Hemodynamically Significant Cardiac Arrhythmias During General Anesthesia for Spine Surgery: A Case Series and Literature Review

Overview

Journal N Am Spine Soc J

Date 2022 Feb 10

PMID 35141581

Authors

Marie-Jacqueline Reisener

Jennifer Shue

Alexander P Hughes

Andrew A Sama

Ronald G Emerson

Carrie Guheen

James D Beckman

Ellen M Soffin

Affiliations

Soon will be listed here.

Abstract

Background Context: Hemodynamically significant bradycardia and cardiac arrest (CA) are rare under general anesthesia (GA) for spine surgery. Although patient risks are well defined, emerging data implicate surgical, anesthetic and neurologic factors which should be considered in the immediate management and decision to continue or terminate surgery.

Purpose: To characterize causes and contributors to significant arrhythmias during spine surgery. We also provide an updated literature review to inform spine care teams and aid in the management of intraoperative bradycardia and CA.

Study Design: Case series and literature review.

Patient Sample: Six patients who underwent spine surgery from 03/2016 to 01/2020 at a single institution and developed unexpected hemodynamically significant arrhythmia.

Outcome Measures: Our primary outcome was to identify potential risk factors of interest for significant arrhythmia during spine surgery.

Methods: Medical records of patients who underwent spine surgery from 03/2016 to 01/2020 at a single institution and developed unexpected hemodynamically significant arrhythmia during spine surgery were identified from a departmental Quality Assurance Database. We evaluated the presence/absence of patient, surgical, anesthetic and neurologic risk factors and estimated the most likely etiology of the event, immediate and subsequent management, whether surgery was postponed or continued and outcomes.

Results: We found a temporal relationship of bradyarrhythmia and CA after somatosensory evoked potential (SSEP) stimulation in 4/6 cases and pharmacy/polypharmacy in 2/6. Surgery was completed in 4/6 patients, and terminated in 2/6 (subsequently completed in both). We found no adverse outcomes in any patients. Our literature review predominately identified case reports for guidance to support decision making. New literaure suggests peripheral nerve blocks and opioid-sparing anesthetic agents should also be considered.

Conclusions: Significant bradycardia and CA during spine surgery does not always require termination of the surgical procedure. Decision making should be undertaken in each case individually, with an updated awareness of potential causes. The study also suggests the need for large prospective studies to adequately assess incidence, risk factors and outcomes.

References

Chin K, Lewis S . Opioid-free Analgesia for Posterior Spinal Fusion Surgery Using Erector Spinae Plane (ESP) Blocks in a Multimodal Anesthetic Regimen. Spine (Phila Pa 1976). 2018; 44(6):E379-E383. DOI: 10.1097/BRS.0000000000002855. View

Singh S, Choudhary N, Lalin D, Verma V . Bilateral Ultrasound-guided Erector Spinae Plane Block for Postoperative Analgesia in Lumbar Spine Surgery: A Randomized Control Trial. J Neurosurg Anesthesiol. 2019; 32(4):330-334. DOI: 10.1097/ANA.0000000000000603. View

Chauhan V, Tiwari A, Rath G, Banik S . Asystole during lumbar discectomy: a case report. J Clin Anesth. 2016; 31:265-6. DOI: 10.1016/j.jclinane.2016.01.014. View

Soffin E, Freeman C, Hughes A, Wetmore D, Memtsoudis S, Girardi F . Effects of a multimodal analgesic pathway with transversus abdominis plane block for lumbar spine fusion: a prospective feasibility trial. Eur Spine J. 2019; 28(9):2077-2086. DOI: 10.1007/s00586-019-06081-3. View

McNulty S, Weiss J, Azad S, Schaefer D, Osterholm J, Seltzer J . The effect of the prone position on venous pressure and blood loss during lumbar laminectomy. J Clin Anesth. 1992; 4(3):220-5. DOI: 10.1016/0952-8180(92)90070-h. View

Kinsella S, Tuckey J . Perioperative bradycardia and asystole: relationship to vasovagal syncope and the Bezold-Jarisch reflex. Br J Anaesth. 2001; 86(6):859-68. DOI: 10.1093/bja/86.6.859. View

Chowdhury T, Petropolis A, Cappellani R . Cardiac emergencies in neurosurgical patients. Biomed Res Int. 2015; 2015:751320. PMC: 4321102. DOI: 10.1155/2015/751320. View

Edgcombe H, Carter K, Yarrow S . Anaesthesia in the prone position. Br J Anaesth. 2008; 100(2):165-83. DOI: 10.1093/bja/aem380. View

Chowdhury T, Narayanasamy S, Dube S, Rath G . Acute hemodynamic disturbances during lumbar spine surgery. J Neurosurg Anesthesiol. 2011; 24(1):80-1. DOI: 10.1097/ANA.0b013e31823ac2d6. View

10.

Murphy G, Avram M, Greenberg S, Shear T, Deshur M, Dickerson D . Postoperative Pain and Analgesic Requirements in the First Year after Intraoperative Methadone for Complex Spine and Cardiac Surgery. Anesthesiology. 2020; 132(2):330-342. DOI: 10.1097/ALN.0000000000003025. View

11.

ALBIN M, Ritter R, PRUETT C, Kalff K . Venous air embolism during lumbar laminectomy in the prone position: report of three cases. Anesth Analg. 1991; 73(3):346-9. DOI: 10.1213/00000539-199109000-00021. View

12.

Prabhakar H, Bithal P, Dash M, Chaturvedi A . Rupture of aorta and inferior vena cava during lumbar disc surgery. Acta Neurochir (Wien). 2004; 147(3):327-9. DOI: 10.1007/s00701-004-0405-2. View

13.

Bourne E, Wright C, Royse C . A review of local anesthetic cardiotoxicity and treatment with lipid emulsion. Local Reg Anesth. 2012; 3:11-9. PMC: 3417942. DOI: 10.2147/lra.s8814. View

14.

Mandal N . More on lumbo-sacral spine surgery and bradycardia. Can J Anaesth. 2004; 51(9):942-3. DOI: 10.1007/BF03018898. View

15.

Brogi E, Kazan R, Cyr S, Giunta F, Hemmerling T . Transversus abdominal plane block for postoperative analgesia: a systematic review and meta-analysis of randomized-controlled trials. Can J Anaesth. 2016; 63(10):1184-1196. DOI: 10.1007/s12630-016-0679-x. View

16.

Naik B, Nemergut E, Kazemi A, Fernandez L, Cederholm S, McMurry T . The Effect of Dexmedetomidine on Postoperative Opioid Consumption and Pain After Major Spine Surgery. Anesth Analg. 2016; 122(5):1646-53. DOI: 10.1213/ANE.0000000000001226. View

17.

Brown J, Rogers J, Soar J . Cardiac arrest during surgery and ventilation in the prone position: a case report and systematic review. Resuscitation. 2001; 50(2):233-8. DOI: 10.1016/s0300-9572(01)00362-8. View

18.

McCorry L . Physiology of the autonomic nervous system. Am J Pharm Educ. 2007; 71(4):78. PMC: 1959222. DOI: 10.5688/aj710478. View

19.

Deschamps A, Carvalho G . Lumbo-sacral spine surgery and severe bradycardia. Can J Anaesth. 2004; 51(3):277. DOI: 10.1007/BF03019113. View

20.

Chowdhury T, Schaller B . The negative chronotropic effect during lumbar spine surgery: A systemic review and aggregation of an emerging model of spinal cardiac reflex. Medicine (Baltimore). 2017; 96(1):e5436. PMC: 5228647. DOI: 10.1097/MD.0000000000005436. View