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A preoperative ECG of a febrile (38.0 °C) 56-year-old Thai man diagnosed with acute appendicitis revealed type-1 Brugada pattern (BrP) (Fig. 1a). His ECG was repeated at 15 and 30 min, which showed type-2 BrP (Fig. 1b). The patient denied clinical manifestations or family history of Brugada syndrome (BrS). He was diagnosed with asymptomatic BrS.
Many asymptomatic BrS unmasked by fever have been reported. Moreover, fever has also triggered ventricular arrhythmias [1]. Electrophysiological study or drug challenge test should be done to stratify the risk of arrhythmias in asymptomatic BrS [2]. However, it is not suitable to perform such a test before emergency operation. Therefore, to avoid exacerbation of ventricular arrhythmias, class IC/IA antiarrhythmic drugs, epidural bupivacaine, acetylcholine, propranolol, propofol, pinacidil, and nicorandil should not be used [3].
In our case, by using general anesthesia, intravenous etomidate was used for induction and seroflurane was used for maintenance. Rocuronium was used as a muscle relaxant. ECG was monitored and external defibrillator was installed for the entire operation. The patient uneventfully went to an appendectomy. His ECG was normal during non-febrile state (Fig. 1c).
Conclusions
In conclusion, we suggest to empirically manage a patient as a high arrhythmia risk to prevent undesired life-threatening events in asymptomatic BrS diagnosed in emergency preoperative evaluation.
References
Adler A, Topaz G, Heller K, Zeltser D, Ohayon T, Rozovski U, Halkin A, Rosso R, Ben-Shachar S, Antzelevitch C, Viskin S. Fever-induced Brugada pattern: how common is it and what does it mean? Heart Rhythm. 2013;10:1375–82.
Stephenson EA, Berul CI. Electrophysiological interventions for inherited arrhythmia syndromes. Circulation. 2007;116:1062–80.
Inamura M, Okamoto H, Kuroiwa M, Hoka S. General anesthesia for patients with Brugada syndrome. A report of six cases. Can J Anaesth. 2005;52:409–12.
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Rattanawong, P., Ngarmukos, T. & Wisaratapong, T. Discovering Brugada syndrome during preoperative evaluation. J Anesth 29, 480 (2015). https://doi.org/10.1007/s00540-014-1935-2
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DOI: https://doi.org/10.1007/s00540-014-1935-2