Delayed recovery from anaesthesia by prof. minnu m. panditrao
DELAYED RECOVERY!What went wrong?
Dr. Minnu Panditrao ConsultantRand Memorial HospitalFreeport, Grand Bahama The Bahamas
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
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?
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?
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?
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?
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
• 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
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
• 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
AetiopathologyMultifactorial : recovery may be delayed due to• Anaesthesia related factors• Surgery related factors• Patient related factors
Anaesthesia related factors• Pharmacological factors• Non pharmacological factors
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
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
Non pharmacological factors• Hypothermia• Hypotension• Hypoxia/hypercapnia• Fluid overload• Equipment malfunction- hypoxic mixtures, overdosing with inhalational A. agents
Generalized Protocol• Airway• Breathing• Circulation• Communication• Delayed Recovery of Consciousness?• Effective Assessment and analysis NMJ monitoring: PNS/ BIS• Facilities/ Equipments available
• Gauge• Human Resources organizing• Intuition/ VIth Sense• Judge again, before discharge: SAS/PADSS• Know/ understand &• Learn from your own and other people’s experiences
Specific situations• Paediatric case• Potentially dangerous mixture of hypothermia, shivering, secretions in Phx,• Shivering causes increased oxygen demand• Secretions cause laryngospasm• Hypoxemia is worsening
• Severe pre-eclampsia• Loaded with drugs like Mg++ ,• Acidosis, Renal dysfunction, electrolyte disequilibrium• NMBDs action gets potentiated• Incomplete reversal• Prolonged recovery
• 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
• 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.
ConclusionDelayed recovery• Multifactorial• No set rules• Many variables• Eternal vigilance• Careful balancing
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