Post op confusion after a minor procedure

[BADMD]

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Last night I was consulted (wearing my Toxicology hat) by the sedation service at my hospital. They were called by the ED regarding a 17 year old female who was a few hours post op from having a tonsil/adenoidectomy at a local surgicenter.

Apparently she was confused, amnestic to recent events and staring at things with wide open eyes. Vitals were "fine." Physical exam was otherwise "normal." The only meds that she received were propofol, fentanyl and sevoflorane. There was nothing for post op nausea and she was never hypoxic per the resident I spoke to. Someone was administering the anesthesics, however I do not know that person's level of training. I also do not know the duration of the surgery. She is not on any medications at baseline (as far as I know - you've got to love 3rd hand information).

They were asking if there was anything to do about this. I rarely deal with side effects and am far more familiar with these meds in overdose. I suspect that, given the duration of action, she should have had minimal effects a few hours after surgery, however I can see some reasons why she might. I suspect that she received something antimuscarinic post op for nausea, however the person I spoke to didn't think anything was given. Since she was not agitated, there is nothing I was going to do, except let time take its course.

So I ask the smartest anesthesia group I know: Is confusion a few hours post op from these 3 meds common or at least known, or would it seem like something else was going on?

 

[IceDoc]

I'd say rare but not unheard of. Drug error and interaction with prior substances are at the top of my list. Who knows what recreational stuff she was using the day prior. Also, a few scopolomine patches could induce the effects you describe (a family member of someone in our dept had complete amnesia of an entire Cruise because of the OD on anti-motion sickness scop patches). If desired, you could test this with a dose of physostigmine and see if symptoms improve.

 

[Carm]

Who makes up a sedation service?

 

[coprolalia]

Physostigmine 30mcg/kg, max 2mg dose. Magic.

-copro

 

[jwk]

Who makes up a sedation service?

Usually RN's with "special training". Hopefully limited to fentanyl and versed, although depending on the Board of Nursing of each particular state, may include propofol.

Unless the "sedation service" was headed by an anesthesiologist, there should be no need to consult them about anything related to general anesthesia.

 

[jwk]

Physostigmine 30mcg/kg, max 2mg dose. Magic.

-copro

I love the brand name - AntiLirium. So apropos.

 

[BADMD]

Who makes up a sedation service?

I was speaking to a resident, but I have no idea exactly.

 

[BADMD]

Physostigmine 30mcg/kg, max 2mg dose. Magic.

-copro

I considered trying physo, however since she was not agitated, I figure it is just better to let things run their course, rather than toss in more meds. I might have been more apt to give it a try if I had history of something antimuscarinic.

The key point being that the consensus seems to be that one would not expect the combination of sedation mentioned to cause significant post op confusion.

 

[2ndyear]

Conversion disorder? Propofol, fentanyl, and sevo go away pretty quick. Sevo has been implicated in post-op confusion, but mainly in kids. 17 year old girls don't really have pedi physiology. The anesthesia care team at the surgi-center should be made aware.

 

[Planktonmd]

Confusion after GA is possible and can last quite a while in some patients regardless of the drugs used although it is more common in certain populations.
Ketamine is another drug that can trigger extended post op weird affect but it seems it was not part of the game here.
Make sure you are not missing something simple like hypoglycemia or recreational drugs.
Physostigmine may work although many would argue that there is no evidence that it is effective.
Otherwise just give her time.

 

[numbmd]

Agree with the above but also check out psych causes. Doesn't sound like the usual or unusual confusion from anesthesia.
Wide eyes and staring? doesn't sound like confusion. Sounds to me more like a PTSD.

 

[Gern Blansten]

I've seen this reaction once before when a Cher CD was played for the duration of the surgery.

 

[numbmd]

I've seen this reaction once before when a Cher CD was played for the duration of the surgery.

 

[Dejavu]

Several times I have seen that blank stare/confusion thing after an uneventful anesthetic. It hangs on for way longer than you think it should and then, quite rapidly, it just goes away on its own. Who knows what causes it, but I don't get excited, anymore, for several hours postop.

One possible way to help diagnose what is going on would be to sequentially reverse the versed, than later, depending on the results, reverse the narc (provided she isn't on chronic narcs (either legal or illegal).

If she straightens up with either of these, you have your diagnosis.

 

[joshmir]

make sure she's wasn't wearing a scopalamine patch behind her ear and nobody knows; I've seen this happen like this; someone may have given/told her to wear it in preop clinic and not documented it; young female, at risk for PONV they may have thought

 

[jetproppilot]

I've seen this reaction once before when a Cher CD was played for the duration of the surgery.

HAHAHAHAHAHAHAHA

 

[Orthonut]

I've seen this reaction once before when a Cher CD was played for the duration of the surgery.

Are you sure you're not MY attending? rotflmao

 

[VentdependenT]

"If I could turn back time"

Cher is a rough ride man. I would take a severe beating over a Cher day in the OR.