Intense vagal episode with induction

[coffeebythelake]

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Healthy mid aged woman, premeditated with versed, fentanyl, lidocaine, then after propofol was pushed gasped a bit, to bradycardia and then went asystolic for 12 seconds. Recovered spontaneously while we were scrambling for epi, atropine and preparing to perform chest compressions. We subsequentlg gave 0.4 mg glycopyrrolate and 15 mg ephedrine. Remained stable after, we continued with induction and did the case.

Anyone have similar experiences with propofol?

 

[deleted162650]

Wasn’t the prop. It was all the other stuff you gave first and the prop was just the icing on the cake.

 

[coffeebythelake]

Wasn’t the prop. It was all the other stuff you gave first and the prop was just the icing on the cake.

Really? Seems unlikely. All premeds were given at least 2to 3 minutes before. And It happened seconds after propofol was administered.

 

[deleted162650]

Yes really

 

[coffeebythelake]

Mechanism?
Still vasovagal?

 

[deleted162650]

Mechanism?
Still vasovagal?

You blunted the sympathetics with the pre-meds. Then she gasped/coughed a bit on induction and yes - vaso-vagalled. Youngish to middle aged healthy females are the worst in this regard. They’re the ones that brady way down on insufflation too.

 

[coffeebythelake]

You blunted the sympathetics with the pre-meds. Then she gasped/coughed a bit on induction and yes - vaso-vagalled. Youngish to middle aged healthy females are the worst in this regard. They’re the ones that brady way down on insufflation too.

Ok, I wasn't exactly sure what you were saying in the beginning. Yes the premeds decreased the sympathetic tone, which led to a more robust vagal episode when propofol was administered. The question then becomes:

1. Is this necessarily predictable? Pt did not report vasovagal episodes in preop because she didn't know what it was called and didnt think it was important (in postop I asked her specifically about this and she said it happens very frequently, including with IVs, biopsies, and getting up suddenly). Pt did not have a low baseline HR.

2. How could it be preventable? It doesnt happen to everyone with hx of vasovagal. Ive seen plenty of people Brady down, but none like this. Should premeditation be avoided then? Should glyco be given prophylactically? Would the intense burning with propofol in the absence of premeditation trigger the same response

 

[Beeftenderloin]

Have had 2 patients this year that reported coding on induction for elective surgeries. One of them had it happen with 2 separate anesthetics.

Both got regional with some sedation. Both got glyco prophylactically (just in case). Both did fine.

 

[T-burglar]

Drug swap? Sux given?

Normal pre op EKG ? Family history of CV disease or any cause of death that could potentially have been cardiovascular?

Hear any murmurs ? bisferiens pulse on SpO2? No arterial line I assume .

I would consider a TEE for such severe Bradyarrythmia. Specifically looking for dynamic LVOT obstruction

 

[fadedrebel]

Had something similar happen to me during training... BP cuff and IV were on the same side. I started pushing propofol while the cuff inflating. Pt was a young for guy and started complaining about the severe burning In his IV arm before bradying down....

 

[Shufflin]

Intense vaginal episode with induction.

Embarrassing to admit but that's how I read the prompt at first glance.

 

[Maverikk]

Ok, I wasn't exactly sure what you were saying in the beginning. Yes the premeds decreased the sympathetic tone, which led to a more robust vagal episode when propofol was administered. The question then becomes:

1. Is this necessarily predictable? Pt did not report vasovagal episodes in preop because she didn't know what it was called and didnt think it was important (in postop I asked her specifically about this and she said it happens very frequently, including with IVs, biopsies, and getting up suddenly). Pt did not have a low baseline HR.

2. How could it be preventable? It doesnt happen to everyone with hx of vasovagal. Ive seen plenty of people Brady down, but none like this. Should premeditation be avoided then? Should glyco be given prophylactically? Would the intense burning with propofol in the absence of premeditation trigger the same response

1. Not so much but demographically as others have said and I agree: more likely females 30-60. A positive history would definitely make me give glyco, a negative history wouldn't make me withhold glyco. Had a case like this, healthy woman for lap chole. Stomach insufflation->asystole. Surgeon was shocked to be starting CPR, asked for atropine, was told chest compressions was the only way atropine would reach the heart.

2. Should premed be avoided? No I think this was a rare case to go that vagal from just premeds and propofol, that being said I don't give a ton of premeds. I sometimes give glyco prophylactically but not usually before induction/intubation, the fentanyl (when given) a few minutes before intubation usually makes them a little more brady but then the intubation brings it back up. If they go back down I work it in before insufflation, also nice for the secretions these ladies sometimes have too.

 

[woopedazz]

1. Not so much but demographically as others have said and I agree: more likely females 30-60. A positive history would definitely make me give glyco, a negative history wouldn't make me withhold glyco. Had a case like this, healthy woman for lap chole. Stomach insufflation->asystole. Surgeon was shocked to be starting CPR, asked for atropine, was told chest compressions was the only way atropine would reach the heart.

We had the same 2 weeks ago in my teaching hospital. No pre-meds given in our case though. Just a traditional insufflation --> vagal response.

 

[fakin' the funk]

Healthy mid aged woman, premeditated with versed, fentanyl, lidocaine, then after propofol was pushed gasped a bit, to bradycardia and then went asystolic for 12 seconds. Recovered spontaneously while we were scrambling for epi, atropine and preparing to perform chest compressions. We subsequentlg gave 0.4 mg glycopyrrolate and 15 mg ephedrine. Remained stable after, we continued with induction and did the case.

Anyone have similar experiences with propofol?

Agree with most here that propofol's properties are not the likely culprit here per se

UNLESS you invoke some kind of severe injection site pain-breathholding-Valsalva event

 

[Ronin786]

Bradycardia

Agree with most here that propofol's properties are not the likely culprit here per se

UNLESS you invoke some kind of severe injection site pain-breathholding-Valsalva event

Bradycardia and or asystole are documented side effects of propofol administration. Propofol blunts the baroreceptor reflex response and causes a direct decrease in heart rate.

Mechanism of Propofol Bradycardia : Anesthesia & Analgesia

An abstract is unavailable. This article is available as a PDF only.

journals.lww.com

 

[chocomorsel]

Bradycardia

Bradycardia and or asystole are documented side effects of propofol administration. Propofol blunts the baroreceptor reflex response and causes a direct decrease in heart rate.

Mechanism of Propofol Bradycardia : Anesthesia & Analgesia

An abstract is unavailable. This article is available as a PDF only.

journals.lww.com

Did not know this. Interesting. I thought it was the other stuff too and still do. But this is interesting to know.

I give all my drugs together. One right after another at induction. Unless the patient is very anxious. Then I may give the Fentanyl before the monitors.

 

[deleted171991]

Bradycardia

Bradycardia and or asystole are documented side effects of propofol administration. Propofol blunts the baroreceptor reflex response and causes a direct decrease in heart rate.

Mechanism of Propofol Bradycardia : Anesthesia & Analgesia

An abstract is unavailable. This article is available as a PDF only.

journals.lww.com

Or it doesn't.

In most cases when I push propofol (with lido, and with 0-50 mcg of fentanyl), the patient gets tachycardic after having lost consciousness. Just watch it next time. I am not a big believer in propofol-induced direct bradycardia (regardless what textbooks say). In premedicated patients, what may happen is that propofol removes the stimulus that was counteracting fentanyl-induced bradycardia.

And yes, I avoid premeds, especially in the OR. Most of the time, they act like a minute before I induce. In my experience, 50 mcg of fentanyl given with propofol and lidocaine are enough to blunt intubation-related excessive tachycardia, even in ASA 4 patients, For everything else, there is esmolol.

 

[MoMoGesiologist]

Or it doesn't.

In most cases when I push propofol (with lido, and with 0-50 mcg of fentanyl), the patient gets tachycardic after having lost consciousness. Just watch it next time. I am not a big believer in propofol-induced direct bradycardia (regardless what textbooks say). In premedicated patients, what may happen is that propofol removes the stimulus that was counteracting fentanyl-induced bradycardia.

And yes, I avoid premeds, especially in the OR. Most of the time, they act like a minute before I induce. In my experience, 50 mcg of fentanyl given with propofol and lidocaine are enough to blunt intubation-related excessive tachycardia, even in ASA 4 patients, For everything else, there is esmolol.

Just curious, why the preference for esmolol over fent?

 

[deleted171991]

Just curious, why the preference for esmolol over fent?

It goes away fast, like the excessive stimulation during laryngoscopy, but I don't really have a preference (except not loading above 100 of fentanyl).

I am less afraid of tachycardia for a minute or two, than of walking away and leaving the patient with a relatively low MAP for 20 (and a CRNA/resident who doesn't do much about it).

 

[narcotics999]

I had one myself after a spinal. Not asystole but enough for me to feel like dying.

Hx of numerous vasovagal attacks since 10, usually associated with dehydration and prolonged standing still.


I had a pt going into asystole during colonoscopy. Glyco, atropine no use. Epi did the trick.

 

[narcotics999]

Bradycardia

Bradycardia and or asystole are documented side effects of propofol administration. Propofol blunts the baroreceptor reflex response and causes a direct decrease in heart rate.

Mechanism of Propofol Bradycardia : Anesthesia & Analgesia

An abstract is unavailable. This article is available as a PDF only.

journals.lww.com

Will it also be Bezold–Jarisch reflex due to significant venous pooling after propofol induction?