LETTER TO EDITOR
Year : 2012 | Volume
: 56 | Issue : 3 | Page : 312--314
Severe haemodynamic disturbances following normal saline irrigation in cerebro-pontine tumour surgery
Tumul Chowdhury, Navdeep Sokhal, Hemanshu Prabhakar
Department of Neuroanesthesiology, Neurosciences Center, All India Institute of Medical Sciences, New Delhi, India
Department of Neuroanesthesiology, Neurosciences Center, 7th Floor, All India Institute of Medical Sciences, New Delhi 110 029
|How to cite this article:|
Chowdhury T, Sokhal N, Prabhakar H. Severe haemodynamic disturbances following normal saline irrigation in cerebro-pontine tumour surgery.Indian J Anaesth 2012;56:312-314
|How to cite this URL:|
Chowdhury T, Sokhal N, Prabhakar H. Severe haemodynamic disturbances following normal saline irrigation in cerebro-pontine tumour surgery. Indian J Anaesth [serial online] 2012 [cited 2013 May 23 ];56:312-314
Available from: http://www.ijaweb.org/text.asp?2012/56/3/312/98798
Intraoperative alterations in haemodynamics are common in neurosurgical patients and may occur due to different mechanisms like raised intracranial pressure, brainstem stimulation, hypothalamic stimulation, etc.  Here, we have reported severe haemodynamic disturbance following saline irrigation during cerebellopontine angle tumour surgery.
A 52-year-old female weighing 60 kg was admitted to the Department of Neurosurgery with complaints of left-sided headache and hearing loss since 1 year. Magnetic resonance imaging showed a left cerebellopontine (CP) angle tumour of 1.2 cm × 1 cm size. The patient was posted for elective retromastoid suboccipital craniotomy and excision of tumour in the right lateral position. All the pre-operative investigations including electrocardiogram (ECG) and chest radiograph were normal. On the day of surgery, the patient was pre-medicated with 0.2 mg glycopyrrolate intramuscularly 1 h before the surgery. In the operating room, routine monitors, i.e. ECG, pulse oximeter (SpO 2 ) and non-invasive blood pressure (NIBP), were attached. General anaesthesia was induced with fentanyl 2 mcg/kg, propofol 2 mg/kg and tracheal intubation, facilitated with rocuronium 1 mg/kg. Trachea was intubated using a 7.5 mm cuffed portex endotracheal tube. Anaesthesia was maintained with isoflurane in oxygen and nitrous oxide mixture (40:60) and intermittent boluses of fentanyl and vecuronium as and when required. Intraoperative invasive monitoring, i.e. central venous pressure and arterial blood pressure, was done using right internal jugular vein and left posterior tibial artery, respectively. The patient was turned to the right lateral position. Blood loss was 700 mL, which was replaced with one unit of blood, and the net fluid balance was positive (600 mL). The tumour was completely excised. Meticulous haemostasis was achieved and dura closure was started. Before the last dural suture, the surgeon flushed the cavity of approximately 1 cm × 1 cm × 1 cm size with rapid bolus of 10 mL saline for observing any bleeding and blood clots. Suddenly, the patient developed severe bradycardia with hypotension (HR< 30/min and IBP = 60/36 mmHg). The surgeon was notified and he stopped further saline irrigation and haemodynamic changes returned to previous levels. Rest of the intraoperative course was uneventful. After completion of the surgery, anaesthesia was reversed and the trachea was extubated after ascertaining full neurological recovery. The patient was discharged from the hospital on the 6 th post-operative day.
Intraoperative bradycardia has been reported in neurosurgical patients due to various reasons. Stimulation of the anterior hypothalamus with surgical stimulus, hydrogen peroxide irrigation or papaverine instillation triggered intense parasympathetic activity leading to bradycardia. , Saline irrigation has been reported to produce bradycardia or even sinus arrest during endoscopic third ventriculostomy and during epilepsy surgery. In the previous case, hypothalamic stimulation was a probable mechanism.  On the other hand, stimulation of the limbic system, such as the hippocampus, amygdala and insular cortex, resulted in bradycardia and hypotension due to increased parasympathetic flow via the vagus nerve during epilepsy surgery.  However, in our case, the forceful irrigation during last dural suture produced the cavitary expansion leading to sudden rise in intracranial pressure and probably irritated the floor of the fourth ventricle, which in turn produced such haemodynamic disturbance.
In conclusion, normal saline bolus irrigation can produce severe haemodynamic disturbances even at the time of dural closure, necessitating continued vigilance during closure. We also suggest that saline irrigation at the time of dural closure should be done very slowly, especially in the posterior fossa and cerebellopontine tumour surgery, as this can produce sudden increase in intracranial pressure and lead to catastrophic consequences.
|1||Kotake Y, Matsumoto M, Yorozu T, Takeda J. Recurrent ST-segment elevation on ECG and ventricular tachycardia during neurosurgical anesthesia. J Anesth 2009;23:115-8.|
|2||Prabhakar H, Bithal PK, Pandia MP, Gupta MM, Rath GP. Bradycardia due to hydrogen peroxide irrigation during craniotomy for craniopharyngioma. J Clin Neurosci 2007;14:488-90.|
|3||Sinha PK, Neema PK, Manikandan S, Unnikrishnan KP, Rathod RC. Bradycardia and sinus arrest following saline irrigation of the brain during epilepsy surgery. J Neurosurg Anesthesiol 2004;16:160-3.|
|4||El-Dawlatly A, Elgamal E, Murshid W Alwatidy S, Jamjoom Z. Anesthesia for third ventriculostomy: A report of 128 cases. Middle East J Anesthesiol 2008;19:847-57.|