Case Report - (2020) Volume 10, Issue 7
Received: 12-Jun-2020
Published:
26-Jun-2020
, DOI: 10.37421/jccr.2020.10.1362
Citation: Chunghee Joo, Eun Jung Cho, Seunghee Cho. â??A Case Report of Seizure-Like Movements after Tonsillectomy under General Anesthesia.â? Clin Case Rep 10 (2020): 1362
Copyright: © 2020 Joo C, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Seizure-like movements after general anesthesia is not common, but it sometimes happens. However, abnormal movements following general anesthesia may be difficult to differentiate because it is difficult to find out the exact cause of these seizure-like movements. These cases can occur at any stage (during induction of anesthesia and emergence from anesthesia and early and late recovery of anesthesia). This is a rare case of seizure-like movement after tonsillectomy under general anesthesia.
Seizure-like movement • Epilepsy • Propofol • General anesthesia • Postoperative
Although uncommon, seizure-like movements after general anesthesia can occur. The causes of such abnormal movements include adverse drug reactions, emotional responses, emergence delirium, and shivering [1]. Because many anesthetic drugs are used during general anesthesia, it is difficult to precisely determine the causative agents of seizure-like movements. There have been case reports in which anesthetic drugs induced myoclonic movements or seizures [2-4]. Here, we present a case of a 24-year-old woman with seizure-like movements after tonsillectomy under general anesthesia.
A 25-year-old, 49 kg female patient with American Society of Anesthesiologists physical status I was admitted to our hospital for elective tonsillectomy under general anesthesia. She had previously undergone closed reduction of nasal bone fractures under general anesthesia at the age of 4 years, during which there were no adverse events. The drug used at that time was ketamine (50 mg). Otherwise, the patient had no underlying diseases and no past medical history. The preoperative laboratory tests, Electrocardiogram (ECG), and chest X-ray were unremarkable. The patient entered the operating room without premedication. General anesthesia was induced with 40 mg of lidocaine, 100 mg of propofol, 40 mg of rocuronium, and 50 mcg of fentanyl. Tracheal intubation was performed without difficulty. Anesthesia was then maintained with 6 vol % of desflurane (40% oxygen and 60% air). The patient was monitored via noninvasive blood pressure (NIBP) measurements, ECG (lead II), pulse oximetry, and capnography. No issues emerged during tonsillectomy. At the end of the operation, the neuromuscular blockade was reversed by 200 mg sugammadex. The operation took 30 minutes, and the duration of anesthesia was 1 hour. On arrival in the Post-Anesthesia Care Unit (PACU), the patient had a mild macular rash on the whole body and complained of pruritus, mild dyspnea, and chills; she also developed shivering. The patient remained cardiovascularly stable. Oxygen was supplied at a flow rate of 5 L/min via face mask. After intravenous injection of 5 mg of dexamethasone and 4 mg of pheniramine, her symptoms and signs resolved. At 150 minutes after the end of anesthesia, she was taken to the general ward, and periodic movements that lasted less than a minute and occurred at intervals of 2–3 minutes appeared; these took the form of uncontrolled generalized tonic clonic seizure-like movements of the whole body. Her head was tilted laterally and backward, and her body became rigid. Lorazepam (2 mg) was administered and her symptoms abated. At 2 hours after the first attack, she complained of rigidity in all extremities and was aware of the seizure-like movements; however, she remained cardiovascularly stable. A neurologist examined the patient and presumed that the abnormal movements were caused by drugs. The next morning, she trembled for 3 seconds on two occasions but had no recollection of any symptoms. Therefore, she underwent diffusion weighted Magnetic Resonance Imaging (MRI). The MRI results were unremarkable. Subsequently, while waiting for electroencephalography, she shook her head for 10 seconds with her eyes closed. Keppra (levetiracetam) was continuously infused. Later that evening, the patient exhibited generalized tonic clonic seizure-like movements for 7 seconds. ; Similar events occurred thereafter, but with shorter duration and longer intervals. The EEG revealed no epileptiform discharge; therefore, Keppra was discontinued and clonazepam (0.5 mg, twice a day) was given instead. At 3 days after surgery, there were no abnormal seizure-like movements, so clonazepam was also discontinued. Abnormal movements did not recur during hospitalization and the patient was discharged on day 7 after the operation. At 7 days after discharge, she did not report any abnormal movements. This report is of a rare case of seizurelike movements after tonsillectomy under general anesthesia. This case study was approved by our Ethics Review Committee and Institutional Review Board (OC19ZESE0060). Written informed consent was obtained from the patient for the publication of this case report.
Extrapyramidal side effects after a single injection of propofol are uncommon. Several cases of propofol-related extrapyramidal symptoms have been reported [5-9]. Acute extrapyramidal symptoms include dystonia (continuous spasms and muscle contractions), akathisia (motor restlessness), parkinsonism (characteristic symptoms including rigidity), bradykinesia (slowness of movement), tremor, and tardive dyskinesia (irregular, jerky movements) [10]. Extrapyramidal symptoms are drug-induced movement disorders that include acute and tardive symptoms. These symptoms are often reported as side effects of antipsychotics but are sometimes related to other drugs, such as anesthetics [5,11]. They may also occur as neurological side effects of general anesthesia in patients without a significant neurologic history. Our patient showed intermittent bouts of sustained contractions of the muscles in the face and extremities, which lasted for 4 days. In the PACU, we thought she was having an allergic reaction to sugammadex because her symptoms included chills, difficulty with breathing, shivering, and redness of the face, neck, arms, and upper chest. After injection of dexamethasone and pheniramine, her symptoms abated. Although there have been case reports of relief of extrapyramidal symptoms after injection of diphenhydramine, our patient did not respond to such treatment [12]. After injection of lorazepam, the abnormal movements stopped. According to the literature, propofol, fentanyl, ramosetron, and nefopam, as well as inhaled anesthetics, can cause perioperative seizurelike movements [13]. In our case, we used a small dose of fentanyl (50 mcg) for induction of anesthesia. Although there have been a few reports of seizures after low-dose fentanyl administration [14,15], seizure activity is usually related to high doses of fentanyl (200 or 500 mcg/kg) [14]. Fentanyl can be the cause of seizure-like movements, but it is unlikely that fentanyl and desflurane can be the cause in our case. The epileptogenic potential of volatile agents may involve destabilization of the cortex and delayed onset of inhibitory signaling [16]. Desflurane use is associated with fewer cortical spikes compared to other inhaled anesthetics (e.g., enflurane and sevoflurane); accordingly, desflurane was used as the inhaled anesthetic agent in our case and it is unlikely that fentanyl and desflurane were the causative agents of seizure-like movements. Although the neurologist presumed that the cause of seizure might occur by one of drugs, there were specific signs like allergic reaction before the seizure-like movements in this case. As there are some case reports about the relationship between allergic reaction and epilepsy [17], seizure-like movements in our case might be related to the allergic reaction in PACU. If sugammadex that we used might cause allergic reaction, it triggers seizure-like movements but there was no case report that sugammadex caused seizure-like movements.
Recently, the relationship between propofol use and perioperative neurologic complications has been studied [18,19]. Although the mechanisms underlying seizure-like movements and neuroexcitatory after propofol administration are not well understood [20], it is hypothesized that the extrapyramidal effects may be due to activation of excitatory pathways in the subcortical region, extended refractory periods in inhibitory pathways in the brainstem and spinal cord, or a combination of both [21]. Neuroexcitation is a rare but well-known side effect of propofol anesthesia and sedation. These abnormal movements usually occur during induction of, and emergence from, anesthesia. Therefore, a rapid change in the propofol concentration in the brain appears to be responsible for seizures [19]. Propofol has a long terminal elimination half-life, Which may be responsible for the slow return of propofol from poorly perfused peripheral compartments back into the central compartment. Hence, the concentrations of propofol can remain high for a long time within the nervous system, producing effects that depend on the balance between inhibitory and excitatory neurons. However, additional studies are needed to precisely determine the biochemical and biophysical origins of neuroexcitation related to propofol. There have been many reports of abnormal movements associated with propofol use [22-25] but no definitive treatment has been developed. Delayed neuroexcitatory symptoms after uneventful anesthesia are uncommon. There is a study that seizure like movements were observed during induction of anesthesia or sedation (24 patients; 34%), during emergence (28; 40%), or delayed (16; 23%) [24]. some cases occur in patients with underlying disease (e.g. renal failure, syncope, and leukemia) [26], history of convulsion [27], or use of propofol/nitrous oxide [28]. Some cases occur in patients administered in continuous propofol infusion [29].
However, our case occurred with only one injection of propofol and abnormal movements were observed during delayed. Abnormal movements following general anesthesia may be difficult to differentiate and can occur in patients without a significant neurologic history. Anesthesiologists should be aware of the pathophysiology, risk factors, and management of perioperative abnormal movements.
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