Yüksek Doz Anestezik Kullanımında Torsades De Pointes Riski
Özet
Bu vaka takdiminde, COVID pnömonisi nedeniyle yoğun bakımda takipli 30 yaşındaki kadın hastada yüksek doz anestezik ajan kullanımına bağlı gelişen Torsades de Pointes (TdP) aritmi vakası ve yönetimi ele alınmaktadır. Ciddi solunum sıkıntısı ve mekanik ventilatör uyumsuzluğu nedeniyle hastaya yüksek dozlarda midazolam, fentanil ve roküronyum uygulanmıştır. Doz artımını takiben QTc aralığı 500 ms'ye uzamış, "R on T fenomeni" sonrasında ventriküler fibrilasyona dejenere olan polimorfik ventriküler taşikardi (TdP) gelişmiştir. İki kez defibrile edilen hastaya magnezyum sülfat ve potasyum desteği sağlanmıştır. Temel tedavi yaklaşımı olarak, QTc uzamasına yol açan yüksek doz anestezik ajanların dozları azaltılmıştır. Bu optimizasyonun ardından QTc değeri normal sınır olan 430 ms düzeyine gerilemiş ve kalıcı bir aritmik olay izlenmemiştir. Vaka, yoğun bakım süreçlerinde çoklu ve yüksek doz ilaç kullanımlarında telemetrik QTc takibinin hayati önemini ve gelişebilecek ölümcül aritmi yönetimini vurgulamaktadır.
This case report presents the management of Torsades de Pointes (TdP) arrhythmia induced by high-dose anesthetic agents in a 30-year-old female patient monitored for COVID pneumonia. Due to severe respiratory distress and mechanical ventilator dyssynchrony, high doses of midazolam, fentanyl, and rocuronium were administered. Following the dose escalation, the QTc interval prolonged to 500 ms, leading to polymorphic ventricular tachycardia (TdP) that degenerated into ventricular fibrillation after an "R on T phenomenon". The patient was defibrillated twice, and intravenous magnesium sulfate along with potassium replacement was initiated. As the primary therapeutic intervention, the doses of the suspected high-dose anesthetic agents were reduced. Following this treatment optimization, the QTc interval returned to its baseline level of 430 ms, and no sustained arrhythmic events recurred. This case highlights the vital importance of telemetric QTc monitoring and prompt management of fatal arrhythmias during multi-drug and high-dose anesthetic utilization in intensive care units.
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