Department of Anaesthetics, City Hospital, Dudley Road, Birmingham B18 7QH, UK *Corresponding author
Accepted for publication: January 7, 2002
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Abstract |
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Br J Anaesth 2002; 88: 8745
Keywords: anaesthetics i.v., propofol; heart, arrhythmia, tachycardia
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Introduction |
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Case report |
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Succinylcholine was not given. As the patient was unconscious, he was turned on to the left lateral position and cricoid pressure maintained until he showed signs of return of protective airway reflexes and awakening. His arterial pressure was 90/60 mm Hg and the sinus rhythm persisted. The patient was kept under observation. After about 2 h, he complained of severe central chest pain along with electrocardiographic changes of myocardial ischaemia. He was transferred to the coronary care unit and underwent thrombolysis with streptokinase. The further clinical course was uneventful and the patient remained in sinus rhythm until discharge.
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Discussion |
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In one of the first cases reported by Hermann and Vettermann,1 2 the child had a chronic ectopic atrial tachycardia of around 150 min1 that was being treated with verapamil and methyl-digoxin. The cardiac rhythm converted to sinus with a rate of 75 min1 during propofol anaesthesia, which reverted to tachycardia about 35 min after cessation of the anaesthetic. In our case, the rhythm remained in sinus after it was converted by propofol.
Several mechanisms have been proposed as an explanation for this effect of propofol. They include indirect effects such as attenuated sympathetic outflow, enhanced vagal tone, altered baroreceptor reflex sensitivity,6 7 and direct effects such as prolonged atrioventricular conduction.18 Animal studies have shown that propofol would be most effective at filtering atrial impulses during supraventricular tachydysrhythmias.9 Animal studies have also revealed different effects on neonatal and adult hearts with a 10 µM concentration of propofol affecting both but a 100 µM concentration affecting only the neonatal hearts.1 In adult humans, the mean blood concentration of propofol at the onset of unconsciousness after a bolus dose of 2 mg kg1 is approximately 56 µM and an adequate level of anaesthesia is maintained with blood concentrations ranging from 1925 µM10 (but note that the concentration of free propofol will be substantially less than this because of the extent of plasma protein binding of the drug). Indeed, transient atrioventricular conduction block has been reported in an adult who received propofol.11 Paradoxically, propofol anaesthesia has also been associated with inducing SVT that deteriorated to ventricular tachycardia.12
Although cricoid pressure was applied in this case, it is unlikely that it would have contributed to the termination of the rhythm for several reasons: the site of the cricoid pressure is away from that for carotid sinus massage, previous attempts at carotid sinus massage were unsuccessful and the conversion to sinus rhythm was noted during propofol injection.
In summary, this report describes a case of SVT in an adult, which converted to sinus rhythm during administration of propofol.
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References |
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