Emergence delirium after propofol anaesthesia

Abstract

Dear Editor: Propofol is a commonly used anaesthetic agent. Recent findings suggest that low-dose propofol sedation reduces the risk of delirium in the elderly [1]. In children, emergence agitation was reported [2], even with convulsions, ataxia and hallucinations [3]. In addition to the rare complication of a propofol infusion syndrome, sexual hallucinations [4, 5], epileptic seizures and seizure-like phenomena [6, 7] were reported. We report a severe delirious and aggressive state during emergence after propofol anaesthesia. A 20-year-old female patient (175 cm, 75 kg) was passed to a gastroenterological service for nausea and vomiting. She had been suffering from Crohn’s disease, continuously treated with prednisolone 5 mg and azathioprine 150 mg for 3 years, adalimumab (TNF-α antagonist) for 3 months and pantoprazole and tropisetron for 2 weeks. The past medical history was negative for drug abuse, alcohol or nicotine abuse, metabolic diseases, allergic reactions or treatment with psychiatric drugs. EEG was normal and there was no history of epilepsy or neurological disorder in the patient or among her relatives. Cranial and abdominal MRI were regular. She had already undergone two gastroscopies under propofol anaesthesia without adverse effects. Anaesthesia was prepared with propofol (1%, 100 mg bolus, 180 mg continuously over 15 min). Sedation was delayed with minimal restlessness. Continuous monitoring showed no relevant hypotonia or hypoxia. During waking, restlessness increased, but the patient was not responsive, and her eyes were closed. She did not recognise her mother, who was present during the gastroscopy, and refused body contact by beating, scratching, biting and crying not to touch her. Here agitation increased and bed rails had to be attached. The patient received prednisolone 125 mg for a coughing fit and midazolam 2 mg for sedation, but without improvement. An epileptic seizure was deemed unlikely due to the intentioned and coordinated movement pattern and the lack of response to midazolam. Finally, after 25 min she received haloperidol 5 mg, which caused a decline of the agitation and aggression within a few minutes, followed by 1 h of sleep. After waking, she was fully orientated and reported dreamless sleep for the period of anaesthesia and complete amnesia regarding the delirious state. Muscle or bone pain or muscle rigidity did not appear. The patient was observed on the normal ward until the following day. Reports of severe or prolonged agitation are sparse [8]; other findings represent the adverse effects of sexual hallucinations or seizure-like phenomena (SLP). The latter is characterised by uncoordinated and tonic–clonic muscle movements [6, 7], opisthotonus and athetoid neck and limb movements [9]. Signs of SLP or grand mal epilepsy did not occur in our patient; rather, she showed intentional, coordinated movements, a purposeful defence reaction and anxiety, whilst being unresponsive. Complete amnesia and a dreamless sleep suggest the absence of sexual hallucinations [4, 5], despite there probably being delusions and anxiety. The sudden decline of all symptoms after haloperidol medication supports the diagnosis of delirium. It has to be discussed whether the new medication was responsible for the incident. Adalimumab may cause mood U. Palm (*) :M. Lieb Department of Psychiatry and Psychotherapy, Ludwig-Maximilian University, Nussbaumstrasse 7, 80336 Munich, Germany e-mail: ulrich.palm@med.uni-muenchen.de