolonged
ventilation(1236hrs),andFreshfrozenplasmatransfusionis
required.
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required.

Arrangeforantidotes

Inj.Naloxoneforsuspectedopioidnarcosis.

Inj.FlumazenilforBenzodiazepineoverdosage.

Checkbloodglucoseandtreataccordingly.

Correctacidbaseandelectrolyteimbalanceifindicated.

Ifnoothercausefound,anintracerebraleventmaybesuspectedanda
fullneurologicalevaluationshouldbeperformed.Radiologicalimaging
(CTorMRI)isoftenrequired.

Conclusion

Delayedawakeningofvaryingdegreeisnotuncommonafteranaesthesia
andmayhaveanumberofdifferentcauses,individualorcombined,which
maybebothdrugornondrugrelatedthuscausingadiagnosticdilemma.
Theprimarymanagementisalwaysinsupportofairway,breathingand
circulation,whilstthecauseissoughtandtreatedasoutlinedabove.

References
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{full_citation}

AuthorInformation

SushmitaSaranagi,Specialist
DeenDayalUpadhyayHospital

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