Delayed Awakening from Anesthesia Following Electrolyte

and Acid-Base Disorders, Two Cases

Majid Razavi1 (MD); Alireza Bameshki2 (MD); MehryarTaghavi Gilani3* (MD)
1.
Assistant professor of Anesthesiology, Cardiac Anesthesia Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.
2.
Associate Professor of Anesthesiology, Cardiac Anesthesia Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.
3.
Assistant professor of Anesthesiology, Research Center for Patients' Safety, Mashhad University of Medical Sciences, Mashhad, Iran.

ARTICLEINFO ABSTRACT

Article type: Introduction: Delayed awakening from anesthesia remains one of the
Case Report biggest challenges that involve anesthesiologists. Most commonly, delayed
awakening is due to drugs effects persistence. Metabolic (like hypo-
hyperglycemia), electrolyte, acid-base disorders and hypothermia may
Article history: cause delayed emergence from anesthesia. Structural disorders of cerebral
Received: 2- Oct-2013 nervous system (like increase in intracranial pressure, brain ischemia) and
Accepted: 19- Dec-2013 psychological disorders can be regarded as other uncommon causes of this
condition. Hypokalemia is induced by low potassium intake, excessive
excretion from gastrointestinal (GI) and kidneys (like using diuretics) or a
Keywords: shift from extracellular space into intracellular space.
Alkalosis Cases: In these two reported cases, although proper measures had been
Delayed emergence taken to reverse the effects of anesthetic drugs, the patients did not regain
General anesthesia their consciousness as fast as expected. The only significant finding in
postoperative tests, along with respiratory alkalosis, was low serum
Hypokalemia
potassium level (K=2.5 and K=2.9 in the first and the second patients,
Impaired consciousness
respectively). Correction of serum potassium (to K=3.3 and K=3.2 in the
first and the second, respectively) improved patients level of
consciousness, and they were discharged from intensive care unit (ICU)
with good general condition.
Conclusion: During surgery; pain, stress, sympathetic increase,
catecholamine release and the consequent β-stimulation, certain drugs,
and respiratory alkalosis due to hyperventilation may cause acute shift of
potassium into the cells, which will be intensified in the patients with
preoperative hypokalemia. Hypokalemia induces consciousness
impairment and increases muscle relaxation, both of which affect patient
awakening. Serum potassium evaluation is recommended in cases of
delayed emergence from anesthesia.

Please cite this paper as:

Razavi M, Bameshki AR, Taghavi Gilani M. Delayed Awakening from Anesthesia Following Electrolyte and Acid-
Base Disorders, Two Cases. Patient Saf Qual Improv. 2014; 2(1): 65-68.

Introduction
patient's awakening is rare, it remains a very
Waking up from anesthesia is one of the most challenging subject for anesthesiologists.
important concerns of anesthesiologists, patients In these cases every anesthesiologist tries to find
and their families (1, 2). Although delay or failure in out the underlying causes and to have them
rectified. In this study, we introduce two patients

© 2014 mums.ac.ir All rights reserved.

Corresponding Author: Mehryar Taghavi Gilani, Research Center for Patients' Safety, Mashhad University of Medical
Sciences, Mashhad, Iran.Email: TaghaviM@mums.ac.ir
Razavi M et al Delayed Emergence of Anesthesia

who had undergone emergency surgery. Patients

were hyperventilated during operation. Consequent
delay in awakening was observed which could
probably be due to hypokalemia. We will discuss the
causes and treatment method.

Case 1
Our first case was a 54-year-old woman
(wt=75kg). She was hospitalized in ENT department
for neck fasciitis. The patient did not have any
history of previous diseases and was treated with
clindamycin, vancomycin and ceftriaxon. After 24
hours, she was scheduled for emergent incision of
the cervical abscess. The only noteworthy finding in
her preoperative tests was a lower limit normal
Figure1: ECG after ICU transfer
serum potassium level (K=3.5). Due to some
difficulties in tracheal intubation, anesthesia
induction was preformed with 100 mg ketamine and
75mg succinylcholine. After respiration recovery,
fentanyl (2µ/kg), propofol (3-4mg/kg/hour) and
atracurium (20mg) were administrated for
anesthesia maintenance. The operation duration
was 105 minutes, patient vital signs were stable
during operation and capnography was preserved
around 30-32 Etco2. At the end of operation after
discontinuing of anesthetic drugs and respiratory
recovery, neostgmine and atropine was
administrated to reverse anesthesia. Furthermore,
the patient received naloxane because of the delay
in waking up. Finally, after a 2 hour interval in
recovery room, patient was delivered to ICU in deep
coma, with stable vital signs and spontaneous
breathing through tracheal tube. In ICU, the patient
received respiratory support by CPAP and her blood
tests were as follow: PH=7.52, PCO2=27.1,
HCO3=21.8, PaO2=133, BS=202, BUN=35, K=2.5, Figure2:ECG before ward transfer
Ca=8.4, Mg=2.2mg/dl, WBC=10200, Hb=11. Having
considered blood test results, 40meq KCL was Case 2
added to each liter of patient intravenous infusion. Our second patient was a 7-year-old boy
In our assessment 24 hours later (during the time (wt=30kg) who had been transferred for
in which the patient had received an approximate esophagoscopy due to foreign body ingestion.
120 meq kcl), she was in confused state and Patient’s preoperative CBC results were normal
received only haloperidol. Blood tests showed and he did not have any history of previous diseases.
following results: PH=7.47, PaCO2=40, HCO3=28.5, Anesthesia was induced by 150 mg thiopentanol,
PaO2=100, BS=140, BUN=15, Cr=0.4, K=2.9. 30 mg Succinylcholine and 100μg fentanyl. For
After spending 48 hours in ICU, our patient fully anesthesia maintenance, 1.5% isoflurane and 60%
regained consciousness, respiratory stability, and N2O was administrated, and the patient received 10
hemodynamic stability. In this stage she was mg atracurium after respiratory recovery. Surgery
extubated. Blood test results in this phase were as took 20 minutes long, and patient’s respiration
follow: PH=7.45, HCO3=26, PaCO2=35, K=3.3, recovered after 1 hour. He was extubated when
Na=135. On the third day our patient was airway reflexes returned, but his GCS was 8-9 in this
transferred from ICU to hospital ward. (Her EKG is stage. Patient`s body temperature was maintained at
shown in Figure 1(admission to ICU) and Figure 2 36-37, and Etco2≈30 during operation.
(in ward). The blood tests in OR showed the following
results: PH=7.45, PCO2=25, HCO3=20, BS=123.

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Razavi M et al Delayed Emergence of Anesthesia

Patient spent four hours in recovery room and he ischemia) (6), psychiatric disorders like hysteria
was delivered to ICU afterwards with following test (2, 7), and the consequent hypernatremia after
results: PH=7.37, PaO2=70, PCo2=25, HCo3=14.4, hepatic hydatid cyst removal (8) may also hinder
SaO2=92%, BUN=10, Cr=0.6, Ca=10.5, Na=135, the process of recovery from anesthesia.
K=2.19, BS=120, Mg=1.8. In both cases of this study, anesthesia was
In ICU, patient received KCl and respiratory inducted by succinylcholine, which may cause
support with facial mask. After 12 hours, he started delayed recovery in patient with cholinesterase
to recover consciousness (GCS=10-11), and his deficiency. Considering patients` spontaneous
blood tests showed the following results: PH=7.40, respiratory recovery at the end of surgery this
PaCO2= 34, PO2= 101, SaO2=99%, Na=133, K=3.2, diagnosis had been ruled out. In evaluating the
BS= 149. Patient was discharged from ICU after 24 possible causes of prolonged anesthesia in patients
hours with full consciousness, stable vital signs and, who had received short-acting drugs with
optimal respiration. intraoperative and postoperative hemodynamic
stability and an acceptable glycemic and
Discussion temperature control with no history of previous
Recovering consciousness from anesthesia and comorbidities (like hypothyroidism, etc), the
awakening depends on various factors related to physician’s attention should be drawn to electrolyte,
patient, anesthesia type, and duration of surgery. acid and base disorders.
When surgery is prolonged, careful evaluation of In both patients, ETCO2 was maintained around
various factors which might affect consciousness 30 mmHg. Hyperventilation due to anxiety, stress,
would be necessary. The most common reason for and iatrogenic (intraoperative) causes leads to
prolonged anesthesia and patients` unconsciousness hypocapnia and its consequences associated with
after anesthesia is persistent effects of anesthetic systemic manifestation. Respiratory alkalosis with
drugs and sedatives (1, 2). Opiates and the carbon dioxide pressure less than 36 mmHg
benzodiazepines are the most common drugs results in reduced intracellular proton
considered in this group. Furthermore, concentration and is in turn, draws potassium ion
neuromuscular block is a cause of patient's into cells. This leads to serum potassium level (K+)
unresponsiveness to stimulations. After evaluating decrease which is correlated to the reduction in
anesthetic drugs, metabolic and endocrine disorders carbon dioxide partial pressure (reduction of
like hypothyroidism (3), severe hypo- 0.5meq/L of potassium per each 10-mmHg
hyperglycemia, other disorders like hypothermia, reduction of PaCO2)(9). Surgery stimulation,
acid and base disorders and electrolytes imbalance sympathetic system stimulation, and releasing
must be taken into consideration in the case of catecholamines, and also diuretics, beta-stimulators,
prolonged anesthesia (3). General anesthesia insulin administration and induced hypothermia
influences the level of serum electrolytes. Moreover, lead to increase potassium transport into cells,
both propofol and ketamine (which have been used reducing serum potassium after anesthesia (9, 10).
in one of our cases) may affect the intracellular Ca The potassium shift and/or excretion due to the
levels through NMDA receptors or voltage- alkalotic state requires a considerable period of time
dependent Ca channels. Calcium is known to induce to produce cardiac arrhythmias. Mild preoperative
neuronal excitability and to increase anesthesia hypokalemia without any clinical features could,
depth (1). Hypocalcemia manifestations are more rapidly deteriorate after iatrogenic hyperventilation
commonly observed in cases with respiratory or surgery stimulation during and after anesthesia
alkalosis versus metabolic alkalosis (4). In our (4). As such, to prevent further complications, even
patients Ca and Mg were in normal limits and there in mild hypokalemic state, monitoring potassium
were no clinical signs of calcium deficiency levels and faster correction seems a wise choice.
(Chevostek's sign or Trosseau's sign). Decrease in Usually, serum potassium levels below 3.5meq/L
serum sodium level (due to low-tonicity liquids are considered as hypokalemia. The common signs
during surgery, or inappropriate secretion of anti of hypokalemia are confusion, decreased level of
diuretic hormone (SIADH) following surgery stress), consciousness, muscle weakness (more in lower
decrease in serum potassium level, and respiratory extremity), constipation, nausea, vomiting, polyuria,
acidosis or alkalosis (2) are examples of electrolytes, depression, decrease in cardiac contractility, and
acid or base disorders. Finally, some rarer change in cardiac rhythm. Hypokalemia causes ECG
conditions such as central anticholinergic syndrome changes, including flat or inverted T waves; large U
(5), structural disorders of nervous system wave (greater than 1 millimeter and greater than T
(e.g. increase in intracranial pressure, bleeding, and waves) could not indicate hypokalemia severity.

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 Razavi M et al Delayed Emergence of Anesthesia

Hypokalemia intensifies the effects of non- Various factors are involved in patients
depolarizing muscle relaxants (11). awakening after anesthesia. These factors have to be
At the time of transfer to ICU, our first patient had considered in evaluating patients with delayed
a preoperative serum potassium=3.3 meq/L, and awakening problem based on their occurrence. Our
her blood tests showed respiratory alkalosis and two patients did not respond to the routine
hypokalemia (K=2.5). Preoperative serum therapeutic measures. The cases were kept in ICU
potassium level was not controlled for the second and more detailed laboratory assessments have
patient who had a rather simple surgery, but at the been preformed. We found that intensified
time of transfer to ICU, signs of mild respiratory hypokalemia due to hyperventilation or
alkalosis and hypokalemia were observed. Both bidirectional effects of general anesthesia and
patients received potassium and their consciousness electrolyte levels may be at play and its persistence
improved with gradual correction of serum after surgery was the cause of the delay in our
potassium, and finally they were transferred to patients` recovering their consciousness. Serum
hospital ward. One limitation of this study was the potassium evaluation is recommended in cases of
lack of bispectral index (BIS) monitoring that delayed awakening from anesthesia.
provides details of the level of anesthesia, though
Acknowledgement
not an essential component of routine monitoring.
The authors are committed to the satisfaction of
Conclusion
the patients presented in this article.

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