Expert: Ronald Levy, M.D. - 4/19/2009

Question
QUESTION: hi,

I have a pacemaker for mobitz type I and II blocks caused by a mutation in the SCN5A gene.  My son was born on 4 July 2008 and my cardiologist wanted to check and see if he inherited the gene because he showed persistent RBBB on ECG tracings with no symptoms.  Unfortunately, he is a carrier of the gene, so our specialists assume the abnormal ECG's and Halters monitors were do to this mutation which is probably accurate.  Anyway, after a number of abnormal halters monitors with zero symptoms we decided to inserted a pacemaker prophylactically just to be safe.  During the surgery the surgeon came and told us that his heart felt kind of spongy, and took a biopsy which turned out to be nothing, that he never really felt a heart like it before.  OK, here is where your wisdom is needed.  After the surgery, still asleep, my son was very very irritable and moaning like he was in a great deal of pain.  The doc ordered more morphine which just made it worse, and worse, and then eventually they gave him Ketamine a few times to settle him.  This lasted for approx 4 hrs or so and he slowly started moaning and moving around the bed like his back was itchy.  By midnight they had given Ketamine a couple more times but it kept wearing off causing him to be in the same state as before.  They decided to take blood and his K was elevated and his CK and Troponin were elevated.  Nobody could figure out why and it values never decreased for about a day and a half.  He was very puffy right after the surgery for a few days too.  He finally woke up about a day after the surgery for a few minutes at a time still uncomfortable and moaning in pain.  The only thing that seemed to work for the pain was the Ketamine which was discontinued after the first night/morning and a benzodiazepine at high dosages for an infant.  

My question to you would be,
As far as post op symptoms and results go like my sons, have you ever seen anything even remotely close to his?
Could any of the medications had interactions during/after the surgery like this?

There are a lot of people still scratching there heads here and a metabolic specialist is unsure of what happened.
The CK and Troponin may have been elevated from the surgery itself and the biopsy of the heart, but that much? and for that long?

Sorry I know this is a bit long, but I wanted to give you a good history so u could paint the best picture you can so we can help my son for future procedures if necessary.
thanx

Dave

ANSWER: First of all, I don't understand why they were giving Ketamine. Ketamine is an anesthetic and while it does have pain relief properties, there are many onther drugs that would be my first choice. (I am assuming that he was not intubated). The other thing is that Ketamine is not usually a drug that a pediatrician gives (usually only an anesthesiologist gives it). As for the CKs, again  I am a litle confused. Generally a pacemaker is a percutaneous procedure. Did they open the chest to place the pacemaker? If not, how could he tell it was spongy? If they did open the chest and manipulate the heart, the CKs could go up. How much, I don't know but the rise is not related to the Ketamine.


Ronald Levy, MD
Professor of Anesthesiology
UTMB-Galveston

---------- FOLLOW-UP ----------

QUESTION: Hi, thanx for your prompt reply.  My son was four months old at the time and the surgeon said they make a small incision just under the xypoid procees and lift up the ribcage enough to get to the heart. Infants bones being so malleable, I guess that was the best way. The leads were stiched on I believe.
Yes my son was intubated.

Do any of his symptoms sound like he had an allergy to the pain meds?
What other drugs would you have used insted of Ketamine?  Keeping in mind the Morphine made it worse.  

Sorry, I forgot to tell you that they were giving Toradol every 4 hours on top of everything else.

Answer
When I asked about intubation, I was talking about post op when he was having the symptoms. Obviously he was intubated for the surgery. I don't thhink he was allergic to any of the meds. As for other drugs, assuming he was not intubated, I would have used Fentanyl (a short acting narcotic). The reason I ask about intubation is that, if he was intubated post-op, then there is a need to keep him asleep (and thus Ketamine is reasonable) although I probably would have gone with Propofol. It's tough to second guess the anesthesiologist as I don't have all the information he has to make that decision.

Ronald Levy, MD
Professor of Anesthesiology
UTMB-Galveston