Year : 2023 | Volume
| Issue : 1 | Page : 91-93
Peripheral nerve block with ropivacaine in Brugada syndrome patient: Anesthetic consideration
Eun Kyung Choi, Sang-Jin Park, Jong Yoon Baek, Myungjin Seo
Department of Anesthesiology and Pain Medicine, Yeungnam University College of Medicine, Daegu, Korea
Eun Kyung Choi
Department of Anesthesiology and Pain Medicine, Yeungnam University College of Medicine, Daegu, Korea, 170, Hyeonchung-ro, Nam-gu, Daegu, Postal Code: 42415
Source of Support: None, Conflict of Interest: None
|Date of Submission||08-Aug-2022|
|Date of Acceptance||09-Aug-2022|
|Date of Web Publication||02-Jan-2023|
Brugada syndrome has a lethal arrhythmogenic risk during surgery or anesthesia. Perioperative drugs, electrolytic disturbances, and autonomic imbalance can trigger cardiac rhythm disturbances and even sudden cardiac death. Patients with this syndrome are at high risk during the perioperative period. However, the safest anesthetic management is still unknown. We report successful anesthetic management with peripheral nerve block (five points) using ropivacaine for lower-limb surgery in a patient with Brugada syndrome.
Keywords: Brugada syndrome, local anesthetics, peripheral nerve block, ropivacaine
|How to cite this article:|
Choi EK, Park SJ, Baek JY, Seo M. Peripheral nerve block with ropivacaine in Brugada syndrome patient: Anesthetic consideration. Saudi J Anaesth 2023;17:91-3
|How to cite this URL:|
Choi EK, Park SJ, Baek JY, Seo M. Peripheral nerve block with ropivacaine in Brugada syndrome patient: Anesthetic consideration. Saudi J Anaesth [serial online] 2023 [cited 2023 Feb 1];17:91-3. Available from: https://www.saudija.org/text.asp?2023/17/1/91/364877
| Introduction|| |
Brugada syndrome (BS) has a lethal arrhythmogenic risk during invasive procedures, surgery, or anesthesia. Genetic mutations related to the encoding of sodium, potassium, or calcium channels of the cardiac conduction system favor this pathological condition. Perioperative drugs, electrolytic disturbances, or autonomic imbalance can trigger cardiac rhythm disturbances and sudden cardiac death even in asymptomatic patients. Therefore, patients with this syndrome are at high risk during the perioperative period. In this study, we report successful anesthetic management with peripheral nerve block (five points) using ropivacaine for lower-limb surgery in patients with BS.
| Case Report|| |
A 66-year-old man (height: 158 cm; weight: 67 kg) underwent removal of a right knee cyst. He had type 2 diabetes mellitus with chronic kidney disease (glomerular filtration rate [GFR]: 50) and a history of myocardial infarction that occurred 12 years prior, with a stent inserted in the right coronary artery. He was diagnosed with BS with a type 1 Brugada pattern on an electrocardiogram (ECG) five years ago and has been followed up with a cardiologist regularly. He had no syncope history or family history of sudden cardiac death. In the preoperative examination, all blood tests, including cardiac enzymes, were normal. Chest radiography revealed no active lung or heart disease. The ECG showed a coved V1 pattern, which remained unchanged [Figure 1]. Transthoracic ECG revealed normal-sized cardiac chambers with normal left ventricular systolic function (ejection fraction: 60%) and concentric left ventricular hypertrophy without regional wall motion abnormality. He stopped aspirin five days before surgery but continued β-blockers and other diabetes medications.
|Figure 1: Preoperative ECG. The typical characteristics of the Brugada type 1 ECG pattern are shown|
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The anesthesiologist planned a peripheral nerve block for surgical anesthesia. In the operating room, ECG, pulse oximetry, and noninvasive blood pressure were monitored throughout the surgery, and a defibrillator was prepared. Initially, blood pressure was 130/80 mmHg, heart rate was 68 beats/min, and oxygen saturation was 98%. Oxygen at a rate of 2 L/min was delivered via nasal cannula.
Peripheral nerve blocks were performed under ultrasound guidance, and needles with a nerve stimulator were used. Local anesthetic (55 cc) was prepared in aseptic conditions, which included 0.75% ropivacaine (15 cc), 2% lidocaine mixed with 0.3 mL of epinephrine (25 cc) and normal saline (15 cc). The patient was placed in the supine position, and the hip was slightly abducted and externally rotated. The femoral, lateral femoral cutaneous, and the obturator nerve were identified by ultrasound. A 22-gauge, 2-inch stimulating needle was advanced to the target nerves and the nerve stimulator was used to localize the nerves by twitching the corresponding muscle. Then, a bolus of local anesthetic was injected for femoral nerve block (20 cc), lateral femoral cutaneous nerve block (5 cc), and obturator nerve block (5 cc). All injection was done slowly with intermittent aspiration. For sciatic nerve block (SNB) and posterior femoral cutaneous nerve block (PFCNB), the patient was laterally positioned and knee was flexed. Both nerves were identified by ultrasound and a 22-gauge, 4-inch stimulating needle was advanced to the target nerves. The nerve stimulator was used by same way and 20 cc for SNB, 5 cc for PFCNB was injected. The patient's position was changed to supine again, and the surgery was initiated. The surgery took 25 min and the cyst was successfully removed. No hemodynamic or ECG pattern change were observed during surgery. The patient's visual analogue scale (VAS) score was 0/10 in post-anesthesia care unit. After 6 hours, the VAS was 3/10. The patient was discharged the day after surgery without any complication.
| Discussion|| |
BS is an autosomal dominant inherited characterized by ion channel mutations in the cardiac conducting system. It predominantly affects men aged 40–45 years. Additionally, the sudden cardiac death rate is 20% in patients without cardiac structural diseases. The ECG pattern of BS comprises three variants according to J point elevations (Types I, II, and III). Type I only has definitive diagnostic criteria, including a coved ST segment elevation (more than 2 mm) followed by a negative T wave in the V1-3 right precordial leads. The other types of ECG patterns are suggestive but not confirmatory.
Arrhythmogenicity in BS is explained by a re-entry mechanism due to repolarization heterogeneity and dispersion, which increases vulnerability to premature ventricular complexes. In particular, arrhythmia becomes more pronounced when vagal activity is predominant, and because malignant arrhythmia can be present during surgery without a preoperative diagnosis of BS, special attention is required for the selection of anesthetics, analgesics, and other drugs. In addition, the optimal anesthetic approach remains controversial. Anesthesia can affect ion channel activity by inducing autonomic nervous system (ANS) activity. Regional anesthesia produces the least autonomic imbalance compared to the other anesthetic methods (general and neroaxial), and postoperative peripheral nerve blocks decrease ANS stimulation due to postoperative pain. Therefore, we selected peripheral nerve block for lower-limb surgery, although local anesthetics have a theoretical arrhythmogenic risk in patients with BS, based on the characteristics of ion channel blockade.
The type and dose of local anesthetic can affect the safety of regional anesthesia. Local anesthetics (lidocaine, bupivacaine, or ropivacaine) may increase the risk of arrhythmia in BS by inducing variable degrees of ion channel block depending on the type and dose. However, there are conflicting reports regarding the use of local anesthetics in patients with BS. Of the local anesthetics, lidocaine induces arrhythmia by acting as a class IC drug, while it might have a positive effect on BS.
Bupivacaine, amino-amide local anesthetics, blocks more intensely to sodium channel than lidocaine, which can increase the proarrythmogenic and cardiotoxic potential. Some reports on the danger of bupivacaine have been described, so recommended to have cautions when using bupivacaine in the BS., Ropivacaine is a long-acting local anesthetic with similar potency to bupivacaine but with less toxicity. Vasques et al. reported a successful anesthetic case of axillary block with ropivacaine in a patient with known BS, but they empirically administered a lipid emulsion to prevent cardiac toxicity. A case of severe arrhythmia after ropivacaine paravertebral block has been reported Therefore, it is difficult to predict the response to local anesthetics in BS, irrespective of the type, when regional or neuroaxial anesthesia is performed. In this study, we used 0.375% ropivacaine for regional anesthesia and postoperative analgesia. In a study by Kim et al., 0.375% ropivacaine had a shorter onset time than 0.25% levobupivacaine for peripheral nerve block as surgical anesthesia. The rapid onset of local anesthesia is important for improving efficacy with respect to time consumption and patient satisfaction. To our knowledge, this is the first report on the use of ropivacaine in peripheral nerve block for lower-limb surgery in a patient with BS.
We selected the regional anesthetic method because of its lower disturbance effect on the ANS. Perioperative peripheral nerve block is performed as a component of postoperative analgesia and surgical procedures. Potential risks like nerve damage, vascular puncture, and systemic toxicity should be considered, even though they can be reduced by technical advancements. Although the doses commonly used in regional anesthesia have lower plasma levels with probable safety, large doses of local anesthetics should be avoided, and close monitoring of patients is needed with the availability of lipid emulsion.
In conclusion, peripheral nerve block (femoral, lateral femoral cutaneous, obturator, sciatic, and posterior femoral cutaneous nerve) using ropivacaine seems to be a safe anesthetic approach for lower-limb surgery in patients with BS. However, vigilance for arrhythmogenic potency and appropriate management is required to avoid catastrophic complications.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Antzelevitch C, Brugada P, Borggrefe M, Brugada J, Brugada R, Corrado D, et al
. Brugada syndrome: Report of the second consensus conference: Endorsed by the Heart Rhythm Society and the European Heart Rhythm Association. Circulation 2005;111:659–70.
Berne P, Brugada J. Brugada syndrome. Circ J 2012;76:1563–71.
Duque M, Santos L, Ribeiro S, Catré D. Anesthesia and Brugada syndrome: A 12-year case series. J Clin Anesth 2017;36:168-73.
Antzelevitch C. Brugada syndrome. Pacing Clin Electro-physiol 2006;29:1130–59.
Carey SM, Hocking G. Brugada syndrome: A review of the implications for the anaesthetist. Anaesth Intensive Care 2011;39:571-7.
Barajas-Martínez HM, Hu D, Cordeiro JM, Wu Y, Kovacs RJ, Meltser H, et al
. Lidocaine-induced Brugada syndrome phenotype linked to a novel double mutation in the cardiac sodium channel. Circ Res 2008;103:396–404.
Clancy CE, Wehrens XH. Mutation-specific effects of lidocaine in Brugada syndrome. Int J Cardiol 2007;121:249–52.
Morrison SG, Dominguez JJ, Frascarolo P, Reiz S. A comparison of the electrocardiographic cardiotoxic effects of racemic bupivacaine, levobupivacaine, and ropivacaine in anesthetized swine. Anesth Analg 2000;90:1308–14.
Phillips N, Priestley M, Denniss AR, Uther JB. Brugadatype electrocardiographic pattern induced by epidural bupivacaine. Anesth Analg 2003;97:264–7.
Vernooy K, Sicouri S, Dumaine R, Hong K, Oliva A, Burashnikov E, et al
. Genetic and biophysical basis for bupivacaine-induced ST segment elevation and VT/VF. Anesthesia unmasked Brugada syndrome. Heart Rhythm 2006;3:1074–8.
Graf BM, Abraham I, Eberbach N, Kunst G, Stowe DF, Martin E. Differences in cardiotoxicity of bupivacaine and ropivacaine are the result of physicochemical and stereoselective properties. Anesthesiology 2002;96:1427–34.
Vasques F, Di Gregorio G, Behr AU. Is prevention better than cure?: Local anesthetics in Brugada syndrome. Reg Anesth Pain Med 2015;40:395–6.
Fujiwara Y, Shibata Y, Kurokawa S, Satou Y, Komatsu T. Ventricular tachycardia in a patient with Brugada syndrome during general anesthesia combined with thoracic paravertebral block. Anesth Analg 2006;102:1590-1.
Kim HJ, Lee S, Chin KJ, Kim JS, Kim H, Ro YJ, et al
. Comparison of the onset time between 0.375% ropivacaine and 0.25% levobupivacaine for ultrasound-guided infraclavicular brachial plexux block: a randomized-controlled trial. Sci Rep 2021;11:4703.
Joshi G, Gandhi K, Shah N, Gadsden J, Corman SL. Peripheral nerve blocks in the management of postoperative pain: Challenges and opportunities. J Clin Anesth 2016;35:524-9.