Vecuronium and Asystole

Started by kppk68, December 01, 2007, 01:55:03 PM

Previous topic - Next topic

0 Members and 1 Guest are viewing this topic.

kppk68

Sir,
Recently i had anaesthetised a 14 yr old girlfor FESS with seotoplasty with no known medical problems except that she was weighing 65kg.
Premedication was tab Ranitidine150mg the night before surgery and one hour before the scheduled time on the day of surgery.An 20G I.V. started and Ringer's lactate fluid used. Monitors included ECG, NIBP, Pulseoximeter.
After preoxygenation for 3 min she was induced with Inj glycopyrrolate0.2mg, pentazocine 12mg, midazolam2mg, propofol 120mg and suxamethonium 100mg and intubated with size 7.0 cuffed endotracheal tube. Throat pack done. Patient ventilated with 70% nitrous oxide with oxygen and 0.5% halothane. After patient came out of suxamethonium, Inj vecuronium 4mg given.At the same time surgeon had started infiltrating the nose with Inj2% Lignocaine with adrenaline 1 in 100000.(For this reason halothane was turned off).
Suddenly patient had bradycardia and asystole. Patient was resuscitated with inj Atropine 0.6mg & 1 ml of inj Adrenaline 1 in 10,000 and cardiac massage given. Patient's heart picked up in 2 min time. Patient was extubated after 1 hour.
My question is
1. what are the causes for bradycadia and asystole other than inj vecuronium and nasal stimulation?
2.Can the panel give me references for vecuronium induced asystole?
3.Is there  any mistake in the anaesthesia technique?

frontier

#1
hi,
its very difficult to say which anaesthetic agent is culprit?both succinylcholine & halothane can cause bradycardia & asystole.even propofol may be contibutory.but it was seen after induction of vecuronium.rapid bolus of vecuronium may also cause this?in my opinion there was no fault in selection of anaesthetic agents?now it may be lignocaine induced toxicity leading to bradycardia & asystole?interaction of propofol & lignocaine-may lead to increased level of lignocaine?interaction of midazolam & lignocaine?regards

jafo1964

Is Pentazocaine 12 mg enough for analgesia?
Halothane was cut off
Plane of anaesthesia and analgesia may have been inadequate
Stimulation in such a scenario like injection or throat pack will stimulate the autonomic system - both sympathetic and parasympathetic.
Usually sympathetic( poly-synaptic outflow) dominates. But rarely you can get a predominance of parasympathetic outflow which can present as bradycardia, bronchospasm, laryngospasm and aystole.

Apart form the list of drugs like halothane and Suxa that can be potential causes i would also like to add

1. Relative hypovolemia due to vasodilatation - decreased preload - Inverse Bainbridge reflex - bradycardia - asystole
2. Bezold Jarisch reflex - hypotension - bradycardia - asystole.
3. Adrenaline in low dose (BETA RECEPTOR) can also produce vasodilatation.

We see a lot of bradycardia with a combination of Propofol, vecuronium and halothane. You have not mentioned BP so may the patient was also haemodynamically unstable. These things can then deteriorate to asystole

I think the current recommended ACLS protocol for asystole, apart from cardiac compression and Atropine is, I think 1 ml of 1 in 1000 adrenaline. You probably made a typographic error. If not maybe it was merely severe hypotension leading to brady-asystolic rhythm. Hence it recovered so easily with such low dose adrenaline.

Think back
Maybe your patient was hypovolemic.
You did not preload(CIVE component)
then Propofol+ Halo+ Hypovolemia + inter-individual variation can produce rare but serious haemdynamic instability


regards

yogenbhatt1

Hi,
Vec induced Brady is some thing an anaesthetist loves. A lazily beating heart is good for itself. but Asystole? Never heard of Vec causing it. Halothane and Propofol are themselves  known to give brady. But again never so much, leading to direct asystole.  Sux? Yes, a nasty culprit. Specially if repeat Sux is given for any reason. your monitors will really come to life with allarms of severe bradycardia and even an arrest.
This looks  more likely to be due to Vaso dilatation eventually leading to arrest. You came out, is more important.