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Ehelepola NDB, Ranathunga RMDC, Abeysundara AB, Jayawardana HMRP, Nanayakkara PSK. Super-refractory status epilepticus, rhabdomyolysis, central hyperthermia and cardiomyopathy attributable to spinal anesthesia: a case report and review of literature. BMC Anesthesiol 2024; 24:132. [PMID: 38582882 PMCID: PMC10998312 DOI: 10.1186/s12871-024-02485-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 03/07/2024] [Indexed: 04/08/2024] Open
Abstract
BACKGROUND There are only six past reports of super-refractory status epilepticus induced by spinal anesthesia. None of those patients have died. Only < 15 mg of bupivacaine was administered to all six of them and to our case. Pathophysiology ensuing such cases remains unclear. CASE PRESENTATION A 27 year old gravida 2, para 1, mother at 37 weeks of gestation came to the operating theater for an elective cesarean section. She had no significant medical history other than controlled hypothyroidism and one episode of food allergy. Her current pregnancy was uneventful. Her American Society of Anesthesiologists (ASA) grade was 2. She underwent spinal anesthesia and adequate anesthesia was achieved. After 5-7 min she developed a progressive myoclonus. After delivery of a healthy baby, she developed generalized tonic clonic seizures that continued despite the induction of general anesthesia. She had rhabdomyolysis, one brief cardiac arrest and resuscitation, followed by stress cardiomyopathy and central hyperthermia. She died on day four. There were no significant macroscopic or histopathological changes in her brain that explain her super refractory status epilepticus. Heavy bupivacaine samples of the same batch used for this patient were analyzed by two specialized laboratories. National Medicines Quality Assurance Laboratory of Sri Lanka reported that samples failed to confirm United States Pharmacopeia (USP) dextrose specifications and passed other tests. Subsequently, Therapeutic Goods Administration of Australia reported that the drug passed all standard USP quality tests applied to it. Nonetheless, they have detected an unidentified impurity in the medicine. CONCLUSIONS After reviewing relevant literature, we believe that direct neurotoxicity by bupivacaine is the most probable cause of super-refractory status epilepticus. Super-refractory status epilepticus would have led to her other complications and death. We discuss probable patient factors that would have made her susceptible to neurotoxicity. The impurity in the drug detected by one laboratory also would have contributed to her status epilepticus. We propose several possible mechanisms that would have led to status epilepticus and her death. We discuss the factors that shall guide investigators on future such cases. We suggest ways to minimize similar future incidents. This is an idiosyncratic reaction as well.
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Affiliation(s)
- N D B Ehelepola
- Teaching (General) Hospital - Peradeniya, Peradeniya, Sri Lanka.
| | | | - A B Abeysundara
- Teaching (General) Hospital - Peradeniya, Peradeniya, Sri Lanka
- Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | | | - P S K Nanayakkara
- Teaching (General) Hospital - Peradeniya, Peradeniya, Sri Lanka
- Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
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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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Foramen magnum meningioma presented as cervical myelopathy in a pregnant COVID-19 patient: A case report. Ann Med Surg (Lond) 2022; 77:103647. [PMID: 35638060 PMCID: PMC9142680 DOI: 10.1016/j.amsu.2022.103647] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 04/15/2022] [Accepted: 04/15/2022] [Indexed: 11/21/2022] Open
Abstract
Introduction Case presentation Clinical discussion Conclusion COVID-19 causes hyperinflammatory state which could lead to tumor progression. There is increase of cytokine expression in meningioma as well as in Covid-19 infection. Further investigation needed to find if there is molecular link between Covid-19 and meningioma disease course.
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Zibbell JE, Peiper NC, Duhart Clarke SE, Salazar ZR, Vincent LB, Kral AH, Feinberg J. Consumer discernment of fentanyl in illicit opioids confirmed by fentanyl test strips: Lessons from a syringe services program in North Carolina. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 93:103128. [PMID: 33487527 DOI: 10.1016/j.drugpo.2021.103128] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 01/11/2021] [Accepted: 01/13/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND The United States (U.S.) continues to witness an unprecedented increase in opioid overdose deaths driven by precipitous growth in the supply and use of illicitly-manufactured fentanyls (IMF). Fentanyl's growing market share of the illicit opioid supply in the U.S. has led to seismic shifts in the composition of the country's heroin supply. The growth in fentanyl supply has transformed illicit opioid markets once offering heroin with fairly consistent purity and potency to a supply overpopulated with fentanyl(s) of inconsistent and unpredictable potency. In response, people who inject drugs (PWID) have developed a number of sensory strategies to detect fentanyl in illicit opioids. The current study examined the accuracy of sensory discernment strategies by measuring study participants' descriptions of the last opioid injected and checked with a fentanyl test strip (FTS) by that test's positive/negative result. The primary objective was to determine associations between FTS results and descriptions of the illicit opioid's physical appearance and physiological effects. METHODS Between September-October 2017, a total of 129 PWID were recruited from a syringe services program in Greensboro, North Carolina and completed an online survey about their most recent use of FTS. Participants were instructed to describe the appearance and effects associated with the most recent opioid they injected and tested with FTS. We conducted bivariate and multivariate analyses to determine differences in positive vs negative FTS results and the physical characteristics and physiological experiences reported. An exploratory analysis was also conducted to describe the types and bodily locations of unusual sensations experienced by PWID reporting positive FTS results. RESULTS For physical characteristics, 32% reported that the drug was white before adding water and 38% reported the solution was clear after adding water. For physiological effects compared to heroin, 42% reported a stronger rush, 30% a shorter high, 30% a shorter time to the onset of withdrawal symptoms, and 42% experienced unusual sensations. In the multivariable model adjusting for demographics and polydrug correlates, white color of drug before adding water, stronger rush, shorter time to withdrawal, and unusual sensations were significantly associated with a positive FTS result. The most common unusual sensations were pins and needles (51%), warming of the head and face (35%), and lightheadedness (30%), and the most common locations where sensations occurred were face and neck (61%), arms/legs (54%), and chest (37%). CONCLUSION We found positive FTS results were significantly associated with the physical characteristics and physiological effects described by PWID. Descriptions concerning physical appearance were consistent with law enforcement profiles of illicitly-manufactured fentanyl and physiological effects were concomitant with scientific and clinical medical literature on iatrogenic fentanyl use. Taken together, these findings suggest sensory strategies for detecting fentanyl in illicit opioids may be an effective risk reduction tool to help consumers navigate unpredictable markets more safely.
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Affiliation(s)
- Jon E Zibbell
- Center for Behavioral Health Epidemiology, Implementation, and Evaluation Research, RTI International, Research Triangle Park, NC, United States.
| | - Nicholas C Peiper
- Pacific Institute for Research and Evaluation, Louisville, KY, United States
| | - Sarah E Duhart Clarke
- Center for Behavioral Health Epidemiology, Implementation, and Evaluation Research, RTI International, Research Triangle Park, NC, United States
| | - Zach R Salazar
- North Carolina Survivors Union, Greensboro, NC, United States
| | | | - Alex H Kral
- Center for Behavioral Health Epidemiology, Implementation, and Evaluation Research, RTI International, Research Triangle Park, NC, United States
| | - Judith Feinberg
- Department of Behavioral Medicine and Psychiatry, West Virginia University, Morgantown, WV, United States
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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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Affiliation(s)
- Manisha Manohar
- Department of Anesthesiology and Critical Care, Maulana Azad Medical College, New Delhi, India
| | - Anju R Bhalotra
- Department of Anesthesiology and Critical Care, Maulana Azad Medical College, New Delhi, India
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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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Uhegwu N, Bashir A, Dababneh H, Hussain M, Misthal S, Mocco JD. Stroke Mimic Secondary to IV Fentanyl Administration. JOURNAL OF VASCULAR AND INTERVENTIONAL NEUROLOGY 2015; 8:17-19. [PMID: 25825627 PMCID: PMC4367802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Fentanyl is a potent opioid used commonly in acute care because of its rapid onset and short duration of action. It has fewer side effects when compared with commonly available opioids, such as morphine and hydromorphine. We report an unusual side effect of transient aphasia following fentanyl administration. A 61-year-old female presented for an elective embolization of a periophthalmic artery aneurysm. She developed immediate episodes of aphasia on two separate occasions following administration of intravenous (IV) fentanyl. The high lipid solubility explains the rapid onset of action of fentanyl as it rapidly passes through the blood-brain barrier and through cell membranes. Immediately following the administration of fentanyl, the patient developed aphasia. There were no other clinical or neurological imaging findings that could account for these symptoms. We believe that aphasia may be an unusual side effect of fentanyl, and it is something clinicians should be aware of.
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Affiliation(s)
- Nnamdi Uhegwu
- Neurosurgery, JFK New Jersey Neuroscience Institute at Seton Hall University, Edison, NJ ; Authors contributed equally
| | - Asif Bashir
- Neurosurgery, JFK New Jersey Neuroscience Institute at Seton Hall University, Edison, NJ ; Authors contributed equally
| | - Haitham Dababneh
- Neurosurgery, JFK New Jersey Neuroscience Institute at Seton Hall University, Edison, NJ ; Authors contributed equally
| | - Mohammed Hussain
- Neurosurgery, JFK New Jersey Neuroscience Institute at Seton Hall University, Edison, NJ
| | - Sara Misthal
- Neurosurgery, JFK New Jersey Neuroscience Institute at Seton Hall University, Edison, NJ
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