Dilemmas to Proceed with High-risk NORA Endoscopy: A Case of Patient with Bradycardia

Colorectal cancer is a leading cause of cancer-related morbidity and mortality worldwide. Early diagnosis through colonoscopy remains a cornerstone in improving prognosis. However, performing such diagnostic procedures in elderly patients with significant co-morbidities poses unique challenges. The elderly population, often characterised by age-related physiological changes and multiple co-existing conditions, is especially vulnerable to perioperative complications, including cardiovascular instability, altered drug metabolism, and neurological disturbances. Authors present a rare and clinically significant case of a 62-year-old male patient with suspected colorectal malignancy and baseline sinus bradycardia, referred for diagnostic colonoscopy. Notably, this patient had previously been deferred from undergoing the procedure due to severe perioperative bradycardia at an outside hospital. Comprehensive preoperative evaluation, including Electrocardiography (ECG), echocardiography, and Holter monitoring, revealed no malignant arrhythmias but persistent physiological bradycardia. During the first colonoscopy attempt, profound bradycardia and hypotension occurred following standard sedation, requiring pharmacologic intervention and the eventual abortion of the procedure. A second attempt revealed intraprocedural hypocalcaemia as a contributing factor to both bradycardia and abnormal limb movements, which was successfully managed with intravenous calcium. A third, carefully adjusted sedation protocol-using preprocedure atropine and ketamine-based sedation-resulted in a stable and successful colonoscopy without complications. This case uniquely underscores the need for an individualised, multidisciplinary anaesthetic strategy in elderly patients with baseline conduction abnormalities undergoing Non Operating Room Anaesthesia (NORA). It highlights the interplay between bradycardia, hypocalcaemia, and sedation, emphasising the importance of proactive management, tailored drug selection, and readiness for cardiac intervention in diagnostic procedures with potential physiological risks.