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Section Editor: Peter J. Davis
Implications of Anesthesia in Children with Long QT Syndrome
Aruna T. Nathan, MBBS, FRCA,* Darryl H. Berkowitz, MB, ChB,† Lisa M. Montenegro, MD,* Susan C. Nicolson, MD,* Victoria L. Vetter, MD, MPH,‡ and David R. Jobes, MD*
BACKGROUND: Patients with congenital long QT syndrome (LQTS) are susceptible to an episodic malignant ventricular tachyarrhythmia known as torsade de pointes, which can result in a cardiac arrest and death. Patients can suffer severe cardiac events resulting in syncope, seizures, and sudden cardiac death during times of physical and emotional stress and when exposed to certain drugs including anesthetics. We describe the occurrence of perioperative adverse events (AEs) related to arrhythmias in children with congenital LQTS exposed to volatile general anesthesia and describe associated risk factors. METHODS: We performed a retrospective cohort study of children with LQTS undergoing general anesthesia for noncardiac surgery or device implant, or revision for cardiac rhythm management. This study was a retrospective chart review with data collection from computerized and electronic patient medical records. RESULTS: Seventy-six patients with congenital LQTS were identiﬁed who had a total of 114 anesthetic encounters. Of the 114 anesthetic encounters, there were 3 AEs, 2 deﬁnite and 1 probable AE, for an incidence of 2.6%. The events occurred in boys (aged 11, 13, and 15 years) while undergoing noncardiac surgery under volatile general anesthesia. All were receiving -blocker therapy preoperatively. The AEs occurred in close proximity to the administration of reversal drugs (anticholinesterase/anticholinergic combinations) and the antiemetic ondansetron. The events occurred during emergence from anesthesia, and exclusively in the group of patients who received both reversal drugs and ondansetron. All were treated successfully with short-term antiarrhythmic drug therapy and discharged the next morning. CONCLUSIONS: There is an increased risk of AEs during periods of enhanced sympathetic activity, especially emergence. This risk seems to be further enhanced if drugs are administered at this time that are known either to prolong the corrected QT interval or the transmural dispersion of repolarization or increase the incidence of tachycardia. Restriction of medications that adversely affect ion channels and intense vigilance and monitoring during this time and in the postoperative phase could help prevent occurrence or progression of AEs. (Anesth Analg 2011;112:1163–8)
ong QT syndrome (LQTS) is a disorder of cardiac ion channels resulting in prolongation of the QT interval on the electrocardiogram (ECG). The use of volatile anesthesia in patients with LQTS continues to be an unresolved clinical issue despite many clinical publications, some proclaiming safety and others offering warnings to the contrary.1–11 The QT interval is defined as the beginning of the QRS complex to the end of the T wave and is used as an indicator of ventricular repolarization12; it is corrected (QTc) for heart rate based on the Bazett formula.13 The diagnosis of LQTS involves more than the measurement of QTc intervals.14 The length of the QT
From the *Division of Cardio-Thoracic Anesthesia, The Children’s Hospital of Philadelphia; †Department of Anesthesia, Pennsylvania Hospital; and ‡Department of Pediatrics, Division of Cardiology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania. Accepted for publication January 21, 2011. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to David R. Jobes, MD, Division of Cardiac Anesthesia, The Children’s Hospital of Philadelphia, 12 NW 40, 3400 Civic Center Blvd., Philadelphia, PA 19104. Address e-mail to firstname.lastname@example.org. edu. Copyright © 2011 International Anesthesia Research Society
interval and changes in the T wave morphology are characteristics used in stratification of LQTS patients at risk of ventricular arrhythmia. Patients with congenital LQTS are susceptible to an episodic malignant ventricular tachyarrhythmia known as torsade de pointes (TdP), which can result in cardiac arrest and death. Patients can suffer severe cardiac events resulting in syncope, seizures, and sudden cardiac death during physical and emotional stress and when exposed to certain drugs. In all genetic subtypes of the syndrome, abnormalities in the ion channels, especially sodium, potassium, and calcium, result in decreases in the outward potassium currents (IKs, IKr, IKl) or increases in the inward sodium or calcium current (INa, ICa-L). These effects increase the action potential duration resulting in prolongation of repolarization and of the QT interval, which is the common phenotype of this condition.15 Twelve LQTS subgroups have been described with LQTS1 to 3 comprising 90% of cases identifiable by genotyping.15,16 Triggers in this disorder are genotype specific and include adrenergic stimulation during exercise and emotional stress (LQTS1, LQTS2), loud noise or startle, emotional states, fear, fright, and exercise (LQTS2), and a pause-dependent trigger mechanism during sleep states
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26 0. Patients were divided into 2 groups. there is a suggestion that a number of patients will have an arrhythmia-related event.20 As with all patients undergoing anesthesia. and discharge summaries for RESULTS Seventy-six consecutive patients with congenital LQTS were identified who underwent a total of 114 anesthetic encounters.Anesthesia in Children with Long QT Syndrome Table 1. The objective of this study was to describe the occurrence of perioperative adverse events (AEs) related to arrhythmias in children with congenital LQTS exposed to volatile general anesthesia and other perioperative physiologic stresses and medications.001 Age ( SD) (y) Male gender Pacemaker or implantable cardioverter deﬁbrillator Volatile anesthetic exposure Table 2. Eligible patients were identified using the following search terms: prolonged QT syndrome.27 11.4 13. there was no change in anesthetic technique for this group of patients (Table 2).17. TX) using nonparametric tests for categorical (Fisher exact) or continuous (MannWhitney U) data. all perioperative medications. An LQTS AE was defined as the occurrence of any arrhythmia requiring treatment with an antiarrhythmic medication or electrical cardioversion.69 1.20 Importantly. Total IV anesthesia (TIVA) with propofol was used in 10 of these encounters.. and long QT interval.36 6. the first line of therapy is -blocker therapy. It seems intuitive that volatile anesthetics that prolong the QT interval through action on myocardial ion channels would place patients at increased risk of development of perioperative arrhythmias. progress notes.1.36 years 6.1 (Stata Corp.77 0. Some patients with LQTS may develop prolongation of the QTc in response to certain drugs or electrolyte imbalances secondary to underlying genetic mutations. and IV sedation in one.4 6.001 0.92 Inhaled anesthesia 103 62 41 42 57 3 IV anesthesia/sedation 11 4 7 3 8 0 Preoperative -blockade 114 66 48 45 69 3 (LQTS3). Demographics are displayed in Table 1. Occurrence of Adverse Events Based on Group and Gender Total encounters Male encounters Female encounters Device Nondevice Intraoperative event/therapy No.19. and hemodynamic and respiratory data were collected.11 12. or even suffer sudden cardiac death despite this therapy. prolonged QTc. These patients were presumed to be at higher risk of having perianesthetic rhythm-related AEs because of the nature of their procedure and the fact that they required devices because of the possibility of high-risk events.7 63 45/45 (100%) 100/103 (97%) P value 0. Of the 114 1164 www. The device group consisted of 30 patients who had 45 anesthetic encounters for placement of a device (pacemaker or implantable cardioverter defibrillator).3 6.74 6.anesthesia-analgesia.10 14. AEs.4 1. LQTS. and postprocedural recovery data including occurrence of arrhythmias. is encouraged in patients with LQTS unless there are contraindications. Demographics and Anesthetic Exposure Adverse event All patients (n 114) 12. hemodynamic instability requiring escalation of cardiovascular support. The record of each eligible patient’s admission for the specific anesthetic encounter was identified in the hospital-based record system (CHARTMAXX ). 114 66 48 45 69 3 Age in 12. However. our computerized anesthesia record system (COMPURECORD ) was accessed to capture all consecutive events through an automatic record capture system for an 8-year period (June 1998 to June 2006).32 12. Patients were cross-referenced in the electronic cardiology database (CardioIMS ) resulting in the confirmation of the diagnosis of congenital LQTS.org ANESTHESIA & ANALGESIA . medications and dose taken before the anesthetic of interest. and operative and postoperative recovery details. specifically examining the admission history. gender. other drugs administered around the time of the AE. College Station.19. Statistical analysis was performed with Stata/SE version 10.7 66 (58%) 45 (40%) 103 (90%) Yes 13. Perioperative stress and anxiety as well as postoperative pain might further increase the risk of arrhythmias. the anesthetic minimum alveolar concentration (MAC). METHODS After obtaining IRB approval. continuation of prescribed antiarrhythmics. The postanesthesia recovery and care of these patients were evaluated by accessing the hospital’s computerized patient record system. name of the procedure performed. or prolongation of hospitalization or admission to the intensive care unit because of arrhythmias in the perioperative period. In those patients in whom perioperative AEs were identified. Patient-specific information obtained included age. medications administered.9%) No 12. Exclusion criteria included patients undergoing cardiac catheterization or cardiac surgery and those patients for whom anesthesia records could not be found. Patients may have subclinical disease that becomes unmasked under certain conditions but returns to the subclinical state when these conditions are removed. there were no data on 12 of 114 encounters.88 6.77 6. Because this system began in the year 2000.9 3 0/45 (0%) 3/103 (2. The noncardiac device group consisted of 46 patients who had 69 anesthetic encounters for all other surgical procedures.18 In LQTS patients. especially -blockers.
and discharged from hospital the next day (Table 5). the male group was younger (males. Sixty-two were males and 48 were females.anesthesia-analgesia.36 years). increasing to 4. but were discharged 24 hours later with no further events. or ondansetron alone.1%) 10 (8. there were no reported AEs. Adverse Events AEs occurred in 3 of 76 patients. The remaining patients received no reversal drugs. and 22. 14.25 MAC in all 3 patients. with the ages being almost identical. anticholinesterase/anticholinergic drug combination) and ondansetron were administered at this time. The AE occurred in close proximity to the administration of IV drugs for reversal of neuromuscular blockade (i.92 years (Table 1). The patients were treated effectively. only patient 2 of the 3 who had AEs had 3 separate anesthetic encounters over an 8. The 1 probable AE occurred in a patient with exposure to isoflurane. with 29.4%) 48 (42.10 6.e. There were no AEs in the encounters using TIVA or IV sedation.74 years. ondansetron. In both of these encounters.. The first encounter was the AE described. Volatile anesthetic concentrations at the time of the AE were at near-awake levels (MAC 0. Interestingly.36 1.63% for the entire cohort. This was in contrast to the 3 male patients who had the AEs whose average age was 13.13% having desflurane.63% for the entire cohort and occurred in males exposed to volatile anesthetics having surgical procedures other than pacemaker or implantable cardioverter defibrillator placement. The second and third encounters involved open reduction and internal fixation of a right-sided radius and ulnar fracture followed 3 months later by removal of hardware. The remaining patients received no reversal drugs. Drugs Used During Emergence from Anesthesia All patients (n 114) 68 (59.01%) 20 (17.84% of the patient encounters involved exposure to volatile anesthetics. IV drugs for reversal of neuromuscular blockade (i.25) in all 3 patients. Desﬂurane Isoﬂurane Sevoﬂurane IV anesthesia with propofol Use of pancuronium for neuromuscular blockade Crossover Between Cohort Groups A number of patients had 1 anesthetic encounter with 5 patients having anesthetic encounters in both the device group and the noncardiac device group. The 1 possible AE occurred in the presence of isoflurane. and desflurane in the other. 11.11 6. There were no AEs in the patients who received propofol anesthesia or the 1 patient who received IV sedation aided by 3% mepivacaine infiltration (Table 3). anticholinesterase/anticholinergic drug combination) and the antiemetic. Upon analysis of the entire cohort.54% having isoflurane. anesthetic encounters. monitored overnight in the cardiac recovery unit. There were no AEs in the 10 patients who received only TIVA with propofol. The 2 definite AEs occurred with exposure to isoflurane in 1 patient. anesthesia was maintained with isoflurane and the patient received reversal at the end of the case without ondansetron.35% if the device group was excluded. The AE occurred exclusively in the group that received both reversal drugs and ondansetron.5%) Adverse event 3 0 0 0 Reversal of neuromuscular blockade ondansetron No ondansetron or reversal of neuromuscular blockade (%) Ondansetron only (%) Reversal of neuromuscular blockade only (%) Postanesthetic Follow-up Of the 102 encounters with full anesthesia data. all in the noncardiac device group. or ondansetron alone. reversal alone.8%) 44 (38. The 3 patients who had AEs were admitted to the postoperative cardiac recovery area with telemetry monitoring.e.77 years versus females. AE Incidence The AE incidence was 2.9%. The AE occurred exclusively in the group that received both reversal drugs and ondansetron with an in-group incidence DISCUSSION Numerous drugs prolong the QT interval and are suspected to serve as triggers for inducing life-threatening May 2011 • Volume 112 • Number 5 www. There were no AEs in these encounters (Table 4). or the 1 patient who received IV sedation aided by 3% mepivacaine infiltration (Table 5). The event incidence was 2. Demographics of Patient Encounters The average age of all patient encounters for the entire cohort was 12. The 2 definite AEs occurred in the presence of isoflurane in 1 patient and desflurane in the other during emergence from anesthesia. reversal alone.6%) 18 (15. The AE occurred at the time of emergence from general anesthesia. Twenty-three patients had multiple anesthetics in each of their respective groups. Volatile anesthetic concentrations were 0.5%) Adverse event 1 2 0 0 2 of 5.7%) 8 (7..org 1165 . When the cohort was divided by gender. 48. The AE occurred during withdrawal of volatile anesthetic while emerging from general anesthesia. Presence of Volatile Anesthetic and Anesthetic Drugs During Anesthesia All patients (n 114) 29 (25. All 3 patients were taking prophylactic -adrenergic blocking medications before admission and had received their -blocker before the surgical procedure.5-month period. 86. In the second encounter. This gender difference disappeared when the encounters were divided into device and noncardiac device groups. there were 52 admissions and 50 discharges from the postanesthesia care unit with no documented AEs in the recovery unit. The third encounter comprised sevoflurane maintenance via a laryngeal mask airway without use of reversal drugs or ondansetron.Table 3.1%) 23 (20.33% having sevoflurane for maintenance of anesthesia. there were 2 definite and 1 probable AEs. There were no AEs in these encounters (Table 4). Table 4.27 6.
especially of the R-on-T variety that can precipitate ventricular fibrillation without a period of TdP.24 Outcome of AE Complete resolution Complete resolution Lidocaine bolus 90 mg 50 mg IV. In our cohort of 76 children with congenital LQTS. Epicardial cells repolarize first. QTc corrected QT interval. nadolol 30 mg twice daily 13 y/male. Only 1 of the observed AEs was described as TdP and resolved with the administration of magnesium. 1166 www. 35. The occurrence of episodes during emergence at a time of increased sympathetic activity.. infusion 30 g/kg/min Complete resolution Table 5. ventricular. Noonan syndrome. TdP can occur under conditions of increased TDR. 35. 5 mg IV Description of AE Tachycardia (heart rate 120 bpm) Bigeminy. Jervell and Lange-Nielsen syndrome. ondansetron. Repolarization occurs asynchronously across the myocardial wall because of nonhomogeneous cellular composition of the myocardial cells and differential density of the various cardiac ion channels producing a physiologic transmural dispersion of repolarization (TDR). QTc 474 ms. administration of anticholinergic and anticholinesterase drugs. LQT long QT.2 kg. A TDR of 75 milliseconds has been found in patients with LQTS. anticholinesterase. and mexiletine. isoﬂurane. nadolol 20 mg bd. Midmyocardial (M) cells. infusion 10 g/ kg/min Treatment of AE Esmolol bolus. 1 2 3 AE adverse event. The normal range for TDR is 40 to 50 milliseconds with the upper limit of normal considered to be 65 milliseconds. anticholinesterase/anticholinergic combination) and ondansetron. such as flecainide. LQT7. All currently used volatile inhaled anesthetics have been reported to prolong the QT interval. vecuronium. tachycardia (heart rate 130 bpm) Emergence from anesthesia Timing Emergence from anesthesia Emergence from anesthesia Drug exposure Sevoﬂurane. One of the events was described as ventricular tachycardia. lidocaine bolus 30 mg IV. we have noted episodes of monomorphic ventricular tachycardia in this population as well.org ANESTHESIA & ANALGESIA . The 3 patients who did have AEs were exposed to reversal drugs (i. and the antiemetic ondansetron support either a synergism of multiple factors with some or possibly minimal contribution of volatile inhaled anesthetics to the arrhythmias. However. Although TdP is the signature arrhythmia associated with LQTS. ondansetron. anticholinesterase. The interval from the peak to the end of the T wave (Tp-e) may be used as a measure of TDR on the precordial ECG leads. potassium supplements 11 y/male. even the incidence of just 1 episode of TdP in 114 anesthetic exposures indicates a continued risk of sudden cardiac death perioperatively. Class I antiarrhythmic drugs.e.Anesthesia in Children with Long QT Syndrome arrhythmias in patients with LQTS. and lidocaine was used to successfully terminate the arrhythmia. QTc 468 ms. The actual clinical incidence of lifethreatening arrhythmias due to prolongation of the QT interval by volatile anesthetics is not known and is difficult to identify because of the concomitant presence of other drugs and circumstances associated with life-threatening arrhythmias in patients with LQTS in the perioperative period. which result in defective inactivation of the cardiac sodium channel. anticholinesterase.7 kg. Description of Adverse Event Occurrence Bilateral inguinal hernia/ hydrocele repair Procedure Oral rehabilitation Oral rehabilitation Demographics 15 y/male. have been used clinically to treat LQTS3. Neither the QRS nor T wave morphology was described. determine the total duration of the action potential. the end of the T wave corresponds with the full recovery of these cells. bd twice a day. the majority of patients did not have AEs despite exposure to volatile anesthetics. mexiletine 300 mg. LQTS3 arises because of mutations in SCN5A. pancuronium. The Tp-e interval is used as an indicator of increased TDR. anticholinergic Sodium pentothal. lidocaine. 53. anticholinergic Torsade de pointes Propranolol bolus 3 mg IV. isoﬂurane. pancuronium. which repolarize last. Similarly. Andersen-Tawil syndrome.anesthesia-analgesia. propranolol (dose unknown) Patient no. these patients may have single premature ventricular contractions. Therefore. it is difficult to know whether the last 2 instances were indeed related to the arrhythmogenicity associated with LQTS. ondansetron. propofol.1 kg. QTc: N/ A.21–23 The third AE was simply described as tachycardia and treated with a -blocker. anticholinergic Sevoﬂurane. desﬂurane. and the peak of the T wave corresponds with the completion of epicardial repolarization.
Additionally. MD. reversal drugs were used in 88 of the 114 patient encounters. Contribution: Conduct of study and manuscript preparation Name: Susan C.27 Postoperative nausea and vomiting (PONV) has a significant role in postanesthesia morbidity and may result in delayed discharge. reversal of neuromuscular blockade without ondansetron. or a more malignant form of the disease. monitoring of ECG changes in response to exposure to frequently used drugs during anesthesia. It provides at best observational data on the incidence of AEs and presumed risk factors in our group of patients. and ondansetron during the emergence phase of the anesthetic. Long QT syndrome and anaesthesia. despite exposure to volatile anesthesia.29 Droperidol received a “black box” warning from the Food and Drug Administration in 2001 as case reports emerged of QT prolongation and TdP when used in high doses. In the entire cohort. and ondansetron. Conclusions and Recommendations There seems to be an increase in the observed incidence of AEs during periods of enhanced sympathetic activity. Berkowitz. ChB. The administration of reversal drugs. anticholinesterase/anticholinergic combinations were found to significantly prolong the QTc interval. Nicolson. the small numbers of subjects. data analysis.25 MAC). data analysis. Again. it was found that both groups of drugs prolong the QTc and warnings against their use in patients with LQTS were issued. inappropriate or inaccurate data entry. Avoidance of offending drugs and intense vigilance and monitoring during this time and in the postoperative phase could help prevent occurrence or progression of AEs. in our study. Booker PD. The occurrence of AEs might also depend on the subtype of LQTS. Contribution: Data analysis and manuscript preparation Name: David R. drugs that are often used during emergence may act in synergy with these triggers and further prolong the QTc to precipitate a ventricular arrhythmia. or neither was used. Future prospective studies are warranted in children with congenital LQTS. It is likely that patients with LQTS with lethal arrhythmias that can be triggered by sympathetic stimuli. and lack of subtyping do not permit firm conclusions. MD. and manuscript preparation REFERENCES 1. and loud noise could be at a higher risk of arrhythmias at the time of emergence when all of these factors occur in concert. and (3) temporal relationship to emergence from anesthesia with presumed increased sympathetic activity. We are unable to comment on the therapeutic compliance of all of our patients who had been prescribed -blocker therapy. the retrospective nature of the study. The retrospective nature of the study raises the possibility of missed events. DISCLOSURES Limitations Our study involved retrospective data collection from computerized records of a small sample of patients with congenital LQTS. the 5-HT3 antagonists became the most widely used group of drugs for PONV. specifically the anticholinergics atropine and glycopyrrolate with the resultant tachycardia has been shown to add to the increased risk of arrhythmias in this set of patients. especially emergence from anesthesia conducted with volatile anesthetics in association with the use of anticholinesterase/anticholinergic drug combinations and the antiemetic ondansetron in children with congenital LQTS.30. no AEs were observed. Tachycardia places these patients at risk of developing TdP and ventricular arrhythmias. the antidopaminergic drug droperidol and the 5-hydroxytryptamine (HT)3 antagonist family of drugs to which the widely used ondansetron belongs. anxiety. there were no AEs in these patients from the time of induction of anesthesia through instrumentation for the device placement.anesthesia-analgesia. and Name: Aruna T. and manuscript preparation Name: Darryl H. MD. conduct of study. MPH. MB. Montenegro. If these 88 encounters are further analyzed (Table 2). The 5-HT3 antagonist family of drugs has also been shown to prolong the QTc. We speculate that genetic subtyping of patients with LQTS could help formulate individualized anesthetic plans for these high-risk patients. especially in combination with the use of reversal drugs.2 In later studies. These observations support the recommendations to avoid ondansetron. fright. After this. Contribution: Conduct of study. the 3 described AEs occurred in close proximity to the administration of reversal drugs. Vetter. which was not uniformly available.90:349 – 66 May 2011 • Volume 112 • Number 5 www.org 1167 . This relationship suggests that a synergism of elements was necessary to produce the arrhythmia. MD. Our ongoing research involves investigating genetic subtyping. Br J Anaesth 2003. Jobes. FRCA.31 In our investigation. Ladusans EJ. It has not been specifically designed or sufficiently powered to determine whether exposure to volatile anesthetics increases the risk of perioperative AEs in patients with congenital LQTS.25–27 In a study of healthy adult patients undergoing otolaryngological surgery. Nathan. This risk seems to be further enhanced if drugs that either prolong QTc or TDR or increase the incidence of tachycardia are administered at this time. which increases cost. Contribution: Study design and conduct of study Name: Lisa M. and the 3 AEs occurred in the group that received both reversal drugs and ondansetron.28 Two groups of drugs have been used as first-line therapies for prevention of PONV. Contribution: Conduct of study and manuscript preparation Name: Victoria L. When ondansetron alone. MBBS. (2) the use of anticholinesterase and anticholinergic combinations. when volatile anesthetic concentrations were quite low ( 0. the 20 patients who received reversal drugs alone had no AEs.The factors common to all 3 of the affected patients were (1) exposure to volatile anesthetic. 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