Anesthetic Influence on Occurrence and Treatment of the Trigemino-Cardiac Reflex

Abstract

Trigeminocardiac reflex (TCR) is defined as sudden onset of parasympathetic dysrhythmia including hypotension, apnea, and gastric hypermotility during stimulation of any branches of the trigeminal nerve. Previous publications imply a relation between TCR and depth of anesthesia. To gain more detailed insights into this hypothesis, we performed a systematic literature review.Literature about occurrence of TCR was systematically identified through searching in Cochrane Central Register of Controlled Trials (CENTRAL), PubMed (MEDLINE), EMBASE (Ovid SP), and the Institute for Scientific Information (ISI Web of Sciences) databases until June 2013, as well as reference lists of articles for risk calculation. In this study, TCR was defined as drop in mean arterial blood pressure and heart rate, both >20% to baseline. We calculated intraoperative cerebral state index (CSI) of each TCR-case using a newly developed method. These data were further divided into 3 subgroups: CSI <40 (deep anesthesia), CSI 40–60 (regular anesthesia), and CSI >60 (slight anesthesia).Including 45 studies with 910 patients, 140 (15%) presented with TCR, and 770 (85%) without TCR during operation. TCR occurrence showed a 1.2-fold higher pooled risk slighter anesthesia (CSI <40: 13%, at CSI 40–60: 21%, and at CSI >60: 27%) compared with deeper anesthesia. In addition, we could discover a 1.3-fold higher pooled risk of higher MABP drop with a strong negative correlation (r = −0.935; r2 = 0.89) and a 4.5-fold higher pooled risk of asystole during TCR under slight anesthesia compared with deeper anesthesia.Our work is the first systematic review about TCR and demonstrates clear evidence for TCR occurrence and a more severe course of the TCR in slight anesthesia underlying the importance of skills in anesthesia management during skull base surgery. Furthermore, we have introduced a new standard method to calculate the depth of anesthesia.

The effect of anesthesia depth on the oculocardiac reflex in strabismus surgery

“…To date, the only successful way to interrupt an OCR is to stop the EOM traction, and then proceed with caution as the surgery is continued [1]. The depth of anesthesia is another presumed factor having an impact on OCR incidence [5,6]. However, there are few studies that clearly show the effect of the anaesthesia depth on OCR.…”

Sinus arrest with prolonged asystole due to the trigeminocardiac reflex during application of local anaesthetic in the nasal mucosa

“…It is also estimated that there is a higher prevalence in children than adults, based on their different, age-related reactivity of the autonomous nerve system. Various general risk factors for the occurrence of the TCR were discussed in the literature, some with stronger evidence (eg, type of surgery and technique,12 light plane anaesthesia13 and fast-acting opioids14) and others without clear evidence (eg, patients cardiac condition and beta-blocking agents). In the case presented h the only possible risk factor was the use of fast-acting opioids such as remifentanil.…”

Trigeminocardiac Reflex: Beyond a skull base Reflex

“…In this work, it seems plausible that chronic form of the TCR is mainly There was a need to adapt and to improve the initial definition of the TCR, even so its genial structure that was the basis of this enormous development of this phenomenon should be maintained. Such work on the definition by Meuwly et al [15] has also led to better and deeper understanding of the behavior of the TCR.…”

“…Probable mechanisms of TCRinduced differential outcomes may include ischemia-induced, more manipulations of cranial nerve structures, more invasiveness of tumors, techniques, types of tumors or combinations of these factors [2,12]. In addition, many other factors including the effect of surgical positioning, type of anesthetics (intravenous vs volatiles), effect of blunt versus sharp dissection, and effect of other various surgical techniques were rarely studied in regards to the TCR phenomenon [15,17]. Future research should be directed toward adequately powered prospective randomized trials.…”

“…The TCR is mainly investigated as an autonomous reflex during skull base interventions [3][4][5][6][7][8][9][10][11] and its role in predicting the surgical outcomes is also explored [12][13][14][15][16][17][18][19]. The role of the TCR is not only limited to certain neurosurgical conditions and recently, it is also linked with various other surgical conditions, sleep disorders, sudden infant death syndrome and other interventions [20,21].…”