Grand Mal Seizure After Extradural Morphine Analgesia

A. Borgeat, J. Biollaz, B. Depierraz, R. Neff
1988 Obstetric Anesthesia Digest  
Major advances have been made in our understanding of the sites and mechanisms of action of opioid agents [1, 2] . Recent reports indicate that effective and prolonged pain relief can be obtained in man by the injection of small doses of morphine or pethidine into either the subarachnoid [3] or the extradural space [4] . As a result, extradural morphine analgesia is being used increasingly by clinicians [5, 6] , especially in obstetrics and gynaecology [7] . Side effects attributed to
more » ... ibuted to extradural morphine are common, possibly dose-related and include nausea and vomiting, pruritus, urinary retention and (more rarely) early and late respiratory depression [8] . Seizure, a theoretical complication of intraspinal administration of opioids [9], has been reported only once before and it happened after what was probably a high pressure intrathecal injection in a patient with known metastatic breast cancer [10] . We report the case of a patient who developed a generalized tonicclonic seizure 6 h after the administration of morphine 3 mg into the extradural space. CASE REPORT A 30-yr-old woman (gravida 4, para 3), weighing 75 kg, was referred to our department for an elective Caesarean section as an ultrasound scan had shown the presence of twins in the breech position at 37 weeks gestation. The actual pregnancy was free of incident; there was no hypertension, oedema or proteinuria. At the age of 19 yr the patient had suffered her first grand mal seizure. Investigations did not reveal any brain lesion and she had no family SUMMARY Following an elective Caesarean section under extradural anaesthesia, a 30-yr-old known epileptic woman (gravida 4, para 3) developed a tonic-clonic seizure. 6 h after the administration of morphine 3 mg into the extradural space. Possible aetiological factors are discussed. history of epilepsy. From that time, she was treated with phenobarbitone 175 mg daily, and suffered one or two grand mal fits each year up to the age of 26 yr. She had had an uneventful pregnancy terminated by forceps delivery under extradural bupivacaine analgesia at age 29 yr. It was decided to utilize extradural anaesthesia. Ringer's solution 1500 ml was infused and the patient was placed in the left lateral decubitus position. Using the "loss of resistance" technique, the extradural space was entered at L2-3 with an 18-gauge Tuohy needle and the catheter was advanced 5 cm cranially without difficulty. An aspiration test revealed neither blood nor CSF and 1 % lignocaine 2 ml was injected through the catheter. As neither motor nor sensory deficit occurred, a second aspiration test (also negative) was carried out 5 min later and 2 % carbonated lignocaine 20 ml (Astra) with freshly added adrenaline 0.1 mg was injected at a rate of 5 ml min~l. The resulting sensory block extended to T5 on both sides. Two male infants (2440 and 2540 g) were delivered with Apgar scores of 8/9/10 and 7/9/10, respectively. A bilateral tubal ligation was performed and a continuous infusion of oxytocin (10 u. in 5% glucose 500 ml over 12 h) was started. At the end of the procedure and following a negative aspiration test, 3 mg of preservative-free morphine (Vifor, Geneva) was administered in 10 ml of physiological saline via the extradural
doi:10.1097/00132582-198810000-00056 fatcat:adwn3xyzijfmpmoek4yfi3x22i