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Sato K, Miyamae Y, Kan M, Sato S, Yaegashi M, Sakanoue W, Sakai H, Sakamoto S, Vaba K. Accelerated Idioventricular Rhythm Following Intraoral Local Anesthetic Injection During General Anesthesia. Anesth Prog 2021; 68:230-234. [PMID: 34911065 PMCID: PMC8674851 DOI: 10.2344/anpr-68-03-09] [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: 05/23/2021] [Accepted: 07/01/2021] [Indexed: 11/11/2022] Open
Abstract
Some anesthetic agents or adjunct medications administered during general anesthesia can cause an accelerated idioventricular rhythm (AIVR), which is associated with higher vagal tone and lower sympathetic activity. We encountered AIVR induced by vagal response to injection-related pain following local anesthetic infiltration into the oral mucosa during general anesthesia. A 48-year-old woman underwent extraction of a residual tooth root from the left maxillary sinus under general anesthesia. Routine preoperative electrocardiogram (ECG) was otherwise normal. Eight milliliters of 1% lidocaine (80 mg) with 1:100,000 epinephrine (80 μg) was infiltrated around the left maxillary molars over 20 seconds using a 23-gauge needle and firm pressure. Widened QRS complexes consistent with AIVR were observed for ∼60 seconds, followed by an atrioventricular junctional rhythm and the return of normal sinus rhythm. A cardiology consultation and 12-lead ECG in the operating room produced no additional concerns, so the operation continued with no complications. AIVR was presumably caused by activation of the trigeminocardiac reflex triggered by intense pain following rapid local anesthetic infiltration with a large gauge needle and firm pressure. Administration of local anesthetic should be performed cautiously when using a large gauge needle and avoid excessive pressure.
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Affiliation(s)
- Kenichi Sato
- Division of Dental Anesthesiology, Department of Reconstructive Oral and Maxillofacial Surgery, School of Dentistry, Iwate Medical University, Morioka, Iwate, Japan
| | - Yoshihisa Miyamae
- Division of Dental Anesthesiology, Department of Reconstructive Oral and Maxillofacial Surgery, School of Dentistry, Iwate Medical University, Morioka, Iwate, Japan
| | - Miwako Kan
- Division of Dental Anesthesiology, Department of Reconstructive Oral and Maxillofacial Surgery, School of Dentistry, Iwate Medical University, Morioka, Iwate, Japan
| | - Shu Sato
- Division of Dental Anesthesiology, Department of Reconstructive Oral and Maxillofacial Surgery, School of Dentistry, Iwate Medical University, Morioka, Iwate, Japan
| | - Motoi Yaegashi
- Division of Dental Anesthesiology, Department of Reconstructive Oral and Maxillofacial Surgery, School of Dentistry, Iwate Medical University, Morioka, Iwate, Japan
| | - Wakana Sakanoue
- Division of Dental Anesthesiology, Department of Reconstructive Oral and Maxillofacial Surgery, School of Dentistry, Iwate Medical University, Morioka, Iwate, Japan
| | - Hiroyuki Sakai
- Joto Dental Clinic, Medical Corporation Hojukai, Akita, Japan
| | - Souhei Sakamoto
- Joto Dental Clinic, Medical Corporation Hojukai, Akita, Japan
| | - Kazuki Vaba
- Okamura Dental Clinic, Morioka, Iwate, Japan
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DesRoches JM, McKeen DM, Warren A, Allen VM, George RB, Kells C, Shukla R. Anesthetic Management Guided by Transthoracic Echocardiography During Cesarean Delivery Complicated by Hypertrophic Cardiomyopathy. ACTA ACUST UNITED AC 2016; 6:154-9. [PMID: 26720049 DOI: 10.1213/xaa.0000000000000275] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We describe the management of a parturient woman with hypertrophic cardiomyopathy who developed a symptomatic accelerated idioventricular rhythm who required an urgent cesarean delivery at 32 weeks. Transthoracic echocardiography helped guide anesthetic management, including epidural dosing, fluid management, and phenylephrine infusion rates. This case demonstrates the application of transthoracic echocardiography to guide anesthetic management in a parturient woman at risk for cardiovascular compromise.
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Affiliation(s)
- Jaclyn M DesRoches
- From the *Department of Women's & Obstetric Anesthesia, IWK Health Centre, Halifax, Nova Scotia, Canada; †Department of Pediatric Cardiology, IWK Health Centre, Halifax, Nova Scotia, Canada; ‡Department of Obstetrics and Gynaecology, Dalhousie University, Halifax, Nova Scotia, Canada; and §Division of Cardiology, Dalhousie University, Halifax, Nova Scotia, Canada
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Nakanishi M, Masumo K, Oota T, Kato T, Imanishi T. Accelerated idioventricular rhythm observed under total intravenous anesthesia using remifentanil, propofol, and rocuronium. JA Clin Rep 2015; 1:12. [PMID: 29497644 PMCID: PMC5818701 DOI: 10.1186/s40981-015-0016-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 09/01/2015] [Indexed: 12/15/2022] Open
Abstract
Accelerated idioventricular rhythm (AIVR) during anesthesia has been described in several drug toxicity such as from cocaine, halothane, desflurane, and propofol. We present the case of a man who developed episodes of AIVR observed under total intravenous anesthesia (TIVA) using remifentanil, propofol, and rocuronium. AIVR during anesthesia was a benign phenomenon, and further examinations after surgery showed no structural heart disease and the daily occurrence of idioventricular arrhythmias. This case suggests that the suppression of sinus and atrioventricular nodal function and the autonomic imbalance caused by propofol and remifentanil may induce AIVR with greater frequency.
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Affiliation(s)
- Mika Nakanishi
- Department of Anesthesia, Osakafu Saiseikai Noe Hospital, Fruichi 1-3-25, Joto-ku, Osaka City, Osaka Japan
| | - Kaoru Masumo
- Department of Anesthesia, Osakafu Saiseikai Noe Hospital, Fruichi 1-3-25, Joto-ku, Osaka City, Osaka Japan
| | - Takako Oota
- Department of Anesthesia, Osakafu Saiseikai Noe Hospital, Fruichi 1-3-25, Joto-ku, Osaka City, Osaka Japan
| | - Takeshi Kato
- Department of Anesthesia, Osakafu Saiseikai Noe Hospital, Fruichi 1-3-25, Joto-ku, Osaka City, Osaka Japan
| | - Toshihiro Imanishi
- Department of Anesthesia, Osakafu Saiseikai Noe Hospital, Fruichi 1-3-25, Joto-ku, Osaka City, Osaka Japan
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Chen M, Gu K, Yang B, Chen H, Ju W, Zhang F, Yang G, Li M, Lu X, Cao K, Ouyang F. Idiopathic accelerated idioventricular rhythm or ventricular tachycardia originating from the right bundle branch: unusual type of ventricular arrhythmia. Circ Arrhythm Electrophysiol 2014; 7:1159-67. [PMID: 25378469 DOI: 10.1161/circep.114.002112] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Accelerated idioventricular rhythm (AIVR) or ventricular tachycardia (VT) originating from the right bundle branch (RBB) is rare and published clinical data on such arrhythmia are scarce. In this study, we will describe the clinical manifestations, diagnosis, and management of a cohort of patients with this novel arrhythmia. METHODS AND RESULTS Eight patients (5 men; median age, 25 years) with RBB-AIVR/VT were consecutively enrolled in the study. Pharmacological testing, exercise treadmill testing, electrophysiological study, and catheter ablation were performed in the study patients, and ECG features were characterized. All RBB-AIVR/VTs were of typical left bundle-branch block morphology with atrioventricular dissociation. The arrhythmias, which demonstrated chronotropic variability, were often isorhythmic with sinus rhythm and were accelerated by physical exercise, stress, and intravenous isoprenaline infusion. The rate of RBB-AIVR/VT varied from 45 to 200 beats per minute. Two patients experienced syncope, and 3 had impaired left ventricular function. Metoprolol was proven to be the most effective drug to decelerate the arrhythmia rate and relieve symptoms. Electrophysiology study was performed in 5 patients and the earliest activation with a sharp RBB potential was localized in the mid or distal RBB area. Catheter ablation terminated the arrhythmia with subsequent RBB block morphology during sinus rhythm. During follow-up, patients' symptoms were controlled with normalization of left ventricular function either on metoprolol or by catheter ablation. CONCLUSIONS RBB-AIVR/VT is an unusual type of ventricular arrhythmia. It can result in significant symptoms and depressed ventricular function and can be successfully treated with catheter ablation.
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Affiliation(s)
- Minglong Chen
- From the Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China (M.C., K.G., B.Y., H.C., W.J., F.Z., G.Y., M.L., X.L., K.C.); and II Medizinische Abteilung, Allgemeines Krankenhaus St. Georg, Hamburg, Germany (F.O.).
| | - Kai Gu
- From the Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China (M.C., K.G., B.Y., H.C., W.J., F.Z., G.Y., M.L., X.L., K.C.); and II Medizinische Abteilung, Allgemeines Krankenhaus St. Georg, Hamburg, Germany (F.O.)
| | - Bing Yang
- From the Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China (M.C., K.G., B.Y., H.C., W.J., F.Z., G.Y., M.L., X.L., K.C.); and II Medizinische Abteilung, Allgemeines Krankenhaus St. Georg, Hamburg, Germany (F.O.)
| | - Hongwu Chen
- From the Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China (M.C., K.G., B.Y., H.C., W.J., F.Z., G.Y., M.L., X.L., K.C.); and II Medizinische Abteilung, Allgemeines Krankenhaus St. Georg, Hamburg, Germany (F.O.)
| | - Weizhu Ju
- From the Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China (M.C., K.G., B.Y., H.C., W.J., F.Z., G.Y., M.L., X.L., K.C.); and II Medizinische Abteilung, Allgemeines Krankenhaus St. Georg, Hamburg, Germany (F.O.)
| | - Fengxiang Zhang
- From the Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China (M.C., K.G., B.Y., H.C., W.J., F.Z., G.Y., M.L., X.L., K.C.); and II Medizinische Abteilung, Allgemeines Krankenhaus St. Georg, Hamburg, Germany (F.O.)
| | - Gang Yang
- From the Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China (M.C., K.G., B.Y., H.C., W.J., F.Z., G.Y., M.L., X.L., K.C.); and II Medizinische Abteilung, Allgemeines Krankenhaus St. Georg, Hamburg, Germany (F.O.)
| | - Mingfang Li
- From the Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China (M.C., K.G., B.Y., H.C., W.J., F.Z., G.Y., M.L., X.L., K.C.); and II Medizinische Abteilung, Allgemeines Krankenhaus St. Georg, Hamburg, Germany (F.O.)
| | - Xinzheng Lu
- From the Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China (M.C., K.G., B.Y., H.C., W.J., F.Z., G.Y., M.L., X.L., K.C.); and II Medizinische Abteilung, Allgemeines Krankenhaus St. Georg, Hamburg, Germany (F.O.)
| | - Kejiang Cao
- From the Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China (M.C., K.G., B.Y., H.C., W.J., F.Z., G.Y., M.L., X.L., K.C.); and II Medizinische Abteilung, Allgemeines Krankenhaus St. Georg, Hamburg, Germany (F.O.)
| | - Feifan Ouyang
- From the Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China (M.C., K.G., B.Y., H.C., W.J., F.Z., G.Y., M.L., X.L., K.C.); and II Medizinische Abteilung, Allgemeines Krankenhaus St. Georg, Hamburg, Germany (F.O.)
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Ryu HY, Kim JY, Lim HK, Yoon J, Yoo BS, Choe KH, Lee SH. Bupivacaine induced cardiac toxicity mimicking an acute non-ST segment elevation myocardial infarction. Yonsei Med J 2007; 48:331-6. [PMID: 17461537 PMCID: PMC2628127 DOI: 10.3349/ymj.2007.48.2.331] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Bupivacaine is widely used as a local anesthetic. Central nervous system (CNS) and cardiovascular toxicity are well known side effects. However, there has been no report of bupivacaine-induced myocardial injury. We present a case of bupivacaine cardiac toxicity mimicking an acute non-ST segment elevation myocardial infarction, which was eventually diagnosed as bupivacaine-induced cardiac toxicity without CNS toxicity. As soon as a healthy young woman at a private clinic was given a spinal anesthesia of 6mg bupivacaine for hemorrhoidectomy, she developed arrhythmia and hypotension. She was transferred to our emergency room. There was an accelerated idioventricular rhythm with ST segment depression on electrocardiogram, coarse breathing sounds with rales on whole lung field and a butterfly sign on the chest radiograph. 2D transthoracic echocardiography (TTE) revealed reduced left ventricle systolic ejection fraction (approximately 27%). There was regional wall motion abnormality of the left ventricle on 2D TTE and the cardiac marker was increased. We diagnosed the patient as having acute non-ST segment elevation myocardial infarction but her impaired cardiac function improved gradually. On the seventh day from admission, there was a complete spontaneous recovery of cardiac function, and coronary angiography revealed a normal coronary artery. Therefore, we firmly believe that bupivacaine directly injures the cardiac cell.
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Affiliation(s)
- Ho Yoel Ryu
- Division of Cardiology, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jang-Young Kim
- Division of Cardiology, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Hyun Kyo Lim
- Department of Anesthesiology and Pain Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Junghan Yoon
- Division of Cardiology, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Byung-Su Yoo
- Division of Cardiology, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Kyung-Hoon Choe
- Division of Cardiology, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Seung-Hwan Lee
- Division of Cardiology, Yonsei University Wonju College of Medicine, Wonju, Korea
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