“Kratschmer” Reflex During Rhinoplasty

Letters to the Editor

the introducer can be used multiple times, it is also cost-effective.

Lakshmi Jayaraman, DA, DNB Nitin Sethi, DNB Arvind Kumar, DOT Jayashree Sood, MD, FFARCS, PGDHHM Department of Anesthesiology Pain and Perioperative Medicine Sir Ganga Ram Hospital New Delhi, India [email protected]

REFERENCE 1. Phelan MP. Use of the endotracheal bou- Figure 4. gie introducer for difficult intubation. Nick in the gum elastic bougie. Am J Emerg Med 2004;22:479–82. DOI: 10.1213/01.ane.0000242645.97899.74 “Kratschmer” Reﬂex During Rhinoplasty

To the Editor: We report an unusual complica- tion following nasal packing after rhinoplasty to illustrate the existence and importance of the primitive “Kratschmer” reflex (1). Kratschmer, in 1870 first described trigeminocardiac and trigemino-respiratory reflexes in cats and rabbits (2,3). There are very few reports of Kratschmer reflex in the literature (4,5). Figure 5. Threading the wire into tracheal tube introducer. A 50-yr-old male ASA grade-I un- derwent rhinoplasty under general anesthesia. At the end of the proce- dure, as his nose was being packed with gauze, he developed sudden bradycardia and bronchospasm for which we gave atropine sulfate 0.6 mg IV. After symptomatic relief, we reversed the neuromuscular blockade and extubated the trachea. In a few minutes he developed severe respiratory distress due to persistent bronchospasm and pulmonary edema. We reintubated the patient’s trachea. In the absence of knowing about other predisposing factors for bronchospasm, we surmised that nasal Figure 6. Gum elastic bougie with the metallic wire inside. packing lead to the Kratschmer reflex. We removed the nasal pack, and the patient was relieved of broncho- intubation stylet (medium). We then (Fig. 6). The result is that the angu- spasm. Because of negative pressure nicked the distal end of the bougie lated tracheal end of the bougie re- pulmonary edema, he required me- and gently threaded the metallic wire mains soft and nontraumatic, but the chanical ventilation for 24 h, after into the introducer, until the wire rest of the bougie is stiff and adjust- which he was weaned off the venti- reached 2 cm from the angled tip able for tracheal intubation. Because lator and tracheally extubated. There

Vol. 103, No. 5, November 2006 © 2006 International Anesthesia Research Society 1337 Letters to the Editor were no further episodes of brady- 5. Blanc VF. Trigeminocardiac reflexes (Edi- used the dental cast model to char- torial). Can J Anaesth 1991;38:696–9. cardia or bronchospasm. 6. Widdicombe J, Lee LY. Airway reflexes, acterize the patient’s retromolar tri- Stimulation of receptors in the tri- autonomic function and cardiovascular gone, and verified adequate room for geminal nerve distribution area re- responses. Environ Health Perspect 2001; placement of a 7.5-mm endotracheal 109 (Suppl 4):579–84. sults in reflex changes in autonomic, 7. Schall B, Probst R, Strebel S. Trigemino- tube. cardiovascular, and respiratory sys- cardiac reflex during surgery in cerebel- We induced anesthesia with IV tems (6). Most of the reports of lopontine angle. Neurosurg Focus 1998;5: fentanyl and propofol, and para- Article 5. Kratschmer reflex described cardio- DOI: 10.1213/01.ane.0000242646.27533.35 lyzed the patient with vecuronium. vascular changes with potent stimuli, We performed oral endotracheal in- such as elevation of bone flap or Dental Cast Model as an tubation and fixed the tube with osteotomies. Lang et al. (4) reported Airway Management wire ligature. After noticing the pa- three cases of possible Kratschmer Planning Tool tient’s passive clenching of teeth, reflex in patients undergoing correc- we checked the adequacy of venti- tive facial osteotomies. The cardiovas- To the Editor: lation and the airway pressures. cular changes during cerebellopontine A 23-yr-old female was sched- Surgery proceeded uneventfully for angle tumor resection suggest the pres- uled for Le Fort I osteotomy ad- 5 h and we extubated the trachea ence of a central induction and efferent vancement, calvaria bone grafting, after ensuring we could maintain a pathway of trigeminocardiac reflex in and rhinoplasty to repair a Class patent airway. Preoperative use of a humans (7). Our case illustrates that II malocclusion and persistent na- dental cast permitted us to proceed moderate stimuli like nasal packing sal deformity. She had undergone with a novel method of airway can evoke Kratschmer reflex. This maxillo-mandibular fixation 5 yr management. patient developed bronchospasm previously for bilateral Le Fort II and laryngospasm as originally de- and nasal bone fracture. In prepara- Indu Sen, MD scribed by Kratschmer in animals tion for surgery, plastic surgeons Jyotsna Wig, MD, FAMS (2,6). In our case, atropine was effec- made a dental cast model to define Suman Arora, MD tive in treating bradycardia but bron- the patient’s precise intraocclusional Department of Anaesthesia and Intensive Care chospasm responded only partially. relationships (Fig. 1). Post Graduate Institute of Medical Education Vigilance during procedures with and Research We explored options for airway Chandigarh, India a potential to provoke a trigemino- management. Surgery did not per- Vipul Nanda, McH cardiac/trigeminorespiratory reflex mit nasal intubation. Invasive tech- is essential. Prompt interventions niques such as tracheostomy (1) or Ramesh K. Sharma, McH like cessation of surgical stimulus, submental intubation (2) carry too Department of Plastic Surgery administration of atropine, local an- Post Graduate Institute of Medical Education much risk of increased morbidity and and Research esthetic infiltration, or blockade of postoperative scarring. Therefore, Chandigarh, India the nerve may be helpful in attenu- we decided upon transoral retro- [email protected] ating or preventing the potentially molar intubation without osteotomy fatal complications of Kratschmer (3) as the ideal airway-management REFERENCES reflex. strategy. Clinical examination using 1. Lewis RJ. Tracheostomies: indications, Nirmala Jonnavithula a gloved finger and roentgenogram timing and complications. Clin Chest Department of Anesthesiology and gave us some idea about space. We Med 1992;13:137–49. Intensive Care Nizam’s Institute of Medical Sciences Punjagutta, Hyderabad, Andhra Pradesh, India [email protected]

REFERENCES 1. Linton RAF. Respiratory system: struc- ture and function of the respiratory tract in relation to anaesthesia. In: Healey TEJ, Knight PR, eds. Wylie and Churchill- Davidson’s a practice of anaesthesia. Sin- gapore: PG Publishing, 1986:4. 2. Widdicombe J. Kratschmer and nasal reflexes. Respir Physiol 2001;127:89–91. 3. Angell-James JE, Daly MB. Some aspects of upper respiratory tract reflexes. Acta Otolaryngol 1975;79:242–52. 4. Lang S, Lanigan DT, Vanderwal M. Tri- geminocardiac reflexes: maxillary and mandibular variants of the oculocardiac reflex. Can J Anaesth 1991;38:757–60. Figure 1. A dental cast model showing retro-molar space.

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