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Wakita R, Aida J, Baba Y, Utsumi N, Nakayama A, Maeda S. Transient bradycardia during local anaesthesia to the oral cavity under intravenous sedation and its associate factors: a prospective observational study. BMC Oral Health 2024; 24:1165. [PMID: 39354469 PMCID: PMC11443804 DOI: 10.1186/s12903-024-04940-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Accepted: 09/20/2024] [Indexed: 10/03/2024] Open
Abstract
BACKGROUND Local anaesthesia in dental procedures is generally safe, although the occurrence of transient bradycardia (TB) has occasionally been reported. TB is often associated with two reflexes, the trigeminal cardiac reflex (TCR) and the vasovagal reflex (VVR) and is characterised by a rapid decrease in heart rate (HR) and blood pressure (BP). The prevalence of TCR is considered low, and its predictors have not been thoroughly investigated, although an association with the gag reflex has been suggested in recent years. METHODS This prospective study assessed TB occurrence during local anaesthesia and its potential associated factors. A comprehensive questionnaire was used to categorise discomforts during dental treatment, and various anxiety scales were used to measure patients' anxiety levels. We investigated HR variability during local anaesthesia administration under sedation and the association between the incidence of TB and gag reflex. Subsequently, logistic regression analysis was performed to assess factors associated with TB occurrence. RESULTS The prospective analysis included 188 patients of 234 initial patients. The analysis revealed a high TB incidence rate of 41% during local anaesthesia administration under sedation. No severe hypotensive events occurred, indicating a relatively benign nature of TB during local anaesthesia. TB occurrence was significantly higher in the group of patients with the gag reflex. Further analysis revealed that both gag reflex and trait anxiety were significantly associated with TB occurrence, whereas dental phobia did not directly correlate with TB. CONCLUSION This study highlights the prominent occurrence of TB during local anaesthesia in dental treatment, which is primarily attributed to TCR activation. The identification of gag reflex and trait anxiety as independent factors associated with TB development may pave the way for TB prevention measures. Further research is required to clarify the mechanisms of TCR and perform safer dental procedures under sedation. Future studies should also aim to elucidate the precise mechanisms underlying TB during local anaesthesia through direct measurements of neural activity. A better understanding of TB in dentistry is crucial for improving patient safety and optimising dental practice protocols.
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Affiliation(s)
- Ryo Wakita
- Department of Dental Anesthesiology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-Ku, Tokyo, 113-8549, Japan.
| | - Jun Aida
- Department of Oral Health Promotion, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-Ku, Tokyo, 113-8549, Japan
| | - Yukiko Baba
- Department of Dental Anesthesiology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-Ku, Tokyo, 113-8549, Japan
| | - Nozomi Utsumi
- Department of Dental Anesthesiology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-Ku, Tokyo, 113-8549, Japan
| | - Ayumu Nakayama
- Department of Dental Anesthesiology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-Ku, Tokyo, 113-8549, Japan
| | - Shigeru Maeda
- Department of Dental Anesthesiology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-Ku, Tokyo, 113-8549, Japan
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Wakita R, BaBa Y, Fukayama H, Maeda S. Factors associated with transient bradycardia during local anesthesia administration to the oral cavity under intravenous sedation: A retrospective cohort study. J Dent Sci 2024; 19:878-884. [PMID: 38618079 PMCID: PMC11010687 DOI: 10.1016/j.jds.2023.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 08/17/2023] [Indexed: 04/16/2024] Open
Abstract
Background/purpose The possibility of triggering the trigeminocardiac reflex (TCR) during oral surgery is considerably lower than that during other surgeries. A reduced heart rate (HR) of ≥20% from baseline is usually considered a diagnostical criterion for the TCR. Our automated anesthesia charting system often revealed cases of slight transient HR decrease during sedation. We aimed to explore its incidence and associated factors during local anesthesia administration under intravenous sedation. Materials and methods This study analyzed the data of 2636 cases that received infiltration anesthesia under intravenous sedation from 2008 to 2010 and had vital signs recorded using an automated anesthesia charting system. Especially, data concerning the average HR before anesthesia and the minimum HR between the initiation and end of anesthesia from anesthetic records were extracted. Moreover, data regarding patients' medical history and unusual reactions during dental treatment were collected. Multivariate logistic regression analysis was performed to identify factors associated with transient bradycardia (TB). Results TB occurred in 472 patients (17.9%); no patient developed hypotension or any associated symptoms, suggesting that intravenous sedation was effective in stabilizing vital signs. The factors associated with TB were younger age, gag reflex, and allergy to local anesthetics. There were no differences in sex, patient history, or dose of sedatives between patients with TB and those without TB. Conclusion The incidence of TB during infiltration anesthesia under sedation was found to be higher than that previously reported. Additionally, young age and gag reflex were identified as factors associated with bradycardia development.
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Affiliation(s)
- Ryo Wakita
- Department of Dental Anesthesiology and Orofacial Pain Management, Division of Oral Health Sciences, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yukiko BaBa
- Department of Dental Anesthesiology and Orofacial Pain Management, Division of Oral Health Sciences, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
| | - Haruhisa Fukayama
- Department of Dental Anesthesiology and Orofacial Pain Management, Division of Oral Health Sciences, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shigeru Maeda
- Department of Dental Anesthesiology and Orofacial Pain Management, Division of Oral Health Sciences, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
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Poe E, Bosley R, Steele R, Chesnut C. Trigeminocardiac Reflex: A Review and Key Implications to Dermatologic Surgery. Dermatol Surg 2023; 49:654-658. [PMID: 37134251 DOI: 10.1097/dss.0000000000003808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
BACKGROUND The trigeminocardiac reflex is a common but underreported occurrence that can vary from benign to life threatening. This reflex can be elicited by placing direct pressure on the globe of the eye or from traction of the extraocular muscles, stimulating the trigeminal nerve. OBJECTIVE To provide a review of potential stimuli for the trigeminocardiac reflex within dermatologic surgery and to discuss management options for the treatment of the trigeminocardiac reflex. METHODS PubMed and Cochrane were used to identify articles and case reports that established scenarios in which the trigeminocardiac reflex was provoked and subsequently how the reflex was managed. RESULTS Within the field of dermatologic surgery, the trigeminocardiac reflex can be stimulated during biopsies, cryoablations, injections, laser treatments, Mohs micrographic surgery, and oculoplastic interventions, most often occurring in an office setting. The most common presentations include significant bradycardia, hypotension, gastric hypermobility, and lightheadedness. The most definitive treatment is cessation of the inciting stimulus, monitoring, and symptomatic management. Glycopyrrolate and atropine are common treatments for severe, intractable cases of the trigeminocardiac reflex. CONCLUSION The trigeminocardiac reflex, while underreported and underrepresented in dermatologic literature and dermatologic surgery settings, should be considered in the setting of bradycardia and hypotension during dermatologic procedures.
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Affiliation(s)
- Emily Poe
- Washington State University College of Medicine, Spokane, Washington
| | - Rawn Bosley
- Chesnut MD Cosmetic Surgery Fellowship, Spokane, Washington
| | - Robert Steele
- Chesnut MD Cosmetic Surgery Fellowship, Spokane, Washington
| | - Cameron Chesnut
- University of Washington School of Medicine, Seattle, Washington
- Chesnut MD Cosmetic Surgery Fellowship, Spokane, Washington
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Khalifa GA, Abd-Elmoniem MF, Mohamed FI. The trigeminocardiac reflex: Does the activation pathway of its efferent arc affect the intensity of the hemodynamic drop during the management of maxillofacial fractures? J Craniomaxillofac Surg 2021; 49:394-402. [PMID: 33632536 DOI: 10.1016/j.jcms.2021.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 11/18/2020] [Accepted: 02/07/2021] [Indexed: 10/22/2022] Open
Abstract
The study aimed to correlate between the stimulated nerve, intensity of trigeminovagal reflex (TVR), and neuropathophysiological pathway by which the efferent arc is activated. Material and methods: A retrospective study included patients who developed TVR during the surgical management of mandibular, midface, and orbital fractures. The reflex was divided into type I, II, III, and IV-TVR according to the following nerves: ophthalmic, maxillary, mandibular, and non-trigeminal nerves, respectively. The magnitude of hemodynamic drops was identified at the intraoperative baseline, during reflex, and postoperatively. The needed time to elicit the reflex, frequency and duration, need for medical intervention, and sequence of the drop were also recorded. P - values < 0.05 was considered significant. Out of 260 patients' files were reviewed, the TVR was observed in only 30 (11.55 %) patients. The ophthalmic nerve activation significantly caused the greatest intensity and magnitude of hemodynamic drop, followed by maxillary nerve, then mandibular division, and the lowest one was non-trigeminal nerves. The highest mean of drops in the mean arterial blood pressure (MABP) was 62.92 ± 2.39 with the type ITVR, whereas those of the type II, III, and IV were 75.5 ±3.98, 81.02±1.31, and 82.22±1.85, respectively. Also, the type I-TVR led to the greatest decrease in the heart rate (HR) with the mean equaled to 52.31± 3.91. The drop percentage in the MABP was -30.5, -17.5, -12, -10.08 for type I, II, III, and IV, whereas those of the HR were - 33.9, -27.13, -26.6, and -25 with type I, II, III, and IV, respectively. All results showed highly significant differences with p-values less than 0.001 when comparing between the baseline and intraoperative values of each TVR type. There is a positive correlation between the activated pathway of the TVR and the intensity of its efferent arc response due to the neural pathway of each division in the brainstem circuitry. Understanding of the pathophysiology and mechanism of the TVR, together with the rapid recognition and treatment could prevent serious negative outcomes, especially when the ophthalmic nerve is stimulated. 1Introduction.
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Affiliation(s)
- Ghada Amin Khalifa
- Maxillofacial Surgery and Diagnostic Science, College of Dentistry, Qassim University, Saudi Arabia; Dental Medicine for Girls, Al Azhar University, 11727, Nasr City, Cairo, Egypt.
| | - Manal Foad Abd-Elmoniem
- Anaesthesia, Intensive Care, and Pain, Faculty of Medicine for Girls, Al Azhar University, 11727, Nasr City, Cairo, Egypt.
| | - Fatma Ibrahim Mohamed
- Oral and Maxillofacial Surgery, Faculty of Dentistry, Deraya University, Minya, Egypt; Dental Medicine for Girls, Al Azhar University, 11727, Nasr City, Cairo, Egypt.
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Wang W, Cai H, Ding H, Xu X. Case report: 2 cases of cardiac arrest caused by rhino-cardiac reflex while disinfecting nasal cavity before endonasal transsphenoidal endoscopic pituitary surgery. BMC Anesthesiol 2021; 21:18. [PMID: 33441081 PMCID: PMC7805189 DOI: 10.1186/s12871-021-01240-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 01/10/2021] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Trigeminal-cardiac reflex (TCR) is a brainstem vagus reflex that occurs when any center or peripheral branch of the trigeminal nerve was stimulated or operated on. The typical clinical manifestation is sudden bradycardia with or without blood pressure decline. The rhino-cardiac reflex which is one type of TCR is rare in clinical practice. As the rhino-cardiac reflex caused by disinfection of the nasal cavity is very rare, we report these two cases to remind other anesthesiologists to be vigilant to this situation. CASE PRESENTATION This case report describes two cases of cardiac arrest caused by rhino-cardiac reflex while disinfecting nasal cavity before endoscopic transsphenoidal removal of pituitary adenomas. Their heart rate all dropped suddenly at the very moment of nasal stimulation and recovered quickly after stimulation was stopped and the administration of drugs or cardiac support. CONCLUSION Although the occurrence of rhino-cardiac reflex is rare, we should pay attention to it in clinical anesthesia. It is necessary to know the risk factors for preventing it. Once it occurs, we should take active and effective rescue measures to avoid serious complications.
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Affiliation(s)
- Wen Wang
- Department of Anaesthesiology, Xiangya Hospital Central South University, Changsha, 410008, Hunan, China
| | - Hongwei Cai
- Department of Anaesthesiology, Xiangya Hospital Central South University, Changsha, 410008, Hunan, China
| | - Huiping Ding
- Department of Anaesthesiology, Xiangya Hospital Central South University, Changsha, 410008, Hunan, China
| | - Xiaoping Xu
- Department of Anaesthesiology, Xiangya Hospital Central South University, Changsha, 410008, Hunan, China.
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Autonomic reflex effect of the inferior turbinate outfracture or bipolar cauterization inferior turbinate reduction surgery. Eur Arch Otorhinolaryngol 2021; 278:1899-1906. [PMID: 33386965 DOI: 10.1007/s00405-020-06508-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 11/17/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE To compare the autonomic reflexes caused by inferior turbinate outfracture or bipolar cauterization for inferior turbinate reduction surgery. METHODS The investigators designed and implemented a prospective study composed of 80 patients who underwent a septoplasty with inferior turbinate reduction. The predictor variable was the type of bilateral reduction operation and included inferior turbinate outfracture with a freer elevator and 20 watts bipolar cauterization for 15 s per side after septoplasty. The primary outcome variable was the intraoperative changes of the heart rate monitored preoperatively and 20 s, 1 min, and 4 min after the turbinate reduction procedure. Other variables were systolic and diastolic blood pressure alterations after the inferior turbinate outfracture or bipolar cauterization procedure. Descriptive and bivariate statistics were computed and the P-value was set at .05. RESULTS The sample was composed of 160 procedures in 80 patients grouped as follows: Outfracture (n = 100) and Cauterization (n = 60). There were no significant differences between the ages; grades of the turbinate hypertrophy; preoperative heart rates; and intraoperative 4th-minute heart rates, systolic and diastolic blood pressures. However, baseline systolic (p < 0.001) and diastolic (p < 0.001) blood pressures of the bipolar cauterization group were higher than outfracture group. Bipolar cauterization did not cause any significant changes in the heart rate, systolic and diastolic blood pressures. Inferior turbinate outfracture procedure caused a significant increase in heart rate (65.4 ± 9.82, p < 0.001), systolic (103 ± 8.62, p < 0.001) and diastolic (63.5 ± 7.37, p < 0.001) blood pressures. CONCLUSION The results of this study suggest that during the inferior turbinate outfracture procedure, it is important to closely monitor sympathetic and parasympathetic reflexes. The surgeon, and anesthesiologist, must be aware of the early stages of the autonomic reflexes during turbinate reduction.
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Leon-Ariza DS, Leon-Ariza JS, Nangiana J, Vargas Grau G, Leon-Sarmiento FE, Quiñones-Hinojosa A. Evidences in Neurological Surgery and a Cutting Edge Classification of the Trigeminocardiac Reflex: A Systematic Review. World Neurosurg 2018; 117:4-10. [DOI: 10.1016/j.wneu.2018.05.208] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Accepted: 05/28/2018] [Indexed: 11/24/2022]
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Huang JIS, Chang HH, Lin CP, Liao WC, Kao CT, Huang TH. Trigeminocardiac reflex during non-surgical root canal treatment of teeth with irreversible pulpitis. J Formos Med Assoc 2017; 117:512-517. [PMID: 28728750 DOI: 10.1016/j.jfma.2017.05.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 05/15/2017] [Accepted: 05/17/2017] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND/PURPOSE Trigeminocardiac reflex (TCR) is a unique clinical incident of acute change in hemodynamic balance, which may lead to hypotension, bradycardia, and even clinical crisis. Up to date, no study so far considers the impact of non-surgical root canal treatment (NSRCT) of irreversible pulpitis teeth under either local infiltration or block anesthesia on hemodynamic change possibly related to TCR. METHODS This study enrolled 111 patients with 138 irreversible pulpitis teeth that were treated by two sessions of NSRCT. The first session involved mainly the removal of vital pulp tissue with the direct stimulation of the dental branches of the trigeminal nerve, and the second session included the root canal enlargement and debridement with minimal disturbance to the dental branches of the trigeminal nerve. Vital signs mainly the blood pressure were recorded during both NSRCT sessions. RESULTS The incidences of NSRCT patients with MABP decrease ≧10%, ≧15%, or ≧20% were all significantly higher in the first NSRCT session than in the second NSRCT session (all the P-values < 0.001). In the first NSRCT session, the incidence of patients with MABP decrease ≧10% was significantly associated with tooth type. For both upper and lower teeth, the patients with premolars treated by NSRCR had significantly higher incidences of MABP decrease ≧10% than those with either anterior or molar teeth treated by NSRCR (all the P-values < 0.05). CONCLUSION We conclude that vital pulp extirpation may lead to a substantial drop in patient's blood pressure possibly related to TCR.
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Affiliation(s)
- James I-Sheng Huang
- School of Dentistry, College of Oral Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Hao-Hueng Chang
- Graduate Institute of Clinical Dentistry, School of Dentistry, National Taiwan University, Taipei, Taiwan; Department of Dentistry, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chun-Pei Lin
- Graduate Institute of Clinical Dentistry, School of Dentistry, National Taiwan University, Taipei, Taiwan; Department of Dentistry, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Wan-Chuen Liao
- Graduate Institute of Clinical Dentistry, School of Dentistry, National Taiwan University, Taipei, Taiwan; Department of Dentistry, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chia-Tze Kao
- School of Dentistry, College of Oral Medicine, Chung Shan Medical University, Taichung, Taiwan; Department of Oral Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Tsui-Hsien Huang
- School of Dentistry, College of Oral Medicine, Chung Shan Medical University, Taichung, Taiwan; Department of Oral Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan.
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Sandu N, Chowdhury T, Meuwly C, Schaller B. Trigeminocardiac reflex in cerebrovascular surgery: a review and an attempt of a predictive analysis. Expert Rev Cardiovasc Ther 2017; 15:203-209. [DOI: 10.1080/14779072.2017.1286983] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Nora Sandu
- Department of Research, University of Southampton, Southampton, UK
| | - Tumul Chowdhury
- Department of Anesthesiology and Perioperative Medicine, University of Manitoba (UOM)/Winnipeg Regional Health Authority (WRHA), Winnipeg, Manitoba, Canada
| | | | - Bernhard Schaller
- Department of Research, University of Southampton, Southampton, UK
- Department of Pathology, University of Buenos Aires, Buenos Aires, Argentina
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Chowdhury T, Nöthen C, Filis A, Sandu N, Buchfelder M, Schaller B. Functional Outcome Changes in Surgery for Pituitary Adenomas After Intraoperative Occurrence of the Trigeminocardiac Reflex: First Description in a Retrospective Observational Study. Medicine (Baltimore) 2015; 94:e1463. [PMID: 26376385 PMCID: PMC4635799 DOI: 10.1097/md.0000000000001463] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Trigeminocardiac reflex (TCR) represents now a nearly ubiquitary phenomenon in skull base surgery. Functional relevance of the intrainterventional TCR occurrence is hitherto only proven for vestibular schwannoma. In a retrospective observational study, 19 out of 338 (8%) enrolled adult patients demonstrated a TCR during transsphenoidal/transcranial surgery for pituitary adenomas. The 2 subgroups (TCR vs non-TCR) had similar patient's characteristics, risk factors, and histology. Preoperatively, there was a similar distribution of normal pituitary function in the TCR and non-TCR subgroups. In this TCR subgroup, there was a significant decrease of that normal pituitary function after operation (37%) compared to the non-TCR group (60%) (P < 0.03). The TCR subgroup therefore demonstrated a 3.15 times (95%CI 1.15-8.68) higher risk for non-normalizing of postoperative pituitary function compared with the non-TCR subgroup (P < 0.03). It is presented, for the first time, an impact of TCR on the functional hormonal outcome after pituitary surgery and strongly underline again the importance of the TCR in clinical daily practice. As a consequence, TCR should be considered as a negative prognostic factor of hormonal normalization after surgery for pituitary adenomas that should be included into routine practice.
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Affiliation(s)
- T Chowdhury
- From the Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, Canada (CT); Department of Neurosurgery, University of Erlangen-Nuremberg, Germany (NC, FA, BM), and Department of Research, University of Southampton, Southampton, UK (SN, SB)
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Lemaitre F, Chowdhury T, Schaller B. The trigeminocardiac reflex - a comparison with the diving reflex in humans. Arch Med Sci 2015; 11:419-26. [PMID: 25995761 PMCID: PMC4424259 DOI: 10.5114/aoms.2015.50974] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Revised: 05/03/2013] [Accepted: 06/30/2013] [Indexed: 12/21/2022] Open
Abstract
The trigeminocardiac reflex (TCR) has previously been described in the literature as a reflexive response of bradycardia, hypotension, and gastric hypermotility seen upon mechanical stimulation in the distribution of the trigeminal nerve. The diving reflex (DR) in humans is characterized by breath-holding, slowing of the heart rate, reduction of limb blood flow and a gradual rise in the mean arterial blood pressure. Although the two reflexes share many similarities, their relationship and especially their functional purpose in humans have yet to be fully elucidated. In the present review, we have tried to integrate and elaborate these two phenomena into a unified physiological concept. Assuming that the TCR and the DR are closely linked functionally and phylogenetically, we have also highlighted the significance of these reflexes in humans.
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Affiliation(s)
- Frederic Lemaitre
- Faculty of Sports Sciences, University of Rouen, Mont-Saint-Aignan, France
| | - Tumul Chowdhury
- Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, Canada
| | - Bernhard Schaller
- Department of Neurosurgery, University Hospital Paris, Paris, France
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Meuwly C, Golanov E, Chowdhury T, Erne P, Schaller B. Trigeminal cardiac reflex: new thinking model about the definition based on a literature review. Medicine (Baltimore) 2015; 94:e484. [PMID: 25654391 PMCID: PMC4602726 DOI: 10.1097/md.0000000000000484] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Trigeminocardiac reflex (TCR) is a brainstem reflex that manifests as sudden onset of hemodynamic perturbation in blood pressure (MABP) and heart rate (HR), as apnea and as gastric hypermotility during stimulation of any branches of the trigeminal nerve. The molecular and clinical knowledge about the TCR is in a constant growth since 1999, what implies a current need of a review about its definition in this changing context. Relevant literature was identified through searching in PubMed (MEDLINE) and Google scholar database for the terms TCR, oculocardiac reflex, diving reflex, vasovagale response. The definition of the TCR varies in clinical as well as in research studies. The main difference applies the required change of MABP and sometimes also HR, which most varies between 10% and 20%. Due to this definition problem, we defined, related to actual literature, 2 major (plausibility, reversibility) and 2 minor criteria (repetition, prevention) for a more proper identification of the TCR in a clinical or research setting. Latest research implies that there is a need for a more extended classification with 2 additional subgroups, considering also the diving reflex and the brainstem reflex. In this review, we highlighted criteria for proper definition and classification of the TCR in the light of increased knowledge and present a thinking model to overcome this complexity. Further we separately discussed the role of HR and MABP and their variation in this context. As another subtopic we gave attention to is the chronic TCR; a variant that is rarely seen in clinical medicine.
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Affiliation(s)
- C Meuwly
- From the University of Basel, Switzerland (CM); The Houston Methodist Research Institute, Houston, Texas, USA (EG); Department of Anesthesia and Perioperative Medicine. University of Manitoba, Winnipeg, Canada (TC); Cardiology, St Anna Clinic, Luzern, Switzerland and University of Basel, Switzerland (PE); Department of Research, University of Southampton, United Kingdom (BS); and Academic Editor, Medicine (BS)
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Rossi R, Lodise M, Lancia M, Bacci M, De-Giorgio F, Cascini F. Trigemino-Cardiac Reflex as Lethal Mechanism in a Suicidal Fire Death Case. J Forensic Sci 2014; 59:833-5. [DOI: 10.1111/1556-4029.12408] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Revised: 02/04/2013] [Accepted: 04/21/2013] [Indexed: 11/28/2022]
Affiliation(s)
- Riccardo Rossi
- Institute of Legal Medicine; Catholic University of the Sacred Heart; Largo Francesco Vito, 1 00168 Rome Italy
| | - Maria Lodise
- Institute of Legal Medicine; Catholic University of the Sacred Heart; Largo Francesco Vito, 1 00168 Rome Italy
| | - Massimo Lancia
- Section of Legal Medicine; University of Perugia; via del Giochetto, snc 06126 Perugia Italy
| | - Mauro Bacci
- Section of Legal Medicine; University of Perugia; via del Giochetto, snc 06126 Perugia Italy
| | - Fabio De-Giorgio
- Institute of Legal Medicine; Catholic University of the Sacred Heart; Largo Francesco Vito, 1 00168 Rome Italy
| | - Fidelia Cascini
- Institute of Legal Medicine; Catholic University of the Sacred Heart; Largo Francesco Vito, 1 00168 Rome Italy
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Chowdhury T, Sandu N, Meuwly C, Cappellani RB, Schaller B. Trigeminocardiac reflex: differential behavior and risk factors in the course of the trigeminal nerve. FUTURE NEUROLOGY 2014. [DOI: 10.2217/fnl.13.62] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
ABSTRACT; The trigeminocardiac reflex (TCR) is a brainstem reflex describing the acute hemodynamic perturbations in neurosurgical patients. The roles of different anatomic locations of this reflex arc on end responses have been found to be variable. In this article, we have highlighted the role and importance of different TCR pathway (peripheral vs central) mechanisms, their manifestations and the various risk factors associated with these. In addition, new insights into various other non-neurosurgical conditions, in special relation to neurointerventional procedures, are also presented in this article. This study is a narrative review based on a PubMed/Google search (from 1 January 1970 to 31 March 2013) on this topic. The common manifestations, such as hypotension and bradycardia, are vagal-dominated responses; however, unusual manifestations, such as hypertension and tachycardia, signify the involvement of the sympathetic nervous system. In addition, there is a complex interaction of the various sensory receptors at the Gasserian ganglion, and this is responsible for the different presentations. There are many surgical as well as nonsurgical risk factors associated with TCR. Interestingly, TCR may affect functional outcome and has been found to be involved in some normal physiological mechanisms, including bruxism. TCR is a complex neurophysiological reflex and there are variable presentations depending upon the peripheral or central stimulation surrounding the Gasserian ganglion. We suggest, for the first time, that if the TCR is initiated at the Gasserian ganglion, it reacts in a different manner from the better-known central or peripheral TCR.
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Affiliation(s)
- Tumul Chowdhury
- Department of Anesthesia & Perioperative Medicine, University of Manitoba, 820 Sherbrook Street, Winnipeg, MB R3A 1R9, Canada
| | - Nora Sandu
- Research University of Southampton, South Academic Block, Tremona Road, Southampton, SO16 6YD, UK
| | - Cyrill Meuwly
- University of Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Ronald B Cappellani
- Department of Anesthesia & Perioperative Medicine, University of Manitoba, 820 Sherbrook Street, Winnipeg, MB R3A 1R9, Canada
| | - Bernhard Schaller
- Research University of Southampton, South Academic Block, Tremona Road, Southampton, SO16 6YD, UK
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Chowdhury T, Sandu N, Sadr-Eshkevari P, Meuwly C, Schaller B. Trigeminocardiac reflex: current trends. Expert Rev Cardiovasc Ther 2013; 12:9-11. [PMID: 24308808 DOI: 10.1586/14779072.2014.862498] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Since the first introduction of the trigeminocardiac reflex (TCR) in 1999, substantial new knowledge about this brainstem reflex has been created. First, by different clinical case reports and case studies, and second, from basic research that gives inputs from bench to bedside. In the present work, the authors therefore introduce the molecular/anatomical knowledge of the TCR and show its different connections to clinical aspects. Special reference is given to prevention and treatment of the TCR; but always with a link to knowledge of the basis sciences. In such a context different topics of future interest are introduced.
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Affiliation(s)
- Tumul Chowdhury
- Department of Anesthesiology and Perioperative Medicine, University of Manitoba, Winnipeg, Canada
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Amirjamshidi A, Abbasioun K, Etezadi F, Ghasemi SB. Trigeminocardiac reflex in neurosurgical practice: Report of two new cases. Surg Neurol Int 2013; 4:126. [PMID: 24233130 PMCID: PMC3815044 DOI: 10.4103/2152-7806.119053] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Accepted: 08/13/2013] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Systemic hypotension, cardiac dysrhythmia especially bradycardia, apnea, and gastric hypermotility occurring presumably after stimulation of any of the sensory branches of trigeminal nerve are coined as trigeminocardiac reflex (TCR). Neither enough is known about the predisposing factors in relation with the intraoperative occurrence of this life threatening reflex, nor about the exact pathophysiology of its brain stem pathway. ENCOUNTERING TWO CASES OF BRADYCARDIA AND HYPOTENSION DURING SURGERY ENCOURAGED THE AUTHORS TO: (1) report these two cases and review similar reports in the relevant literature, (2) discuss the suggested mechanisms for such an event, and (3) report the result of a prospective cohort of precisely checked cases in a sister article, to remind the younger neurosurgical community of a possible and bothering even mortal, but avoidable complication in their everyday practice. CASE DESCRIPTION The first case was a 71-year-old male who developed bradycardia and hypotension while packing his large sella tursica with autologous fat after removing a large nonfunctional pituitary adenoma transsphenoidally to prevent cerebrospinal fluid leakage. The changes in his vital signs were detected and controlled rapidly. The second case was a 52-year-old female who underwent right pterional craniotomy for right clinoidal meningioma. She developed severe bradycardia and hypotension after skin closure completed and just when the subgaleal drain was connected to the aspirating bag and negative pressure maintained in the subgaleal region. Both cases could be managed successfully after on time detection of such life threatening complication and proper management. CONCLUSION WE DO NOT INTEND ONLY TO ADD TWO NEW CASES OF TCR OCCURRING IN THE PERIOPERATIVE PERIOD IN NEUROSURGICAL PRACTICE, BUT WE WISH TO RAISE THE QUESTION: (a) what could be the predisposing factors for development of such issue for better handling of the problem and (b) stress upon careful continuous mapping of the vital signs during surgery and even till very late after operation.
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17
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Bhargava D, Thomas S, Chakravorty N, Dutt A. Trigeminocardiac Reflex: A Reappraisal with Relevance to Maxillofacial Surgery. J Maxillofac Oral Surg 2013. [PMID: 26224999 DOI: 10.1007/s12663-013-0541-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
PURPOSE The purpose of this paper was to undertake a review of literature on trigeminocardiac reflex in oral and maxillofacial online data-base and discuss the pathophysiology, risk factor assessment, presentation of the reflex, prevention, management with emphasis on the role of the attending anaesthetist and the maxillofacial surgeon. MATERIALS AND METHODS The available literature relevant to oral and maxillofacial surgery in online data-base of the United States National Library of Medicine: Pubmed (http://www.ncbi.nlm.nih.gov/pubmed/) was searched. The inclusion criterion was to review published clinical papers, abstracts and evidence based reviews on trigeminocardiac reflex relevant to oral and maxillofacial surgery. RESULTS Sixty-five articles were found with the search term "trigeminocardiac reflex" in the literature searched. Eighteen articles met the inclusion criteria for this study. The relevant data was extracted, tabulated and reviewed to draw evidence based conclusions for the management of trigeminocardiac reflex. CONCLUSIONS Conclusions were drawn and discussed based on the reviewed maxillofacial literature with emphasis on the anaesthetist's and the surgeon's role in the management of this detrimental event in maxillofacial surgical practice.
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Affiliation(s)
- Darpan Bhargava
- Department of Oral and Maxillofacial Surgery, Peoples College of Dental Sciences and Research Center, Peoples University, Bhanpur, Bhopal, M.P. India
| | - Shaji Thomas
- Department of Oral and Maxillofacial Surgery, Peoples College of Dental Sciences and Research Center, Peoples University, Bhanpur, Bhopal, M.P. India
| | - Nupur Chakravorty
- Department of Anesthesiology, L.N Medical College and Research Center and J.K Hospital, J.K Town, Sarvdharm C-Sector, Kolar Road, Bhopal, M.P. India
| | - Ashutosh Dutt
- Department of Oral and Maxillofacial Surgery, Peoples College of Dental Sciences and Research Center, Peoples University, Bhanpur, Bhopal, M.P. India
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Radvansky BM, Husain Q, Cherla DV, Choudhry OJ, Eloy JA. In-office vasovagal response after rhinologic manipulation. Int Forum Allergy Rhinol 2012. [PMID: 23193039 DOI: 10.1002/alr.21121] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Advances in endoscopic sinus surgery have led to a greater number of in-office procedures away from the traditional operating room setting. Rhinologists acting independently of anesthesiologists must be prepared for potential complications, such as vasovagal response (VVR), that may arise during in-office rhinologic manipulations. In this study, we review our experience with this condition and discuss risk factors and a management algorithm for in-office VVR. METHODS A retrospective analysis at a large tertiary referral center was performed on all patients undergoing in-office endoscopic procedures with rhinologic manipulation between July 2008 and June 2012. A total of 4973 patients underwent in-office endoscopic procedures and 8 patients with VVR were identified. Demographic data, diagnosis, procedure performed, and outcomes were reviewed. RESULTS Eight patients out of 4973 (0.16%) experienced VVR during in-office endoscopic procedures. Seven (87.5%) of these 8 patients recovered from the VVR within 30 minutes and subsequently completed their scheduled procedure. One (12.5%) of the 8 patients did not fully recover after 30 minutes and was sent to the Emergency Department, where he was stabilized and subsequently discharged. The most common comorbidities in these 8 patients with VVR were hypercholesterolemia in 3 patients (37.5%), and hypertension and benign prostatic hyperplasia, each found in 2 patients (25.0%). CONCLUSION Although the incidence of VVR during rhinologic procedures is low, rhinologists should be familiar with this condition and be prepared for its management.
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Affiliation(s)
- Brian M Radvansky
- Department of Otolaryngology-Head and Neck Surgery, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark, NJ 07103, USA
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