Acute Dystonia-Induced Airway Compromise During Emergence from Anaesthesia: Implications of Propofol and Ondansetron Administration to  Patients with Previous Neuroexcitatory Phenomena

Acute dystonic reactions have been reported during emergence from anaesthesia following the use of propofol or/and ondansetron. We present a 37-year-old lady who developed recurrent and severe involuntary movements and abnormal postures in the upper body during emergence from anaesthesia following propofol and ondansetron, given as part of a general anaesthetic for a gynaecological procedure. Reactions were recurrent and severe with associated spells of severe desaturation. Abnormal movements were reported previously following metoclopramide (IV). Acute dystonic reactions with associated laryngeal dystonia were suspected in the context of clinical findings and by exclusion of others. The frequency and severity of reactions were reduced following benztropine (IM) and midazolam (IV). They were completely controlled following the second dose of benztropine, which was given two hours after the first dose. Oxygenation and ventilation were maintained with gentle bag/mask ventilation during the spells of desaturation. As reported in the literature, Propofol and/or ondansetron are the most likely causative agent(s) alone or in combination. She made an uneventful recovery. Evidence for dystonic reactions following propofol and ondansetron is limited, hence likely to be underdiagnosed and treated empirically with disastrous outcomes. We alert the anaesthetists and intensivists to use propofol and ondansetron with caution in patients who reported previous neuroexcitatory phenomena.