Case Study by

Jack 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 PatientRight 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.

MedicationsCPAP at nightBystolicLevothyroxineEstradiolTopamaxLyricaTramadol

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.

IntraoperativePatient remained spontaneously breathing

Vitals stable

Total Hip was replaced in 54 minutes

Post Operative RecoveryPt woke up with tonic clonic jerking motions

Protect

Airway

Propofol

Secured AirwaySeizures

Intubation “Being Careful”

Roll to ICU

ICUEEG

CT

Neurology Consult

PathophysiologyEpilepsy 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?

TramadolCentral 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

TramadolRacemic 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 AdvantagesMetabolized 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 Continue85 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

ConclusionTramadol 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, Hghighi Borhani 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.

Questions