Electrocautery induced artifactual ST segment depression in leads II, III and aVF on intra operative 5-lead electrocardiogram

Abstract

To the Editor, We describe a case of electrocautery-induced artifactual inferior wall ischemic changes in a 31 year old male patient with chronic kidney disease (CKD) undergoing repeat live donor kidney transplantation. He was a known case of CKD since last 7 years and undergone live donor kidney transplantation 6 years back. He was on maintenance hemodialysis twice a week again since a year. He was continued to be hypertensive since last 10 years even after kidney transplantation and was on three anti hypertensive medications. He had dyspnea on exertion class II and New York Heart Association status II. His preoperative 12-lead electrocardiogram (ECG) showed normal sinus rhythm with left ventricular hypertrophy (LVH). Echocardiogram reported concentric LVH, mild mitral regurgitation, mild pulmonary artery hypertension, minimal pericardial effusion and left ventricular ejection fraction of 40 %. All anti hypertensive medications were continued till morning on day of surgery. In the operating room, 5-lead ECG, pulse oximetry and non-invasive blood pressure monitoring was applied on non-fistula arm. Anesthesia was induced with fentanyl, propofol and atracurium. Right internal jugular central venous catheter was placed under ultrasound guidance and surgery was allowed to start. Immediately after skin incision, ST segment depression was noted in lead II (Fig. 1a). He was hemodynamically stable with blood pressure of 147/89 mm Hg and pulse rate of 88 per minute. ST segment depressions were temporary and intermittent with the use of unipolar electrocautery by surgeon. Correct placement of ECG electrodes was confirmed and all lead ECG view was seen on monitor to look at other leads for similar changes. It was noticed that ST segment depressions were present in lead II, III and aVF with slight ST elevation in aVR (Fig. 1b). These intermittent and temporary ECG changes were present and reproducible throughout the surgery. Electrocautery (anode) plate was applied on posterior aspect of upper part of right thigh, quite away from the ECG electrodes. Monitor used was one attached to Datex-Ohmeda S/5 Avance anesthesia workstation and was in routine use without similar occurrence in other cases. Post operative his 12-lead ECG was same as preoperative and enzyme marker (troponin T, troponin I and CK-MB) were negative for ischemia or infarction. Electrocautery induced artifact in intraoperative ECG showing ST changes have been reported previously. Jain et al. [1, 2] reported electrocautery induced ST segment depression in two different patients with coronary artery disease undergoing non cardiac surgeries. In an another case reported by Jain et al. [3] showed ST segment elevation in lead V5 with concurrent ST depression in lead II, in a CKD patient undergoing cadaveric kidney transplantation. Similar ST segment depression was also reported by Ketchey et al. [4]. In present case ST segment depressions were noted in lead II, III and aVF, and this point toward diagnosis of inferior wall ischemia or it can be a mirror image of ischemia in another area (e.g. anterior ischemia) or other non-ischemic diseases. Being an American society of anesthesiologist physical status grade III patient, kidney transplant recipient patient is always at great suspicion for perioperative cardiac arrhythmias, myocardial ischemia and infarction. The five S. L. Solanki (&) K. Kishore V. K. Goyal Department of Anesthesiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Rae-Bareilly Road, Lucknow 226014, India e-mail: me_sohans@yahoo.co.in