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Alternating asystole and atrial fibrillation after infusion of propofol and remifentanil with target-controlled infusion.

Hwang WJ, Park CO, Lee Y - Korean J Anesthesiol (2014)

View Article: PubMed Central - PubMed

Affiliation: Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea.

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We describe a case of alternating asystole and atrial fibrillation occurred immediately after start of target-controlled infusion (TCI) of propofol and remifentanil, and late diagnosis of sick sinus syndrome... Postoperative 24 hr-Holter electrocardiography showed a normal sinus rhythm with ten paroxysmal atrial fibrillations with three compensatory pauses of less than 3 s... The target of infusion was the effect-site concentration; Propofol and remifentanil were infused at 2.0 µg/ml in the Schnider model and 1.5 ng/ml in the Minto model, respectively... About 1 min after infusion, electrocardiography revealed atrial fibrillation followed by an asystole of a few seconds... The infusion of propofol and remifentanil was stopped, and electrocardiography restored to a normal sinus rhythm with no additional arrhythmias after approximately 5 min... An initial bolus is necessary to reach the target concentration, and high initial plasma peak concentration is followed... Previous studies found that higher infusion rates of propofol or remifentanil were associated with a significantly higher number of adverse effects... To reduce adverse effects by the overshoot, limiting the drug infusion by adjustment of maximal flow rate or maximal plasma concentration is suggested... In present case, the initial infusion rate of remifentanil for initial loading was 2.27 µg/kg/min for 6 s... If we reduced the maximal flow rate to 100 ml/hr, it might have been 1.11 µg/ kg/min for 20 s with the same target of effect-site concentration... Even though a prolongation of the time to target might occur, we could reduce the risk of adverse events... In conclusion, special attention is needed in the administration of anesthetics with vagomimetic effects in patients with advanced age, with preexisting cardiac disease, and who take drugs associated with cardiac conduction.

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Alternating arrhythmia of asystole and atrial fibrillation after the admisnitration of propofol and remifentanil by target-controlled infusion.
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Figure 1: Alternating arrhythmia of asystole and atrial fibrillation after the admisnitration of propofol and remifentanil by target-controlled infusion.

Mentions: When routine monitors were applied including the bispectral index, the vital sign was 125/85 mmHg- 78 /min- 20 /min- 36.7℃ and SpO2 was 95%. Electrocardiography showed a normal sinus rhythm of 78 /min followed by a sudden change to an atrial fibrillation of 150-160 /min, and blood pressure was 170/100 mmHg. To reduce her anxiety, midazolam 2 mg was administered intravenously. Normal sinus rhythm of 80 /min was restored, and blood pressure was 120/80 mmHg. Anesthesia was induced with etomidate 6 mg and rocuronium 40 mg, and no change was observed on electrocardiography. The main fluid was infused in the antecubital area at a constant speed of 120 ml/hr. Propofol and remifentanil were infused for anesthetic maintenance right after the cannulation site of main fluid by a TCI (Orchestra® Base Primea, Fresenius Vial, Brezins, France). The target of infusion was the effect-site concentration; Propofol and remifentanil were infused at 2.0 µg/ml in the Schnider model and 1.5 ng/ml in the Minto model, respectively. The maximal infusion rate of both drugs was 1,200 ml/hr. The maximal plasma concentrations of propofol and remifentanil were 30.0 µg/ml and 50.0 ng/ml, respectively. About 1 min after infusion, electrocardiography revealed atrial fibrillation followed by an asystole of a few seconds. Atropine 0.5 mg and epinephrine 0.1 mg were administered intravenously twice, but no change was noted on electrocardiography, and an alternating arrhythmia of asystole and atrial fibrillation occurred continuously (Fig. 1). A radial artery was cannulated and blood pressure was monitored continuously. Systolic blood pressure was 120-140 mmHg during atrial fibrillation, and unmeasurable during asystole. Arterial blood gas revealed no remarkable electrolyte disturbance. The infusion of propofol and remifentanil was stopped, and electrocardiography restored to a normal sinus rhythm with no additional arrhythmias after approximately 5 min. The infused dose and duration of propofol and remifentanil were 31.6 mg for 20 s and 22.6 µg for 24 s, respectively.


Alternating asystole and atrial fibrillation after infusion of propofol and remifentanil with target-controlled infusion.

Hwang WJ, Park CO, Lee Y - Korean J Anesthesiol (2014)

Alternating arrhythmia of asystole and atrial fibrillation after the admisnitration of propofol and remifentanil by target-controlled infusion.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4295971&req=5

Figure 1: Alternating arrhythmia of asystole and atrial fibrillation after the admisnitration of propofol and remifentanil by target-controlled infusion.
Mentions: When routine monitors were applied including the bispectral index, the vital sign was 125/85 mmHg- 78 /min- 20 /min- 36.7℃ and SpO2 was 95%. Electrocardiography showed a normal sinus rhythm of 78 /min followed by a sudden change to an atrial fibrillation of 150-160 /min, and blood pressure was 170/100 mmHg. To reduce her anxiety, midazolam 2 mg was administered intravenously. Normal sinus rhythm of 80 /min was restored, and blood pressure was 120/80 mmHg. Anesthesia was induced with etomidate 6 mg and rocuronium 40 mg, and no change was observed on electrocardiography. The main fluid was infused in the antecubital area at a constant speed of 120 ml/hr. Propofol and remifentanil were infused for anesthetic maintenance right after the cannulation site of main fluid by a TCI (Orchestra® Base Primea, Fresenius Vial, Brezins, France). The target of infusion was the effect-site concentration; Propofol and remifentanil were infused at 2.0 µg/ml in the Schnider model and 1.5 ng/ml in the Minto model, respectively. The maximal infusion rate of both drugs was 1,200 ml/hr. The maximal plasma concentrations of propofol and remifentanil were 30.0 µg/ml and 50.0 ng/ml, respectively. About 1 min after infusion, electrocardiography revealed atrial fibrillation followed by an asystole of a few seconds. Atropine 0.5 mg and epinephrine 0.1 mg were administered intravenously twice, but no change was noted on electrocardiography, and an alternating arrhythmia of asystole and atrial fibrillation occurred continuously (Fig. 1). A radial artery was cannulated and blood pressure was monitored continuously. Systolic blood pressure was 120-140 mmHg during atrial fibrillation, and unmeasurable during asystole. Arterial blood gas revealed no remarkable electrolyte disturbance. The infusion of propofol and remifentanil was stopped, and electrocardiography restored to a normal sinus rhythm with no additional arrhythmias after approximately 5 min. The infused dose and duration of propofol and remifentanil were 31.6 mg for 20 s and 22.6 µg for 24 s, respectively.

View Article: PubMed Central - PubMed

Affiliation: Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea.

AUTOMATICALLY GENERATED EXCERPT
Please rate it.

We describe a case of alternating asystole and atrial fibrillation occurred immediately after start of target-controlled infusion (TCI) of propofol and remifentanil, and late diagnosis of sick sinus syndrome... Postoperative 24 hr-Holter electrocardiography showed a normal sinus rhythm with ten paroxysmal atrial fibrillations with three compensatory pauses of less than 3 s... The target of infusion was the effect-site concentration; Propofol and remifentanil were infused at 2.0 µg/ml in the Schnider model and 1.5 ng/ml in the Minto model, respectively... About 1 min after infusion, electrocardiography revealed atrial fibrillation followed by an asystole of a few seconds... The infusion of propofol and remifentanil was stopped, and electrocardiography restored to a normal sinus rhythm with no additional arrhythmias after approximately 5 min... An initial bolus is necessary to reach the target concentration, and high initial plasma peak concentration is followed... Previous studies found that higher infusion rates of propofol or remifentanil were associated with a significantly higher number of adverse effects... To reduce adverse effects by the overshoot, limiting the drug infusion by adjustment of maximal flow rate or maximal plasma concentration is suggested... In present case, the initial infusion rate of remifentanil for initial loading was 2.27 µg/kg/min for 6 s... If we reduced the maximal flow rate to 100 ml/hr, it might have been 1.11 µg/ kg/min for 20 s with the same target of effect-site concentration... Even though a prolongation of the time to target might occur, we could reduce the risk of adverse events... In conclusion, special attention is needed in the administration of anesthetics with vagomimetic effects in patients with advanced age, with preexisting cardiac disease, and who take drugs associated with cardiac conduction.

No MeSH data available.


Related in: MedlinePlus