Asystolic Cardiac Arrest Following Pneumoperitoneum From Vagal-Mediated Bradycardia During Laparoscopic Gynaecologic Surgery: A Case Report.

Vagal-mediated bradycardia is a rare adverse reaction to peritoneal insufflation during laparoscopic procedures. We report an occurrence of vagal-mediated bradycardia during an elective gynaecological procedure, which resulted in an asystolic cardiac arrest. A 55-year-old female patient underwent an elective laparoscopic bilateral salpingo-oophorectomy for multiple symptomatic fibromas. She had no significant past medical history. She had one previous general anaesthetic for a hysteroscopy two years prior. This was carried out under a supraglottic airway device with no documented complications. Systematic clinical examination was also unremarkable, and preoperative routine bloods showed no significant abnormalities. Induction of anaesthesia was uncomplicated and unremarkable. On initiation of peritoneal insufflation, the patient had an instantaneous and significant sinus bradycardia that did not respond to boluses of atropine. She subsequently had an asystolic cardiac arrest. Return of spontaneous circulation occurred on deflation of her peritoneum. The multidisciplinary team (MDT) decision was to terminate the surgery. The patient remained stable post-operatively, and all cardiac investigations were normal. Laparoscopic procedures entail manipulation of pelvic structures and abdominal nerves, notably during peritoneal carbon dioxide insufflation. Severe vagal reactions have been shown to occur, and this can lead, not uncommonly, to an asystolic cardiac arrest. Preventative recommendations currently include limiting peritoneal pressure to 15 mmHg during insufflation, pre-medicating with vagolytic agents, and careful consideration of co-morbid risk factors. Treatment options focus on the intraoperative cardiac arrest protocol outlined by the Association of Anaesthetists of Great Britain and Ireland (AAGBI) and supportive care, including immediate termination of further gas insufflation and deflation of the abdomen. Atropine can also be used to treat bradycardia.  Anaesthetists should be aware of this life-threatening adverse reaction and understand risk factors, preventative measures and treatment options available during laparoscopic procedures.