Bezold-Jarisch Reflex Presenting With Bradypnea, Bradycardia, and Hypotension Following Combined Spinal Epidural Prior to Cesarean Section: A Case Report.

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.

Anesthesia Approach to Managing Severe Hemorrhagic Shock and Anemia With Non-transfusion Alternatives in a Practicing Jehovah's Witness: A Case Report.

Traumatic hemorrhagic shock is a common yet life-threatening occurrence across the United States and is typically managed with blood transfusions as the standard of care. However, providers caring for a Jehovah's Witness patient who refuses transfusions due to religious reasons face unique ethical challenges in upholding evidence-based shock resuscitation protocols while respecting the patient's autonomy and faith-based stance that strictly prohibits blood products. We present a complex clinical case of a 46-year-old Jehovah's Witness who developed severe hemorrhagic shock, partial amputation, and critical anemia after a traumatic 40-mile-per-hour motorcycle collision resulting in comminuted fractures and arterial disruption. Despite receiving emergent blood transfusions initially, further transfusions were declined once his identity as a practicing Jehovah's Witness was disclosed. His hemoglobin plunged to dangerously low levels of 4.6 g/dL before stabilizing to 5.3 g/dL with pharmaceutical alternatives including intravenous iron, high-dose erythropoietin, and phlebotomy minimization. Respecting patient convictions while delivering effective evidence-based shock management created significant ethical conflicts given the proven efficacy of blood transfusions. However, this complex case demonstrates that through meticulous medical and surgical care coordinated by a multi-disciplinary team applying customized non-transfusion techniques, traumatic hemorrhagic shock and life-threatening anemia can still achieve favorable outcomes without relying on transfusions when respecting faith-based refusal of blood products.

Carotid Sinus Tumor-Induced Positional Bradycardia and Hypotension After Extubation: A Case Report.

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.