Case 15: Life-Threatening Arrhythmia in a 5-Month-Old
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A 5-month-old child was scheduled for elective correction of transposition of the great arteries (Senning procedure). She was diagnosed with the transposition immediately after birth, and a balloon septostomy was performed with good result. Prior to this proposed operation, the child was in good physical condition and weighed 5.9Kg. She tolerated the operation well and came off cardiopulmonary bypass uneventfully. She was paralyzed, ventilated, and sedated postoperatively. Her cardiovascular system was supported with small continuous doses of dopamine, phentolamine, and epinephrine with good effect. However, a persistent tachycardia ranging from 140 to 230 beats per minute led to a decrease in mean arterial pressure and contributed to renal insufficiency with a rising creatinine. Peritoneal dialysis was initiated successfully. However, the tachyarrhythmia did not improve (Fig. 1). Digoxin (Lanoxin) 0.16, 0.08, and 0.08 mg was given according to recommendation for children aged 2 weeks to 2 years. (0.04–0.06 mg/kg was given IV during the next hours). Unfortunately, no improvement was seen, and episodes of tachycardia up to 360 beats/min were observed even after the child was fully digitalized. Verapamil, propranolol, lidocaine, and phenytoin were given with no effect on this life-threatening arrhythmia. The patient was now completely anuric. An arterial blood gas showed the pH 7.33, pCO2 33 mmHg, BE – 7.7 mmol/l, and pO2 is 92 mmHg on FiO2 0.4. The child had been in the ICU for over 24 h, and of great concern now was the fact that the serum potassium had risen to 5.9 mmol/l. The standard recommended treatment of high potassium, including normalizing the pH and giving glucose-insulin infusion, was started. The peritoneal dialysis fluid with potassium-free solutions was now used. Despite all this, a repeat potassium showed a further increase to 7.8 mmol/l (Fig. 2). Serum calcium and magnesium were within normal limits. The child was now critical; as besides the increased serum potassium and anuria, her cardiovascular system showed a heart rate of 300 beats per min and a mean arterial pressure of 48 mm Hg.
KeywordsNeonate Arrhythmia Senning procedure Cardiopulmonary bypass General anesthesia Digoxin Digoxin toxicity Digoxin-specific antibody fragments
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