bradycardia & hypotension

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militarymd

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This case baffled me a little. See what you guys think.

38 year old ASA I woman going to OR for TVH. NKDA, No meds. Vitals: hr 60 bp 120/80 afebrile.

Case done under GETA. EBL about 50 cc. Surgical time about 1 hour.

PACU course unremarkable. Post op pain management with IVPCA using dilaudid.

I was called to the ward within 2 hours after discharge from PACu for "narcotic overdose".

On arrival to the ward, the patient is awake and alert and in pain. Report from the ward nurse is that she was hypotensive and unresponsive, so 0.4 mg of narcan was given for presumed narcotic overdose.

My assessment: patient is clearly not narcotized on my arrival although she was hypotensive. Thready pulse with NIBP at 60/40. Pulse was 55 bpm.

Not knowing what else was going on, I opened up the IV and gave LR as quick as I could while I continued my assessment of the patient and review of her medical record.

neuro: awake/alert and oriented. and complaining of pelvic pain (4/10)
Chest: clear
CV: rrr no mrg...hr 50 to 60
abdomen: tender as expected from surgery, but not distended
genital exam: no obvious bleeding

What does everyone think?
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militarymd said:
This case baffled me a little. See what you guys think.

38 year old ASA I woman going to OR for TVH. NKDA, No meds. Vitals: hr 60 bp 120/80 afebrile.

Case done under GETA. EBL about 50 cc. Surgical time about 1 hour.

PACU course unremarkable. Post op pain management with IVPCA using dilaudid.

I was called to the ward within 2 hours after discharge from PACu for "narcotic overdose".

On arrival to the ward, the patient is awake and alert and in pain. Report from the ward nurse is that she was hypotensive and unresponsive, so 0.4 mg of narcan was given for presumed narcotic overdose.

My assessment: patient is clearly not narcotized on my arrival although she was hypotensive. Thready pulse with NIBP at 60/40. Pulse was 55 bpm.

Not knowing what else was going on, I opened up the IV and gave LR as quick as I could while I continued my assessment of the patient and review of her medical record.

neuro: awake/alert and oriented. and complaining of pelvic pain (4/10)
Chest: clear
CV: rrr no mrg...hr 50 to 60
abdomen: tender as expected from surgery, but not distended
genital exam: no obvious bleeding

What does everyone think?
Click to expand...

Primarily, Mil, I'd worry about an occult bleed. Why isnt she tachycardic? I dont know. Maybe the opiods are opposing the sympathetic response.

Stat H&H. If its low, you've got your answer.

If its acceptable, give her a liter (or more, maybe she's behind) of crystalloid, DC the opiods for the time being.
 
jetproppilot said:
Primarily, Mil, I'd worry about an occult bleed. Why isnt she tachycardic? I dont know. Maybe the opiods are opposing the sympathetic response.

Stat H&H. If its low, you've got your answer.

If its acceptable, give her a liter (or more, maybe she's behind) of crystalloid, DC the opiods for the time being.
Click to expand...

And if that stuff doesnt work, something more sinister may be lurking. Tell me if the above stuff is/isn't on the mark. If not, we'll go through the "more sinister stuff" workup. Can't write more now since I've gotta bathe my two year old prodigy.
 
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MS IV here

my thoughts.

Could the pt have had an intraop MI and then progressed onto having cardiogenic shock? This could explain the paradoxical hypotension/brady. Yah i know you said she's a ASA I and she is relatively young, but.....

Other DDx could maybe be septic shock or some sort of sympatho-tectomy (?sp).

BTW, MMD, you said her pulse was thready. Where did you feel the pulse? Just curious because if I'm not mistaken shouldnt a radially palpated pulse be a rough estimate of a syst BP of 90. I think a femorally palpated one estimates one of atleast 80.

My thoughts
 
What about some type of anaphylactoid reaction? I can't explain the bradycardia, however. Another possibility is medication error (i.e. beta blocker given to wrong patient).
camkiss
 
Was she nauseated at all?

Narcan can cause hypotension and arrythmias (generally tachy) but it can cause bradycardia if nausea and vomiting is involved. Vagally mediated.
 
Could it be a reaction to pain from abrupt reversal of analgesia? I've heard of patients vagaling out from severe pain (but I've never seen it myself).
 
Noyac said:
Was she nauseated at all?

Narcan can cause hypotension and arrythmias (generally tachy) but it can cause bradycardia if nausea and vomiting is involved. Vagally mediated.
Click to expand...

No nausea, just pain.
 
Praetorian said:
Could it be a reaction to pain from abrupt reversal of analgesia? I've heard of patients vagaling out from severe pain (but I've never seen it myself).
Click to expand...

I thought of that also, but her HR remained stablely low for the rest of her eventful day.
 
I was taught, and I taught that in the perioperative period, bleeding is the number one cause of hypotension in certain patient populations.

The patient I described would certainly fall into that category.

Her slow heart rate made me think about other causes though.

She responded to IVF with increased BP, but her heart rate stayed low. When I examined her, I palpated her radial, carotid, and femoral pulses....I really couldn't palpate her radial...that made me worried.

I sent off some stat labs, and sent her back to the PACU for further treatment and monitoring.

HCT came back 23%


So, it was bleeding, but her heart rate confused me then and it still baffles me
 
I'll vote for hypovolemia and a "mysterious unexplained herbal side-effect". :laugh:
 
Peritoneal collections of fluid causing even mild distension can cause a vagally mediated bradycardia. It would seem to fit the situation you described.
 
UTSouthwestern said:
Peritoneal collections of fluid causing even mild distension can cause a vagally mediated bradycardia. It would seem to fit the situation you described.
Click to expand...

Good point, but her bradycardia persisted throughout the subsequent operative procedure which showed bleeding tracking retroperitoneally.

The lesson I took away from this experience was: don't let red herrings confuse you.
 
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Bezold-Jarisch reflex.

i had to, it's by far the best named reflex.
 
fishtolive said:
Bezold-Jarisch reflex.

i had to, it's by far the best named reflex.
Click to expand...

That reflex extinguishes once you start filling the LV.
 
Med error. Somebody gave her a beta blocker and sure as hell won't fess up now about it.
 
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rn29306 said:
Med error. Somebody gave her a beta blocker and sure as hell won't fess up now about it.
Click to expand...

certainly possible.
 
militarymd said:
I

I sent off some stat labs, and sent her back to the PACU for further treatment and monitoring.

HCT came back 23%


So, it was bleeding, but her heart rate confused me then and it still baffles me
Click to expand...

The famed Bezold-Jarisch reflex could be a possibility. Yes, yes, more studied in dogs and might not even exist in humans, but sometimes patients don't read the textbooks...and maybe there's some K9 family history. From Miller: "Severe hypotension and bradycardia (i.e., Bezold-Jarisch reflex).... The cause is presumed to be stimulation of intracardiac mechanoreceptors by decreased venous return, producing an abrupt withdrawal of sympathetic tone and enhanced parasympathetic output. This effect results in bradycardia, hypotension, and syncope."

So the Hct was telling of the cause, and perhaps this patient had a stronger Bezold-Jarisch reflex arc (initiated by lack of ventricular filling) than the average person resulting in her bradycardia. Did her heart rate come up after resuscitation?

Also, as we know, anesthesia can blunt the tachycardic response to hypovolemia. Does anyone know how long we reasonably could expect that effect to last?

Just some thoughts on this last call night before New Year's break.
 
MilitaryMD:
One major point to comment on from my perspective: was her heart reactive (i.e., "appropriately" responding) once you intubated/extubated her? If so, then you know that something happened after you handed her off in the PACU. My guess would be a medication error, rather than some weird vagally mediated bradycardia.
 
rn29306 said:
Med error. Somebody gave her a beta blocker and sure as hell won't fess up now about it.
Click to expand...
Good guess with all the heavy emphasis on periop beta blockers these days. I've never seen so many bradycardic patients...
 
IceDoc said:
The famed Bezold-Jarisch reflex could be a possibility. Yes, yes, more studied in dogs and might not even exist in humans, but sometimes patients don't read the textbooks...and maybe there's some K9 family history. From Miller: "Severe hypotension and bradycardia (i.e., Bezold-Jarisch reflex).... The cause is presumed to be stimulation of intracardiac mechanoreceptors by decreased venous return, producing an abrupt withdrawal of sympathetic tone and enhanced parasympathetic output. This effect results in bradycardia, hypotension, and syncope."

So the Hct was telling of the cause, and perhaps this patient had a stronger Bezold-Jarisch reflex arc (initiated by lack of ventricular filling) than the average person resulting in her bradycardia. Did her heart rate come up after resuscitation?

Also, as we know, anesthesia can blunt the tachycardic response to hypovolemia. Does anyone know how long we reasonably could expect that effect to last?

Just some thoughts on this last call night before New Year's break.
Click to expand...

She did not develop tachycardia at any point during my interaction with her....awake, under anesthesia, hypovolemic, or resuscitated.

that is what baffled me.
 
bogatyr said:
So the lesson is never believe the OB/GYNs when they say there was only 50cc of blood loss?
Click to expand...
That's from Anesthesia 101!!! :laugh:
 
If I recall, the Bezold-Jarisch Reflex also involves some apnea. Was she apneic at the time the nurse gave narcan?
 
No, she was awake.

The nurses gave narcan for hypotension.
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jetproppilot said:
More importantly, I want access to Mil's new smileys!
Click to expand...

right click on them, and you can see where they are hosted.
 
militarymd said:
No, she was awake.

The nurses gave narcan for hypotension.
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Earlier, you said hypotensive and UNresponsive...awake upon your arrival to the bedside. So the nurse presumably gave narcan for unresponsiveness, correct?
 
canjosh said:
Earlier, you said hypotensive and UNresponsive...awake upon your arrival to the bedside. So the nurse presumably gave narcan for unresponsiveness, correct?
Click to expand...

the nurses reported to me that the patient was "unresponsive". I never personally saw the patient unresponsive.

The same nurses have called codes for patients who were asleep.

I doubt she was unresponsive.
 
militarymd said:
.

The same nurses have called codes for patients who were asleep.

.
Click to expand...

:laugh: :laugh: :laugh:
 
militarymd said:
the nurses reported to me that the patient was "unresponsive". I never personally saw the patient unresponsive.

The same nurses have called codes for patients who were asleep.

I doubt she was unresponsive.
Click to expand...


Ahh, yes. I'm familiar with those.
 
How well do you believe the number? I might have believed it in someone who was over-narcotized, but not somebody mentating well in pain.

If she's mentating well, how much faith can you really have in this NIBP number? Same for the pulse, is the HR a palpated number or machine-number? Anything remarkable on the rhythm strip? 12-lead? What's her cap refill like? I agree that the lack of radial pulse is disturbing, as is the hct. Any change with pushing on her liver?
 
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