A case of cardiac arrest caused by suspected-induced Bezold-Jarisch reflexes in beach chair shoulder arthroscopic surgery

Patient, male, 55 years old, 169 cm, 60kgDue to "injury after the right shoulder pain, limited movement for 1 month, aggravated 5d" hospitaldiagnosisis a right shoulder sleeve injury, proposed in the arm plexus nerve block , full hemp down the right shoulder arthroscopic examination and shoulder sleeve repairPast history: Smoking 10 to 20 pieces/d; Penicillin allergyNo other special medical history, physical examination and laboratory examination results did not show significant abnormalitiespatients prior to the anaesthetic preparation of the line of ultrasound-guided lower arm plexus nerve block (intermuscular groove, 0.5% ropless 20ml), the anaesthetic effect is satisfactory, no adverse reactions, vital signs stable40min rear room, regular monitoring, HR78 times/min, BP140/70mmHg, SpO2 98%Anesthetic induction: Midazolam 2mg, acetate 1mg, relying on miede 20mg, Shufentani 25 mg, Rocum amalla 50mg, Airol 50mg static injection, placed in 8.0ID wire threaded trachea duct ductPulmonary ventilation: VT460ml, RR15 times/min, Ppeak14 to 16 cmH2O; right Metamimi 24 ?g/h, propofol 200mg/h, Riffentani 200 g/h for anesthesia maintenance, maintenance BIS at 45 to 60placed 60 degrees beach chair position, at this time BP from 128/65mmHg to 95/57mmHg, HR from 72 times / minute to 68 times / minute, to give benzene adrenaline 50 sg static injection, the effect is not good, to appropriately increase the liquid speed, after dopamine 2mg static injection, BP, HR maintained at 95/60mmHg, 65 times / minute15min to klinmycin (0.6g/100ml) prior to the start of the operation and drip stake in 20minAt the beginning of the operation 58min, the shoulder sleeve is being repaired on the platform, HR from 64 times / burst to 38 times / minute, ECG show Q-T period extension, then appear edgheic speed, cardiac arrest, BP from 88/61mm to Hg46/33mmHgimmediately rescue: suspended intravenous anaesthetic drugs, 2% Lidocaine 5 ml, methyl strong pine dragon 0.5g, epinephrine 100 sg intravenous injection, beach chair immediately began chest pressure, 1min leveling body position after continued chest pressure, intravenous injection of epinephrine 900 sgChest compression 3.5min, restore sinus heart rhythm, BP rapidly raised, HR rapidly increased, until the recovery, BP, HR stable at 115/65mmHg, 75 times / left and rightAfter stopping chest compression, it was found that the patient's torso appeared a sexual cyanosis, and there was no obvious swelling in the right neck and shoulder by thoracic ultrasound: each room, valve structure, myocardial contraction and diaphragm did not see significant abnormalities, the heart cavity did not see gas During the operation, hemorrhage was not much, urine 100 ml, inlet 1000 ml (900 ml of sodium compound chloride and 100 ml antibiotic ) The artery, the venous tube in the right neck is pressed, the blood gas is checked, the temperature is measured 34.9 degrees C, and on the basis of the original temperature blanket insulation, the temperature is raised by a heater Blood gas after cardiac arrest after 15min: pH7.33, PO2 431.7mmHg, PCO2 36.3mmHg, BE-5.2mmol/L, K-4.08mmol/L, Ca2 1.20m/L, HB134g/L; after cardiac arrest 60min, patients recover from sudden breathing, etc .5mm; Blood gas after cardiac arrest of 70min: pH7.34, PO2 409.5mmHg, PCO2 40.5mmHg, BE-3.0mmol/L, K-3.52mmol/L, Ca2 1.00mmol/L, HB114g/L; End of cardiac arrest 90min surgery, return to UIC treatment THE ICU TREATS ECG MONITORING, DRUG SEDATION, VENTILATOR SUPPORT, ACID SUPPRESSION, MAINTENANCE OF WATER ELECTROLYTE BALANCE, REHYDRATION, CARDIOMYOMYOSIS SUPPORT, AND CLOSELY OBSERVES ECG CHANGES Back to ICU6h, offline pull pipe, God clear language Day 2 Check ECG: T-wave inversion; myocardial enzyme selevated; bedside chest sheet not visible abnormality The cardiology consultation concluded that coronary spasms were not ruled out and recommended that aspirin, poivirs to myocardial enzyme spectrum be restored to the normal range After surgery 5d was transferred back to the general ward After 6d was discharged from the hospital, the myocardial enzyme spectrum returned to the normal range to inquire about the medical history: self-described when riding a bicycle suddenly fainted to the ground, about 1min after waking up, without any discomfort, did not seek medical treatment; , coronary vein symhttple examination: the near section of the right crown narrow (40%), Holter and the heart super did not see obvious abnormalities ; discuss suspected that the cause of the patient's cardiac arrest was Bezold-Jarisch (BJR), based on the patient's performance during surgery BJR system the of blood vessels caused by the reduction of blood vessel - vaguation reflex, mainly in the slow heart rate, blood pressure drop The patient from the beginning of surgery to the occurrence of tachycardia, the amount of fluid 1000ml, and preoperative fasting water time is longer, arm plexus nerve block can cause peripheral blood vessel dilation, so that the amount of blood return decreased, coupled with the beach chair position, the capacity further insufficient, induced BJR, thus causing the tachycardia, blood pressure reduction, until cardiac arrest There is a pressure receptor in the left ventricle, when the left heart room capacity is reduced when excited, through BJR, the heart rate slows down, to extend the left ventricle filling time, increase the heart rate, the main manifestation is the heart rate slowdown and blood pressure drop Be aware of this possibility when heart palpitations occur or even cardiac arrest In addition, too much anaesthetic may exacerbate the situation the patient into the operating room front arm plexus nerve block, after entering the room to full hemp, surgery under the whole hemp composite nerve block, the operation continued propofol, riffentany, right Metmemyding pump injection, blood vessel dilation is more serious, the patient after hemp induction to routine monitoring BIS, maintained at 45 to 60, according to BIS value adjustment of the depth of anesthesia, to avoid the deep anaesthetic Other suspected causes can be eliminated: coronary artery spasms (inthetic failure to capture abnormal changes in ECG, after surgery coronary artery angiography shows only 40% stenosis in the immediate end of the right coronary artery); When body temperature); Klinmycin allergy (Klinmycin has the risk of causing prolonged QT inter-period, cutting-edge torsional ventricular speed and polymorphic ventricular tachycardia, often in patients with liver and renal dysfunction, heart insufficiency, myocardial ischemia, primary QT interstitial period and electrolyte disorders, but not allergic when applied again in 2 operations) However, when these factors exist together, it may aggravate the patient's arrhythmia and other conditions, not conducive to the patient's prognosis BJR reflex trigger: BJR reflexes occur in the form of insufficient capacity, vasculitopathy, intravenous pressure, such as in patients with severe bleeding (bleeding volume of 800ml), vertebral blockpatients (especially when the anaesthetic plane is higher - T6), nerve blockpatients, there may be peripheral blood vessel dilation, back heart volume decreased and induced BJR, can lead to adverse consequences, should be alert to this possibility BJR reflex
prevention and treatment: (1) capacity management : for patients with intravertebral block or nerve block, the anaesthetic injection should be appropriately expanded; (2) adjust the patient's position: such as pregnant women's intravertebral obstruction lag, alert to the occurrence of reclining syndrome, take the left-leaning position; Kim and others also reported a case of BJR after placing a folding knife, and a return to a flat position and a bad recovery (3) Drug treatment: ephedrine because of its strong heart and contraction of blood vessels, but better-effect drugs However, in the event of cardiac arrest, you should use epinephrine as early as possible Choose vascular active drugs to be careful, and to be closely observed The case alerts you to be alert to the possibility of BIR reflexes and to dispose of it correctly when heart palpitations occur during surgery and blood pressure is lowered In addition, for patients with whole hemp compound nerve block or epidural block, vascular dilation is serious, to actively supplement the capacity, appropriately reduce the amount of whole hemp drug, cycle fluctuations, carefully select vascular active drugs, and closely observe, in order to minimize the occurrence of dangerous situations