Paradoxical Reaction to Hypnotics in Intensive Care Unit

Area of Science:

• Intensive Care Medicine
• Neuropharmacology
• Anesthesiology

Background:

• Paradoxical reactions (PR) to benzodiazepines are documented.
• PR following propofol sedation is less common, typically observed in operating room anesthesia.
• This report details a rare instance of PR to both midazolam and propofol.

Observation:

• A 78-year-old patient with multiorgan failure experienced severe restlessness, muscle spasms, and stiffness during intensive care unit (ICU) stay.
• These symptoms persisted despite treatment for ventilator-acquired pneumonia and acute kidney failure.
• No clear neurological cause was identified for the patient's agitation.

Findings:

• A diagnosis of paradoxical reaction to both midazolam and propofol was made.
• The patient exhibited difficult withdrawal from these sedatives.
• Favorable clinical progression was observed following the diagnosis and management adjustment.

Implications:

• Paradoxical reactions in the ICU setting are exceptionally rare.
• This case is unique due to severe PR to both midazolam and propofol.
• Clinicians should consider paradoxical reactions as a cause of refractory agitation in the ICU after excluding other etiologies.