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A Novel Mechanism Causing Bradycardia During Right Lung Pleurodesis

Markewich, Stephen D., MD; Stanger, Ryan P., MD; Lucas, Warner J., MD, DDS; Feins, Richard H., MD; Kyle, Robert W., DO; Zvara, David A., MD

Section Editor(s): Saidman, Lawrence

doi: 10.1213/ane.0b013e3181b3b5ae
Letters to the Editor: Letters & Announcements
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Department of Anesthesiology; smarkewich@primecare.org (Markewich)

Department of Anesthesiology (Stanger)

Department of Anesthesiology (Lucas)

Department of Cardiothoracic Surgery (Feins)

Department of Anesthesiology (Kyle)

Department of Anesthesiology; University of North Carolina; Chapel Hill, North Carolina (Zvara)

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To the Editor:

Talc pleurodesis is common in cases of recurrent malignant pleural effusion to prevent fluid reaccumulation.1 Chest pain, fever, and supraventricular arrhythmias are common side effects.2 The following highlights a novel side effect from the aerosol spray propellant dichlorodifluoromethane (Freon-12) used in Sclerosol®, a form of aerosolized talc.

A 71-yr-old, 104-kg man presented for right-sided talc pleurodesis. Under direct visualization, Sclerosol was sprayed through the delivery nozzle toward the right mediastinum. Within 10 s, sinus bradycardia developed with a decrease in heart rate from 82 to 34 bpm. The talc spray was discontinued, ephedrine and atropine administered, and the heart rate returned to normal.

In a subsequent experiment involving a plastic model of the right chest, the cooling properties of Sclerosol spray were assessed. Two temperature probes were placed in the model and underwent warming until they were 37.2°C and 36.9°C, respectively. Sclerosol was then sprayed into the chest model approximately 20 cm from the temperature sensors. There was an immediate decrease in temperature after onset of talc spray and each reached 0°C within 7 s. In response to these findings, routine intraoperative temperature monitoring was expanded to include a mediastinal temperature probe in a subsequent patient undergoing talc pleurodesis with the results shown in Figure 1.

Figure 1.

Figure 1.

Anesthesiologists and surgeons should be aware of the potential for significant bradycardia with talc pleurodesis using Sclerosol. Exposure of mediastinal structures to direct continuous propellant spray may increase the likelihood of this event.

Stephen D. Markewich, MD

Department of Anesthesiology

smarkewich@primecare.org

Ryan P. Stanger, MD

Department of Anesthesiology

Warner J. Lucas, MD, DDS

Department of Anesthesiology

Richard H. Feins, MD

Department of Cardiothoracic Surgery

Robert W. Kyle, DO

Department of Anesthesiology

David A. Zvara, MD

Department of Anesthesiology

University of North Carolina

Chapel Hill, North Carolina

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REFERENCES

1.Yildirim H, Metintas M, Ucgun I, Erginel S, Alatas F, Kurt E, Metintas S, Ak G. Talc pleurodesis: systemic inflammatory response. Turkish Resp J 2006;7:65–70
2.Genofre EH, Marchi E, Vargas FS. Inflammation and clinical repercussions of pleurodesis induced by intrapleural talc administration. Clinics 2007;62: 627–34
© 2009 International Anesthesia Research Society