[Downloadedfreefromhttp://www.joacp.orgonSaturday,April19,2014,IP:117.197.237.
133]||ClickheretodownloadfreeAndroidapplicationforthisjournal
Letters to Editor
Intraoperative pulseless
ventricular tachycardia after
Ondansetron
Sir,
Ondansetron is a 5-hydroxytryptamine (HT)3 receptor
antagonist safely used in the management of postoperative
nausea and vomiting.[1] Cardiovascular adverse effects like
myocardial infarction, arrhythmias such as atrial fibrillation,
asystole, and ventricular tachycardia (VT) were rarely
reported in adults. We report a case of severe intraoperative
pulseless VT after intravenous ondansetron administration
which was successfully resuscitated. We have obtained
written informed consent for reporting this case from the
patient.
A 25-year-old lady (48 kg) American Society of
Anesthesiology (ASA) physical class I with history of
infertility was posted for diagnostic hysterolaparoscopy.
Her airway and baseline investigations were unremarkable.
Anesthesia was induced with propofol, fentanyl, and
atracurium and maintained with oxygen, nitrous oxide, and
isoflurane. Perioperative period was uneventful. Twenty
minutes before extubation, ondansetron (Emset from Cipla
Ltd, Mumbai) 4 mg intravenous (IV) was given to prevent
postoperative nausea and vomiting. Within 3 min, she
developed VT [Figure 1] and hypotension with feeble pulse.
Immediate cardiopulmonary resuscitation (CPR) was started
with 2 minute cycles of high quality chest compressions at
the rate of at least 100/minute, simultaneously with 10
breaths being delivered with an inspired oxygen (FiO2) of
100%. All anesthetic agents and surgical procedure were
discontinued. Securing femoral arterial access, blood gas
(BG) sample was taken immediately. Defibrillation using
a biphasic shock of 200 J was delivered and five cycles
CPR failed to revert into sinus rhythm. High quality CPR
was continued. BG report suggested mild hypercarbia (47
mmHg), hypomagnesemia (0.55 mmol/L), and hypokalemia
(2.6 Meq/L). Immediately CPR was supplemented with
2 g magnesium sulfate (MgSO4) infused over 5 min via
Figure 1: Electrocardiography (ECG) showing ventricular tachycardia with
hypotension in monitor
Journal of Anaesthesiology Clinical Pharmacology | April-June 2014 | Vol 30 | Issue 2
external jugular vein followed by a slow infusion of potassium
chloride. After the infusion of MgSO4, a repeat 200 J
biphasic shock was delivered followed by 2 minutes of
CPR. This time her rhythm reverted back to sinus and
electrocardiography (ECG) was suggestive of QT interval
prolongation [Figure 2]. She was then shifted to ICU
under monitoring and put on elective ventilatory support.
Adrenaline infusion was started and continued for few hours,
following which she was hemodynamically stable without
inotropes and regained consciousness within 12 h and was
subsequently extubated.
5-HT3 receptor antagonists are known to cause cardiac
arrhythmias by several mechanisms.[2] There are ligand
gated ion channels located on presynaptic terminals of
autonomic nervous system.[3] Bradycardia can occur due to
parasympathetic nervous system mediated actions and are
observed during laparoscopy. But in our case VT occurred
during laparoscopic surgery. Prolongation of QRS or QT
interval has been reported with granisetron, ondansteron,
and dolasetron leading to ventricular tachyarrhythmias
though not commonly in healthy population.[4] Molecular
level affinity of ondansetron to human tissue by human
ether-a-go-go-related gene (HERG) programmed K +
channel lead to prolongation of cardiac repolarization and
QT prolongation.[5] In our case ondansetron induced QT
prolongation triggered by electrolyte disturbances thereby
leading to pulseless VT. The cardiovascular effects of
serotonin are mediated by 5HT2-4 receptors, which are
distributed throughout the cardiovascular system including
Bezold-Zarish reflex pathway. Blocking of this reflex by
ondansetron can cause tachyarrhythmia.[6] 5HT3 receptor
blockade may also lead to unopposed action of 5HT2 and
5HT4 receptors resulting in VT.
To conclude, intraoperative ECG monitoring is lifesaving in
our case, thus must be applied to any case under anesthesia
even it is minor operation with ASA I patient. Ondansetron
should be used cautiously in patient with deranged electrolytes.
Sukhen Samanta, Kajal Jain1, Sujay Samanta1,
Tanmoy Ghatak
Figure 2: ECG demonstrated prolong QT after sinus rhythm
293
[Downloadedfreefromhttp://www.joacp.orgonSaturday,April19,2014,IP:117.197.237.133]||ClickheretodownloadfreeAndroidapplicationforthisjournal
Letters to Editor
Department of Critical Care Medicine,
Sanjay Gandhi Post Graduate Institute
of Medical Sciences, Lucknow,
1
Department of Anaesthesia and Intensive Care,
Post Graduate Institute of Medical Education and Research,
Chandigarh, Punjab, India
Address for correspondence: Dr. Sukhen Samanta,
New PG Hostel, Room No. 218,
Sanjay Gandhi Post Graduate Institute of Medical Sciences,
Lucknow - 226 014, Uttar Pradesh, India.
E-mail: dr.sukhensamanta@gmail.com
References
1. Habib AS, Gan TJ. Evidence-based management of postoperative
nausea and vomiting: A review. Can J Anesth 2004;51:326-41.
2. Kasinath NS, Malak O, Tetzlaff J. Atrial fibrillation after
ondansetron for prevention and treatment of postoperative
nausea and vomiting: A case report. Can J Anaesth 2003;50:
229-31.
3. Saxena PR, Villaln CM. Cardiovascular effects of serotonin
agonists and antagonists. J Cardiovasc Pharmacol 1990;15:S17-34.
4. Saxena A, Chand T, Arya SK, Puri R, Mittal A, Shukla V.
Ondansetron-induced ventricular tachycardia in a patient of
caesarian section. J Obstet Anaesth Crit Care 2012;2:103-4.
5. McKechnie K, Froese A. Ventricular tachycardia after ondansetron
administration in a child with undiagnosed long QT syndrome.
Can J Anesth 2010;57:453-7.
6. Afonso N, Dang A, Namshikar V, Kamat S, Rataboli PV. Intravenous
ondansetron causing severe bradycardia: Two cases. Ann Card
Anaesth 2009;12:170-1.
Access this article online
Quick Response Code:
Website:
www.joacp.org
DOI:
10.4103/0970-9185.130123
Post thoracotomy
cardiorespiratory arrest:
Perhaps avoidable?
Sir,
Extensive tumor handling and resection in lung surgeries
are associated with an increased incidence of morbidity and
mortality. We report a rare life-threatening complication
following lung surgery in the immediate postoperative period.
Patient was a diagnosed case of right lung sarcoma scheduled
for right pneumonectomy, admitted with the complaints of
294 Journal of Anaesthesiology Clinical Pharmacology | April-June 2014 | Vol 30 | Issue 2
gradually increasing breathlessness on exertion for 3 months
and hemoptysis for 7 days. On performing endoscopic
snaring of right bronchial intraluminal mass [Figure 1],
patient had symptomatic relief for few days, but the symptoms
again recurred. Chest X-ray revealed homogeneous opacity
over right middle and lower zone [Figure 2]. Computed
tomography chest and positron emission tomography scan
findings were suggestive of right lung mass [Figure 3]
which was abutting the right cardiac border and encasing
the right main bronchus with segmental collapse of the lower
lobe. Pulmonary Function Test findings were suggestive of
restrictive airway disease. The possibility of inoperability
was explained and high-risk informed consent for surgical
intervention was obtained. After achieving One Lung
Ventilation Left thoracotomy was performed, but tumor
could not be removed completely due to the intense adherence
of the mass to major vessels, attempts to debulk and relieve
the bronchial obstruction were unsuccessful, and thorax was
closed after inserting an Inter Costal Drain.
Due to inadequate spontaneous tidal volume, Double Lumen
Tube was replaced with oral EndoTracheal Tube and pressure
support ventilation was planned. Patient was shifted to
postanesthesia care unit (PACU) with normal hemodynamic
parameters but within 10 min of reaching the PACU SpO2,
Invasive Blood Pressure decreased rapidly, ventilator showed
high airway pressure (Paw >40 cm of H2O). Airway
obstruction was suspected as even manual ventilation was
difficult. Electrocardiogram showed ventricular fibrillation
alongwith absent carotid pulses, necessitating external cardiac
massage and defibrillation, with resultant return of spontaneous
circulation (ROSC) and sinus rhythm. Fresh blood was
observed in the EndoTracheal Tube which was continuing
despite suctioning, and tumor bleed was suspected, hence
fiberoptic bronchoscopy performed at that time revealed a
tumor mass obstructing left main bronchus, and bleeding from
the right bronchus. With ongoing resuscitative measures the
patient was shifted to the operation theater (OT) and rigid
bronchoscopy was performed. On piece meal removal of tumor
from left main bronchus, oxygen saturation increased and
ionotropes were weaned gradually.
Various causes of hemodynamic instability and cardiac
arrest after thoracic surgery are well-documented in the
literature such as hemorrhage, cardiac tamponade, cardiac
herniation, and tension pneumothorax.[1-3] Our patient had
acute cardiorespiratory arrest within minutes of shifting to
postanesthesia care unit; a very high Paw and inability to ventilate
manually raised possibility of acute tension pneumothorax or
airway obstruction. On the contrary fibreoptic bronchscopy
revealed migrated tumor tissue blocking the left main bronchus.