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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.



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