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Dystonia and parkinsonism: case report A 35-year-old woman experienced generalised dystonia with features of parkinsonism after she received fentanyl and morphine; her response to naloxone pointed to the causative role of these two agents. The woman, who 3 months earlier had experienced a 2-hour, spontaneously resolving episode of abnormal movements upon emergence from general anaesthesia after receiving alfentanil, propofol, oxytocin, ketorolac and paracetamol [acetaminophen], was scheduled to undergo diagnostic hysterectomy, intrauterine contraceptive device implantation and laparoscopic myomectomy. She received fentanyl 150µg along with propofol, lidocaine and rocuronium bromide for anaesthesia induction, and fentanyl 200µg as bolus doses, sevoflurane and rocuronium bromide for anaesthesia maintenance; she also received perioperative ketorolac. Following a 2-hour uneventful procedure, she developed severe painful dystonia involving all four limbs upon emergence from anaesthesia, with 1- to 2-minute ongoing episodes every 5 minutes. Her pain was treated with morphine 2mg and paracetamol, but the severity of her abnormal movements worsened with the development of hypomimia with abolished blink rate, hypophonia, diffuse rigidity and severe bradykinesia, and she became distressed and tachycardic. Dystonic movements in her hands persisted, but parkinsonism signs predominated. The woman was treated with clonidine and midazolam, but her dystonia did not improve. Two hours after symptom onset, she was treated with IV naloxone, and her dystonic movements immediately and completely resolved. Four hours later, the woman received three carefully titrated doses of fentanyl 25µg, paracetamol and ketorolac for pain. Her dystonic symptoms did not recur, and she was discharged without symptoms the following day. Subsequent genetic studies identified polymorphisms of her glycoprotein-P and catechol-O-methyltransferase genes that were consistent with increased susceptibility to opioid effects and toxicity. Author comment: "Altogether, the genetic constellation demonstrated in this patient and the dramatic response to naloxone strongly support a key role of opioids at the basis of the acute movement disorders reported here, and reasonably rule out a causal or contributing effect of the propofol and sevoflurane that she also received." Iselin-Chaves IA, et al. Naloxone-responsive acute dystonia and parkinsonism following general anaesthesia. Anaesthesia 64: 1359-1362, No. 12, Dec 2009 801156527 Switzerland

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Reactions 16 Jan 2010 No. 1284