Sevoflurane
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Seizure-like activity: case report A 29-year-old man developed seizure-like activity while receiving sevoflurane for anaesthesia. The man was obese, had a cousin with epilepsy and a history of minor concussion 5 years previously. He presented for elective left inguinal hernia repair. Anaesthesia was induced with propofol and fentanyl. A laryngeal mask airway was placed and ventilation was assisted with sevoflurane in oxygen until spontaneous respiration resumed. Anaesthesia was maintained with sevoflurane, in an end-tidal concentration of 1.8–2.6% with a minimum alveolar concentration (MAC) of 0.9–1.3, in an air-oxygen mixture. He received morphine for postoperative analgesia. After 3 hours, the procedure was completed and sevoflurane was discontinued. As he began to emerge from anaesthesia, with an end-tidal sevoflurane concentration of about 0.8% and MAC of 0.4, he developed generalised tonic-clonic seizure-like activity. He had symmetrical tonic-clonic movements of all extremities with a duration of about 30 seconds. He did not have purposeful movement or respond to verbal commands or painful stimuli. The man received IV propofol and his seizure activity stopped immediately. His sevoflurane concentration was increased briefly, and ventilation was assisted with the laryngeal mask airway and 100% oxygen until spontaneous respiration resumed. Sevoflurane was discontinued and emergence occurred, but generalised seizure-like activity recurred at a similar end-tidal concentration. He also had jaw and chest rigidity, and tachycardia. Progressively, manual ventilation became more difficult. He received IV midazolam and his seizure-like activity subsided. He received IV succinylcholine and propofol. His laryngeal mask airway was removed and an endotracheal tube was placed. He received ventilation with 100% oxygen and was moved to the surgical ICU. During transportation, he had another tonic-clonic episode and, upon arrival, two more episodes of seizure-like activity. He received IV boluses of midazolam, a propofol infusion, and a phenytoin loading dose followed by maintenance therapy. Arterial blood gas analysis revealed respiratory acidosis and hypercarbia, with a pH of 7.20 and PaCO2 of 64mm Hg. With intermittent mandatory ventilation, the values normalised. He had no further seizure-like activity. Propofol was stopped and, the following morning, he was weaned from ventilation. After extubation, he showed normal neurological and mental status and had no recollection of the perioperative events. On postoperative day 2, he was discharged receiving oral phenytoin. After 6 weeks, a cranial MRI scan was normal, and phenytoin was discontinued. He had an uneventful recovery. Mohanram A, et al. Repetitive generalized seizure-like activity during emergence from sevoflurane anesthesia. Canadian Journal of Anesthesia 54: 657-661, No. 8, 801091197 Aug 2007 - USA
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Reactions 25 Aug 2007 No. 1166
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