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DP04: PERIOPERATIVE ANESTHETIC MANAGEMENT OF A PATIENT WITH BRUGADA SYNDROME UNDERGOING URGENT NONCARDIAC SURGERY
Phillip Cifuentes, MD; Stephan Mouhanna, MD; Lori J Gilbert, MD; Benjamin T Houseman, MD, PhD
Memorial Healthcare System
Introduction: Brugada syndrome is an inherited cardiac channelopathy with a prevalence of approximately 0.05%. It is characterized by distinct electrocardiographic abnormalities, an increased risk of ventricular arrhythmias and cardiac arrest. It is separated into three types each with their own distinct electrocardiographic findings and associated risk. Triggers include fever, surgical stress, and electrolyte disturbances, many of which are encountered in the perioperative setting.
Case Presentation: A 42-year-old female with a history of type 2 Brugada syndrome presented with abdominal pain accompanied by nausea and vomiting. Imaging revealed a 7-mm left ureteral stone with associated hydronephrosis. The patient was tachypneic and tachycardic, with a leukocytosis (24.2 ×10?/L). Urology recommended urgent left retrograde pyelography and ureteroscopy with ureteral stent placement. Preoperative evaluation revealed an implantable loop recorder, a history of recent catheter ablation, and multiple episodes of syncope, including an event that occurred upon arrival to the emergency department. Review of personal telemetry demonstrated episodes of supraventricular tachycardia and one 22-second sinus pause. Cardiology care had been provided at an outside institution, and no recent loop recorder interrogations or cardiology documentation were available for review. Given the patient’s clinical deterioration and the urgent nature of the procedure, the case proceeded. Arterial blood pressure monitoring was established via a left radial arterial line, and external defibrillation equipment was placed on the patient. The procedure was performed under monitored anesthesia care using etomidate, fentanyl, lidocaine, and midazolam. The patient maintained normal sinus rhythm and hemodynamic stability throughout the case. Postoperatively, the patient was transferred to the intensive care unit for continued intravenous antibiotic therapy and was subsequently discharged home in stable condition.
Discussion: This case highlights perioperative considerations in a patient with Type 2 Brugada syndrome, prior syncope, and limited cardiac evaluation who required urgent surgery.
Perioperative management focuses on electrocardiographic monitoring, strict electrolyte and temperature regulation, and appropriate analgesia to maintain hemodynamic stability. The use of external defibrillation pads is recommended for all patients throughout the perioperative period regardless of baseline device status. Implantable cardioverter defibrillator (ICD) placement remains the standard for prevention in survivors of prior cardiac arrest or sustained ventricular tachycardia and in patients with spontaneous Type 1 patterns and syncope. ICD placement is considered in patients with type 2 or 3 Brugada syndrome that demonstrate high-risk features such as syncope secondary to ventricular arrhythmias or inducible ventricular fibrillation from electrophysiologic studies. Type 2 brugada with high risk features such as syncope made this patient a possible candidate for ICD placement, despite lacking one on presentation.
Anesthetic management should minimize autonomic instability and avoid agents that potentiate sodium channel dysfunction. Lidocaine is preferred for local anesthesia due to its short duration of action. Beta-blockers and cholinergic agents should be avoided due to the risk of bradyarrhythmias. In this case, monitored anesthesia care with etomidate, fentanyl, lidocaine and midazolam allowed for stable hemodynamics throughout the procedure.
This case demonstrates that with appropriate preparation and multidisciplinary awareness, urgent surgical procedures can be performed safely in this high-risk population.
