周術期心房頻拍に対してデクスメデトミジン塩酸塩が有用であった2乳幼児例
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1 症例報告 PEDIATRIC CARDIOLOGY and CARDIAC SURGERY VOL.29 NO.5 ( ) Key words: Ectopic atrial tachycardia, perioperative care, dexmedetomidine, infant, left ventricular dysfunction 1 2 Effectiveness of Dexmedetomidine for Perioperative Ectopic Atrial Tachycardia in Infants with Congenital Heart Disease Kazuto Fujimoto 1 Hiroaki Kise 1 Takanari Fujii 1 Shigeru Sakurai 1 Atsushi Itoh 1 Kozo Ishino 1 Hideshi Tomita 1 Shigeru Uemura 1 Nobuo Oyama 2 Takashi Soga 2 1) Cardiovascular Center, 2) Children s Medical Center,Showa University,Northern Yokohama Hospital,Kanagawa,Japan Background: Although Dexmedetomidine DEXis primarily classified as a sedativeseveral foreign studies have suggested that DEX is effective for perioperative atrial and junctional ectopic tachycardiawe report the efficacy of DEX for perioperative ectopic atrial tachycardia in two infants with congenital heart disease Case1: Patch closure of ventricular septal defects VSDsusing the Sandwich method and pulmonary artery PAplasty were carried out in an 1-year-6 month old boy who previously underwent PA banding for multiple muscular VSDsEctopic atrial tachycardia EATwith a rate of 180 bpm was initiated followed by hypotension on post-operative day POD22Overdrive pacingamiodaronelandiolol hydrochloride LANa few sedativesas well as a muscle relaxant agent were not effective for this EATWe discontinued LAN following hypotension complicated by left ventricular LVdysfunctionwhile started DEX infusion of 0.7g/kg/hrAfter DEX administrationeat was terminated without hypotension Case2: A 2-year-6-month old boy of Truncus arteriosuswho previously underwent PA resection and rt-m-blalock-taussig shuntwas operated using the Rastelli procedure and VSD patch closureeat about a rate of 190 bpm was initiated with hypotension-on 1PODOverdrive pacinga sedativeand as a muscle relaxant agent were not effective for this EATWe started DEX infusion of 0.6g/kg/hrAfter DEX administrationeat was terminated successfully None of the patients developed any adverse events, such as bradycardia and hypotension Conclusion: DEX appears to have novel antiarrhythmic properties for acute termination of EAT on perioperative infants associated with congenital heart diseasethis report suggests that DEX may safely terminate EAT in cases complicated by LV dysfunction 要旨背景 :DEXAT DEX 2 症例 1: HR 180 / EATAMD EF AMD DEX 0.7g/kg/hr 症例 2:2 2 Blalock-Taussig Rastelli 平成 25 年 9 月 1 日 53
2 263 HR190 / EAT DEX 0.6g/kg/hr 2 まとめ :DEX AT はじめに AT 25 50% 12 DEX2 3 DEX AT 2 方法 DEX 投与の適応と投与方法 AT DEX 0.7g/kg/hr g/ kg/hr DEX DEX DEX DEX 症例 ,115g PABSpO2 80% 1 6 Sandwich patch EF 40% HR180 / AT Fig. 1AT AT AMD5mg/kg/hr 22 AT AMD 9mg/kg/hr LAN5g/kg/min LAN AMD DEX 0.7g/kg/hr 28 DEX 30 DEX 33 Fig. 2 症例 ,901gapgar 8/9 Van Praagh A1 2 Rastelli Blalock-Taussig shunt 5mm 1 3 CT 2 2 Rastelli Yamagishi Conduit 14mm HR 190 ATE Fig. 3AT 日本小児循環器学会雑誌第 29 巻第 5 号
3 264 Fig.1 Electrocardiogram prior to operation (left,pre),just after operation (middle,post Op),at AT (right,at)in case 1. Recording speed was 25 mm/sec Heart rate was 180 bpm at AT AT-Atrial tachycardia Fig.2 Clinical course after operation in case 1 平成 25 年 9 月 1 日 55
4 265 Pre a Post Op AT Pre Ⅰ Ⅴ1 Ⅱ Ⅴ2 Ⅲ Ⅴ3 ⅤR Ⅴ4 ⅤL Ⅴ5 ⅤF Ⅴ6 a a Fig 3 Post Op AT lectrocardiogram prior to operation left Pre just after operation middle Post Op at AT right AT in E case 2 Recording speed was 25 mm/sec V6 lead was recorded by temporary A lead A lead was implanted by the apex of right appendage Heart rate was about 190 bpm at AT The black arrow shows P wave heart rate beats/min systolic BP mmhg EF extubation 140 discharge heart rate systolic BP EF fentanyl VEC DEX Fig POD days 4μg/kg/Hr 0.1 mg/kg/hr 0.6μg/kg/Hr Clinical course after operation in case 2 日本小児循環器学会雑誌 第29巻 第5号
5 266 l 4g/kg/ hr 0.1mg/kg/hr DEX 0.6 g/kg/hr DEX 2 3 DEX Fig. 4 考察 DEX 2 4 D 2.4 2A 5 DEX 6 2A HR 2B DEX NPPV 2 24 DEX DEX 8 2 DEX DEX 24 DEX Fallot Maze DDD mode 3 DEX VVI mode 910 DEX AT AT DEX g/kg/hr 93% DEX AT 75% 44 DEX inotrope score 11 1 EF 40% DEX AT DEX AT DEX 0.7g/kg/hr DEX DEX Purkinje 12 AT DEX ATP camp L Ca2+ 15 平成 25 年 9 月 1 日 57
6 267 DEX DEX AT AT DEX DEX L P Ca2+ Ca K+ 16 DEX DEX 結 AT DEX 2 DEX DEX AT 語 参考文献 1Pfammatter JPBachmann DCWagner BPet al: Early postoperative arrhythmias after open-heart procedures in children with congenital heart diseasepediatr Crit Care Med 20012: Valsangiacomo ESchmid ERSchüpbach RWet al: Early postoperative arrhythmias after cardiac operation in children Ann Thorac Surg : Chrysostomou C, Sanchez-de-Toledo J, Wearden Pet al: Perioperative use of dexmedetomidine is associated with decreased incidence of ventricular and supraventricular tachyarrhythmias after congenital cardiac operationsann Thorac Surg : Bradley C: Dexmedetomidine--a novel sedative for postoperative sedationintensive Crit Care Nurs : Coursin DBCoursin DBMaccioli GA: Dexmedetomidine Curr Opin Crit Care 20017: Herr DLSum-Ping STEngland M: ICU sedation after coronary artery bypass graft surgery: dexmedetomidine-based versus propofol-based sedation regimensj Cardiothorac Vasc Anesth : Ebert TJHall JEBarney JAet al: The effects of increasing plasma concentrations of dexmedetomidine in humans Anesthesiology : Lam FBhutta ATTobias JDet al: Hemodynamic effects of dexmedetomidine in critically ill neonates and infants with heart diseasepediatr Cardiol : Shepard SMTejman-Yarden SKhanna Set al: Dexmedetomidine-related atrial standstill and loss of capture in a pediatric patient after congenital heartsurgerycrit Care Med : Chrysostomou CBeerman LShiderly Det al: Dexmedetomidine: a novel drug for the treatment of atrial and junctional tachyarrhythmias during the perioperative period for congenital cardiac surgery: a preliminary study Anesth Analg : Lam FRansom CGossett JMet al: Safety and efficacy of dexmedetomidine in children with heart failurepediatr Cardiol : Hammer GBDrover DRCao Het al: The effects of dexmedetomidine on cardiac electrophysiology in children Anesth Analg : Kantoch MJ: Supraventricular tachycardia in childrenindian J Pediatr : Hayashi YSumikawa KMaze Met al: Dexmedetomidine prevents epinephrine induced arrhythmias through stimulation of central alpha two adrenoreceptors in halothane anesthetized dogsanesthesiology : Parent BAMunoz RShiderly Det al: Use of dexmedetomidine in sustained ventricular tachycardiaanaesth Intensive Care : Nacif-Coelho CCorrea-Sales CChang LLet al: Perturbation of ion channel conductance alters the hypnotic response to the alpha 2-adrenergic agonist dexmedetomidine in the locus coeruleus of the ratanesthesiology : 日本小児循環器学会雑誌第 29 巻第 5 号
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