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 Table of Contents  
LETTER TO EDITOR
Year : 2020  |  Volume : 7  |  Issue : 2  |  Page : 146-147

Acute pressor response in prone position during spinal surgery


Department of Anaesthesia and Critical Care, Command Hospital (Southern Command), Armed Forces Medical College, Pune, Maharashtra, India

Date of Submission05-Jan-2019
Date of Decision04-Mar-2019
Date of Acceptance26-Nov-2019
Date of Web Publication8-Oct-2020

Correspondence Address:
Saurabh Sud
Department of Anaesthesia and Critical Care, Command Hospital (Southern Command), Armed Forces Medical College, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cjhr.cjhr_3_19

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How to cite this article:
Hooda B, Sud S, Dwivedi D, Singh S. Acute pressor response in prone position during spinal surgery. CHRISMED J Health Res 2020;7:146-7

How to cite this URL:
Hooda B, Sud S, Dwivedi D, Singh S. Acute pressor response in prone position during spinal surgery. CHRISMED J Health Res [serial online] 2020 [cited 2020 Oct 24];7:146-7. Available from: https://www.cjhr.org/text.asp?2020/7/2/146/297575



Sir,

Acute hemodynamic response encountered during surgeries performed in prone position is hypotension.[1],[2] Cervical and thoracic spinal surgeries in the prone position evoke a similar hemodynamic response, whereas it is reported rarely with lumbosacral segment surgeries.[3]

We report a rare incidence of pressor response in prone position, in a 45-year-old female weighing 52 kg who underwent laminectomy and posterior fixation for anterolisthesis of lumbar fourth and fifth vertebra. Preanesthesia assessment was within normal limits. Preoperative consent and nil per oral status were confirmed. Standard monitoring ensued includes qCON 2000 monitor (Quantium Medical, Mataró, Spain) which calculates qCON index and qNOX index, which correlates with the level of consciousness and probability of response to a noxious stimulus. Continuous invasive blood pressure (IBP) monitoring was done after cannulating left radial artery. General anesthesia was administered with injection fentanyl 100 μg intravenous (IV) and injection propofol 100 mg IV. The airway was secured with a 7.0-mm ID size cuffed flexometallic endotracheal tube (O) after administrating injection atracurium 25 mg IV and the anesthesia was maintained with oxygen/nitrous oxide/sevoflurane (1%–2%).

Surgery progressed satisfactorily after making the patient prone. Two hours into surgery, the IBP suddenly increased from baseline value of 122/82 to 200/130 mmHg. Heart rate (HR) increased from baseline value of 82/min to 133/min with qCON 2000 monitor depicting qCON of 45 and qNOX of 51, indicating adequate depth of anesthesia and analgesia. At this juncture, the common causes of intraoperative hemodynamic fluctuations including lighter plane of anesthesia and inadequate analgesia were ruled out. Other uncommon causes namely thyroid storm, carcinoid syndrome, pheochromocytoma, syringe swap or iatrogenic infusion of vasopressors, autonomic dysreflexia, myocardial ischemia, and pneumothorax were also excluded.[4]

The neurosurgeons were immediately notified following which the screw applied to fix pedicle implant was immediately removed and the hemodynamics settled immediately. As the surgeon's reattempted fixation of the implant with the screw, twofold increases in IBP and HR were observed. Surgeons changed the direction of the screw in the third attempt which resulted in minimal hemodynamic change [Figure 1]. Rest of the intraoperative period was uneventful, and the patient was extubated supine. The patient was discharged from postanesthesia care unit after 20 min.
Figure 1: Axial T2-weighted magnetic resonance imaging at the level of L5 vertebra. Yellow arrow revealing initial path of the fixing screw and the red arrow showing the changed path of screw fixation

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The cause of sudden rise in BP and HR could be due to handling of lumbar nerve roots affecting the autonomic ganglion indirectly which is present in the vicinity of the operative field. In spinal surgeries, direct stimulation of autonomic ganglion seems unlikely, but the screw could have led to the stimulation of lumbar nerve roots, which is a more convincing reason of the exaggerated autonomic response in our index case. Chowdhury et al. had a similar pressor response in their patient of Pott's spine being operated in prone position which perhaps was a result of handling of the nerve roots.[5]

Although this phenomenon is rarely presented in the literature, its occurrence cannot be ruled out. Therefore, one should be very vigilant when the surgeons are operating in the vicinity of nerve roots in prone position in patients with limited cardiopulmonary reserve as it can result in an adverse perioperative event.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to b'e reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Dharmavaram S, Jellish WS, Nockels RP, Shea J, Mehmood R, Ghanayem A, et al. Effect of prone positioning systems on hemodynamic and cardiac function during lumbar spine surgery: An echocardiographic study. Spine (Phila Pa 1976) 2006;31:1388-93.  Back to cited text no. 1
    
2.
Poon KS, Wu KC, Chen CC, Fung ST, Lau AW, Huang CC, et al. Hemodynamic changes during spinal surgery in the prone position. Acta Anaesthesiol Taiwan 2008;46:57-60.  Back to cited text no. 2
    
3.
Hambly PR, Martin B. Anaesthesia for chronic spinal cord lesions. Anaesthesia 1998;53:273-89.  Back to cited text no. 3
    
4.
Blacker SN, Brown CQ, Tarant NS. Autonomic dysreflexia-like syndrome in a T12 paraplegic during thoracic spine surgery. Anesth Analg 2010;111:1290-2.  Back to cited text no. 4
    
5.
Chowdhury T, Narayanasamy S, Dube SK, Rath GP. Acute hemodynamic disturbances during lumbar spine surgery. J Neurosurg Anesthesiol 2012;24:80-1.  Back to cited text no. 5
    


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