Spinal anesthesia in a patient with congenital complete atrioventricular block

Congenital complete atrioventricular block is a rare cardiac conduction abnormality that predisposes to arrhythmias and cardiac arrest. Recommendations for the anesthetic management of patients with this condition are based on the few case reports that have been published. We describe the successful use of spinal anesthesia for ankle osteosynthesis in a patient with asymptomatic congenital complete atrioventricular block detected during preoperative assessment.     

A case report of aortic stenosis complicated with complete atrioventricular block

A case of aortic stenosis complicated with complete atrioventricular block preoperatively was reported. The patient was a 73-year-old woman who had been suffering from dyspnea and fatigability. Preoperative echocardiography revealed severe left ventricular hypertrophy, marked left ventricular-aortic pressure gradient (144 mmHg), and the impairment of left ventricular distensibility. Therefore, DDD pacemaker was implanted in addition to aortic valve replacement. Postoperative cardiac catheterization revealed that cardiac output was increased about 25% by DDD pacing compared with VVI pacing. It is more reasonable to employ DDD pacemaker to the case of which distensibility is impaired.     

Intermittent complete left bundle branch block during general anesthesia

We report a case of intermittent complete left bundle branch block (CLBBB) which occurred during general anesthesia. An 83-year-old female was scheduled for upper lobectomy of the right lung under general anesthesia. Her preoperative 12-lead ECG showed atrial fibrillation and ST-depression in V4-6. Anesthesia was induced with propofol and pentazocine, and maintained with 0.5-1.5% isoflurane, 0-50% nitrous oxide in oxygen under close monitoring and appropriate respiratory management. The operation was performed uneventfully. Several minutes after the end of surgery, on converting her into the supine position from the left lateral decubitus position, widened QRS complexes, later diagnosed as CLBBB, appeared on ECG. At that time, heart rate was 92 beats x min(-1). After the administration of esmolol hydrochloride, heart rate decreased rapidly in a few minutes and ECG returned to normal conduction from CLBBB. We diagnosed this as rate-dependent intermittent CLBBB. Although intermittent CLBBB continued until the next day, the patient was asymptomatic and cardiac enzymes were within normal ranges. The intermittent CLBBB, which occasionally occurs during anesthesia, makes the diagnosis of myocardial ischemia and acute myocardial infarction difficult. The present case suggests that esmolol can be used effectively and safely to distinguish CLBBB as a benign disorder from myocardial ischemia in a patient with CLBBB.     

Complete atrioventricular block during anesthesia

PURPOSE: To describe a case of asymptomatic first degree atrioventricular block with a bifascicular block that progressed to complete atrioventricular block during anesthesia. This potentially fatal block was successfully treated with transesophageal ventricular pacing. CLINICAL FEATURES: A 67-yr-old man was scheduled for microvascular decompression of the right trigeminal nerve under general anesthesia. His preoperative ECG showed first degree atrioventricular block with complete right bundle branch block and left anterior hemiblock, but he had experienced no cardiovascular symptoms. Anesthesia was induced with sevoflurane 5%, and maintained with isoflurane 1.5-2% in oxygen. Fifteen minutes later in the left lateral decubitus position, the systolic arterial blood pressure suddenly decreased from 80 mmHg to 0 mmHg. Then, the ECG abruptly changed from sinus rhythm to complete atrioventricular block. The heart was unresponsive to drug therapy such as atropine 1.3 mg and isoproterenol 0.5 mg, or transcutaneous pacing but transesophageal pacing was successful. CONCLUSION: Asymptomatic first degree atrioventricular block with bifascicular block advanced to complete atrioventricular block during anesthesia. The block was successfully managed with transesophageal pacing.     

Sudden cardiac arrest after induction of general anesthesia: a case report

We experienced sudden cardiac arrest after induction of general anesthesia using isoflurane. The patient had had paroxysmal atrial fibrillation for one year and had been treated with digoxin and cibenzoline succinate. Sinus rhythm appeared soon after the start of closed chest compression. However cardiac arrest recurred, and we inserted a temporary pacemaker catheter to stabilize the circulatory status. She awoke from anesthesia without any complications. The diagnosis of sick sinus syndrome (SSS) was made postoperatively and she had a permanent pacemaker implanted. We thought that the hidden SSS had been the cause of this sudden cardiac arrest.     

A case of tension pneumothorax after general anesthesia

A 72-year-old male patient was scheduled for extirpation of the right kidney and ureter with partial resection of the bladder. Anesthesia was maintained with general and epidural anesthesia. After the end of surgery, he awoke and his spontaneous ventilation seemed to be good. Soon after extubation, he developed cyanosis and circulatory arrest. Immediately cardiopulmonary resuscitation was performed and regular beating of the heart was restored about 6 minutes after cardiac arrest. A chest x-ray showed pneumothorax on right side and he was diagnosed as tension pneumothorax caused by injury of the right diaphragmatic pleura during surgery. Pneumothorax was improved by drainage of the right thoracic cavity, and he was transferred to the intensive care unit. After 4 days of hypothermic therapy, he showed no neurological deficit and recurrence of pneumothorax was not observed. We should be aware of the occurrence of pneumothorax during perioperative period in the patients who underwent surgical procedure in the vicinity of the diaphragm.     

Predictors of hypotension after induction of general anesthesia

Hypotension after induction of general anesthesia is a common event. In the current investigation, we sought to identify the predictors of clinically significant hypotension after the induction of general anesthesia. Computerized anesthesia records of 4096 patients undergoing general anesthesia were queried for arterial blood pressure (BP), demographic information, preoperative drug history, and anesthetic induction regimen. The median BP was determined preinduction and for 0-5 and 5-10 min postinduction of anesthesia. Hypotension was defined as either: mean arterial blood pressure (MAP) decrease of >40% and MAP <70 mm Hg or MAP <60 mm Hg. Overall, 9% of patients experienced severe hypotension 0-10 min postinduction of general anesthesia. Hypotension was more prevalent in the second half of the 0-10 min interval after anesthetic induction (P < 0.001). In 2406 patients with retrievable outcome data, prolonged postoperative stay and/or death was more common in patients with versus those without postinduction hypotension (13.3% and 8.6%, respectively, multivariate P < 0.02). Statistically significant multivariate predictors of hypotension 0-10 min after anesthetic induction included: ASA III-V, baseline MAP <70 mm Hg, age > or =50 yr, the use of propofol for induction of anesthesia, and increasing induction dosage of fentanyl. Smaller doses of propofol, etomidate, and thiopental were not associated with less hypotension. To avoid severe hypotension, alternatives to propofol anesthetic induction (e.g., etomidate) should be considered in patients older than 50 yr of age with ASA physical status > or =3. We conclude that it is advisable to avoid propofol induction in patients who present with baseline MAP <70 mm Hg.     

Ondansetron given before induction of anesthesia reduces shivering after general anesthesia

The neurotransmitter pathways involved in the mechanism of postanesthetic shivering (PAS) are poorly understood. Meperidine, clonidine, and physostigmine are all effective treatments, indicating that opioid, alpha(2)-adrenergic, and anticholinergic systems are probably involved. We investigated the effect of ondansetron, a 5-HT(3) antagonist used to treat postoperative nausea and vomiting, on intraoperative core and peripheral temperatures and PAS. Eighty-two patients (age, 18-60 yr) undergoing orthopedic, general, or urological surgery were randomized into three groups in this double-blinded, placebo-controlled, study: Group O4 (n = 27) received ondansetron 4 mg IV, Group O8 (n = 27) received ondansetron 8 mg IV, and Group C (n = 28) received saline IV immediately before the anesthetic induction. Core (tympanic) and fingertip temperature (dorsum of middle finger) were recorded. Anesthesia was induced with IV fentanyl 1 microg/kg and propofol 2.0-2.5 mg/kg and maintained with 1 minimum alveolar anesthetic concentration isoflurane in 70% nitrous oxide/oxygen. The occurrence of shivering was documented clinically during recovery by nursing staff, who were unaware of the group assignment. PAS occurred in 16 of 28 (57%) patients in Group C, compared with 9 of 27 (33%) in Group O4 (P = 0.13) and 4 of 27 (15%) patients in Group O8 (P = 0.003). Within each group, core temperature decreased and peripheral temperature increased significantly, but there were no significant differences among the groups at any time interval. We conclude that ondansetron 8 mg IV given during the induction of anesthesia prevents PAS without affecting the core-to-peripheral redistribution of heat during general anesthesia. This suggests that serotonergic pathways have a role in the regulation of PAS. Implications: In a randomized, double-blinded, placebo-controlled, clinical study, ondansetron 8 mg IV, given just before the induction, reduced the incidence of postanesthetic shivering compared with saline. The anticipated core-to-peripheral redistribution of body temperature during general anesthesia was not affected. This implies that ondansetron probably acts by a central inhibitory mechanism, and that 5-hydroxytryptaminergic pathways have a role in regulating postanesthetic shivering.     

Lateral trans-biceps popliteal block for elective foot and ankle surgery performed after induction of general anesthesia

BACKGROUND: The purpose of this study was to determine safety and efficacy of lateral transtendinous popliteal blocks performed after induction of general anesthesia for intraoperative and postoperative pain control in elective foot and ankle surgery. METHODS: The charts of 475 consecutive patients were retrospectively reviewed. The technique was a lateral transtendinous popliteal block under nerve stimulator direction (described in the text). Patient records were retrospectively evaluated from the postanesthesia care unit, as well as at followup on postoperative day 1 and weeks 2, 6, and 12. RESULTS: The block was complete in 398 patients (83.7%). An incomplete block was found in 77 patients (16.2 %). In the incomplete category, 21 patients (4.4%) had no pain but some motor function, 32 patients (6.5%) reported mild to moderate pain, and 24 patients (5.3%) had severe pain. The average block duration was 16.5 hours. There were no adverse effects documented in any patient at followup. CONCLUSIONS: Lateral popliteal nerve block after induction of general anesthesia appears to be safe and effective for intraoperative and postoperative pain control in elective foot and ankle surgery.     

Case of Takotsubo cardiomyopathy after induction of general anesthesia

Takotsubo cardiomyopathy is a cardiac syndrome characterized by transient left ventricular dysfunction. A 79-year-old woman was scheduled for posterior lumbar interbody fusion for spinal compression fracture. After induction of general anesthesia, her blood pressure collapsed with significant ST rise in I, aVL, V3-V5. Emergent transthoracic echocardiography revealed excessive contraction of the base and severe hypokinesis of the apex suggesting Takotsubo cardiomyopathy. Chronic hypovolemia and electrolyte disorder due to habitual glycerin enema were considered to be causes of this sudden cardiac collapse.     

Transient complete atrioventricular block during renal transplantation

A 25-year-old female underwent renal transplantation. The patient had no complication preoperatively except hypertension. Preoperative electrocardiogram revealed no abnormality. Anesthesia was maintained with sevoflurane. Donor kidney was perfused with University of Wisconsin (UW)'s solution (4 degrees C) after removal. Transient complete atrioventricular block appeared twice after reperfusion of the transplanted kidney. Adenosine in the UW's solution was considered the major cause of atrioventricular block in this patient. Attention must be paid to the occurrence of atrioventricular block and bradycardia shortly after reperfusion in the case where UW's solution was used for donor kidney perfusion.