Asystole may be the most severe sequela of the trigeminocardiac reflex: A comment on “Asystole due to trigemino-cardiac reflex: A rare complication of trans-sphenoidal surgery for pituitary adenoma”

Abstract

Dear Professor Kaye, We read with interest the recently published report by Seker et al. that demonstrates the occurrence of the trigemino-cardiac reflex (TCR) resulting in asystole in a patient undergoing transsphenoidal (TS) surgery for pituitary adenoma. As mentioned by the authors, this reflex may be elicited during any stage of TS surgery. We wish to state that although the occurrence of asystole due to the TCR has never been reported during TS surgery, this complication is not entirely new, as far as the TCR is concerned. Stimulation of the trigeminal nerve anywhere along its course may result in elicitation of this reflex. At times, the stimulation may be severe enough to produce asystole as demonstrated in our report where this complication occurred during skin flap elevation. Asystole could be considered as one of the most severe sequelae of the TCR. Cessation of the surgical stimulus and administration of atropine are recommended treatments for the TCR. However, this may not hold true in every patient, as demonstrated in our report. At times the TCR may not respond to atropine administration, and anesthesiologists may have to administer pressor agents to maintain haemodynamics. The TCR in such situations may be refractory to conventional treatment. TCR is now a well-recognized entity seen during cranial and maxillofacial surgery. We agree with the authors that the literature does not identify TCR as a possible complication of TS surgery. However, with growing evidence of