Bradycardia and Severe Bispectral Index Drop Following Femoral Nerve Block by Dexmedetomidine due to Accidental Vascular Puncture: A Case Report

  • Elham Memary Shahid Beheshti University of Medical Sciences
  • Alireza Mirkheshti Shahid Beheshti University of Medical Sciences
  • Shahram Sayadi Shahid Beheshti University of Medical Sciences
  • Ali Arhami Dolatabadi Shahid Beheshti University of Medical Sciences
Keywords: dexmedetomidine, anesthesia, bradycardia, hypotension, alpha-2 adrenoceptor agonist


A 25-year-old Afghan male was presented to the emergency department with femoral shaft fracture following fall from the height. The patient was subjected to femoral nerve block and general anesthesia. First try for performing nerve block led to vascular puncture. Therefore, the needle was removed and re-inserted 1 cm lateral to first puncture site and DEX injected slowly with aspiration check after every 5 mL to avoid intravascular injection. Immediately after injection, heart rate dropped to 40, blood pressure decreased to 85/50 mmHg and the BIS dropped to 30. Because of not spontaneous resolving the situation atropine and ephedrine were ordered that resulted to regain hemodynamic stability.

It is likely that vascular puncture during peripheral nerve block can lead to some adverse events that need to be monitored precisely.


Adams R, Brown G, Davidson M, Fisher E, Mathisen J, Thomson G, et al. Efficacy of dexmedetomidine compared with midazolam for sedation in adult intensive care patients: a systematic review. Br J Anaesth. 2013;111(5):703-10.

Abdallah FW, Abrishami A, Brull R. The facilitatory effects of intravenous dexmedetomidine on the duration of spinal anesthesia: a systematic review and meta-analysis. Anesth Analg. 2013; 117(1):271-8.

Bagatini A, Gomes CR, Masella MZ, Rezer G. Dexmedetomidine: Pharmacology and Clinical Application. Bagatini A, Gomes CR, Masella MZ, Rezer G. Dexmedetomidine: pharmacology and clinical application. 2002; 52(5):606-17.

Devasya A, Sarpangala M. Dexmedetomidine: A Review of a Newer Sedative in Dentistry. J Clin Pediatr Dent. 2015; 39(5):401-9.

Chen K, Lu Z, Xin YC, Cai Y, Chen Y, Pan SM. Alpha-2 agonists for long-term sedation during mechanical ventilation in critically ill patients. Cochrane Database Syst Rev. 2015;1.

Luetz A, Goldmann A, Weber-Carstens S, Spies C. Weaning from mechanical ventilation and sedation. Curr Opin Anaesthesiol. 2012; 25(2):164-9.

BouAkl I, Bou-Khalil P, Kanazi G, Ayoub C, El-Khatib M. Weaning from mechanical ventilation. Curr Opin Anaesthesiol. 2012; 25(1):42-7.

Kim J, Kim WO, Kim H-B, Kil HK. Adequate sedation with single-dose dexmedetomidine in patients undergoing transurethral resection of the prostate with spinal anaesthesia: a dose–response study by age group. BMC anesthesiology. 2015;15(1):1.

Zanaty OM, El Metainy SA. A Comparative Evaluation of Nebulized Dexmedetomidine, Nebulized Ketamine, and Their Combination as Premedication for Outpatient Pediatric Dental Surgery. Anesth Analg. 2015; 121(1):167-71.

Hwang W, Lee J, Park J, Joo J. Dexmedetomidine versus remifentanil in postoperative pain control after spinal surgery: a randomized controlled study. BMC Anesthesiol. 2015; 15(1):1.

Negi S, Sen I, Arya V, Sharma A. Dexmedetomidine versus fentanyl as coadjuvants of balanced anaesthesia technique in renal transplant recipients. Middle East J Anesthesiol. 2014; 22(6):549-57.

Ge D-J, Qi B, Tang G, Li J-Y. Intraoperative Dexmedetomidine Promotes Postoperative Analgesia in Patients After Abdominal Colectomy: A Consort-Prospective, Randomized, Controlled Clinical Trial. Medicine. 2015; 94(43):e1727.

Liang F, Ouyang M, Wang H. [Effects of dexmedetomidine on propofol dosage in target-controlled infusion and hemodynamics during laparoscopic surgery under general anesthesia]. Nan Fang Yi Ke Da Xue Xue Bao. 2015; 35(10):1497-500.

Alimohammadi H, Baratloo A, Abdalvand A, Rouhipour A, Safari S. Effects of pain relief on arterial blood O2 saturation. Trauma Mon. 2014; 19(1):e14034.

Baratloo A, Rouhipour A, Forouzanfar MM, Safari S, Amiri M, Negida A. The Role of Caffeine in Pain Management: A Brief Literature Review. Anesth Pain Med. 2016; 6(3): e33193.

Wang C-G, Ding Y-L, Han A-P, Hu C-Q, Hao S, Zhang F-F, et al. Adding dexmedetomidine to ropivacaine for lumbar plexus and sciatic nerve block for amputation of lower limb in high-risk patient-a case report. Int J Clin Exp Med. 2015; 8(8):14184-7.

Kirksey MA, Haskins SC, Cheng J, Liu SS. Local Anesthetic Peripheral Nerve Block Adjuvants for Prolongation of Analgesia: A Systematic Qualitative Review. PloS One. 2015; 10(9):e0137312.

Dolatabadi AA, Hatamabadi HR, Shahrami A, Shojaee M, Matin S. Femoral nerve block in patients with femoral shaft fractures in emergency department. J Basic Appl Sci Res. 2013; 3(11):15-9.

Memari E, Hosseinian MA, Mirkheshti A, Arhami-Dolatabadi A, Mirabotalebi M, Khandaghy M, et al. Comparison of histopathological effects of perineural administration of bupivacaine and bupivacaine-dexmedetomidine in rat sciatic nerve. Exp Toxicol Pathol. 2016; pii: S0940-2993(16)30125-7.

Wu H-H, Wang H-T, Jin J-J, Cui G-B, Zhou K-C, Chen Y, et al. Does dexmedetomidine as a neuraxial adjuvant facilitate better anesthesia and analgesia? A systematic review and meta-analysis. PloS One. 2014; 9(3):e93114.

Ren C, Chi M, Zhang Y, Zhang Z, Qi F, Liu Z. Dexmedetomidine in postoperative analgesia in patients undergoing hysterectomy: a CONSORT-prospective, randomized, controlled trial. Medicine. 2015; b94(32):e1348.

Hoy SM, Keating GM. Dexmedetomidine: a review of its use for sedation in mechanically ventilated patients in an intensive care setting and for procedural sedation. Drugs. 2011; 71(11):1481-501.

Sardesai SP, Patil KN, Sarkar A. Comparison of clonidine and dexmedetomidine as adjuncts to intravenous regional anaesthesia. Indian J Anaesth. 2015; 59(11):733-738.

Abdallah FW, Dwyer T, Chan VW, Niazi AU, Ogilvie-Harris DJ, Oldfield S, et al. IV and Perineural Dexmedetomidine Similarly Prolong the Duration of Analgesia after Interscalene Brachial Plexus BlockA Randomized, Three-arm, Triple-masked, Placebo-controlled Trial. Anesthesiology. 2016; 124(3):683-95.

Tong Y, Ren H, Ding X, Jin S, Chen Z, Li Q. Analgesic effect and adverse events of dexmedetomidine as additive for pediatric caudal anesthesia: a meta‐analysis. Paediatr Anaesth. 2014; 24(12):1224-30.

Abdallah F, Brull R. Facilitatory effects of perineural dexmedetomidine on neuraxial and peripheral nerve block: a systematic review and meta-analysis. Br J Anaesth. 2013; 110(6):915-25.

Agarwal S, Aggarwal R, Gupta P. Dexmedetomidine prolongs the effect of bupivacaine in supraclavicular brachial plexus block. J Anaesthesiol Clin Pharmacol. 2014; 30(1):36-40.

Konakci S, Adanir T, Yilmaz G, Rezanko T. The efficacy and neurotoxicity of dexmedetomidine administered via the epidural route. Eur J Anaesthesiol. 2008; 25(5):403-9.

Walker S, Yaksh T. New caudal additives in children: benefit vs. risk? Acta Anaesthesiol Scand. 2009; 53(8):1097-8

Shehabi Y, Grant P, Wolfenden H, Hammond N, Bass F, Campbell M, et al. Prevalence of Delirium with Dexmedetomidine Compared with Morphine Based Therapy after Cardiac SurgeryA Randomized Controlled Trial (DEXmedetomidine COmpared to Morphine-DEXCOM Study). Anesthesiology. 2009; 111(5):1075-84.

Hong JY, Kim W, Yoon Y, Choi Y, Kim SH, Kil H. Effects of intravenous dexmedetomidine on low‐dose bupivacaine spinal anaesthesia in elderly patients. Acta Anaesthesiol Scand. 2012; 56(3):382-7.

She YJ, Zhang ZY, Song XR. Caudal dexmedetomidine decreases the required concentration of levobupivacaine for caudal block in pediatric patients: a randomized trial. Paediatr Anaesth. 2013; 23(12):1205-12.

Xiang Q, Huang D, Zhao Y, Wang G, Liu Y, Zhong L, et al. Caudal dexmedetomidine combined with bupivacaine inhibit the response to hernial sac traction in children undergoing inguinal hernia repair. Br J Anaesth. 2013; 110(3):420-4.

El-Hennawy A, Abd-Elwahab A, Abd-Elmaksoud A, El-Ozairy H, Boulis S. Addition of clonidine or dexmedetomidine to bupivacaine prolongs caudal analgesia in children. Br J Anaesth. 2009;103(2):268-74.

Neogi M, Bhattacharjee DP, Dawn S, Chatterjee N. A comparative study between clonidine and dexmedetomidine used as adjuncts to ropivacaine for caudal analgesia in paediatric patients. J Anaesthesiol Clin Pharmacol. 2010; 26(2):149.

Niu XY, Ding XB, Guo T, Chen MH, Fu SK, Li Q. Effects of Intravenous and Intrathecal Dexmedetomidine in Spinal Anesthesia: A Meta‐Analysis. CNS Neuroscience and Therapeutics. 2013;19(11):897-904.

Baumgart D, Haude M, Görge G, Liu F, Ge J, Große-Eggebrecht C, et al. Augmented α-adrenergic constriction of atherosclerotic human coronary arteries. Circulation. 1999; 99(16):2090-7.

Feldman J, Fellmann L, Bousquet P. The central hypotensive effect induced by α2-adrenergic receptor stimulation is dependent on endothelial nitric oxide synthase. J Hypertens. 2008; 26(5):1033-6.

Piao G, Wu J. Systematic assessment of dexmedetomidine as an anesthetic agent: a meta-analysis of randomized controlled trials. Arch Med Sci. 2014;10(1):19-24.

Yildiz M, Tavlan A, Tuncer S, Reisli R, Yosunkaya A, Otelcioglu S. Effect of dexmedetomidine on haemodynamic responses to laryngoscopy and intubation. Drugs R D. 2006; 7(1):43-52.

Soliman R, Hassan A, Rashwan A, Omar A. Prospective, randomized controlled study to assess the role of dexmedetomidine in patients with supratentorial tumors undergoing craniotomy under general anesthesia. Middle East J Anaesthesiol. 2011; 21(1):23-33.

Talke P, Lobo E, Brown R. Systemically administered α2-agonist-induced peripheral vasoconstriction in humans. Anesthesiology. 2003; 99(1):65-70.

Talke P, Chen R, Thomas B, Aggarwall A, Gottlieb A, Thorborg P, et al. The hemodynamic and adrenergic effects of perioperative dexmedetomidine infusion after vascular surgery. Anesth Analg. 2000; 90(4):834-9.

Selim MF, Elnabtity A, Mohamed A, Hasan A, Mohamed A. Comparative evaluation of epidural bupivacaine–dexmedetomidine and bupivacaine–fentanyl on Doppler velocimetry of uterine and umbilical arteries during labor. J Prenat Med. 2012; 6(3):47-54.

Zhang Y, Wang C-S, Shi J-H, Sun B, Liu S-J, Li P, et al. Perineural administration of dexmedetomidine in combination with ropivacaine prolongs axillary brachial plexus block. Int J Clin Exp Med. 2014; 7(3):680-5.

Gupta R, Bogra J, Verma R, Kohli M, Kushwaha JK, Kumar S. Dexmedetomidine as an intrathecal adjuvant for postoperative analgesia. Indian J Anaesth.. 2011; 55(4):347-51.

Deutsch E, Tobias JD. Hemodynamic and respiratory changes following dexmedetomidine administration during general anesthesia: sevoflurane vs desflurane. Paediatr Anaesth. 2007; 17(5):438-44.

Berkenbosch JW, Tobias JD. Development of bradycardia during sedation with dexmedetomidine in an infant concurrently receiving digoxin. Pediatr Crit Care Med. 2003; 4(2):203-5.

Zhou LJ, Fang XZ, Gao J, Zhangm Y, Tao LJ. Safety and Efficacy of Dexmedetomidine as a Sedative Agent for Performing Awake Intubation: A Meta-analysis. Am J Ther. 2015.

Subramanyam R, Cudilo EM, Hossain MM, McAuliffe J, Wu J, Patino M, et al. To Pretreat or Not to Pretreat: Prophylactic Anticholinergic Administration Before Dexmedetomidine in Pediatric Imaging. Anesth Analg. 2015; 121(2):479-85.

How to Cite
Memary E, Mirkheshti A, Sayadi S, Arhami Dolatabadi A. Bradycardia and Severe Bispectral Index Drop Following Femoral Nerve Block by Dexmedetomidine due to Accidental Vascular Puncture: A Case Report. Arch Anesth & Crit Care. 2(4):263-6.
Case Report(s)