Journal: AANA Journal 76(1):25-27, 2008. 10 References
Reprint: Louisiana State University Health Science Center School of Nursing, New Orleans, LA (MA Geisz-Everson, CRNA, MS) RO.02 JU0822/172 ©2008
Faculty Disclosure: Abstracted by R. Ouellette, who has nothing to disclose.
Asystole during laryngoscopy is an uncommon occurrence. It has been attributed to vagal reflexes, inadequate depth of anesthesia, and the use of vagotonic drugs. Pericardial effusion, an increased amount of pericardial fluid surrounding the heart, is a common feature in neoplastic diseases but occurs less frequently than pleural effusions. Malignant pleural effusion is a common life-threatening problem in patients with advanced malignancies including breast cancer. This case report is of a 53-year-old woman scheduled for surgical treatment of a pericardial and pleural effusion. She was diagnosed with breast cancer for which she received chemotherapy with the last dose 2 years before this hospitalization. Previously, she had been surgically treated for pericardial and pleural effusions without incident.
The patient was taken to the operating room and sedated with 2 mg of midazolam while femoral central lines were inserted. After preoxygenation anesthesia was induced with 500 mcg of fentanyl in divided doses: lidocaine 100 mg; etomidate 8 mg; and succinylcholine 120 mg. During insertion of the double-lumen endobronchial tube, the patient became asystolic and her central venous pressure and arterial line waveforms flattened. After removal of the laryngoscope, she returned to a normal sinus rhythm and normal blood pressure. A second attempt met with the same results. The patient was easily ventilated and given atropine 0.4 mg IV. When her heart rate began to increase, her trachea was intubated without difficulty or incident. A pericardial window and video-assisted thoracoscopy with talc pleurodesis was performed and her vital signs remained stable. At the end of the case, the anesthesia team and surgeon decided to ventilate the patient overnight in the ICU. The tube was exchanged for a single-lumen endotracheal tube without incident. The patient was tracheally extubated the next day without further complications.
When anesthetizing patients with malignant neoplasms and pericardial and/or pleural effusions, close monitoring of the cardiac rhythm is vital. These patients appear to have highly vagotonic functioning. When fentanyl or sympatholytic agents are administered, the patient may be at increased risk for bradyarrhythmias and asystole during laryngoscopy and vagal stimulating maneuvers. |
