Skip to main content

Brugada Syndrome - The implications for the anesthesiologist

Most Brugada Syndrome (BrS) patients tolerated anesthesia without untoward disease-related complications. 

 Propofol and local anesthetics carry a theoretical risk of arrhythmogenic potential in BrS patients, but clear evidence is lacking. However, awareness of their potential to induce arrhythmias warrants caution, especially with propofol infusions. 
Bupivacaine causes depression of the rapid phase of depolarisation and remains bound to sodium channels longer than other local anaesthetic agents and should be avoided in BrS patients. Regional anaesthetic techniques, especially peripheral nerve blocks, may be considered using limited doses and local anaesthetic adjuncts.
Drugs that block sodium channels such as procainamide and flecainide are contraindicated. Beta-adrenergic blockade and alpha-receptor stimulation (norepinephrine and methoxamine) can augment ST elevation in BrS, whereas beta-adrenergic stimulation minimises such manifestations. Perioperative beta-blockade should be avoided. Ephedrine has been used to treat perioperative hypotension because of its dual action. The use of a low-dose dopamine infusion to maintain heart rate has been described. It is widely advocated to have an infusion of isoprenaline available in case intraoperative ST segment changes occur. Neostigmine can cause ST segment elevation and some authors suggest avoiding it.

 In addition to standard monitoring, ST trend analysis and 5-lead ECG monitoring have been suggested.


Patients with an ICD in place should ideally have it turned off preoperatively to prevent monopolar diathermy causing inappropriate activation. All patients, including those without an ICD, should have external defibrillator pads placed prior to induction of anaesthesia.


Factors that might exacerbate ST segment elevations and subsequently lead to dysrhythmias (e.g., hyperthermia, bradycardia, and electrolyte imbalances, such as hyper- and hypokalemia and hypercalcemia) should be avoided or corrected.
References:
S.M.Carey, Brugada syndrome - a review of the implications for the anaesthetist, Anaesth Intensive Care 2011; 39: 571-577
 2011 Sep;58(9):824-36. doi: 10.1007/s12630-011-9546-y. Epub 2011 Jun 23. - Anesthetic management of patients with Brugada Syndrome: a case series and literature review.



Labels:

Comments

Post a Comment

Popular posts from this blog

The pressure volume loop...

In the pressure-volume loop below, cardiac work is best represented by:   the area of the curve  the slope of the line from points C to D  the distance of the line from points C to D  the slope of a line from points A to D .. .. ... .... ... .... .... .... In the pressure-volume loop below, cardiac work is best represented by:  the area of the curve Cardiac work is the product of pressure and volume and is linearly related to myocardial oxygen consumption. Cardiac work is best represented by the area of the curve of a pressure-volume loop.
Post a Comment
Read more

Anaphylaxis updates part 2- Empty Ventricle Syndrome

Patients with anaphylaxis should not suddenly sit, stand, or be placed in the upright position. Instead, they should be placed on the back with their lower extremities elevated or, if they are experiencing respiratory distress or vomiting, they should be placed in a position of comfort with their lower extremities elevated. This accomplishes 2 therapeutic goals: 1) preservation of fluid in the circulation (the central vascular compartment), an important step in managing distributive shock; and 2) prevention of the empty vena cava/empty ventricle syndrome, which can occur within seconds when patients with anaphylaxis suddenly assume or are placed in an upright position. Patients with this syndrome are at high risk for sudden death. They are unlikely to respond to epinephrine regardless of route of administration, because it does not reach the heart and therefore cannot be circulated throughout the body
Post a Comment
Read more

Steroids In Perioperative period...The Multi-purpose Drugs

1-Steroids are not Bronchodilator ,but have well established usefulness in hyper-reactive airway. They are also said to have a permissive role for bronchodilator medication. They can be administered orally, parenterally or in aerosol form 2- Steroids have been commonly used in chemotherapy for prevention of nausea along with other anti-emetic agents . Dexamethasone was found to be highly effective when given immediately before induction rather than at the end of anesthesia . 3- Steroids do exert analgesic effects. Various routes of administration of steroids include parentral, local infiltration at operated site , as an adjuvant in nerve blocks and central-neuraxial blockade. 4 - Steroids cannot be the mainstay of therapy in anaphylaxis because of the delayed onset of action, so they are used as adjunct after initial treatment with epinephrine. 5- Steroids (Dexamethsone) are of value in reduction or prevention of cerebral edema associated with parasitic infections and neopla...
1 comment
Read more