Prolonged myoclonus and meningism following propofol

Abstract

Accepted for publication 5th April, 1995. Propofol was introduced into clinical practice in 1986, and since then has been given to over 16 million patients worldwide (data provided by Zeneea formerly ICI Pharma). The incidence of adverse effects has been low and confined mainly to excitatory neurological manifestations. Increased use, however, has unveiled a broadening spectrum of such phenomena, and here we describe the fLrst case of meningism occurring in association with propofol administration.Case report A 15-yr-old boy, weighing 52 kg, presented for removal of dental wires under general anaesthesia. These had been inserted five weeks previously for fixation of a fractured mandible, and on that occasion anaesthesia (O2:N20: isoflurane following induction with thiopentone) had been uneventful. The patient had no previous medical history, and had not sustained a head injury or loss of consciousness when fracturing his mandible. There was no history of epilepsy, drug abuse or recent infections.The patient presented as a day case and was unpremedicated. On arrival in theatre intravenous access was established and 50 Isg of fentanyl were given. Monitoring consisted of non-invasive blood pressure measurement, ECG, and pulse oximetry. After pre-oxygenafion, anaesthesia was induced with propofol 175 nag, and this was not accompanied by excitatory phenomena or pain on injection. The dental wires were quickly removed (one minute), and no further anaesthetic agents were administered. On resumption of spontaneous ventilation the patient was brought to the recovery room where five minutes alter induction of anaesthesia he developed generalised myoclonic jerking. These spasmodic contractions were asynchronous in nature, involved the muscles of his arms, trunk and legs, and were exacerbated by attempts to rouse him. He remained unresponsive and was noted to have a marked disconjugate gaze and pupillary dilatation. This state persisted for 35 min and during this time temperature, blood pressure, heart rate, arterial blood gas, and blood glucose measurements were within normal limits. Then the patient regained conseiousness but there was no improvement in the myoclonus. Diazemuls, 5 mg/v, was administered with minimal effect on the myoclonic jerking.

Fentanyl-induced rigidity during emergence from general anesthesia potentiated by venlafexine

“…2 The myotonic and dystonic movements, muscular hypertonus, opisthotonus, and seizures may appear as late as five hours after administration. [2][3][4][5] Our patient did not show opisthotonus or any dystonic movements, which are two principal signs of propofol neuroexcitation. The delayed presentation, three hours after the single bolus of propofol, also makes the diagnosis of propofol neuroexcitation improbable.…”

Severe Neuroexcitatory Reaction: A Rare and Underrecognized Life-Threatening Complication of Propofol-Induced Anesthesia

“…A large spectrum of abnormal movements has been reported in this setting: myoclonus, 3 increase in muscle tone ranging from diffuse rigidity and extensor movements to opisthotonos 4 and dystonic reactions that can be either focal—for example masseteric or laryngeal 5,6 or generalized. 7,8 These abnormal movements are generally accompanied by disorders of consciousness, ranging from intermittent loss of consciousness to marked agitation and even delirium, sometimes referred to as “propofol frenzy.” 9 Since there are no uniform diagnostic criteria for this condition, we think that all these cases may have been labeled as severe neuroexcitatory reactions.…”

Propofol and Seizure-Like Activity

“…Potential adverse effects include injection-induced pain, arterial hypotension, bradycardia, and respiratory depression (1)(2)(3). Central nervous system (CNS) side effects are rare, but some of them, such as generalized tonic-clonic convulsions or opisthotonus are very important complications after propofol injection (4)(5)(6)(7)(8). Involuntary muscle contractions not precisely confirmed with EEG changes are not rare in obstetric or gynecologic outpatient procedures, where propofol is especially preferred (9,10).…”