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!