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Canadian Journal of Anesthesia

, Volume 51, Issue 3, pp 226–230 | Cite as

Witnessed asystole during spinal anesthesia treated with atropine and ondansetron: a case report

  • Robert M. MartinekEmail author
Regional Anesthesia and Pain

Abstract

Purpose

To present a case of asystole during spinal anesthesia that responded to atropine and ondansetron and to discuss the possible pathophysiology with special emphasis on the Bezold-Jarisch reflex and the role of 5-HT3 receptors in mediating bradycardia and sympathoinhibition.

Clinical features

A 50-yr-old, 97-kg, healthy male presented for elective left high tibial osteotomy. Spinal anesthesia was induced uneventfully at L3–4 with 11.25 mg of hyperbaric 0.75% bupivacaine and morphine 0.25 mg. Thirteen minutes after induction, the incision site was infiltrated with 20 mL of 0.5% bupivacaine with epinephrine 5μg·mL−1 for intraoperative hemostasis, resulting in an increase in heart rate from 74 to 90 beats·min−1. Three minutes after infiltration of the incision site, the patient’s heart rate dropped to 48 beats·min−1, accompanied by a blood pressure of 107/51 mmHg, SpO2 97%, and a sinus bradycardia on the electrocardiogram. The electrocardiographic complexes suddenly disappeared with loss of the pulse oximeter waveform. Pre-drawn atropine 0.6 mgiv and ondansetron 4 mgiv were administered within seven seconds of the event. After an asystolic period of 30 to 40 sec, but before chest compressions were initiated, vital signs returned to normal with no other sequelae.

Conclusion

Exogenous epinephrine may have triggered the Bezold-Jarisch reflex and subsequent asystole. It is postulated that the combination of atropine and ondansetron may have played a key role in resuscitation by blocking the serotonergic and cholinergic receptors in the afferent and efferent limbs of this vagally-mediated reflex.

Keywords

Atropine Bupivacaine Ondansetron Granisetron Chest Compression 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Asystolie pendant la rachianesthésie traitée avec de l’atropine et de l’ondansétron: une étude de cas

Résumé

Objectif

Présenter un cas d’asystolie, survenue pendant la rachianesthésie, qui a réagit à l’atropine et à l’ondansétron, et discuter de la physiopathologie possible en insistant sur le réflexe Bezold-Jarisch et sur le rôle des récepteurs de 5-HT3 comme médiateurs de la bradycardie et de la sympatho-inhibition.

Éléments cliniques

Un homme de 50 ans, de 97 kg et en bonne santé, devait subir une ostéotomie tibiale gauche réglée. La rachi-anesthésie a été induite sans problème au niveau L3–4 avec 11,25 mg de bupivacaïne hyperbare à 0,75 % et 0,25 mg de morphine. Treize minutes après l’induction, le site de l’incision a été infiltré avec 20 mL de bupivacaïne à 0,5 % et de l’épinéphrine à raison de 5 μg·mL−1 pour l’hémostase peropératoire, ce qui a provoqué une élévation de la fréquence cardiaque de 74 à 90 battements·min−1. Trois minutes après l’infiltration, la fréquence cardiaque a chuté à 48 battements·min−1. On notait aussi une tension artérielle de 107/51 mmHg, une SpO2 à 97 % et une bradycardie sinusale à l’électrocar-diogramme. Les complexes électrocardiographiques ont disparu soudainement avec la perte des ondes à l’oxymètre de pouls. Les doses de 0,6 mg d’atropine iv et de 4 mg d’ondansétron iv ont été administrées en moins de sept secondes suivant l’incident. Après une période asystolique de 30 à 40 s, mais avant le début des compressions thoraciques, les signes vitaux sont revenus à la normale sans autre conséquence.

Conclusion

L’épinéphrine exogène a pu déclencher le réflexe de Bezold-Jarisch et l’asystolic subséquente. On croit que la combinaison d’atropine et d’ondansétron a pu jouer un rôle clé dans la réanimation en bloquant les récepteurs sérotoninergiques et cholinergiques des branches afférentes et efférentes de ce réflexe à médiation vagale.

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Copyright information

© Canadian Anesthesiologists 2004

Authors and Affiliations

  1. 1.Brantford General HospitalBrantfordCanada

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