Hypotensive bradycardic events during shoulder arthroscopic surgery under interscalene brachial plexus blocks

Improving visualization in shoulder arthroscopy

Arthroscopic shoulder procedures are one of the most common procedures used to restore function through minimally invasive techniques. With the demand for shoulder arthroscopic procedures comes the need for safe, effective, and efficient surgery that maximizes patient outcomes while minimizing complications. Many variables contribute to visualization in shoulder arthroscopy including vascular anatomy, blood pressure control, arthroscopic pump systems, turbulence control, epinephrine, and tranexamic acid. Furthermore, patient positioning can have a dramatic effect on visualization with both the beach chair position and lateral decubitus positioning having various strengths and weaknesses depending on the intended procedure being performed. The purpose of this review is to examine the benefits and complications reported in the literature for improving visualization in shoulder arthroscopy.

Scoping review of complications associated with epinephrine use in arthroscopy fluid

Purpose: To identify if addition of epinephrine to irrigation fluid can result in any intra-operative or post-operative complications. It was hypothesized that significant adverse events would be identified with the use of epinephrine in arthroscopic fluid.Methodology: In accordance with PRISMA guidelines (Appendix 2), an electronic database search was conducted, from inception to February 2019 including MEDLINE, EMBASE, Cochrane, CENTRAL, and Scopus (MeSH search). All English-language studies that addressed complications associated with arthroscopic use of epinephrine were included. Defined outcome measures were any reported intra- or post-operative adverse events secondary to epinephrine use. Data collection included: patient demographics, comorbidities, surgical intervention, epinephrine concentration in irrigation fluid, reported complications, and details of the associated clinical prodrome.Results: Three hundred and ninety-three abstracts were screened with 22 studies identified and reviewed in detail. Of these seven case reports and four randomized trials met the inclusion criteria (1999-2017). The case reports encompassed nine patients (seven females and two males) with an average age of 38.8 years (range 19 to 52 y). Five had shoulder arthroscopies, two had knee scopes and two had hip scopes. A pattern of reported complications was noted in all reports in association with epinephrine including hypertension, tachycardia with or without evolving arrhythmia and/or pulmonary edema. One patient died. Of the four randomized trials, three did not report any adverse events in relation to epinephrine with one trial associating epinephrine to the occurrence of hypotensive bradycardic events in the setting of shoulder arthroscopy in the beach-chair position.Conclusion: While a causal association cannot be established, Anesthetists and Orthopedic Surgeons should be aware of the noted pattern of symptoms in patients undergoing epinephrine-assisted arthroscopy.Clinical relevance: While the incidence of epinephrine-related complications is rare, this review raises awareness to the pattern of reported symptoms, as it could help with identification and treatment should this rare complication be encountered.

Local anesthetic volume in ultrasound-guided interscalene block and opioid consumption during shoulder arthroscopic surgery: A retrospective comparative study

Interscalene block (ISB) is commonly performed for regional anesthesia in shoulder surgery. Ultrasound-guided ISB enables visualization of the local anesthetic spread and a reduction in local anesthetic volume. However, little is known about the appropriate local anesthetic dose for surgical anesthesia without sedation or general anesthesia. The purpose of our study was to evaluate the appropriate local anesthetic volume by comparing intraoperative analgesics and hemodynamic changes in ISB in arthroscopic shoulder surgery.Overall, 1007 patients were divided into groups 1, 2, and 3 according to the following volume of local anesthetics: 10-19, 20-29, and 30-40 mL, respectively. The use of intraoperative analgesics and sedatives, and the reduction in intraoperative maximum blood pressure and heart rate were compared through retrospective analysis.Fentanyl was used in 55.6% of patients in group 1, which was significantly higher than in those groups 2 and 3 (22.3% and 30.7%, respectively); furthermore, it was also higher than those in groups 2 and 3 in dose-specific comparisons (P < .05). The percent of the maximum reduction in intraoperative systolic blood pressure and heart rate in group 3 was significantly higher than those in groups 1 and 2. Ephedrine administration was lower in group 2 than that in other groups (P < .05). The incidence of hypotensive bradycardic events was lowest (9.1%) at the local anesthetic volume of 24 mL as revealed by the quadratic regression analysis (R2 = 0.313, P = .003).Decreasing the local anesthetic volume to less than 20 mL for ultrasound-guided ISB as the sole anesthesia increases the opioid consumption during shoulder arthroscopic surgery. Local anesthetics >30 mL or increased opioid consumption with <20 mL of local anesthetics could increase the risk of cardiovascular instability intraoperatively. Our findings indicate that 24 mL of local anesthetic could be used to lower the incidence of hypotensive bradycardic events.

Bezold-Jarisch reflex causing bradycardia and hypotension in a case of severe dystrophic cervical kyphotic deformity: a case report and review of literature

PURPOSE

A 17-year-old adolescent with neurofibromatosis and severe cervicothoracic deformity was identified to have thoracic inlet compression leading to bradycardia and hypotension, only during prone positioning, and we discuss its successful management.

METHODS

Preoperative halo-gravity traction reduced the deformity from 126° to 91°. During prone positioning, sudden onset bradycardia was followed by asystole, which disappeared immediately on turning over to supine position. Surgery was called off after two additional failed attempts of prone positioning.

RESULTS

A retrospective analysis of CT and MRI showed severe narrowing of the thoracic inlet. In this patient, the right thoracic inlet was severely narrow, and prone positioning caused a further dynamic compromise stimulating right vagal nerve. The right vagus supplies the sinoatrial node, which is the natural pacemaker of the heart, and its stimulation causes sympathetic inhibition. Bezold-Jarisch reflex is a cardio-inhibitory reflex occurring due to vagal stimulation resulting in sudden bradycardia, asystole, and hypotension. To facilitate prone positioning, the medial end of the clavicles, along with limited manubrium excision, was performed relieving the vagal compression. C2-T4 instrumented decompression followed by anterior reconstruction and cervical plating was performed. The postoperative period was uneventful, and the final deformity was 45°.

CONCLUSION

Bezold-Jarisch Reflex as a result of narrow thoracic inlet caused by cervical kyphosis and compensatory hyperlordosis of the upper thoracic spine has never been reported. This case highlights the need to introspect into thoracic inlet morphology in severe cervicothoracic deformities. Thoracic inlet decompression is an efficient way of addressing this unique complication.

Adverse heart rate responses during beach-chair position for shoulder surgeries - A systematic review and meta-analysis of their incidence, interpretations and associations

Background and Aims

Evaluations of adverse heart rate (HR)-responses and HR-variations during anaesthesia in beach-chair-position (BCP) for shoulder surgeries have not been done earlier. We analysed the incidence, associations, and interpretations of adverse HR-responses in this clinical setting.

Methods

We performed a meta-analysis of trials that reported HR-related data in anaesthetised subjects undergoing elective shoulder surgeries in BCP. Studies included prospective, randomised, quasi-randomised and non-randomised, controlled clinical trials as well as observational cohorts. Literature search was conducted in MEDLINE, EMBASE, CINHAL and the Cochrane Central Register of Controlled Trials of the 21^st century. In the first analysis, we studied the incidence and associations of bradycardia/hypotension-bradycardia episodes (HBE) with respect to the type of anaesthesia and different pharmacological agents. In the second, we evaluated anaesthetic influences, associations and inter-relationships between monitored parameters with respect to HR-behaviours.

Results

Among the trials designed with bradycardia/HBE as a primary end point, the observed incidence of bradycardia was 9.1% and that of HBE, 14.9% and 22.7% [(for Interscalene block (ISB) ± sedation) subjects and general anaesthesia (GA) + ISB, respectively]. There was evidence of higher observed risk of developing adverse HR-responses for GA subjects over ISB (Risk Difference, P < 0.05). Concomitant use of β-agonists did not increase risk of HBEs (P = 0.29, I ²= 11.4%) or with fentanyl (P = 0.45, I ²= 0%) for ISB subjects (subgroup analysis). Fentanyl significantly influenced the HR-drop over time [meta-regression, estimates (standard error), 14.9 (5.4), 9.8 (4.3) and 17 (2.6); P = 0.007, 0.024 and <0.001; for early, mid and delayed periods, respectively] in GA subjects. With respect to number of subjects experiencing cerebral desaturation events (CDEs), total intravenous anaesthesia (TIVA)- propofol had higher risk over inhalational anaesthesia (P = 0.006, I ² = 86.7%). Meta-correlation analysis showed relationships between the HR and rSO₂(regional cerebral oxygen saturation) or SjvO₂(jugular venous oxygen saturation) values (r = 0.608, 95%CI, 0.439 to 0.735, P < 0.001, I ²= 77.4% and r = 0.397, 95%CI, 0.151 to 0.597, P < 0.001, I ²= 64.3%, respectively).

Conclusions

There is not enough evidence to claim the associations of adverse HR-responses with any specific factor. HR-fall is maximal with fentanyl and its variability is associated with changes in rSO₂. Fall in rSO₂ could be the common link triggering adverse HR-responses in BCP.

Retrospective analysis of risk factors of hypotensive bradycardic events during shoulder arthroscopic surgery under interscalene blockade in the sitting position

Background

Hypotensive bradycardic events (HBEs) are a frequent adverse event in patients who underwent shoulder arthroscopic surgery under interscalene block (ISB) in the sitting position. This retrospective study was conducted to investigate the independent risk factors of HBEs in shoulder arthroscopic surgery under ISB in the sitting position.

Methods

A total of 2549 patients who underwent shoulder arthroscopic surgery under ISB and had complete clinical data were included in the study. The 357 patients who developed HBEs were included in the HBEs group, and the remaining 2192 in the non-HBEs group. The potential risk factors for HBEs, such as age, sex, past medical history, anesthetic characteristics, and intraoperative medications were collected and compared between the groups. Statistically significant variables were included in a logistic regression model to further evaluate the independent risk factors for HBEs in shoulder arthroscopic surgery under ISB.

Results

The incidence of HBEs was 14.0% (357/2549). Logistic regression analysis revealed that the intraoperative use of hydralazine (odds ratio [OR] 4.2; 95% confidence interval [CI] 2.9–6.3), propofol (OR 2.1; 95% CI 1.3–3.6), and dexmedetomidine (OR 3.9; 95% CI 1.9–7.8) before HBEs were independent risk factors for HBEs in patients who received shoulder arthroscopic surgery under ISB.

Conclusions

The intraoperative use of antihypertensives such as hydralazine and sedatives such as propofol or dexmedetomidine leads to increased risk of HBEs during shoulder arthroscopic surgery under ISB in the sitting position.

Risk factors associated with hypotensive bradycardic events during open shoulder surgery in the beach chair position

BACKGROUND

Shoulder surgery in the beach chair position frequently causes hypotensive bradycardic events (HBEs), which are potentially associated with an increased risk of cerebral hypoperfusion. Here, we aimed to investigate the incidence and characteristics of symptomatic HBEs that require pharmacological interventions, and to identify specific risk factors associated with symptomatic HBEs.

METHODS

We retrospectively examined the records of all patients aged ≥ 18 years who underwent shoulder arthrotomy in the beach chair position between January 2011 and December 2018 at Samsung Medical Center. For patients who experienced HBEs while in the beach chair position, the minimum heart rate and systolic blood pressure were noted, as was the total dose of ephedrine or atropine.

RESULTS

Symptomatic HBEs occurred in 61.0% of all cases (256/420). Two patients with symptomatic HBEs experienced postoperative neurological complications. Multivariable logistic regression analysis showed that preoperative interscalene brachial plexus block (ISB) and advanced age were risk factors associated with symptomatic HBEs (odds ratio [OR]: 3.240, 95% CI: 2.003, 5.242, P < 0.001; OR: 1.060 for each 1-year increase, 95% CI: 1.044, 1.076, P < 0.001, respectively). Receiver operating curve analysis revealed that a threshold of 62 years of age had a moderate degree of accuracy for predicting symptomatic HBEs (area under curve: 0.764, 95% CI: 0.720, 0.804, P < 0.001).

CONCLUSIONS

Considering the increasing risk of neurocognitive complications with aging, proactive hemodynamic management is needed, especially for elderly patients undergoing shoulder surgery in the beach chair position using ISB.

DOES THE ANESTHESIA TECHNIQUE AFFECT ARTERIAL PRESSURE AND REGIONAL CEREBRAL OXYGEN SATURATION DURING SHOULDER ARTHROSCOPY IN THE BEACH CHAIR POSITION?

- This study aimed to investigate the impact of posture and anesthesia techniques on blood pressure changes, heart rate and regional cerebral oxygen saturation during shoulder arthroscopy in the beach chair position (BCP). Sixty patients were included in this prospective cohort study: 30 patients mechanically ventilated and subjected to general anesthesia (GA) and 30 patients subjected to interscalene block (ISB) without mechanical ventilation. Noninvasive blood pressure, heart rate (HR), peripheral blood oxygen saturation and regional oxygen saturation of the brain were measured in twelve predefined points during perioperative period. The GA group patients had significantly lower mean arterial pressure and heart rate values compared to patients in ISB group during BCP (p<0.001). There was a significant difference in regional cerebral saturation between the groups measured only in points of induction and emergence from anesthesia in favor of GA group when receiving 100% oxygen (p<0.001). Changes in the mean arterial pressure and regional cerebral oxygen saturation for both brain hemispheres correlated only at the 10^th minute after setting up BCP in GA patients (right, p=0.004 and left, p=0.003). This correlation did not exist in the ISB group patients at any of the points measured. Cerebral desaturation events recorded in both groups were not statistically significantly different. Results of this study demonstrated that GA preserved regional cerebral oxygenation in a safe range during BCP despite changes in the arterial blood pressure and heart rate in comparison to ISB.

Profound Prolonged Bradycardia and Hypotension after Interscalene Brachial Plexus Block with Bupivacaine

BACKGROUND

Interscalene brachial plexus blocks have been a routinely performed method of anesthesia for shoulder surgery that decreases the need for general anesthesia, length of stay, and recovery time. We describe a case of bupivacaine toxicity after an interscalene block.

CASE REPORT

The patient was a 66-year-old man who presented to our Emergency Department by emergency medical services from an ambulatory surgery center where he had undergone rotator cuff surgery, with bradycardia and hypotension. His symptoms began upon completion of the surgery in which he received interscalene nerve block with bupivacaine and lidocaine. He was given three doses of 0.5 mg atropine and one dose of 1 mg epinephrine for a heart rate of 40 beats/min without any improvement prior to arrival. His bradycardia was refractory to atropine. He was started on a dopamine drip and transferred to the coronary care unit. The timing of his symptoms, minutes after his regional nerve block, and his complete recovery with only supportive care, make the diagnosis of bupivacaine toxicity likely. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Despite the safety profile of local anesthetics, we must be aware of their potential side affects. Whereas most adverse reactions are secondary to misdirection of anesthetic or accidental vascular puncture, local anesthetic systemic toxicity (LAST) is the major cause of significant adverse events with regional anesthesia. As regional anesthesia becomes more common, emergency physicians must be more aware of the potential complications and be able to both diagnose and treat.

The effect of norepinephrine versus epinephrine in irrigation fluid on the incidence of hypotensive/bradycardic events during arthroscopic rotator cuff repair with interscalene block in the sitting position

PURPOSE

To compare the occurrence rate of hypotensive and bradycardic events (HBEs) during arthroscopic rotator cuff repair performed with interscalene brachial plexus block anesthesia in the sitting position in 2 groups of patients who underwent the procedure with norepinephrine or epinephrine added to the irrigation fluid. The secondary objective was to evaluate the efficacy of norepinephrine in comparison with epinephrine in controlling intraoperative bleeding and maintaining adequate visualization of the arthroscopic field of view during the procedure. We hypothesized that norepinephrine added to the irrigation fluid during shoulder arthroscopy in the sitting position would reduce the occurrence of HBEs, allowing optimal intraoperative bleeding control.

METHODS

One hundred twenty patients underwent an arthroscopic rotator cuff repair performed under peripheral anesthesia and in the beach-chair position. Patients were randomly divided into 2 groups of 60 cases each: Norepinephrine (0.66 mg/L) and epinephrine (0.33 mg/L) were added to irrigation bags in group N and group E, respectively. The primary outcome was the occurrence rate of HBEs during surgery. The secondary outcomes were timing of onset of HBEs, accompanying symptoms, and intraoperative bleeding that impaired arthroscopic visualization. The clarity of the visual field was rated postoperatively by the surgeon using a visual analog scale. Comparison between groups for all baseline variables and outcome measurements was performed with the χ(2) or Fisher exact test, as appropriate, for categorical variables and the Student t test or Mann-Whitney U test, as appropriate, for continuous variables. Significance was set at P < .05.

RESULTS

One patient was excluded from group E because of block failure; therefore 119 patients were finally included in the study. Comparison between groups showed no significant differences in baseline characteristics. The occurrence rate of HBEs was significantly greater in group E (n = 15) than in group N (n = 5) (P = .02). No differences between groups were found in the average time of onset of HBEs, accompanying symptoms, and clarity of the visual field.

CONCLUSIONS

Continuous administration of norepinephrine, 0.66 mg/L, diluted in irrigation fluid during arthroscopic rotator cuff repair with the patient in the beach-chair position reduces the incidence of HBEs and is as effective as epinephrine in controlling intraoperative bleeding and maintaining the visual clarity of the surgical field.

LEVEL OF EVIDENCE

Level I, randomized clinical study.

A comparison of three methods for postoperative pain control in patients undergoing arthroscopic shoulder surgery

Background

Arthroscopic shoulder operations (ASS) are often associated with severe postoperative pain. Nerve blocks have been studied for pain in shoulder surgeries. Interscalene brachial plexus blocks (ISB) and an intra-articular injection (IA) have been reported in many studies. The aim of the present study is to evaluate the effect of ISB, a continuous cervical epidural block (CCE) and IA as a means of postoperative pain control and to study the influence of these procedures on postoperative analgesic consumption and after ASS.

Methods

Fifty seven patients who underwent ASS under general anesthesia were randomly assigned to one of three groups: the ISB group (n = 19), the CCE group (n = 19), and the IA group (n = 19). Patients in each group were evaluated on a postoperative numerical rating scale (NRS), their rescue opioid dosage (ROD), and side effects.

Results

Postoperative NRSs were found to be higher in the IA group than in the ISB and CCE groups both at rest and on movement. The ROD were 1.6 ± 2.3, 3.0 ± 4.9 and 7.1 ± 7.9 mg morphine equivalent dose in groups CCE, ISB, and IA groups (P = 0.001), respectively, and statistically significant differences were noted between the CCE and IA groups (P = 0.01) but not in between the ISB and CCE groups.

Conclusions

This prospective, randomized study demonstrated that ISB is as effective analgesic technique as a CCE for postoperative pain control in patients undergoing ASS.

The interplay between sympathetic overactivity, hypertension and heart rate variability (review, invited)

The control of arterial pressure is a complex interaction of the long- and short-term influences of hormones, local vascular factors, and neural mechanisms. The autonomic nervous system and its sympathetic arm play important roles in the regulation of blood pressure, and overactivity of sympathetic nerves may have an important role in the development of hypertension and related cardiovascular disorders. The baroreceptor system opposes either increases or decreases in arterial pressure, and the primary purpose of the arterial baroreflex is to keep blood pressure close to a particular set point over a relatively short period of time. The ability of the baroreflex to powerfully buffer acute changes in arterial pressure is well established, but the role of the arterial baroreceptor reflex in long-term control of arterial pressure has been a topic of many debate and controversy for decades. The sympathetic nervous system and arterial baroreceptor reflex control of renal sympathetic nerve activity has been proposed to play a role in long-term control of arterial pressure. The aim of this paper has been to review the postulated role of sympathetic activation.

Cardiovascular consequence of reclining vs. sitting beach-chair body position for induction of anesthesia

The sitting beach-chair position is regularly used for shoulder surgery and anesthesia may be induced in that position. We tested the hypothesis that the cardiovascular challenge induced by induction of anesthesia is attenuated if the patient is placed in a reclining beach-chair position. Anesthesia was induced with propofol in the sitting beach-chair (n = 15) or with the beach-chair tilted backwards to a reclining beach-chair position (n = 15). The last group was stepwise tilted to the sitting beach-chair position prior to surgery. Hypotension was treated with ephedrine. Continuous hemodynamic variables were recorded by photoplethysmography and frontal cerebral oxygenation (ScO₂) by near infrared spectroscopy. Significant differences were only observed immediately after the induction when patients induced in a reclining beach-chair position had higher mean arterial pressure (MAP) (35 ± 12 vs. 45 ± 15 % reduction from baseline, p = 0.04) and ScO₂ (7 ± 6 vs. 1 ± 8% increase from baseline, p = 0.02) and received less ephedrine (mean: 4 vs. 13 mg, p = 0.048). The higher blood pressure and lower need of vasopressor following induction of anesthesia in the reclining compared to the sitting beach-chair position indicate more stable hemodynamics with the clinical implication that anesthesia should not be induced with the patient in the sitting position.

Cardiovascular effects of abduction shoulder sling in elderly patients; is it really safe?

OBJECTIVE

The purpose of the prospective study is to investigate the cardiovascular effects of abduction shoulder sling (ASS) in elderly patients who underwent rotator cuff surgery.

METHODS

The study included 49 consecutive patients older than 50 years (mean 59.3 ± 8.2 years) who underwent arthroscopic rotator cuff repair surgery and used ASS in postoperative period. All cases underwent Holter electrocardiographic monitoring before (24 h) and after (48 h) the operation. The Holter findings were read by an experienced cardiologist and a pause of longer than 3 s and heart rate of <40 bpm was evaluated as significant bradycardia.

RESULTS

One patient (61-year-old male) described feeling faint (presyncope) which was confirmed with the Holter finding of a pause more than 3 s which occurred in the day time. Two other patients (52-year-old male, and 62-year-old female) reported severe dizziness (hypotensive attack) which required admission to a general practitioner. However, Holter findings were normal in these patients. These three cases were referred to cardiology department for evaluation of carotid hypersensitivity syndrome (CSH). CSH was confirmed with tests made with provocative maneuvers in a sitting position. CSH was defined as at least 3 s of asystole (cardio-inhibitor type) during carotid massage or systolic blood pressure falling below 50 mmHg (vaso-depressor type). All three patients were obese patients and BMI was higher than 30.

CONCLUSIONS

ASS may trigger CSH in short necked and obese patients by exerting mechanical stimulation to the carotid sinus. These patients should be informed about symptoms and signs of CSH and educated on the proper use of ASS and correct positioning of shoulder strap. CSH should be kept in mind in patients who present with dizziness, presyncope and palpitation during the postoperative period.

Effect of interscalene brachial plexus block on heart rate variability

Background

Interscalene brachial plexus block (ISB) may be followed by cardiovascular instability. Until date, there is no clear picture available about the underlying mechanisms of ISB. In this study, we aimed to determine the changes in heart rate variability (HRV) parameters after ISB and the differences between right- and left-sided ISBs.

Methods

We prospectively studied 24 patients operated for shoulder surgery in sitting position and divided them into two respective groups: R (right-sided block = 14 pts) and L (left-sided block = 10 pts). HRV data were taken before and 30 min after the block. Ropivacaine without ephedrine was used for the ISB through an insulated block needle connected to a nerve stimulator. Statistical analysis implemented chi-square, Student's and t-paired tests. Skewed distributions were analyzed after logarithmic transformation.

Results

All the studied patients had successful blocks. Horner's syndrome signs were observed in 33.3% of the patients (R = 5/14, L = 3/10; [P = 0.769]). There were no significant differences in pre-block HRV between the groups. The application of ISB had differential effect on HRV variables: R-blocks increased QRS and QTc durations and InPNN50, while a statistical decrease was seen in InLF. L-blocks did not show any significant changes. These changes indicate a reduced sympathetic and an increased parasympathetic influence on the heart's autonomic flow after R-block.

Conclusions

Based on the obtained results we conclude that ISB, possibly through extension of block to the ipsilateral stellate ganglion, alters the autonomic outflow to the central circulatory system in a way depending on the block's side.

In-office vasovagal response after rhinologic manipulation

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.