May 18, 2012
Phenomenon
From the Greek word, φαινόμενoν ,
plural Phenomena, is any observable
occurrence. Phenomena are often, but
not always, understood as “appearances”
or ‘experiences’. These are themselves
sometimes understood as involving
qualia.
www.wikipedia.org
The Patient
 Right Total Hip Replacement
 70 Female, 96.4 Kg, 165.1 cm
 Allergies: Vistril, diazepam, oxycodone, hydromorphone,
vicodin and midazolam.
 Hx: HTN, Arthritis, degenerative Joint Disease, Chronic
Pain, OSA, Hypothyroidism, Cardiac catheter and
migraine headaches.
 ASA 3
 Sx: Lumber 4 laminectomy, appendectomy, Lap
cholecystectomy and left total hip replacement.
 Patient reported no previous anesthetic complications.
Medications
CPAP at night
Bystolic
Levothyroxine
Estradiol
Topamax
Lyrica
Tramadol
Expressed Desire
8 week ago patient had a
Successful Left Total Hip
Replacement
Anesthesia Plan
Spinal
TIVA
Previous anesthesia record
was used to formulate plan.
Intraoperative
Patient remained spontaneously
breathing
Vitals stable
Total Hip was replaced in 54 minutes
Post Operative Recovery
Pt woke up with tonic clonic jerking
motions
Protect
Airway
Propofol
Secured Airway
 Seizures
 Intubation “Being Careful”
 Roll to ICU
ICU
EEG
CT
Neurology Consult
Pathophysiology
 Epilepsy is not a disease, but rather a
symptom of a disorder of neuronal
dysfunction.
 A seizure results from the discharge of
an aggregate of neurons that depolarize
in synchronous fashion.1
Tramadol
Induce Seizures?
Tramadol
 Central acting analgesic
 Tx: Chronic Pain
 Decreases the seizure Threshold
 Moderate affinity for the mu, weak kappa and delta
 5-10 times less potent than Morphine.2
Tramadol
 Racemic mixture of 2 Enatiomers
 1 inhibits neuronal reuptake of norepinephrine
 1 inhibits 5-hydroxytrptamine (serotonin, 5-HT2c)
reuptake, which contributes to lowering the seizure
threshold.
 These enhance the function of spinal descending
inhibitory pathway and utilizes the action of mu
receptors.2
Tramadol Advantages
 Metabolized by the liver P-450 to the metabolite O-
desmethyltramadol , which exerts its stereo-selective
pain relieving effect.
 Minimum depressant effects on breathing.
 Decreases post op shivering.
 Does not cause organ toxicity or major sedative side
effects
 Does not cause tolerance or addition.3
Tramadol Dependence Study
The Arab Journal of Psychiatry 2011. (22):76-78.
 Crossection study of 36 patients in addiction unit in
Bagdad, Iraq.
 90% were on Tramadol alone
 7 patients were medical profession
 Average daily dose was 400-5000 mg. Mean 1000 mg.
 22% experienced at least one seizure.
Tramadol Disadvantages
 Decrease gastric emptying
 Interaction with coumadin
 Lowering the seizure Threshold producing drug
related seizures, by blocking 5-HT2c.
 Inhibition of GABA-A receptors at high doses
 Serotonin Toxicity with SSRI’s
Tramadol Induced Siezure: Report of 106 patients.
IRCMJ 2010; (12): 49-51.
 92 patients had a new onset provoked seizures.
 14 patients had previous known epilepsy.
 86 of patients were abusing Tramadol
 20 of the patients were prescribed Tramadol
 The Dose of Tramadol before seizures was 50 to 1500mg.
106 Patients Continue
 85 developed seizure with a daily dose equal to or less
than 400mg.
 21 developed seizures with doses above 400mg.
 EEG normal in 50, non-specific diffused slowing in 49,
and epileptic form discharges in seven patients.
 All patients had normal brain CT scans
Seizures Associated with
Intoxication and Abuse of Tramadol
Clinical Toxicology 2006; 44:143-146
Seizures Associated with
Intoxication and Abuse of Tramadol
Clinical Toxicology 2006; 44:143-146
Conclusion
 Tramadol can cause dependency
 Tramadol can cause Seizures, especially when exposed
for longer periods of time and at Toxic dose levels.
 Further research is needed within the geriatric
population.
References
 Hines RL, Marschall KE. Anesthesia and Co-Existing Disease. 5th ed.
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Philadelphia: Churchill Livingstone 2008; 10A:232-234.
Stoelting RK, Hillier, SC. Pharmacology & Physiology in Anesthetic Practice.
4th ed. Philadelphia: Lippincott Williams & Wilkins 2009; 3:117.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock, MC. Clinical
Anesthesia. 6th ed. Philadelphia: Lippincott Williams &Wilkins 2009; 25:629630.
Mohammed R, Lafta Al-Aboodi. Tramadol dependence in the addiction unit
of Baghdad: a cross sectional study. The Arab Journal of Psychiatry 2011;
22:76-78.
Nesic N, Martinovic Z, Jovanovic-Cupic V. Seizures Associated with
Intoxication and Abuse of Tramadol. Clinical Toxicology 2006; 44:143-146.
Petramgar P, Hghighi Borhani A. Tramadol Induced Seizure: Report of 106
Patients. Iranian Red Crescent Medical Journal 2010; 12(1):49-51.
Pedramfar P, Mosallaei SH. The Effect of Provoked Agents on Control of
Epilepsy. Iranian Journal of Neurology 2008; 7:191-197.
Raffa RB, Stone DJ. Unexceptional Seizure Potential of Tramadol or Its
Enantiomers or Metabolites in Mice. The Journal of Pharmacology and
Experimental therapeutics 2008; 325:500-506.
Questions