My father had open heart sugery. After the surgery he now hasﾠslurred speech that comes and goes. One day his speech is fine, butﾠ2 days later it may be slurred. Can this be a prolonged effect of anesthesia? 

Open heart surgery is one of the miracles of modern medicine, and cardiac surgeons are incredibly proficient now at repairing or replacing heart valves, and restoring blood flow to the heart muscle with bypass grafts. Unfortunately however, the incidence of brain impairment after open heart surgery is still fairly high. 

Stroke is the most serious outcome (1.5 to 5.2%); postoperative delirium (confusion)(10 to 30%) and short-term (33 to 83%) as well as long-term cognitive (thinking) changes (20 to 60%) are more common. The chances of these complications occuring are reduced somewhat in so-called "beating heart" surgery that does not use a heart-lung bypass machine, but not all patients are candidates for this type of procedure, not all surgeons are expert with it, and it does not solve all the brain side-effect problems. 

Neurological problems like slurred speech are associated with several factors including cerebral microemboli (small particles of arterial plaque that are dislodged into the circulation and go to the brain), global cerebral hypoperfusion (not enough blood flow to the brain), inflammation, and genetic susceptibility. Postoperative pain and medications used to treat pain are also possible factors. Older persons and those with diabetes and severe arterial disease are at higher risk. 

The role of anesthesia in these syndromes is still being investigated. Clinical studies cannot easily distinguish between the effects of illness, hospitalization, surgery, and anesthesia. Depression of brain and nerve function is a part of anesthesia but this is expected to be reversible. Short-term impairment of cognitive (thinking) and psychomotor performance is common after general anesthesia. This is called postoperative cognitive dysfunction (POCD) and at one time was usually attributed to incomplete removal of drugs from the body.  However we now know that general anesthesia affects brain function at all levels, including nerve membranes, receptors, ion channels, neurotransmitters, cerebral blood flow, and metabolism. Surgery itself activates immune mechanisms and inflammation. All these factors can affect brain cell function for weeks, months, or even longer. POCD also occurs frequently in noncardiac surgery patients, especially the elderly (about 10% of the time inf act), indicating that some element of surgery and/or anesthesia contributes to this condition. 

Hi, I recently had general anesthesia twice in 14 days (50 minutes each time) I coincidentally had my appendix and gall bladder both go bad at the same time. I am usually good under pressure and wasn`t worried about the surgeries at all. Yet I have had an exacerbation of symptoms related to my mental illness. (Schizo-affective disorder) My physician and psychologist both told me that my symptoms were related to the anesthesia, pain medication and fact of going through two major drudgeries (both physical healing and natural stress). My psychiatrist echoed that anesthetics can remain in your body for months. I am very frustrated and anxious most of the time. And my performance at work is being disrupted. Anyway, how do these factors (anesthesia, pain meds, and physical healing) play into mental function. And what is the likelihood of prolonged brain chemistry problems for me vs. peoples general recovery time from anesthesia and these types of surgeries? I am 31 years old if that helps. 

Thanks for your question. It's a common question - can anesthesia have persistent effects on mental function? Unfortunately, we don't really have a lot of good science yet to answer that question. We kow that the drugs themselves are eliminated from the body in a period of hours to days. There is some evidence, primarily in very young animals, and in elderly people and animals, that despite the elimination of the drugs from the body, anesthetic agents can have unexpectedly prolonged effects on brain function. This might be due to effects at a cellular level that run their course over time, and is manifested in elderly people by a syndrome sometimes known as postoperative cognitive dysfunction. There are ongoing studies to try to identify who is most at risk for these kinds of problems, and whether particular anesthetic agents are the culprits. So far it seems that there aren't any particular drugs that in clinical practice are worse or better than any others. It also seems that the only group at clearly increased risk are elderly patients with early signs of dementia. I don't know of any evidence that persons with schizophrenia or schizo-affective disorder, or anxiety disorders, experience persistent problems after anesthesia. In addition, it is difficult, impossible really, to separate out the effects of the surgery, and the physical and psychological stress which accompanies major surgery, from the effects of anesthesia, pain, and pain medications, and other pharmaceuticals. As I've pointed out before, there are very few people today willing to undergo major surgery without anesthesia!! 

I am a 45 yr. old female, had spinal fusion surgery Sept. `05, was in surgery approx. 6 hrs. I had more than what I consider moderate problems with memory and concentration for several months after surgery. I discussed this with my surgeon and he said the effects from the anesthesia should lessen and then disappear within one year. I`m still waiting. I was very concerned about returning to work (I sell modular homes and was the sales manager for my location) due to my inability to think quickly, but particularly because words that I have used all my life now escape me. That seems to be the most glaring effect, I suppose because I know what I want to say, but can`t remember the word that would best communicate my thought. It is very frustrating. I also have some lingering memory issues. I don`t get lost in Wal-Mart anymore, but something is wrong. I know my productivity at work has suffered. Do I need to have an assessment with someone or should I give it more time? I worry about my situation if this gets worse or if I ever need anesthesia again. 

Thanks for your question. Your lingering problems with memory and thinking must be a real worry. As I have said elsewhere in this forum, there is some evidence accumulating that seems to implicate general anesthesia in causing problems such as the one you've described, particularly in the elderly (but you are too young to qualify!). The scientific evidence is not very strong and one of the difficulties those studying this phenomenon is that of separating the effects of surgery from the effects of anesthesia. The two go together unless we can find people to undergo surgery without anesthesia, or vice versa. Not likely! The second possibility is that you have some underlying brain disorder that is not at all related to, but has coincided with, your anesthetic and surgery. Those two theories are not mutually exclusive. It seems that some people with early Alzheimers disease (not that I am suggesting you have this), who have less "reserve" of brain function, will undergo a sharp deterioration after surgery and anesthesia. The hospital experience "unmasks" the underlying condition. The studies suggest that improvement in mental function continues for at least 6 months, maybe longer, so don't lose hope. It is important I believe to "exercise" your brain so don't give up, and try to do things, including reading, that keep you mentally a bit stretched. If you need another anesthetic in the future, you should obviously mention your concerns to your anesthesiologist. Depending on the surgery it might be possible to avoid general anesthesia and offer you regional anesthesia instead. The studies do not yet clearly show that regional anesthesia is better for the return of cognitive function than general anesthesia but it seems intuitive that there would be less effect. Another option is for your anesthesiologist to use one of the new brain activity monitors. These allow the anesthetic to be adjusted so that less is used. Please remember that this is not a diagnostic service. If you continue to have problems you should seek attention from your doctor, and possibly a referral to a neurologist. 

I have been put to sleep around 6-8 times for knee surgery over the past 5 years. My question is can this cause long terms problems or side effects? I have noticed changes in myself since the last time I was put to sleep in May 2005. Thank you. 

It's hard to know what you might mean by "changes in myself" but I will guess that you mean personality, emotional or other mental changes. Chronic illness and repeated hospitalization is a major stress in anybody's life so there is no need to assume that anesthetics are responsible for changes in how you feel. There is also the effect on the body of surgery, which you can think of as a form of controlled physical trauma, and the body's healing process, during which stress hormones are produced and the body's reserves are drawn upon. Having said that, there is some evidence from recent studies which suggests that anesthesia in elderly patients can have effects on cognitive (brain) function lasting longer than a few weeks. Exactly what effects, how long they persist, which drugs or techniques are involved, and how to avoid these long term effects are issues still being explored. 

My mother-in-law just had uncomplicated elbow surgery. Although previously she was diagnosed with beginning Alzheimer`s (78 years old), she has extreme difficulty in cognitive abilities. She is currently in her 4th day at the hospital with no narcotics and still cannot do basic recognition or memory skills. Before this, she was cooking, cleaning, ordering clothing, conversing well. On the second day she seemed to be coming `around`, but the 3rd day she was back to square 1. Is this normal and how should we move forward? Would reinstalling the IV help flush the system. She does take Aricept. 

We are recognizing more and more that difficulty with mental functioning after surgery is a real problem in the elderly. It now has an official label - Postoperative Cognitive Dysfunction (POCD). Unfortunately little is known about how to predict it, reduce the risk, or treat it. 

For instance, although you might expect regional or local anesthesia to have less impact than general anesthesia, the studies so far do not show this. Certainly, sedative drugs and narcotics can cause confusion in the elderly and should probably be minimized if POCD is a concern. 

If your mother-in-law has early Alzheimer's disease she would be at higher risk of POCD. The fact that she was "coming around" on day two is encouraging, as many elderly patients will take a lot longer to recover cognitively after major surgery. It suggests that the lingering effects of anesthesia were coming to an end. Now she has had a setback it would be important to have a thorough medical evaluation to look for one of the many causes of such a decline. Examples: medications, interactions between medications, electrolyte problems, heart problems, breathing or lung disorders, sleep disturbance, pain, mini-strokes, kidney or liver disease, etc. 

Reinserting the IV would not necessarily be the solution. "Flushing the system" is an appealing concept but has no basis I know of in medical science. However if your mother-in-law is not eating or drinking properly now, the IV may help keep her hydrated. 

I have been under general anesthesia 3 times in my forty years: once for tonsils, as a child (8 years old); once for a tooth extraction at 9 years old; and at the age of 29 for wisdom teeth extraction. I never worried about it: it was no big deal and, fortunately, everything went fine. I seem to become a "chicken" the older I get! A friend, quite a smart person, told me that general anesthesia is a.) cumulative in one`s body/brain, and b.) can cause all kinds of problems, such as memory loss and mental impairment!!! I know that this sounds silly. It sounds ridiculous. But I am supposed to have an elective procedure (uterine polyp removal...not medically necessary at all) that I would really like to have done. If it were necessary, I`d say, "Go ahead," and not care. Since it`s a bit elective, her words scared me a bit. Not a lot, just a bit. I guess I just would rather limit the times I have to use gen. anesth. Is there any truth to this? I know it sounds ridiculous, but I`m glad to have this anonymous forum on which to ask! Thank you. 

Great question! And not ridiculous at all. I think that fears of this sort, though not uncommon, arise in societies where so many other, more critical threats to existence, have been neutralized! You are perhaps one of the fortunate ones living in a place where such fears take the place of concerns about war, famine or pestilence! To answer your question most directly and honestly, we don't have all the data we need to say conclusively that there are no long term effects of general anesthesia in young (that includes you!) healthy individuals. We do have the experience of many hundreds of millions of anesthetics conducted around the world over more than 150 years that do not seem to have caused obvious brain damage in those individuals. Doesn't that reassure you just a little bit?! Anesthesia really is one of the greatest scientific advances of mankind. Anesthetic drugs, with a few exceptions, (the drug pentothal is one) are not chemically detectable in the body more than a few hours or days after administration. So to say they accumulate, in the traditional sense of being measurable, is not correct. On the other hand, to state that general anesthetics are cumulative invites a deeper analysis. In a sense everything we take into our body, whether it is food, air or drugs is cumulative. The body takes these substances and alters them through digestion, metabolism and other chemical processes. Certain constituents of those substances then become part of us! And what about the effects of the multitude of chemicals in our environment that we are breathing in or ingesting or even absorbing through our skins each day? Your exposure over a lifetime to these mostly poorly studied chemicals seems to be much more likely to result in some sort of long term effect than general anesthesia for less than an hour! There is a little bit of evidence, although controversial, that some elderly patients have memory and thinking deficits that last more than a few days after anesthesia, up to several months. There is even one study suggesting that patients who had a low measurement on a brain monitor during general anesthesia, indicating they were deeply asleep, had a higher mortality than patients with a higher number. But this is difficult data to interpret. The problem sorting all of this out is that anesthesia is accompanied by the stress of surgery and it's not easy to separate the effects of the two. Is it the stress of surgery and the body's response to tissue injury that causes its own problems, or is it the anesthesia, of one sort or another, that causes difficulties? If it's anesthesia then is it an all or none effect or is it dose-related? If you are really concerned about the general anesthetic then keep in mind there are alternatives. Firstly, you can have deep sedation rather than general anesthesia, thus limiting the amount of medicine you are given. The sedation can be accompanied by a paracervical block given by your surgeon - ask him/her about this. Secondly, unless you really are a "chicken" you could opt for a regional anesthetic - that is a spinal or epidural anesthetic - without being given any sedative or anesthetic drugs at all. You would need to discuss these options with your anesthesiologist and surgeon. Finally, I wonder whether you have understood your surgeon correctly. "Elective" does not usually mean that you could have the surgery or not have it. It means that the surgery is not urgent. If there is a uterine polyp it probably needs to come out. Again, check with your surgeon! 

My father recently had a AAA surgery on May 13, he survived the odds but was hospitalized in the ICU Unit for 2 1/2 months. One of the medication that was given was Midazolam 10 mg. When trying to wake him up after heavy sedation, he would become agitated, so they would sedate him again for fear he would injure himself. Almost 2 months later the doctors came to the conclusion the Midazolam after long duration through IV could cause amnesia, confusion so they started weaning him off this medication but substitued Haldol in place if needed. Along with this medication he is on the Clonidine Patch for lower back pain from previous injury. I was also told that with my father getting a Peg Tube possibly they would start Anitriptlyline-15 MG, Concidez, or Neurontin/Gabapentin 100 Mg. 

What is happening right now is my father is very confused, believes that he has seen people, believes that he has more grandchildren than actual.ﾠHe is still hospitalizedﾠand this is where all his confusion is occuring. Our main concern is could it be the Midazolam that is possibly still in his system? Last dose was July 11, of 1 Mg. but as I mentioned he was on Midazolam from May-July 5th with 10 mg, then weaned from 7 mg, down to 5mg, then 2 mg then 1mg. This along with the other medication that is currently being used for his lower back pain. We are very concerned as to why my father is so unsure of his whereabouts, and his previous life, even though he is fully alert. 

Midazolam is a drug of the benzodiazepine class. Valium is another example. These drugs are very commonly used for sedation in critically ill patients. Your father has obviously been through a very difficult time, been extremely ill, and presumably received a wide variety of different medicines and treatments. Although it is tempting to focus on one particular "culprit" for the current problem with his mental state, his condition may be due to a variety of factors, of which midazolam could be one. 

Midazolam, although a pretty safe and very useful drug, can cause amnesia and confusion, especially in the elderly, and especially if used over a prolonged time. It seems appropriate that the midazolam was reduced and then stopped. It is also likely that after three weeks there is not going to be any significant amount of midazolam left in your father's body. 

Other possible factors that may explain your father's problems include: Other drugs used for sedation or pain management, pre-existing brain problems such as dementia, vascular disease, electrolyte disturbances, brain injury from low blood pressure or low oxygen, nutritional problems, liver or kidney function problems, etc. Unfortunately, the recovery from major illness in the elderly may take a very long time and require a lot of effort from caregivers, family and of course the patient. I hope your father soon regains his memory and his sense of who and where he is. 

After a fall I had to have my spleen removed. After the operation I did not waken and remained incoherent for 3 weeks. I`m bipolar and it really screwed up my mind. Can you tell me why this occurred? 

I'm not an expert in bipolar disorder but there are a few things I can say based on the limited information you've given me. First, I don't know of any studies that show that persons with bipolar disorder react any differently to general anesthesia than other people. On the other hand, if you are taking medications for this condition, it is possible that there may have been an interaction between those medications and the anesthesia, lengthening the time it took you to awaken fully. I think it is rather unlikely however that the difficulty you had over the following 3 weeks would have had anything to do with the anesthetic. The medications we use are gone from your system within hours or days, and currently we do not believe that they cause long term effects, except possibly in the elderly. Bipolar disorder is a condition that fluctuates even without surgery or anesthesia. What triggers a worsening in your case? Environmental stresses can certainly worsen things, and major surgery has got to be one of the most significant stresses that anyone can face in their lives. Having your spleen removed is something necessary only after a serious injury. How did you fall? Were you suffering from a worsening of your bipolar disorder at that time? I think you need not fear anesthesia in the future, only be sure to tell your anesthesiologist as much as you can about your previous experience, preferably with a copy of the relevant hospital records and an accurate list of your current medications. 

I had two surgeries within two months, The first was a rib resection for Thoracic Outlet Sydrome. The second was to repair two ruptured discs in my neck (C5/6 and C6/7). I seem to be experiencing some aphasia, memory problems, and concentration issues that were not present prior to these surgeries. I am a 47 year female in overall good health, although I am about 40 lbs.overweight. I am active and work full time as the Director of a Mental Health agency. I returned to work full time on April 30 and have really noticed the above sx and just not feeling as "sharp" mentally. Could my sx be a result of these two surgeries and related anesthesia? As far as I know both surgeries went fine with no complications. The rib resection was a much longer recovery time. 

Thanks for your question. The official terminology is "postoperative cognitive dysfunction" or POCD. A study from Denmark in the late 90s showed that this phenomenon is perhaps more common than we have previously thought, at least in elderly patients (over 60). About 25% of patients had cognitive deficits 1 week after major non-cardiac surgery. This decreased to about 10% after 3 months - still pretty high. This study triggered renewed interest into what, up until then, may have been thought of as something supported only by anecdotes, not scientific study. In this study, a second operation was a risk factor for early, but not late (3 months) cognitive dysfunction. The study was done in elderly patients. Someone of your relative youth would be expected to have less of a problem with POCD but there isn't a whole lot of study data to document this. 

The obvious conclusion would be that general anesthesia, whose "target", after all, is the brain, causes this impairment of brain function. The surprising thing is that regional anesthesia and general anesthesia are associated with about the same number of problems. In fact, one study showed a higher incidence of problems with regional (epidural) anesthesia. 

The difficulty with this area of study is that surgery cannot be performed without anesthesia, so you can't really separate out the effects of surgery and the recovery process, from the effects of anesthesia. No-one is volunteering to have surgery without anesthesia to help answer the research question! The encouraging thing is that the studies seem to show most patients improve for at least 3 months and probably longer, so you still have a ways to go. 

Of course, many things other than your recovery from the surgery can affect mental sharpness. Are you getting enough sleep? Eating right? Have support at home? Do you smoke? Are you in pain? It's going to be stressful going back to a busy job after only a month of recuperation so psychological factors may also come into play.