Brugada syndrome is characterized by right bundle branch block, ST segment elevation in the precordial leads and sudden death caused by ventricular fibrillation. We present two successful anaesthetic management cases in patients with Brugada syndrome. Accepted for publication 8 May 2004Key words: Brugada syndrome; complications; electrocardiography; sudden death.# Acta Anaesthesiologica Scandinavica 48 (2004) I N 1992 a new syndrome was described consisting of syncope or sudden death in patients with a structurally normal heart and an electrocardiogram (ECG) characteristic of right bundle branch block with ST segment elevation in leads V 1 to V 3 . This condition was named 'Brugada syndrome' (1). The syndrome is genetically determined and caused by mutations in the gene SCN5A on chromosome 3, encoding the human cardiac sodium channel (2).There are few reports of anaesthetic management of patients with Brugada syndrome, and especially regional anaesthesia of patients with Brugada syndrome. Therefore, we report one case of regional anaesthesia and one case of general anaesthesia in patients with Brugada syndrome. Case report Case 1A 33-year-old man was presented for an emergency orthopaedic operation due to open fracture of the patella. One year ago, before admission, Brugada syndrome was diagnosed in routine cardiologic evaluation. He had no past history of syncope and there was no family history of sudden death. On admission, a physical examination revealed no abnormal findings except ECG findings showing the coved-type ST segment elevation in leads V 1 to V 3 with a right bundle branch block (Fig. 1). Echocardiography showed a normal heart with an ejection fraction of 60%. Electrophysiology study revealed normal sinus node function, but non-sustained ventricular tachycardia was induced by electric ventricular stimulation.Having been informed of the associated risks, the patient was taken to the operating room and routine monitors were applied. A radial arterial cannula was inserted under local anaesthetic. Prior to the induction of anaesthesia, an external defibrillator was prepared. Spinal tapping was carried out at the L4/5 space in right lateral position. Afterwards, 0.5% bupivacaine hydrochloride 10 mg was injected intrathecally and satisfactory spinal block was achieved up to the T 10 dermatome.During the operation, ECG and continuous blood pressure were monitored and showed no abnormalities.After a 2-h operation, the patient was transferred to the post anaesthetic care unit (PACU) and postoperative pain was controlled with intravenous patientcontrolled analgesia (PCA) using opioids and NSAID. Postoperative recovery was uneventful. Case 2A 56-year-old male with L 1 vertebral body compression fracture scheduled for spine fusion under general anaesthesia. His preoperative 12-lead ECG showed a complete right bundle branch block and ST segment elevation (Fig. 2). There was no family history of sudden death. Several years ago, before admission, he had one history of syncope attack. Echocardiogram showed no s...

SummaryThis study examined the effectiveness of different propofol infusion target concentrations on cough suppression, during a target-controlled remifentanil infusion. Four hundred patients were randomly assigned to receive propofol target effect-site concentrations of 0, 3.0, 4.5, or 6.0 lg.ml )1 . When the propofol effect-site concentration reached the target, remifentanil was administered at a target effect-site concentration of 4.0 ng.ml )1 . Episodes of cough were recorded over a 2-min period after remifentanil commencement, and graded as mild (1-2), moderate (3-4), or severe (5 or more). The overall incidence of cough was significantly decreased in by propofol 6.0 lg.ml )1 compared with 0 or 3.0 lg.ml )1 propofol (p < 0.001). The incidence of severe cough was significantly lower with propofol 6.0 lg.ml )1 compared with 3.0 lg.ml )1 (p = 0.03). A propofol target effect-site concentration of 6.0 lg.ml )1 effectively suppressed remifentanil-induced cough when remifentanil was administrated at a target effect-site concentration of 4.0 ng.ml )1 .

During laparoscopic hepatic resection, an abrupt decrease in FE'CO 2 (from 28 mmHg to 9 mmHg) associated with near cardiac arrest occurred concomitantly with hepatic vein laceration and the use of an argon beam coagulator system. During venous gas embolism, transesophageal echocardiography (TEE) proved the transpulmonary passage of the gas. In the post-operative period, the patient developed pulmonary edema and made a full recovery after 5 days. This is a case report of a possible paradoxic carbon dioxide (CO 2 ) and argon gas embolism by transpulmonary passage during laparoscopic hepatic resection. Accepted for publication 19 April 2007Key words: Venous gas embolism; Argon beam coagulation system; laparoscopy. used in laparoscopic procedures, there is a risk of CO 2 and/or argon gas embolism (1-3). During venous gas embolism, systemic embolization by transpulmonary passage is a rare occurrence; however, it can occur when the filtering capacity of the lungs for venous gas embolism is impaired (4-7). To the best of our knowledge, this is a rare case of CO 2 and argon gas systemic embolization by transpulmonary passage which was proved by transesophageal echocardiography (TEE). Case reportA female patient (61 years, 62 kg, ASA II) underwent resection of the left lobe of the liver for a stone in the intrahepatic duct. She had no specific medical illness on routine laboratory testing. The patient was premedicated with glycopyrrolate [0.2 mg intravenously (i.v.)]. Anesthesia was induced with thiopentone and was maintained with 1.0-2.0 vol% isoflurane in 50% oxygen with air. The fresh gas flow was 4 l/min. Muscle relaxation was carried out with rocuronium. Ventilation was mechanically controlled and adjusted to maintain an end-tidal concentration of carbon dioxide (FE' CO2 ) between 35 and 45 mmHg throughout surgery with a positive end-expiratory pressure (PEEP) of 5 cm H 2 O. Arterial blood pressure was monitored invasively from the right femoral artery, and oxygen saturation with a pulse oximeter (SpO 2 ). Central venous pressure (CVP) was measured intermittently through an indwelling catheter. After the induction of anesthesia, arterial blood gas analysis was normal. Four trocars were inserted and connected to the carbon dioxide source and were insufflated into the abdomen. Intra-abdominal pressure was regulated to less than 12 mmHg. The operation was performed in the head-up position. During dissection, the surgeon used an ABC system (Force Argon TM II; Valleylab TM , Boulder, CO). Three hours after the start of the operation, an abrupt decrease in FE'CO 2 (from 28 mmHg to 9 mmHg) and SpO 2 (from 100% to below 50%) was noted. After a few seconds, systolic blood pressure decreased from 120 mmHg to near zero, and heart rate fell from 75 beats/min to near zero. A gas embolism was suspected, and the surgeon was informed. They acknowledged the laceration of the left hepatic vein. The CO 2 gas was disconnected and 0.4 mg of atropine and 1 mg of epinephrine were given through the CVP catheter. For a moment, the lungs wer...

BackgroundIntravenous fentanyl has been used for acute postoperative pain management, but has not always provided reliable adequate analgesia, including patient-controlled analgesia (PCA). The purpose of this study was to investigate the efficacy of time-scheduled decremental infusion of fentanyl for postoperative analgesia.MethodsNinety-nine patients, aged 20-65 years, undergoing laparoscopic-assisted hysterectomy using total intravenous anesthesia (TIVA) were randomly assigned into one of the three groups. Their background infusions of fentanyl diluent (2 ml/hr of diluent was equivalent with 0.5 µg/kg/hr of fentanyl) with PCA were maintained at the fixed-rate of 2 ml/hr until the postoperative 24 hr (FX2-2-2), or at the decremental rates of 6.0, 4.0, 2.0 ml/hr (D6-4-2) and 8.0, 4.0, 2.0 ml/hr (D8-4-2). The visual analogue score (VAS), incidence of inadequate analgesia, frequency of PCA intervention, and side effects were evaluated.ResultsVAS was significantly higher in FX2-2-2 than in D6-4-2 and D8-4-2 until postoperative 3 hr (P < 0.05). After postoperative 4 hr, VAS was significantly higher in FX2-2-2 than D8-4-2 (P < 0.05). The incidence of inadequate analgesia of FX2-2-2 was significantly greater than D6-4-2 (P = 0.038) and D8-4-2 (P < 0.001) until postoperative 1 hr. None of the patients had ventilatory depression, and postoperative nausea and vomiting were not significant among the groups.ConclusionsThe time-scheduled decremental background infusion regimens of fentanyl, based on the pharmacokinetic model, could provide more effective postoperative pain management after TIVA, and the side effects and the risk for morbidity were not different from the fixed-rate infusion regimen.

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