Title: Anaesthesia for scoliosis correction surgery complicated by severe recalcitrant bradycardia upon prone positioning in an adolescent with Prader-Willi syndrome
Journal Title: Southern African Journal of Anaesthesia and Analgesia
Volume: Volume 19
Issue: Issue 3
Publication Date: January 2013
Start Page: 171
End Page: 173
Published online: 12 Aug 2014
Author: I Conrick-Martin FCAI, MCRPI, FJFICMI Specialist Registrar in Anaesthesiaa*, CM Walshe FCAI, FJFICMI Consultant Anaesthetistb, K Carson MD, FFARCSI, FJFICMI Consultant Anaesthetist and Intensivista, D McCormack FRCS, MCh Consultant Orthopaedic Surgeonc & K O'Brien FFARCSI Consultant Anaesthetista
a Department of Anaesthesia, Intensive Care and Pain Medicine, Children's University Hospital, Temple Street, Dublin, Ireland.
b Department of Anaesthesia and Intensive Care Medicine, Beaumont Hospital, Dublin, Ireland
c Department of Orthopaedic Surgery, Children's University Hospital, Temple Street, Dublin, Ireland
Abstract: A 13-year-old adolescent presented for correction of an 85-degree idiopathic thoracic scoliosis. She was known to have Prader-Willi syndrome. Previous general Anaesthesia for non-spinal surgery had been uneventful. On two occasions following uneventful induction and total intravenous Anaesthesia (TIVA) maintenance, she developed severe recalcitrant bradycardia with hypotension that was resistant to anticholinergics, inotropes and vasopressors upon prone positioning. Immediate resolution occurred upon a return to the supine position. On each occasion, she emerged from Anaesthesia with no untoward sequelae. Cardiac investigations, including echocardiography, electrocardiography (ECG), troponin and creatine kinase-MB fraction levels were all within the normal range, and ventricular function was good. It was necessary to urgently proceed with the surgery as the scoliosis was progressive, with risks of cardiovascular and respiratory compromise. Additionally, she was scheduled to recommence growth hormone therapy postoperatively to treat her growth retardation. Ultimately, she received propofol for induction of Anaesthesia and TIVA with propofol and remifentanil infusions for the maintenance of Anaesthesia. Post-induction, a transvenous pacing wire was placed under ECG guidance. A transoesphageal probe was inserted and cardiac function monitored throughout the procedure. Upon prone positioning, she again developed a bradycardia which responded to pacing and surgery was carried out uneventfully. Clinical examination and extensive investigations had failed to demonstrate any specific underlying cause for her repeated positional arrhythmia. Therefore, we deduced that the bradycardia was due to a hypervagal response provoked by prone positioning and because of the severity of the scoliosis. We are unaware of reports of such a complication in the literature.
Accepted: 4 Mar 2013
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