Torsade de pointes during sevoflurane anesthesia in a child with congenital long QT syndrome

We present a case of congenital long QT syndrome which developed torsade de pointes during sevoflurane anesthesia for implantation of an internal cardioverter-defibrillator. The diagnosis, implications and treatment are discussed.     

Torsade de pointes and long QT syndrome following major blood transfusion

We report a rare complication following transfusion of a large volume of blood in an adult patient. An electrophysiological disturbance of the cardiac cycle with prolongation of the QT interval developed, which was followed by recurrent episodes of torsade de pointes, a unique form of ventricular tachycardia. The most likely cause of this acquired long QT syndrome was hypomagnesaemia secondary to massive blood transfusion. Treatment with a magnesium infusion restored the QT interval to normal and temporary ventricular pacing prevented further ventricular arrhythmias.     

Torsade de pointes (TdP) observed during general anesthesia for cerebral aneurysm clipping in a patient with QT prolongation

A 55-year-old woman underwent emergency cerebral aneurysm clipping for subarachnoid hemorrhage (SAH). Her past and family history was unremarkable. Preoperative blood examinations were within normal ranges except for a slight decrease in serum potassium level. ECG showed a prolonged QTc interval (0.54 sec). General anesthesia was induced with propofol, fentanyl and vecuronium, and maintained with 1-1.5% sevoflurane, 50% nitrous oxide in oxygen and intermitted doses of fentanyl. About three hours after starting the operation, bigeminal pulse appeared followed by torsade de pointes. This arrhythmia returned to sinus rhythm by continuous infusion of lidocaine, and operation was performed completely. At the end of the operation, prolonged QT interval (QTc 0.71 sec) was noted. Her postoperative course was unremarkable and she was discharged on postoperative day 44. QT prolongation is a frequently seen ECG abnormality in a patient with SAH. In anesthetic management in this situation, it is important to monitor QT interval closely as well as to use anesthetics that would not exacerbate QT interval prolongation.     

Sevoflurane-associated torsade de pointes in a patient with congenital long QT syndrome genotype 2

Although patients with congenital long QT syndrome (c-LQTS) are considered to be at high risk for anesthesia, few reports describe c-LQTS genotype-specific considerations for anesthesia. We describe a case of torsade de pointes (TdP) caused by sevoflurane in a patient with c-LQTS genotype 2 (LQT2). A 39-year-old woman diagnosed with c-LQTS was scheduled for an elective therapeutic abortion. Immediately after starting the operation, the patient developed TdP. Since pulseless ventricular tachycardia was sustained despite intravenous injection of lidocaine, defibrillation was performed. Analysis of the electrocardiogram revealed that the corrected QT interval before anesthesia was 530 ms and 2.0% sevoflurane markedly prolonged the corrected QT interval to 693 ms. Postoperative studies revealed a mutation in the KCNH2 gene. Anesthesiologists should note that patients with LQT2 could be more susceptible to volatile anesthetics than are those with other major genotypes. Genotype-specific management of anesthesia may reduce the risk of developing TdP during the perioperative period.     

Ventricular tachycardia during general anesthesia in a patient with congenital long QT syndrome

PURPOSE: Congenital long QT syndrome is characterized by a corrected QT interval of at least 440 msec on the electrocardiogram and has been associated with recurrent syncope, documented ventricular arrhythmia and sudden death. There have been numerous articles over the past 20 years describing isolated instances of surgical and anesthesia related complications but the general anesthetic management of the condition remains unclear. CLINICAL FEATURES: An 11-yr-old female with documented long QT syndrome, with two episodes of syncope in the past, was admitted for emergency drainage of left periorbital cellulitis. Anesthesia was induced with propofol, fentanyl and rocuronium, and initially maintained with nitrous oxide and halothane. After 20 min, the patient developed ventricular tachycardia (torsade de pointes). Lidocaine 1 mg.kg(-1) iv was given and the rhythm reverted to normal sinus. Halothane was discontinued and the surgery proceeded without further incident. CONCLUSIONS: Our review of the literature revealed that patients with long QT syndrome whose symptoms are well controlled prior to surgery tend to do well regardless of the anesthetic chosen. There are, however, theoretical reasons to avoid anesthetics which either sensitize the myocardium to catecholamines or which cause an increase in circulating levels of catecholamines.     

Awareness during anesthesia with sevoflurane: a case report

We report a case of a patient who experienced awareness during general anesthesia with sevoflurane. A 71-year-old man, weighing 57 kg, was operated on for a malignant tumor of the parotid gland. He was given 2 mg diazepam orally as a premedication. General anesthesia was induced by thiamylal 200 mg, fentanyl 50 microg, and up to 5% of sevoflurane. Muscle relaxation was obtained with vecuronium 6 mg, and the patient was intubated. After induction, fentanyl 150 microg was added, but no other intravenous anesthetics or muscle relaxants were used. The end-expiratory concentration of sevoflurane was maintained at 0.8% to 1.7% before the start of surgery, and 1.5% to 2.9% during surgery. The operation lasted for 10.4 hours. His left eye was guarded by ointment but kept open for observation by the surgeon of facial movement following muscle stimulation. The surgical course, emergence, and the postoperative course were uneventful. On the fifth postoperative day, the patient started to describe his visual memory during the operation, although he did not remember any pain or discomfort. We believe that visual input through his open eyes, the effect of cranial bone oscillation by the surgery, and the idiosyncrasy of the patient contributed to his intraoperative recall.     

Total intravenous anesthesia for repositioning an implantable defibrillator in a patient with long QT syndrome

We report the case of a 27-year-old woman with congenital long QT syndrome (LQTS) who was scheduled for surgery to reposition an implantable defibrillator. Given the risk of sudden death due to fatal ventricular arrhythmia, the woman required implantation of a defibrillator with pacemaker capability. Combined anesthesia-analgesia was used in order to minimize the risk of ventricular arrhythmia caused by increased serum concentrations of catecholamines. When cardioversion, defibrillation and anti-tachycardia functions had been deactivated, anesthesia was induced with propofol, fentanyl and rocuronium. Anesthesia was maintained with an infusion of propofol and remifentanil. We describe the pathophysiology and treatment of LQTS and discuss anesthetic management for repositioning a defibrillator in a patient with congenital LQTS.     

Dexmedetomidine infusion overdose during anesthesia: A case report

A 12‐kg infant was given intravenous dexmedetomidine 0.2 µg kg^‐1 min^‐1 as an adjunct for general anesthesia. The 60‐fold increase in dexmedetomidine infusion rate caused a biphasic response with initial hypertension followed by bradycardia and hypotension requiring inotropic support. No postoperative or long‐term sequelae were noted. Dexmedetomidine infusion is usually delivered as µg kg^‐1 h^‐1.     

Spinal anesthesia for Cesarean section in a parturient with long QT syndrome

PURPOSE: To report the first use of spinal anesthesia for Cesarean section (CS) in a parturient with a long QT syndrome (LQTS) and an automatic implantable cardiac defibrillator (AICD). Although both general and epidural anesthesia have been described for CS in patients with LQTS, there are no previous case reports on the use of spinal anesthesia. The clinical features, diagnosis, treatment and anesthetic management of LQTS are discussed. CLINICAL FEATURES: A 31-yr-old woman, gravida 2 para 1 known to have LQTS and an AICD, presented in labour at 35 weeks gestation, three weeks before her scheduled CS. Her previous delivery by CS under spinal anesthesia at our institution was uneventful. On this occasion, we elected to administer spinal anesthesia because she was asymptomatic (no arrhythmia or cardiac arrest) for the last few years, was hemodynamically stable, and had received uneventful spinal anesthesia before. CONCLUSION: Spinal anesthesia was used safely for CS in this parturient with LQTS.     

先天性无痛无汗症患儿七氟醚吸入麻醉1例

先天性无痛无汗症(congenital insensitivity to pain with anhidrosis,CIPA)是一种以痛觉丧失、无汗、反复发热、自残、发育迟缓、不同程度的智力低下为主要临床表现的周围神经病,这是一种因编码酪氨酸激酶受体A(tyrosine kinase receptor A,TrkA)蛋白的神经营养因子酪氨酸激酶受体1型(neurotrophic tyrosine kinase receptor type 1,NTRK1)基因失活突变造成的常染色体隐性遗传病。文章报道1例痛觉丧失、无汗、智力低下,外伤后胫骨骨折的先天性无痛无汗症6岁男孩,该患儿仅用七氟醚吸入麻醉即得到了满意的麻醉效果,血流动力学未发生显著波动。     

Acquired long QT syndrome and elective anesthesia in children

We present the case of a child who had had a previous episode of torsades de pointes (TdP) and who was scheduled for elective surgery under general anesthesia. The pathophysiology of this condition and the anesthesia concerns are discussed. An 8-year-old male with a history of osteogenic sarcoma had undergone an uneventful limb salvage procedure 2 years earlier. During a subsequent admission to the hospital, he had had a cardiopulmonary arrest with complete recovery. Telemetry electrocardiogram (ECG) rhythm recordings obtained during the event showed TdP that degenerated into ventricular fibrillation, which then terminated spontaneously. On a subsequent ECG, the QTc interval was 694 ms. The prolonged QT interval was attributed to homeopathic use of cesium chloride supplements and the QT interval normalized after cesium was stopped. He presented for an elective procedure and, with an anesthetic plan that emphasized medications without known effect on the QT interval, had an uneventful perioperative course. The optimal anesthesia plan for patients with prolonged QT or those suspected to be at risk for prolongation of the QT interval has not been well described. Available evidence suggests that using total intravenous anesthesia with propofol may be the safest and was used uneventfully in this case. Additionally, this case emphasizes the need to inquire about the use of supplements and naturopathic medications, even in children, that may have life-threatening side effects or interactions with anesthetic agents.     

Manifestation of Long QT syndrome with normal QTc interval under anesthesia: a case report

Patients with congenital Long QT are known to have normal QT interval in symptom-free period and in the early years of life. Precipitating factors like surgical stress, interactions with anesthetic agents prolonging QT interval, and electrolyte imbalances can manifest with life threatening arrhythmias in congenital or acquired Long QT syndrome. We report a case of concealed LQTS manifesting under anesthesia and its subsequent perioperative course.