Propofol induced myoclonus?

[Groove]

Anybody ever seen this? I seem to always get the weird anesthesia reactions that never happen to anyone else.

I was doing moderate sedation on this lady in her 60s, ASA 3, s/p total left shoulder about 1.5 months ago and the orthopod sent her in after doing an XR in the office that showed prosthetic dislocation. I do all my usual pre-sedation assessment, get everything ready, yada yada. All my back up stuff in the room, ortho talks rads into rolling a c-arm down from the OR and we're ready. I push about 50-75mg prop and the lady starts having these really intense, rhythmic myoclonic jerking over her entire body. Facial muscles, arms, legs, torso, abdomen. I can tell from the ETCO2 monitor that it's actually impairing her ability to take a deep breath. The entire facial muscles were also involved. Each rhythmic contraction was about 2 per second and it lasted a full 2 minutes. I pried one of her eyes open and there wasn't any gaze deviation and it didn't appear to resemble any traditional seizure activity. I immediately cancelled the procedure and told the orthopods that I was sorry but she was having atypical myoclonic activity that I wasn't sure if it was d/t the propofol or some other neurologic syndrome and recommended a full anesthesia consult and reduction in a more controlled setting (OR) and that she would probably need GA. I didn't want to risk pushing more prop and having a more sustained reaction especially given the respiratory compromise. I never had to bag her.

I actually had an anesthesiologist patient last night and ran the case by him and he said he had heard of it before but never experienced it but had colleagues who had. I tried doing a pubmed search and get scattered case reports. It seems like a rare reaction. It was my first time encountering it. Weird.

DEFINE_ME

https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/pdf/10.1111/j.1365-2044.2009.06035.x

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[southerndoc]

Only seen myoclonus with etomidate. I've seen under sedation cause some people to flex their muscles but not a true myoclonus. If I saw myoclonus with propofol, I'd probably just give more propofol.

 

[RustedFox]

Seen with etomidate as well.
Haven't seen it with propofol, but I haven't given enough propofol.

 

[BoardingDoc]

Anybody ever seen this? I seem to always get the weird anesthesia reactions that never happen to anyone else.

I was doing moderate sedation on this lady in her 60s, ASA 3, s/p total left shoulder about 1.5 months ago and the orthopod sent her in after doing an XR in the office that showed prosthetic dislocation. I do all my usual pre-sedation assessment, get everything ready, yada yada. All my back up stuff in the room, ortho talks rads into rolling a c-arm down from the OR and we're ready. I push about 50-75mg prop and the lady starts having these really intense, rhythmic myoclonic jerking over her entire body. Facial muscles, arms, legs, torso, diaphragm. I can tell from the ETCO2 monitor that it's actually impairing her ability to take a deep breath. The entire facial muscles were also involved. Each rhythmic contraction was about 2 per second and it lasted a full 2 minutes. I pried one of her eyes open and there wasn't any gaze deviation and it didn't appear to resemble any traditional seizure activity. I immediately cancelled the procedure and told the orthopods that I was sorry but she was having atypical myoclonic activity that I wasn't sure if it was d/t the propofol or some other neurologic syndrome and recommended a full anesthesia consult and reduction in a more controlled setting (OR) and that she would probably need general anesthesia. I didn't want to risk pushing more prop and having a more sustained reaction especially given the respiratory compromise. I never had to bag her.

I actually had an anesthesiologist patient last night and ran the case by him and he said he had heard of it before but never experienced it but had colleagues who had. I tried doing a pubmed search and get scattered case reports. It seems like a rare reaction. It was my first time encountering it. Weird.

DEFINE_ME

https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/pdf/10.1111/j.1365-2044.2009.06035.x

Never seen it. Also never seen an orthopedist do a procedure in my ER, but I work in a small community shop. As soon as you mentioned getting a c arm, I knew I was going to have a hard time personally relating to whatever came next.

 

[Radetzky]

Not uncommon to get seizure like movements that last 10-15 seconds, especially when giving lower doses. Prolonged myoclonus I haven’t seen but apparently reported in the literature.

 

[GassYous]

Way more common with etomidate. I have seen it at least twice with propofol but it was at the end of the case. Patient started shivering and making weird movements after I went down on the prop drip. I think it is from being "light". I would either lighten or deepen the anesthesia. With only 50-75 I would probably have given some more and proceeded with the case. No long term effects afaik

I think what you did was totally reasonable

 

[Janders]

I’ve seen in more than once w/ etomidate (and I’ve nearly stopped using etomidate for non-RSI sedation).

Only once was it truly impressive, young guy with a wide complex tach and mild hypotension (turns out to be an RV-originated VT, once EP ablated it). Late evening, not much going on in the hospital, the nursing supervisor brings a gaggle of nursing students to watch the show. Patient thinks this is awesome.

Give him a smack of etomidate before we cardiovert him. He goes out. Makes a couple twitches. I say something about “ah yes, a common side effect you can see with etomidate is myo…” and he has what looks remarkably like a GTC seizure, but squinting I can sorta tell this is just extreme myoclonus.

One nursing student literally screams.
One loudly announces she’s calling a code blue.
One eager student rapidly moves to bedside, apparently to perform chest compressions.

It takes all of my charisma and charming ice-veined-calm to restore order without resorting to violence. Anyway I convince everyone just to standby and watch the myoclonus, which lasted a solid 30-40s, before it he ceased moving enough for the lifepak to properly read his rhythm again and for me to feel comfortable cardioverting him.

He woke up and admitted feeling like he just got a solid workout at the gym.

… actually regaling ya’ll with that story reminded me of ANOTHER similar event where the nursing supervisor brought 8 students to watch an RSI/Intubation, the RN gave the etomidate then for some reason couldn’t give the sux for another 45 seconds or so. No big deal, but the patient had some significant myoclonus as the etomidate hit her and the students reacted with utter pandemonium, literally screaming/crying/yelling/calling a code. While I’m up at the head of the bed calmly saying “uh, everyone, things are fine, the vitals are fine, uh… the patient has a pulse, I’m putting the tube in now. Yeah its easily in, um the pulse ox is 100% um… guys? Its ok! Guys…”

So now I sadly have to give the “no one is allowed to panic unless I panic” speech to groups of students.

 

[Groove]

I’ve seen in more than once w/ etomidate (and I’ve nearly stopped using etomidate for non-RSI sedation).

Only once was it truly impressive, young guy with a wide complex tach and mild hypotension (turns out to be an RV-originated VT, once EP ablated it). Late evening, not much going on in the hospital, the nursing supervisor brings a gaggle of nursing students to watch the show. Patient thinks this is awesome.

Give him a smack of etomidate before we cardiovert him. He goes out. Makes a couple twitches. I say something about “ah yes, a common side effect you can see with etomidate is myo…” and he has what looks remarkably like a GTC seizure, but squinting I can sorta tell this is just extreme myoclonus.

One nursing student literally screams.
One loudly announces she’s calling a code blue.
One eager student rapidly moves to bedside, apparently to perform chest compressions.

It takes all of my charisma and charming ice-veined-calm to restore order without resorting to violence. Anyway I convince everyone just to standby and watch the myoclonus, which lasted a solid 30-40s, before it he ceased moving enough for the lifepak to properly read his rhythm again and for me to feel comfortable cardioverting him.

He woke up and admitted feeling like he just got a solid workout at the gym.

… actually regaling ya’ll with that story reminded me of ANOTHER similar event where the nursing supervisor brought 8 students to watch an RSI/Intubation, the RN gave the etomidate then for some reason couldn’t give the sux for another 45 seconds or so. No big deal, but the patient had some significant myoclonus as the etomidate hit her and the students reacted with utter pandemonium, literally screaming/crying/yelling/calling a code. While I’m up at the head of the bed calmly saying “uh, everyone, things are fine, the vitals are fine, uh… the patient has a pulse, I’m putting the tube in now. Yeah its easily in, um the pulse ox is 100% um… guys? Its ok! Guys…”

So now I sadly have to give the “no one is allowed to panic unless I panic” speech to groups of students.

@Janders those were great stories 👍🏻 😂

 

[coffeebythelake]

Yeah it happens especially if you don't give lidocaine or fentanyl beforehand.

Also.. you sure you are doing moderate sedation / conscious sedation? That dose as a bolus probably get you into deep+ sedation territory.

 

[Groove]

Yeah it happens especially if you don't give lidocaine or fentanyl beforehand.

Also.. you sure you are doing moderate sedation / conscious sedation? That dose as a bolus probably get you into deep+ sedation territory.

Most of my moderate sedations start out with 50mg bolus, followed by ~20mg aliquots slowly titrated for effect. I pull up 2 sticks of 100mg. I try to go easy on the old ladies but some of the young guys can absolutely soak that stuff up. It's not uncommon for me to have to use 150mg for the young, healthy basketball players with shoulder dislocations. Most of what we probably do in the ED you guys would technically consider more of a deep sedation and it's not necessarily poor technique/training or anything, we just need really good muscle relaxation to get some of these joints back in and they have to be pretty out for that to happen.

I've never used lidocaine or fentanyl prior to propofol sedation. I usually don't want any respiratory compromise compounded with the propofol and I'm not really worried about analgesia because once they are out and the shoulder is back in, the pain is going to be fixed for the most part. What's the use of lidocaine? I just did a search and seems like there are some newer articles showing reduced propofol needed for sedation? NM, I just found the article where it showed decreased myoclonus in etomidate sedation. I suppose that's why you guys use it. I can't seem to find much on propofol induced myoclonus + lidocaine but I assume it would have the same improvement. I probably never see etomidate myoclonus because I only use it during intubation and as soon as I give it, it's shortly followed by a paralytic most of the time. I may start incorporating lidocaine into my moderate sedations though for the decreased incidence of myoclonus. Thanks for the tip.

 

[GassYous]

Lido helps get them a little deeper and if you mix it with the prop it helps with the burn.

 

[BoardingDoc]

I've never used lidocaine or fentanyl prior to propofol sedation.

I almost always use fent with prop. It synergizes well and decreases the amount of prop you need to use.

My general move is 50mcg fent (100 if they're in tons of pain or are 100+kg) followed by ~0.5mg/kg prop. Half the people I treat are good to go at that level. The rest need another small prop bolus. They also tend to wake up faster when they get the combo as the total amount of prop they get is lower.

 

[DrOwnage]

Also.. you sure you are doing moderate sedation / conscious sedation? That dose as a bolus probably get you into deep+ sedation territory

Agreed. Usually 50-70mg is what we give as an initial bolus to get someone to tolerate an EGD scope going down their throat without moving much, which is deep sedation. This is given you actually wait the 60-90 seconds or so for maximal prop effect.

 

[Rendar5]

Saw this for the first time in my 10year career yesterday on a hip reduction. anaesthesia was actually doing a deep sedation for us. As soon as it happened, they just bolused more and it instantly resolved.

 

[Radetzky]

Most of my moderate sedations start out with 50mg bolus, followed by ~20mg aliquots slowly titrated for effect. I pull up 2 sticks of 100mg. I try to go easy on the old ladies but some of the young guys can absolutely soak that stuff up. It's not uncommon for me to have to use 150mg for the young, healthy basketball players with shoulder dislocations. Most of what we probably do in the ED you guys would technically consider more of a deep sedation and it's not necessarily poor technique/training or anything, we just need really good muscle relaxation to get some of these joints back in and they have to be pretty out for that to happen.

I've never used lidocaine or fentanyl prior to propofol sedation. I usually don't want any respiratory compromise compounded with the propofol and I'm not really worried about analgesia because once they are out and the shoulder is back in, the pain is going to be fixed for the most part. What's the use of lidocaine? I just did a search and seems like there are some newer articles showing reduced propofol needed for sedation? NM, I just found the article where it showed decreased myoclonus in etomidate sedation. I suppose that's why you guys use it. I can't seem to find much on propofol induced myoclonus + lidocaine but I assume it would have the same improvement. I probably never see etomidate myoclonus because I only use it during intubation and as soon as I give it, it's shortly followed by a paralytic most of the time. I may start incorporating lidocaine into my moderate sedations though for the decreased incidence of myoclonus. Thanks for the tip.

Combining opiates and propofol helps enhance the muscle relaxation that you need for those relocations. Propofol itself is poor at reducing muscle tone relative to its degree of sedation

 

[CoolDoc1729]

Most of my moderate sedations start out with 50mg bolus, followed by ~20mg aliquots slowly titrated for effect. I pull up 2 sticks of 100mg. I try to go easy on the old ladies but some of the young guys can absolutely soak that stuff up. It's not uncommon for me to have to use 150mg for the young, healthy basketball players with shoulder dislocations. Most of what we probably do in the ED you guys would technically consider more of a deep sedation and it's not necessarily poor technique/training or anything, we just need really good muscle relaxation to get some of these joints back in and they have to be pretty out for that to happen.

I've never used lidocaine or fentanyl prior to propofol sedation. I usually don't want any respiratory compromise compounded with the propofol and I'm not really worried about analgesia because once they are out and the shoulder is back in, the pain is going to be fixed for the most part. What's the use of lidocaine? I just did a search and seems like there are some newer articles showing reduced propofol needed for sedation? NM, I just found the article where it showed decreased myoclonus in etomidate sedation. I suppose that's why you guys use it. I can't seem to find much on propofol induced myoclonus + lidocaine but I assume it would have the same improvement. I probably never see etomidate myoclonus because I only use it during intubation and as soon as I give it, it's shortly followed by a paralytic most of the time. I may start incorporating lidocaine into my moderate sedations though for the decreased incidence of myoclonus. Thanks for the tip.

Prop 50 bolus plus additional doses of 20 is exactly what I typically do as well, most commonly for hip dislocations or ankle reductions where really solid muscle relaxation is needed for several minutes .. for quick procedures like a shoulder I use etomidate bolus 10-18mg based on size and age. I feel like the people are still just moderately sedated, maybe because we jump right into the very painful procedure ..

 

[Groove]

I almost always use fent with prop. It synergizes well and decreases the amount of prop you need to use.

My general move is 50mcg fent (100 if they're in tons of pain or are 100+kg) followed by ~0.5mg/kg prop. Half the people I treat are good to go at that level. The rest need another small prop bolus. They also tend to wake up faster when they get the combo as the total amount of prop they get is lower.

Propofol alone titrated to deep sedation versus propofol in combination with opioids and/or benzodiazepines and titrated to moderate sedation for colonoscopy - PubMed

Propofol in combination with fentanyl and/or midazolam can be titrated to moderate levels of sedation without substantial loss of satisfaction and with shorter recovery times compared with propofol titrated to deep sedation throughout the procedure.

pubmed.ncbi.nlm.nih.gov

Interesting. Exactly the opposite effect of what I would have anticipated. I might start trying this...

 

[CoolDoc1729]

Propofol alone titrated to deep sedation versus propofol in combination with opioids and/or benzodiazepines and titrated to moderate sedation for colonoscopy - PubMed

Propofol in combination with fentanyl and/or midazolam can be titrated to moderate levels of sedation without substantial loss of satisfaction and with shorter recovery times compared with propofol titrated to deep sedation throughout the procedure.

pubmed.ncbi.nlm.nih.gov

Interesting. Exactly the opposite effect of what I would have anticipated. I might start trying this...

I appreciate feedback/ideas on sedation. I think this is one of the most nuanced things we do as emergency physicians. I have learned propofol kind of on the fly .. I started residency right after MJ died so we were not allowed to use it (our institutional policy was for only anesthesia to use propofol .. for my entire training). I love this idea to hopefully reduce the need for boluses at the end of the procedure.. thank you.