TACHYCARDIA - BRADYCARDIA SYNDROME IN A PATIENT UNDERGOING PERTROCHANTERIC FRACTURE REPAIR UNDER SPINAL ANESTHESIA

Abstract

Background: Sick sinus syndrome (SSS) is an abnormality of a cardiac impulse formation as a result of sinus node dysfunction that could be presented as a diverse heart rate and rhythm abnormalities. SSS is the most common in the elderly people. In most of the cases the etiology of the SSS remains unknown, but the majority of the patients are experiencing some stage of coronary artery disease (1). Case Report: We present an 89 years old female patient undergoing pertrochanteric fracture repair under spinal anesthesia. Her preoperative evaluation did not reveal any pathologic findings. All vital signs were stable prior to the surgery. The patient has received 2.4 ml of Bupivacaine 0.5% and 10 mcg of Fentanyl. Dural puncture was done in an aseptic technique at the L3-L4 level and clear liquor was seen prior to the anesthetic application. The first hour of the surgery went uneventful, after what abrupt onset of tachycardia of 109bpm was seen followed by bradycardia of 48bpm. The episodes of tachycardia followed with bradycardia were repeating till the patient entered a bigeminy rhythm with the lowest hearth rate of 45, after what 0.5 mg of atropine was given and restoration of normal sinus rhythm was seen. The patient was monitored postoperatively in PACU and followed up at the Traumatology ward while there were not seen any vital signs deterioration. Discussion: We’ve researched PubMed from 1994-2017 and we’ve found 8 case reports in patients undergoing general anesthesia, one undergoing general and epidural anesthesia and one under spinal anesthesia. Eight of 10 patients were previously healthy without known cardiac disease and one with peripheral artery disease. Different types of conduction and heart rate abnormalities, including asystole, were seen in all of the cases after induction of the patients under anesthesia. In our case during the surgery the patient developed multiple episodes of tachycardia followed with bradycardia without subjective discomfort. The resolution of the tachycardia-bradycardia syndrome after giving the 0.5 mg of atropine shows a possible relationship between the local anesthetic application and the onset of the SSS manifestation. References: 1. Brignole M1.; Sick sinus syndrome; Clin Geriatr Med. 2002 May;18(2):211-27. Learning points: SSS can be precipitated perioperatively because of increased vagal tone caused by anesthesia or surgical intervention. As general anesthetics, local anesthetics could also trigger intraoperative manifestation of SSS.