Is Prevention or Knowledge Better Than a Cure for the Trigeminal Cardiac Reflex?

Abstract

We read with interest the article by Lubbers et al 1 Lubbers H.T. Zweifel D. Gratz K.W. Kruse A. Classification of potential risk factors for trigeminocardiac reflex in craniomaxillofacial surgery. J Oral Maxillofac Surg. 2010; 68: 1317 Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar in which the authors evaluated predisposing factors and classified surgical risk factors for potential trigeminal cardiac reflex (TCR). The TCR originates because of stimulation of the trigeminal nerve anywhere along its course intracranially and extracranially. 2 Prabhakar H. Anand N. Chouhan R.S. Bithal P.K. Sudden asystole during surgery in the cerebelopontine angle. Acta Neurochir (Wien). 2006; 148: 699 Crossref PubMed Scopus (43) Google Scholar , 3 Prabhakar H. Rath G.P. Arora R. Sudden cardiac standstill during skin flap elevation in a patient undergoing craniotomy. J Neurosurg Anesthesiol. 2007; 19: 203 Crossref PubMed Scopus (22) Google Scholar In neurosurgical practice, occurrence of TCR is not uncommon. The authors provided a detailed account of the predisposing factors that have been mentioned in previous articles and in a recently published update. 4 Schaller B. Cornelius J.F. Prabhakar H. et al. The trigemino-cardiac reflex: An update of the current knowledge. J Neurosurg Anesthesiol. 2009; 21: 187 Crossref PubMed Scopus (144) Google Scholar The authors classified various surgeries as low, medium, and high risk for occurrence of TCR. However, the article lacks detailed information for such classification. Lubbers et al 1 Lubbers H.T. Zweifel D. Gratz K.W. Kruse A. Classification of potential risk factors for trigeminocardiac reflex in craniomaxillofacial surgery. J Oral Maxillofac Surg. 2010; 68: 1317 Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar recommended a prophylactic administration of intravenous atropine 0.5 mg just before any surgical manipulation known to be risky for TCR. We differ in opinion from the authors in this conclusion. The statement cannot be generalized, especially in neurosurgical patients. Masking the signs of TCR by prophylactic administration of an anticholinergic may lead to inadvertent nerve handling and damage. In the absence of a warning signal, vital centers may be damaged by the operating surgeon. It must also be recognized that at times the TCR may be refractory to conventional management, and one may have to administer vasopressors to maintain hemodynamics. 5 Prabhakar H. Ali Z. Rath G.P. Trigemino-cardiac reflex may be refractory to conventional management in adults. Acta Neurochir (Wien). 2008; 150: 509 Crossref PubMed Scopus (34) Google Scholar Classification of Potential Risk Factors for Trigeminocardiac Reflex in Craniomaxillofacial SurgeryJournal of Oral and Maxillofacial SurgeryVol. 68Issue 6PreviewTrigeminocardiac reflex (TCR) in craniomaxillofacial surgery can lead to severely life-threatening situations. At least mild forms are probably much more common than the existing surgical literature suggests. Therefore, the aim of this presentation of cases and literature review was to evaluate the predisposing factors leading to a classification of risk factors for potential TCR and to give information concerning preventive measures and management procedures. Full-Text PDF In replyJournal of Oral and Maxillofacial SurgeryVol. 68Issue 8PreviewThank you very much for your contribution. We agree with anesthesiologists Prabhakar et al that one should not try to mask the TCR in any type of risky surgery, but this was not mentioned in our article. In addition, we did not generalize; on the contrary, we did specify that the classification was for our patients, not for neurosurgical practice. Therefore, the proposed classification is not based on neurosurgery. Full-Text PDF