A case of propofol-induced delayed-onset refractory myoclonic seizures

Propofol-Induced Fasciculations in a Patient With Obstructive Sleep Apnea: A Case Report

We report a case of a 39-year-old male patient who developed propofol-induced fasciculations during the induction of general anesthesia. The patient had a history of moderate obstructive sleep apnea and was intolerant to continuous positive airway pressure therapy. He subsequently underwent the insertion of a hypoglossal nerve stimulator as a viable surgical intervention. The patient had a drug-induced sleep endoscopy that showed a 100% obstruction at the velum and the oropharynx, mainly in the anteroposterior and lateral directions. The patient experienced a smooth induction and emergence from general anesthesia, except for a brief episode of myoclonus-like movement in the bilateral upper extremities after propofol administration. The patient recovered well and reported an improvement in his sleep quality and daytime symptoms.

Comparison of the influence of low dose etomidate and propofol as priming dose on the incidence of etomidate induced myoclonus: a randomised, double-blind clinical trial

BACKGROUND

Though hemodynamically stable, etomidate is known for its myoclonus side effect following induction. The main aim of this study is an effective attempt to decrease the incidence of myoclonus with a priming agent.

METHODS

A prospective, double-blind study was carried out on 50 adults posted for elective surgery. After premedication, priming was done with etomidate 0.03 mg.kg-1 (Group E) and propofol 0.2 mg.kg-1 (Group P), i.e., 1/10th of induction dose. After 60 seconds of priming, patients were induced with etomidate by titrating dose over 60 seconds until loss of verbal command and eyelash reflex. The grading of myoclonus, induction dosage, and hemodynamics for 10 minutes post induction were recorded.

RESULTS

In the study, only 4 cases had myoclonus. Grade 1 myoclonus was encountered in three cases of etomidate group, while only one case in the propofol group had grade 2 myoclonus which was not statistically significant (p-value: 0.12). There was a significant reduction in the etomidate induction dosage in both groups.

CONCLUSION

Priming with etomidate and propofol is equally effective in reducing myoclonus with the added benefit of hemodynamic stability and reduction of an induction dose of etomidate (> 50%).

Unusual Set of Adverse Effects During Right-Unilateral Ultrabrief Electroconvulsive Therapy Led to the Discovery of a Brain Tumor: A Case Report

We describe a case of a right-handed, 42-year-old, Caucasian female patient who manifested a set of unusual adverse effects during maintenance ultrabrief right-unilateral electroconvulsive therapy (ECT)-generalized myoclonic secondary seizure with lateralization nonresponsive to repeated intravenous diazepam application, deviation of the tongue and the head to the left, ping-pong gaze with nystagmoid jerks, postictal hypoactive confusion state lasting 15 minutes (with a total time to recovery 30 minutes), and likely Todd's paralysis after the procedure (subsided within 24 hours). These adverse effects led to a thorough clinical investigation and eventually the discovery of a brain tumor. In the article, we hypothesize about the possible interaction between the intracranial mass and ECT and provide a literature overview on the topic. Cases like this are likely underreported, and although several studies demonstrate that ECT can be applied safely to patients with an intracranial mass, this report demonstrates that brain tumor can interfere with ECT in an unpredictable way and have severe consequences (eg, unresponsiveness to diazepam when attempting to halt the seizure as our patient). Unusual symptoms after ECT, albeit reversible, such as in this case report, should be followed by a thorough neurological check-up to exclude any underlying organic pathology.

Myoclonic movement after general anesthesia: A case report and review of the literature

RATIONALE

Myoclonic movement is a rare side effect after general anesthesia. Since we use various intravenous agents during general anesthesia recently, it is troublesome to find out the exact cause of this neurologic complication.

PATIENT CONCERNS

A 31-year-old female patient without any past medical history underwent hip arthroscopic surgery under general anesthesia.

DIAGNOSES

Although there was no specific event during the operation, she showed a sudden myoclonic movement confined to left upper extremity in recovery room.

INTERVENTIONS

We administered anticonvulsant agents intrvenously, the myoclonus was stopped shortly but recurred over again. As we stopped the patient-controlled analgesia due to nausea, the symptom halted.

OUTCOMES

There was no significant abnormality in electroencephalography or brain diffusion magnetic resonance imaging, which was taken after the event.

LESSONS

Clinicians should carefully consider the pharmacologic characteristics and neurologic adverse effects of all administered agents when myoclonus occurs after general anesthesia.

Refractory status epilepticus complicated by drug-induced involuntary movements

New onset refractory status epilepticus (NORSE) is a neurological emergency and difficult to treat condition. We report a case of involuntary movements resulting from thiopentone sodium infusion during the management of refractory status epilepticus. A young woman was admitted with fever and NORSE in the neurology intensive care unit. In addition to supportive measures, she was treated with intravenous lorazepam, phenytoin sodium, sodium valproate, midazolam and thiopentone sodium. While on thiopentone sodium, she developed involuntary twitches involving her upper limbs and face with EEG showing no evidence of ongoing status epilepticus. Because of the temporal relationship with thiopentone infusion, we tapered the dose of thiopentone sodium, which resulted in the disappearance of the movements. The patient recovered well with no recurrence of the seizures during the hospital stay.

Status epilepticus attributed to inadvertent intrathecal injection of cefazolin during myelography

OBJECTIVE

To describe a case of status epilepticus believed to be a consequence of inadvertent intrathecal administration of cefazolin in a dog undergoing a myelogram.

CASE SUMMARY

A 4-year-old, 6.5 kg, male neutered Dachshund was referred for evaluation of an acute onset hind limb paraparesis. While performing a lumbar myelogram, cefazolin was inadvertently injected into the ventral subarachnoid space. Subsequent refractory seizure activity was attributed to the epileptogenic effects of intrathecally administered cefazolin. Supportive therapy led to eventual complete recovery.

NEW OR UNIQUE INFORMATION PROVIDED

Although epileptogenic effects of intrathecally administered cefazolin are well documented in the human and experimental animal model literature, to the authors' knowledge this has not been characterized in the veterinary literature. This case highlights the need to be diligent and mindful when one administers medications, and describes the management of a dog adversely affected as a consequence of a medical error.

Abnormal motor activity during anaesthesia in a dog: a case report

Seizures or convulsions that occur during anaesthesia in veterinary patients are infrequently reported in the literature. Consequently, the incidence of such events is unknown. Several drugs commonly used in clinical veterinary anaesthesia have been shown to induce epileptiform activity in both human clinical patients and experimental candidates. The present case report describes convulsions in a four-year old male Bernese mountain dog during maintenance of anaesthesia with isoflurane after premedication with acepromazine and methadone followed by co-induction with propofol and ketamine. The dog had no history of previous convulsions. The use of several sedative and anaesthetic drugs makes it difficult to find one single causative pharmaceutical.