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Table of Contents
LETTER TO EDITOR  
Year : 2013  |  Volume : 16  |  Issue : 1  |  Page : 69-71
Ventricular extrasystole during peri-operative intravenous dexmedetomidine infusion


1 Department of Anaesthesiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
2 Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Parel, Mumbai, India

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Date of Web Publication2-Jan-2013
 

How to cite this article:
Srivastava D, Solanki SL, Pradhan K, Singh PK. Ventricular extrasystole during peri-operative intravenous dexmedetomidine infusion. Ann Card Anaesth 2013;16:69-71

How to cite this URL:
Srivastava D, Solanki SL, Pradhan K, Singh PK. Ventricular extrasystole during peri-operative intravenous dexmedetomidine infusion. Ann Card Anaesth [serial online] 2013 [cited 2019 Jul 16];16:69-71. Available from: http://www.annals.in/text.asp?2013/16/1/69/105379


The Editor,

A 19 year old female weighing 45 kg was posted for left sided laparoscopic pyeloplasty for congentinal pelvi-ureteric junction obstruction and gross hydronephrosis. Her physical status was ASA class I. Her hemogram, coagulogram, liver fuction test, renal function test, serum electrolytes, preoperative chest X-ray and 12 lead electrocardiogram (ECG) revealed no abnormality. In the operating room, monitoring started with five-lead ECG, pulse oximetry and non-invasive blood pressure, and baseline parameters were noted. A peripheral vein was cannulated in left foreram. Initially, dexmedetomine (DEX) bolus, 1 μg/kg was given over 10 minute, which was followed by its infusion at 0.4 μg/kg/h. Anesthesia was induced with 3 μg/kg fentanyl, 1 mg/ kg propofol and 0.1 mg/kg vecuronium. Trachea was intubated with a 7.5 mm ID cuffed endotracheal tube. A 14F Ryle's tube was placed for gastric decompression. Anesthesia was maintained with sevoflurane (inspiratory concentration 2.5%) in oxygen and air (40:60). The ventilation was controlled and guided by end-tidal CO2 (etCO2) monitoring. The patient was positioned right lateral, pneumoperitonium was created and surgery started. About 25 minutes later, ventricular extrasystoles (VE) were noted. VE were 7-8 per minute. The patient was hemodynamically stable with heart rate of 65/minute, blood pressure of 118/78 mmHg, etCO2 was 36 mmHg; peak airway pressure was 25 mmHg, end-tidal sevoflurane concentration was 2.2%. Arterial blood gas analysis showed pH 7.39, PO2 189 mmHg, PCO2 41 mmHg, HCO3 19 mmol/l, BE - 6 mmol/l and SpO2 98%, Na + 132 mEq/l, K + 4.2 mEq/l. During VE, the intra-abdominal pressure ranged between 13-15 mmHg with carbon dioxide flow of 3 L/min. The surgery was stopped and pneumoperitonium was decompressed, despite decompression, VE persisted. The peak airway pressure decreased to 14 mmHg after decompression of pneumoperitonium. DEX infusion was stopped. After 15 minutes, VE diminished and finally stopped. The surgical procedure was restarted after creating pneumoperitonium to intra-abdonimal pressure between 13-14 mmHg and the surgery lasted for two-hours, no further VE were observed. At the end of surgery, neuromuscular blockade was reversed with neostigmine 50 μg/kg and glycopyrrolate 10 μg/kg. The trachea was extubated and the patient was shifted to postoperative anesthesia care unit for monitoring. Postoperatively, her 12 lead ECG was similar to the preoperative one. She was shifted to ward in evening and discharged on 3 rd postoperative day.

The VEs are bizarre ECG complexes triggered by an ectopic focus. The incidence of VE in clinically normal population is 1% as detected by a standard ECG and 40-75% as detected by 24-48 hours ambulatory ECG recordings. [1] The presence of more than 5 VE in one minute is said to increase cardiac risk in the perioperative period. [2] There is an increased potential for ventricular fibrillation or intraoperative cardiac asystole. [2],[3] Pre-existing heart disease is a known cause of perioperative cardiac arrhythmia. Laparoscopy and pneumoperitonium has been described to be associated with occurrence of sinus tachycardia and VE due to release of catecholamines. [4] Bradyarrhythmias (sinus bradycardia, atrio-ventricular dissociation and asystole) has also been described in relation to laparoscopy and pneumoperitonium due to vagal mediated cardiovascular reflexes, precipitated by stretching of peritoneum. [4] In the present case, VE persisted despite the decompression of pneumoperitonium. Airway obstruction, hypoxia, hypercarbia, low inspiratory oxygen fraction, and inhalational agent halothane are associated with occurrence of ventricular arrhythmias. [3] Light plane of anesthesia and inadequate analgesia are other causes of intra-operative VE and arrhythmias. [3] Depth of anesthesia and analgesia were adequate in our patient as no increase in heart rate and blood pressure were observed during skin incision and laparoscopic port placement. Electrolyte imbalance was also ruled out as a possible cause of VE.

DEX is an α-2 receptor agonist, being increasingly used intraoperatively as sole agent and as adjuvant with other anesthetic agents for its excellent sedative, anxiolytic and analgesic properties. Hypotension and bradycardia are known cardiovascular effects of DEX. The incidence of bradycardia and hypotension is increased when DEX is administered with drugs with negative chronotropic effects commonly used in operating room like propofol, suxamethonium, beta-adrenergic antagonist and anticholinesterase. Bradycardia exaggerated during hypothermia or during vagotonic procedures such as laryngoscopy and following large or rapid bolus doses of DEX. [5] DEX is reported to be useful for treatment and prevention of intra-operative and post-operative tachyarrhythmias during cardiac surgery in pediatric patients. [5],[6] Chrysostomou et al.,[6] reported successful management of atrial and junctional tachyarrhythmias during perioperative period in congenital cardiac surgeries. LeReiger et al.,[5] also reported successful management of a case of junctional ectopic tachycardia during tetralogy of Fallot repair with high doses of dexmedetomidine. They described antiarrhythmic properties of DEX as secondary to stimulation of α2A -adrenergic receptors in the dorsal motor nucleus of the vagus nerve thereby increasing vagal efferent output to the myocardium. However, occurrence of VE during perioperative infusion of intravenous DEX is not reported in literature.We are unable to explain the mechanism of occurrence of VE in this case. However, after exclusion of all other known causes and temporal association of disappearance of VE with stopping of the DEX infusion, we believe that DEX may be the cause of intra-operative VE in our otherwise healthy patient.

 
   References Top

1.Kennedy HL, Whitlock JA, Sprague MK, Kennedy LJ, Buckingham TA, Goldberg RJ. Long-term follow-up of asymptomatic healthy subjects with frequent and complex ventricular ectopy. N Engl J Med 1985;312:193-7.  Back to cited text no. 1
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2.Goldman L, Caldera DL, Nussbaum SR, Southwick FS, Krogstad D, Murray B, et al. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med 1977;297:845-51.  Back to cited text no. 2
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3.Ganny AS, Aguma SA. Intraoperative ventricular bigeminy: Report of 5 cases. Ann Afr Med 2005;4:72-82.  Back to cited text no. 3
    
4.Myles PS. Bradyarrhythmias and laparoscopy: A prospective study of heart rate changes with laparoscopy. Aust N Z J Obstet Gynaecol 1991;31:171-3.  Back to cited text no. 4
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5.LeRiger M, Naguib A, Gallantowicz M, Tobias JD. Dexmedetomidine controls junctional ectopic tachycardia during Tetralogy of Fallot repair in an infant. Ann Card Anaesth 2012;15:224-8.  Back to cited text no. 5
[PUBMED]  Medknow Journal  
6.Chrysostomou C, Beerman L, Shiderly D, Berry D, Morell VO, Munoz R. Dexmedetomidine: A novel drug for the treatment of atrial and junctional tachyarrhythmias during the perioperative period for congenital cardiac surgery: A preliminary study. Anesth Analg 2008;107:1514-22.  Back to cited text no. 6
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Correspondence Address:
Sohan L Solanki
Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Parel, Mumbai
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.105379

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