Episode of Conscious change and aphasia under CSE on TKR Presented by Ri 黃園媛 Ri 莊惠蓉 Ri 莊惠蓉 Directed by VS 劉漢平

Patient data 84 y/o, female 84 y/o, female bil. Knee pain for 2 years, esp L’t side bil. Knee pain for 2 years, esp L’t side denied any systemic disease : denied any systemic disease : DM(-) ( sugar AC 134 ) HTN (-) DM(-) ( sugar AC 134 ) HTN (-) history of epilepsy or seizure : denied history of epilepsy or seizure : denied history of CVA : denied history of CVA : denied drug allergy history : denied drug allergy history : denied

Patient data previous op hx : nil previous op hx : nil smoking / alcohol drinking : nil smoking / alcohol drinking : nil Psychiatric history : nil Psychiatric history : nil Plasma electrolyte before surgery : Plasma electrolyte before surgery : Na 135 K 3.9 Cl 100 Sugar AC 134 Na 135 K 3.9 Cl 100 Sugar AC 134 EKG : normal sinus rhythm EKG : normal sinus rhythm CXR : no active lung lesion CXR : no active lung lesion

Patient data Bil. Knee OA Bil. Knee OA R’t TKR and arthroscopy on 12/11 R’t TKR and arthroscopy on 12/11 under spinal anesthesia, ( L3/4 ) under spinal anesthesia, ( L3/4 ) marcain 14 mg, pentothol 75 mg marcain 14 mg, pentothol 75 mg block level : T10 block level : T10

During Operation During Operation L’t TKR on 12/16 L’t TKR on 12/16 under CSE ( L4-L5 ) with 25 gauge spinal needle and 18 gauge epidural under CSE ( L4-L5 ) with 25 gauge spinal needle and 18 gauge epidural Heavy marcaine 12 mg (intrathecal), Heavy marcaine 12 mg (intrathecal), morphine 2 mg (epidural) in 10 ml. N/S morphine 2 mg (epidural) in 10 ml. N/S posture during and after injection : posture during and after injection : lateral decubitus then supine position lateral decubitus then supine position any drug administered before op ? any drug administered before op ?

During operation pneumatic tournique, 350 mmHg pneumatic tournique, 350 mmHg p’t was not responding to verbal commands or to deep pain few minutes later ( about min after CSE ) p’t was not responding to verbal commands or to deep pain few minutes later ( about min after CSE ) frothing, and uprolling of the eyeballs : nil frothing, and uprolling of the eyeballs : nil not preceded by nausea and vomiting not preceded by nausea and vomiting no complaints of chest pain, inability to breathe or weakness of the upper limbs immediately before loss of consciousness no complaints of chest pain, inability to breathe or weakness of the upper limbs immediately before loss of consciousness Pupil dilatation : nil Pupil dilatation : nil

During operation Hemodynamic : HR80 BP 80/150 mmHg Hemodynamic : HR80 BP 80/150 mmHg respieratory pattern : spontaneous, smooth respieratory pattern : spontaneous, smooth RR ? RR ? saturation : % at 9:15-9:45 am saturation : % at 9:15-9:45 am without O2 mask without O2 mask ETCO2 : not monitored ETCO2 : not monitored

During operation P’t consciousness recovered spontaneously 3-5 min later before any treatment P’t consciousness recovered spontaneously 3-5 min later before any treatment Sensory block at T4 level After the episode, she was quite well as before, and the operation was kept going for 2 hrs without other complication. Sensory block at T4 level After the episode, she was quite well as before, and the operation was kept going for 2 hrs without other complication. Neurologic deficit : nil Neurologic deficit : nil

The problem on this woman Conscious loss Conscious loss Aphasia Aphasia Others:nil Others:nil

Discussion Blood perfusion Blood perfusion Hypoxemia; hypoxia Hypoxemia; hypoxia deep venous thrombosis deep venous thrombosis Drug flux Drug flux overdose overdose high level of spinal anesthesia (ex ) cephalad spread high level of spinal anesthesia (ex ) cephalad spread Complication of CSE (or SA or EA ) Complication of CSE (or SA or EA ) Underlying disease Underlying disease

Anaesthesia, 2000, 55, p42-64 Complication of CSE Life-threatening complication : Life-threatening complication : large dose, high block, inappropriate catheter large dose, high block, inappropriate catheter placement, drug flux placement, drug flux Infection : Infection : meningitis, epidural abscess meningitis, epidural abscess Neurological damage : Neurological damage : spinal needle paraesthesia, hematoma, spinal needle paraesthesia, hematoma, other unexplained neurological damage other unexplained neurological damage

What to do when conscious loss ? Check vital sign Check vital sign Check machine Check machine keep airway ---oxygenation ---circulation keep airway ---oxygenation ---circulation Find out the problem Find out the problem blood perfusion blood perfusion hypoxia ;hypoxemia hypoxia ;hypoxemia overdose or other complication about CSE overdose or other complication about CSE

case report case report 1. a healthy parturient under SA for C/S 2 ml 0.5% heavy bupivacaine 2 ml 0.5% heavy bupivacaine 20 min after SA Loss conscious for 1 hr, hemodynamically stable BJA 85(3) /9 20 min after SA Loss conscious for 1 hr, hemodynamically stable BJA 85(3) /9 2.cardiac arrest occurred after an C/S under SA, resuscitated successfully., early adrenalin is recommended early adrenalin is recommended Scull TJ. Carli F. Department of Anesthesia,McGill university,Quebec Canada Scull TJ. Carli F. Department of Anesthesia,McGill university,Quebec Canada

3.a 41 female with GA 41 wks, CSE under sitting position L2-3 CSE under sitting position L2-3 10μg sufentanil ﹢ 2.5mg bupivacaine 10μg sufentanil ﹢ 2.5mg bupivacaine 15min mental status change ﹢ aphasia 15min mental status change ﹢ aphasia ﹢ increased salivation ﹢ increased salivation vital sign stable, vital sign stable, 100min recover without any SE. 100min recover without any SE. alert throughout episode but can ’ t alert throughout episode but can ’ t speak. speak.

4.a 27y/o woman G3P2 under CSE, 25μg fentanyl ﹢ 2.5mg bupivacaine continuous EA : 25μg fentanyl ﹢ 2.5mg bupivacaine continuous EA : 0.06% bupi+2μg/ml fentanyl 0.06% bupi+2μg/ml fentanyl 25 min 25 min RR: 6 HR:100 SaO2 94% BP:105/55 RR: 6 HR:100 SaO2 94% BP:105/ IV naloxane – 1-2 min vital sign stable ----IV naloxane – 1-2 min vital sign stable 15min start to speak unfluently but not 15min start to speak unfluently but not fully alert fully alert

40min(65min) became less responsive, 40min(65min) became less responsive, then another naloxane then another naloxane (80μg) was given, the (80μg) was given, the situation became better situation became better 30 ’ (95 ’ ) speak fluently 30 ’ (95 ’ ) speak fluently 1hr after delivery, fully alert but 1hr after delivery, fully alert but incomplete recall of incomplete recall of this event this event

Discussion (4) cephalad spread of sufentanil with CSF cephalad spread of sufentanil with CSF Sufentanil spread to speech area without significant respiratory depress(rare) Sufentanil spread to speech area without significant respiratory depress(rare) bupivacaine on the cranial nerve at the brain stem level bupivacaine on the cranial nerve at the brain stem level Overdose with agent — excessive sedation Overdose with agent — excessive sedation Dose not discussed now Dose not discussed now Morphine into CSF Morphine into CSF

In our p ’ t as her discription, she was alert during the whole episode and could response to our stimulation if she wanted except verbal response as her discription, she was alert during the whole episode and could response to our stimulation if she wanted except verbal response

too nervous too nervous Remain unclear Remain unclear Ps: SA vs GA Ps: SA vs GA