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Adhikari G, Ghimire S, Adhikari G, Aryal K, Kandel N. Transient aphonia following spinal anesthesia during emergency cesarean section: Case report and review of literature. Clin Case Rep 2023; 11:e7979. [PMID: 37808568 PMCID: PMC10558678 DOI: 10.1002/ccr3.7979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/27/2023] [Accepted: 09/18/2023] [Indexed: 10/10/2023] Open
Abstract
Subarachnoid block with local anesthetic agents is a well-established anesthesia technique among pregnant females for labor analgesia and cesarian delivery. Although it is considered a reliable and safe technique for both mothers and fetuses, unexpected high or low levels of block may occur due to accidental injection of these agents into different meningeal spaces other than intended. Hypotension, bradycardia, headache, and failed anesthesia are common complications of spinal anesthesia. Though rare, neurological complications like aphonia, dysphagia, and tingling sensation have also been reported. The article reports a case of a 22-year-old primigravida who sustained transient aphonia following intrathecal administration of bupivacaine for an emergency cesarian section for meconium-stained liquor with fetal distress. There were no other neurological manifestations or features suggestive of high spinal block. The sensory level of the block was fixed to T6 with hemodynamic stability throughout aphasia with an episode of hypotension preceding aphonia. Aphonia commenced 9 min after the spinal anesthesia continued for a total duration of 15 min. Neurological examination, relevant investigations, and consultations were done to make a diagnosis. Thus, it is important to be aware of the possible neurological complications associated with spinal anesthesia.
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Affiliation(s)
- Gauri Adhikari
- Department of AnaesthesiaNepalese Army Institute of Health Sciences‐ College of MedicineKathmanduNepal
| | - Suson Ghimire
- Department of AnaesthesiaPatan Academy of Health Sciences (PAHS)PatanNepal
| | - Gopal Adhikari
- Department of AnaesthesiaNepalese Army Institute of Health Sciences‐ College of MedicineKathmanduNepal
| | - Krishnaraj Aryal
- Department of MedicineTribhuvan University Institute of MedicineKathmanduNepal
| | - Narayan Kandel
- Department of MedicineTribhuvan University Institute of MedicineKathmanduNepal
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Balko RA, Katzka DA, Murray JA, Alexander JA, Mara KC, Ravi K. Same-day opioid administration in opiate naïve patients is not associated with opioid-induced esophageal dysfunction (OIED). Neurogastroenterol Motil 2021; 33:e14059. [PMID: 33350541 DOI: 10.1111/nmo.14059] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 11/13/2020] [Accepted: 11/17/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Opioid-induced esophageal dysfunction (OIED) is a recognized complication of chronic opioid use. However, the impact of acute opioid administration on esophageal motility remains unclear. METHODS Opioid naïve patients with high-resolution manometry (HRM) <480 min following esophagogastroduodenoscopy (EGD) (opioid-HRM) and a control group with HRM <36 h prior to EGD between January 1, 2016, and November 10, 2018, from a single institution were identified. EGDs were performed exclusively with versed and fentanyl. KEY RESULTS One hundred and seventy-four patients were identified, with 83 (47.7%) opioid-HRM and 91 (52.3%) controls. Mean time from EGD to HRM was 229 (78-435) min. Baseline clinical features and HRM indications were similar between opioid-HRM and controls. Chicago classification v3.0 defined HRM findings were similar between groups. Major motility disorders as defined by the Chicago classification v3.0 occurred at a similar frequency among opioid-HRM and controls (27.7% vs. 36.3%, p = 0.23). Mean distal contractile integrity (DCI) was higher in opioid-HRM (1939.3 ± 1318.9 vs. 1792.2 ± 2062.3 mmHg∙cm∙s, p = 0.043), but maximum DCI, distal latency, and integrated relaxation pressure did not differ between groups. Subgroup analysis assessing time and dose dependency did not identify differences in individual manometric parameters and Chicago classification v3.0 diagnosis between patients with HRM <240 min after EGD, >240 min after EGD, ≥125 mcg of IV fentanyl, <125 mcg IV fentanyl and controls. CONCLUSIONS AND INFERENCES Same-day acute opioid administration did not affect HRM findings in opioid naïve patients. Studies assessing the pathophysiology of and duration-dependent relationship with opioids in OIED are needed.
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Affiliation(s)
- Ryan A Balko
- Department of Gastroenterology, Hepatology Mayo Clinic, Rochester, MN, USA
| | - David A Katzka
- Department of Gastroenterology, Hepatology Mayo Clinic, Rochester, MN, USA
| | - Joseph A Murray
- Department of Gastroenterology, Hepatology Mayo Clinic, Rochester, MN, USA
| | | | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Karthik Ravi
- Department of Gastroenterology, Hepatology Mayo Clinic, Rochester, MN, USA
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Akhaddar A, Salami M, Darouassi Y. Transient lower cranial nerve palsies following spinal anesthesia with bupivacaine-fentanyl combination for transurethral resection of the prostate. Pan Afr Med J 2020; 35:62. [PMID: 32537066 PMCID: PMC7250197 DOI: 10.11604/pamj.2020.35.62.4005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 03/18/2015] [Indexed: 11/11/2022] Open
Abstract
Spinal anesthesia is a widely used regional anesthesia for many infra-umbilical surgical procedures with proven efficacy and safety. However, although rare, some neurologic complications can occur with potentially life threatening consequences. Among them, lower cranial nerve palsies have been rarely reported in the literature. We report such a case in a 75-year-old man with transient dysphagia, dysphonia and spinal accessory nerve palsy occurring four days after spinal anesthesia for transurethral resection of the prostate. His symptoms completely resolved spontaneously within 2 weeks. The possibility of lower cranial nerve palsies should be added to the potential complications during or following spinal anesthesia with bupivacaine-fentanyl combination. Although transitional, this complication may occur few days after the procedure and need to be promptly recognized, carefully evaluated and treated by conservative measures.
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Affiliation(s)
- Ali Akhaddar
- Department of Neurosurgery, Avicenne Military Hospital, Marrakech, Morocco.,Department of Neurosurgery, Mohammed V Military Teaching Hospital, Rabat, Morocco.,University of Mohammed V Souissi, Rabat, Morocco
| | - Mohcine Salami
- Department of Neurosurgery, Mohammed V Military Teaching Hospital, Rabat, Morocco.,University of Mohammed V Souissi, Rabat, Morocco
| | - Youssef Darouassi
- University of Mohammed V Souissi, Rabat, Morocco.,Department of Oto-Rhino-Laryngology, Mohammed V Military Teaching Hospital, Rabat, Morocco
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Effects of morphine and midazolam on pharyngeal function, airway protection, and coordination of breathing and swallowing in healthy adults. Anesthesiology 2015; 122:1253-67. [PMID: 25853450 DOI: 10.1097/aln.0000000000000657] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Drugs used for sedation in anesthesia and intensive care may cause pharyngeal dysfunction and increased risk for aspiration. In this study, the authors investigate the impact of sedative doses of morphine and midazolam on pharyngeal function during swallowing and coordination of breathing and swallowing. METHODS Pharyngeal function, coordination of breathing and swallowing, and level of sedation were assessed by manometry, videoradiography, measurements of respiratory airflow, and a visual analog scale in 32 healthy volunteers (age 19 to 35 yr). After baseline recordings, morphine (0.1 mg/kg) or midazolam (0.05 mg/kg) was administered intravenously for 20 min, followed by recordings at 10 and 30 min after the end of infusion. RESULTS Pharyngeal dysfunction, seen as misdirected or incomplete swallowing or penetration of bolus to the airway, increased after morphine infusion to 42 and 44% of swallows compared with 17% in baseline recordings. Midazolam markedly increased incidence of pharyngeal dysfunction from 16 to 48% and 59%. Morphine prolonged apnea before swallowing, and midazolam increased the number of swallows followed by inspiration. CONCLUSION Morphine and midazolam in dosages that produce sedation are associated with increased incidence of pharyngeal dysfunction and discoordinated breathing and swallowing, a combination impairing airway protection and potentially increasing the risk for pulmonary aspirations.
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Gupta B, Ramchandani S, Balakrishnan I, Kumar A. Transient aphonia, aphagia and facial tingling following intrathecal administration of fentanyl. Anesth Essays Res 2015; 8:93-5. [PMID: 25886113 PMCID: PMC4173577 DOI: 10.4103/0259-1162.128921] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Subarachnoid block with local anaesthetic agent and opiod as an adjuvant is a well-known technique with a good record of safety. However, some rare neurological complications like aphonia, dysphagia and tingling sensation have been reported following their administration in pregnant females posted for labour analgesia or caesarean section. We report a case of transient aphonia, aphagia and facial tingling following intrathecal administration of bupivacaine along with fentanyl for lower limb wound debridement in a male patient.
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Affiliation(s)
- Babita Gupta
- Department of Anaesthesia and Critical Care, JPNATC, AIIMS, New Delhi, India
| | - Sarita Ramchandani
- Department of Anaesthesia and Critical Care, JPNATC, AIIMS, New Delhi, India
| | - Ira Balakrishnan
- Department of Anaesthesia and Critical Care, JPNATC, AIIMS, New Delhi, India
| | - Atin Kumar
- Department of Radiology, JPNATC, AIIMS, New Delhi, India
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Anson JA, McQuillan PM. Transient unilateral brachial plexopathy and partial Horner's syndrome following spinal anesthesia for cesarean section. J Anaesthesiol Clin Pharmacol 2014; 30:273-5. [PMID: 24803773 PMCID: PMC4009655 DOI: 10.4103/0970-9185.130073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
A healthy 21-year-old primigravida presented for elective cesarean section. At 45 min after intrathecal (IT) injection of bupivacaine, morphine and fentanyl she developed dysphagia, right sided facial droop, ptosis and ulnar nerve weakness. This constellation of signs and symptoms resolved 2 h later. Based on the time course and laterality of her symptoms, as well as the pharmacologic properties of spinal opioids, we believe her symptoms can be attributed to the IT administration of fentanyl.
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Affiliation(s)
- Jonathan A Anson
- Department of Anesthesiology, Penn State Milton S. Hershey Medical Center Hershey, PA, USA
| | - Patrick M McQuillan
- Department of Anesthesia, Penn State Milton S. Hershey Medical Center Hershey, PA, USA
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SAVILAMPI JOHANNA, AHLSTRAND REBECCA, MAGNUSON ANDERS, WATTWIL MAGNUS. Effects of remifentanil on the esophagogastric junction and swallowing. Acta Anaesthesiol Scand 2013; 57:1002-9. [PMID: 23713743 DOI: 10.1111/aas.12134] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2013] [Indexed: 12/31/2022]
Abstract
BACKGROUND A recent study demonstrated that reflux is associated with impaired pressure augmentation in the esophagogastric junction (EGJ), caused by diaphragmal contractions during inspiration. It is unknown whether this augmentation is influenced by opioids. Swallowing difficulties can be a poorly recognised side effect of remifentanil. Here, we investigated whether remifentanil influences inspiratory EGJ augmentation and evaluated subjective swallowing difficulties induced by remifentanil. We also used the peripheral opioid receptor antagonist methylnaltrexone to evaluate whether these effects are centrally or peripherally mediated. METHODS Ten healthy volunteers participated in a double-blind, randomised, cross-over trial at the University Hospital in Örebro, Sweden. They were studied on two different occasions, during which they were randomly assigned to receive either methylnaltrexone 0.15 mg/kg or saline subcutaneously 30 min before the target-controlled infusion of remifentanil of 3 ng/mL. EGJ pressures were measured by high-resolution manometry. Swallowing difficulties were assessed when volunteers performed dry swallows. The outcomes were the differences in EGJ pressures at baseline and during remifentanil infusion and with methylnaltrexone vs. placebo. Differences in swallowing difficulties before and during remifentanil, and with methylnaltrexone vs. placebo were also recorded. RESULTS Remifentanil decreased the inspiratory EGJ augmentation and induced swallowing difficulties. No statistically significant differences between methylnaltrexone and placebo occasions were found. CONCLUSIONS Remifentanil may increase risk for gastroesophageal reflux by decreasing the inspiratory EGJ augmentation. The clinical significance of remifentanil-induced swallowing difficulties is to be studied further. Given the limited sample size, it cannot be concluded whether these effects are centrally or peripherally mediated.
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Affiliation(s)
- JOHANNA SAVILAMPI
- Department of Anesthesiology and Intensive Care; Örebro University Hospital; Örebro; Sweden
| | - REBECCA AHLSTRAND
- Department of Anesthesiology and Intensive Care; Örebro University Hospital; Örebro; Sweden
| | - ANDERS MAGNUSON
- Department of Anesthesiology and Intensive Care; Örebro University Hospital; Örebro; Sweden
| | - MAGNUS WATTWIL
- Department of Anesthesiology and Intensive Care; Örebro University Hospital; Örebro; Sweden
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Ray BR, Baidya DK, Gregory DM, Sunder R. Intraoperative neurological event during cesarean section under spinal anesthesia with fentanyl and bupivacaine: Case report and review of literature. J Anaesthesiol Clin Pharmacol 2012; 28:374-7. [PMID: 22869950 PMCID: PMC3409953 DOI: 10.4103/0970-9185.98349] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Neurological events similar to transient ischemic attack in a peripartum woman are uncommon. Cerebral complications of preeclampsia, thrombo-embolic phenomena, or high spinal can mimic such situations. Spinal anesthesia with local anesthetic and opioid is an established anesthetic technique for cesarean section. Although intrathecal opioids are safe for both the mother and fetus; some unusual complications such as dysphagia alone or associated with facial numbness, aphasia, have been reported. We report a case of transient aphonia and tingling sensation over the face without any dysphagia after intrathecal administration of bupivacaine and fentanyl for cesarean section.
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Affiliation(s)
- Bikash Ranjan Ray
- Department of Anaesthesia, All India Institute of Medical Sciences, New Delhi, India
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Van de Velde M. Modern neuraxial labor analgesia: options for initiation, maintenance and drug selection. ACTA ACUST UNITED AC 2010; 56:546-61. [PMID: 20112546 DOI: 10.1016/s0034-9356(09)70457-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
In the present review we outline the state-of-the-art of neuraxial analgesia. As neuraxial analgesia remains the gold standar of analgesia during labor, we review the most recent literature on this topic. The neuraxial analgesia techniques, types of administration, drugs, adjuvants, and adverse effects are investigated from the references. Most authors would agree that central neuraxial analgesia is the best form to manage labor pain. When neuraxial analgesia is administered to the parturient in labor, different management choices must be made by the anesthetist: how will we initiate analgesia, how will analgesia be maintained, which local anesthetic will we use for neuraxial analgesia and which adjuvant drugs will we combine? The present manuscript tries to review the literature to answer these questions.
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Affiliation(s)
- M Van de Velde
- Department of Anesthesiology, University Hospitals Gasthuisberg, Katholieke Universiteit Leuven, Leuven, Belgium.
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Abstract
BACKGROUND Opiates have well characterized (troublesome) untoward effects on the gastrointestinal tract. Opioid bowel dysfunction has been a subject of research and even drug design, but surprisingly little is known with regard to clinical effects of opiates on the oesophagus. AIM To characterize opiate effects on motor function of the oesophagus in patients presenting with dysphagia. METHODS Retrospective review of 15 patients with dysphagia referred for oesophageal manometry while on chronic opiates. Manometry was completed during opiate use and in three cases, after opiates were discontinued. RESULTS All patients demonstrated motility abnormalities. Incomplete lower oesophageal sphincter (LOS) relaxation (11.5 +/- 1.6 mmHg) was seen in most cases. Ten patients demonstrated nonperistaltic contractions in > or =3 of 10 swallows. Additional abnormalities included high amplitude contractions; triple peaked contractions; and increased velocity. The average resting lower oesophageal sphincter (LOSP) met criteria for hypertensive LOS in three patients. These features were suggestive of spasm or achalasia. Repeat manometry off opiates was performed in three cases. LOS relaxation was noted to be complete upon repeat manometry in these cases. There was also improved peristalsis and normal velocity. CONCLUSIONS A range of manometric abnormalities were seen in patients with dysphagia in the setting of opiate use: impaired LOS relaxation, high amplitude/velocity and simultaneous oesophageal waves. These data suggest that the oesophagus is susceptible to the effects of opiates and care must be taken before ascribing dysphagia to a primary oesophageal motility disorder in patients taking opiates.
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Affiliation(s)
- R. KRAICHELY
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - A. S. ARORA
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - J. A. MURRAY
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota
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Walldén J, Thörn SE, Wattwil M. The delay of gastric emptying induced by remifentanil is not influenced by posture. Anesth Analg 2004; 99:429-34, table of contents. [PMID: 15271718 DOI: 10.1213/01.ane.0000121345.58835.93] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Posture has an effect on gastric emptying. In this study, we investigated whether posture influences the delay in gastric emptying induced by opioid analgesics. Ten healthy male subjects underwent 4 gastric emptying studies with the acetaminophen method. On two occasions the subjects were given a continuous infusion of remifentanil (0.2 microg. kg(-1). min(-1)) while lying either on the right lateral side in a 20 degrees head-up position or on the left lateral side in a 20 degrees head-down position. On two other occasions no infusion was given, and the subjects were studied lying in the two positions. When remifentanil was given, there were no significant differences between the two postures in maximal acetaminophen concentration (right side, 34 micromol. L(-1); versus left side, 16 micromol. L(-1)), time taken to reach the maximal concentration (94 versus 109 min), or area under the serum acetaminophen concentration time curve from 0 to 60 min (962 versus 197 min. micromol. L(-1)). In the control situation, there were differences between the postures in maximal acetaminophen concentration (138 versus 94 micromol. L(-1); P < 0.0001) and area under the serum acetaminophen concentration time curves from 0 to 60 min (5092 versus 3793 min. micromol. L(-1); P < 0.0001), but there was no significant difference in time taken to reach the maximal concentration (25 versus 47 min). Compared with the control situation, remifentanil delayed gastric emptying in both postures. We conclude that remifentanil delays gastric emptying and that this delay is not influenced by posture.
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Affiliation(s)
- Jakob Walldén
- Department of Anesthesia and Intensive Care, Orebro University Hospital, 701 85 Orebro, Sweden.
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Kuczkowski KM. Advances in obstetric anesthesia: ambulation during labor with combined spinal-epidural analgesia. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2004. [DOI: 10.1080/22201173.2004.10872364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Kuczkowski KM. Respiratory arrest in a parturient following intrathecal administration of fentanyl and bupivacaine as part of a combined spinal-epidural analgesia for labour. Anaesthesia 2002; 57:939-40. [PMID: 12190769 DOI: 10.1046/j.1365-2044.2002.279317.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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