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