Atropine injection followed by coronary artery spasm with ventricular tachycardia during spinal anesthesia -A case report-
A 44-year-old female, height and weight of 158 cm; 53 kg, was scheduled for a varicosectomy and a communicating vein ligation of the bilateral varicose veins.\nThe patient's family history, past history, obstetric history, and social history were unremarkable.\nUpon admission, vital signs were stable with a normal physical examination. The electrocardiogram (ECG) displayed a normal sinus rhythm at 57 beats per minute at normal intervals ().\nThe patient's vital signs on arrival to the operation room showed a blood pressure of 134/72 mmHg and heart rate of 90-93 beats/min.\nWith the patient in the lateral decubitus position, spinal anesthesia was administered using a 25-gauge Quincke-type needle with 12 mg of bupivacaine (Marcaineheavy®) at the L3-L4 interspace.\nThe patient was placed in the supine position for 10 minutes, where the blood pressure lowered to 120/70 mmHg and the heart rate decreased to 82-85 beats/min. The maximal level of the sensory block to cold temperature was T8.\nThereafter, 2.5 mg of midazolam were given intravenously\nfor the sedation and resolution of anxiety.\nThe patient's blood pressure was then stabilized to 110-90/65-45 mmHg. After one hour since the start of the operation, the patient's heart rate began to gradually decrease. However, since the patient's blood pressure was stable and she was successfully sedated, we decided to observe and no supplementary evaluation of block level was performed. Two hours after the administration of the spinal anesthesia, the heart rate dropped to 42-45 beats/min, and 0.5 mg of atropine was injected intravenously. The patient's heart rate rose to 60 beats per minute within 5 minutes. Shortly after, premature ventricular contraction occurred in the ECG followed by ventricular tachycardia, where the patient's heart rate increased to 140 beats per minute and the blood pressure to 120/60 mmHg ( and ). The patient complained of chest discomfort, but was capable of communication and cooperation. At that time, the upper sensory block level to cold temperature was T10. The patient was given 10 mg of esmolol intravenously. After 2-3 minutes, the patient's ECG presented an elevation in the ST with a heart rate of 62 beats/min (). After the termination of the operation, the patient was transferred to the intensive care unit. Laboratory tests at the moment of ventricular tachycardia were nonspecific. The CPK-MB was 19.7 ng/ml; and Troponin I peaked at 6.38 ng/ml, where both subsequently returned back to normal within 2 days. Thyroid function test and fasting lipid profile were within normal limits.\nCoronary angiography (CAG) that was performed after the operation showed luminal stenosis of up to 40% at the middle left anterior descending coronary artery (mLAD), while left circumflex artery (LCX) and right coronary artery (RCA) showed no significant signs of luminal stenosis. Ultrasonic cardiography (UCG) that was performed after the operation showed an ejection fraction of 40%, akinesia at the LCX territory with mild left ventricle (LV) systolic dysfunction, and impaired relaxation. According to the CAG and UCG results that were obtained by the consultation of the department of cardiology, the patient was diagnosed with VT due to vasospasm. After the administration of calcium channel blockers, the patient was discharged 3 days later without any further symptoms.