Taiwanese Journal of Obstetrics and Gynecology
Volume 45, Issue 3 , Pages 208-214, September 2006

Perioperative Vasovagal Syncope with Focus on Obstetric Anesthesia

  • Pei-Shan Tsai

      Affiliations

    • Department of Anesthesiology, Hsinchu Mackay Memorial Hospital, Hsinchu, Taiwan
    • Corresponding Author InformationCorrespondence to: Dr Pei-Shan Tsai, Department of Anesthesiology, Hsinchu Mackay Memorial Hospital, 690, Section 2, Guangfu Road, Hsinchu 300, Taiwan
    • ,
  • Chih-Ping Chen

      Affiliations

    • Department of Obstetrics and Gynecology, Mackay Memorial Hospital, Taipei, Taiwan
    • ,
  • Ming-Song Tsai

      Affiliations

    • Prenatal Diagnosis Center, Cathay General Hospital, Taipei, Taiwan

Accepted 9 March 2006.

Article Outline

Summary

Vasovagal syncope refers to a reflex cardiovascular depression that gives rise to loss of consciousness with bradycardia and profound vasodilatation. This response commonly occurs during regional anesthesia, hemorrhage or supine inferior vena cava compression in pregnancy. The changes in circulatory response from the normal maintenance of arterial pressure to parasympathetic activation and sympathetic inhibition may cause severe hypotension. This change is triggered by reduced cardiac venous return as well as episodes of emotional stress, excitement or pain. Occasionally, these vasovagal responses may be unpredictable and may dramatically proceed to asystole with circulatory collapse, and may even result in death. In these circumstances, hypotension may be more severe than that caused by bradycardia alone, because of unappreciated vasodilatation. Regional anesthesia, decreased venous return, hemorrhage and abnormal fetal presentation cumulatively increase the risk of vasovagal syncope in cesarean section patients. When a vasovagal response occurs, ephedrine is the drug of first choice because of its combined action on the heart and peripheral blood vessels. Epinephrine must be used early in established cardiac arrest, especially after high regional anesthesia.

Key Words:  anesthesia , asystole , bradycardia , hemorrhage , vasovagal syncope

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References 

  1. Shen WK , Gersh BJ . Fainting: approach to management . In:  Low PA editors. Clinical Autonomic Disorders: Evaluation and Management . 2nd edition. Philadelphia: Lippincott-Raven; 1997;p. 649–679
  2. Kapoor WN . Syncope . N Engl J Med . 2000;343:1856–1862
  3. Kinsella SM , Tuckey JP . Perioperative bradycardia and asystole: relationship to vasovagal syncope and Bezold-Jarisch reflex . Br J Anaesth . 2001;86:859–868
  4. Matsukawa K , Shindo T , Shirai M , Ninomiya I . Nitric oxide mediates cat hindlimb cholinergic vasodilation induced by stimulation of posterior hypothalamus . Jpn J Physiol . 1993;43:473–483
  5. Fenton AM , Hammill SC , Rea RF , Low PA , Shen WK . Vasovagal syncope . Ann Intern Med . 2000;133:714–725
  6. Dietz NM , Halliwill JR , Spielmann JM , et al.   Sympathetic withdrawal and forearm vasodilation during vasovagal syncope in humans . J Appl Physiol . 1997;82:1785–1793
  7. Shastry S , Dietz NM , Halliwill JR , Reed AS , Joyner MJ . Effects of nitric oxide synthase inhibition on cutaneous vasodilation during body heating in humans . J Appl Physiol . 1998;85:830–834
  8. Miller RD . In: Anesthesia . 5th edition. Philadelphia: Chuchill Livingstone; 2000;p. 739
  9. Grimm DR . Neurally mediated syncope: a review of cardiac and arterial receptors . J Clin Neurophysiol . 1997;14:170–182
  10. Caplan RA , Ward RJ , Posner K , Cheney FW . Unexpected cardiac arrest during spinal anesthesia: a close claims analysis of predisposing factors . Anesthesiology . 1998;68:5–11
  11. Morillo CA , Ellenbogen KA , Pava LF . Pathophysiologic basis for vasodepressor syncope . Syncope . 1997;15:233–249
  12. Van Lieshout JJ , Wieling W , Karemaker JM , Eckberg DL . The vasovagal response . Clin Sci . 1991;81:575–586
  13. Van Lieshout JJ , Wieling W , Karemaker JM . Neural circulatory control in vasovagal syncope . Pacing Clin Electrophysiol . 1997;20:753–763
  14. McMichael J . Clinical aspects of shock . J Am Med Assoc . 1944;124:275–281
  15. Barcroft H , Edholm OG , McMichael J , Sharpey-Schafer EP . Post hemorrhagic fainting. Study by cardiac output and forearm flow . Lancet . 1944;1:489–491
  16. Bonica JJ , Kennedy WF , Akamatsu TJ , Gerbershagen HU . Circulatory effects of peridural block: III. Effects of acute blood loss . Anesthesiology . 1972;36:219–227
  17. El-Sayed H , Hainsworth R . Relationship between plasma volume, carotid baroreceptor sensitivity and orthostatic tolerance . Clin Sci . 1995;88:463–470
  18. Hansen R . Ohnmacht and Schwangerschaft . Klin Wochenschr . 1942;21:241–245
  19. Kinsella SM , Lohmann G . Supine hypotensive syndrome . Obstet Gynecol . 1994;83:774–788
  20. Lees MM , Scott DB , Kerr MG , Taylor SH . The circulatory effects of recumbent postural change in late pregnancy . Clin Sci . 1967;32:453–465
  21. Hart PS , Yanny W . Needle phobia and malignant vasovagal syndrome . Anaesthesia . 1998;53:1002–1004
  22. Hampl KF , Schneider MC . Vasovagal asystole before induction of general anesthesia . Eur J Anaesth . 1994;11:131–133
  23. Keane TK , Hennis PJ , Bink-Boelkens MTE . Non-drug related asystole associated with anaesthetic induction . Anaesthesia . 1991;46:38–39
  24. Mimura T, Funatsu H, Yamagami S, Usui T, Ono K, Araie M, et al. Vasovagal syncope evoked by needle phobia when inserting a contact lens . Ophthalmic Physiol Opt . 2005;25:171–173
  25. Chan SK , Karmakar MK , Chui PT . Local anesthesia outside the operating room . HKMJ . 2002;8:106–113
  26. Khurana RK . Eye examination-induced syncope role of trigeminal afferents . Clin Auton Res . 2002;12:399–403
  27. Sharpey-Schafer EP . Syncope . Br Med J . 1956;3:506–509
  28. McConachie I . Vasovagal asystole during spinal anesthesia . Anaesthesia . 1991;46:281–282
  29. Sprung J , Abdelmalak B , Schoenwald PK . Vasovagal cardiac arrest during the insertion of an epidural catheter and before the administration of epidural medication . Anesth Analg . 1998;86:1263–1265
  30. Carpenter RL , Caplan RA , Brown DL , Stephenson C , Wu R . Incidence and risk factors for side effects of spinal anesthesia . Anesthesiology . 1992;76:906–916
  31. Tarkkila P , Isola J . A regression model for identifying patients at high risk of hypotension, bradycardia, and nausea during spinal anesthesia . Acta Anaesthesiol Scand . 1992;36:554–558
  32. Peters J , Kutkuhn B , Medert HA , Schlaghecke R , Schuttler J , Arndt JO . Sympathetic blockade by epidural anesthesia attenuates the cardiovascular response to severe hypoxemia . Anesthesiology . 1990;72:134–144
  33. Rosenberg JM , Wahr JA , Sung CH , Oh YS , Gilligan LJ . Coronary perfusion pressure during cardiopulmonary resuscitation after spinal anesthesia in dogs . Anesth Analg . 1996;82:84–87
  34. Geffin B , Shapiro L . Sinus bradycardia and asystole during spinal and epidural anesthesia: a report of 13 cases . J Clin Anesth . 1998;10:278–285
  35. Liguori GA , Sharrock NE . Asystole and severe bradycardia during epidural anesthesia in orthopedic patients . Anesthesiology . 1997;86:250–257
  36. Almquist A , Goldenberg IF , Milstein S , et al.   Provocation of bradycardia and hypotension by isoproterenol and upright posture in patients with unexplained syncope . New Engl J Med . 1989;320:346–351
  37. Wasserstrum N . Nitroprusside in preeclampsia. Circulatory distress and paradoxical bradycardia . Hypertension . 1991;18:79–84
  38. Nolan TE , Hankins GD . Myocardial infarction in pregnancy . Clin Obstet Gynecol . 1989;32:68
  39. Norris MC . In: Obstetric Anesthesia . 2nd edition. Philadelphia: Lippincott Williams & Wilkins; 1999;p. 30
  40. Holmes F . Spinal analgesia and caesarean section. Maternal mortality . J Obstet Gynaecol Br Emp . 1957;64:229–232
  41. Holmes F . The supine hypotensive syndrome. Its importance to the anesthetist . Anaesthesia . 1960;15:298–306
  42. Morgan GE , Mikhail MS , Murray MJ . In: Clinical Anesthesiology . 3rd edition. New York: McGraw-Hill; 2002;p. 830
  43. Thomas C . The incidence and risk factors for cardiac arrest during emergency tracheal intubation: a justification for incorporating the ASA guidelines in the remote location . J Clin Anesth . 2004;16:508–516
  44. Hashiba M , Okutomi T , Saito K , Amano K , Okamoto H , Hoka S . A case of cardiac arrest at induction of anesthesia for postpartum hysterectomy . Masui . 2002;51:1355–1358
  45. Ruiz K . Asystole on induction . Anaesthesia . 1989;44:698–699
  46. Stienstra R , Veering BT . Intrathecal drug spread: is it controllable? . Reg Anesth Pain Med . 1998;23:347–351
  47. Nishikawa T , Anzai Y , Namiki A . Asystole during spinal anesthesia after change from Trendelenburg to horizontal position . Can J Anaesth . 1988;35:406–408
  48. Green NM , Brull SJ . Physiology of Spinal Anesthesia . 4th edition. Baltimore, MD: Williams & Wilkins; 1994;
  49. Mackey DC , Carpenter RL , Thompson GE , Brown DL , Bodily MN . Bradycardia and asystole during spinal anesthesia: a report of three cases without morbidity . Anesthesiology . 1989;70:866–868
  50. Lewis T . Vasovagal syncope and the carotid sinus mechanism with comments on Gowers's and Nothnagel's syndrome . Br Med J . 1932;1:873–876
  51. Connolly SJ , Sheldon R , Thorpe KE , et al.   Pacemaker therapy for prevention of syncope in patients with recurrent severe vasovagal syncope: second vasovagal pacemaker study (VPS II): a randomized trial . JAMA . 2003;289:2224–2229
  52. Brown DL , Carpenter RL , Moore DC , et al.   Cardiac arrest during spinal anesthesia . Anesthesiology . 1988;68:971–972

PII: S1028-4559(09)60226-6

doi:10.1016/S1028-4559(09)60226-6

Taiwanese Journal of Obstetrics and Gynecology
Volume 45, Issue 3 , Pages 208-214, September 2006

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