Wild Case today!!!!

marc · Sep 7, 2003

I had a similar situation here in nyc --

we were removing a small external anal tag in the office on a 21yr old male

after 2cc of 1% lido with epi was given he becam irrational and decompenstated into a tonic clonic episode

his pressure dropped to 60/0 and pulse was >160.

75mg of benedryl was given and iv was put in 16g wide open

after 1hr he was totally awake and appropriate but groggy

he became stable with vs and ekg after 3hr he was sent home

--

we were all convinced he was allergic to lido or had a near life comprmising vasal vagal reaction

later in the day our front desk clerk who also was our certified medical assistant told me that he needed to speak to me alone ----

he then revealed that the patient who was a friend of his had told him that he had just taken ectacy that morning to help him relax -- before coming in

needless to say our front desk cna is no longer with us and the patient never came back.

was it possible that the patient you shared about had take some illicit rx? We would have never thought unless our worker fessed up

just a thought?

Tenesma · Sep 8, 2003

A few issues here:

1) curling toes and decrebrating are not necessarily a feature of a tonic-clonic seizure - this could very well have been too light of an anesthetic for a teenager with pharyngeal/laryngeal stimulation from LMA... while lidocaine at that dose (ideal is 1-1.5mg/kg) is good at suppressing most laryngeal reflexes, the propofol dose was way too low - Even though the LMA does not enter the trachea, it can still be an extremely stimulating event - which in turn can be dangerous, because such stimulation in somebody with an unprotected airway (which is essentially what an LMA is: unprotected airway) can easily lead to silent or even overt aspiration... as a rule of thumb I don't use LMAs for drug users, alcoholics, athletes as they are all very difficult to get deep enough to avoid aspiration with an LMA. This patient should have easily received 150 to 250mg of propofol...

2) what decreased the likelihood of a seizure even more is that the patient received Versed which increases seizure threshold as well as propofol - now while it is true that lidocaine can cause CNS disturbance, that is usually seen with a much higher dose (400-500mg)

3) patient preference shouldn't take precedence - and who gives a crap what the surgeon wants or doesn't want (he is not trained in anesthesia) - what should take precedence what is most appropriate and what is safest for the patient. If the patient is willing to be cooperative then this should have been a digital block - if the patient appears likely to be combative during a block then a MAC is viable - However I do agree with Loisane, in teenagers sometimes it is worth biting the bullet and administering a GA for a teenager

4) digital blocks don't rely on circulation as they are meant to be peri-neuronal --- so it doesn't matter what is going in with the circulation, it is a very easy block to obtain with two injection sites - or if you want you can do an ankle block (the digital block would be better in this circumstance) - just make sure you aren't using any epinephrine in your local as this is a digit - now if it has been a long time since you have done blocks, you could request the surgeon to place the digital block

5) AVM malformations: are arterio-venous malformations.... how can venous circulation which has a lower pressure gradient now shoot up into the arterial circulation which has a higher pressure gradient??? it would defy basic physiology for this to happen. So you can scratch that off your list as a reason for the reaction - and this should also answer the question about IV abusers and AVMs. there is no correlation

6) the kid with the anal tag - 2cc is such a minimal dose that this would be extremely unlikely to precipitate such a huge allergic reaction - unless it was mistakenly administered IV, but still unlikely.... Vaso-vagal sounds more appropriate in this setting (i don't know to what extent Ecstasy would have contributed to the agitation?) however in general with a vaso-vagal reaction you will also see an acute bradycardia before you see tachycardia.

Bottomline, I would have done a digital block (and talked the patient through it - without the parents around as teenagers and parents tend to feed off each other) and held her hand and that would have been the extent of my involvement. Plus this should be a 3-5 minute procedure, so a general would only slow your "excellent" surgeon's day down :) as that would add another 30-45 minutes of downtime, as well as necessitate ASA required post-GA recovery time ....

my 2 cents

yoga crna · Sep 8, 2003

Interesting case. It is always fun to look at a situation in retrospect. I would suggest that lidocaine 100 mg is a little high, if your purpose was to stop the burning from the propofol injection. 10 mg works well for me. Propofol 70 mg was a low dose for those teenage hormones. They need a lot of premed, including narcotics, large induction dose of propofol and a strong orderly around for when they wake up. Consider that he may have been hyperventilating, causing his carbon dioxide to decrease and even lowering the seizure threshold.

I do a lot of teenagers for rhinoplasty surgery and know that their response to drugs can be strange--particularly on emergence.

Let us know the end-result. I bet the neuro work-up is negative.

Yoga