Midazolam, Spinal Anesthesia, and Myoclonic Jerks
Bibliographic record
Abstract
To the Editor: We report the case of a 78-yr-old man who presented for elective femorotibial bypass grafting surgery. The patient’s medical history included chronic obstructive pulmonary disease, coronary artery bypass grafting, and chronic renal failure requiring peritoneal dialysis. Routine blood tests were normal except for Na+ (131 mmol/L), K+ (3.4 mmol/L), urea (27.4 mmol/L), and creatinine (924 μmol/L). Midazolam (1 mg) was administered intravenously and lumbar spinal anesthesia performed using isobaric bupivacaine (17.5 mg), epinephrine (100 μg), and morphine (150 μg). Immediately thereafter, during the insertion of a catheter into the radial artery, the patient became agitated with involuntary, spasmodic movements of both arms (myoclonic jerks). While unresponsive to verbal commands, he was hemodynamically stable and breathing spontaneously (SaO2 96% with o2 delivered at 3 L/min through a face mask). Interpreted as a paradoxical response to midazolam, intravenous boluses of propofol were given resulting in upper airway obstruction necessitating endotracheal intubation (thiopental 200 mg, rocuronium 40 mg, fentanyl 100 μg). Anesthesia was maintained with desflurane and nitrous oxide. The surgery was uneventful. On emergence from anesthesia, the myoclonic jerks were observed again and the trachea remained intubated. In the recovery room, further examination of previous blood tests showed a low magnesium level of 0.52 mmol/L prompting the administration of 2 g magnesium over 15 min. The myoclonic jerks resolved and the trachea was extubated. The neurological examination on the next day was normal. We propose that the unusual occurrence of myoclonic jerks in this patient was a manifestation of metabolic encephalopathy (hypomagnesemia and chronic renal failure) combined with central sensory deafferentation from neuraxial blockade and midazolam. Marina Galeone, MD Bernhard Montreuil, MD John Stewart, MD Thomas Schricker, MD, PhD
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.001 | 0.008 |
| Meta-epidemiology (narrow) | 0.001 | 0.001 |
| Meta-epidemiology (broad) | 0.002 | 0.001 |
| Bibliometrics | 0.001 | 0.001 |
| Science and technology studies | 0.001 | 0.001 |
| Scholarly communication | 0.002 | 0.003 |
| Open science | 0.002 | 0.001 |
| Research integrity | 0.010 | 0.006 |
| Insufficient payload (model declined to judge) | 0.003 | 0.002 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".