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Case presentation

Case presentation. A 5y6m/o boy with congenital long QT syndrome received ICD implantation and defibrillation test … .. 2003-12-22 Ri 朱俊霖 & 黃堃碩. Brief history. A 5y6m/o boy diagnosed as TOF (Tetralogy of

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Case presentation

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  1. Case presentation A 5y6m/o boy with congenital long QT syndrome received ICD implantation and defibrillation test….. 2003-12-22 Ri朱俊霖&黃堃碩

  2. Brief history • A 5y6m/o boy diagnosed as TOF (Tetralogy of Fallot) since birth with normal chromosome s/p total correction at 3 y/o at 國泰 H. due to cyanosis and dyspnea • In this October, he slipped down and hit the occipital head • The next morning, strange sound with sputum, breathless, pale looking with upgazing, and consciousness change

  3. Brief history • On 11/13, similar situation showed up again, urinary incontinence and pulseless were noted this time and CPR was done. • At 員生 hospital, intubation and DC shock was performed and cardioconversion then he was then transferred to 彰基 H.

  4. Brief history in 彰基 H. • In the same day evening, multiple VT attacks and DC shocks for many times were done. • Besides, suspected seizure attack with head nodding was noted and Valium was given • 11/14, amiodarone (6.4μg/kg/min) with Lidocaine (40μg/kg/min) was given but arrhythmia persisted, then TCP (transcutaneous pacemaker)was set

  5. Brief history in our hospital • Transfer to our hospital on 11/17 • Due to still VT, emergency temporary intravenous pacemaker was placed • After that, his condition improved and consciousness became more clear • After reviewing previous EKG, QT interval was prolonged with giant and broad base T wave • Congenital long QT syndrome is highly possible

  6. Long QT syndrome • QTc normal range is within 0.44 sec • Congenital & Acquired • Ion channel abnormalities & drug induced • Prone to torsades de pointes cause transient light-headedness or syncope or sudden cardiac death

  7. Congenital long QT syndrome • Autonomic nervous system can trigger the actual arrhythmias • Intravenous β-adrenergic blockade, intravenous Mg2+, pacing or lidocaine • Placement ICD (implantable cardioverter defibrillator) should be considered for patient with resistant arrhythmia

  8. Brief history • ICD was implant on 921205 in cath room under general anesthesia with LMA • Defibrillation test was performed on 921212 under ETGA in cath room

  9. Anesthesia for ICD implantation Premedication Dormicum Induction • Fentanyl 50μg • Midazolam 2.5 mg • Xylocaine 30 mg • SCC 40 mg Maintain : • O2 and isoflurane • With LMA 2 ½# s/p PRBC 1U

  10. Anesthesia for defibrillation test Induction : • Atropine 0.2 mg • Dormicum 2 mg • Thiopental 100mg Maintain : • Sevoflurane and O2 • ET tube and A line monitor 了

  11. ICD overview ICD Overview

  12. ICD Background • Emergency medical system and techniques of resuscitation advanced sudden death from cardiac arrest • Either not survive, or severe long-term cognitive and motor impairment • 1970s : Dr. Michel Mirowski and Morton Mower  implantable device, automatically monitor and analyze cardiac rhythm and deliver defibrillating shock when VF occurs • 1980s: first clinical implantation ~~N Engl J Med 2003; 349:1836-1847, Nov 6, 2003.~~

  13. Components and function • A pulse generator, one or more leads for pacing and defibrillation electrodes • Gradual reduction in the size of the pulse generator and progressive increase in functions • Defibrillation lead: 1. high-energy shock 2. epicardial vs. transvenous 3. contain one or two coils 4. contain bipolar electrodes, used for ventricular pacing and sensing ~~N Engl J Med 2003; 349:1836-1847, Nov 6, 2003.~~

  14. Detection of arrhythmia • Sensing :define the time between each R wave produced by ventricular depolarization cardiac rhythm • More than one tachycardia detection zone • Fastest rates: VF zone un-synchronized high energy shock • Lower rates : VT zone  anti-tachycardia pacing or low-energy synchronized shock ~~N Engl J Med 2003; 349:1836-1847, Nov 6, 2003.~~

  15. Detection of arrhythmia • In ventricular tachycardia zone • Sinus tachycardia or supraventricular tachycardia inappropriate therapy D/D: Single-chamber  1. Sudden onset : sinus v.s. ventricular tachycardia 2. Stability of cardiac cycle length : detect Af Dual –chamber information of atrial electrogram ~~N Engl J Med 2003; 349:1836-1847, Nov 6, 2003.~~

  16. Management of arrhythmia • VF : electrical defibrillation as the sole therapy • VT :1. Antitachycardia pacing (ATP) 2. Cardioversion (synchronized shock) 3. Defibrillation  Tiered therapy • Bradycardia : pacing ~~N Engl J Med 2003; 349:1836-1847, Nov 6, 2003.~~

  17. Detection of arrhythmia • Spontaneous terminated arrhythmia  prevent unnecessary shock reanalyze the rhythm before delivering shocks (re-detection) • Other functions: 1. pacing modes 2. stored electrograms for sensed arrhythmia 3. detect atrial arrhythmia and deliver appropriate therapy (atrial defibrillator for Af) 4. bi-ventricular pacing for cardiac re- synchronization (CHF, intraventricular conduction delay, like LBBB)

  18. Device implantation • Thoracotomy • Transvenous non-thoracotomy system -- prepectoral (subcutaneous) -- subpectoral (submuscular) Throught left subclavain vein, cephalic or axillary vein Could be performed either under sedation with local anesthesia or general anesthesia

  19. Implantation testing • Lead testing, defibrillation testing, ICD system testing Lead testing: • Correct position tip as close to the apex of RV as possible • Minimum acceptable R –wave amplitude is >5mV ensure satisfied sensing during VF ##Correct positioning of the endocardial lead in the apex of the right ventricle during the insertion of an implantable cardiodefibrillator (ICD) under general anesthesia, when cardiac function is generally poor, is most important. We describe herein a method of using intraoperativeesophageal echocardiography in combination with fluoroscopy to confirm fixation of the endocardial ICD lead in the right ventricular apex. ~~ Journal Article Surgery Today. 31(9):848-9, 2001. ~~

  20. Implantation testing Defibrillation testing : • Repeated induced VF and defibrillation • VF is induced by a critical timed T-wave shock, very rapid burst pacing, or occasionally alternating current • DFT : the minimum energy producing defibrillation success ICD system testing: • Intraoperative testing if the entire system, make sure it can work!!

  21. Complications

  22. ICD and anesthesia

  23. Volatile agents and fentanyl affect DFTAnesthesia & Analgesia. 95(5):1147-53, table of contents, 2002 Nov. • under local or regional analgesia and sedation or under general anesthesia (GA) by using a variety of volatile or IV drugs • first study to investigate the influence of halothane, isoflurane, and IV fentanyl (fentanyl is the most frequent intraoperative opioid used for cardiac patients) on the DFT during ICD implantation in humans

  24. Volatile agents and fentanyl affect DFTAnesthesia & Analgesia. 95(5):1147-53, table of contents, 2002 Nov. • Compared with local anesthesia combined with intermittent small-dose propofol, these three anesthetics increased the DFT. • neither repetitive fibrillation/defibrillation events over time nor N2O/oxygen itself was the cause for the negatively affected myocardial response to the defibrillator, but rather halothane, isoflurane, and fentanyl themselves.

  25. Volatile agents and fentanyl affect DFTAnesthesia & Analgesia. 95(5):1147-53, table of contents, 2002 Nov. • Whereas N2O/oxygen-based GA with halothane, isoflurane, or fentanyl at the tested clinical concentrations or doses increased the minimal DFT during ICD implantation, the subcutaneous lidocaine plus IV propofol technique minimized it while providing equal patient satisfaction.

  26. General anesthesia versus local anesthesia with IV sedation Local anesthesia with IV sedation result in --higher success rate --less complication --shorter implantation and fluoroscopy times --shorter hospitalization ~~American Journal of Cardiology. 81(3):302-5, 1998 Feb 1. ~~Journal of Cardiothoracic & Vascular Anesthesia. 10(6):764-6, 1996 Oct ~~ Pacing & Clinical Electrophysiology. 23(1):96-105, 2000 Jan.

  27. Local anesthesia won’t impair cardiac function • Patients who received ICDs under local anesthesia had significantly greater values of ejection fraction in preoperative examination than values in patients who received ICDs under general anesthesia ~~Masui - Japanese Journal of Anesthesiology. 48(7):747-52, 1999 Jul.

  28. Complete history and physical examination should be recorded Monitor : ECG leads Intra-arterial catheter Central venous cannula TEE Pulse oximeter An external cardioverter defibrillator should be available ICD implantation and anesthesia

  29. ICD implantation and anesthesia Sedation includes thiopental sodium 25mg or propofol 10 mg, midazolam 0.5 mg or diazepam 1~2 mg. Fentanyl 0.025 mg • It is desirable to produce deep sedation with loss of response to glabellar tap or loud auditory stimulation (ramsey sedation score 5 to 6)

  30. ICD implantation and anesthesia Medication : • Volatile agent is discouraged • Nitrous oxide was avoided • Avoid drugs with anticholinergic or sympathomimetic properties

  31. DFT and anesthesia • Propoful bolus is titrated to achieve short periods of unconsciousness before induction of tachydysrhythmias and shocks • 100 percent oxygen during the induction of ventricular fibrillation

  32. Anesthesia for ICD implanted p’t • Obtaining complete information and model number of the ICD • exposure to a magnet could inactivate tachycardia sensing and delivery of therapy • Avoid using nitrous oxide

  33. In our patient • During implantation, general anesthesia and isoflurane were given • During DFT, general anesthesia and sevoflurane were given; A line was set for monitor BP • N2O was avoided in both operation

  34. Thanks for your attention!! Thanks for your attention!! Wake up!! :P

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