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A 64-year-old woman with familial pulmonary fibrosis underwent bilateral lung transplantation under general anesthesia with midazolam, propofol, and fentanyl. Her post-transplant immunosuppression regimen consisted of prednisone, azathioprine, and tacrolimus. She was initially alert and following commands but on postoperative day 3 became increasingly somnolent, necessitating reintubation. Sodium, renal and liver function tests, and CSF analysis (including opening pressure) were normal. Noncontrast CT scan of the head was unrevealing with no early evidence of cerebral edema. EEG showed diffuse delta with frequent 1- to 2-Hz triphasic waves. Her somnolence was attributed to her tacrolimus level (66.8 ng/mL) and the medication was held with normalization of the level by postoperative day 4. On postoperative day 5, she had persistent arrhythmic twitching of her left arm that within a minute generalized to a full-blown convulsive status epilepticus. Multiple doses of Ativan, totaling 10 mg, and 20 mg/kg PE of …

Pearls & Oy-sters: Status epilepticus from hyperammonemia after lung transplant