When the patient “goes under” without induction: psychogenic unresponsiveness mimicking general anesthesia — a case report

Background : Altered mental status (AMS) in the operating room before induction is uncommon and potentially hazardous. When unresponsiveness occurs without sedative exposure yet clinically resembles general anesthesia, rapid, structured evaluation is crucial to avoid iatrogenesis and to identify functional or metabolic etiologies. Case presentation: A 72-year-old woman with type 2 diabetes, Alzheimer’s dementia, and epilepsy presented for elective removal of a right-ankle external fixator. In the operating room, prior to induction, she became acutely unresponsive to verbal and noxious stimuli. Vital signs and oxygenation were stable with preserved spontaneous respiration. Immediate assessment confirmed airway patency; a rapid response was activated while point-of-care testing identified hyperglycemia (>300 mg/dL). Chart review showed missed anti-hyperglycemic and anti-seizure doses after admission; no opioids, benzodiazepines, or sedatives had been given in the prior 24 h. The case was postponed for medical optimization and she returned to baseline mentation following insulin therapy. The next day, after successful hardware removal performed under peripheral nerve block only (no propofol, benzodiazepine, dexmedetomidine, or opioid), she again became completely unresponsive (~1 h post-procedure). A stroke code (NIHSS 30) was activated. CT head and CT angiography were negative for hemorrhage or large-vessel occlusion; EEG showed diffuse background slowing without epileptiform discharges. Laboratory results were unremarkable. She recovered spontaneously to her cognitive baseline. Multidisciplinary consensus favored psychogenic (functional) unresponsiveness in a vulnerable brain (dementia/epilepsy), with an initial episode additionally triggered by severe hyperglycemia. Conclusions : Psychogenic unresponsiveness can mimic the clinical appearance of general anesthesia in perioperative settings. Anesthesiologists should apply a rapid bedside framework—airway and oxygenation, point-of-care glucose/electrolytes, medication reconciliation, and targeted neuroimaging/EEG—to avoid unnecessary intubation or anesthetic exposure and to coordinate timely multidisciplinary care.