The nasocardiac reflex

Abstract

SummaryThe oculocarcliac r~f l e s is well tiescribed and rect~gnisrd in anacstlzesiu. The nasocumiuc reflies is ILJSS bvcll-known. We describe u clinical marzifestution of this reJlex and describe the relevant m a t o r n j~. This w f l e .~ rmq' be obturided during general anaesthesia. ( h i r i g generul unuesthesiu. Key wordsSitrpr-j,; car. nose and throat Coniplications; dysrhythniia.The oculocardiac reflex is well described and recognised in anaesthesia.' The nasocardiac reflex3 is less well-known. We present a manifestation of this reflex which occurred during a routine rhinological operalion. Case historyA 69-year-old male was admitted for intranasal antrostomies. The patient's history revealed rcspiratory difficulty caused by a nasal blockage but no other respiratory problcm. Hc took regular exercise, had no symptoms of cardiac ischacmia, was taking no medication and admitted to no allergies. Hc had a dircct laryngoscopy under local anaesthesia 2 months prcviously and a general anaesthetic in the past for hacmorrhoidectomy. That anaesthetic passed without incident. On cxamination he was an obese inan and weighed 92 kilograms with a pre-operative blood pressure of 170/100 mmHg. A pre-operative electrocardiogram revealed sinus rhythm with a rate of 65 beats/minute and n o evidence ofischaemic heart disease. The PR interval was at the upper limit of normal at 0.2 second.The patient was premedicaled one hour pre-operatively orally with temarepam 30 mg. Blood pressure on arrival in thc anacsthetic room was 170j100 mmHg as measured with ; z mcrcury sphygmomanometer. He was pre-oxygenated and anaesthesia induced with thiopentone 400 mg, fentanyl 100 pg and suxamethoniuin 100 mg. Tracheal intubation was performed and adcquatc vcntilation of thc lungs vcrilicd by auscultation. Anaesthesia was maintaincd with nitrous oxide 66%, oxygen 33% and isoflurane I YO. Muscular relaxation was maintaincd with atracuriuin 30 mg. The patient was connected to a noninvasive pressure monitor and electrocardiogram and the pulse was monitored by digital plethysmometry. The surgeon introduced a nasal speculum into the right naris and the turbinate bones were manipulated. A profound bradycardia was noted immediately with only one complex seen on the clcctrocardiogram monitor for two complete sweeps (8 scconds duration). The surgeon was asked to stop operating and the inspired oxygen concentration increased to 100%. Atropine 0.5 mg was given intravenously and normal salinc 500 ml was infused rapidly. The electrocardiogram indicated sinus rhythm with a rate of 65 beatshninute, 2 minutcs aftcr thc administration of atropine, and over the next 10 minutes the blood prcssurc was restored to 100 mmHg systolic having previously bccn unrecordable. Nitrous oxide and isoflurane were re-introduccd at this stage and. having given atropine intravenously, it was considered safe to continue. Howcvcr, as soon as the nasal speculum was re-introduccd into the nose and the inferior turbinatcs wcre touched with forceps a further profound bradycardia was...

The effect of ketamine on clinical endpoints of hypnosis and EEG variables during propofol infusion

“…We stimulated the nasal mucosa at a frequency of 100∫10 Hz for three 2-s durations over 10 s intermittently because in the preliminary experiments we observed that the longer duration of stimulation did not increase the occurrence of NBMR, but increased the likelihood of nasal bleeding. We did not observe any untoward bradycardia or hypotension in any of our patients due to nasal stimulation, as reported previously (15,16).…”

The circulatory responses to tracheal intubation in children: a comparison of the oral and nasal routes

“…Fourthly, previous studies have shown that nasal intubation can stimulate the nasocardiac reflex, which is a vagal reflex and contributes to the significant bradycardiac response associated with the stimulation of the nasal mucosa [5,8, 12].…”

Sinus Arrest Induced by Trivial Nasal Stimulation During Alfentanil-Nitrous Oxide Anaesthesia

“…A search of the literature reveals reports describing various nasocardiac reflexes with a neurological basis in the trigeminovagal arc [10,[13][14][15][16]. These reports document that stimulation of the nasal mucosa may elicit a host of responses including apnoea, closure of the larynx, bradycardia, arrhythmias, vasomotor changes and sudden death [10,13].…”

“…Death after trivial nasal stimulation, for example sneezing, has been reported in patients with myocardial disease [14,15]. Baxandall and Thorn [16] have reported profound bradycardia in an anaesthetized patient during turbinate bone manipulation. These authors describe the maxillary division of the trigeminal nerve (the innervation of the turbinates) as the afferent limb of this nasocardiac reflex.…”