Western Visayas Medical Center
Q. Abeto Street, Mandurriao, Iloilo City
Department of Anesthesiology
Presents
“The Mask”
A case of Trigeminal Neuralgia
October 16, 2019
(Venue)
(time)
Rogelio G. Blanco Jr., MD
First Year Resident
CASE PROTOCOL
This is a case of patient L.M,, a 45 years old female, single, Filipino, Roman Catholic, and a resident of Sambag, Jaro, Iloilo City.
Informant: The patient herself
Chief Complaints:
Facial Swelling
History of Present Illness:
3 months prior to admission, the patient noted presence of a pimple on his right nares. No other associated signs and
Past Medical History
The patient had no known history of Illness, previous hospitalizations or surgical procedures. No known allergies to food
and drugs. No history of trauma or accidents.
Family History:
The patient had a known family history of diabetes milletus on both maternal and paternal side.
No other heredo-familial disease is noted on both sides of the patient’s family.
Personal/Social/Environmental History:
Patient is a college graduate
The patient is a former accountant, currently a non-smoker and not an alcoholic beverage drinker. They have access to potable
water and electricity.
REVIEW OF SYSTEMS
General:
(+) Weight loss
(+) Loss of appetite
(-) Fever
Integument:
(-) Jaundice
(-) Skin Rashes
(-) Dryness
Head:
(-) Dizziness
(+) Pain on her mandibular area
Eyes:
(-) Eye pain
(-) Eye discharges
(-) Redness of eyes
(-) Excessive Tearing
(-) Blurred vision
Ears:
(-) Earache
(-) Decreased Hearing
(-) Discharges
Respiratory System:
(-) Difficulty of breathing
(-) Shortness of breath
(-) Cough
(-) Hemoptysis
Cardiovascular System:
(-) High Blood Pressure
(-) Chest Pain
Gastrointestinal System:
(-) Constipation
(-) Diarrhea
(-) Vomiting
(-) Abdominal Pain
Genitourinary System:
(-) Dysuria
(-) Polyuria
(-) Urinary Retention
Musculoskeletal System:
(-) Joint Pain
(-) Joint Swelling
(-) Muscle Pain
(-) Muscle atrophy
Nose:
(-) Nasal discharges
(-) Anosmia
(-) Congestion
Neurologic System:
(+) Dizziness
(-) Seizures
(-) Numbness
(-)Tremors
Throat:
(-) Pain in swallowing
(-) Hoarseness
(-) Dysphagia
Hematologic System:
(-) Anemia
(-) Hematoma
(-) Bleeding
Mouth:
(-) Dry lips
(-) Cracked lips
Endocrine System:
(-) Heat Intolerance
(-) Cold Intolerance
Physical Examination
General Survey:
The patient was seen at bed. She was awake, conscious, coherent, and not in
cardiopulmonary distress.
VITAL SIGNS:
Temperature: 37.5°C per axilla
BP: 120/90 mmHg
CR: 101 bpm
RR: 20 cpm
O2 sat: 99%
Anthropometrics:
Weight: 38kg
Height: 5’0
BMI: 16.4 kg/m2 (Severely underweight)
Head and neck
Normocephalic, with tenderness noted at mandibular area. Patient had symmetrical
auricles. No discharges noted on both external auditory canal No tenderness or masses noted on
both ears. No alar flaring. Lips and tongue are dry. The neck has no masses and no neck vein
engorgement, no tenderness
Cardiovascular System
Adynamic precordium, no deformities were noted. Patient had regular cardiac rate and rhythm
with no murmurs noted. Point of maximal impulse at the 5th ICS midclavicular line.
Chest and Lungs
Symmetrical chest expansion, no use of accessory muscles, no chest retractions. Symmetrical
tactile fremitus on all lung fields, no tenderness or masses noted. Clear breath sounds noted, no
wheeze or rhonchi noted
Abdomen
Soft, flabby, nontender abdomen. No rashes or scars noted. Normoactive bowel sounds and no
bruits heard.
Upper and Lower Extremities:
Grossly normal upper and lower extremities. There was no pallor, CRT <2seconds. He had full
and equal pulses on all extremities. He had full range of motion on all extremities.
Skin & Nails
Patient has brown skin. No scars or lesions noted on the extremities. Skin is warm. Normal
capillary refill of less than 2 seconds.
Neurologic:
The patient is GCS 15 (E4V5M6). He was alert, conscious, and coherent
Diagnostics:
CBC (8/26/2019)
Hemoglobin
Hematocrit
WBC
Platelet count
14
0.42
9,4
Adequate
Coagulation (8/26/2019)
Prothrombin Time
13.1 seconds
% Activity
100%
INR
1.00
APTT
25.8 seconds
Chemistry (8/26/2019)
Sodium
140.50
Potassium
3.68
Creatinine
77.57
FBS(4/13/19)
6.28
Chest Xray 4/12/19
No Significant Cardiopulmonary Findings
Electrocardiogram 4/12/19
Normal Sinus Rhythm
Initial Impression:
Trigeminal Neuralgia
Course in the wards
 1st Hospital Day
Patient was admitted at the emergency room under the service of neurosurgery. Was put on NPO
temporarily. Blood examination and diagnostics were requested (CBC with APC, blood typing, serum
sodium, potassium and creatinine, prothrombin time and cranial CT scan). Intravenous fluid was
started with PNSS 125cc/hr. The patient was subsequently referred to department of anesthesiology
for pain management.
Patient was seen at the emergency room complaining of pain on her right face area particularly
on her forehead. It is persistent with a duration of 2-4 minutes. It is characterized by prickling,
throbbing, burning. It is aggravated by extremes of temperature, brushing her teeth, and sour or spicy
food and extreme movement.
Fentanyl 30mcg slow IV was given in titrated doses. It relived her pain from 8/10 to 0/10. PCA
fentanyl was started with the following settings:
Concentration: 20mcg/ml
Rate: 14mcg/hr
Demand: 8mcg
Lockout: 10 minutes
Other pain medications were requested such as: Pregabalin with the following doses: Pregabalin
50mg/cap at 8am, Pregabalin 75mg/cap at 8pm.
Paracetamol 600mg IV every 6hoursx 4 doses was given.
 2nd Hospital Day
Patient had episodes of pain on the right side of her face and forehead. It is characterized by
burning, throbbing, electricity like. VAS score of 7-9/10 lasting about 36 minutes after chewing. She
mentioned of fear of eating/chewing. Preferred liquids as of now. 9/87 doses of Fentanyl given per
demand. Plan is to increase PCA settings.
Concentration: 20mcg
Rate: 18mcg/hr
Demand 10mcg
Lockout 10mins
Other pain medication such as Pregabalin and Paracetamol were continued.
 3rd Hospital Day
Patient had another episode of throbbing, electric like pain at right side of her face with VAS of
7/10 lasting for 51 minutes. It is aggravated by talking and relived to VAS 4/10 after pressing her PCA.
PCA setting is increased to the following values.
Concentration: 20mcg
Rate: 19mcg/hr
Demand: 12mcg
Lockout 10mins.
Other pain medications were continued. Patient was advised to avoid very hot nor cold
food as well as to have small frequent feedings.
 4th Hospital Day
In the morning patient had complained of 1 episode of hot, throbbing electric-like pain at right
side of her face while eating with VAS of 7/10. Patient had pressed her PCA 3 times and the intensity
of her pain was decreased from VAS 7/10-3/10. Pain lasted for 50 minutes. PCA settings was
increased to the following values:
Concentration: 20mcg
Rate: 25mcg/hr
Demand: 14mcg
Lockout 10mins.
Patient had 4 episode of vomiting. Complained of epigastric pain and vomits every time she eats
bread. Ranitidine 50mg every 8 hours was given She still complained of electric like and throbbing
pain on the right of her face. It is aggravated every time she eats from VAS 0/10 to 8/10. PCA settings
were maintained and other pain medications were still continued. She was advised to avoid very hot
and cold food and beverages.
 5th Hospital Day
Patient is now comfortable with VAS score of 0/10 with occasional episode of pain with pain
score of 4/10 which now lasts for 4 minutes. PCA settings were maintained.
 6th Hospital Day
Patient had occasional complaints of pain with VAS score of up to 7/10. She pressed her PCA
13/18 attempts in 24 hours. PCA settings were maintained as well her other pain medications.
 7th Hospital Day
Patient had sudden attack after eating bread. Complained of nausea, which she correlated with
poor intake and Fentanyl. PCA settings were maintained as well her other pain medications.
 9th Hospital Day
Patient complained of pain after eating which occurred at an average of 3 episodes each day
particularly after every meal. Most severe attack is said to be at VAS 7/10. It usually relieved by PCA
press. Patient complained of not having a bowel movement since admission. Abdomen is soft and
non-distended. She was started with Lactulose 30ml once a day at bedtime and as needed if still with
no bowel movement for 3 days. PCA Fentanyl was maintained with the same setting as well as other
pain medications.
 10th Hospital Day
Patient had 1 attack of pain during bedtime. She was able to fall asleep. Still with no bowel
movement. Oral Morphine Sulfate 10mg/tab (MST), 1 tab every 8hours round the clock was started.
1st dose was given. Pregabalin dose was shifted to Pregabalin 150mg/cap, 1 cap every 12 hours (8am
and 8pm). PCA setting was revised.
Concentration: 20mcg
Rate: 0mcg/hr
Demand: 15mcg
Lockout 10mins.
Strict opioid precaution was advised.
 11th Hospital Day
Patient complaints of pain every time she takes morphine tablet. She complaints of pain every
time she is exposed to air from fans. Able to sleep without interruption but still had no episode of
bowel movement since. Morphine tablet was continued as well as her Pregabalin. PCA Fentanyl
settings were maintained.
 12th Hospital Day
Patient complained of pain while she changed her clothes. Pain is also aggravated by talking and
eating. Still with no bowel movement. Bisacodyl suppository given. Pain medications were continued.
Duloxetine 30mg/tab, 1 tab at 8pm was started.
 13th Hospital Day
Patient had 2 episodes of pain attacks during the evening while eating and using the toilet.
Patient is now able to speak with no pain and able to take bowel movements. Pain medications were
continued.
 14th Hospital Day
Patient had no episode of pain and comfortable. Her Fentanyl PCA was discontinued. Morphine
sulphate 10mg plain 1 tab every hour was started as rescue dose
 15th Hospital Day
Patient had an episode of severe pain during dinner while eating mashed fruit. It was relieved
after taking rescue dose of morphine 10mg tab plain. Pain medications were continued.
 16th Hospital Day
Patient had various attacks of pain which ranges from VAS 6-9/10 triggered by eating, elevating
hands. She took 7 tablets of morphine sulphate plain rescue dose. Pregabalin dosage was increased to
200mg/tab, 1 tab TID. Other pain medications were continued.
 17th Hospital Day
Patient had a total of 9 episodes of breakthrough pain which the intensities ranges from VAS68/10. She had 1 episode of vomiting after patient tries to eat. Morphine rescue dose was taken 4
times during this time. Morphine sulfate MST dosage was increased to Morphine MST 10mg/tab, 2
tabs BID. Other medications were continued.
 18th Hospital Day
Patient had 8 attacks of breakthrough pain which ranges from VAS 5-8/10 after eating. Claims to
eat despite episodes of breakthrough pain. Pain medications were continued.
 20th Hospital Day
Patient is now not in pain and is comfortable. She is now able to take bath without bouts of pain.
No rescue doses taken for the span of 24 hours. Pain medications were maintained.
 24th Hospital Day/Pre-operative Visit
Patient was scheduled for elective Microvascular decompression via rectosigmoid approach
right. Anesthesia preoperative visit was done. Patient was seen and examined and history as well as
physical examination were reviewed. Informed consent was obtained. The patient was put on NPO at
midnight and the following pre-operative medications were given such as Ranitidine 50mgIV 1 hour
prior to surgery, and Ondansetron 4mg slow IV 1 hour prior to surgery. She was cleared by the
department of Internal Medicine as Moderate Risk.
Anesthesia Pre-operative Assessment:
Patient is classified ASA2, Mallampati class 1. Case was referred to consultant on deck. The plan
was to do general endotracheal anesthesia.
Proposed Procedure:
Microvascular decompression via rectosigmoid approach right
Anesthetic Technique:
General Endotracheal Anesthesia
Intraoperative Course:
The patient was received in the Operating Room awake, conscious, cooperative, and not in
cardiopulmonary distress. He was attached to basic monitors. Oxygen supplementation was
started at 5LPM via face mask. The initial vital signs were: blood pressure of 100/60mmHg ,
cardiac rate of 71 bpm, respiratory rate of 13 cpm, and oxygen saturation 99%. The
Intravenous line was patent and infusing well. Midazolam 3mgIV was given prior to
induction.
Plan was to do general endotracheal anesthesia-balanced anesthesia. Preoxygenation was
done. Induction medications were given. Direct laryngocopy done using Machintosh blade 4.
Her laryngeal grade was 2. Endotracheal tube size 7 cuffed inserted. ID level at 28 cms and
attached to semi closed circuit system with CO2 absorber. With equal breath sounds. Vital
signs were stable after intubation. Patient was then placed on park bench position.
The patient was maintained on sevoflurane (MAC 0.6-1), Remifentanil (2-3.3mg/ml),
Propofol (3-3.2mg/ml). Rouronium was used as a muscle relaxant. Other medication given
intraoperatively were Tranexamic acid 1 gram IV. There was an episode of hyptension of
80/60mmHg after 2 hours and 30 minutes after the start of procedure. Ephedrine 5mgIV was
given which increased her blood pressure to 100/60 mmHg. The entire procedure was
uneventful and lasted for about 3 hours. The estimated blood loss was 300cc. A total of 700
cc of crystalloids and 1300 cc of colloid was infused. Neuromuscular blocked reversal agent
was used (Sugammadex). The patient was then extubated prior to transfer to PACU with the
following vital signs: BP150/90mmHg, CR51bpm, RR20cpm, O2 saturation 100%
Procedure Done:
Microvascular decompress
Postoperative Course:
The patient was transferrred to the recovery room GCS15 (E4V5M6) awake with
spontaneous breathing, with stable vital signs and not in cardiopulmonary distress, with a
VAS score of 2-3/10. Oxygen therapy was continued at 5 LPM. Patient was attached to
monitors and vital signs monitoring was continued. Patient was placed on moderate to high
back rest with aspiration precaution. Suctioning of secretions was done as needed.
Postoperative pain medications were given. After approximately 4 hours of stay at the PACU,
the patient was transferred to the ward fully awake, with stable vital signs, no desaturations,
and not in cardiopulmonary distress. Oxygen therapy was continued at the wards.
Postoperative Medications:
- Tramadol drip (Tramadol 100 mg in 98cc PNSS to run for 8 hours) x 3 cycles then shift to
- Tramadol 50mg/tab 1 tablet every 6 hours for 3 days
- Ketorolac 30 mgs IV every 6 hours x 3 more doses then shift to
- Celecoxib 200 mg/cap, 1 capsule two times a day for 3 days
-Paracetamol 600mg IV every 6 hours x 6 doses then as needed for breakthrough pain
24 hours post surgery, patient had stable vital signs, awake, comfortable with VAS of 0/10. Note of
brownish discharge with minimally soaked dressing. Wound dressing done by ENT resident on daily
basis. Medical and pain medications were continued.
72 hours post surgery, decrease in facial swelling noted. Patient was able to open his eyes, still with
minimal yellowish discharge. Patient had febrile episodes. However,the patients other vital signs were
stable and the patient was not in cardiopulmonary distress. On the same day, laboratory results
showed positive for MRSA. Thus patient was transferred to isolation room. Pain medications were
continued and contact precaution was emphasized.
7days post surgery, patient was given Bisacodyl 2 suppositories per rectum due to absence of BM for
6 days. Patient had stable vital signs. Daily wound dressing and antibiotics were continued. Patient
was now for transfer to MM2.
12 days post surgery, decrease in discharge noted, no swelling, no complaints of pain. Patient had a
stable vital signs. Daily wound dressing was continued and still for completion of IV antibiotics.
16 days post surgery, antibiotics were completed, no complaints of pain. The patient had a good eye
opening with minimal granulation tissue and patient had stable vitals signs. Patient was then cleared
for discharge and was advised to follow up at the out patient department 1 week after discharge.
Final Diagnoses:
Facial Abscess with Cavernous Sinus Thrombosis
Diabetes Milletus TypeII-Insulin Requiring; Methicillin Resistant Staphylococcus
Infection
Electrolyte Imbalance Hyponatremia
Aureus