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LETTERS TO EDITOR
Year : 2021  |  Volume : 15  |  Issue : 4  |  Page : 457-458

Postoperative bradycardia following bladder exstrophy surgery: An anesthesiologist's nightmare


1 Department of Trauma and Emergency, All India Institute of Medical Sciences, Patna, Bihar, India
2 Department of Anaesthesiology, All India Institute of Medical Sciences, Patna, Bihar, India
3 Department of Paediatric Surgery, All India Institute of Medical Sciences, Patna, Bihar, India

Correspondence Address:
Amarjeet Kumar
Room No. 503, B-Block, OT Complex, All India Institute of Medical Sciences, Patna - 801 507, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sja.sja_257_21

Rights and Permissions
Date of Submission08-Apr-2021
Date of Decision10-Apr-2021
Date of Acceptance11-Apr-2021
Date of Web Publication02-Sep-2021
 


How to cite this article:
Kumar A, Sinha C, Sinha AK, Surabhi, Singh S, Singh K. Postoperative bradycardia following bladder exstrophy surgery: An anesthesiologist's nightmare. Saudi J Anaesth 2021;15:457-8

How to cite this URL:
Kumar A, Sinha C, Sinha AK, Surabhi, Singh S, Singh K. Postoperative bradycardia following bladder exstrophy surgery: An anesthesiologist's nightmare. Saudi J Anaesth [serial online] 2021 [cited 2021 Dec 5];15:457-8. Available from: https://www.saudija.org/text.asp?2021/15/4/457/325282



Urinary bladder exstrophy–epispadias complex (EEC) is a rare congenital genitourinary malformation (prevalence 1/10,000) and is characterized by an evaginated bladder plate, epispadias, and an anterior defect of the pelvis (pubic diastasis), pelvic floor abdominal wall, and spine (7% anomalies).[1] A multidisciplinary team consisting of surgeons, anesthesiologists, pediatricians, nutritionists, pharmacologists, nurses, and child life specialists are essential for a better outcome. Intraoperative anesthesiologist challenges include opioid-based respiratory depression, hemodynamic instability due to blood loss because of pelvic osteotomies in older children, increase fluid loss from exposed bowel in bladder augmentations, inadequate assessment of volume status (no urine output measure), overhydration resulting in flooding of the surgical field by patient's urine, severe postoperative pain because pelvic external fixator in situ and lower extremity traction, and long duration of surgery.

Here, we report a clinical situation of 1.5-year-old male child who presented with exstrophy of bladder with epispadias along with developmental dysplasia of the hip. Surgery was planned for functional closure of the bladder with bilateral Salter's osteotomy and external fixation. General anesthesia with a caudal epidural block was given. Written and informed consent was taken for publication. The whole intraoperative period was uneventful, and the patient's trachea was extubated successfully. In the postoperative period, we detected sudden bradycardia with associated oxygen desaturation 10 minutes after shifting from the operating room. For the management of bradycardia, the patient's trachea was reintubated and underwent three cycles of cardiopulmonary resuscitation. On arterial blood gas (ABG) examination, severe metabolic acidosis (pH 7.205, pCO2 43.3 mmHg, pO2 306.8 mmHg, base deficit 10.9 mmol/L, lactate 4.7 mmol/L) was detected. Acidosis was corrected by infusing a mixed solution of sodium bicarbonate (8.4%) and dextrose 10% (1:1 ratio) along with proper hydration to the patient. The patient's trachea was extubated successfully after correction of acidosis and overnight mechanical ventilation. The possible differential diagnosis made by the anesthesiologist team includes hypoxia, hypovolemia, acidosis, electrolyte abnormalities, opioid overdose, and bladder traction. We ruled out hypoxia as a cause of bradycardia because bradycardia started before oxygen desaturation. Normal respiratory drive ruled out opioid overdose. The diagnosis of metabolic acidosis as a cause of bradycardia was made following the ABG report.

Metabolic acidosis is common in patients undergoing extensive surgery involving significant blood loss.[2] This might be due to a combination of blood loss and electrolyte disturbances following the administration of large amounts of crystalloid, colloid, and blood products. The base deficit, an indicator of metabolic acidosis, correlated directly with the severity of hemorrhagic shock and can be used in quantifying the response to hemorrhage in both traumatic and nontraumatic patients.[3] The maximum base deficit was recorded after the end of surgery.[4],[5] In our case, at the end of the surgery, base deficit detected was 10.9 mmol/L. The cause of acidosis might be due to inadequate hydration because of poor assessment of volume status during the intraoperative period, underestimated actual blood loss (disappears into the pelvic tissues), blood transfusion related, long duration of surgery, and poor acid clearance because of pediatric age-group, or a combination of the above. During the intraoperative period, we advocate judicious use of intravenous fluids with CVP (central venous pressure) monitoring, invasive blood pressure monitoring, regular monitoring of pH, base deficit, hemoglobin, and electrolytes in patients at-risk for blood loss (osteotomies) and multimodal approach to analgesia. Meticulous attention to fluid intake and output should is also required.

Declaration of patient consent

Taken from the patient.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ebert A-K, Reutter H, Ludwig M, Rösch WH. The exstrophy-epispadias complex. Orphanet J Rare Dis 2009;4:23.  Back to cited text no. 1
    
2.
Marietta M, Facchini L, Pedrazzi P, Busani S, Torelli G. Pathophysiology of bleeding in surgery. Transplant Proc 2006;38:812-4.  Back to cited text no. 2
    
3.
Rixen D, Siegel JH. Bench-to-bedside review: Oxygen debt and its metabolic correlates as quantifiers of the severity of haemorrhagic and post-traumatic shock. Crit Care 2005;9:441-53.  Back to cited text no. 3
    
4.
Choi AY, Ahmad NS, de Beer DA. Metabolic changes during major craniofacial surgery. Paediatr Anaesth 2010;20:851-5.  Back to cited text no. 4
    
5.
Hugot P, Sicsic J-C, Schaffuser A, Sellin M, Corbineau H, Chaperon J, et al. Base deficit in immediate postoperative period of coronary surgery with cardiopulmonary bypass and length of stay in intensive care unit. Intensive Care Med 2003;29:257-61.  Back to cited text no. 5
    




 

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