Ventricular Tachycardia encountered in the pre-induction period in an
anxious patient


Charu Deva, Savita Bansal, Satinder Gombar
Dept. Of Anaesthesia, Government Medical College, Chandigarh, India

Charu Deva MD,DA
House No 174
Sec 19 A
India  160019


The triggering of ventricular arrhythmias, by a host of factors has been
well known in the peri-operative period.  We report an unusual case of
ventricular ectopics and tachycardia in the pre-induction phase precipitated
by an anxiety in an apprehensive patient undergoing elective

Key words

Ventricular / tachycardia / anxiety


The onset of ventricular tachycardia in patients undergoing anaesthesia is a
frightening occurrence regardless of the precipitating factors.

Patients undergoing surgery tend to be anxious.  The anxiety attendant on
the prospect of major surgery may precipitate cardiac complications in an
unsedated patient (1). Increased anxiety may also increase the stress
hormones (2). Following the current concepts of stress conditions involving
emotional disturbances of various kinds such as the anticipation of
undergoing an operation are said to increase the activity of the sympathetic
adrenal system (3). Anxiety if significantly marked causes all the signs of
sympathetic stimulation and stress.  The heart rate and systolic pressure
rise and there may be ventricular ectopics and in certain circumstances,
ventricular fibrillation (4). This report describes a case in which
ventricular tachycardia was encountered in the preinduction period in an
anxious patient.

Case History

A forty eight-year-old female patient the history of intermittent right
hypochondrial pain
for one year. She was diagnosed as a case of chronic cholecystitis with
cholelithiasis and a laparoscopic cholecystectomy was planned for her. Her
associated problem was
cervical spondylitis for the preceding eight years for which she was
receiving cinnarizine 25 mg once a day and aspirin 325 mg twice a day.

There were no other significant complaints.  She was an anxious patient and
had a number of queries regarding surgery and anaesthesia. On general
physical examination there was no pallor, cyanosis or edema .  Her pulse
rate was 84/mt and B.P 136/90 mmHg.

Respiratory system and Cardiovascular system examinations yielded unremarkable

Her preoperative investigations including ECG were all within normal limits.
She was accepted for the proposed surgery. Aspirin was stopped 10 days prior
to surgery and was replaced by paracetamol for pain relief.  On the day of
surgery, premedication was prescribed as Tablet Alprazolam 0.25 mg.,
Injection Morphine 7.5 mg. and Promethazine 25mg intramuscularly but was
omitted due to oversight on the part of the nursing team.  The patient's
preoperative vital signs were as follows:

Pulse Rate 104/min, B.P 147/94 and a Respiratory Rate of 18/min.  

She was extremely anxious and preoperative assurance by the involved anaesthetist did
not allay her fears. On the table she was preoxygenated for 3 minutes.
Injection Morphine 6mg was given I/V.  Injection Thiopentone 2.5% had just
been started intravenously when the patient was noted to have runs of
ventricular ectopics. Xylocard 60 mg I/V was administered but the ectopics
persisted. Pavulon 4 mg I/V was given, she was ventilated with 100% oxygen
by facemask. I/V xylocard infusion was started at the rate of 1 mg/mt.
Rhythm stablised and the patient was intubated with 7.5 mm-cuffed
endotracheal tube after giving an additional 2-mg of pavulon.  Anaesthesia
was maintained with O2, N2O, and isoflurane 0.4% . She was ventilated
through closed circuit with circle absorber.

It was decided at this moment to proceed with  open conventional
cholecystetomy instead of the laparoscopic procedure. Pulse rate, saturation,
NIBP, ETCO2 and ECG were monitored throughout surgery.  Vitals were well
maintained throughout surgery.  There were occasional ventricular ectonics
but they disappeared towards the end of surgery.  Reversal of anaesthesia
was achieved with  Glycopyrrolate 0.5 mg and neostigmine 2.5 mg.  A bolus of
Xylocard 60mg was also given  Suction of oral cavity was done and once
respiration was well established, she was extubated.  The patient was
shifted to the recovery room and was given 40% O2 by venti mask and kept
under observation. Xylocard drip was tapered off and stopped as no ectopics
were encountered.

Her postoperative electrolytes were found to be normal with a Na+ (134
meq/l) and K+ (3.8 meq/l). A post operative 12 lead ECG was done. ECG showed
infrerolateral ischaemic changes.  There was no accompanying chest pain or
breathlessness. A nitroglycerine(NTG) drip was started at the rate of 2.5-5
microgrammes/mt and the patient was shifted to ICU for further treatment and

In the ICU her pulse, BP, Saturation, Urine Output and Electrolytes were
monitored, all of which were within normal limits. Serial 12 lead ECG's were
done, all of which showed persistent ischaemic changes.  The NTG infusion was
continued till the 3rd postop day. All her ECG changes reverted on the third
day. Oral Isosorbide-Mononitrate20 mg bid, Aspirin 100mg od and
Glyceryl-Trinitrate  S/L SOS were started before tapering her NTG infusion.
She remained asymptomatic throughout and was transferred to the parent ward
on the 4th post operative day and discharged from hospital on the 9th post
operative day.


Arrhythmias are common during surgery.  Bertrand et al reported an 84
percent incidence of supraventricular and ventricular arrhythmias in 100
patients during surgery.  They were most common during endotracheal
intubation and extubation and occured more frequently  in patients with
pre-existing cardiac disease (60 percent verus 37 percent). Several major
contributing factors to the development of peri-operative arrhythmias are
anaesthetics. (halothane, enflurance), abnormal arterial blood gases or
electrolytes, endotracheal intubation, vagal reflexes, CNS stimulation and
dysfunction of autonomic nerve system, pre-existing cardiac disease, central
venous cannulation and location of surgery(5).  In our case, none of these
factors could be attributed to development of arrhythmia.
Ventricular tachycardia is a run of a rapidly repeated ectopic beats,
arising from the ventricle that are potentially life threatening
(6).Ventricular tachycardia generally accompanies some form of structural
heart disease (most commonly IHD) but may also be associated with
non-ischaemic cardiomyopathies, metabolic disorders, drug toxicity but it
frequently  occurs in the absence of any heart disease or other predisposing
factors. Sustained VT is almost always symptomatic and is often associated
with the development of myocardial ischaemia as was seen in this case (7).
Anxiety is a subjective phenomenon; the term includes a feeling of
apprehension, uncertainty and fear.  The presence of anxiety may complicate
the induction of anaesthesia and alter the pharmaco-kinetics of the agents
used by inducing catecholamins release(8)  Most ambulatory patients are very
anxious inspite of the anaesthesiologist preoperative communication with
them (9).
Circadian variation in the occurrence of  myocardial events such as sustained
ventricular tachycardia has been reported.  Factors affecting circadian
variation include exogeneous factors like mental stress, anxiety and
physical activity.  The cardiovascular disorders occur with the greatest
frequency between 6 A.M and 12 A.M (10).  In the present case, the
ventricular tachycardia occurred during this period.

In a study by Moser et al assessment of anxiety levels and subsequent
in-hospital complications like reinfarction, sustained ventricular tachycardia
and ventricular fibrillation were studied.  4.9 times more complications were
encountered in-patients with higher levels of anxiety (11). A study by Fell
et al has shown that plasma adrenaline concentrations increased
significantly by 40% in the period immediately before surgery and this
correlated significantly with the increase in expressed anxiety. Significant
amount of anxiety is present 6 days before surgery in a non prepared patient
(12) .

 Our patient exhibited a fair amount of apprehension and anxiety although we
could not score the levels. Moreover, the premedication to allay the anxiety
was omitted due to oversight on the part of nursing team.   This probably
resulted in a sudden increase in the levels of catecholamines leading to the
development of ventricular ectopics followed by tachycardia.
Morphine had been given intravenously  but it was unlikely that the ectopics
could have been precipitated solely by an opioid.
The ventricular tachycardia was successfully managed with lignocaine and by
deepening the plane of anaesthesia.  There was the advent of myocardial
ischaemia and EKG changes in the post operative  period were probably a
result of sustained ventricular tachycardia (7).
We conclude by stating that anxiety and apprehension can be a precipitating
factor in the development of arrythmia in susceptible patients undergoing
surgery. Therefore an appropriate premedicant to accomplish alleviation of
anxiety, fear or apprehension in patients preoperatively should be
administered. Also psychological preparation during the pre op visit by the
anaesthetist should be carried out. Anxiety  levels should be scored by an
appropriate scoring system such as MAACL(Multiple Affect Adjective Check
List), LVAAS, Visual Analogue Scale (VAS) .  Every attempt should be made to
allay the anxiety by pharmacological and psychological methods to avoid
excess release of  endogenous catecholamines leading to catastrophes.


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First Published 14.2.2000

Last edited: 02/14/00