Canadian Journal of Anesthesia

, Volume 49, Issue 9, pp 973–977 | Cite as

Propofol for electrical storm; a case report of cardioversion and suppression of ventricular tachycardia by propofol

Cardiothoracic Anesthesia, Respiration and Airway

Abstract

Purpose

To present a case report where propofol abolished recurrent ventricular tachycardia (VT) and to suggest a mechanism by which this may have occurred.

Clinical features

A 65-yr-old male was admitted to the intensive care unit (ICU) with electrical storm. Recurrent episodes of VT persisted despite maximal anti-arrhythmic therapy and resulted in a prolonged ICU course and the need for intra-aortic balloon pump support. This was complicated by an ischemic limb, necessitating an anesthetic for femoral thrombectomy. On several occasions while in the ICU, episodes of VT had resolved with boluses of propofol prior to planned cardioversion. In the operating room, episodes of non-sustained VT resolved after a bolus of propofol and remained suppressed for the duration of the case with the use of a propofol infusion.

Conclusion

The effects of propofol on cardiac conduction and on the autonomic nervous system have been studied but its effects on arrhythmias are not well documented. In this case report, propofol was associated with the resolution and suppression of VT. Recent evidence suggests that sympathetic blockade may be an effective treatment for electrical storm. This may be the mechanism by which propofol can abolish this arrhythmia intraoperatively.

Le propofol et la tempête électrique; l’observation d’un cas de cardioversion et de suppression de la tachycardie ventriculaire par le propofol

Résumé

Objectif

Présenter un cas où le propofol a aboli une tachycardie ventriculaire récurrente (TV) et tenter d’expliquer le mécanisme qui a produit cet effet.

Éléments cliniques

Un homme de 65 ans a été hospitalisé à l’unité des soins intensifs (USI), victime d’une tempête électrique. Des épisodes récurrents de TV ont persisté malgré un traitement antiarythmique maximal et ont entraîné un traitement prolongé à l’USI et le besoin d’un ballon intra-aortique. La situation s’est compliquée par une ischémie d’un membre, ce qui a nécessité une anesthésie pour thrombectomie fémorale. À quelques reprises, à l’USI, des épisodes de TV ont été traités avec des bolus de propofol avant la cardioversion planifiée. Dans la salle d’opération, des épisodes non soutenus de TV ont été supprimés après un bolus de propofol et sont demeurés ainsi pendant toute la durée de l’intervention avec l’utilisation d’une perfusion de propofol.

Conclusion

Les effets du propofol sur la conduction cardiaque et sur le système nerveux autonome ont été étudiés, mais ses effets sur les arythmies ne sont pas encore bien connus. Dans le cas présent, le propofol est associé à la résolution et à la suppression de TV. Des observations récentes portent à croire que le blocage sympathique pourrait traiter efficacement la tempête électrique. C’est peut-être le mécanisme par lequel le propofol peut abolir l’arythmie pendant l’opération.

References

  1. 1.
    Nademanee K, Taylor R, Bailey WE, Rieders DE, Kosar EM. Treating electrical storm. Sympathetic blockade versus advanced cardiac life support-guided therapy. Circulation 2000; 102: 742–7.PubMedGoogle Scholar
  2. 2.
    Miro O, de la Red G, Fontanals J. Cessation of paroxysmal atrial fibrillation during acute intravenous propofol administration (Letter). Anesthesiology 2000; 92: 910.PubMedCrossRefGoogle Scholar
  3. 3.
    Hermann R, Vettermann J. Change of ectopic supraventricular tachycardia to sinus rhythm during administration of propofol. Anesth Analg 1992; 75: 1030–2.PubMedCrossRefGoogle Scholar
  4. 4.
    dos Santos JET. Propofol suppresses premature atrial contractions during anesthesia (Letter). Pediatr Cardiol 1998; 19: 272.PubMedCrossRefGoogle Scholar
  5. 5.
    Alphin RS, Martens JR, Dennis DM. Frequency-dependent effects of propofol on atrioventricular nodal conduction in guinea pig isolated heart. Mechanism and potential antidysrhythmic properties. Anesthesiology 1995; 83: 382–94.PubMedCrossRefGoogle Scholar
  6. 6.
    Pires LA, Huang SKS, Wagshal AB, Kulkarni RS. Electrophysiological effects of propofol on the normal cardiac conduction system. Cardiology 1996; 87: 319–24.PubMedCrossRefGoogle Scholar
  7. 7.
    Ikeno S, Akazawa S, Shimizu R, et al. Propofol does not affect the canine cardiac conduction system under autonomic blockade. Can J Anesth 1999; 46: 148–53.PubMedGoogle Scholar
  8. 8.
    Sharpe MD, Dobkowski WB, Murkin JM, Klein G, Yee R. Propofol has no direct effect on sinoatrial node function or on normal atrioventricular and accessory pathway conduction in Wolff-Parkinson-White Syndrome during alfentanil/midazolam anesthesia. Anesthesiology 1995; 82: 888–95.PubMedCrossRefGoogle Scholar
  9. 9.
    Lavoie J, Walsh EP, Burrows FA, Laussen P, Lulu JA, Hansen DD. Effects of propofol or isoflurane anesthesia on cardiac conduction in children undergoing radiofrequency catheter ablation for tachydysrhythmias. Anesthesiology 1995; 82: 884–7.PubMedCrossRefGoogle Scholar
  10. 10.
    Saarnivaara L, Hiller A, Oikkonen M. QT interval, heart rate and arterial pressures using propofol, thiopentone or methohexitone for induction of anaesthesia in children. Acta Anaesthesiol Scand 1993; 37: 419–23.PubMedGoogle Scholar
  11. 11.
    Lischke V, Wilke HJ, Probst S, Behne M, Kessler P. Prolongation of the QT-interval during induction of anesthesia in patients with coronary artery disease. Acta Anaesthesiol Scand 1994; 38: 144–8.PubMedGoogle Scholar
  12. 12.
    Kleinsasser A, Kuenszberg E, Loeckinger A, et al. Sevoflurane, but not propofol, significantly prolongs the Q-T interval. Anesth Analg 2000; 90: 25–7.PubMedCrossRefGoogle Scholar
  13. 13.
    Cohen TJ, Chengot T, Quan C, Peller AP. Elevation of defibrillation thresholds with propofol during implantable cardioverter-defibrillator testing. J Invasive Cardiol 2000; 12: 121–3.PubMedGoogle Scholar
  14. 14.
    Ebert TJ, Muzi M. Propofol and autonomic reflex function in humans. Anesth Analg 1994; 78: 369–75.PubMedGoogle Scholar
  15. 15.
    Krassioukov AV, Gelb AW, Weaver LC. Action of propofol on central sympathetic mechanisms controlling blood pressure. Can J Anaesth 1993; 40: 761–9.PubMedGoogle Scholar
  16. 16.
    Robinson BJ, Ebert TJ, O’Brien TJ, Colinco MD, Muzi M. Mechanisms whereby propofol mediates peripheral vasodilation in humans. Sympathoinhibition or direct vascular relaxation? Anesthesiology 1997; 86: 64–72.PubMedCrossRefGoogle Scholar
  17. 17.
    Deutschman CS, Harris AP, Fleisher LA. Changes in heart rate variability under propofol anesthesia: a possible explanation for propofol-induced bradycardia. Anesth Analg 1994; 79: 373–7.PubMedGoogle Scholar
  18. 18.
    Sochala C, Van Deenen D, De Ville A, Govaerts MJM. Heart block following propofol in a child. Paediatr Anaesth 1999; 9: 349–51.PubMedCrossRefGoogle Scholar
  19. 19.
    Munoz R, Goldberg ME, Cantillo J, Subramoni J, Nemiroff MS. Perioperative arrhythmias with a propofolbased anesthetic. J Clin Anesth 1991; 3: 149–52.PubMedCrossRefGoogle Scholar
  20. 20.
    Jayamaha JEL, Dowdle JR. Acceleration of ventricular tachycardia following propofol in a patient with heterotopic cardiac transplant. Cardioversion of ventricular tachycardia in the native heart. Anaesthesia 1993; 48: 889–91.PubMedCrossRefGoogle Scholar
  21. 21.
    Dorian P, Cass D. An overview of the management of electrical storm. Can J Cardiol 1997; 13(Suppl A): 13A-7A.PubMedGoogle Scholar
  22. 22.
    Saliba WI, Natale A. Ventricular tachycardia syndromes. Med Clin N Am 2001; 85: 267–304.PubMedCrossRefGoogle Scholar
  23. 23.
    Gottlieb SS, McCarter RJ, Vogel RA. Effect of betablockade on mortality among high-risk and low-risk patients after myocardial infarction. N Engl J Med 1988; 339: 489–97.CrossRefGoogle Scholar
  24. 24.
    Credner SC, Klingenheben T, Mauss O, Sticherling C, Hohnloser SH. Electrical storm in patients with transvenous implantable cardioverter-defibrillators. Incidence, management and prognostic implications. J Am Col Cardiol 1998; 32: 1909–15.CrossRefGoogle Scholar
  25. 25.
    Arnar DO, Xing D, Lee H, Martins JB. Prevention of ischemic ventricular tachycardia of Purkinje origin: role for alpha(2)-adrenoceptors in Purkinje? Am J Physiol Heart Circ Physiol 2001; 280: H1182–90.PubMedGoogle Scholar
  26. 26.
    Meissner A, Eckardt L, Kirchhof P, et al. Effects of thoracic epidural anesthesia with and without autonomic nervous system blockade on cardiac monophasic action potentials and effective refractoriness in awake dogs. Anesthesiology 2001; 95: 132–8.PubMedCrossRefGoogle Scholar
  27. 27.
    Scott NB, Turfrey DJ, Ray DAA, et al. A prospective randomized study of the potential benefits of thoracic epidural anesthesia and analgesia in patients undergoing coronary artery bypass grafting. Anesth Analg 2001; 93: 528–35.PubMedCrossRefGoogle Scholar

Copyright information

© Canadian Anesthesiologists 2002

Authors and Affiliations

  1. 1.Department of AnaesthesiologyQueen’s UniversityKingstonCanada

Personalised recommendations