Unusual Hypotension and bradycardia not responding to Atropine

 

A 72yr old with no comorbidity was posted for Lumbar spine fixation Aparently ASA I and Airway OK had a Cardiology clearance for stable CV status at rest and Echo finding Degenarative AV and MV, diastolic dysfunction and Normal LV function. On OT table BP 140/93HR 59, Induced with Glyco Midaz, Pentazocin,Vec. ---> O2+N2O+Iso 

5mins ,After the patient was turned and transfered to OT table, when the lines were fixed and monitor connected , it was found the pt has Hypotension and bradycardia but Spo2 100% ,subsequenrly 1+1+1 amps of atropine could hardly increased the HR to more than 60

As there was no significant change in status,for 15mins, We decided to cancel the surgery. as it is more disastrous to resucitate a patient in prone position, Brought back to Supine in the trolley, I  cheked his preop ECG.HR was low with Left Axis deviation and poor progression of R from V2 to V6. I was  told the patint was seen by another cardiologist who had advised for Coronary Angiogram, which pt refused and checked with other cardiologist

I did not try Isoprenaline or diluted adrenaline to raise HR. I did not find any heart block.

The pt was not reversed with Neostigmine but ventilates out slowly until muscle relaxation wares off.. By next 30min or so he was stable BP but still HR <85

Now the Question is why the Brady cardia was resistant to injection of Atropine, 

What could be the possible cause in this 

Anxiety and tension can create Havoc. A good counselling was the key to success in this case

Anxiety and tension can be so worrisome for all..  There are no shortcut … here is a long story…..

The patient was a 40 year old lady House wife posted for Abominal/ Vaginal hysterectomy. Pre op evaluation by surgeon and Cardiologists  cleared for surgery and Anaesthesia. All were said to be normal with mild well controlled HTN on drugs But The anaesthetist of that day did not see the pt. Patient was fasting. Opn scheduled at about 6PM. Pt had established IV line and 500 ml of NS infused in her cabin. Plan was Spinal anaesthesia 

      On the ot table pt connected to monitor ECG  NIBP and Pulse oxymeter. The NIBP recorded was 225  / 160 ,  HR was around 120. A second  and third reading was almost the same. All paramedics in OT asked the pt why she is in tension. Her answer was NO. 

Though every one knew this could be anxiety and tension and injected with Midas 2 mg IV. After 3 min though slight reduction of Pulse and BP , at 5 mins  it again shot up, The anaesthetist was reluctant to take up the case.

     She was again sent to cardiologist for advise ,and he observed her BP and HR as normal. She was posted next day. This time the Anaesthetist was another one. ( We are 4 anaesthetist take up anaesthetist job on rotation) 

     Again on the OT table similar incident happened with high BP and tachy cardiac. Again after observing for 15 mins with sedation and assurance, it was far away normal . The second Junior Anesth was reluctant to take up the case. 

     Next day  she was  supposed to be discharged with another date fixed. Surgeon interacted with me about the case . I agreed to take up the challenge but wanted to see the patient ,

     In her cabin room she was quiet. I asked her if she sees some ghosts in OT. She laughed. I talked to her for 20 mins anout family her likes and dislikes and life at home and society..I also told her my work in Foreign country, in Libya, Dubai and Australia.. I did not measure her BP but just checked the pulse and examined her chest for confidence building. 

       My days of Anaesthwas after 3 days and she agreed to stay back and not go home. I promised and assured her I will do something special . And on that day I will be with her from room to OT table. She and her husband almost touched my feet.

      On the day of surgery I came to her room .Just took her hand and checked the pulse. It appeared to be OK.

      On the OT table the BP recorded was 178/ 110 but I ignored. Made her sit up and did a dural puncture explaining each step of my action. From antiseptic painting to local anaesthetic infiltration. With a 25G needle and a single prick CSF  was flowing . And 3 ml of Heavy Bupivicane was injected . Explained her what it will feel next. Also injected 3 mg of Midazolam.Covered her eyes and an Oxygen mask with 3 L flow.

     The operation went on smoothly and miraculously her BP was maintained at 

112/66 and HR of 86  through out the operation with minimal fluctuation like a magic.

      In recovery room she asked me how was the operation. I replied her I did not see operation I was taking care of her Anaesthesia. 

      Later I learnt she wanted to see me , but I was preparing to leave for USA and couldn’t not see her.

Multiple cardiac problem and anaesthesia

Recently I was to evaluate a case planned for Vaginal Hysterectomy with procedentia prolapse repair. She is 70 yr old and moving around in side house..very much disturbed with complete prolapse and badly wants this operation. She is from a rular area and local OG specialists and Anaesth ,donnot want to take up the case..for...

       She had a checkup with a cardiologist and the Echo findings were broadly A case of CAD, AS, AR,(mild) ,LVH as well as an LV annerism in LAD area. EF 42%. Some RWMA, mild Systolic dysfunction as well as  diastolic dysfunction. While I was discussing the risk for Anaesthesia and surgery. She said she does not want to die, though she is not afraid of death.             She admitted the cardiologist advised to do the operation where there is good  ICU there is good Anaesthesia doctor and a cadiologist standby ( all mis pronounced).

The only reason I thought to take up the case. She moves around the house , does

 cooking etc . Breathlessness is there but not that evident with everyday life except on a somewhat longer walk or climbing stair.

 The most impressive thing she told (advised)  me to give an injection in back, there will be (anaesth/ Numbness), no pain ,in lower part, ( do not know from where she got he idea). let the heart stay in its place and  have its problem...

I smiled at her idea. Tried to convince with examples, how heart reacts to any thing that happens in body inside and outside. Finally she agreed that  I am the one to give her anaesth.. and she is ready.

What should be my plan of Anaesth ? 

Low Spinal minimal fall of BP,or  GA with drugs that least interfere the cardiac function ?

After 2 weeks I decided to go for a low spinal anaesthesia  T12 and below

In a sitting position 2 mo Heavy Bupivicaine +Fentanyl 50mcg injected at L2-3

BP on table before 180/ 111, but settled at 130/80 .An inj Midazolam 3 mg IV made her sleep well.

Rest were uneventful.

Problem of difficult intubation in a case ankylosis cervical bone

 

CURRICULUM VITAE

 

 

NAME                                                   PRASANNA KUMAR MISHRA

BIRTH DATE                                        27TH OCTOBER 1951

ADDRESS                                             PLOT NO. 10, ANNAPURNA HOUSING COMPLEX, SHERTER CHHAK, TULSIPUR.                                                       CUTTACK - 753008    ODISHA

                                                                TEL NO. 0671-2363323, MOB:  9437026526 

 EMAIL:  pkm51@yahoo.com, pkmishra1951@gmail.com

Presently Working as                          Consultant Anaesthesia and Critical Care Ashwini Hospital, Cuttack

Educational Qualification

                                1, MBBS                 M K C G Medical College, BERHAMPUR, Odisha                            1975

                                2.  M D ( Anaesthesiology ) SCB Medical College, CUTTACK                                        1979

Fellowship :        Interventional Pain Management, Daradia Pain Institute, Kolkatta

Visiting Fellow:  Napean Institute of Critical Care , Sydney Australia

 

Work & experience

                1.             Resident Post Graduate SCB Medical College                                                1977- 1979

                2,             Lecturer/ Tutor  Anaesthesiology     VSs Medical College                           Sept 1981-  Jun1991

                3.             -  do -                                                      SCB Medical College                           Jun 1991- Jan 1997

                4.             Assst Prof Anaesthesiology,              MKCG Medical College                      Jan 1997-   Sept 1999

                5.                    - do -                                                SCB Medical College                          Sept 1999- Jun .2002

                6              Associate prof Anaesthesiology        SCB Medical College                          Jun 2002- Jun 2006

                7.             Professor of Anaesthgesiology          SCB Medical College                           Jun 2006-  Dec2009

                8.                 -do  -                                                   VSS Medical College                            Dec 2009 - Oct 2011

                9                   -  do -                                                 K I M S, Bhubaneswar                         July 2012 - Feb- 2015

                10            Prof Anaesthesiology                          Apollo Hospital, Bhubaneswar          Mar 2015- Mar 2019  

              11.          Consultant Anaesthesia and Critical Care , Ashwini Hospital

                                Accredited teacher IDCCM,IDCCN, Ashwini Hospital, Cuttack                    March 2019  cont

                12.         Prof & HOD Emergency Medicine , Ashwini Hospital, Cuttack                        2022........... Cont.

 

Specialised experience::

                                 Cardiac surgery ( Open Heart ), Interventional pain management , Critical care

Nature of Job

                a. Specialised patient care Anaesthesia in all kinds of surgery including Neuro surgery, Cardiac surgery under CPB, Thoracic surgery & Laparoscopic surgery

                b. General Teaching to Undergraduate and post graduate students

                c. Guide to post Graduate Students in thesis & research work  d. Examiner to Post graduate students in Anaesthesia to various Universities

                d. Teaching to students of IDCCM, IDCCN,  Em MEdicine

               

TEACHER :

o    Member editorial Board  Ind J Anaesthesia  2009-2010 - 2 years

o    Peer Reviewer Ind J Critical Care Medicine: 10 article

 

                 Publications .. and presentations

PUBLICATIONS

1.             Respiratory embrassment and delay in recovery following General Anaesthesia in a patient of   Congenital Rubella syndrome - A Case report _ Ind J Anaesthsia  2001 ;45 ( 4 ):p-298

                2.             Letter to Editor: Anaesthesia for congenital Rubella Syndrome

                                                                Ind J Anaesthesia  2002; 46( 1) : 64

                                                                Ind J Anaesthesia  2002 46 ( 3 ) p-:226

                3,             Efficacies and Inefficiencies in Different Anaesthesia MAchine

                                                                Ind J Anaesthesia 2002  46 ( 5 )

4.             Letter to Editor : Accidental injection of Large doses of Neostigmine methyle sulphate      intrathecally:    Ind J Anaesthesia  2004   48 (1 )  p-64

                5.             Homonymus Hemianopia- A coincidene following short General Anaesthesia - A case report

                                                                Ind j Anaesthesia  2004   48 ( 3 ) p-228

                6.             Letter to Editor : Can N2O Cylinder be overe filled

                                                                Ind J Anaesthesia  2005  49 ( 5) p 437

                7.             Effect of Oral Gabapentine on post operative epidural Analgesia. Rath S. Mishra PK

                                                                Ind J of Pain 2009 ; 23 ( 2 ) 308-312

                8.             Letter to Editor:  Euthanesia an ethical risk,  Mishra PK

                                                                Ind J of Medical Ethics  Dec 2011 Vol 8 ( 4 )  261-262

9	Burn from DC Defibrillator  a small price to pay- A case report  Pattanaik, NK , Mishra PKMishra PK
		J Evolution of Med Dent Sci. 2016 ; 5(83) ;6226-6227
		Pattnaik NK, Mishra PK. 7, DOI: 10.14260/jemds/2016/1406
10	Atypical location of a Right Atrial Myxoma- A case report
		Intnl J of Med Res and Pharmaceutical Sci:  Vol 3, Issue12 Dec 2016 :p 1-6
		ISSN : 2349-5340	Impact factor ( PIF):3.109

          11.              Deep vein thrombosis: Review and update. Review Article  ,  Pattnaik,N K, Mishra, PK ( 2016)  J. Evolution Med. Dent Sci.Vol 5;Issue 103   Dec26,2016:P7605

                                eISSN- 2278-4802, pISSN- 2278-4748

        12              INTUBE STUDY: An International Multi centre study:

 COLLABERATING AUTHOR, Dr Prasanna Mishra, Dr Sampat Dash., Ashwini Hospital, Cuttack. Published JAMA 2018                                                                Original Investigation | ,Intubation Practices and Adverse Peri-intubation Events in critically Ill Patients From 29 Countries

     13  A prospective observational study of prevalence, incidence, and prognostic implications

 of right-sided heart failure in acute respiratory distress syndrome patients. ( 2023 )

Sahu, C. Rao K. S. Mishra P. Panda R. Int J Res Med Sci. 2023 Dec;11(12):4324-4328

     14.    Supraclavicular brachial plexus block with and without dexamethasone as an adjuvan  t to local anesthetics- an observational study. ( 2023)

Sahu C, Rao KS, Mishra PK, Panda R. Student’s Journal of Health Research Africa, Vol 4 No.9( 2023)

 PRESENTATIONS IN CONFERENCES

                1.             AN UN USUAL FOREIGNBODY IN TRACHEA

                2.             LMA - WHATS NEW ? EAST ZONE CONFERENCE

                3.             DID I MAKE A MISTAKE ? Annual National Conf ISA, Bhubaneswar 2003

                4.             UNFAITHFUL SLAVE VALVE - POSTER PRESENTATION

                5.             ACUTE LUNG INJURY: REPORT OF 5 CASES: CRITICARE CONGRESS NEWDELHI

                5.             ACID BASE BALANCE; MANAGEMENT OF RESP ACIDOSIS, Annual Conf ISA Chennai

                6.             VOLATILE ANAESTHETIC AGENTS  YESTERDAY TODAY & TOMORROW

                                                Annual National conf ISA, Cochine

                7.             TURP SYNDROME IN NON TURP CASES -POSTER PRESENTATION

                8.             NEWER MODALITIES OF MANAGEMENT OF ACUTE PAIN .: Annual National Conf ISA

                                                                              Guwahati :2013

                9.             ANAESTHETIC IMPLICATION OF PRONE POSITION IN ELDERLY: Annual Conf ISA LUDHIANA 2016

10            ANAESTHESIA FOR INFERTILITY TREATMENT: Annual Conf ISA Kolkatta-2017

                11.  .       ANALYSIS OF LIFE AFTER DEATH: NDE SYNDROME. Annual Conf ISA, AGRA 2018

                12            Prof S Parmanik Oration : East Zone Annual Conference PURI – 28 Sept 2016

                                “ PAINS AND PLEASURES IN ANAESTHESIA “

 

LIFE MEMBER   I M A , ( Indian Medical Association)

I S A ( INDIAN SOCIETY OF ANAESTHESIOLOGIST),

ISCCM ( Indian Society of Critical Care Medicine )

ISSP  ( Indian Society for  study of pain )

     Member Face Book group   GIVE   ( Global Anaesthesia            

My Blog posts: https://www.blogger.com/blogger.g?blogID=8433572811259396978#allposts

 

 Headache for Anaesthtists:

PDPH is sometimes severe and disabling, WHEN THE HEAD ACHE CONTINUES BEYOND nearly 2 weeks, it makes the heache for Anaesthetist as well.

The patient still blames the anaesthetist for her brain problem, May be she was right . Here is the analysis.

CASE REPORT AND ANALYSIS:

A 40 yr old Lady, ASA-I ,with no co morbidity was posted for Vaginal Hysterectomy under Spinal Anaesthesia. Her Hb,DC,TLC,Platalate,Urea Creatinine, Na, K were all in normal limit.

After an IV line established 500ml NS given Her BP was 134/88 HR 90/min SpO2 99% and a sitting spinal was done successsfully in a single attempt with a 25G needle when CSF was clear and normal pressure, Bupivivaine heavy 2.8 ml was adminstered, After positioning Blood pressure dropped to 92/66 and an Injection Ephedrine 5 mg 2 doses was given IV and the BP rose to 140/86. Rest of intra op was uneventful

She developed headache about 24 hrs later, which was positional and diagnosed as PDPH, She was reassured by Nursing staff that it happens sometimes after Spinal injection and will disappear in 2-3 days, along with Paracetamol 1gm BD ,advised to lie down more as it was positional. It improved in next 3-4 days and she was discharged.

About 5 days later at home she again she developed headache the intensity increased , It was disabling with disturbed sleep and other activity , there was more pain in nape of neck, and some rigidity. She was readmitted to the hospital which was exclusively an obst and Gyn Hospital. The Anaesthetist was consulted

O/E it was found she was in distress, had some fever for 3-4 days, The head ache was disabling and no more positional There was neck rigidity, TLC count 14000.A differential diagnosis of re appearnce of PDPH, Meningigm, Meningitis, SAH was suspected.

When she was asked for a repeat spinal puncture and CSF analysis for presence of blood and/or cell count, she vehemently refused. So she was referred to a nearby Neuro center for a CT scan which confirmed the diagnosis of SAH. ( PIC -1 ). The neuro surgeon further advised a CT angio which confirmed an Anneurism in MCA ( middle cerebral artery ) area, ( PIC-II) which was clipped next day and the patients head ache decreased and in 7 days she was back to normal.

ANALYSIS: Major Neurologic complecations following Spinal anaesthesia is not common, but headache,Septic and aseptic meningitis,Arachnoiditis, Myelitis, Chordaequina syndrome are known since long , reported as early as 1946 ( JAMA 1946 ;132 (12) 679-685)

Risk factor for PDPH: (1) younger age, (2) pregnancy, (3) use of largebore needle. Theory for PDPH is Bimodal, a) Low Spinal fluid volume b) relative vasodilation in response to stretching intracrannial anchoring structure.

General Anaesthesia is advocated in Anneurism with control of mean arterial pressure, airway protection and Oxygenation.

There are plenty of case reports of Anneurism rupture after Spinal Anaesthesia.

Anaesthetists from Basil, successfully manages a known case of Giant Aneurism with Epidural Anaesthesia with out any complication .

They have explained that the Aneurism is at danger of rupture if the differential pressure of ( Transmural aneurism pressure) ( MAP) – Intra cranial Preessure( ICP ) increase by either raise in MAP or fall in ICP after fall in CSF pressure that raises Intramural pressure.

So a fluctuation of BP resulting in high intramural pressure against a low intracrannial pressure following Spinal Anaesthesia and csf leak could have resulted the rupture of Annurysm.

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