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Prevention and Management of Perioperative Dysrhythmias. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00015-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Effects of opioid receptor agonist and antagonist medications on electrocardiogram changes and presentation of cardiac arrhythmia: review article. J Interv Card Electrophysiol 2021; 63:471-500. [PMID: 34674120 DOI: 10.1007/s10840-021-01072-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 10/03/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND/PURPOSE Mortality associated with prescription opioids has significantly increased over the past few decades and is considered a global pandemic. Prescribed opioids can cause cardiac arrhythmias, leading to fatal outcomes and unexpected death, even in the absence of structural cardiac disease. Despite the extent of cardiac toxicity and death associated with these medications, there is limited data to suggest their influences on cardiac electrophysiology and arrhythmias, with the exception of methadone. The goal of our review is to describe the possible mechanisms and to review the different ECG changes and arrhythmias that have been reported. METHODS A literature search was performed using Google Scholar, PubMed, Springer, Ovid, and Science Direct to identify studies that demonstrated the use of prescription opioids leading to electrocardiogram (ECG) changes and cardiac arrhythmias. RESULTS Many of the commonly prescribed opioid medications can uniquely effect the ECG, and can lead to the development of various cardiac arrhythmias. One of the most significant side effects of these drugs is QTc interval prolongation, especially when administered to patients with a baseline risk for QTc prolongation. A prolonged QTc interval can cause lethal torsades de pointes and ventricular fibrillation. Obtaining an ECG at baseline, following a dosage increase, or after switching an opioid medication, is appropriate in patients taking certain prescribed opioids. Opioids are often used first line for the treatment of acute and chronic pain, procedural sedation, medication opioid use disorders, and maintenance therapy. CONCLUSIONS To reduce the risk of cardiac arrhythmias and to improve patient outcomes, consideration of accurate patient selection, concomitant medications, electrolyte monitoring, and vigilant ECG monitoring should be considered.
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Niimi N, Yuki K, Zaleski K. Long QT Syndrome and Perioperative Torsades de Pointes: What the Anesthesiologist Should Know. J Cardiothorac Vasc Anesth 2020; 36:286-302. [PMID: 33495078 DOI: 10.1053/j.jvca.2020.12.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 11/16/2020] [Accepted: 12/07/2020] [Indexed: 02/08/2023]
Affiliation(s)
- Naoko Niimi
- Department of Anesthesiology, Juntendo University, Tokyo, Japan.
| | - Koichi Yuki
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA; Department of Anesthesia, Harvard Medical School, Boston, MA
| | - Katherine Zaleski
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA; Department of Anesthesia, Harvard Medical School, Boston, MA
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Abstract
Ventricular arrhythmias are associated with significant morbidity and mortality. In the perioperative period, more than 10% of patients undergoing a general anesthetic have an abnormal heart rhythm. Arrhythmia development is a dynamic interplay between an arrhythmogenic substrate, myocardial electrophysiologic properties, modifying factors, and triggering factors. Imbalances in the autonomic nervous system can lead to increased myocardial excitability, which is a major contributor to the pathophysiology of ventricular tachyarrhythmias. Myocardial excitability and ventricular arrhythmogenesis is modulated perioperatively through hemodynamic management, electrolyte balance, anesthetic agents, or regional anesthetic and surgical techniques.
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Affiliation(s)
- Kimberly Howard-Quijano
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Biomedical Science Tower W1401, 200 Lothrop Street, Pittsburgh, PA 15213, USA.
| | - Yuki Kuwabara
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Biomedical Science Tower W1401, 200 Lothrop Street, Pittsburgh, PA 15213, USA
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Behzadi M, Joukar S, Beik A. Opioids and Cardiac Arrhythmia: A Literature Review. Med Princ Pract 2018; 27:401-414. [PMID: 30071529 PMCID: PMC6244110 DOI: 10.1159/000492616] [Citation(s) in RCA: 96] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Accepted: 08/02/2018] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE One of the most important side effects of opioids is their influence on the electrical activity of the heart. This review focusses on the effects of opioids on QT interval prolongation and their arrhythmogenic liability. METHODS By using various keywords, papers published up to 2018 in different databases were searched and identified. The search terms were opioids names, corrected QT interval, human-ether-a-go-go gene, torsades de pointes (TdP), cardiac arrhythmias, opioid dependence and other relevant terms. It emphasized the effects of each opioid agent alone on electrocardiogram (ECG) and some interactions. RESULTS Available data indicate that some opioids such as methadone are high-risk even at low doses, and have potential for prolongation of the QT interval and development of TdP, a dangerous ventricular tachycardia. A number of opioids such as tramadol and oxycodone are intermediate risk drugs and may develop long QT interval and TdP in high doses. Some other opioids such as morphine and buprenorphine are low-risk drugs and do not produce QT interval prolongation and TdP at least in routine doses. Opium-consumers are at higher risk of supra-ventricular arrhythmias, sinus bradycardia, cardiac block and atrial fibrillation. CONCLUSION The cardiac arrhythmogenicity of various opioids is different. Methadone has a higher capability to induce long QT interval and dangerous arrhythmias in conventional doses than others. To reduce of arrhythmogenic risk, high doses of opioids must be used cautiously with periodic monitoring of ECG in high-risk consumers such as patients under opioid maintenance treatment.
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Affiliation(s)
- Mina Behzadi
- Cardiovascular Research Center, Institute of Basic and Clinical Physiology Sciences and Department of Physiology and Pharmacology, Afzalipour Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Siyavash Joukar
- Cardiovascular Research Center, Institute of Basic and Clinical Physiology Sciences and Department of Physiology and Pharmacology, Afzalipour Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran
- Physiology Research Center, Institute of Basic and Clinical Physiology Sciences, Kerman University of Medical Sciences, Kerman, Iran
| | - Ahmad Beik
- Physiology Research Center, Institute of Basic and Clinical Physiology Sciences, Kerman University of Medical Sciences, Kerman, Iran
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Kwon CH, Kim SH. Intraoperative management of critical arrhythmia. Korean J Anesthesiol 2017; 70:120-126. [PMID: 28367281 PMCID: PMC5370296 DOI: 10.4097/kjae.2017.70.2.120] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 01/30/2017] [Accepted: 01/31/2017] [Indexed: 02/01/2023] Open
Abstract
The incidence of intraoperative arrhythmia is extremely high, and some arrhythmias require clinical attention. Therefore, it is essential for the anesthesiologist to evaluate risk factors for arrhythmia and understand their etiology, electrophysiology, diagnosis, and treatment. Anesthetic agents reportedly affect normal cardiac electrical activity. In the normal cardiac cycle, the sinoatrial node initiates cardiac electrical activity through intrinsic autonomous pacemaker activity. Sequential atrial and ventricular contractions result in an effective cardiac pumping mechanism. Arrhythmia occurs due to various causes, and the cardiac pumping mechanism may be affected. A severe case may result in hemodynamic instability. In this situation, the anesthesiologist should eliminate the possible causes of arrhythmia and manage the condition, creating hemodynamic stability under proper electrocardiographic monitoring.
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Affiliation(s)
- Chang Hee Kwon
- Division of Cardiology, Department of Internal Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Seong-Hyop Kim
- Department of Anesthesiology and Pain Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
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Cho JS, Kim SH, Shin S, Pak HN, Yang SJ, Oh YJ. Effects of Dexmedetomidine on Changes in Heart Rate Variability and Hemodynamics During Tracheal Intubation. Am J Ther 2016; 23:e369-76. [PMID: 24832388 DOI: 10.1097/mjt.0000000000000074] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Sympathetic hyperactivation during tracheal intubation prolongs the QT interval and increases the risk of arrhythmias. We investigated if dexmedetomidine pretreatment affected autonomic nervous system balance and QT intervals during intubation. Sixty-six patients were randomized to receive 1.0 μg/kg fentanyl (group F, n = 22), 0.5 μg/kg dexmedetomidine (group D0.5, n = 22), or 1.0 μg/kg dexmedetomidine (group D1.0, n = 22) before induction. Autonomic nervous system balance was assessed by the ratio of low-frequency/high-frequency (LF/HF) power for heart rate variability at baseline (T0), before intubation (T1), and after intubation (T2). QT intervals were corrected by the Bazett's formula (QTc) and compared at baseline, before intubation, and 1, 2, and 3 minutes after intubation. The LF/HF ratio was higher after intubation compared with that at T0 in group F (P < 0.001). There were no significant changes in groups D0.5 and D1.0. The LF/HF ratio was significantly higher in group F compared with those in groups D0.5 and D1.0 after intubation (7.9 vs. 2.1 and 2.5; P < 0.001). The heart rate was increased for 3 minutes after intubation in group F, whereas only for 1 minute after intubation in groups D0.5 and D1.0, compared with that at baseline. More patients in group F had QTc greater than 440 ms compared with that in group D0.5 or D1.0 (8 vs. 1 and 2; P = 0.005) at 1 minute after intubation. In contrast to 1.0 μg/kg fentanyl, pretreatment with 0.5 or 1.0 μg/kg dexmedetomidine suppressed sympathetic hyperactivity and attenuated QTc prolongation during intubation.
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Affiliation(s)
- Jin Sun Cho
- Departments of 1Anesthesiology and Pain Medicine and 2Cardiology, Yonsei University College of Medicine, Seoul, Republic of Korea; and 3Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
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Ramakrishna H, O’Hare M, Mookadam F, Gutsche JT, Shah R, Augoustides JG. Sudden Cardiac Death and Disorders of the QT Interval: Anesthetic Implications and Focus on Perioperative Management. J Cardiothorac Vasc Anesth 2015; 29:1723-33. [DOI: 10.1053/j.jvca.2015.07.026] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Indexed: 12/19/2022]
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Öztürk T, Ağdanli D, Bayturan Ö, Çikrikci C, Keleş GT. Effects of conventional vs high-dose rocuronium on the QTc interval during anesthesia induction and intubation in patients undergoing coronary artery surgery: a randomized, double-blind, parallel trial. ACTA ACUST UNITED AC 2015; 48:370-6. [PMID: 25714880 PMCID: PMC4418369 DOI: 10.1590/1414-431x20144294] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 11/11/2014] [Indexed: 11/26/2022]
Abstract
Myocardial ischemia, as well as the induction agents used in anesthesia, may cause
corrected QT interval (QTc) prolongation. The objective of this randomized,
double-blind trial was to determine the effects of high- vs
conventional-dose bolus rocuronium on QTc duration and the incidence of dysrhythmias
following anesthesia induction and intubation. Fifty patients about to undergo
coronary artery surgery were randomly allocated to receive conventional-dose (0.6
mg/kg, group C, n=25) or high-dose (1.2 mg/kg, group H, n=25) rocuronium after
induction with etomidate and fentanyl. QTc, heart rate, and mean arterial pressure
were recorded before induction (T0), after induction (T1), after rocuronium (just
before laryngoscopy; T2), 2 min after intubation (T3), and 5 min after intubation
(T4). The occurrence of dysrhythmias was recorded. In both groups, QTc was
significantly longer at T3 than at baseline [475 vs 429 ms in group
C (P=0.001), and 459 vs 434 ms in group H (P=0.005)]. The incidence
of dysrhythmias in group C (28%) and in group H (24%) was similar. The QTc after
high-dose rocuronium was not significantly longer than after conventional-dose
rocuronium in patients about to undergo coronary artery surgery who were induced with
etomidate and fentanyl. In both groups, compared with baseline, QTc was most
prolonged at 2 min after intubation, suggesting that QTc prolongation may be due to
the nociceptive stimulus of intubation.
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Affiliation(s)
- T Öztürk
- Department of Anesthesiology and Reanimation, School of Medicine, Celal Bayar University, Manisa, Turkey
| | - D Ağdanli
- Department of Anesthesiology and Reanimation, School of Medicine, Celal Bayar University, Manisa, Turkey
| | - Ö Bayturan
- Department of Cardiology, School of Medicine, Celal Bayar University, Manisa, Turkey
| | - C Çikrikci
- Department of Anesthesiology and Reanimation, School of Medicine, Celal Bayar University, Manisa, Turkey
| | - G T Keleş
- Department of Anesthesiology and Reanimation, School of Medicine, Celal Bayar University, Manisa, Turkey
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Ağdanlı D, Öztürk T, Ütük O, Keleş GT. Effects of High-Dose Rocuronium on the QTc Interval During Anaesthesia Induction in Patients Undergoing Coronary Artery Bypass Graft Surgery. Turk J Anaesthesiol Reanim 2014; 42:245-50. [PMID: 27366430 DOI: 10.5152/tjar.2014.64326] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Accepted: 10/21/2013] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE Existing myocardial damage in coronary artery disease patients causes prolonged QT syndrome. The primary objective of this trial is to explore the effects of different doses of the muscle relaxant agent rocuronium (0.6 mg kg(-1) and 1.2 mg kg(-1)) on QTc following anaesthetic induction. The second objective is to determine the incidence and kinds of arrhythmias. METHODS In this prospective and randomized trial, patients undergoing elective coronary artery revascularization surgery were included in one of two groups. Both groups took the same anaesthetic induction agents: midazolam and fentanyl. Rocuronium was administered in Group 1 (n=20) with dose of 0.6 mg kg(-1) and in Group 2 (n=20) with a dose of 1.2 mg kg(-1) for muscle relaxation. Heart rate, average arterial pressure and QTc were recorded before induction (T0), after induction (T1), after muscle relaxant (T2), and 2 minutes (T3) and 5 minutes after intubation (T4). RESULTS QTc was significantly longer 2 minutes after intubation (in Group 1 and Group 2, respectively, 447.9±28.3 and 466.1±37.8 ms) than at the beginning (respectively, 426.9±25.7, 432.0±35.5 ms) (p<0.01). In the intergroup comparison, average QTc values were similar in all trial periods (p>0.05). The prevalence of arrhythmias in between Group 1 (35%, n=7) and Group 2 (15%, n=3) was similar (p=0.06). Arrhythmias were recorded 2 minutes after intubation in both groups (n=10, 25%). CONCLUSION In patients undergoing coronary artery revascularization surgery, rocuronium doses of 0.6 mg kg(-1) and 1.2 mg kg(-1) prolong the QTc interval after intubation. Cardiac arrhythmias related to long QTc arising after intubation should be taken into consideration.
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Affiliation(s)
- Doğuş Ağdanlı
- Clinic of Anaesthesiology, Van İpekyolu State Hospital, Van, Turkey
| | - Tülün Öztürk
- Department of Anaesthesiology and Reanimation, Celal Bayar University Faculty of Medicine, Manisa, Turkey
| | - Ozan Ütük
- Clinic of Cardiology, Grandmedical Hospital, Manisa, Turkey
| | - Gönül Tezcan Keleş
- Department of Anaesthesiology and Reanimation, Celal Bayar University Faculty of Medicine, Manisa, Turkey
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Staikou C, Stamelos M, Stavroulakis E. Impact of anaesthetic drugs and adjuvants on ECG markers of torsadogenicity. Br J Anaesth 2014; 112:217-230. [DOI: 10.1093/bja/aet412] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Effects of esmolol, lidocaine and fentanyl on P wave dispersion, QT, QTc intervals and hemodynamic responses to endotracheal intubation during propofol induction: a comparative study. Rev Bras Anestesiol 2013; 63:235-44. [DOI: 10.1016/s0034-7094(13)70223-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Accepted: 03/03/2012] [Indexed: 11/30/2022] Open
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Fazio G, Vernuccio F, Grutta G, Re GL. Drugs to be avoided in patients with long QT syndrome: Focus on the anaesthesiological management. World J Cardiol 2013; 5:87-93. [PMID: 23675554 PMCID: PMC3653016 DOI: 10.4330/wjc.v5.i4.87] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Revised: 03/05/2013] [Accepted: 03/29/2013] [Indexed: 02/06/2023] Open
Abstract
Long QT syndrome incidence is increasing in general population. A careful pre-, peri- and post-operative management is needed for patients with this syndrome because of the risk of Torsades de Pointes and malignant arrhythmias. The available data regarding prevention of lethal Torsades de Pointes during anesthesia in patients with long QT syndrome is scant and conflicting: only case reports and small case series with different outcomes have been published. Actually, there are no definitive guidelines on pre-, peri- and post-operative anesthetic management of congenital long QT syndrome. Our review focuses on anesthetic recommendations for patients diagnosed with congenital long QT syndrome furnishing some key points for preoperative optimization, intraoperative anesthetic agents and postoperative care plan, which could be the best for patients with c-long QT syndrome who undergo surgery.
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Collins RT. Clinical significance of prolonged QTc interval in Williams syndrome. Am J Cardiol 2011; 108:471-3. [PMID: 21550581 DOI: 10.1016/j.amjcard.2011.03.071] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2011] [Revised: 03/16/2011] [Accepted: 03/16/2011] [Indexed: 01/05/2023]
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Abstract
PURPOSE Opioids may affect changes in the corrected QT interval (QTc) during anesthetic induction. This study examine whether a single bolus of remifentanil would prolong QTc after laryngeal mask airway (LMA) insertion during sevoflurane induction. MATERIALS AND METHODS Forty women of American Society of Anesthesiologists physical status 1 (ASA PS1) undergoing gynecological surgery were studied. All patients were induced using three vital capacity inhalation inductions with 5% sevoflurane. Two minutes after induction, the inspiratory concentration of sevoflurane was reduced to 2%. Using double-blinded randomization, patients were allocated into one of two groups, receiving either saline (placebo group, n = 20) or 0.25 μg.kg⁻¹ remifentanil (remifentanil group, n = 20) over a period of thirty seconds. Sixty seconds later, LMA insertion was performed. Recordings were taken with a 12-lead electrocardiogram at baseline, 2 min after induction and 1 and 3 min after LMA insertion. QTc was calculated by Bazett's formula. The mean arterial pressure (MAP) and heart rate (HR) were also measured at each time point. RESULTS The QTc interval was significantly prolonged in the placebo group as compared to the remifentanil group at 1 min after LMA insertion (467.8 ± 16.5 vs. 442.7 ± 21.3 ms, p < 0.001). However, there was no significant difference in QTc at 3 min after LMA insertion between the two groups. MAP and HR were significantly higher in the placebo group (p < 0.001). CONCLUSION A single bolus of remifentanil is safe method to attenuate prolonged QTc associated with insertion of LMA.
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Affiliation(s)
- Eun Sung Kim
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea School of Medicine, Seoul, Korea
| | - Hae Wone Chang
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea School of Medicine, Seoul, Korea
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KENYON CHRISTINEA, FLICK RANDALL, MOIR CHRISTOPHER, ACKERMAN MICHAELJ, PABELICK CHRISTINAM. Anesthesia for videoscopic left cardiac sympathetic denervation in children with congenital long QT syndrome and catecholaminergic polymorphic ventricular tachycardia--a case series. Paediatr Anaesth 2010; 20:465-70. [PMID: 20337957 PMCID: PMC3332532 DOI: 10.1111/j.1460-9592.2010.03293.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To describe our experience in the anesthetic management of pediatric patients who have undergone left cardiac sympathetic denervation (LCSD) for congenital long QT syndrome (LQTS) and catecholaminergic polymorphic ventricular tachycardia (CPVT). BACKGROUND Long QT syndrome and CPVT predispose patients to ventricular arrhythmias and sudden death. One treatment option for these patients is LCSD. When these patients present for LCSD or other surgical procedures, anesthetic management is challenging, as many medications may exacerbate QT prolongation. METHODS Retrospective review of the electronic medical records of 22 pediatric patients who underwent LCSD between November 2005 and December 2008. RESULTS Six patients (27%) received midazolam as a premedication. Eleven patients (50%) underwent inhalation induction with sevoflurane. Eighty-six percentage received either sevoflurane or isoflurane for maintenance of anesthesia, while the remaining 14% received a propofol infusion. Nine patients (41%) received esmolol infusions intraoperatively, while one patient (4.5%) received a labetalol infusion. Three patients (14%) received lidocaine infusions. no significant cardiac or other events occurred in any of these patients in the perioperative period. CONCLUSIONS Important anesthetic considerations in this population include avoidance of sympathetic stimulation, correction of any abnormal electrolytes, and the immediate availability of a defibrillator and magnesium sulfate to treat arrhythmias. Anxious patients may benefit from premedication to reduce sympathetic tone. We have safely used both volatile agents and propofol for induction and maintenance of anesthesia. In our experience, intraoperative infusions of beta-blockers and lidocaine seem to be helpful in reducing arrhythmogenic potential, especially in patients with profound QT prolongation.
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Affiliation(s)
| | - RANDALL FLICK
- Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
| | | | - MICHAEL J. ACKERMAN
- Department of Pediatrics, Mayo Clinic, Rochester, MN, USA,Department of Medicine, Mayo Clinic, Rochester, MN, USA,Department of Molecular Pharmacology & Experimental Therapeutics, Mayo Clinic, Rochester, MN, USA
| | - CHRISTINA M. PABELICK
- Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA,Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, USA
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Smithburger PL, Seybert AL, Armahizer MJ, Kane-Gill SL. QT prolongation in the intensive care unit: commonly used medications and the impact of drug–drug interactions. Expert Opin Drug Saf 2010; 9:699-712. [DOI: 10.1517/14740331003739188] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Erdil F, Demirbilek S, Begec Z, Ozturk E, But A, Ozcan Ersoy M. The effect of esmolol on the QTc interval during induction of anaesthesia in patients with coronary artery disease. Anaesthesia 2009; 64:246-50. [DOI: 10.1111/j.1365-2044.2008.05754.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Kim DH, Kweon TD, Nam SB, Han DW, Cho WY, Lee JS. Effects of target concentration infusion of propofol and tracheal intubation on QTc interval*. Anaesthesia 2008; 63:1061-4. [DOI: 10.1111/j.1365-2044.2008.05564.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Chang DJ, Kweon TD, Nam SB, Lee JS, Shin CS, Park CH, Han DW. Effects of fentanyl pretreatment on the QTc interval during propofol induction. Anaesthesia 2008; 63:1056-60. [PMID: 18616522 DOI: 10.1111/j.1365-2044.2008.05559.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Prolongation of the corrected QT (QTc) interval is associated with various anaesthetic drugs. The QTc prolongation may become more exacerbated during laryngoscopy and intubation, which is possibly caused by sympathetic stimulation. The aim of this study was to investigate the effects of fentanyl on the QTc interval during propofol induction in healthy patients. The patients were randomly allocated to receive either fentanyl (n = 25) or saline (n = 25) before induction. The QTc interval was significantly prolonged immediately after intubation in control group compared to preceding values, but it did not change in the fentanyl group. The number of patients with the prolonged QTc interval exceeding 20 ms immediately after intubation compared to the baseline values was 14 in the control group and seven in the fentanyl group. In conclusion, pretreatment with fentanyl 2 microg x kg(-1) significantly attenuated QTc prolongation associated with laryngoscopy and tracheal intubation during propofol induction.
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Affiliation(s)
- D J Chang
- Department of Anaesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
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Owczuk R, Wujtewicz MA, Sawicka W, Piankowski A, Polak-Krzeminska A, Morzuch E, Wujtewicz M. The effect of intravenous lidocaine on QT changes during tracheal intubation. Anaesthesia 2008; 63:924-31. [DOI: 10.1111/j.1365-2044.2008.05525.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Kweon TD, Nam SB, Chang CH, Kim MS, Lee JS, Shin CS, June DB, Han DW. The effect of bolus administration of remifentanil on QTc interval during induction of sevoflurane anaesthesia. Anaesthesia 2008; 63:347-51. [DOI: 10.1111/j.1365-2044.2007.05372.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Drake E, Preston R, Douglas J. Brief review: anesthetic implications of long QT syndrome in pregnancy. Can J Anaesth 2007; 54:561-72. [PMID: 17602043 DOI: 10.1007/bf03022321] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
PURPOSE To review the effects of the long QT syndrome (LQTS) in the parturient and the current anesthetic management of patients with LQTS. SOURCE Relevant articles were obtained from a MEDLINE search spanning the years 1980-2006 and a PubMed search spanning the years 1949-2006. Bibliographies of retrieved articles were searched for additional articles. PRINCIPAL FINDINGS The prevalence of LQTS in the developed world is one per 1,100 to 3,000 of the population. Clinically, LQTS is characterized by syncope, cardiac arrest and occasionally, by a history of seizures. The QT interval can also be prolonged by drugs, electrolyte imbalances, toxins and certain medical conditions. Long QT syndrome patients are at risk of torsades de pointes and ventricular fibrillation. Medical management aims to reduce dysrhythmia frequency. The LQTS is subdivided into different groups (LQT1-6) depending on the cardiac ion channel abnormality. Torsades can be precipitated by adrenergic stimuli such as stress or pain (LQT1 and 2), sudden noises (LQT2) or whilst sleeping (LQT3). Patients with LQTS require careful anesthetic management as they are at high risk of torsades perioperatively despite minimal data on the effects of anesthetic agents on the QT interval. While information on effects of LQTS in pregnancy is limited, the incidence of dysrhythmia increases postpartum. Isolated case reports of patients with LQTS women highlight several peripartum dysrhythmias. CONCLUSION An understanding of LQTS and the associated risk factors contributing to dysrhythmias is important for anesthesthesiologists caring for parturients with LQTS.
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Affiliation(s)
- Elizabeth Drake
- Department of Anesthesia, BC Women's Hospital, Vancouver, British Columbia V6H 3N1, Canada.
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Burjorjee JE, Milne B. Propofol for electrical storm; a case report of cardioversion and suppression of ventricular tachycardia by propofol. Can J Anaesth 2002; 49:973-7. [PMID: 12419728 DOI: 10.1007/bf03016886] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
PURPOSE To present a case report where propofol abolished recurrent ventricular tachycardia (VT) and to suggest a mechanism by which this may have occurred. CLINICAL FEATURES A 65-yr-old male was admitted to the intensive care unit (ICU) with electrical storm. Recurrent episodes of VT persisted despite maximal anti-arrhythmic therapy and resulted in a prolonged ICU course and the need for intra-aortic balloon pump support. This was complicated by an ischemic limb, necessitating an anesthetic for femoral thrombectomy. On several occasions while in the ICU, episodes of VT had resolved with boluses of propofol prior to planned cardioversion. In the operating room, episodes of non-sustained VT resolved after a bolus of propofol and remained suppressed for the duration of the case with the use of a propofol infusion. CONCLUSION The effects of propofol on cardiac conduction and on the autonomic nervous system have been studied but its effects on arrhythmias are not well documented. In this case report, propofol was associated with the resolution and suppression of VT. Recent evidence suggests that sympathetic blockade may be an effective treatment for electrical storm. This may be the mechanism by which propofol can abolish this arrhythmia intraoperatively.
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Affiliation(s)
- Jessica E Burjorjee
- Department of Anaesthesiology, Queen's University, Kingston, Ontario, Canada
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Affiliation(s)
- Samir Patel
- Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
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Michaloudis D, Fraidakis O, Lefaki T, Kanakoudis F, Askitopoulou H. Anaesthesia and the QT interval in humans: effects of halothane and isoflurane in premedicated children. Ugeskr Laeger 1998; 15:623-8. [PMID: 9884845 DOI: 10.1097/00003643-199811000-00001] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The effects of halothane and isoflurane followed by subsequent administration of vecuronium on the QT interval have been investigated during the induction of anaesthesia. Fifty-eight children, ASA I, without cardiovascular and electrolyte abnormalities and not receiving any medication were studied. Anaesthesia was induced with either halothane (n = 28) or isoflurane (n = 30), and was maintained until the end of the study with end-tidal concentrations of 2.5-3%. Recordings of ECG, heart rate and systolic arterial pressure were obtained at the following times: prior to induction of anaesthesia; 1 and 3 min after stable end-tidal concentrations of the induction agent had been reached; 1 and 3 min following vecuronium administration; at the time of tracheal intubation; 1 and 3 min later. Halothane significantly shortened the QTc interval (P < 0.05); isoflurane prolonged it (P < 0.001). Heart rate decreased significantly after halothane administration (P < 0.01); in contrast, heart rate increased after induction of anaesthesia with isoflurane (P < 0.05), increasing further after laryngoscopy and tracheal intubation (P < 0.001). Systolic arterial pressure decreased significantly (P < 0.001) in both groups after induction of anaesthesia and remained decreased until the end of the study. It is concluded that halothane may be a better choice than isoflurane for children with a long QT interval.
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Affiliation(s)
- D Michaloudis
- Anaesthetic Department, University Hospital, Crete, Greece
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