Unconscious patient after elective bilateral total knee arthroplasty.

We present the case of a 66-year-old coach of a national shooting team who had degenerative osteoarthritis in his both knees, but otherwise was healthy and took no regular medication. Neither he nor his family had any cardiovascular risk factors. He did not smoke or use alcohol. His ability to walk was restricted because of osteoarthritis. He was scheduled for bilateral total knee arthroplasty in March 2013. Before surgery, the orthopedist found the range of motion in the knees to be good, no flexion contracture was observed, and flexion was 120 degrees. Both knees were stable ; the varus deformity was 3 degrees. The bone quality in the radiographs was normal. Auscultation of heart and lungs was normal; ECG and laboratory values were within normal limits. The operation was performed under combined spinal and epidural anesthesia, and vital signs were stable throughout the operation, which lasted for 3.5 hours. Normal, cemented, cru-ciate-retaining knee replacement was performed using intra-medullary guides in femur and tibia in both knees. During the second knee surgery, the patient had a short period of confusion when the tourniquet was released. After the surgery, he was observed in the recovery room overnight. Blood pressure and oxygen concentration were normal, and enoxaparine 40 mg daily was started as thrombosis prophylaxis. In the morning, he spoke normally with his daughter and the anaesthesiologist. He was moved to the ward. Thirty minutes later, he was found unconscious. He was extending his upper and flexing his lower limbs, and his head and neck were extended. The pupils were of equal size and reacted normally to light, but he had vertical nystagmus. The patient was sweating and had a fever of 38.5°C. Chest radiograph and brain and chest CT were normal. After consulting the neurologist on call, the patient was transferred to the emergency room within the university hospital. In the emergency room, the patient did not open his eyes, and his gaze was abnormal with the eyes moving from side to side. He did not speak or obey commands. He periodically extended his upper limbs, while flexing his left lower limb. There was flexion to pain in all limbs, and the muscle tone was increased in the upper limbs. Glasgow Coma Scale score was 5. Babinski sign was present on both sides. Next, a cerebral CT angiography was ordered, and the patient was intubated and sedated because of decreased level of …