Compartment Syndrome in Surgical Patients Mary E

Ⅵ CASE REPORTS

Anesthesiology 2001; 94:705 © 2001 American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc. Compartment Syndrome in Surgical Patients Mary E. Warner, M.D.,* Lisa M. LaMaster, B.A.,† Amy K. Thoeming, B.S.N.,† Mary E. Shirk Marienau, M.S., C.R.N.A.,* Mark A. Warner, M.D.‡

COMPARTMENT syndrome is a potentially devastating curred in traumatized limbs or limbs that were subject to postoperative complication that can occur during or ischemia from vascular surgical procedures were ex- after surgery. It is a tissue injury that causes pain, ery- cluded. All surgical episodes must have been performed thema, edema, and hypoesthesia of the nerves in the while patients underwent general or regional anesthesia affected area. In general, fasciotomy must follow clinical or local anesthesia with or without sedation. A single Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/94/4/705/330517/0000542-200104000-00026.pdf by guest on 01 October 2021 diagnosis quickly to prevent permanent tissue damage.1 trained reviewer abstracted all records. Outcomes of If undiagnosed or diagnosed late, it may cause severe these patients at least 2 yr after the index surgeries were rhabdomyolysis, irreversible nerve deficits, loss of limb, obtained. A survey of the impact of the syndrome on or even death. A high proportion of cases have been daily activities, rated as mild, moderate, or major, was reported to occur in patients undergoing surgical proce- obtained from all patients with persistent neurologic dures while in the lithotomy position.1–12 dysfunction of at least 2 years’ duration. Mild impact was Perioperative compartment syndrome for which there defined as “often noticeable but not associated with any is no readily apparent cause (e.g., secondary to trauma or limitation of activities of daily living.” Moderate impact arterial embolism after vascular surgery) is not well- was defined as “always noticeable and associated with understood. Therefore, we reviewed the outcomes of a some limitation of one or more activities of daily living.” large number of surgical procedures to determine this Major impact was defined as “always noticeable and complication’s frequency and to further characterize its associated with significant limitation of multiple activi- natural history and outcomes. ties of daily living.”

Statistical Analysis Methods The frequency of compartment syndrome was calcu- With Mayo Institutional Review Board approval, the lated along with the corresponding 95% confidence in- medical database at Mayo Medical Center, Rochester, terval. The frequencies of compartment syndrome for Minnesota, was reviewed to glean the data of all patients various patient positions were compared with the fre- who had undergone an index (i.e., initial) surgical epi- quency of this event in patients in the supine position sode and, within 5 days, a subsequent fasciotomy during using the Fisher exact test. Because less than 20 cases the 10-yr study period from July 1, 1989 to June 30, were identified, a case–control evaluation for risk factors 1999. Each unique anesthetic was considered to repre- was not performed. sent a single surgical episode, regardless of the number of procedures performed during that anesthesia. We attempted to glean only cases in which perioperative Results positioning or some unrecognized characteristic or During the study period, 499,214 patients underwent event may have caused the compartment syndrome. 572,498 surgical episodes. Nineteen percent (95,269) Therefore, cases of compartment syndrome that oc- underwent more than one surgical episode. The anesthetic care provided during the 572,498 surgical epi- Additional material related to this article can be found on the sodes included general or combined general and re- c ANESTHESIOLOGY Web site. Go to the following address, click on gional anesthetics in 401,567 episodes (70.1%), regional Enhancements Index, and then scroll down to find the appro- anesthetics in 62,133 episodes (10.9%), and local anes- priate article and link. http://www.anesthesiology.org thetics or sedation in 108,798 episodes (19.0%). The predominant patient position during these 572,498 surgical episodes was supine in 462,204 episodes (80.1%), * Assistant Professor of Anesthesiology, Mayo Medical School, Rochester, lithotomy in 52,319 episodes (9.1%), lateral decubitus in Minnesota. † Student Registered Nurse Anesthetist, Mayo School of Health Related Sciences, Mayo Clinic, Rochester, Minnesota. ‡ Professor of Anesthesi- 19,422 episodes (3.4%), and either prone, other posi- ology, Mayo Medical School, Rochester, Minnesota. tions, or unknown in 38,553 episodes (6.7%). Just over Received from the Department of Anesthesiology, Mayo Foundation, Roches- half of the 499,214 patients were female (52.2%, n ϭ ter, Minnesota. Submitted for publication June 2, 2000. Accepted August 31, 2000. Supported by the Mayo Foundation, Rochester, Minnesota. 260,591). The mean age (Ϯ SD) of the surgical popu- Address reprint requests to Dr. Warner: Department of Anesthesiology, Mayo lation was 49.2 Ϯ 18.3 yr, with ages ranging from 0 to Clinic, 200 First Street SW, Rochester, Minnesota 55905. Address electronic mail to: [email protected]. Individual article reprints may be purchased 108 yr. through the Journal Web site, www.anesthesiology.org. Overall, 485 of the 499,214 patients (0.1%) underwent

Anesthesiology, V 94, No 4, Apr 2001 705 706 CASE REPORTS a fasciotomy. Just over half of these patients (51.3%, n ϭ Postfasciotomy surveillance was obtained for all pa- 249) underwent this procedure secondary to trauma. tients, either until resolution of their neurologic symp- Compartment syndrome developed in 173 patients toms or, for those who had persistent symptoms, for at (35.7%), necessitating fasciotomy within 48 h of a vas- least 2 yr. The symptoms of six patients resolved within cular surgical procedure. Eighteen patients (3.7%) expe- the ﬁrst year, including two who had complete neuro- rienced the syndrome after an arterial embolic event logic recoveries within 2 weeks of fasciotomy. Six of the associated with recent onset of atrial ﬁbrillation, 12 patients remaining seven patients had persistent neurologic def- (2.5%) had a perfusion-limiting lower extremity cancer of icits and pain of at least 2 years’ duration. One patient, a the bone or vasculature, and 20 patients had a variety of 36-yr-old man who underwent a 6.3-h craniotomy in a miscellaneous conditions. There was no apparent preexist- lateral decubitus position, had development of compart-

ing cause for compartment syndrome in 13 patients (2.7%). ment syndromes in his left forearm and hand, resulting Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/94/4/705/330517/0000542-200104000-00026.pdf by guest on 01 October 2021 The patient and procedure characteristics and outcomes of in arterial thrombosis and eventual forearm amputation these 13 patients are described in table 1. on the fourth postoperative day. In a surveillance survey The frequency (and 95% confidence interval) for com- of the seven patients with persistent deficits of at least 2 partment syndrome requiring fasciotomy in the absence years’ duration, one patient reported that her disability of apparent preexisting causes was 2.3 per 100,000 mildly impacted her daily living functions, three re- surgical episodes overall (1.2–3.9 per 100,000). The ported a moderate impact on daily functions, and three same figures for this event in only those patients to described the impact as major. whom general anesthetics were administered during their surgical episodes were 3.2 per 100,000 patients (1.7 to 5.5 per 100,000). It was more likely to occur in patients Discussion who underwent procedures while in the lithotomy or lateral decubitus positions than in a supine position. This Compartment syndrome is considered to occur primar- problem developed in 5 of the 462,204 patients in a supine ily in patients who undergo procedures while in the position (1 per 92,441). In contrast, it developed in 6 of lithotomy position. Our data confirm that compartment 52,319 patients in the lithotomy position (1 per 8,720) and syndrome is more likely to develop with no apparent 2 of 19,422 patients in the lateral decubitus position (1 per cause when the patient is in the lithotomy position than 9,711). The event frequencies for patients in the lithotomy in a supine position. However, we were surprised by and lateral decubitus positions were much higher (P Ͻ three of our findings: (1) patients in lateral decubitus 0.001 and P ϭ 0.03, respectively) than the frequency for positions unexpectedly had a high frequency of com- patients in a supine position. partment syndrome, (2) compartment syndromes neces- There were few characteristics that distinguished the sitating fasciotomies of the upper extremities developed 13 patients in whom compartment syndrome developed in three patients (23%), and (3) nearly half of the patients with no apparent preexisting cause. Their ages ranged in whom compartment syndromes developed in the from 17 to 67 yr; they underwent a variety of proce- lower extremities underwent procedures while in the dures, ranging from reimplantation of fingers to hemipel- supine position. There are few case reports of upper vectomy; and they were positioned in a variety of surgi- extremity compartment syndrome with causes other cal configurations. All underwent procedures during than trauma or vascular surgery. With the exception of a administration of general anesthetics. The one notewor- few reports of compartment syndrome developing in the thy characteristic was their relatively long surgical pro- lower extremities of patients who were positioned cedures. These ranged from 3.2 to 15.7 h, with an prone in “tucked,” “kneeling,” or “knee-chest” positions average duration of 7.2 h. In contrast, the average dura- for lumbar spine surgery,13–15 nearly all other reports of tion of procedures for all patients during this 10-yr study position-related compartment syndrome of the lower period was 2.7 h. extremities occur in patients undergoing procedures Compartment syndrome always was characterized by while in the lithotomy position. pain and compartment pressures of 50 mmHg or greater. The cases of upper extremity compartment syndrome Although swelling and sensory loss of the affected limbs were unexpected. Nambisan and Krakousis16 have de- were common, they were not ubiquitous (table 1). Eight scribed a young adult in whom a compartment syn- patients (61%) had the syndrome in one leg, two patients drome of the downside shoulder, arm, and forearm de- (15%) had bilateral involvement of their legs, and three veloped 1 day after a 9-h procedure in a lateral decubitus patients (23%) had compartment syndromes of an upper position to remove a tumor from the thoracic vertebrae. extremity. The average time from the end of surgery to The authors speculated that the “axillary” or chest roll the first noted symptoms was 40 h (range, 6–78 h). under the medial wall of the axilla either was too thin to Compartment pressures usually were measured in at elevate the chest wall to relieve pressure on the axillary least two compartments of affected extremities, and the structures or had moved cephalad into the axilla and pressures ranged from 50 to 90 mmHg. compressed the axillary structures. Martin1 has reported

Anesthesiology, V 94, No 4, Apr 2001 CASE REPORTS 707

Table 1. Patient and Procedure Characteristics and Outcomes

Procedure Postoperative Compartment Age Gender Duration Surgical Interval Pressures Fasciotomy (yr) (M/F) Surgical Procedure Predisposing Conditions (h) Position (h)* Symptoms (mmHg)† Sites Outcome

17 F Right femur resection Ewing sarcoma 4.6 Supine 76 Pain, foot drop 60 Left leg Persistent foot drop, resolved within 6 months 27 M Right ACL Ligament injury 7.0 Supine 52 Pain, sensory loss 80 Left leg Complete recovery reconstruction in 1 week 27 F Right hemipelvectomy Osteosarcoma 13.1 Left lateral 8 Pain, motor 60 Left hand Persistent motor decubitus dysfunction, and sensory loss swelling at2yr Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/94/4/705/330517/0000542-200104000-00026.pdf by guest on 01 October 2021 36 M Right craniotomy Hypothalamic glioma 6.3 Left lateral 32 Pain, motor 80 Left forearm Arterial thrombosis; decubitus dysfunction, and hand forearm swelling amputation, day 4 38 M Liver resection Hepatoma 3.2 Supine 6 Pain, sensory loss 65 Right forearm Complete recovery at 2 weeks 46 M Multiple ﬁnger Auger injury, right hand 15.7 Supine 70 Pain, sensory loss 70 Left leg Decreased sural reimplantation nerve sensation at2yr 47 F Pelvic exenteration Ovarian cancer 4.8 Lithotomy 46 Pain, sensory loss, 60, 80 Bilateral legs Complete recovery swelling in 4 months 48 F Low anterior Chronic ulcerative colitis 3.8 Lithotomy 58 Pain, sensory loss 70 Right leg Foot drop at 5 yr resection 54 F Lysis bowel Small bowel obstruction, 3.3 Lithotomy 18 Cold foot, pain, 75 Left leg Foot drop, adhesions previous ACA foot drop decreased sensation, and pain at 3 yr 54 M Finger reimplantation Chainsaw injury, right hand 10.6 Supine 26 Pain, swelling, 65 Right leg Complete recovery sensory loss at1yr 58 M Pelvic exenteration Leiomyosarcoma, intraoperative 8.2 Lithotomy 78 Pain, swelling, foot 90, 60 Bilateral legs Bilateral foot drop hypotension drop at6yr 64 F Radical abdominal Cervical cancer 4.3 Lithotomy 30 Pain, swelling, foot 80 Right leg Complete recovery hysterectomy drop at 8 months 67 M Cystectomy Transitional cell carcinoma 8.1 Lithotomy 25 Pain, foot drop 50 Left leg Residual weakness at2yr

* Time from index surgery to fasciotomy. † Compartment pressures before fasciotomy. ACL ϭ anterior cruciate ligament; ACA ϭ adenocarcinoma. the malpractice action of a patient in whom an isolated limbs above the heart, decreasing perfusion pressure to forearm compartment syndrome and anterior interosse- them. Four of our 10 patients in whom lower extremity ous neuropathy developed. The plaintiff alleged that a compartment syndromes developed underwent proce- binder used to retain his supinated forearm on an arm dures while in supine and ﬂat positions. Three of these board during general anesthesia and surgery was too patients were fairly young and quite healthy; the third tight or compressive and caused the complication. Un- also was young and healthy except for the presence of a fortunately, there is insufﬁcient information (e.g., size or Ewing sarcoma in her right femur. In these cases, it position of the axillary roll or compressive effect of arm appears that neither of these two characteristics of Mar- binders) known about our three cases to speculate on tin1 was present. the cause. Two of our patients who had compartment We were unable to perform a risk factor analysis using syndromes were in the lateral decubitus position, and case–control methodology because of the small number the problem occurred in their dependent extremities. of cases. Clearly, the frequency of compartment syn- Our third patient was in the supine position, with both drome with no apparent cause is higher in patients arms tucked at the sides, and compartment syndrome of undergoing procedures while in the lithotomy and lat- his right forearm developed. eral decubitus positions compared with supine posi- Most case reports describe lithotomy positioning as tions. However, long surgical duration is one other fac- the major predisposing factor to compartment syndrome tor that occurs commonly in these 13 cases. The in the lower extremities.1–12 Martin1 notes that charac- duration of our cases ranged from 3.2 to 15.7 h, all teristics of lithotomy positions that may increase the risk longer than our mean duration of 2.7 h for all cases of compartment syndrome include increasing weight of performed during the study period. Intuitively, pro- the lower extremities against supportive devices, reduc- longed immobility or external compressive forces from a ing compartment capacity, and elevation of the lower variety of sources, including positioning, and pathophys-

Anesthesiology, V 94, No 4, Apr 2001 708 CASE REPORTS iologic changes within extremity compartments during 2. Peters P, Baker SR, Leopold PW, Taub NA, Burnand KG: Compartment syndrome following prolonged pelvic surgery. Brit J Surg 1994; 81:1128–31 long procedures and anesthetics may be etiologic fac- 3. Khalil IM: Bilateral compartment syndrome after prolonged surgery in the tors. However, data from this study and numerous iso- lithotomy position. J Vasc Surg 1987; 5:879–81 4. Scott JR, Daneker G, Lumsden AB: Prevention of compartment syndrome lated case reports are insufficient to confirm any primary associated with the dorsal lithotomy position. Am Surg 1997; 63:801–6 factors. The characteristics of these cases suggest that 5. Slater RR, Weiner TM, Koruda MJ: Bilateral leg compartment syndrome complicating prolonged lithotomy position. Orthopedics 1994; 17:954–9 perioperative compartment syndrome can occur in ap- 6. Montgomery CJ, Ready LB: Epidural opioid analgesia does not obscure parently conventional conditions of care, for reasons diagnosis of compartment syndrome resulting from prolonged lithotomy position. ANESTHESIOLOGY 1991; 75:541–3 that currently are beyond our understanding. 7. Tuncer R, Zorludemir U: Lower limb compartment syndrome following In summary, we found that compartment syndrome urethroplasty. Brit J Urol 1997; 79:646 8. Schwartz LB, Stahl RS, DeCherney AH: Unilateral compartment syndrome with no apparent cause necessitating fasciotomy oc- after prolonged gynecologic surgery in the dorsal lithotomy position. J Reproduct Med 1993; 38:469–71 curred infrequently and in both the upper and lower Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/94/4/705/330517/0000542-200104000-00026.pdf by guest on 01 October 2021 9. Angermeier KW, Jordan GH: Complications of the exaggerated lithotomy extremities of patients in this surgical population. Pa- position: a review of 177 cases. J Urol 1994; 151:866–8 tients in the lithotomy and lateral decubitus positions 10. Fabbri LP, Nucera M, Fontanari P, Loru G, Marsili M, Barbagali G: Bilateral compartment syndrome following prolonged anesthesia in the lithotomy posi- were more likely to have this problem than those in tion. Can J Anaesth 1997; 44:678–9 supine positions. Approximately one half of patients 11. Lydon JC, Spielman FJ: Bilateral compartment syndrome following prolonged surgery in the lithotomy position. ANESTHESIOLOGY 1984; 60:236–8 with compartment syndrome who underwent fas- 12. Svendson LB, Flink P, Wojdemann M, Riber C, Mogensen T, Secher NH: ciotomy in this study population had persistent neuro- Muscle oxygenation saturation during surgery in the lithotomy position. Clin Physiol 1997; 17:433–8 logic deficits and pain 2 yr afterwards. 13. Gordon BS, Newman W: Lower nephron syndrome following prolonged knee-chest position. J Bone Joint Surg (Am) 1953; 35:764–8 14. Aschoff A, Steiner-Milz H, Steiner H-H: Lower limb compartment syndrome following lumbar discectomy in the knee-chest position. Neurosurg Rev 1990; 13:155–9 References 15. Keim HA, Weinstein JD: Acute renal failure: A complication of spine fusion in the tuck position. J Bone Joint Surg (Am) 1970: 52:1248–50 1. Martin JT: Compartment syndromes: Concepts and perspectives for the 16. Nambisan RN, Karakousis CP: Axillary compression syndrome with neu- anesthesiologist. Anesth Analg 1992; 75:275–83 ropraxia due to operative positioning. Surgery 1989; 105:449–54

Anesthesiology 2001; 94:708–9 © 2001 American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc. The Use of Intravenous Nitroglycerin in a Case of Spasm of the Sphincter of Oddi during Laparoscopic Cholecystectomy Hirokatsu Toyoyama, M.D.,* Nobutaka Kariya, M.D.,† Ichiro Hase, M.D.,‡ Yoshiro Toyoda, M.D.§

SPASM of the sphincter of Oddi still occurs during chole- 140/100 mmHg, and her heart rate was 80 beats per minute and regular cystectomy. Some reports indicate that the spasm, induced at the time of admission. She had no history of medication for hyper- by morphine, can be reversed by injection of naloxone,1 tension. Laboratory data, including liver function test results, were 2 3 within normal limits. Drip infusion cholecystography provided clear nalbuphine, and glucagon. Others maintain that nitro- visualization of the gallbladder and biliary ducts. 4 5 glycerin or nifedipine can relax the sphincter of Oddi The preanesthetic medication consisted of meperidine (35 mg intra- muscle. We recently encountered spasm of the sphincter muscularly), atropine (0.5 mg intramuscularly) and famotidine (20 mg of Oddi during a laparoscopic cholecystectomy and treated intramuscularly). In the operating room, the usual monitors were put it successfully with intravenous nitroglycerin. in place. After a single epidural injection of morphine (2 mg/4 ml normal saline), general anesthesia was induced with thiopental (100 mg intravenously) followed by vecuronium (5 mg intravenously) Case Report and maintained with isoflurane (0.3–1.0%) and nitrous oxide–oxygen (fractional inspired oxygen tension, 0.33). Nicardipine was adminis- A 52-yr-old woman weighing 55 kg was scheduled to undergo tered to control blood pressure because the patient remained hyper- elective laparoscopic cholecystectomy. Her blood pressure was tensive (170/100 mmHg) after induction. The first cholangiogram via the cystic duct tube showed obstruction to the flow of radiographic contrast at the terminal end of the common bile duct (fig. 1). This was * Staff Anesthesiologist, § Chief Anesthesiologist, Department of Anesthesia, confirmed with a second cholangiogram. Because we speculated that Osaka Kosei-Nenkin Hospital. † Research Associate, ‡ Postgraduate, Depart- the obstruction might be the result of spasm of the sphincter of Oddi ment of Anesthesiology and Intensive Care Medicine, Osaka City University induced by epidural morphine, we injected naloxone (0.2 mg intrave- Medical School. nously). However, a third cholangiogram, performed 5 min late, Received from the Department of Anesthesia, Osaka Kosei-Nenkin Hospital, Osaka, Japan, and the Department of Anesthesiology and Intensive Care Medi- showed continued obstruction. We then administered nitroglycerin cine, Osaka City University Medical School, Osaka, Japan. Submitted for publi- (0.1 mg) at 0.01 mg/min for 20 min intravenously in place of the cation March 6, 2000. Accepted for publication November 15, 2000. Support was nicardipine, and we finally achieved satisfactory passage of contrast provided solely from institutional and/or departmental sources. material to the duodenum (fig. 2). The postoperative course of the Address reprint requests to Dr. Toyoyama: Department of Anesthesia, Osaka patient was uneventful. The next day, the C tube was removed after Kosei-Nenkin Hospital, 4-2-78 Fukushima, Fukushima-ku, Osaka 553-0003, Japan. Address electronic mail to: [email protected]. Individual article reprints excellent flow of contrast material to the duodenum had been may be purchased through the Journal Web site, www.anesthesiology.org. confirmed.

Anesthesiology, V 94, No 4, Apr 2001 CASE REPORTS 709 Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/94/4/705/330517/0000542-200104000-00026.pdf by guest on 01 October 2021

Fig. 1. The first cystic duct cholangiogram. The intrahepatic biliary tract and common bile duct are visualized dilated by dye Fig. 2. The final cystic duct cholangiogram after injection of injection. The narrowing appearance of the distal common nitroglycerin. Free flow of contrast medium into the duodenum duct, with its tapering bird-beak shape, and the absence of can be seen, and the whole biliary tract is of normal size. radiographic dye flow into the duodenum are shown. than does nitroglycerin. In summary, this report shows Discussion that, when the spasm of the sphincter of Oddi occurs Several factors that may cause intraoperative spasm of during laparoscopic cholecystectomy, anesthesiologists the sphincter of Oddi have been reported. These include can take an active part in treating it effectively with perioperative usage of opioids, operative manipulation intravenous nitroglycerin. of the common bile duct, and injection of cold or irri- tating contrast medium.6 We used meperidine, which References 7,8 has been shown to be less likely to induce spasm, as 1. Richard LM, Oscar JV, Robert KS, Gale ED: Naloxone reversal of chole- part of the preanesthetic medication. Although we can- dochoduodenal sphincter spasm associated narcotic administration. ANESTHESIOL- OGY 1978; 48:437 not rule out completely the effect of epidural morphine 2. Harold KH, Neal WF: Opioid-induced spasm of the sphincter of Oddi on the sphincter, ineffectiveness of naloxone indicates apparently reversed by nalbuphine. Anesth Analg 1992; 74:308–10 3. Jones RM, Fiddian-Green R, Knight PR: Narcotic-induced choledochoduo- that another cause is more likely. The chief cause of the denal sphincter spasm reversed by glucagon. Anesth Analg 1980; 59:946–7 spasm in our case might be operative manipulation or 4. Staritz M, Poralla T, Ewe K, Meyer Zum Büschenfelde K-H: Effect of glyceryl trinitrate on the sphincter of Oddi motility and baseline pressure. Gut 1985; irritation caused by the contrast medium. 26:194–7 Nitroglycerin can relax vascular smooth muscles, in- 5. Guelrud M, Mendoza S, Rossiter G, Ramirez L, Barkin J: Effect of nifedipine on sphincter of Oddi motor activity: Studies in healthy volunteers and patients cluding that of the gastrointestinal tract. Moreover, it is with biliary dyskinesia. Gastroenterology 1988; 95:1050–5 reported to have a dilating effect on the sphincter of 6. Chessick KC, Black S, Hoye SJ: Spasm and operative cholangiography. Arch 4 Surg 1975; 110:53–7 Oddi. Nitroglycerin has been used to facilitate endo- 7. Hardman JG, Limbird LE, Molinoff PB, Ruddon RW, Gilman AG: Goodman 9 scopic removal of common bile duct stones and to & Gilman’s The Pharmacological Basis of Therapeutics, 9th edition. New York: 10 McGraw-Hill, 1995, pp 532 reverse the spasm induced by narcotic usage. On the 8. Elta GH, Barnett JL: Meperidine need not be proscribed during sphincter of other hand, it has been suggested that nifedipine can Oddi manometry. Gastrointest Endosc 1994; 40:7–9 9. Staritz M, Poralla T, Dormeyer HH, Meyer Zum Büschenfelde K-H: Endo- reduce the pressure of the sphincter and may have scopic removal of common bile duct stones through the intact papilla after therapeutic potential for the treatment of sphincter of medical sphincter dilation. Gastroenterology 1985; 88:1807–11 5 10. Velosy B, Madacsy L, Lonovics J, Csernay L: Effect of glyceryl trinitrate on Oddi dyskinesia. Our case seems to indicate that nicar- the sphincter of Oddi spasm evoked by prostigmine-morphine administration. dipine may have a less dilating effect on the sphincter Eur J Gastroenterol Hepatol 1997; 9:1109–12

Anesthesiology, V 94, No 4, Apr 2001 710 CASE REPORTS

Anesthesiology 2001; 94:710–1 © 2001 American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc. Electrocautery-induced Tachycardia in a Rate-responsive Pacemaker David T. Wong, M.D.,* William Middleton, M.D.†

ELECTRIC interference by cautery on demand pacemak- level of T6 was obtained. Vital signs were stable, and a three-lead ers can cause inhibition and loss of pacing.1 We report a electrocardiogram showed P waves at 100 beats/min and ventricular case in which electrocautery induced a pacemaker in paced rhythm at 60 pulses/min (ﬁg. 1, top). Surgery was initiated. Each time unipolar electrocautery (with ground pad on thigh position Force ventricle-paced, ventricle-sensed, inhibited, rate-respon- 40; Valleylab Inc., Boulder, CO) was used, the paced ventricular rate Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/94/4/705/330517/0000542-200104000-00026.pdf by guest on 01 October 2021 sive (VVIR) mode to pace at a programmed maximum gradually increased to a plateau at 130 pulses/min (ﬁg. 1, bottom). The rate of 130 pulses/min. patient was asymptomatic, and his blood pressure was 120/85 mmHg. Conversely, each time electrocautery was stopped, the paced rate gradually returned to 60 pulses/min. The paced rates of 60 and 130 Case Report pulses/min were the minimum and maximum programmed settings in the VVIR mode. Electrocautery usage did not cause pacemaker inhibi- A 59-yr-old man was scheduled for elective transurethral resection of tion or loss of pacing. Surgery was completed without complications. prostate surgery for benign prostatic hypertrophy. He had a history of While in the postanesthetic recovery unit, electrocardiographic mon- third-degree heart block necessitating the insertion of a VVIR pace- itoring showed paced rhythm at 60 pulses/min throughout. maker (META II, 1204H; Telectronics, Englewood, CO) 5 yr previously. The patient’s pacemaker function was assessed to be satisfactory 1 month before surgery. Preoperative ECG showed complete pacemaker dependency and ventricular pacing at a rate of 60 pulses/min. In the Discussion operating room, spinal anesthesia was performed, and 1.5 ml hyper- baric bupivacaine, 0.75%, was administered. A satisfactory sensory Review of pacemaker information indicates that this single-lead ventricular pacemaker is of the rate-responsive type programmed in rate-responsive mode2,3 (VVIR * Assistant Professor, † Lecturer, Department of Anesthesiology, University of 60–130 pulses/min). The rationale for rate responsive- Toronto. ness is to increase the rate of cardiac pacing during Received from the Department of Anesthesiology, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Canada. Submitted periods of physical activities. This pacemaker uses the for publication August 25, 2000. Accepted for publication November 30, 2000. principle of thoracic bioimpedance.2 An increase in Supported in part by the Department of Anesthesiology, Toronto Western Hos- pital, University Health Network, University of Toronto, Toronto, Canada. minute ventilation sensed by changes in thoracic bioim- Address reprint requests to Dr. Wong: Department of Anesthesiology, Toronto pedance leads to a proportional increase in cardiac pac- Western Hospital, 399 Bathurst Street, Toronto, Ontario, Canada M5T 2S8. ing rate. Address electronic mail to: [email protected]. Individual article reprints may be purchased through the Journal Web site, www.anesthesiology.org. The following is our proposed mechanism for the

Fig. 1. (Top) Ventricular paced rhythm at 60 pulses/min. Small amplitude pacer spikes are seen before each paced QRS complex. Underlying P-wave activities at a rate of 100 beats/min are seen also. (Bottom) Ventricular paced rhythm at 130 pulses/min immediately after cessation of electrocautery. Small amplitude pacer spikes are seen before each paced QRS complex.

Anesthesiology, V 94, No 4, Apr 2001 CASE REPORTS 711 rapid pacing noted. Many medical devices, in addition to lowing for patients with rate responsive pacemakers pacemakers, use the technology of bioimpedance.3‡In undergoing surgery.2,3‡ First, these pacemakers should this case, when electrocautery is used in this patient be reprogrammed out of the rate-responsive mode be- with a rate-responsive pacemaker, the pacemaker senses fore exposure to electrocautery or other medical devices the mixture of bioimpedance signals as an indication of with electromagnetic interference. Second, the maxi- elevation of minute ventilation, resulting in sensor drive mum rate-responsive programmed rate may be de- pacing at 130 pulses/min.5,6‡ creased to a rate that the patient can tolerate without As most anesthesiologists are unfamiliar with rate-re- side effects. sponsive pacemakers, and facing the situation of rapid ventricular pacing in the perioperative setting may lead

to two problems. First, rapid ventricular pacing may Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/94/4/705/330517/0000542-200104000-00026.pdf by guest on 01 October 2021 References result in supply–demand imbalance and myocardial ischemia. Second, pacemaker-induced tachycardia may be 1. Bourke ME: The patient with a pacemaker or related device. Can J Anaesth 1996; 43:R24–32 misinterpreted as intrinsic ventricular tachycardia, re- 2. Anderson C, Madsen GM: Rate-responsive pacemakers and anaesthesia: A sulting in inappropriate treatment. consideration of possible implications. Anaesthesia 1990; 45:472–6 3. Telectronics Pacing Systems: META II Model 1204H: Physician’s Manual. After reviewing the literature, we recommend the fol- Telectronics Pacing Systems, Englewood, 1991 4. Chew EW, Troughear RH, Kuchar DL, Thorburn CW: Inappropriate rate change in minute ventilation rate responsive pacemakers due to interference by ‡ Burlington DB: Interaction between minute ventilation rate-adaptive pace- cardiac monitors. PACE 1997; 20:276–82 makers and cardiac monitoring and diagnostic equipment. Available at: 5. Wallden J, Gupta A, Carlsen H: Supraventricular tachycardia induced by www.fda.gov/cdrh/safety/minutevent.html. Accessed October 14, 1998. Datex patient monitoring system (letter). Anesth Analg 1998; 86:1339

Anesthesiology, V 94, No 4, Apr 2001