Kawasaki disease and anaesthesia

Peripheral Gangrene Associated with Kawasaki Disease and Successful Management Using Prostacycline Analogue: A Case Report

We report a case of child-onset Kawasaki disease that presented as a prolonged fever and manifested with coronary aneurysms and peripheral gangrene of the lower limbs. Therapy with intravenous immunoglobulins, corticosteroids, aspirin, anticoagulants, and ilomedine, a prostacyclin analogue, resulted in rapid improvement in the patient's condition without extremity loss. Those treating patients with Kawasaki disease must be aware of possible vascular ischemia in the disease process that is reversible by early intervention treatments, including the use of a prostacycline analogue, that improve quality of life.

A 15-year review of children with Kawasaki's Syndrome having general anesthesia or deep sedation

BACKGROUND

Children with Kawasaki's syndrome (KS), also known as Kawasaki's disease or 'mucocutaneous lymph node syndrome', have approximately 20-25% incidence of developing coronary artery aneurysms (CAA), stenosis or obliteration if not appropriately diagnosed and treated. In addition some children have myocarditis, pericardial effusions and/or cardiac arrhythmias during the acute phase of KS. Even with current treatment protocols, 2-4% will still be at risk of coronary artery pathology and the long-term implications regarding future coronary artery disease are unknown. Many of these children present for surgical or diagnostic procedures requiring general anesthesia or deep sedation. Only sporadic case reports have been published on the anesthetic experiences of such patients.

METHODS

With Institutional Review approval, we reviewed the medical records of all children with discharge diagnosis of KS from 1985 to 2000 for those receiving general anesthesia or deep sedation. Data abstracted from the medical records included information on any surgical procedures performed any time after onset of KS symptoms, type of anesthetic, perioperative monitoring and presence or absence of operative or perioperative complications.

RESULTS

A total of 178 children with KS were identified of whom 47 (26.4%) received either general anesthesia (34) or deep sedation (13). There were no deaths; one child developed congestive heart failure in the immediate postoperative period associated with KS myocarditis. Five (15%) of those having general anesthesia initially were either not diagnosed as having KS or had no preoperative cardiac evaluations. None of the children having general anesthesia had ST segment analysis, invasive monitoring or troponin measurements perioperatively.

CONCLUSIONS

The high incidence of serious myocardial complications attributable to KS reported in the pediatric literature is rarely noted in the anesthesia literature. We feel there is a potential for more serious perioperative complications among KS children, although we can only speculate why complications are not more frequently encountered. Anesthetists involved in pediatric services are encouraged to consider KS in their diagnosis of children presenting with febrile illnesses with rashes and to consider the possibility of KS myocardial compromise if they encounter unexpected deterioration perioperatively. Preoperative ultrasound examination and perioperative monitoring (e.g. ST segment analysis and troponin measurements) for myocardial compromise are encouraged if KS is suspected.

Peripheral gangrene in adult-onset Kawasaki disease

Kawasaki disease (KD) is an acute vasculitis characterized by marked tropism of the coronary vessels. Usually a childhood disease, KD can occasionally be observed in adults. We report a case of adult-onset KD that presented as a prolonged fever of unknown origin with subsequent development of severe vasculitis, manifested by coronary aneurysms and peripheral gangrene of the lower limbs. Therapy with intravenous immunoglobulins, corticosteroids, aspirin, anticoagulants, and prostacyclin analogue resulted in rapid improvement in the patient's condition but he required partial distal amputation for irreversible gangrene. Peripheral ischaemia leading to gangrene is a very rare feature of KD vasculitis with only 19 cases previously published in the Medline-indexed literature. The outcomes of those patients were poor, being either fatal or requiring distal amputation. All prior cases affected young children less than 1 year old and, to the best of our knowledge, the present case is the first description of peripheral gangrene in adult-onset KD.

The anaesthetic management of a case of Kawasaki's disease (mucocutaneous lymph node syndrome) and Beckwith-Weidemann syndrome presenting with a bleeding tongue

An unusual case of a 13-month-old child with Kawasaki's disease and the Beckwith-Weidemann syndrome is presented. The child, while anticoagulated with warfarin and aspirin to prevent extension of a coronary artery thrombus, fell and lacerated the tongue resulting in haemorrhage and significant swelling. The ongoing haemorrhage, combined with difficulty in securing venous access resulted in the child becoming shocked. Surgical intervention was required to stem the haemorrhage. The anaesthetic management of a shocked child with a coronary artery aneurysm and thrombosis, a potentially difficult airway and a full stomach is described.