the differential diagnosis of dystonia includes : adverse drug reaction , local anesthetic reaction , emergence delirium , hysterical response , and shivering . summaries of case reports of dystonic reactions following propofol or ondansetron have been published . however , to our knowledge , there has been no case report of a patient demonstrating delayed dystonic movements after general anesthesia occurring only when falling asleep , with no additional symptoms and the patient being totally unaware of the movements . a 10-year - old , 35 kg , american society of anesthesiologists physical status i girl was scheduled for outpatient foot surgery . after premedication with midazolam 10 mg per oral , an uneventful induction of anesthesia was performed with sevoflurane , followed by placement of an intravenous ( iv ) line . propofol 30 mg and alfentanil 0.125 mg were given to facilitate the placement of a laryngeal mask airway ( lma ) . iv medications administered during the 60 minute procedure included : fentanyl 0.01 mg , morphine 4 mg , ketorolac 15 mg and dexamethasone 4 mg . at the completion of surgery , the patient was transported to the post anesthesia care unit ( pacu ) , where she recovered quickly . after about 45 minutes in the pacu , the patient was returned to the same day surgery unit where she received acetaminophen with codeine for pain control . approximately two hours after emergence from anesthesia , the patient complained of nausea and ondansetron 3 mg was administered iv . approximately 30 minutes later she started having jerking movements of her arms and torso every time she would drift off to sleep . initially the movements lasted for several seconds but during the course of the day these movements developed into shaking , seizure - like movements of her upper body and head lasting several minutes . diphenhydramine 25 mg iv was given as an attempt to treat a dystonic reaction but did not result in any improvement . the symptoms persisted at home ( video 1 - provided by the patient 's parents and oral and written consent to publish pictorial content of the procedure was obtained ) . over the next four days the symptoms the differential diagnoses of postoperative dystonic movements include adverse drug reaction , local anesthetic reaction , emergence delirium , hysterical response , and shivering . the diagnosis of hysterical response is unlikely although a psychogenic reaction could not absolutely be ruled out . most of the reported cases of abnormal movements induced by propofol , the phenomena occurred during induction , emergence or shortly thereafter , while the patients were awake and fully aware of the involuntary movements . in some of these cases there was the appearance that the patients were non - responsive when in all reality the patient was able to hear and see the world around them . there have also been reports describing delayed onset of propofol induced neuro - excitatory symptoms starting more than 60 minutes after emergence from anesthesia . islander and vinge reported 5 out of 44 cases and saravanakumar reported 6 out of 12 cases of postoperative dystonic movements with delayed onset of symptoms ( 85 min to 44 hours after emergence ) . our patient had received 30 mg of propofol during induction and the time from propofol injection to dystonic reaction was more than 3 hours . seizures are highly unlikely because the symptoms immediately subsided when awakening the patient and there were no postictal symptoms . the patient was never diagnosed with seizures , however , this diagnosis can not entirely be ruled out . the onset of symptoms after ondansetron has been reported to start in close proximity to the administration of the drug . in our case these movements include jerky movements of the head , neck , torso , and limbs , similar the movements in our patient . however , unlike in the previously described cases , our patient was not aware of the dystonic movements that only occurred after falling asleep . rhythmic movement disorder ( rmd ) is classified as a sleep - wake transition disorder according to the international classification of sleep disorders ( icsd ) . rmd is seen most frequently in infants and usually will disappear by four or five years of age , with a few cases presenting later in childhood and rarely in adulthood . using the flow chart shown in figure 1 , other movement disorders including dystonia , which occurs primarily during wakefulness , can be ruled out . modified after walters , a. flow chart for the differential diagnosis of sleep - related movement disorders.(complex : movements seem goal directed , purposeful . rmd : rhythmic movement disorder ) the movements most commonly seen with rmd include head banging , head rolling , body rocking and body rolling , exactly like the movements in our patients ( video 1 ) . the origin and cause of these movements is not yet known though it has been shown that this phenomenon is relatively benign . if they occur , they can be very disturbing and threatening for the patient , their families as well as their healthcare providers . because of the nature of the movements observed in our patient , we believe to present the first case of sleep - related rmd after general anesthesia .
dystonic movements after general anesthesia are very rare . 
 the differential diagnosis includes adverse drug reaction , local anesthetic reaction , emergence delirium , hysterical response , and shivering . 
 we present a case of a 10-year - old , otherwise healthy girl undergoing outpatient foot surgery . 
 involuntary jerking movements of her arms and torso every time she would drift off to sleep started about 2.5 hours after emergence from general anesthesia . 
 the patient was easily arousable and absolutely unaware of the movements . 
 these movements lasted for several days before they resolved completely . 
 we believe to present the first case of sleep - related rhythmic movement disorder after general anesthesia , considering the nature of the movements in our patient .