What is the assessment and management plan for a post-operative patient who experienced a vasovagal (vasovagal syncope) episode after excision?

From the Guidelines

A vasovagal episode in a post-operative excision patient requires immediate assessment and management to prevent morbidity and mortality, with the primary goal of restoring cerebral blood flow and preventing further complications. The patient should be placed in a supine position with legs elevated to improve cerebral perfusion. Vital signs, including heart rate, blood pressure, respiratory rate, and oxygen saturation, should be assessed promptly, with a focus on identifying bradycardia and hypotension, which are characteristic of vasovagal responses 1.

Assessment and Management Plan

• Ensure a patent airway and administer supplemental oxygen if oxygen saturation drops below 94% to prevent hypoxia.
• Discontinue any triggering stimuli, such as pain or anxiety-inducing factors, which can exacerbate the vasovagal response.
• Provide intravenous fluids (normal saline 500-1000mL) to increase intravascular volume and help stabilize blood pressure.
• If bradycardia is severe (heart rate <40 bpm) or symptomatic, consider administering atropine 0.5mg IV, which can be repeated every 3-5 minutes to a maximum of 3mg, as guided by the patient's response and clinical judgment 1.
• For persistent hypotension, vasopressors like phenylephrine (100-500 mcg IV bolus) may be necessary to maintain adequate blood pressure and perfusion of vital organs.

Prevention of Recurrence

• Investigate potential causes of the vasovagal episode, including pain, dehydration, medication effects, or blood loss, to address underlying issues.
• Prevent recurrence by ensuring adequate hydration, effective pain control, and gradual position changes to minimize orthostatic stress.
• Recognize that vasovagal episodes are triggered by excessive parasympathetic activation and sympathetic withdrawal, often in response to pain, emotional stress, or orthostatic changes, especially in susceptible post-operative patients 1.

Given the potential for significant morbidity and mortality associated with vasovagal episodes in the post-operative period, prompt and effective management is crucial to improve patient outcomes and quality of life.

From the FDA Drug Label

HIGHLIGHTS OF PRESCRIBING INFORMATION These highlights do not include all the information needed to use EPHEDRINE SULFATE INJECTION safely and effectively. See full prescribing information for EPHEDRINE SULFATE INJECTION. EPHEDRINE SULFATE injection, USP, for intravenous use Initial U. S. Approval: 2016 INDICATIONS AND USAGE Ephedrine Sulfate Injection, USP is an alpha- and beta- adrenergic agonist and a norepinephrine-releasing agent indicated for the treatment of clinically important hypotension occurring in the setting of anesthesia ( 1) DOSAGE AND ADMINISTRATION Treatment of hypotension developing during anesthesia: Bolus intravenous injection: 5 to 10 mg as needed, not to exceed 50 mg.

The patient had a vasovagal episode post-operatively. To assess the patient, monitor their blood pressure, heart rate, and symptoms. The management plan for hypotension in this setting may include administering ephedrine 5 to 10 mg as needed, not to exceed 50 mg, as a bolus intravenous injection 2. Key considerations:

• Monitor blood pressure closely
• Be aware of the potential for tachyphylaxis and tolerance with repeated administration of ephedrine 2
• Consider alternative pressors if ephedrine is ineffective
• Monitor for adverse reactions, such as nausea, vomiting, and tachycardia 2

From the Research

Assessment of Vasovagal Reaction

• The patient's medical history should be reviewed to identify any previous episodes of vasovagal syncope or related conditions 3
• Physical examination should include vital signs, such as heart rate and blood pressure, to assess for any signs of bradycardia or hypotension 4
• The patient's symptoms should be evaluated, including any prodromal symptoms, such as lightheadedness or nausea, to determine the severity of the vasovagal reaction 5

Management Plan

• Moderate sedation and anxiolytics may be used to prevent vasovagal reactions, but their side-effect profiles should be considered 6
• Antimuscarinics and IV fluids may be administered prophylactically to prevent vasovagal reactions, with a relatively low side-effect profile 6
• Closed loop stimulation (CLS) and cardioneuroablation (CNA) may be considered as therapeutic modalities for managing vasovagal syncope 7
• Patients with a history of vasovagal syncope may be predisposed to experiencing brief potentiated episodes of severe bradycardia and even cardiac arrest following spinal anesthesia, and should be closely monitored 3
• A multidisciplinary approach to the study of the pathophysiology of vasovagal syncope may yield new insights into its management 4