Cardiac arrest caused by intramyometrial injection of vasopressin during a robotic-assisted laparoscopic myomectomy

Abstract

Vasopressin is a locally-injected vasoconstrictor used to reduce bleeding during gynaecological surgery. However, even in these cases, vasopressin can induce adverse effects, including bradycardia, myocardial infarction and cardiac arrest. Elevated blood concentrations of vasopressin may induce the sympathoinhibitory reflex by increasing blood pressure and augment the sympathoinhibitory reflex by activating the area postrema. In addition, pneumoperitoneum formation needed for laparoscopy as well as physiological changes caused by steep Trendelenburg positions used during robotic surgeries may cause bradycardia. Shoulder braces used to prevent slipping from a steep Trendelenburg position may also be hazardous. This case report describes a 31-year-old female patient who underwent a scheduled robotic-assisted laparoscopic myomectomy in a steep Trendelenburg position. The patient experienced a cardiac arrest 2 min after the vasopressin injection and was treated accordingly. There were no abnormal findings on the postoperative laboratory studies, chest X-ray and electrocardiogram. The patient also had clear consciousness with no other notable symptoms. The patient was discharged on postoperative day 2. The report discusses the potential adverse effects of local vasopressin injection during robotic-assisted laparoscopic myomectomy.

Sudden bradycardia and impending cardiac arrest by intra-myometrial vasopressin in laparoscopic myomectomy: a case report and review of literature

“…3 Lee et al reported a case of severe bradycardia and cardiac arrest during robotic assisted myomectomy after infiltration of vasopressin in doses of 20 IU (20 IU diluted in 40 ml of normal saline). 4 The patient was success-fully revived with atropine 0.5 mg, reversal of Trendelenburg position and supportive care. They attributed bradycardia to physiologic effects of vasopressin, pneumoperitoneum in steep Trendelenburg position for laparoscopy, shoulder braces for robotic surgery which add to carotid sinus compression and lowered sympathetic activity leading to bradycardia.…”

“…Although intra-myometrial vasopressin results in very good surgical hemostasis it may cause adverse cardiac events like bradycardia, arrhythmia, cardiac arrest and pulmonary oedema and lethal catastrophe if not diagnosed and managed soon. [1][2][3][4] We report a case of successful resuscitation following bradycardia and impending cardiac arrest by intra-myometrial injection of vasopressin in a case of laparoscopic myomectomy.…”

Assessment of the perioperative effect of vasopressin in patients undergoing laparoscopic myomectomy: A double-blind randomised study

“…[ 24 ] Lee et al . [ 25 ] reported a case of severe bradycardia (26 bpm) followed by cardiac arrest after intramyometrial injection of vasopressin (20 units, 0.5 unit/ml) and the heart recovered completely after atropine administration. Kabade et al .…”

Hemodynamic changes following accidental infiltration of a high dose of vasopressin

“…Severe vasoconstriction, which manifested as more than a 50% decrease in the diameters of the radial and brachial arteries on echograms, was reported to follow vasopressin infiltration. 9 Because our hospital had a case of cardiac arrest after vasopressin infiltration in 2017, 10 all robotic gynecological surgeries that include vasopressin infiltration, together with monitoring the PPI, monitor the diameter changes of radial and brachial arteries as indices of the patient's reaction to vasopressin. For the current case, the diameters of the radial and brachial arteries initially decreased after vasopressin infiltration but recovered 1 hour later.…”