The document discusses various reasons for delayed recovery from anesthesia, including pharmacological factors related to specific drugs, surgery-related issues, and patient-specific factors. It provides case examples of delayed recovery and recommends having a generalized protocol as well as understanding specific situations to properly manage patients and prevent complications. Vigilance and careful balancing of many variables by an experienced anesthesiologist are important to avoid morbidity and mortality from delayed recovery.

1. DELAYED
RECOVERY!
What went wrong?

2. Dr. Minnu
Panditrao
Consultant
Rand Memorial Hospital
Freeport, Grand Bahama
The Bahamas

9. Clinical scenarios
• Case of a 4 year old for Cong. Hernia Repair
• Case of a 19 year old post LSCS, for severe PET
• Case of a 70 year old for colonoscopy under
sedation
• Case of a 65 year old for TURP surgery

10. 4 year old for Cong. Hernia Repair
• Uneventful surgical procedure under GA,
• Extubated, was OK,
• Started shivering, developed
stridor/laryngospasm
• In spite of oxygen delivery getting cyanosed
• What to do?

11. 19 year old post LSCS, for severe PET
• Emergency LSCS under GA
• In spite of good intra operative course
• After reversal, not gaining consciousness
• Hypertension, tachycardia
• Not responding to verbal commands
• What to do?

12. 65 year old for colonoscopy
• Only I. V. conscious sedation was given
• Propofol and midazolam were used.
• Started having Ventricular premature beats
• Inj. Xylocaine 1mg/ kg was given
• Now, drowsy, bradycardic and unresponsive
• What to do?

13. 70 year old for TURP surgery
• under spinal
• hypotensive, tachycardia in recovery room
• Was given Bolus of crystalloids
• Now, become depressed, drowsy
• Hypotension worsened, SPO2 fallen further
• In spite of all efforts worsening
• What to do?

14. Introduction
• Post –operative Recovery
• Fast/smooth recovery is the essence of a
properly conducted anesthetic procedure
• Instances of delayed recovery
• Anaesthesiologist held responsible
• Wastage of O. T. time & resources
• Morbidity/ rarely mortality
• “What went Wrong” Analysis

15. • A conscious individual is awake and aware of
his/her surroundings and identity (as defined
by oxford dictionary)*
• Consciousness represents a continuum with
varying depths of awareness.
• Coma (Greek: koma) a state of sleep or
unconsciousness from which the patient can’t
be aroused
*
Oxford dictionaries: 2012 edition

16. Glasgow Coma Scale - GCS
• Used to quantify the depth of unconsciousness
• Was used for prediction of outcome in patients
of traumatic brain injury
• GCS scores visual(E), verbal(V) and
movement(M) responses to stimulation
• A GCS of(E2V3M3= GCS)< 8 defines Coma

17. • Delayed recovery of consciousness, vital and
cognitive functions is associated with
General Anaesthesia
• Delayed recovery of sensory or motor function
may occur after neuraxial/regional anaesthesia

18. Aetiopathology
Multifactorial : recovery may be delayed due to
• Anaesthesia related factors
• Surgery related factors
• Patient related factors

19. Anaesthesia related factors
• Pharmacological factors
• Non pharmacological factors

20. Pharmacological factors
• Inadvertent administration of an inappropriate dose
of an anaesthetic agent which is inappropriate for
 the size/age/condition of the patient or
 the duration of surgery
• Increased sensitivity to normal dosage
• Decreased metabolism/excretion & active metabolites
• Co-adminiteration of synergistic drugs

21. Various anaesthetic drugs
• Benzodiazepines
• Opioids
• Intravenous anaesthetic agents
• Inhalational anaesthetic agents
• NMBDs

22. Various phenomena at work
 Synergism/ potentiation
Benzodiazepines + Opioids e.g. Midazolam and
Fentanyl, diazepam + pentazocine …….
 Increase in Context Sensitivity Half time
Intravenous Agents, after prolonged use
co-administration of other depressants
 Blood & Lipid solubility
Inhalational agents
 NMBDs
excessive dose, co-administration of other drugs
surgery finishes earlier, pre-mature reversal

23. Non pharmacological factors
• Hypothermia
• Hypotension
• Hypoxia/hypercapnia
• Fluid overload
• Equipment malfunction- hypoxic mixtures,
overdosing with inhalational A. agents

24. Patient related factors
• Age
• Sex
• Hereditary/genetic factors: polymorphisms
• Co-morbidities
• Endocrine/metabolic factors
• Preoperative medications
• Addictions - alcohol, drugs

25. Surgery related factors
• Prolonged surgical time
• Type of surgical procedure

26. Delayed recovery from regional
anaesthesia
• Nerve injuries
• Nerve compressions
• Wrong drug dose/conc. injected
• Effect of adjuvant
• Hypersensitivity to L. A. A., preservative, adjuvant

27. How to tackle the problems
• Generalized Protocol
• Specific factors

28. Generalized protocol
• A
• B
• C
• D
• E
• F
• ………………….!

29. Generalized Protocol
• Airway
• Breathing
• Circulation
• Communication
• Delayed Recovery of Consciousness?
• Effective Assessment and analysis
NMJ monitoring: PNS/ BIS
• Facilities/ Equipments available

30. • Gauge
• Human Resources organizing
• Intuition/ VIth Sense
• Judge again, before discharge: SAS/PADSS
• Know/ understand &
• Learn from your own and other people’s
experiences

31. Specific situations
• Paediatric case
• Potentially dangerous mixture of
hypothermia, shivering, secretions in Phx,
• Shivering causes increased oxygen demand
• Secretions cause laryngospasm
• Hypoxemia is worsening

32. • Severe pre-eclampsia
• Loaded with drugs like Mg++ ,
• Acidosis, Renal dysfunction, electrolyte
disequilibrium
• NMBDs action gets potentiated
• Incomplete reversal
• Prolonged recovery

33. • Elderly patients coming for “ Conscious
Sedation”
• In spite of Pre-medication: GI instrumentation
causes “transient Ventricular Premature
Contractions”, bradycardia due to vagal
stimulation
• Watchful/judicious non-interference
• Xylocaine will worsen the bradycardia

34. • TURP syndrome: hypervolemia, dilutional
hyponatremia, progressive cerebral oedema
• “Water Intoxication Syndrome”
• Imminent C H F
• Bolus of Crystalloid does not help,
• Precipitates frank Pulmonary Oedema.

35. Recent advances!
• Opioids
• Intravenous anaesthetic agents
• Inhalational anaesthetic agents
• NMBDs
• Local Anaesthetic Agents

36. Novel
• Enantiomers/
chirality
• Specificity
• Selective relaxant
binding Agent
• Unique
metabloism

38. Conclusion
Delayed recovery
• Multifactorial
• No set rules
• Many variables
• Eternal vigilance
• Careful balancing

39. Conclusion
• correct understanding of aetiopathology
• Precise, prompt and appropriate decisions
by a skillful Aneasthesiologist can avert
a major impending crisis and the
associated morbidity/mortality