Letters to Editor
for 48 hours after surgery and was discharged from the
hospital on the sixth postoperative day.
Providing adequate analgesia is a key factor in
preventing postoperative respiratory complications
in cardiac surgery patients. Opioids, even when
administered in novel ways, may contribute to
pulmonary complications by causing respiratory
depression. Therefore analgesics that do not depress
respiration, for example, nonsteroidal antiinflammatory
drugs (NSAID) are considered a good option in this
setting. In our setup NSAIDs are routinely used for
postoperative analgesia with rescue analgesia provided
with opioids. Our patient was getting intramuscular
ketorolac without much benefit. Intermittent fentanyl
was making the patient drowsy and further worsening
his condition. Therefore, rather starting a new drug,
we started administering ketorolac via PCA. The use
of ketorolac via PCA has been shown to reduce opioid
requirements in children.[1] Our objective was to reduce
the requirement of fentanyl, which whenever given
to the child for breakthrough pain was making him
drowsy. By starting ketorolac with PCA, we not only
negated the opioid requirement but also reduced the
total dose of ketorolac consumed. The total dose of
ketorolac was half of what it would have been if it was
given as an intravenous infusion at recommended rates
of 0.17 mg/ kg/h.[1] A contributing factor could be that it
gave the child better control of his pain management,
helped him remain alert and diverted his attention
from pain. He also became an active participant
in the physiotherapy sessions, which led to better
postoperative recovery and timely discharge from the
ICU. PCA allows the patients to titrate the analgesic dose
to the extent of their pain. It reduces the apprehension
of older children and adolescents about pain because
they can control it. The PCA pumps for the delivery
of NSAIDs should be considered a valuable mode of
analgesia, especially in the patient population where
opioids may contribute to respiratory complications
postoperatively.
Amit Rai, Usha Kiran1
Departments of Anesthesiology and 1Cardiac Anesthesia, All India
Institute of Medical Sciences, New Delhi, India
Address for correspondence:
Dr. Amit Rai,
9, SFS Hauz Khas Apartments, Hauz Khas, New Delhi, India.
E-mail: drraiamit@gmail.com
REFERENCES
1. Forrest JB, Heitlinger EL, Revell S. Ketorolac for postoperative pain
management in children. Drug Saf 1997;16:309-29.
Annals of Cardiac Anaesthesia    Vol. 16:1   Jan-Mar-2013
Access this article online
Quick Response Code: Website:
www.annals.in
PMID:
***
DOI:
10.4103/0971-9784.105378
Ventricular
extrasystole during
peri-operative
intravenous
dexmedetomidine
infusion
The Editor,
A 19 year old female weighing 45 kg was posted for left
sided laparoscopic pyeloplasty for congentinal pelvi-
ureteric junction obstruction and gross hydronephrosis.
Her physical status was ASA class I. Her hemogram,
coagulogram, liver fuction test, renal function test,
serum electrolytes, preoperative chest X-ray and 12 lead
electrocardiogram (ECG) revealed no abnormality. In the
operating room, monitoring started with five-lead ECG,
pulse oximetry and non-invasive blood pressure, and
baseline parameters were noted. A peripheral vein was
cannulated in left foreram. Initially, dexmedetomine
(DEX) bolus, 1 µg/kg was given over 10 minute, which
was followed by its infusion at 0.4 µg/kg/h. Anesthesia
was induced with 3 µg/kg fentanyl, 1 mg/ kg propofol
and 0.1 mg/kg vecuronium. Trachea was intubated with
a 7.5 mm ID cuffed endotracheal tube. A 14F Ryle's tube
was placed for gastric decompression. Anesthesia was
maintained with sevoflurane (inspiratory concentration
2.5%) in oxygen and air (40:60). The ventilation was
controlled and guided by end-tidal CO2 (etCO2)
monitoring. The patient was positioned right lateral,
pneumoperitonium was created and surgery started.
About 25 minutes later, ventricular extrasystoles (VE)
were noted. VE were 7-8 per minute. The patient
was hemodynamically stable with heart rate of 65/
69
 Letters to Editor
minute, blood pressure of 118/78 mmHg, etCO2 was
36 mmHg; peak airway pressure was 25 mmHg, end-
tidal sevoflurane concentration was 2.2%. Arterial
blood gas analysis showed pH 7.39, PO2 189 mmHg,
PCO2 41 mmHg, HCO3− 19 mmol/l, BE - 6 mmol/l
and SpO2 98%, Na+ 132 mEq/l, K+ 4.2 mEq/l. During
VE, the intra-abdominal pressure ranged between
13-15 mmHg with carbon dioxide flow of 3 L/min.
The surgery was stopped and pneumoperitonium was
decompressed, despite decompression, VE persisted.
The peak airway pressure decreased to 14 mmHg after
decompression of pneumoperitonium. DEX infusion
was stopped. After 15 minutes, VE diminished and
finally stopped. The surgical procedure was restarted
after creating pneumoperitonium to intra-abdonimal
pressure between 13-14 mmHg and the surgery lasted
for two-hours, no further VE were observed. At the
end of surgery, neuromuscular blockade was reversed
with neostigmine 50 µg/kg and glycopyrrolate 10 µg/kg.
The trachea was extubated and the patient was shifted
to postoperative anesthesia care unit for monitoring.
Postoperatively, her 12 lead ECG was similar to the
preoperative one. She was shifted to ward in evening
and discharged on 3rd postoperative day.
The VEs are bizarre ECG complexes triggered by an
ectopic focus. The incidence of VE in clinically normal
population is 1% as detected by a standard ECG
and 40-75% as detected by 24-48 hours ambulatory
ECG recordings.[1] The presence of more than 5 VE
in one minute is said to increase cardiac risk in
the perioperative period. [2] There is an increased
potential for ventricular fibrillation or intraoperative
cardiac asystole.[2,3] Pre-existing heart disease is a
known cause of perioperative cardiac arrhythmia.
Laparoscopy and pneumoperitonium has been
described to be associated with occurrence of sinus
tachycardia and VE due to release of catecholamines.[4]
Bradyarrhythmias (sinus bradycardia, atrio-ventricular
dissociation and asystole) has also been described
in relation to laparoscopy and pneumoperitonium
due to vagal mediated cardiovascular reflexes,
precipitated by stretching of peritoneum. [4] In the
present case, VE persisted despite the decompression
of pneumoperitonium. Airway obstruction, hypoxia,
hypercarbia, low inspiratory oxygen fraction, and
inhalational agent halothane are associated with
occurrence of ventricular arrhythmias. [3] Light plane of
anesthesia and inadequate analgesia are other causes
of intra-operative VE and arrhythmias. [3] Depth of
anesthesia and analgesia were adequate in our patient
as no increase in heart rate and blood pressure were
70
observed during skin incision and laparoscopic port
placement. Electrolyte imbalance was also ruled out
as a possible cause of VE.
DEX is an α-2 receptor agonist, being increasingly used
intraoperatively as sole agent and as adjuvant with other
anesthetic agents for its excellent sedative, anxiolytic
and analgesic properties. Hypotension and bradycardia
are known cardiovascular effects of DEX. The incidence
of bradycardia and hypotension is increased when DEX
is administered with drugs with negative chronotropic
effects commonly used in operating room like propofol,
suxamethonium, beta-adrenergic antagonist and
anticholinesterase. Bradycardia exaggerated during
hypothermia or during vagotonic procedures such as
laryngoscopy and following large or rapid bolus doses
of DEX.[5] DEX is reported to be useful for treatment
and prevention of intra-operative and post-operative
tachyarrhythmias during cardiac surgery in pediatric
patients.[5,6] Chrysostomou et al.,[6] reported successful
management of atrial and junctional tachyarrhythmias
during perioperative period in congenital cardiac
surgeries. LeReiger et al.,[5] also reported successful
management of a case of junctional ectopic tachycardia
during tetralogy of Fallot repair with high doses of
dexmedetomidine. They described antiarrhythmic
properties of DEX as secondary to stimulation of
α2A-adrenergic receptors in the dorsal motor nucleus
of the vagus nerve thereby increasing vagal efferent
output to the myocardium. However, occurrence of VE
during perioperative infusion of intravenous DEX is
not reported in literature.We are unable to explain the
mechanism of occurrence of VE in this case. However,
after exclusion of all other known causes and temporal
association of disappearance of VE with stopping of the
DEX infusion, we believe that DEX may be the cause
of intra-operative VE in our otherwise healthy patient.
Divya Srivastava, Sohan L. Solanki1,
Krishna Pradhan, Prabhat K. Singh
Department of Anaesthesiology, Sanjay Gandhi Postgraduate
Institute of Medical Sciences, Lucknow, 1Anaesthesiology, Critical
Care and Pain, Tata Memorial Hospital, Parel, Mumbai, India
Address for correspondence:
Dr. Sohan Lal Solanki,
Department of Anaesthesiology, Critical Care and Pain,
Tata Memorial Hospital, Parel, Mumbai, India.
E-mail: me_sohans@yahoo.co.in
REFERENCES
1. Kennedy HL, Whitlock JA, Sprague MK, Kennedy LJ, Buckingham TA,
Goldberg RJ. Long-term follow-up of asymptomatic healthy subjects
with frequent and complex ventricular ectopy. N Engl J Med
1985;312:193-7.
Annals of Cardiac Anaesthesia    Vol. 16:1    Jan-Mar-2013
 Letters to Editor

2. Goldman L, Caldera DL, Nussbaum SR, Southwick FS, Krogstad D, tachyarrhythmias during the perioperative period for congenital cardiac
Murray B, et al. Multifactorial index of cardiac risk in noncardiac surgical surgery: A preliminary study. Anesth Analg 2008;107:1514-22.
procedures. N Engl J Med 1977;297:845-51.
3. Ganny AS, Aguma SA. Intraoperative ventricular bigeminy: Report of
5 cases. Ann Afr Med 2005;4:72-82. Access this article online
4. Myles PS. Bradyarrhythmias and laparoscopy: A prospective study
Quick Response Code: Website:
of heart rate changes with laparoscopy. Aust N Z J Obstet Gynaecol
www.annals.in
1991;31:171-3.
5. LeRiger M, Naguib A, Gallantowicz M, Tobias JD. Dexmedetomidine PMID:
controls junctional ectopic tachycardia during Tetralogy of Fallot repair ***

in an infant. Ann Card Anaesth 2012;15:224-8.

DOI:
6. Chrysostomou C, Beerman L, Shiderly D, Berry D, Morell VO, Munoz R. 10.4103/0971-9784.105379
Dexmedetomidine: A novel drug for the treatment of atrial and junctional

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