Definition
Differential diagnosis of delayed emergence can be classified into one of three causes: drug effects, metabolic disorders, or neurologic disorders. If a patient doesn’t “wake” after an anesthetic you have to go down these three in that particular order.
Delayed Emergence Rapid Panel
- Vital signs (including temperature)
- Twitch monitor
- Neurologic Exam (pupils, cranial nerves, reflexes, response to pain)
- Fingerstick glucose
- ABG with electrolytes
- Make arrangements for naloxone, flumazenil, physostigmine, imaging (ex. CT scan)
Drug Effects
Included under drug effects are:
- Residual anesthetic (volatile, propofol, barbiturates, ketamine)
- Excess narcotics – can be reversed by naloxone (40 ucg boluses) – remember it’s short-acting
- Preoperative sedatives – too much midazolam? – reversed by flumazenil 0.2 mg q1min up to 1 mg
- Physostigmine 1.25 mg IV can reverse cholinergic effects (ex. scopolamine) and possibly the effects of anesthetic agents (Stanford Delayed Emergence Protocol)
- Inadequate reversal or no reversal of muscle relaxation or rarely pseudocholinesterase deficiency – edrophonium/atropine work faster (1-2 mins) than neostigmine/glycopyrrolate (peak effect around 10 mins) and may be indicated in this setting
- Acute alcohol intoxication or other illicit drugs rendering unconsciousness extending the length of the anesthetic
Emergence Protocol
Metabolic Disorders
Included under metabolic disorders are:
- Hypercarbia – check a gas, may need to ventilate postoperatively until the patient resumes adequate spontaneous ventilation
- Hypoxemia – may require mechanical ventilation or supplemental oxygen
- Acidosis – correct the underlying disorder (metabolic/respiratory)
- Hypoglycemia/Hyperglycemia – check a gas, correct as indicated
- Hyponatremia – correct slowly such as not to create central pontine myelinolysis
- Hypothermia/Hyperthermia – correct as indicated
- Underlying metabolic disorder – e.g. liver disease
Neurologic Disorders
Included under neurologic disorders are:
- New ischemic event
- Cerebral Hemorrhage
- Seizures or post-ictal state
- Increased ICP or pre-existing obtundation
Remember if the patient is unable to protect airway reflexes then it is best to maintain a secure airway (keep them intubated) until the patient is awake and able to protect their airway.
Similar keyword: Delayed emergence: DDx
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