| OPISTHOTONUS AND MYOCLONIC MOVEMENTS FOLLOWING PROPOFOL |
A 44 yrs old man with ASA Risk I was posted for urethral dilatation. Total intravenous anaesthesia was planned for the surgery and the patient was premedicated with I.V. Pethidine and Glycopyrrolate. Then the patient was induced immediately with injection Propofol 100mg after connecting all essential monitors (NIBP, SPO2, ECG). Two minutes after the induction of anaesthesia patient developed dystonia with opisthotonus which lasted for 60 seconds and then the patient developed myoclonic movements on both upper limbs.
These myoclonic movements persisted for 5 minutes. During the dystonia and myoclonic movements, airway was maintained and 100% Oxygen administer through Magill’s circuit with face mask. Patient was haemodynamically stable during that period and SaO2 was 98-100%. Patient recovered consciousness completely once myoclonic movements ceased.
There was no neurological deficit. On enquiring the patient retrospectively, he had no previous history of seizures or head injury. In the above case, since Pethedine, Glycopyrrolate and Propofol are the drugs used, the occurrence of opisthotonus and myoclonic movements can be attributed only to Propofol. Reviewing the literature the same side effects are reported with Propofol with incidence rate less man 1%.
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| DISCUSSION |
| Propofol is the most frequently used intravenous anaesthetic drug today. Propofol is used for induction and maintenance of anaesthesia, as well as for sedation in and outside the operating room |
| Side Effect: |
| These less frequent events are derived from experience in over 8 million patients (derived from publications and marketing experience). |
Incidence
I. Greater than 1%
-ProbablyCausallyRelated
II. Less than 1%
A) - ProbablyCausallyRelated
B) - Probably Causal Relationship unknown |
Incidence greater than 1% - Probably Causally Related |
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Anesthesia/MAC Sedation |
ICU Sedation |
Cardiovascular: |
Bradycardia
Hypotension* [Peds: 17%]
[Hypertension Peds: 8%]
(see also CLINICAL PHARMACOLOGY) |
Bradycardia, Decreased
Cardiac Output,
Hypotension 26% |
Central Nervous System: |
Movement* [Peds: 17%] |
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Injection Site: |
Burning/Stinging or Pain, 17.6% |
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[Peds: 10%] |
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Metabolic/Nutritional: |
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Hyperlipemia* |
Respiratory: |
Apnea |
Respiratory Acidosis |
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During Weaning* |
Skin and Appendages: |
Rash [Peds: 5%] |
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Events without an * or % had an incidence of 1%-3% |
* Incidence of events 3% to 10% |
Incidence less than 1% - Probably Causally Related |
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Anesthesia/MAC Sedation |
ICU Sedation |
Body as a Whole: |
Anaphylaxis/Anaphylactoid
Reaction, Perinatal Disorder |
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Cardiovascular: |
Premature Atrial Contractions,
Syncope |
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Central Nervous System: |
Hypertonia/Dystonia, Paresthesia |
Agitation |
Digestive: |
Hyper salivation |
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Musculoskeletal: |
Myalgia |
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Respiratory: |
Wheezing |
Decreased Lung Function |
Skin and Appendages: |
Flushing, Pruritus |
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Special Senses: |
Amblyopia |
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Urogenital: |
Cloudy Urine |
Green Urine |
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Incidence less than 1% - Causal Relationship Unknown |
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Anesthesia/MAC Sedation |
ICU Sedation |
Body as a Whole: |
Asthenia, Awareness, Chest Pain
Extremities Pain, Fever,
Increased Drug Effect,
Neck Rigidity/Stiffness, Trunk Pain |
Fever, Sepsis, Trunk Pain,
Whole Body Weakness |
Cardiovascular: |
Arrhythmia, Atrial Fibrillation,
Atrioventricular Heart Block,
Bigeminy, Bleeding, Bundle
Branch Block, Cardiac Arrest,
ECG Abnormal, Edema,
Extrasystole, Heart Block,
Hypertension, Myocardial
Infarction, Myocardial
Ischemia, Premature Ventricular
Contractions, ST Segment
Depression, Supraventricular
Tachycardia, Tachycardia,
Ventricular Fibrillation |
Arrhythmia, Atrial
Fibrillation, Bigeminy,
Cardiac Arrest,
Extrasystole, Right
Heart Failure, Ventricular
Tachycardia |
Central Nervous System: |
Abnormal Dreams, Agitation,
Amorous Behavior, Anxiety,
Bucking/Jerking/Thrashing,
Chills/Shivering, Clonic/
Myoclonic Movement,
Combativeness, Confusion,
Delirium, Depression,
Dizziness, Emotional
Lability, Euphoria, Fatigue,
Hallucinations, Headache,
Hypotonia, Hysteria,
Insomnia, Moaning, Neuropathy,
Opisthotonos, Rigidity,
Seizures, Somnolence, Tremor,
Twitching |
Chills/Shivering,
Intracranial Hypertension,
Seizures, Somnolence,
Thinking Abnormal |
Digestive: |
Cramping, Diarrhea, Dry Mouth,
Enlarged Parotid, Nausea,
Swallowing, Vomiting |
Ileus, Liver Function
Abnormal
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Hematologic/Lymphatic: |
Coagulation Disorder,
Leukocytosis |
. |
Injection Site: |
Hives/Itching, Phlebitis,
Redness/Discoloration |
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Metabolic/Nutritional: |
Hyperkalemia, Hyperlipemia
Increased |
BUN Increased, Creatinine, Dehydration,
Hyperglycemia, Metabolic
Acidosis, Osmolality
Increased |
Respiratory: |
Bronchospasm, Burning in
Throat, Cough, Dyspnea,
Hiccough, Hyperventilation,
Hypoventilation, Hypoxia,
Laryngospasm, Pharyngitis,
Sneezing, Tachypnea, Upper
Airway Obstruction |
Hypoxia |
Skin and Appendages: |
Conjunctival Hyperemia,
Diaphoresis, Urticaria |
Rash |
Special Senses: |
Diplopia, Ear Pain, Eye Pain,
Nystagmus, Taste Perversion, Tinnitus |
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Urogenital: |
Oliguria, Urine Retention |
Kidney Failure |
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Pathophysiology of CNS Effect: |
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Hypnotic Action: |
Mediated by potentiating gamma amino butyric acid induced chloride current through binding to beta sub unit of GABA. |
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Seductive Effect: |
GABA A receptor on hippocampus and prefrontal contents. Alpha2 adrenoreceptor indirect role. NMDA receptor modulation. |
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Spinal cord: |
Depressive action on neurons of spinal cord Acts on GABA and glycine receptors of spinal dorsal horn neurons. |
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Anti emetic action: |
Decreases serotonin in Area Postrema. |
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Well being state: |
Increase Dopamine concentration in Nucleus – Accumbens (a phenomenon noted in drug abuse and pleasure seeking behaviour). |
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Although the etiology of convulsions by Propofol is controversial, the convulsion occurred in the above case seems to be related to Glycinergic as well as Glutamate receptors. |
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Other Related Incidents and Case Reports: |
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Myoclonic seizure during Propofol-Alfentanil anesthesia |
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Anesthetist. 1992 Jul;41(7):426-30. Kerz T, Jantzen JP. |
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We report a case of seizure-like movements during Propofol-Alfentanil anaesthesia for an elective craniotomy. These seizure-like movements can be related to the use of either anaesthetic agent. A synergistic effect of Propofol and Alfentanil in the generation of seizure-like movements cannot be excluded. Propofol's pro- or anticonvulsive action is unclear. |
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Convulsion, ataxia and hallucinations following Propofol. |
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Department of Anaesthesiology, Vejle Hospital, Denmark. |
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A 6-year old fit girl experienced convulsions 44 h after an otherwise uneventful anaesthesia with Propofol, Alfentanil and Nitrous oxide. Child was kept sedated for 6.5 h for further investigation with infusion of Propofol amounting in total to 1600mg. After having regained consciousness, she was strikingly ataxic and remained so for 5 days with two episodes of hallucinations lasting for 2 h. |
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Case of convulsion induced by Propofol |
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Department of Anaesthesia , Yokosuka Municipal Hospital. |
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A 71-year-old man was scheduled for laryngomicrosurgery under total intravenous anaesthesia. Anaesthesia was induced and maintained with Propofol. Seven to eight minutes after induction of anaesthesia, convulsion was observed first on his lower limbs and then on his all limbs and the head which lasted for 25 minutes. Later neurological examination revealed normal functions. |
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Conclusion: |
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The etiology of convulsions due to Propofol is controversial. Reviewing the literature the convulsion occurred in the above case may be related to Glycinergic as well as Glutamate receptors stimulation.
The above case is reported to highlight the rare side effects of Propofol so that we won’t be bewildered when we encounter similar situation in future. |
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References: |
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Krasowski M.D. , Nishikawa K, Nikonaeva N, et al: Methionine 286in transmembrane domain 3 of the GABAA receptor beta subunit controls a binding cavity for Propofol and other alkyl phenol general anaesthetics. Neuropharmacology 41:952-964,2001 |
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Pain L,Jeltsch H, Lehmann O,et al:Central cholinergic depletion induced by 192 IgG-saporin Alleviates the sedative effects of Propofol in rats.Br J Anaesth 85:869-873, 2000. |
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Antognini JWang X Piercy M, Carstens E:Propofol directly depresses lumbar dorsal horn neuronal responses to noxious stimulation in goats.Can J Aneasth 47:273-279. 2000 |
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Dong XP,Xu TL: The actions of Propofol on Gamma-amino butyric acid-A and Glycine receptors in acutely dissociated spinal dorsal horn neurons of the rat.Anesth Analg 95:907-914,2002. |
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Pain L,Gobaille S Schleef C, et al: In vivo Dopamine measurements in the Nucleus Accumbens after non anesthetic and anesthetic doses of Propofol in rats.Anesth Analg 95:915-919. 2002. |
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Cechetto DF, Diab T, Gibson CJ, Gelb AW: The effects of Propofol in the Area Postrema of rats.Anesth Analg 92:934-942, 2001. |
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pub med- Medline-PMID – 9689285 |
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Sneyd Jr. Excitatory events associated with Propofol anaesthesia a review (Journal of the Royal Society of Medicine 1992; 85:288-91.) |
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The internet drug index |
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