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Seizure in a Patient Receiving Epidural Meperidine After Cesarean Section
Abstract Number: F5D-3
Abstract Type: Case Report/Case Series
Meperidine has long been associated with decreased seizure threshold as a result of the neurotoxic metabolite normeperidine. While being a known complication of the medication, this is the first documented case in which epidural administration likely led to seizures. The following case describes a patient receiving a meperidine PCEA postoperatively after a cesarean section that developed general tonic-clonic seizures and a comprehensive workup led to no other obvious etiologies. A G3P1011 22 year old at 41w0d was admitted for repeat cesarean section. The procedure went without complication and the epidural was used for postoperative pain control with administration of meperidine via PCEA. The PCEA settings were as follows: basal rate of 10mg/hr, bolus dose of 10mg, lock out of 15 min, and an hourly limit of 40mg. The patient had utilized the function frequently overnight, and the decision was made to increase the basal rate to 3mL/hr for poor pain control which improved for the remainder of the day. During the thirtieth hour, the patient had a reported seizure that was described as general tonic-clonic lasting two minutes. The epidural was immediately turned off and the patient was transferred to the ICU for further management and work up. Several hours later the patient had her second seizure, which included loss of bowel and bladder function. Complete workup for the etiology was negative and the patient was transferred out of the ICU the following day. Upon review of PCEA, the patient was found to have received a total of 618 mg of meperidine over a 20 hour timeframe.
Meperidine undergoes hepatic metabolism by N-demethylation and is renally excreted [Gutstein]. In patients with a compromise in either system, there is a greater risk for complications due to increased concentration or decreased elimination. The exact mechanism by which normperidine induces seizures is not completely understood however rat studies have confirmed that the mechanism is not dopaminergic or cholinergic [Plummer]. Nordberg et al. states that the upper dose limit should be limited to 600mg/day. While limitations are present for maximum hourly volume delivery this event resulted in additional limitations for 4 hour time frames.