Dabbous et al., Analg Resusc: Curr Res 2013, 2:2 http://dx.doi.org/10.4172/2324-903X.1000107 Analgesia & Resuscitation : Current Research Case Report a SciTechnol journal sigmoidoscope was immediately removed; cardiopulmonary Reflex Bradycardia and resuscitation was initiated with chest compressions, intravenous administration of epinephrine 1mg and rapid intravenous infusion Cardiac Arrest Following of Lactated Ringer. The patient responded to this management in Sigmoidoscopy under General one minute with a momentary escalation of the heart rate to 90/ min, blood pressure to 170/70 mmHg and ETCO2 to 35mmHg. The Anesthesia hemodynamics gradually settled to baseline in a couple of minutes (Table 1). The sigmoidoscope was again introduced slowly and the Alia S Dabbous1*, Jean J Esso1, Mabelle C Baissari1 and Ahmad M Abu Leila1 proposed surgery was continued with no further untoward incident. Surgery lasted around 45 minutes; the patient was hemodynamically stable and, was extubated uneventfully. In the post anesthesia care Introduction unit, a cardiac consultation was obtained; EKG was done and was Reflex bradycardia is a rare but well recognized complication completely normal. that may occur during anesthesia. Anesthestic drugs, surgical stimuli The patient was transferred to the regular floor; postoperative and hypoxia can be its triggering agents [1]. There are many factors course was uneventful. He was discharged home the following day that augment this entity and may result in severe bradycardia or without any further incident. arrest [2-4]. To the best of our knowledge, this is the first report on the development of asystole during sigmoidoscopy under general Discussion anesthesia. We put forth the following reasons to substantiate our case in favor Case of increased vagal tone culminating in asystole. During induction of general anesthesia, we gave 150 mcg of fentanyl simultaneously A 47-year-old man was scheduled for sigmoidoscopy and with 200 mg of propofol. There was no hemodynamic response to hemorrhoidectomy; his past medical history was significant for chronic anesthesia induction or tracheal intubation. No further analgesia was hypertension, gastroesophageal reflux disease and dyslipidemia. He given. Maintenance of anesthesia was by 35-65 % Oxygen-N O and was on Telmisartan, Atorvastatin, Aspirin, and Rabeprazole. He had 2 0.4-0.8% isoflurane. Heart rate remained stable for 25 minutes after no previous history of vasovagal reaction. His preoperative vital signs induction. Symptomatic bradycardia with hypotension only occurred were essentially normal and physical examination was unremarkable. at the time of anal dilation that was resistant to 0.5 mg atropine and The routine laboratory examination taken preoperatively including led to asystole. electrolytes were normal. A twelve-lead Electrocardiogram (EKG) showed normal sinus rhythm. The mechanism of vagal reflex during sigmoidoscopy is primarily due to the stimulation of the pelvic splanchnic nerves that supply A proposed plan of general anesthesia was discussed with the patient. He received no premedication. On arrival to the operating the anal canal. These nerves carry parasympathetic fibers and, room, intravenous access was secured and one liter Lactated Ringer consequently the intense vagal stimulation that occurs following was started. Monitors (EKG, pulse oximetry and noninvasive blood anal dilation results in cardiac changes and bradycardia [5]. This pressure) were placed. Anesthesia was induced with fentanyl 150 bradycardia leading to asystole has been described during colonoscopy mcg, lidocaine 100 mg, propofol 200 mg, and cisatracurium 10 mg. with sedation in a patient with history of neurocardiogenic syncope The airway was secured with an 8.0mm endotracheal tube. Anesthesia [6]. This effect can be more prominent in young age, for there is an was maintained by oxygen: N2O (35: 65%) and isoflurane (0.4-0.8%). inverse relationship between vagal modulation and age [7]. Also, the During the next 20 minutes, the patient’s pulse and blood pressure light level of anesthesia can potentiate the occurrence of bradycardia remained stable with a heart rate around 70/min and a blood pressure [8]. of about 120/80mmHg, ETCO2 of 30-35 mmHg and ET isoflurane In our patient, the sudden onset of asystole during anal dilation, is 0.6%. A total of 500 ml of Lactated Ringer was given. The patient was the result of reflex bradycardia that could have occurred in view of the then placed in a lithotomy position in view of sigmoidoscopy. At relatively young age of our patient and, the light level of anesthesia. the time of anal dilation, 25 minutes later, an episode of bradycardia immediately occurred with a drop in heart rate from 72 to 33/ Conclusion min accompanied by a remarkable decrease in the systolic blood This is the first case of asystole reported during sigmoidoscopy. pressure from 120 to 68 mmHg and a drop in ETCO2 to 14mmHg, Reflex bradycardia, coupled to the young age of the patient and the 0.5 mg atropine was given to no avail and asystole followed. The light level of general anesthesia seem to be the direct cause. Prompt *Corresponding author: Alia S Dabbous, American University of Beirut Medical resuscitation saved our patient. Symptomatic bradycardia leading to Center, PO Box: 11-0236, Riad El Solh, Beirut, Lebanon, E-mail: [email protected] asystole can happen during sigmoidoscopy under general anesthesia. Received: March 27, 2013 Accepted: July 27, 2013 Published: July 31, 2013 Adequate prevention, recognition and management can be effective. All articles published in Analgesia & Resuscitation : Current Research are the property of SciTechnol, and is protected by International Publisher of Science, copyright laws. Copyright © 2013, SciTechnol, All Rights Reserved. Technology and Medicine Citation: Dabbous AS, Esso JJ, Baissari MC, Abu Leila AM (2013) Reflex Bradycardia and Cardiac Arrest Following Sigmoidoscopy under General Anesthesia. Analg Resusc: Curr Res 2:2. doi:http://dx.doi.org/10.4172/2324-903X.1000107 Table 1: Hemodynamics changes. Time (min) 0 20 25 26 27 30 45 60 120 HR (beats/min) 69 72 33 asystole 90 70 76 80 72 BP (mmHg) 122/87 120/80 68/43 Undetectable 170/70 128/80 123/75 120/72 130/80 PetCO2 (mmHg) 30 31 14 0 35 31 30 30 31 References 5. Fletcher GF, Earnest DL, Shuford WF, Wenger NK (1968) Electrocardiographic changes during routine sigmoidoscopy. Arch Intern Med 122: 483-486. 1. Doyle DJ, Mark PW (1990) Reflex bradycardia during surgery. Can J Anaesth 37: 219-222. 6. Sharma G, Boopathy Senguttuvan N, Juneja R, Kumar Bahl V (2012) Neurocardiogenic syncope during a routine colonoscopy: an uncommon 2. Mizuno J, Mizuno S, Ono N, Yajima C, Arita H, et al. (2005) [Sinus arrest malignant presentation. Intern Med 51: 891-893. during laryngoscopy for induction of general anesthesia with intravenous fentanyl and propofol]. Masui 54: 1030-1033. 7. De Meersman RE, Stein PK (2007) Vagal modulation and aging. Biol Psychol 74: 165-173. 3. Kinsella SM, Tuckey JP (2001) Perioperative bradycardia and asystole: relationship to vasovagal syncope and the Bezold-Jarisch reflex. Br J 8. Yi C, Jee D (2008) Influence of the anaesthetic depth on the inhibition of the Anaesth 86: 859-868. oculocardiac reflex during sevoflurane anaesthesia for paediatric strabismus surgery. Br J Anaesth 101: 234-238. 4. Lang SA, Van der Wal M (1994) Death from the oculocardiac reflex. Can J Anaesth 41: 161. Author Affiliation Top 1American University of Beirut Medical Center, Lebanon Submit your next manuscript and get advantages of SciTechnol submissions 50 Journals 21 Day rapid review process 1000 Editorial team 2 Million readers More than 5000 Publication immediately after acceptance Quality and quick editorial, review processing Submit your next manuscript at ● www.scitechnol.com/submission Volume 2 • Issue 2 • 1000107 • Page 2 of 2 •.