Focal convulsion and opioids

Started by yogenbhatt1, February 22, 2009, 04:13:56 AM

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yogenbhatt1

A case for PCNL with a few stones, which the surgeon thought that he may take time. Sequential spinal and Epidural( saperate space) was given to the patient. He was 34 yrs and no positive history.
Surgery got over in 15 mins after scope was put, as he saw the stones just opp the scope and it was over. Since Epidural cath was put, we put Inj. Bupivacain 0.1 % and inj. Buprenorphin 60 mcg( total 15 ml vol) for post op analgesia. We regularly use this combination and we do not have Morphin.
About 2 hours after the shifting of patient in the ward, we recv a call to see the patient urgently.
     He was getting severe pain in the back, severe sposmodic jerks of the lower limbs, and electric current feeling, almost 30 -40 times a min.
      We could not place it, but the patient was in severe pain and with all relatives in the room it was difficult to explain the situation.
      We started Fentany for pain and Medazolam as sedative. He would sleep for some time and when ever disturbed, he would get up and start convulsing again. He was fully conscious. He had raised exensor tone, planter exention, raised knee jerk, and was screaming with discomfort.
A neurologist was involved, and he suspected Epidural Hematoma.( Pt  had increased tone and all sensations were still normal- so not fitting a picture of hematoma). He was taken for MRI, which came normal.
On surfing through net, we could locate few cases reported like this. As per them, it was focal convulsions arising from multiple places, induced by low dose opioids. Though Buprenorphin was not mentioned as one of the drugs, but we presumed that it may be the cause( Topped up with IV fentanyl given by us). Almost all reported cases had a history of Epilepsy.
After this we just put him on Medaz infusion and he was fully controlled in half an hour. Shifted from ICCU  and went home in 3 days.
I request comments and observations.

sandiphari

FOR SA WHICH DRUG GIVEN? LIGNOCAINE MAY PRODUCE  TOXICITY OR  HIGH DOSAGE  OF BUPI. IN SA &EA , SA  NEEDLE  SIZE  IS  ALSO  PLAY IMP. ROLE, 25/27 NO  HAVE HIGH  CONS. OF  DRUG  AT  LOCAL  AREA &FURTHUR  TOP  UP  DOSAGE  MAY  GIVE  RISE  TO  HIGH  DOSAGES.

yogenbhatt1

As per your question, part one, we had injected 2.5 ml (12.5mg) of Bupivacain Heavy, and had acted too.
It shows that the drug was in right plane and not in epidural vessals, which is still low to cause toxic dose at 12.5 mg IV Stat. The drug acted very well till the surgery was over and the pt was shifted to the room.
The whole thing started 3 hours after the surgery, and by now the action of spinal must be over. That is why we felt that it has nothing to do with Spinal, but opioid.
We injected 0.1 % Bupivacain with Buprenorphin 60 mcg at the end of the surgery and was never repeated, as the cath was removed when the convusions started.
Regards