Intraop shivering? seizure?

[anbuitachi]

How do you tell the difference between intraop shivering vs seizure for patient under GA, with no eeg?

I had a patient the other day , hit his head, bleed, requiring craniectomy. During closure suturing at the end of surgery, surgeon says 'patient is shivering'. i could tell from the monitors (EKG, pulse ox), and i looked over drape and patients entire body is just shivering rapidly.

this patient is under GA propofol infusion, with paralysis (i guess it partially wore off), esophageal Temp of 37.4F. had 2g keppra in ED. otherwise vitals stable

it lasted maybe 20 seconds. i gave more roc. and out of precaution, more keppra and some midaz. few minutes post event, his HR went to 140, and systolic down to ~90 from 140.

any ideas? recs?

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[UscGhost]

I don't think shivering occurs under GA. Although I don't necessarily have any literature on that.

I would presume that was a seizure, especially given the type of surgery

 

[abolt18]

Given the circumstance, I'd err on the side of caution and treat as a seizure. And obviously make sure they're warm enough (like your patient was). I think you did what I would do. However I'd not give the roc until I could tell that the shivering had stopped from my interventions.

 

[repititionition]

there are case reports of SZ under propofol GA, confirmed by EEG. Was there a drain? Pneumocephalus? Without a new irritant, during closure this seems exceedingly unlikely. Distinguishing this movement from other causes, generally propofol myoclonus or shivering (which is very unlikely as you mentioned) is impossible without EEG.

It was probably propofol myoclonus, but you did the right thing in any case.

 

[MirrorTodd]

How do you tell the difference between intraop shivering vs seizure for patient under GA, with no eeg?

I had a patient the other day , hit his head, bleed, requiring craniectomy. During closure suturing at the end of surgery, surgeon says 'patient is shivering'. i could tell from the monitors (EKG, pulse ox), and i looked over drape and patients entire body is just shivering rapidly.

this patient is under GA propofol infusion, with paralysis (i guess it partially wore off), esophageal Temp of 37.4F. had 2g keppra in ED. otherwise vitals stable

it lasted maybe 20 seconds. i gave more roc. and out of precaution, more keppra and some midaz. few minutes post event, his HR went to 140, and systolic down to ~90 from 140.

any ideas? recs?

I presume the prop was at GA levels?

Kinda random, but my pt recently was getting a TMJ surgery, heavy marijuana user, she got 4mg versed, 100mcg fent in OR prior to induction and had still wide awake, like barely even felt it. Induction/intubation (w/ sux) went fine, pt was chill, sevo, turned the bed and the surgeons started wrapping her head with the towels (lifting her head and such), and her whole body was shaking with clonic like activity. Wasn't sure if it was light anesthesia, pt was at 1.2 MAC or if she was seizuring. No hx of intracranial pathology. I've witnessed a lot of grand mal seizures from my older brother and it was fairly similar (just not as violent as a grand mal), appearing more than the typical shivering one sees in PACU.

 

[epidural man]

I presume the prop was at GA levels?

Kinda random, but my pt recently was getting a TMJ surgery, heavy marijuana user, she got 4mg versed, 100mcg fent in OR prior to induction and had still wide awake, like barely even felt it. Induction/intubation (w/ sux) went fine, pt was chill, sevo, turned the bed and the surgeons started wrapping her head with the towels (lifting her head and such), and her whole body was shaking with clonic like activity. Wasn't sure if it was light anesthesia, pt was at 1.2 MAC or if she was seizuring. No hx of intracranial pathology. I've witnessed a lot of grand mal seizures from my older brother and it was fairly similar (just not as violent as a grand mal), appearing more than the typical shivering one sees in PACU.

Sevo can cause epileptiform EEG activity.

 

[Mehd School]

You saw an intra op seizure.

I've had two and both were with open cranial vaults and both were as obvious as the one you're describing. Went away with propofol push and some versed on the backend to raise the threshold. Both had already gotten keppra. And to my surprise, both neurosurgeons were trying to argue that it was not a seizure despite it obviously being one and the neurologist alerting the neuromonitoring tech that the patient had just experienced a seizure.

 

[anbuitachi]

You saw an intra op seizure.

I've had two and both were with open cranial vaults and both were as obvious as the one you're describing. Went away with propofol push and some versed on the backend to raise the threshold. Both had already gotten keppra. And to my surprise, both neurosurgeons were trying to argue that it was not a seizure despite it obviously being one and the neurologist alerting the neuromonitoring tech that the patient had just experienced a seizure.

i asked the neurosurgeon as well who wasnt sure either. but told her about my plan and she agreed.

 

[anbuitachi]

I presume the prop was at GA levels?

Kinda random, but my pt recently was getting a TMJ surgery, heavy marijuana user, she got 4mg versed, 100mcg fent in OR prior to induction and had still wide awake, like barely even felt it. Induction/intubation (w/ sux) went fine, pt was chill, sevo, turned the bed and the surgeons started wrapping her head with the towels (lifting her head and such), and her whole body was shaking with clonic like activity. Wasn't sure if it was light anesthesia, pt was at 1.2 MAC or if she was seizuring. No hx of intracranial pathology. I've witnessed a lot of grand mal seizures from my older brother and it was fairly similar (just not as violent as a grand mal), appearing more than the typical shivering one sees in PACU.

yea 125mcg/kg/min

he came in gcs 4

 

[Mehd School]

i asked the neurosurgeon as well who wasnt sure either. but told her about my plan and she agreed.

The first time I saw it I was EXTREMELY skeptical as we were, as I mentioned, doing neuromonitoring. So this patient was on a pretty giant slug of propofol gtt, had gotten versed, keppra and had a Remi infusion going. If this was a knee surgery I would have known it was something else but it turns out that actively poking Brain parenchyma can lower the seizure threshold to a level that you can't quite overcome until the surgeon cuts it out.

 

[abolt18]

there are case reports of SZ under propofol GA, confirmed by EEG. Was there a drain? Pneumocephalus? Without a new irritant, during closure this seems exceedingly unlikely. Distinguishing this movement from other causes, generally propofol myoclonus or shivering (which is very unlikely as you mentioned) is impossible without EEG.

It was probably propofol myoclonus, but you did the right thing in any case.

Have you ever actually seen propofol myoclonus on someone who's at a steady-state GA depth propofol gtt? I've only ever seen it on induction.

 

[anbuitachi]

Have you ever actually seen propofol myoclonus on someone who's at a steady-state GA depth propofol gtt? I've only ever seen it on induction.

also propofol myoclonus isnt like shivering imo

 

[deleted875186]

Have you ever actually seen propofol myoclonus on someone who's at a steady-state GA depth propofol gtt? I've only ever seen it on induction.

Agree with this. Sounds most likely for seizure based on the situation alone, not sure how reliable seeing gross movement is in differentiating a seizure from something else. I say unless neuromonitoring is on and you can say no seizure, treat it as such. I would have avoided rocuronium to make sure I aborted the presumed seizure.

 

[anbuitachi]

Agree with this. Sounds most likely for seizure based on the situation alone, not sure how reliable seeing gross movement is in differentiating a seizure from something else. I say unless neuromonitoring is on and you can say no seizure, treat it as such. I would have avoided rocuronium to make sure I aborted the presumed seizure.

good point.

 

[repititionition]

Have you ever actually seen propofol myoclonus on someone who's at a steady-state GA depth propofol gtt? I've only ever seen it on induction.

no, only during induction and emergence, though I imagine that they were emerging as he mentioned they were closing.

 

[anbuitachi]

no, only during induction and emergence, though I imagine that they were emerging as he mentioned they were closing.

wasnt emerging much since not extubating. was titrating propofol down but was still at 125mcg/kg/min. young patient

 

[coffeebythelake]

Marijuana user? Robust young patient? 125 mcg/kg/min propofol might not be much

 

[anbuitachi]

Marijuana user? Robust young patient? 125 mcg/kg/min propofol might not be much

trauma patient. gcs4. no history known

 

[Mehd School]

trauma patient. gcs4. no history known

probably has a history of seizures

 

[repititionition]

probably has a history of seizures

 

[Radetzky]

Dilated pupils during event would confirm a seizure. But obviously can have seizure without dilated pupils

 

[anbuitachi]

probably has a history of seizures

possible.. but young patient with high alcohol level, crashed into random object...