Abstract
AimTo report a case of severe respiratory depression with PCA fentanyl use simulating stroke in a patient who underwent routine elective endoluminal graft repair for abdominal aortic aneurysm (AAA)Case presentationA 78-year-old obese lady underwent routine endoluminal graft repair for AAA that was progressively increasing in size. Following an uneventful operation postoperative analgesia was managed with a patient-controlled analgesia (PCA) device with fentanyl. On the morning following operation the patient was found to be unusually drowsy and unresponsive to stimuli. Her GCS level was 11 with plantars upgoing bilaterally. A provisional diagnosis of stroke was made. Urgent transfer to a high-dependency unit (HDU) was arranged and she was given ventilatory support with a BiPap device. CT was performed and found to be normal. Arterial blood gas (ABG) analysis showed respiratory acidosis with PaCO2 81 mmHg, PaO2 140 mmHg, pH 7.17 and base excess -2 mmol/l. A total dose of 600 mcg of fentanyl was self-administered in the 16 hours following emergence from general anaesthesia. Naloxone was given with good effect. There was an increase in the creatinine level from 90 μmol/L preoperatively to 167 μmol/L on the first postoperative day. The patient remained on BiPap for two days that resulted in marked improvement in gas exchange. Recovery was complete.
Highlights
Endoluminal repair for abdominal aortic aneurysms (AAA) has become an established technique for patient undergoing elective surgery
Repair is usually achieved with small groin incisions that may be managed with less aggressive analgesia regimens than those reserved for open repair [1]
She had past medical history of osteoarthritis and had undergone bilateral mastectomy in 1995. She had a transient ischaemic attack (TIA) 2 months prior to surgery with no carotid stenosis. She underwent endoluminal graft repair for AAA performed under general anaesthesia
Summary
Endoluminal repair for abdominal aortic aneurysms (AAA) has become an established technique for patient undergoing elective surgery. Arterial blood gases showed respiratory acidosis (pH = 7.17, PCO2 = 81 mmHg, PO2 = 140 mmHg, HCO3 = 29 mmol/l, base excess = -2 mmol/l, O2 saturation = 98%, anion gap 12) She was immediately transferred to the High-Dependency Unit (HDU) where BiPap (ventilatory support) was commenced. The PCA machine was programmedto deliver 20 μg bolus of fentanyl with a five minute lockout time interval She improved with ventilatory support over the following two days, weaned to Venturi face mask and discharged on room air. PCA pumps are used when the duration of surgery is long or the wound is large or there is significant fentanyl use in the recovery room This is our practice in Royal Perth Hospital. There was no follow up CT Scan or MRI to exclude stroke as it was not indicated clinically
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