So, recently I've been obsessed with giving IV lido at the end of my cases. I did notice that some of my wakeups seemed a slower, but I was getting these incredible wakeup (pt smiling with the tube in, crazy stuff like that).

So today I did a TKA on a 75yo, pretty sick ASA III (s/p stroke, out of control HTN, etc). She had weakenss and tingling (from the stroke) on the operative side so we didn't give her a FNB.

BP in the room was in the 190s preinduction (takes an ACE, clearly not enough). I ended up giving her 250mcg of fent (200 with induction) and 2 mg of hydromorphone. My narctoic dosing was based on her response to surgical stim. Tourniquet time was only up for 15min. Case took about 1.5hrs. Right before we headed in the room she took celebrex/tylenol/10mg of oxycontin PO. I expected her to wake up in pain and hypertensive.

Now I had given her an LTA (with epi), but I'm not convincing that they last that long and I wanted a super smooth wakeup.

I gave her 50mg of roc for intubation and she was really slow coming back, so I didn't get her back breathing until the very end as I wanted to wait as long as possible before I reversed her.

So, when they started closing I gave her 80mg of lido (she was 95kg).

Long story short, she just would not wake up. Her pupils were not small, but she was really slow in starting to breath. At one point she would open her eyes to my voice, but then go back to sleep with pretty poor ventilatory effort.

When she finally woke up, she never coughed and it was clear that the tube was not bothering her at all. In the PACU she was wide wake with no pain.

MDA said it was defiantly the lido and that it was a HUGE mistake to give a elderly person that much lido. He suggested 20mg as a max dose with no LTA.

Wakeup may have taken as long as 15mins. It was the longest wakeup I've ever had. I feel like it may just been residual gas and a good dose of narc, but it was an odd wakeup that makes me think it could have been lido. Obviously, I should have just relied on LTA It was a big mistake and one of my PDs was on site, so I'm sure I'm going to catch hell.

Defiantly trying to learn from these mistakes.