Post op seizures

[urge]

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I was called to see a pt that was tachycardic. Upon reviewing the record and questioning the pacu nurse I found ot the pt woke up seizing after an ortho procedure. They did a Ct scan (normal), loaded dilatin and ativan. Pt has been unresponsive to verbal commands since the procedure was finished. Arouses to painful stimulation. Pt had GA with des, fent, dilaudid, and ketamine drip (200mg total). Never had a seizure before. Labs are all ok. What do you think is the problem? I blame the ketamine. How would you handle the case?

 

[coprolalia]

Intra-op CVA. Normal CT scan early does not detect an embolic stroke.

Re-scan in 24-48 hours. Or take them to interventional radiology and do a cerebral angiogram.

-copro

 

[zippy2u]

Embolic phenomenon causing the CVA. It ain't the ketamine. Copro is spot on. Serial head scans over the next few days in the ICU will reveal the problem. Unfortunate case and everybody and their momma will attempt to place the blame on anesthesia. Regards, ---Zippy

 

[coprolalia]

The prevalence of PFO is about 25 percent in the general population. In patients who have stroke of unknown cause (cryptogenic stroke), the prevalence of PFO increases to about 40 percent. This is especially true in patients who have had a stroke at age less than 55 years.

http://www.clevelandclinic.org/heartcenter/pub/guide/disease/congenital/pfo.htm

-copro

 

[huktonfonix]

while you need to rule out a CVA, I think the timeline is important too. How long after the case is the pt. still unresponsive. The patient has a lot of reasons to still be obtunded including the ketamine. For example how much ativan was the patient "loaded" with? If its an hour or two out from the case, I wouldnt be extremely concerned. If its six hours or so out then CVA would be higher on my list. Oh yeah, still seizing is also on my differential. An EEG may be in order.

 

[Noyac]

I always felt that sz's after anesthesia were unlikely although my attendings told me otherwise. I had one pt sz on emergence but he had uncontrolled epilepsy and we were putting a vagal n. stimulator in to control his sz's.

I am afraid that something very bad has occurred with your pt. Time will tell.

 

[militarymd]

How long after surgery is this?

3 hours
the next day
the next week...

I would do the usual monitoring stuff...but I wouldn't worry too much until 6 hours have passed after end of surgery.

 

[Noyac]

How long after surgery is this?

3 hours
the next day
the next week...

I would do the usual monitoring stuff...but I wouldn't worry too much until 6 hours have passed after end of surgery.

Why 6 hrs Mil?

 

[militarymd]

Why 6 hrs Mil?

Arbitary number that I've arrived at over the years as a time period when you either have to "shi t or get off the pot" time frame.

You can usually wait that long before you really have to do anything else....

and after 6 hours, you can pretty much count on anesthesia drugs being gone....with rare exceptions.

 

[Noyac]

Arbitary number that I've arrived at over the years as a time period when you either have to "shi t or get off the pot" time frame.

You can usually wait that long before you really have to do anything else....

and after 6 hours, you can pretty much count on anesthesia drugs being gone....with rare exceptions.

I thought so.

 

[zippy2u]

Hott Damm, I'm majorly disappointed. I was hopin' that the magical 6 hrs was derived from some whiz-bang guru landmark study done with 7653 case reports over 11 years crunching statistical #s by IBM's Big Blue...."Arbitrary"--total blasphemy I say. Now, in Zip's case I would have quoted you the 6 hrs because that's when I get off call... Regards, ---Zip

 

[urge]

I gave some metoprolol for the HR. Repeated a blood gas, which was ok. Since I was still blaming the ketamine, I didn't pay much attention to her mental status. I wasn't that concerned with embolic stroke since the pt didn't have long bone surgery. An hour later I went to check on the pt and to my surprise was totally awake with no gross neurologic deficit. It took like 4 hrs for the pt to wake up.

I looked up the relationship of ketamine and seizures. Most of the papers I saw said that ketamine was an anti-seizure drug. A few of them said that it can induce seizures in people with epilepsy. My ketamine theory doesn't seem to have much literature support but I'm sticking to it.

 

[jwk]

I'm still trying to figure out why with des + narcs that one would have any use or need for a ketamine drip.

 

[nutmegs]

people who are on chronic narcotics get it with the rest of their mix here. I need to learn more about why.

 

[huktonfonix]

also coulda been drugs + post ictal

 

[urge]

I'm still trying to figure out why with des + narcs that one would have any use or need for a ketamine drip.

It's kind off popular where I'm at. "Multimodal" pain management. Seems to work. I'm not sure if it is because pt's are too gorked out to complain of pain.

 

[Planktonmd]

It's kind off popular where I'm at. "Multimodal" pain management. Seems to work. I'm not sure if it is because pt's are too gorked out to complain of pain.

Are you sure it was a seizure?
In my experience most of the cases when people describe a seizure at emergence they are actually describing some combination of shivering, bucking and maybe some myoclonic activity.
Then after they diagnose that alleged seizure they blast the patient with some drug to suppress it and the end result would be a patient that would not wake up and appears post-ictal.

 

[VentdependenT]

You guys ever get called by a vigilant PACU nurse about post-op anisocoria?

 

[militarymd]

You guys ever get called by a vigilant PACU nurse about post-op anisocoria?

Nope, my PACU nurses like the patients kinda unresponsive....

although I do document anisocoria preoperatively ....so all they have to do is look in my preop if they had questions.

 

[Noyac]

No but I had a nurse call me last week b/c the pt had a nystagmus. She failed to look at my pre-op assessment w/c documented the nystagmus. She also failed to remember that I told her about it when I dropped him off in the pacu.

 

[urge]

Are you sure it was a seizure?

I don't know for sure. I did not witness said seizure. I only know what I have been told. Your thoughts crossed my mind too, but I had no evidence to back it up.

Funny thing is I relieved the anesthesiologist who did the case and he didn't say anything about this mess before leaving. His report was "there is a second case to start but I don't know what it is, and I don't know who the anesthetist will be, bye".

 

[coprolalia]

You guys ever get called by a vigilant PACU nurse about post-op anisocoria?

You ever look at someone's eyes after you give them Reglan? I don't care how much narcotic you give. Freaky.

-copro

 

[danielmd06]

I was called to see a pt that was tachycardic. Upon reviewing the record and questioning the pacu nurse I found ot the pt woke up seizing after an ortho procedure. They did a Ct scan (normal), loaded dilatin and ativan. Pt has been unresponsive to verbal commands since the procedure was finished. Arouses to painful stimulation. Pt had GA with des, fent, dilaudid, and ketamine drip (200mg total). Never had a seizure before. Labs are all ok. What do you think is the problem? I blame the ketamine. How would you handle the case?

Out of curiosity, what was the final verdict on this patient? Was an EEG or f/u CT scan completed? MRI brain?

Has she recovered completely?