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LETTER TO THE EDITOR
Year : 2018  |  Volume : 4  |  Issue : 3  |  Page : 159-160

Spontaneous Severe Hypoglycemia: Cause of Delayed Emergence


Maulana Azad medical college, Delhi, India

Date of Web Publication31-Dec-2018

Correspondence Address:
Dr. Divya Gahlot
Maulana Azad medical college, Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mamcjms.mamcjms_28_18

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How to cite this article:
Gahlot D, Saxena KN, Singh R. Spontaneous Severe Hypoglycemia: Cause of Delayed Emergence. MAMC J Med Sci 2018;4:159-60

How to cite this URL:
Gahlot D, Saxena KN, Singh R. Spontaneous Severe Hypoglycemia: Cause of Delayed Emergence. MAMC J Med Sci [serial online] 2018 [cited 2019 Aug 19];4:159-60. Available from: http://www.mamcjms.in/text.asp?2018/4/3/159/249025





Dear Editor,

A 61-year-old nondiabetic, nonalcoholic female with no other comorbidity was scheduled to undergo laparoscopic cholecystectomy under general anesthesia for gallstone disease. On preanesthetic checkup, nothing remarkable was found, and all the investigations had normal values. Induction of anesthesia was performed with intravenous propofol and fentanyl. Intraoperative period was also uneventful with no hemodynamic alterations. A total of 1.5 litres of Ringer lactate was used intraoperatively. The surgery lasted for a total of 60 to 70 min, and after completion of the surgery, reversal of neuromuscular blockade was performed. The patient was drowsy, but was breathing adequately, so endotracheal tube was removed. Her consciousness did not improve but deteriorated over time. Arterial blood gas analysis was normal, and the patient was not hypothermic and was breathing adequately. After ruling out other causes of delayed emergence, a blood sugar test was performed and was found to be “low” as per glucometer reading (blood sugar <30 mg/dl). A volume of 100 ml of 50% dextrose was given intravenously, and the patient became conscious and responsive within 3 to 4 min of dextrose infusion. Observation in the postanesthesia care unit revealed no neurological sequelae, and she was discharged on the second postoperative day.

Approximately 10% of the anesthetic accidents occur in the immediate postoperative period.[1] Delayed emergence is one of the complications seen in the early postoperative period. Causes attributed to delayed awakening are persistent effect of anesthetics, decreased cerebral perfusion pressure, acid–base disorder, and metabolic complications such as hypothermia, dyselectronemia, and hypoglycemia.[2],[3] Hypoglycemia as a cause of delayed emergence is usually suspected in patients with diabetes mellitus, liver Disease, alcohol abuse, sepsis, undergoing major surgeries such as pheochromocytoma excision, and pediatric age group.

Typically, there is a reversal of glucagon:insulin ratio intraoperatively due to decreased insulin, resulting in increased blood glucose levels. Elevated catecholamine concentrations, sympathetic stimulation, and increased insulin urinary loses are the other causes of raised blood sugars in the intraoperative period.[4] Thus, profound hypoglycemia during emergence is a rare entity in a patient with no other comorbidity. In addition, anesthesia masks cognitive dysfunction, the most sensitive clinical marker of hypoglycemia, and only the symptoms due to sympathetic stimulation such as diaphoresis and tachycardia are seen in an anesthetized patient, which were absent in this patient intraoperatively.[5] Thus, delayed emergence at the time of reversal due to hypoglycemia in a nondiabetic, nonalcoholic adult patient with no other comorbidity undergoing a mild-risk surgery was not suspected.

On detailed questioning, the patient’s relatives revealed a prolonged preoperative fasting period. The patient fasted for 14 h (since 11 pm the night before surgery). The spontaneous severe hypoglycemia found in this case might be attributed to prolonged starvation. Thus to conclude, spontaneous hypoglycemia should be thought as a cause of delayed emergence even in unsuspected cases and should be treated promptly. In addition, inadvertent hypoglycemia can be prevented by avoiding prolonged preoperative fasting periods, measuring preoperative and intraoperative blood glucose of all the patients, and administering glucose-containing fluids to the patients scheduled for surgery later during the day.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Zelcer J, Wells DG. Anaesthesia related recovery room complications. Anaesth Intens Care 1987;15:168-74.  Back to cited text no. 1
    
2.
Ackland GL, McGlennan AP. Acute, severe hypoglycemia occurring during general anesthesia in a nondiabetic adult. Int Anesth Res Soc 2007;105:553-4.  Back to cited text no. 2
    
3.
Khare A, Meena S, Sethi P, Bafna U, Gill N. Anaesthesia due to severe hypoglycemia in a non-diabetic adult. J Coll Physicians Surg Pak 2015;25:627.  Back to cited text no. 3
    
4.
Weissman C. Nurtition and metabolics. In: Miller’s anesthesia. 8th ed. Philadelphia: Elsevier 2015. pp 3126.  Back to cited text no. 4
    
5.
Wiesli P, Schwegler B, Schmid B, Spinas GA, Schmid C. Minimental state examination is superior to plasma glucose concentrations in monitoring patients with suspected hypoglycemic disorders during the 72-hour fast. Eur J Endocrinol 2005;152:605-10.  Back to cited text no. 5
    




 

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