背景:瑞芬太尼,一种超短效μ阿片受体激动剂,由于出色的可调性,通常用于麻醉管理。已知瑞芬太尼会引起窦性心动过缓,然而,因为它对心脏传导系统具有直接的负变时效应,并且通过副交感神经系统具有间接的负变时效应。
方法:一名8岁的日本男孩因第四脑室脑肿瘤被诊断为急性脑积水,并接受了紧急手术。影像学检查显示脑干受压。安排了内镜下第三脑室造瘘术和脑室腹腔分流术。在全身麻醉诱导期间开始使用瑞芬太尼,但心电图显示窦性心动过缓,然后是Wenckebach型房室传导阻滞,然后完成房室传导阻滞.立即停用瑞芬太尼,我们用硫酸阿托品.完全性房室传导阻滞恢复为窦性心律。瑞芬太尼重新启动后,然而,心电图再次显示窦性心动过缓,Wenckebach型房室传导阻滞,然后完成房室传导阻滞.再次立即停用瑞芬太尼,我们注射了肾上腺素,然后完全性房室传导阻滞恢复为窦性心律。使用芬太尼代替瑞芬太尼,并连续输注多巴胺。此后没有再发生完全性房室传导阻滞。
结论:这是已知的首例因服用瑞芬太尼导致颅内压升高的儿科患者发生完全房室传导阻滞的病例。
BACKGROUND: Remifentanil, an ultra-short-acting µ-opioid receptor agonist, is commonly used for anesthetic management due to excellent adjustability. Remifentanil is known to cause sinus bradycardia, however, because it has a direct negative chronotropic effect on the cardiac conduction system and there is an indirect negative chronotropic effect via the parasympathetic nervous system.
METHODS: An 8-year-old Japanese boy was diagnosed with acute hydrocephalus due to a brain tumor in the fourth ventricle and underwent emergency surgery. Imaging examination showed brainstem compression. Endoscopic third ventriculostomy and ventriculoperitoneal shunt surgery were scheduled. Remifentanil was started during induction of general anesthesia, but electrocardiogram showed sinus bradycardia, then Wenckebach-type atrioventricular block, and then complete atrioventricular block. Remifentanil was immediately discontinued, and we administered atropine sulfate. Complete atrioventricular block was restored to sinus rhythm. When remifentanil was restarted, however, the electrocardiogram again showed sinus bradycardia, Wenckebach-type atrioventricular block, and then complete atrioventricular block. Remifentanil was again immediately discontinued, we administered adrenaline, and then complete atrioventricular block was restored to sinus rhythm. Fentanyl was used instead of remifentanil with continuous infusion of dopamine. There has since been no further occurrence of complete atrioventricular block.
CONCLUSIONS: This is the first known case of complete atrioventricular block in a pediatric patient with increased intracranial pressure seemingly caused by administration of remifentanil.