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Steroids are commonly prescribed medications that have a wide range of adverse effects. Bradycardia is one of the rare but significant side effects of steroid use, and only a few cases have been reported with bradycardia as a side effect. In this report, we present a case of a woman in her early 50s who developed severe symptomatic sinus bradycardia following high-dose administration of intravenous hydrocortisone, initiated for acute exacerbation of Crohn’s disease. Her symptoms entirely resolved after discontinuation of the steroid. This case highlights the importance of obtaining baseline ECG and cardiac monitoring in patients treated with pulsed high-dose steroids.

The most common cause of congenital heart block (CHB) is neonatal lupus, an acquired autoimmune disease caused by transplacental transfer of maternal antibodies to the fetus. A full-term female neonate was admitted to neonatal intensive care unit for severe bradycardia with stable haemodynamics. The mother, showing no clinical symptoms or any particular history, was transferred to our tertiary centre for profound fetal bradycardia. At birth, the infant’s ECG showed a third-degree atrioventricular block and echocardiography was normal. Cardiac neonatal lupus was confirmed with positive maternal anti-Ro antibodies. Under close monitoring, the infant tolerated the bradycardia well (median 67 beats per minute (bpm)) and was discharged on day 6 of life. There was no indication for pacemaker, but she would be on regular follow-up with a paediatric cardiologist. This article holds an important insight as it is the first confirmed case of autoimmune CHB in Cambodia in which the mother’s antibody was found only after diagnosis on the neonate.

We describe a unique case of intrathecal baclofen overdose mimicking brainstem death, during bilateral anterior cingulate cortex deep brain stimulation (DBS) for pain. A 37-year-old man with chronic regional pain syndrome requiring an intrathecal baclofen pump underwent DBS under general anaesthesia and experienced an intraoperative generalised tonic–clonic seizure on dural opening. Once the operation was completed, the patient was noted to have fixed, dilated pupils bilaterally and was transferred for an emergency computed tomography scan of the head, which did not reveal any acute intracranial pathology. The patient was transferred to the intensive care unit for management of concurrent hypotension, bradycardia and supportive management of his low Glasgow Coma Scale (GCS) score. A trial of atropine to counter the bradycardia was unsuccessful. Intrathecal baclofen toxicity was suspected as a diagnosis of exclusion, necessitating urgent aspiration of the baclofen pump. The patient’s GCS score improved after pump aspiration and he was discharged home several days later. It was noted that the intrathecal baclofen pump had been refilled several days previously and the patient had reported intermittent episodes of somnolence. In perioperative patients with intrathecal baclofen pumps in situ, baclofen toxicity should always be considered as a differential in perioperative complications, even if it is considered a rare event.

A patient with bradycardia and an idioventricular rhythm was observed. According to cardiologists, there is no reliable drug treatment for bradycardia with an idioventricular rhythm; instead, the sole treatment is a pacemaker. In the course of this case, it was shown that acupuncture can restore the heart rhythm from bradycardia to normocardia, and from idioventricular with third-degree atrioventricular node block and an average heart rate of 34 BPM, to normal sinus rhythm with a heart rate of 71 BPM. Additionally, at the end of the treatment, the patient's number of episodes of ventricular extrasystole decreased 36 times (3289 versus 91 episodes). These results show that research on this technique should be continued.

Transcutaneous cardiac pacing (TCP) is a lifesaving procedure for patients with certain types of unstable bradycardia. We aimed to assess the difference in the pacing thresholds between the anteroposterior (AP) and anterolateral (AL) pacer pad positions. The second aim was to characterize the severity of chest wall muscle contractions during TCP.In this prospective crossover trial, we enrolled patients presenting to the electrophysiology laboratory for elective cardioversion. After successful cardioversion, sedated participants were sequentially paced in both positions. The study procedure concluded after successful capture or inability to achieve capture by 140 mA (the pacer's maximum output) in both positions. Pacing thresholds were compared between positions, using a student's paired t-test, assigning a value of 141 mA to any trials with non-capture.Forty-one patients were screened; 20 were enrolled in the study. Seven participants were excluded from the paired analysis (three were prevented from pacing in the second position at the anesthesiologist's discretion, and 4 did not capture in either position). The study population consisted of 14 men and 6 women with a median age of 65 years. The mean pacing threshold was 33 mA lower (P = 0.001, 95% CI 20-45) in the AP (93 mA) versus the AL (126 mA) position. The median contraction severity score was 3 in the AL position versus 4 in the AP position (P = 0.005).Placing pacer pads in the AP position requires less energy to capture. Major resuscitation guidelines may favor the AP position for TCP.gov Identifier: NCT03898050 https://clinicaltrials.gov/ct2/show/NCT03898050.

BACKGROUND: Bradycardia and asystole events are common among patients treated with maintenance hemodialysis. However, triggers of these events in patients on maintenance hemodialysis (HD), particularly during the long interdialytic period when these events cluster, are uncertain. METHODS: The Monitoring in Dialysis Study (MiD) enrolled 66 patients on maintenance HD who were implanted with loop recorders and followed for 6 months. We analyzed associations of predialysis laboratory values with clinically significant bradyarrhythmia or asystole (CSBA) during the 12 hours before an HD session. Associations with CSBA were analyzed with mixed-effect models. Adjusted negative binomial mixed-effect regression was used to estimate incidence rate ratios (IRR) for CSBA. We additionally evaluated associations of CSBA at any time during follow-up with time-averaged dialytic and laboratory parameters and associations of peridialytic parameters with occurrence of CSBA from the start of one HD session to the beginning of the next. RESULTS: There were 551 CSBA that occurred in the last 12 hours of the interdialytic interval preceding 100 HD sessions in 12% of patients and 1475 CSBA events in 23% of patients overall. We did not identify significant associations between dialytic parameters or serum electrolytes and CSBA in the last 12 hours of the interdialytic interval in adjusted analyses. Median time-averaged ultrafiltration rate was significantly higher in individuals without CSBA (9.8 versus 8, P=0.04). Use of dialysate sodium concentrations ≤135 (versus 140) mEq/L was associated with a reduced risk of CSBA from the start of one session to the beginning of next. CONCLUSIONS: Although a few factors had modest associations with CSBA in some analyses, we did not identify any robust associations of modifiable parameters with CSBA in the MiD Study. Further investigation is needed to understand the high rates of arrhythmia in the hemodialysis population.

Background. Pacemakers are used to treat syncope in patients with bradyarrhythmia; however, the risk of recurrent syncope has only been investigated in few and smaller studies. Objective. The aim of this study was to investigate the risk of recurrent syncope after pacemaker implantation in patients with bradyarrhythmia and prior syncope. Methods. This retrospective, population-based cohort study included patients with a prior syncope and implantation of a pacemaker using data from the Danish nationwide registers from 1996 to 2017. Cumulative incidence and cox regression was used to estimate the 5-year incidence and the risk of recurrent syncope, respectively. Results. In total, 11,126 patients (median age: 78 years, interquartile range: 69–85, 56% male) were included and the 5-year cumulative incidence of recurrent syncope was 19.6% (95% confidence interval (CI): 18.8–20.3%). Sinus node dysfunction (hazard ratio [HR]: 1.29, 95%CI: 1.17–1.42) and unspecified type of bradyarrhythmia (HR: 1.32, 95%CI: 1.15–1.52) were associated with an increased risk of syncope compared to advanced atrioventricular (AV) block. Male sex (HR: 1.22, 95%CI: 1.22–1.34), cerebrovascular disease (HR: 1.17, 95%CI: 1.05–1.30), and prior number of syncopes were significantly associated with a higher HR of recurrent syncope. Conclusion. Almost one-in-five patients with bradyarrhythmia and prior syncope who had a pacemaker implanted had a recurrent syncope within five years. A higher risk of syncope was observed among patients with sinus node dysfunction and unspecified type of bradyarrhythmia compared to AV block. Male sex, cerebrovascular disease, and prior number of syncopes were associated risk factors of recurrent syncope.

Aims Permanent transseptal left bundle branch area pacing (LBBAP) is a promising new pacing method for both bradyarrhythmia and heart failure indications. However, data regarding safety, feasibility and capture type are limited to relatively small, usually single centre studies. In this large multicentre international collaboration, outcomes of LBBAP were evaluated. Methods and results This is a registry-based observational study that included patients in whom LBBAP device implantation was attempted at 14 European centres, for any indication. The study comprised 2533 patients (mean age 73.9 years, female 57.6%, heart failure 27.5%). LBBAP lead implantation success rate for bradyarrhythmia and heart failure indications was 92.4% and 82.2%, respectively. The learning curve was steepest for the initial 110 cases and plateaued after 250 cases. Independent predictors of LBBAP lead implantation failure were heart failure, broad baseline QRS and left ventricular end-diastolic diameter. The predominant LBBAP capture type was left bundle fascicular capture (69.5%), followed by left ventricular septal capture (21.5%) and proximal left bundle branch capture (9%). Capture threshold (0.77 V) and sensing (10.6 mV) were stable during mean follow-up of 6.4 months. The complication rate was 11.7%. Complications specific to the ventricular transseptal route of the pacing lead occurred in 209 patients (8.3%). Conclusions LBBAP is feasible as a primary pacing technique for both bradyarrhythmia and heart failure indications. Success rate in heart failure patients and safety need to be improved. For wider use of LBBAP, randomized trials are necessary to assess clinical outcomes.

Guidelines have recommended the use of dexmedetomidine or propofol for sedation after cardiac surgery, and propofol monotherapy for other patients. Further outcome data are required for these drugs.This systematic review and meta-analysis was prospectively registered on PROSPERO. The primary outcome was ICU length of stay. Secondary outcomes included duration of mechanical ventilation, ICU delirium, all-cause mortality, and haemodynamic effects. Intensive care patients were analysed separately as cardiac surgical, medical/noncardiac surgical, those with sepsis, and patients in neurocritical care. Subgroup analyses based on age and dosage were conducted.Forty-one trials (N=3948) were included. Dexmedetomidine did not significantly affect ICU length of stay across any ICU patient subtype when compared with propofol, but it reduced the duration of mechanical ventilation (mean difference -0.67 h; 95% confidence interval: -1.31 to -0.03 h; P=0.041; low certainty) and the risk of ICU delirium (risk ratio 0.49; 95% confidence interval: 0.29-0.87; P=0.019; high certainty) across cardiac surgical patients. Dexmedetomidine was also associated with a greater risk of bradycardia across a variety of ICU patients. Subgroup analyses revealed that age might affect the incidence of haemodynamic side-effects and mortality among cardiac surgical and medical/other surgical patients.Dexmedetomidine did not significantly impact ICU length of stay compared with propofol, but it significantly reduced the duration of mechanical ventilation and the risk of delirium in cardiac surgical patients. It also significantly increased the risk of bradycardia across ICU patient subsets.

Bradycardia, renal failure, atrioventricular (AV) nodal blockade, shock, and hyperkalemia (BRASH) syndrome is a recently-established entity precipitated by medication-induced AV nodal blockade. Despite its serious consequences, including death, clinical presentations, risk factors, and outcomes of the syndrome have not been well defined. We aim to summarize the existing evidence of BRASH syndrome.According to the PRISMA Extension for Scoping Reviews, we performed a search on MEDLINE and EMBASE for articles with keywords including"BRASH syndrome" and "bradycardia, renal failure, atrioventricular nodal blockade, shock, and hyperkalemia," from the inception of these databases to March 4, 2022.34 articles, including one observational study, 15 conference abstracts, and 18 case reports and case series, were included. While most patients were on beta blockers (83.3%) or calcium channel blockers (45.2%), other medications such as amiodarone were identified as precipitating agents. Atropine or glucagon were ineffective in reversing patients' symptoms, and 59.5% required inotropes or chronotropes. 7.1% expired due to BRASH syndrome.This systematic review summarizes the clinical characteristics of BRASH syndrome. Further studies to identify risks associated with the onset of BRASH syndrome and awareness of the critical syndrome are warranted.

β-Blocker therapy, specifically nadolol, is the recommended treatment for long QT syndrome (LQTS). Previous studies assessing maternal and fetal outcomes were published before the nadolol era.The purpose of this study was to examine contemporary maternal and fetal outcomes in the treatment of LQTS during pregnancy.We queried the Inherited Arrhythmia Database at Cleveland Clinic and identified all pregnant patients with LQTS from January 2001 through January 2020. Collected data included use and timing of β-blockers, maternal arrhythmic events, fetal growth restriction, neonatal hypoglycemia, and bradycardia.Among 68 live-birth pregnancies in 31 women with LQTS (mean age 29 ± 5.9 years; mean corrected QT interval 468 ± 39 ms), there were 5 arrhythmic events in 4 mothers. All arrhythmic events occurred in the postpartum period, and there were no arrhythmic events in patients taking β-blockers. In patients diagnosed with LQTS and treated with β-blockers (n = 27 [41%]), nadolol was the most commonly prescribed agent throughout pregnancy and the postpartum period (n = 16 [60%]). The rate of intrauterine growth restriction was not significantly different in fetuses exposed to β-blockers vs unexposed (P = .08). In the postnatal period, hypoglycemia was not seen and 1 patient in the exposure group had bradycardia.Arrhythmic events were only seen in the postpartum period in those not treated with β-blockers. Events occurred as late as 9 months postpartum. β-Blocker therapy, specifically nadolol, was not associated with a higher incidence of intrauterine growth restriction. Moreover, neonatal bradycardia was rare and hypoglycemia was not observed.

Asystole or bradycardia is a relatively uncommon side effect seen in patients undergoing endovascular embolization using dimethylsulfoxide based liquid embolic agents. We present a case of a patient who underwent dural arteriovenous fistula embolization and experienced bradycardia during Onyx injection but was stabilized and the procedure was completed successfully.

Although dexmedetomidine (DEX) is a widely used analgesic and sedative agent for endoscopic procedures, cardiovascular complications, such as bradycardia and hypotension, are frequently experienced. We herein report the first case of asystole-induced bradycardia due to DEX during endoscopic submucosal dissection (ESD). An 81-year-old man without cardiovascular diseases was referred for gastric carcinoma. ESD was started after administering a loading dose of DEX followed by a continuous maintenance infusion of DEX. The patient's heart rate gradually decreased, and then cardiac arrest occurred. DEX has a risk of cardiac arrest, so bradycardia should not be underestimated during sedation with DEX.

Human grayanotoxin poisoning is distinctly uncommon in North America, as the predominant source of human exposure is honey made by bees pollinating rhododendron species in the Mediterranean. We present a case of confirmed grayanotoxin poisoning from honey imported from Turkey.A 61-year-old man developed nausea, lightheadedness, and lost consciousness. Onset was 30 min after the ingestion of honey that was brought to the United States from Turkey. Emergency medical services found him bradycardic, hypotensive, and unresponsive. He was treated with atropine, saline, and oxygen, at which point his heart rate and blood pressure improved, and he regained consciousness. A similar episode several days earlier was followed by a brief unrevealing hospitalization. He was again hospitalized, and had a normal echocardiogram, telemetric monitoring, and complete laboratory studies. Grayanotoxins I and III were subsequently identified in the patient's blood, urine, and honey. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Grayanotoxins are diterpenoids found in rhododendron species, whose clinical effects span multiple organ systems including gastrointestinal, cardiac, and neurologic. Treatment is largely supportive, and a good response to atropine and intravenous fluids has been described. Laboratory confirmation of grayanotoxins is not available in a short enough turnaround time to be clinically useful during immediate management, but confirmatory testing may obviate further unnecessary evaluation. Grayanotoxins are likely to remain a rare source of poisoning in North America, but recurrent bradycardia without alternative etiology should prompt a thorough exposure history, which may reveal, as in this case, a treatable toxicologic etiology.

Implanting a ventricular demand leadless pacemaker (VVI-LPM) for patients with non-atrial fibrillation (AF) bradyarrhythmias such as sick sinus syndrome (SSS) or high-grade (i.e., second- or third-degree) atrioventricular (AV) block is not recommended unless they have limited vascular access or a high infection risk; nevertheless, an unexpectedly high number of VVI-LPM implantations have been performed. This study investigated the clinical outcomes of these unusual uses.Methods and Results:This study retrospectively analyzed 193 patients who were newly implanted with a VVI-LPM or an atrioventricular synchronous transvenous pacemaker (DDD-TPM) for non-AF bradyarrhythmias at a high-volume center in Japan from September 2017 to September 2020. Propensity score-matching produced 2 comparable cohorts treated with a VVI-LPM or DDD-TPM (n=58 each). Each group had 20 (34%) patients with SSS and 38 (66%) patients with high-grade AV block. During a median follow up of 733 (interquartile range 395-997) days, there were no significant differences between the VVI-LPM and DDD-TPM groups regarding late device-related adverse events (0% vs. 4%, log-rank P=0.155), but the VVI-LPM group had a significantly increased readmission rate for heart failure (HF) (29% vs. 2%, log-rank P=0.001) and a tendency to have higher all-cause mortality (28% vs. 4%, log-rank P=0.059).The implantation of a VVI-LPM for non-AF bradyarrhythmias increased the incidence of HF-related rehospitalization at the mid-term follow up compared to the use of a DDD-TPM.

Remimazolam is an ultrashort-acting benzodiazepine that is potentially a practical option for procedural sedation in colonoscopy.To test the hypothesis that remimazolam could provide a noninferior discharge time to propofol for ambulatory colonoscopy.A prospective, randomised, double-blind, noninferiority clinical trial.Ambulatory endoscopy centre.A total of 132 adult participants undergoing ambulatory colonoscopy were enrolled.Participants were randomly assigned in a 1 : 1 ratio to receive propofol or remimazolam for sedation.The primary outcome was discharge time after a colonoscopy, assessed using the Modified Postanaesthetic Discharge Scoring System scale. Secondary outcomes included induction time, emergence time, the extent of recovery upon arrival in the postanaethesia care unit, fatigue, endoscopist and patient satisfaction and adverse events.The median discharge time was 24 min in the remimazolam group versus 21 min in the propofol group, with a difference of 2 min [95% confidence interval (CI), 0 to 4 min], meeting the criteria for noninferiority. Injection pain occurred in 11 of 66 (17%) participants receiving remimazolam versus 32 of 66 (49%) participants receiving propofol ( P 0.001); hypotension occurrence was 20% versus 47%, ( P 0.001), respectively, and bradycardia 6% versus 20%, ( P = 0.019), respectively. Compared with propofol, the patient satisfaction score was higher in the remimazolam group ( P 0.001).For sedation in ambulatory colonoscopy, compared with propofol, remimazolam provides a noninferior discharge time. Furthermore, remimazolam is associated with less injection pain, lower risks of hypotension and bradycardia, and improved patient satisfaction.Chinese Clinical Trial Registry, identifier: ChiCTR2100048678.

Screening examinations for retinopathy of prematurity (ROP) are critical to reduce ROP-related vision loss; however, the procedure is painful and uncomfortable, and topical anesthetics do not completely suppress the pain responses. The number of safe and effective pharmacological options to reduce pain during eye examinations for ROP screening in preterm infants is limited. This study compared the efficacy of oral ibuprofen and oral paracetamol in reducing pain during screening for ROP in preterm infants. This prospective observational study was conducted at a tertiary-care neonatal intensive care unit. Forty-four preterm infants with gestational age of 32 weeks and less undergoing ROP screening were included. Each enrolled infant received either oral ibuprofen 10 mg/kg (n = 22) or oral paracetamol 10 mg/kg (n = 22) 1 hour before eye examination. The primary outcome measure was pain assessed by the Neonatal Pain, Agitation, and Sedation Scale (N-PASS). Secondary outcome measures were tachycardia, bradycardia, desaturations, and crying time. The groups were similar for gestational age, birth weight, and postnatal age at examination (P.05). The mean N-PASS scores were not significantly different between the oral ibuprofen and oral paracetamol groups (8.64 ± 1.57 vs 8.50 ± 1.71, respectively, P = .605). Moreover, no significant intergroup differences were observed in the crying time and the incidence of tachycardia/bradycardia and desaturation (P.05). Ibuprofen or paracetamol administered orally before ROP screening in preterm infants had similar analgesic effects and did not significantly alleviate pain during eye examination.

Heart rate variability (HRV) is commonly used within sleep and cardiovascular research, yet HRV reliability across various sleep stages remains equivocal. The present study examined the reliability of frequency- and time-domain HRV within stage-2 (N2), slow-wave (SWS), and rapid-eye-movement (REM) sleep during both stable and disrupted sleep. We hypothesized that high-frequency (HF) HRV would be reliable in all three sleep stages, low-frequency (LF) HRV would be reliable during N2 and SWS, and that disrupted sleep via spontaneous cortical arousals would decrease HRV reliability. Twenty-seven participants (11 men, 16 women, 26 ± 1 yr) were equipped with laboratory polysomnography for 1 night. Both frequency- and time-domain HRV were analyzed in two 5- to 10-min blocks during multiple stable and disrupted sleep cycles across N2, SWS, and REM sleep. HF HRV was highly correlated across stable N2 (r = 0.839, P < 0.001), SWS (r = 0.765, P < 0.001), and REM (r = 0.881, P < 0.001). LF HRV was moderate-to-highly correlated during stable cycles of N2 sleep (r = 0.694, P < 0.001), SWS, (r = 0.765, P < 0.001), and REM (r = 0.699, P < 0.001) sleep. When stable sleep was compared with disrupted sleep, both time- and frequency-domain HRV were reliable (α > 0.90, P < 0.05) in N2, SWS, and REM, except for LF HRV during SWS (α = 0.62, P = 0.089). In conclusion, time- and frequency-domain HRV demonstrated reliability across stable N2, SWS, and REM sleep, and remained reliable during disrupted sleep. These findings support the use of HRV during sleep as a tool for assessing cardiovascular health and risk stratification. NEW & NOTEWORTHY Heart rate variability (HRV) is a commonly employed indirect estimate of cardiac autonomic activity during sleep with limited reliability studies. Nocturnal frequency-domain HRV was reliable across differing stable sleep cycles of stage-2 (N2), slow-wave (SWS), and rapid-eye-movement (REM) sleep. Moreover, frequency- and time-domain HRV were reliable during stable and disturbed sleep, except SWS low-frequency HRV. Our finding supports nocturnal HRV as a potential tool for cardiovascular risk stratification.

Purpose The pathophysiology and hemodynamic management of acute spinal cord injuries, including the use of intravenous and enteral vasoactive agents, are reviewed. Summary Spinal cord injuries are devastating neurological insults that in the acute setting lead to significant hemodynamic disturbances, including hypotension and bradycardia, that are influenced by the level of injury. High thoracic (usually defined as at or above T6) and cervical injuries often manifest with hypotension and bradycardia due to destruction of sympathetic nervous system activity and unopposed vagal stimulation to the myocardium, whereas lower thoracic injuries tend to result in hypotension alone due to venous pooling. Initial management includes maintaining euvolemia with crystalloids and maintaining or augmenting mean arterial pressure with the use of intravenous vasoactive agents to improve neurological outcomes. Choice of vasopressor should be based on patient-specific factors, particularly level of injury and presenting hemodynamics. This review includes the most recent literature on intravenous vasopressors as well as the limited evidence supporting the use of enteral vasoactive agents. Enteral vasoactive agents may be considered, when clinically appropriate, as a strategy to wean patients off of intravenous agents and facilitate transfer outside of the intensive care unit. Conclusion The hemodynamic management of acute spinal cord injuries often requires the use of vasoactive agents to meet mean arterial pressure goals and improve neurological outcomes. Patient-specific factors must be considered when choosing intravenous and enteral vasoactive agents.

Background Dexmedetomidine is commonly used to achieve light sedation in patients on extracorporeal membrane oxygenation (ECMO) despite minimal evidence. In vivo studies have shown dexmedetomidine sequestration in ECMO circuits, and higher doses may be used to overcome sequestration. Objective The purpose of this study was to compare safety and efficacy of dexmedetomidine at standard versus high doses in ECMO Methods A retrospective analysis of adult ECMO patients was performed. Patients were compared as receiving either standard-dose (≤1.5 µg/kg/h) or high-dose (>1.5 µg/kg/h) dexmedetomidine. Safety outcomes included new onset bradycardia or hypotension. Efficacy was compared by the addition of concomitant sedative and analgesic agents. Results One hundred five patients were evaluated, with 20% of patients in the high-dose group. Comparing standard and high dosing, no significant differences were seen in primary safety outcomes including bradycardia (49% vs 38%, P = 0.46), hypotension (79% vs 71%, P = 0.56), or addition of vasopressors (75% vs 71%, P = 0.78). Need for concomitant analgesic agents and propofol was similar between groups. Conclusion and Relevance This represents the first evaluation of use of high-dose dexmedetomidine in ECMO. Rates of dexmedetomidine higher than 1.5 µg/kg/h were commonly used in patients on ECMO, with similar rates of adverse effects and need for concomitant propofol and analgesic agents. While high-dose dexmedetomidine may be as safe as standard dose, no additional efficacy was found.

Out of operating room sedation with propofol by non-anaesthesiologists (Non Anaesthesiologist Administration of Propofol: NAAP) is a growing practice. This is due to the increase in minimally invasive diagnostic and therapeutic procedures requiring sedation, and the difficulty of anaesthesiology services to respond adequately to this demand.The main objective of this study is to assess the safety of a programme of nurse sedationist-administered target controlled infusion (TCI) of propofol in colonoscopies supervised by anaesthesiologists.Over a period of 6 months, all ASA I and II patients who required colonoscopy and met the inclusion criteria were included in the study. A total of 381 colonoscopies were performed. Episodes of desaturation, hypo- or hypertension, bradycardia or tachyarrhythmia and the need for anaesthesiology assistance during sedation were analysed. After the procedure, patient satisfaction was assessed on a scale of 1-5, and pain was assessed on a numerical verbal scale of 1-5.A small percentage (5%) of patients presented oxygen saturation of less than 90%, without requiring mask ventilation; 7.35% presented hypotension, 3.94% presented bradycardia, and the supervising anaesthesiologist was called in 22% of cases. Patient satisfaction at the end of the procedure was 4.27 out of 5.Sedation during colonoscopy in ASA I and II patients following an agreed protocol can be safely administered by nurse sedationists under the supervision of an anaesthesiologist.

A 6-month-old girl presented to hospital via ambulance with a decreased conscious level (initial Glasgow Coma Scale of 3) and an abnormal breathing pattern described as diaphragmatic flutter. She then developed abnormal movements and continued to have episodes of fluctuating conscious levels so was transferred to a tertiary hospital paediatric intensive care unit for further investigation. During her 16-day stay in hospital, she continued to experience discrete episodes of drowsiness, bradycardia, unusual breathing patterns and abnormal movements which were associated with agitation, tachycardia, hypertension and insomnia. The patient underwent extensive investigation for her symptoms and, after some delay in waiting for initial results before considering a urine drug screen, she was ultimately found to have lisdexamfetamine and clonidine in her urine drug screen. Her symptoms subsequently resolved after her mother’s visits were restricted.

An 83-year-old man suddenly lost consciousness, and his blood pressure dropped. Results of blood analysis were within normal range. A chest radiograph showed enlargement of the left mediastinum. Computed tomographic scan of the chest showed a large mass surrounding the left common carotid artery in the left upper mediastinum. Histology revealed a large B-cell lymphoma. A Holter ECG showed transient sinus bradycardia and atrioventricular block. The power spectrum revealed increase in power of high frequency, suggesting that general vagal activity might be related to bradycardia. Evaluation of autonomic system from high frequency and low frequency components may be useful in examining the mechanisms of sudden bradycardia and/or hypotension of unknown origin.

Bradycardia is an under-studied manifestation of hyperkalemia potentially associated with adverse outcomes. We sought to systematically describe emergency department (ED) patients that present with severe bradycardia (heart rate50) associated with severe hyperkalemia (potassium ≥6.0 mEQ/L) and identify factors associated with the receipt of hemodynamic support.Retrospective, single-center, case series performed at an urban, tertiary-care hospital from 1/1/2014 to 6/30/2020. We included consecutive adult ED patients presenting simultaneously with severe bradycardia and severe hyperkalemia. Patients with prehospital cardiac arrest, hemolyzed potassium specimens, or only point-of-care lab results were excluded. Detailed information, including chronic medications, electrocardiogram (ECG) features, and potassium/heart rate-directed treatments, was abstracted from the ED medical record. Intensive care utilization and in-hospital outcomes were also recorded. Factors associated with receipt of bradycardia-targeted treatment in the ED were determined with univariate comparisons.We screened 319 records and included 87 patients [mean age 72.5 (95% CI 53-92), 55% female, median heart rate 43 (38-47) beats/min, mean potassium 7.1 (95% CI 5.6-8.7) mEQ/L]. Cardiovascular (hypertension 82%, congestive heart failure 28%) and renal (dialysis dependence 30%) comorbidities were common. Many patients were prescribed negative chronotropic agents (84%) or potassium-retaining (52%) chronic medications. Common presenting scenarios were missed hemodialysis, isolated acute renal failure, or acute renal failure in the setting of concomitant critical illness. ECG revealed: junctional rhythm (39%), peaked T waves (27%), and QRS prolongation (30%). Twenty-eight (32%) patients exhibited hypotension and 34 (40%) altered mentation. Thirty-three (38%) patients received hemodynamic support, including 12 (14%) requiring temporary cardiac pacing. Forty-two (48%) patients received emergent renal replacement therapy and 57 (66%) were admitted to the intensive care unit. Hospital mortality was 10%. Factors associated with receipt of hemodynamic-targeted treatment included a lack of dialysis dependence, junctional rhythm, and concomitant presentation with hypothermia, acidemia, or sepsis.Patients presenting with severe bradycardia represent a unique phenotype of ED patients with hyperkalemia that may require significant resuscitation and critical care resources. Further research on the treatment of this uncommon, but potentially life-threatening condition is needed.

Many different sedation concepts for magnetic resonance imaging have been described for prematurely and term-born infants, ranging from "no sedation" to general anesthesia. Dexmedetomidine is an alpha-2 receptor agonist that is frequently used to sedate older children, because the anesthesiologist can easily adjust sedation depth, the patient maintains spontaneous breathing, and awakens rapidly afterwards.The present study evaluates whether dexmedetomidine could safely be used as the sole sedative for prematurely and term-born infants less than 60 weeks postconceptional age undergoing diagnostic procedures.We performed a retrospective monocentric analysis of n = 39 prematurely and term-born infants (60 weeks postconceptional age or a body weight5 kg) who were sedated with dexmedetomidine for an MRI at a German university hospital from August 2016 to November 2018.Successful imaging was achieved in all cases. The median initial bolus of dexmedetomidine administered over 10 min was 1.39 μg kgThese results indicate that dexmedetomidine can be safely used for procedural sedation in the high-risk cohort of prematurely and term-born infants less than 60 weeks postconceptional age. Apnea during procedural sedation and subsequent stay in the recovery room is avoided, but bradycardia remains a relevant risk that may require treatment.

BACKGROUND: To compare oxygen saturation (SpO2) and heart rate (HR) recorded by a reference wired pulse oximeter to a wireless pulse oximeter in inpatient neonates. METHODS: Term infants born≥37 + 0 weeks and preterm infants born≤35 + 0 weeks gestation were enrolled and time-matched data pairs were obtained. The primary outcome was intraclass correlation coefficient and r-values between the two oximeters for heart rate and oxygen saturation. RESULTS: Thirty term and 20 preterm neonates were enrolled. There was a high degree of correlation between the two oximeters for HR (r = 0.926) among all 50 infants, and excellent interclass correlation (ICC = 0.961), but there were no bradycardia episodes in either term or preterm infants. There was a lesser degree of correlation for SpO2 values in the term and preterm groups (r = 0.242; 0.521, respectively) along with moderate interclass correlation (ICC = 0.719) but few episodes of hypoxemia≤90% occurred in enrolled subjects. CONCLUSIONS: There were no significant differences between the wireless and reference wired oximeters for assessing HR. There was less correlation between the two oximeters for monitoring SpO2 in both the term and preterm group. Wireless pulse oximetry may have practical advantages for use in inpatient neonates, but additional studies are needed that include bradycardia and desaturation events to delineate this question.

BACKGROUND: Increased cardiorespiratory events with bradycardia and oxygen desaturation have been reported in very low birthweight (VLBW) infants following stressors such as immunizations. These events are difficult to quantify and may be mild. Our group developed an automated algorithm to analyze bedside monitor data from NICU patients for events with bradycardia and prolonged oxygen desaturation (BDs) and used this to compare BDs 24 hours before and after potentially stressful interventions. METHODS: We included VLBW infants from 2012–2017 with data available around at least one of four interventions: two-month immunizations, retinopathy of prematurity (ROP) examinations, ROP therapy, and inguinal hernia surgery. We used a validated algorithm to analyze electrocardiogram heart rate and pulse oximeter saturation data (HR, SpO2) to quantify BD events of HR

Background and ObjectivesEpilepsy is associated with an increased risk of cardiovascular disease and premature mortality, including sudden unexpected death in epilepsy (SUDEP). Serious cardiac arrythmias might go undetected in routine epilepsy and cardiac investigations.MethodsThis prospective cohort study aimed to detect cardiac arrhythmias in patients with chronic drug-resistant epilepsy (≥5 years duration) using subcutaneous cardiac monitors for a minimum follow-up duration of 12 months. Participants with known cardiovascular disease or those with abnormal 12-lead ECGs were excluded. The device was programmed to automatically record episodes of tachycardia ≥140 beats per minute (bpm), bradycardia ≤40 bpm for ≥3 seconds, or asystole ≥3 seconds.FindingsThirty-one patients underwent subcutaneous cardiac monitoring for a median recording duration of 2.2 years (range 0.5–4.2). During this time, 28 patients (90.3%) had episodes of sustained (≥30 seconds) sinus tachycardia, 8/31 (25.8%) had sinus bradycardia, and 3 (9.7%) had asystole. Three patients (9.7%) had serious cardiac arrhythmias requiring additional cardiac interventions. Among them, 2 patients had prolonged sinus arrest and ventricular asystole (>6 seconds), leading to pacemaker insertion in one, and another patient with epileptic encephalopathy had multiple episodes of recurrent nonsustained polymorphic ventricular tachycardia and bundle branch conduction abnormalities. The time to first detection of a clinically significant cardiac arrhythmia ranged between 1.2 and 26.9 months following cardiac monitor insertion.DiscussionImplantable cardiac monitors detected a high incidence of clinically significant cardiac arrhythmias in patients with chronic drug-resistant epilepsy, which may contribute to the incidence of premature mortality, including SUDEP.

Background Cardiovascular sequelae of coronavirus disease 2019 (COVID-19) infection have been explored by clinicians and researchers all over the world. Objective The purpose of this study was to evaluate the incidence of atrioventricular block (AV) in patients hospitalized for COVID-19 and its association between in-hospital morbidity and mortality. Methods In-hospital electrocardiograms (ECGs) of 438 patients were compared with their prior or baseline ECGs to ascertain the development of new onset AV block. Patients who developed new AV blocks were then followed at 30 and 90 days post-discharge to check for resolution of AV block. Demographic characteristics, clinical characteristics, and complications during their hospital stay were evaluated. Major complications including respiratory failure requiring oxygen supplementation and mechanical ventilation, sepsis, deep vein thrombosis, elevated troponins, hospital and intensive care unit (ICU) length of stay, as well as death were compared between those who developed new onset AV blocks and those who did not. Results Based on our single center study, the incidence of new onset AV blocks among patients admitted for COVID-19 during the study period was 5.5 cases per 100 patients. New onset AV blocks were not associated with longer hospital and ICU length of stay, increased intubation rates, or increased mortality. Conclusion Although the development of a new onset AV block is most likely multifactorial and not solely due to COVID-19, it is still important for clinicians to be mindful about the possibility of developing symptomatic bradycardia and life-threatening arrhythmias in patients admitted for COVID-19. This can be achieved by appropriate rhythm monitoring in-patient but the need for a cardiac event monitor upon discharge is unlikely to be necessary. Careful history taking, including family and drug use history is also of great importance as emerging drug therapies for COVID-19 have potential arrhythmogenic effects., Graphical abstract Image, graphical abstract

Objective. This study explored the systematic evaluation and meta-analysis of different concentrations of PCP on the risk of long-term bradycardia in fetuses. Methods. Cochrane Library, Embase, PubMed, China Biomedical Literature Service, CNCNKI, and Wanfang database were computerized to collect all case-control studies on the association between variety classes and different concentrations of environmental pollutant gas to fetal of prolonged bradycardia. After evaluating the quality of the inclusion study and extracting valid data, meta-analysis was performed using Stata15 software. Relative hazards were calculated using the Mantel-Haenszel method and the random effect model, and P values and I2 values were used for heterogeneity evaluation. When heterogeneity occurs, subgroup analysis and sensitivity analysis were used to explore the sources. Results. A total of 15 studies were included, including 1202 patients with fetal of prolonged bradycardia and 1380 in the control population. Meta-analysis showed that there was no statistical difference in PCP P = 0.90 , I2 = 0%, Z = 0.13), but there was a statistical difference in PCP > 5 mg/L (OR = 1.73, 95% CI (1.15, 2.58), P = 0.008 , I2 = 0%, Z = 2.65), PCP > 10 mg/L (OR = 1.75, 95% CI (1.19, 2.57), P = 0.004 , I2 = 14%, Z = 2.85), and PCP >15 mg/L (OR = 2.02, 95% CI (1.38, 2.95), P = 0.0003 , I2 = 77%, Z = 3.61). Conclusion. In this study, we found that different concentrations of PCP increased the risk of long-term bradycardia in fetuses, and the risk coefficient increased with the increase of PCP concentration.

Approximately one in every 700 babies in the United States is born with Down syndrome, or 0.14%. Children with Down syndrome have cognitive impairment and congenital malformations necessitating frequent occurrences of general anesthesia and surgery. The thoughtful perioperative care of children with Down syndrome is relevant and acutely complex for the pediatric anesthesiologist. Behavior, sedation, hypotonia, upper airway obstruction, venous access, and bradycardia are omnipresent concerns apart from the surgical pathology. Down syndrome is also associated with autonomic nervous system dysfunction, a comorbidity that is overlooked in discussions of perioperative care and is described thus far in adults. Autonomic nervous system function or dysfunction may explain the phenotypical features of the perioperative challenges listed above. For this reason, understanding the development and measurement of autonomic nervous system function is important for the pediatric anesthesiologist. Definition and quantification of sympathetic and parasympathetic function will be reviewed.

COVID-19 has recently been associated with the development of bradyarrhythmias, although its mechanism is still unclear. We aim to summarize the existing evidence regarding bradyarrhythmia in COVID-19 and provide future directions for research. Following the PRISMA Extension for Scoping Reviews, we searched MEDLINE and EMBASE for all peer-reviewed articles using keywords including"Bradycardia," "atrioventricular block," and "COVID-19″ from their inception to October 13, 2021. Forty-three articles, including 11 observational studies and 59 cases from case reports and series, were included in the systematic review. Although some observational studies reported increased mortality in those with bradyarrhythmia and COVID-19, the lack of comparative groups and small sample sizes hinder the ability to draw definitive conclusions. Among 59 COVID-19 patients with bradycardia from case reports and series, bradycardia most often occurred in those with severe or critical COVID-19, and complete heart block occurred in the majority of cases despite preserved LVEF (55.9%). Pacemaker insertion was required in 76.3% of the patients, most of which were permanent implants (45.8%). This systematic review summarizes the current evidence and characteristics of bradyarrhythmia in patients with COVID-19. Further studies are critical to assess the reversibility of bradyarrhythmia in COVID-19 patients and to clarify potential therapeutic targets including the need for permanent pacing.