Year : 2016 | Volume
: 9 | Issue : 3 | Page : 452--454
Anaesthetic concerns with intramyometrial vasopressin during myomectomy
Geetanjali Chilkoti, Medha Mohta, Shivika Nath, Ashok Kumar Saxena, Priyanka Khurana
Department of Anesthesiology and Critical Care, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India
A 1404, Jaipuria Sunrise Greens, Ahimsa Khand, Indirapuram, Ghaziabad - 201 014, Uttar Pradesh
Vasopressin, a potent vasoconstrictor, has often been used intramyometrially to prevent blood loss during surgical management of uterine myomas. Various lethal complications reported with its use include bradycardia, unmeasurable blood pressure, loss of palpable peripheral pulse, marked pallor, arrhythmia, pulmonary oedema and cardiac arrest. We herein report a case of uterine myomas in which intramyometrial vasopressin-induced complications such as bradycardia, absent pulse and marked pallor were observed with very low dose and concentration (i.e. 1.5 U and 0.1 U/ml). This could be attributed to the coexistence of hypertension in our patient. Here, we discuss the anaesthetic concerns with the use of intramyometrial vasopressin and reinforce the need for dogmatic guidelines envisaging the recommended safe dose and concentrations of intramyometrial vasopressin and proper patient selection.
|How to cite this article:|
Chilkoti G, Mohta M, Nath S, Saxena AK, Khurana P. Anaesthetic concerns with intramyometrial vasopressin during myomectomy.Ain-Shams J Anaesthesiol 2016;9:452-454
|How to cite this URL:|
Chilkoti G, Mohta M, Nath S, Saxena AK, Khurana P. Anaesthetic concerns with intramyometrial vasopressin during myomectomy. Ain-Shams J Anaesthesiol [serial online] 2016 [cited 2021 Apr 18 ];9:452-454
Available from: http://www.asja.eg.net/text.asp?2016/9/3/452/189089
Myomectomy is usually associated with excessive bleeding, and a local intramyometrial infiltration of vasopressin is often used to reduce the operative blood loss. Vasopressin use has been reported to be associated with serious complications such as bradycardia, arrhythmias, pulmonary oedema and cardiac arrest ,. We herein report a case of sudden severe bradycardia and vasospasm immediately after a low dose intramyometrial injection of vasopressin during myomectomy and its anaesthetic concerns.
A 37-year-old woman, weighing 60 kg, a known hypertensive, was scheduled for myomectomy under regional anaesthesia. Hypertension was controlled on tab. telmisartan 20 mg once a day. The patient was accepted for anaesthesia under American Society of Anesthesiologists grade-II. She complained of heavy and prolonged vaginal bleeding since the last 6 months. She had received 1 U whole blood 2 days before surgery, and the post-transfusion hemoglobin was 10.5 g%. All preoperative investigations and airway assessment were within normal range. The patient received tab. telmisartan 20 mg and tab. alprazolam 0.5 mg on the night prior and tab. alprazolam 0.5 mg on the morning of the surgery with few sips of water. In the operation theatre, standard routine monitoring was instituted, which showed noninvasive blood pressure 126/70 mmHg, heart rate (HR) 80/min and 99% SpO2. An intravenous line was secured and coloading was performed with Ringer's lactate solution. Combined spinal epidural block was given in the L3–L4 interspace using a needle through needle technique, and 3 ml of 0.5% bupivacaine with 25 µg fentanyl was administered in the subarachnoid space. Sensory block level of T6 was achieved within 5–7 min. Oxygen was administered through a face mask. The patient remained hemodynamically stable following subarachnoid block (SAB). After approximately 30 min of starting surgery, she developed bradycardia with HR less than 40/min, unrecordable blood pressure (BP), with normal ECG complexes. The radial and brachial arteries were not palpable during this period; however, carotid artery was palpable. The patient complained of nausea and vomiting. Atropine 0.6 mg was administered intravenously. Defibrillator and all resuscitative drugs and equipments were kept ready. On examination, the conjunctiva and tongue looked very pale. On enquiring the surgeons, they admitted injecting 10–15 ml vasopressin (equivalent to the dose of 1–1.5 U) of 0.1 U/ml concentrations into the myometrium, which was prepared by diluting 20 U vasopressin in 200 ml of normal saline. The patient at this time was observed to be drowsy but arousable and responding to verbal commands. She denied any complaints of anxiety, headache, chest pain, palpitation or difficulty in breathing during this period. Level of sensory block was rechecked and was found to be below T6. At this time, HR and BP were found to be 100/min and 170/90 mmHg, respectively. Within 15–20 min, the colour of the conjunctiva became normal and HR and BP became 80/min and 126/80 mmHg, respectively. The total duration of surgery was approximately 90 min and the perioperative period thereafter remained uneventful.
Vasopressin, a hormone naturally secreted by the posterior pituitary, acts on V1 and V2 receptors present in blood vessels and the kidney. Anaesthesiologists use vasopressin in cardiopulmonary resuscitation, diabetes insipidus and as a vasopressor in septic shock. In gynaecological practice, vasopressin, a potent vasoconstrictor, is often used intramyometrially to reduce blood loss during myomectomy .Vasopressin acts by constricting the smooth muscles in the walls of the capillaries, small arterioles and venules. The vasoconstrictive effects of intramyometrial vasopressin manifest within seconds with a half life of 10–20 min and a duration of action of 2–8 h . There are some case reports of serious complications such as bradycardia, cardiovascular collapse and death associated with the use of intramyometrial vasopressin during myomectomy ,,. The use of intramyometrial vasopressin to decrease blood loss during myomectomy has not been approved by the United States Food and Drug Association but still it has been used commonly in clinical practice.
Anaesthetic concerns with the use of intramyometrial vasopressin include the use of a safe dose/concentration and anticipation, prevention, early identification and treatment of associated lethal complications. It is prudent to establish the safe dose and concentration of intramyometrial vasopressin. It is recommended to use low doses of intramyometrial vasopressin considering the fact that vasopressin gets absorbed into rich blood supply of uterine myoma. In clinical practice, a dose of 20 U diluted in 100 ml of normal saline (0.2 U/ml) is often used. The lethal complications such as severe bradycardia and cardiovascular collapse have also been reported with the low doses in the range of 5–11 U ,,,. In 1958, a preliminary report on the use of 4 U intramyometrial vasopressin in 13 patients undergoing laparoscopic myomectomy did not report any lethal complications . Deschamps and Krishnamurthy  have reported bradycardia and atrioventricular block with intramyometrial vasopressin at a dose as low as 3 U of 0.5 U/ml. The maximal safe dose of intramyometrial vasopressin has not been established; however, Frishman  suggested a routine intramyometrial dose of 2 U, with a maximum of 4–6 U to avoid hemodynamic complications.
Besides the dose, the concentration of vasopressin solution used is also equally important. Hung et al.  and Zullo et al.  have reported adverse events such as pulmonary oedema and bradycardia after the intramyometrial injection of 12–20 U of vasopressin with concentration of 2 U/ml; however, the concentration as low as 1 U/ml has also been reported with adverse events . Similar to the present case, Jayaram et al.  have reported complications even with concentrations as low as 0.1 U/ml; however, the dose administered was not documented. On the basis of these previous reports, recently, Butala et al.  recommended 0.05–0.3 U/ml concentration of dilute vasopressin to avoid its lethal complications.
In the present case, the patient presented with the vasoconstrictive effects of intramyometrial vasopressin intraoperatively – that is, marked pallor, bradycardia and absent peripheral pulses – following very low dose (1–1.5 U) and concentration (0.1 U/ml) of intramyometrial vasopressin. The occurrence of complications with such low dose and concentration could be attributed to the coexistence of hypertensive disorder . On literature search, we could not retrieve any guidelines with regard to the recommended safe dose and concentration of intramyometrial vasopressin and the proper patient selection.
The use of intramyometrial vasopressin may be contraindicated in women with medical comorbidities such as cardiovascular, vascular or renal disease. Dogmatic guidelines including the safe dose and concentration of intramyometrial vasopressin and proper patient selection is warranted. Close communication between the anaesthesiologist and gynaecologist is of paramount importance to prevent, identify and treat the complications related to intramyometrial vasopressin.
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|1||Nezhat F, Admon D, Nezhat CH, Dicorpo JE, Nezhat C Life-threatening hypotension after vasopressin injection during operative laparoscopy, followed by uneventful repeat laparoscopy. J Am Assoc Gynecol Laparosc 1994; 2:83-86.|
|2||Hobo R, Netsu S, Koyasu Y, Tsutsumi O. Bradycardia and cardiac arrest caused by intramyometrial injection of vasopressin during a laparoscopically assisted myomectomy. Obstet Gynecol 2009; 113(Pt 2):484– 486.|
|3||Hung MH, Wang YM, Chia YY, Chou YM, Liu K Intramyometrial injection of vasopressin causes bradycardia and cardiac arrest – report of two cases. Acta Anaesthesiol Taiwan 2006; 44:243-247.|
|4||Zullo F, Palomba S, Corea D, Pellicano M, Russo T, Falbo A, et al. Bupivacaine plus epinephrine for laparoscopic myomectomy: a randomized placebo-controlled trial. Obstet Gynecol 2004; 104:243-249.|
|5||Dillon TF, Marbury BE, Bonsnes RW. Vasopressin as a hemostatic in gynaecological surgery; a preliminary report. Obstet Gynaecol 1958; 11:363.|
|6||Deschamps A, Krishnamurthy S. Absence of pulse and blood pressure following vasopressin injection for myomectomy. Can J Anaesth 2005; 52:552– 553.|
|7||Frishman G. Vasopressin: if some is good, is more better? Obstet Gynecol 2009; 113(Pt 2):476-477.|
|8||Butala BP, Shah VR, Parikh BK, Jayaprakash J, Kalo J. Bradycardia and severe vasospasm caused by intramyometrial injection of vasopressin during myomectomy. Saudi J Anaesth 2014; 8:396– 398.|
|9||Jayaram L, Sinha A, Punhani D. Intramyometrial vasopressin; anaesthesiologist′s nightmare. J Anesthesiol Clin Pharamcol 2013; 29:135– 136.|
|10||Kongnyuy EJ, Wiysonge CS. Interventions to reduce haemorrhage during myomectomy for fibroids. Cochrane Database Syst Rev 2011; 9: CD005355.|