Expert: Ronald Levy, M.D. - 9/5/2008

Question
Hello,
My grandfather is currently in the ICU at a local hospital. A few days ago he
broke his femur and went in for surgery to repair it. He has had congestive
heart failure in the past and has some difficulty breathing. The
anesthesiologist said that if during the course of the surgery his blood
pressure went low or he had trouble breathing, he would put in another IV
and keep the tube in his mouth to help him breathe, then wean him slowly off
the anesthesia until he awoke later that night or in the morning. I had never
heard of this before, but he seemed to have a game plan and knew what he
was doing.

Later that night his blood pressure dropped so low that he wouldn't wake up,
being nearly dead. He was unresponsive to light, touch, or even pain when
they inserted a needle into his artery, and his eyes were forced open, unable
to close. They immediately started getting him on a medicine that would
raise his blood pressure, a blood transfusion, and lots of IV bags, and his
heart rate has picked up to the point now where he can look around, close his
eyes, and understand where he is and the situation. However, his BP is still
extremely low and he's having trouble recovering. Right now it's about
125/33.
This actually happened to him 16 years ago, the exact same results from
coming out of anesthesia after surgery where his BP was extremely low and
uncontrollable. I have also been in for surgery a few times with anesthesia,
and the last time my blood pressure also dropped extremely low and I had to
have another IV immediately put in my other hand and tended to carefully for
the remainder of the surgery.

My questions: is this something relating to general anesthesia, and should I
be worried about future operations? Do you know what could be causing the
reaction and is it preventable? Do you have any ideas what could have gone
wrong, or what can be done to ensure it won't happen? Do you have any other
advice or thoughts on this? I have been searching the internet for answers but
can't seem to find any scenarios similar to this, and even the doctors aren't
sure why it happened.. I was hoping you might have an idea so at the very
least I can use the information to make decisions on surgeries in the future.

My sincerest thanks for reading,
Lisa

Answer
First of all, a lot of what you describe as low BP and can't wake up, have little to do with each other. Let's start with your grandfather. I don't know his age or his health history, but it is not unusual for elderly patients to have hypotension in the OR. Furthermore, a femur fracture can cause a 2 liter blood loss (without being recognized). Obviously I haven't seen your grandfathers aneshtetic record so most of what I say is conjecture, but that being understood, it is not unusual for patients to remain intubated overnight or even to not wake up immediately after surgery. Particularly, if they chose not to extubate him, they would have heavily sedated him so that he would be comfortable with the tube in. This may explain why he was not arousable. As for the amount of IV fluids, blood, etc., again this is not an unusual amount. You said they put an arterial line in and the BP was 125/33. While the 33 doesn't sound correct (does he have aortic insufficiency?), the systolic pressure is actually not bad. It sounds to me like he is recovering but the process will be slow (As it is for most elderly people). As for you, you say you were also hypotensive during surgery but that is also normal. Assuming your pressure didn't get too low, we exepct the pressure to drop because of the lack of external stimulation. This is not a problem and you have nothing to worry about for future operations.

I hope this answers your questions,

Ronald Levy, MD
Professor of Anesthesiology
UTMB-Galveston