Central Journal of ISA

Open Access Open Access  Restricted Access Subscription Access

Interscalene Block-Potential for Cardiac Arrest


Affiliations
1 (DA, DNB), Consultant Anaesthesiologist, Sanjeevani Hospital, India
2 (DA, MD), Consultant Anaesthesiologist, Sanjeevani Hospital, India
 

A 52 year Hypertensive female with normal examination and routine investigations including ECG for upper end humerus surgery was given PNS guided interscalene block supplemented with superficial cervical plexus block. After 20 min, due to inadequate block action, routine general anaesthesia was supplemented. At 25 min post induction of GA, just when surgery was to be started, there was sudden unresponsive hypotension with bradycardia culminating in asystole. CPCR started according to ACLS led to ill sustained ROSC followed by pulse less Ventricular tachycardia twice which reverted with prompt defibrillation. We achieved ROSC with sinus tachycardia, RBBB and ST elevation in lateral leads. Inj nikoran dil and enoxaparin were started empirically for ischemic event. After 1 hr of the event ECG done at ICU admission showed normal sinus rhythm with no ischemic changes. Serum electrolytes, ABG, 2D Echocardiography revealed no abnormality. She was extubated fully awake with no neuro deficits. Coronary angiography showed minor block amenable to medical management. She took discharge after 2 days and was subsequently lost to follow up.

Keywords

Cardiac Arrest, Interscalene Block.
User
Notifications
Font Size

  • Nunnally ME, O’Connor MF, Kordylewski H, Westlake B, Dutton RP. The incidence and risk factors for perioperative cardiac arrest observed in the national anesthesia clinical outcomes registry. Anesth. Analg. 2015; 120(2):364-70. PMID:25390278.

  • Jagadeesan J, Kannan R, Dujon D. Ventricular standstill: a complication of intrapleural anesthesia using bupivacaine in a patient with free transverse rectus abdominus myocutaneous flap breast reconstruction. Ann. Plast. Surg. 2007; 59:445-6.

  • Levsky ME, Miller MA. Cardiovascular collapse from low dose bupivacaine. Can. J. Clin. Pharmacol. 2005; 12:e240−e5.

  • Di Gregorio G, Neal JM, Rosenquist RW, Weinberg GL. Clinical presentation of local anesthetic systemic toxicity: A review of published cases, 1979 to 2009. Reg. Anesth. Pain. Med. 2010; 35(2):181-7.

  • Gupta A, Hsu G, Steinberg D. Cardiac arrest during shoulder arthroscopy under interscalene nerve block and general anesthesia in the beach chair position [abstract]. Reg. Anesth. Pain. Med. 2012.

  • Song SY, Roh WS. Hypotensive bradycardic events during shoulder arthroscopic surgery under interscalene brachial plexus blocks. Korean J. Anesthesiol. 2012; 62(3):209-19.

  • Bishop JY, Sprague M, Gelber J, Krol M, Rosenblatt MA, Gladstone J, et al. Interscalene regional anesthesia for shoulder surgery. J. Bone Joint Surg. Am. 2005; 87:974-9.

  • Brull R, McCartney CJL, Sawyer RJ, von Schroeder HP. The indications and applications of interscalene brachial plexus block for surgery about the shoulder. Acute Pain. 2004; 6:57-77.

  • Fredrickson MJ, Ball CM, Dalgleish AJ. Analgesic effectiveness of a continuous versus single-injection interscalene block for minor arthroscopic shoulder surgery. Reg. Anesth. Pain Med. 2010; 35:28-33.

  • D’Alessio JG, Weller RS, Rosenblum M. Activation of the bezoldjarisch reflex in the sitting position for shoulder arthroscopy using interscalene block. Anesth. Analg. 1995; 80:1158-62.

  • Liguori GA, Kahn RL, Gordon J, Gordon MA, Urban MK. The use of metoprolol and glycopyrrolate to prevent hypotensive/bradycardic events during shoulder arthroscopy in the sitting position under interscalene block. Anesth. Analg. 1998; 87:1320-25.

  • Seo KC, Park JS, Roh WS. Factors contributing to episodes of bradycardia hypotension during shoulder arthroscopic surgery in the sitting position after interscalene block. Korean J. Anesthesiol. 2010; 58:38-44.

  • Vester-Andersen T, Christiansen C, Hansen A, Sorensen M, Meisler C. Interscalene brachial plexus block: Area of analgesia, complications and blood concentrations of local anesthestics. Acta. Anaesthesiol Scand. 1981; 25:81-4.

  • D’Alessio JG, Rosenblum M, Shea KP, Freitas DG. A retrospective Comparison of interscalene block and general anesthesia for ambulatory surgery shoulder arthroscopy. Reg. Anesth. 1995; 20:62-8.

  • Kahn RL, Hargett MJ. Beta-adrenergic blockers and vasovagal episodes during shoulder surgery in the sitting position under interscalene block. Anesth. Analg. 1999; 88:378-81.

  • Campagna JA, Carter C. Clinical relevance of the Bezold-Jarisch reflex. Anesthesiology. 2003; 98(5):1250-60.

  • Hemmings HC Jr, Egan TD. Pharmacology and Physiology for Anesthesia: Foundations and Clinical Application. Philadelphia, PA: Elsevier Saunders; 2013.

  • Hasanein R, El-Sayed W. The effect of ondansetron in preventing the hypotensive bradycardic events during shoulder arthroscopy done under interscalene block in the sitting position. Egypt J. Anaesth. 2014; 30(3):305-10.

  • Liguori GA, Kahn RL, Gordon MA, Urban MK. Mechanisms of hypotension and bradycardia during regional anesthesia in the sitting position. Anesthesiology. 2004; 100(1):191-2.

  • Campagna JA, Carter C. In reply [letter]. Anesthesiology. 2004; 100(1):192-3.

  • Prinzmetal MKR, Merliss R, Wada T, Bor N: Angina pectoris. A variant form of angina pectoris. Am. J. Med. 1959; 27:375-88.

  • Sidi A, ET AL: Coronary vasospasm during anesthesia induction: Awarenss, recognition, possible mechanisms, anesthestic factors, and treatment. J. Clin. Anesth. 2008; 20:64-9.

  • Inazumi T, Shimizu H, Mine T, Iwasaki T: Changes in autonomic nervous activity prior to spontaneous coronary spasm in patients with variant angina. Jpn. Circ. J. 2000; 64:197-201.

  • Cohen DJ, Foley RW, Ryan JM: Intraoperative coronary artery spasm successfully treated with nitroglycerin and nifedipine. Ann. Thorac. Surg. 1983; 36:97-100.

  • Song SY, Son SH, Kim SO, Roh WS. Intravenous fentanyl during shoulder arthroscopic surgery in the sitting position after interscalene block increases the incidence of episodes of bradycardia hypotension. Korean J. Anesthesiol. 2011; 60:344-50.

  • D’Alessio JG, Weller RS, Rosenblum M. Activation of the bezold-jarisch reflex in the sitting position for shoulder arthroscopy using interscalene block. Anesth. Analg. 1995; 80:1158-62. [PubMed].

  • Sia S, Sarro F, Lepri A, Bartoli M. The effect of exogenous epinephrine on the incidence of hypotensive/bradycardic events during shoulder surgery in the sitting position during interscalene block. Anesth. Analg. 2003; 97:583-8. [PubMed].

  • Seo KC, Park JS, Roh WS. Factors contributing to episodes of bradycardia hypotension during shoulder arthroscopic surgery in the sitting position after interscalene block. Korean J. Anesthesiol. 2010; 58(1):38-44.

  • Kwak HJ, Lee JS, Lee DC, Kim HS, Kim JY. The effect of a sequential compression device on hemodynamics in arthroscopic shoulder surgery using beach-chair position. Arthroscopy. 2010; 26:729-33.

  • Kinsella SM, Tuckey JP. Perioperative bradycardia and asystole: Relationship to vasovagal syncope and the bezold-jarisch reflex. Br. J. Anaesth. 2001; 86:859-68. [PubMed].

  • Kahn R, Hargett M. Beta-adrenergic blockers and vasovagal episodes during shoulder surgery in the sitting position under interscalene block. Anesth. Analg. 1999; 88(2):378−81.

  • Eglen RM, Lee CH, Khabaz M, et al. Comparison of potencies of 5-HT3 receptor antagonists at inhibiting aversive behavior to illumination and the von Bezold-Jarisch reflex in the mouse. Neuropharmacology. 1994; 33(2):227-34.

  • Brown SGA. Clinical features and severity grading of anaphylaxis. J. Allergy Clin. Immunol. 2004; 114(2):371-6.

  • Panjo GB, Crisafulli J, Calminiti L, Marseglia GL, Cardinale F, Paravati F, Caffarelli C. Peri-operative allergy: Therapy. Int. J. Immunopath. Phar. 2011; 24(3):101-4.


Abstract Views: 415

PDF Views: 145




  • Interscalene Block-Potential for Cardiac Arrest

Abstract Views: 415  |  PDF Views: 145

Authors

Neha Mehta
(DA, DNB), Consultant Anaesthesiologist, Sanjeevani Hospital, India
Kalpesh Shah
(DA, MD), Consultant Anaesthesiologist, Sanjeevani Hospital, India

Abstract


A 52 year Hypertensive female with normal examination and routine investigations including ECG for upper end humerus surgery was given PNS guided interscalene block supplemented with superficial cervical plexus block. After 20 min, due to inadequate block action, routine general anaesthesia was supplemented. At 25 min post induction of GA, just when surgery was to be started, there was sudden unresponsive hypotension with bradycardia culminating in asystole. CPCR started according to ACLS led to ill sustained ROSC followed by pulse less Ventricular tachycardia twice which reverted with prompt defibrillation. We achieved ROSC with sinus tachycardia, RBBB and ST elevation in lateral leads. Inj nikoran dil and enoxaparin were started empirically for ischemic event. After 1 hr of the event ECG done at ICU admission showed normal sinus rhythm with no ischemic changes. Serum electrolytes, ABG, 2D Echocardiography revealed no abnormality. She was extubated fully awake with no neuro deficits. Coronary angiography showed minor block amenable to medical management. She took discharge after 2 days and was subsequently lost to follow up.

Keywords


Cardiac Arrest, Interscalene Block.

References