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Lumbo-sacral spine surgery and severe bradycardia

Montréal, Québec

To the Editor:

A 37-yr-old woman weighing 95 kg underwent L5 to S1 spinal decompression for left sided lower leg pain and weakness. Preoperative evaluation revealed no history of heart disease, arrhythmia or syncope, and no baseline electrocardiogram (ECG) was ordered for this otherwise healthy patient. Her only medication was naproxen 500 mg po q 12 hr prn. After an uneventful induction with 35 µg of sufentanil, 150 mg of propofol and 50 mg of rocuronium, endotracheal intubation was performed and general anesthesia was maintained with desflurane and a sufentanil infusion of 5 µg•hr^-1. The patient was then placed in the prone position. Her vital signs were all within normal range when the incision was made. As the surgery progressed, two episodes of relative bradycardia, heart rate (HR) < 45 beats•min^-1 were observed which occurred coincidentally with the surgeons brief use of the electrocautery in the lumbo-sacral segments. Both times, the patient’s HR quickly increased to a baseline of 85 beats•min^-1 when stimulation was stopped, and the episodes were wrongly interpreted as interference with the ECG. Shortly thereafter, as the surgeons were maintaining hemostasis with the prolonged use of the electrocautery, HR decreased below 10 beats•min^-1 for at least 30 to 35 sec. Atropine (0.6 mg) was given twice, which increased HR to 40 beats•min^-1. Ephedrine (10 mg) was then given and HR rose to 100 beats•min^-1, to slowly stabilize around 75 beats•min^-1 for the remainder of the surgery. There was no non-invasive blood pressure measurement during the period of severe bradycardia. For the first ten minutes post-ephedrine, the patient was hypertensive (180/100 at five minutes and 160/90 mmHg at ten minutes). All other blood pressures were within normal limits. A Medline search from 1966 to 2003 did not disclose similar occurrences of severe bradycardia during lumbo-sacral spine surgery. We interpret the episode of severe bradycardia in this otherwise healthy patient as a stimulation of afferent parasympathetic nerve endings causing a reflex-celiac (vagovagal) reaction. This reaction would be a parallel to reflex bradycardia seen with rectal distention or testicular manipulation. No untoward event resulted from this episode and the patient recovered normally from the surgery and anesthesia. We therefore suggest vigilance with surgery in the region of the posterior sacral segments. This episode reinforces our belief in the practice of having vagolitic and sympathomimetic drugs available at all times to rapidly treat hemodynamically compromising episodes of severe bradycardia.

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