Delayed Emergence



Failure to regain consciousness as expected within 20-30 min of the end of a surgical procedure - with all anesthetic off.


Anesthesic effect:

  • Residual drug effects
    • Absolute or relative overdose
    • Potentiation of agents by prior medications or intoxication.
    • Organ dysfunction (e.g. renal, liver) interfering with metabolism/excretion
  • Hypercapnia/hypoxemia
  • Hypothermia (<34 C)


  • Hypo/hyperglycemia
  • Metabolic disturbances (Hyponatremia, hypo/hypercalcemia, hypomagnesemia)


  • Neurologic insults (seizure/post ictal state or Increased ICP)
  • Perioperative stroke
    • Risk Factors: A Fib, hypercoagulable state, intracardiac shunt
    • Incidence: 0.4% with low-risk procedures; 2.5-5% with high risk prcoedures.


  • Administer reversal agents:

    • Naloxone 0.40mg - 2mg IV Q2-3 min (can dilute to give in 0.04mg increments). If no response after 10mg, reconsider narcoic overdose as cause for delayed emergence.
    • Flumazenil 0.2 mg IV bolus 45-60 seconds over 15 min. No more than 3mg total in one hour.
    • Physiostigmine 1-2 mg IV (for central cholinergic syndrome)
    • Neostigmine - maximum of 5 mg IV. Give with glycopyrolate.
  • Ensure patient is normothermic (use bair hugger, warm the room).

  • Check ABG for PaO2, PaCO2, glucose and electrolytes.
  • Consider neurological insults (seizures/strokes/increased ICP).