Ventricular fibrillation during spinal surgery

Abstract

The recent case report by Drs Reid and Appleton (Anaesthesia 1999; 54: 364–7) highlights difficulties in the management of children with Duchenne's muscular dystrophy presenting for scoliosis surgery. We have, however, concerns with the recommendations they make for the pre- and peroperative management of such cases. Firstly, they state that ‘a standard electrocardiogram is the simplest and most reliable tool for detecting cardiac involvement in DMD’. We would take issue with this statement. The cardiomyopathy which develops in patients with DMD may result in reduced ventricular ejection fraction. Whilst an electrocardiogram will detect conduction defects in the DMD heart, it may be quite normal in the presence of a reduced left ventricular ejection fraction. A resting echocardiographic study may not accurately predict the cardiovascular response to operative stress, as the authors state; however, it is a mandatory pre-operative investigation in these patients. A pre-operative reduction in the left ventricular ejection fraction to below 50% in the resting patient is significant and should be considered a contra-indication to surgery [1]. Second, the authors state in their summary that ‘If possible, full invasive monitoring should be instituted pre-operatively, especially for operations which can be associated with large fluid shifts’. It is our opinion that both invasive arterial monitoring and central venous pressure monitoring again are absolutely mandatory in this group of patients. If access is a problem, as in their case, then we would suggest, as has happened in our centre in the past, that either a surgical cut down is performed to attain an arterial line or, indeed, the femoral vessels are utilised. If invasive arterial monitoring cannot be achieved, it would be reasonable to abandon the procedure until a future date. Fluid shifts during spinal surgery can be enormous, and in our opinion cannot be managed adequately without such monitoring.