She entered the operating room at 9am and came out at 5pm. The doctor said: She had delayed awakening.

Recently, when I visit patients before surgery, I always encounter patients and their families asking how long the anesthesia will last and whether they can wake up. I carefully sorted out these questions from patients and their families at night and prepared to discuss this issue from a case of delayed awakening after gynecological total hysterectomy.

Today, Aunt Gao, who was scheduled to undergo laparoscopic hysterectomy under general anesthesia, was taken to the operating room and kept saying she was very nervous. She repeatedly asked me, "Doctor, how long will this anesthesia take? Will I wake up? How long will it take to wake up?"

"Auntie, don't be afraid. Trust our anesthesiologist and professional team. They will help you fall asleep easily and wake up peacefully after the operation."

As usual, when facing anxious patients, especially menopausal women, I checked and anesthetized them as soon as possible. At 10 a.m., I gave etomidate, fentanyl, and rocuronium bromide in turn through intravenous induction. Thirty seconds later, Aunt Gao fell asleep smoothly. The operation ended at 12:32, and the entire operation lasted 152 minutes. As usual, the surgeon sutured the skin and stopped taking the medicine, and added analgesics and antiemetics.

Due to the conversion to laparotomy, rocuronium bromide was added three times during the operation, and 2 mg/kg of sugammadex sodium was given intravenously immediately after the skin suture was completed for antagonism. The same magical operation did not allow Aunt Gao to wake up peacefully within the expected time. Of course, it doesn’t matter if she can’t wake up and extubate in a short time. In order not to affect the subsequent operation, she was sent to the post-anesthesia recovery room for monitoring. After entering the room, mechanical controlled ventilation was continued. The vital signs were stable, and I returned to the operating room to continue anesthesia.

At 5:30 pm, I passed by the resuscitation room and seemed to see a gynecological patient being sent out from the door. After a closer look, it was Aunt Gao. I asked a few simple questions and Aunt Gao was able to answer the questions to the point. She also said thank you, Dr. Long, for your hard work. The family member greeted me at the door and said in a somewhat complaining tone that I went in at 9:30 in the morning. When I came out at 5:30, the doctor said that it was a routine minor surgery and the surgery had been over long ago. How could she not wake up for so long? It was so worrying.

So, here comes the question. For this case, we have to mention two terms: postoperative recovery after general anesthesia and delayed recovery. Postoperative recovery after general anesthesia is the end of the operation from the cessation of all anesthetic drugs to the patient's full awakening (conscious, correct answers to simple questions, unobstructed airway, restored throat reflex, normal muscle strength), which usually takes 30-60 minutes. Delayed recovery. At present, the delayed recovery in China's anesthesia quality control refers to 90 minutes after the end of general anesthesia, excluding cerebrovascular accidents, the patient's consciousness has not recovered, that is, command movements, orientation ability and preoperative memory have not recovered, etc. Awakening delay will not only affect the turnover of operating tables in the hospital's operating room and reduce work efficiency, but also lead to prolonged mechanical ventilation and intensive care time for patients, increase the risk of other complications, and even lead to death in severe cases.

What are the possible reasons for Aunt Gao's delayed awakening after general anesthesia? The relevant literature review may include the following parts:

1. Drug factors: Aunt Gao is in menopause. Although there is no problem with her liver and kidney function in laboratory tests, a little bit of drugs may cause obvious accumulation and slow down the metabolism of anesthetic drugs. Also, whether anesthetic psychotropic drugs, monoamine oxidase inhibitors, and selective serotonin reuptake inhibitors were used before the operation, these may affect the metabolism of anesthetic drugs and enhance the inhibitory effect of anesthetic and analgesic drugs on the central nervous system. Studies have shown that the accumulation and residue of anesthetic sedatives and opioid lipophilic intravenous anesthetics are the main reasons for delayed awakening after general anesthesia. Residual muscle relaxation will not cause delayed awakening, but long-term muscle relaxation may also be related to delayed awakening.

Second, surgical factors: Gynecological surgery is usually performed in the Trendelenburg position plus lithotomy position, and the angle is greater than 30 degrees. Increased venous return, long-term head-down position, and cerebral congestion and edema may also cause delayed awakening. In addition, if the operation time is too long, the anesthesia time will be extended accordingly. Anesthetic drugs will affect the postoperative awakening time through multiple pathways such as the central nervous system and the peripheral nervous system.

3. Patient factors: Elderly patients or young children have decreased central tolerance to drugs, and some anesthetic drugs need to be appropriately reduced according to their physical condition. Elderly patients are in a state of systemic degeneration, with reduced levels and activity of neurotransmitters. They are prone to overdose of sedatives and muscle relaxants, and are prone to drowsiness and delayed awakening after surgery. When elderly patients also have cardiopulmonary diseases, abnormal liver and kidney function, especially fragile patients, the quality of postoperative awakening is greatly reduced, and they have to stay in the recovery room for a longer time to reach a level of wakefulness. Elderly patients with neurological diseases such as cognitive dysfunction, epilepsy, and stroke before surgery are more likely to experience delayed awakening after surgery due to their own nervous system dysfunction and interactions with therapeutic drugs.

4. Perioperative patient environmental factors : Intraoperative hypokalemia, water-electrolyte disorders, carbon dioxide accumulation and acid-base balance disorders can all cause delayed awakening; in addition, intraoperative hypothermia, especially for the elderly and young children, reduces the ability to regulate body temperature and slows down drug metabolism.

5. Special and rare causes : DWM posterior cranial fossa malformation; local anesthesia near the brainstem after cranial surgery; venous infiltration, such as accumulation of subcutaneous general anesthetics; delayed awakening caused by psychogenic coma, etc.

The next day, I performed routine postoperative follow-up and explained to Aunt Gao's family the various possibilities for slow perioperative awakening. They also understood and gave me a thumbs up, saying that anesthesia is actually not simple.

References:

[1] Li Yehua, Cao Hui, Zhou Xinggen, et al. Effects of different degrees of muscle relaxation on early postoperative recovery in patients undergoing laparoscopic gastrectomy[J]. Journal of Clinical Anesthesiology, 2023, 39(03): 275-279.

[2] Feng Zhenxin, Zhao Liang, Cai Weihua, et al. Research progress on functional neural network of general anesthesia resuscitation[J]. Journal of Clinical Anesthesiology, 2022, 38(12): 1317-1321.

[3] Hu Lang, Zhang Yi. Research progress on the mechanism of delayed awakening after general anesthesia in elderly patients[J]. Journal of Zunyi Medical University, 2020, 43(05): 673-678.

[4] Liu Keqing, Wang Guang, Wang Jianxi, et al. A case of delayed awakening after laparoscopic hysterectomy[J]. Journal of Clinical Rational Drug Use, 2018, 11(04): 172.

Long Xiaoju, Department of Anesthesiology, Guilin Medical College Hospital

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