50th Annual Regional Anesthesiology and Acute Pain Medicine Meeting

Post-Operative Bezold-Jarisch Reflex with Asystole after Monitored Anesthesia Care

BACKGROUND

•Sinus bradycardia is a common arrhythmia in surgery, often requiring no treatment[1]

•The Bezold-Jarisch reflex is a cardioinhibitory reflex, mediated by intracardiac vagal sensory neurons, that can cause hypotension, bradycardia, apnea, and syncope[2]

•Anesthetic agents may potentiate the Bezold-Jarisch response and cause severe bradycardia in predisposed patients, with potential for asystole

CASE PRESENTATION

•67M ASA2 with h/o sinus bradycardia, prior uncomplicated general anesthesia, presented for resection of R parietal BCC

Operative Events

•Preoperative scalp block of bupivacaine 0.5% (8 mL), dexmedetomidine (30 mcg), dexamethasone (2 mg), epinephrine (100 mcg)

•Moderate sedation/analgesia maintained w/ dexmedetomidine load (74 mcg), low-dose propofol infusion (327 mg), ketamine (100 mg) and fentanyl (50 mg) doses

•Injection of 5 cc’s lidocaine 1% by ENT

•Postoperative Events

•45 minutes following arrival to PACU, suddenly became unresponsive with nonpalpable pulses and asystole on EKG

•Following 30 seconds of compressions, pulse was palpable in 40s

•1mg atropine given with HR 40s → 70s, BP 130/80, and regaining of consciousness

•Labs and Imaging

VBG: 7.36 / 42 / 71 Lactate: 1.3

hsTrop: <5 CBC, CMP: Within normal limits

EKG: no ST changes or TWIs, QTc normal

POCUS: good contractility on PLAX, substernal views

•Admitted for overnight monitoring on telemetry; CXR wnl; discharged in AM with no complications

DIFFERENTIALS

LAST

But very far below maximum dose

Max dose of bupivacaine 0.5% with epinephrine: 47.89 mL

Following 8 mL bupivacaine 0.5%, remaining safe dose of lidocaine: 31.03 mL

Block occurred 3 hours prior

ACS

•No evidence of cardiac ischemia

•Rapid improvement uncharacteristic

Intracranial event

•No Cushing triad or signs increased ICP

•No neurologic PE findings

Other

•No electrolyte abnormalities, acidosis

DISCUSSION

•Dexmedetomidine and fentanyl may have contributed to vagal overstimulation alongside propofol-induced blunting of the baroreceptor response

•ISO underlying sinus bradycardia, LV preload was sufficiently reduced to mechanically induce Bezold-Jarisch reflex

•Management: ACLS protocol, assessing for reversible causes

•Medications (beta-blockers, calcium channel blockers), severe electrolyte imbalances, acute coronary syndrome, and intracranial events should all be ruled out

•Suspected Bezold-Jarisch reflex is treated with ephedrine, atropine, and preload augmentation which can rapidly reverse vagal-induced bradycardia

LEARNING POINTS

Consider Jezold-Barisch as an etiology for otherwise unexplained post-operative cardiovascular arrest

Consider all cardiac dysrhythmias in plan!

50th Annual Regional Anesthesiology and Acute Pain Medicine Meeting

POST-OPERATIVE BEZOLD-JARISCH REFLEX WITH ASYSTOLE AFTER MONITORED ANESTHESIA CARE

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