The patient had chronic pain and opioid use related to multiple cervical and lumbar disc herniations and radiculopathy. At some point, a pain pump was proposed, and a pain pump trial was scheduled.
During the trial, the operative report notes that the patient had 2.5 mL of Fentanyl injected into the L5-S1 interthecal space.
The physiatrist who did the intrathecal injection noted:
"Immediately following the procedure, patient was noted to have reduced respirations. Upon flipping the patient over, [his] face was noted to be pale. Airway was started immediately. O2 Saturation was noted to be 100% however patient still non-responsive. Narcan 0.4 mg was administered. Decadron 8 mg and metoprolol 5 mg was administered. EMS was called and patient was transferred to the hospital."
The anesthesia note describes the patient as "not breathing" and "color purple" when he was turned from prone to supine. The EMS records reflect that the doctor told EMS providers that the patient had received 50 mcg of fentanyl.
Once at the hospital, the patient failed extubation initially, developing tongue edema with severe stridor and severe hypoxia, and went into full cardiorespiratory arrest. He was resuscitated, but suffered a series of further complications.
Files:
No questions yet!
Do you believe there might have been medical error?
Determining if a medical error occurred is difficult with the given information. To determine if the procedure was performed correctly I would need to examine the operative report as well as any intraoperative fluoroscopic images. Respiratory depression is possible after the administration of intrathecal opioids, and lipophilic ones such as fentanyl have a quicker onset. However, even with fentanyl, onset should take minutes not be instantaneous. The trial dosing may be appropriate depending on whether the patient was opioid-tolerant or naive. There could be other factors that lead to injury such as stretcher location to flip the patient.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Again I would need more information to determine.
What makes you a good expert for this case?
I am a dual board-certified pain management with significant experience trialing, implanting, and managing pain pumps.
How often do you encounter cases similar to this one in your practice?
I perform pump trials on a regular basis every few months.
Want to open a case or submit response?
Comments are accepted only from Pain Medicine (Physical Medicine and Rehabilitation) experts.