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Year : 2013  |  Volume : 54  |  Issue : 5  |  Page : 361  

Chronic haemodynamic disturbances in neurointensive care: First description

1 Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, Canada
2 Department of Neurocritical Care, All India Institute of Medical Sciences, New Delhi, India
3 Department of Neuroanesthesiology and Neurocritical Care, Medanta-The Medicity Hospital, Gurgaon, Haryana, India

Date of Web Publication28-Nov-2013

Correspondence Address:
Tumul Chowdhury
Department of Anesthesia and Perioperative Medicine, 2nd Floor, Herry Medovy House, 671-William's Ave, Health Sciences Center, University of Manitoba, Winnipeg R3E 0Z2, Canada

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0300-1652.122377

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How to cite this article:
Chowdhury T, Goyal K, Sapra H. Chronic haemodynamic disturbances in neurointensive care: First description. Niger Med J 2013;54:361

How to cite this URL:
Chowdhury T, Goyal K, Sapra H. Chronic haemodynamic disturbances in neurointensive care: First description. Niger Med J [serial online] 2013 [cited 2023 Sep 30];54:361. Available from: https://www.nigeriamedj.com/text.asp?2013/54/5/361/122377


Cardiovascular changes are frequently observed complications in neurosurgical patients and may be attributed to Cushing's reflex, brainstem manipulations and other neurogenic reflexes. [1] Although many haemodynamic instabilities result from obvious directly handling or stimulation of particular nerve or brain region; however, we have reported a case in which indirect cause contributed the severe haemodynamic disturbances in our patient.

A middle-aged patient with severe he ad injury (GCS < 8) patient admitted to intensive care unit for ventilatory support and further management. He had lacerated wound over right parietal bone and developed scalp abscess on third day of admission in ICU. MRI showed deep lacerated wound and culture of wound revealed fungal growth. Both plastic surgeon as well as neurosurgeon decided to debride the wound. The full-thickness debridement was done and small craniotomy was done on RT parietal region. Surgeon did vacuum-assisted closure (V.A.C) and set a negative pressure of 100 mm Hg. Two days later, patient started to develop intermittent bradycardia (HR <45/min) with (BP 80/60 mm Hg) followed by arrhythmias including bigeminy, ventricular premature beat and wide complex ventricular tachycardia. Fluid boluses, lignocaine 1 mg/kg, and ion tropic support (nor adrenaline infusion) were given. Arterial blood gas analysis, 2 D-Echo, X-ray chest, and CT scan were done but all investigations were in conclusive. To rule out reverse coning, we stopped the negative pressure suction and all of a sudden haemodynamic disturbances subsided. The rest of the management remained the same with antibiotics, mechanical ventilation and alternate day dressing without negative suction.

The VAC system has been shown to promote wound healing and facilitate graft viability. [2] However, it can produce catastrophic haemodynamic disturbances in neurosurgical patients. Few cases highlighted the immediate postoperative bradycardia due to use of subgaleal negative pressure drain to avoid extradural haematoma. [3],[4] However, our case highlights chronic haemodynamic consequences of VAC dressing in head injury patient. In our case negative pressure applied indirectly transmitted through dura and gradually produced stretching of nerves and in turn caused reverse herniation. Dura is innervated by meningeal branch of the fifth nerve. Dural stimulation has been reported to incite trigeminal cardiac reflex (TCR) and may produce similar symptoms such as hypotension and bradycardia but manifestation of wide array of arrhythmias point towards reverse herniation. [5] In addition, dural stretch can produce TCR; however, very late haemodynamic changes in this patient rule out TCR as a probable diagnosis. The reversal of haemodynamic disturbances after removal of negative suction also suggests our hypothesis.

In conclusion, although the role of V.A.C dressing is proven to effective for wound healing in many areas of body but certainly the head region imposes greatest risks of haemodynamic instability, hence, need greater caution for its use and with vigilant haemodynamic monitoring.

   References Top

1.Agrawal A, Timothy J, Cincu R, Agarwal T, Waghmare LB. Bradycardia in neurosurgery. Clin Neurol Neurosurg 2008;110:321-7.  Back to cited text no. 1
2.Andrews BT, Smith RB, Goldstein DP, Funk GF. Management of complicated head and neck wounds with vacuum-assisted closure system. Head Neck 2006;28:974-81.  Back to cited text no. 2
3.Karamchandani K, Chouhan RS, Bithal PK, Dash HH. Severe bradycardia and hypotension after connecting negative pressure to the subgaleal drain during craniotomy closure. Br J Anaesth 2006;96:608-10.  Back to cited text no. 3
4.Toshniwal GR, Bhagat H, Rath GP. Bradycardia following negative pressure suction of subgaleal drain during craniotomy closure. Acta Neurochir (Wien) 2007;149:1077-9.  Back to cited text no. 4
5.Lv X, Li Y, Jiang C, Wu Z. The incidence of trigeminocardiac reflex in endovascular treatment of dural arteriovenous fistula with onyx. Interv Neuroradiol 2010;16:59-63.  Back to cited text no. 5

This article has been cited by
1 Trigeminocardiac reflex in cerebrovascular surgery: a review and an attempt of a predictive analysis
Nora Sandu,Tumul Chowdhury,Cyrill Meuwly,Bernhard Schaller
Expert Review of Cardiovascular Therapy. 2017; : 1
[Pubmed] | [DOI]


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