Eyelid opening apraxia refers to a specific inability to open the eyelids. This may result from non-dominant hemispheric strokes. On superficial examination it will mimic unconsciousness, but upon further examination the patient is awake and able to respond to stimuli with their extremities.
I've seen a similar phenomenon of eyelid opening apraxia a few times following discontinuation of propofol sedation among intubated patients. Essentially, patients wake up from propofol but their ability to open their eyes lags behind the rest of their neurological normalization. Over time this will spontaneously resolve.
Unfortunately, post-propofol eyelid apraxia is often misinterpreted in various ways:
- Patients may appear agitated, because they are disconcerted by being unable to open their eyes (as well as the endotracheal tube, of course). This could be misinterpreted as being “too agitated to be extubated” – leading to re-sedation and continuation of mechanical ventilation.
- Failure to “wake up” promptly off propofol may be interpreted as evidence of a severe brain injury (leading to CT scans, neurological consultations, etc.).
Thus, failure to recognize this phenomenon leads to incorrect management. However, if you can recognize it correctly this is really neat, because you can reassure the patient that they are fine and within ~20 minutes they will recover and can be extubated.
After searching a while in the medical literature, I finally found a report of this phenomenon. It seems to have been lost in the sands of time, but I think this is describing the same phenomenon that I'm seeing: (2297098)
So the next time you're having trouble with a patient emerging from propofol sedation, ask them to follow commands with their extremities. Maybe you will discover this. Maybe not. But I believe that it's out there. I'd be super interested to see if other folks have encountered this as well.
Opening image: Photo by Ryoji Iwata on Unsplash
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Thank you your interesting presentation “isolated inability of opening eyelid” for propofol is thought it can be at some cases and at least 20 minutes to be waited without doing any examination
excellent, Josh. thank you.
tom fiero, merced
I am a patient and had a routine colonoscopy today, with propofol used for sedation. After the procedure I was unable to open my eyelids for upwards of a half hour. Stimulating them, via massage, was what finally made them open. My doctors and nurses were baffled and said they had never seen this happen before. I googled what happened and found your article.
Awesome to see this! Had a stroke ACA/MCA stroke patient who was intubated for bradycardia during ICA stenting. She was able to follow commands and when i lifted her eyelids she looked at me and grabbed at my badge with her functioning hands.
I was totally baffled at the discrepancy. We did end up resedating her and the next day on the SAT she does great.
Isolated handgrip research on anesthesia induction has surprising rates of ability to continue responding with hand-grip squeezes after intubation. In this technique a BP cuff is used to keep neuromuscular blockers out of the studied arm. Patients almost always close their eyes with propofol inductions, but could this occasionally represent an isolated drug effect and not true loss of consciousness? I’ve had many patients on emergence who won’t open their eyes, but have no hesitation to purposefully move all extremities.
https://pubs.asahq.org/anesthesiology/article/126/2/214/18656/Incidence-of-Connected-Consciousness-after