Slipping Into Unconsciousness: General Anesthesia in the Vulnerable, Concussed Brain

Most of the focus surrounding the outcomes and use of general anesthesia has been on two populations – pediatric patients and elderly patients. This is due to the vulnerability of the young, developing brain and the aging brain. In an article titled “The Hidden Dangers of Going Under,” it is posed that the negative effects of general anesthesia in older adults may be due to the binding targets of the drug to the surface proteins of neurons in the brain which decrease in abundance with age. Input from experts suggests that the brain in an older adult may have a difficult time lighting up the connections within the brain that may have broken down under general anesthesia. 

What does this mean for the vulnerable, concussed or post-concussed brain in which there is already poor circuitry and difficulty lighting up connections? The very anesthetics used do such a great job because they incapacitate the surface proteins of neurons that are responsible for regulating attention, memory, learning and sleep. 

“Although physicians have known about the possibility of such confusion since at least the 1980s, they had decided, based on the then available evidence, that the drugs used to anesthetize a patient in the first place were unlikely to be responsible. Instead, they concluded, the condition occurred more often because of the stress of surgery, which might in turn unmask an underlying brain defect or the early stages of dementia. Studies in the past four years have cast doubt on that assumption, however, and suggest that a high enough dose of anesthesia can in fact raise the risk of delirium after surgery. Recent studies also indicate that the condition may be more pernicious than previously realized: even if the confusion dissipates, attention and memory can languish for months and, in some cases, years.”1

Because of so many variables and factors that go into surgery, scientists have struggled to point out causality between anesthesia and poor outcomes and symptoms. Anesthesia is only a piece of the puzzle and with so many compounding factors, can it truly be the culprit for worsening of preoperative symptoms in the concussed patient? I am going to address some of these components.

Are the negative effects of anesthesia dose dependent?

As research continues to be published on this topic, the amount of anesthesia given is being evaluated and considered. Is there a greater risk the deeper someone slips into unconsciousness?

Using EEG, we finally have more information as to what happens to the brain under anesthesia. EEG (electroencephalography) is similar to an EKG of the heart but measures the electrical activity of the brain. Most anesthesiologists do not monitor brain activity during surgery, though one anesthesiologist holds a strong stance on this topic and believes every patient’s brain should be monitored during surgery. Neuroscientist and anesthesiologist, Emery Brown, monitors all of his patients in surgery via EEG and believes this should be common practice. This way, the dosing of anesthesia can be very individualized and adjusted precisely for each patient.2,3

You can imagine that your neurons are constantly firing and communicating with each other as you think, move, talk, assess your environment and surroundings. One of the most common anesthetics used today, propofol, shuts down these neurons within seconds of administration. The communicating and firing throughout your brain comes to a halt. The frequency of neurons in an awake, healthy brain spike approximately 10 times per second. After the initiation of the anesthetic, those spikes drop to once per second or even less.The fewer electrical spikes throughout the brain means the deeper the anesthesia which is where EEG monitoring comes into play. By viewing real time activity of the brain, the anesthesia dose can be adjusted accordingly per patient.

A study was conducted in Hong Kong in 2013, assessing the outcomes of patients receiving general anesthesia with one group monitored via EEG to keep the brain’s electrical activity as high as possible and the other group monitored via heart rate and blood pressure only. 462 of the patients were in the EEG group and 459 in the other. 16% of the patients who received light anesthesia based on EEG monitoring, displayed confusion postoperatively as compared to 24% of the patients in the standard of care group. Looking at long term outcomes, 15% of patients who received standard of care anesthesia experienced lingering mental setbacks for at least three months compared to 10% in the EEG group.1

It seems EEG monitoring of patients in surgery should become standard of care and could aid in preventing some of these long-lasting, poor outcomes. 

Would regional anesthesia be better for the concussed patient than general?

What if instead of general anesthesia they used a regional block with conscious sedation? Could this potentially protect the brain from the negative effects of general anesthesia?

Regional anesthesia uses local anesthetics to block a nerve of a large area. Conscious sedation is often used with it as a way to offer a comfortable environment for the patient without them completely losing consciousness. The goal of conscious sedation is to make you feel relaxed; you may feel drowsy or loopy. For instance, a patient may undergo hand surgery by having a nerve blocked in the upper arm or wrist in combination with conscious sedation. In theory, this sounds like a better bet for concussed patients. They can perhaps avoid the incapacitation of neuron communication, potential fluctuations in blood pressure and blood flow to the brain. 

The bonus of this is that the patient can undergo a procedure or surgery without losing consciousness and can avoid some of the negatives of general anesthesia. Although, is this always the case?

Anesthesiologist, Frederick Sieber, conducted a study comparing delirium in patients receiving regional versus general anesthesia. All patients were undergoing surgery for hip fractures and were 65 and older. The regional anesthesia group received propofol for conscious sedation and an anesthetic to numb the nerves coming from the spinal cord. The depth of anesthesia achieved was monitored via the standard of care with heart rate and blood pressure. Simultaneously, a computer which Sieber and his team could not see, was monitoring the electrical activity of a patient’s brain using electrodes on the forehead. Sieber was astonished at what he saw. He found that “Eighty-seven percent of patients’ brain activity dipped low enough to qualify as general anesthesia during at least part of the surgery.” Based on this, he suspects it is “common for patients getting regional anesthesia to receive so much sedative drug that they are actually in a state of general anesthesia.”1

Without EEG monitoring of the brain and using the current standard of care monitoring of heart rate and blood pressure, patients may receive so much sedative that they end up in a state of general anesthesia anyway. This is also something to consider in the concussed patient. For me personally, I had thought choosing regional over general would erase all of the concerns but as this shows, the result may just be the same.

Part III

Discussed next are other important factors to consider: the stress of surgery itself, site of surgery, inflammation produced by surgery and if the effects of anesthesia on the brain are completely reversible.


1. The Hidden Dangers of Going Under 
2. This is your brain under anesthesia
3. General Anesthesia Causes Telltale Brain Activity Patterns

Surgery Considerations for the Concussed Patient: Is the Brain At Stake?

man holding another man s head

The advent of general anesthesia completely altered the course of surgery from a barbaric, hazardous, Frankenstein-like horror to a humane and often life-saving intervention. Thanks to general anesthesia, the trauma associated with the surgery to both the medical staff and patients due to horrific screams, pain, terror and death was eliminated. 

Some of the first substances attempted to minimize pain associated with surgery were wine and opium. For hundreds of years, various herbs were used. Ether was first synthesized from alcohol in 1540 followed by the discovery of nitrous oxide (laughing gas) in 1722. Both ether and laughing gas were used solely for entertainment purposes and ether follies became a popular gathering. People would gather, sniff ether together and get high. It wasn’t until the mid-19th century when these entertaining intoxicants were considered for medical use. 

William Morton, dentist, was experimenting ways in which he could perform dental procedures pain-free on his patients and first considered laughing gas. At one of the ether follies, Harvard chemist, Charles Jackson, witnessed a man who sustained a significant leg injury while high on ether and he did not show any evidence of pain. He advised Morton to use ether for his procedures.

Morton proceeded with the use of ether in several dental procedures. He then got in contact with surgeon, John Warren, who gave him permission to anesthetize his patient with ether. Together, they proceeded with the first public demonstration of surgery using ether-induced general anesthesia on October 16, 1846, now called Ether Day. In just a few short months following, the world of surgery took a drastic change as ether-induced anesthesia was used in surgeries across the globe.1 Today, we have various anesthetic agents to choose from for surgery.

As a topic that continues to be brought to light, I felt it best to address it again. Many concussed patients might find themselves in a similar situation – deciding to proceed with a surgery or not. The risks in relation to brain injury recovery and the potential for worsening preoperative symptoms and even causing a prolonging of concussion symptoms are not typically discussed at length prior to proceeding. 

Thankfully, with the evolution from literally no sedation or anesthesia, to wine and opium, to laughing gas and ether follies, and now to a wide variety of anesthetic agents, we can undergo surgery without the unspeakable and unfathomable agony experienced in the past. Only, underneath the surface, long-lasting lingering effects of general anesthesia may still continue to haunt patients. With the evidence currently available, can we really blame anesthesia for such outcomes?

I have connected with several people who wanted to gain more insight and discuss moving forward with a surgery during their own respective brain injury recoveries. Faced again with a similar predicament recently, I was reminded of my blog post entailing an elective surgery that occurred within three months of my TBI. While awareness has heightened regarding this very topic, more research is required. I reviewed some of the literature discussed in my previous blog post which will be re-visited but also pose new questions and concerns regarding surgical outcomes in the concussed patient.

I was astounded by the percentage of concussed patients that are faced with this same predicament. Within one year of concussion, typically in the first month, about 8-12% of these patients will present for surgery.Another study showed 5% of recently concussed patients underwent elective surgeries unrelated to the concussion within one week of injury.3 The significant percentage of concussed patients faced with the prospect of going under the knife could simply be due to the increased risk of musculoskeletal injury they face due to changes in attention, cognition, hand eye coordination, reaction time, etc. In reality, these percentages may be higher due to the fact that there are no concussion screening tests implemented preoperatively. With such a prevalence of concussion patients presenting for surgery, the outcomes should be considered. 

There are some questions that come to mind when considering surgery during TBI recovery:

  • How will surgery itself affect the brain and specifically how will it affect brain recovery?
  • How will general anesthesia affect the brain and specifically how will it affect brain recovery?
  • How likely is it that surgery will worsen preoperative concussion symptoms?
  • Are the effects of general anesthesia on the brain entirely reversible?
  • How will the inflammation produced from surgery affect the brain?
  • How will surgery recovery in combination with concussion recovery affect quality of life?
  • Does the specific surgical site play a part in recovery of the brain?

Here’s what we do know:

  • Surgery itself is stressful and multifactorial!
  • General anesthesia can negatively affect the brain.
  • All surgeries and trauma to any part of the body produces inflammation. 
  • Inflammation can negatively affect the brain.
  • The general consensus from surveyed anesthesiologists is that elective surgery should be postponed until patient concussion symptoms are stable or have completely abated. Keep in mind, the brain continues to heal long after symptoms disappear. Symptom disappearance does NOT mean the brain is fully healed.

Advice to the concussed patient considering or undergoing surgery:

My best advice to any patient with brain trauma who is in a predicament because they are recommended surgery during brain injury recovery and to those who are unable to postpone the surgery is to read the science and literature that is available. It is best to empower yourself with this information and bring it to your provider for discussion. Consider your current quality of life and think about how the recovery of another part of the body would affect your quality of life which includes your mental health. Consider your current symptoms and the risk involved with worsening of those very symptoms postoperatively.

Discuss these concerns with your surgeon and also ask to discuss these concerns with the anesthesiologist that will be in the surgery with you. There are now intraoperative goals specifically for TBI patients. As this is still an issue on the rise, it is wise to discuss these established goals5 with both your surgeon but more importantly, your anesthesiologist:

  • Cerebral blood flow autoregulation is likely impaired after TBI so even mild hypotension should be avoided to reduce the risk of cerebral hypoperfusion
  • Maintenance of mean arterial pressure at the patient’s baseline value or higher is therefore appropriate
  • Hypovolemia should be treated using isotonic normal saline rather than hypotonic fluids, which could cause cerebral edema, or colloids, which have been associated with poor outcomes in TBI
  • Since hypocarbia (reduced carbon dioxide in the blood) in the face of impaired pressure autoregulation may lead to cerebral ischemia, mechanical ventilation should be adjusted to maintain normocarbia during surgery

In my next post, I will discuss the specific questions posed in this post in detail and review studies available on this front. Is general anesthesia the culprit or are the compounding factors surrounding surgery itself to blame for poor outcomes and worsening of preoperative symptoms?


1. Ether day: an intriguing history
2. Is a Concussed Brain a Vulnerable Brain? Anesthesia after Concussion
3. Concussion in the Perioperative Period: A Common Condition Requiring More Investigation
4. Anesthesia for the patient with a recently diagnosed concussion: think about the brain!