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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 3  |  Issue : 2  |  Page : 115-117

A case of cardiac arrest during insertion of an epidural needle and before the administration of any epidural medication


Department of Anaesthesiology, PIMS, Puducherry, Tamil Nadu, India

Date of Submission29-Aug-2017
Date of Acceptance14-Oct-2017
Date of Web Publication8-Jan-2018

Correspondence Address:
Ramyavel Thangavelu
No. 3C, Sarathy Enclave, 2 ND Cross, Rajaji Nagar, Puducherry
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrsm.jcrsm_50_17

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  Abstract 

Cardiac arrest following regional anesthesia is a relatively common and often a grave complication. A number of cases have been reported in literary sciences. Here, we report a case of 28-year-old young adult female posted for femur nailing surgery who sustained a cardiac arrest on insertion of epidural needle even before epidural catheter could be secured or any epidural medication was administered. Fortunately, she was successfully resuscitated with timely and appropriate cardiopulmonary resuscitative efforts. Here, we consider excess vagal activity associated with excess anxiety to be the probable cause of syncope and hypoxia leading to tachyarrhythmia and finally culminating to cardiac arrest. The present case report would probably allow us to explore the possible causes of such an unusual and possibly an avoidable event. Careful preoperative assessment of patient anxiety level, reassurance, good sedative premedication, alternate positioning for regional technique, and finally close monitoring and prompt intervention would definitely improve outcomes.

Keywords: Cardiac arrest, epidural, hypoxia, sedative premedication, tachyarrhythmia


How to cite this article:
Thangavelu R, Bacthavassalame AT, Venkatesh RR, George SK. A case of cardiac arrest during insertion of an epidural needle and before the administration of any epidural medication. J Curr Res Sci Med 2017;3:115-7

How to cite this URL:
Thangavelu R, Bacthavassalame AT, Venkatesh RR, George SK. A case of cardiac arrest during insertion of an epidural needle and before the administration of any epidural medication. J Curr Res Sci Med [serial online] 2017 [cited 2018 Jul 19];3:115-7. Available from: http://www.jcrsmed.org/text.asp?2017/3/2/115/222420


  Introduction Top


Cardiac arrest during epidural anesthesia has been attributed to local anesthetic overdose or sympathetic blockade causing autonomic imbalance.[1] In the literature, the reported incidence of cardiac arrest following epidural anesthesia is 0.01%.[2] In almost all of these cases, cardiac arrest occurred after administration of epidural/regional local anesthetic or in the immediate recovery period.[3] However, cardiac arrest due to psychogenic causes/vasovagal collapse due to fear and anxiety on attempting regional anesthesia has rarely been described.[4] Vasovagal syncope has been associated with a 6% mortality rate.[5] Here, we report a patient who experienced cardiac arrest due to probable vasovagal syncope due to excess anxiety that occurred during insertion of an epidural needle.


  Case Report Top


A 28-year-old female patient (weight 75 kg, height 155 cm) was posted for closed reduction and Intramedullary interlocking (IMIL) nailing of fracture shaft of femur electively. There was a history of road traffic accident 1 day back while riding pillion on a bike. There were no injuries elsewhere. Her medical history had no known comorbidities. Examination findings and investigations were normal. The patient received tablet ranitidine and lorazepam the night and morning of surgery as premedication. Combined spinal–epidural anesthesia was selected ideal for this patient. Benefits/risks of regional anesthesia over general anesthesia were explained to the patient, and written informed consent was obtained. On arrival in the theater, monitors were connected and routine monitoring was started. Eighteen-gauge intravenous cannula was established and fluid preload given. Baseline parameters revealed a value of 128/80 mmHg of blood pressure (BP), a heart rate (HR) of 89/min, and a SpO2 of 100%. However, as we started the process of positioning the patient for epidural, she started becoming nervous and HR rose up to 100/min. Then, 1 mg of midazolam was given intravenously, and the patient positioned in sitting position with head bent. After cleaning and draping, L3–L4 space was identified and local infiltration was done with 2 ml of 2% lignocaine. Epidural needle was then inserted into the space and advanced gently to identify the epidural space. At this point, the patient suddenly became unresponsive with uprolling of eyes and a short generalized myoclonic movement and collapsed. She was positioned supine, and electrocardiogram (ECG) tracing revealed a wide complex tachycardia with a fall in oxygen saturation to 68%. noninvasive BP (NIBP) was unrecordable. However, carotid pulse was present and feeble. A bolus dose of 12 mg injection ephedrine was given and fluids rushed. The patient was gasping with irregular shallow breaths. Bag and mask ventilation with 100% oxygen was started. The patient was then intubated. By now, the carotid pulse was no longer palpable, and ECG tracing continued to show wide complex tachycardia more in favor of a polymorphic ventricular tachycardia (VT) with no proper SpO2 tracing. Cardiopulmonary resuscitation was initiated. Meanwhile charging the defibrillator, injection adrenaline 1 mg intravenous was given. Once defibrillator was charged, prompt defibrillation was attempted with a 200-Joules biphasic shock. Cardiopulmonary resuscitation (CPR) was resumed promptly after delivery of shock. The rhythm reverted to normal sinus rhythm with ST depression and a tachycardia of around 170/min. CPR was discontinued. NIBP recorded a BP of 186/102 mmHg. Carotid pulse was now palpable. ST depression gradually diminished with HR coming down to 140/min and a BP of 150/100 mmHg. SpO2 by now was 96% with 100% oxygen. Arterial blood gas and electrolytes were sent. Cardiologist was consulted, and an on-table echo revealed global hypokinesia with no arterial thrombus, evidence of embolus, or any other valvular abnormality. Blood sample was sent for cardiac enzymes. A 12-lead ECG was taken which showed sinus tachycardia with ST depression. Spontaneous respirations had resumed with irregular shallow breaths. To facilitate good ventilation, the patient was paralyzed with injection vecuronium 6 mg intravenously. Injection Lasix 20 mg slow intravenous was given with titration. Clinical status of the patient was explained to the bystanders, and the patient was shifted to the intensive care unit (ICU) where she was started on antibiotics. The patient resumed good respiratory efforts the immediate next day, but the sensorium assessment revealed constant low Glasgow Coma Scale scores and so extubation was deferred. Review echo showed mild hypokinesia with an ejection fraction of approximately 45%. Routine blood investigations and blood gas were repeated at frequent intervals and were found to be normal. A magnetic resonance imaging brain was planned to look for any foci of infarct which showed a normal study. By the 2nd day, her sensorium had improved. The patient was put on continuous positive airway pressure mode of ventilation, and after it showed a good expired tidal volume and a normal blood gas, the patient was extubated on the 2nd day. Subsequently 1 day later, she was reposted for femur nailing surgery. Adequate anxiolytic premedication was given in the preoperative period. General anesthesia with endotracheal intubation and opioid analgesia were chosen as the anesthesia of choice this time. The 3-h surgical procedure was completed uneventfully. The patient was extubated and shifted to ward.


  Discussion Top


Cardiac arrest fatalities during regional anesthesia are actually surprisingly common.[2],[3] Some of the theories put forward explaining arrest following regional anesthesia are pacemaker stretch reflex, low-pressure baroreceptor reflex, and Bezold–Jarisch reflex.[6] However, in our case, cardiac arrest occurred even before administering any medication epidurally. Hence, above-mentioned theories do not seem to offer any plausible etiology. Vasovagal collapse with loss of peripheral vascular tone seems to partially explain the course of events in our case. We believe that extreme anxiety, pain, and fear associated with the needle prick might be the reason for vasovagal activity causing arrest. However, this vasovagal presentation is unique in our case since cardiac arrest manifested with wide complex tachycardia culminating to pulseless VT instead of more common bradycardia and asystole (associated with vagal activity). A brief period of hypoxia at the time of collapse would probably have precipitated the tachyarrhythmia. A report published by Sprung et al.[7] revealed a case of cardiac arrest during the insertion of an epidural catheter. There was a short period of asystole in this case which reverted immediately with medication, and they went ahead with the planned surgery in the same setting. In our case, even though the rhythm reverted with defibrillation, complete return to normal sensorium and respiration took 2 days in the ICU before the patient could be extubated safely.

Any triggering event such as pain and anxiety can cause a transient catecholamine surge that causes activation of the C fibers in the myocardium inducing bradycardia and vasodilation.[6],[8] In addition, positioning the patient in upright sitting posture seems to have its own contribution in vasovagal bradycardia/asystole due to decrease in venous return.[9]

At present, some of the drugs proposed for the prevention of neurocardiogenic syncope are beta-blockers, anticholinergics, and Selective serotonin reuptake inhibitors (SSRIs).[10] Attention to proper preoperative assessment to identify patients with increased anxiety or previous any episodes should be elicited. In addition, neuraxial blockade in such situations should be attempted in recumbent position (left/right lateral). Adequate and generous local anesthesia before attempting neuraxial blockade should be considered with sedation. Finally, if these do not suffice, one should not hesitate in choosing general anesthesia with more liberal sedative and anticholinergic premedication as the sole choice of anesthesia.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Liguori GA, Sharrock NE. Asystole and severe bradycardia during epidural anesthesia in orthopedic patients. Anesthesiology 1997;86:250-7.  Back to cited text no. 1
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2.
Pollard JB. Cardiac arrest during spinal anesthesia: Common mechanisms and strategies for prevention. Anesth Analg 2001;92:252-6.  Back to cited text no. 2
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3.
Sostaric S, Xoremur K. Sudden cardiorespiratory arrest following spinal anesthesia. Periodicum Biologrum 2013;115:283-8.  Back to cited text no. 3
    
4.
Frerichs RL, Campbell J, Bassell GM. Psychogenic cardiac arrest during extensive sympathetic blockade. Anesthesiology 1988;68:943-4.  Back to cited text no. 4
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5.
Wolfe DA, Grubb BP, Kimmel SR. Head-upright tilt test: A new method of evaluating syncope. Am Fam Physician 1993;47:149-59.  Back to cited text no. 5
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6.
Mark AL. The bezold-jarisch reflex revisited: Clinical implications of inhibitory reflexes originating in the heart. J Am Coll Cardiol 1983;1:90-102.  Back to cited text no. 6
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7.
Sprung J, Abdelmalak B, Schoenwald PK. Vasovagal cardiac arrest during the insertion of an epidural catheter and before the administration of epidural medication. Anesth Analg 1998;86:1263-5.  Back to cited text no. 7
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8.
Maloney JD, Jaeger FJ, Fouad-Tarazi FM, Morris HH. Malignant vasovagal syncope: Prolonged asystole provoked by head-up tilt. Case report and review of diagnosis, pathophysiology, and therapy. Cleve Clin J Med 1988;55:542-8.  Back to cited text no. 8
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9.
Caplan RA, Ward RJ, Posner K, Cheney FW. Unexpected cardiac arrest during spinal anesthesia: A closed claims analysis of predisposing factors. Anesthesiology 1988;68:5-11.  Back to cited text no. 9
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10.
Lazarus JC, Mauro VF. Syncope: Pathophysiology, diagnosis, and pharmacotherapy. Ann Pharmacother 1996;30:994-1005.  Back to cited text no. 10
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