Forde-Thielen and Konia Journal of Medical Case Reports 2011, 5:257 http://www.jmedicalcasereports.com/content/5/1/257 C A S E R E P O R T JOURNAL OF MEDICAL CASE REPORTS Open Access Asystole following positive pressure insufflation of right pleural cavity: a case report Kari M Forde-Thielen and Mojca R Konia* Abstract Introduction: Adverse hemodynamic effects with severe bradycardia have been previously reported during positive pressure insufflation of the right thoracic cavity in humans. To the best of our knowledge, this is the first report of asystole during thoracoscopic surgery with positive pressure insufflation. Case presentation: A 63-year-old Caucasian woman developed asystole at the onset of positive pressure insufflation of her right hemithorax during a thoracoscopic single-lung ventilation procedure. Immediate deflation of pleural cavity, intravenous glycopyrrolate and atropine administration returned her heart rhythm to normal sinus rhythm. The surgery proceeded in the absence of positive pressure insufflation without any further complications. Conclusions: We discuss the proposed mechanisms of hemodynamic instability with positive pressure thoracic insufflation, and anesthetic and insufflation techniques that decrease the likelihood of adverse hemodynamic events. Introduction Hemodynamic consequences of pleural cavity positive pressure insufflation during thoracoscopic procedures have been described in the literature. While some of these reports show minimal clinically significant effects, others show serious hemodynamic consequences. One potentially severe complication, asystole, has not pre- viously been reported. We present the case of a female patient who underwent right thoracoscopic mediastinal lymph node dissection with one-lung ventilation and developed hypotension and asystole at the commence- ment of positive pressure insufflation of her right hemi- thorax. We discuss the proposed mechanisms for the development of hemodynamic changes and asystole as well as ways in which the safety of thoracoscopic surgery can be improved. Case presentation A 63-year-old Caucasian woman with subcarinal and left hilar lymphadenopathy presented to our hospital for a right thoracoscopic mediastinal lymph node dissection. Our patient had a history of endometrial adenocarcinoma, and lymphadenopathy was noted on a follow-up * Correspondence: konia012@umn.edu Department of Anesthesiology, University of Minnesota, Box 294, B515 Mayo Memorial Building, 420 Delaware Street, SE, Minneapolis, MN 55455, USA computed tomography scan. At the time of the initial presentation, three years ago, the carcinoma was treated surgically. The post-surgical course at that time was com- plicated with deep vein thrombosis and pulmonary embo- lism, which were treated with anticoagulation therapy and the placement of an inferior vena cava filter. Our patient denied any residual shortness of breath or limitation of activity. She was participating in water aerobics and was able to walk up a flight of stairs easily without shortness of breath. Her history was also significant for gastroesopha- geal reflux disease and dyslipidemia. Our patient’s medica- tions included ranitidine and simvastatin. She did not report any allergies. A physical exam was unremarkable except for obesity (weight 119 kg; height 165 cm). Standard American Society of Anesthesiologists (ASA) monitors were placed. After a rapid sequence induction (fentanyl 1 μg/kg, lidocaine 1 mg/kg, propofol 2 mg/kg, succinylcholine 1.5 mg/kg) our patient was intubated with a 39 French left-sided double lumen endotracheal tube. Anesthesia was maintained with desflurane 5-6%, fentanyl (total intraoperative dose 300 μg), vecuronium 4 mg and fraction of inspired oxygen (FiO2) at 1.0. Our patient was turned to the left lateral position and the correct position of the endotracheal tube was confirmed with fiberoptic bronchoscopy. Left sided one-lung ventilation was initiated (tidal volume 300cc, respiratory rate 16/min, © 2011 Forde-Thielen and Konia; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.