Abstract
Most drug-induced extrapyramidal symptoms are due to blockade of dopaminergic receptors and are treated with anticholinergic drugs. We report a patient with severe postoperative extrapyramidal symptoms which responded to physostigmine and indicated a different aetiology. A young, healthy female outpatient developed severe extrapyramidal symptoms after an uneventful 50 min anaesthetic with thiopentone, fentanyl (100 μg), enflurane, and nitrous oxide. Although the trachea was not extubated until she obeyed commands, the patient developed opisthotonus, which resolved initially after treatment with thiopentone (40 mg), diazepam (5 mg), and diphenhydramine (50 mg). The opisthotonus recurred approximately 25 min later, in association with torticollis, obtundation, and periodic apnoea. A tentative diagnosis of central anticholinergic syndrome was proposed, and fentanyl was considered to have been responsible. Naloxone (0.4 mg) induced no improvement, but physostigmine (2 mg) reversed the dystonic symptoms and periodic apnoea and improved her mental status. The response to physostigmine may have been due specifically to increased levels of acetylcholine at the cholinergic receptors, or to a nonspecific analeptic effect.
Résumé
La plupart des symptômes extrapyramidaux reliés à l’usage de médicaments sont causés par un blocage des récepteurs dopaminergiques et répondent bien aux anticholinergiques. Nous avons observé en postopératoire desmanifestations extrapyramidales répondant à l’usage de physostigmine, ce qui trahit une étiologie différente. Suite à une anesthésie de 50 minutes au thiopental, fentanyl (100 μg), enflurane et protoxyde d’azote et la détubation de la trachée après retour de la conscience, une jeune femme présenta un opisthotonos. Quarante mg de thiopental, 5 mg de diazépam et 50 mg de diphenhydramine parvinrent à contrer l’opisthotonos qui réapparu 25 minutes plus tard associé cette fois à un torticolis, de la stupeur et des pauses respiratoires. Avec un diagnostic présomptif de syndrome anticholinergique central attribuable au fentanyl, on essaya sans résultat 0,4 mg de naloxone. Deux mg de physostigmine suffirent à faire disparaître la dystonie et les pauses respiratoires et à améliorer l’état de conscience de la patiente. Cette réponse à la physostigmine peut être attribuable à une augmentation la quantité d’acétylcholine sur les récepteurs cholinergiques ou à un effet analeptique non-spécifique.
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Dehring, D.J., Gupta, B. & Peruzzi, W.T. Postoperative opisthotonus and torticollis after fentanyl, enfiurane, and nitrous oxide. Can J Anaesth 38, 919–925 (1991). https://doi.org/10.1007/BF03036975
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DOI: https://doi.org/10.1007/BF03036975