Case Study by Jack Garcia, SRNA

1. Case Study byJack Garcia, SRNA May 18, 2012

3. 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

4. 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.

5. Medications • CPAP at night • Bystolic • Levothyroxine • Estradiol • Topamax • Lyrica • Tramadol

6. Expressed Desire 8 week ago patient had a Successful Left Total Hip Replacement

7. Anesthesia Plan Spinal TIVA Previous anesthesia record was used to formulate plan.

8. Intraoperative • Patient remained spontaneously breathing • Vitals stable • Total Hip was replaced in 54 minutes

9. Post Operative Recovery • Pt woke up with tonic clonic jerking motions • Protect • Airway • Propofol

10. Secured Airway • Seizures • Intubation “Being Careful” • Roll to ICU

11. ICU • EEG • CT • Neurology Consult

12. 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

13. Tramadol Induce Seizures?

14. 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

16. 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

17. 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

18. 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.

19. 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

20. 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.

21. 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

22. Seizures Associated with Intoxication and Abuse of TramadolClinical Toxicology 2006; 44:143-146

23. Seizures Associated with Intoxication and Abuse of TramadolClinical Toxicology 2006; 44:143-146

26. 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.

27. 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.

28. Questions