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Sagray E, Wackel PL, Cannon BC. Cardiac arrhythmias in Primary Hypokalemic Periodic Paralysis: Case report and Literature Review. HeartRhythm Case Rep 2022; 8:719-723. [PMID: 36310724 PMCID: PMC9596356 DOI: 10.1016/j.hrcr.2022.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Awuah DO, Hussain MS, Ponnapalli A, Deliwala SS, Seedahmed EM, Bachuwa G. Refractory familial hypokalaemic periodic paralysis leading to cardiovascular compromise. BMJ Case Rep 2022; 15:e246674. [PMID: 35131788 PMCID: PMC8823031 DOI: 10.1136/bcr-2021-246674] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2021] [Indexed: 11/03/2022] Open
Abstract
Familial hypokalaemic periodic paralysis (FHPP) is a rare neuromuscular disorder that is classified under periodic paralysis (PP), which is characterised by episodes of muscle weakness. Common triggers include intense exercise, fasting or consumption of carbohydrate-rich meals. Hypokalaemic PP has an incidence of 1 in 100 000; despite the temporal association, cardiac manifestations are exceedingly rare. We present a case of FHPP, a channelopathy presenting with severe refractory hypokalaemia. The challenges with our patient were maintaining potassium levels within normal ranges and initiating a close follow-up plan. Due to the lack of clinical guidance in our case, many aspects of care, including surveillance, medications and genetic testing, remain unaddressed. Medical management includes aggressive correction with supplements, potassium-sparing diuretics and carbonic anhydrase inhibitors. Severe cases of dysrhythmias, especially ventricular fibrillation, require electrophysiology evaluation and possible implantation of a defibrillator to prevent sudden cardiac death.
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Affiliation(s)
- Dominic O Awuah
- Internal Medicine, Hurley Medical Center, Flint, Michigan, USA
| | | | | | | | | | - Ghassan Bachuwa
- Internal Medicine, Hurley Medical Center, Flint, Michigan, USA
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Zagorda B, Camdessanché JP, Féasson L. Pregnancy and myopathies: Reciprocal impacts between pregnancy, delivery, and myopathies and their treatments. A clinical review. Rev Neurol (Paris) 2021; 177:225-234. [PMID: 33648783 DOI: 10.1016/j.neurol.2020.09.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 09/07/2020] [Accepted: 09/30/2020] [Indexed: 11/16/2022]
Abstract
During pregnancy, women undergo physical and physiological changes, which can impact the neuromuscular disease course, but also delivery and fetus health. Generally, there is little impact on the disease course, but sometimes an impairment is noticed, which could be attributed to pregnancy and not to disease progression. Cardiac and respiratory functions have to be assessed at the beginning of pregnancy and a close follow-up is mandatory in case of disorder. Labour and delivery are often impacted. Labour is prolonged because of muscle weakness that is an increased risk of instrumental delivery or Cesarean sections. Patients with myotonic dystrophy are at risk of postpartum hemorrhage. Fetal loss can be associated with fetal disease in myotonic dystrophy, and is at high risk for patients with active inflammatory myopathy only.
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Affiliation(s)
- B Zagorda
- Service de médecine physique et de réadaptation, Hôpital Bellevue, CHU de Saint-Étienne, Saint-Étienne, France; Centre référent maladies neuromusculaires rares, CHU de St Étienne, Euro-NmD, Saint-Étienne, France
| | - J-P Camdessanché
- Service de neurologie, Hôpital Nord, CHU de Saint-Étienne, Saint-Étienne, France; Centre référent maladies neuromusculaires rares, CHU de St Étienne, Euro-NmD, Saint-Étienne, France
| | - L Féasson
- Unité de myologie, service de physiologie clinique et de l'exercice, Hôpital Nord, CHU de Saint-Étienne, Saint-Étienne, France; Centre référent maladies neuromusculaires rares, CHU de St Étienne, Euro-NmD, Saint-Étienne, France.
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Hassett CE, Cho SM, Suarez JI. Tachyarrhythmias and neurologic complications. HANDBOOK OF CLINICAL NEUROLOGY 2021; 177:151-162. [PMID: 33632434 DOI: 10.1016/b978-0-12-819814-8.00004-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Tachyarrhythmias are abnormal heart rhythms with a ventricular rate of 100 or more beats per minute. These rhythms are classified as either narrow or wide-complex tachycardia with further subdivision into regular or irregular rhythm. Patients are frequently symptomatic presenting with palpitations, diaphoresis, dyspnea, chest pain, dizziness, and syncope. Sudden cardiac death may occur with certain arrhythmias. Recognizing tachyarrhythmia and understanding its management is important as a wide spectrum of neurologic complications have been associated with such arrhythmias. The purpose of this chapter is to provide a comprehensive overview on the neurologic complications of tachyarrhythmias, neurologic adverse events of antiarrhythmic interventions, and neurologic conditions that can precipitate tachyarrhythmia.
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Affiliation(s)
- Catherine E Hassett
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Sung-Min Cho
- Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Jose I Suarez
- Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
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Frappaolo A, Vadnais M. Familial hypokalemic periodic paralysis in pregnancy: A case report. J Obstet Gynaecol Res 2019; 45:1608-1612. [PMID: 31215737 DOI: 10.1111/jog.14015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 05/15/2019] [Indexed: 11/27/2022]
Abstract
Familial hypokalemic periodic paralysis (f-hypoPP) is a rare neuromuscular disorder causing intermittent muscle paralysis. Pregnancy can exacerbate f-hypoPP, yet obstetric management is not well documented. We present a case of a nulliparous woman with f-hypoPP, outlining a complete prenatal care plan generalizable to other women with known f-hypoPP. To our knowledge, this is the first obstetric f-hypoPP case to prioritize intrapartum oral potassium over intravenous potassium, as well as to outline the importance of multidisciplinary care. The patient had a spontaneous vaginal delivery at term with an uneventful postpartum period. Muscle weakness and episodes of relative hypokalemia in the second trimester and during labor were effectively treated with oral potassium supplementation. Care was provided by a multidisciplinary team, and caution was taken to avoid known triggers of paralytic episodes.
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Affiliation(s)
- Anna Frappaolo
- Maternal-Fetal Medicine, Atrius Health, Boston, Massachusetts, USA
| | - Mary Vadnais
- Maternal-Fetal Medicine, Atrius Health, Boston, Massachusetts, USA
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Staikou C, Stamelos M, Stavroulakis E. Perioperative management of patients with pre-excitation syndromes. Rom J Anaesth Intensive Care 2018; 25:131-147. [PMID: 30393770 PMCID: PMC6211613 DOI: 10.21454/rjaic.7518.252.stk] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 07/11/2018] [Indexed: 11/27/2022] Open
Abstract
Patients with pre-excitation abnormalities are at a high risk for life-threatening perioperative arrhythmias. In Wolff-Parkinson-White syndrome, the anaesthetics used for invasive diagnostic testing/ablation, should not affect cardiac electrophysiology; propofol, sevoflurane, fentanyl, sufentanil, alfentanil are suitable. In non-ablative surgery, propofol, sevoflurane, isoflurane, fentanyl, alfentanil, sufentanil have been used safely. Among neuromuscular blockers, cis-atracurium, rocuronium and vecuronium are good choices. Ketamine, pancuronium and pethidine should be avoided because of their sympathomimetic actions. Anticholinergic/ anticholinesterase combinations for neuromuscular block reversal should preferably be omitted, while sugammadex seems more attractive. In regional anaesthesia, addition of epinephrine and high sympathetic blocks should be avoided. Hypotension should be treated with pure alpha-adrenergic agonists. Other pre-excitation abnormalities associated with different accessory pathways are the Mahaim Fiber and Lown-Ganong-Levine syndrome. Sympathetic activation should be avoided. Total intravenous anaesthesia with propofol probably represents the safest option. A careful anaesthetic plan and close cooperation with cardiologists are mandatory for successful management.
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Affiliation(s)
- Chryssoula Staikou
- Department of Anaesthesiology, Aretaieio Hospital, Medical School, University of Athens, Athens, Greece
| | - Mattheos Stamelos
- Department of Anaesthesiology, Aretaieio Hospital, Medical School, University of Athens, Athens, Greece
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Sengul T, Saracoglu A, Sener S, Bezen O. The use of sugammadex in a pregnant patient with Wolff-Parkinson-White syndrome. J Clin Anesth 2016; 33:1-4. [PMID: 27555124 DOI: 10.1016/j.jclinane.2015.12.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Revised: 05/15/2015] [Accepted: 12/21/2015] [Indexed: 11/29/2022]
Abstract
Wolff-Parkinson-White (WPW) syndrome is a rare pre-excitation syndrome which develops when atrioventricular conduction occurs through a pathologic accessory pathway known as the bundle of Kent instead of atrioventricular node, hence resulting in tachycardia. Patients with WPW syndrome may experience various symptoms arising from mild-to-moderate chest disease, palpitations, hypotension, and severe cardiopulmonary dysfunction. These patients are most often symptomatic because of cardiac arrhythmias. In this case report, we present an uneventful anesthetic management of a pregnant patient with WPW syndrome undergoing cesarean delivery. A 23-year-old American Society of Anesthesiologists class 2 pregnant patient was diagnosed with WPW syndrome. Her preoperative 12-lead electrocardiogram showed a sinus rhythm at 82 beats per minute, a delta wave, and a short PR interval. After an uneventful surgery, sugammadex 2mg/kg was administered as a reversal agent instead of neostigmine. Then she was discharged to her obstetrics service. Serious hemodynamic disorders may occur in patients with WPW syndrome due to development of fatal arrhythmias. Neostigmine used as a reversal agent in general anesthesia can trigger such fatal arrhythmias by leading changes in cardiac conduction. We believe that sugammadex, which is safely used in many areas in the scope of clinical practice, can be also used for patients diagnosed with WPW syndrome.
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Affiliation(s)
- Turker Sengul
- Department of Anesthesiology and Reanimation, Bilim University Medical Faculty, Istanbul, Turkey.
| | - Ayten Saracoglu
- Department of Anesthesiology and Reanimation, Bilim University Medical Faculty, Istanbul, Turkey
| | - Sibel Sener
- Department of Anesthesiology and Reanimation, Bilim University Medical Faculty, Istanbul, Turkey
| | - Olgac Bezen
- Department of Anesthesiology and Reanimation, Bilim University Medical Faculty, Istanbul, Turkey
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Abstract
Hypokalemic periodic paralysis is a rare genetic disorder characterized by recurrent attacks of skeletal muscle weakness with associated hypokalemia which is precipitated by stress, cold, carbohydrate load, infection, glucose infusion, hypothermia, metabolic alkalosis, anesthesia, and steroids. We encountered one such incidence of prolonged recovery after general anesthesia, which on further evaluation revealed a case of hypokalemic paralysis. The key to successful management of such a patient was vigilant pre-operative evaluation, perioperative monitoring, and aggressive treatment of hypokalemia when it occurs.
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Affiliation(s)
- Haider Abbas
- Department of Anaesthesiology, King George's Medical University, Lucknow, India
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Practical aspects in the management of hypokalemic periodic paralysis. J Transl Med 2008; 6:18. [PMID: 18426576 PMCID: PMC2374768 DOI: 10.1186/1479-5876-6-18] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2007] [Accepted: 04/21/2008] [Indexed: 11/26/2022] Open
Abstract
Management considerations in hypokalemic periodic paralysis include accurate diagnosis, potassium dosage for acute attacks, choice of diuretic for prophylaxis, identification of triggers, creating a safe physical environment, peri-operative measures, and issues in pregnancy. A positive genetic test in the context of symptoms is the gold standard for diagnosis. Potassium chloride is the favored potassium salt given at 0.5–1.0 mEq/kg for acute attacks. The oral route is favored, but if necessary, a mannitol solvent can be used for intravenous administration. Avoidance of or potassium prophylaxis for common triggers, such as rest after exercise, high carbohydrate meals, and sodium, can prevent attacks. Chronically, acetazolamide, dichlorphenamide, or potassium-sparing diuretics decrease attack frequency and severity but are of little value acutely. Potassium, water, and a telephone should always be at a patient's bedside, regardless of the presence of weakness. Perioperatively, the patient's clinical status should be checked frequently. Firm data on the management of periodic paralysis during pregnancy is lacking. Patient support can be found at .
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Pedroviejo V, Planas A, Ayuso M, Chaves R. [Spinal anesthesia in a patient with periodic paralysis due to familial hypopotassemia]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2008; 55:259-260. [PMID: 18543516 DOI: 10.1016/s0034-9356(08)70564-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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Donovan L, Parkins VM, Mahalingham A. Thyrotoxic periodic paralysis in pregnancy with impaired glucose tolerance: a case report and discussion of management issues. Thyroid 2007; 17:579-83. [PMID: 17614780 DOI: 10.1089/thy.2006.0288] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONTEXT Thyrotoxic periodic paralysis (TPP) is an unusual presentation of hyperthyroidism in women. The occurrence of this condition in the context of pregnancy is even more uncommon. Impaired glucose tolerance, pregnancy, and TPP impact overall management of thyrotoxicosis. There is little guidance in the literature for management under this constellation of circumstances. PATIENT AND INTERVENTION This is a case report of a previously healthy 36-year-old Filipino female presenting at 15 weeks gestation with tetraparesis, hypokalemia, and new onset Graves' disease with impaired glucose tolerance. Normal thyroid function was achieved in the mother without further episodes of TPP and a healthy, euthyroid male was delivered at 38 weeks gestation. Acute and long-term management strategies used in this case are described in detail. CONCLUSIONS A synthesis of the available literature allowed development of a practical management strategy applicable to a variety of situations involving TPP in pregnancy.
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Affiliation(s)
- Lois Donovan
- Division of Endocrinology, Department of Internal Medicine, University of Calgary and the Calgary Health Region, Calgary, Alberta, Canada.
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Yamakage M, Namiki A. Calcium channels--basic aspects of their structure, function and gene encoding; anesthetic action on the channels--a review. Can J Anaesth 2002; 49:151-64. [PMID: 11823393 DOI: 10.1007/bf03020488] [Citation(s) in RCA: 102] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
PURPOSE To review recent findings concerning Ca(2+) channel subtype/structure/function from electrophysiological and molecular biological studies and to explain Ca(2+) channel diseases and the actions of anesthetics on Ca(2+) channels. SOURCE The information was obtained from articles published recently and from our published work. PRINCIPAL FINDINGS Voltage-dependent Ca(2+) channels serve as one of the important mechanisms for Ca(2+) influx into the cells, enabling the regulation of intracellular concentration of free Ca(2+). Recent advances both in electrophysiology and in molecular biology have made it possible to observe channel activity directly and to investigate channel functions at molecular levels. The Ca(2+) channel can be divided into subtypes according to electrophysiological characteristics, and each subtype has its own gene. The L-type Ca(2+) channel is the target of a large number of clinically important drugs, especially dihydropyridines, and binding sites of Ca(2+) antagonists have been clarified. The effects of various kinds of anesthetics in a variety of cell types have been demonstrated, and some clinical effects of anesthetics can be explained by the effects on Ca(2+) channels. It has recently become apparent that some hereditary diseases such as hypokalemic periodic paralysis result from calcium channelopathies. CONCLUSION Recent advances both in electrophysiology and in molecular biology have made it possible to clarify the Ca(2+) channel structures, functions, genes, and the anesthetic actions on the channels in detail. The effects of anesthetics on the Ca(2+) channels either of patients with hereditary channelopathies or using gene mutation techniques are left to be discovered.
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Affiliation(s)
- Michiaki Yamakage
- Department of Anesthesiology Sapporo Medical University School of Medicine Sapporo Hokkaido Japan.
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