RESUMO
Unwanted initiation of intrinsic cardiac reflexes can precipitate bradycardia and cardiac arrest after spinal anaesthesia. We report the case of a 40-year-old man who suffered sudden asystolic cardiac arrest following spinal anaesthesia prior to planned abdominal surgery, likely due to the initiation of one or more intrinsic cardiac reflexes including the Bezold-Jarisch reflex, the reverse Bainbridge reflex and the pacemaker stretch reflex. The characteristics of this patient placed him at increased risk of this underappreciated cause of bradycardia and hypotension. We present a summary of the physiology and clinical features relevant to this case and the considerations for avoidance of similar complications after spinal anaesthesia.
RESUMO
Published data suggest that the type of general anaesthesia used during surgical resection for cancer may impact on patient long-term outcome. However, robust prospective clinical evidence is essential to guide a change in clinical practice. We explored the feasibility of conducting a randomised controlled trial to investigate the impact of total intravenous anaesthesia with propofol vs. inhalational volatile anaesthesia on postoperative outcomes of patients undergoing major cancer surgery. We undertook a randomised, double-blind feasibility and pilot study of propofol total intravenous anaesthesia or volatile-based maintenance anaesthesia during cancer resection surgery at three tertiary hospitals in Australia and the USA. Patients were randomly allocated to receive propofol total intravenous anaesthesia or volatile-based maintenance anaesthesia. Primary outcomes for this study were successful recruitment to the study and successful delivery of the assigned anaesthetic treatment as per randomisation arm. Of the 217 eligible patients approached, 146 were recruited, a recruitment rate of 67.3% (95%CI 60.6-73.5%). One hundred and forty-five patients adhered to the randomised treatment arm, 99.3% (95%CI 96.2-100%). Intra-operative patient characteristics and postoperative complications were comparable between the two intervention groups. This feasibility and pilot study supports the viability of the protocol for a large, randomised controlled trial to investigate the effect of anaesthesia technique on postoperative cancer outcomes. The volatile anaesthesia and peri-operative outcomes related to cancer (VAPOR-C) study that is planned to follow this feasibility study is an international, multicentre trial with the aim of providing evidence-based guidelines for the anaesthetic management of patients undergoing major cancer surgery.
