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Ann Thorac Surg 1997;63:1215-1216
© 1997 The Society of Thoracic Surgeons

Correspondence

Ventricular Tachycardia After Ultrafiltration During Cardiopulmonary Bypass

Yasushi Terada, MD, Toshio Mitsui, MD, Wahei Mihara, MD, Makoto Tanaka, MD

Departments of Cardiovascular Surgery and Anesthesiology, Institute of Clinical Medicine, University of Tsukuba, Tsukuba-shi, Ibaraki-ken 305, Japan

To the Editor:

We report ventricular tachycardia immediately after coronary artery bypass grafting in a patient on chronic renal dialysis in whom ultrafiltration was employed during cardiopulmonary bypass.

A 59-year-old man, who was diagnosed as having angina due to left main trunk lesion, diabetes mellitus, and chronic renal failure due to diabetic nephropathy, underwent double coronary artery bypass grafting on August 15, 1996. He had been on hemodialysis for 78 months. The serum potassium level was 4.1 mEq/L before cardiopulmonary bypass. Because of a severely calcified coronary artery, the procedure was completed with difficulty with the use of cardioplegic arrest.

To remove the excess water and potassium, ultrafiltration during cardiopulmonary bypass was used. The amount of fluid removed was 4350 mL, and 3,900 mL of fluid was added to maintain bypass flow. The serum potassium level was 6.6 mEq/L at aortic declamping and 5.1 mEq/L at the end of cardiopulmonary bypass.

Immediately after weaning from bypass, ventricular arrhythmias occurred with hemodynamic instability. Catecholamine administration was started. Antiarrhythmic agents could not control the arrhythmias. Ventricular tachycardia developed and was intractable. Finally, a bolus injection of fentanyl citrate, 0.25 mg, dramatically controlled the ventricular tachycardia and stabilized the hemodynamics. An anesthesiologist suspected that the anesthesia became inadvertently lighter. After that, the course was quite uneventful.

High-dose fentanyl is satisfactory for the induction and maintenance of anesthesia with regard to hemodynamic and fluid requirements [1, 2]. About 80% of fentanyl is bound to plasma proteins [3]. Protein binding of fentanyl limits drug availability at receptor sites. The molecular weight of fentanyl is 366 daltons.

Ultrafiltration removes water and electrolytes but no protein. Drugs that are not bound to protein are removed as determined by their molecular weight [4]. The Hemoconcentrator (HC-100M; MERA, Inc, Tokyo, Japan) that we used is composed of 10,000 polypropylene fibers with an internal diameter of 200 µm and has an effective surface area of 1.0 m2. The sieving coefficient is 1.0 for molecular weights less than 10,000 daltons.

Under high-dose fentanyl anesthesia, a supplemental dose of fentanyl may be necessary to ensure anesthesia when a large amount of plasma water is removed by ultrafiltration during cardiopulmonary bypass.

References

  1. Lunn JD, Stanley TH, Eisele J, Webster L, Woodward A. High dose fentanyl anesthesia for coronary artery surgery: plasma fentanyl concentration and influence of nitrous on cardiovascular responses. Anesth Analg 1979;58:390–5.[Abstract/Free Full Text]
  2. Stanley TH, Webster LR. Anesthetic requirements and cardiovascular effects of fentanyl-oxygen and fentanyl-diazepam-oxygen anesthesia in man. Anesth Analg 1978;57:411–6.[Abstract/Free Full Text]
  3. Meuldermans WEG, Hurkmans RMA, Heykants JJP. Plasma protein binding and distribution of fentanyl, sufentanil, alfentanil and lofentanil in blood. Arch Int Pharmacodyn Ther 1982;257:4–19.[Medline]
  4. Magilligan DJ, Oyama C. Ultrafiltration during cardiopulmonary bypass: laboratory evaluation and initial clinical experience. Ann Thorac Surg 1984;37:33–9.[Abstract]




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