Rev. Bras. Anestesiol. vol.64 número5

RevBrasAnestesiol.2014;64(5):365---368

REVISTA

BRASILEIRA

DE

ANESTESIOLOGIA

www.sba.com.br

CLINICAL

INFORMATION

The

development

of

ventricular

fibrillation

due

to

etomidate

for

anesthetic

induction:

a

very

rare

side

effect,

case

report

Murat

Karcioglu

,

Isil

Davarci

,

Nuray

Kirecci

,

Adnan

Burak

Akcay

,

Selim

Turhanoglu

_,

_Kasim

_Tuzcu

_,

_Sedat

_Hakimoglu

_,

_Seckin

_Akkucuk

_,

_Akin

_Aydogan

a_{DepartmentofAnesthesiologyandReanimation,FacultyofMedicine,MustafaKemalUniversity,Hatay,Turkey} b_{DepartmentofCardiology,FacultyofMedicine,MustafaKemalUniversity,Hatay,Turkey}

c_{DepartmentofGeneralSurgery,FacultyofMedicine,MustafaKemalUniversity,Hatay,Turkey}

Received28February2013;accepted10June2013 Availableonline16October2013

KEYWORDS

Etomidate; Inductionof anesthesia; Ventricular fibrillation

Abstract

Backgroundandobjectives: Ventricularfibrillationoccurringinapatient canresultin unex-pectedcomplications. Here,ouraimistopresentacaseofventricularfibrillationoccurring immediatelyafteranesthesiainductionwithetomidateadministration.

Casereport: Afifty-six-year-oldfemalepatientwithapre-diagnosisofgallstoneswasadmitted totheoperatingroomforlaparoscopiccholecystectomy.Theinductionwasperformedby eto-midatewithabolusdoseof0.3mg/kg.Severeandfastadductionappearedinthepatient’sarms immediatelyafterinduction.AtachycardiawithwideQRSandventricularrate188beat/min wasdetected onthemonitor.TherhythmturnedtoVFduringthepreparationof cardiover-sion.Immediatelywe performeddefibrillationtothepatient.Sinusrhythmwasobtained.It wasdecidedtopostponetheoperationduetothepatient’sunstablecondition.

Conclusion: Inadditiontootherknownsideeffectsofetomidate,veryrarely,ventricular tachy-cardia andfibrillationcan bealsoseen.Tothebestofourknowledge, thisisthefirstcase regardingetomidatecausingVFintheliterature.

© 2013SociedadeBrasileirade Anestesiologia.Publishedby ElsevierEditoraLtda.Allrights reserved.

PALAVRAS-CHAVE

Etomidato;

Induc¸ãodaanestesia; Fibrilac¸ãoventricular

Desenvolvimentodefibrilac¸ãoventricularporcausadeetomidatoparainduc¸ão anestésica:umefeitocolateralmuitoraro,relatodecaso

Resumo

Justificativaeobjetivos: Aocorrênciadefibrilac¸ãoventricularemumpacientepoderesultar em complicac¸õesinesperadas.Nossoobjetivoéapresentarumcasodefibrilac¸ãoventricular queocorreuapósainduc¸ãoanestésicacomadministrac¸ãodeetomidato.

∗_{Correspondingauthor.}

E-mail:muratkarcioglu@hotmail.com(M.Karcioglu).

0104-0014/$–seefrontmatter©2013SociedadeBrasileiradeAnestesiologia.PublishedbyElsevierEditoraLtda.Allrightsreserved.

366 M.Karciogluetal.

Relatodecaso:Pacientedosexofeminino,56anos,compré-diagnósticodecálculosbiliares, foiadmitidanasaladecirurgia paracolecistectomialaparoscópica. Aanestesiafoiinduzida comaadministrac¸ãodeetomidatocomuma doseembolusde0,3mg/kg. Apaciente apre-sentouumagraveerápidaaduc¸ãodosbrac¸oslogoapósainduc¸ão.TaquicardiacomQRSlargo efrequênciaventricularde188bpmforamdetectadasnomonitor.Oritmoconverteu-seem fibrilac¸ãoventricular(FV)duranteapreparac¸ãoparaacardioversão.Apacientefoi imediata-mente submetidaadesfibrilac¸ão.Oritmo sinusalfoi obtido.Decidimosadiaracirurgia por causadacondic¸ãodeinstabilidadedapaciente.

Conclusão:Alémdosefeitos secundáriosconhecidosdeetomidato, taquicardiaventriculare fibrilac¸ão,emboramuitoraramente,tambémpodemserobservadas.Atéondesabemos,esse éoprimeirocasonaliteraturadeFVcausadoporetomidato.

©2013SociedadeBrasileiradeAnestesiologia.PublicadoporElsevierEditoraLtda.Todosos direitosreservados.

Introduction

Ventricularfibrillation(VF)isacardiacpathologyinwhich theventricleis completely chaoticand does notcontract effectively.VFcancauseveryseriousendpoints.Etomidate isahypnoticagentthathasastablecardiovascularprofile andresultsinminimalrespiratorysideeffects.Forthis rea-son,itiscommonlypreferredfortheinductionofanesthesia inhemodynamicallyunstablepatients.1

The reported side effects related to etomidate are myoclonus,vomiting,painoninjectionsite,and adrenocor-ticalsuppression.2

Inrarecases,otheradverseeffectsregardingetomidate havebeen mentioned.Inthe currentreport,we aimedto presentacaseinwhichVFdevelopedduringinductionwith etomidateinapatientunderwentlaparoscopic cholecystec-tomy due to gallstones.In the literature, this is the first reportinvestigatingthisassociation.

Figure1 PreanestheticECGImage.

Case

report

A fifty-six-year-old female patient with a pre-diagnosis of gallstones was admitted to the operating room for laparoscopic cholecystectomy. The patient’s history of hypertension with the irregular use of an antihyperten-sivedrugwasknownduringthepre-anesthesiaevaluation. Routine biochemical and hematological tests were nor-mal. ECG wasin normal sinus rhythm (Fig.1), heart rate was74beats/min,PAchest X-raywasnormal,and consid-ered ASA II. The patient was monitored, and the initial arterial blood pressure (BP): 140/110mmHg, heart rate: 118beats/min,presenceof sinus tachycardia rhythm,and peripheraloxygensaturation(SpO2):98%weredetected.

Thedevelopmentofventricularfibrillationduetoetomidate 367

Figure2 VTImage.

Figure3 PostextubationECGimage.

movementswereconsideredtobeduetoetomidateanda doseof0.6mg/kgrocuronium(Esmeron®_{N.V.OrganonOss,} Netherlands)wasgiven.Atthistime,BPwas150/110mmHg, SpO2was98%,heartratewas110---130beats/min,andthe heart rate increased gradually. A tachycardia with wide QRS and ventricular rate 188beat/min was detected on themonitor(Fig.2).Bloodpressurewasseenasdecreased to 90/60mmHg. The rhythm turned to VF during the preparation of cardioversion. Immediately we performed defibrillation to the patient (biphasic shock with 200J). Sinusrhythmwasobtained.Wedecidedtogiveamiodarone tothepatienttoavoidrecurrentVT.

A150mgofIVamiodarone(Cordarone® _{MefarIstanbul,} Turkey)loadingdosewasappliedwithin15minandwas fol-lowedbymaintenancetherapy.Itwasdecidedtopostpone theoperationduetothepatient’sunstablecondition.

Anesthesia was maintained with oxygen, air, sevoflu-rane(Sevorane®_{AbbottLaboratoriesLtd.,UK)andfentanyl} (Fentanyl® _{Janssen N.V., Belgium). Thirty-seven minutes} after the induction of anesthesia, the patient started to breathe spontaneously and extubation was proposed. The patient was extubated and admitted to the inten-sive care unit (ICU). A cardiology consultation was made in ICU. On patient echocardiography, Left ventricle (LV)

diameters were normal, systolic function was adequate, Left atrium (LA)dilatation was(4.1cm), 1+ mitral regur-gitation and 2---3+ tricuspid regurgitation were noted, pulmonary hypertension was present (35---40mmHg), and ejectionfraction (EF) wasevaluated as63%. Sinus tachy-cardia (120beats/min) and nonspecific ST changes in the patient’sECG(Fig.3)werefoundbythecardiologists. Hema-tological,biochemical, thyroid function tests werewithin normallimits.

The patient was discharged after threedays following upintheICU.Twoweekslater,thepatientwasadmittedfor thelaparoscopiccholecystectomy.Thepatientwasoperated withoutanycomplication,withtheinductionbythiopental, fentanylandrocuronium,andsenthome.

Discussion

368 M.Karciogluetal.

Encounteringunpredicteddisordersarecommonduring anesthesiainduction, themaintenance ofanesthesia, and awakening from anesthesia. In this case, we reported a process of ventricular tachycardia and fibrillation occur-ring immediately after the induction of anesthesia with etomidate.The well-knownside effects of etomidate are myoclonus, pain on injection site, and adrenal suppres-sion. The mechanism of myoclonus is not clear, though it is a form of seizure activity. High doses of etomidate depress cortical activity before than subcortical activity, andresearchers have proposed thatthis is a disinhibition phenomenon.3,4_{Subcorticalneuronalactivityinhibitordrugs}

suchasbenzodiazepines andopioidspreventthe develop-mentofmyoclonus.5

Etomidateinjectionhassideeffectsintermsofpainand myoclonusbecauseitisformulatedwithpropyleneglycol.6,7

However,analternatepharmaceuticalformulationexiststo reducethepainofinjection.Inthisnewformulation, etomi-dateisdissolvedinafatemulsioncomposedofmediumand longchaintriglycerides.8_{Inastudy,usingonlyasinglebolus}

dose of etomidatecause adrenal dysfunctionin aspect of hypocortisolemia.9_{Thisimpairedfunctionresultsina}

tran-sientandclinicallyinsignificanteffectonadrenalgland.7,9

Insomecases,adrenaldysfunctioncanbeveryimportant. Thereforepractitionersmustbeawareof thisinformation regardingthedrug.

Case reports related to adrenal adverse effects with etomidateare common.However, the cardiovascularside effects are found in only one report associated with the drug. Etomidate typically does not alter myocardial con-tractility and cardiac output.10 _{Fideler et al. reported a}

caseofthyrotoxicosisoccurringafterapplyingamiodarone treatment to a patient with heart failure and suffering fromatrialfibrillationforthefirsttime.Thyroidectomywas plannedwhenhyperthyroidismwasunresponsivetomedical treatment.Thestaffnoteddecreasedbloodpressureafter inductionwithetomidate,sufentaniland rocuronium,and norepinephrineinfusionwasstartedbeforethepatienthad VFfollowedby cardiacarrest.11 _{Inourcase, thepatient’s}

thyroidfunctiontests werenormaland nosignificant car-diacpathologywasdetectedexceptforthedevelopmentof sinus tachycardia anda slightrise in blood pressureprior toinductionintheoperatingroom.Theinjectionof etomi-datewasconsideredtobetheonlyprobableetiologyforthe developmentofVTandVF.

WhenetomidateandVFwereinvestigatedusingtheFDA Adverse Event Reporting System (FAERS), a total of 4 VF eventshadbeenreportedforetomidate.12

According toanothersource, 1023cases of etomidate-relatedadverseeffectshavebeenfound.Amongthem,VF wasreportedin23patients(2.25%).Ofthesecases,72.7% werefemales,27.3%weremales,22.7%wereintherange of 0---1 years old,13.6% in the rangeof 20---29 years old,

4.5%intherangeof30---39yearsold,27.3%intherangeof 50---59yearsold,31.8%percentovertheageof60years.The drugsusedinthesepatientswithVFwereSufentanilcitrate, Propofol, Fentanyl,Rocuroniumbromide, andAmiodarone HCL.13

Asaresult,itis suggestedthat thedevelopmentof VF inthiscase, aftertheexclusionoftheprobable etiologies may bedue totheinduction withetomidate. To thebest ofourknowledge,thisisthefirstcaseregardingetomidate causing VFin theliterature.We aimedtoreportthat fol-lowinginductionwithetomidateVFcanoccurinrarecases, andearlydiagnosisandimmediateinterventionwithclose follow-uparerequiredtoachievepositiveoutcomesinthese patients.

Conflicts

of

interest

Theauthordeclaresnoconflictsofinterest.

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