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Dystonic reaction after anesthesia

Toronto, Ontario

To the Editor:

A healthy 24-yr-old woman had a tonsillectomy under general anesthesia with propofol, mivacurium, air, O_2, isoflurane. She also received 4 mg ondansetron and bupivacaine 0.5% with epinephrine was injected into the faucial pillars as a prophylaxis for nausea, vomiting and postoperative pain. The procedure lasted 40 min and the trachea was extubated when she was awake. Fifteen minutes after arrival in PACU, she started to have dystonic movements affecting the upper limb, chest and lower limbs. The patient was awake and responsive and was very nervous. Vital signs were normal, temperature 37°C, BP 130/80, heart rate 120. She was given incremental doses of midazolam to 2 mg, but the dystonic movements persisted. The pupils were equal and reactive and patient had no pain. The differential diagnosis was adverse drug reaction, local anesthetic reaction, emergence delirium, hysterical response and post anesthetic shivering. Local anesthetic reaction is unlikely as only 5 ml bupivacaine were given. The possibility of adverse drug reaction to ondansetron or propofol was entertained. The dystonic movements lasted three hours. Neurological consultation was requested and was thought to be a psychogenic reaction.

Ondansetron produces dystonic reactions in chronic use¹and propofol produces dystonic reaction, seizures and opisthotonus.^2,3 Hysterical reaction and delirium usually respond to sedation. Post anesthetic shivering involves the whole body and is often associated with rigidity. There is a recent report of exitatory phenomena with propofol.⁴

References

1 Wilde MI, Markham A. Ondansetron. A review of its pharmacology and preliminary clinical findings in novel applications. Drugs 1996; 52: 773–94.[Medline]

2 Mäkelä JA, Iivanainen M, Pieninkeroinen IP, Waltimo O, Lahdensuu M. Seizures associated with propofol anesthesia. Epilepsia 1993; 34: 832–5.[Medline]

3 Saunders PRI, Harris MNE. Opisthotonus and other unusual neurological sequelae after outpatient anaesthesia. Anaesthesia 1990; 45: 552–7.[Medline]

4 Islander G, Vinge E. Severe neuroexcitartery symptoms after anesthesia - with focus on propofol anaesthesia. Acta Anaesthesiol Scand 2000; 44: 144–9.[Medline]

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