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Tue Feb 26 14:18:45 GMT 2008

Very educative.  Is this a problem in epidural
anesthesia and particularly, for epidural pain control
also, like we trauma surgeons often request for rib
fractures?  If so, how long does the risk last,
because these patients may have an epidural catheter
for several days.

Sanjay

--- Ivan Hronek <ivanhronek at yahoo.com> wrote:

> That's all I got Yaghi..
> 
> Summary 
> While many factors can contribute to cardiac arrest
> during spinal anesthesia, vagal responses to
> hypovolemia often play a key role. It is well
> established that vagal responses can be triggered by
> decreases in preload. JB Pollard, Stanford.
>
http://www.apsf.org/resource_center/newsletter/2001/fall/04cardiac.htm
> 
> 
> 
> It is postulated that the etiology
> of the bradycardia and asystole might be
> a reflex mechanism such as the Bezold-Jarisch
> reflex (4). H.Hyderally, Mt. Sinai J Med. 1/2 2002.
> http://www.mssm.edu/msjournal/69/v69_1&2_055_056.pdf
> 
> 
> High levels of spinal or epidural blockade can
> produce severe hypotension. In a review of closed
> claims of patients who suffered perioperative
> cardiac arrest, a series of cases were identified
> that involved generally healthy patients undergoing
> spinal anesthesia.[178] Common features of these
> cases and subsequent case series[179] included high
> dermatomal levels of spinal anesthesia, liberal use
> of sedatives, and hypotension accompanied by
> bradycardia. The authors noted that adverse outcomes
> seemed to be associated with delays in recognition
> of the problem, delays in instituting airway support
> (particularly in sedated patients), and delays in
> administration of direct-acting combined á- and
> â-adrenergic agonists such as epinephrine. Although
> mild degrees of hypotension generally respond well
> to indirect-acting sympathomimetics such as
> ephedrine or incremental dosing of phenylephrine,
> the combination of severe hypotension and
> significant bradycardia under
>  spinal anesthesia should in most clinical settings
> be treated promptly with incremental dosing of
> epinephrine.
> (Miller textbook)
>   
> When properly conducted, spinal anesthesia has
> proved to be extremely safe. Caplan and
> associates[109] identified 14 cases of sudden
> cardiac arrest in healthy patients receiving spinal
> anesthesia. Because these cases seemed to appear
> suddenly after stable hemodynamic status, they
> concluded that a poorly understood potential exists
> for sudden cardiac arrest in healthy patients. It
> can be debated whether this represented a lack of
> vigilant monitoring and treatment as opposed to some
> mysterious physiologic explanation.[128] It is clear
> that hypoxemia and oversedation are not required for
> severe bradycardia and asystole to develop during
> well-conducted spinal anesthesia.[49][129] Likewise,
> it is clear that the development of severe
> brady-cardia after spinal anesthesia is not a new
> phenomenon but has been recognized for many
> years.[130][131] In any case, it should be
> emphasized that cardiovascular changes can occur
> rather suddenly after spinal anesthesia, and
>  as Auroy and colleagues[114] highlight, these
> events continue to occur. (Miller textbook)
> 
> 
> 128. Zornow MH, Scheller MS: Cardiac arrest during
> spinal anesthesia [letter].  Anesthesiology  1988;
> 68:970. 
> 129. Mackey DC, Carpenter RL, Thompson GE, et al:
> Bradycardia and asystole during spinal anesthesia: A
> report of three cases without morbidity. 
> Anesthesiology  1989; 70:866. 
> 130. Thompson KW: Fatalities from spinal anesthesia.
>  Anesth Analg  1934; 13:75. 
> 131. Wetstone DL, Wong KC: Sinus bradycardia and
> asystole during spinal anesthesia.  Anesthesiology 
> 1974; 41:87.
> 
> Ivan Hronek MD 
> SFMC, Los Angeles
> cell: 310 487-3288
> http://health.groups.yahoo.com/group/Anesthideas/
> Don't fight darkness. Bring the light, and darkness
> will disappear.
> Maharishi Mahesh Yogi
> 
> 
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>  
> 
> 
> 
> ----- Original Message ----
> From: aktham yaghi <yaktham at gmail.com>
> To: "Trauma &, Critical Care mailing list"
> <trauma-list at trauma.org>
> Sent: Monday, February 25, 2008 7:58:46 AM
> Subject: Re: cause of hypotension in shock/trauma
> 
> Ivan
> Then
> My question is why do you see bradycrdia with
> hypotension in spinal
> anaesthesia (Lumber L2-3) not due to the dose of
> local anaesthetics?
> Aktham Yaghi MD
> FNsP, Bratislava, Ruzinov- ICU- KAIM
> Clinic of Anaesthesia and Intensive Care Medicine
> Comenius University,Faculty of Medicine
> Ruzinovska 6
> 82606 Bratislava
> Slovak Republic
> yaktham at gmail.com
> 
> 2008/2/24 IVAN HRONEK <ih7 at msn.com>:
> 
> > Neurogenic shock is hypotension with or without
> bradycardia - depending on
> > the cause - in high spinal cord lesions they will
> be bradycardic as to the
> > interruption of cardiac sympathetic accelerators.
> In neurogenic shock due to
> > brain lesion or thoracic spine injury the
> bradycardia is not necessarily
> > present. The term is "relative bradycardia" i.e.
> heart rate not
> > appropriate to the degree of hypotension ..which
> your patient actually could
> > be told to have - a HR of 110/min in a young man
> with a barely palpable
> > pulse is certainly not a high enough reflex heart
> rate, you'd expect at
> > least 140 / min or so.
> > The problem with teaching about shock is that the
> bradycardia is the one
> > thing one can easily remember about spinal shock -
> however, it does not have
> > to be present and then everyone is surprised.
> > As dr. M. would say, a gentle clinician's touch is
> required here - this is
> > the time to use it  - the diff.dg is clinical and
> that is whether or not
> > the patient's skin is cold and clammy or warm and
> dry - hypovolemic vs.
> > neurogenic shock.
> >
> >
> >
> >
> >
> >
> >
> > Patients with neurogenic shock are hypotensive and
> usually have warm, dry
> > skin.8 Bradycardia is characteristic but not
> universal.
> > ...www.accessmedicine.com/content.aspx?aID=588768
> - Similar pages
> >
> >
> >
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>      
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Sanjay Gupta
Tel: 412 335 6304

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etiology of bradycardia in spinal