18) Complications of General Anaesthesia - Neurological

Complications

Post-Operative Headache:

Headaches occur in approximately 17% of patients after an anaesthetic. They are more common in
patients who normally experience frequent headaches; prolonged fasting times; and patients with a
daily caffeine consumption > 400 mg (~ 4 cups of coffee).

Post-Operative Drowsiness And Dizziness:

Drowsiness after discharge occurs in approximately 40% of patients and dizziness in 18%.
Intravenous fluid 1 L intra-operatively has been reported to reduce post-operative drowsiness and
dizziness.

Post-Operative Cognitive Dysfunction:

Post-operative cognitive dysfunction (POCD) most commonly occurs in elderly patients and is usually
of mild severity, effecting memory and concentration. In a multicenter study of patients over 60
years old, POCD was present in 25% after 1 week and 10% at three months. Up to 14% of general
surgical patients develop post-operative delirium. There was no difference in long-term cognitive
function between general and regional anaesthesia. POCD may persist in 1% of patients.

Note that POCD is as much a complication of surgery or acute illness as it is due to anaesthesia. It is
very difficult to separate the relative contribution to POCD of each.

Peri-Operative Cerebrovascular Accident:

Peri-operative cerebrovascular accident (CVA) occurs in between 0.1 and 3% of general surgical
patients. On average these occur on the 7th post-operative day (range: day 1-10). Risk factors
include:

 Advanced age
 Previous CVA – 10x increased risk: 2%; mortality 60%.
 Hypertension – 4x increased risk.
 Peripheral vascular disease
 Chronic Obstructive Airway Disease
 Atrial fibrillation
 Carotid artery stenosis
 Obstructive sleep apnoea
Awareness:

The incidence of conscious awareness with recall and severe pain is occurs in less than 1 in 3000
general anaesthetics. Conscious awareness without pain is more common, occurring in between 1 in
150 to 1000. Risk factors for awareness include:

 Nitrous oxide-only anaesthesia, without volatile agent – 1 in 14.

 Opioid-only anaesthesia.
 Total intravenous anaesthesia – 1 in 500.
 Trauma, cardiac and obstetric anaesthesia.

The Australian Incident Monitoring Study highlighted that the majority of cases of awareness were
due to drug error or neglecting to provide volatile anaesthesia after induction. Vigilance and careful
consideration of the anaesthetic technique are key importance in avoiding awareness.

Peripheral Neuropathy:

Peripheral nerve injury following general anaesthesia is estimated to occur in 1 in 1000 cases,
although recent studies suggest the incidence may be higher. Most commonly this involves the ulnar
nerve, followed by the brachial plexus and lumbosacral nerves. Careful position of the limbs,
avoidance of extremes of extension or flexion and careful documentation of pre-existing neuropathy
(especially in diabetics) is essential to avoid development of neuropathy.