Neurological sequelae in children after prolonged propofol infusion

Abstract

SummaryNeurological sequelae occurred in two children after the withdrawal of an infusion of propofol administered during admission to the Intensive Care Unit for respiratory tract obstruction. Key wordsAnaesthetics, intravenous; propofol. Complications; neurological. Intensive care.Propofol infusions have been used as part of anaesthetic techniques for a variety of surgical procedures, with mean infusion rates in the range of 6.2-15.6 mg.kg-'.h-' [ 1 4 . Propofol has also been used successfully in the Intensive Care Unit (ICU) for rapid control of depth of sedation. Infusion rates of about 3 mg.kg-'.h-' in patients in ICU have allowed rapid awakening on discontinuation of the infusion after periods of up to 4 days [5, 61. Younger patients appear to require larger doses both for induction and maintenance of anaesthesia (50% and 25% respectively) compared with adults [3, 71. Case historiesCase 1. A 4-year-old boy was admitted to another hospital with stridor secondary to a presumed viral infection of the upper respiratory tract. His trachea was intubated and he was sedated with midazolam before being transferred to the ICU at this hospital.On arrival he was restless despite administration of intravenous boluses of midazolam, and a n infusion of propofol was started. This infusion was continued for 4 days (Table I). When the infusion was discontinued he developed abnormal movements which were thought to be grand ma1 convulsions. These movements continued despite treatment with diazepam, chlormethiazole, phenobarbitone, phenytoin and paraldehyde. They consisted of fine twitching movements of the muscles of his face, head and shoulders, and also occurred distally in both arms and legs. He was able to open his eyes spontaneously and to follow his mother's movements. He was unable to swallow saliva and appeared to have generalised muscle weakness. His arms and legs were flaccid with depressed reflexes and he required mechanical ventilation for the next 4 days. He received no further sedation apart from the anticonvulsant therapy, which was discontinued after 3 days when there was no further evidence of epilepsy.Seven days after propofol had been discontinued, muscle power and tone were normal although he had developed exaggerated tendon reflexes and ankle clonus. He was noted to be ataxic when he was strong enough to walk.The child was anaesthetised with halothane to assess the larynx after the trachea had been intubated for 2. 9 and 12 days but on each occasion he developed stridor on emergence from anaesthesia and required re-intubation. On the 9th day of intubation his larynx looked slightly inflamed and he appeared to have a vocal cord palsy. Bronchoscopy was normal. His trachea was extubated successfully on the 14th day after admission.Diagnoses of encephalitis, metabolic disorder, peripheral or autonomic neuropathy, and some form of reaction to propofol were considered. The cause of his neurological signs remained unresolved. There were no abnormal findings on examination of serum electrolytes, glucose, ammonia,...

Neurodegeneration in Newborn Rats Following Propofol and Sevoflurane Anesthesia

“…Currently, neurological sequelae in children submitted to prolonged propofol infusion have been described in case reports (Lanigan et al 1992;Trotter and Serpell 1992). After surgery was performed in newborn infants for transposition of the great arteries, prolonged intensive care (and hence prolonged exposure to sedatives) is associated with reduced intelligence quotients at 8 years of age (Newburger et al 2003).…”

Sedation and Analgesia in Paediatric Intensive Care Units

“…[54][55][56][57] These concerns have probably been overemphasised since no true electroencephalographic evidence of seizure activity has ever been documented with the abnormal movements seen with propofol administration. More importantly, propofol is considered by many to be a valuable agent in the treatment of patients with refractory status epilepticus.…”

Propofol for Sedation and Control of Intracranial Pressure in Children

“…Additional concerns include the reports of unusual neurologic manifestations including opisthotonic posturing, myoclonic movements (especially in children), and seizure-like activity [23, 24, 25]. These concerns have probably been overemphasized since no electroencephalographic evidence of seizure activity has been documented with the abnormal movements seen with propofol administration.…”