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Episode of Conscious change and aphasia under CSE on TKR

Episode of Conscious change and aphasia under CSE on TKR. Presented by Ri 黃園媛 Ri 莊惠蓉 Directed by VS 劉漢平. Patient data. 84 y/o, female bil. Knee pain for 2 years, esp L’t side denied any systemic disease : DM(-) ( sugar AC 134 ) HTN (-)

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Episode of Conscious change and aphasia under CSE on TKR

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  1. Episode of Conscious change and aphasia under CSE on TKR Presented by Ri 黃園媛 Ri 莊惠蓉 Directed by VS 劉漢平

  2. Patient data • 84 y/o, female • bil. Knee pain for 2 years, esp L’t side • denied any systemic disease : DM(-) ( sugar AC 134 ) HTN (-) history of epilepsy or seizure : denied history of CVA : denied • drug allergy history : denied

  3. Patient data • previous op hx : nil • smoking / alcohol drinking : nil • Psychiatric history : nil • Plasma electrolyte before surgery : Na 135 K 3.9 Cl 100 Sugar AC 134 • EKG : normal sinus rhythm • CXR : no active lung lesion

  4. Patient data • Bil. Knee OA • R’t TKR and arthroscopy on 12/11 under spinal anesthesia, ( L3/4 ) marcain 14 mg, pentothol 75 mg block level : T10

  5. During Operation • L’t TKR on 12/16 • under CSE ( L4-L5 ) with 25 gauge spinal needle and 18 gauge epidural • Heavy marcaine 12 mg (intrathecal), morphine 2 mg (epidural) in 10 ml. N/S • posture during and after injection : lateral decubitus then supine position • any drug administered before op ?

  6. During operation • pneumatic tournique, 350 mmHg • p’t  was not responding to verbal commands or to deep painfew minutes later ( about 10-20 min after CSE ) • frothing, and uprolling of the eyeballs : nil • not preceded by nausea and vomiting • no complaints of chest pain, inability to breathe or weakness of the upper limbs immediately before loss of consciousness • Pupil dilatation : nil

  7. During operation • Hemodynamic : HR80 BP 80/150 mmHg • respieratory pattern : spontaneous, smooth RR ? • saturation : 93-94 % at 9:15-9:45 am without O2 mask • ETCO2 : not monitored

  8. During operation • P’t consciousness recovered spontaneously 3-5 min later before any treatment • Sensory block at T4 level After the episode, she was quite well as before, and the operation was kept going for 2 hrs without other complication. • Neurologic deficit : nil

  9. The problem on this woman • Conscious loss • Aphasia • Others:nil

  10. Discussion • Blood perfusion • Hypoxemia; hypoxia • deep venous thrombosis • Drug flux • overdose • high level of spinal anesthesia (ex ) cephalad spread • Complication of CSE (or SA or EA ) • Underlying disease

  11. Complication of CSE • Life-threatening complication : large dose , high block, inappropriate catheter placement, drug flux • Infection : meningitis, epidural abscess • Neurological damage : spinal needle paraesthesia, hematoma, other unexplained neurological damage Anaesthesia, 2000, 55, p42-64

  12. What to do when conscious loss ? • Check vital sign • Check machine • keep airway ---oxygenation ---circulation • Find out the problem • blood perfusion • hypoxia ;hypoxemia • overdose or other complication about CSE

  13. case report • a healthy parturient under SA for C/S 2 ml 0.5% heavy bupivacaine 20 min after SA Loss conscious for 1 hr, hemodynamically stable BJA 85(3)474-6 2000/9 2.cardiac arrest occurred after an C/S under SA, resuscitated successfully. , early adrenalin is recommended Scull TJ. Carli F. Department of Anesthesia ,McGill university ,Quebec Canada

  14. 3.a 41 female with GA 41 wks, CSE under sitting position L2-3 10μg sufentanil ﹢2.5mg bupivacaine 15min mental status change﹢aphasia ﹢increased salivation vital sign stable , 100min recover without any SE . alert throughout episode but can’t speak.

  15. 4.a 27y/o woman G3P2 under CSE , 25μg fentanyl ﹢2.5mg bupivacaine continuous EA : 0.06% bupi+2μg/ml fentanyl 25 min RR: 6 HR:100 SaO2 94% BP:105/55 ----IV naloxane –1-2 min vital sign stable 15min start to speak unfluently but not fully alert

  16. 40min(65min) became less responsive , then another naloxane (80μg) was given , the situation became better 30’(95’) speak fluently 1hr after delivery , fully alert but incomplete recall of this event

  17. Discussion (4) • cephalad spread of sufentanil with CSF • Sufentanil spread to speech area without significant respiratory depress(rare) • bupivacaine on the cranial nerve at the brain stem level • Overdose with agent—excessive sedation • Dose not discussed now • Morphine into CSF

  18. In our p’t • as her discription, she was alert during the whole episode and could response to our stimulation if she wanted except verbal response

  19. too nervous • Remain unclear • Ps: SA vs GA

  20. Thanks for your attention

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