Ether Resources for Anesthesia Research and Education

Delayed Emergence from Anesthesia

Confirm that all anesthetic agents (inhalational/intravenous) are off.

Check for residual muscular paralysis with train of four monitor and reverse neuromuscular blockade as appropriate.

Consider narcotic reversal- start with 40 mcg of naloxone IV repeat q 2 minutes up to 0.2 mg.

Consider inhalational anesthetic reversal with 1.25 mg of physostigmine IV.

Consider benzodiazepine reversal- start with 0.2 mg flumazenil IV q 1 minute up to 1 mg.

Check blood glucose level and treat hypo or hyperglycemia.

Check arterial blood gas and electrolytes
            Rule out CO2 narcosis from hypercarbia
            Rule out hypo or hypernatremia

Check patient’s temperature and actively warm if less than 34 C.

Perform neurological exam if possible: exam pupils, symmetric motor movement, presence or absence of gag/cough.

Obtain stat head CT scan and consult neurology/neurosurgery to rule out possible cerebral vascular accident (CVA).

If residual sedation/coma persists despite evaluating all the possible causes, monitor the patient in the ICU with neurology follow up and frequent neurological exams.  Repeat the CT scan in 6-8 hours if no improvement.


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