Abstract
A 67-year old male underwent uneventful robotic-assisted thoracoscopic resection of a solitary pulmonary fibrous tumor. Immediately following extubation at the completion of the surgical procedure, the patient developed respiratory distress that did not resolve with treatment. Benadryl provided only temporary relief. Midazolam and hydromorphone were given for anxiolysis and analgesia respectively, which provided transient relief of symptoms. Propofol was given to decrease upper airway reflexes. Adequate reversal from nondepolarizing neuromuscular blockade was confirmed with nerve stimulator. A flexible laryngoscope was introduced nasally to visualize the vocal cords, which revealed intermittent tremulousness of the vocal cords, adduction of bilateral vocal cords to the midline, and minimal to absent opening with inspiration, without any apparent injury or blood, saliva, or vomit noted in or around the glottic opening. The patient was then given diazepam and reintubated. Given the patient’s history of difficulty breathing after previous surgery and the lack of vocal cord movement, dystonic reaction to propofol was suspected. The patient remained intubated for two hours in the post-anesthesia care unit before being extubated uneventfully.
1
Introduction
Propofol is the most commonly used anesthetic induction agent. At present, there have been a limited number of described cases of propofol-related seizure-like and/or dystonic reactions . Dystonic reactions have most frequently been reported as jerky movements of the extremities or opisthotonos . Despite numerous case reports, no clear consensus regarding the neurogenic origin and therapeutic strategy for these adverse reactions has been reached. This report describes a case of vocal fold dystonia, observed as postoperative stridor. Given the widespread use of propofol, this treatable and potentially life-threatening medication reaction should be considered when assessing any patient with postoperative stridor and abnormal vocal fold motion in a patient who has been given propofol. It is important to review cases such as this to determine an appropriate therapeutic treatment plan, as well as to identify potential strategies to prevent further adverse outcomes.
2
Materials and methods
2.1
Initial case presentation
A 67-year old 85-kilogram man underwent an uneventful thoracoscopic robotic assisted left upper lobe wedge resection of a solitary fibrous tumor under general anesthesia. The patient’s medical history included well-controlled hypertension, coronary artery disease (status post drug-eluting stent placement), chronic atrial fibrillation, and a chronic left basal ganglia lacunar infarct. The patient denied drug allergies, although he did describe an episode of “difficulty breathing” after a previous inguinal hernia surgery under sedation using propofol that resolved with an unknown “reversal agent”. During this thoracic procedure the patient was intubated atraumatically with a 39Fr double lumen endotracheal tube for the duration of the five-hour operation. On indirect video laryngoscopy, the pharmacologically paralyzed vocal cords appeared without any visible pathology.
Immediately after extubation, the patient developed respiratory distress and stridor that did not resolve with jaw thrust and continuous positive airway pressure, the standard treatments for suspected laryngospasm. Midazolam 3 mg and hydromorphone 0.4 mg were given for anxiolysis and analgesia respectively, which provided transient relief of symptoms. Propofol 20 mg was given to decrease upper airway reflexes. Adequate reversal from nondepolarizing neuromuscular blockade was confirmed with nerve stimulator. The patient’s preoperative calcium level was within normal limits. The patient’s oropharynx had been thoroughly suctioned prior to extubation and he was alert, oriented, and following commands as we attempted our various interventions. A flexible laryngoscope was introduced nasally to visualize the vocal cords, which revealed intermittent tremulousness of the vocal cords, adduction of bilateral vocal cords to the midline, and minimal to absent opening with inspiration, without any apparent injury or blood, saliva, or vomit noted in or around the glottic opening.
2
Materials and methods
2.1
Initial case presentation
A 67-year old 85-kilogram man underwent an uneventful thoracoscopic robotic assisted left upper lobe wedge resection of a solitary fibrous tumor under general anesthesia. The patient’s medical history included well-controlled hypertension, coronary artery disease (status post drug-eluting stent placement), chronic atrial fibrillation, and a chronic left basal ganglia lacunar infarct. The patient denied drug allergies, although he did describe an episode of “difficulty breathing” after a previous inguinal hernia surgery under sedation using propofol that resolved with an unknown “reversal agent”. During this thoracic procedure the patient was intubated atraumatically with a 39Fr double lumen endotracheal tube for the duration of the five-hour operation. On indirect video laryngoscopy, the pharmacologically paralyzed vocal cords appeared without any visible pathology.
Immediately after extubation, the patient developed respiratory distress and stridor that did not resolve with jaw thrust and continuous positive airway pressure, the standard treatments for suspected laryngospasm. Midazolam 3 mg and hydromorphone 0.4 mg were given for anxiolysis and analgesia respectively, which provided transient relief of symptoms. Propofol 20 mg was given to decrease upper airway reflexes. Adequate reversal from nondepolarizing neuromuscular blockade was confirmed with nerve stimulator. The patient’s preoperative calcium level was within normal limits. The patient’s oropharynx had been thoroughly suctioned prior to extubation and he was alert, oriented, and following commands as we attempted our various interventions. A flexible laryngoscope was introduced nasally to visualize the vocal cords, which revealed intermittent tremulousness of the vocal cords, adduction of bilateral vocal cords to the midline, and minimal to absent opening with inspiration, without any apparent injury or blood, saliva, or vomit noted in or around the glottic opening.
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