1. Prepared Exclusively for KKUH 2010 Neurological Deficit Following Combined Spinal-Epidural for Knee Arthroplasty Tariq Alzahrani MD Assistant Professor College of Medicine King Saud University

2. Prepared Exclusively for KKUH 2010 Pre operative Assessment 83 years old male patient admitted through the clinic with bilateral osteoarthritis for left total knee replacement. Patient seen one day preoperative and he is not known to have any medical illness, surgical history for RT shoulder surgery under general anesthesia without complication, all lab results within normal range, normal ECG and CXR. The plan for ( CSE),N PO, premedicated with ranitidine 150 mg PO 2 hours pre op.

3. Prepared Exclusively for KKUH 2010 Intra Operative The patien came to OR theater at 2:45 pm and 18G canula inserted and standard monitoring connected. CSE technique : sitting position sterilization done with iodine CSE set B / Braun L3-L4 loss of resistance(air) after 6 cm 27 G pencil point spinal needle, clear CSF heavy marcaine 0.5% 2cc + fentanyl 25 mcg epidural catheter threaded, back flow, catheter out

4. L4-L5,the catheter fixed at 12 cm at skin supine position,O 2 face mask, Foley catheter inserted surgery time 3:30 hemodynamicaly stable NIBP(160-180 / 90-80) 50 mcg fentanil Prepared Exclusively for KKUH 2010

5. OR SHEET

6. Prepared Exclusively for KKUH 2010 Recovery Room Surgery finished at 6:15 pm Awake, breathing spontaneously (Spo 2 98%, BP 144/98, PULSE 72 bpm, RR 17/min Start epidural infusion of (marcaine 0.0625% with fentanyl 2 mcg ) at 5 ml / h, pain (3/10 on numerical pain score). Routine evaluation (sensory, motor function and pain score) patient was able to do dorsal & planter flexion and sensory level was at L1 checked by ice and the patient shifted to the word at 7:30 pm. The nurse stuff receive the patient in the word awake, conscious, vital signs stable, epidural cath. inside.

7. Prepared Exclusively for KKUH 2010 APS SHEET

8. Prepared Exclusively for KKUH 2010 1st day post operative  Patient stable  Seen by pain management team and another order made for new infusion bag of the same concentration and infusion rate increased to 8 ml /h  Patient seen by surgical team and the dressing changed.  Physiotherapy started on bed and they try to mobilize him with difficulty but the patient made one step.

9. Prepared Exclusively for KKUH 2010 2 nd & 3 rd day post operative Able to move Rt foot toes little but no movement in Lt foot toes and he cannot lift both legs Sensation intact Pain management team discontinue the epidural infusion and decide to remove the catheter next day at morning according to coagulation profile result and they hold clexan dose to be restarted 4 hours after catheter removal and they start him on Tylenol 3 orally q 6 h. 3 rd & 4 th day post op the same situation, the motor power still weak and epidural catheter still in.

10. Prepared Exclusively for KKUH 2010 5 th day post operative  Epidural catheter removed  Weakness of both lower limps more in right side  Sensation start to deteriorate, referred to neurologist.

11. Prepared Exclusively for KKUH 2010 Neurological examination LOWER LIMB RIGHT LEFT TONE decreased decreased POWER proximal 1/5 proximal 1/5 distal planter flex 4/5 planter flex 2/5 dorsi flex 3/5 dorsi flex2/5 REFLEXES decreased decreased SENSATION DECREASED BELOW THE KNEE SPHINCTER INCONTINENCE.

12. Prepared Exclusively for KKUH 2010 Results of Investigations MRI no evidence of intra spinal collection, diffuse degenerative disc disease Lumber puncture normal NCS & EMG done after four days due to technical error in the machine sever axonal type neuropathy, neuroradiculopathy on the lower limb, sparing the sensory fibers. Diagnosed: cauda epuina syndrome???? Dexamethazone IV 10 mg, 6mg Q 6 H Advise aggressive physiotherapy.

13. Prepared Exclusively for KKUH 2010 Follow Up The neurologist and physiotherapist follow up the patient and he was improving slowly as the motor power became better and sensation intact Hemodynamic stable and uneventful hospital stay.

14. Prepared Exclusively for KKUH 2010 34 days  Unfortunately, abscess at surgical site (staph A) from the wound, cloxacilline sarted  GA uneventful  1 st day, complete sensory loss in both lower limb ?????

15. Prepared Exclusively for KKUH 2010 40 days  Urea=22, Creat=225, Na= 144, albumin= 11  Conscious and stable and diagnosed as a case of pre renal azotemia and the IV fluid normal saline and albumin 20% 100ml OD for three days.

16. Prepared Exclusively for KKUH 2010 41days  Confused with decrease level of conscious and jerky movement of upper limb and trunk observed with neck stiffness  BP=140/60, HR= 65, RR = 26, Spo 2 = 86% on room air  O 2 face mask  Phenytoin

17. Prepared Exclusively for KKUH 2010 44 days( 1 day before shifting to SICU) Feverish with shivering, restlessness, agitated, SOB, confused O/E (GCS 10/15, CHEST abnormal breathing sound, CVS s 1 +s 2 + 0 irregular rhythm, Abdomen tense and distended ) 1. fungal or TB meningitis ??? encephalitis?? 2. new hospital acquired pneumonia 3. new onset of atrial fibrillation 4. hypernatremia The ID team start tazocine 2.25 gm q 8 h, continue cloxacilline + vancomycine, septic screen Cardiac consultation for AF Nephrology consultation for renal impairment. The patient shifted to SICU

18. Prepared Exclusively for KKUH 2010 SICU ( 45 days) Became tachepnic, tachycardia, Spo 2 87%, intubated. During SICU stay the patient develop septic shock, acute renal failure, ARDS, AND LOW PLATLET (coagulopathy). Clinically: 1. CVS : ON INOTROPIC SUPPORT 2. CNS : SEDATED 3. RESP: SEVER ARDS 4. KEDNIY: ON CRRT 5. ID : BLOOD CULTURE IS GRAM –VE BACILLI.

23. SUMMARY TNS, typically persisting over 1–3 days have been reported after the use of bupivacaine at an incidence of up to 1%. The incidence of persistent neurological sequelae after subarachnoid anaesthesia varies between 0.01 and 0.7%. In electophysiological, histopathological, behavioural and neuronal cell models, lidocaine and tetracaine appear to have a greater potential for neurotoxicity than bupivacaine. CSE or Spinal. Mechanism is unknown. Prepared Exclusively for KKUH 2010

24. Thank you