Authors: Ba L
Cureus 17(11): e96646, November 12, 2025, 10.7759/cureus.96646
This case report describes a 74-year-old woman who experienced prolonged unresponsiveness followed by significant postoperative agitation after an otherwise uneventful general anesthetic for laser ablation of a laryngeal tumor. The core message is that delayed emergence in older adults can be multifactorial, and psychological predispositions may meaningfully interact with physiologic aging and anesthetic pharmacodynamics.
The patient had longstanding hypertension (telmisartan) and was notably anxious and tense preoperatively, but no formal psychological screening was performed. Induction included midazolam, fentanyl, propofol, and rocuronium; maintenance was sevoflurane and remifentanil with BIS maintained between 50–60. Neuromuscular blockade was reversed with sugammadex, and midazolam was antagonized with flumazenil. Despite end-tidal sevoflurane reaching 0% and BIS staying above 90 for about 10 minutes, the patient remained unresponsive to verbal stimuli for more than two hours in PACU.
During this period, she had restored motor strength, normal pupillary responses, and withdrawal to painful stimuli, but she became agitated with RASS scores of +2 to +3. Serial arterial blood gases did not show a persistent metabolic or respiratory explanation: an early mild respiratory acidosis improved on repeat testing. With common causes (residual anesthetic effect, hypothermia, persistent hypoventilation, incomplete reversal of paralysis, major metabolic derangement, obvious neurologic catastrophe) felt to be unlikely based on the workup and clinical exam, she was observed and ultimately recovered spontaneously about three hours after surgery, without recall.
A key historical clue emerged from the family: a nearly identical episode occurred two years earlier after anesthesia, and they described her as having an anxious, “stubborn” temperament. The author argues this pattern supports a psychological contribution that may amplify or prolong emergence phenomena in vulnerable older adults—especially in the setting of age-related pharmacodynamic sensitivity—leading to an appearance of delayed awakening with agitation that can be difficult to attribute to a single physiologic cause.
Key Points
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Delayed emergence in older adults may persist even after apparent clearance/reversal of common anesthetic contributors (volatile, benzodiazepine, neuromuscular blockade), and can be accompanied by agitation rather than calm somnolence.
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Serial ABGs and focused bedside neuro exam can help exclude persistent hypoventilation, metabolic derangements, and obvious neurologic injury when delayed awakening occurs.
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A prior history of similar episodes and prominent preoperative anxiety/personality traits may signal a psychological component that meaningfully shapes emergence.
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Consider adding brief preop psychological screening (anxiety/depression tools) for older adults with strong anxiety traits or prior atypical emergence, and tailor anesthetic plans accordingly (e.g., minimize benzodiazepines, continue EEG-guided dosing, emphasize nonpharmacologic calming and orientation strategies).
What You Should Know
Delayed awakening is often approached as a “rule-out” problem (drug effect, metabolic issue, hypothermia, neuro event). This case is a reminder to also ask, early, about prior emergence problems and baseline anxiety/behavioral traits—because those factors can change how an older patient transitions through emergence and can present as prolonged unresponsiveness plus agitation even when the usual physiologic culprits look unlikely.
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