RESUMO
Regional progression of head and neck malignancies can lead to carotid sinus tumors, causing hemodynamic instability and carotid sinus syndrome (CSS). A 60-year-old male with tonsillar squamous cell carcinoma developed profound positional bradycardia and hypotension immediately after extubation following dental extraction. The patient developed recurrent episodes of positional bradycardia and hypotension, leading to eventual pacemaker placement. Further workup revealed a large mass in the left neck and necrotic cervical lymphadenopathy, indicating CSS from malignancy compression. This case highlights the need for consideration of CSS in patients with known head and neck malignancy, particularly when postural hypotension and bradycardia are present.
RESUMO
The Bezold-Jarisch reflex (BJR) is an inhibitory reflex characterized by bradycardia, hypotension, and apnea originating from ventricular mechanoreceptors. BJR is an uncommon but serious complication of neuraxial anesthesia. We present a case of a 33-year-old female undergoing combined spinal-epidural anesthesia prior to cesarean delivery who developed profound BJR, resulting in emergent actions. Within minutes of injection, she became severely bradycardic (HR: 17 bpm) and hypotensive (SBP: 30s mmHg) with bradypnea (RR: 6/min) and was treated with epinephrine. Fetal bradycardia prompted emergency cesarean section. Following delivery, the patient developed ventricular tachycardia, which was treated with intravenous fluids and cardiac monitoring. Both patient and neonate were discharged in stable condition on postoperative day four. This case illustrates the rapid maternal and fetal compromise associated with BJR during neuraxial anesthesia and the need for prompt recognition and treatment. Key steps include stopping anesthesia, intravenous fluid, left-lateral positioning, judicious vasopressors, fetal monitoring, and preparing for emergent delivery.
RESUMO
Anesthesiologists support nerve stimulator insertion procedures, including occipital nerve stimulator placement for refractory headache disorders. Sedation during these cases can be challenging on account of variable surgical stimuli and surgery positioning that contribute to neck flexion, potentially compromising the airway. Greater patient comfort and safety may be found in performing permanent occipital stimulator placement procedures entirely under general anesthesia, assuming that appropriate stimulation patterns can be achieved in patients who are unable to provide intraoperative feedback. The purpose of this study is to describe our initial experience with occipital nerve stimulator placement performed entirely under general anesthesia and the resulting stimulation patterns, and to review the medical literature regarding the anesthetic techniques used during these novel neurosurgical procedures. After institutional review board approval, we reviewed the records of 5 patients who underwent permanent occipital nerve stimulator placement under general anesthesia. Appropriateness of the postoperative stimulation patterns was noted in addition to complications. The medical literature was searched for occipital stimulation surgery studies that also described the anesthetic technique. We found that all 5 patients underwent uncomplicated general anesthetics. Postoperative occipital stimulation was nonpainful and symmetrical for all. The literature search provided little information on the anesthetic technique; most procedures were performed at least in part under local anesthesia with sedation. On the basis of this small case series, we conclude that the occipital nerve stimulator systems can be successfully placed under general anesthesia while still achieving the desired occipital region stimulation. Further studies are needed to correlate occipital nerve stimulator placement under general anesthesia and long-term headache control.