I hope you can provide me with an answer or at least point me in the right direction. Last week, my father (74), had heart surgery in which he had 4 bypasses and a new valve put in. Let me give you a little more background information before I go into the problem. 

Earlier this month we found that he has a really large tumor on his pituitary gland and that it is compressing his optic nerve causing loss of vision. He was scheduled to have the tumor removed, but had to see his cardiologist first. Unfortunately, the cardiologist had tests done and he had to have the bypasses and the new valve, which leads me to the present. Also, he has been taking medications for high blood pressure and prostate, and pain meds for his arthritis. 

He had the heart surgery last Monday, and today is 8 days later and he has finally come out of the Anaesthesia more. It took him about 5 days to be able to start moving his limbs (left side arms and legs moved before the right side of the body). On day 7 he finally had his tubes removed from his mouth, and can speak. However, sometimes what he says does not make sense (as if he is dreaming) and he can not open his eyes (he can open his left half way). When his eye is open, he can not see! 

Apparently, no one in the hospital knows what is happening. Finally, after over a week, some doctors acknowledged that they don`t know what is wrong. He`s had CT scans which showed no strokes, his heart is working perfectly, he can talk, today he started eating. Neurologists, cardiologists, endocronoligists are all stumped. Hopefully, you can shed some light on his situation and put us at some ease of at least knowing what is happening. The doctors said some people take longer, but that he is a real outlier being in ICU still after a week. 

Thanks for your question. I'm afraid I cannot shed any light. That of course is what is missing, literally, in your father's case. It sounds like a rather complex set of problems that really can only be understood, despite your very detailed account, with careful review of all the medical details. 

Neurologic (brain) problems are a leading cause of trouble after open heart surgery. This can include generalized symptoms like confusion and disorientation, as well as focal symptoms (loss of function in a specific area, like movement, or visual loss). The standard approach is to look for, and fix, the fixable things, including minimizing sedative agents as far as possible, maintaining "homeostasis" (blood pressure, oxygen, electrolytes, hemoglobin, etc) and then hoping for recovery over time. In terms of the visual loss, I suppose it is possible that the pituitary tumor has enlarged, because of edema, bleeding into the tumor, or rapid growth of the tumor. This should be apparent on a CT or MRI scan. 

My nephew was burned 70% of his body (third degree) two years ago this Christmas. He was kept in a medically induced coma for 7 weeks. He underwent approximately 35 surgeries in two years for skin grafting and muscle flaps. At the time of the accident he was 28 years old. His last surgery was May 2006. He needs to have another surgery in February 2007. Most of his surgeries were for between 6 and 8 hours at a time and at least one was for 14 hours (the muscle flap). He is still on pain medication and will probably remain so for at least 6 more months. 

We have noticed huge changes in his personality. I realize that such a severe accident would cause personality changes and mood swings but am concerned about the amount of anesthesia that has been used to sedate him for the many surgeries. He has huge memory gaps and his short term memory is almost non-existent. He gets very tired and he falls asleep even while eating. 

I am wondering if there could be any neurological problems associated with all of the anesthesia he was given and for the length of time he was kept sedated. Since he must have more surgery in the future should he first be checked by a neurologist to see if there is any brain damage and would a neurologist be able to check for effects of long use anesthesia? 

Wow. Your nephew has been through an incredibly traumatic time. There are very few people who have survived 70% full thickness burns. It is not at all surprising that he has problems with fatigue, memory gaps, and changes in personality. To focus on the anesthesia as a cause of his problems is I think a mistake. Without skilled anesthesiologists your nephew would probably not be around. 

Does repeated general anesthesia (for surgical procedures) have direct effects on the brain? Well, it is not possible to rule that out entirely. We are learning more and more about the subtle effects of anesthetic agents on brain cells, immunity and various molecular pathways. There may in fact be some effects that persist beyond the time that the drugs themselves are gone from the body. Whatever effects do occur seem more likely to happen in the elderly patient. 

As far as the prolonged sedation in the ICU is concerned, the effects of this approach are also increasingly recognized as having some potential harm. When heavy sedation is used, current guidelines recommend turning off the sedation periodically - at least once per day. This may not always be possible - there are good reasons for using the sedation - and a patient as severely, critically ill, as your nephew may be just such a case. 

A neurologist would certainly be able to assess your nephew for brain damage through various means, including a simple physical examination, and to what degree he is impaired. However, this will probably not have any impact on the need for, or type of, anesthesia selected for any future surgical procedures. Such an assessment may be useful for other reasons such as helping your nephew regain abilities to function in normal life. 

Everytime they would try to wake my father up after quadruple bypass, he would go into convulsions. What is the cause of this and will it leave him with any side effects? 

Over a period of 10 yrs., I`ve had 3 long cervical and 1 long lumbar spinal fusion. My voice has changed; sounds rasping when I`m tired; I have problems swallowing; learned to Heimlich myself when food gets stuck, and even have sudden muscle spasms trying to swallow saliva and think I`m going to choke to death. One surgeon said all the tubes put in during surgery could affect vocal cords, muscles, and nerves. What advice or help is there to relieve these problems? Does any of this also cause me to slur my words when I`m tired? I`d truly appreciate your insight. Many thanks. 

I`m sorry to hear of your difficulties. Recent studies are showing that endotracheal intubation ﾖ that is, the insertion of a plastic breathing tube into the windpipe ﾖ can cause minor damage to the vocal cords in a surprisingly high number of patients. This can occur even when the intubation is performed by an expert and appears to go absolutely smoothly. When the larynx (voice box) is examined with special instruments after apparently routine intubation, bruising or swelling of the vocal cord structures is often seen. This minor damage causes hoarseness which, fortunately, almost always improves over a few days. Unfortunately, endotracheal intubation is necessary for most surgeries on the spine, and we have not yet discovered ways to protect our patients from these minor injuries. More severe or permanent damage to the larynx (voice box) from endotracheal intubation is quite rare. Risk factors may include rheumatoid arthritis and the use of steroid medications. It is not clear whether damage to the voice box increases with the duration of the surgical procedure, but in someone who has had several long procedures, the chances of injury are probably higher. The symptoms other than hoarseness that you mention ﾖ problems swallowing, food obstruction, muscle spasms and slurred speech, do not sound like they are connected to the tubes youﾒve had placed during surgery. They raise the possibility of a neurologic (nerve) problem, or a throat disorder, that might possibly be related to your previous surgical procedures but may also have nothing at all to do with them. I would strongly advise that you seek a specialist referral to an appropriate professional, such as an ear, nose and throat doctor or a neurologist. 

My husband recently had batteries replaced in his Medtronics neurostimulators which are implanted on each side of his chest. The first time was 4.5 years ago which conscious sedation was used and he had no reaction afterwards. This time which was in early November the new neurosurgeon and hospital used general anesthesia we were not given a choice. Since this was same-day surgery we returned home immediately afterwards. The next day or so I noticed that he was not behaving normally, nor could he stand or walk whatsoever. He has had Parkinsons for 17 years and neurostimulators for 7. We returned to the hospital where he remained for an entire week, mostly in Physical Therapy/Rehab to learn how to stand and walk again. Could the type of anesthesia used have made a difference this time. We want to avoid another episode of this kind in the future as batteries need replacing from time to time. Thanks! 

I am going to assume that what you have described is a relapse, or worsening, of your husband's Parkinson's disease. I assume also that the "neurostimulators" are deep brain stimulation electrodes. (These assumptions might not be correct and you must of course discuss these issues with your doctors.) 

General anesthetics by definition, are drugs with effects on the central nervous system. I am not aware of any published studies indicating that general anesthesia causes a worsening or relapse of Parkinson's disease. Parkinson's is a disease in which deterioration can occur for a variety of reasons - please check with your neurologist. It is possible that adjustments were made to your husband's medication before or after the procedures that might have caused the changes you describe. It is also possible that the settings of the stimulators were changed or that their function has in some way been altered. 

Because it is nearly 5 years since the original procedure it is probable that the disease has advanced, and this alone could mean less resilience and a longer period of recovery. 

There is a syndrome of "postoperative cognitive dysfunction" (POCD) that is being actively investigated. It is not clear whether it is surgery, or anesthesia, or some interaction of the two that is responsible for cognitive and behavior changes, mainly in the elderly, seen in some patients after various kinds of procedures. 

My own philosophy when treating any patient with a degenerative brain disorder, is that less is better. In these patients I would support a choice of light sedation rather than deep general anesthesia wherever possible. Unfortunately this technique is not always practical or safe. In addition, no study has yet shown a decrease in any cognitive changes with the use of sedation rather than general anesthesia. 

I have been reading material that suggests MG can often "unmask" itself, or, there is a relationship between trauma, surgery and anesthesia, and the onset of MG. I have had back problems for years and spent many days in hospitals for treatment, including traction, drugs for relief, and a surgery in 1998. In your opinion, can trauma related to this "accelerate" the onset of MG? 

I am not familiar with the material you have been reading that suggests an unmasking or acceleration of myasthenia gravis in the circumstances you describe. But it is not suprising that trauma, surgery and anesthesia would all have a significant impact on the course of this auto-immune illness. Changes could occur in a variety of ways. 

For instance, certain anesthesia drugs are known to have measurable suppressant effects on the immune system. 

Secondly, the stress of surgery itself alters the hormonal environment of the body (producing higher levels of adrenal hormones) which would also have effects on immune function. 

It is not uncommon for anticholinesterase drugs used in myasthenia gravis to be discontinued immediately prior to surgery, possibly because of concerns about the interaction with anesthesia medications. When treatment is restarted, it may be difficult to establish the appropriate dose of medication because of all the other changes taking place. For example, the absorption of orally administered medications may be delayed or decreased. 

Finally, it may be difficult in some circumstances to distinguish between the symptoms of myasthenia and the general weakness or malaise associated with recovery from a major surgical procedure. As you know, myasthenia gravis can have "spontaneous" episodes of worsening and improvement. For this reason, and the reasons I have described above, it may be difficult to predict the response of an individual with this disease to surgery and anesthesia. For more information I suggest you check with your neurologist. 

My father has not been diagnosed yet but has a significant tremor in his right arm. His neurologist said it is probably Parkinson`s Disease. Dad does not feel he needs medicine for it yet. He had his colon resected in `98 (stage III cancer). Now his cancer blood marker is rising and his oncologist says an operation would be too much of a risk for him because anesthesia can aggravate motion disorders permanently. Is this true for both local and general anesthesia? Dad had no problems with his previous colon resection operation. Thanks for your help. 

ﾠThank you for your interesting question. The short answer is that anesthesia can be safely administered to patients with Parkinson`s Disease. 

In patients with Parkinson`s disease undergoing surgery, the administration of anesthesia does however require some special precautions. For example, anesthetic drugs that affect dopamine, (the brain chemical which is thought to be reduced in Parkinson`s disease), should probably be avoided. Secondly, problems can occur from the interaction of anesthetic agents with the drugs used to treat Parkinson`s disease. Finally, under anesthesia certain problems may occur more commonly in those affected by Parkinson`s disease than in healthy patients. These include increased or decreased blood pressure, irregular heartbeat, aspiration, and breathing difficulties. 

Despite the aforementioned, we frequently administer both general and regional anesthesia to patients with Parkinson`s disease without causing any obvious harm to them. I am not aware of any studies that have documented a permanent worsening in movement disorder due to anesthesia - I would be very interested to learn of such a study. I think it is unwise to deny a patient his needed cancer surgery on these grounds. Remember to advise the anesthesiologist of your concerns, and consider asking for a pre-surgery consultation to discuss them.