Cardiac arrest during spinal anaesthesia in a patient with undiagnosed Brugada syndrome

Anaesthetic Management of a Patient with Brugada Syndrome in Total Knee Arthroplasty

We report the case of a 52-year-old female diagnosed with Brugada syndrome (BrS) scheduled to undergo right total knee arthroplasty. General anaesthesia was induced and maintained with thiopental intravenous sodium + remifentanil and sevoflurane + remifentanil infusion, respectively. Rocuronium bromide was used as the muscle relaxant. The defibrillator was ready for use with the electrodes on the patient. Sugammadex was used for muscle relaxant antagonization. Postoperative analgesia was provided by intermittent morphine HCL via an epidural catheter, intravenous patient-controlled analgesia (Meperidine), and intravenous tenoxicam. The patient was discharged on the 6th day without any problem. Anaesthetic management of patients with BrS is challenging for anaesthesiologists, because fatal cardiac arrhythmias can be triggered by many drugs commonly used in the perioperative period such as bupivacaine, lidocaine, neostigmine, propofol, succinylcholine, ketamine, and tramadol. In these cases, a detailed preoperative evaluation including family history, avoidance of drugs triggering arrhythmia, taking precautions against arrhythmia, and using the agents that are reported to be safe are essential for patient safety.

Infraclavicular Brachial Plexus Block and Sugammadex Use in a Paediatric Patient with Wolff-Parkinson--White Syndrome

Background

Wolff–Parkinson–White (WPW) syndrome is a rare disease that can cause various patterns of tachyarrhythmias. The main goal of anaesthesiologists for the perioperative anaesthetic management of WPW patients must be to avoid sympathetic stimulation and prevent tachyarrhythmias.

Case

A 9-year-old male patient with a diagnosis of WPW syndrome, who underwent emergency surgery for supracondylar humerus fracture, is presented. General anaesthesia in combination with infraclavicular brachial plexus (ICBP) block was performed successfully without any complications. For the reversal of neuromuscular block, sugammadex was uneventfully used. Intraoperative sympathetic discharge due to surgical intervention was prevented with ICBP block. The ICBP block has also provided good postoperative analgesia.

Conclusions

Sugammadex is a good alternative for the reversal of neuromuscular blocks to avoid the undesirable effects of cholinergic drugs. Peripheral regional blocks that require relatively large doses of local anaesthetics can be safely performed with utmost attention in paediatric WPW patients.

Diagnosis of type 2 Brugada pattern: insights from a pilot survey

BACKGROUND

Differentiation of Type 2 Brugada Pattern (BP) from incomplete right bundle branch block or normal rSr' pattern can be insidious. The aim of this study was to assess interobserver and intraobserver agreement in the diagnosis of type 2 BP in a cohort of cardiologists with different skills.

METHODS

We collected 14 ECGs with a positive terminal deflection of the QRS complex in lead V1 and V2 at the 4^th intercostal space. We proposed these ECGs, specifying to use 2012 Consensus conference criteria for diagnosis of type 2 BP, to 42 participants: 14 arrhythmologists, 14 general cardiologists and 14 electrophysiology (EP) fellows. The same 14 ECGs, with a different order, were proposed fifteen days later to the same cohort to assess intraobserver variability. Authors analyzed all 14 ECGs in order to assess whether 2012 Consensus Conference criteria for BP were fulfilled. All patients underwent provocative test with IC antiarrhythmics drugs (flecainide) in order to exclude or confirm the diagnosis of Brugada Syndrome (BrS).

RESULTS

Slight interobserver agreement (Fleiss K<0.20) in the diagnosis of type 2 BP was observed in all three categories of cardiologists. Considering five operators per class, intraobserver agreement is variable (k ranging from 0.000 to 0.857), with a slight superiority of arrhytmologists (k minimum value 0.276; k maximum value 0.857).

CONCLUSIONS

This study demonstrated, for the first time, a low interobserver agreement in diagnosis of type 2 BP in categories of cardiologists with different abilities. Reproducibility of type 2 BP diagnosis (intraobserver agreement) is poor, even among experts. These findings highlight the difficulties in analysis of ECG with BrS suspicion and, therefore, underscore the key role of clinical and anamnestic data.