Opioid Mismanagement in a Chiari 1 Patient Led to Sudden Unexpected Nocturnal Death

June 2014 - As studies on Chiari advance, there are less and less reports on sudden unexpected nocturnal death (SUND) due to the mismanagement of pain medications. The World Health Organization terms SUND as a natural or unexpected death within 24 hours of an illness symptom. Understanding neurological impairments and SUND in those with a Chiari I malformation (CM1) is not well understood, but valuable research is being compiled and analyzed for future awareness. Furthermore, doctors Feredoon Roohi, Toby Gropen, and Roger Kula emphasize the use of basic strategies that may prevent SUND in individuals with CM1.

In this month’s case study, we will be discussing how an administration of narcotics (to manage pain) had an unfortunate effect on the life of a 29-year-old man. He was first admitted into the Long Island College Hospital for nausea, vomiting, and blurred vision from a persistent headache. For four years, he suffered from recurring migraines related to CM1 which steadily increased in frequency and severity.

After performing a complete MRI of the brain, the report states that the man had an 18 mm herniation of the cerebral tonsils and an enlarged fourth ventricle filled with cerebral spinal fluid. He expressed that he did not have weakness in his limbs, paresthesia, or difficulty breathing. He did not have a history of heart problems, hypoglycemia, alcohol abuse, or seizures, nor did he have a family record of neurological issues or cardiac ailments. The medicines he had been using prior to his hospital stay included acetaminophen, hydrocodone, and ibuprofen.

The 29-year-old’s vitals were then taken—his lungs were clear, he was alert and familiar with his surroundings, he did not have neck stiffness, the pupils in his eyes reacted to light perfectly fine, and visual fields were also normal. However, he had an unstable gait and also had a slight drift in his eyes when trying to focus. He was labeled in stable condition considering that most of his vitals were typically healthy. The doctors then discussed management of his persistent migraine pain before undergoing surgery.

They soon decided that he would take 60 mg of codeine and 650 mg of acetaminophen by mouth and receive the following medications by IV: 10 mg morphine sulfate, 4 mg hydromorphone, and 10 mg of metoclopramide. After 26 hours in the neurosurgical ward, he complained about a severe headache and about four hours later, he had passed away.

When sensitive centers of the brain (such as the medulla) are impaired due to short- or long-term narcotic use, the possibility of unfortunate complications such as respiratory depression and sleep-related breathing irregularities, sleep apnea, and unexpected death during sleep greatly increase. Taking small doses of opiate-based medicines at night can trigger central sleep apnea, even in those without a history of nightly abnormal breathing.

Nocturnal hypoxia and hypercapnia, which are associated with sleep-related breathing disorders, can cause an increase in intracranial pressure (ICP) that can displace the brain and compress the brainstem and upper spinal cord. By the brainstem being compressed, sudden unexpected noctornal death is unavoidable for individuals battling CM1, such as the 29-year-old, who pass away from sleep-related breathing difficulties due to the administration of opioids.

Dr. Roohi, Dr. Gropen, and Dr. Kula then discuss immediate decompression surgery with the removal of the top two or three cervical vertebrae for those suffering from persistent migraines. They also examine the possibility of a minimally invasive drainage procedure for CM1 fighters with hydrocephalus, or fluid accumulation inside the brain. The doctors co-authoring this report believe that an urgent, minimally invasive operation or shunt placement along with pain medications and monitored vitals may have saved the 29-year-old man who passed away from the unmonitored administration of narcotics.

Furthermore, the doctors comment that those diagnosed with symptomatic CM1 who are admitted into a hospital should always be looked after because of the increased risk of developing syringomyelia, sleep apnea, or other distinct symptoms associated with Chiari; furthermore, surgery should be scheduled immediately if the patient’s condition becomes worse.

Prescriptions such as acetaminophen and nonsteroidal anti-inflammatory drugs should be used to manage pain in those recently diagnosed with CM1 because the use of opioids may alter the normalcy of the respiratory system and create other complications which can lead to an individual passing away. However, if pain is severe, narcotics can still be used, but the physician should be knowledgeable about possible side effects.

All Chiari patients should know that inappropriate management of pain can have negative effects on their health. Dr. Roohi, Dr. Gropen, and Dr. Kula agree that more attention should be given to the safe and appropriate use of medications—especially in the case of opioids for treatment of pain.

Author’s Note: This case of sudden unexpected nocturnal death was not written to scare those with Chiari. On the contrary, it was written to spread awareness on the precautionary management of narcotics when it comes to Chiari-1 patients. Since surgery was delayed in the case of this 29-year-old man and his vitals were not monitored with the use of opioids, his death was untimely and unexpected. Please make sure to consult your doctor about possible solutions to any form of unmanageable pain you may be experiencing.

Ed. Note: The opinions expressed above are solely those of the author. They do not represent the opinions of the editor, publisher, or this publication. Ms. Eubanks is not a medical doctor and does not give medical advice. Anyone with a medical concern is strongly encouraged to seek professional medical care.

Jennifer Eubanks

Jennifer Eubanks
Chiari Community Columnist

Ms. Eubanks is a professional writing and researching scholar from Purdue University Northwest. After being diagnosed with a Chiari I Malformation in 2011, she quickly decided that being conquered was not an option—she was committed to fight and pursue a budding love of healthcare/medical writing. Spreading awareness and hope to others battling Chiari is her largest motivator alongside educating others who have not heard about the condition. Reporting for Ideas in Motion Media and tutoring at the Writing Center (Purdue University North Central) has been immensely beneficial to her success as well as all the remarkable individuals who helped her become the composer and analyst she is today.