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Correspondence |
Nagano, Japan
We thank Dr. Errando and Dr. Peiró for their interest in our case report.1 We reported an abrupt sinus arrest of six seconds duration in a patient under general anesthesia. Atropine 0.5 mg was ineffective in resolving the sick sinus syndrome, and the arrhythmia progressed to atrial flutter with high-degree atrioventricular block.
The fundamental therapeutic challenge of profound bradycardia, as observed in the case reported, or cardiac arrest is successful resuscitation. Vasopressor agents such as ephedrine or epinephrine help maintain preload by their vasoconstrictive action. We attributed the reversal of circulatory collapse to epinephrine’s ability to maintain adequate coronary perfusion.
However, we are not sure whether atropine should be considered the second choice of treatment for an arrhythmia caused by an imbalance between sympathetic and parasympathetic tone, even in non-critical cases. The prophylactic administration of vasopressor agents such as ephedrine or epinephrine for such arrhythmias may result in unnecessary hypertension, tachycardia, or ventricular irritability when inhalational anesthesia is administered.2 We believe that, similar to treatment of bradycardia during spinal anesthesia,3 the stepwise escalation of treatment of bradycardia from atropine to ephedrine or epinephrine should also be recommended for bradycardia occurring under general anesthesia. We encourage the administration of vasopressor agents together with atropine, especially in life-threatening situations. However, we still feel that the administration of an adequate dose of atropine should be the primary treatment for this type of arrhythmia.
References
1 Maruyama K, Mochizuki N, Hara K. High-degree atrioventricular block after the administration of atropine for sinus arrest during anesthesia (Letter). Can J Anesth 2003; 50: 528–9.
2 Pollard JB. Cardiac arrest during spinal anesthesia: common mechanisms and strategies for prevention. Anesth Analg 2001; 92: 252–6.
3 Johnston RR, Eger EI II, Wilson C. A comparative interaction of epinephrine with enflurane, isoflurane, and halothane in man. Anesth Analg 1976; 55: 709–12.
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