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Canadian Journal of Anaesthesia

, Volume 40, Issue 10, pp 968–970 | Cite as

Severe respiratory depression after epidural morphine in a patient with myotonic dystrophy

  • Kohji Ogawa
  • Hiroshi Iranami
  • Takeshi Yoshiyama
  • Hiroshi Maeda
  • Yoshio Hatano
Clinical Reports
Accepted:

Abstract

We describe a patient with myotonic dystrophy who underwent cholecystectomy, and developed severe respiratory depression following epidural administration of morphine to provide post-operative analgesia. At preoperative assessment, he demonstrated near normal vital capacity and maximal voluntary ventilation, but the presence of chronic ventilatory failure with a resting value of PaCO2 51 mmHg. Anaesthesia was produced by a combination of epidural and light general anaesthesia without intravenous anaesthetics, narcotics or neuromuscular relaxants. Five hours after epidural administration of 2 mg morphine, the patient developed severe respiratory depression with a PaCO2 of 93 mmHg. Intravenous naloxone resulted in transient improvement in minute volume, suggesting that epidural morphine was responsible for the depression. Epidural morphine can cause unexpected respiratory depression, even at a small dose, because of the sensitivity of the respiratory centre to morphine in patients with myotonic dystrophy.

Key words

analgesia: epidural analgesics: morphine complications: respiratory musculoskeletal: myotonic dystrophy 

Résumé

Un patient atteint de dystrophie myotonique est opéré pour une cholécystectomie. Il développe par la suite une dépression respiratoire grave après l’administration épidurale de morphine pour l’analgésie postopératoire. Au moment de l’évaluation préopératoire, ses tests de fonction pulmonaire révèlent une capacité vitale presque normale et une ventilation volontaire maximale, mais aussi des signes d’insuffisance respiratoire chronique dont une PaCO2 à 51 mmHg. L’anesthésie consiste en une association épidurale avec anesthésie générale légère sans injection iv d’anesthésiques, d’opiacés ou de myorelaxants. Cinq heures après l’administration épidurale de morphine 2 mg, le patient entre en dépression respiratoire profonde avec une PaCO2 qui monte à 93 mmHg. De la naloxone intraveineuse produit une amélioration transitoire du volume-minute, ce qui suggère que la morphine épidurale est responsable de la dépression. La morphine épidurale peut provoquer une dépression respiratoire inattendue, même à petites doses à cause de la sensibilité à la morphine du centre respiratoire des malades atteints de dystrophie myotonique.

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References

  1. 1.
    Aldridge LM. Anaesthetic problems in myotonic dys trophy: a case report and review of the Aberdeen experience comprising 48 general anaesthetics in a further 16 patients. Br J Anaesth 1985; 57: 1119–30.PubMedCrossRefGoogle Scholar
  2. 2.
    Katz J, Steward DJ. Anesthesia and Uncommon Pediatric Diseases. Philadelphia: W.B. Saunders Co., 1987.Google Scholar
  3. 3.
    Katz J, Benumof JL, Kadis LB. Anesthesia and Uncom mon Diseases. 3rd ed. Philadelphia: W.B. Saunders Co., 1990.Google Scholar
  4. 4.
    Mudge BJ, Taylor PB, Vanderspek AFL. Perioperative hazards in myotonic dystrophy. Anaesthesia 1980; 35: 492–5.PubMedCrossRefGoogle Scholar
  5. 5.
    Paterson RA, Tousignant M, Skene DS. Caesarean sec tion for twins in a patient with myotonic dystrophy. Can Anaesth Soc J 1985; 32: 418–21.PubMedGoogle Scholar
  6. 6.
    Harmon VM, Cunningham AJ, Hutchinson M, McNicho las W Aspiration pneumonia and coma — an unusual presentation of dystrophica myotonia. Can Anaesth Soc J 1986; 33: 803–6.CrossRefGoogle Scholar
  7. 7.
    Cousins MJ, Mather LE. Intrathecal and epidural admin istration of opioids. Anesthesiology 1984; 61: 276–310.PubMedCrossRefGoogle Scholar
  8. 8.
    Gustafsson LL, Schildt B, Jacobsen K. Adverse effects of extradural and intrathecal opiates: report of a nationwide survey in Sweden. Br J Anaesth 1982; 54: 479–86.PubMedCrossRefGoogle Scholar
  9. 9.
    Reiz S, Westeberg M. Side-effect of epidural morphine (Letter). Lancet 1980; 2: 203–4.PubMedCrossRefGoogle Scholar
  10. 10.
    Kilburn KH, Eagan JT, Sieker HO, Heyman A. Cardiopulmonary insufficiency in myotonic and progressive muscular dystrophy. N Engl J Med 1959; 261: 1089–96.PubMedCrossRefGoogle Scholar
  11. 11.
    Carroll JE, Zwillich CW, Weil JV. Ventilatory response in myotonic dystrophy. Neurology 1977; 27: 1125–8.PubMedGoogle Scholar
  12. 12.
    Youssef MS. Extradural fentanyl and dystrophia myotonica (Letter). Anaesthesia 1989; 44: 360–1.PubMedCrossRefGoogle Scholar
  13. 13.
    Bromage PR, Camporesi EM, Durant PAC, Nieben CH. Rostral spread of epidural morphine. Anesthesiology 1982; 56: 431–6.PubMedCrossRefGoogle Scholar

Copyright information

© Canadian Anesthesiologists 1993

Authors and Affiliations

  • Kohji Ogawa
    • 1
  • Hiroshi Iranami
    • 1
  • Takeshi Yoshiyama
    • 1
  • Hiroshi Maeda
    • 1
  • Yoshio Hatano
    • 1
  1. 1.Department of AnesthesiologyWakayama Medical CollegeWakayamaJapan

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