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A conscious individual is awake and aware of their surroundings and identity. The Glasgow Coma Scale though developed for trauma has remained a reliable means of assessing consciousness. A GCS <8 is defined as Coma.

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The time taken to emerge to full consciousness is affected by Patient factors, Anaesthetic factors, Duration of surgery, Painful stimulation

There are many different variables affecting drug metabolism in patients. The ideal dose for one patient may not be for another.

Will cause prolonged unconsciousness in elderly or in overdose but not usually at doses used for induction or anxiolysis by themselves. When administered with other drugs such as high dose opioids. Usually metabolised by P450 system.

Produce analgesia, sedation and respiratory depression; the intensity of each action varies between subjects and can be difficult to predict. ` Dose response also affected by co-administered drugs. ` Also affected is the response of Carbon Dioxide receptors in the brainstem with reduced sensitivity.
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Can mimic prolonged unconsciousness and also cause hypoventilation. Duration of action of these drugs also affected by a number of other factors. Patient factors such as plasma cholinesterase deficiency can also prolong the blockade.

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Termination of action is by redistribution. Also affected by the context sensitive half life Emergence usually occurs with 80% reduction in effect site concentration. For Example with propofol after a two hour TIVA infusion emergence takes 36 minutes.

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Emergence from volatile agent anaesthesia depends upon pulmonary elimination of the drug and MAC awake (the end-tidal concentration associated with eye-opening to verbal command). MAC Awake is 30% of the MAC. Pulmonary elimination is determined by alveolar ventilation, bloodgas partition co-efficient and dose (MAC hours)

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Hypoglycaemia Hyperglyceamia. Hyponatremia and water excess Hyernatremia and dehydration. Uraemia.

Neurological and respiratory changes occur with decreasing temperature, e.g. confusion (<35C), unconsciousness (<30C), apnoea (<24C), absent cerebral activity (<18C). Cardiac output decreases with a decrease in temperature and arrhythmias occur. Low cardiac output affects circulation and drug pharmacokinetics, as well as tissue perfusion.

Postoperative respiratory failure causes hypoxaemia, hypercapnia or both. The causes of respiratory failure are multiple and may be classified into neurological, pulmonary, and muscular.

A number of different pathologies can cause cerebral hypoxic damage resulting in coma. Damage may be primary or secondary.

There are a number of causes which can cause prolonged unconsciousness. In patients with delayed awakening a stepwise approach is advisable.