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Anesthetic management for a patient with Wolff-Parkinson-White syndrome undergoing tonsillectomy155
Anesthetic Management for a Patient with Wolff-Parkinson-
White S yndrome undergoing Tonsillectomy
Masayuki Oshima“, Yoichi Shimada“, Atsuhiro S akamoto“, Ryo Ogawa“
We present here a patient with Wolff-Parkinson-
wnite ,(WPW) syndrome, who was anesthetized with
propofbl du血g palatine tonsillectomy.
Case
A palatine tonsillectomy was planned for a 33-year-
old 165 cm and 59 kg, female with chronic tonsillitis.
Preoperative exami lation血dicated no specific find-
ings except for the WPW syndrome detected by
electrocardiogram (Fig.). B ased on a more detailed
examination using a Holter electrocardiogram, she was
diagnosed as having WPW syndrome.
Anesthetic management
No preanesthetic medication was administered to
the patient. After establishing the venous line on the
left forearm, O.025 mg of fentanyl was administered
intravenously and target controlled infusion was
carried out to obtain a target blood concentration of
propofol of 3 pt g/mi. Vecuronium (3 mg) was also
administered intravenously to facilitate tracheal in-
tubation. Anesthesia was maintained using fentanyl
(total amount of O.1 mg), propofol (target blood
concentration of 3-4 pt g/ml), nitrous oxide and oxygen.
In addition to local administration of 1 90 lidocaine
containing epinephrine (5 pt g/mi) around the tonsil,
disopyramide was continuously administered. in-
travenously at 200 mgth to avoid tachyarrythmias.
Delta wave was apparent from the induction to the end
*Deparment of Anesthesiology,, Nippon Medical School,
Tokyo, Japan
of anesthesia, but perioperative hemodynamics were
relatively stable. Postoperatively, disappearance of the
muscle relaxant action of vecuronium was confirmed
and the patient was extubated without antagonizing the
muscle relaxant effect, and returned to her ward.
Discussion
Sadowski and Moyers i) established that successful
anesthetic management of the WPW syndrome and its
variants depends on avoiding tachyarrythmias by
suppression of sympathetic stimulation and is predict-
ed upon understanding the electrophysiologic and
clinical manifestations. Therefore, we avoided using
atropine as the preanesthetic medication as well as for
reversal of the muscle relaxant.
Although a report showed that the delta wave was
disappeared following propofol administration2), it is
considered that propofol does not affect the refractory
periods of the atriovenuicular node, right ventricle and
accessory pathway3). We could administer propofol
safely for the induction and maintenance of anesthesia.
in addition to propofol, fentanyl and nitrous oxide
were also used to maintain anesthesia. Neither fentanyl
nor nitrous oxide had a modifying effect on the
refractory periods of the accessory pathway4).
Patients with WPW syndrome may have two maj or
types of arrhythmias: auial flutter fibrillation or
atrioventricular reciprocating tachycardia. Atrial flut-
ter fibrillation can be life-threatening in patients with
short anterograde refractory periods of the accessory
pathway, since it may deteriorate to ventricular
fibrillation. Disopyramide have beneficial effects on
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156 循環:制御第24巻第2号(2003)
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Fig. Preoperative 12-lead electrocardiogram showing Wolff-Parkinson-White syndrome.
accessory pathway conduction in patients with WPW
syndromeS・6). Because local administration of lidocaine
containing epinephrine around the tonsil may lead to
tachycardia, disopyramide was continuously adminis-
tered to prevent it. However, disopyramide is useful
and safe in patients with normal ventricular function
who have atrial fibrillation and a predominant vent-
ricular response over an accessory atrioventricular
pathway5-8). Therefore, prophylactic administration of
disopyramide may have little effect.
Conclusion
A patient with WPW syndrome was anesthetized
with target controlled infusion of propofol during
palatine tonsillectomy without any sequelae.
This case report was partly presented at the 22nd
annual meeting of The Japan Society for Clinical
Anesthesia (Kofu, Nov. 2002).
References
1 ) Sadowski AR, Moyers JR : Anesthetic management of the
Woliif-Parktnson-White syndrome. Anesthesiology 51 :
553-556, ユ979
2) Sekt S, lchimiya T, Tsuchida H, et al : A case of
normalization of Wolff-Parkinson-wnite syndrome conduc一
3)
4)
5)
6)
7)
8)
tion during propofol anesthesia. Anesthesiology 90 :
1779-1781, 1999
Sharpe MD, Dobkowski WB, Murkin JM, et al : Propofol
has no direct effect on smoatrral node function or on normal
atrroventncular and accessory pathway conduction in
Wolff-Parkinson-White syndrome during alfentaniVmi-
dazolam anesthesia. Anesthesiology 82 : 888-895, 1995
Gomez-Arnau J, Marquez-Montes J, Avello F : Fentanyl
and droperidol effects on the refractorJness of the accessory
pathway in the Wolff-Parkinson-White syndrome. Anest-
hesiology 58:307-313, 1983
Spurrell RAJ, Thorburn CW, Carnm J, et al:Effects of
disopyramide on electrophysiological propenies of special-
ized conduction system in man and on accessory at-
rioventrlcular pat lway皿Wolff-Parkinson-White syn-
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Kerr CR, Prystowsky EN, Smith WM, et al:Elect-
rophysiologic effects of disopyramide phosphate in patients
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Bennetr DH : DisQpyramide in patients vvith the Wolff-
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(Circ Cont 24 : 155 ’一 156, 2003)
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