delayed recovery from anaesthesia by prof. minnu m. panditrao
DESCRIPTION
Prof. Minnu M. Panditrao analyses the very common and potentially dangerous problem/s of the Delayed post-ooperative/ anaesthetic recovery and how to overcome the problemTRANSCRIPT
What went wrong?
DELAYED RECOVERY!
Consultant Rand Memorial HospitalFreeport, Grand Bahama
The Bahamas
Dr. Minnu Panditrao
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
Aetiopathology
Multifactorial : 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 anaesthetic drugs
• Benzodiazepines
• Opioids
• Intravenous anaesthetic agents
• Inhalational anaesthetic agents
• NMBDs
Synergism/ potentiation Benzodiazepines + Opioids e.g. Midazolam and Fentanyl, diazepam + pentazocine …….
Increase in Context Sensitivity Half timeIntravenous 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
Various phenomena at work
Non pharmacological factors
• Hypothermia
• Hypotension
• Hypoxia/hypercapnia
• Fluid overload
• Equipment malfunction- hypoxic mixtures,
overdosing with inhalational A. agents
Patient related factors
• Age
• Sex
• Hereditary/genetic factors: polymorphisms
• Co-morbidities
• Endocrine/metabolic factors
• Preoperative medications
• Addictions - alcohol, drugs
Surgery related factors
• Prolonged surgical time
• Type of surgical procedure
Delayed recovery from regional anaesthesia
• Nerve injuries
• Nerve compressions
• Wrong drug dose/conc. injected
• Effect of adjuvant
• Hypersensitivity to L. A. A., preservative, adjuvant
How to tackle the problems
• Generalized Protocol
• Specific factors
Generalized protocol
• A• B• C• D• E• F• ………………….!
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.
Recent advances!
• Opioids
• Intravenous anaesthetic agents
• Inhalational anaesthetic agents
• NMBDs
• Local Anaesthetic Agents
Novel
• Enantiomers/ chirality• Specificity• Selective relaxant
binding Agent• Unique
metabloism
Conclusion
Delayed 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
Thank You!