Friday November 17, 2006
Iatrogenic induced Brugada syndrome !!

Scenario: You admitted a patient in ICU with COPD exacerbation, requiring mechanical intubation. You started patient on cocktail of nebulizer treatments, IV steroid, antibiotic coverage, standard ICU prophylaxes and propofol for short term sedation as you expected recovery and extubation within 48-72 hours. Next day, nurse noticed ST elevation in V2 lead. You ordered EKG (ECG) and indeed new ST elevations noted in leads V1 to V3 changes along with Right-Bundle-Branch-Block (RBBB). You acquired cardiology consult and cardiologist was excited to report you that this is a Brugada syndrome. As far as you remember, Brugada syndrome is a hereditary and a genetic disease. And you are wondering - isn't the EKG was normal on admission ?


A; Propofol induced EKG findings look like Brugada syndrome.

The Brugada syndrome is a genetic syndrome said to be autosomal dominant associated with SCN5A gene. Clinically, it appears as EKG findings of right bundle branch block and ST segment elevation in V1 to V3 (J point elevation) with a structurally normal heart. It goes unnoticed and cause either syncopal episodes or sudden death. Mean age of death is 40 years but can happen at any point in life time. It is very common in asian people and acquired different names as Lai Tai (death during sleep) in Thailand, Bangungut (scream followed by sudden death during sleep) in Philippines and Pokkuri (unexpected sudden death at night) in Japan.

Recently, it has been reported in HeartRhythm that Brugada syndrome like EKG findings may be the earliest finding of propofol infusion syndrome (PRIS) and early recognition with discontinuation of propofol may save lives as mortality of PRIS is more than 80%.


Related site: www.brugada.org


Reference: click to get abstract

1. Electrocardiographic changes predicting sudden death in propofol-related infusion syndrome - HeartRhythmVolume 3, Issue 2, Pages 131-137 (February 2006)