Chapter 24
Troubleshooting Anesthetic Recovery
Time to land!
Andrew Claude
College of Veterinary Medicine, Mississippi State University, USA
- Q. What is meant by “anesthesia recovery” and why is it important?
- A. Anesthesia recovery refers to the interval from the cessation of anesthetic delivery until the patient regains a gag or swallow reflex, is extubated, regains consciousness, remains sternal, and/or regains the ability to walk [1]. The length of time to anesthesia recovery depends on multiple factors, including patient health, body temperature, anesthetic drugs used, and length of anesthesia. Generally speaking, longer recovery times are associated with debilitating diseases, hypothermia, excessive anesthetic depth, and long anesthetic procedures. Serious anesthetic related complications can occur during recovery from general anesthesia. Nearly 50% of canine and greater than 60% of feline deaths occur within 48 h post-operatively [2].
- Q. Are there ways to hasten patient recovery from inhalant anesthesia?
- A. Elimination of inhalant anesthetic agents follows the opposite pharmacokinetics as agent uptake [3]. During recovery an anesthetized patient will reverse steadily to a conscious state through the planes of anesthesia: eye position returns to normal; reflexes and muscle movements become apparent; and vital signs increase [1]. If the patient is ventilating sufficiently, inhalant anesthetic off-loading can be hastened by shutting off the anesthetic vaporizer, briefly disconnecting the patient from the breathing circuit, flushing the anesthetic vapors into the scavenging system, and reattaching the patient to the breathing circuit. A patient breathing 100% oxygen or room air with no residual inhalant will recover faster than a patient breathing oxygen on an anesthetic circuit that still contains trace levels of inhalant agent. The most important point, however, is that the patient must be ventilating (either spontaneously or with assistance) in order for them to clear the inhalant from their body, as all modern inhalants are primarily eliminated via the lungs.
- Q. How do I monitor my post-anesthetic patient during recovery?
- A. The duties of monitoring the anesthetized patient do not stop when the anesthetic agent is discontinued. Patient monitoring should continue until the patient is extubated, sternal, at near-normal body temperature, and able to ambulate or at least hold up their head without assistance. Important patient parameters to monitor during the post-anesthetic period include: cardiovascular status (mucus membrane color and capillary refill times, heart rate/sounds and blood pressure); ventilation (respiratory rate, lung sounds, especially in respiratory compromised patients); oxygenation (pulse oximetry, arterial blood gases – especially in patients with respiratory compromise); level of analgesia (pain scoring and proper modes of pain management); body temperature (supplemental or heat reduction as needed); patient tolerance of the endotracheal tube (return of gag reflex and swallowing); and signs of aversive behaviors (emergence delirium or dysphoria). As the patient regains consciousness and voluntary control, the degree of monitoring can be reduced gradually. Monitoring values and drug doses administered during the post-anesthetic period should be properly chronicled in the patient’s anesthetic record.
- Q. What is the difference between emergence delirium and dysphoria?
- A. Emergence delirium, also called post-anesthetic excitement, has multiple potential causes. Pharmacological factors include residual effects of anesthetic drugs on both divisions of the central nervous system (extrapyramidal and cerebral). In humans arterial hypoxemia and hypercapnia can contribute to post-anesthetic agitation and delirium due to functional mental impairment [4]. Behavioral causes of emergence delirium include post-anesthetic anxiety, confusion and agitation. In many cases of emergence delirium patients often respond to intervention such as touch and spoken language.
Post-anesthetic opioid dysphoria can clinically resemble emergence delirium, however the patients do not respond to intervention. Please see below for a more detailed discussion.
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- Q. How do I monitor my post-anesthetic patient during recovery?
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