Case Study by Jack Garcia, SRNA
Case Study by Jack Garcia, SRNA. May 18, 2012. Phenomenon. From the Greek word, φαινόμεν o ν , plural Phenomena, is any observable occurrence. Phenomena are often, but not always, understood as “appearances” or ‘experiences’. These are themselves sometimes understood as involving qualia.
Case Study by Jack Garcia, SRNA
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Case Study byJack Garcia, SRNA May 18, 2012
Phenomenon From the Greek word, φαινόμενoν , plural Phenomena, is any observable occurrence. Phenomena are often, but not always, understood as “appearances” or ‘experiences’. These are themselves sometimes understood as involving qualia. www.wikipedia.org
The Patient • Right Total Hip Replacement • 70 Female, 96.4 Kg, 165.1 cm • Allergies: Vistril, diazepam, oxycodone, hydromorphone, vicodin and midazolam. • Hx: HTN, Arthritis, degenerative Joint Disease, Chronic Pain, OSA, Hypothyroidism, Cardiac catheter and migraine headaches. • ASA 3 • Sx: Lumber 4 laminectomy, appendectomy, Lap cholecystectomy and left total hip replacement. • Patient reported no previous anesthetic complications.
Medications • CPAP at night • Bystolic • Levothyroxine • Estradiol • Topamax • Lyrica • Tramadol
Expressed Desire 8 week ago patient had a Successful Left Total Hip Replacement
Anesthesia Plan Spinal TIVA Previous anesthesia record was used to formulate plan.
Intraoperative • Patient remained spontaneously breathing • Vitals stable • Total Hip was replaced in 54 minutes
Post Operative Recovery • Pt woke up with tonic clonic jerking motions • Protect • Airway • Propofol
Secured Airway • Seizures • Intubation “Being Careful” • Roll to ICU
ICU • EEG • CT • Neurology Consult
Pathophysiology • Epilepsy is not a disease, but rather a symptom of a disorder of neuronal dysfunction. • A seizure results from the discharge of an aggregate of neurons that depolarize in synchronous fashion.1
Tramadol Induce Seizures?
Tramadol • Central acting analgesic • Tx: Chronic Pain • Decreases the seizure Threshold • Moderate affinity for the mu, weak kappa and delta • 5-10 times less potent than Morphine.2
Tramadol • Racemic mixture of 2 Enatiomers • 1 inhibits neuronal reuptake of norepinephrine • 1 inhibits 5-hydroxytrptamine (serotonin, 5-HT2c) reuptake, which contributes to lowering the seizure threshold. • These enhance the function of spinal descending inhibitory pathway and utilizes the action of mu receptors.2
Tramadol Advantages • Metabolized by the liver P-450 to the metabolite O-desmethyltramadol , which exerts its stereo-selective pain relieving effect. • Minimum depressant effects on breathing. • Decreases post op shivering. • Does not cause organ toxicity or major sedative side effects • Does not cause tolerance or addition.3
Tramadol Dependence StudyThe Arab Journal of Psychiatry 2011. (22):76-78. • Crossection study of 36 patients in addiction unit in Bagdad, Iraq. • 90% were on Tramadol alone • 7 patients were medical profession • Average daily dose was 400-5000 mg. Mean 1000 mg. • 22% experienced at least one seizure.
Tramadol Disadvantages • Decrease gastric emptying • Interaction with coumadin • Lowering the seizure Threshold producing drug related seizures, by blocking 5-HT2c. • Inhibition of GABA-A receptors at high doses • Serotonin Toxicity with SSRI’s
Tramadol Induced Siezure: Report of 106 patients. IRCMJ 2010; (12): 49-51. • 92 patients had a new onset provoked seizures. • 14 patients had previous known epilepsy. • 86 of patients were abusing Tramadol • 20 of the patients were prescribed Tramadol • The Dose of Tramadol before seizures was 50 to 1500mg.
106 Patients Continue • 85 developed seizure with a daily dose equal to or less than 400mg. • 21 developed seizures with doses above 400mg. • EEG normal in 50, non-specific diffused slowing in 49, and epileptic form discharges in seven patients. • All patients had normal brain CT scans
Seizures Associated with Intoxication and Abuse of TramadolClinical Toxicology 2006; 44:143-146
Seizures Associated with Intoxication and Abuse of TramadolClinical Toxicology 2006; 44:143-146
Conclusion • Tramadol can cause dependency • Tramadol can cause Seizures, especially when exposed for longer periods of time and at Toxic dose levels. • Further research is needed within the geriatric population.
References • Hines RL, Marschall KE. Anesthesia and Co-Existing Disease. 5th ed. Philadelphia: Churchill Livingstone 2008; 10A:232-234. • Stoelting RK, Hillier, SC. Pharmacology & Physiology in Anesthetic Practice. 4th ed. Philadelphia: Lippincott Williams & Wilkins 2009; 3:117. • Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock, MC. Clinical Anesthesia. 6th ed. Philadelphia: Lippincott Williams &Wilkins 2009; 25:629-630. • Mohammed R, Lafta Al-Aboodi. Tramadol dependence in the addiction unit of Baghdad: a cross sectional study. The Arab Journal of Psychiatry 2011; 22:76-78. • Nesic N, Martinovic Z, Jovanovic-Cupic V. Seizures Associated with Intoxication and Abuse of Tramadol. Clinical Toxicology 2006; 44:143-146. • Petramgar P, HghighiBorhani A. Tramadol Induced Seizure: Report of 106 Patients. Iranian Red Crescent Medical Journal 2010; 12(1):49-51. • Pedramfar P, Mosallaei SH. The Effect of Provoked Agents on Control of Epilepsy. Iranian Journal of Neurology 2008; 7:191-197. • Raffa RB, Stone DJ. Unexceptional Seizure Potential of Tramadol or Its Enantiomers or Metabolites in Mice. The Journal of Pharmacology and Experimental therapeutics 2008; 325:500-506.
