January 16, 2016

Mrs. “X” underwent a laparoscopy and hysterectomy in March of 2004 in Faridabad. Surgery was uneventful and patient was extubated. Soon thereafter it was noticed that her saturation was falling and her motor response was still inadequate. She still was under deeper sedation.

On examination her pupils were constricted though still responding to light stimuli.
She was not responding to verbal commands.
She was intubated again and shifted to the ICU. Her blood pressure was stable.

She was seen by the intensivist and physician and a plethora of diagnosis was mooted from hypoxia during surgery to brain stem herniation etc.
Finally the right diagnosis of hypersensitivity to fortwin was arrived at and the antidote Naloxone was ordered to be given. This was very rarely present in those days in any chemist shop or hospital. It was somehow arranged from Delhi and injections were administered showing dramatic results in recovery of the patient much to the joy of the surgeon!

Mrs. Alka, seven years later in April 2011 underwent a laparoscopic hysterectomy at the same hospital in Faridabad. Surgery went off well and was uneventful.
Again this time patient took a longer time to come out of anaesthesia and the only saving grace this time was the fact that she was breathing on her own satisfactorily to maintain saturation but again motor response was totally inadequate and pupils were constricted.

This time having had the past experience Naloxone was administered promptly and she did not require intubation again or ICU care. This time though repeated doses (7 injections of 400mg) needed to be given as response was not as dramatic. Patient recovered well in a few hrs and was responding to verbal commands well.

Discussion:
1) Hypersensitivity to fortwin and like drugs does exist and must be kept in mind during reversal of patients.
2) In patients who are hypothyroid again one needs to remember that drug action gets prolonged and hence dosage must be adjusted accordingly.
3) Keeping Naloxone handy in the emergency drug trays especially in operating theatres may be a good and life saving idea.
4) Healthy suspicion bearing from the knowledge of this entity again may help in less panic a situation and smooth management!