prepared exclusively for kkuh 2010 neurological deficit following combined spinal-epidural for knee...

Prepared Exclusively for KKUH 2010

Neurological Deficit Following Combined Spinal-Epidural for Knee

Arthroplasty

Tariq Alzahrani MD

Assistant Professor

College of Medicine

King Saud University


Pre operative Assessment

83 years old male patient admitted through the clinic with bilateral osteoarthritis for left total knee replacement.

Patient seen one day preoperative and he is not known to have any medical illness, surgical history for RT shoulder surgery under general anesthesia without complication, all lab results within normal range , normal ECG and CXR.

The plan for ( CSE) ,N PO, premedicated with

ranitidine 150 mg PO 2 hours pre op.


Intra Operative

The patien came to OR theater at 2:45 pm and 18G canula inserted and standard monitoring connected.

CSE technique : sitting position sterilization done with iodine CSE set B / Braun L3-L4 loss of resistance(air) after 6 cm 27 G pencil point spinal needle , clear CSF heavy marcaine 0.5% 2cc + fentanyl 25 mcg epidural catheter threaded , back flow, catheter out

L4-L5 ,the catheter fixed at 12 cm at skin supine position,O2 face mask, Foley catheter

inserted surgery time 3:30 hemodynamicaly stable NIBP(160-180 / 90-80) 50 mcg fentanil



OR SHEET


Recovery Room

Surgery finished at 6:15 pm Awake, breathing spontaneously (Spo2 98%, BP 144/98 ,

PULSE 72 bpm, RR 17/min Start epidural infusion of (marcaine 0.0625% with fentanyl 2

mcg ) at 5 ml / h , pain (3/10 on numerical pain score). Routine evaluation (sensory, motor function and pain score)

patient was able to do dorsal & planter flexion and sensory level was at L1 checked by ice and the patient shifted to the word at 7:30 pm.

The nurse stuff receive the patient in the word awake, conscious, vital signs stable, epidural cath. inside.


APS SHEET


1st day post operative

Patient stable Seen by pain management team and another order

made for new infusion bag of the same concentration and infusion rate increased to 8 ml /h

Patient seen by surgical team and the dressing changed.

Physiotherapy started on bed and they try to mobilize him with difficulty but the patient made one step.


2nd & 3rd day post operative

Able to move Rt foot toes little but no movement in Lt foot toes and he cannot lift both legs

Sensation intact Pain management team discontinue the epidural

infusion and decide to remove the catheter next day at morning according to coagulation profile result and they hold clexan dose to be restarted 4 hours after catheter removal and they start him on Tylenol 3 orally q 6 h.

3rd & 4th day post op the same situation, the motor power still weak and epidural catheter still in.


5th day post operative

Epidural catheter removed Weakness of both lower limps more in right

side Sensation start to deteriorate, referred to

neurologist.


Neurological examination

LOWER LIMB RIGHT LEFT TONE decreased decreased

POWER proximal 1/5 proximal 1/5 distal planter flex 4/5 planter flex 2/5 dorsi flex 3/5 dorsi flex2/5

REFLEXES decreased decreased

SENSATION DECREASED BELOW THE KNEE SPHINCTER INCONTINENCE.


Results of Investigations MRI no evidence of intra spinal collection, diffuse

degenerative disc disease Lumber puncture normal NCS & EMG done after four days due to technical

error in the machine sever axonal type neuropathy, neuroradiculopathy on the lower limb, sparing the sensory fibers.

Diagnosed: cauda epuina syndrome???? Dexamethazone IV 10 mg , 6mg Q 6 H Advise aggressive physiotherapy.


Follow Up

The neurologist and physiotherapist follow up the patient and he was improving slowly as the motor power became better and sensation intact

Hemodynamic stable and uneventful hospital stay.


34 days

Unfortunately , abscess at surgical site (staph A) from the wound , cloxacilline sarted

GA uneventful 1st day, complete sensory loss in both lower

limb ?????


40 days

Urea=22 , Creat=225, Na= 144 , albumin= 11

Conscious and stable and diagnosed as a case of pre renal azotemia and the IV fluid normal saline and albumin 20% 100ml OD for three days.


41days

Confused with decrease level of conscious and jerky movement of upper limb and trunk observed with neck stiffness

BP=140/60 , HR= 65 , RR = 26 , Spo2= 86% on room air

O2 face mask Phenytoin


44 days( 1 day before shifting to SICU)

Feverish with shivering , restlessness , agitated, SOB, confused

O/E (GCS 10/15, CHEST abnormal breathing sound, CVS s1+s2+0 irregular rhythm , Abdomen tense and distended )

1. fungal or TB meningitis ??? encephalitis?? 2. new hospital acquired pneumonia 3. new onset of atrial fibrillation 4. hypernatremia

The ID team start tazocine 2.25 gm q 8 h , continue cloxacilline + vancomycine , septic screen

Cardiac consultation for AF Nephrology consultation for renal impairment. The patient shifted to SICU


SICU ( 45 days)

Became tachepnic , tachycardia , Spo2 87% , intubated.

During SICU stay the patient develop septic shock , acute renal failure , ARDS , AND LOW PLATLET (coagulopathy).

Clinically:1. CVS : ON INOTROPIC SUPPORT 2. CNS : SEDATED3. RESP: SEVER ARDS 4. KEDNIY: ON CRRT 5. ID : BLOOD CULTURE IS GRAM –VE BACILLI .

SUMMARY

TNS, typically persisting over 1–3 days have been reported after the use of bupivacaine at an incidence of up to 1%.

The incidence of persistent neurological sequelae after subarachnoid anaesthesia varies between 0.01 and 0.7%.

In electophysiological, histopathological, behavioural and neuronal cell models, lidocaine and tetracaine appear to have a greater potential for neurotoxicity than bupivacaine.

CSE or Spinal. Mechanism is unknown.



Thank you

prepared exclusively for kkuh 2010 neurological deficit following combined spinal-epidural for knee...

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