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LETTER TO THE EDITOR

"Kratschmer" Reflex During Rhinoplasty

Department of Anesthesiology and; Intensive Care; Nizam’s Institute of Medical Sciences; Punjagutta, Hyderabad,; Andhra Pradesh, India; pvlnm{at}rediffmail.com

To the Editor:

We report an unusual complication following nasal packing after rhinoplasty to illustrate the existence and importance of the primitive "Kratschmer" reflex (1). Kratschmer, in 1870 first described trigeminocardiac and trigemino-respiratory reflexes in cats and rabbits (2,3). There are very few reports of Kratschmer reflex in the literature (4,5).

A 50-yr-old male ASA grade-I underwent rhinoplasty under general anesthesia. At the end of the procedure, as his nose was being packed with gauze, he developed sudden bradycardia and bronchospasm for which we gave atropine sulfate 0.6 mg IV. After symptomatic relief, we reversed the neuromuscular blockade and extubated the trachea. In a few minutes he developed severe respiratory distress due to persistent bronchospasm and pulmonary edema. We reintubated the patient’s trachea. In the absence of knowing about other predisposing factors for bronchospasm, we surmised that nasal packing lead to the Kratschmer reflex. We removed the nasal pack, and the patient was relieved of bronchospasm. Because of negative pressure pulmonary edema, he required mechanical ventilation for 24 h, after which he was weaned off the ventilator and tracheally extubated. There were no further episodes of bradycardia or bronchospasm.

Stimulation of receptors in the trigeminal nerve distribution area results in reflex changes in autonomic, cardiovascular, and respiratory systems (6). Most of the reports of Kratschmer reflex described cardiovascular changes with potent stimuli, such as elevation of bone flap or osteotomies. Lang et al. (4) reported three cases of possible Kratschmer reflex in patients undergoing corrective facial osteotomies. The cardiovascular changes during cerebellopontine angle tumor resection suggest the presence of a central induction and efferent pathway of trigeminocardiac reflex in humans (7). Our case illustrates that moderate stimuli like nasal packing can evoke Kratschmer reflex. This patient developed bronchospasm and laryngospasm as originally described by Kratschmer in animals (2,6). In our case, atropine was effective in treating bradycardia but bronchospasm responded only partially.

Vigilance during procedures with a potential to provoke a trigeminocardiac/trigeminorespiratory reflex is essential. Prompt interventions like cessation of surgical stimulus, administration of atropine, local anesthetic infiltration, or blockade of the nerve may be helpful in attenuating or preventing the potentially fatal complications of Kratschmer reflex.

REFERENCES

1. Linton RAF. Respiratory system: structure and function of the respiratory tract in relation to anaesthesia. In: Healey TEJ, Knight PR, eds. Wylie and Churchill-Davidson’s a practice of anaesthesia. Singapore: PG Publishing, 1986:4.
2. Widdicombe J. Kratschmer and nasal reflexes. Respir Physiol 2001;127:89–91.[Web of Science][Medline]
3. Angell-James JE, Daly MB. Some aspects of upper respiratory tract reflexes. Acta Otolaryngol 1975;79:242–52.[Medline]
4. Lang S, Lanigan DT, Vanderwal M. Trigeminocardiac reflexes: maxillary and mandibular variants of the oculocardiac reflex. Can J Anaesth 1991;38:757–60.[Web of Science][Medline]
5. Blanc VF. Trigeminocardiac reflexes (Editorial). Can J Anaesth 1991;38:696–9.[Web of Science][Medline]
6. Widdicombe J, Lee LY. Airway reflexes, autonomic function and cardiovascular responses. Environ Health Perspect 2001; 109 (Suppl 4):579–84.[Web of Science][Medline]
7. Schall B, Probst R, Strebel S. Trigeminocardiac reflex during surgery in cerebellopontine angle. Neurosurg Focus 1998;5: Article 5.

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