A cardiovascular collapse occurred in the beach chair position for shoulder arthroscopy under general anesthesia -A case report-
The patient was male, aged 50, 169 cm and 72 kg, and visited the hospital to undergo shoulder joint surgery with a damaged in the right rotator cuff. Although he had diabetes that was diagnosed ten years before, he did not undergo treatment for it; however, blood sugar level had been controlled. Preoperative endocrinologic evaluation revealed no abnormal findings. The patient sometimes complained of palpitations and underwent tests for that in another hospital, but no anomaly was found and he was being followed-up. Nonspecific ST-T wave change was found in the preoperative electrocardiograph. No specific findings were found in the chest radiograph or echocardiogram, and laboratory findings were normal. Premedication was not administered. Vital signs just before induction and after arriving in the operation room were as follows: blood pressure of 160/90 mmHg, heart rate of 70/min, and oxygen saturation of 97%, and electrocardiography showed normal sinus rhythm. Anesthesia was induced with pentothal sodium 300 mg, fentanyl 100 µg, and rocuronium bromide 50 mg, and the endotracheal tube (inner diameter 8.0 mm) was inserted orally. For maintenance of anesthesia, 50% N2O - O2, sevoflurane 3 vol%, and remifentanil 0.05 µg/kg/min were used. After vital signs were stabilized, concentration of sevoflurane was adjusted to 1.5 vol% and atropine sulfate 0.5 mg was intravenously injected just before changing the patient's position from supine to a sitting position (beach chair position 70-80°). One or two minutes after sitting position, heart rate was suddenly reduced from 80/min to 30/min or less, and blood pressure was 70/40 mmHg. But no electrocardiograhic changes were noted. Intravenous injection of atropine sulfate 0.5 mg was immediately given, but heart rate and blood pressure did not change. After stopping the administration of remifentanil and sevoflurane, 1 : 10,000 epinephrine 1 ml (10 µg) was intravenously injected, and the patient was moved to the supine position. Heart rate soon recovered to 90/min, and blood pressure returned to 120/60 mmHg. The results of the arterial blood gas analysis at that time were within normal range. Through the discussion with surgeons, we decided to postpone the operation. Detailed tests were performed a 24-hour electrocardiography and echocardiography, and the patient was suspected of having vasovagal syncope suspect. The head-up tilt testing and circulatory assessment diagnosed BJR as the cause. A sufficient amount of fluid was supplied and a β-sympatholytic was orally administered as the preventive treatment. Following preoperative administration of anticholinergic and sedative, anesthesia was induced well with desflurane and remifentanil. Afterwards, the operation was performed without any specific findings.