VAGAL PADA SPINAL

R3 ILY
IDENTITAS PASIEN
• NY SA
• Perempuan
• 41 tahun
• Dx: kista ovarii sinistra, CA mamae sinistra on hormonal terapi
• pro histeroskopi diagnostik sd aff iud
Anamnesis
• Nyeri perut bawah hilang tinbul 1 bulan terakhir, disertai keluar
darah dari jalan lahir selama 3 minggu.
• Riwayat Ca mamae 4 tahun yang lalu, sudah mastektomi tahun
2018, kemoterapi 6x radiasi 25x, saat ini on hormonal terapi obat
rutin tamoxifen
• Demam- batuk- pilek- sesak-, riw nyeri dada (-)
• Komorbid - asma- penyakit jantung- alergi -
Px Fisik

• KU CM
• TD 114/72
• Hr 70x/menit
• Rr 20 x/m
• Suhu 36,5c
• Spo2 99 % room air

• K/L Conj anemis -/-, sklera ikterik -/-

• Thorax: vesikuler +/+, suara tambahan -/-, cor s1s2 reg murmur-
• Abdomen: BU+ supel , NT + nyeri tekan di regio suprapubik
• Ext: akral hangat, crt<2 detik
Px Penunjang
Px Penunjang
Px Penunjang
Px Penunjang

Sinus Rhythm, normoaxis HR 56x/menit

Px Penunjang

Echo tanggal 31.10.22

Dimensi ruang jantung normal
Fungsi sistolik global dan segmental LV baik dengan EF 74
%
Fungsi diastolik LV normal
Fungsi sistolik RV normal
Fungsi katup baik
Kesimpulan
Pasien status fisik asa 2 keganasan, pneumonitis radiasi pulmo sinistra

Rencana pembiusan dengan RA SAB sitting position, median

approach, puncture di L4-L5, dengan jarum quinckee 27G, agen
bupivacaine hiperbarik 0,5% 10 mg
Kronologis
• Pasien tiba di ruang 1.03. Pasien dipasang monitor, loading cairan
500cc, TTV HR 68x/menit TD 112/78 RR 20x/menit sp02 99%RA
• Dilakukan puncture pertama, median approach di L4-L5 jarum 27g,
gagal puncture, TTV HR 88x/menit Td 120/85 RR 22x/menit spo2
99% RA pasien
• Marking ulang, dilakukan puncture kedua, median approach di L3-
L4 jarum 27g, gagal puncture TTV HR 95x/menit TD 130/88 RR
25x/menit SpO2 98% RA, pasien mengeluhkan nyeri
Kronologis
• Marking ulang, saat akan dilakukan Puncture ketiga, pasien mulai
mengeluhkan pusing dan berkunang kunang TTV HR 45x/menit, TD
60/45 SPO2 97% RA  pasien diposisikan tidur,oksigenasi NK 3
lpm loading cairan 250cc, ephedrine 10 mg
• TTV TD 105/68 HR 65x/menit, SpO2 99% NK 3 lpmmkeluhan
pusing pasien berkurang, pasien diposisikan kembali, dilakukan
puncture L3-L4 dengan pendekatan paramedian, bupivacaine
hiperbarik 0,5% 10 mg
Kronologis
• Durante Tindakan berlangsung selama 40 menit dengan TTV TDS
100-112 TDS 60-70 HR62-70x/menit SpO2 98-99% NK 3 lpm
• Saat pemantauan di RR TTV TDS 105-120 TDS 65-78x/menit SPO2
99% nk 3lpm, tidak ada keluhan
• A 36-year-old female patient, primigravida, 14 weeks pregnancy
with dermoid cyst of uterus size 20 cm × 13 cm
• ASA-I pro elective exploratory laparotomy
• Preoperative investigations were within normal limit.
• Fasting (solid food—8 h and clear liquid—3 h).
• Premedication included oral alprazolam (0.5 mg), ranitidine (150
mg), and metoclopramide (10 mg)
• ASA standard monitors— electrocardiograph (ECG), noninvasive
blood pressure (NIBP), and pulse oximetry (SpO2)
• was preloaded with 500 mL of ringer lactate.
• The patient was a bit apprehensive and anxious.
• 25 G Quincke spinal needle was introduced in L3–L4 intervertebral
space,
• 1 cm of insertion the patient suddenly complained of lightheadedness
with nausea, following which she collapsed within a few seconds
• The patient was repositioned to a supine and the vitals were PR —
28/min, NIBP — 85/50 mm Hg, and SpO2 — 99% on room air.
• atropine 0.5 mg IV injection was given,
• 100% oxygen.
• The patient was placed in a left lateral position and jaw thrust.
• Blood was drawn for blood sugar and arterial blood gas (ABG) analysis.
• PR — 105/min, NIBP — 102/60 mm Hg, and SpO2 — 100%.
• Blood sugar was 84 mg/dL
• ABG was within normal limit
• The case was postponed
• Echo revealed no abnormality
• The case was rescheduled on the next day under general
• anesthesia.
• The vitals remained stable during the surgery.
• At the end of surgery she was extubated smoothly and shifted to
postoperative care unit
The common causes of syncope :
• hypoglycemia
• hypoxia,
• seizure,
• electrolyte disturbances,
• cardiogenic abnormalities,
• acute hemorrhage,
Lempert T, Bauer M, Schmidt D. Syncope: A videometric analysis of 56 episodes of transient
• intoxication, cerebral hypoxia. Ann Neurol 1994;36:233-7.
Asadi-Pooya AA, Nikseresht A, Yaghoubi E. Vasovagal syncope treated as epilepsy for 16 years.

• Vasovagal attack.
Iran J Med Sci 2011;36:60-2.
Erden I, Yalcin S, Ozhan H. Syncope caused by hyperkalemia during use of a combined therapy
with the angiotensin-converting enzyme inhibitor and spironolactone. Kardiol Pol
2010;68:1043-6.
• Vasovagal syncope:reflex of the involuntary nervous system:
bradycardia and dilatation of blood vessels
• Three distinct phases:
• Prodromal phase,
• Loss of consciousness,
• postsyncopal phase.
• Emotional stress, trauma, pain, sight of blood, prolonged standing :
precipitating factors
• Lying down or removing the stimulus may abort the syncopal episode.
Nair N, Padder FA, Kantharia BK. Pathophysiology and management of
neurocardiogenic syncope. Am J Managed Care 2003;9:327-34.
• Vasovagal reactions have been described to be associated with
anxiety and pain during venepuncture
• Pain and anxiety may cause fainting during induction of
regional anesthesia

Sprung J, Abdelmalak B, Schoenwald PK. Vasovagal cardiac arrest during the insertion of an
epidural catheter and before the administration of epidural medication. Anesth Analg
1998;86:1263–5.
• Vasovagal response is characterized by an inappropriate combination
of bradycardia and paradoxical
• Central triggers, such as severe pain, anxiety, fear, and emotional
stress, can cause vasovagal response.
• Most vasovagal episodes are self-limited are easily treated.
• Sympathetic compensatory mechanism is usually blocked, during or
neuraxial block-induced sympathectomy.

Kinsella SM, Tuckey JP. Perioperative bradycardia and asystole:

relationship to vasovagal syncope and the Bezold-Jarisch reflex.
Br J Anaesth 2001; 86: 859-68.
Predisposisi
• Pendarahan
• Regional Anestesi
• Orthostasis
• Kompresi vena cava inferior saat kehamilan

Kinsella SM, Tuckey JP. Perioperative bradycardia and asystole:

relationship to vasovagal syncope and the Bezold-Jarisch reflex.
Br J Anaesth 2001; 86: 859-68.
Operation
Strabismus surgery oculocardiac reflex
Anesthesia for ophthalmic or pelvic surgery
manipulations of the abdominal contents : peritoneum or traction of the
visceral ligaments

Kinsella SM , Tuckey JP. Perioperative bradycardia and

asystole: relationship to vasovagal syncope and the Bezold-
Jarisch reflex. Br J Anaesth. 2001;86(6):859-68. 
Coventry DM, McMenemin I, Lawrie S. Bradycardia during
intraabdominal
surgery. Modification by pre-operative anticholinergic
agents. Anaesthesia 1987; 42: 835-9.
• Preexisting hypovolemia before induction of regional anesthesia
leads to cardiovascular collapse
• should receive bolus of lactated Ringer’s injection before neural
blockade
• position for insertion of a spinal or epidural needle is thought to
be safer than the sitting position
• Sedation may be beneficial during regional anesthesia

Kinsella SM, Tuckey JP. Perioperative bradycardia and

asystole:
relationship to vasovagal syncope and Bezold-Jarisch
reflex. Br J Anaesth 2001;86:859–68.
• A standard sequence using atropine, ephedrine and then
epinephrine to treat bradycardia during spinal anaesthesia.
•  Ephedrine is the most logical choice for a single agent to treat
profound bradycardia or asystole during regional anaesthesia
• For asystole or persistent severe bradycardia, epinephrine should be
used early.

Kinsella SM, Tuckey JP. Perioperative bradycardia and

asystole:
relationship to vasovagal syncope and Bezold-Jarisch
reflex. Br J Anaesth 2001;86:859–68.
Terima Kasih