In Depth | March 2014 Plastic Surgery Practice

By Amanda R. Kirzner, DO, MPH

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Naked Socialite Jumps to Her Death After Facelift

The sensational story grabbed headlines from the beginning. British socialite Sandra D’Auriol, 53, had a facelift, reportedly woke up agitated, stripped naked, and plunged to her death off of a 15-story building in Beverly Hills, Calif. As details of the tragedy began to emerge, medical experts suggested that D’Auriol could have been experiencing postanesthesia-induced psychosis. The story sent shock waves throughout the medical community, and left many cosmetic surgeons wondering if their patients were at risk.

Patients with postanesthetic psychosis commonly experience hallucinations, time-space disorientation, recollection of fastidious events, anxiety, and even paranoia. Improved methods of delivering anesthesia and the development of simpler and more rapid operative techniques have diminished the number of patients who have postoperative psychiatric events in recent years, but it can still occur.

The exact pathophysiology of postanesthetic psychosis is not well understood.  General anesthesia affects brain function at all levels, including neuronal membranes, receptors, ion channels, neurotransmitters, cerebral blood flow, and metabolism. It also affects stress-regulating transmission, the alteration of intracellular signal transduction systems, as well as more essential cellular processes that play an important role in neurotransmitter synthesis and release, including the intraneuronal signal transduction and the second messenger system. Interrupting any or all of these functions can alter mood, memory, and motor function, and cause behavioral changes, which can manifest as postanesthetic psychosis.

Emergence delirium refers to a prolonged change in mental status after the administration of anesthesia. The onset is thought to be a response to a disorienting situation. It’s an acute state of confusion where an altered or dissociated state of consciousness causes reduced ability to focus, sustain, or shift attention, resulting in a cognitive or perceptual disturbance that is not caused by a pre-existing, established, or evolving dementia.

The patient is often irritable, uncooperative, uncompromising, thrashing, moaning, incoherent, or crying. This commonly occurs in elderly patients. Interestingly, there has been an increased incidence in emergence delirium among elderly patients undergoing orthopedic procedures and cardiac bypass surgery. The reason for the correlation with orthopedic surgery is unknown. However, during cardiac bypass, the heart is stopped and blood is circulated throughout the body by a bypass machine, which alters cellular metabolism. This alteration can lead to a change in mental state, or postanesthetic psychosis, in up to 60% of cardiac bypass patients.

Emergence delirium is thought to be a result of pain, hypoxia, hypercarbia, urinary retention, electrolyte imbalance (most often hyponatremia), and central, drug-induced anticholinergic activity. Other major risk factors for postoperative delirium besides age include substance abuse prior to surgery as well as poor functional status.

The various functions of the central muscarinic cholinergic system and its multiple interactions with drugs of anesthesia lead to the conclusion that the inhibition of muscarinic cholinergic receptors likely has a pivotal role in the pathogenesis of postoperative delirium and postoperative cognitive dysfunction. Treatment of this type of delirium after surgery should be directed toward the underlying cause (if it is known).

Patients can also experience a shorter, but similar response called emergence agitation. The highest incidence of emergence agitation is in children aged 2 to 4, where it has been attributed to the increased use of the rapid-onset, low-solubility inhaled anesthetic agents. Most of the time it does not last very long, especially if the parent is present in the postanesthesia care unit.

Awareness, ability to diagnose, and an understanding of the cause of psychotic symptoms that emerge following surgery must be established if physicians are to provide better care and more effective treatment for their patients.

Amanda R. Kirzner, DO, MPH, is slated to begin her anesthesia training in July 2014. She can be reached via PSPeditor@allied360.com.

Original citation for this article: Kirzner, A. Ripped from the headlines: Are your plastic surgery patients at risk for postanesthesia-induced psychosis?, Plastic Surgery Practice. 2014; March: 30.