CASE REPORT

INTRAVENOUS MIDAZOLAM - ROLE IN THE TREATMENT

OF HYPERVENTILATION SYNDROME
Jyoti V. Kulkarni, Anil S. Joshi, Kanchan Shah
1. Assistant Professor. Department of Anaesthesiology, Government Dental College,
Aurangabad.
2. Assistant Professor. Department of Medicine, Government Medical College, Aurangabad.
3. Associate Professor. Department of Oral and Maxillofacial Surgery, Government Dental
College, Aurangabad.

CORRESPONDING AUTHOR:
Jyoti Vasantrao Kulkarni,
7, Bharat Nagar, Opp Indraprastha Enclave,
Jyoti Nagar, Aurangabad,
Maharashtra, pin 431005
E-mail: jyotianil.joshi71@gmail.com
ABSTRACT: BACKGROUND: Hyperventilation syndrome (HVS) also known as
irritable Heart, Da Costas syndrome or soldiers heart is induced by stress. It
comprises various symptoms like hyperventilation, breathlessness, Lightheadedness, dizziness carpal-pedal spasm, tachycardia and numbness or
paraesthesia and unconsciousness1. MATERIAL AND METHOD: Twenty seven
years man, driver by occupation was posted for surgical extraction of impacted
lower right third molar tooth under local anesthesia. After inferior alveolar nerve
block with Lignocaine and Adrenaline he developed giddiness and started
hyperventilating himself. He developed light headedness, chest pain, and feeling
of compression over chest, tingling in hand and perioral region. It was followed
by breathlessness and carpopedal spasm. Surgical procedure was abandoned.
Patient was shifted to bed.
To relieve anxiety & pain intravenous Midazolam and Tramadol was given.
Patient was asked to rebreathe through paper bag. Breathlessness was treated
by Oxygen supplementation through face mask. Next day he was operated under
local anesthesia and intravenous sedation with Midazolam and Fentanyl.
CONCLUSION: Intravenous midazolam is effective not only in treating the
patient of Hyperventilation syndrome but it also helps to prevent it.
KEY WORDS Intravenous Midazolam, Hyperventilation syndrome, Tramadol
INTRODUCTION: Hyperventilation syndrome (HVS) also known as irritable
Heart, Da -Costas syndrome or soldiers heart is induced by stress or anxiety. It
comprises various symptoms like hyperventilation, breathlessness, lightheadedness, dizziness, carpal-pedal spasm, tachycardia, numbness or
paraesthesia and unconsciousness. 1It may be acute or chronic.. It is common in
young females; female to male ratio is 7:1 and age 15 to 55 years. Stress leads
to hyper adrenergic response. Even though it was reported that vasovagal
syncope is the most common emergency, acute hyperventilation syndrome is
also known to occur in dentistry. We want to report a case of acute

Journal of Evolution of Medical and Dental Sciences/ Volume 2/ Issue 15/ April 15, 2013
Page-2459

CASE REPORT
hyperventilation syndrome in a patient posted for surgical extraction of right
lower last molar tooth.
CASE REPORT: In dental OPD a 27 year old man, driver by occupation was posted for
surgical
extraction of impacted lower right third molar tooth under local anesthesia.
Procedure was started after administration of inferior alveolar block with 2ml of
2% lignocaine with adrenaline. Patient was complaining of giddiness & sweating
for which he was given supine position. He felt comfortable so procedure was
restarted but within few minutes, he started hyperventilating himself. We tried to
relieve his anxiety by reassuring him but still hyperventilation was continued.
Also he was complaining of light headedness, chest pain, feeling of compression
over chest, tingling in hand and perioral region. Surgical procedure was
abandoned. Patient was shifted to bed.
On examination he had tachycardia and tachypnea, spo2 was
98%.Intravenous Midazolam 2mg and Tramadol 50 mg was given to relieve
anxiety and pain. But still hyperventilation was continued and it was followed by
an apneic spells. He developed carpopedal spasm. He was treated with
intravenous Midazolam 2mg. followed by Intravenous Calcium gluconate5ml.
During apnea he was ventilated with ambo bag and Face mask with oxygen
supplementation. He was monitored with pulse oximeter and Cardiac monitor.
His ECG was normal. After deep sedation slowly his respiratory pattern became
normal in about 15minutes.Patient was admitted to ward and was investigated to
rule out ischemic heart disease. His CPK-MB, SGOT and SGPT was normal. No
abnormality was detected on ECG and other investigations. Next day surgery
was done under sedation Midazolam 2mg andFentanyl100gm intravenously
along with inferior alveolar nerve block with Lignocaine and Adrenaline. Patient
was monitored with pulse oximeter
and cardiac monitor. Surgery was uneventful.
DISCUSSION: Hyperventilation syndrome (HVS) is said to be due to extreme
anxiety which is common in dentistry. Etiology of HVS is not known but affected
person appears to have abnormal respiratory response to stress, Sodium, lactate
and other emotional trigger. Systemic causes of HVS include metabolic acidosis,
drug intoxication, hyperpnoea, cirrhosis or organic central nervous system
disorders.
Hypocapnoea with respiratory alkalosis is common finding secondary to
hyperventilation. With decline of 1mm of Hg arterial CO 2 tension there is 2%
reduction in cerebral perfusion leading to cerebral hypoxia 1. Respiratory alkalosis
increases affinity of Oxygen to hemoglobin and associated hypophosphatemia
impairs generation of 2-3 DPG (diphosphoglycerate), both this leads to reduced
availability of Oxygen to tissues1.
Cardiovascular response is related to duration of hyperventilation 1. Initially
decrease in systemic vascular resistance and blood pressure with tachycardia is
present 1. Within four to seven minutes this response is lost. Patient develops
coronary vasospasm, coronary insufficiency and chest pain mimics like angina.
Journal of Evolution of Medical and Dental Sciences/ Volume 2/ Issue 15/ April 15, 2013
Page-2460

CASE REPORT
Dyspnea and chest pain may persist for prolong duration and are not caused by
only hypocapnea but also excessive use of thoracic musculature 1.
If not treated patient may develop muscular twitching, carpopedal spasm
and tetany due to hypocalcaemia. Pulse oxymetry is normal; ABG shows normal
PH, low PaCO2, low HCO3, respiratory alkalosis. ECG shows abnormal lowering or
inversion of the T-wave and, less frequently, depression of the ST segment 2.
Patient of HVS is treated by termination of the procedures, giving upright
position, reassuring him and by breathing Carbon di oxide enriched air. It is
advisable to give intramuscular Valium 10mg or intravenous Dormicum 5mg and
monitor vital signs.
Drug therapy in patients with HVS is essentially a symptomatic treatment. 3
Reassure the patient, terminate procedure, correction of respiratory alkalosis by
breathing CO2 enriched air through paper bag or full face mask or hand cupped
over face is the definitive treatment1,4.
To relive anxiety Benzodiazepines are given along with opiates. Beta-adrenergic
blockers are useful for removing sympathetically mediated symptoms such as
palpitations, trembling, and sweating4. Monoamine oxidase inhibitors may be
prescribed in patients with panic anxiety and multiple automatic symptoms 3.
Clomipramine and imipramine also help to restore Paco 2to normal in states of
panic.3. Benzodiazepines reduce subjective complaints and treat HVS 3,5.
Benzodiazepines are generally used for prevention of HVS 2,4.But according
to Gregory Magarian anxiolytic or antidepressant medication are not much
useful4.While Shigemasa Tomiokaetal found that propophol is not effective in
treating HVS, he observed improvement in condition of patient after
administration of intravenous Midazolam5.
A beta-adrenergic blocker, propranolol hydrochloride 1.0 mg, was
administered intravenously before the tooth extractions 4 may be effective for
HVS. It is effective in patients who are extremely sensitive and has increased
sympatho-adrenal tone. In these patients propranolol decreases heart rate
without causing a depression in blood pressure 5. However it should be
administered carefully and frequent monitoring of blood pressure,
electrocardiography, and cardiac function is necessary 4.
We used intravenous Midazolam and Tramadol to relieve anxiety and pain.
Patient was operated on next day under sedation and local anesthesia. Aim
behind reporting the case is to make all anesthetists aware of 1HVS which is easy
to treat but difficult to diagnose. As anxiety or stress is the precipitating factor it
is advisable to do the minor dental surgical procedures under sedation to avoid
such complications.
CONCLUSION: HVS can be treated by reassurance of patient, termination of
procedure, ventilation of patient with CO 2 enriched air, anxiolytics and
analgesics. If hypoxia is noted Oxygen supplementation is advisable. Intravenous
Midazolam is effective in relieving anxiety and all symptoms of HVS. Opioids are
preferred to relive pain. To avoid such complications it is advisable to do all minor
dental surgical procedures under local anesthesia and conscious sedation.
REFERENCES:
Journal of Evolution of Medical and Dental Sciences/ Volume 2/ Issue 15/ April 15, 2013
Page-2461

CASE REPORT
1.

2.

3.
4.

5.

GREGORY J MAGARIAN, DEBORAH A MIDDAUGH & DOUGLA LINZ,

Hyperventilation syndrome : A Diagnosis Begging for Recognition, Topics in
primary Care medicine May 1983-138-5
PAUL N. YU.; BERNARD J. B. YIM,.; C. ALPHEUS STANFIELD,
Hyperventilation Syndrome: Changes in the Electrocardiogram, Blood
Gases And Electrolytes during Voluntary Hyperventilation; Possible
Mechanisms and Clinical Implications Arch Intern Med. 1959; 103(6):902913.
JOZEFOWICZ R F; Neurological manifestation of pulmonary disease
Neurolclin 1989Aug7(3) 605-16
SHIGEMASA TOMIOKA, NOBUYOSHI NAKAJO ;Beta-adrenergic blocker for
hyperventilation syndrome in dentistry: A report of three cases; Oral
Science International (2011)8; 34 35
SHIGEMASA TOMIOKA, MASAAKI TAKECHI, NAOHIRO OHSHITA, AND
NOBUYOSHI NAKAJO; Propofol Is Not Effective for Hyperventilation
Syndrome; anesthesia & analgesia March 2001 vol. 92 no. 3 781-782

Journal of Evolution of Medical and Dental Sciences/ Volume 2/ Issue 15/ April 15, 2013
Page-2462