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Baigent AV, Morris EAJ. Severe acute drug-induced dystonia in the post-operative period requiring tracheal re-intubation. Anaesth Rep 2023; 11:e12258. [PMID: 37974908 PMCID: PMC10646813 DOI: 10.1002/anr3.12258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2023] [Indexed: 11/19/2023] Open
Abstract
Ondansetron is a highly selective 5-hydroxytryptamine receptor antagonist and the most commonly used anti-emetic for the prevention of postoperative nausea and vomiting. Ondansetron has a low affinity for dopamine receptors and so extrapyramidal side effects are rare. Here, we present the case of a 14-year-old girl who developed a severe post-operative acute dystonic reaction which included oculogyric crisis. We believe that ondansetron was the most likely cause, although propofol may have been a synergistic or alternative causative agent. The patient had no significant past medical history and had previously undergone two uneventful general anaesthetics which included both ondansetron and propofol. The prolonged duration and severity of the reaction and failure to fully respond to specific treatments resulted in the need for tracheal intubation and transfer to a paediatric intensive care unit. She subsequently recovered uneventfully with no ongoing neurological sequalae. Ondansetron-induced dystonic reactions are rare and unpredictable and can occur in patients who have previously received the drug without complication. They are thought to be caused by an imbalance between inhibitory and excitatory neurotransmitters in the extrapyramidal system. Specific treatments include anticholinergics, antihistamines and benzodiazepines.
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Affiliation(s)
- A. V. Baigent
- Department of AnaesthesiaRoyal United HospitalBathUK
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Elhusseiny AM, Grush A, Dagi LR. Acute, severe dystonia after strabismus surgery in a patient on propofol, ondansetron, and bupropion. J AAPOS 2020; 24:312-314. [PMID: 32693169 DOI: 10.1016/j.jaapos.2020.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/20/2020] [Accepted: 05/22/2020] [Indexed: 10/23/2022]
Abstract
Acute, severe dystonia is a frightening and potentially life-threatening surgical complication. We describe the case of a 41-year-old woman who experienced postoperative drug-induced dystonia after elective strabismus surgery. In this case, the medications likely responsible were propofol, ondansetron, and, possibly, bupropion.
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Affiliation(s)
- Abdelrahman M Elhusseiny
- Department of Ophthalmology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Artem Grush
- Department of Anesthesia, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts
| | - Linda R Dagi
- Department of Ophthalmology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
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Prolonged drug-induced myoclonus: is it related to palonosetron? J Anesth 2016; 30:1063-1066. [PMID: 27510560 DOI: 10.1007/s00540-016-2228-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Accepted: 08/02/2016] [Indexed: 10/21/2022]
Abstract
We report a case of drug-induced myoclonus possibly related to palonosetron, a second-generation 5-hydroxytryptamine-3 receptor antagonist which was administered as a prophylaxis for postoperative nausea and vomiting in a 28-year-old female. The recurrent episodes of myoclonus jerk involving the head, neck and shoulder persisted for a period of 4 days. The patient also exhibited an episode of severe bradycardia leading to hypotension 7 h after surgery. To our knowledge, this is the first report presenting these adverse events potentially associated with the use of palonosetron.
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Hawthorne JM, Caley CF. Extrapyramidal Reactions Associated with Serotonergic Antidepressants. Ann Pharmacother 2015; 49:1136-52. [PMID: 26185277 DOI: 10.1177/1060028015594812] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE Extrapyramidal reactions (EPRs) associated with serotonergic antidepressant treatments have been reported since 1958. These reactions can be distressing for patients and complicate treatment. Our objective was to complete a follow-up review of published EPR cases reported for serotonergic antidepressants. DATA SOURCES Published cases between January 1998 and May 2015 were collected through a medical literature search. Citation reference lists were also searched manually. STUDY SELECTION AND DATA EXTRACTION Identified cases were reviewed for patient age, gender, psychiatric diagnosis, dosage, time to reaction onset, concurrent medications, and EPR description. Cases were excluded when there was not a clear description, if descriptions were not consistent with accepted definitions, or if the written English was poor. We included cases of akathisia, dystonia, dyskinesia, parkinsonism, or mixed EPRs. Authors scored each case using the Naranjo adverse drug reaction probability scale. DATA SYNTHESIS We identified 86 published reports involving 91 patients; selective serotonin reuptake inhibitors were implicated in 80.2% of cases. All EPR types were reported: 17 akathisia cases, 18 dyskinesia cases, 27 dystonia cases, 19 parkinsonism cases, and 10 mixed EPR cases. EPRs typically occurred within 30 days of either treatment initiation or dose increase. Age, gender, antidepressant dosing, or concurrent antipsychotic treatment did not appear to broadly contribute to EPR risk. Naranjo scores ranged from 2 to 8. CONCLUSIONS Case reports associating serotonergic antidepressants with EPRs continue to be published. Practitioners are advised that monitoring for such is important. Rigorous research efforts are needed to better understand the clinical risk factors for these adverse drug reactions.
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Diaz-Parlet J, Subramani S. Dystonic reaction associated with ondansetron administration in a patient with normal pressure hydrocephalus. J Clin Anesth 2015; 27:423-5. [PMID: 25935832 DOI: 10.1016/j.jclinane.2015.03.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Revised: 03/02/2015] [Accepted: 03/30/2015] [Indexed: 10/23/2022]
Abstract
A 77-year-old female with normal pressure hydrocephalus underwent urgent revision of the abdominal component of a ventriculoperitoneal shunt. Upon emergence from an uneventful general anesthetic, the patient exhibited cogwheel rigidity with decerebrate posturing and a markedly irregular respiratory rate. This prohibited extubation and prompted an unplanned intensive care unit admission. Ondansetron was the only medication administered that had previously been associated with dystonic reactions. In a previous procedure, the patient had been given ondansetron without a similar reaction. This presentation may have been provoked by existing pathology such as her underlying normal pressure hydrocephalus and small increases in intracranial pressure.
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Abstract
This chapter reviews the spectrum and mechanisms of neurologic adverse effects of commonly used gastrointestinal drugs including antiemetics, promotility drugs, laxatives, antimotility drugs, and drugs for acid-related disorders. The commonly used gastrointestinal drugs as a group are considered safe and are widely used. A range of neurologic complications are reported following use of various gastrointestinal drugs. Acute neurotoxicities, including transient akathisias, oculogyric crisis, delirium, seizures, and strokes, can develop after use of certain gastrointestinal medications, while disabling and pervasive tardive syndromes are described following long-term and often unsupervised use of phenothiazines, metoclopramide, and other drugs. In rare instances, some of the antiemetics can precipitate life-threatening extrapyramidal reactions, neuroleptic malignant syndrome, or serotonin syndrome. In contrast, concerns about the cardiovascular toxicity of drugs such as cisapride and tegaserod have been grave enough to lead to their withdrawal from many world markets. Awareness and recognition of the neurotoxicity of gastrointestinal drugs is essential to help weigh the benefit of their use against possible adverse effects, even if uncommon. Furthermore, as far as possible, drugs such as metoclopramide and others that can lead to tardive dyskinesias should be used for as short time as possible, with close clinical monitoring and patient education.
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Affiliation(s)
- Annu Aggarwal
- Center for Brain and Nervous System, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, India
| | - Mohit Bhatt
- Center for Brain and Nervous System, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, India.
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Abstract
Iatrogenic disease is one of the most frequent causes of hospital admissions and constitutes a growing public health problem. The most common type of iatrogenic neurologic disease is pharmacologic, and the central and peripheral nervous systems are particularly vulnerable. Despite this, iatrogenic disease is generally overlooked as a differential diagnosis among neurologic patients. The clinical picture of pharmacologically mediated iatrogenic neurologic disease can range from mild to fatal. Common and uncommon forms of drug toxicity are comprehensively addressed in this chapter. While the majority of neurologic adverse effects are listed and referenced in the tables, the most relevant issues are further discussed in the text.
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Affiliation(s)
- Luciano A Sposato
- Department of Clinical Neurological Sciences, London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada
| | - Osvaldo Fustinoni
- INEBA Institute of Neurosciences, Buenos Aires, Argentina; Faculty of Medicine, University of Buenos Aires, Buenos Aires, Argentina.
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Beatty NC, Nicholson WT, Langman LJ, Curry TB, Eisenach JH. Pharmacogenetic workup of perioperative serotonin syndrome. J Clin Anesth 2013; 25:662-5. [PMID: 24096103 DOI: 10.1016/j.jclinane.2013.06.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Revised: 06/01/2013] [Accepted: 06/10/2013] [Indexed: 10/26/2022]
Abstract
Serotonin syndrome is gaining attention in perioperative and chronic pain settings due to the growing prevalence of multimodal therapies that increase serotonin levels and thereby heighten patient risk. A patient's genetic make-up may further increase the risk of serotonin syndrome. A case of serotonin syndrome on emergence after general anesthesia is presented. A subsequent cytochrome P4502D6 genetic test result suggested a potential alteration in metabolism. For this patient, who was taking combination antidepressant medications and receiving common perioperative medicines, additive pharmacodynamic effects converged with a pharmacogenetic predisposition, resulting in serotonin syndrome.
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Affiliation(s)
- Nicole C Beatty
- Department of Anesthesiology, Mayo Clinic, Rochester, MN 55905, USA.
| | | | - Loralie J Langman
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA
| | - Timothy B Curry
- Department of Anesthesiology, Mayo Clinic, Rochester, MN 55905, USA
| | - John H Eisenach
- Department of Anesthesiology, Mayo Clinic, Rochester, MN 55905, USA
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Jo YY, Kim YB, Yang MR, Chang YJ. Extrapyramidal side effects after metoclopramide administration in a post-anesthesia care unit -A case report-. Korean J Anesthesiol 2012; 63:274-6. [PMID: 23060988 PMCID: PMC3460160 DOI: 10.4097/kjae.2012.63.3.274] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2011] [Revised: 10/14/2011] [Accepted: 10/14/2011] [Indexed: 01/23/2023] Open
Abstract
Although the incidence of extrapyramidal reactions associated with metoclopramide has been reported to be approximately 0.2%, such reactions are rare in the anesthetic field. Several anesthetic adjuvants, including ondansetron and pregabalin, have also been associated with extrapyramidal side effect. Here, the authors report the case of a 47-year-old patient, previously administered pregabalin and ondansetron, who developed extrapyramidal side effects after a single injection of metoclopramide (10 mg) in a post-anesthesia care unit.
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Affiliation(s)
- Youn Yi Jo
- Department of Anesthesiology and Pain Medicine, Gachon University of Medicine and Science Gil Medical Center, Incheon, Korea
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Budde AO, Freestone-Bernd M, Vaida S. Rhythmic movement disorder after general anesthesia. J Anaesthesiol Clin Pharmacol 2012; 28:371-3. [PMID: 22869949 PMCID: PMC3409952 DOI: 10.4103/0970-9185.98347] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Dystonic movements after general anesthesia are very rare. The differential diagnosis includes adverse drug reaction, local anesthetic reaction, emergence delirium, hysterical response, and shivering. We present a case of a 10-year-old, otherwise healthy girl undergoing outpatient foot surgery. Involuntary jerking movements of her arms and torso every time she would drift off to sleep started about 2.5 hours after emergence from general anesthesia. The patient was easily arousable and absolutely unaware of the movements. These movements lasted for several days before they resolved completely. We believe to present the first case of sleep-related rhythmic movement disorder after general anesthesia, considering the nature of the movements in our patient.
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Affiliation(s)
- Arne O Budde
- Department of Anesthesiology, Penn State University College of Medicine, Milton S. Hershey Medical Center, PA USA
| | - Megan Freestone-Bernd
- Department of Anesthesiology, Penn State University College of Medicine, Milton S. Hershey Medical Center, PA USA
| | - Sonia Vaida
- Department of Anesthesiology, Penn State University College of Medicine, Milton S. Hershey Medical Center, PA USA
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Šimurina T, Mraović B, Mikulandra S, Sonicki Z, Sulen N, Dukić B, Gan TJ. Effects of high intraoperative inspired oxygen on postoperative nausea and vomiting in gynecologic laparoscopic surgery. J Clin Anesth 2010; 22:492-8. [DOI: 10.1016/j.jclinane.2009.10.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2009] [Revised: 09/15/2009] [Accepted: 10/31/2009] [Indexed: 10/18/2022]
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Minisini AM, Pauletto G, Andreetta C, Bergonzi P, Fasola G. Anticancer drugs and central nervous system: Clinical issues for patients and physicians. Cancer Lett 2008; 267:1-9. [DOI: 10.1016/j.canlet.2008.02.051] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2007] [Revised: 02/21/2008] [Accepted: 02/22/2008] [Indexed: 11/16/2022]
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Zhang Z, Wang Y, Wang Y, Xu F. Antiemetic placebo: Reduce adverse drug interactions between chemotherapeutic agents and antiemetic drugs in cancer patients. Med Hypotheses 2008; 70:551-5. [PMID: 17703892 DOI: 10.1016/j.mehy.2007.06.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2007] [Accepted: 06/24/2007] [Indexed: 11/24/2022]
Abstract
Cancer patients receiving chemotherapy often require a wide range of drugs to manage symptoms of their cancer. The adverse drug interactions are common in the field of medical oncology. Chemotherapy-induced nausea and vomiting (CINV) continues to have a considerable effect on the physical and psychological well-being of patients with cancer, despite significant advances in antiemetic drugs since the 1990s. Fortunately, evidence-based interventions suggested that to a certain extent antiemetic effects can be achieved by use of placebo appropriately. Placebo effect can be reinforced by conferring much meaning. Thus physician can replace antiemetic drugs with reinforced meaningful antiemetic placebo to get better prevention and treatment efficacy for CINV while reduce the unnecessary adverse drug interactions induced by antiemetic drugs and chemotherapeutic agents.
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Affiliation(s)
- Zhongyi Zhang
- Department of Clinical Pharmacology, Second Medical College, Southern Medical University, Guangzhou, China
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Fujii Y. Prophylaxis of Postoperative Nausea and Vomiting in Patients Scheduled for Breast Surgery. Clin Drug Investig 2006; 26:427-37. [PMID: 17163275 DOI: 10.2165/00044011-200626080-00001] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Breast surgery performed under general anaesthesia is associated with a high incidence of postoperative nausea and vomiting (PONV). Between 60% and 80% of patients undergoing mastectomy (with axillary dissection) experience PONV. Pharmacological approaches have been investigated to reduce PONV after breast surgery. Traditional antiemetics (droperidol and metoclopramide) are frequently used for the prevention of PONV during the first 24 hours after anaesthesia. The available non-traditional antiemetics that have been shown to be effective for prophylaxis against PONV are dexamethasone, clonidine, propofol and supplemental oxygen. Antiserotonins (ondansetron, granisetron, tropisetron, dolasetron and ramosetron) are highly effective for preventing PONV for 24 hours postoperatively, compared with traditional antiemetics. Ramosetron is effective for the long-term (up to 48 hours) prevention of PONV. Better results can be obtained by combining antiemetics, because they have different sites of action. Combination antiemetic therapy is often effective for preventing PONV after breast surgery. Combinations of an antiserotonin (granisetron or dolasetron) and droperidol or dexamethasone are more effective than monotherapy with antiserotonins. A non-pharmacological technique is acupuncture at the P6 (Nei-Kuan) point. Overall, these pharmacological and non-pharmacological approaches reduce the incidence of PONV following breast surgery. Most of the published trials indicate improved prophylaxis of PONV following breast surgery by avoiding risk factors, and by using effective antiemetic agents in women scheduled for mastectomy (with axillary dissection). The clinician must weigh the benefits of using pharmacological and non-pharmacological approaches for PONV against the risk of occurrence of adverse events.
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Affiliation(s)
- Yoshitaka Fujii
- First Department of Anaesthesiology, Toho University School of Medicine, Ohmori-Nishi, Tokyo, Japan.
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Spiegel JE, Kang V, Kunze L, Hess P. Ondansetron-induced extrapyramidal symptoms during cesarean section. Int J Obstet Anesth 2005; 14:368-9. [PMID: 16154341 DOI: 10.1016/j.ijoa.2005.06.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2004] [Revised: 06/01/2005] [Accepted: 06/01/2005] [Indexed: 10/25/2022]
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Horiot JC. Prophylaxis versus treatment: is there a better way to manage radiotherapy-induced nausea and vomiting? Int J Radiat Oncol Biol Phys 2004; 60:1018-25. [PMID: 15519770 DOI: 10.1016/j.ijrobp.2004.07.722] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2004] [Revised: 07/15/2004] [Accepted: 07/23/2004] [Indexed: 11/16/2022]
Abstract
Nausea and vomiting are two of the most distressing side effects of radiotherapy and cytotoxic drugs, which currently are often combined to treat moderately advanced and advanced solid tumors. Inadequate control of these symptoms may result in significant patient suffering and decrease in the patient's quality of life, which has been shown to decrease patients' compliance to treatment, with potential impact on disease outcome. It is, therefore, important that radiation oncologists recognize the need for adequate prophylactic treatment of radiation-induced nausea and vomiting (RINV) to avoid the detrimental effects on patients' quality of life, and optimize chances for cure. The 5-hydroxytryptamine type 3 (5-HT(3))-receptor antagonists have been proved to provide effective antiemetic therapy in patients undergoing highly emetogenic radiotherapy. Nevertheless, several large surveys have shown that optimal treatments are not always used. Hence, a risk exists that waiting for RINV symptoms rather than prescribing prophylactic antiemetic treatment may lead to increased patient suffering, poorer disease control, and less cost-effective therapy options. Prophylactic management with an effective 5-HT(3)-receptor antagonist should offer a better treatment option for patients at high to moderate risk of RINV. Adequate control of RINV should contribute to patient compliance to treatment, improved therapy outcomes, and decreased burdens on nursing and health care resources.
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Abstract
We treated a patient who developed transient multifocal encephalopathy with extrapyramidal symptoms (oromandibular dystonia, oculogyric crisis, and limb dystonia) in temporal proximity to ondansetron administration on emergence from general anesthesia. No other medications known to cause extrapyramidal reactions were administered. Although these symptoms resolved fully, the presentation was dramatic and resembled the symptoms of structural brain injury. Ondansetron is used frequently as an antiemetic agent in many clinical settings and is not limited to surgical patients. Therefore, the entire medical community should be cognizant of this potential adverse reaction.
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Affiliation(s)
- Matthew J Ritter
- Department of Anesthesiology, Mayo Clinic, Rochester, Minn. 55905, USA
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