3120 Polyethylene Glycol-Based Bowel Preparation Induced Episodic Sinus Arrest: The Bezold-Jarisch Reflex

Abstract

INTRODUCTION: The Bezold–Jarisch reflex (BJR) is a cardiac reflex that increases parasympathetic tone and inhibits sympathetic activity, resulting in a clinical triad of bradycardia, hypotension, and peripheral vasodilation. This reflex can be activated by chemical stimuli, such as anesthesia, or by reduced cardiac venous return. Inappropriate reflex bradycardia or asystole can occur. CASE DESCRIPTION/METHODS: A 51-year-old female with no past medical history underwent bowel preparation with a polyethylene glycol-based solution for a routine screening colonoscopy. Before anesthesia was administered, the patient became unresponsive and clonic with a 3-4 second sinus pause. On physical exam, the patient was dehydrated. Electrolyte findings were within normal limits, aside from sodium level of 123 mmol/L. The patient eventually recorded a sinus pause of 30 seconds and a transvenous pacemaker was placed for episodic sinus arrest. The Bezold–Jarisch reflex is a diagnosis of exclusion. The patient had a negative D-dimer, three non-detectable troponin levels and a CT pulmonary angiogram negative for pulmonary embolism. Two electrocardiograms showed normal sinus rhythm, with repeat showing sinus bradycardia; intervals were within normal limits. A transthoracic echocardiogram showed an ejection fraction of 65% with no valvular disease or structural abnormalities. After the patient was fluid resuscitated and electrolytes were optimized, no further episodes were recorded. The patient was fitted with an event monitor and discharged home with close follow up. She remained asymptomatic at outpatient appointment. DISCUSSION: The patient's bowel preparation for her colonoscopy resulted in hypovolemic hyponatremia, upregulating her renin-angiotensin-aldosterone system, whichvagally mediated her episodic sinus arrest via the Bezold–Jarisch Reflex. Given the increasing rate of colonoscopies, this case report highlights the importance of electrolyte-balanced hydration in preventing a potential BJR.

Dexamethasone blunts postspinal hypotension in geriatric patients undergoing orthopedic surgery: a double blind, placebo-controlled study

“…Hypotension and bradycardia are the most frequent complications reaching up to one- third in non-obstetric populations [ 1 ]. The main cause of post spinal anesthesia (PSA) hypotension is the decrease in the sympathetic outflow causing arterial vasodilatation, a decrease in venous return and consequently the activation of the Bezold Jarish reflex (BJR) [ 2 ] that elicits a triad of bradycardia, vasodilatation and further hypotension [ 3 , 4 ]. BJR is elicited by activation of 5-HT 3 receptors within the intracardiac vagal nerve endings [ 5 ].…”

Dexamethasone blunts postspinal hypotension in geriatric patients undergoing orthopedic surgery: a double blind, placebo-controlled study

“…Hypotension and bradycardia are the most frequent complications reaching up to one-third in non-obstetric populations (1) . The main cause of post spinal anesthesia (PSA) hypotension is the decrease in the sympathetic out ow causing arterial vasodilatation, a decrease in venous return and consequently the activation of the Bezold Jarish re ex (BJR) (2) that elicits a triad of bradycardia, vasodilatation and further hypotension (3,4) . BJR is elicited by activation of 5-HT 3 receptors within the intracardiac vagal nerve endings (5) .…”

Dexamethasone Blunts Post-Spinal Hypotension in Geriatric Patients Undergoing Orthopedic Surgery: A Double Blind, Placebo-Controlled Study

“…Hypotension and bradycardia are the most frequent reaching up to one-third in non-obstetric populations (1) . The main cause of post-spinal hypotension is the decrease in the sympathetic out ow causing arterial vasodilatation, decrease in venous return and consequently the activation of the Bezold Jarish re ex (BJR) (2) that elicit a triad of bradycardia, vasodilatation and further hypotension (3,4) . BJR is elicited by activation of 5-HT 3 receptors within the intracardiac vagal nerve endings (5) .…”