Why so Rigid? A Case of Wooden Chest Syndrome During a Routine TEE
Jose Barrientos, MD, George Eigbire, MD, Eduardo Venegas, MD, Syed Saad, MD, Brian Allen, MD, Mehnaz Rahman, MD, Neeraj Jain, MD, FACC
Background: Opiates used in procedural sedation are associated with several well-known complications. We describe a rare case of fentanyl-induced chest wall rigidity syndrome during transesophageal echocardiography (TEE). Case: A 60-year-old male with hypertension and diabetes presented for an elective TEE to assess for cardiac embolic source pursuant to stroke. He has no known drug allergies or adverse reactions to sedation. The patient was in his usual state of health on the day of the procedure. Routine moderate sedation with 2 mg of intravenous midazolam and 100 mcg of fentanyl was administered. He required dose escalation of both agents to achieve adequate conscious sedation. The TEE probe was advanced incrementally and immediately retracted as an unusual amount of resistance was encountered. To offset this resistance, additional sedation was administered at this time for a cumulative dose of midazolam 4 mg and fentanyl 200 mcg. The patient’s oxygen saturation was noted or rapidly decline by pulse oximetry. Attempts to manually ventilate the patient were hampered by a tense jaw. His chest and abdomen were also found to be rigid. His blood pressure and heart rate remained within normal limits during the interim as reversal agents for the sedative agents were procured. The patient was given naloxone 0.4 mg and flumazenil 1mg with near instantaneous improvement in rigidity and allowed for bag-valve mask ventilation. Oxygen saturations improved and intubation was unnecessary. The patient returned to his baseline mentation post procedure. A repeat TEE was later performed with propofol sedation and went without complication. Discussion: Fentanyl as an extremely potent analgesic can result in dose-dependent respiratory depression, hypoxia and death. Less commonly, fentanyl and its analogs can rapidly induce vocal cord closure (laryngospasm) and severe rigidity of the chest wall and diaphragm despite using doses well within the therapeutic range. This phenomenon of fentanyl-induced respiratory muscle rigidity (FIRMR) and laryngospasm is clinically known as wooden chest syndrome (WCS). It occurs within 2 minutes after injection and lasts for about 8 to 15 minutes. It is managed with intravenous muscle paralytics (e.g., succinylcholine), naloxone and is often followed by endotracheal intubation. WCS with fentanyl or its analogs is very rare. Although this occurrence is possible at any dose, a more rapid onset and severe rigidity correlates with higher doses. Of note, future fentanyl repeat challenge is possible. Conclusion: WCS is a rare complication that occurs within minutes of fentanyl administration characterized by sudden respiratory failure. It can be treated promptly with naloxone, paralytics and mechanical intubation depending on its severity. WCS should be a recognized adverse effect by cardiovascular specialists.
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