We present a case of 19-year-old woman (weighing 110 kg, 180 cm height, muscular built),
in refractory seizure with difficult intravenous cannulation. She was a known case
of epilepsy since 4 years of age and had delayed milestones. She underwent deep brain
stimulation (DBS) surgery in October 2013 for the same reason and was well controlled
on phenytoin and levetiracetam until 3 weeks back. Since 3 weeks, her seizure frequency
(tonic) had progressively increased from one to two episodes in a month to approximately
two to three episodes every 5 minutes lasting for ~ 10 to 15 seconds now.
When patient was received at midnight, she was restless and agitated from her long
journey from Zambia to New Delhi. She had a conspicuous language barrier and only
understood her mother. It was decided to start her on a loading dose of phenytoin
and levetiracetam, and that is when the trouble started. We were unable to gain intravenous
access. The patient had dark skin texture and collapsed veins due to dehydration.
After a few failed attempts of cannulation, she started to get furious at the mere
sight of venous cannula and even started to throw the cannulas at us and made attempts
to bite. It was only possible to attempt cannulation during her episodes of seizure.
However, those short windows of few seconds were not helpful.
We took parental permission to sedate her using intramuscular midazolam and attempt
cannulation. However, this attempt backfired, as even after three 5 mg intramuscular
midazolam injections, her seizures did not disappear but decreased in frequency making
our chances of attempting cannulation fewer. They made her drowsy and more irritable
because she was unable to sleep. Fortunately, her airway and breathing were never
compromised. She did not allow us to apply pulse oximeter, but we kept an oxygen mask
at 10 L/min flow near the head end of the bed. Every prick made her more agitated.
At times she snatched the cannula and tried to poke the staff with it. We decided
to put a femoral line in her. However, despite eight nursing staff trying to restrain
her, she overpowered them and no number of restrains on the patient were enough.
Finally, when nothing worked, a call was taken to bring an anesthesia workstation
from operating theater (OT) to intensive care unit (ICU). During her one episode of
seizure, we managed to anesthetize the patient on a mask, preprimed with sevoflurane.
We supported her ventilation with intermittent positive-pressure ventilation. Neurosurgical
team attempted a venous cut-down on the ankle (for great saphenous vein) but were
unsuccessful. We inserted right internal jugular central venous catheter under ultrasound
guidance, and finally after 3 hours of struggle, we were able to gain a venous access.
The patient was then loaded with antiepileptics (phenytoin 2 g and levetiracetam 1.5
g) and started on propofol infusion. She remained on low sedating dose of propofol
(at 100–200 mg/h) for 4 days to keep her at a Richmond Agitation Sedation Score of
−1 to −2. She did not need any respiratory support during this time. It was realized
that seizure frequency was coinciding with DBS signaling. During her 6-day stay in
ICU, video electroencephalography (VEEG) was done four times, and antiepileptics and
DBS setting were adjusted three times. At the end of sixth day, her seizures were
well controlled. The patient was discharged on seventh day with advice for regular
follow-up.
We here highlight the fact that in such a crisis situation, inhalational anesthesia
helped us calm a patient. Sedating with inhalational agents is a known method for
intravenous cannulation for children in OT. However, no inhalational agent is currently
approved for ICU sedation, but various off-label uses are in progress.[1] We suggest that ICUs (especially those manned by anesthesiologist) should have an
anesthesia workstation present or available for standby use from OT, for providing
short procedural sedation or to overcome such a crisis situation. Various algorithms
of gaining peripheral venous access involving ultrasonography,[2] infrared lights[3] are not useful when the patient is not cooperative. Inhalational agent might seem
the extreme end, but it surely is the quickest way to calm a patient with no intravenous
access.
