Harna B, Arya S. Tramadol overdose in total knee arthroplasty: A case report. World J Clin Cases 2025; 13(25): 104742 [DOI: 10.12998/wjcc.v13.i25.104742]
Corresponding Author of This Article
Bushu Harna, MD, Department of Orthopaedics, Indus International Hospital, No. 22 Ambala Road, Dera Bassi, Mohali 160507, Punjab, India.
bushu.edu@gmail.com
Research Domain of This Article
Medicine, General & Internal
Article-Type of This Article
Case Report
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Tramadol overdose in total knee arthroplasty: A case report
Bushu Harna, Shivali Arya
Bushu Harna, Department of Orthopaedics, Indus International Hospital, Mohali 140507, Punjab, India
Shivali Arya, Department of Radiology, Lifetree Healthcare, Zirakpur 140603, Punjab, India
Co-first authors: Bushu Harna and Shivali Arya.
Author contributions: Harna B and Arya S wrote manuscript and contributed equally to this manuscript as co-first authors. Harna B collected data; Arya S read proof.
Informed consent statement: Informed consent was taken from the patient for publishing the data.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Bushu Harna, MD, Department of Orthopaedics, Indus International Hospital, No. 22 Ambala Road, Dera Bassi, Mohali 160507, Punjab, India.
bushu.edu@gmail.com
Received: December 31, 2024 Revised: April 27, 2025 Accepted: May 21, 2025 Published online: September 6, 2025 Processing time: 188 Days and 21.9 Hours
Abstract
BACKGROUND
Tramadol is a synthetic opioid analgesic commonly employed in postoperative pain control due to its moderate efficacy and comparatively favorable safety profile. Nonetheless, overdose can result in significant adverse effects, notably central nervous system depression. This risk is amplified in individuals with chronic kidney disease (CKD), where reduced renal clearance may potentiate drug accumulation and toxicity. Elderly patients are particularly at risk owing to age-associated alterations in pharmacokinetics and pharmacodynamics. We describe a case of tramadol overdose in a 77-year-old male with stage 3 CKD following total knee arthroplasty.
CASE SUMMARY
A 77-year-old male with diabetes mellitus and CKD stage 3 underwent elective right total knee arthroplasty for grade 4 osteoarthritis under spinal anesthesia. Preoperative evaluation revealed deranged renal function tests but no other significant abnormalities. Postoperative pain was managed with multimodal analgesics, including intravenous tramadol and a buprenorphine skin patch. On postoperative third day, the patient was found unconscious (Glasgow Coma Scale 8/15) with mild respiratory depression. Investigations ruled out stroke, pulmonary embolism, or other cardiopulmonary events. Elevated serum tramadol levels suggested opioid toxicity exacerbated by impaired renal clearance. The buprenorphine patch was removed, and diuresis was initiated. Supportive management, including prophylactic intubation, led to recovery of consciousness within 48 hours, and the patient was extubated and mobilized by postoperative sixth day. Pain control was maintained with oral paracetamol and pregabalin. The patient was discharged on postoperative tenth day in stable condition with improved pain scores and mobility. This case underscores the need for cautious use of tramadol in elderly patients with CKD due to impaired drug clearance and the potential for toxicity. It highlights the importance of close monitoring, judicious analgesic use, and prompt management of complications to ensure favorable postoperative outcomes in high-risk populations.
CONCLUSION
This case underscores the necessity for judicious tramadol administration in elderly patients with CKD, as diminished renal function markedly impairs drug clearance, predisposing to toxicity. Vigilant assessment of renal function and individualized dose adjustments are essential to mitigate the risk of adverse events in this demographic. Clinicians should maintain a heightened awareness of potential opioid toxicity in postoperative patients presenting with unexplained neurological manifestations. Timely identification and initiation of appropriate supportive measures are pivotal in achieving favorable clinical outcomes.
Core Tip: Clinicians should be aware of opioid toxicity in total knee arthroplasty patients. Cautions should be taken in the presence of kidney disorders. Tramadol and buprenorphine patches were commonly utilized in postoperative analgesia of knee arthroplasty. The combination of these drugs was not recommended and should be monitored for any adverse effects. It is better to use pre-emptive analgesia with minimum use of opioids.
