Asystole during Suspension Laryngoscopy: Case Report, Literature Review, and Prophylactic Strategies

Cassettari, Arthur Justi; Santos, Érica Cristina Campos E; Semenzati, Graziela Oliveira; Crespo, Agrício Nubiato

doi:10.1155/2020/9260564

Cited by 5 publications

(9 citation statements)

References 15 publications

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“…In most patients, these hemodynamic responses are transient; however, in patients with cardiovascular and/or cerebrovascular diseases, these responses might produce dangerous complications ( 25 ). Patients undergoing suspension laryngoscopic surgery encounter the same cardiac reaction secondary to the sympathetic reflex and release of catecholamines, even though the stimulation is much more intensive and is sustained much longer than the transient process of endotracheal intubation ( 26 , 27 ). Paltura et al demonstrated that aerosolized lidocaine could inhibit the sympathetic reflex and block the SLN to effectively improve hemodynamics ( 27 ), and the effects of SLNB were proven in our study again.…”

Section: Discussionmentioning

confidence: 99%

Ultrasound-Guided Block of the Internal Branch of the Superior Laryngeal Nerve Reduces Postoperative Sore Throat Caused by Suspension Laryngoscopic Surgery: A Prospective Randomized Trial

et al. 2022

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ObjectiveSuspension laryngoscopy is commonly used in operative laryngology. Although it is efficient and minimally invasive in most cases, it can lead to postoperative sore throat (POST) and cough. Because of intensive stimulation by the rigid metal suspension laryngoscope, procedures must be implemented under general anesthesia. Together, these factors increase the possibility of postoperative complications. Blocking the internal branch of the superior laryngeal nerve (SLN) is useful in inhibiting the endotracheal intubation stress response. Thus, we evaluated the efficacy of ultrasound-guided block of the internal branches of the superior laryngeal nerve to improve postoperative complications.MethodsA total of 64 patients was scheduled for elective laryngeal cancer resection, and suspension laryngoscopic surgery was performed under general anesthesia with a block of the internal branch of the superior laryngeal nerve (group iSLNB, n = 32) and without a block (group C, n = 32). Patients in group iSLNB received ultrasound-guided blocks of the internal branches of superior laryngeal nerve bilaterally (0.2% ropivacaine, 2 ml each side). The primary outcome measures were the incidence and severity of sore throat and cough assessed 0.5, 2, 6, and 24 h after tracheal extubation. The secondary outcome measures were heart rate and mean arterial pressure on arrival in the operating room (T0), at endotracheal intubation (T1), upon insertion of the suspension laryngoscope (T2), 5 min after insertion (T3), at tracheal extubation (T4), and 5 min after extubation (T5). Blood glucose levels were measured at T0, T3, and T5.ResultsThe incidence and severity of POST and cough in the iSLNB (internal branch of superior laryngeal nerve block) group were significantly reduced within 6 h after extubation compared with those in the control group, regardless of whether swallowing was present (P < 0.05). Compared to the control group from T0–T5, except at T0, the iSLNB group had significantly lower heart rate and mean arterial pressure (P < 0.05). Compared to T0, at other time points, the heart rates in the control group were significantly increased (P < 0.05), and the mean arterial pressures at other time points in the iSLNB group were significantly lower than those at T0 (P < 0.05). The blood glucose levels at T3 and T5 in the iSLNB group were significantly reduced compared with those in the control group (P < 0.05).ConclusionUltrasound-guided block of the internal branch of the superior laryngeal nerve might effectively ameliorate postoperative complications secondary to suspension laryngoscopic surgery with endotracheal intubation under general anesthesia and improve hemodynamic stability.Clinical Trial Registrationhttps://www.chictr.org.cn, identifier: ChiCTR2100049801.

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Section: Discussionmentioning

confidence: 99%

Ultrasound-Guided Block of the Internal Branch of the Superior Laryngeal Nerve Reduces Postoperative Sore Throat Caused by Suspension Laryngoscopic Surgery: A Prospective Randomized Trial

et al. 2022

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“…Ultimately, bradycardia or asystole could be caused by an increase in vagal response through the parasympathetic nerve fibers from the vagus nerve to the sinoatrial node. Thus, even in the absence of the previously mentioned opioid dose problems, several other conditions could increase vagal tone, that is, induce vagal stimulation and reflex upon laryngeal manipulation, resulting in severe reflexive bradycardia and asystole [5][6][7].…”

Section: Discussionmentioning

confidence: 99%

“…One suspected mechanism is the direct stimulation of the vagus nerve, also known as the laryngo-cardiac reflex [8]. It is often triggered in suspension laryngoscopy when the blade tip lifts the supraglottic area or laryngeal surface of the epiglottis [5,6]. Following stimulation through mechanical irritation to areas innervated by an internal branch of the superior laryngeal nerve, a sensory branch of the vagus nerve, the afferent signal through the vagus nerve is received by the solitary nucleus of the medulla, and the resulting efferent parasympathetic signal through the vagus nerve leads to bradycardia.…”

Section: Discussionmentioning

confidence: 99%

“…Following stimulation through mechanical irritation to areas innervated by an internal branch of the superior laryngeal nerve, a sensory branch of the vagus nerve, the afferent signal through the vagus nerve is received by the solitary nucleus of the medulla, and the resulting efferent parasympathetic signal through the vagus nerve leads to bradycardia. Continuous intense stimulation has been reported to cause asystole [5]. Due to the required stimulation level, simply placing the laryngoscope on the laryngeal surface of the epiglottis without any significant tension would not lead to bradycardia [7,9].…”

Section: Discussionmentioning

confidence: 99%

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Multiple sinus pauses during suspension laryngoscopy with external laryngeal manipulation in hyperextended neck position in a patient with enlarged cervical lymph nodes: a case report

2023

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Suspension laryngoscopy is a commonly performed procedure for effective laryngeal microsurgery (LMS). Although it is associated with few adverse events, cardiac complications such as severe arrhythmia induced by exaggerated vagal tone may arise during this procedure. Here, I present the case of a 52-year-old female patient who presented with a suspected thyroid follicular neoplasm and enlarged cervical lymph nodes. LMS was planned to remove a vocal fold polyp before the thyroid surgery. The patient was placed in a Boyce-Jackson position, and suspension laryngoscopy was performed. However, several sinus pauses were detected whenever external laryngeal manipulation (ELM) was performed to improve surgical field exposure, which was presumed to be attributed to vagal stimulation or reflex induced by numerous external and internal factors during laryngeal manipulation. The suspected mechanism was the direct stimulation of the vagus nerve termed the laryngo-cardiac reflex, or carotid sinus reflex, a type of baroreceptor reflex. When the first episode of sinus pause occurred, the effect-site target concentration of propofol was unadjusted after checking the bispectral index level indicating an adequate anesthetic depth, but ELM was discontinued. When the second episode occurred, ELM could not be stopped until good laryngeal visualization was achieved. Then, the patient received 0.2 mg of intravenous glycopyrrolate. Her heart rate returned within the normal range whenever ELM was not applied. When performing suspension laryngoscopy, the head and neck positioning, the procedure itself and laryngeal manipulation may act as external factors that could induce an exaggerated vagal response. Further, patients with head and neck tumors have various internal factors, such as tumor itself, cervical lymphadenopathy or post-irradiation fibrosis, which can affect the carotid sinus and deteriorate the vagal response. Therefore, careful preoperative evaluation is required to identify these internal factors in advance and take proper care to minimize the additional influence of external factors.

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“…As in our patient's case, the vital signs may immediately recover without any problems; however, there are reports of cases in which cardiopulmonary resuscitation was needed. [14,15] Therefore, anesthesiologists should be aware of the possibility of induction of the laryngocardiac reflex during intubation.…”

Section: Discussionmentioning

confidence: 99%

Sinus pause during nerve integrity monitoring tube insertion following anesthetic induction with a low-dose neuromuscular blocking agent

Byun¹,

Jeon²

2021

Medicine

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Rationale: Nerve integrity monitoring (NIM) tubes are commonly used in thyroid surgery to prevent recurrent laryngeal nerve injury. To achieve the optimal electromyographic signal for NIM as intraoperative neural monitoring (IONM), the neuromuscular blocking agent (NMBA) dose should be low. The use of a low-dose NMBA increases the anesthetic and analgesic agent dose required to attenuate the laryngeal reflex during intubation. In addition, since the NMBA onset time is delayed, depending on the situation, anesthesia may become excessively deep or shallow before intubation.Patient's concern: A 51-year-old woman scheduled for thyroid lobectomy received 0.3 mg/kg of rocuronium. Three minutes later, when the NIM tube was inserted through the vocal cord, the patient's heart rate (HR) was undetectable for 2 seconds.Diagnosis: We suspected that the use of a high-dose anesthetic agent and remifentanil or the laryngocardiac reflex induced the sinus pause.Interventions: To maintain the anesthetic depth, we administered 6 vol% of desflurane. Because the patient's systolic blood pressure was 70 mmHg and HR was 30 beats/min, we discontinued the remifentanil infusion and administered 8 mg of ephedrine.Outcomes: The patient's vital signs recovered to normal levels. Subsequently, there were no episodes of bradycardia or arrhythmia. Conclusion:Sinus pause or severe bradycardia may occur due to the laryngocardiac reflex or the administration of a high-dose anesthetic and analgesic agent during tracheal intubation in patients who received a low-dose NMBA for IONM induction using an NIM tube. Anesthesiologists should be aware of these risks and take precautions to maintain adequate anesthesia, be prepared to administer vasoactive drugs to increase the blood pressure and HR if needed, and, if possible, intravenously administer lidocaine to attenuate the laryngeal reflex during intubation.

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Asystole during Suspension Laryngoscopy: Case Report, Literature Review, and Prophylactic Strategies

Cited by 5 publications

References 15 publications

Ultrasound-Guided Block of the Internal Branch of the Superior Laryngeal Nerve Reduces Postoperative Sore Throat Caused by Suspension Laryngoscopic Surgery: A Prospective Randomized Trial

Ultrasound-Guided Block of the Internal Branch of the Superior Laryngeal Nerve Reduces Postoperative Sore Throat Caused by Suspension Laryngoscopic Surgery: A Prospective Randomized Trial

Multiple sinus pauses during suspension laryngoscopy with external laryngeal manipulation in hyperextended neck position in a patient with enlarged cervical lymph nodes: a case report

Sinus pause during nerve integrity monitoring tube insertion following anesthetic induction with a low-dose neuromuscular blocking agent

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