Cardiac arrest in a patient with anterior fascicular block after administration of dexmedetomidine with spinal anesthesia

Kim, Baek Jin; Kim, Bong Il; Byun, Sung June; Kim, Eugene; Sung, Shin Yeung; Jung, Jin Yong

doi:10.1097/md.0000000000005278

Cited by 18 publications

(16 citation statements)

References 8 publications

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“…In contrast to the low number of SAEs reported in RCTs, some case reports described cardiac arrest during the intraoperative period after dexmedetomidine infusion. 92e95 In these cases, patients had a prior cardiovascular system abnormality, 93,94 or were taking chronotropic and negative inotropic drugs simultaneously. 95 In two cases, the procedure was performed under spinal anaesthesia promoting the activity of the parasympathetic system.…”

Section: Strengths and Weaknesses Of Our Methodologymentioning

confidence: 99%

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Perioperative adverse events attributed to α2-adrenoceptor agonists in patients not at risk of cardiovascular events: systematic review and meta-analysis

Demiri

Antunes

Fletcher

et al. 2019

British Journal of Anaesthesia

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Background: Several systematic reviews have reported the benefits of perioperative a2-adrenoceptor agonist use for various conditions, but safety evidence is poorly documented. Methods: We performed a systematic review focusing on adverse events. We searched the MEDLINE, Embase, LILACS, Cochrane, and Clinical Trials Register databases for RCTs comparing the effects of a2-adrenoceptor agonists and placebo during non-cardiovascular surgery under general anaesthesia, for any indication, in patients not at risk of cardiovascular events. The primary outcome was the incidence of severe adverse events during or after a2-adrenoceptor agonist administration. The secondary endpoints were other adverse events. A meta-analysis was carried out on the combined data. Evidence quality was rated by the Grading of Recommendations Assessment, Development and Evaluation method. Results: We included 56 studies (4868 patients). Our review, based on moderate-quality evidence, revealed that hypotension occurred frequently during the preoperative and postoperative periods, for both clonidine and dexmedetomidine. Bradycardia was reported only with dexmedetomidine. In contrast, dexmedetomidine seemed to protect against intraoperative hypertension and tachycardia. Subgroup analysis suggested that the risk of hypotension and bradycardia persisted after cessation of treatment. Interestingly, intraoperative hypotension and postoperative bradycardia were not observed with a bolus dosage of dexmedetomidine less than 0.5 mg kg À1 or with continuous administration alone. Conclusions: Pooled data for the incidence of adverse events associated with use of a2-adrenoceptor agonists in various perioperative contexts provide high-confidence evidence for a risk of hypotension and bradycardia, and protective effects against hypertension and tachycardia. Protocol registration: CRD42017071583.

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Section: Strengths and Weaknesses Of Our Methodologymentioning

confidence: 99%

“…95 In two cases, the procedure was performed under spinal anaesthesia promoting the activity of the parasympathetic system. 93,94…”

Section: Strengths and Weaknesses Of Our Methodologymentioning

confidence: 99%

Perioperative adverse events attributed to α2-adrenoceptor agonists in patients not at risk of cardiovascular events: systematic review and meta-analysis

Demiri

Antunes

Fletcher

et al. 2019

British Journal of Anaesthesia

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“…Although the incidence of severe bradycardia is low, there are some case reports of dexmedetomidine-related cardiac arrest. Cardiac conduction disorders, including left anterior fascicular block [81] and first-degree AV block [82], and the co-administration of amiodarone and dexmedetomidine [83,84] are potential factors contributing to the development of asystole, especially during general or regional anesthesia. In addition, caution should be taken when administering dexmedetomidine to patients with volume depletion or vasoconstriction.…”

Section: Safetymentioning

confidence: 99%

Dexmedetomidine: present and future directions

Lee

2019

Korean J Anesthesiol

230

154

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Dexmedetomidine, a potent and highly selective α-2 adrenoceptor agonist, has been described as a unique sedative with analgesic, sympatholytic, and respiratory-preserving properties [1]. It has been approved by the U.S. Food and Drug Administration for short-term sedation (< 24 h) of initially intubated and mechanically ventilated adult patients in the intensive care unit (ICU) and for sedation of non-intubated patients during surgical and other procedures. Although dexmedetomidine is now widely used for the above indications in the ICU and the operating room [2], its clinical applications have been greatly expanded in recent decades due to many favorable physiological effects [3]. This review aims to summarize the current knowledge of dexmedetomidine and discuss its applications, including off-label use, in various clinical settings. Review Article Dexmedetomidine is a potent, highly selective α-2 adrenoceptor agonist, with sedative, analgesic, anxiolytic, sympatholytic, and opioid-sparing properties. Dexmedetomidine induces a unique sedative response, which shows an easy transition from sleep to wakefulness, thus allowing a patient to be cooperative and communicative when stimulated. Dexmedetomidine may produce less delirium than other sedatives or even prevent delirium. The analgesic effect of dexmedetomidine is not strong; however, it can be administered as a useful analgesic adjuvant. As an anesthetic adjuvant, dexmedetomidine decreases the need for opioids, inhalational anesthetics, and intravenous anesthetics. The sympatholytic effect of dexmedetomidine may provide stable hemodynamics during the perioperative period. Dexmedetomidine-induced cooperative sedation with minimal respiratory depression provides safe and acceptable conditions during neurosurgical procedures in awake patients and awake fiberoptic intubation. Despite the lack of pediatric labelling, dexmedetomidine has been widely studied for pediatric use in various applications. Most adverse events associated with dexmedetomidine occur during or shortly after a loading infusion. There are some case reports of dexmedetomidine-related cardiac arrest following severe bradycardia. Some extended applications of dexmedetomidine discussed in this review are promising, but still limited, and further research is required. The pharmacological properties and possible adverse effects of dexmedetomidine should be well understood by the anesthesiologist prior to use. Moreover, it is necessary to select patients carefully and to determine the appropriate dosage of dexmedetomidine to ensure patient safety.

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“…Atropine and epinephrine injection were used for cardiopulmonary resuscitation in this patient, and she recovered without any complications. 8) To the best of our knowledge, our report is the second report of cardiac arrest after injection of dexmedetomidine with spinal anesthesia. In comparison to the patient reported by Kim et al, our patient had no preoperative ECG abnormalities.…”

Section: Discussionmentioning

confidence: 67%

Asystole During Administration of Dexmedetomidine with Spinal Anesthesia: A Case Report

Amano

Tateda

Inoue

2018

J St. Marianna Univ

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Dexmedetomidine is a useful sedative drug that does not cause severe respiratory depression but sometimes causes hypotension or bradycardia. We encountered a case in which asystole occurred during transurethral lithotomy (TUL) that was performed under spinal anesthesia with administration of dexmedetomidine. The patient was a 73-year-old man whose medical history included radiation therapy for prostate cancer and TUL, which had been performed under spinal anesthesia without incident. Results of preoperative examination were unremarkable, and electrocardiography (ECG) showed sinus rhythm with heart rate of 74 bpm. Spinal anesthesia was administered with 3.4 mL of 0.5% hyperbaric bupivacaine, and upper level sensory loss was confirmed at T10. Ten minutes after injection of the bupivacaine, dexmedetomidine was administered for sedation at a loading dose of 3 μg/kg/h over 10 minutes; it was continued at 0.4 μg/kg/h. The patient's vital signs were stable, but because his SpO 2 on room air decreased to 93%, oxygen inhalation was started, and the dexmedetomidine was reduced to 0.2 μg/kg/h. Upon completion of the operation, 115 minutes after the bupivacaine injection, the patient groaned, and almost simultaneously, his heart rate decreased to 30 bpm and progressed to asystole. The dexmedetomidine infusion was stopped, and 0.5 mg of atropine was injected intravenously. Before chest compressions were started, sinus rhythm returned, and the patient regained consciousness. No ECG abnormalities were found. Upper level sensory block at T10 was reconfirmed. The patient was discharged the next day without complications. We reasoned that the asystole resulted as an adverse effect of the dexmedetomidine, from a vagal reflex, and from the spinal anesthesia. Our case illustrates both the importance of avoiding the administration of dexmedetomidine above the recommended dose during spinal anesthesia and the need for careful ECG monitoring and observation of hemodynamics in patients undergoing TUL.

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Cardiac arrest in a patient with anterior fascicular block after administration of dexmedetomidine with spinal anesthesia

Cited by 18 publications

References 8 publications

Perioperative adverse events attributed to α2-adrenoceptor agonists in patients not at risk of cardiovascular events: systematic review and meta-analysis

Perioperative adverse events attributed to α2-adrenoceptor agonists in patients not at risk of cardiovascular events: systematic review and meta-analysis

Dexmedetomidine: present and future directions

Asystole During Administration of Dexmedetomidine with Spinal Anesthesia: A Case Report

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