LETTER TO EDITOR
Year : 2012 | Volume
| Issue : 4 | Page : 429
An unusual cause for delayed induction and recovery: Faulty cannula fixation technique
Parnandi Bhaskar Rao, Neha Singh, Trichu R Ramachandran
Department of Anaesthesiology and Critical Care, Pondicherry Institute of Medical Sciences, Pondicherry, India
Department of Anaesthesiology and Critical Care, P.I.M.S, Pondicherry 605 014
Source of Support: None, Conflict of Interest: None
|Date of Web Publication||10-Jan-2013|
|How to cite this article:|
Rao PB, Singh N, Ramachandran TR. An unusual cause for delayed induction and recovery: Faulty cannula fixation technique. Saudi J Anaesth 2012;6:429
|How to cite this URL:|
Rao PB, Singh N, Ramachandran TR. An unusual cause for delayed induction and recovery: Faulty cannula fixation technique. Saudi J Anaesth [serial online] 2012 [cited 2023 Mar 29];6:429. Available from: https://www.saudija.org/text.asp?2012/6/4/429/105900
Splints are part of the dressing for peripheral i.v. cannulae in children to prevent accidental dislodgement. Here we report a case of delayed onset and recovery from anesthesia secondary to faulty cannula fixation technique.
A 2-month-old male term baby diagnosed as a case of hypertrophic pyloric stenosis was posted for surgical correction. History, general and systemic examination, and laboratory evaluation did not reveal any abnormality. No sedative premedication was required for parental separation. The patient was received with a 1-day-old intravenous cannula with running fluid through an infusion pump. Standard intraoperative monitoring techniques were used and a thermal blanket was used to keep the baby warm. On table, he received glycopyrrolate 0.01 mg/kg, fentanyl 2 μg/kg and midazolam 0.05 mg/kg, thiopentone 5 mg/kg, and vecuronium bromide 0.1 mg/kg. Successful laryngoscopy and tracheal intubation could be done only after 6 min of induction and deepening of anesthesia. Anesthesia was maintained with oxygen, nitrous oxide, and sevoflurane with intermittent boluses of fentanyl and vecuronium bromide. Satisfactory muscle relaxation was achieved only after repeated saline flushes following each bolus of vecuronium bromide (0.05 mg/kg). He showed no signs of recovery for 2 more hours of surgical closure with no response to neostigmine reversal. To our surprise, improvement in the recovery was achieved only after releasing the tight splint dressing. There was a reduction in the resistance to a repeat saline flush. Rest of his hospital course was uneventful.
We experienced delayed onset of i.v. anesthetics with a prolonged duration of neuromuscular blockade in our patient. Although the prolonged effect of the drugs in pediatric patients can be explained by multiple factors,  delayed onset and delayed recovery which responded dramatically to the release of the tight splint dressing generates concern.
In comparison to adults, children respond differently to anesthesia medications due to several factors. Elimination half-life is usually prolonged in infants, shortened in children, and lengthened again in teenagers approaching adulthood. 
Midazolam per se does not prolong recovery time  and fentanyl has been claimed to hasten recovery.  Time to recovery was longer than expected of the effect of thiopentone only, that is, a burst suppression duration of 11.1±5.6 min. Although sevoflurane is associated with a faster onset and recovery characteristics, it can augment vecuronium-induced neuromuscular blockade,  but not enough to explain delayed onset of action and response to releasing the tight fixation.
Although controversial, splints and armboards are part of the fixation procedure for peripheral i.v. cannulae in children. They should be strapped with the limb in a natural position to prevent restriction of nerve and blood supply, because at times, tight fixation may lead to venous occlusion, and thus resulting in increased transit time of the drug to the heart as we experienced.
Thus tight fixation of peripheral i.v. cannula should also be considered as a possible cause for delayed onset and recovery from anesthesia and due care should be taken to double check the integrity of an already established i.v. line before initiating anesthesia cascade.
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