1
|
Kuntz MT, Eagle SS, Dalal A, Samouil MM, Staudt GE, Londergan BP. What an anesthesiologist should know about pediatric arrhythmias. Paediatr Anaesth 2024. [PMID: 39148245 DOI: 10.1111/pan.14980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2024] [Revised: 07/31/2024] [Accepted: 08/02/2024] [Indexed: 08/17/2024]
Abstract
Identifying and treating pediatric arrhythmias is essential for pediatric anesthesiologists. Pediatric patients can present with narrow or wide complex tachycardias, though the former is more common. Patients with inherited channelopathies or cardiomyopathies are at increased risk. Since most pediatric patients present for anesthesia without a baseline electrocardiogram, the first identification of an arrhythmia may occur under general anesthesia. Supraventricular tachycardia, the most common pediatric tachyarrhythmia, represents a broad category of predominately narrow complex tachycardias. Stimulating events including intubation, vascular guidewire manipulation, and surgical stimulation can trigger episodes. Valsalva maneuvers are unreliable as treatment, making adenosine or other intravenous antiarrhythmics the preferred acute therapy. Reentrant tachycardias are the most common supraventricular tachycardia in pediatric patients, including atrioventricular reciprocating tachycardia (due to a distinct accessory pathway) and atrioventricular nodal reentrant tachycardia (due to an accessory pathway within the atrioventricular node). Patients with ventricular preexcitation, often referred to as Wolff-Parkinson-White syndrome, have a wide QRS with short PR interval, indicating antegrade conduction through the accessory pathway. These patients are at risk for sudden death if atrial fibrillation degenerates into ventricular fibrillation over a high-risk accessory pathway. Automatic tachycardias, such as atrial tachycardia and junctional ectopic tachycardia, are causes of supraventricular tachycardia in pediatric patients, the latter most typically noted after cardiac surgery. Patients with inherited arrhythmia syndromes, such as congenital long QT syndrome, are at risk of developing ventricular arrhythmias such as polymorphic ventricular tachycardia (Torsades de Pointes) which can be exacerbated by QT prolonging medications. Patients with catecholaminergic polymorphic ventricular tachycardia are at particular risk for developing bidirectional ventricular tachycardia or ventricular fibrillation during exogenous or endogenous catecholamine surges. Non-selective beta blockers are first line for most forms of long QT syndrome as well as catecholaminergic polymorphic ventricular tachycardia. Anesthesiologists should review the impact of medications on the QT interval and transmural dispersion of repolarization, to limit increasing the risk of Torsades de Pointes in patients with long QT syndrome. This review explores the key anesthetic considerations for these arrhythmias.
Collapse
Affiliation(s)
- Michael T Kuntz
- Department of Anesthesiology, Division of Pediatric Cardiac Anesthesiology, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - Susan S Eagle
- Department of Anesthesiology, Division of Cardiothoracic Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Aarti Dalal
- Department of Pediatrics, Division of Cardiology, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - Marc M Samouil
- School of Medicine, Meharry Medical College, Nashville, Tennessee, USA
| | - Genevieve E Staudt
- Associated Anesthesiology, PC, Iowa Methodist Medical Center, Des Moines, Iowa, USA
| | - Bevan P Londergan
- Department of Anesthesiology, Division of Pediatric Cardiac Anesthesiology, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
| |
Collapse
|
2
|
Maddali M, Kandachar P, Al-Abri I, Al-Yamani M. Diagnostic lacunae and implications of an automated implantable cardioverter defibrillator implantation in a child with type 3 Long QT (LQT3) syndrome. Ann Card Anaesth 2022; 25:210-213. [PMID: 35417973 PMCID: PMC9244276 DOI: 10.4103/aca.aca_13_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
A diagnosis of congenital long QT interval syndrome based on history and electrocardiogram was made in a child in the absence of readily available genetic testing. A genotype 3 (LQT3) was suspected after exclusion of other variants as the child was non-responsive to beta-blocker and sodium channel blocker medication. As the child continues to show episodic bradycardia, polymorphic ventricular ectopy, and T-wave alternans, a single-chamber automated implantable cardioverter-defibrillator implantation was done successfully. This report highlights how the diagnosis of LQT3 was arrived at as well as the anesthetic challenges in the management of patients with LQTS.
Collapse
|
3
|
Yaman F, Baydogan N, Bilir A, Incesulu A. Anesthesia for a Child with Congenital Long QT Syndrome, a Case Report and Literature Review. Anesth Essays Res 2021; 15:149-151. [PMID: 34667364 PMCID: PMC8462433 DOI: 10.4103/aer.aer_48_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 06/06/2021] [Accepted: 06/06/2021] [Indexed: 11/25/2022] Open
Abstract
Long QT syndrome is an inherited disorder of the heart's electrical activity that may also be associated with malignant arrhythmia and cause sudden death. In addition to this inherited condition, several commonly used anesthetic drugs can prolong the QT interval. We present here a 17-month-old male patient who underwent general anesthesia for a cochlear implant. No cardiac arrhythmia was observed in the patient, whose muscle relaxant effect was reversed using sugammadex. The application of intravenous anesthetics was preferred to maintain anesthesia for this patient and was safely applied.
Collapse
Affiliation(s)
- Ferda Yaman
- Department of Anesthesiology and Reanimation, Faculty of Medicine, University of Eskişehir Osmangazi, Eskişehir, Turkey
| | - Nurdan Baydogan
- Department of Anesthesiology and Reanimation, Faculty of Medicine, University of Eskişehir Osmangazi, Eskişehir, Turkey
| | - Ayten Bilir
- Department of Anesthesiology and Reanimation, Faculty of Medicine, University of Eskişehir Osmangazi, Eskişehir, Turkey
| | - Armagan Incesulu
- Department of Otolaryngology, Faculty of Medicine, University of Eskişehir Osmangazi, Eskişehir, Turkey
| |
Collapse
|
4
|
Anesthesia for Long QT Syndrome. CURRENT ANESTHESIOLOGY REPORTS 2021. [DOI: 10.1007/s40140-021-00480-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
5
|
Kojima A, Mi X, Fukushima Y, Ding WG, Omatsu-Kanbe M, Matsuura H. Elevation of propofol sensitivity of cardiac I Ks channel by KCNE1 polymorphism D85N. Br J Pharmacol 2021; 178:2690-2708. [PMID: 33763865 DOI: 10.1111/bph.15460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 03/13/2021] [Accepted: 03/16/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND AND PURPOSE The slowly activating delayed rectifier K+ channel (IKs ), composed of pore-forming KCNQ1 α-subunits and ancillary KCNE1 β-subunits, regulates ventricular repolarization in human heart. Propofol, at clinically used concentrations, modestly inhibits the intact (wild-type) IKs channels and is therefore unlikely to appreciably prolong QT interval in ECG during anaesthesia. However, little information is available concerning the inhibitory effect of propofol on IKs channel associated with its gene variants implicated in QT prolongation. The KCNE1 single nucleotide polymorphism leading to D85N is associated with drug-induced QT prolongation and therefore regarded as a clinically important genetic variant. This study examined whether KCNE1-D85N affects the sensitivity of IKs to inhibition by propofol. EXPERIMENTAL APPROACH Whole-cell patch-clamp and immunostaining experiments were conducted in HEK293 cells and/or mouse cardiomyocyte-derived HL-1 cells, transfected with wild-type KCNQ1, wild-type or variant KCNE1 cDNAs. KEY RESULTS Propofol inhibited KCNQ1/KCNE1-D85N current more potently than KCNQ1/KCNE1 current in HEK293 cells and HL-1 cells. Immunostaining experiments in HEK293 cells revealed that pretreatment with propofol (10 μM) did not appreciably affect cell membrane expression of KCNQ1 and KCNE1 proteins in KCNQ1/KCNE1 and KCNQ1/KCNE1-D85N channels. CONCLUSION AND IMPLICATIONS The KCNE1 polymorphism D85N significantly elevates the sensitivity of IKs to inhibition by propofol. This study detects a functionally important role of KCNE1-D85N polymorphism in conferring genetic susceptibility to propofol-induced QT prolongation and further suggests the possibility that the inhibitory action of anaesthetics on ionic currents becomes exaggerated in patients carrying variants in genes encoding ion channels.
Collapse
Affiliation(s)
- Akiko Kojima
- Department of Anesthesiology, Shiga University of Medical Science, Otsu, Japan
| | - Xinya Mi
- Department of Physiology, Shiga University of Medical Science, Otsu, Japan
| | - Yutaka Fukushima
- Department of Anesthesiology, Shiga University of Medical Science, Otsu, Japan
| | - Wei-Guang Ding
- Department of Physiology, Shiga University of Medical Science, Otsu, Japan
| | | | - Hiroshi Matsuura
- Department of Physiology, Shiga University of Medical Science, Otsu, Japan
| |
Collapse
|
6
|
Soghomonyan S, Stoicea N, Ackermann W, Bhandary SP. PONV management in patients with QTc prolongation on the EKG. Front Pharmacol 2021; 11:565704. [PMID: 33551794 PMCID: PMC7861054 DOI: 10.3389/fphar.2020.565704] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 11/25/2020] [Indexed: 11/15/2022] Open
Abstract
Postoperative nausea and vomiting (PONV) is a commonly encountered problem in surgical practice. It delays discharge from the post-anesthesia care unit, requires additional resources to treat, and may increase the morbidity in some patients. Many effective drugs are available to treat or prevent PONV, however many of these drugs have the potential to prolong the QTc on the electrocardiogram (EKG) and increase the risk of serious ventricular arrhythmias, in particular, torsade de pointes. The QTc prolongation may be a manifestation of a genetic mutation resulting in abnormal myocyte repolarization or it may be acquired and associated with the use of various medications, electrolyte disorders, and physiological conditions. Patients predisposed to QTc prolongation presenting for surgery constitute a challenging group, since many drugs commonly used for PONV management will put them at risk for perioperative serious arrhythmias. This is an important topic, and our mini-review is an attempt to highlight the problem, summarize the existing experience, and generate recommendations for safe management of PONV for patients, who are at increased risk of QTc prolongation and arrhythmias. Focused prospective studies will help to find definitive answers to the discussed problems and challenges and develop specific guidelines for clinical application.
Collapse
Affiliation(s)
- S Soghomonyan
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - N Stoicea
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - W Ackermann
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - S P Bhandary
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| |
Collapse
|
7
|
Kojima A, Fukushima Y, Itoh H, Imoto K, Matsuura H. A computational analysis of the effect of sevoflurane in a human ventricular cell model of long QT syndrome: Importance of repolarization reserve in the QT-prolonging effect of sevoflurane. Eur J Pharmacol 2020; 883:173378. [DOI: 10.1016/j.ejphar.2020.173378] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 06/26/2020] [Accepted: 07/13/2020] [Indexed: 10/23/2022]
|
8
|
Hashimoto E, Kojima A, Kitagawa H, Matsuura H. Anesthetic Management of a Patient With Type 1 Long QT Syndrome Using Combined Epidural-Spinal Anesthesia for Caesarean Section: Perioperative Approach Based on Ion Channel Function. J Cardiothorac Vasc Anesth 2019; 34:465-469. [PMID: 31371065 DOI: 10.1053/j.jvca.2019.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 06/30/2019] [Accepted: 07/02/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Eisuke Hashimoto
- Department of Anesthesiology, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Akiko Kojima
- Department of Anesthesiology, Shiga University of Medical Science, Otsu, Shiga, Japan.
| | - Hirotoshi Kitagawa
- Department of Anesthesiology, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Hiroshi Matsuura
- Department of Physiology, Shiga University of Medical Science, Otsu, Shiga, Japan
| |
Collapse
|