Recurrent Psychogenic Coma Following Tracheal Stenosis Repair

Abstract

Medication, intracranial hemorrhage, infarction, infection, hypoxia, organ failure, and nutritional deficiency may cause unconsciousness following successful emergence from anesthesia. A 39-year-old woman with a history of tracheal stenosis, depression, and anxiety had complete unconsciousness on 3 separate occasions following surgical repair of her tracheal stenosis. In each case, the patient's endotracheal tube had been removed; she was alert and oriented to person, time, and place; and she was admitted to the hospital for observation. Within a few hours after the tube was removed, the patient became abruptly unconscious for periods of 36, 18, and 30 hours. Each time, the results of cardiac, pulmonary, metabolic, and neurologic examinations and radiological studies were normal. We hypothesize that the patient's apparent comas were the result of an underlying conversion disorder precipitated by unresolved psychological conflict surrounding a long history of abuse in which she was repeatedly smothered by a pillow.

Repeated episodes of difficulty with arousal following general anesthesia in a patient with ulnar neuropathy

“…Regardless, delayed emergence in a patient who previously experienced "functional" delayed awakening should alert the anesthesiologist to the possibility of a psychiatric cause. Indeed, in the majority of previously reported cases, the patient had a signifi cant psychiatric history, including primary psychiatric disorders (depression, bipolar disorder, posttraumatic stress disorder, anxiety, or substance abuse history) [4,[6][7][8]11,14] and/or personality disorder (borderline and histrionic personality traits) [3,4]. Our patient had undergone preoperative psychiatric evaluation which did not reveal either a psychiatric or a personality disorder.…”

“…Psychogenic coma following general anesthesia is rare [3,4,[6][7][8][10][11][12][13][14][15]. Most previous cases involved female patients undergoing otolaryngologic or gynecologic procedures.…”

“…Repeat episodes of psychogenic delayed awakening have been reported in four patients. [3,4,7,12] Our patient differed in that she experienced episodes of uneventful emergence from general anesthesia that alternated with episodes of delayed awakening. Review of her medical record could not identify an obvious organic mechanism to explain the delayed awakening.…”

“…Because psychogenic coma is a diagnosis of exclusion, patients undergo an extensive work-up to identify potentially lifethreatening conditions. These patients usually have an underlying psychiatric or psychological condition, personality disorder, or external incentive for symptom fabrication [3,4,[6][7][8]10,11]. We report a unique case of a woman with no history of psychiatric disorders or were dilated, responsive to light, and 7 mm in diameter.…”

“…However, there are rare situations in which delayed emergence from anesthesia may be the result of psychogenic factors ("psychogenic coma"); namely, factitious, conversion, and dissociative disorders [3][4][5][6][7][8][9]. Because psychogenic coma is a diagnosis of exclusion, patients undergo an extensive work-up to identify potentially lifethreatening conditions.…”