Transient paralysis after administration of a single dose of cyclizine

Abstract

SummaryTwo patients with underlying neuromuscular disorders developed varying degrees of paralysis after a single dose of cyclizine, one necessitating full mechanical ventilation. These cases appear to be unique in the literature and represent an increasing spectrum of adverse reactions seen with the greater use of cyclizine. Recently, there have been case reports [1,2] implicating cyclizine in probable dystonic reactions. The withdrawal of droperidol has been cited as a reason for the resurgence in popularity of cyclizine. Clinicians need to be aware that extra-pyramidal reactions can occur following administration of this drug, and that these symptoms need to be recognised and treated promptly. We present two patients who received correctly administered doses of cyclizine diluted in 10 ml water and given slowly intravenously. Both cases resulted in profound muscle weakness. Case 1A 19-year-old girl, weighing 24 kg, with Russell-Silver syndrome [3] and scoliosis underwent elective posterior instrumentation of the spine between T3 and L1. She was anaesthetised by total intravenous anaesthesia with propofol and remifentanil infusions and her lungs were ventilated with an air-oxygen mixture. No relaxant was used. Surgery was uneventful and she returned to the critical care unit for elective postoperative ventilation and was later extubated. Following this, she received PCA morphine for pain relief, set to deliver 0.5 mg boluses with a 5 min lockout. She became fluid overloaded on the second postoperative day, which was managed with fluid restriction and a small dose (1 mg) of furosemide, with a good response. She developed nausea and was treated initially with intravenous ondansetron 3 mg followed 30 min later by intravenous metoclopramide 3 mg with good effect. The same two drugs were repeated 12 h later in identical dosages but spaced apart by 2 h. This time they were ineffective and consequently 2 h later, she was given intravenous cyclizine 15 mg. Ten minutes later, she developed what appeared to be a flaccid paralysis of all her limbs, with loss of reflexes and an up-going gaze. She was unresponsive to oral commands. This spontaneously resolved over the next 10 min. She continued to breath effectively during the period of hypotonia. Blood was taken for serum tryptase assay to exclude a type 3 hypersensitivity reaction, but this subsequently was reported as normal. A yellow card was sent to the Committee on Safety of Medicines (CSM), reporting a suspected adverse drug reaction. Case 2A fit 19-year-old, Anglo-Indian male undergoing squint surgery lasting 1 h had an uneventful spontaneously breathing anaesthetic using a laryngeal mask airway for airway control. He received glycopyrronium, propofol and fentanyl at induction and anaesthesia was maintained with isoflurane in an oxygen and nitrous oxide gas mixture. During the procedure, intravenous ketorolac 15 mg was administered. At the end of surgery, the surgeon performed a retro-ocular nerve block with 0.25% levo-bupivacaine 3 ml. In recovery, following an epi...

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“…dose. After originally postulating that patients with central nervous system disease may be at higher risk for these dystonic reactions [58,59,60], there have also been reports of otherwise healthy patients also experiencing dystonic reactions associated with cyclizine use (at 50 mg i.v.) [61,62].…”

Transient paralysis after cyclizine administration

“…Transient respiratory paralysis has previously been reported in an anaesthetised patient and in two patients with known neuromuscular disorders , but we believe this to be the only reported case of transient respiratory paralysis in an otherwise healthy patient recovering from surgery.…”

“…In two patients, BIS values increased during seizures [1], but it decreased in three others [2][3][4]. High-voltage lowfrequency EEG waves are well associated with epileptic activity [5], and have been previously reported during BIS-monitored seizures [2][3][4].…”

Transient paralysis after administration of cyclizine

“…We write in response to the report of two patients with neuromuscular disorders who developed paralysis after cyclizine [1]. We have a similar case to report, but our patient had no known neuromuscular disorder.…”

“…The patients described in Sandhu et al. 's report [1] were both having operations associated with muscle problems – scoliosis and squint surgery. The second patient was also found to have Hirschsprung's disease and a pseudocholinesterase deficiency.…”