Letters to Editor
REFERENCES 1. Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG, et al. Practice guidelines for management of the difficult airway: An updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2013;118:251‑70. 2. York JE, Wharen RE, Bloomfield EL. Esophageal tear in a patient undergoing stereotactic brain biopsy under general anesthesia. J Anesth 2009;23:432‑5. 3. Langeron O, Semjen F, Bourgain JL, Marsac A, Cros AM. Comparison of the intubating laryngeal mask airway with the fiberoptic intubation in anticipated difficult airway management. Anesthesiology 2001;94:968‑72. 4. Ferson DZ, Rosenblatt WH, Johansen MJ, Osborn I, Ovassapian A. Use of the intubating LMA‑Fastrach in 254 patients with difficult‑to‑manage airways. Anesthesiology 2001;95:1175‑81. 5. Fukutome T, Amaha K, Nakazawa K, Kawamura T, Noguchi H. Tracheal intubation through the intubating laryngeal mask airway (LMA‑Fastrach) in patients with difficult airways. Anaesth Intensive Care 1998;26:387‑91. Access this article online Quick response code Website: www.ijaweb.org
DOI: 10.4103/0019-5049.155007
Cardiac arrest from tramadol and fentanyl combination Sir, Tramadol is a centrally acting atypical opioid analgesic commonly used in the treatment of moderate to severe pain. It has a low affinity to µ opioid receptors and also inhibits the reuptake of serotonin and norepinephrine. Fentanyl is a potent, synthetic opioid with a rapid onset of action and strong affinity to µ receptor. Both the drugs are considered to have a high safety profile and used widely in anaesthesia. Fentanyl and tramadol impair presynaptic reuptake of serotonin and in combination with other serotonergic medications can cause serotonin syndrome. We report a case where premedication with the two drugs in therapeutic doses led to serotonin syndrome with severe life‑threatening cardiac arrhythmia. A 43‑year‑old male American Society of Anaesthesiologists physical status1 patient, with 254
radicular pain was scheduled for C5–6 anterior cervical discectomy. He was on gabapentin 150 mg tid and ibuprofen 200 mg bid for pain relief since 1 month. Preanaesthetic evaluation had been insignificant, and and so was the examination prior to shifting into the theatre. After connecting standard monitors and preoxygenation, intravenous (i.v.) fentanyl 50 µg (0.83 µg/kg, in dilution of 1 ml = 50 µg) was administered. Patient was agitating, and pain was thought to be the cause of his agitation. For the fear of developing chest wall, rigidity another agent was considered instead of higher doses of fentanyl. I.v. tramadol 75 mg (1.25 mg/kg, in dilution of 1 ml = 20 mg) was administered slowly over 2–3 min. Immediately a supraventricular rhythm (SVT) with a rate of 180/min and ventricular ectopics were noted on the monitor. It soon deteriorated to ventricular tachycardia (VT) and then into ventricular fibrillation (VF). Cardiopulmonary resuscitation (CPR) was initiated, and airway was secured with endotracheal intubation. Defibrillation with biphasic mode (200 J) was administered thrice during the CPR cycle without sustained sinus rhythm. Injection amiodarone 300 mg bolus was administered after 3rd shock after which sustained sinus rhythm was achieved. After initiating maintenance amiodarone infusion (0.5 mg/kg/h for 24 h) and vasoactive support (noradrenaline and adrenaline infusion at 20 mcg/min) patient was shifted to the intensive care unit (ICU). In the ICU, ventilation was continued for a day with midazolam and morphine for sedation and analgesia. A bedside echocardiogram revealed a good cardiac contractility and output. Induced hypothermia at 34°C was maintained for the day. The next day vasoactive drugs were weaned off, and the patient was awake and successfully extubated. Amiodarone was changed to oral mode of administration and patient was discharged to the ward on 2nd day. The combination of tramadol and fentanyl for premedication is seldom used. The combination has improved tolerance for awake endotracheal intubation[1] and has reduced the incidence of supraventricular arrhythmia in patients undergoing pulmonary resection.[2] Fentanyl associated fatalities have been primarily due to respiratory depression as even low concentrations lead to it.[3] Life‑threatening central nervous system (CNS) Indian Journal of Anaesthesia | Vol. 59 | Issue 4 | Apr 2015
Letters to Editor
and cardiac complications are generally found after tramadol ingestion at high doses with unintentional or intentional suicidal attempts. Ahmadi et al., after analysing the cases of tramadol intoxication found mortality rate of 0.97%. Most of the cases have been reported in conjunction with other drugs such as CNS depressants.[4] However, Shadnia et al., reported two fatalities with tramadol intoxication without any co‑ingestions.[5] In therapeutic doses, both tramadol and fentanyl have been implicated in serotonin toxicity though tramadol is more notorious for severe toxicity.[6] Serotonin toxicity is marked by the triad of neuromuscular excitation, autonomic stimulation and changes in mental state. Based on the clinical profile we suspected serotonin syndrome to be causative for the complication in our patient. The features of toxicity from drug combination develop rapidly after onset of effective blood levels of the second drug. The autonomic features such as tachycardia and tachypnea are not usually severe.[6] In our patient, the administration of i.v. fentanyl initiated the toxicity features (agitation) which became more pronounced with tramadol dose. However, the cardiac signs erstwhile considered not to be of serious consequence, in our patient caused near fatal arrhythmia. The rhythm quickly transformed from SVT to VT and then to VF [Figure 1].No role of use of gabapentin preoperatively in this peroperative drug interaction between fentanyl and tramadol could be explained. To our knowledge and belief, this is the first report of serotonin toxicity with tramadol and fentanyl combination, in therapeutic doses without any other serotonergic medication. The inability to monitor serum drug level has been a limitation, but the absence of any other drug administered prior to fentanyl and tramadol effectively establishes the aetiology. This case report highlights the dangers of combining two drugs with potential of serotonin toxicity and the severity of cardiac complication that can even be near fatal.
Figure 1: Electrocardiogram tracing of the rhythm during cardiopulmonary resuscitation Indian Journal of Anaesthesia | Vol. 59 | Issue 4 | Apr 2015
Shalini Nair, Tony Thomson Chandy1 Department of Neurological Sciences, Neuro ICU, 1 Department of Anaesthesia, Christian Medical College, Vellore, Tamil Nadu, India Address for correspondence: Dr. Shalini Nair, Department of Neurological Sciences, Neuro ICU, Christian Medical College, Vellore, Tamil Nadu, India. E‑mail: [email protected]
REFERENCES 1.
Wang SY, Mei Y, Sheng H, Li Y, Han R, Quan CX, et al. Tramadol combined with fentanyl in awake endotracheal intubation. J Thorac Dis 2013;5:270‑7. 2. Jiang Z, Dai JQ, Shi C, Zeng WS, Jiang RC, Tu WF. Influence of patient‑controlled i.v. analgesia with opioids on supraventricular arrhythmias after pulmonary resection. Br J Anaesth 2009;103:364‑8. 3. Kuhlman JJ Jr, McCaulley R, Valouch TJ, Behonick GS. Fentanyl use, misuse, and abuse: A summary of 23 postmortem cases. J Anal Toxicol 2003;27:499‑504. 4. Ahmadi H, Rezaie M, Hoseini J. Epidemiology analysis of poisonings with Tramadol. J Forensic Res 2012;3:151. 5. Shadnia S, Soltaninejad K, Heydari K, Sasanian G, Abdollahi M. Tramadol intoxication: A review of 114 cases. Hum Exp Toxicol 2008;27:201‑5. 6. Gillman PK. Monoamine oxidase inhibitors, opioid analgesics and serotonin toxicity. Br J Anaesth 2005;95:434‑41. Access this article online Quick response code Website: www.ijaweb.org
DOI: 10.4103/0019-5049.155008
Our encounter with left superior vena cava Sir, A Left Sided Superior Vena Cava (LSVC) is usually an incidental finding, which is revealed during insertion of central venous lines in asymptomatic patients. However if detected, the patient should be investigated for the presence of congenital cardiac ailments. We had a 28 years male who had a left sided loculated pleural effusion, who was posted for a left sided open decortication under general anaesthesia. For monitoring central venous pressure and in anticipation of use of vasoactive drugs, we placed a 7‑French triple lumen catheter in the left subclavian vein by supraclavicular approach under ultrasound guidance. Post‑operatively 255
Copyright of Indian Journal of Anaesthesia is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
REFERENCES 1. Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG, et al. Practice guidelines for management of the difficult airway: An updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2013;118:251‑70. 2. York JE, Wharen RE, Bloomfield EL. Esophageal tear in a patient undergoing stereotactic brain biopsy under general anesthesia. J Anesth 2009;23:432‑5. 3. Langeron O, Semjen F, Bourgain JL, Marsac A, Cros AM. Comparison of the intubating laryngeal mask airway with the fiberoptic intubation in anticipated difficult airway management. Anesthesiology 2001;94:968‑72. 4. Ferson DZ, Rosenblatt WH, Johansen MJ, Osborn I, Ovassapian A. Use of the intubating LMA‑Fastrach in 254 patients with difficult‑to‑manage airways. Anesthesiology 2001;95:1175‑81. 5. Fukutome T, Amaha K, Nakazawa K, Kawamura T, Noguchi H. Tracheal intubation through the intubating laryngeal mask airway (LMA‑Fastrach) in patients with difficult airways. Anaesth Intensive Care 1998;26:387‑91. Access this article online Quick response code Website: www.ijaweb.org
DOI: 10.4103/0019-5049.155007
Cardiac arrest from tramadol and fentanyl combination Sir, Tramadol is a centrally acting atypical opioid analgesic commonly used in the treatment of moderate to severe pain. It has a low affinity to µ opioid receptors and also inhibits the reuptake of serotonin and norepinephrine. Fentanyl is a potent, synthetic opioid with a rapid onset of action and strong affinity to µ receptor. Both the drugs are considered to have a high safety profile and used widely in anaesthesia. Fentanyl and tramadol impair presynaptic reuptake of serotonin and in combination with other serotonergic medications can cause serotonin syndrome. We report a case where premedication with the two drugs in therapeutic doses led to serotonin syndrome with severe life‑threatening cardiac arrhythmia. A 43‑year‑old male American Society of Anaesthesiologists physical status1 patient, with 254
radicular pain was scheduled for C5–6 anterior cervical discectomy. He was on gabapentin 150 mg tid and ibuprofen 200 mg bid for pain relief since 1 month. Preanaesthetic evaluation had been insignificant, and and so was the examination prior to shifting into the theatre. After connecting standard monitors and preoxygenation, intravenous (i.v.) fentanyl 50 µg (0.83 µg/kg, in dilution of 1 ml = 50 µg) was administered. Patient was agitating, and pain was thought to be the cause of his agitation. For the fear of developing chest wall, rigidity another agent was considered instead of higher doses of fentanyl. I.v. tramadol 75 mg (1.25 mg/kg, in dilution of 1 ml = 20 mg) was administered slowly over 2–3 min. Immediately a supraventricular rhythm (SVT) with a rate of 180/min and ventricular ectopics were noted on the monitor. It soon deteriorated to ventricular tachycardia (VT) and then into ventricular fibrillation (VF). Cardiopulmonary resuscitation (CPR) was initiated, and airway was secured with endotracheal intubation. Defibrillation with biphasic mode (200 J) was administered thrice during the CPR cycle without sustained sinus rhythm. Injection amiodarone 300 mg bolus was administered after 3rd shock after which sustained sinus rhythm was achieved. After initiating maintenance amiodarone infusion (0.5 mg/kg/h for 24 h) and vasoactive support (noradrenaline and adrenaline infusion at 20 mcg/min) patient was shifted to the intensive care unit (ICU). In the ICU, ventilation was continued for a day with midazolam and morphine for sedation and analgesia. A bedside echocardiogram revealed a good cardiac contractility and output. Induced hypothermia at 34°C was maintained for the day. The next day vasoactive drugs were weaned off, and the patient was awake and successfully extubated. Amiodarone was changed to oral mode of administration and patient was discharged to the ward on 2nd day. The combination of tramadol and fentanyl for premedication is seldom used. The combination has improved tolerance for awake endotracheal intubation[1] and has reduced the incidence of supraventricular arrhythmia in patients undergoing pulmonary resection.[2] Fentanyl associated fatalities have been primarily due to respiratory depression as even low concentrations lead to it.[3] Life‑threatening central nervous system (CNS) Indian Journal of Anaesthesia | Vol. 59 | Issue 4 | Apr 2015
Letters to Editor
and cardiac complications are generally found after tramadol ingestion at high doses with unintentional or intentional suicidal attempts. Ahmadi et al., after analysing the cases of tramadol intoxication found mortality rate of 0.97%. Most of the cases have been reported in conjunction with other drugs such as CNS depressants.[4] However, Shadnia et al., reported two fatalities with tramadol intoxication without any co‑ingestions.[5] In therapeutic doses, both tramadol and fentanyl have been implicated in serotonin toxicity though tramadol is more notorious for severe toxicity.[6] Serotonin toxicity is marked by the triad of neuromuscular excitation, autonomic stimulation and changes in mental state. Based on the clinical profile we suspected serotonin syndrome to be causative for the complication in our patient. The features of toxicity from drug combination develop rapidly after onset of effective blood levels of the second drug. The autonomic features such as tachycardia and tachypnea are not usually severe.[6] In our patient, the administration of i.v. fentanyl initiated the toxicity features (agitation) which became more pronounced with tramadol dose. However, the cardiac signs erstwhile considered not to be of serious consequence, in our patient caused near fatal arrhythmia. The rhythm quickly transformed from SVT to VT and then to VF [Figure 1].No role of use of gabapentin preoperatively in this peroperative drug interaction between fentanyl and tramadol could be explained. To our knowledge and belief, this is the first report of serotonin toxicity with tramadol and fentanyl combination, in therapeutic doses without any other serotonergic medication. The inability to monitor serum drug level has been a limitation, but the absence of any other drug administered prior to fentanyl and tramadol effectively establishes the aetiology. This case report highlights the dangers of combining two drugs with potential of serotonin toxicity and the severity of cardiac complication that can even be near fatal.
Figure 1: Electrocardiogram tracing of the rhythm during cardiopulmonary resuscitation Indian Journal of Anaesthesia | Vol. 59 | Issue 4 | Apr 2015
Shalini Nair, Tony Thomson Chandy1 Department of Neurological Sciences, Neuro ICU, 1 Department of Anaesthesia, Christian Medical College, Vellore, Tamil Nadu, India Address for correspondence: Dr. Shalini Nair, Department of Neurological Sciences, Neuro ICU, Christian Medical College, Vellore, Tamil Nadu, India. E‑mail: [email protected]
REFERENCES 1.
Wang SY, Mei Y, Sheng H, Li Y, Han R, Quan CX, et al. Tramadol combined with fentanyl in awake endotracheal intubation. J Thorac Dis 2013;5:270‑7. 2. Jiang Z, Dai JQ, Shi C, Zeng WS, Jiang RC, Tu WF. Influence of patient‑controlled i.v. analgesia with opioids on supraventricular arrhythmias after pulmonary resection. Br J Anaesth 2009;103:364‑8. 3. Kuhlman JJ Jr, McCaulley R, Valouch TJ, Behonick GS. Fentanyl use, misuse, and abuse: A summary of 23 postmortem cases. J Anal Toxicol 2003;27:499‑504. 4. Ahmadi H, Rezaie M, Hoseini J. Epidemiology analysis of poisonings with Tramadol. J Forensic Res 2012;3:151. 5. Shadnia S, Soltaninejad K, Heydari K, Sasanian G, Abdollahi M. Tramadol intoxication: A review of 114 cases. Hum Exp Toxicol 2008;27:201‑5. 6. Gillman PK. Monoamine oxidase inhibitors, opioid analgesics and serotonin toxicity. Br J Anaesth 2005;95:434‑41. Access this article online Quick response code Website: www.ijaweb.org
DOI: 10.4103/0019-5049.155008
Our encounter with left superior vena cava Sir, A Left Sided Superior Vena Cava (LSVC) is usually an incidental finding, which is revealed during insertion of central venous lines in asymptomatic patients. However if detected, the patient should be investigated for the presence of congenital cardiac ailments. We had a 28 years male who had a left sided loculated pleural effusion, who was posted for a left sided open decortication under general anaesthesia. For monitoring central venous pressure and in anticipation of use of vasoactive drugs, we placed a 7‑French triple lumen catheter in the left subclavian vein by supraclavicular approach under ultrasound guidance. Post‑operatively 255
Copyright of Indian Journal of Anaesthesia is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
