Cardiac arrest in a toddler treated with propranolol for infantile Hemangioma: a case report

Abstract

BackgroundPropranolol has become the first-line treatment for complicated Infantile Hemangioma (IH), showing so far a good risk-benefit profile.Case presentationWe report the case of a toddler, on propranolol, who suffered cardiac arrest during an acute viral infection. She had a neurally-mediated syncope that progressed to asystole, probably because of concurrent factors as dehydration, beta-blocking and probably individual susceptibility to vaso-vagal phenomena. In fact a significant history of breath-holding spells was consistent with vagal hyperactivity.ConclusionsThe number of patients treated with propranolol for IHs will increase and sharing experience will help to better define the safety profile of this drug.

Cardiac Evaluation before and after Oral Propranolol Treatment for Infantile Hemangiomas

“…Although its exact mechanism of action on hemangiomas is unclear, it has been hypothesized to involve vasoconstriction, the inhibition of angiogenesis, the induction of apoptosis, the inhibition of nitric oxide production, and the regulation of the renin–angiotensin system [ 19 ]. Several serious complications have been reported in infants receiving propranolol for His [ 20 ]: bradycardia [ 21 ], hypotension, prolonged atrioventricular (AV) conduction intensification of AV block [ 22 ], bronchospasm, and hypoglycemia or related seizures [ 23 ]. However, none of our 64 IH patients exhibited severe toxicities on cardiac function and arrhythmias.…”

Deep coma in a child treated with propranolol for infantile hemangioma

“…With almost 1000 hits in the medline for “propranolol and hemangioma”, we found only one randomized, controlled trial of oral propranolol in IH [7, 12]. As more physicians have begun using propranolol as “a miracle drug” for IH, reports of side effects have also increased [6, 7, 9, 14, 15, 19–26].…”

“…Infantile hemangiomas (IH) are benign tumors of vascular endothelium affecting about 5-10% of infants [1–9]. The approach to the treatment of IH should be individualized, based upon the size of the lesion, morphology, location, presence or possibility of complications [10, 11].…”

Retrospective case series of increased oral propranolol dosage for infantile hemangiomas

“…Many providers have thus continued to prescribe 2 mg/kg/d, per Léauté‐Labrèze's original report, given the known efficacy and to minimize the risk of rare but serious side effects associated with systemic beta‐blockers. Although no significant difference in side effects was observed between doses of 1 and 3 mg/kg/d in the propranolol RCT, serious adverse events including cardiac arrest, severe hyperkalemia, and hypoglycemic coma have been documented in case reports of 2 mg/kg/d dosing of propranolol for IH 4‐6 . As propranolol side effects are known to correlate with peak serum concentrations, it is expected that higher doses will increase this risk as supported by evidence from one study in adults 7,8 …”

“…Although no significant difference in side effects was observed between doses of 1 and 3 mg/ kg/d in the propranolol RCT, serious adverse events including cardiac arrest, severe hyperkalemia, and hypoglycemic coma have been documented in case reports of 2 mg/kg/d dosing of propranolol for IH. [4][5][6] As propranolol side effects are known to correlate with peak serum concentrations, it is expected that higher doses will increase this risk as supported by evidence from one study in adults. 7,8 Controversy also surrounds the potential benefit of increased dosing for the minority of patients with recalcitrant IH that fail to respond to 2 mg/kg/d of propranolol.…”