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Srivastav A 2013
Srivastav A 2013
for 48 hours after surgery and was discharged from the Access this article online
hospital on the sixth postoperative day. Quick Response Code: Website:
www.annals.in
minute, blood pressure of 118/78 mmHg, etCO2 was observed during skin incision and laparoscopic port
36 mmHg; peak airway pressure was 25 mmHg, end- placement. Electrolyte imbalance was also ruled out
tidal sevoflurane concentration was 2.2%. Arterial as a possible cause of VE.
blood gas analysis showed pH 7.39, PO2 189 mmHg,
PCO2 41 mmHg, HCO3− 19 mmol/l, BE - 6 mmol/l DEX is an α-2 receptor agonist, being increasingly used
and SpO2 98%, Na+ 132 mEq/l, K+ 4.2 mEq/l. During intraoperatively as sole agent and as adjuvant with other
VE, the intra-abdominal pressure ranged between anesthetic agents for its excellent sedative, anxiolytic
13-15 mmHg with carbon dioxide flow of 3 L/min. and analgesic properties. Hypotension and bradycardia
The surgery was stopped and pneumoperitonium was are known cardiovascular effects of DEX. The incidence
decompressed, despite decompression, VE persisted. of bradycardia and hypotension is increased when DEX
The peak airway pressure decreased to 14 mmHg after is administered with drugs with negative chronotropic
decompression of pneumoperitonium. DEX infusion effects commonly used in operating room like propofol,
was stopped. After 15 minutes, VE diminished and suxamethonium, beta-adrenergic antagonist and
finally stopped. The surgical procedure was restarted anticholinesterase. Bradycardia exaggerated during
after creating pneumoperitonium to intra-abdonimal hypothermia or during vagotonic procedures such as
pressure between 13-14 mmHg and the surgery lasted laryngoscopy and following large or rapid bolus doses
for two-hours, no further VE were observed. At the of DEX.[5] DEX is reported to be useful for treatment
end of surgery, neuromuscular blockade was reversed and prevention of intra-operative and post-operative
with neostigmine 50 µg/kg and glycopyrrolate 10 µg/kg. tachyarrhythmias during cardiac surgery in pediatric
The trachea was extubated and the patient was shifted patients.[5,6] Chrysostomou et al.,[6] reported successful
to postoperative anesthesia care unit for monitoring. management of atrial and junctional tachyarrhythmias
Postoperatively, her 12 lead ECG was similar to the during perioperative period in congenital cardiac
preoperative one. She was shifted to ward in evening surgeries. LeReiger et al.,[5] also reported successful
and discharged on 3rd postoperative day. management of a case of junctional ectopic tachycardia
during tetralogy of Fallot repair with high doses of
The VEs are bizarre ECG complexes triggered by an dexmedetomidine. They described antiarrhythmic
ectopic focus. The incidence of VE in clinically normal properties of DEX as secondary to stimulation of
population is 1% as detected by a standard ECG α2A-adrenergic receptors in the dorsal motor nucleus
and 40-75% as detected by 24-48 hours ambulatory of the vagus nerve thereby increasing vagal efferent
ECG recordings.[1] The presence of more than 5 VE output to the myocardium. However, occurrence of VE
in one minute is said to increase cardiac risk in during perioperative infusion of intravenous DEX is
the perioperative period. [2] There is an increased not reported in literature.We are unable to explain the
potential for ventricular fibrillation or intraoperative mechanism of occurrence of VE in this case. However,
cardiac asystole.[2,3] Pre-existing heart disease is a after exclusion of all other known causes and temporal
known cause of perioperative cardiac arrhythmia. association of disappearance of VE with stopping of the
Laparoscopy and pneumoperitonium has been DEX infusion, we believe that DEX may be the cause
described to be associated with occurrence of sinus of intra-operative VE in our otherwise healthy patient.
tachycardia and VE due to release of catecholamines.[4]
Bradyarrhythmias (sinus bradycardia, atrio-ventricular Divya Srivastava, Sohan L. Solanki1,
dissociation and asystole) has also been described Krishna Pradhan, Prabhat K. Singh
in relation to laparoscopy and pneumoperitonium Department of Anaesthesiology, Sanjay Gandhi Postgraduate
due to vagal mediated cardiovascular reflexes, Institute of Medical Sciences, Lucknow, 1Anaesthesiology, Critical
Care and Pain, Tata Memorial Hospital, Parel, Mumbai, India
precipitated by stretching of peritoneum. [4] In the
Address for correspondence:
present case, VE persisted despite the decompression Dr. Sohan Lal Solanki,
of pneumoperitonium. Airway obstruction, hypoxia, Department of Anaesthesiology, Critical Care and Pain,
Tata Memorial Hospital, Parel, Mumbai, India.
hypercarbia, low inspiratory oxygen fraction, and E-mail: me_sohans@yahoo.co.in
inhalational agent halothane are associated with
occurrence of ventricular arrhythmias. [3] Light plane of REFERENCES
anesthesia and inadequate analgesia are other causes
of intra-operative VE and arrhythmias. [3] Depth of 1. Kennedy HL, Whitlock JA, Sprague MK, Kennedy LJ, Buckingham TA,
Goldberg RJ. Long-term follow-up of asymptomatic healthy subjects
anesthesia and analgesia were adequate in our patient with frequent and complex ventricular ectopy. N Engl J Med
as no increase in heart rate and blood pressure were 1985;312:193-7.
2. Goldman L, Caldera DL, Nussbaum SR, Southwick FS, Krogstad D, tachyarrhythmias during the perioperative period for congenital cardiac
Murray B, et al. Multifactorial index of cardiac risk in noncardiac surgical surgery: A preliminary study. Anesth Analg 2008;107:1514-22.
procedures. N Engl J Med 1977;297:845-51.
3. Ganny AS, Aguma SA. Intraoperative ventricular bigeminy: Report of
5 cases. Ann Afr Med 2005;4:72-82. Access this article online
4. Myles PS. Bradyarrhythmias and laparoscopy: A prospective study
Quick Response Code: Website:
of heart rate changes with laparoscopy. Aust N Z J Obstet Gynaecol
www.annals.in
1991;31:171-3.
5. LeRiger M, Naguib A, Gallantowicz M, Tobias JD. Dexmedetomidine PMID:
controls junctional ectopic tachycardia during Tetralogy of Fallot repair ***
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