A conscious individual, as defined in theOxford English Dictionary, is ‘awake andaware of their surroundings and identity’.However, consciousness represents a con-tinuum with varying depths of consciousness.Coma is derived from the Greek ‘koma’meaning a state of sleep; more specifically, itis defined medically as ‘a state of unrespons-iveness from which the patient cannot bearoused’.By convention we use the Glasgow comascale (GCS) to provide a rapid, reproduciblequantification of depth of unconsciousness.Although the GCS was developed for assess-ment and prediction of outcome in traumaticbrain injury, it remains a useful tool to assessconscious state regardless of the causativefactor. The GCS scores verbal, movementand visual responses to stimulation; a GCS
8 defines coma.
Causes of prolongedunconsciousness after anaesthesia
The causes of prolonged unconsciousnessafter anaesthesia are summarized in Table 1.The time taken to emerge to full consciousnessis affected by patient factors, anaestheticfactors, duration of surgery and painful stimu-lation. Non-pharmacological causes may haveserious sequelae; thus, recognizing theseorganic conditions is important.
The residual effects of a drug (after adminis-tration has ceased) are influenced by a numberof factors, as outlined in Table 1. With somany variables, it is not surprising thatadministration of an ideal dose to one patientcan have a very different effect on an appar-ently similar patient.
Benzodiazepines are used for anxiolysisand pre-medication; co-induction facilitatesthe hypnotic and sedative properties of otheragents. Used alone, benzodiazepines areunlikely to cause prolonged unconsciousnessexcept in susceptible, elderly patients or whengiven in overdose. However, central nervoussystem (CNS) depression can prolong theeffects of other anaesthetic agents. Benzo-diazepines combined with high-dose opioidscan have a pronounced effect on respiratorydepression, producing hypercapnia andcoma. Midazolam is metabolized by the sameP450 iso-enzyme as alfentanil, such that co-administration prolongs the actions of bothdrugs.
Opioids produce analgesia, sedation andrespiratory depression; the intensity of eachaction varies between subjects and can bedifficult to predict. As noted previously,dose–response is affected by co-administeredsedatives and analgesia and by patient factors.There are two major mechanisms resulting incoma: respiratory depression and direct seda-tion via opioid receptors. The sensitivity of the brainstem chemoreceptors to carbon dio-xide is reduced by opioids with consequentdose-dependant respiratory depression andresultant hypercapnia. This may affect clear-ance of volatile agents and carbon dioxide;both can cause unconsciousness. The directopioidreceptoreffectvarieswithdrugpotency,half-life, metabolism and patient sensitivity.Active metabolites of morphine and meperid-ine (pethidine) prolong the duration of action,especially in the presence of renal failure.
Neuromuscular block in the conscious patientcan mimic unconsciousness. In addition, neur-omuscular blockers may result in prolongedunconsciousness after operation if a residualblock causes hypoventilation. A large numberof pharmacological interactions with neur-omuscular blocking agents prolong neuromus-cular block; these are outlined in Table 2.
The majority of drug interactions with non-depolarizing neuromuscular blocking agentsprolong blockade by interfering with calcium,the second messenger involved in acetylcholine
Delayed recovery fromanaesthesia is oftenmultifactorial.Consider drug interactionswith neuromuscular blockingagents.Metabolic abnormalities willnot present with the usualsigns and symptoms in theanaesthetized patient.Organic causes of prolongedunconsciousness may haveimportant sequelae thatshould be managedappropriately.Rarely, disassociative statesmay present with episodes of unconsciousness with noother identifiable cause.
Rhona C F Sinclair BMedSci BM BSMRCP
Senior House Officer Department of AnaesthesiaDerbyshire Royal Infirmary Derby DE1 2QYUK
Richard J Faleiro BSc (Hons) DCHFRCA
Consultant in Anaesthesia andPain MedicineDepartment of AnaesthesiaDerbyshire Royal Infirmary Derby DE1 2QYUK Tel: 01332 347141 ext. 4747Fax: 01332 254963E-mail: email@example.com(for correspondence)
Continuing Education in Anaesthesia, Critical Care & Pain | Volume 6 Number 3 2006doi:10.1093/bjaceaccp/mkl020
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Delayed recovery of consciousnessafter anaesthesia
Rhona C F Sinclair B MedSci BM BS MRCPRichard J Faleiro BSc (Hons) DCH FRCA