THE CASE : • Shanti 35 F
• Case of primary infertility (married 18 year back & taking Treatment for last 15 years)
• Posted for myomectomy (USG : 6.6x4.4x4.0 Right lateral wall )
• No major medical or surgical illness in the past Assessed under ASA I
• The case was done under spinal anaesthesia, 3.4ml (Heavy) bupivacane was given in the L3 – L4 space under SAP. Level – T6.
• Abdomen opened & Uterine Fibroid identified
• Injection vasopressin 20U diluted in 50ml normal saline, out of which 25ml (10U) was injected over the fibroid to minimize blood loss.

THE CASE : Immediately after injection of Vasopressin patient had BP :191/142 mmHg and suddenly developed bradycardia with HR falling to 41/min, then to 25/ min and then……. flat line. All these events occurred within 1 min.

THE CASE :
• Normal sinus rhythm was seen in the monitor.
• Carotid pulse checked to rule out pulseless electrical activity.
• Carotid pulse present.
• CPR stopped.
• PR was 160/min and BP 180/110mmHg
• Patient opened eyes to commands.
• Patient was intubated after administering titrated doses of propofol and succinylcholine and ventillated.

THE CASE :
• As the vitals gradually returned to normal range, we decided to go ahead with the surgery.
• The only significant finding when we restarted the procedure was a mild ischemic pattern in the ECG in the form of flat T wave.
• Within half an hour this also became normal.
• Surgery lasted totally for 90 minutes.
• Blood loss was minimal.
• Through out the procedure patient was stable and was frequently coming out of muscle relaxant, which was supplemented as and when needed.

THE CASE :
• Patient’s response was assessed. Patient was reversed and good spontaneous respiration was established.
• Patient was responding to commands. Tone, power and reflexes were normal and Trachea was extubated.
• Patient was shifted to PACU and 12 lead ECG showed no signs of ischemia.
• Bedside 2DEcho was done postoperatively - EF 50% .
• Mild LV dysfunction (because of intra op cardiac arrest)
• Echo done after 48 hours - EF : 68%
• Patient had a smooth recovery and was discharged home.

REFERENCES :

REASON FOR ARREST :
• One school of thought is that vasopressin induced increase in blood pressure causes a vagal mediated decrease in the heart rate.
• The vasoconstrictive effects of vasopressin may simultaneously, cause coronary artery vasospasm, resulting in cardiac ischemia.
• In many of the case reports of vasopressin induced bradycardia and cardiac arrest, the dose of vasopressin administered, exceeded 5 units or the vasopressin was injected into a vessel unintentionally

TAKE HOME MESSAGES:
• The Anaesthetist should be alert when the surgeon is injecting vasopressin.
• Double check that that it is not injected into a blood vessel
• DON’T exceed a total dose of 5U. Using a solution of 0.1U/ml the maximum injection is 50mL.
• Vasopressin has a short half life in circulation, if needed repeat injection 45-60 minutes after the first may be safe.
• Be cautious in patients with established coronary artery or myocardial disease.

REFERENCES :
• Persistent occurrence of bradycardia during laparoscopic cholecystectomies in low-risk patients Reed DN Jn, Duff JL; Dig Surg. 2000;17(5) : 513-517
• “ Give vasopessin to reduce bleeding in gynaecologic surgery” Robert L.Barbieri,MD ; OBG Management March 2010 Vol 22 No 3
• Vasopressin: Its current role in anesthetic practice; Jayanta K. Mitra, Jayeeta Roy, and SaikatSengupta ; Indian J Crit Care Med. 2011 Apr-Jun; 15(2): 71–77.
• Bradycardia and cardiac arrest caused by intramyometrial injection of vasopressin during a laparoscopically assisted myomectomy.Hobo R, Netsu S, Koyasu Y, Tsutsumi O Obstet Gynecol. 2009;113(2 Pt 2):484.
• Intramyometrial injection of vasopressin causes bradycardia and cardiac arrest--report of two cases. Hung MH, Wang YM, Chia YY, Chou YM, Liu K ActaAnaesthesiol Taiwan. 2006;44(4):243.
• Pulmonary edema: a complication of local injection of vasopressin at laparoscopy. Tulandi T, Béique F, Kimia M FertilSteril. 1996;66(3):478.