ventricular tachycardia occurred in a hyp othermic
TRANSCRIPT
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Ventricularătachycardiaăunderăhypothermia 393
Ventricularătachycardiaăoccurredăinăaăhypăothermic
patientăduringăemergenceăfromăgeneralăanesthesia
NaoăAoyamaâďźăMutsuhitoăKikuraâďźâďźăTomosueăTakadaââďźăShigeruăKatohďźâ
ăăăăăăăăăăăShunsukeăFujiiďźâďźăYukakoăObataďźâďźăShigehitoăSatoâââďź
Summary Introduction
ăăAă76ďźyearďźoldămanăunderwentătransďźurethralăresecďź
tionăofăbladderătumorăandălaparoscopicătotal
nephroureterectomyăofătheăleftărenalăpelvicăandăbladďź
derătumorăunderăgeneralăanesthesiaăcombinedăwith
lumbarăepiduralăanesthesiaďźăPrematureăventricular
contractionsăandăsubsequentăventricularătachycardia
occurredăatăemergenceăfromăanesthesiaďźăwhenăhis
rectalătemperatureăwasă33ďź50CďźăFollowingăcardiac
massageăandălidocaineăadministrationďźănormalăsinus
rhythmăwasăobtainedďźăTheăarrhythmiasăwereăsusďź
pectedătoăbeămainlyădueătoăanăincreaseăofăventricular
alphaä¸ăandăbetaďźadrenoreceptorăactivationăinducedăby
perioperativeăhypothermiaăandămildăhypercapniaďź
Keyăwordsďźăhypothermiaďźăventricularătachycardiaďź
torsadeădeăpointesďźăgeneralăanesthesiaďźăepiduralăanesďź
thesia
ăăăâJuniorăStaffăAnesthesiologistďźăDepartmentăofăAnestheďź
ăăăsiologyăandăPainăClinicďźăSeireiďźMikatabaraăGeneralăHosďź
ăăăpitalďźăShizuokaďźăJapan
ăăâďźSeniorăStaffăAnesthesiologistďźăDepartmentăofăAnestheďź
ăăăsiologyăandăPtainăClinicďźăSeireiďźMikatabaraăGeneralăHosďź
ăăăpitalďźăShizuokaďźăJapan
âââSeniorăSta¥făAnesthesiologistďźăDepartmentăofăAnestheďź
ăăăsiologyăandălntensiveăCareďźăHamamatsuăMedicalăCenterďź
ăăăShizuokaăJapanăďźandăâďźďź
ďźďźďźďźProfessorăandăChairmanďźăDepartmentăofăAnesthesiolďź
ăăăogyăandălntensiveăCareďźăHamarnatsuăUniversityăSchool
ăăăofăMedicineďźăShizuokaďźăJapan
Theăperioperativeămaintenanceăofănoçżothermiaăis
associatedăwithăaăreducedăincidenceăofămorbidăcardiac
eventsăandăventricularătachycardiaDďźăandăperioperaďź
tiveăcardiovascularămorbidityăcontinuesătoăbeăanăimďź
portantăclinicalăproblemăforămostăpatientsăbeingăconďź
sideredăforămajorănoncardiacăsurgery23ďźďźăAdvanced
ageďźăperiphera1ăvascularăarteriosclerosisďźăscheduled
abdominalăsurgica1ăprocedureďźăopenălegăpositionďźăand
generalăandăepiduralăcombinedăanesthesiaăhaveăbeen
reportedătoăbeărisksăforătheăperioperativeădysrhythďź
miasiďźďźăWeăreportăventricularătachycardiaăpossibly
inducedăbyăhypothermiaăinăanăelderlyăpatientăundergoďź
ingăurologicalăsurgeryăunderăgenera1ăandăepidural
anesthesiaďź
Caseăreport
ăăAă76ďźyearďźoldămanďź154ďź3cmďźă44ďź2kgďźăwasăschedďź
uledăforătransďźurethralăresectionăofăbladderătumorăand
laparoscopicătotalănephroureterectomyăofătheăleftăreďź
nalăpelvicăandăbladderătumorďźăTheăpreoperativeăconďź
ditionăofătheăpatientăwasăAmericanăSocietyăAnesthesiďź
ologistsăďźASAďźăllďźăNewăYorkăHeartăAssociationăClassiďź
ficationăŚďźăandăweăhadănotăobservedăanyămedicalăhisďź
toryăaboutădyspneaăorăchestăpainăonăeffortďźăTheăpaďź
tientăhadănotăreceivedăbetaďźblockadeăorăanyăother
medicationăpreoperativelyďźăElectrocardiographyăand
chestăXďźraysăshowedănoăabnormalăfindingsďźăHemaďź
tologicălaboratoryăvaluesăwereăalsoăwithinătheănormal
rangeďźălnătheăwardďźăhisăheartărateăandăbloodăpressure
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394 垪ç°ĺśĺžĄçŹŹ25塝珏4ĺˇďź2004ďź
wereă76ăbeatsăperăminutesăandă134ďź75ďź94ďźmmHgďź
respectivelyďźăandăhisăbodyătemperatureămeasuredăin
theăaxillaryăwasă36ďź40Cďźăandătheăcoreătemperatureăin
theăoperatingăroomămeasuredăinătheăeardrumăwas
36ďź30CďźăAnăepiduralăcatheterăwasăplacedăatătheălumďź
bară3ďź4ăintervertebra1ăspaceăbeforeăinductionăofăgenďź
era1ăanesthesiaďźăandă10ďźoălidocaineă5miăandă100ďźLrgăof
fentanylăwereăadministeredďźăfollowedăbyăcontinuous
infusionăofă10ďźoălidocaineăată5ďź7mlďźhourăviaătheăcatheterďź
Generalăanesthesiaăwasăinducedăwithă5mgădroperidolďź
2stglkgăfentanylďźă1ďź5mgďźkgăpropofolďźăandăOďź2mglkg
vecuroniumďźăandămaintainedăwithă1ďź5ďź20ďźoăsevoflurane
andă500ďźoănitrousăoxideăinăoxygenăunderăcontrolled
ventilationătoămaintainătheăP2CO2ăatăbetweenă35ăand
40mmHgďźăTheăpatientăwasămonitoredăwithăllďźlead
electrocardiographďźăleftăradialăarterialăbloodăpressureďź
pulseďźoxymetryďźăandăendďźtidalăcapnogramďźAnesthesia
intelligentămonitoringăsystemiTMďźăHelsinkiďźăFinlandďźďź
Allăfiuidălinesăwereăwarmedăduringătheăoperationďźăand
aăheatďźmoistureăexchangeădeviceăandăaăcirculating
waterămattressăďźTďźpumpďźăGaymarăindustriesďźălncďźďźăNYďź
USAďźăwereăsetăată38ďź50Cďź
ăăFirstďźătransďźurethralăresectionăofăbladderătumorăwasăăăăăâ
performedăforă45ăminutesăinătheăopenălegăpositionďź
andăsecondďźătota1ălaparoscopicănephrectomyăfollowed
byăopenăureterectomyăwasăperformedăforătheănextă3
hoursăandă37ăminutesăinătheărightălateralăjackďźknife
positionďźăRectalătemperatureădecreasedătoă33ďź5â
afterătransďźurethralăresectionăofăbladderătumorďźăand
wasăkeptăată33ďź2ďź33ďź3âăuntilăcompletionăofăsurgeryďź
Afterăsurgeryďźăforcedďźairăwarmingăwasăstartedďźăand
theăpatientăwasăventilatedăwithă1000ďźoăoxygenďźăThe
oxygenăsaturationďźSpO2ďźăonătheărightăfootăshowed
970ďźoďźăandăthatăonătheăleftăfootă700ďźoďźăTheăheartărate
andăbloodăpressureăwereă63ăbeatsăperăminuteăand
113ďź62mmHgďźărespectivelyďźăAfterăconfirmingăsponďź
taneousărespirationďźăatropineă1ďźOmgăandăneostigmine
2ďźOmgăwereăadministeredďźăApproximatelyă10ăminďź
utesălaterďźă5ďź6ăprematureăventricularăcontractionsăper
minuteăwereărecognizedďźăandăthenďźăelectrocardiograph
wasăchangedătoăventricularătachycardiaďźFigďźă1ďźďź
Afterăcardiacămassageăďź120ătimesiminďźăandăintravenous
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ăăăăăăăăăăăăFigureă1ăVentricularăTachycardiaăandăradialăarteryăbloodăpressure
Electrocardiogramăďźllďźleadďźăandăleftăradialăarteryăbloodăpressureăduringătheăepisodeăofăventricularătachycardiaďź
Figureă1ďźAăandă1ďźBăareăchronologicalďź
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administrationăofă2mgďźkgăofă20ďźoălidocaineďźăventricular
tachycardiaădisappearedăandănormalăsinusărhythmăwas
obtainedăwithinălăminuteďźăArterialăbloodăgasăanalysis
atăthisăpointăindicatedăpHďźă7ďź301ďźăPaCO2ďźă7ďźOkPa
ďź53mmHgďźăďźăPaO2ďźă62ďź6kPaăďź471mmHgďźăďźăandăHCO3ä¸ďź
26mmovaďźăâOtherăelectrolyteăandăcellăbloodăcount
dataăwereăNaâďźă140mmovaďźăKâďźă3ďź5mmovaďźăCa2âďź
1ďź16rnmolďź1ďźăHtă310ďźoďźăandăHbă11gďźdlďź
ăăNteră15ăminutesăofătheăepisodeďźăalthoughătheărectal
temperatureăwasăstillălowďź33ďź90Cďźďźătheătemperatures
ofăeardrumăandătheăaxillaryăwereă35ďź60Căandă36ďź40Cďź
respectivelyďźăThenďźătheăpatientăwasăextubatedďźăNo
arrhythmiaăorăanyăischemicăchangesăwereăobservedăin
theă12ăleadsăofătheăelectrocardiogramďźăandătheăheart
rateăandăbloodăpressureăwereă72ăbeatsăperăminuteăand
127ďź71mmHgďźărespectivelyďźăSpO2ăshowedărecovery
toă1000ďźoăinăbothărightăandăleftăfeetďźălntraoperatively
administeredătotalăfluidăwasă2500mlďźăurineăoutputăwas
850mlďźăandăbleedingăwasă57mlďź
Discussions
ăăWeăpresentedăaăcaseăofăventricularătachycardiaăthat
occurredăinăaăhypothermicăpatientăduringăemergence
fromăanesthesiaďźăWeăconsideredăthatătheămainăcause
ofăventricularătachycardiaăwasăhypothermiaăunder
generalăandăepiduralăcombinedăanesthesiaďźăHypoďź
thermiaăisăanăindependentăpredictorăofămorbidăcardiac
eventsä¸omăaămultivariateăanalysisďźăindicatingăaă55䝼
ä¸eductionăofăriskăwhenănormothermiaăisămaintainedâďźăďź
Theăpatientăwasăatăhighăriskăofăpostoperativeăhypoďź
thermiaăandăsubsequentăarrhythmiaďźăbecauseăofăadďź
vancedăageďźăperipheralăvascularăarteriosclerosisďź
scheduledăabdominalăsurgicalăprocedureďźăopenăleg
positionďźăandăgeneralăandăepiduralăcombinedăanestheďź
siaât4ďźďźăTheăincidenceăofăhypothermiaăisămoreăfreďź
quentăinăpatientsăunderăregionalăblockăcombinedăwith
generalăanesthesiaăthanătheăpatientsăwithăgeneral
anesthesiaăaloneâďźďźăTheăpatientâsăhypothermicăstate
startedăjustăafterătheăinductionăofăgeneralăanesthesia
andăcontinuedătoătheăendăofăsurgeryďźsurgicalăproceďź
dureďźăaboută5ăhoursďźďźăWeăcouldănotăignoreătheăposďź
sibilityăthatătheătemperatureăofătheăfluidsăusedăduring
resectionăofătheătumorăwasănotăappropriatelyăwarmed
Ventricularătachycardiaăunderăhypothermia 395
upătoă37ďź40âďźăAbruptăincreaseăofăeardrumătemperaďź
tureămightăbeăattributedătoătheăsensorăbeingăaffected
byăforcedďźairăwarmingďź
ăăWeăshouldăhaveăusedăforcedďźairăwarmingăfromăthe
beginningăofăsurgeryďźăForcedďźairăwarmingăisămore
effectiveăforămaintainingăbodyătemperatureăthanăcircuďź
latingăwaterămattressesďźăairwayăheatingăandăhumidifiďź
cationďźăorăintravenousăfluidăwarming5ďźďźăandădecreases
theăincidenceăăťofăshiveringlďźăandăadrenergicăresponse7ďźăďź
Ventricularătachycardiaăoccurredăjustăafterătheăcessaďź
tionăofăgeneralăanesthesiaăandăadministrationăofăneoďź
stigmineăandăatropineďźăTheăpatientăshouldăhaveăbeen
keptăunderăgenera1ăanesthesiaăinăcontrolledăventilaďź
tionăwithoutăreversingătheăeffectăofămuscleărelaxant
untilătheăcoreătemperatureărecoveredătoăatăleastă36ďź5ďź
37ďź00Cďźălnăaăhypothermicăpatientďźăanestheticsămay
protectăpatientsăfromătheăincidenceăofăventricular
tachycardiaăbyăattenuatingăalphaä¸ăandăbetaďźadrenergic
aďźctivationďźăsuchăasďźă1ďźpotentiationăofănorepinephrine
response7ďźďźă2ďźalphaďźmediatedăventricularăectopyădue
toătheăincreasedădelayedăafterădepolarizationďźăwhich
triggersăincreasedăactivityăinăPurkinjeăfibers8ďźďźăand
3ďźăbetaďźadrenoreceptorăactivationăbyănorepinephrine9ďźăďź
ăăTheăcausesăofăventricularătachycardiaăareăconsidďź
eredătoăbeăabnormalitiesăofătheămyocardialăionăchannelďź
whichăareăaggravatedăbyăsympatheticănerveăactivationďź
psychotropicădrugsďźăantibioticsďźăanticancerădmgsďź
electrolyteăabnormalitiesăďźsuchăasăhypokalemiaďźăhypoďź
calcemiaďźăorăhypomagnesemiaďźăďźămyocardialăpotassium
channelăblockingďźăantiďźhyperlipidemiaădrugďźăcerebral
hemorrhageďźăischemicăcoronaryădiseaseďźămitralăvalve
diseaseďźăhypothermiaďźăandăhypothyroidismâOďźďźălnăthe
presentăcaseďźătheăKďźălevelăwasă3ďź5mmoMăandătheăCa2â
levelăwasă1ďź16mmovaďźăandăhypokalemiaăandăhypocalďź
cemiaămightăhaveăcontributedătoăaăcauseăofăventricular
tachycardiaďźăAlthoughăweădidănotămeasureătheăMafâ
levelďźăweăcouldănotăignoreătheăpossibilityăofăhypomagďź
nesemiaăasăaăcontributorăofăthisăarrhythmiaďź
ăăWeăshouldădiscussăotherăpossibleăfactorsăthatăproďź
moteătheăoccurrenceăofăventricularătachycardiaďź
Firstďźăiçżtheăarterialăbloodăgasăanalysisăafterărecovery
fromăventricularătachycardiaďźăPaCO2ăwasă53mmHgďź
andăhypercapniaămightăhaveăpromotedăventricularătachyä¸
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396 垪ç°ĺśĺžĄçŹŹ25塝珏4ĺˇďź2004ďź
cardiaďźăSecondďźăQTăprolongationăandăseriousăarďź
rhythmiaăhaveăbeenăreportedăinăpatientsăreceiving
droperidoliiăťâ2ďźďźăandăweăcannotăneglectătheăpossibility
thatădroperidolămightăbeăoneăofătheăcausesăofătheăinďź
ductionăofăventricularătachycardiaăinătheăpresentăcaseďź
althoughăarrhythmiaăoccurredăafterăseveralăhours
followingăadministrationăofădroperidolďź
ăăInătheăpresentăcaseďźăSpO2ăonătheărightăfootăwasă970ďźoďź
andăonătheăleftăfootăwasă700ďźoăwhenăsurgeryăwasăcomďź
pletedďźăTheăreasonăwhyătheădataăonătheăleftăfoot
wereălowerăthanăthatăofăonătheărightăfootăisănotăclearďź
Howeverďźătheăconstrictionăofătheăperipheralăvasculaďź
tureăofătheăleftăfootădueătoăhypothermiaăandătheăright
lateralăjackďźknifeăpositionămightăhaveăcausedătheădisďź
sociationăofădataăbetweenătheărightăandăleftăfeetďź
ăăInăconclusionďźăweăexperiencedăaăcaseăthatăshowed
ventricularătachycardiaăduringăemergenceăfromăgenďź
era1ăanesthesiaďźăWeăconsideredăthatăarrhythmias
wereămainlyăinducedăbyăventricularăalphaä¸ăandăbetaďź
adrenoreceptorăactivationăunderăperioperativeăhypoďź
thermiaăandămildăhypercapniaăafterăreversalăofămuscuďź
1arărelaxantďźăltămightăbeărecommendedătoămaintain
generalăanesthesiaăuntilărecoveryătoănormothermiaďź
especiallyăinăelderlyăpatientsďź
References
1ďźăFrankăSMďźăFleisherăLAďźăBreslowăMJďźăetăalďźăPerioperaďź
ăăătiveămaintenanceăofănorrnothemiaăreducesătheăinciďź
ăăădenceăofămorbidăcardiacăeventsďźăAărandomizedăclinical
ăăătrialďźăJAMAă1997ďźă277ďźă1127ďź34ďź
2ďźăManganoăDTďźăPerioperativeăcardiacămorbidityďźăAnesďź
ăăăthesiologyă1990ďźă72ďźă153ďź84ďź
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4ďźăSesslerăDIďźăPerianestheticăthermoregulationăandăheat
ăăăbalanceăinăhumansďźăFASEBăJă1993ďźă7ďźă638ďź44ďź
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ăăămildăperioperativeăhypothermiaďźăAărandomizedăclinical
ăăătrialďźăAnesthesiologyă1995ďźă82ďźă83â93ďź
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ăăăSaundersăCoďźă1990ďźăpďź312ďź30ďź
10ďźăAtleeăJLďźăPerioperativeăcardiacădysrhyttmiasďźădiagnosis
ăăăandămanagementďźăAnesthesiologyă1997ďźă86ďźă1397ďź424ďź
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12ďźăDershwitzăMďźăDroperidolďźăshouldătheăblackăboxăbeălight
ăăăăgrayďźăJăClinăAnesthă2002ďźă14ďźă598ďź603ďź
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