Appropriate and aggressive treatment of postoperative pain is one of the primary goals of postanesthesia care, in order to ensure patient comfort and minimize complications related to increased sympathetic nervous system activity (hypertension, tachycardia, myocardial ischemia, agitation). Certain steps are essential in achieving and maintaining adequacy of analgesia in the initial postoperative period. A key principle in the provision of optimal postoperative analgesia is to initiate therapy intraoperatively with appropriate use of one or more of the following modalities:
1. intermediate and long-acting opioid analgesics titrated towards the end of surgery (e.g. fentanyl 25-50 Mg intravenously or morphine 1-2 mg increments intravenously);
2. non-steroidal anti-inflammatory analgesics (e.g. ketorolac 15-30 mg intravenously);
3. infiltration of the surgical wound with local anesthetic;
4. intra-articular infiltration with opioid and/or local anesthetic (joint surgery);
5. intrathecal or epidural opioid/local anesthetic (thoracic, abdominal, gynecological, and major orthopedic surgery). Persistent sedation
Delayed recovery from anesthesia is less common, but an organized and thorough approach is required when this problem occurs. First, the times and amounts of all preoperative and intraoperative anesthetic medications should be carefully documented, as recovery profiles based on drug doses, the duration of administration, and clinical recovery times are relatively predictable (Table...!). Second, an appropriate physical examination should be conducted, including a firm tactile stimulus to elicit arousal. Findings should then allow establishment of a differential diagnosis, for which the most common causes of delayed recovery can be established ( Table.3). It should be appreciated that, even when using higher concentrations of long-acting anesthetic drugs, all patients should be responsive within a period of 10 to 60 min after surgery. In the rare circumstance where the diagnosis remains elusive, a complete neurological examination should be performed in consultation with a neurologist.
Table 3 Causes of delayed recovery from anesthesia
As residual effects of anesthetic drugs represent the single most common cause of delayed recovery, treatment is generally expectant. However, possible contributing factors such as hypothermia, hypercarbia, etc. should be treated aggressively. When delayed recovery from opioids is suspected, naloxone may be administered intravenously in 40-Mg increments four times every 2 to 4 min, with due care to avoid reversal of opioid-induced analgesia. In general, unless a patient has received massive doses of opioid analgesic, 0.2 mg of naloxone will induce arousal when unconsciousness is secondary to opioid effects. Nalbuphine, which is an opioid agonist-antagonist, is an effective alternative in doses of 2.5 to 10 mg intravenously. When delayed recovery is thought to be secondary to residual effects of benzodiazepines, flumazenil may be administered in increments of 0.1 mg intravenously to a maximum dose of 0.2 mg. It is important to appreciate that the duration of effect of a single dose of flumazenil is shorter than that of the commonly used benzodiazepine agonists midazolam and diazepam, and that resedation may occur. Furthermore, flumazenil does not specifically reverse the respiratory depressant effects of this class of central nervous system depressants.
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