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Zhao Y, Wang J, Li M, Ma T, Zhang X, Xu X, Zeng M, Peng Y. The Influence of Trigeminocardiac Reflex on Postoperative Cardiac Adverse Events in Patients Undergoing Cerebellopontine Angle Tumor Resections: A Case-Control Study. World Neurosurg 2023; 172:e291-e298. [PMID: 36623723 DOI: 10.1016/j.wneu.2023.01.010] [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: 11/23/2022] [Revised: 01/02/2023] [Accepted: 01/03/2023] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To assess the potential impact of the trigeminocardiac reflex (TCR) on postoperative adverse cardiac events and to identify predictors of the TCR in cerebellopontine angle surgery. METHODS Patients undergoing elective cerebellopontine angle surgery from October 1, 2015, to September 30, 2020, were recruited consecutively for this retrospective case-control study. The TCR was evaluated by reviewing electronic anesthesia records and defined as a drop in heart rate was >20%. Controls were identified from the same retrospective cohort and matched by age, sex, and similar (±5 days) surgery date in the ratio of 1:2. RESULTS Of 2446 patients, 68 (2.78%) experienced TCR episodes. A total of 97 TCR episodes occurred among the 68 patients. In 2 TCR episodes, severe cardiac complications developed after surgery-myocardial injury in one case and cardiac arrest in the other case. The prevalence of adverse cardiovascular events was higher in the TCR group (60.3% vs. 36.0%, P = 0.001) than in the control group. The independent risk factor for the TCR in the multivariate condition logistic regression was tumor compression of the brainstem (odds ratio = 2.36, 95% confidence interval 1.40-3.95; P = 0.001). CONCLUSIONS Intraoperative TCR episodes seemed to be associated with postoperative adverse cardiac events in patients undergoing cerebellopontine angle surgery. Moreover, tumor compression of the brainstem might be a risk factor for TCR episodes.
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Affiliation(s)
- Yan Zhao
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Juan Wang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Muhan Li
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Tingting Ma
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xingyue Zhang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xin Xu
- Department of Anesthesiology, Cancer Hospital Chinese Academy of Medical Sciences, Beijing, China
| | - Min Zeng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuming Peng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
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Hydroxyzine Dihydrochloride Premedication Is a Necessity for Pediatric Patients Undergoing Strabismus Surgery: An Observational Prospective Clinical Trial. J Ophthalmol 2022; 2022:4137144. [PMID: 36189149 PMCID: PMC9519320 DOI: 10.1155/2022/4137144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 08/26/2022] [Accepted: 09/02/2022] [Indexed: 11/24/2022] Open
Abstract
Objective In this single-blind, observational prospective clinical trial, we aimed to determine and compare the effects of premedication with hydroxyzine plus midazolam and midazolam alone on the incidence of oculocardiac reflex (OCR). Methods Forty-five patients were divided into three groups. Group M received 0.5 mg/kg midazolam alone, Group H received 0.5 mg/kg hydroxyzine plus 0.5 mg/kg midazolam, and Group HM received 1 mg/kg hydroxyzine plus 0.5 mg/kg midazolam. The Ramsay Sedation Scale (RSS), the heart rates (HR1: after induction of anesthesia; HR2: before retraction of orbital muscle; and HR3: right after retraction of orbital muscle), the muscles with OCR, and the incidence of OCR (20% decrease of the HR right after the traction) were recorded and compared between the three groups. Results The mean HR1, HR2, and HR3 values were significantly increased (p=0.002, p < 0.001, p < 0.001) and the incidence of OCR (p=0.004) was significantly decreased in Group H and in Group HM (for all, p < 0.01) compared to Group M. The most common orbital muscle in which OCR occurred was the rectus medialis. Conclusion Premedication with a combination of 0.5 or 1 mg hydroxyzine with 0.5 mg midazolam significantly reduced the incidence of OCR compared to premedication with midazolam alone. This study was registered on https://clinicaltrials.gov/ with number NCT03806270.
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El Ouarradi A, Kantri A, Bensahi I, Merzouk F, Elkettani C, Mohamed S. Brain tumor revealed by atrial sinus block. LA TUNISIE MEDICALE 2021; 99:1192-1195. [PMID: 35288927 PMCID: PMC8974422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Bradycardia is rare in children and may be asymptomatic or cause fatigue or discomfort leading to syncope. It may be a warning sign of underlying pathology. A check-up for a cardiac or extra-cardiac organic cause should be performed. We report the case of an 8-year-old child admitted to the emergency room for bradycardia with a sino-atrial block that caused syncope. The assessment has objectified a brain tumor. We will discuss the different mechanisms that can explain the occurrence of bradycardia during a brain tumor, and the specificities of the management.
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Affiliation(s)
- Amal El Ouarradi
- 1-Department of cardiology, Cheikh Khalifa Hospital / Mohammed VI University of Health Sciences (UM6SS), Casablanca, Morocco
| | - Aziza Kantri
- 2-Department of Anastasia, Cheikh Khalifa Hospital / Mohammed VI University of Health Sciences (UM6SS), Casablanca, Morocco
| | - Ilham Bensahi
- 1-Department of cardiology, Cheikh Khalifa Hospital / Mohammed VI University of Health Sciences (UM6SS), Casablanca, Morocco
| | - Fatimazahra Merzouk
- 1-Department of cardiology, Cheikh Khalifa Hospital / Mohammed VI University of Health Sciences (UM6SS), Casablanca, Morocco
| | - Chafik Elkettani
- 2-Department of Anastasia, Cheikh Khalifa Hospital / Mohammed VI University of Health Sciences (UM6SS), Casablanca, Morocco
| | - Sabry Mohamed
- 1-Department of cardiology, Cheikh Khalifa Hospital / Mohammed VI University of Health Sciences (UM6SS), Casablanca, Morocco
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Ryan A, Gurney M, Steinbacher R. Suspected vagal reflex and hyperkalaemia inducing asystole in an anaesthetised horse. Equine Vet J 2021; 54:927-933. [PMID: 34738246 PMCID: PMC9543672 DOI: 10.1111/evj.13535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 08/26/2021] [Accepted: 10/18/2021] [Indexed: 12/02/2022]
Abstract
A 10‐year‐old 466 kg mustang gelding presented to an equine referral hospital for surgical repair of nasal, frontal and lacrimal bone fractures from an unknown trauma. Surgical repair was performed under general anaesthesia, including a right‐sided maxillary regional anaesthetic block with mepivacaine hydrochloride. Progressive hyperkalaemia was documented perianaesthetically (T‐3 mins; 134 mins after induction; potassium 6.4 mmol/L (ref 3.5‐5.1 mmol/L). Perianaesthetic bradycardia was attributed to alpha −2 agonist infusion administration, and other characteristic ECG changes (flattened P waves, narrow T waves of increased amplitude, prolonged QRS complex) were not documented. Asystole occurred 137 min after induction of anaesthesia; however, a review of the available literature suggests the degree of hyperkalaemia documented was unlikely to be the primary cause of asystole but may have been a contributing factor. It is hypothesised that a trigeminocardiac reflex was the primary contributory factor to asystole in the described case, and may represent a maxillomandibulocardiac reflex that has not been previously described in the horse.
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Affiliation(s)
- Aoife Ryan
- University of Veterinary Medicine, Vienna, Austria.,Anderson Moores Veterinary Specialists, Winchester, UK
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Sahu A, Koht AH. Unusual Manifestations of the Trigeminocardiac Reflex During Awake Craniotomy: A Case Report and Review of the Literature. A A Pract 2021; 15:e01508. [PMID: 34388136 DOI: 10.1213/xaa.0000000000001508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The trigeminocardiac reflex (TCR) is triggered by stimulation of a branch of the trigeminal nerve and results in vagally mediated bradycardia, hypotension, apnea, and gastrointestinal hypermotility. In the operating theatre, patients susceptible to TCR are typically under general anesthesia; thus, cardiac abnormalities are the most common manifestation. Our case highlights the less common intraoperative manifestations of gastric hypermotility and apnea in a patient undergoing awake craniotomy for tumor resection. Prompt recognition, removal of stimuli, and airway management prevented catastrophic complications while facilitating completion of the procedure.
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Affiliation(s)
- Anirban Sahu
- From the Department of Anesthesiology, Northwestern University, Chicago, Illinois
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Abstract
BACKGROUND A typical oculocardiac reflex (OCR) is a moderate trigemino-vagal bradycardia elicited by tension on an extraocular muscle (EOM) during strabismus surgery; however, many other orbital stimuli can elicit cardiac slowing including retinopathy of prematurity examination. METHODS World literature related to trigeminovagal and oculocardiac reflex covering over 15,000 patients including 51 randomized clinical trials and case reports are analyzed and reviewed. Under an ongoing observational trial in Alaska, anesthetic, patient and surgical influences on routine strabismus surgery using prospective, uniform EOM tension are compared seeking sufficient sample size to characterize this individually widely variable cardiac response. RESULTS With adequate sample size, and emphasizing clinical studies controlling type of EOM, muscle tension amount and duration, anticholinergic and opioid medications, the following augment OCR; rapid-acting opioids and dexmedetomidine while OCR is reduced in older patients, the right eye, less EOM tension, deeper inhaled agents, hypocarbia, anticholinergic medications and orbital block. In re-operations, the former are relatively poor predictors of subsequent OCR. CONCLUSION Profound bradycardia can occur in almost 10% of strabismus surgery cases without anticholinergic preventive measures, but reliable prediction of OCR remains elusive. With foreknowledge and careful anesthetic monitoring of the patient before EOM manipulation, residual adverse sequelae from OCR are fortunately very rare. Despite well over a century of experience, the teleology for this occasionally dramatic cardiac response to eye surgery is still not known.
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Affiliation(s)
- Robert W Arnold
- The Alaska OCR Study, Alaska Blind Child Discovery, Alaska Children’s EYE & Strabismus, Anchorage, AK, 99508, USA
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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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