Post-operative apnoea caused by breath-holding spells (pdf) paperity anoxia anoxica


Charles H. Hubbert, M.I)., pediatric anesthesiol- ogy, le bonheur children’s hospital


848 adams ave., memphis, tennessee 38103



CASE REPORT arousable. An uneventful post-operative course allowed discharge on the sixth day. DISCUSSION


History of breath-holding spells became apnoeic and

Cyanotic after emergence from anaesthesia. Brief

Ventilation with oxygen was the only therapy

Required for the breath-holding spell.

Breathholding as a cause of post-operative apnoea was

Not found in a review of the recent literature. The

Pathophysiology ofbreath-holdingand a

Differential diagnosis of postoperative apnoeas are


A two-and-a-half-year-old white male

Underwent operation for right ureteroneocystostomy.Anoxia anoxica

There was a history of breath-holding spells

Beginning at the age of eighteen months.

Preoperative evaluation revealed a weight of 14 kg,

Haematocrit 35 per cent, normal electrolytes and

Urinalysis, and an estimated blood volume of 1050

Ml. Intramuscular hydroxyzine 25 mg and

Atropine 0.2 mg were given pre-operatively. Mask

Induction of anaesthesia using halolhane, nitrous

Oxide and oxygen was followed by pancuronium

1.5 mg intravenously for tracheal intubation.

Anaesthesia was maintained with morphine

Sulfate 6 mg, nitrous oxide-oxygen (2:1), and

Hyperventilation. During the two-and-one-half-hour

Procedure pancuronium 1.0 mg was given, 0.5 mg

Being given 45 minustes before the end of the

Operation. This relaxant was adequately reversed

anoxia anoxica

By atropine 0.3 nag and neostigmine 0.9 rag. Blood

Loss of 160 ml was replaced by 250 ml of

Quarterstrength saline in five per cent dextrose and 600

Ml of lactated ringer’s solution. After the nitrous

Oxide was discontinued he became responsive,

Ventilated adequately and helped with a smooth

Extubation. While being transferred to the

Recovery room, he became apnoeic and cyanotic. After

Ventilation by mask with 100 per cent oxygen for

Approximately one to one and a half minutes, he

Resumed spontaneous respirations and was easily

Breath-holding spells ~-3 are non-epileptic

Episodes of unconsciot, sness precipitated by fear,

Rage, weeping, pain, or fl’ustration occt, rring

Primarily in children under six years of age.Anoxia anoxica

These spells are initiated by a spontaneous

Weber-valsalva M a n o e u v e r in which the child

Holds his breath and tries to exhale against a

Closed glottis. The resulting high inlrathoracic

Pressure forces blood out of the vena cavae

Away fi’om the heart, reducing venous return.

The pumping action of the heart fails and the

Blood pressure falls precipitously, producing

A significant reduction in cerebral blood flow.

Neurophysiological explanations suggest a

Byper-sensitive vaga] system with brain stem

Centres reacting excessively to painful or

Emotional stimuli. Cardiac inhibition and respiratory

Arrest then lead to apnoea, cerebral anoxia, and

Unconsciousness. Thus, in response to a

Provoking incident, the child ceases to breathe in

anoxia anoxica

Expiration, develops cyanosis, experiences syncope,

And becomes unconscious and apnoeic.

The electroencephalogram (EEG)4 during

Breath-holding shows no seizure discharges, but

Transitory slow waves may appear. In some

Children the spells may be followed by a decrease in

Voltage or flattening of the EEG. Occasionally,

Convulsive movements may occur, but without

Change in the EEG.

Common causes of post-operative apnoea

Include hyperventilation, inadequate reversal of

Muscle relaxants or narcotics, and hypothermia

In infants. These aetiologies produce apnoea

Which persists at the end of the surgical

Procedure, although narcotic depression and

Hypothermia may produce recurring apnoea.

Hyperventilation was excluded after return of

anoxia anoxica

Spontaneous respiration. In our practice morphine

0.4 to 0.5 mg/kg used routinely for operations

Lasting over two hours has not produced

Respiratory depression or apnoea and brief

Ventilation with oxygen would not have been sufficient


Therapy if morphine was the cause. Hypothermia

And hypovolaemia were not present in or

Applicable to this case. Recurarization without

Overdosage of relaxant and after adequate reversal of the

Block with neostigmine probably does not occur

Except when gallamine is used in patients with

Renal disease. 5 this patient’s apnoea would be

Limited to breath-holding or certain types of

Seizures, 6 barring an unlikely stt’oke.

Though breath-holding is usually benign and

anoxia anoxica

Well-tolerated, the hypoxia possible in the

Immediate post-operative period could further

Compromise cerebral and cardiac oxygenation.

Supported ventilation with oxygen then becomes

Specific therapy. Attempts at further therapy for

Reversal of the narcotic or muscle relaxant would

Be inappropriate and could complicate


After recovery from anaesthesia for a

Urological procedure a two-and-a-half-year-old

Child with a history of breath-holding spells

Became apnoeic and cyanotic in the immediate

Post-operative period. The pathophysiology of

Breath-holding as the cause of the apnoea is

Disc u ~ e d . M a n a g e m e n t i n c l u d e s ventilation with

Oxygen and avoidance of inappropriate treatment

With drugs to reverse muscle relaxants or

anoxia anoxica

Narcotic anesthetics.

Le spasme du sanglot classique est un 6pisode

D’apn6e non 6pileptique avec perte de

Conscience, dgcfench6 par la crainte, la rage, les

Pleurs, la douleur ou la frustration, et survenant

Surtout chez fenfant de moins de six ans.

Un enfant de deux ans et demi avec une histoire

De spasme du sanglot a prgsentg un dpisode

D’apnde et de cyanose apr~s dveil d’une

Anesthdsie. Une ventilation de courte dut’6e h

Foxyg~ne a 6t6 la seule th~rapie ndcessaire.

Une revue de la littgrature rdcente ne

Mentionne pas cette entitg comme cause d’apn6e

Post-opdratoire. La pathophysiologie du spasme

Du sanglot ainsi que le diagnostic diffdrentie[ de

I’apnge post-opdratoire sont discut~s.