1 case of malignant arrhythmia after general anesthesia in patients with complete right beam branch conduction block

1Patient informationpatient, male, 59 years old, primary school teacher, height 165 cm, body mass 58 kg, due to "nasal congestion, nasal thick for many years" admission,diagnosis"chronic sinusitis", intended in the general anaesthetic "several sinus window opening under the endoscopy." Old and healthy, no special medical historyelectrocardiogram (ECG) shows: sinus heart rate (HR) is 68 times/min, complete right beam conduction block, echocardiogram (UCG) shows: left ventricle shortening score (FS) 28%, left ventricle blood score (LVEF) 54%, second-tip valve mild reflux, left ventricular contraction function reducedThere were no abnormalities in the laboratory examination, and no obvious abnormality was observed in the chest examinationHeart function level II, cardiology consultation does not provide special treatment adviceAfterthe patient entered the chamber, the right upper limb open venous channel, infusion of sodium potassium magnesium calcium glucose injection 10mL/min, routine vital signs monitoring, automatic non-invasive sleeve band blood pressure (NIBP), pulse oxygen saturation (SpO2), five-conductive co-cardiocardiogram, exhalation of end carbon dioxide (PETCO2)Patient in-room NIBP133/75mmHg, HR68 times/min, SpO2 96%, ECG shows complete right beam conduction blockmask oxygen absorption downstream vein rapid induction, in order of administration: Midazolam 2mg, Shufentani 25 mg, propofol 100mg, Rocum bromide 50mgAfter 1min in the visual laryngos under the trachea intubation, after the successful intubation mechanical control ventilation, moisture volume (VT) 400 to 500mL, respiratory frequency (RR) for 12 times / min, maintain PETCO2 at 35 to 45mmHgInhale with 1% heptifluoride ether during the preparation of the operation, while targeting the infusion of propofol and riffintani maintain the depth of anesthesiaAfter the surgeon disinfected the sterile sheet, the patient's HR began to declineHR down to 50 times/min, immediately give Atropin 0.5mg static note, HR slightly up and then immediately decline, HR reached 22 times / min still have a downward trend, NIBP38/20mmHg, immediately give Atropine 0.5mg, dopamine 5mg, HR rose to 87 times / min, NIBP118/76mmHg Since then, the veins continue to pump isopropylene epinephrine 0.05 to 0.06 sg/ (kg.min), maintain HR between 55 to 70 times / min, the patient's vital signs stable, the surgeon continued surgery, the end of the operation 15min to give Parisib sodium 40mg, dexamethason 10 mg, Toane Jon 2mg after the operation is complete, close the heptafluoree volatile tank and stop pumping propofol, riffinani, ipropyl epinephrine Patients suddenly occurred burst chamber speed, after stopping the drug 1min HR rose to 170 times / min, NIBP is 56/34mmHg, immediately intravenously given Xins ming 1mg, HR down to 105 times / min, NIBP 132/82mmHg, continuous observation, waiting for the patient to stabilize after the anesthesia recovery room (PACU) resuscitation After entering PACU15min, the patient's consciousness is restored, the self-breathing is good, can be opened as directed by the doctor, full oral sputum after the tube, oxygen absorption After THE PACU observed 1h, the patient's vital signs were stable, conscious, accessible in communication, and there was no obvious discomfort, and he was sent back to the ward The next day follow-up patients were generally in good condition, with SpO2 more than 95% and BP stable at 90/60mmHg or above After 3d discharge, no anaesthetic-related complications were found 2 Discuss the combined with the medical history and the entire treatment process, this patient in the course of malignant arrhythmia , consider the following reasons (1) the basic situation of cardiovascular : in this case, the patient's preoperative ECG and the five-conduction electrocardiogram in the operating room showed complete right beam conduction block Full right beam conduction block is very common, in adults 1% to 5% of adults will appear, and age increase, the probability of occurrence increased, has been considered a benign arrhythmia, relative to the complete left beam conduction block, the degree of attention is not high, in clinical practice is often ignored However, studies have shown that complete right beam conduction is associated with cardiovascular risk and overall mortality, and studies have found that patients with complete right beam conduction may also have ventricular fibrillation and Brugada syndrome, which is more likely to have ventricular fibrillation than normal patients Ozeke and other studies have found that Brugada syndrome may be masked in the ECG with a complete right beam conductivity block, with about 3.1% hiding Brugada syndrome The ECG of the complete right beam shone is characterized by the QRS wave with significant widening of the I-conductor, the V1, V2 guide with small r-wave, large R-wave or R-wave twin peak, and the T-wave in the opposite direction to the QRS main wave Expert
Consensus, presented by the Heart Rhythm Association and the European Heart Rhythm Association in 2005
refers to the diagnostic criteria for Brugada syndrome: ECG has three main subtypes: Type I right chest conductor is characterized by "dome- " ST segment elevation, characterized by J-point or elevated ST segment vertices of 2mm, accompanied by T-wave inversion, no obvious ionic line separation Type II J-wave elevation (-2mm) causes the ST segment gradually downward oblique up, "saddle-type", accompanied by forward or two-way T-wave; In addition to , Brugada syndrome is often accompanied by P-wave or QRS wave widening, ST segments can vary, sometimes Brugada syndrome ECG appears hidden, if not carefully identified, detailed medical history, often ignore the diagnosis of Brugada syndrome In this case, brugada syndrome may be combined with the presence of malignant arrhythmia, due to the surgery of the five-conduction electrocardiogram sensitivity is not high, and vulnerable to the electric knife and surrounding muscle activity, the contact of the guide and other conditions, and clinically insufficient understanding of Brugada syndrome, can not be well distinguished Isopropyl epinephrine is suitable for malignant arrhythmias in surgery, and studies have shown that isopropyl epinephrine can effectively control electrical storms caused by Brugada syndrome, which is the preferred drug in this case Therefore, when the patient appears in the preoperative complete right beam conduction block, it is necessary to timely through the multi-conduction electrocardiogram to identify whether the presence of both Brugada syndrome and ventricular fibrillation, to be paid attention to, while closely monitoring during surgery (2) Anaesthetic Causes: Although there are cases of propylene phenol to induce patients with cardiac arrest, but very few, and most of them occur in the introduction of propofol immediately appear symptoms, shfentanil administration will also cause the patient's heart rate decline, but its non-release of histamines, compared to fentanyl on the cardiovascular system is very small the slow dose of administration during anaesthetic induction in this case occurred in the process of disinfection of the tissue by the surgeon after the completion of trachea intubation and did not meet the previous reports And after the operation gave analgesic connection, stop the whole hemp drug and isopropyl epinephrine, the patient appeared in the burst chamber speed, affecting hemodynamics Combined with the case situation, there is no support for anesthesia as the main cause of this adverse event , the treatment of malignant arrhythmia in the adverse events of this case is timely and reasonable The presence of this adverse event may be the main factor of the patient's original complete right beam conduction block hidden Brugada syndrome, intravenous general anaesthetic may also play a certain auxiliary role Through the treatment of patients in this case, for ECG diagnosis as a complete right beam conduction block perioperative patients should be paid attention to, preoperative identification of Brugada syndrome, during surgery to pay close attention to the patient's vital signs, alert to the possible malignant arrhythmia and timely treatment, reduce the risk of anesthesia, improve the safety of perioperative surgery