“Doc, I could hear everything… I just couldn’t move.”
Words that no anesthesia team ever wants to hear — but we did.
Case Snapshot
A 9-year-old child with drug-resistant epilepsy was scheduled for a craniotomy. Years of frequent seizures had left him physically and emotionally drained. MRI revealed a localized seizure focus, making him an ideal candidate for surgical intervention — his best chance at a seizure-free life.
Preoperative Profile
- Weight: 25 kg
- Current Medications: Phenytoin, Valproate, Levetiracetam
- Lab Findings: Mildly elevated liver enzymes
Anesthetic Plan:
- Induction: Propofol + Fentanyl
- Muscle Relaxation: Atracurium
- Maintenance: Sevoflurane
- Monitoring: EEG for intraoperative seizure detection
- Visual Insight: Crisis in Real Time
The Moment Everything Changed
Just two minutes post-induction, unexpected signs emerged:
- The child’s eyes opened.
- Heart rate spiked, facial grimacing was evident.
- Despite sevoflurane at 3%, the child remained conscious and reactive.
We escalated:
Additional propofol, fentanyl, midazolam, and ketamine were given.
- No sedation
- No improvement
It became terrifyingly clear: We were witnessing anesthetic resistance — and worse, signs of intraoperative awareness in a paralyzed child.
Why the Drugs Failed
- The child’s chronic use of antiepileptic drugs had triggered:
- Liver enzyme induction, leading to accelerated drug metabolism
- Desensitization of GABA and NMDA receptors
- Potential subclinical seizures, disrupting the sedative effect
This neurological storm made standard anesthesia protocols ineffective.
Visual Insight: Anesthetic Resistance in Numbers
Post-Op Aftermath
- The child regained consciousness crying and panicked.
- He vividly recalled hearing our voices and feeling the first moments of surgery.
- This confirmed the worst: anesthetic awareness — a traumatic, rare event.
- He was later referred for pediatric psychological care to help process the experience.
Key Clinical Lessons
- Patients on chronic AEDs may resist standard anesthetics
- Depth-of-anesthesia monitoring (BIS) is essential in high-risk cases
- Always prepare a second-line anesthetic plan
- The emotional and psychological impact of awareness must never be underestimated
Final Reflections
- This case challenged everything we thought we knew.
- Despite planning, preparation, and textbook protocols, we were humbled by the resilience of the human brain — especially one conditioned to fight neurological storms.
- It reminded us that true anesthesia care is not just science — it’s anticipation, vigilance, and adaptation.
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