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LETTERS TO EDITOR
Year : 2021  |  Volume : 22  |  Issue : 2  |  Page : 195-196
 

Persistent guidewire-induced arrhythmias following central venous catheterization in traumatic brain injury


Department of Anaesthesia, PGIMER, Chandigarh, India

Date of Submission31-Mar-2021
Date of Decision23-Apr-2021
Date of Acceptance03-May-2021
Date of Web Publication29-Sep-2021

Correspondence Address:
Dr. Nidhi Singh
Department of Anesthesia, Level 4, Nehru Building, PGIMER, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TheIAForum.TheIAForum_46_21

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How to cite this article:
Thakur H, Singh N, Makkar JK, Jain K. Persistent guidewire-induced arrhythmias following central venous catheterization in traumatic brain injury. Indian Anaesth Forum 2021;22:195-6

How to cite this URL:
Thakur H, Singh N, Makkar JK, Jain K. Persistent guidewire-induced arrhythmias following central venous catheterization in traumatic brain injury. Indian Anaesth Forum [serial online] 2021 [cited 2021 Dec 7];22:195-6. Available from: http://www.theiaforum.org/text.asp?2021/22/2/195/326980




Sir,

A 43-year-old male was posted for emergency left frontotemporoparietal decompressive hemicraniectomy for left temporal depressed fracture [Figure 1]. Glasgow Coma Scale (GCS) was E3 V2 M5 and random blood sugar (RBS) was 220 mg/dl. In the operation theater, routine intravenous induction was done. The right subclavian vein was localized using a landmark approach. After ensuring free flow of blood, the guidewire was inserted. As the guidewire crossed the 15 cm mark, runs of rhythm disturbances (heart rate [HR] around 220/min) were observed varying between paroxysmal supraventricular tachycardia and atrial fibrillation (AF). Blood pressure (BP) was around 130/70 mm Hg. Arrhythmias persisted even after slight withdrawal of guidewire to 10 cm and subsequent complete removal. Maneuvers to resolve the arrhythmias included carotid massage on either side, Adenosine 6 + 12 mg, and Esmolol 40 mg + 40 mg in incremental doses as per the rhythm observed. With these measures, HR decreased to around 150/min. However, arrhythmias persisted with an irregularly irregular rhythm suggestive of AF with hemodynamic stability [Figure 2]. A femoral line was inserted and amiodarone 150 mg over 20 min was administered followed by an infusion (1 mg/min) over the next 6 h. Once HR of 120/min was achieved decompressive craniectomy and tracheostomy were done and the bone flap was placed in the abdomen.
Figurer 1: Noncontrast head computed tomography head of the patient

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Figure 2: Patient vitals

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Intraoperatively, the HR and BP ranged between 140–170/min and 140–160/70–80 mm Hg, respectively. Amiodarone infusion continued intraoperatively with the return of normal sinus rhythm toward the end of surgery. The patient was shifted on amiodarone infusion for overnight mechanical ventilation. Arrhythmias did not recur throughout the hospitalization period. The patient had a ventilatory stay of 3 days and was discharged on day 7 with tracheostomy in situ (GCS E4VTM5).

Neuro-cardiac kinship in an acute neurological collapse is widely acknowledged.[1] A comparable mechanism may be an unfamiliar cause of complications following traumatic brain injury (TBI). Complex synergism of brain injury-induced systemic catecholamine surge, neuroinflammatory and neuroendocrine responses, called the “catecholamine hypothesis” is central to the pathophysiology of neurogenic cardiac afflictions.[1],[2] Cardiac dysfunction is reported in 13% of TBI patients with a higher prevalence of diabetes mellitus.[3] Our patient also had raised in-hospital RBS recordings, although this is not uncommon after the stress of trauma itself. Underlying cardiac dysfunction due to TBI seemingly predisposed this patient to cardiac arrhythmias with subtle endocardial mechanical irritation by the guidewire.

We report guidewire-induced sustained arrhythmia unresponsive to traditional measures. In TBI patients, overzealous guidewire insertion should be avoided. About 15 cm as minimum length should be considered the limit for guidewire insertion, in consideration of height, during right internal jugular venous catheterization.[4] Appreciation of the mechanistic alliance of heart and brain allows us to anticipate such complications. Finally, residents working in tertiary institutes with busy emergency rooms in developing countries like ours are often required to put central lines using landmark technique under immense work pressure with minimal monitoring and limited resources. At least, electrocardiogram monitoring is recommended. In TBI patients, an experienced anesthesiologist putting an ultrasound-guided central line in real-time under standard monitoring should be the standard of care.

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 be 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.
Mazzeo AT, Micalizzi A, Mascia L, Scicolone A, Siracusano L. Brain-heart crosstalk: The many faces of stress-related cardiomyopathy syndromes in anaesthesia and intensive care. Br J Anaesth 2014;112:803-15.  Back to cited text no. 1
    
2.
Serri K, El Rayes M, Giraldeau G, Williamson D, Bernard F. Traumatic brain injury is not associated with significant myocardial dysfunction: An observational pilot study. Scand J Trauma Resusc Emerg Med 2016;24:31.  Back to cited text no. 2
    
3.
Venkata C, Kasal J. Cardiac dysfunction in adult patients with traumatic brain injury: A prospective cohort study. Clin Med Res 2018;16:57-65.  Back to cited text no. 3
    
4.
Yoshimura M, Nakanishi T, Sakamoto S, Toriumi T. Confirmation of optimal guidewire length for central venous catheter placement using transesophageal echocardiography. J Clin Anesth 2016;35:58-61.  Back to cited text no. 4
    


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